Traumatic pedestrian and bicyclist injuries associated with intoxication.

BACKGROUND: Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma. METHODS: We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n = 69) to those with negative screens (n = 25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED). RESULTS: Overall, 38 (55%) of injured patients with positive screen were pedestrians and 31 (45%) were bicyclists. Fentanyl was the most commonly detected drug (n = 38; 40%), followed by opiates (n = 27; 29%), and tetrahydrocannabiol (THC) (n = 23; 25%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p < .01), require an operative procedure (p < .05), or intensive care unit admission (p < .05). CONCLUSION: Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.

Rapid, high-yield production in plants of individualized idiotype vaccines for non-Hodgkin's lymphoma.

BACKGROUND: Animal and clinical studies with plant-produced single-chain variable fragment lymphoma vaccines have demonstrated specific immunogenicity and safety. However, the expression levels of such fragments were highly variable and required complex engineering of the linkers. Moreover, the downstream processing could not be built around standard methods like protein A affinity capture. DESIGN: We report a novel vaccine manufacturing process, magnifection, devoid of the above-mentioned shortcomings and allowing consistent and efficient expression in plants of whole immunoglobulins (Igs). RESULTS: Full idiotype (Id)-containing IgG molecules of 20 lymphoma patients and 2 mouse lymphoma models were expressed at levels between 0.5 and 4.8 g/kg of leaf biomass. Protein A affinity capture purification yielded antigens of pharmaceutical purity. Several patient Igs produced in plants showed specific cross-reactivity with sera derived from the same patients immunized with hybridoma-produced Id vaccine. Mice vaccinated with plant- or hybridoma-produced Igs showed comparable protection levels in tumor challenge studies. CONCLUSIONS: This manufacturing process is reliable and robust, the manufacturing time from biopsy to vaccine is <12 weeks and the expression and purification of antigens require only 2 weeks. The process is also broadly applicable for manufacturing monoclonal antibodies in plants, providing 50- to 1000-fold higher yields than alternative plant expression methods.

Interferon-containing controlled-release polymers for localized cerebral immunotherapy.

Controlled-release ethylene-vinyl acetate copolymers (EVAc), which were used previously for the in vivo intracerebral delivery of chemotherapeutics, were evaluated as a possible route of localized intracerebral delivery of interferon (IFN). Natural mouse IFN-alpha/beta (Mu-IFN-alpha/beta) was incorporated into polymers at 5% or 10% by weight with 2 x 10(4) U or 4 x 10(4) U, respectively. In vitro and in vivo studies of the release of Mu-IFN-alpha/beta from EVAc polymers showed the released IFN to be biologically active, as determined by the inhibition assay of viral cytopathic effect (CPE). Evaluation of the in vitro kinetics of release showed that most of the IFN activity was released in the first 4 days, with the rest being released thereafter. The in vivo kinetic release of Mu-IFN-alpha/beta from intracerebrally implanted polymers showed that most of the IFN activity was released within 24 h after polymer implantation in the hemisphere ipsilateral to the polymer. This IFN activity gradually decreased over the next 72 h, with a significant linear trend (p < 0.0001). The hemisphere contralateral to the implanted polymer showed no significant levels of IFN activity throughout the 4 days of evaluation. By contrast, blood levels of IFN increased from day 1 to day 4, showing a significant linear trend (p = 0.0125), with IFN levels on day 4 being significantly higher (p < 0.05) than on day 1 after polymer implant. This study demonstrates the feasibility of intracranial controlled local delivery of IFN using a polymer delivery device.

Selective permeability of [3H]-D-mannitol and [14C]-carboxyl-inulin across the blood-brain barrier and blood-spinal cord barrier in the rabbit.

