Surgical management of solitary metastatic melanoma.

The results of non-surgical treatment of advanced stage melanoma are disappointing. Carefully selected stage IV melanoma patients can profit from an aggressive surgical approach. The possibilities of surgical treatment of solitary and single-organ metastasis of melanoma are discussed for most common metastatic sites.

Nephron-sparing radical excision of a giant perirenal liposarcoma involving a solitary kidney.

We describe our experience in a patient with a congenital solitary kidney encased by a perirenal liposarcoma managed by nephron-sparing excision. The best predictor of survival with liposarcoma is complete resection of the tumor. Generally a diffuse peri-renal liposarcoma arising within Gerota's fascia would necessitate a radical nephrectomy. Having a congenitally solitary kidney, this patient refused nephrectomy, therefore a kidney-sparing excision of his liposarcoma was attempted. To obtain negative margins and to provide a nephron-sparing excision, the capsule of the kidney was resected with the mass. Direct extension into the diaphragm necessitated an en bloc resection of 4 x 6 cm of the left hemidiaphragm. The defect was reconstructed with a Gortex patch graft. Pathology revealed a 32 x 22 x 8-cm liposarcoma with areas of sclerosing liposarcoma and poorly differentiated spindle cell sarcoma, focally Grade 3 of 3, with the remaining tumor being Grade 1. There was diaphragmatic invasion, but all surgical margins were negative. At 22 months CT follow-up, the patient has no radiographic evidence of disease. Excision of this mass with the renal capsule allowed our patient to be margin negative and maintain normal renal function. This is the only report in the literature describing nephron-sparing resection of a giant perirenal liposarcoma involving a solitary kidney.

Deep Impact: excavating comet Tempel 1.

Deep Impact collided with comet Tempel 1, excavating a crater controlled by gravity. The comet's outer layer is composed of 1- to 100-micrometer fine particles with negligible strength (<65 pascals). Local gravitational field and average nucleus density (600 kilograms per cubic meter) are estimated from ejecta fallback. Initial ejecta were hot (>1000 kelvins). A large increase in organic material occurred during and after the event, with smaller changes in carbon dioxide relative to water. On approach, the spacecraft observed frequent natural outbursts, a mean radius of 3.0 +/- 0.1 kilometers, smooth and rough terrain, scarps, and impact craters. A thermal map indicates a surface in equilibrium with sunlight.

Dumbbell-like bifunctional Au-Fe3O4 nanoparticles.

Dumbbell-like Au-Fe(3)O(4) nanoparticles are synthesized using decomposition of Fe(CO)(5) on the surface of the Au nanoparticles followed by oxidation in 1-octadecene solvent. The size of the particles is tuned from 2 to 8 nm for Au and 4 nm to 20 nm for Fe(3)O(4). The particles show the characteristic surface plasmon absorption of Au and the magnetic properties of Fe(3)O(4) that are affected by the interactions between Au and Fe(3)O(4). The dumbbell is formed through epitaxial growth of iron oxide on the Au seeds, and the growth can be affected by the polarity of the solvent, as the use of diphenyl ether results in flower-like Au-Fe(3)O(4) nanoparticles.

Spectroscopic identification and direct imaging of interfacial magnetic spins.

Using x-ray absorption spectromicroscopy we have imaged the uncompensated spins induced at the surface of antiferromagnetic (AFM) NiO(100) by deposition of ferromagnetic (FM) Co. These spins align parallel to the AFM spins in NiO(100) and align the FM spins in Co. The uncompensated interfacial spins arise from an ultrathin CoNiOx layer that is formed upon Co deposition through reduction of the NiO surface. The interfacial Ni spins are discussed in terms of the "uncompensated spins" at AFM/FM interfaces long held responsible for coercivity increases and exchange bias. We find a direct correlation between their number and the size of the coercivity.

Cell density and phosphorylation control the subcellular localization of adenomatous polyposis coli protein.

