Single-cell Transcriptional Analysis of the Cellular Immune Response in the Oral Mucosa of Mice

Periodontal health is dependent on a symbiotic relationship of the host immune response with the oral microbiota. Pathologic shifts of the microbial plaque elicit an immune response that eventually leads to the recruitment and activation of osteoclasts and matrix metalloproteinases and the eventual tissue destruction that is evident in periodontal disease. Once the microbial stimulus is removed, an active process of inflammatory resolution begins. The goal of this work was to use scRNAseq to demonstrate the unique cellular immune response across three distinct conditions of periodontal health, disease, and resolution using mouse models. Periodontal disease was induced using a ligature model. Resolution was modeled by removing the ligature and allowing the mouse to recover. Immune cells (Cd45+) were isolated from the periodontium and analyzed via scRNAseq. Gene signature shifts across the three conditions were characterized and shown to be largely driven by macrophage and neutrophils during the periodontal disease and resolution conditions. Resolution of periodontal disease was characterized by the differential regulation of unique gene subsets. Clustering analysis characterized multiple cellular subpopulations within B Cells, macrophages, and neutrophils that demonstrated differential expansion and contraction across conditions of periodontal health, disease, and resolution. Interestingly, we identified a transcriptionally distinct macrophage subpopulation that expanded during the resolution condition and demonstrated an immunoregulatory gene signature. We identified a cell surface marker for this resolution-associated macrophage subgroup (Cd74) and validated the expansion of this subgroup during resolution via flow cytometry. This work presents a robust immune cell atlas for study of the immunological changes in the oral mucosa during three distinct conditions of periodontal health, disease, and resolution and it improves our understanding of the cellular and molecular markers that characterize health from disease for the development of future diagnostics and therapies.

Long-term outcome of image-guided percutaneous radiofrequency ablation of lung metastases: an open-labeled prospective trial of 148 patients

BACKGROUND

Image-guided percutaneous radiofrequency ablation (RFA) has been proposed as an efficacious local therapy for lung metastases in nonsurgical candidates. Reports of long-term outcome from this treatment have been limited.

METHODS

A prospective open-labeled trial of RFA was initiated in November 2000 for treatment of lung metastases in nonsurgical candidates. RFA was carried out under fluoroscopic computed tomography. Treatment complications and survival parameters were analyzed.

RESULTS

Of 148 patients treated, 66 patients (46%) had a complete response, 38 patents (26%) had a partial response, 57 patients (39%) had stable disease and 23 patients (16%) had progressive disease. The median progression-free survival was 11 months [95% confidence interval (CI) 9-14]. The median overall survival and 3- and 5-year survivals were 51 months (95% CI 19-83) and 60% and 45%, respectively. Disease-free interval (P = 0.013) and response to treatment (P = 0.002) were independent predictors for overall survival. Complications occurred in up to 45% of patients, of which 45 patients (30%) required chest tube placement.

CONCLUSION

This analysis confirms that RFA of lung metastases may achieve long-term survival in nonsurgical candidates with an acceptable complication rate hence supporting its incorporation into the oncosurgical management of lung metastases for the purposes of cure, stabilization and disease prolongation.

Results from a phase II randomized, placebo-controlled, double-blind trial suggest improved PFS with the addition of pertuzumab to gemcitabine in patients with platinum-resistant ovarian, fallopian tube, or primary peritoneal cancer

