Protons safely allow coverage of high-risk nodes for patients with regionally advanced non-small-cell lung cancer.

Our objective was to determine if protons allow for the expansion of treatment volumes to cover high-risk nodes in patients with regionally advanced non-small-cell lung cancer. In this study, 5 consecutive patients underwent external-beam radiotherapy treatment planning. Four treatment plans were generated for each patient: 1) photons (x-rays) to treat positron emission tomography (PET)-positive gross disease only to 74 Gy (XG); 2) photons (x-rays) to treat high-risk nodes to 44 Gy and PET-positive gross disease to 74 Gy (XNG); 3) protons to treat PET-positive gross disease only to 74 cobalt gray equivalent (PG); and 4) protons to treat high-risk nodes to 44 CGE and PET-positive gross disease to 74 CGE (PNG). We defined high-risk nodes as mediastinal, hilar, and supraclavicular lymph nodal stations anatomically adjacent to the foci of PET-positive gross disease. Four-dimensional computed tomography was utilized for all patients to account for tumor motion. Standard normal-tissue constraints were utilized. Our results showed that proton plans for all patients were isoeffective with the corresponding photon (x-ray) plans in that they achieved the desired target doses while respecting normal-tissue constraints. In spite of the larger volumes covered, median volume of normal lung receiving 10 CGE or greater (V10Gy/CGE), median V20Gy/CGE, and mean lung dose were lower in the proton plans (PNG) targeting gross disease and nodes when compared with the photon (x-ray) plans (XG) treating gross disease alone. In conclusion, proton plans demonstrated the potential to safely include high-risk nodes without increasing the volume of normal lung irradiated when compared to photon (x-ray) plans, which only targeted gross disease.

Budd-Chiari syndrome in a kitten, caused by membranous obstruction of the caudal vena cava.

An eight-month-old, male domestic shorthair kitten developed progressive abdominal distension over a six-week period. Abdominocentesis revealed a fluid with high protein (3.8 g/dl) and moderate cellularity. Infectious, cardiovascular, and neoplastic causes of posthepatic obstruction were ruled out. Partial obstruction and stenosis of the caudal vena cava (CVC) at the level of the diaphragm were detected on a contrast venogram. Exploratory surgery revealed a fibrous, web-like membrane at the site of obstruction. Resection of the stenotic segment of the CVC was not possible because of the junction of the left hepatic veins and CVC just caudal to the lesion. A 3 by 6-mm, oval Dacron patch graft was sutured into the venotomy site. Postoperative complications included fever and leukocytosis, eosinophilic pleural effusion, and transient congestive heart failure associated with volume overload. The cat is normal 16 months after surgery, with no recurrence of ascites. This is the first reported case of Budd-Chiari syndrome (BCS) in a domestic kitten. Documented herein is the first successful treatment of BCS in a small animal using a vascular, prosthetic patch graft.

Survival results in adult patients treated for medulloblastoma.

The records of all 27 adult patients (age, greater than or equal to 16 years) diagnosed with cerebellar medulloblastoma between 1968 and 1986 were reviewed. Twenty-four patients (89%) were treated with postoperative megavoltage irradiation. Twenty of these patients underwent craniospinal irradiation. Sixteen patients received greater than 5000 cGy to the posterior fossa (range, 2340 to 6600 cGy; median, 5490 cGy). Forty-eight percent of patients also received adjuvant chemotherapy. A 5-year and 10-year actuarial survival rate of 48% was achieved. The use of adjuvant chemotherapy did not improve survival in this series. All relapses occurred within 35 months of diagnosis (median time to relapse, 23.5 months), except one patient who had a recurrence in the posterior fossa at 140 months. The posterior fossa was the most common site of treatment failure and represented 50% of all initial relapses. All survivors had no sequelae, except one in whom leukoencephalopathy developed after craniospinal irradiation and intrathecal methotrexate administration. The survival results obtained in this series compare favorably with other reported modern adult medulloblastoma series.

Principles of measles control.

