Driving developments in UK oesophageal radiotherapy through the SCOPE trials

BACKGROUND

The SCOPE trials (SCOPE 1, NeoSCOPE and SCOPE 2) have been the backbone of oesophageal RT trials in the UK. Many changes in oesophageal RT techniques have taken place in this time. The SCOPE trials have, in addition to adopting these new techniques, been influential in aiding centres with their implementation. We discuss the progress made through the SCOPE trials and include details of a questionnaire sent to participating centres. to establish the role that trial participation played in RT changes in their centre.

METHODS

Questionnaires were sent to 47 centres, 27 were returned.

RESULTS

100% of centres stated their departmental protocol for TVD was based on the relevant SCOPE trial protocol. 4DCT use has increased from 42 to 71%. Type B planning algorithms, mandated in the NeoSCOPE trial, were used in 79.9% pre NeoSCOPE and now in 83.3%. 12.5% of centres were using a stomach filling protocol pre NeoSCOPE, now risen to 50%. CBCT was mandated for IGRT in the NeoSCOPE trial. 66.7% used this routinely pre NeoSCOPE/SCOPE 2 which has risen to 87.5% in the survey.

CONCLUSION

The results of the questionnaires show how participation in national oesophageal RT trials has led to the adoption of newer RT techniques in UK centres, leading to better patient care.

Transformed follicular lymphoma (tFL): consolidation therapy may improve survival

PURPOSE

Retrospective study to evaluate the outcome of patients with transformed follicular lymphoma (tFL) treated with rituximab-containing chemotherapy and consolidation.

PATIENTS AND METHODS

Patients diagnosed with tFL from 2003 to 2013 treated with consolidation therapy with last follow-up in December 2015 were identified from the institutional lymphoma database and included in this study. Data collected included age, gender, stage, interval to tFL diagnosis, R-IPI score, histological diagnosis and therapy. The treatment algorithm used was stratified for age, performance status (PS) and sibling donor availability using R-chemotherapy induction followed by consolidation with allogeneic stem cell transplant (SCT), autologous SCT, Zevalin or rituximab maintenance (RM). Patients with B-cell lymphoma with features intermediate between diffuse large B-cell lymphoma and Burkitt's lymphoma (BCL-U), with FISH-proven t(14;18) and t(8;14) and their variants were excluded.

RESULTS

Four hundred patients were diagnosed with FL of whom 26 (7%) developed histologically proven tFL. The group was predominantly male (73%) with a median age at transformation of 53 (range 27-72) years and 85% presented with stage III/IV disease. Thirteen (50%) patients presented with de novo tFL and the remainder had previously diagnosed FL, with a median time to transformation of 5.7 (range 1-15) years. The median follow-up time from tFL diagnosis to December 2015 is 8 (range 4-14) years. All patients received immuno-chemotherapy achieving an overall response rate (ORR) of 100%. Fourteen (54%), patients were transplant eligible and based on donor availability, six had an auto-SCT only, five had an allo-SCT only and three had a matched unrelated allo-SCT for a post-auto-SCT relapse. The 12 patients (46%) who were not transplant eligible were consolidated with rituximab maintenance (RM) in nine (35%) and Zevalin in three (11%) cases. The overall survival (OS) and progression-free survival (PFS) for the series at 5 years were, 92 and 73%, respectively.

CONCLUSION

This consecutively treated series of 26 patients with tFL have had a better outcome than expected which may be due to the use of rituximab-chemotherapy and a consolidation strategy based on age, PS and availability of a sibling donor.

