Etiology and Mechanism of Intermittent Hypoxemia Episodes in Spontaneously Breathing Extremely Premature Infants

OBJECTIVE

To evaluate the mechanisms leading to intermittent hypoxemia (IH) episodes in spontaneously breathing extremely premature infants at 32 weeks and 36 weeks postmenstrual age (PMA).

METHODS

We studied spontaneously breathing premature infants born at 23-28 weeks of gestational age who presented with IH episodes while on noninvasive respiratory support at 32 or 36 weeks PMA. Daytime recordings of arterial oxygen saturation (SpO2), esophageal pressure, respiratory inductive plethysmography of the abdomen, chest wall, and their sum were obtained during 4 hours at 32 weeks and 36 weeks PMA. IH episodes (SpO2 <90% for ≥5 seconds) and severe IH episodes (SpO2 < 80% for ≥5 seconds) were classified as resulting from apnea, active exhalation and breath holding, reduced tidal volume (VT), or reduced respiratory rate (RR) during the preceding 60 seconds.

RESULTS

Fifty-one infants with a mean gestational age of 25.9 ± 1.5 weeks and a mean birth weight of 846 ± 185 g were included. Of these, 31 and 41 were included in the analysis at 32 weeks and 36 weeks PMA, respectively. At both 32 weeks and 36 weeks PMA, greater proportions of all IH episodes and severe IH episodes were associated with active exhalation and breath holding than with apnea, reduced RR, or reduced VT. The severity and duration of the IH episodes did not differ between mechanisms.

CONCLUSIONS

In this group of premature infants, the predominant mechanism associated with daytime IH was active exhalation and breath holding. This etiology is more closely associated with behavioral factors than abnormal respiratory control and can have implications for prevention.

Effect of the Target Range on Arterial Oxygen Saturation Stability in Extremely Premature Infants

OBJECTIVE

The aim of this study was to compare the effect of targeting arterial oxygen saturation (SpO2) in the high (93-95%) versus the low portion (90-92%) of the recommended range of 90-95% on oxygenation stability in extremely premature infants.

METHODS

Premature infants of ≤28 weeks of gestational age who received a fraction of inspired oxygen (FiO2) > 0.21 after day 14 were eligible. FiO2 was adjusted by a dedicated investigator to keep SpO2 between 90-92% and 93-95% for 2 h each in random sequence. Episodes of intermittent hypoxemia (IH) were defined as SpO2 <90% for ≥10 s; severe IH episodes were defined as SpO2 <80% for ≥10 s. Hyperoxemia was defined as SpO2 >95% or >98%.

RESULTS

Eighteen premature infants were enrolled. Their (mean ± SD) GA was 26 ± 1.5 w. Seven infants were on mechanical ventilation, 4 infants on nasal ventilation, and 7 infants on nasal cannula. They were on a mean FiO2 0.38 ± 0.12 at study entry. Episodes of IH and severe IH were more frequent during the low compared to the high target (36.6 [27.0-41.3] vs. 16.0 [7.8-19.0], p < 0.001; 8.4 ± 9.3 vs. 3.2 ± 4.3, p = 0.002). The proportions of time with SpO2 >95% and >98% were greater with the high target (13.9 ± 11 vs. 34.1 ± 15.4%, p < 0.001; 0.9 [0-5.7] vs. 3.4 [0.5-16.1]%, p = 0.002).

CONCLUSION

In this group of extremely premature infants, targeting SpO2 at the lower portion of the recommended range resulted in more frequent episodes of IH. However, targeting the higher SpO2 range led to more hyperoxemia. This trade-off warrants further investigation.

Efficacy of late postnatal dexamethasone on weaning from invasive mechanical ventilation in extreme premature infants

OBJECTIVE

To evaluate the short-term respiratory effects of PND in a cohort of ventilator-dependent premature infants.

STUDY DESIGN

Clinical data from 106 infants 23-28 weeks gestation who received PND for weaning from MV during 2011-2017 were evaluated. PND was started at a dose of 0.1 mg/kg/d tapered over 5-7 d. Treatment success was defined as extubated and free from MV on d14 after start of treatment.

