Empowerment, community mobilization and social change in the face of HIV/AIDS.

BACKGROUND: On the basis of recent social and behavioral research, together with more than a decade of practical experience in countries around the world, an important shift has begun to take place in the models or paradigms that have been developed to understand and respond to the HIV/AIDS epidemic. A growing awareness of the complex social, cultural, political and economic forces shaping the epidemic - and, in particular, of the link between the social injustice and increased vulnerability to HIV infection - has led to the reformation of both theory and practice aimed at responding to AIDS and meeting the needs of those most affected by the epidemic. HIV/AIDS PREVENTION: The focus of HIV/AIDS prevention efforts has increasingly shifted from models aimed at changes in individual risk behavior to models aimed at community mobilization. An earlier emphasis on information-based educational campaigns has given way to intervention programs aimed at enablement and empowerment in the face of the epidemic. PERSPECTIVES: These developments have been linked to a new awareness of the fundamental connection between public health and human rights, and to a new understanding of the fight against AIDS as part of a much broader process of social change aimed at redressing structures of inequality, intolerance and injustice.

Structural barriers and facilitators in HIV prevention: a review of international research.

OBJECTIVES: This article provides an overview of a growing body of international research focusing on the structural and environmental factors that shape the spread of the HIV/AIDS epidemic, and create barriers and facilitators in relation to HIV-prevention programs. OVERVIEW OF STRUCTURAL-FACTORS LITERATURE: Most of the research on structural and environmental factors can be grouped into a small number of analytically distinct but interconnected categories: economic (under)development and poverty; mobility, including migration, seasonal work, and social disruption due to war and political instability; and gender inequalities. An additional focus in research on structural and environmental factors has been on the effects of particular governmental and intergovernmental policies in increasing or diminishing HIV vulnerability and transmission. INTERVENTIONS: A smaller subset of the research on structural factors describes and/or evaluates specific interventions in detail. Approaches that have received significant attention include targeted interventions developed for heterosexual women, female commercial sex workers, male truck drivers, and men who have sex with men. CONCLUSIONS: The structural and environmental factors literature offers important insights and reveals a number of productive intervention strategies that might be explored in both resource-rich and -poor settings. However, new methodologies are required to document and evaluate the effects of the structural interventions, which by their very nature involve large-scale elements that cannot be easily controlled by experimental or quasi-experimental research designs. Innovative, interdisciplinary approaches are needed that can move beyond the limited successes of traditional behavioral interventions and explicitly attempt to achieve broader social and structural change.

A kinetic evaluation of blood-brain barrier permeability in human brain tumors with [68Ga]EDTA and positron computed tomography.

Twelve patients with primary and metastatic brain tumors were evaluated with [68Ga]ethylenediaminetetraacetate (EDTA) and positron computed tomography. Using a two-compartment tracer kinetic model, forward (K1) and reverse (k2) rate constants for molecular diffusion across the blood-brain barrier (BBB) were obtained and averaged 0.0029 +/- 0.0016 (mean +/- SD) ml/min/g for K1 and 0.0310 +/- 0.0156 min-1 for k2. Most tracer kinetic models are based on the assumption that tissue radioactivity contains no vascular component or require independent measures of cerebral blood volume (CBV) which are then subtracted from the measure tissue activity. The model in this work differs from that approach by assuming a vascular compartment in the tissue kinetic data. This vascular parameter is estimated from sequential measurements of activity concentrations in regions with an intact BBB or from measurements of 68Ga concentrations in the plasma (the input function). Thus, this approach does not require the assumption of a zero vascular contribution, does not require a separate measurement of CBV, and uses the criteria of constrained estimation to provide estimates of the local CBV and molecular diffusion through the BBB. Estimates of the relative CBV of the lesions in four studies (three subjects) with [68Ga]EDTA correlated well with those obtained with the C15O hemoglobin technique (correlation coefficient of 0.97).

