Phosphorylation of the prolyl isomerase Cyclophilin A regulates its localisation and release from the centrosome during mitosis

The centrosome acts as a protein platform from which proteins are deployed to function throughout the cell cycle. Previously, we have shown that the prolyl isomerase Cyclophilin A (CypA) localizes to the centrosome in interphase and re-localizes to the midbody during mitosis where it functions in cytokinesis. In this study, investigation of CypA by SDS-PAGE during the cell cycle reveals that it undergoes a mobility shift during mitosis, indicative of a post-translational modification, which may correlate with its subcellular re-localization. Due to the lack of a phospho-specific antibody, we used site-directed mutagenesis to demonstrate that the previously identified serine 77 phosphorylation site within CypA is important for control of CypA centrosome localization. Furthermore, CypA is shown to interact with the mitotic NIMA-related kinase 2 (Nek2) during interphase and mitosis, while also interacting with the Nek2-antagonist PP1 during interphase but not during mitosis, suggesting a potential role for the Nek2-PP1 complex in CypA phospho-regulation. In support of this, Nek2 is capable of phosphorylating CypA in vitro. Overall, this work reveals that phosphorylation of CypA at serine 77 is important for its release from the centrosome during mitosis and may be regulated by the activity of Nek2 and PP1 during the cell cycle.

Abstract P2-08-43: Can optoacoustic imaging combined with ultrasound non-invasively offer prognosis for breast cancer molecular subtypes?

Aim: To investigate the role of optoacoustic imaging combined with gray-scale ultrasound (OA/US) to better differentiate between breast cancer molecular subtypes.

Materials and Methods:

This prospective 5-center study was performed in the Netherlands between March 2015 and February 2016. Only masses considered suspicious at conventional diagnostic breast ultrasound (US) were included. The study was approved by the institutional ethical boards of the participating hospitals and written informed consent was obtained from all patients. Dedicated breast radiologists evaluated the included masses using OA/US and scored the internal and external OA/US features accordingly. Spearman Correlation was used to analyze the relationship between OA/US features and mitotic figures. The same statistical method was also used to evaluate the correlation between OA/US features and percentages of ER, PR and Ki67. Wilcoxon-Mann-Whitney tests were used to analyze the relationship between OA/US features and molecular subtypes of breast cancer (Luminal A, Luminal B, Triple Negative and HER2-enriched breast cancers).

Results: Overall, 209 patients with 215 breast lesions were included in this study. Sixty-seven masses were considered malignant and the 59 masses classified as invasive breast cancers were included in the final mitotic figures, ER, PR, Ki-67 and molecular subtype analyses. Significant correlations were found between OA/US Total Internal Features and ER (p = 0.0333) and Ki-67 (p = 0.0092) percentages. Regarding molecular subtypes, Internal Vessels (p = 0.0257), Total Internal Features (p = 0.0196) and combined Total Internal and External Features (p = 0.0289) helped to differentiate between Luminal A and Luminal B cancers. Internal Vessels (p = 0.0030), Internal Blush (p = 0.0044), Total Internal Hemoglobin (p = 0.0053), Total Internal Features (p = 0.0010), Total Internal divided by Total External Features (p=0.0255) and combined Total Internal and External Features (p = 0.0108) helped to differentiate between Luminal A and Triple Negative breast cancers. Total Internal Features showed a borderline result (p = 0.0551) regarding the differentiation between Triple Negative and HER2-enriched subtypes.

Conclusions: The use of OA/US features to non-invasively differentiate between breast cancer molecular subtypes may help to establish an earlier prognosis and treatment planning, potentially decreasing costs and facilitating larger scale diagnosis. Future research with larger sample sizes may confirm these preliminary results.

Citation Format: Menezes GL, Mann RM, Meeuwis C, Bisschops B, Veltman J, Lavin PT, van de Vijver MJ, Pijnappel RM. Can optoacoustic imaging combined with ultrasound non-invasively offer prognosis for breast cancer molecular subtypes? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-43.

Abstract P5-02-04: Opto-acoustic imaging of breast masses: Correlation with breast biopsy prognostic indicators

Purpose: The Imagio™ OA/US breast imaging system, a diagnostic opto-acoustic (OA) imaging device bearing the CE Mark, is in the U.S. FDA Premarket Approval process. OA/US provides both functional (relative oxygenation/de-oxygenation) and anatomic (angiogenesis) information that is co-registered and temporally interleaved in real time with gray-scale ultrasound that may improve discrimination between benign and malignant masses. We recently reported correlation studies demonstrating tumor-zone specific OA attributes in histopathologic grade I versus grade III malignancies. The relationship between OA attributes (individual feature scores or summed feature results) and pathologically-determined prognostic markers (PDPM) in malignant lesions is the subject of this report.

Materials and Methods: In this HIPAA-compliant, IRB-approved prospective multi-center trial across 16 U.S clinical sites; 1,808 masses in 1,739 subjects assessed as BI-RADS 3, 4 or 5 were imaged with OA/US. Of these, 655 were invasive malignancies and the subject of this analysis. Each mass was scored by 8 blinded readers on 3 internal zone features of the tumor nidus and 2 external features (0-5, 6) of the tumor boundary and peripheral zones (OA attributes). Pathologic diagnoses were confirmed by an experienced central breast pathologist blinded to the OA assessment. Tumor histologic classification and grading was performed in all subjects.Evaluation of tumor estrogen receptor (ER) and progesterone receptor (PR) were performed at each site by immunohistochemistry (IHC) and was reported as percent of tumor cells expressing the receptor or, as positive if greater than 1%. Tumor HER2-neu expression was reported by IHC as 0, 1+ (negative, not over-expressed), 2+ (indeterminate) and 3+ (over-expressed). All 2+ results reflexed to fluorescence in-situ hybridization (FISH) and reported as over-expressed or not over-expressed. Tumor Ki-67 expression was evaluated with IHC and reported as percent of tumor cells positive for the antigen.

Statistical analysis of categorical measures of PDPM is in process and will be performed using a two-way Analysis of Variance (ANOVA) and Tukey HSD (honest significant difference) test for pairwise comparisons. This ANOVA will be repeated for each PDPM to test which specific PDPM sub-categories are related to OA attributes. Correlation coefficients will be generated for PDPM that are continuous, not categorical. All statistical testing will be done at a 5% significance level.

Results: A total of 655 invasive and 22 DCIS were scored for internal (nidus) and external (boundary and periphery) OA attributes and compared with PSBC as defined by ER, PR, Her2 and Ki-67 expression. Of these, 108 were Luminal-A (LA), 153 Luminal-B (LB), 80 Triple-negative (TN), 23 Her2-enriched (HER2) and 314 unclassified (including 22 DCIS). OA attributes differentiated LA (99%CI 2.8,3.1) from TN (99%CI 3.1,3.4), p=0.027 and HER2 (99%CI 3.1,3.6), p=0.036. OA features strongly suggested LA vs. LB (99%CI 3.1,3.3) subtype, p=0.060. LB vs.TN(p=0.59) and HER2(p=0.41) were non-significant. TNBC vs. HER2 was p=0.62.

Citation Format: Grobmyer SR, Butler R, Neuschler EI, Stavros AT, Aitchison RD, Lavin PT, Tucker FL. Opto-acoustic imaging of breast masses: Correlation with breast biopsy prognostic indicators [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-02-04.

Abstract P4-02-08: Opto-acoustic imaging of the breast: Downclassification and upclassification of suspicious breast masses

Background

Imagio® is an opto-acoustic (OA) breast imaging system designed to concomitantly collect OA images together with diagnostic ultrasound (CDU). The device is intended to improve distinction between benign and malignant masses. In this interim analysis of the post-market surveillance MAESTRO study we report the results of 75 patients who had breast masses classified as BI-RADS 4a and 4b by CDU.

Aim

We assessed OA's sensitivity, specificity, and its ability to downgrade benign masses and upgrade malignant masses based on the probability of malignancy (POM) and BI-RADS category.