RESULT

Treatment was successful in 83 (78%) infants. Demographics and age of treatment did not differ between groups. In the failure group, a higher proportion were on HFOV and FiO₂ ≥ 0.50 before treatment, compared to the successful group.

CONCLUSION

In most infants, PND resulted in successful weaning from MV. Reduced need for oxygen in infants not extubated may be beneficial, but it is unknown if this offsets the risks. The long-term effects PND in ventilator dependent infants need to be evaluated.

0074 Inhibitory Neurons in the Dorsomedial Medulla Promote REM Sleep

Introduction

The neural circuits controlling rapid eye movement (REM) sleep, and in particular the role of the medulla in regulating this brain state, remains an active area of study. Previous electrophysiological recordings in the dorsomedial medulla (DM) and electrical stimulation experiments suggested an important role of this area in the control of REM sleep. However the identity of the involved neurons and their precise role in REM sleep regulation are still unclear.

Methods

The properties of DM GAD2 neurons in mice were investigated through stereotaxic injection of CRE-dependent viruses in conjunction with implantation of electrodes for electroencephalogram (EEG) and electromyogram (EMG) recordings and optic fibers. Experiments included in vivo calcium imaging (fiber photometry) across sleep and wake states, optogenetic stimulation of cell bodies, chemogenetic excitation and suppression (DREADDs), and connectivity mapping using viral tracing and optogenetics.

Results

Imaging the calcium activity of DM GAD2 neurons in vivo indicates that these neurons are most active during REM sleep. Optogenetic stimulation of DM GAD2 neurons reliably triggered transitions into REM sleep from NREM sleep. Consistent with this, chemogenetic activation of DM GAD2 neurons increased the amount of REM sleep while inhibition suppressed its occurrence and enhanced NREM sleep. Anatomical tracing revealed that DM GAD2 neurons project to several areas involved in sleep / wake regulation including the wake-promoting locus coeruleus (LC) and the REM sleep-suppressing ventrolateral periaquaductal gray (vlPAG). Optogenetic activation of axonal projections from DM to LC, and DM to vlPAG was sufficient to induce REM sleep.

Conclusion

These experiments demonstrate that DM inhibitory neurons expressing GAD2 powerfully promote initiation of REM sleep in mice. These findings further characterize the dorsomedial medulla as a critical structure involved in REM sleep regulation and inform future investigations of the REM sleep circuitry.

Support

R01 HL149133

0071 A Medullary Circuit Controlling REM Sleep

Introduction

Rapid eye movement (REM) sleep is a distinct brain state known for its association with vivid dreaming in humans, though it is also crucial for other mental processes such as memory consolidation and emotion regulation. REM sleep is punctuated by phasic neurophysiological events known as pontine (P)-waves, which are thought to contribute to the cognitive functions of REM sleep. However, little is known about the neural circuits regulating these P-waves, or those responsible for initiating REM sleep itself. Here, we show that a yet unstudied population of medullary neurons expressing corticotropin-releasing-hormone (CRH) are important for controlling both the induction of REM sleep and its phasic events.

Methods

To measure the endogenous activity of CRH+ neurons in the dorsomedial medulla (dmM), we injected the calcium indicator GCaMP6 in the dmM of CRH-Cre mice. To optogenetically manipulate dmM CRH+ neuron activity, we delivered either an excitatory (ChR2) or inhibitory (iC++) opsin to the dmM of CRH-Cre mice. To record P-waves, we implanted microelectrodes to record local field potentials in the subcoeruleus region of the pons.

Results

Fiber photometry recordings showed that dmM CRH+ neurons are selectively active during REM sleep, and optogenetic stimulation and inhibition of this population is sufficient to promote and reduce REM sleep, respectively. Additionally, dmM CRH+ neuron activity is correlated with P-waves in the pons, and optogenetic activation of dmM CRH+ cells reliably triggers P-waves during REM sleep. Finally, histological examination of fluorescently labeled dmM CRH+ axons revealed strong projections to several pontine areas involved in P-wave generation as well as modulation of the theta rhythm during REM sleep.

