Psychiatric intensive care after two years

The following is a descriptive study of Willoughby Ward, a psychiatric intensive care unit, opened in Parkside Hospital, Macclesfield, in July 1986. It provides a moderately secure facility for the treatment of psychiatric patients within both Crewe and Macclesfield Health Authorities. The unit has 15 beds, of which two are funded and used by Crewe area, where, unlike Macclesfield, the psychiatric unit is located in the district general hospital. Managed as a locked ward, the patients are admitted under the provisions of the Mental Health Act 1983. As well as being mentally ill as defined in the Act, the patients were disturbed to a degree as to be unmanageable in open conditions.

Patient safety in orthopaedics

We summarise and highlight the safety concerns within the field of trauma and orthopaedic surgery with particular emphasis placed on current controversies and reforms within the United Kingdom National Health Service.

Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee

Previous studies from single centres or single-surgeon series report good early and mid-term results for high tibial osteotomy (HTO) in the treatment of osteoarthritis of the knee. However, the survivorship of HTO at a national level is unknown. This registry-based study included 3195 high HTOs performed between 1987 and 2008. Kaplan-Meier analysis revealed an overall survivorship of 89% (95% confidence interval (CI) 88 to 90) at five years and 73% (95% CI 72 to 75) at ten years, when conversion to total knee replacement was taken as the endpoint. Females and patients aged > 50 years had worse survivorship than males or patients aged ≤ 50 years (hazard ratio (HR) 1.26 (95% CI 1.11 to 1.43) and HR 1.41 (95% CI 1.23 to 1.64), respectively). The survivorship of HTOs performed between 1998 to 2008 was worse than for those performed between 1987 and 1997.

Utility of photography to confirm skin lesion response assessed using a severity weighted assessment tool (SWAT) in cutaneous T-cell lymphoma (CTCL)

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Background: In Oct 2006, FDA approved vorinostat for treatment of cutaneous manifestations of CTCL–based on response rate and duration of response observed in CTCL skin lesions. Response was determined by change in SWAT score at follow up compared to the baseline score. SWAT Score: sum of % Body Surface Area weighted by factor 1, 2, or 4 for patch (no elevation from normal skin), plaque (< 5 mm elevation) and tumor (= 5 mm elevation), respectively. All responses but one were partial. A partial response required = 50% reduction in whole body SWAT score lasting = 4 weeks. FDA also reviewed serial photographs of all patients (standard whole body views and close-ups of skin lesions), submitted as supportive evidence. Methods: An expert external reviewer, blind to SWAT scores, adjudicated responses by examining photographs and response determinations by photographs and by SWAT scores were compared. Results: Based on SWAT scores, skin lesions in 18 of 61 stage = IIB CTCL patients responded to vorinostat; there were 17 partial and 1 complete responses. Blinded reviewer adjudicated 4 photographs not evaluable (reasons: blurred image, color or light problem, wrong label), easily confirmed 7 responses, and called 7 responses equivocal. Responses seemed easier to determine in skin lesions with tumors or ulcers. Predominantly patch or plaque lesions were harder to evaluate: patches due to poor color reproduction and plaques due to inability to palpate. A response from plaque to patch morphology decreases SWAT score 50%, but the change may not manifest adequately in a photograph. Small sample size did not allow a reliable statistical analysis for correlation between different lesion types and ability to confirm objective responses (based on SWAT scores) by photography. Conclusions: Photography allows a limited evaluation of skin lesions in CTCL: inability to measure lesion thickness in photographs limits direct confirmation of SWAT scores. Photography complements SWAT evaluation: in half the cases in the vorinostat pivotal trial, a response by SWAT score was easily confirmed by the reviewer blind to SWAT scores. Further experience and technological advances in photography may reduce the number of not evaluable photographs.

No significant financial relationships to disclose.

