Treatment Concept and Technical Considerations of Biportal Endoscopic Spine Surgery for Lumbar Spinal Stenosis

Decompression is a major component of surgical procedures for degenerative lumbar spinal stenosis (LSS). In addition to sufficient decompression to guarantee the relief of neurological pain, compensating surgical instability after wider laminectomy and foraminotomy and instrumentation with caging and fusion with grafting are performed to secure or restore the foraminal dimension and correct coronal/sagittal imbalance for longer survival of the adjacent segment. Endoscopic spinal surgery (ESS) has been developed under the flag of successful decompression while preserving structural integrity as much as possible with the help of magnification and illumination. ESS provides a technical possibility and feasibility for solving LSS by decompression alone. Recently, many endoscopic trials have been conducted to overcome conventional surgical treatment that requires wider dissection, escape inevitable complications from surgical damage, and compensate for the fusion technique. However, biportal ESS has some technical limitations, including clinical difficulties in accessibility for more moderate to severe stenosis and challenges for complicated conditions with segmental ventral slip, isthmic defect, stenosis combined with foraminal stenosis or foraminal disk rupture, or degenerative segmental scoliosis with disk height collapsing and endplate fatigue fracture. Because decompression alone is a skill for eliminating pathologies, there is no function of preserving degenerative structure or stopping the recurrence of disk degeneration or subsidence. This review of clinical reports investigated the possibility of biportal ESS for treating degenerative lumbar disorders by sufficient decompression and adequate elimination of various pathologies and decreasing technical complications. The results of this study may help develop better innovative spinal surgical techniques in the near future.

Antinociceptive Effects of Botulinum Toxin Type A on Trigeminal Neuropathic Pain

Previous studies have demonstrated that botulinum toxin type A (BoNT-A) attenuates orofacial nociception. However, there has been no evidence of the participation of the voltage-gated sodium channels (Navs) in the antinociceptive mechanisms of BoNT-A. This study investigated the cellular mechanisms underlying the antinociceptive effects of BoNT-A in a male Sprague-Dawley rat model of trigeminal neuropathic pain produced by malpositioned dental implants. The left mandibular second molar was extracted under anesthesia, followed by a miniature dental implant placement to induce injury to the inferior alveolar nerve. Mechanical allodynia was monitored after subcutaneous injection of BoNT-A at 3, 7, or 12 d after malpositioned dental implant surgery. Subcutaneous injections of 1 or 3 U/kg of BoNT-A on postoperative day 3 significantly attenuated mechanical allodynia, although 0.3 U/kg of BoNT-A did not affect the air-puff threshold. A single injection of 3 U/kg of BoNT-A produced prolonged antiallodynic effects over the entire experimental period. Treatment with BoNT-A on postoperative days 7 and 12, when pain had already been established, also produced prolonged antiallodynic effects. Double treatments with 1 U/kg of BoNT-A produced prolonged, more antiallodynic effects as compared with single treatments. Subcutaneous administration of 3 U/kg of BoNT-A significantly inhibited the upregulation of Nav isoform 1.7 (Nav1.7) expression in the trigeminal ganglion in the nerve-injured animals. These results suggest that antinociceptive effects of BoNT-A are mediated by an inhibition of upregulated Nav1.7 expression in the trigeminal ganglion. BoNT-A is therefore a potential new therapeutic agent for chronic pain control, including neuropathic pain.

Bilateral Femoral Neck Insufficiency Fractures after Use of a Long-term Anti-resorptive Drug Therapy for Osteoporosis: A Case Report

A 78-year-old woman developed an insufficiency fracture on her right femoral neck without trauma after four years of treatment with a bisphosphonate. Her fracture was fixed by two screws and her anti-osteoporotic drug was changed from an anti-resorptive to an anabolic agent. Seven months later, however, she sustained similar insufficiency fracture on the left femoral neck and was treated with the same method. She developed right inguinal pain again approximately eight months after her right side operation. The results of imaging tests revealed that her insufficiency fracture was converted to complete fracture, and that the fracture gap had widened as well. Her right hip was revised with hemiarthroplasty. A histological exam of the fracture site revealed evidence of decreased bone healing. Long-term administration of anti-resorptive drug prevents bone healing and remodeling and can result in atypical fractures of the femoral neck. Osteosynthesis was difficult to accomplish despite the application of proactive fixation. Therefore, more rigid fixation and careful postoperative treatment should be considered.

Functional properties of tooth pulp neurons responding to thermal stimulation

The response properties of tooth pulp neurons that respond to noxious thermal stimulation of the dental pulp have been not well-studied. The present study was designed to characterize the response properties of tooth pulp neurons to noxious thermal stimulation of the dental pulp. Experiments were conducted on 25 male ferrets, and heat stimulation was applied by a computer-controlled thermode. Only 15% of tooth pulp neurons (n = 39) responded to noxious thermal stimulation of the teeth. Tooth pulp neurons were found in both the superficial and deep nuclear regions of the subnucleus caudalis (Vc) and in the interface between the nucleus caudalis and interpolaris (Vc/Vi). Thirty-seven neurons had cutaneous receptive fields and were classified as either NS (16) or WDR (21) neurons. Repeated heat stimulation of the dental pulp sensitized and increased the number of electrically evoked potentials of tooth pulp neurons. These results provide evidence that both the Vc and Vc/Vi regions contain neurons that respond to noxious thermal stimulation of the dental pulp, and that these cells may contribute to the sensitization process associated with symptomatic pulpitis.

Early dexamethasone relieves trigeminal neuropathic pain

The analgesic effects of dexamethasone on neuropathic pain have been controversial. The present study investigated the effects of dexamethasone on mechanical allodynia in rats with mal-positioned dental implants. Under anesthesia, the left mandibular second molar was extracted and replaced by a miniature dental implant to injure the inferior alveolar nerve. Nociceptive behavior was examined on each designated day after surgery. Mal-positioned dental implants significantly decreased air-puff thresholds both ipsilateral and contralateral to the injury site. Distinct mechanical hyperalgesia and cold and thermal hypersensitivity were also observed bilaterally. Daily administration of dexamethasone produced prolonged anti-allodynic effects (25 or 50 mg/kg, i.p.), but failed to reduce mechanical allodynia when it had already been established. Therefore, our findings provide that early treatment with dexamethasone is important in the treatment of nociceptive behavior suggestive of trigeminal neuropathic pain.

The surgical treatment for spinal intradural extramedullary tumors

Background

We wanted to investigate the results of surgical treatment and analyze the factors that have an influence on the neurologic symptoms and prognosis of spinal intradural extramedullary (IDEM) tumors.

Methods

The spinal IDEM tumor patients (11 cases) who had been treated by surgical excision and who were followed up more than 1 year were retrospectively analyzed. Pain was evaluated by the visual analogue scale (VAS) and the neurologic function was assessed by Nurick's grade. The pathological diagnosis, the preoperative symptom duration, the tumor location on the sagittal and axial planes and the percentage of tumor occupying the intradural space were investigated. In addition, all these factors were analyzed in relation to the degree of the preoperative symptoms and the prognosis. On the last follow-up, the MRI was checked to evaluate whether or not the tumor had recurred.

Results

The most common diagnosis was schwannomas (73%), followed by meningiomas (18%). The percentage of tumor occupying the intradural space was 82.9 ± 9.4%. The VAS score was reduced in all cases from 8.0 ± 1.2 to 1.2 ± 0.8 (p = 0.003) and the Nurick's grade was improved in all cases from 3.0 ± 1.3 to 1.0 ± 0.0 (p = 0.005). The preoperative symptoms were correlated with only the percentage of tumor occupying the intradural space (VAS; r² = 0.75, p = 0.010, Nurick's grade; r² = 0.69, p = 0.019). One case of schwannoma recurred.