5507

Background: Pertuzumab (P) is a humanized monoclonal antibody that blocks the ability of HER2 to heterodimerize with other HER/ErbB receptors. As a single agent, P has demonstrated clinical activity in relapsed/refractory epithelial ovarian cancer (EOC). Since platinum-resistant (CDDP-R) EOC remains a difficult disease to treat, this phase II study was conducted to determine if addition of P to gemcitabine (G) would improve results. Methods: Patients with CDDP-R EOC (including ovarian, fallopian tube, or primary peritoneal cancer) who had received up to one prior treatment for CDDP-R disease were randomized to Gem 800 mg/m2 on D1, 8 of a 21-day cycle ± P or placebo (pl). P was given as an 840 mg initial dose followed by 420mg IV every 3 weeks. Tumor response was assessed by RECIST every 6 weeks using GOG criteria. The primary endpoint was progression free survival (PFS). Results: One hundred thirty patients (n = 65 each treatment cohort) were treated. Clinical characteristics were balanced between the treatment groups. Pts received a median of 2 prior regimens (range 1–6) for EOC. Based on 83 events, the adjusted hazard ratio for PFS was 0.67 (95% CI: 0.43–1.02), p =0.06 in favor of P+Gem. The median PFS was 3.0 months (0–8.7 months) vs. 2.6 months (0–9+ months), and the PFS rate at 4 months was 49% vs. 34% in the P+Gem and Gem/pl arms, respectively. The most common AEs increased in the P-treated pts were fatigue, nausea, diarrhea, back pain, Gr 3–4 neutropenia, rash, headache, stomatitis, epistaxis, and rhinorrhea. Clinically significant CHF was reported in one patient in the pertuzumab cohort. There was no imbalance in the LVEF results between treatment arms. One patient who received pertuzumab + gemcitabine experienced an adverse event that resulted in death (hemolytic-uremic syndrome). Conclusions: These data suggest that pertuzumab may add activity to gemcitabine as reflected by improvements in PFS in patients with CDDP-R ovarian, primary peritoneal, or fallopian tube cancer. Survival data will be presented at ASCO.

No significant financial relationships to disclose.

Novel phase II study design of MORAb-003, a monoclonal antibody against folate receptor alpha in platinum-sensitive ovarian cancer in first relapse

5583

Background: Folate receptor alpha (FRA) is over-expressed in the majority of epithelial ovarian cancers (EOC) but largely absent from normal tissue. MORAb-003 (M3) is a humanized monoclonal antibody to FRA. Binding of M3 to FRA blocks phosphorylation by Lyn kinase; mediates FRA-positive tumor cell killing; and suppresses tumor growth in xenograft models. High-dose M3 is non-toxic in monkeys. A phase 1 study showed no significant AEs and suggestions of efficacy in platinum-resistant EOC. This phase 2 efficacy study will determine the efficacy of M3 in platinum-sensitive EOC in first relapse, either as a single agent (SA) in asymptomatic relapse, or in combination with platinum and taxane (P/T) in symptomatic relapse, and to maintain a second response. Methods: Subjects with EOC in first relapse are eligible. For CA125 elevation without symptoms (± measurable disease) the subject receives SA M3 until progression. For symptomatic relapse the subject receives P/T and M3. Subjects with CR or PR receive SA M3 maintenance therapy with the objective of prolonging the second remission longer than the first. Endpoints include CA125 and CT scans. ORR and PFS will be determined for each arm. Results: To date, 15 subjects have been treated, 8 in combination therapy and 7 on single-agent M3. No significant drug-related adverse events have been reported. All subjects treated with the combination of M3 and P/T for symptomatic relapse who have reached at least the first evaluation point have achieved a normalization of CA125 and reduction of tumor size (CR or PR) by CT scan using RECIST criteria, including 3 of 3 subjects with first remissions of 6 to 9 months. Early responses have been observed in the SA M3 treatment arm. Conclusions: This first phase 2 study will determine the efficacy of M3, either as SA or in combination with P/T chemotherapy to achieve a meaningful response rate in EOC in first relapse, and to maintain the second remission longer than the subject’s own first remission. These data will be used to define the most effective phase of disease in which to use M3, and to focus a pivotal study on the area of greatest efficacy. The early results continue to demonstrate activity of M3 in EOC.

No significant financial relationships to disclose.

Percutaneous radiofrequency ablation of lung tumours: Results in first 100 consecutive patients