Hypercalcaemia-induced kidney injury caused by the vitamin D analogue calcitriol for psoriasis: a note of caution when prescribing topical treatment

A 55-year-old man with severe plaque psoriasis presented with a 2-week history of feeling generally unwell with lethargy and thirst. His symptoms had developed 6 weeks after commencement of the topical vitamin D3 analogue calcitriol. Investigations revealed hypercalcaemia and acute-on-chronic kidney injury, probably directly induced by systemic absorption of vitamin D3 following extensive topical use. Topical calcitriol had been started as a steroid-sparing agent to reduce the patient's liberal potent corticosteroid usage during anti-tumour necrosis factor-alfa therapy. Topical vitamin D analogues are commonly prescribed in dermatological and general practice, with hypercalcaemia being a rare but potentially serious adverse effect. This case serves to outline key factors that may predispose to hypercalcaemia, such as disease extent, quantity of drug applied, comorbidities and concurrent medications, and it highlights the importance of considering these factors when prescribing topical therapies.

Disseminated coxsackievirus A6 affecting children with atopic dermatitis

Coxsackievirus A6 (CV-A6) is an emerging pathogen that has in recent years been associated with atypical hand, foot and mouth disease. This manifests as a generalized papular or vesicular eruption, which may be associated with fever and systemic disturbance. We report a series of six children presenting to a single centre in the UK with disseminated CV-A6 infection on a background of atopic dermatitis (AD). Our patients exhibited a widespread papular or vesicular eruption in association with exacerbation of AD. Several of our cases mimicked eczema herpeticum, but the extent was more generalized, and individual lesions were discrete rather than clustered and were less circumscribed in character. This series highlights that CV-A6 infection may be encountered in the UK, and should be considered in the differential diagnosis of an acute exacerbation of AD, particularly in children.

Drug reaction with eosinophilia and systemic symptoms: is cutaneous phenotype a prognostic marker for outcome? A review of clinicopathological features of 27 cases

BACKGROUND

Drug reaction with eosinophilia and systemic symptoms (DRESS) describes a heterogeneous group of severe adverse reactions to medications. The cutaneous phenotype has a number of guises, accompanied by a variety of systemic features including fever, haematological abnormalities and visceral involvement, most commonly the liver. Clinical markers of prognosis have not been identified.

OBJECTIVES

To assess the cutaneous signs and dermatopathological features of DRESS in order to identify potential prognostic markers.

METHODS

We reviewed the clinical features, dermatopathology and outcomes of 27 consecutive cases of DRESS presenting to a single unit.

RESULTS

Four distinct patterns of cutaneous involvement were identified: an urticated papular exanthem (13/27 patients), a morbilliform erythema (three of 27), an exfoliative erythroderma (three of 27) and an erythema multiforme-like (EM-like) reaction consisting of atypical targets (eight of 27). All patients mounted a fever, most developed lymphadenopathy (24/27) and peripheral eosinophilia (25/27) and the most common organ involved was the liver (27/27). Review of the dermatopathic features of patients with DRESS demonstrated a superficial spongiotic dermatitis in the majority of cases (16/27). A smaller number of cases showed basal cell vacuolar degeneration and necrotic keratinocytes (nine of 27). The patients with these biopsy findings more commonly had an EM-like cutaneous phenotype, and more severe hepatic involvement. Three patients died, two following failed liver transplants.

CONCLUSIONS

Our series is the first in which a detailed dermatological assessment has been made of consecutive patients presenting with DRESS, and the largest U.K. series to date. Our results suggest a possible prognostic role of the cutaneous and dermatopathic findings in DRESS in predicting the severity of visceral involvement in this syndrome. What's already known about this topic? • Drug reaction with eosinophilia and systemic symptoms (DRESS) has a heterogeneous clinical presentation, with a skin eruption of variable morphology. • DRESS carries considerable morbidity and mortality, usually hepatic in origin, although renal, pulmonary and pericardial involvement can be seen. What does this study add? •   The cutaneous phenotype in DRESS can be categorized as an urticated papular exanthem, a morbilliform erythema, exfoliative erythroderma or erythema multiforme-like (EM-like). •   An EM-like eruption DRESS may be prognostic of more severe hepatic involvement.