Loss of functional adenomatous polyposis coli protein (APC) leads to uncontrolled proliferation of colonic epithelial cells, as evidenced by polyp formation, a prelude to carcinogenesis. As a tumor suppressor, APC targets the oncogene beta-catenin for proteasome-mediated cytoplasmic degradation. Recently, it was demonstrated that APC also interacts with nuclear beta-catenin, thereby reducing beta-catenin's activity as a transcription cofactor and enhancing its nuclear export. The first objective of this study was to analyze how cellular context affected APC distribution. We determined that cell density but not cell cycle influenced APC's subcellular distribution, with predominantly nuclear APC found in subconfluent MDCK and intestinal epithelial cells but both cytoplasmic and nuclear APC in superconfluent cells. Redistribution of APC protein did not depend on continual nuclear export. Focusing on the two defined nuclear localization signals in the C-terminal third of APC (NLS1(APC) and NLS2(APC)), we found that phosphorylation at the CK2 site increased and phosphorylation at the PKA site decreased NLS2(APC)-mediated nuclear translocation. Cell density-mediated redistribution of beta-galactosidase was achieved by fusion to NLS2(APC) but not to NLS1(APC). Both the CK2 and PKA sites were important for this density-mediated redistribution, and pharmacological agents that target CK2 and PKA instigated relocalization of endogenous APC. Our data provide evidence that physiological signals such as cell density regulate APC's nuclear distribution, with phosphorylation sites near NLS2(APC) being critical for this regulation.

Identification of a gamma-tubulin-binding domain in BRCA1.

We previously reported (L-C. Hsu and R. L. White, Proc. Natl. Acad. Sci. USA, 95: 12983-12988, 1998) that hypophosphorylated BRCA1 is associated with mitotic centrosomes in vivo, perhaps through its interaction with gamma-tubulin. In vitro evidence presented here indicates that full-length BRCA1 protein generated by in vitro translation interacts with gamma-tubulin. A specific domain of BRCA1 protein, BRCA1 fragment no. 3 (BF3; amino acids 504-803), is both necessary and sufficient to bind gamma-tubulin. BF3 and gamma-tubulin coimmunoprecipitated when coexpressed in cells. In addition, expression of BF3 interfered with the interaction between BRCA1 and gamma-tubulin. Stable transformants of COS-7 cells that overexpressed BF3 showed a reduced growth rate partly because of increased apoptosis. Furthermore, overexpression of BF3 in COS-7 cells results in the accumulation of mitotic cells with multiple centrosomes and abnormal spindles. Okadaic acid, an inhibitor of protein phosphatases types 1 and 2A, induces hyperphosphorylation of BRCA1, a reduction of both BRCA1 and gamma-tubulin associated with mitotic centrosomes, and an accumulation of abnormal spindle formation. Thus, attenuating the interaction between BRCA1 and gamma-tubulin, and their association with mitotic centrosomes, may induce an increase of aneuploid cell population and contribute to tumorigenesis.

What in vitro models of infection can and cannot do.

The science of pharmacodynamics analyzes the relationship between an antimicrobial's bactericidal effects and its pharmacokinetics. Ideally, randomized and well-controlled clinical trials are the best way to determine pharmacodynamic properties. However, in vitro models that recapitulate in vivo drug clearance profiles represent an increasingly important technology for carrying out pharmacodynamic studies in a more cost-effective, timely, and easily controlled fashion. Although in vitro pharmacodynamic models cannot incorporate all variables seen in vivo, they do provide valuable information for the drug development process and the determination of optimal dosing regimens.

Antimicrobial cycling: the future or a fad?

OBJECTIVE: To assess the current evidence of the value of cycling of antimicrobials to control the emergence of resistance or to reverse existing resistance to antimicrobials. DATA SOURCES: Articles were obtained through a MEDLiNE search of the English-language literature from 1966 to January 2000. Additionally, references from retrieved publications were reviewed to identify further articles. STUDY SELECTION AND DATA EXTRACTION: All investigations of switching between or cycling among antimicrobials were evaluated. Studies switching between or cycling among specific drugs or classes of drugs within institutional settings were included in this review. DATA SYNTHESIS: Studies involving cycling among different aminoglycosides suggest that, although temporary decreases in resistance can be documented, resistance usually rebounds rapidly on completion of the cycle and return to the original agent. Switching between classes of antimicrobials has produced inconsistent results and has been shown to replace resistance to one agent with resistance to another. Mathematical models using both in vitro and clinical data have suggested that, due to residual resistance in the population, cycling among drug classes is unlikely to yield long-term reductions in antimicrobial resistance, especially if a high level of antimicrobial resistance exists. CONCLUSIONS: Cycling among different antimicrobials to reverse resistance trends is currently not supported by published literature. Cycling to prevent the emergence of resistance may ultimately be more useful; however, no studies have evaluated this concept. Well-designed prospective studies are needed to evaluate the potential clinical value of antimicrobialcycling.

Breast conservation: trends in a major southern metropolitan area compared with surrounding rural counties.

