Neurodevelopmental outcome in full-term newborns with refractory neonatal seizures.

AIM: This retrospective study describes the prognosis of full-term newborns with refractory neonatal seizures, comparing the need for treatment with two versus three or more antiepileptic drugs. METHODS: We reviewed our database (January 2002-December 2007) to include newborns with refractory neonatal seizures and abnormal electroencephalogram. Group A consisted of 17 newborns with two antiepileptic drugs. Group B consisted of 29 newborns with three or more antiepileptic drugs. Outcome was determined at 2 years of age using the Dutch Bayley Scales of Infant Development or a neurodevelopmental classification scheme. RESULTS: Group A and group B were comparable regarding to a variety of demographic and aetiologic factors. Thirteen newborns died before 2 years of age and one was lost to follow-up. Normal development at 2 years of age was found in 50% and 5% for group A and B, respectively. Severe neurodevelopmental delay at 2 years of age was found in 30% and 68% for group A and B, respectively. CONCLUSION: The number of antiepileptic drugs probably reflects increased seizure burden and is--in that way--related to poor outcome. This may be useful information for early prediction of adverse neurological outcome in the first days of life.

Transfection effect of microbubbles on cells in superposed ultrasound waves and behavior of cavitation bubble.

The combination of ultrasound and ultrasound contrast agents (UCAs) is able to induce transient membrane permeability leading to direct delivery of exogenous molecules into cells. Cavitation bubbles are believed to be involved in the membrane permeability; however, the detailed mechanism is still unknown. In the present study, the effects of ultrasound and the UCAs, Optison on transfection in vitro for different medium heights and the related dynamic behaviors of cavitation bubbles were investigated. Cultured CHO-E cells mixed with reporter genes (luciferase or beta-gal plasmid DNA) and UCAs were exposed to 1 MHz ultrasound in 24-well plates. Ultrasound was applied from the bottom of the well and reflected at the free surface of the medium, resulting in the superposition of ultrasound waves within the well. Cells cultured on the bottom of 24-well plates were located near the first node (displacement node) of the incident ultrasound downstream. Transfection activity was a function determined with the height of the medium (wave traveling distance), as well as the concentration of UCAs and the exposure time was also determined with the concentration of UCAs and the exposure duration. Survival fraction was determined by MTT assay, also changes with these values in the reverse pattern compared with luciferase activity. With shallow medium height, high transfection efficacy and high survival fraction were obtained at a low concentration of UCAs. In addition, capillary waves and subsequent atomized particles became significant as the medium height decreased. These phenomena suggested cavitation bubbles were being generated in the medium. To determine the effect of UCAs on bubble generation, we repeated the experiments using crushed heat-treated Optison solution instead of the standard microbubble preparation. The transfection ratio and survival fraction showed no additional benefit when ultrasound was used. These results suggested that cavitation bubbles created by the collapse of UCAs were a key factor for transfection, and their intensities were enhanced by the interaction of the superpose ultrasound with the decreasing the height of the medium. Hypothesizing that free cavitation bubbles were generated from cavitation nuclei created by fragmented UCA shells, we carried out numerical analysis of a free spherical bubble motion in the field of ultrasound. Analyzing the interaction of the shock wave generated by a cavitation bubble and a cell membrane, we estimated the shock wave propagation distance that would induce cell membrane damage from the center of the cavitation bubble.

Pluronic block copolymers: novel functions in ultrasound-mediated gene transfer and against cell damage.

Pluronics have been investigated as vectors for drug and gene delivery in vitro and in vivo and were demonstrated to have high efficiency for gene transfer in vivo. However, they alone do not enhance gene transfer in vitro. We examined three pluronics, F127, L61 and P85, for their effects on ultrasound (US)-mediated gene transfer in three cell lines, 3T3-MDEI, C2C12 and CHO. The polymers showed differential effects on cell viability and transfection efficiency in a dose-dependent manner. All the polymers were unable to facilitate gene transfer when used alone, but enhanced US-mediated gene transfer significantly at concentrations around the critical micelle concentration in the three cell lines. F127 showed no significant toxicity at any concentration and protected the cells against US-mediated damage at a high concentration. L61 decreased cell viability significantly in a dose-dependent manner, whereas P85 showed mild toxicity when its concentration was at or above 0.05%.

Randomized trial of observation versus adjuvant therapy with cyclophosphamide, fluorouracil, prednisone with or without tamoxifen following mastectomy in postmenopausal women with node-positive breast cancer.

