Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology

AIM

To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported.

RESULTS

FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01).

CONCLUSION

Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

The impact of ovariectomy on cardiac excitation-contraction coupling is mediated through cAMP/PKA-dependent mechanisms

Ovariectomy (OVX) promotes sarcoplasmic reticulum (SR) Ca²⁺ overload in ventricular myocytes. We hypothesized that the cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA) pathway contributes to this Ca²⁺ dysregulation. Myocytes were isolated from adult female C57BL/6 mice following either OVX or sham surgery (surgery at ≈1mos). Contractions, Ca²⁺ concentrations (fura-2) and ionic currents were measured simultaneously (37°C, 2Hz) in voltage-clamped myocytes. Intracellular cAMP levels were determined with an enzyme immunoassay; phosphodiesterase (PDE) and adenylyl cyclase (AC) isoform expression was examined with qPCR. Ca²⁺ currents were similar in myocytes from sham and OVX mice but Ca²⁺ transients, excitation-contraction (EC)-coupling gain, SR content and contractions were larger in OVX than sham cells. To determine if the cAMP/PKA pathway mediated OVX-induced alterations in EC-coupling, cardiomyocytes were incubated with the PKA inhibitor H-89 (2μM), which abolished baseline differences. While basal intracellular cAMP did not differ, levels were higher in OVX than sham in the presence of a non-selective PDE inhibitor (300μM IBMX), or an AC activator (10μM forskolin). This suggests the production of cAMP by AC and its breakdown by PDE were enhanced by OVX. Consistent with this, mRNA levels for both AC5 and PDE4A were higher in OVX in comparison to sham. Differences in Ca²⁺ homeostasis and contractions were abolished when sham and OVX cells were dialyzed with patch pipettes containing the same concentration of 8-bromoadenosine-cAMP (50μM). Interestingly, selective inhibition of PDE4 increased Ca²⁺ current only in OVX cells. Together, these findings suggest that estrogen suppresses SR Ca²⁺ release and that this is regulated, at least in part, by the cAMP/PKA pathway. These changes in the cAMP/PKA pathway may promote Ca²⁺ dysregulation and cardiovascular disease when ovarian estrogen levels fall. These results advance our understanding of female-specific cardiomyocyte mechanisms that may affect responses to therapeutic interventions in older women.

Impaired sinoatrial node function and increased susceptibility to atrial fibrillation in mice lacking natriuretic peptide receptor C

Natriuretic peptides (NPs) are critical regulators of the cardiovascular system that are currently viewed as possible therapeutic targets for the treatment of heart disease. Recent work demonstrates potent NP effects on cardiac electrophysiology, including in the sinoatrial node (SAN) and atria. NPs elicit their effects via three NP receptors (NPR-A, NPR-B and NPR-C). Among these receptors, NPR-C is poorly understood. Accordingly, the goal of this study was to determine the effects of NPR-C ablation on cardiac structure and arrhythmogenesis. Cardiac structure and function were assessed in wild-type (NPR-C(+/+)) and NPR-C knockout (NPR-C(-/-)) mice using echocardiography, intracardiac programmed stimulation, patch clamping, high-resolution optical mapping, quantitative polymerase chain reaction and histology. These studies demonstrate that NPR-C(-/-) mice display SAN dysfunction, as indicated by a prolongation (30%) of corrected SAN recovery time, as well as an increased susceptibility to atrial fibrillation (6% in NPR-C(+/+) vs. 47% in NPR-C(-/-)). There were no differences in SAN or atrial action potential morphology in NPR-C(-/-) mice; however, increased atrial arrhythmogenesis in NPR-C(-/-) mice was associated with reductions in SAN (20%) and atrial (15%) conduction velocity, as well as increases in expression and deposition of collagen in the atrial myocardium. No differences were seen in ventricular arrhythmogenesis or fibrosis in NPR-C(-/-) mice. This study demonstrates that loss of NPR-C results in SAN dysfunction and increased susceptibility to atrial arrhythmias in association with structural remodelling and fibrosis in the atrial myocardium. These findings indicate a critical protective role for NPR-C in the heart.

The impact of ovariectomy on calcium homeostasis and myofilament calcium sensitivity in the aging mouse heart

This study determined whether deficiency of ovarian estrogen starting very early in life promoted age-associated Ca(2+) dysregulation and contractile dysfunction in isolated ventricular myocytes. Myocytes were isolated from anesthetized C57BL/6 female mice. Animals received an ovariectomy or sham-operation at one month and were aged to ~24 months. Excitation-contraction coupling parameters were compared in fura-2 loaded myocytes (37°C). While Ca(2+) transients were larger and faster in field-stimulated myocytes from ovariectomized mice, ovariectomy had no effect on peak fractional shortening. Similarly, ovariectomy had no effect on fractional shortening measured in vivo by echocardiography (values were 60.5 ± 2.9 vs. 60.3 ± 2.5% in sham and ovariectomized, respectively; n=5 mice/group). Ovariectomy did decrease myofilament Ca(2+) sensitivity, as evidenced by a 26% increase in the Ca(2+) required to activate actomyosin MgATPase in ovariectomized hearts. Larger Ca(2+) transients were attributable to a 48% increase in peak Ca(2+) current, along with an increase in the amplitude, width and frequency of Ca(2+) sparks measured in fluo-4 loaded myocytes. These changes in Ca(2+) handling were not due to increased expression of Ca(2+) channels (Cav1.2), sarcoplasmic reticulum Ca(2+) ATPase (SERCA2) or Na(+)-Ca(2+) exchanger in ovariectomized hearts. However, ovariectomy increased sarcoplasmic reticulum Ca(2+) stores by ~90% and promoted spontaneous Ca(2+) release from the sarcoplasmic reticulum when compared to sham controls. These observations demonstrate that long-term ovariectomy promotes intracellular Ca(2+) dysregulation, reduces myofilament Ca(2+) sensitivity and increases spontaneous Ca(2+) release in the aging female heart.

Abstract 3712: 2-Methoxyestradiol inhibits Barrett's esophageal adenocarcinoma growth and aggressive phenotypes through differential regulation of β-catenin-E-cadherin-axis

The purpose of this study was to evaluate whether 2-methoxyestradiol (2-ME2), a promising anticancer agent, modulates Barrett's esophageal adenocarcinoma (BEAC) cell growth and behavior through cellular pathway involving beta-catenin in partnership with E-cadherin, which appears to play a critical role in the induction of antitumor responses in cancer cells. We found that 2-ME2 markedly reduced the BEAC cell proliferation via regulating apoptotic machinery such as Bcl-2 and Bax. It may nullify the aggressive behavior of the cells by reducing the migratory behavior. Expressions of beta-catenin and E-cadherin and binding of these two proteins is activated in a 2-ME2-dependent fashion in Bic-1 cells. Moreover, over expressions of these two proteins may be due to the stabilization of these proteins by 2-ME2. We found that 2-ME2-induced anti-migratory effects are mediated through the beta-catenin -E-cadherin signaling pathways. In view of these results, we determined whether 2-ME2 reduces BEAC tumor growth. Administration of 2-ME2 significantly decreased the growth of BEAC cells xenografted on the flank of nude mice. The evidence presented points out that the impact of 2-ME2 on beta-catenin-orchestrated signal transduction plausibly plays a multi-faceted functional role to inhibit the proliferation and cell migration of 2-ME2 treated malignant cells and it could be a potential candidate in novel treatment strategies for Barrett's esophageal adenocarcinoma

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3712.