Conclusions

The degree of neurologic symptoms was correlated with the percentage of tumor occupying the intradural space. All the tumors were able to be excised through the posterior approach. The postoperative neurologic recovery was excellent in all the cases regardless of any condition. Therefore, aggressive surgical excision is recommended even for cases with a long duration of symptoms or a severe neurologic deficit.

Intracisternal administration of chemokines facilitated formalin-induced behavioral responses in the orofacial area of freely moving rats

The present study investigated the effects of intracisternal administration of MCP-1, Rantes or IL-8 on pain transmission in the orofacial area. We also investigated mechanisms of hyperalgesic responses produced by intracisternal administration of IL-8. An orofacial formalin test was employed to assess the effects of chemokines on nociceptive processing. For each animal, the number of behavioral responses and the time spent grooming, rubbing and/or scratching the facial region proximal to the formalin injection site was recorded for nine successive 5-min intervals. Intracisternal administration of MCP-1, Rantes or IL-8 significantly increased formalin-induced scratching behavioral responses in the orofacial area. Intracisternal pretreatment with indomethacin, a non-selective cyclooxygenase inhibitor, did not block IL-8-induced hyperalgesia. Pretreatment with 100 microg propranolol, a non-selective beta-adrenergic receptor antagonist and 50 microg atenolol, a selective beta(1)-adrenergic receptor antagonist, inhibited the number of scratches and the duration of scratching produced by 1 ng of IL-8 injected intracisternally. These results indicate that intracisternal administration of chemokines produce a hyperalgesic response with an orofacial inflammatory pain model and that the IL-8-induced hyperalgesia is mediated by central beta(1)-adrenergic receptor.

Peripheral glutamate receptors participate in interleukin-1β-induced mechanical allodynia in the orofacial area of rats

The present study was performed to examine peripheral cytokine-induced mechanical allodynia in the orofacial area and to investigate whether peripheral excitatory amino acids participate in the cytokine-induced mechanical allodynia. Experiments were carried out on male Sprague-Dawley rats. After interleukin-1beta (IL-1beta) was applied subcutaneously to the orofacial area, we examined withdrawal responses produced by air puffs applied to the IL-1beta injection site. The threshold of air puffs that produced withdrawal behavioral responses decreased significantly in a dose-dependent manner after injection of IL-1beta. Pretreatment with an IL-1 receptor antagonist abolished the decrease in the threshold of air puffs. Pretreatment with dl-2-amino-5-phosphonvaleric acid, an N-methyl-d-aspartic acid (NMDA) receptor antagonist, did not affect IL-1beta-induced mechanical allodynia. However, pretreatment with 6,7-dinitroquinoxaline-2,3-dione, a non-NMDA receptor antagonist, abolished the decrease in the threshold of air puffs. These results suggest that peripheral cytokine can produce mechanical allodynia in the orofacial area and that excitatory amino acids can modulate IL-1beta-induced mechanical allodynia via non-NMDA receptors.

Central cyclooxygenase-2 participates in interleukin-1β-induced hyperalgesia in the orofacial formalin test of freely moving rats

The present study was performed to investigate effects of central cyclooxygenase (COX) on interleukin (IL)-1beta-induced hyperalgesia in the orofacial area. Experiments were carried out on 72 male Sprague-Dawley rats weighing 220-280 g. Surgical procedures were performed under pentobarbital sodium. We examined noxious behavioral scratching responses induced by 50 microl of 5% formalin injected subcutaneously into the vibrissa pad without any restraints. The orofacial formalin responses exhibited two distinct phases with early responses (0-10 min) and continuous prolonged responses (11-45 min). Intracisternal injection of 100 pg IL-1beta significantly increased noxious behavioral responses. Pretreatment with indomethacin, a non-selective COX inhibitor, or NS-398, a selective COX-2 inhibitor, blocked IL-1beta-induced hyperalgesic responses. However, pretreatment with SC-560, a selective COX-1 inhibitor, did not change hyperalgesic response to IL-1beta. These data suggest that central IL-1beta modulates the transmission of nociceptive information in the orofacial area and that central COX-2 plays an important role in IL-1beta-induced hyperalgesia.

Immortalization of human embryonic fibroblasts by overexpression of c-myc and simian virus 40 large T antigen

SV40 large T antigen, a viral oncoprotein, is known to immortalize human diploid fibroblast by soaking up cellular RB and p53, but its frequency is extremely low. Additional genetic alteration is necessary for single-step immortalization. We attempted to find out what this alteration is by overexpressing cellular signal mediator genes; c-myc and cyclin D frequently amplified in many cancer cells. Overexpression of cyclin D did not affect the immortalization, but, overexpression of c-myc along with T antigen could immortalize normal human diploid fibroblast. Several cellular markers tested during immortalization process showed that p21, a cyclin-dependent kinase inhibitor and a marker of cellular senescence, disappeared in the life span-extended cells by T antigen and in the immortalized cells by c-myc. p21 was, however, elevated in the senescent cells and in the cells of crisis. Interestingly, p16 was upregulated whenever T antigen is overexpressed. Telomerase activity was also activated only in the immortalized cells. These results suggest that overexpression of c-myc contributes to immortalization of human diploid fibroblast by activating telomerase activity and suppressing p21 activity.

Cytoprotective effect of Scutellaria baicalensis in CA1 hippocampal neurons of rats after global cerebral ischemia

Based on the use of Scutellaria baicalensis for the treatment of stroke in traditional Oriental medicine, the current study was carried out to evaluate neuroprotective effects of S. baicalensis after transient global ischemia using rat 4-vessel occlusion model. Methanol extracts from the dried roots of S. baicalensis (0.1-10 mg/kg) administered intra-peritoneally significantly protected CA1 neurons against 10 min transient forebrain ischemia as demonstrated by measuring the density of neuronal cells stained with Cresyl violet. Methanol extract of S. baicalensis inhibited microglial tumor necrosis factor-alpha (TNF-alpha) and nitric oxide production, and protected PC12 cells from hydrogen peroxide-induced toxicity in vitro.

A case of cutaneous bronchogenic cyst over the left scapula

Bronchogenic cyst is noted shortly after birth or in early childhood and usually presents as a swelling or draining sinus in the presternal area. Its origin and pathogenesis can be explained as a developmental anomaly of the tracheobronchial buds from the primitive foregut. The patient was a 4-year-old boy with a child-fist-sized soft mass over his left scapula, which had been detected at birth and had been gradually growing. Grossly, it appeared to be a simple cyst with clear mucoid fluid. Histopathological study demonstrated a unilocular cyst composed of ciliated pseudostratified columnar epithelia, interspersed goblet cells, smooth muscles, and mucous glands on the cyst wall, which are features compatible with cutaneous bronchogenic cyst.

Microinjection of arginine vasopressin into the central nucleus of amygdala suppressed nociceptive jaw opening reflex in freely moving rats

This study was performed to examine the antinociceptive effect after microinjection of arginine vasopressin (AVP) into the central nucleus of amygdala. We recorded the jaw opening reflex in freely moving rats. After injection of 0.2 or 0.4 nM AVP into the central nucleus of amygdala, digastric electromyogram (dEMG) was suppressed to 55 +/- 5% or 88 +/- 3 of the control. Artificial cerebrospinal fluid had no effects on the basal dEMG activity. V(1) vasopressin receptor antagonist blocked the suppressive effect produced by microinjection of 0.4 nM AVP from 53 +/- 3 to 81 +/- 3% of the control. However, V(2) vasopressin receptor antagonist did not affect changes in dEMG. We observed dEMG activity after intracerebroventricular injection of naloxone, methysergide, or phentolamine. All drugs did not affect the basal dEMG activity at our dose. Naloxone blocked the suppressive effect of 0.4 nM AVP from 42 +/- 4 to 79 +/- 5% of the control. Methysergide also inhibited the suppression of dEMG from 44 +/- 3 to 83 +/- 6% of the control. However, phentolamine, an alpha-adrenergic receptor antagonist, did not affect the suppression of dEMG. These results indicate AVP in the central nucleus of amygdala has potent analgesic effects in the orofacial area. The antinociception of central AVP seems to be mediated by opioid and serotonergic pathways.