Methods

Seventy-five patients with 78 breast masses were evaluated with OA prior to biopsy. For each mass, the radiologist scored 5 OA features, assigned a POM and BI-RADS category. OA sensitivity, specificity, and BI-RADS downgrade and upgrade percentages were assessed with and without contribution from a previously derived nomogram.

Results

The mean POM difference between malignant and benign masses was higher for OA (37%) than for CDU (27%). OA specificity was 43% without the nomogram and 68% with the nomogram. OA sensitivity was 97% with and without the nomogram. With OA 43% of benign masses could be downgraded and 47% of malignant masses could be upgraded in BIRADS category.

Conclusion

These results appear to confirm the previously reported ability of OA to improve the differentiation between benign and malignant masses compared to CDU alone, to potentially decrease negative biopsies, and to upgrade BI-RADS category in malignant masses. The MAESTRO study (n=200) may further confirm these results.

Citation Format: Menezes GLG, Pijnappel RM, Meeuwis C, Bisschops B, Veltman J, Lavin PT, Mann RM. Opto-acoustic imaging of the breast: Downclassification and upclassification of suspicious breast masses [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-02-08.

Abstract P4-02-03: Breast biopsy histology relationships with opto-acoustic imaging of breast masses

Purpose: The Imagio® breast imaging system, a diagnostic opto-acoustic (OA) imaging device bearing the CE Mark, is in the U.S. FDA Premarket Approval process. OA provides both functional (relative oxygenation/de-oxygenation) and anatomic (angiogenesis) information that is co-registered and temporally interleaved in real time with gray-scale ultrasound that may improve distinction between benign and malignant masses. OA imaging pathology correlation was performed to elucidate the histologic features of OA features of breast cancers.

Methods and Materials: A multicenter postmarket surveillance and clinical follow-up study was conducted in five Dutch sites in which 209 women with breast masses underwent OA prior to biopsy. Histopathology examination of the biopsies revealed 146 benign masses (mostly fibroadenomas) and 76 malignant masses (mostly invasive ductal carcinomas). For invasive ductal carcinomas, histologic grade and the features used to assess histologic grade (nuclear pleomorphism, tubule formation, and mitotic count) were assessed. For each mass, 5 pre-determined OA features, 3 internal features, and 2 external features were evaluated. The 3 internal scores (vessels, blush, and hemoglobin) and 2 external features (capsular boundary zone and peripheral boundary zone) were separately and collectively summed for testing relationships with traditional histopathology measures using a two-sided Jonckheere-Terpstra test of ordered outcomes. Distribution differences between benign and malignant masses were performed using a Wilcoxon Rank Sum test for each internal, external, and summed total internal, external, and total score.

Results: The mean differences were significantly higher for malignant vs. benign for internal vessels (p=0.0009), internal blush (p=0.0085), external boundary zone (p<0.0001), and external peripheral zone (p<0.0001), but not internal hemoglobin. Mean Total Internal Score, Total External Score, and Total Internal and External Score were all significantly higher (all p<0.01) for malignant vs. benign. Among invasive carcinomas, Total Internal Score and Total Internal and External Score were significantly higher for higher histologic tumor grade (p=0.04, 0.02), significantly higher Total External Score and Total Internal and External Score for higher tubule score (p=0.06, 0.03), slightly higher Total Internal Score and Total Internal and External Score for higher nuclear pleomorphism score (p=0.04, 0.05), and slightly higher Total Internal Score for higher mitotic score (p=0.03).

Conclusion: OA feature summary scores appear to differentiate between benign vs. malignant and correspond to histologic grade and scoring components of histologic grade. The U.S. investigational PIONEER pivotal study (n=2,095) may further confirm these results.

Citation Format: van de Vijver M, Lavin PT, Stavros AT. Breast biopsy histology relationships with opto-acoustic imaging of breast masses [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-02-03.

Abstract P4-03-02: Up-classification of suspicious breast masses using opto-acoustic imaging

Purpose: Breast cancer diagnostic methodologies have been optimized to achieve increased sensitivity at the expense of relatively low specificity. Seno Medical's opto-acoustic (OA) imaging fuses real time co-registered, temporally interleaved laser optic and ultrasound imaging showing dual functional (hemoglobin de-oxygenation) and morphology findings for breast masses using a hand-held probe. We present data from the PIONEER Pilot study (n=100). We have shown improved specificity for OA relative to the ultrasound component (IUS) and the site determination by conventional diagnostic ultrasound (CDU). We now examine the BI-RADS upgrades for 36 malignant masses achieved by OA versus IUS and the site determinations using CDU.

Materials and Methods: A total of 7 independent registration readers (IRRs) blindly assessed all 36 malignant masses using IUS first and OA second without any knowledge of clinical data or outcome. Among the cancers, there were 2 BI-RADS 4b, 12 BI-RADS 4c, and 22 BI-RADS 5 according to participating site radiologists' CDU evaluations. IRRs trained to identify and score three OA internal features and two OA external features for all masses were immediately offered the results of two nomograms based on their OA feature scores to predict the Probability of Malignancy (POM), which was then used to assign a BI-RADS category.

Results: Combining data from all 7 readers, OA findings enabled upgrades of site CDU-determined BI-RADS categories 43% of the time for BI-RADS 4b and 29% for BI-RADS 4c; in contrast, the overall percentages of IUS upgrades versus site CDU were 21% for BI-RADS 4b and 10% for BI-RADS 4c. Overall, 12% of all OA reads resulted in upgrades in contrast to 4.4% for IUS compared to site CDU BI-RADS classifications. Relative to IUS, the overall percentages of OA upgrades were 58% for BI-RADS 4b and 34% for BI-RADS 4c. OA has comparable sensitivity to IUS.

Conclusions: OA was more likely than IUS to result in a BI-RADS upgrade of a malignant mass. If subsequently confirmed, OA findings may help identify more cancers prior to biopsy. The 2,095 PIONEER Pivotal Study will allow for confirmation.

Clinical Relevance: The ability to upgrade BI-RADS 4b and 4c for cancer masses is an unmet need. If verified, these findings could provide additional evidence to confirm a malignant mass earlier and spare subsequent diagnostic evaluations. This may help plan the efficient identification and excision of malignant masses.

Citation Format: Lavin PT, Stavros AT, Ulissey MJ. Up-classification of suspicious breast masses using opto-acoustic imaging. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-03-02.

A multicenter, randomized controlled trial comparing a single intra-articular injection of Gel-200, a new cross-linked formulation of hyaluronic acid, to phosphate buffered saline for treatment of osteoarthritis of the knee

OBJECTIVE

To compare the safety and efficacy of a single intra-articular (IA) injection of a new cross-linked hyaluronic acid product, Gel-200, with phosphate buffered saline (PBS, control) in a multi-center randomized controlled trial in patients with symptomatic osteoarthritis (OA) of the knee.

DESIGN

Patients were randomized 2:1 to receive a single injection of Gel-200 or PBS, after joint aspiration. The primary measure of effectiveness was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscores by 100-mm Visual Analog Scale (VAS); secondary outcomes included: total WOMAC, physical function, and stiffness subscores; patient and physician global assessments of disease activity, Outcome Measures in Rheumatology Clinical Trials and Osteoarthritis Research Society International (OMERACT-OARSI) strict responders, as well as safety of Gel-200.

RESULTS

Of 379 patients randomized, safety was evaluated in 377 and efficacy in 375 (98.9% randomized) in the intent-to-treat population. Effectiveness of Gel-200 by WOMAC pain subscores was statistically significant at week 13 (P=0.037). Mean improvements from baseline in WOMAC pain subscores consistently favored Gel-200 at each visit. Effectiveness of Gel-200 treatment was statistically significant over weeks 3-13 by WOMAC total score, physical function, and physician global evaluations (P<0.05). The number of "strict" OMERACT-OARSI responders was statistically significant from weeks 6 to 13 (P=0.022). Adverse events were not significantly different between treatment groups, including serious adverse events considered related to study treatment.

CONCLUSIONS

This trial demonstrated that a single injection of Gel-200 was well tolerated and relieved pain associated with symptomatic OA of the knee over 13 weeks.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NTC 00449696.