Cutaneous infection with Alternaria tenuissima in an immunocompromised patient

A 28-year-old man, on immunosuppressive therapy for a recent kidney-pancreas transplant, presented to our department with an unusual violaceous nodule on his right knee. A biopsy specimen showed a granulomatous response in the dermis, surrounding numerous fungal cells and septate hyphae. Fungal cultures yielded dark grey colonies, which were identified as Alternaria tenuissima. To our knowledge this is the first report of A. tenuissima infection reported in the U.K.

A granulomatous response to tribal medicine as a feature of the immune reconstitution syndrome

Summary Immune reconstitution is a well recognized phenomenon associated with the use of highly active antiretroviral therapy (HAART) for HIV infection. After the administration of HAART there is a rise in CD4 T-cell count in the circulation brought about by cessation of HIV replication. This allows the body to respond to antigens that it previously ignored. This manifests itself most commonly as an overt illness to previously ignored pre-existing infections such as Mycobacterium tuberculosis, herpes simplex virus, varicella zoster virus, hepatitis B and C viruses, cytomegalovirus, cryptococcal infection, human papilloma virus and molluscum contagiosum. There are further reports of reactions to sarcoid and tattoo pigment and one previous case reported of a granulomatous reaction to a foreign body. We report another case of a foreign body granuloma reaction, to tribal medicine implanted in tribal marks made in childhood in a Zimbabwean woman. This reaction is part of the immune reconstitution syndrome.

Serum S100 concentrations are not useful in predicting micrometastatic disease in cutaneous malignant melanoma

BACKGROUND

S100 protein is an acidic calcium binding protein that is expressed by melanoma cells. Elevated serum values of S100 have been described in metastatic disease and it has been suggested that it may be used as an adjunct to staging and monitoring of treatment. Micrometastatic disease in the sentinel lymph node can be demonstrated by sentinel node biopsy (SNB) and the sentinel node status is known to be the most important predictor of relapse.

OBJECTIVES

To determine whether serum S100 concentrations could predict the presence of micrometastatic disease.

METHODS

Thirty-one patients with primary cutaneous melanoma > 1 mm were recruited from referrals to the Melanoma clinic. All patients had serum S100 concentrations evaluated prior to undergoing SNB. Serum S100 concentrations were established using an immunoluminometric method. Sentinel nodes were identified using a dual technique with both radiolabelled colloid (residual from preoperative lymphoscintigraphy) and blue dye according to the MD Anderson Cancer Center protocol. Results Nine of these 31 patients had evidence of micrometastatic disease on SNB. The mean serum S100 concentration of those with positive SNBs was 0.027 microg L-1 compared with 0.045 microg x L(-1) in patients with negative SNBs (normal < 0.14 microg x L(-1)). No patient in the study demonstrated raised concentrations of serum S100.

CONCLUSIONS

We conclude that serum S100 concentrations do not predict the presence of micrometastatic melanoma in sentinel nodes in primary cutaneous melanoma.

Comparison of Positron Emission Tomography Scanning and Sentinel Node Biopsy in the Detection of Micrometastases of Primary Cutaneous Malignant Melanoma

PURPOSE: Sentinel node biopsy (SNB) is a surgical technique for detecting micrometastatic disease in the regional draining nodes. 2-fluorine-18-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) scanning is an imaging technique that can detect clinically undetectable metastases. This prospective study was undertaken to compare the sensitivity of FDG-PET scanning with SNB in the detection of micromatastatic malignant melanoma.

PATIENTS AND METHODS: Fifty consecutive patients (23 women, 27 men; mean age, 53 years) with primary melanoma >1 mm thick or lymphatic invasion were recruited (mean, 2.41 mm). Primary lesions had been narrowly excised (<1 cm). Patients underwent PET scanning followed by SNB, using a dual technique. Preoperative lymphoscintigraphy was used to identify the draining basin. Lymph nodes were examined histologically and immunostained for S100 and HMB 45.