2-methoxyestradiol inhibits Barrett's esophageal adenocarcinoma growth and differentiation through differential regulation of the beta-catenin-E-cadherin axis

The purpose of this study was to evaluate whether 2-methoxyestradiol (2-ME(2)), a promising anticancer agent, modulates Barrett's esophageal adenocarcinoma (BEAC) cell growth and behavior through a cellular pathway involving beta-catenin in partnership with E-cadherin, which seems to play a critical role in the induction of antitumor responses in cancer cells. We found that 2-ME(2) markedly reduced the BEAC cell proliferation through regulating apoptotic machinery such as Bcl-2 and Bax. It may nullify the aggressive behavior of the cells by reducing the migratory behavior. Expressions of beta-catenin and E-cadherin and binding of these two proteins is activated in a 2-ME(2)-dependent fashion in Bic-1 cells. Moreover, overexpressions of these two proteins may be due to the stabilization of these proteins by 2-ME(2). We found that 2-ME(2)-induced antimigratory effects are mediated through the beta-catenin-E-cadherin signaling pathways. In view of these results, we determined whether 2-ME(2) reduces BEAC tumor growth. Administration of 2-ME2 significantly decreased the growth of BEAC cells xenografted on the flank of nude mice. The evidence presented points out that the effect of 2-ME(2) on beta-catenin-orchestrated signal transduction plausibly plays a multifaceted functional role to inhibit the proliferation and cell migration of 2-ME(2)-treated malignant cells and it could be a potential candidate in novel treatment strategies for Barrett's esophageal adenocarcinoma.

Dietary factors and cancer chemoprevention: an overview of obesity-related malignancies

Obesity is a growing health problem in developed nations and in countries that are in the process of westernization like India. Obesity is linked with several health disorders such as hypertension and cardiovascular diseases, Type 2 diabetes, dyslipidemia and certain cancers. Currently, obesity-related malignancies, e.g., cancers of the breast, prostate and colon are the leading cancers in the industrialized societies. An increased amount of fat or adipose tissue in an overweight or obese person probably influences the development of cancer by releasing several hormone-like factors or adipokines. The majority of adipokines are pro-inflammatory, which promote pathological conditions like insulin resistance and cancer. On the other hand, many recent studies have shown that adiponectin, an anti-inflammatory adipokine, has anti-cancer and insulin-sensitizing effects. Adiponectin exerts its physiological functions chiefly by activation of AMP kinase via adiponectin receptors. Interestingly, several fruits and vegetables may contain adiponectin-like molecules or may increase the biosynthesis of adiponectin in our body. Studies on adiponectin analogues or adiponectin receptor agonists are a promising area of cancer chemoprevention research. In general, fruits and vegetables contain various dietary substances such as vitamins, minerals (like calcium and selenium), fiber and phytochemicals or phenolic compounds (like flavonoids and vanilloids), which may act as anti-cancer agents. Similarly, several dietary constituents including phytochemicals may have anti-obesity effects. Consumption of such dietary compounds along with caloric restriction and physical activity may be helpful in preventing obesity-related cancers. For this review article, we searched PubMed primarily to get the relevant literature.

Down-regulation of death-associated protein kinase-2 is required for beta-catenin-induced anoikis resistance of malignant epithelial cells

Resistance of solid tumor cells to anoikis, apoptosis induced by cell detachment from the extracellular matrix, is thought to be critical for the ability of these cells to grow anchorage independently within three-dimensional tumor masses and from metastases. Beta-catenin, a major oncoprotein, can inhibit anoikis of cancer cells via unknown mechanisms. In an effort to identify these mechanisms we found that beta-catenin blocks anoikis of malignant kidney and intestinal epithelial cells and promotes their anchorage-independent growth by down-regulating death-associated protein kinase-2 (DAPk-2), a pro-apoptotic protein whose cellular functions have so far remained unexplored. We found that beta-catenin-induced down-regulation of DAPk-2 requires the presence of the transcription factor Tcf-4, a known mediator of beta-catenin signaling. We also observed that DAPk-2 contributes to the execution of anoikis of the non-malignant epithelial cells. Thus, beta-catenin-induced down-regulation of DAPk-2 represents a novel signaling mechanism by which beta-catenin promotes the survival of malignant epithelial cells following their detachment from the ECM and enables these cells to grow in an anchorage-independent manner.

Dose effect of soy supplementation in prostate cancer: a pilot study

We performed a pilot study to determine the dose effect of soy supplement on serum hormonal levels, estrogen receptor alpha (ERalpha) and androgen receptor (AR) expression in patients scheduled to undergo prostatectomy. Cohorts of 3-4 eligible patients received escalating doses of a commercial soy supplement, Flav-ein, from the time of study enrollment until prostatectomy. Serum levels of prostate specific antigen (PSA), testosterone, and estrogen were measured at study enrollment and prior to prostatectomy. AR and ERalpha expression was evaluated in the pretreatment biopsy specimen and post-treatment prostatectomy specimen using immunohistochemical analysis. A total of 13 patients were enrolled in this pilot study and 11 patients were assessable for response. With soy supplementation, serum testosterone levels decreased in 9 of 11 patients and estrogen levels decreased in 8 of 10 patients in a dose-dependent manner. There was a variable effect on ERalpha expression with downregulation of receptor expression seen at the highest dose level. There was no effect on AR expression. In conclusion, supplementation with this commercial soy product produced a consistent decrease in serum sex hormone levels. Additional studies are needed to evaluate a potential dose effect on ERalpha expression.

Modulation of cell-cycle regulatory signaling network by 2-methoxyestradiol in prostate cancer cells is mediated through multiple signal transduction pathways

2-Methoxyestradiol (2-ME(2)), a promising anticancer drug, induces growth arrest and apoptosis in various androgen-dependent (LNCaP) and -independent (DU145 and PC-3) prostate cancer cell lines. Moreover, flow cytometric analysis indicated a novel dual impact of 2-ME(2) on the cell division cycle of prostate cancer cells. Chronic exposure of high doses of 2-ME(2) enhance the accumulation of cells in S and G2/M phases, while cell numbers in the G1 phase were reduced significantly by this treatment. Because cyclin B1 overexpression, induction of cdc2 phosphorylation, and its regulatory proteins wee1 and phospho-cdc25C (interphase and mitotic forms) by 2-ME(2) treatment correlated with the induction of apoptosis, growth arrest at the G2/M phase, and accumulation of the S phase, we reasoned that cyclin B1 and cdc2 phosphorylation and its upstream regulatory molecular networks may be associated with the ultimate impacts of 2-ME(2). Because phosphorylation of cdc2 and upregulation of wee1 by 2-ME(2) can be abolished by both extracellular receptor kinase (ERK) inhibitor (U0126) and c-Jun N-terminal kinase (JNK) inhibitor (SP600125), our studies indicate that the 2-ME(2)-induced upregulation of wee1 and subsequent cdc2 phosphorylation are mediated through mitogen-activated protein kinase (MAPK)-ERK-JNK signaling pathways.