WHO's Expanded Programme on Immunization has significantly helped to reduce global morbidity and mortality from measles. Recently, some African countries with high vaccine coverage levels have reported measles outbreaks in children above the current target age group for immunization. Outbreaks such as these are to be expected, unless close to 100% of the population are immunized with a vaccine which is 100% effective. Success of an immunization programme requires identification of the distribution and ages of susceptible children and reduction of their concentration throughout the community. Priority should be given to urban and densely populated rural areas. In large urban areas, high coverage of infants must be achieved soon after the age at which they lose their maternal antibodies and become susceptible. This will be facilitated by the introduction of high-dose measles vaccines which can be given at 6 months of age. Where measles incidence is increasing among children aged over 2 years, immunization of older children may be considered during contacts with the health care system, or at primary school entry, if this does not divert resources from immunization of younger children. Health workers should be informed of the predicted changes in measles epidemiology following immunization. The collection, analysis and use of data on measles (vaccine coverage, morbidity and mortality) should be improved at all levels of the health care system in order to monitor the immunization programme's overall impact, identify pockets of low coverage, and allow early detection of and response to measles outbreaks.

Worldwide control of disease through immunization. Progress and prospects.

In summary, tremendous advances have been made over the past 15 years toward the development of effective national immunization programs throughout the world. Immunization levels among children in the developing world have risen dramatically, and in some instances, now equal or exceed levels in industrialized nations. There is no room for complacency, however, because millions of children remain incompletely immunized and many die each year from measles, pertussis, and neonatal tetanus. Immunization activities need to be intensified, accelerated, and sustained within the context of the primary health care system. Expansion of immunization programs to include additional vaccines and other simple health interventions will yield further benefits in the years ahead.

Vaccinations in the health strategies of developing countries.

The initiative established by the World Health Organization in 1974 under the title of the Expanded Programme on Immunization (EPI) has resulted in immunization programmes being strengthened in developing countries so that they now cover 66% of children reaching their first birthday with a dose of DPT or polio vaccines. Immunization programmes are currently preventing over 2 million deaths among children in developing countries from measles, neonatal tetanus and whooping cough. Future challenges for the EPI include: raising and sustaining immunization coverage; controlling the target diseases, with specific focus on the control of measles, the elimination of neonatal tetanus and the eradication of poliomyelitis; introducing new or improved vaccines; promoting other primary health care practices; and research and development. Immunization will become an increasing priority for developing and industrialized countries alike as an increasing array of vaccines become available for public health use. Further research to simplify and reduce the costs of vaccine production and administration and to better understand the factors contributing to the acceptability of immunization services is needed as a complement to research to develop additional vaccines.

Differences in secretion of prostacyclin by venous and arterial endothelial cells grown in vitro in a static versus a mechanically active environment.

The objective of this study was to compare the effect of cyclic tension on prostacyclin secretion by venous and arterial endothelial cells. Early passage endothelial cells from bovine aortas and venae cavae were subjected to cyclic deformation (up to 17% elongation and 60 cycles/min). On posttreatment days 3 and 5 a radioimmunoassay was used to assess supernatant fluids from the endothelial cells for prostacyclin activity. The results indicate that in vitro (1) under static or control conditions, venous endothelial cells secrete significantly more prostacyclin (an increase of 1.5- and 4.8-fold on days 3 and 5, respectively) than do arterial endothelial cells isolated from the same animal and (2) prostacyclin secretion by mechanically deformed venous and arterial endothelial cells was significantly less than static control cultures on days 3 and 5. However, prostaglandin I2 secretion remained at higher levels in cyclically deformed venous endothelial cells than in cyclically deformed arterial endothelial cells. These data suggest that endothelial cells from the vena cava have a greater capacity for prostacyclin secretion than have their aortic counterparts. If these observations are maintained in vivo, greater prostacyclin secretion by venous endothelial cells could represent a homeostatic mechanism aimed at reducing thrombus formation in low-velocity areas of the vasculature.

Global control of vaccine-preventable diseases: how progress can be evaluated.

In the developing world, excluding China, less than 40% of infants receive a third dose of diphtheria-tetanus-pertussis or poliovirus vaccines. More than 3 million children still die annually from measles, neonatal tetanus, and pertussis, while more than a quarter of a million children are crippled by poliomyelitis. Acceleration of existing efforts, with the use of approaches that must differ according to the requirements of individual countries, constitutes the overriding priority for the Expanded Programme on Immunization (EPI). In evaluating immunization programs, priority should be placed on monitoring immunization coverage and disease incidence. Routine reports are essential for this purpose, although they may usefully be supplemented by surveys. The problems revealed by an evaluation of immunization programs can be taken as being generic to the health services as a whole, until proven otherwise. Therefore, in remedying these problems, approaches that improve the health services as a whole should be sought.

Immunizing the children of the world: progress and prospects.