Selective permeability across the blood-brain and blood-spinal cord barriers was studied in a rabbit experimental model. To maintain steady state levels of the tracers in the circulation, 50muCi each of [3H]-D-mannitol and [14C]-carboxyl-inulin were administered as a bolus and by slow intravenous infusion for 60, 90 and 120 minutes; 90 min proved to be the optimal equilibration time for uptake of radioactive tracers into central nervous system (CNS) regions. Kinetic transfer of [3H]-D-mannitol and [14C]-carboxyl-inulin from blood into CNS was computed as apparent transfer constant (KD). The KD for [3H]-D-mannitol in regions of brain (cerebrum, cerebellum, mid-brain, pons and brain stem), and spinal cord (cervical, thoracic and lumbar) were 0.033 to 0.054 microliter/min/g-1 and 0.053 to 0.065 microliter/min/g-1, respectively. The KD for [14C]-carboxyl-inulin into brain and spinal cord regions were 0.016 to 0.033 and 0.037 to 0.054 microliter/min/g-1, respectively. Of the regions of spinal cord and brain examined, lumbar cord appears to be the most permeable. The KD values pooled for samples of the spinal cord show a significant increase in uptake of [3H]-D-mannitol (p = 0.0043) and [14C]-carboxyl-inulin (p = 0.0001) compared to samples of brain. The blood-spinal cord barrier was more permeable to these substances than the blood-brain barrier.

Improved long term survival after intracavitary interleukin-2 and lymphokine-activated killer cells for adults with recurrent malignant glioma.

BACKGROUND: The median survival for adults with glioblastoma multiforme (GBM) is 12 months, despite surgery, radiation, and chemotherapy. Regimens using interleukin-2 (IL-2) plus lymphokine-activated killer (LAK) cells have been beneficial against systemic cancers, albeit with significant toxicity. METHODS: Nineteen adults with recurrent malignant glioma (5 GBMs, and 4 anaplastic astrocytomas (AA)), Karnofsky performance status 60 or greater, were treated with intracavitary autologous LAK cells plus IL-2 after reoperation. Lymphokine-activated killer cells and IL-2 were given on day 1, and IL-2 alone was given 5 times during a 2-week cycle. This cycle was repeated at 2 weeks to constitute one 6-week course of therapy. Each two-cycle course of treatment was repeated at 3-month intervals for patients with stable disease or response to therapy. At the conclusion of immunotherapy, all patients were offered chemotherapy, generally carmustine or procarbazine, including responders. Corticosteroids were strictly limited during immunotherapy. Sequential reservoir aspirates were obtained for microbiologic and cytologic analyses. RESULTS: The maximal tolerated dose for a 12-dose course of therapy was 1.2 million international units (MIU) per dose. Dose-limiting, cumulative IL-2-related central nervous system (CNS) toxicity was observed at 2.4 MIU per dose. Three responses were confirmed by computed tomography scan during therapy: one complete response (CR) (1 AA), and two partial responses (PR) (2 GBM); as well as a significant increase in GBM survival. One additional CR (GBM) was observed at 17 months. The median survival for immunotherapy patients with GBM was 53 weeks after reoperation (N = 15) (mean, 87.9 +/- 21.4 weeks, standard error for the mean), with 8 of 15 surviving more than 1 year (53%). The median survival for 18 contemporary patients with GBM reoperated and treated with chemotherapy was 25.5 weeks (mean, 27.4 +/- 3.7 weeks), with 1/18 alive at 1 year (> 6%). Six of the 15 patients with GBM had additional surgery or biopsy, and chemotherapy after immunotherapy. The contribution of subsequent chemotherapy to survival cannot be discounted. CONCLUSIONS: Lymphokine-activated killer cells and IL-2 can be administered safely within the CNS resulting in improved long term survival in patients with recurrent glioblastoma. Increased survival was associated with significant biologic changes characterized by a regional eosinophilia, and extensive lymphocytic infiltration. A prospective randomized clinical trial is warranted.

Surgical Treatment of Metastatic Brain Tumors.

Metastasis to the brain is a major cause of mortality and morbidity in patients with cancer. Lung, breast, and renal cancers as well as melanomas are particularly prone to producing this complication. Brain metastases may be clinically silent or may be detected as a result of various neurologic symptoms, and they may present in patients with or without extracranial manifestations of the primary cancer. Various management approaches are available, and decisions on which treatment will provide most benefit are best made with multidisciplinary input. Surgical resection is considered for patients with single or adjacent metastases who are in good performance status and whose systemic cancer, if present, is likely to be indolent or controlled.

Lumbosacral spinal intradural extramedullary paciniomyolipoma: magnetic resonance imaging, computed tomography, and pathology findings.