Smoking initiation and cessation in Norway and the United States: a comparison of two cross-sectional surveys

PURPOSE

Smoking prevalence in a population is affected by the proportion of adolescents who start to smoke, and the proportion of smokers who quit. Smoking prevalence has declined linearly in the US and in the state of California during the last 2 decades. Due to an increase in female smoking, the Norwegian smoking prevalence has been stable at around 35% since 1980, while other European countries have seen reductions of at least 10 percentage points.

METHODS

We compared data from two cross-sectional studies; one from Western and Central Norway (n = 5014), and one from Northern California (Stanford Five-City Project) (n = 2189).

RESULTS

Norwegian smoking prevalence figures were significantly higher in all age-sex groups younger than 60 years. The proportion of former smokers was not different, suggesting that the differences between the samples are due to higher smoking initiation in Norway. University education was the most potent covariate of both ever-smoking and current smoking across samples and gender. Amount of physical exercise was associated with never-smoking in Norway, but not in the US. Having smoking parents was related to ever-smoking in women but not in men in both samples. Smoking parents also was related to current smoking in Norway but not in the US.

IMPLICATIONS

Norway should increase efforts to prevent smoking initiation among adolescents, and especially among girls.

Pathways by which SES and ethnicity influence cardiovascular disease risk factors

Little is known about pathways by which socioeconomic status (SES) translates into individual differences in cardiovascular disease (CVD) risk factors. Because the socioeconomic structure is not the same for all ethnic subgroups, the pathways that lead to the development of CVD risk factors may vary by both SES and ethnicity. We used data from a large national survey to examine the independent associations of two indicators of SES (education and income) and ethnicity with six primary CVD risk factors. We then used data on smoking that reflected a temporal sequence to examine the extent to which SES and ethnicity influenced smoking at three different time points, from smoking onset, to a serious quit attempt, to successful quitting. These analyses provide an understanding of the relationships between SES, ethnicity, and CVD risk factors and suggest that if the timing, focus, and content of intervention programs take pathways into account they will result in more successful outcomes.

Central-amygdaloid carbachol suppressed nociceptive jaw opening reflex in freely moving rats

1. Experiments were carried out in rats with stimulating electrodes implanted in the dental pulp, recording electrodes inserted into the anterior digastric muscle, and indwelling cannula implanted in the central amygdaloid nucleus and the cisterna magna area. 2. Injection of 4.4 nM and 8.8 nM carbachol into the central amygdaloid nucleus suppressed digastric electromyogram (dEMG) to 81 +/- 8% and 47 +/- 9% of the control, respectively. 3. Atropine, a muscarinic receptor antagonist, blocked the suppression of dEMG in response to the administration of 8.8 nM carbachol into the amygdala. However, a mecamylamine, a nicotinic receptor antagonist, did not affect changes in dEMG. 4. Intracisternal naloxone, an opioid receptor antagonist, reduced the suppression of dEMG from 47 +/- 10 to 72 +/- 12% of the control. 5. Intracisternal methysergide, a serotonin receptor antagonist, also reduced the suppression of dEMG from 50 +/- 9 to 78 +/- 9% of the control. 6. The carbachol-induced antinociception from the central amygdaloid nucleus was attributed to opioid and serotonergic descending inhibitory influences on nociceptive pathways.

The effects of marital transitions on changes in physical activity: results from a 10-year community study

The potential effects of making a marital transition on subsequent physical activity were evaluated across a ten-year period in a population-based sample of 302 women and 256 men ages 25 to 75 years. Subjects completed a structured interview at five timepoints throughout the ten-year period during which they reported on their physical activity level as well as marital status. The transition from a married to a single state did not affect physical activity relative to remaining married when analyses of either slopes or mean values were used. In contrast, the transition from a single to a married state resulted in significant positive changes in physical activity relative to remaining single throughout the study period when physical activity slopes, though not means, were compared. The results suggest that marriage may potentially set the stage for natural changes in physical activity that could be capitalized on through appropriate intervention, but additional research is needed to verify this in light of the inconsistent pattern of findings.

Determinants of cholesterol screening and treatment patterns. Insights for decision-makers

BACKGROUND

Adult cholesterol screening and treatment policies by the National Cholesterol Education Program recommend that physicians screen all adults aged > 20 [corrected]. On the other hand, the American College of Physicians recommends that healthy young adult men aged > 35 and premenopausal women aged > 45 not be screened due to concerns about the cost of and health risks associated with overuse of pharmacologic therapy in lieu of lifestyle modification.

OBJECTIVES

The objectives of this study were to determine the type of treatment (lifestyle vs. pharmacologic) that physicians actually prescribe for individuals screened for elevated cholesterol.

METHODS

Self-report data were derived from the 1989-1990 cross-sectional survey of the Stanford Five-City Project on 1,883 Latino and Anglo men and women aged 20 to 74 years of age. A four-stage sequential design was conducted using multiple stepwise regression analyses with a significance cutpoint of P < .01.

RESULTS

Young adult men and women were significantly less likely to report ever having been screened (OR 1.02; 95% CI 1.07-1.09). Individuals of low socioeconomic status (SES) were also significantly less likely to report ever being screened (OR, 1.12; CI, 1.08-1.16), as were Latino men and women, regardless of age (OR 1.57; CI, 1.14-2.18). There were no significant differences in the pattern of physician care utilization among low SES or Latino individuals during the previous 12-month period. Among those under physician care to lower cholesterol, young adults were more likely to be prescribed lifestyle modification (OR, 0.95; CI, 0.92-0.98).

CONCLUSIONS

Our results suggest that although young adults are less likely to be screened, if screened they are more likely to be prescribed lifestyle modification than pharmacologic treatment for elevated cholesterol. The lower prevalence of screening among low SES and Latino individuals suggests the need for policy discussions to reduce these disparities.

Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994

CONTEXT

Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences.

OBJECTIVE

To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES.

DESIGN

Third National Health and Nutrition Examination Survey conducted between 1988 and 1994.

SETTING

Eighty-nine mobile examination centers.

PARTICIPANTS

A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination.

MAIN OUTCOME MEASURES

Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus.

RESULTS

As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P<.001). In addition, women of lower SES from each of the 3 ethnic groups had significantly higher prevalences of smoking and physical inactivity and higher levels of BMI and non-HDL-C than women of higher SES (P<.001).

CONCLUSIONS

These findings provide the greatest evidence to date of higher CVD risk factors among black and Mexican American women than among white women of comparable SES. The striking differences by both ethnicity and SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for black and Mexican American women, as well as for women of lower SES in all ethnic groups.

Central NO is involved in the antinociceptive action of intracisternal antidepressants in freely moving rats

The present study was performed to examine the central effects of antidepressants on nociceptive jaw opening reflex after intracisternal injection. we also investigated the mechanisms of central antinociceptive action of intracisternal antidepressants. We recorded the jaw opening reflex in freely moving rats and chose to administer antidepressants intracisternally in order to eliminate the effects of anesthetic agents on the pain assessment and evaluate the importance of the spinal site of action of antidepressants. After intracisternal injection of 15 microg imipramine, digastric electromyogram (dEMG) was decreased to 76+/-6% of the control. Intracisternal administration of 30 microg desipramine, nortriptyline or imipramine suppressed dEMG remarkably to 48+/-2, 27+/-8, or 25+/-5% of the control, respectively. The suppression of dEMG was maintained for 50 min. L-NG-Nitroarginine methyl ester (NAME) blocked the suppression of dEMG from 32+/-2 to 81+/-5% of the control. These results indicate that antidepressants produce antinociception through central mechanisms in the orofacial area. The central NO pathway seems to be involved in the antinociception of intracisternal antidepressants at supraspinal sites.