Conclusion

Our results suggest that dmM CRH+ neurons are involved in controlling REM sleep initiation as well as phasic events within REM sleep. These neurons thus constitute an important component of the brainstem circuitry regulating REM sleep.

Support

National Institutes of Health (R01 HL149133)

[Splenic cysts as an incidental finding--what's next?]

HISTORY AND ADMISSION FINDINGS

A 55-year-old woman presented comfortable and well-nourished for a check up. The physical examination remained without pathological results. However lipase parameter in serum was conspicuously elevated we performed an ultrasound examination.

EXAMINATIONS

An abdomen sonography revealed besides regular pancreas morphology a hypoechoic lesion of 11 × 10 mm in the liver and multiple hypoechoic inhomgeneous lesions in the spleen. Because of the inhomogeneous results and septa we decided to arrange an abdomen computer tomography (CT) in which the complex of cysts was stated with a size of 59 × 44 mm. As the differential diagnosis of the cysts could be an echinococcosis or amoebic infection we performed a serological analysis at the first appointment and 4 weeks later. Both test results were negative.

TREATMENT AND COURSE

Eight years later we indicated a magnetic resonance tomography (MRI with MRCP) to exclude a compression of the pancreatic duct by the splenic or liver cysts because the lipase und C-reactive protein (CRP) in serum was rising up again . The MRI scan showed a progression of the splenic cysts complex to 88 × 69 mm and the liver cyst to 25 × 20 mm without signs for compression or a malignant process. A correlation between elevated lipase and splenic cysts was not evident. Despite progression of the splenic cysts we decided in view of the comfortable condition of the patient and negative serological analysis for a conservative proceeding in terms of regular check ups.

CONCLUSION

From our point of view also in extended non-parasitic splenic cysts it is reasonable to follow a nonoperative regime as long as clinical complaints, parasitic genesis and malignant process can be excluded.

Expression and intracellular localization of ACA and TRA-1-81 in smooth muscle cell tumors

We studied the expression and intracellular localization of ACA and TRA-1-81 in smooth muscle cell tumors. The study was performed on tissue specimens obtained during surgery from patients with uterine leiomyoma and leiomyosarcoma (mean age 34 and 51 years, respectively). ACA was present in leiomyoma, leiomyosarcoma, and control myometrium. Intracellular expression of ACA varied in different types of tumors and was minimum in normal myometrium and maximum in leiomyosarcoma. Membrane localization of the protein is typical of common and cellular leiomyoma, while in the growth zones of mitotically active leiomyoma and leiomyosarcoma the reaction product was primarily located in tumor cell cytoplasm. TRA was detected in some leiomyosarcoma cells. Thus, ACA dysregulation was revealed in the growth zones of leiomyomas and in leiomyosarcomas, which manifested in enhanced expression of this protein and its detachment from the plasma membrane, which leads ACA translocation into the cytoplasm and nucleus of tumor cells and potentiates their proliferative activity.

Targeting Intrinsically-Resistant Breast Cancer Stem Cells with Gamma-Secretase Inhibitors