7714

Background: Treatment modalities for patients with primary and secondary lung malignancies who are not surgical candidates are limited. Radiofrequency ablation is a minimally invasive, lung sparing therapeutic alternative that may provide local disease control for these patients. The study reported our experience with first 100 consecutive patients who underwent radiofrequency ablation of their lung tumours. Methods: From November 2000 to December 2006, the clinical and treatment-related information regarding the 100 consecutive patients (58 males, mean age of 65 years) with 240 lung tumours treated by radiofrequency ablation were collected prospectively. Radiofrequency ablation was performed percutaneously under CT guidance with local anaethesiologic assistance and conscious sedation using a RITA Starbust XL electrode. The patients were hospitalized overnight and followed at one week, one month and then every three months with CT to evaluate treatment outcome and complications. Results: Five patients had primary lung carcinoma while the remaining patients had pulmonary metastases from extra-thoracic malignancies, with colorectal cancer being the most common primary site (68%), followed by renal cell carcinoma (8%) and uterine leiomyosarcoma (5%). The mean number of pulmonary lesions ablated was 2.4 per patient; the mean size of lesion ablated was 2.2 cm in diameter. Fifteen patients had second-time RFA; 4 patients underwent third- or fourth-time RFA for pulmonary recurrence. There was no post-procedural mortality and the overall morbidity rate was 42%. The most common complication was pneumothorax, which occurred in of 31% of procedures (n=39/127) with 20 (16%) requiring chest tube placement. After a median follow-up of 24 months (range 1 to 70 months), 72% of RFA treated lesions did not progress. The overall median disease-free interval was 13 months, with 1-, 3- and 5- year disease-free survival of 55%, 22% and 7% respectively. The overall median survival was 34 months with 1-, 3- and 5-year- survival of 85%, 49% and 33% respectively. Conclusions: Percutaneous radiofrequency ablation is an emerging therapy with promising results when surgical resection of pulmonary malignancy cannot be performed.

No significant financial relationships to disclose.

Pilot study of selective internal radiation therapy (SIRT) for patients with unresectable neuroendocrine liver metastases (NETLM)

15096

Background: Few effective treatment options exist for inoperable NETLM. A prospective single-unit study assessed safety and efficacy of radioactive yttrium90 resin (SIR) in 34 patients with unresectable (NETLM). Method: Microspheres were administered via temporary percutaneous hepatic artery catheter with concomitant 7day 5-flurouracil infusion. Patients were monitored prospectively and treatment response measured by CT imaging and chromogranin A (CgA). Results: 34 patients (22 male), mean age 61 years (range 32–79) were treated with SIRT from December 2003 to December 2005. Mean follow-up 28.9 months, (95% CI 23.4 to 32.3). Complications were: post-embolitic pain and lethargy 1 week-1 month; 3 radiation gastritis, 2 of whom developed a duodenal ulcer. RECIST response on CT scan of 34 patients at 1 month: PR 9 (26%); SD 22 (65%); PD 3 (9%); 32 at 6 months, PR 7 (22%); SD 19 (59%); PD 6 (19%); 29 at 12 months CR 2 (7%); PR 3 (10%); SD 16 (55%); PD 8 (28%); 16 at 18 months, CR 4(25%); PR 1 (6%); SD 8 (50%); PD =3 (19%); 8 at 24 months, CR 4 (50%);SD 2 (25%),PD 2 (25%); 6 at 30 months, CR 2 (33%); SD 2 (33%); PD 2 (33%). CgA U/L fall from entry was: 19 (26%) at one month; 15 (43%) at 6 months; 15 (52%) at 9 months; 11 (57%) at 12 months; 8 (38%) at 24 months and 4 (80%) at 30 months. At 36 months from entry 11 (32%) have died; 8 (24%) have PD; 9 (26%) have SD and 6 (18%), (15 to 30 months) have CR on CT scan. Conclusion: SIRT is a promising treatment option for patients with in-operable NETLM.

No significant financial relationships to disclose.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei from appendiceal mucinous neoplasms

BACKGROUND

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has been used to treat pseudomyxoma peritonei. The aim of this prospective study was to evaluate survival outcome and treatment-related prognostic markers in patients who underwent CRS and PIC for pseudomyxoma peritonei from appendiceal mucinous neoplasms.

METHODS

Survival data and 12 clinicopathological and treatment-related prognostic variables for survival were obtained prospectively in 50 consecutive patients (23 men). Univariate analysis was used to determine their prognostic significance for overall survival, determined from the time of CRS.

RESULTS

The mean(s.d.) age was 52(12) years. Eighteen patients had moderate complications, and six patients had severe complications that required operation or intensive care support. Two patients died after surgery. The actuarial 5-year survival rate was 69 per cent. Univariate analysis demonstrated that the extent of previous surgery (P = 0.045) and Ronnett's histopathological classification (P < 0.001) were significantly related to overall survival.

CONCLUSION

CRS combined with PIC was associated with improved survival in patients with less extensive previous surgery and diffuse peritoneal adenomucinosis histopathological type.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma: non-mucinous tumour associated with an improved survival

AIMS

Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has been reported as a treatment option for patients with peritoneal carcinomatosis from colorectal carcinoma.

METHODS

Thirty patients with colorectal peritoneal carcinomatosis underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy. All appendiceal cancers were excluded. All patients were followed until January 2006 or death. Univariate analysis was performed to evaluate significant prognostic factors for overall survival, defined from the time of surgery.