Craniofacial skeletal fixation using biodegradable plates and cyanoacrylate glue

This study examined the feasibility of fixation of craniofacial bone using Lactosorb biodegradable plates adhered to bone with butyl-2-cyanoacrylate adhesive (Histoacryl) in a pig. The stability and bone-healing characteristics of this rigid fixation method were studied and compared with standard rigid fixation using metal plates and screws on osteotomy sites in the frontal bones and infraorbital rims. Rectangular osteotomies (2.0 x 3.0 cm) were performed on the right and left sides of the frontal bone and wedge-shaped osteotomies (1.5 x 1.7 cm) were made on the left and right infraorbital rims in seven Yorkshire pigs. Metal plates were applied with screws to the osteotomies on one side, and the other side was fixed with a biodegradable plate and butyl-2-cyanoacrylate. The animals were sacrificed at 8 weeks, and both sides were compared biomechanically and histologically. Radiographic, biomechanical, and histologic analyses were performed to evaluate skeletal stability, contour, accurate positioning of bony fragments, bone healing, and maximum torque to failure of the repair sites. Clinical and radiographic observations demonstrated stability of the bone fragments without any evidence of displacement. According to Student's t test for paired data, no statistical difference was found in the maximum torque to failure of fragments fixed with biodegradable plates and glue compared with those fixed with metal plates and screws (p > 0.05), whether or not a gap existed at the osteosynthesis site. Although the sample size was small, no differences were noted between the two types of treatment groups. This study demonstrates that rigid internal fixation of osteotomized cranial bone fragments using biodegradable plates and butyl-2-cyanoacrylate is as effective as metal plate and screw fixation in this animal model.

Effects of chronic central administration of losartan on the cardiovascular and hormonal responses to hemorrhage in conscious rats

Our objective was to assess the effects of chronic central angiotensin II (Ang II) blockade on the basal regulation of blood pressure, heart rate (HR), arginine vasopressin (AVP), renin, epinephrine (EPI), norepinephrine (NE) and on cardiovascular and hormonal responses to hemorrhage in conscious rats. Losartan (4 micrograms/h), or artificial cerebrospinal fluid (aCSF), was chronically infused into a lateral ventricle by using an osmotic minipump for 6 days at a rate of 1 microliter/h. Compared with aCSF controls, chronic losartan treatment significantly decreased the basal level of blood pressure (from 117 +/- 2.3 to 106 +/- 2.2 mmHg, P < 0.01) and increased the HR (from 357 +/- 3.7 to 410 +/- 6.6 beats/min, P < 0.01). Plasma renin concentration increased 3-fold (from 6.1 +/- 0.6 to 19.2 +/- 1.6 ng.ml(-1).h(-1), P < 0.01). Basal levels of AVP, EPI and NE were not different between two groups. Blood pressure immediately after hemorrhage and its compensatory recovery following hemorrhage was not different in both groups. Immediately after hemorrhage, however, in the losartan-treated rats, the HR was distinctly lower than that of aCSF controls, even at 10 min after hemorrhage. Hemorrhage produced a significant increase in the plasma concentrations of AVP, renin, EPI and NE. Chronic losartan treatment markedly augmented the AVP, renin and EPI responses to hemorrhage. These results strongly suggest that Ang II acting through AT1 receptors in the brain plays a significant physiological role in the regulation of basal blood pressure, HR and renin release. In addition, centrally acting Ang II may be one of the important mediators for cardiovascular regulations and hormone releases in response to hemorrhage.

Surgical model to assess the effects and optimal timing of craniofacial fixation

An in utero swine model of craniofacial deformity was developed as a potential alternative to neonatal models currently used for evaluating the optimal timing and long-term effects of rigid fixation techniques on a growing cranium. At 75% gestation, seven fetal piglets were randomly selected to undergo periosteal stripping of frontal and parietal bone segments with and without extensive coronal suture fusion procedures with cyanoacrylate adhesive. Fetal swine were killed postpartum at 4 and 11 weeks after fusion to assess craniofacial deformity. Piglets undergoing coronal fusion had slight deviation of the nose-snout toward the side of fusion and taller cranial vaults. The vertical cranial index of the experimental fusion group was 0.34 in comparison to a vertical index of 0.27 for the controls, suggesting abnormal vertical height expansion. There was no difference in the horizontal cranial index of either control or experimental fusion groups. Neither sows nor piglets were lost to anesthetic complications, uterine sepsis, or preterm labor during the initial laparotomy or subsequent cesarean delivery.

Prenatal exposure to tobacco smoke and childhood brain tumors: results from the United States West Coast childhood brain tumor study

Data from a large, population-based case-control study were analyzed to investigate the relationship between prenatal exposure to tobacco smoke and childhood brain tumors (CBTs). A total of 540 CBT patients, diagnosed between 1984 and 1991, were identified from population-based tumor registries in 19 West Coast counties that included Seattle, WA (13 counties), San Francisco, CA (5 counties), and Los Angeles, CA (1 county). Random digit dial was used to select 801 control subjects from the three geographical regions to obtain a case:control ratio of 1:2 in San Francisco and Seattle and 1:1 in Los Angeles. The data first were analyzed separately by geographical site and then were combined with adjustments made for gender, age at the time of diagnosis (or reference date of control subjects), birth year of the index child, and maternal race. No association was found between the risk of CBTs and maternal or paternal smoking before pregnancy and there was no association between CBTs and maternal smoking during pregnancy [odds ratio (OR) = 0.98; 95% confidence interval (CI) = 0.72-1.3]. A slightly increased OR for CBTs was found for paternal smoking during pregnancy in the absence of maternal smoking (OR = 1.2; 95% CI = 0.90-1.5) and for maternal exposure to passive smoke from any source (OR = 1.2; 95% CI = 0.95-1.6). The results of this analysis are consistent with results from several prior epidemiological studies that showed no significant association between CBTs and maternal smoking before or during pregnancy or maternal exposure to passive smoke during pregnancy.

Intraocular melanoma linked to occupations and chemical exposures

We conducted a case-control study in the western United States to determine the relation between occupations or chemical exposures and increased risk of uveal melanoma. Among men (221 patients, 447 controls), we found increased risks for occupational groups who had intense exposure to ultraviolet light [odds ratio (OR) = 3.0; 95% confidence interval (CI) = 1.2-7.8], welding exposure (OR = 2.2; 95% CI = 1.3-3.5), and asbestos exposure (OR = 2.4; 95% CI = 1.5-3.9 for most likely exposed). The highest odds ratio was for the small number of men (nine cases, three controls) who were chemists, chemical engineers, and chemical technicians (OR = 5.9; 95% CI = 1.6-22.7). Odds ratios also were elevated for exposures to antifreeze, formaldehyde, pesticides, and carbon tetrachloride, but these findings, based on recall of specific chemical exposures, are more subject to recall bias than the findings based on occupational groups.

Cutaneous melanoma in women: anatomic distribution in relation to sun exposure and phenotype

An analysis of the relationship between the anatomic site of cutaneous melanoma, sun exposure, and phenotype was conducted in 355 women with histologically confirmed superficial-spreading melanoma and in 935 control subjects. The most frequent site for superficial-spreading melanoma was the leg. However, when major sun-related and phenotype risk factors were examined by site, risk ratios were lowest for melanomas that occurred on the leg. A history of frequent sunburns during elementary or high school, increased number of self-assessed large nevi, and blond hair were more strongly associated with melanoma sites other than the leg. Tumors on the trunk were more likely than tumors at other sites to be associated with histological evidence of a preexisting nevus. Results of this work indicate that associations between melanoma phenotypic factors may differ by anatomic site.

