The Association of Variants within Types V and XI Collagen Genes with Knee Joint Laxity Measurements

Joint laxity is a multifactorial phenotype with a heritable component. Mutations or common polymorphisms within the α1(V) (COL5A1), α1(XI) (COL11A1) and α2(XI) (COL11A2) collagen genes have been reported or proposed to associate with joint hypermobility, range of motion and/or genu recurvatum. The aim of this study was to investigate whether polymorphisms within these collagen-encoding genes are associated with measurements of knee joint laxity and computed ligament length changes within the non-dominant leg. One hundred and six healthy participants were assessed for genu recurvatum (knee hyperextension), anterior-posterior tibial translation, external-internal tibial rotation and ligament length changes during knee rotation of their non-dominant leg. Participants were genotyped for COL5A1 rs12722 (T/C), COL11A1 rs3753841 (C/T), COL11A1 rs1676486 (T/C) and COL11A2 rs1799907 (A/T). The genotype-genotype combination of any two or more of the four COL5A1 rs12722 CC, COL11A1 rs3753841 CC, COL11A1 rs1676486 TT and COL11A2 rs1799907 AA genotypes was associated with decreased active and passive knee hyperextension. These genotype-genotype combinations, including sex (male), increased age and decreased body mass collectively, also contributed to decreased passive knee hyperextension. These findings suggest that COL5A1, COL11A1 and COL11A2 gene-gene interactions are associated with knee hyperextension measurements of the non-dominant leg of healthy individuals.

Investigating the association between COL1A1 and COL3A1 gene variants and knee joint laxity and ligament measurements

BACKGROUND

Joint laxity is a multifactorial phenotype with a heritable component. Type I collagen gene (COL1A1) mutations cause connective tissue disorders with joint hypermobility as a clinical feature, while variants within COL1A1 and type III collagen gene (COL3A1) are associated with musculoskeletal injuries. The aim of this study was to investigate whether COL1A1 and COL3A1 variants are associated with measurements of non-dominant knee joint laxity and computed ligament length changes.

METHODS

106 moderately active uninjured participants were assessed for genu recurvatum, anterior-posterior tibial translation, external-internal tibial rotation and calculated ligament length changes during knee rotation. Participants were genotyped for COL1A1 rs1107946, rs1800012 and COL3A1 rs1800255.

FINDINGS

The COL1A1 rs1107946 GG genotype had significantly larger external rotation [GG: 5.7° (4.9°;6.4°) vs GT: 4.6° (4.2°;5.5°), adjusted P = 0.014], internal rotation [GG: 5.9° (5.3°;6.6°) vs GT: 5.4° (4.7°;6.2°), adjusted P = 0.014], and slack [GG: 18.2° ± 3.2° vs GT: 16.1° ± 3.1°, adjusted P = 0.014]. The GG genotype at both COL1A1 variants had significantly larger active displacement [GG + GG: 6.0 mm (3.8 mm;8.0 mm) vs other genotype combinations: 4.0 mm (2.5 mm;6.0 mm), P < 0.001] and maximum displacement [GG + GG: 8.0 mm (6.9 mm;10.6 mm) vs other genotype combinations: 6.0 mm (5.0 mm;9.0 mm), P = 0.003]. COL1A1 rs1107946 significantly contributed to increased external and internal rotation in multilinear regression models, while both COL1A1 variants, significantly contributed to increased active displacement and slack. Larger medial and lateral cruciate ligament length changes were reported in participants with GG genotypes at both COL1A1 variants.

INTERPRETATION

These findings suggest that the COL1A1 variants are associated with knee rotational laxity and changes in ligament length.

Efficacy of high-intensity home mechanical stretch therapy for treatment of shoulder stiffness: a retrospective review

Background

Shoulder stiffness resulting in motion loss can be caused by numerous conditions, the most common of which is adhesive capsulitis. Surgical intervention is often necessary when conservative methods fail. High-intensity stretch (HIS) treatment may be able to provide increased motion gains while avoiding the cost and complications of surgery.