Role of myocardial temperature measurement in monitoring the adequacy of myocardial protection during cardiac surgery

Inadequate myocardial protection continues to be encountered despite improved methods of cardioplegia delivery. Although myocardial temperature is commonly monitored to assess the adequacy of cardioplegia delivery, its relationship to the metabolic status of the myocardium has not been investigated. We prospectively reviewed patients who underwent valvular heart surgery with blood (n = 47) or crystalloid (n = 48) cardioplegia and continuous measurement of intraoperative myocardial tissue pH and temperature. We previously demonstrated a high correlation (r = 0.99) between extracellular myocardial pH, levels of intracellular hydrogen ion concentration, and a lowering of tissue ATP during coronary occlusion. Clinically, optimal metabolic protection was defined as the absence of myocardial tissue acidosis during the period of aortic occlusion as quantified by a temperature-corrected integrated mean pH of 6.8 or greater, which has been shown to be predictive of a favorable postoperative outcome. Age, bypass time, myocardial temperature, myocardial tissue pH at the onset of aortic occlusion, cross-clamp time, and volume of cardioplegia were not significantly different between blood and crystalloid groups. Linear regression analysis demonstrated no significant correlation between mean myocardial tissue pH and the corresponding mean myocardial temperature in either group during aortic occlusion. There was also no correlation between the mean myocardial tissue pH and volume of cardioplegia delivered in both groups. These data demonstrate wide intercardiac and intracardiac variability in the degree of regional tissue acidosis encountered during of hypothermic cardioplegia. Cardioplegia delivery guided by measurement of myocardial temperature or by standardized protocol did not prevent the occurrence of tissue acidosis and thus, did not ensure optimal metabolic protection of the heart. In 95 patients undergoing valvular heart surgery with cold blood or crystalloid cardioplegia, there was no correlation between myocardial tissue pH and mycardial temperature or between myocardial tissue pH and volume of cardioplegia administered. Temperature is a poor indicator of the metabolic state of the myocardium.

Efficacy and safety of intraarticular sodium hyaluronate in knee osteoarthritis. ORTHOVISC Study Group

A prospective, multicenter, randomized, double-blind, controlled trial was conducted in 226 patients with knee osteoarthritis to evaluate the safety and efficacy of intraarticular injections of sodium hyaluronate. Patients were randomized to three weekly injections of 30 mg sodium hyaluronate or physiologic saline (control) and were observed for an additional 25 weeks. In comparison with the control group, among patients who completed at least 15 weeks of the study and whose Western Ontario and McMaster Universities Osteoarthritis Index pain score for the contralateral knee was less than 12 at baseline, sodium hyaluronate injection resulted in improvement in Western Ontario and McMaster Universities Osteoarthritis Index pain score, patient and investigator global assessments, and pain on standing from Weeks 7 to 27. Fifty-eight percent of patients treated with sodium hyaluronate achieved a 5-unit or greater improvement in mean pain score from Weeks 7 through 27, compared with 40% of control patients. In addition, nearly twice as many patients treated with sodium hyaluronate as with saline (30% versus 17%, respectively) achieved a net improvement of at least 7 units. In contrast to treatment with saline, Western Ontario and McMaster Universities Osteoarthritis Index pain score for the contralateral knee was inversely related to the magnitude of improvement after treatment with sodium hyaluronate. Few side effects were attributed to treatment, and no differences between treatment groups were seen in this respect (sodium hyaluronate, nine [8%]; saline, 11 [10%]). The incidence of injection site reactions was low (sodium hyaluronate, 1.2 %; saline, 1.5%). The results indicate that sodium hyaluronate treatment is well tolerated and produces statistically and clinically significant improvement of symptoms in patients with mild to moderate knee osteoarthritis in whom pain in the contralateral knee is relatively modest.

The impact of variable tint optics (Transitions Gray) on vision-related quality of life in normal volunteers: a randomized clinical comparison in a warm climate

PURPOSE

A randomized crossover comparison of Transitions Gray variable tint optics (VTO) vs clear and fixed-tint lenses was undertaken to evaluate the impact of VTO on vision-related quality of life (VRQOL) in a warm climate.

METHODS

Fifty-nine patients were randomized to one of four lens crossover groups: Transitions-->clear; clear-->Transitions; Transitions-->fixed-tint; fixed-tint-->Transitions. Each lens was worn for 30 days. VRQOL was measured using a newly developed and validated questionnaire instrument-the Transitions VRQOL. Changes in visual acuity were assessed by functional exam.

RESULTS

Overall, Transitions was associated with the greatest improvement in VRQOL relative to clear and fixed-tint lenses without compromise in acuity. Transitions proved statistically superior to clear lenses, most notably in vision comfort both indoors and outdoors. Seventy percent of all patients selected Transitions as their primary lens at the end of the study.

CONCLUSIONS

Transitions brand VTO offer patients significant and clinically meaningful improvements in VRQOL superior to clear lenses. VRQOL assessments provide clinicians with valuable information above and beyond visual acuity to help optimize lens product selection and enhance patient satisfaction.

The effectiveness of one-on-one nurse education on the outcomes of high-risk adult and pediatric patients with asthma

The effects of an asthma self-management program on asthma outcomes were evaluated in adult and pediatric patients with asthma who were considered at high risk (i.e., those who were not in control of their disease as determined by resource utilization, medication use, or lack of use). The program consisted of one-on-one nurse-to-patient ("nurse champion") education and subsequent assessment of asthma outcomes using the Asthma Quality Assessment System (AQAS) questionnaire, which measured asthma severity, patient quality of life, asthma awareness and knowledge, confidence in managing asthma, use of peak flow meters, asthma symptoms, medication use, lost work or school days, and affect of asthma. Over the course of six months, nurse champions educated 201 patients from four managed care plans and collected data at baseline and during four follow-up sessions. Adult patients and pediatric patient caregivers reported significant improvements in quality of life, and clinical and process measures. Significant increases in asthma knowledge were observed immediately after patient education, including greater than 89% increase in the proportion of patients who reported that they know "a lot" about the "things that cause asthma symptoms." Significant decreases were also found in work or school days missed, urgent care utilization, and hospital admission rates. Appropriate preventive care visits increased by more than 40%. These results indicate that the nurse champion program was associated with an improvement in asthma outcomes in high-risk adult and pediatric patients and warrant further evaluation in controlled studies. Incorporating one-on-one education programs into asthma management is an effective and rapid means of improving asthma outcomes.

Strategies to increase the use of autogenous arteriovenous fistula in end-stage renal disease

The purpose of this retrospective study was to review our experience with a consecutive group of end-stage renal disease (ESRD) patients using simple strategies to increase the use of autogenous vascular access, and determine whether the current trend of using synthetic bridge-graft fistula (BGF) rather than autogenous arteriovenous fistula (AVF), could be reversed, despite an aging population and broadening criteria for hemodialysis. All patients for vascular access surgery had careful preoperative clinical examination of the arm veins with outflow occlusion to determine the venous anatomy and continuity. Where no veins were apparent or their continuity in doubt, selective preoperative venography was performed. Where veins were unsatisfactory for forearm AVF, new or modified surgical procedures to use both the basilic and cephalic veins in the upper arm were performed. Intraoperative angioscopy was used to monitor vein quality and surgical technique. Ninety-eight primary vascular access procedures were performed in 76 patients, 75 (76.5%) AVF (forearm, n = 41; upper arm, n = 34) and 23 (23.5%) BGF. Forty-one of 76 (54%) had already had at least one previous access procedure prior to this study. More than one access procedure was needed in 16 patients. Preoperative venography was performed in 22 (22.4%) and intraoperative angioscopy in 45 (45.9%) of the 98 procedures. The number of revisions required to maintain patency was significantly higher for BGF (37 revisions in 14/23) than AVF (16 revisions in 13/75) (p < 0.0001, Poisson test) with an annualized secondary revision rate of 1.168 for BGF and 0.173 for AVF (p < 0.0001, Poisson test). AVF had both longer primary (p = 0.0001, log rank test) and secondary patency (p = 0.038, log rank test) than BGF. AVF as the primary vascular access can be significantly increased and the current trend of using BGF reversed with the use of simple clinical strategies to evaluate the suitability of the arm veins for vascular access.