RESULTS

There were 13 male patients. The mean age at the time of surgery was 54years. There was no hospital mortality. The mean duration of hospital stay was 27days. The overall median survival was 29months, with 1- and 2-year survival of 72% and 64%, respectively. Twenty-one patients had complete cytoreduction and their 1- and 2-year survival rates were 85% and 71%, respectively. Univariate analysis demonstrated that patients with non-mucinous colorectal adenocarcinoma, Peritoneal Cancer Index (PCI) < or =13, and complete cytoreduction were associated with an improved survival.

CONCLUSIONS

This study reported on 30 patients who underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis. Patients with mucinous tumour had relatively more extensive intraperitoneal disease. Non-mucinous colorectal adenocarcinoma, PCI < or =13, and complete cytoreduction were associated with an improved survival.

A randomized phase II trial with gemcitabine with or without pertuzumab (rhuMAb 2C4) in platinum-resistant ovarian cancer (OC): Preliminary safety data

13001

Background: Pertuzumab (P), a humanized HER2 antibody, represents a new class of targeted agents called HER dimerization inhibitors (HDIs). P inhibits dimerization of HER2 with EGFR, HER3 and HER4, and subsequently inhibits signaling through MAP and PI3 kinases. Single agent P has demonstrated clinical benefit in advanced OC (ASCO 2005 abstract #5051). Methods: 40 pts with platinum-resistant OC (progressed within 6 months of receiving a platinum-based chemotherapy) were enrolled in this 1:1 randomized, double blind, placebo controlled trial of gemcitabine with or without P. Gemcitabine was administered IV on day 1 and 8 at 800 mg/m2 of a 21 day cycle. Blinded placebo or 420 mg P was administered IV on day 1. Gemcitabine was dose reduced for neutropenia or thrombocytopenia. P was not dose reduced. Results: 40 pts have been enrolled and treated with at least 1 cycle of gemcitabine in combination with blinded study drug. The median age was 58.5 (range 18–82); 26 had PS ECOG 0, 13 ECOG 1, 1 ECOG 2. The most common grade 3/4 events were neutropenia in 7 pts (17.5%), thrombocytopenia in 6 pts (15%), small bowel obstruction in 4 pts (10%), constipation in 3 pts (7.5%) and elevated ALT in 3 pts (7.4%). There was one grade 3 diarrhea, but no grade 3 or 4 rash. There were 4 serious adverse events (SAEs) attributed to study drug. These were a pleural effusion, thrombocytopenia, febrile neutropenia, and a deep vein thrombosis. Nine pts required one or two dose reductions of gemcitabine for hematological toxicity. Of 29 pts with post-baseline echo or MUGA values obtained, no pt had LVEF drop to <50%. The adverse events evaluated after 40 pts did not meet the prespecified criteria to call for an independent safety monitoring board evaluation of unblinded data. Conclusions: Preliminary safety data indicate that pertuzumab or placebo combined with gemcitabine is well tolerated with no unexpected additive toxicity. The nature and frequency of the adverse events are similar to what has been observed with either single agent gemcitabine or P. Updated data will be presented at ASCO.

[Table: see text]

Percutaneous radiofrequency ablation of inoperable pulmonary metastases from colorectal cancer

3502

Background: This current study was an open, prospective and nonrandomized phase II study, which critically evaluated the prognostic parameters for local disease-free survival (DFS) and overall survival (OS) in patients who underwent percutaneous radiofrequency ablation (RFA) for inoperable colorectal pulmonary metastases (CRPM). Methods: The inclusion criteria were patients who had inoperable CRPM, due to number, distribution, poor performance status or patients’ refusal to accept surgery. The exclusion criteria were lesions > 6 per hemithorax; diameter of metastases > 5 cm; bleeding diathesis; and/or significantly compromised lung function. All patients underwent percutaneous RFA with a radiological clear margin of at least 2 cm. The end-points of this study were local DFS and OS, determined from the time of RFA intervention. Ten clinical and six treatment-related prognostic parameters were assessed in univariate and multivariate analyses. All patients were reviewed at one week, one month and every three months thereafter with chest CT. Fifty-five patients entered into the study. The follow-up was complete and the median follow-up was 24 months (6 to 40). Results: The median local DFS was not reached and 2-year local DFS was 57%. Univariate analysis demonstrated that largest size of lung metastasis, location of lung metastases, post-RFA CEA at 1 month and 3 months were significant for local DFS. In multivariate analysis, largest size of lung metastasis of ≤ 3 cm and post-RFA CEA of ≤ 5 ng/ml at 1 month were independently associated with an improved local DFS. The median OS was 33 months (4 to 40), with 1-, 2-, and 3-year survival of 85%, 64% and 46%, respectively. Univariate analysis demonstrated that interval between the diagnoses of colorectal cancer and pulmonary metastasis; largest size of lung metastasis and location of lung metastases were significant for OS. In multivariate analysis, only size of lung metastasis of ≤ 3 cm was independently associated with an improved OS. Conclusions: Percutaneous RFA of inoperable CRPM may have a useful role in patients with a lesion of ≤ 3 cm.