Objectives

The purpose of this study was to review data from patients who were prescribed a HIS device to recover their shoulder motion to determine the efficacy of the device. The hypotheses were that patients would achieve significant range of motion (ROM) gains and that ROM would increase to a level at which patients would be able to avoid a motion loss surgery and perform activities of daily living.

Methods

Clinical notes were reviewed for patients whose progress plateaued after 4 weeks of therapy and were subsequently prescribed the HIS device after failing to meet their treatment goals. ROM data were recorded for external rotation, abduction, forward flexion, and internal rotation. Pre- and post-treatment ROM data were compared using t-tests.

Results

Significant ROM gains were seen in all planes of motion (p < 0.001). Patients gained an average of 29.9° in external rotation with a last recorded rotation of 59.2°. In abduction, patients gained 40.5° with a last recorded abduction of 123.3°. In forward flexion, patients gained 30.3° with a last recorded flexion of 138.7°. In internal rotation, patients gained 15.2° with a last recorded rotation of 57.6°. These last recorded ranges of motion were sufficient to perform nearly all activities of daily living.

Conclusions

The HIS device was effective in treating patients with shoulder motion loss as demonstrated by the significant ROM gains in all planes of motion. The ability for a patient to recover lost motion quickly without surgery is of great value to quality of life and in healthcare cost savings. We believe this high-intensity stretch device should be considered for use by patients who are at risk for a motion loss surgery.

The development and evaluation of a computer-assisted teaching programme for intrapartum fetal monitoring

OBJECTIVE

The development and evaluation of a computer-assisted teaching programme of cardiotocography and acid-base balance.

DESIGN

Randomised controlled trial.

PARTICIPANTS

One hundred and seventeen midwifery and obstetric staff at Derriford Hospital, Plymouth.

METHODS

The obstetricians and midwives were randomly allocated to use the teaching programme, either early or late. The late group (control) used the teaching programme three months after the early group. To assess the effect of the teaching programme, participants were tested on four occasions over eight months by a multiple choice questionnaire. Two questionnaires on ease of use were also completed.

MAIN OUTCOME MEASURES

Multiple choice questionnaire scores and opinion questionnaire results.

RESULTS

The mean score in the early group improved from 50-8% (test 1, pre-teaching programme) to 70.2% (test 2, post-teaching programme). The mean score in the control group was 50.3% (test 1) and 54.8% (test 2). Knowledge was retained up to seven months.

CONCLUSIONS

The teaching programme was effective in improving knowledge of acid-base balance and cardiotocography and can be used by all staff whilst on duty on the labour ward.

A multicentre comparative study of 17 experts and an intelligent computer system for managing labour using the cardiotocogram

OBJECTIVES

To investigate 1. whether an intelligent computer system could obtain a performance in labour management comparable with experts when using cardiotocograms (CTGs), patient information, and fetal blood sampling and 2. whether experts could be consistent and agree in their management of labour.

SUBJECTS

An intelligent computer system and 17 clinicians experienced in fetal monitoring from 16 centres in the UK.

DESIGN

Fifty cases with complete intrapartum CTGs and clinical data were reviewed by each expert and the system independently on two occasions, at least one month apart. Each CTG was scored in 15 min segments according to a protocol and estimates of the cervical dilatation and fetal scalp blood pH were given when requested.

MAIN OUTCOME MEASURES

Consistency and agreement in the recorded scores, agreement and timing of cases recommended for caesarean sections, fetal blood sampling rates, intervention in cases with poor outcome and intervention in cases with good clinical outcome.

