Can a practicing surgeon detect early lymphedema reliably?

BACKGROUND: Lymphedema may be identified by simpler circumference changes as compared with changes in limb volume. METHODS: Ninety breast cancer patients were prospectively enrolled in an academic trial, and seven upper extremity circumferences were measured quarterly for 3 years. A 10% volume increase or greater than 1 cm increase in arm circumference identified lymphedema with verification by a lymphedema specialist. Sensitivity and specificity of several different criteria for detecting lymphedema were compared using the academic trial as the standard. RESULTS: Thirty-nine cases of lymphedema were identified by the academic trial. Using a 10% increase in circumference at two sites as the criterion, half the lymphedema cases were detected (sensitivity 37%). When using a 10% increase in circumference at any site, 74.4% of cases were detected (sensitivity 49%). Detection by a 5% increase in circumference at any site was 91% sensitive. CONCLUSIONS: An increase of 5% in circumference measurements identified the most potential lymphedema cases compared with an academic trial.     

Intrathecally applied flurbiprofen produces an endocannabinoid-dependent antinociception in the rat formalin test

It is generally accepted that the phospholipase-A2-cyclooxygenase-prostanoids-cascade mediates spinal sensitization and hyperalgesia. However, some observations are not in line with this hypothesis. The aim of the present work was to investigate whether different components of this cascade exhibit nociceptive or antinociceptive effects in the rat formalin test. Intrathecal (i.th.) injection of prostaglandin E2 (PGE2) induced a dose-dependent antinociceptive effect on the formalin-induced nociception. Furthermore, thimerosal, which inhibits the reacylation of arachidonic acid thereby enhancing arachidonic acid levels, had an antinociceptive effect rather than the expected pronociceptive effect when given i.th. While the phospholipase A2 inhibitor methyl arachidonyl fluorophosphonate (MAFP; i.th.) had a significant antinociceptive effect, its analogue palmitoyl trifluoromethyl ketone (PTFMK; i.th.) had no significant effect on the formalin-induced nociception. However, MAFP, but not PTFMK, showed a cannabinoid CB1 agonistic effect as shown by the inhibition of electrically evoked contractions of the vas deferens isolated from CB1 wild-type mice but not of that from CB1 knockout mice. The antinociceptive effect of MAFP was completely reversed by the CB1 receptor antagonist AM-251 (i.th.), thus attributing such effect to its CB1 agonistic effect. Moreover, the antinociceptive effect of the cyclooxygenase inhibitor, flurbiprofen (i.th.) was reversed by the co-administration of AM-251, but not by PGE2. Finally. the combination of phenylmethylsulfonyl fluoride (PMSF; intraperitoneal), which inhibits the degradation of anandamide through the inhibition of fatty acid amidohydrolase, with thimerosal (i.th.) produced a profound CB1-dependent antinociception. The present results show that endocannabinoids play a major role in mediating flurbiprofen-induced antinociception at the spinal level.     

The relative contributions of the prosthetic and sound limb to balance control in unilateral transtibial amputees

In unilateral transtibial amputees maintenance of standing balance is compromised due to the lack of active ankle control in the prosthetic limb. The purpose of this study is to disentangle the contribution of the prosthetic and sound limb to balance control following waist-pull perturbations. We compared the contribution of the hip and ankle joints to balance control of 15 unilateral transtibial amputees and 13 able-bodied controls after been externally perturbed through release of a pulling force. Perturbations were applied in four different directions. Outcome measure was the proportion of joint moment integrated over time generated by the hip and ankle joints in order to restore static stability after perturbation. Analyses revealed that perturbations in backward/forward direction were recovered mainly by the ankle strategy. The amputees compensated for the absence of active ankle control in the prosthetic limb by increasing the ankle moment in the sound limb. Interestingly, the passive properties of the prosthetic foot contributed to balance control, which has important implications for prosthetic fitting and standing stability in lower limb amputees. Amputees and controls resisted perturbations in medio-lateral direction by generating the necessary hip moments. Finally, these findings are discussed with respect to prosthetic design and rehabilitation processes.     

