Spectroscopy enhances the information content of optical mammography.

Near-infrared (NIR) diffuse optical spectroscopy and imaging may enhance existing technologies for breast cancer screening, diagnosis, and treatment. NIR techniques are based on quantitative measurements of functional contrast between healthy and diseased tissue. In this study we measured the spectral dependence of tissue absorption (mu(a)) and reduced scattering (mu'(s)) in the breasts of 30 healthy women and one woman with a fibroadenoma using a seven-wavelength frequency-domain photon migration probe. Subjects included pre- and postmenopausal women between the ages of 18 and 64. Multi-spectral measurements were used along with a four-component fit to determine the concentrations of de-oxy and oxy-hemoglobin, water and lipids in breast. The scattering spectral shape was also quantified. Our measurements demonstrate that the measured concentrations of NIR analytes correlate well with known breast physiology. Although the tissue scattering at a single wavelength was found to have little value as a functional parameter, the dependence of the scattering on wavelength provided key insights into breast composition and physiology. Lipids and scattering spectra in the breast were found to increase and decrease, respectively, with increasing body mass index. Simple calculations are also provided to demonstrate potential penalties from ignoring the contributions of water and lipids in breast measurements. Finally, water is shown to be a possible indicator for detecting a fibroadenoma, whereas the hemoglobin saturation was found to be a poor indicator. Multi-spectral measurements, compared to measurements restricted to one or two wavelengths, provide additional information that may be useful in managing breast disease.

Novel and recurrent mutations in lamin A/C in patients with Emery-Dreifuss muscular dystrophy.

Emery-Dreifuss muscular dystrophy (EDMD) is characterized by slowly progressive muscle wasting and weakness; early contractures of the elbows, Achilles tendons, and spine; and cardiomyopathy associated with cardiac conduction defects. Clinically indistinguishable X-linked and autosomal forms of EDMD have been described. Mutations in the STA gene, encoding the nuclear envelope protein emerin, are responsible for X-linked EDMD, while mutations in the LMNA gene encoding lamins A and C by alternative splicing have been found in patients with autosomal dominant, autosomal recessive, and sporadic forms of EDMD. We report mutations in LMNA found in four familial and seven sporadic cases of EDMD, including seven novel mutations. Nine missense mutations and two small in-frame deletions were detected distributed throughout the gene. Most mutations (7/11) were detected within the LMNA exons encoding the central rod domain common to both lamins A/C. All of these missense mutations alter residues in the lamin A/C proteins conserved throughout evolution, implying an essential structural and/or functional role of these residues. One severely affected patient possesed two mutations, one specific to lamin A that may modify the phenotype of this patient. Mutations in LMNA were frequently identified among patients with sporadic and familial forms of EDMD. Further studies are needed to identify the factors modifying disease phenotype among patients harboring mutations within lamin A/C and to determine the effect of various mutations on lamin A/C structure and function.

Non-invasive in vivo characterization of breast tumors using photon migration spectroscopy.

Frequency-domain photon migration (FDPM) is a non-invasive optical technique that utilizes intensity-modulated, near-infrared (NIR) light to quantitatively measure optical properties in thick tissues. Optical properties (absorption, mu(a), and scattering, mu(s)', parameters) derived from FDPM measurements can be used to construct low-resolution (0.5 to 1 cm) functional images of tissue hemoglobin (total, oxy-, and deoxy-forms), oxygen saturation, blood volume fraction, water content, fat content and cellular structure. Unlike conventional NIR transillumination, FDPM enables quantitative analysis of tissue absorption and scattering parameters in a single non-invasive measurement. The unique functional information provided by FDPM makes it well-suited to characterizing tumors in thick tissues. In order to test the sensitivity of FDPM for cancer diagnosis, we have initiated clinical studies to quantitatively determine normal and malignant breast tissue optical and physiological properties in human subjects. Measurements are performed using a non-invasive, multi-wavelength, diode-laser FDPM device optimized for clinical studies. Results show that ductal carcinomas (invasive and in situ) and benign fibroadenomas exhibit 1.25 to 3-fold higher absorption than normal breast tissue. Within this group, absorption is greatest for measurements obtained from sites of invasive cancer. Optical scattering is approximately 20% greater in pre-menopausal versus post-menopausal subjects due to differences in gland/cell proliferation and collagen/fat content. Spatial variations in tissue scattering reveal the loss of differentiation associated with breast disease progression. Overall, the metabolic demands of hormonal stimulation and tumor growth are detectable using photon migration techniques. Measurements provide quantitative optical property values that reflect changes in tissue perfusion, oxygen consumption, and cell/matrix development.