Molecular basis of protective effect by crocetin on survival and liver tissue damage following hemorrhagic shock

Hemorrhagic shock (HS) causes reduction of cellular energy stores, as measured by levels of ATP and ADP. Furthermore, energy depletion may cause mitochondrial damage, which in turn leads to cell death by apoptosis. The hypothesis of the present study is that by enhancing the recovery of cellular ATP and ADP and mitochondrial damage can be reduced, and the extent of apoptosis minimized. Crocetin, a carotenoid compound, appears to enhance the diffusion of oxygen in aqueous solution, and hence may improve energy stores both to the cell and within it. HS was produced in Sprague-Dawley rats by withdrawing blood from the carotid cannula until a mean arterial pressure of 35-40 mm Hg was reached, and then maintained by further withdrawals of blood for 30 and 60 min. Crocetin was administered 2-4 mg/kg in resuscitation fluid through venus cannula and the animals survived for 24-48 h after HS. Experiments designed to promote tissue reconstitution of ATP using crocetin indicate that these approaches are successful in increasing ATP post-hemorrhage and survival. Crocetin treatment also inhibited cellular damage as indicated by increase of Bcl-2 following decrease in cytosolic cytochrome c and caspase-3 after resuscitation. The prolonged energy deficit seen after hemorrhagic shock can produce late damage and rapid restoration of ATP levels to baseline can reduce apoptosis. In conclusions, crocetin can minimize the cellular damage as evidenced by apoptosis and increased the survival of rats.

Stimulation of MCF-7 tumor progression in athymic nude mice by 17beta-estradiol induces WISP-2/CCN5 expression in xenografts: a novel signaling molecule in hormonal carcinogenesis

There was 100% solid tumor formation following inoculation of MCF-7 cells. However, MCF-7 tumor progression was significantly greater in the mice exposed to 17beta-estradiol (17beta-E2) compared to unexposed mice. WISP-2/CCN5 mRNA expression was correspondingly increased in 17beta-E2 exposed MCF-7 tumors compared to unexposed xenografts. Moreover, estrogen exposure followed by anti-estrogen tamoxifen treatment drastically inhibited the tumor growth and WISP-2 expression in nude mice. Therefore, the study suggests that higher WISP-2/CCN5 expression by estrogen may be associated with the estrogen-induced growth of MCF-7 tumors in vivo. Finally, overexpression of WISP-2/CCN5 may be considered as a prognostic marker of estrogen-sensitive tumor growth.

Growth factors involved in prostate carcinogenesis

Prostate cancer is the most common non-skin cancer affecting men in United States and the second leading cause of death after lung cancer. The clinical course of patients after given diagnosis of prostate cancer is highly variable and the underlying reasons for such variability remain elusive. To better understand the pathophysiology of prostate cancer, there has been a push to elucidate the molecular mechanisms that mediate the development and progression of prostate cancer. Recent literature has pointed that a complex interplay between various cytokines, growth factors, and androgen receptors regulate the growth and functions of the prostate gland. Amongst the currently implicated anomalous pathways involved in prostate oncogenesis, the IGF-IGFBP axis has been demonstrated to play a very important role, although the precise molecular events regulated by IGF remain to be elucidated. The tumor promoting functions of VEGF has been defined in tumor angiogenesis and currently remains the central focus of anti-angiogenesis therapy in prostate cancer. Another key cytokine, TGF-beta has tumor-suppressor functions in normal prostate gland, but its pleiotropic functions in prostate cancer are influenced by the hormonal state of the disease. In partnership with other deregulated growth factor signaling, the TGF-beta cascade has also been implicated in the spread of prostate cancer. Lastly, members of the EGFR family, particularly the HER2 receptor, have also been recognized as crucial elements of aberrant signal transduction pathways, which induce activation of downstream signaling, involved in cellular proliferation, cell survival, and angiogenesis. The abnormal function of a number of growth factors in prostate cancer biology explains the heterogeneity of its histologic grade, mode of presentation and disease prognosis. At the same time, continued research in this field allows for the potential development of drug therapies against a diverse pool of cancer causing targets.

Novel germline mutations in breast cancer susceptibility genes BRCA1, BRCA2 and p53 gene in breast cancer patients from India

Mutations in breast cancer susceptibility genes, BRCA1 and BRCA2 account for more than 80% of hereditary breast and ovarian cancers. p53 tumor suppressor gene that controls cellular growth and differentiation is also known to be mutated in more than 50% of human cancers including breast cancer. We have carried out a study on BRCA1 and BRCA2 along with p53 gene mutations in both sporadic as well as familial breast cancer patients from India where breast cancer is fast emerging as a major cancer among premenopausal urban women. We examined 124 untreated primary breast cancer patients comprising 100 sporadic and 24 familial cases including 56 age-matched healthy controls for the presence of BRCA1, BRCA2 and the p53 gene mutations using PCR-SSCP and direct nucleotide sequencing. Certain frequently mutated exons such as 2, 5, 11, 13 and 20 of BRCA1, exons 2, 9, 11 (for 6174delT), 18 and 20 of BRCA2 and 4-9 exons of p53 gene were analyzed in sporadic breast cancer while all 22 coding exons of BRCA1 including its flanking intronic regions along with above mentioned exons of BRCA2 and p53 gene were analyzed in familial breast cancer patients. We identified six patients (25%) with BRCA1 mutation of which three were found to be of novel type one in exon 16 (4956insG) and two in exon 7 (Lys110Thr) (Ser114Pro) out of 24 familial breast cancer patients studied from two different geographic regions/populations of India. Two sisters from a single family (12.5%) out of eight families from Goa with Portuguese colonial origin showed presence of founder Ashkenazi Jewish BRCA1 mutation (185delAG) along with (IVS7 561-34T>C; IVS18 5271 + 66G > A). While from New Delhi, four (25%) of 16 breast cancer families showed BRCA1 mutations; a frame shift protein truncating (4956insG), a transition nonsense (Gln1395Stop) and two amino acid substitutions (Lys110Thr) and (Ser114Pro). Only one (4%) p53 mutation (Val97Ile) in its exon 4 along with BRCA1 mutation (4956insG) could be detected. No major sequence variation in BRCA2 gene was observed except for G203A at 5' UTR of exon 2, a common population polymorphism in two Goan patients who also showed silent nucleotide change for amino acid serine at codon 1436 of BRCA1 gene. None of the 100 sporadic breast cancer patients revealed any protein truncating or deleterious BRCA1 or BRCA2 gene mutation. Interestingly, three (3%) p53 mutations in its exon 5 were detected in sporadic breast cancer patients. Although three novel BRCA1 mutations including a founder Ashkenazi Jewish BRCA1 mutation were recorded in Indian women with familial breast cancer, the overall prevalence of BRCA gene mutations in Indian women with a family history of breast cancer appears to be low.