Topoisomerase II alpha expression in normal, inflammatory, and neoplastic conditions of the gastric and colonic mucosa

Topoisomerase II alpha (TP) excises and reconnects double-stranded super-coiled DNA during the replicative cell cycle. We studied the localization of TP and Ki-67 in inflammatory and neoplastic mucosal lesions of the stomach and of TP in similar conditions of the colon. TP expression was correlated with tumor stage, grade, and survival time in the colonic tumors to evaluate its potential utility as a predictive marker for clinical outcome. Forty-three sections of chronic gastritis, lesions indefinite for dysplasia, low- and high-grade dysplasia, and gastric adenocarcinomas were immunostained with antibody against TP and Ki-67. For the colon, 71 sections of normal mucosa, chronic colitis, hyperplastic polyps, adenomas, and carcinomas were examined; fresh tissue was analyzed by flow cytometry. Expression of TP in non-neoplastic gastric mucosa was maximal in neck/foveolar cells and focal in surface and deep gland cells. Increased surface and deep gland positivity was found in low-grade dysplasia and a diffuse distribution of positive cells in high-grade dysplasia and carcinoma. The Ki-67 staining pattern was similar. TP in non-neoplastic colon was restricted to the lower crypt zone; it was greatly expanded in the surface/upper crypt region in adenomas and was diffuse in carcinomas. Flow cytometric analysis revealed TP expression mainly in the S and G2/M phase, with higher labeling index in tumors. There was no correlation of TP with stage, grade, or survival times in the colonic tumors. Staining for TP and Ki-67 might help in the distinction of inflammatory and neoplastic lesions of the stomach and colon.

Association between sucrase-isomaltase and p53 expression in colorectal cancer

BACKGROUND

Sucrase-isomaltase (SI) is a tissue-based phenotypic marker that is an independent prognostic factor in colorectal cancer (CRC). DF3 and galectin 3 are two other tissue-based markers that are upregulated during neoplastic transformation. Because p53 mutations are acquired during neoplastic progression, we reasoned that alterations in SI and p53 may be associated despite an apparent lack of biological interaction.

METHODS

Paraffin sections from 183 patients who underwent surgery at New England Deaconess Hospital (NEDH) between 1965 and 1977 were analyzed first by immunohistochemistry (IHC) for the expression of the markers SI, DF3, and galectin 3, which were scored as absent or present. Paraffin sections from a second group of 59 patients who underwent surgery at NEDH between 1985 and 1992 were analyzed by IHC for the expression of p53 as well as SI, DF3, and galectin 3. p53 nuclear staining was scored as absent or present. Previous work has shown that p53 is mutated in all cells with nuclear staining and in 10% of tumors that are unstained.

RESULTS

SI expression was not associated with the expression of either DF3 or galectin 3, and neither DF3 nor galectin 3 were prognostic factors in CRC. None of the phenotypic markers were associated with any of the clinicopathologic variables. However, 21 of 24 p53-positive cases (88%) expressed SI, whereas 15 of 35 p53-negative cases (43%) were also SI negative (p = 0.02, Fisher exact test). p53 expression was not associated with expression of DF3 or galectin 3.

CONCLUSIONS

SI expression and p53 mutation are associated significantly in CRC. Although the mechanism underlying such an association in presently unknown, the association may define a subset of patients with a worse prognosis.

The effect of aspartame as part of a multidisciplinary weight-control program on short- and long-term control of body weight

This study investigated whether the addition of the high-intensity sweetener aspartame to a multidisciplinary weight-control program would improve weight loss and long-term control of body weight. One hundred sixty-three obese women were randomly assigned to consume or to abstain from aspartame-sweetened foods and beverages during 16 wk of a 19-wk weight-reduction program (active weight loss), a 1-y maintenance program, and a 2-y follow-up period. Women in both treatment groups lost approximately 10% of initial body weight (10 kg) during active weight loss. Among women assigned to the aspartame-treatment group, aspartame intake was positively correlated with percentage weight loss during active weight loss (r = 0.32, P < 0.01). During maintenance and follow-up, participants in the aspartame group experienced a 2.6% (2.6 kg) and 4.6% (4.6 kg) regain of initial body weight after 71 and 175 wk, respectively, whereas those in the no-aspartame group gained an average of 5.4% (5.4 kg) and 9.4% (9.4 kg), respectively. The aspartame group lost significantly more weight overall (P = 0.028) and regained significantly less weight during maintenance and follow-up (P = 0.046) than did the no-aspartame group. Percentage weight losses at 71 and 175 wk were also positively correlated with exercise (r = 0.32, P < 0.001; and r = 0.34, P < 0.01, respectively) and self-reported eating control (r = 0.37, P < 0.001; and r = 0.33, P < 0.01, respectively). These data suggest that participation in a multidisciplinary weight-control program that includes aspartame may facilitate the long-term maintenance of reduced body weight.

Assessment of dietary intakes of cadets at the US Military Academy at West Point

OBJECTIVE

A study was conducted at the US Military Academy, West Point, NY, to assess the nutritional adequacy of menus and dietary intakes of the cadets and to determine the effect of the optional weekday evening meal policy on nutrient intakes.

METHODS

Dietary intakes were obtained over a 7-day period using a diary-interview technique. Volunteer cadets, 118 males and 86 females, recorded their own intakes and were interviewed by dietitians to verify food records. Cadets were categorized by gender and divided into three groups based on whether they consumed 0-1, 2-3, or 4-5 weekday evening meals in the Cadet Mess.

RESULTS

Multivariate methods were used to assess compliance with Military Recommended Dietary Allowances (MRDA) and nutrient densities as well as the role of gender, number of weekday evening meals consumed in the West Point Cadet Mess, and the use of nutritional supplements during the study week. The number of weekday evening meals consumed in the Cadet Mess, was positively correlated with the nutrient intakes of the cadet groups. The female 0-1 group had the highest proportion of individuals with mean intakes providing < 70% MRDA for vitamin B6, folate, vitamin A, magnesium, or zinc. Snacks provided from 24% to 32% of the energy intakes of the female groups and were often substituted for meals, particularly by cadets who ate the fewest meals in the Cadet Mess.

CONCLUSIONS

Diet counseling is recommended to help these cadets choose more nutritious meals and snacks. University and college students that choose not to purchase some of their meals from campus dining facilities could have similar dietary intake patterns and nutritional shortcomings.

The new era in breast cancer. Invasion, size, and nodal involvement dramatically decreasing as a result of mammographic screening

OBJECTIVE

To describe the magnitude of changes and opportunities that may arise for simplified surgical procedures for women with breast cancer because of the decreasing size and lymph node involvement in invasive breast cancer and earlier presentation of noninvasive and invasive breast cancer. DESIGN AND MAIN OUTCOME ASSESSMENT: Cases (N=1001) of breast cancer from a tertiary and a community hospital between 1989 and 1993 were analyzed for invasion, size, nodal status, and change over time.

RESULTS

Ductal carcinoma in situ constituted 14% and 18% of the cancers at the two hospitals. At the tertiary and community hospitals, the mean maximum diameters were 2.1 and 2.0 cm, respectively, and the median maximum diameters were 1.5 and 1.7 cm, respectively, for invasive breast cancer. Twenty-nine percent and 28%, respectively, were 1 cm or less in diameter. Axillary nodal metastases occurred in only 31% of the invasive cancers (tertiary hospital); only 10% had more than three nodal metastases. In the T1a and T1b cases, nodal metastases occurred in only 10% and 43% of the positive nodes were solitary; only 16% had more than three nodal metastases. The proportion of ductal carcinoma in situ, T1a and T1b, and node-negative cases increased significantly over time.