Background: We showed previously that tumorigenic, mammosphere-forming human breast cancer cells characterized by high CD44 and low or undetectable CD24 levels (CD44+/CD24-/low) are intrinsically resistant to conventional chemotherapy, and therefore may be responsible for cancer relapse. Our goal is identify novel drugs that selectively target these chemotherapy-resistant, tumor-initiating cells. Gene expression analysis of CD44+/CD24-/low cells vs. non-tumorigenic cells implicated the Notch, PI3K, and Hedgehog signaling pathways in regulating CD44+/CD24-/low cells. Thus, Notch, PI3K-AKT, and/or Hedgehog inhibitors may eliminate this unique subpopulation of cancer cells, either alone or in combination with chemotherapy, and could improve patient outcome. To test this hypothesis, we are carrying out a series of preclinical and clinical studies using a gamma-secretase inhibitor (GSI) to target the Notch pathway. Methods: For preclinical studies, stable xenograft lines were generated by transplantation of human tumor biopsy fragments into immunocompromised mice. Mice with tumors (n = 32, 150-300 mm3) were randomized to four treatment groups: 1) vehicle control, 2) chemotherapy: docetaxel 3) drug: GSI (MRK-003, Merck) or 4) combination: docetaxel + MRK-003. During treatment, mice were monitored for tumor volume and body weight. At the end of the treatment cycle, residual tumors were characterized by FACS for the percentage of CD44+/CD24-/low cells, as well as for mammosphere-forming efficiency (MSFE) and tumor-initiating capacity. In a complementary clinical trial, breast cancer biopsies taken before and after treatment with GSI (MK-0752, Merck) were characterized for expression of CD44, CD24, and ALDH by FACS and for MSFE. Results and Conclusions: In preclinical studies using two independent triple negative xenograft lines, Notch pathway inhibition reduced mammosphere formation but did not affect tumor volume, with no consistent change in marker expression by FACS. In patient samples, MSFE also declined after the first cycle of GSI/chemotherapy and remained low after subsequent cycles. This response corresponded with a stasis of metastatic growth during five cycles of treatment, but metastatic burden began to increase coincident with the sixth cycle of treatment. Marker analysis suggests that GSI treatment chemo-sensitizes a significant proportion of the otherwise chemo-resistant CD44+/CD24-/low cell population indicating that they are dependent on the Notch pathway for survival. The decrease of MSFE in both preclinical and clinical studies suggests that inhibition of the Notch pathway by GSI may reduce the number of tumorigenic cancer cells that would otherwise remain after chemotherapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 48.

Bone Mineral Density (BMD) Changes at 1 Year in Postmenopausal Women Who Are Not Receiving Adjuvant Endocrine Therapy for Breast Cancer (BCA)

Background: Adjuvant therapy for breast cancer (BCA) may be associated with an increased risk for osteoporosis. This prospective, observational study evaluates BMD changes in postmenopausal women undergoing adjuvant chemotherapy (CTX) for early stage BCA, in the absence of endocrine therapy.Methods: Women who have been postmenopausal for at least 5 years, and who were recently diagnosed with Stage 0-III BCA were eligible to undergo serial BMD if adjuvant endocrine therapy was not recommended. Study BMDs were performed at baseline, 1 and 2 years. All patients (pts) were counseled on calcium, vitamin D and weight bearing exercise. This study was designed to assess serial changes in BMD in the individual and to compare changes in those treated with CTX to those who received no systemic therapy (observation). The study was closed prior to reaching target sample size due to slow accrual.Results: Sixteen pts enrolled. Eleven pts received CTX with a dose dense anthracycline and taxane containing regimen and 5 pts received no systemic adjuvant therapy. Twelve pts, median age 63 (range 52-80), have completed the 1 year assessment and are reported here. Two pts treated with CTX and 1 pt on observation were on bisphosphonates at study entry. Baseline BMD mean in gm/cm2 at the lumbar spine (LS) was 1.112 (range 0.807-1.389) and total hip (TH) was 0.989 (range 0.760-1.213). At 1 year, mean BMD at LS was 1.078 (range 0.767-1.347) and TH was 0.956 (range 0.753-1.210). For all 12 pts at 1 year, the individual BMD changes in LS & TH BMD ranged from 10% loss to 2% gain, with 8 of the 9 CTX treated pts losing 1-10% of BMD and the 3 pts on observation staying within 2% of baseline. The mean dosage of dexamethasone used during CTX by the 9 CTX pts was 230 mg (range 156-288mg). The 3 observation pts had no exposure to steroids during the parallel time period.Conclusions: This prospective, observational study supports the hypothesis that adjuvant CTX, and/or its supportive medications, may be associated with acute changes in BMD in postmenopausal women. Patient follow up continues.Funded by Susan G. Komen for the Cure POP0402593

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1066.

[Pneumonia with empyema during varicella]

Chicken pox is usually considered a benign viral affection; however, possible infectious complications are observed. Although cutaneous infections are well described, bacterial pneumonia with empyema is more exceptionally reported.