Following mastectomy for node-positive breast cancer, 261 postmenopausal women were randomized to observation or adjuvant treatment with cyclophosphamide, fluorouracil, prednisone (CFP) alone or combined with tamoxifen (T). Doses used were: C, 150 mg/m2 intravenously (IV) days 1 to 5; F, 300 mg/m2 IV days 1 to 5; P, 10 mg by mouth 3 times daily on days 1 to 7; and T, 10 mg by mouth 2 times daily. A total of ten courses of treatment, administered every 6 weeks, was planned and T was stopped 6 weeks after the last course of CFP. Two hundred thirty-four patients were fully eligible and evaluable. With a median observation time slightly in excess of 5 years, the proportion of recurrences on each arm were: CFP, 29 of 75 (39%); CFPT, 29 of 71 (41%); and observation, 50 of 88 (57%). Relapse-free survival distributions for both CFP and CFPT were superior to observation (both two-sided P = .01). Considering prognostic factors in covariate analysis revealed two-sided P = .0006 for CFP v observation and P = .0003 for CFPT v observation. No substantial difference was identified between CFP and CFPT. Survival data are not yet mature with 31% dead; and, although slight separations of the curves exist in favor of the treatment arms, no significant differences in survival have been seen. Both adjuvant therapy programs are well tolerated and there were no treatment-related deaths. Further maturation of the data is required to determine if the advantages in relapse-free survival will be translated into any overall survival benefit which must be considered the goal of primary interest.

A novel technique to measure splanchnic transit time using microbubble ultrasound.

OBJECTIVE: The objective of this study was to measure splanchnic transit time by intravenous injection of a microbubble. MATERIALS AND METHODS: Ten volunteers were examined before and after eating. After Doppler indices of splanchnic circulation were obtained, the superior mesenteric artery (SMA) and vein (SMV) were simultaneously interrogated using power Doppler ultrasound after intravenous injection of a microbubble. Contrast arrival in the SMA and subsequently the SMV was recorded and splanchnic transit time calculated from differences in the time-intensity curves. RESULTS: Splanchnic transit time decreased significantly after eating (mean 11 vs. 6.9 seconds; P = 0.007), reflecting splanchnic hemodynamics. Between-subject variability attributable to repeated measurements was least for the SMA resistive index (17%) but 56% for the new index, suggesting poor reproducibility. CONCLUSION: Splanchnic transit time may be measured by microbubble injection but is subject to considerable measurement error. Newer microbubbles and imaging methods may allow more reproducible measurements.

Delivery of oligodeoxynucleotides into human saphenous veins and the adjunct effect of ultrasound and microbubbles.

Therapy with naked oligodeoxynucleotides (ODNs, molecular weight: 3000 to 7500) provides an elegant means of modulating gene expression without the problems associated with conventional gene therapy, but the relatively low transfer efficiency on intravascular administration is a limitation to clinical application. Ultrasound, which can be potentiated by microbubbles, shows promise as a method of delivering macromolecules such as plasmid DNA and other transgenes into cells. Since uptake of molecules into cells depends on their molecular weight, it might be expected that the delivery of ODNs, which are relatively small, will be facilitated by ultrasound and microbubbles. In the present study, we delivered ODNs into veins using ultrasound and microbubbles. First, we quantified the uptake of fluorescent-labeled ODNs into intact ex vivo human saphenous veins and isolated smooth muscle cells from the veins, evaluating the effect of ultrasound and microbubbles on uptake. Ultrasound potentiated the delivery of ODN in cells, except at high concentrations. When intact veins were studied, we achieved nuclear localization of fluorescent-labeled ODNs in cells. This increased with increasing concentration and incubation time and was not potentiated by ultrasound, even when microbubbles were used. We then applied a therapeutic ODN (antisense to intercellular adhesion molecule 1, ICAM-1) to vein samples and documented a functional inhibition of gene expression in a sequence-specific manner at the protein level with immunohistochemistry and western blot analysis. Again, no significant difference was seen with adjunct ultrasound. These observations suggest high diffusion of ODNs into human saphenous veins in this ex vivo model, indicating potential applications to inhibition of vascular bypass graft occlusion and other vasculopathies. Although microbubble-ultrasound was of value with cells in culture, it was not beneficial with intact veins.

High-dose preoperative external beam and intraoperative irradiation for locally advanced pancreatic cancer.