CONCLUSIONS

Within the next decade, the proportion of all breast cancers that are ductal carcinoma in situ will approach 33%, and invasive cancers will approach 1 cm in median maximum diameter. Therapy simplification will be logical because of very small size, low risk of recurrence after breast conservation, and excellent prognosis, and might include increased breast conservation, avoidance of axillary nodal dissection, and omission of radiation therapy to conserve breasts. Adjuvant therapy will be based on the prognostic features of the primary cancer and findings from careful histologic examination of the sentinel lymph nodes.

Sucrase-isomaltase is an independent prognostic marker for colorectal carcinoma

PURPOSE

Expression of disaccharidase sucrase-isomaltase (SI) is significantly enhanced during neoplastic transformation of colonic epithelium. Our study was designed to determine whether expression of SI within primary tumors was significantly associated with survival in patients with colorectal carcinoma (CRC).

METHODS

SI expression was analyzed by immunohistochemistry in paraffin sections from 182 Stage I to III CRC that had been resected for cure at the New England Deaconess Hospital between 1965 and 1977. Expression was scored as absent or present in 1 to 50 percent or more than 50 percent of tumor cells. Associations were explored among SI expression, other clinical or pathologic variables, and overall survival. The data set is mature, with 91 (56 percent) patients who had died of CRC at a median follow-up of 96 months.

RESULTS

Fifty-five percent of primary CRC expressed SI. When the multivariate Cox analysis was performed, nodal status, T stage, primary site, grade, and SI expression were independent covariates. SI expression was not associated with the expression of other clinicopathologic variables but increased the risk of death from colorectal carcinoma by 1.83-fold.

DISCUSSION

These results indicate that SI is a prognostic marker for CRC that is independent of stage-related variables in patients who have undergone potentially curative resections.

Intense sweeteners use and weight change among women: a critique of the Stellman and Garfinkel study

OBJECTIVE

The purpose of this study was to evaluate the work of Stellman and Garfinkel who speculated, based on epidemiologic data, that users of intense sweeteners are more likely than nonusers to gain weight.

METHODOLOGY

We analyzed the study's design and statistical analysis to determine whether the conclusions of Stellman and Garfinkel were supported by the data.

RESULTS

Several methodological flaws and inappropriate statistical analyses were identified. These included: use of data from an unrelated study for which they were not intended; failure to correct for bias due to convenience sampling; use of data from a subpopulation without validation; and stratification of subjects by outcome data.

CONCLUSION

Our analysis indicates that the data from the study in question do not allow one to draw conclusions about a relationship between use of intense sweeteners and weight change. Furthermore, data from well-designed clinical trials have shown that aspartame is not associated with weight gain, and when used as part of a balanced deficit diet, can facilitate weight loss.

Role of angioscopy in reoperation for the failing or failed infrainguinal vein bypass graft

The purpose of this retrospective study is to review our ongoing experience with the use of angioscopy during reoperation for failed or failing infrainguinal vein bypass grafts and define the role of angioscopy in the management of this clinically demanding patient group. All hospital records, arteriograms, and intraoperative angioscopic video recordings of 79 consecutive failed or failing grafts (76 patients) examined with angioscopy during reoperation between 1987 and 1993 were reviewed. Clinical and intraoperative data, comparison of the preoperative arteriogram and intraoperative angioscopic findings, and surgical decisions or interventions resulting from the additional angioscopic findings were collated and analyzed according to a predetermined protocol. Sixty-six additional angioscopic findings were noted during the 79 reoperations and resulted in 61 additional interventions and surgical decisions with salvage of all or part of the graft in 90.9% in the early (< 30 day) failed (group 1), 84.6% in the late (> 30 day) failed (group 2), and 90.3% in the late (> 30 day) failing grafts (group 3). The amount of residual thrombus within the graft, as assessed by angioscopy after all interventions, was the critical determinant for overall early graft patency (p < 0.001) and long-term patency for all the subgroups after reoperation (group 1, p < 0.001; group 2, p = 0.0016; and group 3, p = 0.0194). Intraoperative angioscopy has an important role in these challenging procedures. It provides additional and useful information that not only influences the conduct and extent of the reoperative surgery but may provide insights into the pathogenesis of graft failure.

Expression of colorectal carcinoma-associated antigens in colonic polyps

Immunohistologic techniques were used to study the expression of colorectal carcinoma-associated antigens in colonic polyps and to compare this with expression in the normal colonic epithelium. Forty-nine polyps were studied using monoclonal antibodies to 16 different blood group and differentiation antigens and carcinoembryonic antigen epitopes. With the Lewis(a) antigen and the two epitopes of CEA recognized by 3D6 and COL-4 expression in polyp tissue was the same as that in the normal colon. Five types of alteration of antigen expression in polyps were seen. The blood group antigens A, B, and Lewis(b), which are expressed only on the right side of the normal adult colon, were detected in both neoplastic and nonneoplastic polyps from the distal colon. The Lewis(x) antigen and the antigen epitopes detected by the antibodies COL-12, CA19-9, ME491, and GA73.3 showed an increased frequency of expression in all types of polyps in comparison with the normal colonic epithelium, while H-type 2, ND4, and the antigen epitope detected by CO29.11 showed a slightly decreased frequency of expression in polyp tissue. The X-like antigen which was expressed in only 7% of normal colon specimens showed increased frequency of expression in polyp tissue with significantly greater expression in neoplastic than hyperplastic lesions (P = 0.003). The TAG-72 antigen was detected only in adenomas with severe dysplasia (P = 0.01), correlating well with premalignant histology. These findings have helped us clarify the variation of antigen expression in colonic polyps and allowed us to define which antigens are worthy of further investigation as markers of possible malignant transformation.

Angioscopically directed interventions improve arm vein bypass grafts

PURPOSE

Our purpose was to determine the incidence and segmental distribution of intraluminal disease in the arm veins of patients in whom saphenous vein was unavailable or inadequate for bypass, determine whether angioscopic evaluation and directed interventions can upgrade the quality of arm vein conduit and improve early graft patency, and describe the angioscopic technique of in situ retrograde arm vein inspection.

METHODS

Retrospective review of 109 infrainguinal arm vein bypass grafts in 104 patients performed with intraoperative angioscopic vein preparation and monitoring between August 1989 and March 1992 was undertaken. Four additional arm veins harvested were discarded because of diffuse disease.

RESULTS

Intraluminal disease was noted in 71 (62.8%) of 113 arm veins, "webs" in 61 (54%), vein sclerosis in 25 (22.1%), localized stenosis in 11 (9.7%), and thrombus in 7 (6.2%). Intraluminal disease was most common in the cephalic (forearm 49.2%; arm 35.1%) and median cubital (33.3%) veins and least common in the basilic vein (11.7%). Eighty-three angioscopically directed interventions in 68 of 71 abnormal arm veins resulted in upgraded vein conduit quality in 47 (66.1%) of 71. Primary patency (< 30 days) was 99 (90.8%) of the 109 grafts, 85 (95.5%) of 89 grafts with normal or upgraded quality conduits, and 14 (70%) of 20 inferior-quality grafts (p = 0.0024). These differences persisted through 1 year by life-table analysis, (p < 0.001).

CONCLUSIONS

Not only is the routine use of the angioscope in arm vein bypass grafting a sensitive technique to detect the intraluminal diseases so prevalent in arm veins but it can also direct endoluminal and surgical interventions that upgrade the quality of the vein conduit and improve early graft patency.