RESULTS: The sentinel node (SN) was identified in all patients. Fourteen patients (28%) had positive SNBs, including eight patients with melanoma <1.5 mm thick. In none of these 14 patients did PET scans identify metastatic disease in the SN or draining basin. In seven patients, the PET scans were positive in other locations, and in four cases, this was suspicious of metastatic disease. However, no patient has developed recurrent melanoma (mean follow-up, 15 months). All patients with positive SNBs underwent therapeutic lymph node dissection. Further lymph node involvement was found in two patients (primary lesions, 1.3 mm and 3.5 mm thick).

CONCLUSION: This study demonstrates the limitations of FDG-PET scanning in staging patients with primary melanoma. SNB is the only reliable method for identifying micrometastatic disease in the regional draining node.

Exon scanning of the entire TSC2 gene for germline mutations in 40 unrelated patients with tuberous sclerosis

Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder resulting in the development of hamartomatous growths in many organs. Genetic heterogeneity has been demonstrated linking the familial cases to either TSC1 at 9q34.3, or TSC2 at 16p13.3. About two-thirds of the TSC cases are sporadic and appear to represent new mutations. While both genes are thought to account for all familial cases, with each representing approximately 50% of the mutations, the proportion of sporadic cases with mutations in TSC1 and TSC2 is yet to be determined. We have examined the entire coding sequence of the TSC2 gene in 20 familial and 20 sporadic cases and identified a total of twenty-one mutations representing 50% and 55% of familial and sporadic cases respectively. Our rate of mutation detection is significantly higher than other published reports. Twenty out of 21 mutations are novel and include 6 missense, 6 nonsense, 5 frameshifts, 2 splice alterations, a 34 bp deletion resulting in abnormal splicing, and an 18 bp deletion which maintains the reading frame. The mutations are distributed throughout the coding sequence with no specific hot spots. There is no apparent correlation between mutation type and clinical severity of the disease. Our results document that at least 50% of sporadic cases arise from mutations in the TSC2 gene. The location of the mutations described here, particularly the missense events, should be valuable for further functional analysis of this tumor suppressor protein.

Alcohol, smoking and psoriasis

Initial anecdotal evidence that both smoking and drinking have an influence on psoriasis have been borne out in more detailed epidemiological studies. However, there appears to be some geographical variation between populations and a marked gender bias. The possibility that simple modifications in lifestyle may reduce both the prevalence and severity of psoriasis offers an exciting potential adjunct to treatment in the future.

Transgenically produced human antithrombin: structural and functional comparison to human plasma-derived antithrombin

Recombinant human antithrombin (rhAT) produced in transgenic goat milk was purified to greater than 99%. The specific activity of the rhAT was identical to human plasma-derived AT (phAT) in an in vitro thrombin inhibition assay. However, rhAT had a fourfold higher affinity for heparin than phAT. The rhAT was analyzed and compared with phAT by reverse phase high-performance liquid chromatography, circular dichroism, fluorophore-assisted carbohydrate electrophoresis (FACE), amino acid sequence, and liquid chromatography/mass spectrography peptide mapping. Based on these analyses, rhAT was determined to be structurally identical to phAT except for differences in glycosylation. Oligomannose structures were found on the Asn 155 site of the transgenic protein, whereas only complex structures were observed on the plasma protein. RhAT contained a GalNAc for galactose substitution on some N-linked oligosaccharides, as well as a high degree of fucosylation. RhAT was less sialylated than phAT and contained both N-acetylneuraminic and N-glycolylneuraminic acid. We postulate that the increase in affinity for heparin found with rhAT resulted from the presence of oligomannose-type structures on the Asn 155 glycosylation site and differences in sialylation.