Radiation-induced cancer as a factor in clinical decision making (the 1989 ASTRO Gold Medal address).

1. Ionizing radiations are weak carcinogens. Under certain conditions they can induce cancers in experimental animals and humans. 2. This potential carcinogenicity has been a deterrent to the use of radiation therapy despite its many advantages in the management of patients with cancers. 3. In a range of clinical situations, such as the irradiation of cancers arising in the head and neck, breast, prostate and skin, an increase of second cancers can not be detected above the natural frequency of additional cancers. In the curative treatment of patients with Hodgkins disease, ionizing radiations are not associated with an increased frequency of leukemias and induced second tumors are no more frequent than following the use of alkylating agents. 4. All second tumors attributed to radiation therapy occur after a latent period of many years and except for leukemia usually are potentially curable. 5. The risks of radiation-induced second cancers are no greater than the risks of operative or anesthetic deaths and these catastrophes are immediate and non-remedial. 6. Therefore, at this time, the potential of radiation-induced cancers should not be a factor in the selection of treatment for patients with cancer.

Second primary cancers of the head and neck following treatment of initial primary head and neck cancers.

The risk of a second primary cancer arising in the head and neck, following surgical or radiation treatment of an initial primary cancer in the head and neck, was evaluated for 2,151 patients whose first cancers were diagnosed and treated at UCLA between 1955 and 1979. Based on follow-up data ranging from 5 to 30 years, the rate of development of second cancers of the head and neck was in excess of 2.5 per 1000 person-years at risk. There was no statistically significant difference in the frequency or post-treatment interval of second primary cancers related to the type of treatment of the first cancer, whether that was surgery, radiation therapy, or surgery plus radiation therapy.

Radiation therapy for Graves' ophthalmopathy: a retrospective analysis.

A retrospective analysis of 29 patients with Graves' ophthalmopathy treated from 1973-1986 was undertaken to evaluate the use of radiation therapy (RT). Most patients presented with advanced disease; 20 had been treated with steroids and 8 had undergone prior surgery with orbital decompression. Post-RT evaluation was performed by the patients' Radiation Oncologist, Ophthalmologist, and Endocrinologist with a median follow-up period of 45 months. The overall assessment of the patients' disease was judged as improved with respect to the majority of signs and symptoms in 48%. Soft tissue changes were relieved in 78% and proptosis reduced in 52%. Ophthalmoplegia responded poorly and was improved in only 24%. After RT, 26/29 (90%) of patients have had no further steroid requirements. Thirteen patients underwent surgery for residual signs/symptoms post radiation therapy, indicating that combined modality may be necessary in many patients with advanced disease.

Salivary gland tumors of the oral cavity.

Between 1961 and 1985, 62 patients with malignant salivary gland tumors of the oral cavity underwent surgery with curative intent at the University of California, Los Angeles (UCLA) Medical center. All patients had a minimum follow-up of 2 years. Fifty of 62 (81%) patients presented with T1-2 primary tumors. The tumors arose from the palate in 41/62 (66%) patients. The most common histologic type was adenoid cystic carcinoma comprising 34 of 62 (55%) cases. Radical resection was performed in 46 cases and wide local excision in 16 patients. Postoperative radiation therapy was used in 24 cases due to advanced stage and/or positive surgical margins. Results of treatment were analyzed by stage of disease, modes of treatment, histology, and surgical extent. Local control of small lesions reached 100% at 10 years with either radical resection alone or local excision. With residual tumor at the surgical margins, the incidence of local recurrence was 4/14 (29%) for those who received adjuvant radiation therapy and 5/10 (50%) for those who did not. The vast majority of mucoepidermoid carcinomas were early stage and low grade. These lesions had an excellent prognosis with a control rate of 100%. In contrast, there was a 29% (10/34) failure rate for adenoid cystic carcinoma. The 5-, 10-, and 15-year actuarial survivals for the whole group were 94%, 84%, and 73%, respectively. Our results indicate that for early stage disease, wide local excision may offer patients the chance to avoid the cosmetically and functionally debilitating effects of radical surgery without compromising treatment outcome. Adjuvant radiation therapy appears to reduce the local recurrence for those with residual tumor at the surgical margins.