Oxidants, antioxidants and carcinogenesis

Reactive oxygen metabolites (ROMs), such as superoxide anions (O2*-) hydrogen peroxide (H2O2), and hydroxyl radical (*OH), malondialdehyde (MDA) and nitric oxide (NO) are directly or indirectly involved in multistage process of carcinogenesis. They are mainly involved in DNA damage leading sometimes to mutations in tumour suppressor genes. They also act as initiator and/or promotor in carcinogenesis. Some of them are mutagenic in mammalian systems. O2*-, H2O2 and *OH are reported to be involved in higher frequencies of sister chromatid exchanges (SCEs) and chromosome breaks and gaps (CBGs). MDA, a bi-product of lipid peroxidation (LPO), is said to be involved in DNA adduct formations, which are believed to be responsible for carcinogenesis. NO, on the other hand, plays a duel role in cancer. At high concentration it kills tumour cells, but at low concentration it promotes tumour growth and metastasis. It causes DNA single and double strand breaks. The metabolites of NO such as peroxynitrite (OONO-) is a potent mutagen that can induce transversion mutations. NO can stimulate O2*-/H2O2/*OH-induced LPO. These deleterious actions of oxidants can be countered by antioxidant defence system in humans. There are first line defense antioxidants such as superoxide dismutase (SOD), glutathione peroxidase (GPx), and catalase (CAT). SOD converts O2*- to H2O2, which is further converted to H2O with the help of GPx and CAT. SOD inhibits *OH production. SOD also act as antipoliferative agent, anticarcinogens, and inhibitor at initiation and promotion/transformation stage in carcinogenesis. GPx is another antioxidative enzyme which catalyses to convert H2O2, to H2O. The most potent enzyme is CAT. GPx and CAT are important in the inactivation of many environmental mutagens. CAT is also found to reduce the SCE levels and chromosomal aberrations. Antioxidative vitamins such as vitamin A, E, and C have a number of biological activities such as immune stimulation, inhibition of nitrosamine formation and an alteration of metabolic activations of carcinogens. They can prevent genetic changes by inhibiting DNA damage induced by the ROMs. Therefore, these antioxidants may be helpful in the treatment of human cancer. However, detailed studies are required to draw a definite conclusion.

Randomized controlled trial of intrasphincteric botulinum toxin A injection versus balloon dilatation in treatment of achalasia cardia

As the few randomized controlled trials available in the literature comparing botulinum toxin (BT) injection with established endoscopic treatment of achalasia cardia, i.e. pneumatic dilatation, showed conflicting results, we conducted a prospective randomized trial. Seventeen consecutive patients with achalasia cardia diagnosed during a period between December 1997 and February 2000 were randomized into two treatment groups [pneumatic dilatation by Rigiflex dilator (n=10), BT injection by sclerotherapy needle into four quadrants of lower esophageal sphincter (LES) (n=7) 80 units in five cases, 60 units in two cases] after dysphagia grading, endoscopy, barium esophagogram, and manometry, all of which were repeated 1 week after treatment. Patients were followed up clinically for 35.2+/-14 weeks. Chi-squares, Wilcoxon rank-sum test, Kaplan-Meier method and log-rank tests were used for statistical analysis. After 1 week, 6/7 (86%) BT-treated vs. 8/10 (80%) dilatation-treated patients improved (P=NS). There was no difference in LES pressure and maximum esophageal diameter in the barium esophagogram in the two groups before therapy. Both therapies resulted in significant reduction in LES pressure. The cumulative dysphagia-free state using the Kaplan-Meier method decreased progressively in BT-treated compared with dilatation-treated patients (P=0.027). Two patients with tortuous megaesophagus, one of whom had failed dilatation complicated by perforation previously, improved after BT. One other patient in whom pneumatic dilatation had previously failed improved in a similar manner. BT is as good as pneumatic dilatation in achieving an initial improvement in dysphagia of achalasia cardia. It is also effective in patients with tortuous megaesophagus and previous failed pneumatic dilatation. However, dysphagia often recurs during 1-year follow up.

Interline Transfer CCD Camera for Gated Broadband Coherent Anti-Stokes Raman-Scattering Measurements

Use of an interline transfer CCD camera for the acquisition of broadband coherent anti-Stokes Raman-scattering (CARS) spectra is demonstrated. The interline transfer CCD has alternating columns of imaging and storage pixels that allow one to acquire two successive images by shifting the first image in the storage pixels and immediately acquiring the second image. We have used this dual-image mode for gated CARS measurements by acquiring a CARS spectral image and shifting it rapidly from the imaging pixel columns to the storage pixel columns. We have demonstrated the use of this dual-image mode for gated single-laser-shot measurement of hydrogen and nitrogen CARS spectra at room temperature and in atmospheric pressure flames. The performance of the interline transfer CCD for these CARS measurements is compared directly with the performance of a back-illuminated unintensified CCD camera.

Fever and multisystem organ failure associated with 17D-204 yellow fever vaccination: a report of four cases

BACKGROUND

In 1998, the US Centers for Disease Control and Prevention was notified of three patients who developed severe illnesses days after yellow fever vaccination. A similar case occurred in 1996. All four patients were more than 63 years old.

METHODS

Vaccine strains of yellow fever virus, isolated from the plasma of two patients and the cerebrospinal fluid of one, were characterised by genomic sequencing. Clinical samples were subjected to neutralisation assays, and an immunohistochemical analysis was done on one sample of liver obtained at biopsy.

FINDINGS

The clinical presentations were characterised by fever, myalgia, headache, and confusion, followed by severe multisystemic illnesses. Three patients died. Vaccine-related variants of yellow fever virus were found in plasma and cerebrospinal fluid of one vaccinee. The convalescent serum samples of two vaccinees showed antibody responses of at least 1:10240. Immunohistochemical assay of liver tissue showed yellow fever antigen in the Kuppfer cells of the liver sample.

INTERPRETATION

The clinical features, their temporal association with vaccination, recovery of vaccine-related virus, antibody responses, and immunohistochemical assay collectively suggest a possible causal relation between the illnesses and yellow fever vaccination. Yellow fever remains an important cause of illness and death in South America and Africa; hence, vaccination should be maintained until the frequency of these events is quantified.

Etiology and management of obscure gastrointestinal bleed--an appraisal from eastern India

OBJECTIVES AND METHOD

Forty patients (mean age 45 years; 24 men) attending a tertiary care hospital in eastern India during the period 1996-2000 were investigated to evaluate the etiology and clinical spectrum of obscure gastrointestinal bleed.