An analysis of deficiencies identified during investigational new drug (IND) application reviews by the Division of Drug Oncology Products (DDOP) of the US FDA

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Background: Regulations require IND application review by the FDA prior to initiation of the clinical study. Deficiencies identified in the study protocol require communication between the FDA reviewers and the Sponsor for resolution. If the deficiencies are not adequately resolved, clinical hold and subsequent delay in the start of the clinical study results. To identify and analyze the commonly encountered IND application deficiencies, data from recent reviews were collected. Methods: Eight clinical reviewers analyzed the deficiencies that had been identified in 268 IND applications reviewed in the DDOP FDA from January 2003 to June 2005. All of the study protocol deficiencies leading to a clinical hold, or requiring resolution prior to study initiation were categorized as deficiencies pertaining to: patient eligibility; starting drug dose; study conduct (toxicity management, dose adjustment, stopping criteria); statistical or endpoints; non-clinical; and other issues. Results: 268 IND applications reviewed over a 30-month period by eight medical officers were analyzed. One hundred and twelve (42%) of the applications had no deficiencies; however, 156 (58%) had one (31%) or multiple (69%) deficiencies. Deficiencies pertained to study conduct/scheme (65%), dose (48%), patient eligibility (46%), others (31%), statistics or endpoints (15%), and non-clinical (4%) issues. In 141 (90%) of the deficient applications the deficiencies were adequately addressed by FDA reviewer-Sponsor communication and the trials could start as scheduled. Fifteen (10%) deficient trials were placed on clinical hold. Fourteen (93%) of these trials had multiple deficiencies that pertained to patient eligibility in 12 (80%), starting drug dose in 12 (80%), study conduct in 11 (73%), other in 7 (47%), and non-clinical and statistical issues in 2 (13%) each. Conclusions: Deficiencies were identified in 58% of the reviewed IND applications: 90% of these were resolved by FDA-Sponsor communication. Only 10% of deficient studies were placed on clinical hold; all except one had multiple deficiencies. The most common deficiencies leading to clinical hold pertained to eligibility of study population and proposed starting drug dose.

No significant financial relationships to disclose.

Failure of sputum eosinophilia after eotaxin inhalation in asthma

BACKGROUND

Eotaxin is a chemokine specific for eosinophils and may play an important role in eosinophil recruitment in asthma. The effects of eotaxin inhalation on sputum and blood eosinophils, exhaled nitric oxide (NO), and bronchial responsiveness were determined.

METHODS

Eotaxin was administered by nebulisation to asthma patients in three studies: (1) an open dose finding study with eotaxin (5, 10 and 20 microg) to two asthmatic subjects; (2) a randomised placebo controlled study with 20 microg eotaxin to five asthmatic subjects and five normal volunteers; and (3) a randomised placebo controlled study with 40 microg eotaxin to nine asthmatics. Forced expiratory volume in 1 second (FEV(1)), exhaled NO, and blood eosinophils were measured before and hourly for 5 hours after nebulisation and at 24 and 72 hours. Methacholine bronchial challenge and sputum induction were performed before and at 5, 24, and 72 hours after nebulisation.

RESULTS

In the two placebo controlled studies there was no change in sputum eosinophil count and sputum eosinophilic cationic protein concentration after eotaxin inhalation compared with placebo. FEV(1), exhaled NO, and methacholine PC(20) did not change. However, high dose eotaxin (40 microg) induced an increase in sputum neutrophil count compared with placebo (p<0.05).

CONCLUSIONS

Inhaled eotaxin up to 40 microg induced no changes in sputum eosinophil count but at 40 microg it increased the sputum neutrophil count. The significance of this finding is unknown.

Male infertility and avascular necrosis of the femoral head

Corticosteroids are an important part of the pharmacological armamentarium against a wide spectrum of diseases. They are powerful drugs that effect all aspects of human metabolism and, although often life-saving, they have a plethora of important side-effects and a narrow therapeutic window. Most side-effects are well known to physicians but we would like to highlight the problem of avascular necrosis associated with cyclical steroid therapy of short duration using moderate doses for an unusual indication.

Dedifferentiated chondrosarcoma: use of MRI to guide needle biopsy

AIM

To describe the use of MRI to identify and biopsy areas of dedifferentiation in patients with a suspected diagnosis of dedifferentiated chondrosarcoma.

