Cerebrospinal Fluid Research aims to provide a specialist platform for high quality articles on all aspects of the cerebrospinal fluid (CSF), bringing together experts working in the field and promoting synthesis and dialogue. This, launch Editorial provides an overview of the field, some history, and highlights some of the journal policies. Cerebrospinal Fluid Research is an open access, online journal that publishes manuscripts on cerebrospinal fluid (CSF) in health and disease in the broadest sense. The CSF, its composition, circulation and absorption play vital roles in normal and abnormal brain function. The fluid within the CSF system is important for normal chemical signaling, physical and chemical buffering, and for neurodevelopment. In disease states, the CSF impacts on neurodevelopmental disorders such as hydrocephalus and neural tube defects, brain inflammation, brain injury and repair, normal pressure hydrocephalus and neurodegenerative diseases such as Alzheimer's, Parkinson's and multiple sclerosis. The CSF can be used as a tool for diagnosis, through composition analysis, and as a window for drug delivery to the brain.th century B.C. recorded the presence of fluid and is thought to have tapped the ventricles in a patient with hydrocephalus. Subsequently, in the 2nd century A.D., Galen described the ventricles and his dogma that the ventricles contained a gaseous vital spirit, lasted for over 1000 years. The return to the fluid hypothesis occurred in 1543 with Vesalius who made detailed observations of the anatomy and noted the presence of a watery humor. Further studies in the 17th and 18th centuries by Valsalva, Haller, and Contugno elaborated and extended this knowledge. Magendie in 1825 made chemical and physiological studies on the fluid and coined the name liquide cephalo-rachidien or fluid cerebrospinal. He saw pulsatile movement and concluded the fluid was under positive pressure. Later in the 19th century the anatomists Key and Retzius made extremely detailed studies of the cavities and the membranes of the brain, and provided a foundation for many 20th century investigations starting with Dixon and Haliburton, 1913 [Fluid within the brain cavities was known of in ancient times. Hippocrates in the 4Physiological studies began in the 1950's with numerous investigations led by Hugh Davson, the 'father' of CSF physiology . It was th century include the measurement and control of CSF secretion by Pappenheimer et al [Cerebrospinal Fluid Research [Particular milestones in the latter half of the 20er et al , and upter et al  and Poller et al , the demer et al , and theer et al . FurtherResearch . The jouCerebrospinal Fluid Research is supported by an international Editorial Board [al Board . Each maCerebrospinal Fluid Research will consider the publication of research articles, reviews, commentaries, book reviews and meeting proceedings. All articles will be published immediately upon acceptance (after peer review) and listed in PubMed. The intention is to publish, as supplements, the proceedings of scientific meetings in relevant subject areas.Cerebrospinal Fluid Research's Open Access policy changes the way in which articles are published. First, all articles become freely and universally accessible online, and so an author's work can be read by anyone at no cost. Second, the authors hold copyright for their work and grant anyone the right to reproduce and disseminate the article, provided that it is correctly cited and no errors are introduced [Cerebrospinal Fluid Research's articles are archived in PubMed Central [troduced . Third,  Central , the US  Central  in Germa Central  in Franc Central , the NatOpen Access has broad benefits for science and the general public. Most importantly, authors are assured that their work is disseminated to the widest possible audience, given that there are no barriers to access their work. In addition, authors are free to reproduce and distribute their work, for example by placing it on their institution's website. Furthermore, there is evidence that free online articles are more highly cited because of their easier availability  and publCerebrospinal Fluid Research looks forward to receiving your submissions.This is an exciting opportunity to disseminate our science in the new world wide medium of electronic publishing.


Umbilical metastases from a malignant neoplasm, also termed Sister Mary Joseph's nodule, are not commonly reported in the English literature, and they have usually been considered as a sign of a poor prognosis for the patient. The present article reports on the current view point on umbilical metastasis besides discussing the epidemiology, clinical presentation, pathophysiology and treatment.A search of Pubmed was carried out using the term 'umblic*' and 'metastases' or metastasis' revealed no references. Another search was made using the term "Sister Joseph's nodule" or sister Joseph nodule" that revealed 99 references. Of these there were 14 review articles, however when the search was limited to English language it yielded only 20 articles. Articles selected from these form the basis of this report along with cross references.The primary lesions usually arise from gastrointestinal or genitourinary tract malignancies and may be the presenting symptom or sign of a primary tumour in an unknown site.A careful evaluation of all umbilical lesions, including an early biopsy if appropriate, is recommended. Recent studies suggest an aggressive surgical approach combined with chemotherapy for such patients may improve survival. Cutaneous metastases localised to the umbilicus are named "Sister Mary Joseph's nodules". In 1949 Sir Hamilton Bailey initially used this eponym in his book "Physical Signs in Clinical Surgery" to describe umbilical metastases, in honour of Sister Mary Joseph, the superintendent nurse and surgical assistant of Dr. William Mayo at St. Mary's Hospital in Rochester . Sister Mary Joseph was the first to note the link between umbilical nodules and intra abdominal malignancy [The occurrence of cutaneous metastases from malignant neoplasms occurs in from 1% to up to 9% of individuals, as determined at autopsy. Those metastases to the umbilicus are uncommon and represent only 10% of all secondary tumours which have spread to the skin ,6. EpideFrom a review of the literature, umbilical neoplastic nodules can be due to a primary tumour in 38% of cases, due to endometriosis in 32% of individuals, and in 30% are actually secondary tumour deposits from a primary tumour elsewhere -11.Sister Mary Joseph's nodules usually present as a painful lump on the anterior