Cutaneous melanoma in women. V. Characteristics of those who tan and those who burn when exposed to summer sun

We studied 338 Caucasian women with superficial spreading melanoma (hereafter called melanoma) and 872 control subjects ages 25-59 years and compared characteristics of women who reported that they tanned with sun exposure with those who reported that they burned. The purpose of the study was to investigate how skin type, as measured by tendency to burn or tan, modified the effect of other melanoma risk factors. There was a clear relation between tendency to burn and prevalence of red hair, light complexion, freckles, and history of sunburns during elementary school and high school. Host factors such as light complexion and increased number of self-assessed large nevi elevated risk of melanoma among women of all skin types. Increased risk for melanoma associated with frequent sunburns during childhood and adolescence was most pronounced for women who burned and then tanned; risk was not substantially elevated for women who burned without tanning. Women who had a history of sunburns had an increased melanoma risk even if they reported tanning.

Central ANG II-receptor antagonists impair cardiovascular and vasopressin response to hemorrhage in rats

The role of brain angiotensin II (ANG II) in mediating cardiovascular, vasopressin, and renin responses to hemorrhage was assessed in conscious spontaneously hypertensive rats (SHR) and in normotensive Wistar-Kyoto (WKY) and Wistar rats. Intracerebroventricular administration of losartan (10 micrograms) and saralasin (1 microgram.microliter-1.min-1) produced a markedly greater fall in blood pressure and a reduced tachycardia during and after hemorrhage (15 ml/kg) compared with the artificial cerebrospinal fluid control in SHR and Wistar rats but not in WKY rats. Vasopressin release after hemorrhage was also impaired, but renin release was enhanced by intracerebroventricular ANG II antagonists in SHR and Wistar rats but not in WKY rats. Losartan and saralasin produced remarkably similar effects on the cardiovascular, vasopressin, and renin responses to hemorrhage. These data suggest that brain ANG II acting through AT1 receptors plays an important physiological role in mediating rapid cardiovascular regulation and vasopressin release in response to hemorrhage. The relative importance of brain angiotensin system may vary in different strains of rate.

Cutaneous melanoma in women. II. Phenotypic characteristics and other host-related factors

A total of 452 women with cutaneous malignant melanoma and 930 control subjects aged 25-59 years participated in a population-based case-control study carried out in the San Francisco Bay Area between 1981 and 1986. Interviews were conducted in the homes of the women. Questions were asked about various phenotypic characteristics, including eye, hair, and complexion color, presence of freckles, and number of nevi, as well as medical history, history of exposure to sunlight, ability to tan, occupation, use of cigarettes and alcohol, and demographic factors. Histologic type of melanoma was considered in the analysis: 355 (79%) women were diagnosed with superficial spreading melanoma, 61 (13%) had nodular melanoma, 13 (3%) had lentigo maligna melanoma, and 23 (5%) had other melanomas that could not be further classified. For all cutaneous melanoma subjects combined, univariate results related to host factors showed that risk increased with the presence of nevi greater than 5 mm in diameter; light eyes, hair, and complexion; freckles; a history of skin cancer other than melanoma; a history of skin cancer in relatives; and maternal and paternal Northern or Central European ancestry. After adjustment for each other and for sun exposure factors, the phenotypic and host factors associated with all types of cutaneous malignant melanoma and superficial spreading melanoma were the presence of large nevi, light hair color, light complexion, and maternal Northern or Central European ancestry. Host factors associated with nodular melanoma after adjustment for other factors were the presence of large nevi, light hair color, ever being overweight by 20 pounds (9 kg) or more, and the presence of freckles.

Cutaneous melanoma in women. I. Exposure to sunlight, ability to tan, and other risk factors related to ultraviolet light

A population-based case-control study of cutaneous malignant melanoma (CMM) was conducted in 452 women with melanoma and 930 control subjects aged 25-59 years in five San Francisco Bay Area counties between 1981 and 1986. Women were interviewed in their homes with regard to history of sunlight exposure and sunburns during different periods in their lives, phenotypic and host characteristics, medical history, occupation, and demographic factors. Data were analyzed by the patients' histologic type of melanoma; 355 women were classified as having superficial spreading melanoma (SSM), 61 had nodular melanoma (NM), 13 had lentigo maligna melanoma, and 23 had other melanomas that could not be further classified upon histologic review by University of California dermatopathologists. Univariate results from analysis of factors related to sun exposure showed that the risk of all histologic types of CMM, SSM, and NM increased with increasing tendency of the subject to sunburn and with history of increased severity and/or frequency of sunburns up to age 12 years. Risk of all types of CMM and SSM also increased with increasing number of sunburns for all age groups and with lack of use of sunscreen. After adjustment for each other and for phenotypic factors, history of sunburn up to age 12 and lack of sunscreen use were the primary sun-related factors associated with an increased risk of all types of CMM and SSM, while tendency to sunburn when exposed to 1/2 hour of noontime sun and lack of use of sunscreen were related to NM. Although having frequent sunburns before age 12 and having severe sunburns before age 12 were both strongly associated with melanoma, having large numbers of sunburns during any time period from elementary school through age 30 years and having sunburns during the 10 years prior to diagnosis or interview were all associated with a doubling of risk for SSM after adjustment for other factors. These results suggest that the increased risk of melanoma related to sunburns is not confined to childhood sunburns. Maintenance of an all-year tan provided no protective effect against melanoma after adjustment for tendency to burn. No association was noted with use of fluorescent lights or exposure to sunlamps for all types of CMM, SSM, or NM.

Cutaneous melanoma in women. III. Reproductive factors and oral contraceptive use

Oral contraceptive use and reproductive factors were investigated in a population-based case-control study of 452 women aged 25-59 years who were diagnosed with cutaneous malignant melanoma during the period 1981-1986 and 930 controls. Ever use of oral contraceptives was reported by 72 percent of melanoma patients and 79 percent of control subjects in this San Francisco Bay Area study, although duration of use was slightly longer for women with superficial spreading melanoma (5.5 years) than for controls (4.3 years). While some subgroups had elevated or reduced odds ratios, no consistent association was observed between cutaneous melanoma risk and oral contraceptive use when use was examined by duration, latency, age at diagnosis, age at first use, and time period of first use. Neither number of live births nor age at birth of the first child was associated with risk for cutaneous melanoma; nor was a history of miscarriage, induced abortion, or endometriosis. No association was observed with regularity of menstrual periods or with use of fertility drugs or hormones to regulate menstrual periods. Women who reported experiencing hyperpigmentation of facial skin during a prior pregnancy had a lowered risk for all cutaneous melanoma (odds ratio (OR) = 0.64, 95% confidence interval (CI) 0.44-0.93) and superficial spreading melanoma (OR = 0.54, 95% CI 0.36-0.83). This effect was more pronounced for light-complexioned women (for superficial spreading melanoma, OR = 0.37, 95% CI 0.20-0.70) than for women with a dark or medium complexion (for superficial spreading melanoma, OR = 0.84, 95% CI 0.48-1.5). Women who reported use of acne medication also had a reduced risk of superficial spreading melanoma (OR = 0.55, 95% CI 0.35-0.84). These results indicate an overall lack of effect of oral contraceptives on cutaneous melanoma risk in this population of women. The reduced melanoma risks associated with hyperpigmentation during a prior pregnancy and use of acne medication (or related hormonal indications for its use) should be studied further.

Cutaneous melanoma in women: ovulatory life, menopause, and use of exogenous estrogens

Factors related to menopause and use of exogenous hormones other than p.o. contraceptives were examined in 452 women ages 25-59 who were diagnosed with cutaneous malignant melanoma. Control subjects for this population-based study in the San Francisco Bay Area were 930 women of the same age. An increased risk was observed for superficial spreading melanoma (SSM) in women who reached natural menopause after age 55 [odds ratio (OR), 3.6; 95% confidence interval (CI), 1.1-11.1], and for women who had had a bilateral oophorectomy within 9 years of their diagnosis with SSM (OR, 2.2; CI, 1.1-4.5). A somewhat elevated risk of melanoma after natural menopause or hysterectomy was no longer statistically significant after adjustment for exogenous hormone use. Prolonged use of p.o. exogenous hormones after hysterectomy for women who had retained at least one ovary was associated with an increased risk of SSM (OR, 5.4; CI, 1.5-19.3), and use of these products for fewer than 5 years after bilateral oophorectomy also was associated with an elevated risk of SSM (OR, 2.9; CI, 1.0-7.8). Conjugated estrogen use was associated with somewhat elevated risks for SSM after hysterectomy with one ovary retained (OR, 2.7; CI, 0.97-7.3) and after hysterectomy with bilateral oophorectomy (OR, 2.1; CI, 0.86-5.0). There was a suggestion of a trend for increased risk of SSM with increased dosage of conjugated estrogens after hysterectomy (P for trend = 0.07). Use of vaginal creams that contained estrogen also was associated with an increased risk of SSM (OR, 1.8; CI, 1.0-3.3).