Efficacy and tolerability of a combination of enalapril and hydrochlorothiazide in the treatment of hypertension measured manually and with an ambulatory blood pressure monitor

The efficacy and tolerability of an enalapril maleate-hydrochlorothiazide combination (EM-HCTZ) were evaluated in a prospective, open-label study in 26 patients with uncomplicated essential hypertension (mean baseline sitting systolic/diastolic blood pressure: 153/103 mmHg) requiring two agents to reduce sitting diastolic blood pressure (SDBP) below 90 mmHg. Their mean age was 52 years. Patients received enalapril 5 mg daily, which was increased to 10 mg if SDBP was not reduced to < 90 mmHg during a 5-week titration period following washout. If blood pressure did not reach that goal, 25 mg hydrochlorothiazide was added. Only patients who required enalapril 10 mg and hydrochlorothiazide 25 mg for control (SDBP < 90 mmHg) at the end of titration received open-label EM-HCTZ as maintenance therapy for 6 weeks. The SDBP of 19 of the 26 patients (73%) who began titration was controlled at the end of titration, and they received maintenance therapy. During maintenance, the mean SDBP decreased from baseline 13.2 mmHg at week 2, 13.3 mmHg at week 4, and 10.1 mmHg at week 6. All changes from baseline were significant. At the end of the maintenance period, SDBP was controlled in 8 (42%) of 19 patients enrolled. One patient was withdrawn from the study because blood pressure was poorly controlled. Ambulatory blood pressure (ABP) was monitored, average outcome was computed for each patient during the 24-hour interval, and with a paired comparison, baseline and follow-up data were compared with the data measured manually. The mean baseline ABP was 9 mmHg lower than the baseline SDBP measured manually (r = 0.58, P = 0.01). Following treatment with EM-HCTZ, mean diastolic blood pressure fell 10 mmHg and mean systolic blood pressure fell 15 mmHg. In summary, EM-HCTZ was highly effective and generally well-tolerated in a substantial proportion of participants whose SDBP remained > 90 mmHg on enalapril 10 mg. Important differences between blood pressure measured manually and with a monitor were also demonstrated.

Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: results of a prospective randomized trial

PURPOSE

This study was designed to determine whether, in primary infrainguinal bypass grafts in which only saphenous vein is used as the graft conduit, routine monitoring with intraoperative angioscopy can improve early graft patency as compared with standard monitoring with intraoperative completion angiography; and to delineate the advantages and disadvantages of these two modalities and their respective roles for the routine monitoring of the infrainguinal bypass graft.

METHODS

A total of 293 patients undergoing primary saphenous vein infrainguinal bypass grafting were prospectively randomized and monitored with either completion angioscopy or completion angiography. Clinical parameters, indications for operation, graft anatomy, and configuration were evenly matched in both groups. Forty-three bypasses were excluded from the study after randomization, including 12 veins randomized to angiogram, deemed inferior, and prepared with angioscopy.

RESULTS

In the 250 bypass grafts (angioscopy 128, angiography 122) there were 39 interventions (conduit, 29; anastomosis, 8; distal artery, 2), 32 with angioscopy and 7 with angiography (p < 0.0001). Twelve (4.8%) of the 250 grafts failed in less than 30 days, four (3.1%) of 128 in the angioscopy group and eight (6.6%) of 122 in the angiography group (p = 0.11 by one-sided hypothesis test).

CONCLUSION

Although no statistical improvement in the proportions of failures in primary saphenous vein bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram was demonstrated, the study delineates a trend that favors completion angioscopy for routine vein graft monitoring and demonstrates the advantages of angioscopy in preparing the optimal vein conduit.

Using autoregressive and random walk models to detect trends and shifts in unequally spaced tumour biomarker data

Continuous time autoregressive (CAR(1)) and random walk models of time series data are provided for detecting non-random shifts and trends of tumour markers in breast cancer patients following resection for cure. The continuous time random walk model with observation error is extended to the case of multiple patient time series. These models can be used to monitor large numbers of patients with time series with few sampling events that are serially correlated and unequally spaced. Further, the methodologies can be used to recommend appropriate testing intervals. A Kalman filter recursive algorithm is used to calculate the likelihood functions arising from the CAR(1) and random walk models and to calculate recursive residuals, which are monitored by Shewhart-cusum schemes.

Efficacy of famotidine in the healing of active benign gastric ulceration: comparison of nonsteroidal anti-inflammatory- or aspirin-induced gastric ulcer and idiopathic gastric ulceration. Long Island Jewish Medical Center Acid-Peptic Study Group

Seventy-one of 85 consecutive patients with endoscopically confirmed active benign gastric ulcers completed an 8-week study to evaluate the effects on healing of famotidine 40 mg given as a single dose at night. The healing rate in the 48 patients in whom the ulcers were associated with nonsteroidal anti-inflammatory drug (NSAID) or aspirin (ASA) use was compared with that in the 23 patients with idiopathic ulcers. Endoscopy, symptom assessments, antacid use, hematology, and serum chemistry were performed at weeks 4 and 8 of treatment. Famotidine 40 mg at bedtime healed 63 (89%) of the 71 ulcers at 8 weeks; the healing rate for NSAID/ASA-associated ulcers was 46 (96%) of 48, which was significantly greater than that for idiopathic ulcers (17 of 23; 74%) (P = 0.0119). Of the 54 patients who returned a questionnaire 1 to 2 years after completing the study, 20% were still taking an NSAID/ASA (mainly for cardiovascular prophylaxis). About half of the patients surveyed were taking anti-ulcer medication. None of these patients had experienced any serious ulcer complication. The results of this study suggest that differentiating NSAID/ASA-induced ulcers from idiopathic ulcers may be important with regard to healing rates and duration of therapy.

Preoperative risk factors that predict hospital length of stay in coronary artery bypass patients > 60 years old

BACKGROUND

The ability to predict prolonged length of stay (LOS) is essential to control escalating hospital costs. Operative mortality is a poor predictor of LOS; morbidity as defined by hospitalization for > 14 days after coronary artery bypass graft surgery (CABG), appears to be responsible for increasing costs. The purpose of this study was to measure preoperative predictive indicators of increased LOS with an eventual plan to offer alternative cost-benefit therapeutic options.

METHODS AND RESULTS

Nine hundred twenty-four consecutive patients (age, 60-86 years) undergoing CABG were retrospectively studied by means of the Cox proportional hazards model. Seventeen variables, excluding death, were analyzed and quantified as to importance, and point totals were calculated for each patient. Scores were 12 for congestive heart failure and intra-aortic balloon assist device; 10, creatinine > 2; 6, intra-aortic balloon assist device only; 5, congestive heart failure only; 3, obesity; 6, age > 75 years; 3, age 70-75 years; and 2, 65-69 years.

CONCLUSIONS

Increasing index score directly correlated with an exponential increase in LOS. These data substantiate the hypothesis that a mathematical model can predict LOS in CABG patients and may offer rational alternative strategies in delivering cost-effective health care.

Comparison of the efficacy and tolerability of Prinivil and Procardia XL in black and white hypertensive patients

The efficacy and tolerability of Prinivil and Procardia XL were compared in 135 (67 black, 68 white) patients with mild to moderate uncomplicated essential hypertension. The goal of therapy was to achieve and maintain a supine diastolic blood pressure (SDBP) of > 90 mmHg or a decrease in SDBP > or = 10 mmHg. Patients received Prinivil 10 to 40 mg once daily or Procardia XL 30 to 120 mg once daily during a titration period of 2 to 8 weeks to achieve the goal blood pressure before a 4-week maintenance period. The mean baseline supine systolic/diastolic blood pressures were 151/97 mmHg in patients receiving Prinivil and 153/99 mmHg in patients receiving Procardia XL. Ninety-one percent of patients receiving Prinivil and 95% of those receiving Procardia XL achieved SDBP control at the end of titration therapy. At the end of the maintenance treatment period, 79% of patients receiving Prinivil and 80% of those receiving Procardia XL had SDBP control. Mean decreases in SDBP from baseline were comparable for both treatment groups. At the end of the titration period, mean decreases were 9.6 mmHg in patients receiving Prinivil and 11.3 mmHg in patients receiving Procardia XL; at the end of the maintenance period, mean decreases were 10.8 mmHg and 12.1 mmHg, respectively. There were no differences in treatment responses in either the black or white hypertensive subgroups. Thus both drugs were equally effective in black and white patients with mild to moderate essential hypertension. Both drugs were generally well tolerated, but the number of adverse experiences requiring discontinuation of therapy was significantly higher (P = 0.03) in patients receiving Procardia XL.

