Paraneoplastic cicatricial pemphigoid.

We report a 39-year-old woman with antiepiligrin cicatricial pemphigoid (CP) in association with non-small cell carcinoma of the lung. At presentation, mucosal lesions showed minimal response to combined systemic immunosuppressive agents. Following the diagnosis of non-small cell lung carcinoma and subsequent treatment with gemcitabine (a second-line chemotherapeutic agent), a significant reduction in both tumour mass and mucosal blistering was observed. Metastatic disease was subsequently associated with recurrent oral erosions. We believe this patient represents the first reported case of paraneoplastic CP.

Management of non-cardiac chest pain: from research to clinical practice.

BACKGROUND: Non-cardiac chest pain assessed by cardiologists in their outpatient clinics or by coronary angiography usually has a poor symptomatic functional and psychological outcome. Randomised trials have shown the effectiveness of specialist psychological treatment with those who have persistent symptoms, but such treatment is not always acceptable to patients and may not be feasible in routine clinical settings. OBJECTIVES: To describe a sample of patients referred to cardiac outpatient clinics from primary care in a single health district who were consecutively reassured by cardiologists that there was not a cardiac cause for their presenting symptom of chest pain. DESIGN: Systematic recording of referral and medical information of patients consecutively reassured by cardiologists. Reassessment in research clinic six weeks later (with a view to inclusion in a randomised trial of psychological treatment, which has been separately reported) and followed up at six months. SETTING: A cardiac clinic in a teaching hospital providing a district service to patients referred from primary care. PATIENTS: 133 patients from the Oxfordshire district presenting with chest pain and consecutively reassured that there was no cardiac cause during the recruitment period; 69 had normal coronary angiograms and 64 were reassured without angiography. INTERVENTION: A subgroup (n = 56) with persistent disabling chest pain at six weeks were invited to take part in a randomised controlled trial of cognitive behavioural treatment. MAIN OUTCOME MEASURES: Standardised interview and self report measures of chest pain, other physical symptoms, mood and anxiety, everyday activities, and beliefs about the cause of symptoms at six week assessment; repeat of self report measures at six months. RESULTS: Patients had a good outcome at six weeks, but most had persistent, clinically significant symptoms and distress. Some found the six week assessment and discussion useful. The psychological treatment was helpful to most of those recruited to the treatment trial, but a minority (15%) of those treated appeared to need more intensive and individual collaborative management. Patients reassured following angiography were compared with those reassured without invasive investigation. They had longer histories of chest pain, more often reported breathlessness on exertion, and were more likely to have previously been diagnosed as having angina, treated with antianginal medication, and admitted to hospital as emergencies. CONCLUSION: These findings suggest a need for "stepped" aftercare, with management tailored according to clinical need. This may range from simple reassurance and explanation in the cardiac clinic to more intensive individual psychological treatment of associated underlying and often enduring psychological problems. Simple ways in which the cardiologist might improve care to patients with non-cardiac chest pain are suggested, and the need for access to specialist psychological treatment discussed.

CA125 and thyroglobulin staining in papillary carcinomas of thyroid and ovarian origin is not completely specific for site of origin.

AIMS: A 70-year-old woman presented with metastatic psammoma body-rich papillary carcinoma in a supraclavicular lymph node. No primary site was evident. The tumour showed strong staining for CA125 and weak staining for thyroglobulin. Prompted by this case we aimed to assess the reliability of immunostaining for CA125 and thyroglobulin in making the distinction between thyroid and ovarian papillary carcinoma. METHODS AND RESULTS: Nine papillary carcinomas of the thyroid and 17 serous papillary carcinomas of the ovary were stained for CA125 and thyroglobulin, as well as CAM 5.2, LP 34, carcinoembryonic antigen (CEA), S100 and diastase/periodic acid-Schiff. Nine of nine thyroid carcinomas stained for thyroglobulin; in addition CA125 was positive in four of nine. Normal surrounding thyroid also showed some reaction. Seventeen of 17 ovarian serous carcinomas were positive for CA125; in addition one case showed moderately strong staining for thyroglobulin. Mucin stains were positive in 14/17 ovarian serous carcinomas, but negative in all thyroid carcinomas. The other antibodies assessed showed no useful differences in staining frequency. CONCLUSION: Many cases of papillary carcinoma of the thyroid show CA125 staining, and this feature therefore has little positive predictive value for an ovarian origin. Occasional cases of ovarian papillary carcinoma may show staining for thyroglobulin, and this result should therefore be interpreted cautiously.

A controlled trial of cognitive behavioural therapy for non-cardiac chest pain.

BACKGROUND: The majority of patients presenting to cardiac clinics with chest pain who are reassured they do not have heart disease or other serious physical disorder continue to experience symptoms, worry about heart disease and restrict their activities. This randomized trial investigated the effectiveness of psychological treatment within routine cardiac care. METHODS: Consecutive patients presenting with chest pain and reassured by a cardiologist they do not have heart disease were reassessed 6 weeks later. Those with persistent limiting symptoms were offered the opportunity to participate in a trial of cognitive behavioural therapy. RESULTS: Thirty-seven subjects agreed to take part. A number of subjects were unenthusiastic about psychological intervention or, following explanation of the study, regarded further treatment as not being necessary. At 3 months there were significant differences between the treatment group and the control group on key outcome measures of symptoms, mood and activity. At 6 months there were fewer differences but significant advantages of treatment in terms of limitation of activities and worry about physical symptoms. CONCLUSION: We conclude that there is a need for 'stepped' further care following reassurance in the cardiac clinic and that cognitive behavioural treatment is effective with those with persistent disabling symptoms.