The prognostic implications of histologic classification and bromodeoxyuridine labeling index of mixed gliomas

To clarify the biological and clinical behavior and prognosis of mixed gliomas, 47 patients underwent intraoperative bromodeoxyuridine (BrdU) labeling studies. The mean age was 27.8 years at symptom onset and 31.8 years at labeling (median, 36 years). Forty-five tumors were supratentorial, 30 were frontal, and two were cerebellar; 16 were recurrent at labeling. The median labeling index (LI) was 1% (range, < 1 to 15.1%). Forty-six tumors has oligodendroglial and astrocytic elements, and one had astrocytic and ependymal elements. The median LI was 4.4% in recurrent tumors and < 1% in primary tumors. A higher BrdU LI correlated with an increased risk of recurrence and a shorter time to recurrence. During a median follow-up of 16 months, four patients died; each had a BrdU LI > or = 4.4%. The median time to recurrence was 4.5 months for tumors with BrdU LI's > 5% but was not reached for tumors with LI's < 5% (p < 0.003). The histologic grade of the oligodendroglial component correlated with the median time to recurrence (8 months for Smith Grade C tumors, not reached for Smith Grade B tumors; p < 0.05); there were too few cases to evaluate the median times to recurrence of Smith Grade A and Grade D tumors. The median time to recurrence was not reached for any astrocytic grade, and there were no significant differences in the Kaplan-Meier survival curves. These findings suggest that the BrdU LI and the grade of the oligodendroglial component of mixed gliomas have prognostic significance.

Contraceptive use among women smokers and nonsmokers in the San Francisco Bay area

BACKGROUND

Women smokers were previously reported to be more sexually active but less likely to use contraception than nonsmokers. Differences in contraceptive choices between the two groups were investigated.

METHODS

Sexually active women, 287 who smoked cigarettes and 263 who did not smoke, were queried about current contraceptive use and demographic, sexual, and reproductive factors.

RESULTS

Sexually active smokers were less likely than nonsmokers to use contraceptives, especially oral contraceptives. The deficit of contraceptive use among smokers was most pronounced in women under age 30, black women, single women, women with some college education, nulliparous women, women who reported early age at first intercourse, and women who reported four or more lifetime sexual partners. In contrast, smokers were more than twice as likely as nonsmokers to use sterilization (P = 0.002). Among women over age 30, prevalence of contraceptive use was similar between the two groups. Oral contraceptives were used by fewer smokers than nonsmokers who were under age 24 (P = 0.01), had a high school education or less (P = 0.01), and/or had never been pregnant (P = 0.03).

CONCLUSIONS

Young, sexually active women who smoked cigarettes were less likely than nonsmokers to have used contraceptives, especially oral contraceptives, while women smokers over age 30 were more likely than nonsmokers to have used sterilization.

Characteristics of women nonsmokers exposed to passive smoke

BACKGROUND

Studies that have investigated the association between exposure to passive smoke and increased risk for disease have had inconclusive results and have raised questions about whether women exposed to passive smoke differ from those not exposed.

METHODS

The study population included 120 women nonsmokers who reported that they had been exposed to passive smoke in the 24 hr prior to the interview and 213 women who reported no exposure. Women were queried about demographic, lifestyle, sexual, and reproductive factors.

RESULTS

Exposed women were younger, less educated, and slightly heavier than nonexposed women. They were more likely to be divorced or separated (OR = 3.3, 95% CI = 1.4-7.6, P = 0.005), to have had first intercourse at or before age 16 (OR = 1.4, 95% CI = 1.0-1.9, P = 0.04), and to have had three or more live births (OR = 2.9, 95% CI = 1.2-6.8, P = 0.02). Women exposed to passive smoke were more likely to have consumed two or more cups of coffee (OR = 2.0, 95% CI = 1.1-3.8, P = 0.03), two or more glasses of beer (OR = 3.7, 95% CI = 1.1-12.5, P = 0.03), or to have smoked marijuana in the past 24 hr (OR = 14.7, 95% CI = 1.8-122.3, P = 0.01) than women who were not exposed. There were no differences noted between exposed and nonexposed women in history of gynecologic diseases or number of cervical microorganisms.

CONCLUSION

Women exposed to passive smoke differed from those not exposed on several factors that should be considered in future studies that seek to investigate smoking-related disease risk.

Efficacy of preoperative donation of blood for autologous use in radical prostatectomy

To determine the amount of blood lost, the number of transfusions, and the effectiveness of preoperative autologous blood donation in radical prostatectomy, 163 patients' records from 1987 to 1991 were reviewed at four university hospitals and three community hospitals. Calculated red cell volume lost was 1003 +/- 535 mL (mean +/- SD), which corresponds to 44 +/- 18 percent (mean +/- SD) of total red cell volume. Preoperative donation of blood for autologous use reduced the rate of transfusion of allogeneic blood from 66 to 20 percent (p < 0.001). Of the patients who donated 1 to 2 units, 32 percent received allogeneic blood; 14 percent of those who donated 3 units received allogeneic blood. Donation of 4 units reduced the allogeneic transfusion rate to 11 percent. However, as the number of units donated increased (1-3 units), the units not transfused also increased (0-21%). Ninety-one (56%) of 163 patients donated fewer than 3 units. Autologous blood donation is effective in minimizing the transfusion of allogeneic blood to radical prostatectomy patients, but many patients do not donate enough blood (< 3 units). The donation of 3 units of blood for autologous use is recommended for patients who undergo radical prostatectomy.

Detection of mutagens in cervical mucus in smokers and nonsmokers

The Salmonella mutagenicity test was used to analyze cervical mucus specimens from 364 smokers and 333 nonsmokers to determine whether the association between smoking and mutagenic cervical mucus that we reported previously among women diagnosed with dysplasia would apply to a larger group of healthy women (E. A. Holly et al., J. Natl. Cancer Inst., 76: 983-986, 1986). Women smokers and nonsmokers between the ages of 18 and 49 who attended eleven clinics and physicians' offices in the San Francisco Bay area for a routine Pap smear were examined to determine whether smokers were more likely to have mutagenic substances in their cervical mucus. About 4% of smokers and 8% of nonsmokers had positive mutagenicity test results (P = 0.02). Cervical mucus with a large number of microorganisms was more likely to have a positive mutagenicity test result than that with fewer microorganisms (test for trend, P = 0.01). Mutagenicity results varied by race and clinic location but were not associated with smoking behavior, sexual behavior, gynecological diagnosis, or diet. Further work is needed to develop methods to detect mutagens in specific body fluids.

Characteristics of women by smoking status in the San Francisco Bay Area

To better understand why smokers are more likely to develop cervical cancer than nonsmokers, we investigated laboratory and demographic differences between the two groups. Women between the ages of 18 and 49 who attended eleven community clinics in the San Francisco Bay Area were studied to investigate differences between smokers and nonsmokers. The 332 smokers and 365 nonsmokers were queried about smoking habits, sexual and reproductive history, and recent diet. Cervical mucus specimens were cultured for yeast, lactobacillus, and other microorganisms. Results showed that white Hispanic women were less likely to smoke than white non-Hispanic women. Smokers, when compared to nonsmokers, consumed larger quantities of coffee, soft drinks, liquor, and beer in the 24 h prior to the interview. Women who smoked were more likely than those who did not smoke to have had first sexual intercourse before age 16, had a greater number of lifetime sexual partners, and were more likely than nonsmokers to have been pregnant. After controlling for number of sexual partners, smokers reported a history of chlamydia, gonorrhea, and/or pelvic inflammatory disease more often than did nonsmokers, and cervical mucus of smokers was more likely than that from nonsmokers to contain greater than 8500 microorganisms/ml.