RESULTS

The patients presented to hospital after mean symptom duration of 2.5 years. They had received an average of 15 units of blood transfusion. Most patients presented with recurrent melena (85%); all had iron-deficiency anemia. A total of 230 investigations (89 gastroscopies, 54 colonoscopies, 25 double-contrast meal and follow-through studies, 14 small bowel enemas, 24 radionuclide scans, 16 mesenteric angiographies and 8 intraoperative endoscopies) yielded positive diagnosis in 87.5% of cases. The diseases encountered were small bowel and colonic angiodysplasias (32.5%), ileal Crohn's disease (20%), intestinal tuberculosis (10%), intestinal tumors (10%), nonspecific small bowel ulcers and strictures (7.5%), Meckel's diverticulum (5%) and hemobilia (2.5%). The etiology remained obscure in 5 (12.5%) cases. Overall success of surgery was 63%; in-hospital mortality was 7.5%.

CONCLUSION

Though obscure gastrointestinal bleed is commonly caused by angiodysplasias, it can be an atypical presentation of Crohn's disease.

Role of lipids, lipoproteins and vitamins in women with breast cancer

OBJECTIVES

Improper balance between the production of reactive oxygen metabolites (ROMs), and antioxidative defense system have been defined as oxidative stress in various pathologic conditions. Lipids, lipoproteins and antioxidative vitamins have been associated with the risk of breast cancer. The present case-control study was conducted to investigate the status of antioxidative vitamins (A, C and E), lipids (total cholesterol; TC and triglycerides; TG), lipoproteins (high-density lipoprotein cholesterol; HDL-C and low-density lipoprotein cholesterol; LDL-C) and retinol-binding protein (RBP) in breast cancer patients. The aim of the study was to find out oxidative stress in breast cancer.

DESIGN AND METHODS

Plasma lipids, lipoproteins and vitamins were estimated in 54 untreated breast cancer patients of different clinical stages and in 42 age- and sex-matched controls.

RESULTS

Plasma TC (p < 0.05), and LDL-C and TG (p < 0.01) were found to be significantly elevated among breast cancer patients as compared to the controls. On the other hand, plasma HDL-C concentration (p < 0.001) and vitamin C and E (p < 0.01) were observed significantly decreased in breast cancer patients than in the controls. The maximum changes in plasma TC, and vitamin C and E concentrations were observed in breast cancer patients with stage IV when compared with controls.

CONCLUSION

The study suggests that higher levels of TC and TG may play important role in carcinogenesis. Furthermore, the elevated plasma LDL-C concentration, which is more susceptible to oxidation, may result in higher lipid peroxidation in breast cancer patients. However, decreased concentrations of HDL-C and vitamin C and E are not likely to be sufficient enough to counter higher ROMs production reported earlier in breast cancer patients that may cause oxidative stress leading to cellular and molecular damage thereby resulting in cell proliferation and malignant conversions.

Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement

Obstetric risk has important implications for reporting and benchmarking quality in today's managed health care environment. Administrative data, including diagnosis related group (DRG) information collected by hospitals, is used by payers and governmental groups for reimbursement, monitoring quality, and setting financial rates. Obstetric conditions that affect the patient experience are coded but do not often contribute to the overall DRG assignment. This strategy, therefore, may provide comparisons that are misleading to consumers and payers. Additionally, financial rates often do not provide adequate reimbursement for the cost incurred in caring for high-risk patients. Finally, risk prediction strategies have historically been used to both identify vulnerable patients for early management and make more equitable comparisons of groups of patients.

Percutaneous transluminal coronary angioplasty with stenting of anomalous right coronary artery originating from left sinus of Valsalva using the Voda guiding catheter: a report of two cases

Coronary arteries of anomalous origin are uncommon and some forms seem to be predisposed to atherosclerosis. We report two cases of successful stent implantation in an anomalous right coronary artery originating from the left sinus of Valsalva using the Voda guiding catheter.

Extents of contamination of top milk and their determinants in an urban slum of Varanasi, India

A community based study to examine the extent of contamination of supplementary milk feeds of 149 children aged 6-24 months was conducted in a semi urban slum of Varanasi, India. Out of 201 children, 149 top milk samples were collected directly from the feeding utensils into a sterile vial and subjected to bacteriological analysis. Overall, 53.7% of milk samples were contaminated by bacteria and among them 16.1% were potentially enteropathogenic in nature. The distribution of pathogens was E. coli (13.4%), Klebsiella spp (5.4%), Enterobacter spp. (5.4%), Pseudomonas aeruginosa (4.7%), Shigella spp. (2.7%) and others (22.1%). The rate of contamination was significantly higher (p < 0.001) in lower income group (73.4%), lower caste (69.6%) and in case of illiterate mothers (69.3%). Bivariate analysis indicated that wherever the afore mentioned parameters of hygiene were adverse, isolation rates increased multifoldely. Multiple logistic regression analysis indicated that the probability of a milk sample being positive for bacterial contamination was higher by 20 times when unclean utensils were used, by 3 times if mothers hands were dirty and by 2.8 time if the mothers were illiterate. The odds of contamination by pathogens was 25.7 times higher if the feeding utensils were dirty.

Evaluation of free radical status in CSF in childhood meningitis

The study was undertaken to investigate the possible role of free radicals and antioxidants in childhood meningitis. Sixty children suffering from acute bacterial meningitis (ABM) or tuberculous meningitis (TBM) according to their clinical and laboratory findings were enrolled in the study. The production of superoxide anions (O2.-), hydrogen peroxide (H2O2) and malondialdehyde (MDA) and the activities of xanthine oxidase (XO), superoxide dismutase (SOD) and glutathione peroxidase (GPx) were monitored in the study groups and findings compared with those in 20 age-matched controls. Children with ABM and TBM who died registered significant increases in the production of O2.- and MDA and in the activities of SOD and CPK compared with survivors. The rate of production of oxidants and MDA and the activities of XO, SOD and CPK were of a much higher magnitude in deceased ABM and in ABM survivors than in fatal TBM and survivors, respectively. The abnormalities in most of the biochemical parameters investigated were more marked in the children with ABM than in TBM and controls (p < 0.001). Increased MDA production and creatine phosphokinase (CPK) activity of different magnitudes in the two study groups suggest varying degrees of tissue damage. The alterations observed in 20 children who died (14 from ABM, 6 from TBM) revealed elevated levels of oxidants, antioxidants and toxicity markers, particularly in ABM patients, which suggests the possibility that natural or synthetic antioxidants might prevent disease progression and tissue damage in childhood meningitis.

Aetiological spectrum of chronic liver disease in eastern India

AIM

To evaluate the aetiologic spectrum of chronic liver disease (CLD) in a tertiary referral center in Eastern India.

METHODS

A total of 175 patients (cirrhosis 166, chronic hepatitis 9) diagnosed by clinical, biochemical, radiological and histopathological (42 cases) parameters were evaluated for aetiology. Investigations included: HBsAg and anti HCV (third generation) by ELISA. HBeAg and HBV DNA were tested in HBsAg positive patients. HCV RNA was tested in anti-HCV positive patients. Markers for autoimmune and Wilson's disease (anti-nuclear antibody, anti smooth muscle antibody, serum ceruloplasmin, urinary copper and slit lamp examination for KF ring) were done where clinically indicated.

