Comparative study of advanced-stage Hodgkin's lymphoma patients treated with either COPP or ABVD drug combinations]

Between January 1985 and March 1988, 45 patients with advanced Hodgkin's disease were randomly assigned to receive either COPP (22 patients) or ABVD (23 patients). 9 and 16 patients achieved complete remission in the COPP and ABVD groups, respectively. One of the complete responders (COPP) relapsed during the follow-up. Patients treated with COPP experienced myelosuppression and neurotoxicity more frequently whereas alopecia and gastrointestinal symptoms were observed among those receiving ABVD. Present data confirm the favorable impact of primary ABVD treatment in advanced Hodgkin's disease.     

High-concentration contrast media in MDCT angiography: principles and rationale

MD-CTA is a powerful and continuously evolving technology for noninvasive (minimally invasive) cardiovascular imaging. CM administration is an integral part of this evolution, and needs to be continuously adopted and optimized to take full advantage of this technology. A basic understanding of physiologic and pharmacokinetic principles, as well as an understanding of the effects of injection parameters on arterial enhancement—in terms of injection rate and injection duration—allow the development of optimized CM delivery protocols for current and future vascular MDCT.     

Broncho-subcutaneous fistula in a patient with reactivation tuberculosis

We report a case of reactivation tuberculosis with the additional complication of a large broncho-subcutaneous fistula in a post-tuberculous lobectomy fibrothorax. The Spiral CT findings of both pathologies are described and the importance of multiplanar reconstruction for establishing the correct diagnosis and planning subsequent surgical therapy is emphasised. Correspondence to: A. A. B ankier     

Perfusion CT measurements predict tumor response in rectal carcinoma

Abdominal Radiology - To evaluate the capacity of perfusion CT imaging to distinguish between complete and incomplete responders after neoadjuvant chemoradiation therapy for rectal carcinoma, with...     

From the Cover: Carnivorous leaves from Baltic amber

The fossil record of carnivorous plants is very scarce and macrofossil evidence has been restricted to seeds of the extant aquatic genus Aldrovanda of the Droseraceae family. No case of carnivorous plant traps has so far been reported from the fossil record. Here, we present two angiosperm leaves enclosed in a piece of Eocene Baltic amber that share relevant morphological features with extant Roridulaceae, a carnivorous plant family that is today endemic to the Cape flora of South Africa. Modern Roridula species are unique among carnivorous plants as they digest prey in a complex mutualistic association in which the prey-derived nutrient uptake depends on heteropteran insects. As in extant Roridula, the fossil leaves possess two types of plant trichomes, including unicellular hairs and five size classes of multicellular stalked glands (or tentacles) with an apical pore. The apices of the narrow and perfectly tapered fossil leaves end in a single tentacle, as in both modern Roridula species. The glandular hairs of the fossils are restricted to the leaf margins and to the abaxial lamina, as in extant Roridula gorgonias. Our discovery supports current molecular age estimates for Roridulaceae and suggests a wide Eocene distribution of roridulid plants.Plant carnivory is traditionally defined as the attraction, capture, and digestion of prey by vegetative traps, with the subsequent uptake of nutrients (1, 2). Some carnivorous plants, however, challenge the boundary of the botanical carnivory concept because they depend on commensal organisms for the digestion of their prey (2, 3). The most famous representative of those plants is Roridula, placed in the monogeneric family Roridulaceae that is endemic to a few localities in the southwestern Cape of South Africa (4, 5).The resinous glandular leaves of both extant species, Roridula dentata and Roridula gorgonias, capture plenty of arthropods. The sticky trapping glue of Roridula is a viscous lipophilic resin containing triterpenoids as major component, which does not allow dissolution of digestive enzymes (6). Consequently, the secretory glands of Roridulaceae lack enzymatic activity (7, 8). For prey-derived nutrient uptake, Roridula depends on two obligately associated heteropteran Pameridea species (family Miridae, “capsid bugs”), which feed on the trapped animals (5, 9). In this “digestive mutualism” (10), the nutrient-rich fecal compounds of these “Roridula bugs” are incorporated by Roridula through nanometer-sized cuticular gaps and serve for a better alimentation in a nutrient-poor habitat (7, 8, 10, 11). The benefit of nutrient uptake from captured prey is the essential criterion for the concept of botanical carnivory (1, 2) and thus includes Roridulaceae (11, 12).Here, we report two leaf fossils from Eocene Baltic amber possessing the relevant morphological features of an adhesive flypaper trap plant that we assign to the Roridulaceae lineage (Figs. 1–3). Both specimens originate from the Jantarny amber mine near Kaliningrad (Russia). The amber-bearing sediments of this fossil site date to 35–47 million years ago (13, 14).Open in a separate windowFig. 1.Carnivorous leaves from Eocene Baltic amber. (A) Overview of the leaf enclosed in amber specimen GZG.BST.27310 showing the adaxial tentacle-free side in slightly oblique view and stalked glands at the margin and on the abaxial side; arrowhead points to the exceptional long tentacle stalk with several branched oak trichomes attached. (B) Overview of the leaf enclosed in amber specimen GZG.BST.27311, showing abundant tentacles on the abaxial side. (C) Margin of abaxial leaf surface with tentacles of different size classes and nonglandular hyaline trichomes. (D) Leaf apex tapering into a sole tentacle. (E and F) Glandular heads with central pore (arrowheads) from both leaves. (Scale bars: A and B, 1 mm; C and D, 100 µm; E, 10 μm; F, 40 μm.)Open in a separate windowFig. 3.Carnivorous leaf from Eocene Baltic amber (A and B; GZG.BST.27310) and leaves of extant Roridula gorgonias (C and D). (A) Exceptionally long tentacle stalk (with several branched oak trichomes attached) of the fossil leaf representing the fifth size class of stalked glands. (B and C) Overviews showing the tentacle-free adaxial surface and tentacles along the leaf margins. (D) Partial leaf tip showing different size classes of stalked glands. (Scale bars: A, 100 µm; B, 500 µm; C and D, 1 mm.)     