RESULTS

The system: 1. Agreed with experts well and significantly better than chance (67.33%, kappa = 0.31, P << 0.001). 2. Was highly consistent (99.16%, kappa = 0.98, P << 0.001) when used by two operators independently. 3. Recommended no unnecessary intervention in cases with normal delivery and good condition (cord artery pH > 7.15, vein pH > 7.20, 5 min Apgar > or = 9 and no resuscitation). This was better than all but two of the experts. 4. Recommended delivery by caesarean section in 11 cases; at least 15 of the 17 experts in each review also recommended caesarean section delivery in these cases. The majority did so within 15 min of the system and two-thirds did so within 30 min. 5. Identified as many of the birth asphyxiated cases (cord arterial pH < 7.05 and BDecf > or = 12, and Apgar score at 5 min < or = 7 with neonatal morbidity) as the majority of experts and one more than was acted upon clinically. The experts were found to be consistent and to agree. There was good agreement in the cases and the timing of caesarean section recommendations. The majority of experts did not recommend operative intervention in cases which had a normal delivery and good outcome, but did recommend operative interventions in 10 of 12 cases delivered with cord arterial pH < 7.05. However, in one of the cases delivered with birth asphyxia, 14 of the 17 experts and the system failed to recommend intervention.

CONCLUSIONS

The system's performance was found to be indistinguishable from the experts' in the 50 cases examined, but it was more consistent. This demonstrates the potential for an intelligent computer system to improve the interpretation of the CTG and decrease intervention. Furthermore, the good performance of most experts in this study demonstrates the potential effectiveness of the CTG and raises important questions regarding why the CTG has fallen short of expectations in current practice.

Delegation to assistive personnel by school nurses--one state's experience

Budget cuts to education, reduction of school health services and an increase in the nursing needs of school-age children have placed pressure on school nurses to delegate nursing procedures to assistive personnel. This paper reports on a study of school nurses in a Midwestern state. Nurses reported refusing to delegate, delegating against their better judgment, delegating without knowledge of the assistant's qualifications or without providing orientation or training, and delegating because they were told to by someone else. The study identified factors considered by nurses when deciding to delegate a procedure, educational preparation for delegation, and problems experienced with delegation.

Scar rupture in labour after previous lower uterine segment caesarean section: the role of uterine activity measurement

A series of 12 trials of scar associated with scar rupture is reviewed. Uterine activity patterns were assessable in 10 of them. Clinical features and characteristics of the intrauterine pressure waveform and uterine activity are discussed in relation to the integrity of the scar.

Comparison of immunologic and enzymatic assay of prostatic acid phosphatase for follow-up and assessment of clinical status of stage D prostate cancer

Prostatic acid phosphatase (PAP) was measured in 70 patients with stage D prostate cancer under different modalities of treatment. PAP was determined by radioimmunoassay (RIA), counter immunoelectrophoresis (CIEP), and enzymatic method using alpha-naphthyl phosphate to compare the usefulness of the three methods in follow-up and assessing the clinical status of stage D prostate cancer. In the regressive state (29 patients), RIA and enzymatic methods correlated well; both gave 17% of abnormal results with a mean value of 4.7 +/- 4.6 and 3 +/- 1.7. Also, in the progressive state (17 patients) the two methods showed similar percentages of abnormal results with a mean value of 40 +/- 38 and 19 +/- 17 for RIA and enzymatic method, respectively. There was greater variability in the stable group owing to the difference in the tumour load. Again the two methods correlated well regarding their diagnostic sensitivity and specificity as a parameter for assessing the clinical response. CIEP, used as a qualitative method, showed more positive than negative results and did not correlate with the clinical state. We feel that the conventional enzymatic method is adequate for follow-up and assessing clinical state of stage D prostate cancer.

The addition of chemotherapy to hormonal therapy for treatment of patients with metastatic carcinoma of the prostate

Patients with advanced prostate carcinoma that had been stabilized by orchiectomy (ORCH) or hormone therapy for at least 3 months, were randomized to either diethylstilbestrol (DES) alone or DES plus Cytoxan or DES plus Emcyt. A total of 188 patients were randomized between July, 1976 and February, 1982 of which 161 were evaluable for objective response to treatment. Objective response rates, response duration, or survival experiences were not demonstrably different between treatment arms, either for all patients or within good or poor prognosis groups determined by initial pain or acid phosphatase level. Subjective improvements in performance status were small for each treatment. Pain relief was somewhat greater in the chemotherapy-hormone combinations than in the DES/ORCH, but the advantage was not statistically significant. Side effects were primarily nausea and vomiting and leukopenia, mostly in the DES + Cytoxan arm. The duration of stabilization prior to entry did not influence response overall, although there were opposing trends within each of the two chemotherapy arms. The premise for combining antitumor agents with hormones before hormone failure is still felt to be a more logical approach than waiting for the ultimate hormone failure, and a combination of hormones plus two antitumor agents is being evaluated in a subsequent ongoing trial where a more rigid design limits the duration of the preentry period of hormone stabilization.