PURPOSE

To describe the clinical characteristics of bacterial pneumonia with empyema associated with chicken pox.

METHODS

This descriptive multicenter retrospective study was based on a questionnaire sent by Internet to 30 French pediatric and pediatric respiratory hospital wards.

RESULTS

We found 4 cases of children (mean age, 19 months) presenting during the chicken pox eruption concomitant bacterial pneumonia with empyema. The average time of diagnosis was 4.5 days after the beginning of the eruption. All the children were febrile and had an average pulsed oxygen saturation of 87%. The inflammatory syndrome was constant with a mean C reactive protein of 253 mg/l. Group A Streptococcus was identified in 3 cases out of 4. Admission to an intensive care unit was necessary for 3 children, 1 of them requiring mechanical ventilation. No clinical or radiological sequelae were observed during the complete year of follow-up.

CONCLUSION

Bacterial pneumoniae with empyema are not current complications of chicken pox but have to be sought when prolonged fever and/or alteration of the health status occurs during chicken pox eruption.

[Non-operative management of a hepatic pseudoaneurysm and a biloma complicating a blunt abdominal trauma]

Hepatic artery pseudoaneurysm and bilioma are rare complications of blunt abdominal trauma in children. We report a case in an 11-year-old patient after a hepatic and splenic blunt trauma following a car accident. The initial evolution was simple with haemodynamic stability. On Day 12, a pseudoaneurysm was discovered on an abdominal magnetic resonance imaging whereas the patient presented a major pain syndrome and an icteric cholestase. Embolisation was realised a few hours later in emergency because of a haemorrhagic shock. On Day 26, an endoscopic retrograde cholangiopancreatography highlighted two bilary leaks: one extrahepatic, the other intrahepatic. The first one was treated with a stent and the second one needed three drains: two peritoneal and one in the biloma. The characteristic of this case relies on the association of two complications. It underlines the need of multidiscipline and non-operative management of pediatric blunt hepatic trauma.

Estrogen receptor genotypes, menopausal status, and the lipid effects of tamoxifen

Tamoxifen induces important changes in serum lipid profiles in some women; however, little information is available to predict which women will experience improved lipid profiles during tamoxifen therapy. As part of a multicenter prospective observational trial in 176 breast cancer patients, we tested the hypothesis that tamoxifen-induced lipid changes were associated with genetic variants in candidate target genes (CYP2D6, ESR1, and ESR2). Tamoxifen lowered low-density lipoprotein cholesterol (P<0.0001) by 23.5 mg/dl (13.5-33.5 mg/dl) and increased triglycerides (P=0.006). In postmenopausal women, the ESR1-XbaI and ESR2-02 genotypes were associated with tamoxifen-induced changes in total cholesterol (P=0.03; GG vs GA/AA) and triglycerides (P=0.01; gene-dose effect), respectively. In premenopausal women, the ESR1-XbaI genotypes were associated with tamoxifen-induced changes in triglycerides (P=0.002; gene-dose effect) and high-density lipoprotein (P=0.004; gene-dose effect). Our results suggest that estrogen receptor genotyping may be useful in predicting which women would benefit more from tamoxifen.

Tamoxifen-induced hot flashes are associated with estrogen receptor polymorphisms