Critical Pathways for Patients with Acute Chest Pain at Low Risk

Critical pathways are predefined protocols that define the crucial steps in evaluating and treating a clinical problem to improve quality of patient care, reduce variability and enhance efficiency. Critical pathways have proliferated for a variety of diagnoses, including evaluation of patients with chest pain, a common and costly complaint. This review will outline the development, implementation, and assessment of critical pathways using as a paradigm our experience with a pathway for patients presenting to the Emergency Department with acute chest pain who are at low risk of myocardial ischemia. The goals of the pathway were to expedite evaluation of low-risk patients and reduce admission rates among these patients and in the cohort overall without compromising outcomes.The pathway was developed by a multidisciplinary team in an iterative process that considered published literature, as well as the experience and consensus of local opinion leaders. Patients at least 30 years old presenting to the Emergency Department of an urban teaching hospital who were pain-free without heart failure or ischemic changes on EKG, but who were not considered appropriate for discharge by the treating physician, were eligible for the critical pathway. The pathway involved one set of creatine kinase-MB enzymes drawn at least 4 hours after pain, a 6 hour observation period after the last episode of pain and exercise testing. Outcomes during evaluation and admission rates were assessed. Clinical outcomes at 7 days and 6 months after evaluation and patient satisfaction at 7 days were also measured.Of 1363 patient visits, 145 (10.6%) were triaged by the pathway: 131 (90.3%) were discharged, 14 (9.7%) were admitted. The overall admission rate decreased from 63% (2898/4595) to 60% (819/1363) [p < 0.05] in comparison to a cohort studied prior to pathway implementation. Pathway patients reported low rates of subsequent cardiac procedures. No deaths or myocardial infarctions were recorded. At 7 days, only 2 respondents (2%) reported going to an Emergency Department since their evaluation. Most respondents (83%) rated their care as very good or excellent.Critical pathways designed to enhance efficiency, reduce variability, and improve the quality of care are becoming increasingly common. Our pathway for evaluation of patients with chest pain at low risk of myocardial ischemia was feasible and safe and was associated with a decline in absolute admission rates. Because of the possibility of concomitant secular trends and the effects of a changing medical environment, further rigorous research on the efficacy of individual pathways is needed.     