Comparison of estramustine phosphate, methotrexate and cis-platinum in patients with advanced, hormone refractory prostate cancer

In this clinical trial of men with advanced prostatic cancer no longer responsive to hormone therapy 189 were randomized to receive estramustine phosphate, methotrexate or cis-platinum. Response evaluations were done in 158 cases. Objective response rates (complete, partial or stabilization of disease) were 34 per cent for estramustine phosphate, 36 per cent for cis-platinum and 41 per cent for methotrexate. Subjective parameters indicated a substantial advantage for pain improvement with methotrexate or cis-platinum over estramustine phosphate. Probabilities of continued response indicated some advantage for methotrexate and median response durations at this time were twice as long for methotrexate (32 weeks) as for cis-platinum (16 weeks), with estramustine phosphate intermediate (23 weeks). Survival rates for the original treatment randomization groups were not different at this time. Side effects of estramustine phosphate consisted primarily of nausea and vomiting and/or anorexia but to a lesser extent than with cis-platinum. These effects were somewhat less for methotrexate, for which the major side effects were stomatitis and leukopenia, as well as hepatic toxicity reflected by elevated serum glutamic oxaloacetic transaminase levels. Other side effects of cis-platinum were less than for methotrexate (no stomatitis), except for signs of renal toxicity (elevations in blood urea nitrogen and serum creatinine), which were greater. Methotrexate had a relatively high level of activity against metastatic, progressive, hormone nonresponsive prostatic cancer, with side effects that were substantial but manageable.

The treatment of Stage III nonseminomatous testicular tumors. Roswell Park Memorial Institute results (1970-1979)

A review of 92 patients with Stage III nonseminomatous tumors treated at Roswell Park Memorial Institute between 1970-1979 was undertaken to verify changes in concepts as related to multiple agent chemotherapy and cytoreductive surgery. Each patient had a minimal follow-up of 18 months. Fifty-three patients were seen before 1975. Eighteen had metastasis to the lungs only. These were treated with a variety of single chemotherapeutic agents and cytoreductive surgery. The survival of this group was 38%. Among 35 patients with lung and visceral involvement seen at the same time, only one patient is alive. Thirty-nine patients were seen after 1975 and treated with multi-drug chemotherapy and cytoreductive surgery. The current survival rate of 23 patients with lung metastasis only is 69%. Among 16 patients with lung and visceral involvement, the present survival rate is 31%. This report confirms the effectiveness of multi-drug therapy in conjunction with cytoreductive surgery in the treatment of disseminated testicular tumors.

High-dose cytoreductive therapy with autologous bone marrow transplantation in advanced malignancies

Twenty-one patients with advanced malignancies received high-dose chemotherapy and/or radiotherapy followed by autologous bone marrow infusion. Eighteen patients (85.7%) had fever greater than or equal to 100 degrees F for a median of 6 days; 14 of these patients required broad-spectrum antibiotics for a median of 13 days. Nineteen patients (90.5%) had a granulocyte count less than 500/mm3 for a median of 11 days. Thrombocytopenia (platelet count less than 50,000/mm3) was observed in 18 patients (85.7%) for a median of 14 days. Mucositis and diarrhea were not common, occurring in six (28.6%) and seven (33.3%) patients, respectively. Of the 21 patients studied, 16 were evaluable for tumor response; there were four complete responses and four partial responses, and two patients who showed no change for variable times. Two patients have unmaintained remissions for greater than 2 years. Our response rate (complete plus partial) is 50%. Our study shows that high-dose cytoreductive therapy can be given with moderate toxicity when combined with autologous bone marrow infusion. Because responses in this group of patients are generally of short duration, we believe that patients with advanced malignancies who have had less exposure to therapy or who have a high likelihood of disease recurrence should be considered for high-dose cytoreductive therapy with autologous transplantation.