No significant financial relationships to disclose.

Radiologically placed temporary hepatic artery catheter for treatment of liver cancer

Summary Hepatic artery infusion (HAI) chemotherapy is associated with higher response rates compared to systemic chemotherapy in those patients with unresectable liver malignancies. Operative hepatic artery catheter (HAC) insertion has significant morbidity and mortality, especially in patients with high-volume disease, some of whom may not respond to HAI chemotherapy. We report our experience in 45 patients with high-volume liver disease who were initially treated with HAI chemotherapy via a radiologically placed temporary HAC to try to select the responders who then went on to have an operative HAC. In these 45 patients who had 62 radiologically placed HAC, we found very few major complications, and certainly no complications such as cholecystitis, vascular or malperfusion problems.

Composition and Dynamics of Plasma in Saturn's Magnetosphere

During Cassini's initial orbit, we observed a dynamic magnetosphere composed primarily of a complex mixture of water-derived atomic and molecular ions. We have identified four distinct regions characterized by differences in both bulk plasma properties and ion composition. Protons are the dominant species outside about 9 RS (where RS is the radial distance from the center of Saturn), whereas inside, the plasma consists primarily of a corotating comet-like mix of water-derived ions with approximately 3% N+. Over the A and B rings, we found an ionosphere in which O2+ and O+ are dominant, which suggests the possible existence of a layer of O2 gas similar to the atmospheres of Europa and Ganymede.

[Radiofrequency ablation (RFA) of lung metastases from colorectal cancer (CRC)-one-year follow-up]

Assess the safety and evidence of efficacy of RFA for colorectal (CRC) lung metastases with follow up to 1 year. Twenty-three patients had percutaneous RFA for 52 colorectal pulmonary metastases under fluoro-CT. Patients received IV conscious sedation and local analgesia with routine hospitalisation/monitoring for 24 h post RFA. Patients had CT scanning at 1 month and then 3 monthly with serum CEA assessment monthly and 3 monthly. All ablations were technically successful. Tumor diameter ranged from 0.3 to 4.2 cm. Pneumothorax occurred in 43% (10 of 23) of patients. Six patients required intercostal chest drain placement. Six patients had a second RFA, 4 for new lesions and 2 patients had a previously treated lesion retreated. Median admission was 2.0 days (range 1-9). Median follow-up is 428 days (range 173-829), with data reported to 1 year in this paper. Five patients died at 5, 6, 8, 8 and 12 months post RFA from extra-pulmonary (1) or widespread (4) disease. One patient developed malignant pleural effusion at 6 months after RFA. Cavitation was seen in nine treated lesions (17%), all resolved with scar tissue contraction by 12 months. Eighteen patients with CT scan follow-up at one year have 40 lesions classified as: disappeared (17), decreased (5), stable/same size (4), increased (14). Percutaneous imaging-guided RFA of multiple CRC pulmonary metastases is a minimally invasive treatment option with modest morbidity. A significant proportion of patients show good evidence of successful local control at one year.

Percutaneous radiofrequency ablation of pulmonary metastases in patients with colorectal cancer

Introduction

This study aimed to assess the safety and efficacy of imaging-guided percutaneous radiofrequency ablation (RFA) for local control of lung metastases from colorectal cancer (CRC).

Methods

Twenty patients with lung metastases from CRC were treated with a RITA® Starburst XL electrode and RITA® 1500 generator using temperature control and impedance monitoring. Patients received intravenous sedation and analgesia, or local anaesthetic, and stayed in hospital for at least 24 h after treatment. RFA was assessed with computed tomography (CT) at 1 week and 1 month, and then every 3 months.