Clinical and echocardiographic correlates of health status in patients with acute chest pain

Objective  To assess the ability of echocardiographic data to predict important functional status outcomes in patients with chest pain. Design  Prospective cohort study. Setting  A large, urban teaching hospital. Patients  Three hundred thirty-three patients admitted from the Emergency Department for evaluation of chest pain. Measurements and Main Results  Patients underwent two-dimensional and Doppler echocardiography as well as a face-to-face interview during their initial hospitalization and a telephone interview 1 year thereafter. The interview included the Medical Outcomes Study 36-Item Short Form (SF-36) health inventory, a generic health status instrument with a physical function subscale. The relation between clinical and echocardiographic factors and functional status was explored by univariable and multivariable linear regression and logistic regression analyses. Multiple clinical and echocardiographic factors correlated significantly with functional status measures at 1 year. For the SF-36 score at 1 year, age, male gender, white race, the presence of rales, and a comorbidity score were independently predictors in multivariate analysis; echocardiographic findings of severe left ventricular dysfunction (parameter estimate [PE] −27.6; 95% confidence interval [CI] −43.1, −12.2) and aortic insufficiency (PE −16.7; 95% CI −26.4, −7.0) added independent predictive information. Explanatory power (r ²) for models using clinical and demographic variables was .27 and increased after inclusion of echocardiographic data to an r ² of .35. Results in the subset of patients (n=148) with acute coronary syndromes such as unstable angina or myocardial infarction were qualitatively similar. Selected factors (rales on examination, electrocardiographic changes suggestive of ischemia, and moderate to severe mitral regurgitation) also predicted which patients would die or have a decline in their functional status. In multivariate analysis, only rales remained an independent predictor of poor outcome (odds ratio 2.4; 95% CI 1.2, 4.5). Conclusions  Echocardiographic data are correlated with measures of functional status in patients with chest pain, but the ability to predict future functional status from clinical or echocardiographic information is limited. Because functional status cannot be predicted adequately from either patients’ characteristics or echocardiographic testing, it must be assessed directly. Dr. Fleischmann is the recipient of a Clinical Investigator Development Award (IK08HL02964-01) from the National Heart, Lung and Blood Institute.     

Dose response and safety study of meloxicam up to 22.5 mg daily in rheumatoid arthritis: a 12 week multicenter, double blind, dose response study versus placebo and diclofenac

OBJECTIVE: This Phase III, placebo and active controlled, multicenter trial evaluated the efficacy and safety of meloxicam 7.5, 15, and 22.5 mg daily for the treatment of rheumatoid arthritis (RA). METHODS: A 12 week, randomized, double blind, double dummy, parallel group trial compared daily oral meloxicam 7.5, 15, and 22.5 mg to placebo (negative control) and diclofenac 75 mg BID (positive control). A total of 894 patients (18 years of age with confirmed RA who flared following an NSAID-free period) were randomized to be treated. Baseline scores for all endpoints were similar among the treatment groups. Patient assessments were at 0, 2, 4, 8, and 12 weeks or early termination. RESULTS: All treatment groups demonstrated significant improvement from baseline (p < 0.001). Meloxicam 7.5 and 22.5 mg was significantly superior to placebo in all 5 primary efficacy endpoints (swollen joint count, tender joint count, patient pain, patient and physician global; all p < 0.05). Diclofenac 150 mg was superior to placebo for 4 of 5 primary efficacy measures (all but swollen joint count; p < 0.05) and meloxicam 15 mg was superior for 3 of 5 primary endpoints (patient pain and patient and physician global). AUC of patient global, patient pain, and modified Health Assessment Questionnaire demonstrated dose-response (p < 0.04), while AUC ACR20 showed a qualitative trend in the same direction. The rate of gastrointestinal (GI) events during the 12 week trial for all doses of meloxicam and diclofenac did not differ significantly from placebo (23.2-32.0%). GI withdrawals were comparable and not significantly different across all treatment groups (4.3-5.7%). CONCLUSION: This trial demonstrated a dose response relationship for meloxicam 7.5, 15, and 22.5 mg using AUC measurement of response for the treatment of RA. All 3 doses of meloxicam. and positive control, were effective in the treatment of RA. The overall incidence rate of GI events did not differ significantly from placebo in either the meloxicam treatment groups or the positive control.