MATERIALS AND METHODS

Low-grade chondrosarcoma is characterized at magnetic resonance imaging (MRI) as having a lobulate, hyperintense appearance on T2-weighted spin-echo sequences. T2-weighted MR images were assessed in 15 patients with a final pathological diagnosis of dedifferentiated chondrosarcoma for regions of atypical reduced signal intensity. Information regarding the site of ultrasound or computed tomography (CT)-guided biopsy was available in 10 cases.

RESULTS

Nine patients were male and six female with a mean age of 60 years (range 25-77 years). The sites involved were the distal femur (n+4) pelvis (n=3) proximal femur (n=4) femoral diaphysis (n=1) proximal humerus (n=2) and proximal tibia (n=1). The dedifferentiated component consisted of osteosarcoma (n=5) malignant fibrous histiocytoma (n=6) spindle cell sarcoma (n=1) leiomyosarcoma (n=1) and pleomorphic sarcoma (n=1). In 14 of the 15 cases, areas of lower signal intensity lacking in lobulation were identified. In nine of the 10 cases, biopsy site included such areas and yielded high-grade sarcoma.

CONCLUSIONS

Dedifferentiation within chondrosarcoma may be identified on T2-weighted MRI as areas of reduced signal intensity. These areas should be the preferred site of biopsy.

Primary osteosarcoma of the breast

Primary osteosarcoma of the breast is a rare malignant tumour. We report such a case in a 77-year-old lady who presented with a hard lump which was clinically and mammographically indistinguishable from a calcified fibroadenoma. Wide local excision of the lesion was carried out. Detailed histological and immunohistochemical features of the tumour are described. Because there was no evidence of metastasis and adequate local excision, no further treatment was considered necessary and she remains disease free at 39 months.

Malignant lymphoma of uterus: a case report with a review of the literature

The female genital tract is rarely the initial manifestation site of malignant lymphomas. Most genital lymphomas arise in the vagina or cervix while those of the uterine corpus are extremely rare. Patients usually present with bleeding, abdominal or pelvic discomfort or back pain but, very infrequently, the tumours are discovered as a result of a routine examination. Our patient was a 67-year-old postmenopausal woman presenting with haematuria and upper abdominal pain. She had several investigations for haematuria including cystoscopy, intravenous urography (IVU) and both renal and pelvic scans. The pelvic scan revealed an enlarged uterus with some calcification suggestive of a fibroid uterus. An abdominal hysterectomy was performed. Histopathology revealed non-Hodgkin's malignant lymphoma of the uterine corpus. She subsequently had post-operative chemotherapy.

Can molgramostim enhance the antitumor effects of cytotoxic drugs in patients with advanced sarcomas?

BACKGROUND

A phase I study was designed for the amalgamation of two previously studied antisarcoma regimens (ifosfamide+doxorubicin and mitomycin+doxorubicin+cisplatin) supported by molgramostim. Thus, we hoped to develop a better regimen for the treatment of advanced sarcomas.

PATIENTS AND METHODS

Fifteen adult advanced sarcoma patients and six other patients were registered and sequentially assigned to receive three progressively more myelosuppressive levels of chemotherapy: level I-ifosfamide 2500 mg/m2 + doxorubicin 40 mg/m2 + cisplatin 60 mg/m2 all given on day 0, followed by molgramostim 5 micrograms/kg every 12 hours for 14 days; level II-exactly the same chemotherapy from level I given on day 1 preceded on day 0 by ifosfamide 2500 mg/m2 and an additional four days of molgramostim given on days-6 through-3; level III-same as level II except for the addition of mitomycin 4 mg/m2 immediately prior to cisplatin on day 1. MENSA 500 mg/m2 was given five times on each day that involved ifosfamide treatment. For all levels, treatment was repeated at four-week intervals.

RESULTS

Preliminary results and toxicity were reported three years ago (J Natl Cancer Inst 86: 312-4, 1994). Mature results confirm these unexpectedly favorable results with five advanced sarcoma patients still surviving after more than three years (four more than four years).