Branch retinal vein obstruction secondary to retinal arteriovenous communication.

PURPOSE: To document a branch retinal vein obstruction secondary to a congenital arteriovenous communication. METHOD: Case report of a young patient with retinal arteriovenous communication. RESULTS: A 12-year-old girl had a grade 2 retinal arteriovenous communication in her right eye. She was asymptomatic and was subsequently followed up. Magnetic resonance imaging of the brain was normal and disclosed no signs of Wyburn-Mason syndrome. Nine years later, she developed a branch retinal vein obstruction in the area of the arteriovenous communication. Six months later, the patient was free of secondary complications of branch retinal vein obstruction; however, she is being followed up to detect any retinal or iris neovascularization. CONCLUSION: Awareness of retinal vascular obstruction associated with arteriovenous communication may help its timely recognition, as well as prompt treatment of potential complications, such as retinal and iris neovascularization.

Intraspinal analgesia for nonmalignant pain: a retrospective analysis for efficacy, safety and feasability in 50 patients.

Objectives. To test the efficacy and safety of intraspinal opioids for patients with nonmalignant pain. Design. A retrospective analysis on 50 patients, 37 females and 13 males, who prior to intraspinal analgesia failed all conventional therapies including strong oral opioid trials. Patients were divided into three groups according to pain type: neuropathic, nociceptive, mixed neuropathic/nociceptive. Morphine equivalent doses were noted at intervals of 1, 2, 3, 4, 5, 6, 9, 12, 24, 36, 48, 60, and 72 months. Global evaluation of pain relief (poor, fair, good, excellent) was obtained at each return visit. Dose requirements, escalations, and decreases were noted and analyzed. Side effects and complications of drug infusion or mechanical devises were noted and tabulated. Results. 7 of 7 patients with nociceptive pain had good (29%) to excellent (71%) pain relief. Sixty percent of the 16 patients with neuropathic pain had good (47%) to excellent (13%) pain relief. Seventy-two percent of the total of patients with mixed pain had good (40%) to excellent (32%) pain relief. When further subdivided, only 59% of the failed back/arachnoiditis sufferers had good (41%) to excellent (18%) pain relief while 100% of the mixed group with non-FBSS diagnoses had good (37%) to excellent (63%) pain relief. Conclusions. Long-term intrathecal opioids are efficacious, practical, and safe for the treatment of nonmalignant pain syndromes. FBSS patients respond similarly to intraspinal analgesia as the patients with neuropathic pain, while the group with mixed pain from other non-FBSS causes respond similarly to the nociceptive pain patients.

Neurologic sequelae of intraspinal drug delivery systems: results of a survey of american implanters of implantable drug delivery systems.

OBJECTIVES. The development of neurological sequelae subsequent to the placement of intraspinal drug delivery systems is particularly distressing. An attempt was made to determine the extent of this problem in both reported and in heretofore unreported cases. Methods. A survey was mailed to 3269 implanters of intraspinal infusional systems to identify new cases of neurological sequelae of pump Implantation. 519 out of 3269 surveys mailed out responded. Results. There were 488 "no" respondents and 31 "yes" respondents to the question: "did any patient of yours develop neurologic sequelae or granulomatous catheter mass formation after implant of their intraspinal catheters?" 6 new, heretofore unreported cases of granulomatous mass formations at catheter tips were reported. 27 cases of neurological sequelae due to other etiologies were also noted. Also presented in this paper are 4 case reports to augment reader understanding of the problem. Conclusions. The problem of post-implant neurological sequelae is potentially devastating. Increased vigilance for early diagnosis may prevent the development of permanent paralysis. Gadolinium enhanced MRI scanning at the catheter tip is the imaging study of choice for diagnosis. Any patient developing a new area of pain, weakness or rapid escalation in intrathecal drug dose should be thoroughly assessed.