RESULTS

A total of 62 (35.4%) patients had HBV related CLD and 6 (9.7%) of them had pre-core mutant. HCV was present in 17/114 (14.9%) cases and none had infection with both viruses. Autoimmunity, Wilson's disease and alcohol were the aetiological factors in 5 (2.8%), 5 (2.8%) and 3 (1.7%) patients respectively. No aetilogy could be found in 18/114 (15.8%) patients.

CONCLUSIONS

It is concluded that HBV is the commonest cause of CLD in Eastern India. Alcohol and HCV are uncommon in this part of the country.

Alterations in antioxidant status during neonatal sepsis

Septicaemia is a major threat to survival during the early stages of life. There are several reports that suggest that reactive oxygen species (ROs) play a role in a wide variety of diseases. We estimated the activity of xanthine oxidase (XO), malondialdehyde (MDA) content, creatine phosphokinase (CPK) activity, activities of key enzymatic antioxidants, such as superoxide dismutase (SOD), glutathione peroxidase (GPx) and peroxidase (PO), and non-enzymatic antioxidants, viz. uric acid (UA) and albumin (ALB), in 30 neonates with sepsis and 20 age-matched controls. The babies were categorized as preterm/term, early onset/late onset, and shock/without shock, as per clinical and laboratory investigations. The study was carried out to evaluate the status of antioxidant enzymes and non-enzymatic antioxidants with a view to suggesting the introduction of antioxidant therapy in neonatal sepsis. The activities of serum XO, CPK, SOD and GPx, and the content of MDA were found to be significantly elevated in the neonates with sepsis when compared with controls. Conversely, the activity of PO and the levels of UA and ALB were decreased. The septic, full-term neonates registered significantly higher CPK activity (70%) than the preterm septic neonates. However, infants with late-onset and shock sepsis had a significant decrease in CPK activity (p < 0.05) compared with their corresponding sub-groups. Likewise, UA levels were found to be 28% depressed (p < 0.05) in the babies with late-onset sepsis and 51% increased (p < 0.001) in babies with shock compared with their respective sub-groups. Neonates with septic shock also registered a significant elevation in GPx activity (28%) compared with those without shock. This study suggests increased production of ROs in neonates with sepsis, as evidenced by the positive regulation of XO, SOD and GPx activity. The elevation of antioxidant enzymes, however, was not so effective as to protect from cellular damage and thereby result in higher MDA production. It is evident that antioxidant therapy might be useful in the management of neonates with sepsis but further detailed clinico-biochemical investigations are required to define effective antioxidant therapy.

Lipid peroxidation, free radical production and antioxidant status in breast cancer

Reactive oxygen metabolites (ROMs), including superoxide anion (O2*-), hydrogen peroxide (H2O2) and hydroxyl radical (*OH), play an important role in carcinogenesis. There are some primary antioxidants such as superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) which protect against cellular and molecular damage caused by the ROMs. We conducted the present study to determine the rate of O2*- and H2O2 production, and concentration of malondialdehyde (MDA), as an index of lipid peroxidation, along with the SOD, GPx and CAT activities in 54 breast cancer (BC) patients. Forty-two age- and sex-matched patients with minor surgical problems, who had no history of any neoplastic or breast disorders, were taken as controls. The rate of O2*- production was significantly higher (p < 0.001) in BC patients than controls, irrespective of clinical stages and menopausal status. Similarly, H2O2 production was significantly higher in BC patients, especially in stage III and postmenopausal groups, as compared to the respective controls. MDA concentration was also observed significantly elevated in stage II (p < 0.001), stage III (p < 0.01), postmenopausal (p < 0.005), and premenopausal (p < 0.02) group as compared to their corresponding controls. SOD and GPx activities were found significantly raised in all the groups (p < 0.001), except the GPx activity was found a smaller alteration in stage IV (p < 0.02). On the contrary, CAT activity was found significantly depressed in all the study groups. The maximum depression was observed in stage II (-61.8%). Lower CAT activity in our study may be the effect of higher production of ROMs, particularly O2*- and *OH. SOD and GPx, however, were less effected by these higher ROMs production. The results of our study have shown a higher ROMs production and decreased CAT activity, which support the oxidative stress hypothesis in carcinogenesis. The relatively higher SOD and GPx may be due to the response of increased ROMs production in the blood. However, the higher SOD and GPx activities may be inadequate to detoxify high levels of H2O2 into H2O leading to the formation of the most dangerous *OH radical followed by MDA. Therefore, administration of CAT may be helpful in the management of BC patients. However, further elaborate clinical studies are required to evaluate the role of such antioxidant enzymes in BC management.

Status of lipid peroxidation and antioxidant enzymes in hypoxic ischemic encephalopathy

OBJECTIVE

To compare the activities of key antioxidant enzymes [superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase] and the level of malonyl dialdehyde (MDA) in neonates with hypoxic ischemic encephalopathy (HIE) and controls.

DESIGN

Prospective cross sectional study.

SETTING

Tertiary care level II neonatal unit of teaching hospital.

METHODS

Fifteen term new borns with HIE were registered for the study whereas normal term appropriate for gestational age babies were enrolled as controls. Clinical features were recorded. Activities of SOD, GPx, catalase and the content of MDA were estimated at 24 hours of age. The results obtained were statistically analyzed.

RESULTS

Activities of SOD and Catalase and the level of MDA were significantly higher in cases as compared to the controls. There was however no significant alternation in the activity of GPx levels in both the groups.

CONCLUSION

The increased activities of antioxidant enzymes are unable to counteract the excessively generated oxidants in vivo, as is evident from the increased MDA levels. Hence, oxygen free radicals may play a significant role in the pathogenesis of HIE.

Status of antioxidants and other biochemical abnormalities in children with dengue fever

During an outbreak of dengue fever in 1996, 66 children between 45 days and 12 years of age with dengue fever and 25 healthy controls were studied for antioxidants and other biochemical abnormalities. As per World Health Organization (WHO) criteria, 14 children were classified as having classical dengue (DEN), 42 with dengue haemorrhagic fever (DHF), and 10 (including three who died) as having dengue shock syndrome (DSS). Superoxide dismutase (SOD), glutathione peroxidase (GPX), and albumin (ALB), the three main antioxidants studied, were found to be abnormal in 96, 94, and 40 per cent of the cases respectively. The levels for aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine phosphokinase (CPK), total protein (TP), total cholesterol (CHO), and triglycerides (TGL) were abnormal in 79, 50, 30, 93, and 67 per cent of the cases respectively. Among the different groups of dengue the abnormalities were more marked in children with DSS than in those with DEN and DHF, especially with respect to ALB, TP, TGL, AST, ALT, and CPK (p < 0.005). This preliminary report of dengue confirms the assumption of free radical generation and alteration in antioxidant status during acute illness. However, to understand their complex interaction in disease progression and therapeutic utility, further studies are required.