PURPOSE: To analyze results of high-dose preoperative external beam irradiation followed by surgical exploration and intraoperative radiation therapy in patients with unresectable pancreatic cancer. METHODS AND MATERIALS: From December 1983 through December 1990, 27 patients with primary unresectable but localized pancreatic adenocarcinoma received high-dose (50 to 54 Gy) external beam irradiation with or without concomitant bolus 5-fluorouracil followed by surgical exploration and intraoperative electron beam irradiation (20 Gy) at the Mayo Clinic. RESULTS: Local control was achieved in 21 of 27 (78%) patients. Actuarial local control at 1, 2, and 5 years was 86%, 68%, and 45%, respectively. In 19 (70%) of the 27 patients, distant metastasis developed, and peritoneal or liver progression (or both) was found in 14 (52%). The actuarial distant metastasis rate at 2 and 5 years was 69% and 83%, respectively. Median survival from the date of diagnosis was 14.9 months. Actuarial 2- and 5-year overall survival was 27% and 7%, respectively. These survival rates are higher (p = 0.001) than the 6% and 0% actuarial 2- and 5-year survival observed in 56 patients who underwent intraoperative radiation therapy followed by postoperative high-dose external beam treatment at our institution. CONCLUSION: Administering the full component of external beam irradiation before exploration and intraoperative radiation therapy may be more appropriate because it allows better patient selection. Unfortunately, altered patient selection was not effective in decreasing the relative risk of abdominal failure. Because effective systemic chemotherapy does not currently exist, whole abdominal irradiation alone or in combination with chemotherapy warrants evaluation.

Local control and survival in locally advanced gastrointestinal cancer.

When conventional modalities (external beam irradiation and chemotherapy +/- resection) are used in the treatment of locally advanced gastrointestinal malignancies, although useful palliation can be achieved in many patients, local control and long-term survival are infrequent. In recent trials, investigators have used fractionated external beam doses of 4500-5000 rad in 180 rad fractions in combination with irradiation boost techniques of intraoperative electrons, or intraoperative or transcatheter brachytherapy (+/- chemotherapy and resection). With colorectal and biliary cancer, both local control and long-term survival appear to be improved, compared to results achieved with conventional treatment. With pancreatic cancer, an apparent improvement has been noted with local control and median survival, but long-term survival has not been altered. For partially resected gastric cancer, the use of intraoperative irradiation has yielded five year survival rates of approximately 20%. With unresectable or residual gastric cancer, accelerated fractionation alone or in combination with chemotherapy has yielded excellent local control, but patients have died as a result of abdominal failure or lung metastases. Prevention of abdominal failures will be necessary to improve long-term survival with pancreatic and gastric cancer. Randomized trials by site are needed to determine if the observed differences seen in prospective nonrandomized trials are real or due to differences in case selection.

Quality control parameters of intraoperative radiation therapy.

We have tried to outline many of the factors which must be considered in the technical delivery of IORT and in subsequent evaluation of these patients. Unless careful attention is given to details of patient selection, surgery, pathology, radiation therapy and follow-up, it is likely that a vast morass of data will be obtained which will be very difficult to interpret. It is the hope of the IORT Working Group that other institutions using IORT will employ our recommendations with regard to dosimetry, follow-up, and the general technical approach. This will likely lead to an earlier understanding of the exact role of this modality in cancer therapy today.

Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma.

Twenty patients with carcinoma of the gallbladder (GB-4 patients) or extrahepatic bile ducts (EHBD-16 patients) received radiation therapy with curative intent between January, 1980 and December, 1982. All 20 received 4500-5000 rad in 180-200 rad fractions to the tumor and regional lymph nodes. A 1000 to 1500 rad external beam boost was delivered in 180-200 rad fractions in 10 patients who received external beam alone or concomitant 5-Fluorouracil (5-FU). Three of the four GB and 5 of the 16 EHBD patients received a transcatheter boost with 192-Iridium (192Ir) to a dose of 2000-2500 rad calculated at a 0.5-0.1 cm radius. An additional 2 patients with EHBD lesions received an intraoperative electron (IORT) boost of 1500-2000 rad in one fraction calculated to the 90% isodose. Survival and patterns of failure were analyzed by site and treatment method. All four patients with GB carcinoma are dead of disease at 5 1/2, 6, 9 and 10 months from the date of diagnosis respectively. Three of the four developed diffuse peritoneal carcinomatosis. Five of the 16 patients with EHBD carcinoma are alive with a median follow-up of 18 months (range 6-23 months). Four of the 5 patients received a transcatheter 192Ir or IORT boost and all are without evidence of disease. Four of 9 patients who had a subtotal resection with transection of tumor, dilatation of the bile ducts with probes or curettement of the bile ducts developed either diffuse peritoneal carcinomatosis (3 patients) or a recurrence in the surgical scar (2 patients). Local failure was documented in 3 of the nine patients treated with external beam alone +/- 5-FU, and has been documented in one of the seven patients who received an IORT or transcatheter 192Ir boost. Further experience is necessary to determine whether this aggressive treatment will result in long-term disease-free survival in these patients.