501

Background: Hot flashes are the most common side effect of tamoxifen. The pharmacogenetic predictors of hot flashes are not known. We hypothesized that estrogen receptor (ER) genotypes that have been associated with clinical phenotypes may predict the frequency and composite score of tamoxifen-associated hot flashes. Methods: We conducted a prospective observational study in 3 academic centers to evaluate the associations between ER and hot flash composite scores in women with breast cancer during the first year of adjuvant tamoxifen treatment. Menopausal status and prior chemotherapy history were collected at baseline. Medication records and validated hot flash diaries were prospectively collected before and following 1, 4, 8 and 12 months of starting tamoxifen. ERa (ESR1) PvuII (rs2234693) and XbaI (rs9340799) genotypes were determined using a Restriction Fragment Length Polymorphism (RFLP) assay; and ERβ (ESR2–02; rs4986938) genotype was determined using a Taqman™ assay. The haplotype of two ESR1 SNPs and their association with the baseline hot flash score were analyzed with haplo.stat function in R. Individual SNPs and their interactions in baseline hot flash score and month 4 hot flash score change were analyzed with SAS PROC GLM. Results: Of the 298 women recruited to the trial, 286 returned their baseline diaries and 251, 239, 214, and 213 women returned their diaries 1, 4, 8, and 12 months after tamoxifen treatment. At baseline, premenopausal women who were homozygous for the ESR1 CG haplotype reported higher hot flash scores (17.2±3.7) than carriers with one or less CG allele (5.2±3.9), p=0.01. After tamoxifen treatment, postmenopausal women with ESR1 PvuII CC and ESR2–02 GG genotype had the greatest increase (p=0.0004) in hot flash score (53.9±16.4) as compared with women with other genotypes (12.5±3.6). Women who were homozygous for the ESR2–02 AA allele were significantly less likely to experience tamoxifen-induced hot flashes than women with at least one G allele (OR=4.0, P=0.0006) regardless of menopausal status and chemotherapy history. CYP2D6 analysis in underway and results will be available for the meeting. Conclusions: Menopausal status, history of prior chemotherapy, and ER genotype may be used to predict who may suffer hot flashes during tamoxifen treatment.

[Table: see text]

Chromosome aberration analysis in peripheral lymphocytes of Gulf War and Balkans War veterans

Chromosome aberrations and sister chromatid exchanges (SCEs) were determined in standard peripheral lymphocyte metaphase preparations of 13 British Gulf War veterans, two veterans of the recent war in the Balkans and one veteran of both wars. All 16 volunteers suspect exposures to depleted uranium (DU) while deployed at the two different theatres of war in 1990 and later on. The Bremen laboratory control served as a reference in this study. Compared with this control there was a statistically significant increase in the frequency of dicentric chromosomes (dic) and centric ring chromosomes (cR) in the veterans' group. indicating a previous exposure to ionising radiation. The statistically significant overdispersion of die and cR indicates non-uniform irradiation as would be expected after non-uniform exposure and/or exposure to radiation with a high linear energy transfer (LET). The frequency of SCEs was decreased when compared with the laboratory control.

Using Student-Collected Practice Data as a Teaching Tool

Research is an intimidating prospect for many students. This brief and fairly simple foray into data collection and analysis did not convince all students to embrace research. It did, however, entice many to consider how to incorporate data collection into their own beginning practices. Students who had stated their aversion to research found themselves arguing for the necessity of data collection to provide evidence for practice changes. There were also students who found the experience yet another busywork paper trail invented by the faculty. They resented the time and effort required for completion of another form during their busy clinical experiences. Other students remained adamantly opposed to considering any changes in what they saw as "appropriate" practice despite evidence to the contrary. An ongoing goal of education is to facilitate lifelong learning and investigation into clinical questions. The faculty plan to survey the graduates to ascertain what data collection efforts, if any, they are currently using. The educational program described in this project closed in December 1998 because of funding restrictions. One of the faculty in this project (Carr) and current colleagues are continuing to use the NMCDS to encourage students to examine and analyze their own practices. An additional use of the data set is for student-initiated research projects that focus on specific clinical questions. One faculty member was part of an effort to institute a similar project in a master's-based nurse-midwifery education program. That database has currently provided data for two master's degree projects. The uses of the NMCDS are not limited to graduate students or advanced practice clinicians. The tool is being used in an undergraduate maternity nursing clinical course to assist students in seeing differences in practice and the possible reasons for those differences. The Division of Research of the ACNM has sponsored the development of similar data collection tools for both ambulatory prenatal and well-woman care. The wellwoman tool is currently in the pilot stage (1999), and will be refined and further tested this year. The use of these data collection tools by advanced practice nurses would provide a wealth of data for both policy setting and clinical research. Educational programs frequently combine coursework for various advanced practice nursing pathways, and nurse-midwifery and nurse practitioner students would benefit from jointly focusing on practice patterns and participating in the analysis of student-collected data. The standardized tools for intrapartum, well-woman care, and antepartum care will be available to all of the 50 ACNM education programs as well as to practicing clinicians.