Despite randomized prospective studies and National Institutes of Health recommendations, surgeons especially in the southern United States have been slow to adopt breast conservation surgery (BCS). Data were analyzed regarding 3,349 cases of stage 0, I, and II breast cancer (1991-1998) from Charlotte-Mecklenburg County, NC; 1057 cases from six surrounding rural counties (1995-1997); and 90,398 cases (1995) from the National Cancer Data Base. During 1995 through 1997 Charlotte-Mecklenburg County had statistically significantly higher rates of BCS compared with six surrounding rural counties for stage I (59% and 42% respectively, P = 0.001) and stage II (37% and 19%, respectively, P = 0.001) breast cancer. The BCS rates in Charlotte-Mecklenburg County (1991-1998) showed the following: Stage 0 rate increased from 17 per cent in 1991 to 78 per cent in 1998 (P = 0.001), stage I rate increased from 31 per cent in 1991 to 65 per cent in 1998 (P = 0.001), and stage II rate increased from 18 per cent in 1991 to 42 per cent in 1998 (P = 0.001). BCS rates for early-stage breast cancer in Charlotte-Mecklenburg County have increased over the last 8 years and now equal national rates; however, patients in surrounding rural counties are not receiving BCS as frequently. There is a need for more widespread education of surgeons, other health care providers, and the general public to increase the use of BCS.

The effect of intracoronary radiation for the treatment of recurrent in-stent restenosis in patients with chronic renal failure.

OBJECTIVES: This study was designed to analyze the in-hospital and six-month clinical and angiographic outcomes of patients with chronic renal failure (CRF) treated with intracoronary radiation for the prevention of recurrence of in-stent restenosis. BACKGROUND: Patients with CRF are at a higher risk than the general population for accelerated atherosclerotic cardiovascular disease and for restenosis after percutaneous coronary intervention. Previous studies have shown the effectiveness of both beta and gamma radiation in preventing recurrent restenosis in patients with in-stent restenosis. METHODS: We studied the in-hospital and six-month clinical and angiographic outcomes of 118 patients with CRF and 481 consecutive patients without CRF who were treated with intracoronary radiation for the prevention of recurrence of in-stent restenosis in native coronaries and saphenous vein grafts. RESULTS: Patients with CRF were usually older, women, hypertensive and diabetic, with multivessel disease and with reduced left ventricular function. In-hospital outcome for patients with CRF was marred by a higher incidence of death, non-Q-wave myocardial infarction and major vascular and bleeding complications. At six-month follow-up, the mortality rate was higher in patients with CRF, 7.6% compared with 1.9% in non-CRF patients (p = 0.003). Restenosis, target lesion revascularization (TLR) and target vessel revascularization (TVR) rates were similar in the two groups. In patients with CRF, radiation therapy compared to placebo reduced restenosis (53.8% vs. 22.6%, p = 0.04), TLR (71.4% vs. 15.3%, p < 0.0001) and TVR (78.6% vs. 23.7%, p = 0.0002). CONCLUSIONS: Intracoronary radiation for the prevention of recurrence of in-stent restenosis achieved similar rates of restenosis and revascularization procedures in patients with and without CRF. Despite this benefit, patients with renal dysfunction continued to have significantly higher in-hospital and six-month adverse outcomes.

Effect of serum from different patient populations on the serum bactericidal test.

We evaluated the effect of serum from normal and uraemic volunteers, neutropenic patients and burn patients on the serum bactericidal test. Serum samples were spiked with ceftazidime to mimic in vivo peak (75 mg/L) and trough (5 mg/L) concentrations. Serum inhibitory and bactericidal titres (SIT and SBT) were performed in triplicate using Escherichia coli ATCC 25922 and Pseudomonas aeruginosa ATCC 27853. For E. coli, the trough SIT and SBT were significantly higher in serum from burn patients compared with normal volunteers (P < or = 0.024). The trough SIT was significantly higher in serum from burn patients compared with neutropenic patients (P = 0.022) and in uraemic patients compared with normal volunteers (P = 0.04). No significant differences between subject populations were found for P. aeruginosa.

Purification and characterization of beta-methylaspartase from Fusobacterium varium.

Beta-methylaspartase (EC 4.3.1.2) was purified 20-fold in 35% yield from Fusobacterium varium, an obligate anaerobe. The purification steps included heat treatment, fractional precipitation with ammonium sulfate and ethanol, gel filtration, and ion exchange chromatography on DEAE-Sepharose. The enzyme is dimeric, consisting of two identical 46 kDa subunits, and requires Mg2+ (Km = 0.27+/-0.01 mM) and K+ (Km = 3.3+/-0.8 mM) for maximum activity. Beta-methylaspartase-catalyzed addition of ammonia to mesaconate yielded two diastereomeric amino acids, identified by HPLC as (2S,3S)-3-methylaspartate (major product) and (2S,3R)-3-methylaspartate (minor product). Optimal activity for the deamination of (2S,3S)-3-methylaspartate (Km = 0.51+/-0.04 mM) was observed at pH 9.7. The N-terminal protein sequence (30 residues) of the F. varium enzyme is 83% identical to the corresponding sequence of the clostridial enzyme.