Mixed neutron/photon irradiation of unresectable squamous cell carcinomas of the head and neck: the final report of a randomized cooperative trial.

Three hundred and twenty-seven patients with inoperable squamous cell carcinomas of the head and neck were entered on a randomized study comparing a mixture of neutron and photon ("mixed beam") radiation therapy with photon/electron radiation therapy. Neutron treatment was delivered with fixed-beam, physics-laboratory-based equipment. Patients with histologically proven tumors of T-stage T2, T3, or T4 and any N-stage were eligible for randomization. Primary tumor sites were limited to cancers originating in the oral cavity, oropharynx, supraglottic larynx, or hypopharynx. Patients entered on this study now have a minimum at-risk follow-up period of 6 years. Study results reveal no significant differences in overall loco-regional tumor control rates or survival. Subgroup analysis reveals significant differences based on whether or not patients presented with positive lymph nodes. Loco-regional tumor control rates for patients presenting with positive lymph nodes were 30% for mixed-beam-treated patients versus 18% for photon-treated patients (p = 0.05). Loco-regional tumor control rates for patients presenting without positive lymph nodes were 64% for photon-treated patients and 33% for mixed-beam-treated patients (p = 0.004). Control of tumor located in the nodal sites favored mixed beam over photons by a margin of 45% (49/109) to 26% (23/87) with a significance of p = 0.004. Possible explanations for these contradictory findings are discussed.

Postoperative irradiation for the prevention of heterotopic bone: analysis of different dose schedules and shielding considerations.

Ninety-seven high risk hips were irradiated postoperatively for prevention of heterotopic bone (HTB) in the UCLA Department of Radiation Oncology from 1980 to 1988. Ninety-two hips in 82 patients were eligible for analysis with a minimum follow-up of 2 months and a median follow-up of 10 months. Forty-nine of the hips had porous coated ingrowth prostheses. From 1980 to 1986, 2 Gy fractions were used to deliver 20 Gy (8 hips), 12 Gy (1 hip), and 10 Gy (27 hips). Since December of 1986, 38 hips received 8 Gy in two increments and 18 hips received a single 7 Gy fraction. All porous ingrowth components were shielded with custom blocks. Six out of 92 hips developed clinically significant (Brooker grade 3 or 4 heterotopic bone). There was one clinically significant failure in 78 hips (1.3%) when irradiation was initiated before post-operative day (POD) #6 and shielding was properly placed. One clinical failure occurred in 38 hips which received 8 Gy in two increments. One clinical failure occurred out of the 18 hips treated with 7 Gy in one fraction. This failure could be related to block malposition. There were four clinical failures in the 36 hips treated with 2 Gy fractions to total doses of 10 Gy, 12 Gy, or 20 Gy. Three of these failures were associated with initiation of treatment after POD #5, and the fourth was related to block malposition. Unshielded trochanteric osteotomies resulted in five migrations and seven fibrous unions for a total non-osseous union rate of 12/36 (33%). Shielding of the remaining 28 trochanteric osteotomies resulted in a non-osseous union rate of 7% (0 migrations and 2 fibrous unions). There were no failures of union of components, and the only side effects noted in the series were the five trochanteric migrations. In conclusion, the use of 8 Gy in two increments or 7 Gy in one fraction was found to be as efficacious as conventional 2 Gy fractionation schemes with no increase in side effects. For optimal results, treatment should be implemented prior to POD #5 with shielding of the trochanteric osteotomy. Postoperative irradiation to prevent HTB can be used in hips with porous components using properly placed blocks to shield the porous region.

Limb salvage therapy for soft tissue sarcomas of the foot.