The effect of an individual's cytochrome CYP3A4 activity on docetaxel clearance

Docetaxel is a chemotherapeutic agent effective in the treatment of various solid tumors. Patients given a standard dose of docetaxel exhibit wide interpatient variation in clearance (CL) and toxic effects. Docetaxel undergoes metabolism by cytochrome CYP3A4. Thus, interpatient variability in CYP3A4 activity may account in part for differences in toxicity and CL. Twenty-one heavily pretreated patients with metastatic sarcomas received docetaxel (100 mg/m2). Hepatic CYP3A4 activity in each patient was measured by the [14C-N-methyl]erythromycin breath test (ERMBT). Blood samples were taken at selected times over the next 24 h for pharmacokinetic analysis. Phenotypic expression of hepatic CYP3A4 activity measured by the ERMBT varied over 20-fold (administered 14C exhaled in 1 h: mean, 2.53%; range, 0.25-5.35%), which is similar to a normal control population. CL of docetaxel varied nearly 6-fold (mean, 21.0 liters/h/m2; range, 5.4-29.1 liters/h/m2). The ERMBT was the best predictor of CL when compared with serum alanine aminotransferase, albumin, alkaline phosphatase, or serum alpha-1-acidic glycoprotein. The natural log of ERMBT accounted for 67% of the interpatient variation in CL. Multivariate analysis showed that the natural log of ERMBT and albumin together accounted for 72% of the interpatient variation in CL. The greatest toxicity was seen in patients with the lowest ERMBT. Hepatic CYP3A4 activity is the strongest predictor of docetaxel CL and accounts for the majority of interpatient differences in CL. Patients with low CYP3A4 activity are at risk for having decreased CL and may thus experience increased toxicity from docetaxel. Those with high activity may be receiving a suboptimal dose. By measuring CYP3A4 activity, the ERMBT may be clinically useful in tailoring doses of CYP3A4 substrates, such as docetaxel, in certain individuals.

Isolated tumor cells are frequently detectable in the peritoneal cavity of gastric and colorectal cancer patients and serve as a new prognostic marker

OBJECTIVE

To evaluate the prognostic significance of isolated tumor cells detected by a panel of various monoclonal antibodies.

SUMMARY BACKGROUND DATA

Previously, we showed by using immunocytology that cancer cells are frequently found in bone marrow and peritoneal cavity samples of gastrointestinal cancer patients.

METHODS

Findings in bone marrow and peritoneal cavity samples were compared and correlated with the 4-year survival rate of 84 gastric and 109 colorectal patients with cancer.

RESULTS

Although positive results in the bone marrow showed little prognostic significance, the peritoneal cavity results correlated with the 4-year survival rate (gastric cancer: p = 0.0038; colorectal cancer: p = 0.0079). Additionally, in subgroups of patients with early (gastric cancer: p = 0.02, colorectal cancer: p = 0.48) and advanced (gastric cancer: p = 0.02, colorectal cancer: p < 0.0001) tumor stages, a correlation of immunocytologic findings and the survival rate was seen.

CONCLUSIONS

The detection of minimal residual disease in the peritoneal cavity serves as a new prognostic marker.

Surgical management of nonneoplastic diseases of the submandibular gland. A follow-up study

A total of 233 patients with nonneoplastic diseases of the submandibular gland were treated between 1966 and 1992 at the otorhinolaryngology department of the University of Göttingen. Of them, 212 patients (91%) suffered from sialadenitis with or without sialolithiasis, and 21 (9%) suffered from other diseases. The first part of the present study analyzes the clinical data with regard to history, symptoms, and therapy. It was found that in most cases (77%) extirpation of the affected gland had been the standard operation. In the second part, the surgical procedures applied are critically assessed. Extirpation of the submandibular gland proved to be an effective therapy in all patients. Side-effects were rare. The management of chronic sialadenitis caused by calculi should include extirpation of the submandibular gland. In case of calculi not causing inflammatory disease, lithotripsy should be considered.