Siah-1 mediates a novel beta-catenin degradation pathway linking p53 to the adenomatous polyposis coli protein.

The adenomatous polyposis coli (APC) tumor-suppressor protein, together with Axin and GSK3beta, forms a Wnt-regulated signaling complex that mediates phosphorylation-dependent degradation of beta-catenin by the proteasome. Siah-1, the human homolog of Drosophila seven in absentia, is a p53-inducible mediator of cell cycle arrest, tumor suppression, and apoptosis. We have now found that Siah-1 interacts with the carboxyl terminus of APC and promotes degradation of beta-catenin in mammalian cells. The ability of Siah-1 to downregulate beta-catenin signaling was also demonstrated by hypodorsalization of Xenopus embryos. Unexpectedly, degradation of beta-catenin by Siah-1 was independent of GSK3beta-mediated phosphorylation and did not require the F box protein beta-TrCP. These results indicate that APC and Siah-1 mediate a novel beta-catenin degradation pathway linking p53 activation to cell cycle control.

Effect of removal of duplicate isolates on cumulative susceptibility reports.

The objective of our study is to assess the impact of different methods of duplicate isolate removal on cumulative susceptibility reports. Over a 1-year period, we studied the effect of 3 methods of duplicate isolate removal on the cumulative percentage susceptibility of 9 Gram-negative bacilli to 15 antimicrobials. Raw data from which no duplicate isolates were removed (NR) were generated by the Sensititre breakpoint susceptibility testing system. D3 and D7 were methods of duplicate isolate removal defined as follows: same patient, bacterial species, irrespective of susceptibility within either three (D3) or seven (D7) calendar days of the date of the previous culture. The third method evaluated was an algorithm utilized by Cerner, a laboratory management program that defines duplicate isolates as follows: same patient, bacterial species, and NCCLS susceptibility category to an individual antimicrobial. Differences in percentage susceptibility between the three methods of duplicate isolate removal and NR were assessed. The number of isolates studied ranged from 80 (E. aerogenes) to 681 (P. aeruginosa). Of the methods of duplicate isolate removal, the highest percentage susceptibility occurred most frequently with Cerner followed by D7 and D3. Differences in percentage susceptibility between methods of removal and NR ranged from -11 to 25%, -5 to 8%, and -3 to 10%, with Cerner, D3, and D7, respectively. The percentage susceptibility was at least 5% higher than NR with a method of removal for 15 individual organism/antimicrobial combinations in which susceptibility was > or = 70% by at least one of the methods. These occurred most frequently with Enterobacter species and Cerner. Although there is no consensus on the ideal method of duplicate isolate removal, one should be cognizant that these manipulations may produce different cumulative susceptibility reports.

TGF-beta1 regulates the expression of multiple max-interacting transcription factors in Balb/MK cells: implications for understanding the mechanism of action of TGF-beta1.

Appropriate transforming growth factor-beta1 (TGF-beta1) signaling is required to preserve homeostasis of diverse tissues during development. At the cellular level, one function of TGF-beta1 that is critical for preserving homeostasis is the ability to arrest cell growth. TGF-beta1 arrests growth by blocking the function of the c-myc proto-oncogene. c-myc function is determined by the level of c-myc expression relative to other Max-interacting transcription factors, and TGF-beta1 has been shown to inhibit c-myc expression by inhibiting c-myc transcription. However, whether TGF-beta1 might also increase the expression of a Max-interacting factor that blocks myc function by competing with myc for Max binding is not known. Therefore, we determined the effect of TGF-beta1 on the expression of Max-interacting transcription factors in Balb/MK cells. We found unexpectedly that Balb/MK cells express both N-myc and c-myc. The pattern of N-myc expression during the cell cycle differs from that of c-myc, indicating that mRNA accumulation is controlled by mechanisms specific to each gene. TGF-beta1 rapidly inhibits N-myc mRNA expression; thus N-myc is a novel target of TGF-beta1 in Balb/MK cells. More importantly, we found that TGF-beta1 induces the expression of the putative tumor suppressor genes Mad4 and Mxi1 in both the Balb/MK and Mv1Lu cell lines. Mad4 and Mxi1 are novel targets of TGF-beta1, known to inhibit cell growth by antagonizing the interaction of Myc with Max. Thus, our results suggest that the induction of Mad4 and Mxi1 may function in tandem with the inhibition of N-myc and c-myc to mediate the growth inhibitory function of TGF-beta1.