Non-cardiac chest pain: why was a brief intervention apparently ineffective?

BACKGROUND: Patients who present with chest pain but have normal coronary angiography and who are told by their cardiologist that they do not have heart disease, have a poor symptomatic, psychological and quality of life outcome and remain concerned about a serious cause of their symptoms. They frequently complain they have not had enough information. The study aimed to test the effectiveness and acceptability of a brief psychological intervention based on cognitive behavioural principles. METHODS: Consecutive patients with chest pain and normal angiograms were assessed and invited to take part in a randomized controlled evaluation. The intervention consisted of an individualized information and discussion session by a specially trained cardiac nurse, together with a handout and cassette providing information and advice and telephone follow-up to discuss progress, answer questions and reiterate advice. RESULTS: The treatment proved to be unacceptable to some patients and there was no evidence of efficacy. CONCLUSIONS: Implications for the preparation of patients undergoing angiography and for the timing and delivery of information and advice following a negative result are discussed.

Effects of road traffic accidents on travel.

Consecutive road traffic accidents attenders with multiple or 'whiplash' neck injuries were assessed following the accident, at 3 months and 1 year. Considerable changes in vehicle-driving behaviour and in attitudes to travel were reported. Concern about travel as a driver and as a passenger was usual. A sizeable proportion of subjects suffered severe and persistent anxiety associated with limitations of everyday life. The findings have implications for clinical assessment and treatment, road safety, and medical reports in compensation proceedings.

Quantification by gas chromatography of N,N'-di-(2-chloroethyl)-phosphorodiamidic acid in the plasma of patients receiving isophosphamide.

A sensitive method, based on gas chromatography using a phosphorus-specific flame photometric detector, has been developed for quantifying N,N'-di-(2-chloroethyl)phosphorodiamidic acid (isophosphoramide mustard), the putative active metabolite of isophosphamide, in human plasma. Phosphoramide mustard was used as internal standard, and the two compounds were converted into separable trimethyl derivatives by reaction with methyliodide in the presence of silver oxide. The chemistry of the derivatization process has been elucidated using gas chromatography-electron impact mass spectrometry and selected ion monitoring. Levels of isophosphamide and of isophosphoramide mustard were measured in the plasma of patients receiving isophosphamide (2 g/sq m). Peak plasma levels of isophosphoramide mustard of 18.6 to 30.3 nmol/ml occurred at 2 to 4 hr, and levels were still appreciable (6.3 to 11.3 nmol/ml) at 24 hr.

Prevention of isophosphamide-induced urothelial toxicity with 2-mercaptoethane sulphonate sodium (mesnum) in patients with advanced carcinoma.

In 8 patients receiving intravenous isophosphamide 2 g/m2 at 2-week intervals for advanced bronchogenic carcinoma the protective effect of 2-mercaptoethane sulphonate sodium (mesnum) against isophosphamide-induced urothelial toxicity was tested in a single-blind crossover trial. With isophosphamide alone, 7 of the 8 patients developed either haematuria or symptoms of bladder irritation; when mesnum was given in addition, only 1 patient had microhaematuria and frequency, and this was in association with a urinary-tract infection. 5 patients then received fifteen courses of isophosphamide in increasing doses of 4 to 8 g/m2 i.v. with mesnum. In contrast to previous experience with isophosphamide at this high dosage, frank haematuria was never seen, microhaematuria was seen after only three courses, and mild dysuria after only one course. Pharmacokinetic studies showed that mesnum did not interfere with the metabolism of isophosphoramide or its active anti-tumour metabolite, isophosphoramide mustard. Mesnum therefore enhances the therapeutic ratio of isophosphamide and may thereby increase its clinical efficacy.

Results of the Royal Marsden Hospital second soft tissue sarcoma schedule (STS II) chemotherapy regimen in the management of advanced sarcoma.

Forty-eight patients with advanced soft tissue sarcoma were treated with a five-drug combination regimen consisting of vincristine, actinomycin D, and cyclophosphamide (Day 1) followed by doxorubicin and an infusion of methotrexate (Day 22). Thirty-seven of the 48 patients were fully evaluable. Of the 37 evaluable patients, two achieved a complete remission and three achieved a partial remission, with an overall response rate of 13.5%. These results compare unfavorably with previously reported series from this and other centers, and the regimen has now been superseded.

Failure of intensive combination therapy (cyclophosphamide, adriamycin, 5-fluorouracil) to control adenocarcinoma or large-cell anaplastic carcinoma of lung.

Eleven patients with advanced adenocarcinoma of lung and six patients with large cell anaplastic carcinoma of lung were treated with combination chemotherapy using cyclophosphamide 1 g/m2 i.v., adriamycin 30 mg/m2 and 5-FU 500 mg/m2 i.v. on days 1 and 8, of a 28 day cycle. In neither group did any patient achieve a complete remission; 1 patient achieved a partial response in each group, and the rest showed no evidence of response. The duration of survival of the responding patients in each group was not significantly longer than those of the non-responders. Toxicity and side effects were considerable in all patients. This study demonstrates that these tumour types are refractory to this form of intensive combination chemotherapy. A literature review suggests that other forms of combination chemotherapy are usually equally ineffective.