An improved methodology for the detection of the common mutation in the FGFR3 gene responsible for achondroplasia.

Homozygous achondroplasia is a neonatal lethal condition which can only be diagnosed in the first trimester of pregnancy by molecular analysis. The vast majority of patients with achondroplasia have a G-->A substitution at position 1138 of the fibroblast growth factor receptor (FGFR3) cDNA sequence, resulting in the substitution of an arginine for a glycine residue at position 380 of the FGFR3 protein. This mutation has typically been detected by SfcI digestion of amplified genomic DNA. We have demonstrated that the SfcI digestion protocol does not consistently distinguish between DNA samples heterozygous and homozygous for the G1138A substitution, and illustrates how the misdiagnosis of a homozygous affected fetus for one carrying only one copy of the G1138A mutation could occur. We report here an improved, simple nonradioactive technique which can reliably and consistently detect the presence of the G1138A mutation both in the heterozygous and homozygous state.

Prediction of Biologic Aggressiveness in Colorectal Cancer by p53/K-ras-2 Topographic Genotyping.

Background: Topographic genotyping is a system of solid tissue molecular analysis designed to correlate microscopic alterations with specific forms of gene damage. In this system, microscopic targets are selected on the basis of cellular and immunohistochemical features. Minute tissue samples corresponding to these targets are precisely removed and analyzed for the presence and specific type of oncogene/tumor suppressor gene damage by means of polymerase chain reaction (PCR) followed by DNA sequencing. In this study, topographic genotyping was used to investigate the prognostic value of p53 and K-ras-2 mutational damage in 204 patients with colorectal cancer from two tertiary care centers. Methods and Results: The intensity and distribution of p53 immunohistochemical staining were correlated with the presence and specific type of mutational change, which resulted in a better understanding of the highly variable nature of p53 immunostaining patterns. Molecular genotype was correlated with the depth and extent of colorectal cancer spread (Dukes B and C) and with survival for follow-up periods of up to 10 years. An algorithm for p53/K-ras-2 genotyping was formulated to include p53 immunohistochemistry and DNA sequencing both of p53 exons 5-8 and of K-ras-2 exons 1 and 2. By using this algorithm, survival was shown to be significantly better in those patients whose tumors manifested normal p53 and K-ras-2 genes (P >.01). Patients with p53-mutated tumors composed a poor prognostic group, characterized by a high rate of intra-abdominal recurrence in the form of peritoneal seeding. Patients with K-ras-2-mutated tumors also composed a poor prognostic group, marked by a tendency for distant hematogenous metastasis involving lung, bone, and brain. Conclusions: Topographic genotyping's molecular diagnostic approach to colorectal cancer combines immunohistochemistry, PCR, and DNA sequencing. It is informative, cost-effective, timely, and yet fully integrated with standard histopathology. The use of this approach by pathologists as a model system for molecular diagnosis of colorectal cancer and other forms of solid tumor malignancy is recommended. As new prognostic molecular lesions are documented for tumor progression and metastasis, topographic genotyping will be well suited to facilitate their clinical application.

Typing of Legionella pneumophila serogroup 1 isolates by degenerate (D-)RAPD fingerprinting.

