Activities of an ethics consultation service in a Tertiary Military Medical Center.

The Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have a mechanism to address issues of medical ethics. Most hospitals, especially those in the military, have an ethics committee composed solely of members who serve as an additional duty. To enhance the ethics consultation service, the 59th Medical Wing created a position under the chief of the medical staff for a full-time, fellowship-trained, medical ethicist. After establishment of this position, the number of consultations increased, a systematic program for caregiver education was developed and delivered, and an organizational presence was achieved by instituting positions on the institutional review board, the executive committee of the medical staff, and the credentials committee. Issues in medical care are becoming increasingly complicated, due in large part to financial stresses and technological advancements. Ethics consultation can help prevent and resolve many of these problems. This report discusses the activities of the first year of a full-time ethicist in a tertiary military medical center.

Peripheral blood hairy cell leukemia cells express only low affinity IL-2 receptors.

Purified leukemia cells from three patients with hairy cell leukemia were studied for IL-2 receptor status. All samples expressed the p55IL-2 receptor subunit. However, none demonstrated sensitivity to the IL-2-diphtheria toxin conjugate, DAB486IL-2, which shows selective cytotoxicity for high affinity IL-2 receptor-bearing cells. In the one case studied with 125I-IL-2 binding, only low affinity IL-2 receptors were noted. These data suggest that hairy cell leukemia cells express only low affinity IL-2 receptors and are insensitive to DAB486IL-2.

PHA induces IL-2 receptors on B-CLL cells and is a potential biological response modifier for the LIL-2-diphtheria toxin, DAB486IL-2.

DAB486IL-2 is an IL-2-diphtheria toxin conjugate which was developed to be specifically cytotoxic to cells bearing high affinity IL-2 receptors. The high affinity IL-2 receptor is a heterodimer comprising p55 and p75 subunits. While the p75 subunit appears to be ubiquitously expressed among the common North American leukemias and lymphomas, the p55 subunit is more restricted in its expression. To broaden the therapeutic relevance of the DAB486IL-2 we have sought physiologically feasible inducers of the p55 IL-2 receptor subunit. This report describes that PHA, in vitro, induces the p55 IL-2 receptor subunit on initially p55-negative B-CLL cells and converts toxin-insensitive leukemia cells to a toxin-sensitive state.

Role of adjuvant therapy in colorectal cancer.

After nearly three decades of consistently disappointing adjuvant therapy trials in resectable colorectal cancer, recently emerging results offer some basis for cautious optimism. Adjuvant fluorouracil-containing regimens appear to confer a modest treatment benefit in completely resected colonic adenocarcinomas. The two most promising chemotherapy approaches at present appear to be the fluorouracil-levamisole and fluorouracil-leucovorin regimens. The optimal schedule and dose of these agents remains to be determined. Portal vein chemotherapy infusion studies have yielded promising but inconclusive results to date. As data from completed or ongoing large group studies become available, the role of this modality will be better clarified. In rectal cancer, adjuvant radiotherapy alone has a modest but consistent ability to reduce local recurrence without demonstrating any survival advantage. The optimal dose and sequencing of radiotherapy remains poorly defined. Two completed cooperative group studies strongly suggest that the optimal use of radiotherapy is in combination with chemotherapy. The independent role of chemotherapy in rectal cancer remains unclear. There is suggestive evidence that adjuvant chemotherapy is more effective with rectal cancer than with primaries arising proximal to the peritoneal reflection. Despite the large number of unresolved questions that remain, the following interim treatment recommendations can be made: 1. Patients with Dukes' B and C rectal and colonic adenocarcinomas should be entered into an appropriate adjuvant clinical trial when feasible. 2. Outside the setting of a protocol, there is a sound rationale to treat Dukes' B and C rectal cancer with combination chemotherapy and postoperative radiotherapy. The chemotherapy could consist of fluorouracil either alone or combined with leucovorin. 3. In more proximal colonic tumors (above the pelvic peritoneal reflection), recently described improvements in survival for patients with Dukes' B disease suggests that adjuvant therapy should be withheld in this group when not participating in a clinical study. Patients with Dukes' C tumors should receive fluorouracil-levamisole.

Discordant human chorionic gonadotropin results giving rise to inappropriate therapy in a case of testicular cancer.

The most widely cited cause of a falsely elevated human chorionic gonadotropin level in patients with germ cell tumors is an elevated level of partially cross-reacting luteinizing hormone. Other causes of discordant human chorionic gonadotropin results (human chorionic gonadotropin elevated in 1 assay but normal in others) in testicular cancer have received scant attention. A patient with pure seminoma was given inappropriate chemotherapy on the basis of an elevated human chorionic gonadotropin level, later shown to be due to a nonspecific serum interfering substance. A discordant human chorionic gonadotropin result should be suspected when the human chorionic gonadotropin is only modestly elevated, there is no serial increase in the human chorionic gonadotropin level and no other evidence of tumor can be found.

Suprasellar germinoma--occult presentation with hypothalamic failure 18 months before diagnosis.

Hormonal evidence of widespread hypothalamic failure, including diabetes insipidus, hyperprolactinaemia, growth failure, hypothyroidism, and adrenal failure, was present in a boy of 14 years. Investigation with computerised axial tomography (CT) and metrizamide encephalography failed to identify any anatomical abnormality at the time of presentation. However, 18 months later papilloedema was noted at which time a suprasellar mass and gross dilatation of the ventricular system were readily identified using CT and a germinoma was subsequently diagnosed and treated. In the light of this experience we recommend that when "idiopathic" hypothalamic failure is diagnosed, imaging procedures, including CT or nuclear magnetic resonance examinations, should be repeated on at least one occasion, after an interval of approximately 6 months.

Gastrointestinal sarcoidosis resembling Crohn's disease.

We describe a patient with disseminated sarcoidosis, who had granulomatous enterocolitis with radiological narrowing of the terminal ileum, and was presumed to have Crohn's disease. At autopsy, there were numerous sarcoid-like granulomata throughout the mucosa of the large and small bowel, but no transmural inflammation, lymphoid aggregates, or strictures, thus making Crohn's disease unlikely. It is proposed that a granulomatous enterocolitis resembling Crohn's disease can be a manifestation of disseminated sarcoidosis.