Prolonged antiplatelet therapy to prevent late thrombosis after intracoronary gamma-radiation in patients with in-stent restenosis: Washington Radiation for In-Stent Restenosis Trial plus 6 months of clopidogrel (WRIST PLUS).

BACKGROUND: Intracoronary gamma-radiation reduces recurrent in-stent restenosis. Late thrombosis (>30 days after radiation therapy) is identified as a serious complication. The Washington Radiation for In-Stent Restenosis Trial (WRIST) PLUS, which involved 6 months of treatment with clopidogrel and aspirin, was designed to examine the efficacy and safety of prolonged antiplatelet therapy for the prevention of late thrombosis. METHODS AND RESULTS: A total of 120 consecutive patients with diffuse in-stent restenosis in native coronary arteries and vein grafts with lesions <80 mm underwent percutaneous coronary transluminal angioplasty, laser ablation, and/or rotational atherectomy. Additional stents were placed in 34 patients (28.3%). After the intervention, a closed-end lumen catheter was introduced into the artery, a ribbon with different trains of radioactive (192)Ir seeds was positioned to cover the treated site, and a dose of 14 Gy to 2 mm was prescribed. Patients were discharged with clopidogrel and aspirin for 6 months and followed angiographically and clinically. All patients but one tolerated the clopidogrel. The late occlusion and thrombosis rates were compared with the gamma-radiation-treated (n=125) and the placebo patients (n=126) from the WRIST and LONG WRIST studies (which involved only 1 month of antiplatelet therapy). At 6 months, the group receiving prolonged antiplatelet therapy had total occlusion and late thrombosis rates of 5.8% and 2.5%, respectively; these rates were lower than those in the active gamma-radiation group and similar to those in the placebo historical control group. CONCLUSIONS: Six months of clopidogrel and aspirin and a reduction in re-stenting for patients with in-stent restenosis treated with gamma-radiation is well tolerated and associated with a reduction in the late thrombosis rate compared with a similar cohort treated with only 1 month of clopidogrel and aspirin.

Comparative in vitro pharmacodynamics of imipenem and meropenem against ATCC strains of Escherichia coli, Staphylococcus aureus and Bacteroides fragilis.

We evaluated the pharmacodynamics of imipenem and meropenem, utilizing time-kill studies over a concentration/MIC (C/MIC) range of 0.0625-1024 for E. coli ATCC 35218 (EC) and S. aureus ATCC 29213 (SA) and from 0.125-512 for B. fragilis ATCC 25285 (BF). Area under the time-kill curves were converted to percent response (%R). AUCs were calculated from drug concentrations corrected for degradation and %R vs. C/MIC and AUC/MIC were fit to a sigmoidal Emax model. Emax was similar for both agents for all organisms. Meropenem was 4x more potent than imipenem against EC based on the MIC and required 7 and 13.5-fold lower AUCs to achieve E50 and E90, (50% and 90% of the maximal response, respectively) respectively, whereas imipenem was 8x more potent than meropenem against SA based on the MIC and required 8 and 13-fold lower AUCs to achieve E50 and E90, respectively. The C/MIC and AUC/MIC to achieve E50 and E90 with imipenem were 2- and fourfold higher, respectively than meropenem against EC. There was less than a twofold difference in C/MICs and AUC/MIC between imipenem and meropenem for both E50 and E90 against SA. Against BF, concentrations and AUCs at E50 were similar for both agents; however, imipenem required 4 to 6-fold higher concentrations and AUC to achieve E90. Although there are differences in the potency of these agents as assessed by the MIC or AUC vs. response, when normalized by the MIC and corrected for drug degradation, these agents displayed similar pharmacodynamic parameter-response relationships.

Clinical pathways for managing patients receiving interleukin 2.

As biologic therapies enter the mainstream for cancer and HIV treatments, clinicians need the knowledge and expertise to safely and competently care for their patients who are undergoing these therapies. This article provides an overview of the immune system, emphasizing the elements that are affected by the biologic agent interleukin 2 (lL-2), lL-2 has been approved for use in the treatment of metastatic renal cell carcinoma and metastatic melanoma. Clinical trials currently are being conducted to determine its use in treating other cancers. The severity of side effects of lL-2 varies with the dose, route, and schedule of administration. The most common effects with all methods of administration are flu-like symptoms. Because the side effects of lL-2 are relatively predictable, clinical pathways offer practical tools for anticipating and managing the toxicities associated with lL-2 administration.