From 1974 to 1988, 20 patients with soft tissue sarcomas of the foot underwent attempted limb preservation at UCLA. Eighteen patients had localized tumor and two had metastases. Sixteen patients had previously untreated tumors and four patients had experienced 2-4 local recurrences before definitive management. Eleven patients had grade 3 sarcomas and nine had grade 2 sarcomas. Fourteen patients had an excisional biopsy and six had an incisional biopsy. At the time of definitive local treatment, nine patients had palpable tumor ranging from 2-10 cm (median 5 cm). Sixteen patients received sequential preoperative chemotherapy and irradiation followed by attempted conservative resection. Four patients underwent immediate conservative resection followed by postoperative irradiation. Preoperative chemotherapy was administered over 3 days intraarterially, intravenously or by a combination of routes. Fifteen patients received 60-90 mg doxorubicin and one received 120 mg doxorubicin plus 220 mg cisplatinum. Preoperative irradiation was delivered in 350 cGy fractions to total doses of 3500 cGy (one patient), 2800 cGy (8) or 1750 cGy (7). Postoperative irradiation doses were 4140-6480 delivered in 180-200 cGy fractions. Fifteen of 16 preoperatively treated patients had limb salvage surgery. Four of these 15 had positive histopathologic margins and none received postoperative irradiation. One patient required a primary amputation due to gross involvement of the os calcis. Three of four patients undergoing immediate conservative excision had positive margins and one had gross residual disease. Five patients received chemotherapy following local treatment: 3 adjuvantly and 2 for metastatic disease. Follow-up for salvage patients ranged from 6 to 99 months (median 36). Local control was achieved in 17 of 19 (90%). Two patients recurred in-field at 24 and 30 months. Fourteen of 15 preoperatively treated and salvaged patients maintained local control. Three of four managed with excision and postoperative irradiation were controlled. The actuarial local control at 3 years was 83%. One patient recurred in the inguinal lymph nodes and three patients died of metastatic disease. The actuarial survival and relapse-free survival at 3 years were 83% and 63%. Eleven patients developed acute complications and four had late complications. Of 14 patients surviving with local control, function was good or excellent in 86%. No patient has required an amputation for complications or a dysfunctional foot. Limb salvage therapy for a selected patient with a soft tissue sarcoma of the foot can reasonably be expected to result in a high probability of local control and useful function without compromising survival.

Biologically effective dose distribution based on the linear quadratic model and its clinical relevance.

PURPOSE: Radiotherapy plans based on physical dose distributions do not necessarily entirely reflect the biological effects under various fractionation schemes. Over the past decade, the linear-quadratic (LQ) model has emerged as a convenient tool to quantify biological effects for radiotherapy. In this work, we set out to construct a mechanism to display biologically oriented dose distribution based on the LQ model. METHODS AND MATERIALS: A computer program that converts a physical dose distribution calculated by a commercially available treatment planning system to a biologically effective dose (BED) distribution has been developed and verified against theoretical calculations. This software accepts a user's input of biological parameters for each structure of interest (linear and quadratic dose-response and repopulation kinetic parameters), as well as treatment scheme factors (number of fractions, fractional dose, and treatment time). It then presents a two-dimensional BED display in conjunction with anatomical structures. Furthermore, to facilitate clinicians' intuitive comparison with conventional fractionation regimen, a conversion of BED to normalized isoeffective dose (NID) is also allowed. RESULTS: Two sample cases serve to illustrate the application of our tool in clinical practice. (a) For an orthogonal wedged pair of x-ray beams treating a maxillary sinus tumor, the biological effect at the ipsilateral mandible can be quantified, thus illustrates the so-called "double-trouble" effects very well. (b) For a typical four-field, evenly weighted prostate treatment using 10 MV x-rays, physical dosimetry predicts a comparable dose at the femoral necks between an alternate two-fields/day and four-fields/day setups. However, our BED display reveals an approximate 21% higher BED for the two-fields/day scheme. This excessive dose to the femoral necks can be eliminated if the treatment is delivered with a 3:2 (anterio-posterior/posterio-anterior (AP/PA): bilaterally opposed (BLO)) dose weighting. With Co-60 beams, the increase of BED with alternate two-fields/day, 1:1 setup was even more pronounced (26%). CONCLUSION: We have demonstrated the feasibility of constructing a biologically oriented dose distribution for clinical practice of radiotherapy. The discordance between physical dose distributions and the biological counterparts based on the given treatment schemes was quantified. The computerized display of BED at nonprescription points greatly enhanced the versatility of this tool. Although the routine use of this implementation in clinical radiotherapy should be cautiously done, depending largely on the accuracy of the published biological parameters, it may, nevertheless, help the clinicians derive an optimal treatment plan with a particular fractionation scheme or use it as a quantitative tool for outcome analysis in clinical research.