Reinvestigation of the synthesis and evaluation of [N-methyl-11C]vorozole,a radiotracer targeting cytochrome P450 aromatase

IntroductionWe reinvestigated the synthesis of [N-methyl-¹¹C]vorozole, a radiotracer for aromatase, and discovered the presence of an N-methyl isomer which was not removed in the original purification method. Herein we report the preparation and positron emission tomography (PET) studies of pure [N-methyl-¹¹C]vorozole.MethodsNorvorozole was alkylated with [¹¹C]methyl iodide as previously described and also with unlabeled methyl iodide. A high-performance liquid chromatography (HPLC) method was developed to separate the regioisomers. Nuclear magnetic resonance (NMR) spectroscopy (¹³C and 2D-nuclear Overhauser effect spectroscopy NMR) was used to identify and assign structures to the N-methylated products. Pure [N-methyl-¹¹C]vorozole and the contaminating isomer were compared by PET imaging in the baboon.ResultsMethylation of norvorozole resulted in a mixture of isomers (1:1:1 ratio) based on new HPLC analysis using a pentafluorophenylpropyl bonded silica column, in which vorozole coeluted one of its isomers under the original HPLC conditions. Baseline separation of the three labeled isomers was achieved. The N-3 isomer was the contaminant of vorozole, thus correcting the original assignment of isomers. PET studies of pure [N-methyl-¹¹C]vorozole with and without the contaminating N-3 isomer revealed that only [N-methyl-¹¹C]vorozole binds to aromatase. [N-methyl-¹¹C]Vorozole accumulated in all brain regions with highest accumulation in the aromatase-rich amygdala and preoptic area. Accumulation was blocked with vorozole and letrozole consistent with reports of some level of aromatase in many brain regions.ConclusionsThe discovery of a contaminating labeled isomer and the development of a method for isolating pure [N-methyl-¹¹C]vorozole combine to provide a new scientific tool for PET studies of the biology of aromatase and for drug research and development.     

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Colorectales Carcinom – Behandlungsalternative durch intraoperative Radiotherapie mittels Afterloading-flab-Technik?

Zusammenfassung. Mit der Afterloading-flab-Technik steht ein technisch einfaches, wenig belastendes Verfahren zur Therapie von Colon- und Rectumcarcinomrezidiven sowie von fortgeschrittenen Prim?rtumoren zur Verfügung. Sie erm?glicht auch bei vorbestrahlten sowie der intraoperativen Radiotherapie (IORT) mit Elektronen wegen des starren Applikationstubus nicht zug?nglichen Patienten die M?glichkeit der intraoperativen Strahlendosiserh?hung. Im vorliegenden Krankengut wurden von Oktober 1994 bis Dezember 1997 27 Patienten mit fortgeschrittenen Prim?rtumoren (8) oder Rezidiven (19) intraoperativ mittels vorgenannter Technik bestrahlt. Nach einem durchschnittlichen Nachbeobachtungszeitraum von 17,1 Monaten sind 8 von 10 R0- oder R1-Resezierten rezidivfrei. Von insgesamt 17 Patienten mit makroskopischem Tumorrest zeigen 5 „stable disease“, 10 sind lokal progredient. Drei Operierte verzeichnen eine w?hrend des Nachuntersuchungszeitraums neu aufgetretene metachrone Fernmetastasierung. Vier Patienten sind verstorben, 2 hiervon tumorbedingt. Schwerwiegende strahlenbedingte Komplikationen wurden nicht beobachtet.      

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Cutaneous Tuberculosis: A Practical Case Report and Review for the Dermatologist

Cutaneous tuberculosis occurs rarely, despite a high and increasing prevalence of tuberculosis worldwide. Mycobacterium tuberculosis, Mycobacterrium bovis, and the Bacille Calmette-Guérin vaccine can cause tuberculosis involving the skin. Cutaneous tuberculosis can be acquired exogenously or endogenously and present as a multitude of differing clinical morphologies. Diagnosis of these lesions can be difficult, as they resemble many other dermatological conditions that are often primarily considered. Further, microbiological confirmation is poor, despite scientific advances, such as the more frequent use of polymerase chain reaction. The authors report a case that illustrates the challenges faced by dermatologists when considering a diagnosis of cutaneous tuberculosis.Mycobacterium tuberculosis is a worldwide, problematic, communicable pathogen that has increasingly been regarded as a notable, serious infection in the United States. The underlying basis of this recent epidemic is dependent on such factors as the association of tuberculosis (TB) with the human immunodeficiency virus (HIV) epidemic, increased immigration from endemic countries, and the transmission of TB in crowded settings, such as healthcare facilities, prisons, and homeless shelters.1–4 Most often TB is an airborne transmissible disease with skin manifestations presenting as a result of hematogenous spread or direct extension from a latent or active foci of infection. However, primary inoculation may occur as a direct introduction of the mycobacterium into the skin or mucosa of a susceptible individual by trauma or injury. Increased risk of acquiring disease occurs with HIV infection, intravenous drug abuse, diabetes mellitus, immunosuppressive therapy, malignancies, end-stage renal disease, and infancy. Cutaneous tuberculosis (CTB) is frequently elusive as it mimics a wide differential diagnosis and also evades microbiological confirmation despite recent advances in sophisticated techniques.5 Although rare, given its worldwide prevalence, it is important for clinicians to recognize the many clinical variants of CTB to prevent missed or delayed diagnoses.