A comparison of estramustine phosphate versus cis-platinum alone versus estramustine phosphate plus cis-platinum in patients with advanced hormone refractory prostate cancer who had had extensive irradiation to the pelvis or lumbosacral area

Single and combination chemotherapy was compared in a clinical trial for men with advanced, metastatic prostate cancer who had received prior pelvic irradiation and had had progression of disease despite hormonal therapy. The 149 patients were randomized to receive estramustine phosphate or cis-platinum alone or in combination. Of the 149 patients 25 (17 per cent) were excluded from the study but 124 were evaluated for response and survival. Entry variables were distributed similarly among patients in each treatment arm. There were no complete or partial responders but there were nearly twice as many patients whose disease was stabilized (33 per cent) on the combination regimen compared to estramustine phosphate (18 per cent) and about a third more than for cis-platinum (21 per cent). Analysis of survival revealed some advantage for patients on combination therapy. Major toxicities for all treatments were nausea and vomiting (62 to 88 per cent) and accompanying anorexia (72 to 95 per cent). Azotemia developed in 45 per cent of the patients receiving combination therapy. In addition an elevation in serum creatinine occurred in 22 per cent of the patients receiving combination therapy and in 17 per cent of those receiving cis-platinum alone. Myelosuppression occurred infrequently.

Transabdominal fine needle aspiration of retroperitoneal lymph nodes in staging of genitourinary tract cancer (correlation with lymphography and lymph node dissection findings)

Percutaneous fine needle aspiration of retroperitoneal pelvic and abdominal lymph nodes was done in 100 patients with clinically localized bladder, prostatic, testis and penile cancer. A diagnosis of metastases to regional lymph nodes was detected by this method in 20 patients. Fine needle aspiration revealed evidence of regional lymph node involvement in 6 of 40 patients (15 per cent) with negative findings on lymphography and computerized tomography scan. Lymph node aspiration was followed by lymph node dissection in 50 patients. The correlation between aspiration and dissection was 68 per cent. The accuracy of obtaining representative material from the lymph node aspiration was 83 per cent. Negative results of lymph node aspiration cannot be used in clinical management. However, positive aspiration results provide the clinician with valuable information obtainable otherwise only by laparotomy or lymph node dissection. Positive aspiration results may spare patients with prostatic and bladder cancer an unnecessary radical operation, and may indicate early chemotherapy or surgery in patients with testis and penile cancer.

Intermittent hemodialysis therapy in the cancer patient

The occurrence of renal failure in the cancer patient presents a series of medical, technical, philosophical, and logistic problems that are rarely found in other patient population groups. In a review of 70 cancer patients requiring intermittent hemodialysis therapy at Roswell Park Memorial Institute over the last 6 years for acute renal failure, 46 (65.7%) of the patients were salvaged from renal failure to allow the use of further therapeutic modalities for their neoplastic disease. Patient survival after successful intermittent hemodialysis therapy was comparable to that expected in the nonazotemic cancer patients submitted to similar anticancer therapy. Hemodialysis should, therefore, be considered and offered in selected cancer patients in acute renal failure.

Transverse colon conduit: a method of urinary diversion after pelvic irradiation

Patients with pelvic malignancies often require irradiation as part of the treatment protocol or as definitive treatment for the malignancy. Subsequent urinary diversion with the low lying small bowel or the descending colon often results in increased morbidity. Therefore, a method of urinary diversion using the transverse colon conduit in an end-to-end ureterocolic anastomosis as described by Wallace was used. Several advantages with this method are identifiable easily and are described. The satisfactory results in the last 30 patients who underwent this procedure after pelvic irradiation are presented. The ureterocolic anastomosis with reflux is of particular importance since it allows retrograde conduitograms to be performed at later dates to evaluate the urothelium for possible recurrent disease.