Fast-neutron therapy in advanced head and neck cancer: a collaborative international randomized trial.

PURPOSE: To compare the efficacy of fast-neutron radiotherapy with that of conventionally fractionated photon therapy in the management of patients with locally advanced squamous cell carcinoma of the head and neck. METHODS AND MATERIALS: Patients with Stage III or IV disease were randomized to receive either 20.4 Gy/12 fractions/4 weeks of neutrons or 70 Gy/35 fractions/7 weeks of photons (control). Between April 1986 and March 1991, 178 patients were entered, 169 of whom were eligible for analysis. The treatment arms were balanced for age, stage, and performance status, but not for primary site of origin. RESULTS: Complete response occurred in 70 and 52% with neutrons and photons, respectively (p = 0.006). Local regional failure at 3 years for all patients was 63% for neutrons and 68% for photons. Actuarial overall survival curves were virtually identical in both study arms, falling to 27% at 3 years. Acute toxicity was similar in the two arms, but late grade 3-5 toxicity was 40% with neutrons compared to 18% with photons (p = 0.008). CONCLUSION: Although the initial response rate was higher with neutrons, permanent local control and survival were not improved, and the incidence of late normal tissue toxicity was increased. As a result, fast-neutron therapy for advanced squamous cell carcinoma of the head and neck can only be recommended for patients in whom the logistic benefit of treatment in 12 sessions over 4 weeks outweighs the increased risk of late toxicity.

Effects of 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP)-induced hemiparkinsonism on the kinematics of a two-dimensional,multijoint arm movement in the rhesus monkey.

The effects of the selective dopaminergic neurotoxin 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP) on the kinematics of two-dimensional arm movements in the primate were studied. Two rhesus monkeys were trained to move a manipulandum at various distances and directions in horizontal space from a centrally located target box. Several kinematic parameters including reaction time, and time and amplitude of peak tangential velocity were analysed. Following an extensive control evaluation period, the animals were unilaterally injected with MPTP into the internal carotid artery. The animals were restudied for up to 289 days following induction of hemiparkinsonism. Larger-amplitude movements (greater than 3.5 cm) were more severely affected than smaller amplitude movements. Both animals exhibited marked changes in the arm movements including increased time-to-peak velocity and decreased peak velocity. The degree of the kinematic changes was spatially dependent, with the decrease in velocity as well as the time-to-peak velocity being more pronounced for the larger, outward movements. Reaction time increased but showed no spatial dependency. Kinematic deficits persisted over the entire time-period studied. Also, the kinematic changes were reduced by levo-3,4 dihydroxyphenylalanine in a dose-dependent manner. Tyrosine hydroxylase immunohistochemistry documented extensive cell loss in the substantia nigra. These results show that both the timing as well as the amplitude of the velocity profiles are disrupted by MPTP consistent with the known akinesia and bradykinesia of parkinsonism. Although abnormalities were present for all directions and distances, a spatial dependency to the deficits was detected. The observation of more pronounced changes for larger, outward movements suggests a role for the basal ganglia in production of larger-amplitude movements directed away from the body.