A new method of intralesional bleomycin therapy in the treatment of recalcitrant warts

We have used a new technique of bleomycin injection to treat intractable palmar, plantar and periungual warts. Following local anaesthesia with topical EMLA (lignocaine and prilocaine) cream, 1 mg/ml bleomycin solution was dropped on to the wart and 'pricked' into the wart using a Monolet needle. We achieved 92% success rate which compares well with other authors whose success rates with intralesional bleomycin vary between 33 and 92%. We conclude that this technique of intralesional bleomycin therapy is an effective, safe and generally well tolerated treatment for recalcitrant warts.

Molecular cloning and characterization of Rosa hybrida dihydroflavonol 4-reductase gene

A full length cDNA clone encoding rose dihydroflavonol 4-reductase (DFR) was isolated from a cDNA library derived from rose petals by screening with the cDNA of Petunia hybrida DFR. Sequence comparison of the rose DFR with reported DFR genes revealed that they are homologous to each other. The amount of DFR mRNA in rose petals was developmentally regulated and paralleled anthocyanin production in petals. Sepals, thorns, styles and stamens also contained anthocyanins and DFR mRNA. No DFR mRNA was observed in mature leaves and a small amount of the transcript was detected in young leaves. A petunia cultivar, whose colour was pale pink due to a deficiency in flavonoid 3'-hydroxylase and flavonoid 3',5'-hydroxylase, was transformed with a binary vector containing a rose DFR cDNA cloned behind a constitutive promoter. Petals and anthers of the resultant transgenic petunia plants were salmon pink and contained pelargonidin, an anthocyanidin rarely found in petunia.

Characterization of O-linked oligosaccharide biosynthesis in cultured cells using paranitrophenyl alpha-D-GalNAc as an acceptor

Aryl-N-acetyl-alpha-galactosaminides (aryl-GalNAc) are acceptor substrates for UDP-Gal:alpha-GalNAc beta 1-3 galactosyltransferase and, in vivo, aryl-GalNAc have been shown to inhibit O-linked oligosaccharide biosynthesis (Kuan et al., J. Biol. Chem. 264, 19271, 1989). Since aryl-GalNAc, appears to enter viable cells and serve as an acceptor for O-glycosylation enzymes, the recovery and characterization of the aryl-oligosaccharides from cell culture medium may reflect cellular pattems of O-glycosylation. To pursue this possibility, the following paranitrophenyl-linked oligosaccharide standards were enzymatically synthesized and characterized by 1H-NMR: Gal beta 1-3(GlcNAc beta 1-6)Gal-NAc alpha-pNp; Gal beta 1-3(Gal beta 1-4GlcNAc beta 1-6)GalNAc alpha-pNp; SA alpha 2-3Gal beta 1-3(SA alpha 2-3Gal beta 1-4GlcNAc,beta 1-6)GalNAc alpha-pNp; SA alpha 2-3Gal beta 1-3GalNAc alpha-pNp. As a model system, MDAY-D2 lymphoid tumour cells were cultured for various periods in medium containing 2 mM GalNAc alpha-pNp. The secreted aryl-oligosaccharides were separated by Biogel P2 chromatography and DEAE HPLC, followed by further fractionation of the disialyl oligosaccharides on an Ultrahydrogel HPLC column. Absorbance of the paranitrophenyl aryl constituent at 303 nm allowed detection at the 10 pmol level and provided a relatively specific means of following the oligosaccharides. MDAY-D2 cells produced disialylated aryl-oligosaccharides at a rate of 20 pmol/h/10(6) cells with a half-time of transit to the cell surface of 13.6 min, a rate consistent with their movement from the Golgi to the cell surface by bulk flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased UDP-GlcNAc:Gal beta 1-3GaLNAc-R (GlcNAc to GaLNAc) beta-1, 6-N-acetylglucosaminyltransferase activity in metastatic murine tumor cell lines. Control of polylactosamine synthesis