Improvement in appropriate autologous donations with local education: 1987 to 1989

Preoperative autologous blood donation for elective surgery patients at university hospitals was underused in the past. More recently, national educational efforts have been made. To test the impact of local surgeon interviews and education, in 1988 the same local educational program was instituted at three university hospitals; three community hospitals were used as controls. Donation by appropriate patients of interviewed surgeons (elective surgery, crossmatch recommended, no contraindications to donation) increased from 24 percent (44/180) to 40 percent (88/222) (p = 0.002) and 15 percent (21/143) to 32 percent (41/127) (p = 0.001) at two university hospitals where the investigator-educators were on site, but not at the three community hospitals. Between 1987 and 1989, donation rates at all six hospitals remained low among patients for whom autologous donation was (probably) less appropriate. Donation rates for type and screen procedures were 3.0 percent (131/4587) in 1987 and 3.0 percent (199/6606) in 1989 (p = 0.67). Donation rates for "no blood order" procedures were 0.2 percent (15/9429) in 1987 and 0.1 percent (9/11,239) in 1989 (p = 0.14). It can be concluded that appropriate autologous blood donations increased at university hospitals where surgeons were individually interviewed and educated by an investigator on site. However, despite this increase, apparently eligible elective surgery patients in 1989 still failed to donate. This situation deserves additional investigation.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) as an adjunct to autologous hemopoietic stem cell transplantation for lymphoma

OBJECTIVE

To determine the hemopoietic effects of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) in patients having autologous hemopoietic stem cell transplantation for Hodgkin or non-Hodgkin lymphoma.

DESIGN

Placebo or GM-CSF was administered after bone marrow or peripheral blood stem cell transplantation or both in a randomized, double-blind phase III trial by daily intravenous infusion (10 micrograms/kg body weight) until absolute neutrophil counts reached greater than or equal to 1000/mm3 on 3 consecutive days.

SETTING

Bone marrow transplantation unit in a university hospital.

PATIENTS

Sixty-nine consecutive patients with Hodgkin or non-Hodgkin lymphoma received GM-CSF (36 patients) or placebo (33 patients).

MEASUREMENTS AND MAIN RESULTS

Patients who received GM-CSF achieved absolute neutrophil counts greater than or equal to 500/mm3 (median, 12 compared with 16 days, P = 0.02) and absolute neutrophil counts greater than or equal to 1000/mm3 (median, 15 compared with 24 days, P less than 0.001) more quickly than patients who received placebo. Multivariate analysis indicated that use of GM-CSF, peripheral blood stem cells, and unpurged bone marrow were the strongest predictors for early neutrophil recovery greater than 500/mm3. Bacterial infections were significantly reduced in the GM-CSF group (P = 0.04). Delayed engraftment (neutrophils less than 500/mm3 at day 30) occurred in 26% and 17% of the placebo and GM-CSF groups, respectively, and correlated with the absence of detectable myeloid progenitor cells (colony-forming units-granulocyte macrophage, CFU-GM) (P less than 0.001) in marrow aspirate specimens obtained on day 15. Time to platelet independence, duration of hospital stay, severe adverse reactions, relapse, and disease-free survival rates did not differ significantly between the two groups.

CONCLUSIONS

Administration of GM-CSF after autologous hemopoietic stem cell transplantation in patients with lymphoma resulted in accelerated myeloid recovery, particularly in patients who received peripheral blood stem cells and nonpurged bone marrow, and was associated with a decreased incidence of bacterial infections.

Ewing's bone sarcoma, paternal occupational exposure, and other factors

To determine risk factors for Ewing's bone sarcoma, the authors interviewed mothers of 43 patients diagnosed between January 1978 and August 1986 and 193 controls in the San Francisco Bay Area, California, regarding medical and occupational history of parents and other factors related to the subjects and their immediate families. Controls were selected by using random digit dial telephone methods. Adjusted relative risk estimates suggest that risks were elevated for children whose fathers were engaged in agricultural occupations during the period from 6 months prior to conception of the subject up to the time of diagnosis for the patients or interview for the controls (relative risk (RR) = 8.8, 95% confidence interval (CI) 1.8-42.7) and for children whose fathers had occupational exposure to herbicides, pesticides, or fertilizers (RR = 6.1, 95% CI 1.7-21.9, p = 0.002). Prior ingestion of poison or an overdose of medication was more common in patients than in controls (RR = 4.4, 95% CI 1.4-13.5). These and other findings should be investigated in larger population-based studies to determine specific factors that may account for the associations.

Highly anaplastic astrocytoma: a review of 357 patients treated between 1977 and 1989

Between May 1977 and August 1989, 357 patients (199 male, 158 female; median age 40 years) with highly anaplastic astrocytomas other than glioblastoma multiforme were treated according to any of several protocols used in studies by the University of California, San Francisco, and the Northern California Oncology Group. The data evaluated were age, Karnofsky Performance Score, survival, time to tumor progression, therapy, and the effect of treatment at the time of progression. The records of 219 patients were taken from the University of California database, and those of the other 138 were taken from the Northern California Oncology Group computer files. Their median Karnofsky Performance Score was 90% (range 40-100%), the overall median survival was projected as 170.9 weeks, and the median time to first tumor progression was 127.3 weeks. The median survival time measured after the first progression was 41.3 weeks. Age and Karnofsky Performance Score had a significant influence on survival and on time to the first tumor progression, whereas extent of surgery and the use of interstitial brachytherapy in the initial therapy did not. We conclude that these patients can expect a median survival of over 3 years, that young age and high Karnofsky Performance Score have a positive influence on survival, and that salvage therapies can extend survival after the onset of tumor progression for nearly a year. Although it did not lengthen survival when used in initial therapy, interstitial brachytherapy used at the time of tumor progression was associated with increased survival.

Thermoradiotherapy of recurrent malignant brain tumors

In an attempt to improve local control and survival over those achieved with brain implant alone, a Phase I/II study of interstitial thermoradiotherapy was undertaken for recurrent malignant gliomas and recurrent solitary brain metastases. Between June 1987 and September 1990, 49 tumors in 48 patients were treated with thermoradiotherapy, including 26 glioblastoma multiforme (GM), 16 anaplastic astrocytomas (AA), 4 adenocarcinomas, and 3 melanomas. Patient age ranged from 18 to 71 years and Karnofsky Performance Status from 40 to 90. Stereotactically implanted catheters were used for both hyperthermia and brachytherapy. Hyperthermia was administered immediately before and after brachytherapy, heating as much of the tumor as possible to 42.5 degrees C for 30 min using helical coil microwave antennas. High-activity iodine-125 sources delivered tumor doses of 32.6 to 63.3 Gy. Complications included reversible neurologic changes in 13 patients, 9 seizures, 4 infections, 1 deep venous thrombosis with pulmonary embolus, and 1 scalp burn. Eighteen patients underwent reoperation for tumor and/or necrosis. Follow-up ranged from 9 to 166+ weeks. The median follow-up for living patients with GM and AA was 37 weeks and 92 weeks, respectively. Actuarial median survival was 47 weeks for patients with GM. For patients with AA, actuarial survival was 65% at 18 months and median survival has not yet been reached. Multivariate analysis showed a strong correlation between freedom from local tumor progression and "T90" temperature or minimum tumor temperature. Interstitial brain thermoradiotherapy is now being evaluated in a randomized Phase II trial for previously untreated GM.