HYPOTHESIS

Molgramostim given subcutaneously in a relatively intensive schedule might enhance the antitumor effects initiated by cytotoxic drugs in patients with advanced sarcomas. This idea should be tested formally in phase III studies.

Primary chemotherapy for clinical stage II nonseminomatous germ cell testicular tumors: selection criteria and long-term results

OBJECTIVE

To determine the treatment option for patients with low-volume stage II nonseminomatous germ cell testicular tumors (NSGCTT) that yields the best survival, is associated with the least morbidity, and avoids "double therapy"--that is, chemotherapy and retroperitoneal lymph node dissection (RPLND).

DESIGN

We reviewed our institutional experience with 28 patients with stage II NSGCTT who received primary chemotherapy between August 1983 and October 1992.

MATERIAL AND METHODS

The 28 study patients (mean age, 28 years; range, 20 to 52) with low-volume stage II NSGCTT were treated with bleomycin, etoposide, and cisplatin. The correlation of response rates with volume of disease and predominant histologic cell type was determined. The duration of survival was measured from the initiation of chemotherapy to the appearance of progressive disease or death or the date of last follow-up visit.

RESULTS

Of the 28 patients treated, 27 (96%) achieved a complete response--20 (71%) with only chemotherapy and an additional 7 (25%) with chemotherapy plus surgical treatment. Twenty-seven patients (96%) remained free of disease after a median follow-up of 72 months. The most frequent complication was cisplatin-associated paresthesias or tinnitus which was noted in 13 patients (46%). In 11 of 15 patients (73%), attempts to have children have been successful.

CONCLUSION

Excellent long-term survival rates in patients with stage II NSGCTT can be achieved with primary chemotherapy. In this series, 71% of patients were spared RPLND. The need for postchemotherapy RPLND seemed to be related to the initial metastatic tumor volume and possibly the histologic features of the primary tumor. Continued refinement in surgical techniques and chemotherapeutic regimens will necessitate the comparison of these two treatment approaches in a randomized prospective trial.

The herpes simplex virus type 1 immediate-early protein ICP27 is obligately required for the accumulation of a cellular protein during viral infection

Lytic infection with herpes virus type 1 (HSV-1) causes the accumulation of a 40-kDa cellular protein (p40) which is also overexpressed in cultured cells transformed by HSV or other agents and in human cervical tumors. Accumulation of p40 is dependent upon viral protein synthesis but not viral DNA replication in the infected cell and occurs in the HSV-1 mutants tsK and tsLB2 in which only a defective ICP4 protein and the four other immediate-early proteins are synthesized. By using a panel of HSV-1 strains, each defective in one of these four proteins, we show that only a mutation in the gene encoding ICP27 abolishes p40 accumulation. The defect in this mutant virus can be rescued by a plasmid encoding ICP27 alone indicating that ICP27 is obligately required for p40 accumulation. The significance of this effect as one aspect of the interaction of viral control proteins with cellular genes is discussed.

Non-Hodgkin's lymphoma of the skin associated with chronic limb lymphoedema

Cutaneous non-Hodgkin's lymphoma developed within a leg affected by chronic lymphoedema. The lymphoedema had followed radiotherapy to bony metastases from a carcinoma of the prostate. Eighteen months after the development of the cutaneous tumours, extracutaneous involvement by the lymphoma became apparent. This is the second report of a non-Hodgkin's lymphoma appearing within a lymphoedematous limb. The possible reasons for such an unusual localization are discussed. Our case report illustrates that cutaneous tumours other than lymphangiosarcomas may localize to a lymphoedematous limb and clinically simulate the Stewart-Treves syndrome.

The nature of cytoplasmic inclusions in cerebellar haemangioblastomas

Intracytoplasmic hyaline globules present in stromal cells in eight of a series of ten cerebellar haemangioblastomas have been shown to contain the glycoprotein alpha-1-antitrypsin.

Darier's disease with salivary gland obstruction

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