High-dose tamoxifen in metastatic renal cell carcinoma

The effectiveness of high-dose Tamoxifen in the treatment of metastatic renal cell carcinoma was evaluated. Fifteen patients were treated for eight weeks with 80 mg of Tamoxifen daily. Side effect were minimal. Results showed progression of disease in 47 per cent of the patients, no change in disease was seen in 40 per cent, and 13 per cent showed a partial objective response. Twenty per cent of patients showed deterioration of performance status. High-dose Tamoxifen does not appear to be useful in the treatment of advanced renal cell carcinoma.

Treatment of testicular tumors arising in patients with previous inguinal and/or scrotal surgery

Of 20 patients with testicular tumors that occurred after previous inguinal and/or scrotal surgery 6 with seminomas were treated with traditional radiation therapy that included the ipsilateral groin, while 14 with nonseminomatous tumors were treated with retroperitoneal lymph node dissection with or without chemotherapy. No patient suffered inguinal lymph node metastases. Based on the satisfactory results in these patients to date and the lack of subsequent detectable recurrence of tumor we do not advocate additional treatment to the superficial inguinal lymph nodes and scrotum.

Estramustine phosphate with multiple cytotoxic agents in treatment of advanced prostatic cancer

Twenty-five patients with histologically proved adenocarcinoma of the prostate were divided into two groups and submitted to combination therapy with estramustine (Estracyt), cyclophosphamide (Cytoxan), 5-fluorouracil, and Cisplatin. Group A consisted of 10 patients newly diagnosed Stage D disease with no prior treatment. Group B consisted of 15 Stage D patients who had become hormonally unresponsive. Group A patients demonstrated an initial 100 per cent response rate including 70 per cent partial objective responses and 30 per cent stabilizations. Group B patients had a 46 per cent response with 39 per cent complete and partial responses and 6 per cent as stabilized. Toxicity was tolerable judged by the NPCP criteria. Both groups of patients are still under study for up to two years to determine if this therapy is superior to other traditional therapies.

Chemotherapy in metastatic, hormone refractory prostatic cancer using chlorambucil in combination with prednisolone versus conjugate, prednimustine (Leo 1031)

Chlorambucil plus prednisolone were administered to 11 patients with metastasis hormone refractory prostatic cancer, and the results were contrasted with a previously reported series of 23 similar patients treated with the chemical conjugate of these two agents, known as prednimustine or Leo 1031. The conjugated form of treatment (Leo 1031) had a limited therapeutic advantage, in that 3 patients experienced shrinkage of an enlarged prostate, 2 of whom also had elevated acid phosphatase levels return to normal and 5 others experienced only subjective improvement. There were, however, more adverse side effects in this group than those noted in patients treated with the combination of agents. Patients treated with the combination of drugs experienced no appreciable tumor shrinkage and none had acid phosphatase return to normal, although some reduction was noted in 8 of 11 patients who had elevated levels initially. Two of the 11 patients were considered stable for twelve months and one other remained ambulatory with mild pain for six months. Thus, to the degree that these studies permit, it is judged that the conjugated agent may have some limited therapeutic advantage not observed when the unconjugated agents were used.

Plasminogen activator content of neoplastic and benign human prostate tissues; fibrin augmentation of an activator activity

The plasminogen activator content of the extracts of excise prostate cancers (25 specimens) was determined with an azocasein assay and found to be on the average 1.7 times higher than that of extracts of excised prostate benign hyperplasias (29 specimens). Both groups contained the same average percentage of human urokinase type activator (approximately 45%) as determined by the inhibition of activity when anti-human urokinase antibody was included in the assay system. The two types of activators were partially purified and found to have distinctly different properties. The most striking difference was the large augmentation of activity o the non-urokinase enzyme in fibrinolysis. The implications of an enhanced fibrinolysis relative to azocaseinolysis (or other) is discussed, particularly with respect to its importance in the quantitation and characterization of activators by different investigators. Highly purified urokinase-like activator was found to be similar to commercial urokinase preparation with respect to molecular weight, isoelectric point, inhibition by the antibody, and inhibition by placenta inhibitor.