A new method to identify clonal strains of pathogenic bacteria has been developed recently in this laboratory. The method utilizes degenerate random amplified polymorphic DNA primers (D-RAPD) to amplify random fragments in crude bacterial lysates, generating reproducible DNA banding profiles or fingerprints. We use this method to type outbreak and non-outbreak isolates of Legionella pneumophila serogroup 1 from four hospitals near to, and affiliated with the University of Pittsburgh Medical Center. Patient isolates from a large outbreak, and nearly half of the contemporaneous environmental isolates showed the same DNA profile. Other isolates derived from non-outbreak patients showed easily distinguishable profiles. Other Legionella isolates collected between 1984 and 1994 were also analysed by this method. Our studies demonstrate that four strains were common among patient and environmental isolates at the four hospitals. These strains were also found to be different from a limited number of isolates from outside the Pittsburgh area. Because of its speed, simplicity and powerful discriminating ability, we believe that the D-RAPD approach provides epidemiologists and hospital infection control teams with a powerful tool in their efforts in analysing and terminating infection outbreaks.

DNA fingerprinting of crude bacterial lysates using degenerate RAPD primers.

Methods for identifying isolates of various pathogenic bacteria by DNA fingerprinting with random primers (RAPD) have been described recently. In these methods many primers are screened and the primers that generate the most informative DNA pattern are selected. A new strategy that simplifies the primer selection process for RAPD fingerprinting has been developed in our laboratory. In this approach, one or more degenerate nucleotides is introduced into the core RAPD primer sequence at various nucleotide positions. Results show that a single degenerate nucleotide in the primer sequence can significantly change the DNA profile obtained for the same template. The more removed the degenerate nucleotide is from the 3' end of the primer, the less dramatic is its effect on banding pattern. This method utilizing degenerate RAPD (D-RAPD) primers was tested on clinical isolates of Legionella pneumoniae, and results were confirmed with nondegenerate RAPD primers. Results obtained with D-RAPD primers were in total agreement with those obtained with nondegenerate RAPD primers. We propose that the use of a core RAPD primer sequence with one or more degenerate nucleotide(s) at various positions can expedite the generation of unique DNA fingerprints individual organisms. A general method for selecting the most useful fingerprinting RAPD primers is discussed.

Intrathecal infusional analgesia for nonmalignant pain: analgesic efficacy of intrathecal opioid with or without bupivacaine.

We report on the analgesic efficacy of intrathecal infusions of opioids alone or in combination with bupivacaine in 16 nonmalignant pain patients with implanted pumps. Three patients had nociceptive pain, five had neuropathic pain, and 8 had mixed pain syndromes. Infusional therapy was delivered over a combined monthly total of 445 mo of therapy (mean, 27.8 mo). Dose requirements appeared to be stable with a mean dose increase of 0.26 mg/mo. Bupivacaine was added to the opioid to enhance pain control in 13 patients who received combination therapy for an average of 11.7 mo/patient. Thirteen patients (81%) reported good to excellent results with opioid alone or opioid combined with bupivacaine. The addition of bupivacaine improved analgesia in two of three patients with nociceptive pain (66.7%), compared to eight of ten patients with a pure or mixed neuropathic component to their pain (80%). We conclude that intrathecal opioids alone or in combination with bupivacaine are efficacious for the treatment of nonmalignant pain states and are relatively free of significant side effects or tolerance.

MR imaging of patients with implanted drug infusion pumps.

The influence of magnetic resonance (MR) imaging on the integrity and function of an implantable, programmable drug infusion pump and the distortion of the image by this device were tested. Six identical pumps were tested in magnetic fields of 1.5 T. Pump memory was not affected by the procedure. The pump rotor stalled (no infusion) as long as the device was within the magnetic field. Drug delivery resumed as programmed after the pump was removed from the field. No structural damage to the electrical or mechanical pump components was detected. The pump caused a circular image artifact (a signal dropout) within 8-10 cm of the device. The authors conclude that MR imaging is accurate if the area of interest is at least 10 cm from the pump, and that with awareness of temporary infusion cessation, it is safe to perform MR imaging in patients with this implanted pump.

Circadian-shaped infusions of floxuridine for progressive metastatic renal cell carcinoma.