Results

Forty-four CRC lung metastases in 19 patients were treated successfully at 25 treatment sessions. Five of 19 patients were retreated for new lesions. There were 13 pneumothoraces following the 25 treatments, and six patients required drainage. The median length of follow-up was 730 (range 148–924) days. Six months after treatment CT demonstrated that three lesions had progressed, 25 metastases were stable or smaller, and 11 were no longer visible. At 12 months five metastases had progressed, 11 were smaller or stable, and nine were not visible.

Conclusion

Percutaneous imaging-guided RFA was associated with modest morbidity. RFA can achieve local control of CRC lung metastases: nine of 25 metastases were not visible on CT at 12 months after treatment.

Percutaneous pulmonary radiofrequency ablation: difficulty achieving complete ablations in big lung lesions

The size of both primary and metastatic lung tumours often exceeds 3 cm in diameter at the time of diagnosis. The radiofrequency (RF) electrodes of the three leading companies currently in use are designed for a maximum ablation diameter of 5 cm. Therefore, the tumour to be ablated should not exceed 3 cm in maximum diameter, as a 1 cm safety ablation margin surrounding the tumour should ideally be achieved. A possible solution in treating larger tumours is to create overlapping ablations, a method successfully used in the radiofrequency ablation (RFA) of liver tumours. We report on the percutaneous overlapping ablation of three large lung metastases, 4 cm, 4.5 cm and 5 cm in their longest diameter. The largest of them showed incomplete ablation with residual viable tumour tissue. The overlapping percutaneous RFA of large lung tumours is feasible although the bigger the lesion, the higher the risk of incomplete ablation appears compared with smaller tumours treated by a single ablation.

Dural arteriovenous fistulae causing pseudotumour cerebri syndrome in an elderly man

The clinical presentation of dural arteriovenous fistulae (DAVF) is dependent on their location and the nature of their venous drainage. The latter plays a critical part in determining whether or not the fistula gives rise to intracranial hypertension, which is present in only a minority of cases. We present a case of the pseudotumour cerebri syndrome in an elderly man with bilateral intracranial DAVF supplied by the occipital arteries. Cerebral angiography was required for definitive diagnosis, and to characterise the abnormal venous drainage. The pathophysiology of intracranial hypertension in DAVF is discussed.

Rectal cancer: changing patterns of referral for radiation therapy 1982-1997

BACKGROUND

The purpose of the present study was to evaluate the changing role of radiation therapy in rectal cancer and to determine the patterns of referral of patients during a 15-year period.

METHODS

From 1982 to 1997, 464 patients with carcinoma of the rectum were referred to the Department of Radiation Oncology, Royal Prince Alfred Hospital: 79% of patients had locoregional disease alone and 21% had distant metastasis. Radiation therapy consisted of irradiation (definitive or palliative) alone to the primary tumour in 9.7% of cases; preoperative radiation in 7.3% of cases: preoperative chemoradiation in 7.5% of patients: postoperative radiation in 15.3% of patients: postoperative chemoradiation in 12.31% of patients: treatment of pelvic recurrence in 23.5% of patients and treatment of metastases in 9.1% of patients. The remainder were treated elsewhere (1.9%) or not treated (13.4%).

RESULTS

There was an average annual 14% increase in referrals over the accrual period. Recurrent rectal cancer decreased from approximately 30% of referrals during 1982-91 to approximately 10% in 1995-7. The use of postoperative adjuvant radiation reached a peak of 50% in 1993. The use of preoperative radiation increased suddenly in 1994 from < 10% to a sustained rate of approximately 30% of referrals. The use of chemoradiation commenced in 1990 for postoperative adjuvant treatment and in 1994 for preoperative treatment. The median survival time from initial diagnosis was 35 months, with 2- and 5-year survival rates of 62 and 28%, respectively. Survivals at 5 years for patients treated with preoperative and postoperative radiation (with or without chemotherapy) and with recurrent disease were 56, 44 and 21%, respectively.

CONCLUSIONS

The present study illustrates the changing role of radiation therapy in the management of rectal cancer. The increase in referrals over the observation period was due to increased multidisciplinary input into the initial management of these patients, based on reported clinical trials. The steady increase in the use of adjuvant therapy has paralleled a decrease in referrals for treatment of recurrence and reflects current clinical results. The sequencing of adjuvant therapy is changing currently, with greater emphasis on preoperative adjuvant treatment. Currently most adjuvant therapy includes chemotherapy.