PIP: The Expanded Program on Immunization was initiated by the World Health Organization in 1974. In 1984, the World Bank, the UN Development Program, the UN Children's Fund, the World Health Organization, and the Rockefeller Foundation formed the Task Force for Child Survival, which, along with private and voluntary groups mobilizes support for the Immunization Program. With collaboration from the US Centers for Disease Control, the World Health Organization has produced training materials for use in various countries and worked with the UN Childrens Fund, which has contributed new cold chain methods for the immunization program. The immunization program provided a building block for a health infrastructure in many countries. It collaborated with the Diarrheal Diseases Control Program to develop integrated training programs, with the Division of Family Health to develop a training module on child spacing, and with the Nutrition Program in introducing vitamin A and iodine supplementation. In 1974, fewer than 5% of children in developing countries were immunized; today 50% are reached with a 3rd dose of polio or diphtheria-pertussis-tetanus vaccines. Immunization started slowly and then increased rapidly since the mid-1980s because the program's 1st objectives were to develop sound national plans and to train a core of competent managers in each country. Measles immunization coverage is low (37%) because the vaccination program is recent and the present vaccine cannot be given before the age of 9 months. Coverage of pregnant women for tetanus is even lower (19%). The number of immunizations could be increased if clinics would provide immunizations during acute care visits. Community mobilization and outside financial assistance are needed; full immunization of 1 child costs $10. The Expanded Program on Immunization hopes to achieve the eradication of polio by 2000 and the eradication of neonatal tetanus and 90% reduction in measles by 1995. Vaccines are being developed for yellow fever, hepatitis B, Japanese encephalitis B, rotavirus, typhoid, shigella, cholera, and leprosy, as well as a measles vaccine that can be given at 6 months. Primary care emphases will be on maternal and child nutrition, diarrheal disease control, birth spacing, and vitamin A and iodine supplementation. The Expanded Program on Immunization will focus on applied research, leaving basic research to be carried out by the Vaccine Development Program, the Basic Vaccinology Program, the Special Program of Research Development and Research Training in Human Reproduction, and the Diseases Control Program.^ieng

Expanded programme on immunization.

The Expanded Programme on Immunization (EPI) was established in 1974 to develop and expand immunization programmes throughout the world. In 1977, the goal was set to make immunization against diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis available to every child in the world by 1990. Problems encountered by the Programme have included: lack of public and governmental awareness of the scope and seriousness of the target diseases; ineffective programme management; inadequate equipment and skills for vaccine storage and handling; and insufficient means for monitoring programme impact as reflected by increasing immunization coverage levels and decreasing incidence of the target diseases. When the EPI was initiated in 1974, fewer than 5% of children in developing countries were receiving a third dose of DPT and poliomyelitis vaccines in their first year of life. These coverage levels have now surpassed 50% in developing countries, and millions of cases of the target disease have been prevented. Over 700,000 measles deaths were prevented by immunization in developing countries in 1987, and an increasing number of neonatal tetanus deaths is now being prevented by maternal immunization and improved childbirth conditions. Poliomyelitis immunization efforts have been so successful that the Pan American Health Organization is leading a drive to eradicate poliomyelitis from the Americas by 1990. The successes of the Programme represent a major public health achievement, but much remains to be done.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The Expanded Programme on Immunization (EPI) was established in 1974 to develop and expand immunization programs throughout the world. In 1977, the goal was set to make immunization against diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis available to every child in the world by 1990. Problems encountered by the Program have included: lack of public and governmental awareness of the scope and seriousness of the target diseases; ineffective program management; inadequate equipment and skills for vaccine storage and handling; and insufficient means for monitoring program impact as reflected by increasing immunization coverage levels and decreasing incidence of the target diseases. When the EPI was initiated in 1974, fewer than 5% of children in developing countries were receiving a 3rd dose of DPT and poliomyelitis vaccines in their 1st year of life. These coverage levels have now surpassed 50% in developing countries, and millions of cases of the target disease have been prevented. Over 700,000 measles deaths were prevented by immunization in developing countries in 1987, and an increasing number of neonatal tetanus deaths is now being prevented by maternal immunization and improved childbirth conditions. Poliomyelitis immunization efforts have been so successful that the Pan American Health Organization is leading a drive to eradicate poliomyelitis from the Americas by 1990. The successes of the Program represent a major public health achievement, but much remains to be done. Measles still kills nearly 2 million children each year, neonatal tetanus kills some 800,000 newborns, and pertussis nearly 600,000 children. 250,000 cases of paralytic poliomyelitis still occur annually. The major challenges now facing the EPI are accelerating and sustaining national immunization efforts.