This report describes a paciniomyolipoma as an intradural tumor of the lumbar spinal cord composed of adipose tissue, striated skeletal muscle, and pacinian corpuscles. Simple lipomas, myolipomas, and other variant lipomas of the spinal cord have been described in the literature; to the authors' knowledge, however, this is the first report of this unusual and unique lipoma.

Results of a randomized trial comparing intra-arterial cisplatin and intravenous PCNU for the treatment of primary brain tumors in adults: Brain Tumor Cooperative Group trial 8420A.

PURPOSE: To test the efficacy of intra-arterial (IA) cisplatin versus intravenous (IV) PCNU for treating primary brain tumors, in a randomized trial (Brain Tumor Cooperative Group [BTCG] Trial 8420A). METHODS: 311 adult patients (ages 19-79 years; median 45) with supratentorial tumors (confirmed histologically) were randomized by nine participating institutions. Patients were required to have completed radiotherapy (4500-6020 cGy to the tumor bed) before randomization. Patients were stratified as either nonprogressive (clinically and radiologically stable) or progressive. Results were analyzed for the 311 patients in the randomized population (RP), and for the 281 patients in the Valid Study Group (VSG) meeting protocol eligibility requirements. 56% of patients in the VSG had glioblastoma multiforme, 33% had other malignant glioma, and 11% had low-grade glioma. 64% were stratified as progressive. 12% had received prior chemotherapy. RESULTS: The group randomized to PCNU had the longer survival (p = 0.06 for the RP, p = 0.07 for the VSG). In the VSG, median survival was 10 months for the cisplatin group, 13 months for the PCNU group. The difference between treatment groups was significant (p < or = 0.02) when adjusted for important prognostic factors. PCNU lead to greater hematotoxicity; cisplatin lead to greater renal toxicity and some ototoxicity. Some cisplatin patients experienced complications associated with IA administration, including six cases of encephalopathy. CONCLUSION: The trial showed a survival advantage to the group randomized to PCNU, although the difference was modest. Coupled with previous BTCG results, these trails suggest that PCNU is an active drug for brain tumors.

Introduction to meningiomas.

Although the biology of meningiomas and their growth rate is becoming progressively more clear and MR imaging with gadolinium enhancement has made a major contribution to the surgeon's capacity to predict his or her ability to carry out a complete removal, there are still some very personal factors involved in the decision to operate. In this brief article, the author analyzes his own decision-making processes that lead him to operate rather than observe a given patient.

Current status of interventional neuroradiology in the management of meningiomas.

Most meningiomas are benign and therefore curable lesions. Currently, the best available treatment is complete surgical resection. Toward this end, interventional neuroradiologists should contribute to the efficient and total removal of tumor mass. Although some controversy exists as to the value of the embolization of meningiomas involving the convexity, preoperative embolization certainly is of value in more complex presentations, including giant meningiomas, meningiomas exhibiting malignant or angioblastic characteristics, as well as those involving the skull base, scalp, or critical vascular structures. Several reports have illustrated the importance of preoperative embolization in reducing blood supply to lesions in surgically inaccessible areas. Moreover, several arguments may be advanced in defense of embolization as a method of devascularization superior to dural vessel ligation at the time of operation. Microemboli enter the vascular bed of the tumor and devascularize the lesion irrespective of collateral circulation. In addition, bilateral dural devascularization is easier to accomplish via endovascular techniques and may obviate the need for surgical exposure of the contralateral side during resections of tumors involving the falx or parasagittal region. The tumor necrosis occurring after devascularization by microparticulate emboli may facilitate surgical manipulation. At a theoretical level, embolization may reduce the likelihood of recurrence, particularly from unnoticed invasion of dural venous sinuses or from the surrounding dura. To achieve these goals, embolization should be as complete as possible. This requires a thorough understanding of the disease process and the vascular anatomy involved and superb technique.

Removal of convexity, parasagittal, and falcine meningiomas.

Convex, parasagittal, and falcine meningiomas represent a group of tumors that naturally fall together in terms of symptoms, surgical technique, and potential problems related to their anterior-posterior location. There are significant differences in the technical aspects of the surgical approaches to these three supratentorial meningiomas, which are reviewed separately in this article.