What can the postanesthesia care unit manager do to decrease costs in the postanesthesia care unit?

The economic structure of the PACU dictates whether a cost-reducing intervention (e.g., reducing the length of time patients stay in the PACU) is likely to decrease hospital costs. Cost-reducing interventions, such as changes in medical practice patterns (e.g., to reduce PACU length of stay), only impact variable costs. How PACU nurses are paid (e.g., salaried v hourly) affects which strategies to decrease PACU staffing costs will actually save money. For example, decreases in PACU labor costs resulting from increases in the number of patients that bypass the PACU vary depending on how the staff is compensated. The choice of anesthetic drugs and the elimination of low morbidity side effects of anesthesia, such as postoperative nausea, are likely to have little effect on the peak numbers of patients in a PACU and PACU staffing costs. Because the major determinant of labor productivity in the PACU is hour-to-hour and day-to-day variability in the timing of admissions from the operating room, a more even inflow of patients into the PACU could be attained by appropriate sequencing of cases in the operating room suite (e.g., have long cases scheduled at the beginning of the day). However, this mathematically proven solution may not be desirable. Surgeons, for example, may not want to lose control over the order of their cases. Guidelines for analysis of past daily peak numbers of patients are provided that will provide data to predict the minimum adequate number of nurses needed. Though many managers already do this manually on an ad hoc basis statistical methods summarized in this article may increase the accuracy.

Carotenoid glycoside esters from the thermophilic bacterium meiothermusruber

The thermophilic bacterium Meiothermus ruber produces a series of carotenoid glycoside esters. The major carotenoid has been identified as 1'-beta-glucopyranosyl-3,4,3',4'-tetradehydro-1', 2'-dihydro-beta,psi-caroten-2-one (1). It is acylated at the 6' '-position of the glucose unit by a series of C10-C17 fatty acids. The structure of 1 was established by spectral means, including complete assignment of the 1H and 13C NMR resonances by inverse 2D NMR spectroscopy. These carotenoids are thought to play roles in stabilizing membranes of this thermophilic organism.

Fluorodeoxyuridine causes bilomas after hepatic cryotherapy

BACKGROUND AND OBJECTIVES

Hepatic cryotherapy is a method of in situ cytodestruction used for unresectable liver tumours that can be combined with regional cytotoxic administration. We have used intra-arterial chemotherapy with 5-fluorouracil (5-FU) after hepatic cryotherapy but changed to 5-fluorodeoxyuridine (FUDR) because of the arterial toxicity of 5-FU. A new complication was seen.

METHODS

A retrospective case note study was performed of 130 patients who had undergone hepatic cryotherapy followed by regional chemotherapy at our centre. Seven patients received FUDR; 123 received 5-FU.

RESULTS

Biloma at the cryotherapy sites was seen in three patients in the FUDR group; two other patients in this group had other types of hepatic collection. Our previous experience with intra-arterial 5-FU in 123 patients after hepatic cryotherapy showed no evidence of this syndrome.

CONCLUSIONS

Intra-arterial FUDR should not be used after hepatic cryotherapy, at least during the immediate postoperative period.

Radiologically placed hepatic artery catheter allows selection of patients with high-volume liver metastases for regional chemotherapy

Regional chemotherapy has achieved high response rates in hepatic metastases from colorectal cancer and has been shown to improve survival significantly. The present paper reports the use of pre-operative regional therapy to establish marker response as a means of selection of patients for surgery. Fourteen patients underwent radiologically placed hepatic artery catheter (HAC) for chemotherapy. In the 11 patients with carcino-embryonic antigen (CEA) fall the patient proceeded to open surgical placement of HAC. The predictive effect of CEA fall following radiological HAC was good. Non-responding patients are clearly spared the discomfort and inconvenience and costs of an unnecessary operation.

Citrobacter farmeri bacteremia in a child with short-bowel syndrome

A case of sepsis in a pediatric patient due to the newly described Citrobacter species C. farmeri is described. Factors predisposing this child to infection included short-bowel syndrome requiring total parenteral nutrition.