Malignant transformation of rodent cell lines by polyoma virus and by activated ras genes is associated with increased UDP-GlcNAc:Man alpha-R beta-1,6-N-acetylglucosaminyltransferase V (GlcNAc-transferase V) activity and it product -GlcNAc beta 1-6Man alpha 1-6Man beta 1-branched Asn-linked oligosaccharides. In this report, we have compared beta 1-6GlcNAc branching of core O- and N-linked oligosaccharides in three experimental models of malignancy, namely (a) rat2 fibroblasts and their malignant T24H-ras-transfected counterpart; (b) benign SP1 mammary carcinoma cells and two metastic sublines of SP1; and (c) the metastatic MDAY-D2 lymphoma cell line and its poorly metastatic glycosylation mutant KBL-1. In addition to the previously reported increase in GlcNAc-transferase V activity, UDP-GlcNAc:Gal beta 1-3GalNAc alpha-R (GlcNAc to GalNAc) beta-1,6-N-acetylglucosaminyltransferase (core 2 GlcNAc-transferase, EC 2.4.1.102) activity was found to be elevated by 70% in the malignant rat2 and SP1 cell lines while several other glycosyltransferase activities were not significantly different. The action of core 2 GlcNAc-transferase followed by beta 1-4Gal-transferase provides an N-acetyllactosamine antenna that can be extended with polylactosamine (i.e. repeating Gal beta 1-4GlcNAc beta 1-3) provided UDP-GlcNAc:Gal beta-R beta 1-3GlcNAc-transferase (GlcNAc-transferase) (i)) activity is present. Polylactosamine content in microsomal membrane glycoproteins was quantitated by labeling the GlcNAc termini resulting from the action of Escherichia freundii endo-beta-galactosidase with bovine galactosyltransferase/UDP-[3H] Gal. Glycopeptidase F- sensitive and -insensitive fractions were measured to assess the N- and O-linked components. In the SP1 tumor model, the metastatic sublines showed increased core 2 GlcNAc-transferase and GlcNAc-transferase V activities but no change in GlcNAc-transferase (i) activity, yet polylactosamine was increased in both O- and N-linked oligosaccharides. In rat2 cells, down-regulation of GlcNAc-transferase (i) following transformation was associated with decreased polyactosamine even though core 2 GlcNAc-transferase and GlcNAc-transferase V were elevated in the cells. Finally, a 3-fold decrease in GlcNAc-transferase V in KBL-1, the glycosylation mutant of MDAY-D2 cells, resulted in complete loss of polylactosamine in N-linked but no change in O-linked polylactosamine content. These results suggest that, provided GlcNAc-transferase (i) is not limiting, the beta 1-6-branching enzymes core 2 GlcNAc-transferase and GlcNAc-transferase V regulate the levels of polyactosamine in O- and N-linked oligosaccharides, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Delta Lys120, a mutation which destabilizes the ribosome-binding domain of ribosomal protein L7/L12

Five-residue-long deletions centered on Ala63, Ala75, and Glu118 of ribosomal protein L7/L12 gave low mutant yields (5% or less) when the mutant genes were cloned in phage M13mp18 and controlled by the L10 promotor. Deletions of Glu118-Lys120 or Lys120 (the COOH-terminus of L7/L12) gave higher mutant yields, up to 50% with L7/L12 delta Lys120. L7/L12 delta Lys120 was not preferentially found in the S100 and not preferentially removed by LiCl washing, but was preferentially extracted from 70S ribosomes in the presence of 28-35% ethanol in 0.25-0.5 M NH4Cl. It follows that delta Lys120 destabilizes the ribosome-binding domain of ribosomal protein L7/L12 in an ethanol-containing solvent, which raises the question whether Lys120 is part of the ribosome-binding domain of L7/L12 during some step of protein synthesis or whether it is essential to preserve the conformation of the physiological ribosome-binding domain under structurally stressful conditions.