Intraoperative and external beam irradiation +/- 5-FU for locally advanced pancreatic cancer.

Because of the poor local control rates obtained with external beam irradiation +/- chemotherapy for locally advanced pancreatic cancer, our institution has used intraoperative radiation therapy (IORT) with electrons to deliver a single "boost" dose of radiation in 52 patients with biopsy-proven adenocarcinoma (primary, unresectable-49; primary, residual-2; and recurrent, unresectable-1). Patients received 4500-5000 rad of fractionated external beam irradiation and an IORT dose of 1750 rad (2 patients) or 2000 rad (50 patients). Acute and chronic tolerance have been acceptable. Documented local progression within either the external beam or IORT fields has been infrequent (3 of 42 evaluable patients or 7%), but there has been little, if any, change in median or long-term survival from that seen in external beam series. This is probably because of a high incidence of liver and peritoneal metastases with pancreatic cancer. A phase II pilot trial, which combines upper or total abdominal irradiation and infusion 5-FU with tumor nodal irradiation plus IORT, is in progress in our institution to evaluate tolerance and the relative incidence of abdominal failures.

Peripheral nerve and ureteral tolerance to intraoperative radiation therapy: clinical and dose-response analysis.

Between April 1981 and July 1984, 51 patients received intraoperative radiation therapy (IORT) as a component of therapy for the management of primary or recurrent pelvic malignancies which were initially unresectable for cure. For these patients, curative surgical alternatives did not exist, or would have involved extensive procedures such as pelvic exenteration, distal sacrectomy, hemipelvectomy, or hemicorporectomy. The primary disease was colorectal in 38 patients. Treatment consisted of external beam radiation (range 3000 to 6890 cGy, median 5040 cGy), surgical debulking when feasible, and an intraoperative electron beam boost to the gross or microscopic residual disease (dose range 1000 to 2500 cGy, median 1750 cGy) utilizing 9-18 MeV electrons. The most common IORT associated toxicities were peripheral neuropathy and ureteral obstruction. None were life-threatening or fatal in severity. Of the 50 patients evaluable for neurotoxicity analysis, 16 (32%) developed peripheral neuropathy consisting of pain in 16 patients, numbness and tingling in 11, and weakness in 8. The pain, numbness and tingling resolved in about 40% of patients, while weakness resolved in only 1 of 8. Sixteen ureters were initially unobstructed by tumor at the time of IORT. Of these, 10 (63%) subsequently showed evidence of obstruction and hydronephrosis. The development of neurotoxicity was more common at IORT doses of 1500 cGy or more versus 1000 cGy. Ureteral obstruction with hydronephrosis occurred more frequently at IORT doses of 1250 cGy or more compared to 1000 cGy. There was no relationship between the likelihood of developing complications and the total external beam dose. The observed dependence of human nerve toxicity primarily on the IORT dose is consistent with data generated from animal experiments.

Abdominal fluid cytology in patients with gastrointestinal malignant lesions.

In a group of 76 patients with various gastrointestinal malignant lesions, we found that peritoneal washings contained tumor cells in 43% of patients with gastric cancer, 22% of those with pancreatic cancer, and 3% of those with colonic cancer. Aside from tumor site, we were unable to identify any criteria that would help to predict the presence of malignant cells in peritoneal fluid specimens. We found no malignant cells on cytology in patients with early localized cancer. The ease of obtaining such data, coupled with the fact that the test is inexpensive, makes cytologic assessment attractive. Furthermore, the results of cytology have been shown to bear a direct relationship to prognosis in some cancers and may serve as an indication for more intensive therapy. The results of sequential cytology tend to support the theory that tumor manipulation may be a source of intraperitoneal spread in certain tumors.

Surgery of the liver, biliary tract, and pancreas.

Biliary, hepatic, and pancreatic surgery at the Mayo Clinic during 1973 was retrospectively examined. A total of 1,137 operations were performed in the 12-month period, with an overall hospital mortality of 2.6%. The operative mortality for 586 elective cholecystectomies for chronic cholecystitis with cholelithiasis was 0.3%--for acute cholecystitis 1.5% and for elective common duct exploration 2.9%. The present review is compared with prior reports in which similar methodology permitted comparisons. Improvement in operative mortality was noted in surgery for cholecystitis and pancreatic and hepatic lesions. The figures drawn from this and previous reports represent more than 10,000 operations on the liver, biliary tract, and pancreas performed at the Mayo Clinic.