Multicenter evaluation of the MicroScan Rapid Gram-Negative Identification Type 3 Panel

The accuracy and performance of the revised MicroScan Rapid Gram-Negative Identification Type 3 Panel (Dade MicroScan Inc., West Sacramento, Calif.) were examined in a multicenter evaluation. The revised panel database includes data for 119 taxa covering a total of 150 species, with data for 12 new species added. Testing was performed in three phases: the efficacy, challenge, and reproducibility testing phases. A total of 405 fresh and stock gram-negative isolates comprising 54 species were tested in the efficacy phase; 96.8% of these species were identified correctly in comparison to the identification obtained either with the API 20E system (bioMérieux Vitek, Hazelwood, Mo.) or by the conventional tube method. The number of correctly identified isolates in the challenge phase, including new species added to the database, was 221 of 247, or 89.5%, in comparison to the number correctly identified by the conventional tube method. A total of 465 isolates were examined for intra- and interlaboratory identification reproducibility and gave an agreement of 464 of 465, or 99.8%. The overall reproducibility of each individual identification test or substrate was 14,373 of 14,384, or 99.9%. The new Rapid Gram-Negative Identification Type 3 Panel gave accurate and highly reproducible results in this multiple-laboratory evaluation.

Outpatient angioplasty: 4-year experience in one practice

Angioplasty is often performed as an inpatient procedure after preliminary angiography. In order to increase efficiency and patient comfort we introduced a policy of performing angioplasty for chronic leg ischaemia as an outpatient whenever possible, using duplex scanning to select suitable lesions. This paper examines the safety and feasibility of this policy over a 4-year period. We prospectively assessed 168 consecutive cases which were planned for outpatient angioplasty from a total of 190 cases undergoing angioplasty and found full agreement between duplex scanning and angiography in 92%. Six patients (4%) developed complications of angioplasty requiring admission and another five were admitted for unexpected organisational reasons. Thus, the complication rate of outpatient angioplasty was 4%. All complications were noted at the time of angioplasty with no unexpected readmissions. Angioplasty for leg ischaemia is feasible and safe to perform as an outpatient using duplex scanning to select appropriate cases.

Computed tomography changes following cryotherapy for hepatic cancer

Encouraging survival and tumour marker results have been described in patients where the focally destructive technique, hepatic cryotherapy, is used to treat primary and secondary hepatic malignancy. Radiology allows assessment of the cryotherapy procedure and follow-up treatment. This paper aims to review and describe the appearance of hepatic cryotherapy by CT.

Tight linkage of pyruvate kinase (PKLR) and glucocerebrosidase (GBA) genes

Two polymorphisms, one in the liver-type pyruvate kinase gene (PKLR) and one in the glucocerebrosidase gene (GBA), both of which are on band q21 of chromosome 1, were found to be tightly linked. Each of three Gaucher disease mutations in 112 chromosomes studied was associated with a unique haplotype. With a conservative assumption about the length of time that the Gaucher disease mutation has been present in the Jewish population, we deduce that the genetic distance between these two loci is probably under 0.2 centimorgans. Four haplotypes are produced by these polymorphic loci, but two of these are relatively uncommon because the polymorphic sites are in linkage disequilibrium. Nonetheless these markers are potentially useful in the prenatal diagnosis of pyruvate kinase deficiency in families who have at least one affected child and may also be helpful in heterozygote detection in families with Gaucher disease where a specific mutation producing the disease in unknown.

Comparison of magnetic resonance imaging and ultrasound in evaluating liver size in Gaucher patients

Comparison is made between the reliability of two imaging methods (ultrasound and magnetic resonance imaging) to measure changes in the size of the liver in patients undergoing treatment for Gaucher disease. The reliability of either modality in estimating liver size is comparable, as is the reliability of demonstrating changes in the size of the liver with time. The precision of the two measurements is roughly the same.

Colectomy and ileostomy in the management of ulcerative colitis

For 30 years, colectomy with ileostomy has been the mainstay of the surgical treatment for ulcerative colitis. Between 1963 and 1985, 535 patients with inflammatory bowel disease were admitted to the Royal Prince Alfred Hospital in Sydney, Australia; 471 had ulcerative colitis and 64 Crohn's colitis. One hundred and eight-six of these patients underwent colonic resection. The proportion of patients who underwent surgery was the same for both disorders. There have been no deaths resulting from the surgical management of inflammatory bowel disease at our hospital since 1965. These patients should be treated safely by standard means before the more elaborate sphincter-saving procedures, currently recommended, are tried.