Surgical management of metastases to the lung

Our experience with 234 patients having resection of metastatic lesions of lung is reviewed. Most bilateral lung metastases were removed though a median sternotomy. Exploration of the contralateral lung with simultaneous removal of all lesions is possible through such an incision, and moreover, it appears to give less pain postoperatively. The over-all median survival time of the patients was 21.4 months, with a surgical mortality of 2.6 per cent. The therapeutic results were analyzed according to various factors. Incomplete resection and the presence of a positive hilar mediastinal node, or both, resulted in poor survival rate of the patients. Generally, the survival rates of the patients were found to be proportional to the disease-free interval and the tumor doubling time. Patients with a solitary lesion and those with two lesions removed had the best survival time. There was no difference in the survival rates of patients with unilateral and bilateral pulmonary multiple metastases. Treatment of metastases to the lung should be carefully planned in consultation with physicians who are acquainted with the natural history of the primary tumor, as lung resection is a part of the multimodal therapy of patients with solid tumor.

Auditory toxicity effects of long-term cis-dichlorodiammineplatinum II therapy in genitourinary cancer patients

To determine the auditory toxicity effects of long-term cis-dichlorodiammineplatinum II therapy, pure tone hearing thresholds were measured prior to therapy and repeated before each subsequent treatment. CDDP was given by a slow intravenous drip method at a low dose of 1 mg/kg body weight, with 37.5 gm mannitol, once a week for six treatments and every 3 weeks thereafter. From a group of 173 genitourinary cancer patients treated, 50 male patients were selected who received at least 12 months of CDDP with no active conductive ear pathology, and whose audiograms obtained at baseline, 6th weeks, 26th weeks, and 52nd weeks of treatment were all available for comparison. Pure tone threshold levels deteriorated across time particularly by the 52nd week and at the higher frequencies. Threshold differences across time were statistically significant and within a linear trend. Of the 50 cases, 30% showed suspect or no ototoxicity, 26% mild, 32% moderate, 2% marked, and 4% showed severe ototoxic changes. Of the two cases who developed severe ototoxicity, one showed complete recovery. There was partial recovery in 26% and no recovery in 54%. Individual variability in susceptibility to and recovery from ototoxicity necessitates systematic audiometric monitoring throughout the therapy.

The use of serum isoenzymes of alkaline and acid phosphatase as possible quantitative markers of tumor load in prostate cancer

The tumor burden of 98 patients with metastatic prostatic cancer was compared longitudinally with the activities of bone (BAP) and liver isoenzymes (LAP) of alkaline phosphatase, total acid phosphatase (AcP), and prostate-specific acid phosphatase (PAP). A quantitative association between these enzyme markers and the tumor mass was suggested by comparing the enzymes with 1) both the treatment response and the estimation of metastasis by radionuclide bone scanning; 2) metastasis based upon radiographic evidence. In addition, an apparent extensive pretreatment bone tumor load was predictive for an elevated BAP activity, which was also a suggestive poor prognosis as previously reported. An elevation of PAP, in contrast to AcP, may precede the clinical disease progression in some patients. Data presented in this report have indicated that the levels of these enzymes compared well with the extent of tumor involvement and therefore may be considered suitable as adjuvant and even quantitative biochemical markers of bone and liver metastasis.

Malignant fibrous histiocytoma of the retroperitoneum and genitourinary tract: a clinicopathological correlation and review of the literature

Malignant fibrous histiocytoma is an uncommon pleomorphic tumor of the soft tissues possibly arising from the histiocyte. A case of malignant fibrous histiocytoma in the retroperitoneal space is reported. Pathologic and clinical features of this lesion as they relate to the retroperitoneum and genitourinary tract are discussed and suggestions for therapy are presented.

Treatment of estrogen-resistant stage D carcinoma of prostate with cis diamminedichloroplatinum

Forty-five patients with rapidly progressive, estrogen-resistant Stage D adenocarcinoma of the prostate were treated with infusions of cis diamminedichloroplatinum (cis platinum) (1 mg./Kg./week) for six weeks initially and every three weeks thereafter. A partial objective response was observed in 13 of 45 patients (29 per cent). This response lasted from two to sixteen months with an average of six months. Eighteen patients (40 per cent) had a significant decrease or disappearance of bone pain and became ambulatory. Six patients (13 per cent) remained stable, and 8 patients (18 per cent) did not respond to treatment and showed progression of their disease. The toxicity of the treatment was mild to moderate. Most of the patients were treated in the outpatient department. Cis platinum appears to be the most effective drug available to date for the treatment of advanced carcinoma of the prostate.