Surgical management of acute pancreatitis.

Acute pancreatitis is a formidable problem that infrequently necessitates surgical intervention. Indications for operation may be divided into four main categories: (1) uncertain diagnosis, (2) deteriorating condition, (3) biliary pancreatitis, and (4) pancreatic abscess. One of the most important contributions concerning acute pancreatitis has been the development of predictive criteria that allow quantitation of the severity of disease and precise comparison of various reported series. During a 2-year period, 222 patients with acute pancreatitis were seen at our institution, and 62 of these patients (28%) underwent operation. Biliary pancreatitis accounted for 63% of our cases. The overall mortality of 24% was directly related to the severity of the pancreatitis. Cholecystectomy, during the same hospital admission, is advised for treatment of biliary pancreatitis.

Localized lymphoplasmacellular pancreatitis forming a pancreatic inflammatory pseudotumor.

Inflammatory pseudotumors (IPTs) of the pancreas are rare. To our knowledge, we report the first case of a pancreatic IPT composed of dense lymphocytic and plasmacellular infiltrates that histologically resembled a primary lymphoplasmacytic lymphoma of the pancreas. In addition, it is the first pancreatic IPT analyzed for latent Epstein-Barr virus, an agent implicated in the pathogenesis of IPTs of the liver and spleen.

Management of recurrent rectal cancer.

In an effort to treat the difficult problem of recurrent rectal cancer more successfully, we embarked on an aggressive therapeutic course involving a combination of field irradiation, surgical debulking, and intraoperative radiation therapy. On the basis of our study of 24 patients treated with this regimen, we estimated the local effectiveness to be as high as 85%. Prolonged survival was achieved in 67% of our patients.

Surgical technique and pitfalls of breast reconstruction immediately after mastectomy for carcinoma: initial experience.

Breast reconstruction immediately after mastectomy is being used with increasing frequency. In a study of the first 100 consecutive patients at our institution who underwent this procedure, with (21 patients) or without (79 patients) later nipple reconstruction, 85% responded affirmatively on a follow-up questionnaire when asked whether they would recommend the procedure to other patients. Moreover, 32% rated their cosmetic results as "perfect." No deaths occurred in the immediate postoperative period, but 13 patients had major complications--most commonly, wound infection or displacement or partial extrusion of the implant. All infections, however, occurred early in the study, and with increasing experience and improved selection of patients, the associated morbidity decreased. For the entire group, the mean duration of hospitalization was 7.8 days, similar to that for patients who undergo mastectomy without reconstruction (7.5 days). The high patient acceptance and the overall good results in this preliminary study support the use of breast reconstruction immediately after mastectomy.

Fine-needle aspiration of the breast.

One of the numerous controversial issues related to the clinical management of breast cancer is the role of fine-needle aspiration (FNA). Despite its enthusiastic use in the diagnosis of thyroid nodules, its application to breast abnormalities has been accepted reluctantly. Breast FNA necessitates technical and interpretative skill and continual practice and is not 100% accurate. It also entails an additional, although moderate, expense. To assess the accuracy and determine the possible role of FNA at our institution, we performed both FNA and excisional biopsy in 100 unselected women with palpable breast nodules and correlated the cytologic and histologic findings. Our results were similar to those in previously published studies. FNA had a false-negative rate of 6%, no false-positive results, and an accuracy of 94%. After reviewing the potential assets and liabilities of this technique, we believe that breast FNA may add a measure of confidence in the diagnosis of benign breast lesions, provides a safeguard for preventing misdiagnosis of malignant lesions, and might expedite and reduce the cost of managing both primary and recurrent breast cancer.

Arteriovenous fistula of the thyroid gland associated with spontaneous bleeding from a flow-induced aneurysm of the inferior thyroid artery.

A case of acute, spontaneous cervical hemorrhage caused by a ruptured aneurysm of the inferior thyroid artery is described. This lesion was accompanied by an arteriovenous fistula within the thyroid gland that caused a flow-induced aneurysm. Diagnosis and treatment were successfully performed by selective angiography with endovascular occlusion and embolization. Both diagnostic and therapeutic management are discussed, and the related literature is reviewed. To our knowledge, this is the first reported case of an aneurysm of a thyroid artery in conjunction with an intraparenchymatous arteriovenous fistula of the thyroid gland.