Technical and biological factors in disease-free survival after hepatic resection for colorectal cancer metastases

Careful patient selection for hepatic resection of colorectal cancer metastases is essential to improve current poor results. Carcinoembryonic antigen level and number of metastases were significant preoperative prognostic indicators of 5-year disease-free survival in patients selected clinically for hepatic surgery. Surgical margin, weight of hepatic tissue resected, carcinoembryonic antigen level, and flow cytometry were significant postoperative prognostic indicators. Patients with a carcinoembryonic antigen level less than 200 ng/mL, 1-cm surgical margins, and less than 1,000 g of liver tissue removed had a greater than 50% estimated 5-year disease-free survival rate. If the metastases were diploid on flow cytometry, an additional survival advantage may have been gained. Inadequate surgical margins led to high rates of liver-only recurrence. Nonhepatic recurrence was unrelated to surgical margins. Intraoperative liver examination by ultrasound during primary colon cancer resection and adjuvant chemotherapy may offer earlier selection of biologically appropriate patients and improved outcome; both recommendations require clinical trials.

Using an autoregressive model to detect departures from steady states in unequally spaced tumour biomarker data

A new method, based on a continuous time autoregressive [CAR(1)] model of time series data, is provided for detecting departures of tumour markers from steady states in breast cancer patients following surgery. A Kalman filter recursive algorithm is used to calculate the likelihood function arising from the CAR(1) model and to calculate recursive residuals, which are monitored by a Shewhart-Cusum scheme. This approach can be used to monitor the serial marker data of large numbers of patients even when the series are short and the data are serially correlated and unequally spaced. Further, the methodology can be used to recommend appropriate testing intervals.

Hemodynamic and metabolic responses to graded microvascular occlusion

The hemodynamic and metabolic consequences of microvascular occlusion, often present in the runoff bed of distal arterial reconstructions, have been difficult to quantitate clinically. To investigate these pathophysiologic relationships, a porcine hindlimb model was developed in which arteriolar patency, which we term outflow capacity, may be quantitatively defined and reduced by serial distal microembolization with 70 microns flow-directed glass bubbles. In 10 anesthetized adult pigs, hindlimb perfusion was limited to femoral artery flow (FAF) by collateral ligation. Serial measurements of outflow resistance (OR), femoral artery flow, and resting muscle pH (mpH), a metabolic index of tissue perfusion, were made as relative outflow capacity (ROC) underwent graded reduction from 1.0 (baseline) to 0 (complete occlusion). Femoral artery flow decreased linearly (FAF = 87 ROC - 3), and outflow resistance increased in hyperbolic fashion (OR = 1.66/ROC) in response to graded peripheral microembolization, whereas resting muscle pH followed a more complex relationship (In mpH = 0.055 ROC + 1.95). An integrated analysis of these results suggests that a 50% to 60% reduction in arteriolar patency represents a critical point beyond which outflow resistance rises rapidly and hindlimb flow decreases to levels that are inadequate to support the metabolic demands of resting tissues.

Comparison of the efficacy and tolerability of lisinopril and sustained-release verapamil in older patients with hypertension

The efficacy and tolerability of lisinopril and sustained release (SR) verapamil hydrochloride were compared in 68 patients (mean age, 60 years) with mild to moderate uncomplicated essential hypertension. The goal of therapy was to achieve and maintain a supine diastolic blood pressure (SDBP) of less than 90 mmHg or a fall in SDBP greater than or equal to 10 mmHg. Patients received lisinopril (10 to 40 mg QD) or verapamil SR (120 to 480 mg QD) during a variable titration period (two to eight weeks) to achieve goal blood pressure prior to a four-week maintenance treatment period. Among the 62 patients who completed the titration period, the mean baseline supine systolic/diastolic blood pressures were 155/97 mmHg for the lisinopril group and 150/95 mmHg for the verapamil SR group. Ninety-seven percent of patients in the lisinopril group and 100% of patients in the verapamil SR group achieved SDBP control at the end of titration therapy. At the end of the maintenance treatment period, 82% of the lisinopril-treated patients and 81% of the verapamil SR-treated patients had SDBP control. Mean decreases in SDBP from baseline were comparable for both treatment groups. At the end of titration, mean decreases were 11.3 mmHg for the lisinopril group and 10.7 mmHg for the verapamil SR group; at the end of maintenance treatment, mean decreases were 10.5 mmHg and 8.5 mmHg. Thus both drugs were equally effective in older patients with mild to moderate essential hypertension. Both drugs were generally well tolerated. One patient in the lisinopril group and four patients in the verapamil SR group experienced adverse effects that required withdrawal from the study.

Comparison of the efficacy and tolerability of lisinopril and sustained-release verapamil in black patients with hypertension

In this clinical study the efficacy and tolerability of lisinopril and sustained-release (SR) verapamil hydrochloride were compared in black patients with mild-to-moderate uncomplicated essential hypertension. The goal of therapy was to achieve a supine diastolic blood pressure (SDBP) of less than 90 mmHg or a greater than or equal to 10-mmHg fall in SDBP. Forty-three patients completed the titration phase, 23 in the lisinopril group and 20 in the verapamil SR group. The mean baseline supine systolic/diastolic blood pressures were 147/98 mmHg for the lisinopril group and 155/100 mmHg for the verapamil SR group. At the end of a two- to eight-week titration period, 87% of the lisinopril-treated patients and 90% of the verapamil SR-treated patients had achieved SDBP control. Six patients were excluded from maintenance therapy: four in the lisinopril group (one because of urticaria and three because of failure to reach goal blood pressure) and two in the verapamil SR group (because of failure to reach goal blood pressure). After eight weeks of maintenance therapy, 68% of the lisinopril-treated patients and 72% of the verapamil SR-treated patients had achieved SDBP control. The mean decreases in SDBP were comparable for both treatment groups. At the end of titration, the mean decreases from baseline were 10.5 mmHg for the lisinopril group and 12.6 mmHg for the verapamil SR group. At the end of maintenance, the mean decreases from baseline were 7.8 mmHg for the lisinopril group and 9.2 mmHg for the verapamil SR group. Adverse experiences were few.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy and tolerability of famotidine and ranitidine on the healing of active duodenal ulcer and during six-month maintenance treatment, with special reference to NSAID/aspirin-related ulcers

The subjects of this multicenter study were 160 patients with endoscopically confirmed active duodenal ulcers, randomly assigned to receive 40 mg of famotidine or 300 mg of ranitidine nightly for four to eight weeks. During a subsequent six-month maintenance treatment phase, the patients received 20 mg of famotidine or 150 mg of ranitidine nightly. After eight weeks of treatment, ulcer healing was endoscopically confirmed in 94% of the 81 famotidine-treated patients and in 80% of the 79 ranitidine-treated patients (P less than 0.01). During the first week of treatment, daytime and nighttime pain scores were significantly lower in the famotidine-treated than ranitidine-treated patients. During the maintenance treatment phase, the ulcer in 79% of 58 famotidine-treated patients and in 81% of 52 ranitidine-treated patients remained healed. Multivariate analysis of factors such as age, sex, smoking, alcohol and coffee consumption, use of nonsteroidal anti-inflammatory drugs (NSAIDs), history of ulcer, and ulcer size and number showed that they had no significant effects on the differences in healing rates between the two treatment groups. The ulcers were all healed in the famotidine-treated patients whose ulcers were associated with the prior use of NSAIDs. The results of this and many other studies indicate that, unless ulcer healing is confirmed by endoscopy, treatment of active duodenal ulcers should continue for six to eight weeks.

A comparison of the efficacy and tolerability of enalapril and sustained-release diltiazem in mild to moderate essential hypertension

The subjects of this multicenter study were 159 patients aged 21 to 76 years with mild to moderate uncomplicated essential hypertension. The patients were randomly assigned to receive up to 40 mg of enalapril daily or 360 mg of sustained-release diltiazem daily for a titration period of eight weeks and then maintenance doses for four weeks. The treatment goal was a supine diastolic blood pressure of less than 90 mmHg or a fall of at least 10 mmHg from baseline. During titration, 62% of the enalapril-treated patients and 51% of the diltiazem-treated patients reached the treatment goal after two weeks, 82% and 74% after four weeks, 87% and 84% after six weeks, and 92% and 87% after eight weeks. During the maintenance period, 85% of the enalapril-treated and 87% of the diltiazem-treated patients maintained the goal blood pressure. Treatment side effects were reported by 21% of the enalapril-treated patients and 29% of the diltiazem-treated patients; treatment was discontinued in two patients from each group because of side effects. It is concluded that both drugs were generally well tolerated and effective in the treatment of adult mild to moderate essential hypertension.