Surgical management of benign tumors of the submandibular gland: a follow-up study

PURPOSE

This retrospective study evaluated data pertaining to history, symptoms, diagnosis, and mode of therapy of patients treated for benign tumors of the submandibular gland.

PATIENTS AND METHODS

The records of 38 patients were reviewed. The patients were divided into three groups: pleomorphic adenoma (first operation), pleomorphic adenoma (second operation for recurrence), and other tumors. Follow-up was done by questionnaires sent to the patient and referring doctor.

RESULTS

The vast majority of patients treated (92%) had had either a first or second operation for pleomorphic adenoma. Follow-up revealed that recurrence did not develop in the group of patients with primary surgery. However, one patient undergoing surgery for recurrent pleomorphic adenoma developed two recurrences. Two patients suffered from slight weakness of the lower lip.

CONCLUSION

Tumor recurrence was found only in the cases of second operation after previous surgery for pleomorphic adenoma. Therefore, the first operation should extirpate the entire gland to minimize the risk of recurrence.

[Immunocytologic detection of disseminated tumor cells in the peritoneal cavity and bone marrow in patients with pancreatic carcinoma]

Despite radical surgical treatment, the prognosis of patients with pancreatic cancer is poor. The success of surgical treatment is often limited due to local recurrence and especially the development of metastases and peritoneal carcinosis by cells which have been seeded already at the time of operation. Immunocytological methods enabled the detection of disseminated cancer cells before their clinical manifestation as demonstrated by this study. Lavage samples from the peritoneal cavity and bone marrow samples from 34 patients with an adenocarcinoma of the pancreas were investigated with a panel of six different monoclonal antibodies against tumor-associated antigens (CEA, CA-19-9, 17-1A, C-54-0, Ra96) and cytokeratin, respectively. Additionally, 43 patients with benign diseases were investigated as a control group. By this method, micrometastases were detected either in the bone marrow or the peritoneal cavity in 76% of pancreatic cancer patients. The occurrence of stained cells in the peritoneal cavity and bone marrow samples correlated with the tumor stage and showed even in early stages (I and II) a detection rate of 43% (bone marrow) and 33% (peritoneal cavity), respectively. No unspecific reactions were found in the control group. The 1-year follow-up shows a significant correlation between tumor cell detection and the survival (p = 0.03). Our study demonstrates that in most patients pancreatic cancer is a disseminated disease at time of diagnosis. It underlines the need for adjuvant postoperative therapy concepts.

Effect of allopurinol on neutrophil superoxide production, chemotaxis, or degranulation

Recent studies examining the effect of allopurinol on bacterial killing by leukocytes [Tubaro et al., Biochem. Pharmac. 29, 3018 (1980); Tritsch and Neiswander, Life Sci. 32, 1359 (1983)] have been interpreted by those authors as proof that xanthine oxidase is the major superoxide producing enzyme in activated leukocytes. To test the assertion that xanthine oxidase is involved in the production of superoxide by activated human neutrophils, the xanthine oxidase content of neutrophils was measured, and the effect of allopurinol on neutrophil functions, including superoxide production, was studied. Neutrophils were found to contain a level of xanthine oxidase insufficient to account for the flux of superoxide associated with neutrophil activation. Allopurinol did not inhibit superoxide production induced by opsonized zymosan, phorbol myristic acetate, or formylmethionylleucylphenylalanine. Furthermore, neither chemotaxis nor degranulation was affected by allopurinol. Allopurinol was also found ineffective in blocking superoxide-mediated carrageenan-induced foot edema in the rat. These studies are interpreted as evidence that xanthine oxidase is not a major superoxide-generating system in activated neutrophils as has been suggested by others.

Wolff-Parkinson-White Syndrome (Short P-R Intervals Associated With Disturbances of Intraventricular Conduction) With Attacks of Paroxysmal Tachycardia in an Infant Aged 8 Months Suffering From Probable Congenital Heart Disease

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