Cytologic criteria used to diagnose adenocarcinoma in pleural effusions

A stepwise logistic regression analysis was employed to evaluate the usefulness of the following criteria to distinguish adenocarcinoma in pleural effusion from benign pleural effusion: increased size of nucleus, increased nuclear to cytoplasmic ratio, irregular nuclear borders, sharply defined cytoplasmic boundaries, large nucleoli, aggregates with variable size nuclei, aggregates with nuclear overlap, irregular noncentral vacuoles, aggregates with nuclear molding, multinucleation, three-dimensional aggregates, aggregates with large cytoplasmic vacuoles, atypical mitoses, nuclear vacuoles, homogeneous cytoplasm, aggregates with associated lymphocytes and neutrophils, and uniform size aggregates. A total of 223 patients with benign pleural effusion cases and 221 patients with adenocarcinoma in their pleural effusion were scored as to the presence or absence of the above criteria. The resulting data were subjected to a stepwise logistic regression analysis that chose increased nuclear/cytoplasmic ratio, irregular nuclear borders, large nucleoli, sharply defined cytoplasmic boundaries, and three-dimensional aggregates as the best criteria to differentiate adenocarcinoma in pleural effusion from benign pleural effusion. When used together, these five features had a sensitivity of 94% and a specificity of 93% for predicting adenocarcinoma.

Evaluation of bromodeoxyuridine in glioblastoma multiforme: a Northern California Cancer Center Phase II study

In a study activated in 1983 and closed in 1987, the Brain Tumor Research Center of the University of California and the Northern California Cancer Center evaluated the effect of bromodeoxyuridine in the treatment of glioblastoma multiforme. A total of 160 patients were evaluable of 173 entered. Patients were to receive a bromodeoxyuridine infusion of 0.8 g/m2 daily over 24 hours for 4 days of each of 6 weeks of radiotherapy directed to the tumor plus a margin delivering a total of 60 Gy. Eligibility requirements included Karnofsky performance status greater than or equal to 70, biopsy or resection and central pathology review by one of the authors. Following radiotherapy patients were to receive chemotherapy with procarbazine, CCNU, and vincristine for 1 year. Median survival was 55.7 weeks and time to failure, 34.5 weeks for the evaluable group of 160 patients. In a univariate analysis the variables that influence survival and time to failure were: age, Karnofsky performance status, bromodeoxyuridine dose and the delivery of at least one procarbazine, CCNU, and vincristine cycle following radiotherapy. In multivariate analysis, age, Karnofsky performance status, and bromodeoxyuridine dose remain significant for time to failure; age and Karnofsky performance status remain significant for survival.

Pancreatic adenocarcinoma: regression analysis to identify improved cytologic criteria

The incidence of pancreatic adenocarcinoma is increasing and it is usually unresectable at the time of diagnosis. Consequently, fine-needle aspiration biopsy (FNAB) is being used more frequently for diagnosis. The reported sensitivity of diagnosing pancreatic adenocarcinoma by FNAB has varied between 50% and 100%. In an attempt to increase the diagnostic sensitivity, we retrospectively reviewed a series of pancreatic FNABs. Fifteen cytologic criteria were evaluated in 78 patients who had pancreatic FNABs. Of these patients, 49 had primary adenocarcinomas and 29 had benign, non-neoplastic lesions. Using a stepwise logistic regression analysis we identified three key cytologic criteria for this diagnosis. Our study identified anisonucleosis (P = 0.001), large nuclei (P = .007), and nuclear molding (P = .03) as the significant cytologic features for diagnosing pancreatic adenocarcinoma. In combination, these three criteria had a sensitivity of 98% and a specificity of 100%.

Rapidly alternating radiotherapy and high dose cisplatin chemotherapy in stage IIIB non-small cell lung cancer: results of a phase I/II study

Alternating radiotherapy and chemotherapy increases tumor cure rates in some animal models with reduced normal tissue damage compared to sequential use of these modalities. To test this concept in non-small cell lung cancer, 23 patients with predominantly Stage IIIB disease were treated on a Northern California Oncology Group pilot study of alternating radiotherapy and high dose cisplatin. Radiotherapy consisted of 6000 cGy delivered in three separate 10-day courses of 200 cGy/fraction/day during weeks 1 and 2, 5 and 6, and 9 and 10. High dose cisplatin, 100 mg/m2 in 3% saline, was administered on weeks 3 and 4, 7 and 8, 11 and 12, and 15 and 16. The response rate in 22 eligible patients is 73% (16/22) with four complete responses and 12 partial responses. Feasibility of this approach is demonstrated by 20/22 patients completing radiotherapy and a median of 2.5 courses of chemotherapy administered. Median survival time is 14.2 months (range 2-40+ months). One- and 2-year survival rates are 64% (14/22) and 41% (9/22), respectively. Hematologic, renal, and radiation-related toxicities were significant but manageable. We conclude that rapid alternation of radiotherapy and a high dose intensity cisplatin regimen is feasible in Stage IIIB non-small cell lung cancer, with a high response rate and acceptable toxicity. The long-term impact on local control and survival remains unclear, although preliminary survival data are encouraging in this poor prognosis population. Further studies of this concept are warranted.

No excess prior cancer in patients with uveal melanoma

To determine whether there were more prior cancers in uveal melanoma patients than in a geographically matched control group, the authors compared the history of prior cancer in 407 uveal melanoma patients who lived in the western United States with that of 870 control subjects. Control subjects were selected by random digit dial and frequency-matched for age at diagnosis of patient, race, and sex. Fifty-one (12.5%) patients and 86 (9.9%) control subjects reported skin cancers whereas 25 (6.1%) patients and 47 (5.4%) control subjects reported other cancers. No statistically significant elevated estimates of relative risk (RR) were found for uveal melanoma with history of skin cancer in either men (RR = 1.4, 95% confidence interval (CI) = 0.87-2.3) or women (RR = 1.1, 95% CI = 0.58-2.0), or with history of other prior cancer in either sex (men, RR = 1.0, 95% CI = 0.42-2.2; women, RR = 1.1, 95% CI = 0.55-2.1). Data from this study do not support an association between prior cancer and increased risk of uveal melanoma.

Demographics and cigarette smoking among women

BACKGROUND

A population-based sample of 893 white women ages 25 to 59 years from five San Francisco, California, Bay Area counties were queried about their demographic characteristics, height, reported weight at age 25, cigarette smoking history, and oral contraceptive and sunscreen use.

METHODS

Multiple logistic regression techniques were used to analyze the data. Forty-three percent of the women in the sample had never smoked more than 100 cigarettes, while 27% were current and 30% were former smokers. Separated or divorced women were more likely to have ever smoked.

RESULTS

Women who were less educated, single, separated, or divorced or had smoked between 10 and 30 cigarettes per day were less likely to quit smoking. Women with less education and a longer history of smoking smoked more cigarettes per day. Women who had never smoked were more likely to use sunscreen and to report their weight as slightly less at age 25 than were smokers.

Uveal melanoma, hormonal and reproductive factors in women

In a case-control study, we explored a potential association between uveal melanoma and reproductive factors in women. Responses from telephone interviews of 186 women diagnosed with uveal melanoma were compared with responses of 423 women without this disease. All women resided in 11 U.S. western states. We observed a decreased risk of uveal melanoma for women who had ever been pregnant [relative risk (RR) = 0.60, 95% confidence interval (CI) = 0.37 -0.95], with an increase in this protective effect with more live births after adjustment for age, menopausal status, eye color, and skin sensitivity to the sun (1-2 births, RR = 0.47,95% CI 0.29-0.78; 3-4 births, RR = 0.38, 95% CI = 0.22-0.64; 5 or more births, RR = 0.33, 95% CI = 0.15-0.71). The largest effect was observed between nulliparous and parous women. No other reproductive factors, including use of oral contraceptives or postmenopausal estrogens, were shown to be related to risk for uveal melanoma. We conclude that most reproductive factors in this population play little or no role in the etiology of uveal melanoma. The association with number of live births must be confirmed in other studies to assure that it is unrelated to confounding factors not measured in this study.