Altered expression of leucocyte sialoglycoprotein in Wiskott-Aldrich syndrome is associated with a specific defect in O-glycosylation

The Wiskott-Aldrich syndrome (WAS) is an X-linked immune deficiency disorder characterized clinically by both lymphocyte and platelet dysfunction. Studies of WAS T lymphocytes have revealed deficient or defective cell surface expression of the highly O-glycosylated leucocyte sialoglycoprotein CD43. To further elucidate the basis for, and functional relevance of, CD43 modifications on WAS lymphocytes, we have studied lymphocytes from two WAS patients with regard to membrane glycoprotein profile and mitogen-induced proliferative responses. CD43 was found to be either absent or altered in size on peripheral blood lymphocytes and lectin-stimulated T cells from both patients. Compared with control cells, the WAS lymphocytes displayed reduced, but measurable proliferative responses to lectins and neuraminidase/galactose oxidase, and virtually no response to periodate, a mitogenic agent which targets sialic acid residues on membrane glycoproteins such as CD43. Analysis of activities of three glycosyltransferases involved in O-glycosylation revealed marked reduction in the level of activity of UDP-N-acetylglucosamine: Gal beta 1-3GalNAc-R beta-1,6-N-acetylglucosamine (beta-1,6-GlcNAc) transferase in one WAS patient and no detectable activity of this enzyme in a second. beta-1,6-GlcNAc transferase activity has recently been shown to increase during T cell activation coincident with changes in the O-linked glycans on CD43. A selective reduction of this glycosyltransferase in WAS lymphocytes suggests that O-linked oligosaccharides may be important to the structure of membrane glycoproteins involved in lymphocyte activation.

Relapse rates in moderately severe chronic psoriasis treated with cyclosporin A

Seventeen patients with chronic psoriasis were given cyclosporin A (CsA) 5 mg/kg per day. Twelve patients cleared within 3 months and their relapse rate, 41% at 6 months, was not significantly different from that previously reported with dithranol or PUVA. This pilot study also suggests that continuing CsA for up to 4 weeks after clinical clearance confers no advantage with regard to relapse. Significant adverse effects on renal function and blood pressure did not occur.

Translational coupling between the ilvD and ilvA genes of Escherichia coli

The hypothesis that translation of the ilvD and ilvA genes of Escherichia coli may be linked has been examined in strains in which lacZ-ilvD protein fusions are translated in all three reading frames with respect to ilvD. In these strains, the nucleotide sequence was altered to obtain premature termination of ilvD translation, and in one strain translation termination of ilvD DNA occurred two bases downstream of the ilvA initiation codon. In the wild-type strain, the ilvD translation termination site was located two bases upstream of the ilvA start codon. In each of the mutant strains, expression of ilvA, as determined by the level of threonine deaminase activity, was strikingly lower than in the wild-type strain. The data suggest that expression of ilvD and ilvA is translationally coupled. By inserting a promoterless cat gene downstream of ilvA, it was shown that the differences in enzyme activity were not the result of differences in the amount of ilvA mRNA produced.

Investigations of factors influencing the prognosis of colon cancer

Six hundred sixty patients from Downstate and Hackensack Medical Centers were restaged and reviewed to establish correlations with survival using Cox's proportional hazards model. Age, sex, tumor size, and total nodes examined in patients with involved nodes did not correlate with survival. Tumor depth, number of involved nodes, and total nodes examined in patients with uninvolved nodes did correlate with survival. Patients with metastatic invasion into an adjacent organ with uninvolved nodes had an excellent 5 year survival rate compared with patients who had full-thickness invasion into the serosa with uninvolved nodes. These observations need to be confirmed. The relationship of some of these factors to currently used staging systems has also been discussed.

North American blastomycosis in Africans

Two young adults, one a native of Libya and one a Sudanese from Saudi Arabia, were referred at different times to the chest service at Westminister Hospital in London with a diagnosis of tuberculosis. They both had neurological deficits due to vertebral lesions. In spite of the fact that neither patient had ever been to North America, diagnoses of North American blastomycosis were established; both patients made remarkable recoveries on amphotericin B therapy.