Statistical analysis of the effects of trial, reader, and replicates on MIC determination for cefoxitin

A pilot study was designed to estimate the variance components in the determination of the MIC of cefoxitin for isolates of the Bacteroides fragilis group. Twenty different organisms were tested, and replicate, trial, and reader variabilities were examined. When the total-variance component was used, if the true MIC was 16 micrograms/ml, then the chance that the observed MIC was between 8 and 32 micrograms/ml, inclusive, was 95%. For all analyses, the isolate (P = 0.0001) and reader (P less than 0.03) effects were significant. The probability of specific MIC observations for various true MICs (over the range of 16 to 32 micrograms/ml at 4-micrograms/ml increments) was calculated. For true MICs of 20, 24, and 28 micrograms/ml, the probabilities of observing an MIC of 16 or 32 micrograms/ml (inclusive) were 86, 75, and 62%, respectively. An upward bias was shown to exist in addition to sources of sizeable variation. The recommendation stemming from recognition of this inherent variability is that ranges of percent susceptibility at various concentrations be included in reports of in vitro susceptibility studies.

Treatment of metastatic renal cell carcinoma with autolymphocyte therapy. Low toxicity outpatient approach to adoptive immunotherapy without use of in vivo interleukin-2

Thirty-six patients with Stage IV renal cell carcinoma were treated with autolymphocyte therapy (ALT). This new form of adoptive immunotherapy is based on the infusion of relatively small numbers of autologous lymphocytes that are depleted of suppressor cells and immunized in vitro by a method designed for antigen-specific activation using a 3M KCl extract of autologous tumor and an autologous lymphokine mixture. Patients received six monthly infusions of immunized lymphocytes, all on an outpatient basis. The majority of patients experienced no toxicity. The few reactions that occurred were minor and self-limiting; none required any medical intervention or subsequent delay in therapy. Patients also received oral cimetidine to reduce in vivo suppressor cell function. Survival at twenty-four months is 36 percent. Median survival is fifteen months, a significant improvement over the natural history of this disease. A multi-site, randomized, controlled trial of ALT in renal cell carcinoma has been initiated to confirm that this treatment causes a significant prolongation of survival with virtually no toxicity in these patients.

Effect of autolymphocyte therapy on survival and quality of life in patients with metastatic renal-cell carcinoma

To assess the value of autolymphocyte therapy (ALT) in the treatment of metastatic renal-cell carcinoma, 90 patients were randomised to receive every month for six months oral cimetidine plus an infusion of autologous peripheral blood lymphocytes activated in vitro by a previously generated autologous lymphokine mixture, or cimetidine alone. The median follow-up was 15 months. Survival time for the autolymphocyte group was approximately 2.5 times that for the cimetidine group (p = 0.008). Patients who had greater than 500 pg interleukin-1 (IL-1) per ml autologous lymphokine mixture had a six-fold survival advantage over those with less than 500 pg/ml (p less than 0.00005). Men treated with ALT had a four-fold survival advantage (p = 0.001) over men who received cimetidine only. Infusion of the cultured autolymphocytes was accompanied by mild, self-limited fever in 11 of the 45 ALT patients, and by only one instance in which fever was accompanied by tachypnoea and hypotension.

Efficacy and tolerability of enalapril and sustained-release verapamil in older patients with mild to moderate essential hypertension

The study involved 113 patients over age 50 years with mild to moderate essential hypertension, randomly assigned to treatment with enalapril (n = 54) or sustained-release verapamil (n = 59). During an eight-week titration period, doses were adjusted to achieve supine diastolic blood pressures (DBP) below 90 mmHg; patients were then given maintenance doses for eight weeks. Mean blood pressures were reduced significantly from 147.7/93.9 mmHg at baseline to 137.7/84.5 mmHg at the end of the maintenance period in the enalapril group and from 155.1/95.1 to 142.4/86.2 mmHg in the verapamil group. In the patients who completed treatment, the mean daily doses required to maintain DBP below 90 mmHg were 9.6 mg of enalapril and 244.9 mg of verapamil. There were 11 treatment failures in the enalapril group and 22 in the verapamil group: eight of the enalapril and 17 of the verapamil patients did not attain goal blood pressures and three and five were withdrawn because of side effects. It is concluded that both enalapril and sustained-release verapamil were generally effective and well tolerated in the treatment of mild to moderate hypertension in the middle-aged and older patients.

The expression of colorectal carcinoma-associated antigens in the normal colonic mucosa. An immunohistochemical analysis of regional distribution

Immunohistologic studies were performed to evaluate the expression and regional distribution of 20 colorectal carcinoma-associated antigens in the colonic mucosa of 12 normal adults. A distinct regional variation was seen in the expression of blood group A, B, Lewis(b), and extended Lewis(y) antigens, which were expressed predominantly in the right colon, whereas Lewis(a), Lewis(y), and H-type 2 were prevalent throughout. Lewis(x) and X-like antigens were only occasionally expressed. Two antibodies against sialylated Lewis(a) showed different staining patterns, with CA19.9 positive in only two biopsies and CO29.11 intensely positive in most. Two of the three antibodies detecting carcinoembryonic antigen epitopes (3d6 and COL-4) stained many biopsies, whereas COL-12 was rarely detected. No regional gradient was found in the expression of the other antigens studied (B72.3, ME491; GA73.3, ND1, and ND4). This mapping data will provide an important baseline for future studies of epitope distribution in the colon in premalignant and neoplastic conditions.

Determinants of the pressor effect of phenylpropanolamine in healthy subjects

Phenylpropanolamine (PPA) is frequently used in over-the-counter diet aids and cold medicines, In view of concern about the safety of this sympathomimetic agent, we undertook a double-blind, multicenter clinical trial to determine the factors that influence the pressor effect of short-term oral administration of PPA in healthy individuals. Eight hundred eighty-one healthy individuals in four categories of body weight were randomized to receive placebo capsules three times per day (n = 286), a 75-mg sustained-release PPA hydrochloride preparation once per day (n = 296) followed by two doses of placebo capsules, or a 25-mg immediate-release PPA hydrochloride preparation three times per day (n = 299). The median age of the study population was 28 years, 56% were men, 73% were white, and 47% were in excess of 30% above their ideal body weight. Measurements of pulse rate and supine and standing blood pressure were made 11 times during the day of PPA administration. A statistically significant but clinically unimportant pressor effect for the short-term administration of PPA was observed. The effect occurred in the first 6 hours after administration and was greater in the sustained-release group. Significant independent determinants of the pressor effect of PPA were baseline diastolic blood pressure, baseline body weight, and treatment.

Ovarian clear cell carcinoma. A clinicopathologic analysis of 44 cases

The clinical aspects and pathologic findings in 44 cases of pure clear cell carcinoma of the ovary are presented. The patients ranged in age from 28 to 78 years (mean, 50.6 years); 54% were nulliparous. Thirty-three percent of the patients had endometriosis in the involved ovary, and an additional 25% had endometriosis only in sites distant from the tumor. Microscopically, three architectural patterns (papillary, tubulocystic, and solid) and four cell types (clear, hobnail, eosinophilic, and flattened) were seen. A predominant tubulocystic architectural pattern was a good prognostic factor (p less than 0.01); however, no significant difference in survival by cell type was found. Grading of the tumors by conventional architectural and cytologic criteria had no predictive value for survival. Stage at presentation was the most important prognostic factor (p less than 0.001), with a 5-year overall survival of 34% and stage I survival of 55%. The poor stage I survival reflects the 15 patients (34%) in the study with stage Iaii lesions. In the 25 patients who developed recurrence, both distant organ involvement (40%) and lymph node involvement (40%) were frequent. Ovarian clear cell carcinoma has unusual pathologic and clinical features, and it represents a distinct histologic type of ovarian carcinoma.