Carcinoma of the lip and selected sites of head and neck skin. A clinical study of 896 patients.

During a period of over 20 years, 896 patients were treated with radiation in Wadsworth Medical Center, Los Angeles, for carcinoma of the lip and selected sites of skin of the head and neck. Basal cell carcinoma (BCC) was found in 467 (52%) patients, squamous cell carcinoma (SCC) in 362 (40%), and the remaining 67 (8%) had tumors with mixed basal and squamous cell features. BCC was the most common tumor (72%) among the 646 skin cancer patients while SCC predominated (99%) among the 250 lip cancer patients. Tumor control correlated well with the size of the lesion, p less than 0.0001. Histology of the lesion also had a significant (p = 0.021) influence on the tumor control rate, which was the highest among the BCC patients when compared with SCC or mixed cell patients. This study has again demonstrated the effectiveness of radiotherapy in controlling small and intermediate size epithelial tumors of the skin and lip. Additionally, irradiation, if administered properly, results in excellent cosmesis and a low incidence of treatment complications. Severe complications of radiotherapy reported in the literature took place at the beginning of this century and are no longer pertinent in the practice of modern radiation oncology. Larger lesions remain a challenge to radiation or surgical dermato-oncologists. A lack of tumor control in such lesions frequently results in a death of patient.

High energy (42-66 MeV reactions) fast neutron dose optimization studies in the head and neck, thorax, upper abdomen, pelvis and extremities.

Five hundred and fifty patients were entered into a set of dose-searching studies designed to determine normal tissue tolerance to high energy (42-66 MeV reactions) fast neutrons delivered in 12 equal fractions over 4 weeks. Participating institutions included: The Fermilab (66 MeV p+----Be), The University of Washington (50 MeVp+----Be), U.C.L.A. (45 MeVH-----Be), M.D. Anderson Hospital (42 MeVH-----Be), and The Cleveland Clinic (42 MeVp+----Be). Patients were stratified by treatment facility and then randomized to receive 16, 18 or 20 Gy for tumors located in the upper abdomen or pelvis, and 18, 20 or 22 Gy for tumors located in the head and neck, thorax or extremities. Following completion of the randomized protocols, additional patients were studied at the 20.4 Gy level in the head and neck, thorax and pelvis. Normal tissue effect scoring was accomplished using the RTOG-EORTC acute and late normal tissue effect scales. Acute Grade 3 + toxicity rates in the head and neck were 19% for 20/20.4 Gy and 20% for 22 Gy. Time adjusted late toxicity rates in the head and neck at 12 months were 15% for 20/20.4 Gy and 0% for 22 Gy. The 18 Gy treatment arm of the head and neck protocol was dropped early in the study after only two patients were accrued. For cases treated in the thorax, acute Grade 3 + toxicity rates were 6% for 18 Gy, 15% for 20/20.4 Gy and 7% for 22 Gy. Late toxicity rates at 12 months were 0% for 18 Gy, 11% for 20/20.4 Gy and 18% for 22 Gy. Acute Grade 3+ toxicity rates in the upper abdomen were 0% for 16 Gy, 8% for 18 Gy and 12% for 20 Gy. There were no Grade 3 + late toxicities in the upper abdomen. In the pelvis, acute Grade 3 + toxicity rates were 0% for 16 Gy, 3% for 18 Gy and 3% for 20/20.4 Gy. Late Grade 3 + toxicities at 24 months were 20% for 16 Gy, 5% for 18 Gy and 24% for 20/20.4 Gy. In extremities, acute Grade 3 + toxicity rates were 7% for 20 Gy and 21% for 22 Gy while at 12 months, late Grade 3 + toxicity rates were 14 and 35%, respectively. The 18 Gy treatment arm of the extremities protocol was dropped early in the study after only two patients were accrued. Factors associated with normal tissue effects in addition to treatment dose are discussed.

Patients with newly diagnosed carcinoma of the breast: validation of a claim-based identification algorithm.