Effect of shipment, storage, anticoagulant, and cell separation on lymphocyte proliferation assays for human immunodeficiency virus-infected patients

Lymphocyte proliferation assays (LPA), which can provide important information regarding the immune reconstitution of human immunodeficiency virus (HIV)-infected patients on highly active antiretroviral therapy, frequently involve shipment of specimens to central laboratories. In this study, we examine the effect of stimulant, anticoagulant, cell separation, storage, and transportation on LPA results. LPA responses of whole blood and separated peripheral blood mononuclear cells (PBMC) to different stimulants (cytomegalovirus, varicella-zoster virus, candida and tetanus toxoid antigens, and phytohemagglutinin) were measured using fresh specimens shipped overnight and frozen specimens collected in heparin, acid citrate dextrose (ACD), and citrate cell preparation tubes (CPT) from 12 HIV-infected patients and uninfected controls. Odds ratios for positive LPA responses were significantly higher in separated PBMC than in whole blood from ACD- and heparin-anticoagulated samples obtained from HIV-infected patients and from ACD-anticoagulated samples from uninfected controls. On separated PBMC, positive responses were significantly more frequent in fresh samples compared with overnight transportation for all antigens and compared with cryopreservation for the candida and tetanus antigens. In addition, viral antigen LPA responses were better preserved in frozen PBMC compared with specimens shipped overnight. CPT tubes yielded significantly more positive LPA results for all antigens, irrespective of the HIV patient status compared with ACD, but only for the candida and tetanus antigens and only in HIV-negative controls compared with heparin. Although HIV-infected patients had a significantly lower number of positive antigen-driven LPA responses compared with uninfected controls, most of the specimen processing variables had similar effects on HIV-positive and -negative samples. We conclude that LPA should be performed on site, whenever feasible, by using separated PBMC from fresh blood samples collected in either heparin or ACD. However, if on-site testing is not available, optimal transportation conditions should be established for specific antigens.

Inversion of (R)- to (S)-ketoprofen in eight animal species

The (R)-enantiomer of the NSAID ketoprofen was administered orally at 20 mg/kg to a series of 8 animal species. In all species, a highly significant degree of inversion occurred after 1 h which varied from 27% (gerbil) to 73% (dog) and persisted or increased in plasma samples obtained 3 h after drug administration. Although the (R)-enantiomer was inactive as an inhibitor of cyclooxygenase, the analgesic effects of that isomer was almost the same as the (S)-isomer in animal analgesic assays, following oral administration of the drugs to mice and rats. Taken together, the present results suggest that (R)-ketoprofen administered alone functioned primarily as a prodrug for (S)-ketoprofen under the experimental conditions of this study.

Evaluation of left ventricular function based on simulated systolic flow dynamics computed from regional wall motion

Left ventricular (LV) chamber flow is undoubtedly influenced by the time-dependent regional motion of the LV wall. In an attempt to obtain diagnostic parameters based on LV chamber flow, we computed the LV chamber, two-dimensional systolic velocity and pressure distribution for two right anterior oblique (RAO) ventriculograms: one normal, one with ischemic coronary artery disease, and several simulations with prescribed abnormal wall motion. The flow fields are obtained by solving the discretized two-dimensional Navier-Stokes equations for viscous, incompressible unsteady flow using the finite analytic method. These solutions were used as a basis for two LV assessment parameters: (1) local pressure gradient near the LV wall, and (2) the central ejection region (CER), defined as the region of flow domain in which the obtained velocity field vectors are aligned +/- 5 degrees from the LV long axis. A CER coefficient, R, derived from the location and orientation of the CER within the LV cavity, is defined such that R = 0 for a heart which produces no CER, and R = 1 for a heart whose contraction is perfectly even along the entire RAO LV outline. The computed local pressure gradients in the ischemic heart near the apical wall region were reduced compared with those computed in the normal heart. An observable decrease in magnitude of the pressure gradients in the apical region for increasing severity of abnormal wall motion was also indicated. However, the prescribed abnormal wall motion simulations generated reduced pressure gradients in regions of abnormal wall motion and normal regions as well. Therefore, the local wall pressure gradient may not be suitable for localization of coronary occlusion but for presence of disease only. The time-averaged CER coefficient was 0.709 for the normal heart and 0.453 for the diseased heart. The CER shifted toward the region of LV wall which exhibits the abnormal motion, and the CER coefficient decreased with increasing severity of abnormal wall motion. The CER coefficient provides a qualitative and quantitative measure of global function that regional wall motion analysis cannot provide, and is a parameter which is sensitive to regional and temporal abnormalities and the resulting compensatory actions which cannot be detected by global parameters.

Alternating and intermittent regimens of zidovudine and dideoxycytidine in patients with AIDS or AIDS-related complex

OBJECTIVE

To determine whether alternating regimens consisting of zidovudine and 2',3'-dideoxycytidine (ddC) reduce the toxicity and maintain or increase the antiretroviral effect associated with each drug alone.

DESIGN

An unblinded, randomized (phase II) clinical trial in which seven treatment regimens were compared.

SETTING

Outpatient clinics of 12 AIDS Clinical Trials Units.

PATIENTS

One hundred thirty-one patients with the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex and serum p24 antigenemia (> or = 70 pg/mL).

INTERVENTION

Treatments included weekly or monthly alternating zidovudine (200 mg every 4 hours) and ddC (0.01 or 0.03 mg/kg body weight every 4 hours); weekly intermittent zidovudine, 200 mg every 4 hours, or ddC, 0.03 mg/kg every 4 hours; and continuous zidovudine.

MEASUREMENTS

Toxicity, CD4 cell counts, serum p24 antigen levels, and clinical end points. Data were analyzed for the first 48 weeks of therapy (median follow-up, 40 weeks).

RESULTS

Hematologic toxicity was significantly less frequent in patients who received zidovudine therapy every other week (11% to 15%) or every other month (11% to 14%) than in those who received continuous zidovudine therapy (33%) (P < 0.02). Weekly alternating therapy with zidovudine and ddC, 0.03 mg/kg, or intermittent therapy with ddC, 0.03 mg/kg, produced high rates of peripheral neuropathy (41% and 50%, respectively). Neuropathy occurred in 10% to 21% of patients in the other three alternating-therapy limbs and in 17% of patients receiving zidovudine alone (intermittently or continuously). Initial increases in CD4 cell counts were sustained in three alternating-therapy limbs, but counts returned to baseline by week 28 in the remaining limbs. The median weight gain at week 48 was significantly greater in patients treated with alternating regimens (0.9 to 3.8 kg) compared with those treated with continuous zidovudine therapy (-0.7 kg) (P = 0.008). Patients treated with alternating regimens and those treated with continuous zidovudine had similarly sustained decreases in p24 antigen levels.

CONCLUSIONS

These findings suggest that alternating therapy with zidovudine and ddC reduces the toxicity associated with each drug alone while maintaining strong antiretroviral activity.