Cavernous angiomas of the internal auditory canal. A case report and review of literature.

Cavernous angiomas of the internal auditory canal (IAC) are rare. They are angiographically occult; and because the clinical symptoms are similar both in intracanalicular cavernous angiomas and acoustic tumors it had been difficult to differentiate pre-operatively both of these pathologies until the advent of magnetic resonance imaging (MRI). Even nowadays the correct diagnosis may be missed if the patient is imaged only with gadolinium enhanced MRI without prior obtaining a non-contrast MRI. These diagnostic difficulties are illustrated by the report of a related case. The importance of thorough neuroradiological investigations stressed and MRI features, surgical management and relevant literature concerning the cavernous angiomas of the internal auditory canal are discussed.

Superiority of PCNU over AZQ in the treatment of primary brain tumors: results of a prospective randomized trial (81-20) by the Brain Tumor Study Group.

PURPOSE: A two-arm randomized clinical trial was performed to determine the efficacy of PCNU and AZQ in the treatment of de novo or recurrent primary brain tumors. An additional objective was to gather information on the administration and toxicity of these compounds, supplementing that obtained previously in phase I/II studies. METHODS: During 1982 and 1983 the Brain Tumor Study Group randomized 152 adult patients with primary brain tumors to receive PCNU 75-100 mg/m2 intravenously (IV) every 8 weeks or AZQ 15 mg/m2 IV once a week for 4 weeks, every 6-8 weeks. All patients who had not received 'full dose' radiotherapy before randomization received it concurrently with the first course of protocol chemotherapy. The data were analyzed for the total randomized population (RP), and for 130 patients in the valid study group (VSG) formed by excluding 22 patients for whom the histologic diagnosis was not documented by central review. RESULTS: Median survival times were 11.0 months for the PCNU group and 8.4 months for the AZQ group. The difference in survival curves was statistically significant for the RP (p = 0.01) and the VSG (p = 0.02). Life-table analysis of the VSG showed estimated 2-year survivals of 34% for PCNU and 11% for AZQ. The advantage of PCNU remained significant (p = 0.006) after adjustment for histopathologic category, age, initial performance status, and interval from initial reported surgery. Myelosuppression was the principal toxicity in both groups.

Central nervous system gangliogliomas. Part 2: Clinical outcome.

The records of 58 patients with gangliogliomas surgically treated between January 1, 1980, and June 30, 1990, were retrospectively reviewed in order to determine long-term survival, event-free survival, and functional outcome resulting after radical resection and to assess the impact of histological grading on outcome. Tumors were located in the cerebral hemisphere in 19 cases, the spinal cord in 30, and the brain stem in nine. Forty-four patients had gross total resection and 14 had radical subtotal resection. Only six patients underwent postoperative irradiation or chemotherapy and, therefore, the outcome was generally related to surgery alone. Of the 58 gangliogliomas, 40 were classified as histological grade I, 16 were grade II, and two were grade III. The median follow-up period was 56 months. There were no operative deaths, and the operative morbidity rate was 5%, 37%, and 33% for cerebral hemisphere, spinal cord, and brain-stem gangliogliomas, respectively. The 5-year actuarial survival rates for cerebral hemisphere, spinal cord, and brain-stem gangliogliomas were 93%, 84%, and 73%, respectively (p = 0.7). The event-free survival rate at 5 years was 95% for cerebral hemisphere gangliogliomas and 36% for spinal cord gangliogliomas (p < 0.05); for brain-stem gangliogliomas the event-free survival rate at 3 years was 53% (p < 0.05). Neurological function at recent follow-up evaluation was stable or improved in 81% of patients. Multivariate analysis (Cox linear regression) revealed tumor location to be the only variable predictive of outcome, with spinal cord and brain-stem gangliogliomas having a 3.5- and 5-fold increased relative risk of recurrence, respectively, compared to cerebral hemisphere gangliogliomas. Histological grade was not predictive of outcome, although in each location there was a trend for higher-grade tumors to have a shorter time to recurrence. It is concluded that radical surgery leads to long-term survival of patients with gangliogliomas, regardless of location, and adjuvant therapy can probably be reserved for special cases.