Multimodal treatment of advanced testicular tumor with radical reductive surgery and multisequential chemotherapy with cis platinum, bleomycin, vinblastine, vincristine and actinomycin D

Advanced testicular tumors in 34 patients were treated by combination chemotherapy with bleomycin, vinblastine, vincristine, cis platinum and actinomycin D. The therapy was divided into 3 phases: 1) induction, 2) consolidation and 3) maintenance. Induction lasted 4 weeks and consisted of 420 mg. bleomycin, 0.2 mg./kg. vinblastine, 4 mg./kg. cis platinum, and 20 mg. prednisone daily. Consolidation lasted 6 weeks and consisted of 5 mg. actinomycin D, 6 mg. vincristine and 6 mg./kg. cis platinum. Maintenance therapy was achieved with 2.5 mg. actinomycin D every 6 weeks and 1 mg./kg. cis platinum every 3 weeks. A tumor reductive operation was done before induction of chemotherapy in 13 patients and after induction of chemotherapy in 12 patients. Nine patients were treated with chemotherapy alone. Three patients with brain metastases received concomitant radiotherapy to the brain (3,000 rads). A previous operation and chemotherapy had failed in 11 patients and previous radiotherapy had failed in 1 patient. All patients treated had at least 1 objective response (34 of 34 or 100 per cent). Partial clinical remission was achieved in 7 of 34 patients (21 per cent). A complete clinical remission was observed in 27 of 34 patients (79 per cent) and of this group 6 had a relapse. At present, 22 of 34 patients are free of disease from 4 to 24 months, with an average of 13 months (65 per cent). The toxicity consisted of nausea, vomiting, mucositis, alopecia, mild leukopenia and tinnitus. This approach seems to be effective in producing long clinical remissions in the majority of patients with advanced disease.

Adjuvant chemotherapy for bladder cancer with doxorubicin hydrochloride and cyclophosphamide: preliminary report

We describe 25 patients with bladder cancer who received adjuvant chemotherapy with doxorubicin hydrochloride and cyclophosphamide after radical cystectomy. Two patients had stage A disease, 3 had stage B, 3 had stage C and 17 had stage D. The 2 patients with stage A tumors have been free of disease for 12 and 15 months, respectively, and the 3 patients with stage B tumors have been free of disease for an average of 25 months. Of the 3 patients with stage C tumors 2 have been free of disease for an average of 34.5 months. Of the 17 patients with stage D tumors 10 have been free of disease for an average of 1 year (59 per cent). These preliminary results seem to indicate the value of adjuvant chemotherapy with doxorubicin hydrochloride and cyclophosphamide in cases of bladder cancer.

Treatment of recurrent and widespread testicular tumor by radical reductive surgery and multiple sequential chemotherapy

There were 37 patients with stages II and III testicular tumors treated by a combination of multisequential chemotherapy and radical reductive surgery. Two protocols were used: 30 patients received bleomycin, vinblastine, platinum, doxorubicin hydrochloride, cyclophosphamide and actinomycin D (protocol A), and 7 patients received bleomycin, vinblastine, vincristine, platinum and actinomycin D (protocol B). A complete clinical remission was achieved in 19 of the 37 patients (51.3 per cent), for an average survival of 12.9 months to date. A partial clinical remission was obtained in 7 patients (18.9 per cent), for an average survival of 14.2 months. Eleven of the patients (29.7 per cent) escaped from therapeutic control. The collective response (complete and partial clinical remissions) represented 70.2 per cent of the patients (26 of 37), with an average survival of 14.8 months. A new approach for the simultaneous excision of metastases in the abdomen and the chest is described and the rational basis for the combination treatment of these tumors is discussed.