The objectives of this study were to validate a claims-based algorithm for identification of patients with newly diagnosed carcinoma of the breast and to optimize the algorithm. Claims data from all females aged 21 years or older who enrolled in a large California health maintenance organization during the study period from October 1, 1994 through March 31, 1996 were analyzed. Medical records of the patients identified through the claims-based algorithm were reviewed to determine whether the patients were correctly identified. The initial algorithm had a positive predictive value of 84% which was similar to the previous study. The percentages of correct identification significantly increased with the patient's age at diagnosis. Other patient demographic characteristics and facility characteristics were not related to the accuracy of the identification. Using a classification tree procedure and additional information from the false-positive cases, the initial algorithm was modified for improvement. The best-modified algorithm had a positive predictive value of 92% while only 0.5% (4/837) of the true-positive cases were excluded. The results once again demonstrated that patients with newly diagnosed carcinomas of the breast can be identified using claims data. These databases provide an efficient and effective tool for performing health services studies on large patient populations.

Acute hepatitis due to Herpes simplex virus in an adult.

A case is described of herpetic hepatitis in a pregnant woman with primary herpetic stomatitis. Intranuclear inclusion bodies and virus particles were found in hepatocytes, and herpes virus was isolated from a liver biopsy and from oral swabs but not from blood. From rising titres of neutralizing and complement-fixing antibody it is concluded that the oral infection was a primary one. Factors predisposing to the hepatitis are discussed.

The Birmingham Histopathology Data Pool: a co-operative project among 10 laboratories.

In 1970 the Birmingham Histopathology Data Pool was established to collect information on biopsies of surgical specimens from three hospitals. The scheme has gradually expanded and 10 hospitals now participate. The pathologist gives each specimen a numerical code based on the Systematised Nomenclature of Pathology (SNOP). The information is processed by computer and stored on cumulative magnetic tape file. At regular intervals (at three, six, and nine months) 'printouts' listing all the information recorded within the interval are produced and a cumulative print-out is issued when the information for a whole year is complete. The data pool system has provided accurate alphabetical and SNOP diagnostic files and has simplified retrieval of data for both follow-up and research purposes. The pathologist may use the computer to retrieve and analyse information from the data pool for this own use or on behalf of clinicians, but he may use information from laboratories other than his own for research purposes and publication only with the permission of the pathologists who submitted the data.

Primary lymphoma of female urethra: long-term control by radiation therapy.

We report a case of primary urethral lymphoma successfully managed by external beam radiation therapy. Long-term freedom from recurrence in this case suggests irradiation is a viable treatment option for this rare malignancy.

Continual intracavitary administration of amphotericin B as an adjunct in the treatment of aspergillus brain abscess: case report and review of the literature.

Aspergillus brain abscess is often a fatal disease, regardless of the mode of therapy. Most often seen in the compromised host, it is notoriously refractory to systemic antifungal agents and intrathecal antimycotics. Even with radical surgical debridement, only 13 patients, including the present case, have survived longer than 3 months after being treated for aspergillus brain abscess or granuloma. Studies have shown poor penetration of amphotericin B into the brain and cerebrospinal fluid. One way to achieve therapeutic levels of the agent near the abscess is through the direct introduction of the agent into the abscess site via an indwelling catheter. In the present case, a woman with an aspergillus abscess of the left temporal lobe was treated by a combination of systemic agents, radical debridement, and local therapy, resulting in a cure with a follow-up of 6 years. This is the first reported instance of the use of long-term, local antifungal therapy delivered to the area of the abscess cavity, using a closed reservoir system, and this patient is only the second renal transplant patient reported to have survived aspergillus brain abscess. This form of treatment produced no untoward long-term side effects or neurological sequelae. Local irrigation with antifungal agents should be considered in conjunction with systemic antifungal drugs and drainage and/or debridement in cases of fungal intracerebral aspergilloma. This technique may also prove useful with other fungal brain lesions.