Sixty-eight unselected patients with progressive metastatic renal cell carcinoma (RCC) were treated between March 1985 and November 1988 with continuous infusion floxuridine (FUDR). Thirty-seven percent of these patients had previously received and failed systemic treatment. Using implantable pumps for automatic drug delivery, FUDR was continuously infused for 14 days at monthly intervals. The starting dose was 0.15 mg/kg/d (intravenous [IV]; n = 61) or 0.25 mg/kg/d (intraarterial [IA]; n = 7); IV doses were increased or decreased in increments of 0.025 mg/kg/d as permitted by toxicity. Diarrhea (with or without mild abdominal cramping) and nausea/vomiting limited the FUDR IV infusion, and hepatic function abnormalities limited FUDR IA infusion. The use of a circadian-modified infusion schedule permitted high FUDR doses to be safely given as compared with a constant rate infusion schedule. Of 63 patients assessable for response, 56 received systemic FUDR infusion. Four complete responses (CRs; 7.1%); and seven partial responses (PRs; 12.5%) were observed (objective response rate, CR plus PR, 19.6 +/- 5.1% [95% confidence limits] ). The median objective response duration was 10.8 months (range, 1 to 18 months; mean, 9.4 +/- 1.6). Four additional patients had minor tumor responses (MRs; 7.1%). In a subgroup of seven assessable patients receiving hepatic arterial FUDR, we observed one CR and three PRs (57.2 +/- 42.8%). Overall, objective response (CR plus PR) was seen in a quarter of assessable patients treated, 15 of 63, while only 15 of the 63 assessable patients (25.4%) have had objective tumor progression. The median follow-up time for all 68 patients was 28 months (range, 1 to 42), and their median survival duration is 15 months (range, 3 to 37 months). Continuous infusion FUDR is an effective outpatient treatment for progressive metastatic RCC, producing durable tumor response and causing little toxicity.

Circadian-based infusional FUDR therapy.

FUDR (5-fluoro-2'-deoxyuridine) is one of the few chemotherapeutic agents with activity against metastatic renal cell cancer. Diarrhea and dehydration with long-term, constant-rate intravenous infusion may be severe and life-threatening. This gastrointestinal toxicity can be reduced by altering the rate of the infusion so that most of the daily dose is given late in the day, and a minimal infusion rate is delivered in the early morning hours. This complex therapy can be automatically administered by the programmable, implantable Synchro-Med Infusion System. Using a circadian modification of infusion delivery, toxicity is diminished and the FUDR dose can be safely increased, which may result in greater anti-tumor activity. This paper describes Phase I studies with 54 patients who were treated with intravenous FUDR. It also discusses results of a Phase II study using circadian-modified intravenous delivery of FUDR in the treatment of 61 patients with renal cell cancer. It outlines the nursing implications for management of the implantable, programmable drug delivery system and addresses the nursing role in preventing, recognizing, and controlling FUDR-associated toxicities.

The microsurgical management of giant retinal tears with trans-scleral retinal sutures.

Eight cases of retinal detachment from giant tears were followed from four months to two years. Patients were treated with a combined procedure, including pars plana vitrectomy, rotation of the patient with air-gas fluid exchange to bring the retina into its normal anatomic position, and trans-scleral retinal sutures, using an external rather than internal approach. Seven of the eight cases were reattached successfully. Methods, materials, and complications are described. Pre- and post-operative information regarding visual acuity and results are listed in tabular form.

Comparison of radioactive phosphorus (32P) uptake test in comparable sized choroidal melanomas and hemangiomas.

We compared 19 choroidal hemangiomas and 21 choroidal melanomas of comparable size as to the percent of radioactive phosphorus 32P uptake. The results were significantly lower in choroidal hemangiomas than in comparable sized melanomas.

An objective analysis of proliferative diabetic retinopathy before and after pars plana vitrectomy.

Nineteen eyes on which pars plana vitrectomy was performed were studied with fluorescein angiography. The degree of background diabetic retinopathy before and after surgical treatment appeared unchanged. The degree of proliferative retinopathy not only was less after surgical treatment, but continued to show regression with time.