Consolidation hemibody radiotherapy following induction combination chemotherapy in high-tumor-burden multiple myeloma

PURPOSE

Curative therapy for multiple myeloma continues to be an elusive goal. This report discusses the Northern California Oncology Group (NCOG) phase I and II trial in high-tumor-burden disease that used a strategy that consisted of induction chemotherapy (vincristine, melphalan, cyclophosphamide, and prednisone [VMCP]) for eight cycles followed by sequential hemibody radiation therapy (RT) and subsequent chemotherapy for an additional eight cycles.

PATIENTS AND METHODS

Seventy-two previously untreated stage III myeloma patients were entered onto the study. Sixty-nine received induction chemotherapy, 40 received induction chemotherapy and hemibody RT, and 23 received induction chemotherapy, hemibody RT, and consolidative chemotherapy.

RESULTS

Twenty-two complete responses (CRs) were obtained by induction chemotherapy, with four additional CRs after RT and consolidative chemotherapy. Nineteen patients developed grade 4 hematologic toxicity primarily after upper hemibody RT. Eight of these developed long-standing neutropenia or thrombocytopenia. Median survival of the group was 134 weeks, which was not significantly different from other approaches.

CONCLUSIONS

Hemibody RT can be combined with chemotherapy as induction therapy and can be safely administered in a community setting. However, as administered here no survival advantage was demonstrated.

Stiffness and strain energy criteria to evaluate the threshold of injury to an intervertebral joint

This study is focused to evaluate the threshold of injury to an intervertebral joint based on its mechanical response. The load-deflection behavior of the intervertebral joint indicated non-linear and sigmoidal characteristics with continuously changing stiffness (a measure of the ability to withstand external force). The load corresponding to the point of zero stiffness was identified, according to the classical theories of mechanics, as the maximum load carrying capacity. Further, the initiation of trauma was defined to occur at the point on the load-deflection curve at which the stiffness begins to decrease for the first time. The load, stiffness and energy absorbing capabilities of normal and degenerated intervertebral joints at the initiation of trauma was determined. Axial compressive load experiments were conducted on nine intervertebral joints of fresh human male cadavers and the resulting load-deflection responses were transformed into stiffness-deflection responses using the derivative principle. Energy characteristics were also derived. Load, stiffness and energy at the initiation of trauma were found to be 9.0 kN, 2850 N mm-1, and 10.2 J for normal and 4.4 kN, 1642 N mm-1, and 5.8 J for degenerated segments, respectively. The load and energy values at failure were 11.0 kN, and 18.0 J for normal and 5.3 kN and 5.7 J for degenerated intervertebral joints, respectively.

Microtrauma in the lumbar spine: a cause of low back pain

Excessive mechanical stress on the intervertebral disc may be one of the causes of low back pain. Most studies testing this thesis, however, have been based on quantification of the mechanical response of functional units at failure. Typically, radiography is used to demonstrate trauma to the vertebral body at the failure load. The description of failure and radiographic demonstration of damage are meaningful in specifying the tolerance limits of the structure. It is important, however, to understand the sequence underlying the initiation of injury, which may occur at subfailure physiological loads. In this study, we identified the initiation of injury to the lumbar spine by subjecting functional units to axial compressive loads using the mechanical response as a basis. Because conventional radiography failed to detect trauma at this level, advanced sectioning techniques were used. The initiation of injury (microtrauma) is defined as the point on the load-deflection curve where the structure exhibits a decreasing level of resistance for the first time before reaching its ultimate load-carrying capacity. The load deflection curve on this basis was classified into the ambient or preload phase, physiological loading phase, traumatic phase, and post-traumatic phase. Structures loaded to the end of the physiological loading phase did not exhibit any yielding or microtrauma. Injury in the form of microfractures of the endplate not detected on radiography, however, was observed under cryomicrotomy for structures loaded into the traumatic loading phase.

DHPG effectively treats CMV infection in heart and heart-lung transplant patients: a preliminary report

Cytomegalovirus (CMV) infection in heart and heart-lung transplant recipients represents a serious if not mortal complication. This study reviews the beneficial effects of 9-(1,3-dihydroxy-2-proproxymethyl) guanine (DHPG), an experimental antiviral agent, in patients with CMV infections. Thirteen of 76 heart and heart-lung transplant patients treated with cyclosporine have developed CMV. Nine of 13 patients developed infections since DHPG has been available. Seven patients received hearts, and two received heart and lungs. Six patients were treated, four heart and two heart-lung recipients; five of six had negative CMV serology before surgery, and all had CMV positive donors. Of the patients not treated, one died at home from disseminated CMV; two had resolution of symptoms and were discharged before the diagnosis was made. In the treated group, three patients had gastrointestinal ulcerative disease, two in the stomach and one in the cecum. The other three patients had CMV pneumonia. DHPG was effective in resolving patient symptoms in five of six patients. The patient who did not respond had a cecal ulcer, multiorgan failure, multiple infections, and died. Two patients with abdominal pain had gastric ulcers that were proved with endoscopy. CMV-induced ulcer disease was diagnosed within 2 hours by fluorescent antibody staining, and resolution was documented by endoscopy. Three patients with CMV pneumonia were treated; two were heart-lung transplant recipients. All started to respond within 72 hours. One heart-lung transplant recipient has had a 9-month course of DHPG because of recurrence of infection when the drug was stopped. The usual dosage was 10 mg/kg/day over 2 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of single vessel coronary artery disease: results of exercise electrocardiography, thallium-201 myocardial perfusion imaging and radionuclide angiography

The sensitivity of the commonly used stress tests for the diagnosis of coronary artery disease was analyzed in 46 patients with significant occlusion (greater than or equal to 70% luminal diameter obstruction) of only one major coronary artery and no prior myocardial infarction. In all patients, thallium-201 perfusion imaging (both planar and seven-pinhole tomographic) and 12 lead electrocardiography were performed during the same graded treadmill exercise test and radionuclide angiography was performed during upright bicycle exercise. Exercise rate-pressure (double) product was 22,307 +/- 6,750 on the treadmill compared with 22,995 +/- 5,622 on the bicycle (p = NS). Exercise electrocardiograms were unequivocally abnormal in 24 patients (52%). Qualitative planar thallium images were abnormal in 42 patients (91%). Quantitative analysis of the tomographic thallium images were abnormal in 41 patients (89%). An exercise ejection fraction of less than 0.56 or a new wall motion abnormality was seen in 30 patients (65%). Results were similar for the right (n = 11) and left anterior descending (n = 28) coronary arteries while all tests but the planar thallium imaging showed a lower sensitivity for isolated circumflex artery disease (n = 7). The specificity of the tests was 72, 83, 89 and 72% for electrocardiography, planar thallium imaging, tomographic thallium imaging and radionuclide angiography, respectively. The results suggest that exercise thallium-201 perfusion imaging is the most sensitive noninvasive stress test for the diagnosis of single vessel coronary artery disease.