abdominal wall. It has irregular margins and a hard fibrous consistency. The surface may be ulcerated and necrotic, with either blood, serous, purulent, or mucous discharge from it. The size of the nodule usually ranges from 0.5 to 2 cm, although some nodules may reach up to 10 cm in size . High-reA full understanding of the mechanisms whereby the tumour spreads to the umbilicus remains unclear. However, following anatomical criteria, and several hypothesis have been proposed.The umbilical ring is a scar invaginated on the abdominal wall between the transversalis fascia and peritoneum. After birth, the foetal cord structures develop into ligaments or peritoneal folds: 1) median umbilical ligament secondary to the obliterating urachus, 2) medial umbilical ligaments ; 3) ligamentum teres  that continues into 4) the falciform ligament. On the lateral umbilical folds the inferior epigastric vessels and, sometimes, a vestigial vitelline duct connecting the umbilicus to the ileum can be recognised. The umbilical region shows a rich arterial supply that includes the inferior epigastric and deep circumflex iliac branches of the external iliac artery, and the superior epigastric branch of the internal mammary artery.The venous drainage includes several anastomotic branches, coming from cranially the axillary vein, through the internal mammary vein, and caudally, the femoral vein through the superficial epigastric vein. In addition, the umbilicus may be connected with the portal system, through small umbilical veins.The lymphatic system connects the umbilical region to the axillary, inguinal, and para-aortic lymph nodes. The deep lymphatic system passes along the falciform ligament, pierces the diaphragm and enters the anterior mediastinum or courses to the nodes around the iliac arteries -15.All these systems  as described represent possible routes by which metastatic tumour cells could implant into the umbilical region.vice versa.It is reasonable to suggest that direct extension of tumour through the peritoneum is the preferred route for gastrointestinal tumours. Furthermore, the common association between hepatic and umbilical metastases might suggests that the hypothesis that the tumour spreads from the primary tumour to the liver through the portal system and then through the lymphatic and/or venous channels, they spread to the umbilicus. It is still unclear if the umbilical tumour spread precedes the hepatic spread or Renal cell carcinoma typically spreads via extra-renal extension, lymphatic dissemination or venous invasion by the tumour. Intraperitoneal spread may occur as a result of disruption of the renal capsule . The disHaematogenous, lymphatic and venous spread all represent valid mechanisms of tumour spread from gynaecological cancers ,14.Usually the presence of an umbilical metastasis indicates a poor prognosis, is a sign of advanced neoplastic disease, and may not be amenable to surgery. The survival of these patients without treatment has been reported to range from 2 to 11 months from the time of initial diagnosis -19.However, recent studies have suggested that there are several factors which are able to influence the prognosis of such patients. Certain data has shown a better survival (mean 9.7 months) in patients who detect an umbilical metastasis before definitive treatment of the primary tumour. In contrast, when the lesion appears after the primary tumour has been treated then the survival for these patients does not exceed the 7.6 months ,17.Moreover, the aetiology of the primary malignancy determines the prognosis. For example, a better survival rate for patients with primary ovarian carcinoma has been reported previously .Finally, the type of treatment seems able to influence the patient's prognosis. Despite some authors proposing only palliative treatment because of these patients poor prognosis ,17,20, rObviously, the appropriateness of such an aggressive treatment approach is determined by the clinical state of the patient.A careful examination of all umbilical lesions is recommended, especially in those patients with gastrointestinal and genitourinary tract malignancies. All umbilical mass lesions should be biopsied to determinate the pathological nature of the lesion.Clinical experience suggests that, whenever it is possible, an aggressive surgical approach combined with chemotherapy treatment may be considered to offer the patient the best survival probability.The author(s) declare that they have no competing interests.RG contributed to conception, design, literature search and preparation of manuscript.MC contributed to conception, design, literature search and preparation of manuscript.FE contributed to conception, design, literature search and preparation of manuscript.MB contributed to conception, design, literature search and preparation of manuscript.All authors read and approved the manuscript


It aims to reduce the intra-operative dissemination of colorectal cancer cells. Recently, the detection of circulating tumour cells has been enhanced by molecular biology techniques. This paper reviews the evidence for the no-touch isolation technique in light of the recent developments in circulating tumour cell detection.Lymphovascular ligation before tumour manipulation during colorectal cancer resection is termed the 'Studies investigating the effect of colorectal cancer surgery on circulating tumour cells were identified by a Medline search using the subject headings colorectal neoplasms and neoplasm circulating cells together with the map term 'no-touch isolation technique'. Further references were obtained from key articles.Molecular biological techniques have improved the detection of circulating colorectal cancer cells. There is a trend towards reduced tumour cell dissemination with the no-touch technique compared with the conventional method. However the benefit in terms of improved patient survival remains unproven.The no-touch isolation technique reduces circulating tumour cell dissemination but further work is needed to determine the significance of this with regards to patient survival. This was proposed by Barnes [Of the patients with colorectal cancer (CRC) undergoing surgery for resectable disease, 30–50% will subsequently develop metastases . Dissemiy Barnes  as a wayy Barnes .Animal studies suggest tumour cells are shed into the circulation during resection of a primary tumour, increasing the likelihood of metastases . However7 normal cells [In recent years, the question of tumour cell dissemination during surgical resection has been re-examined following the introduction of molecular biology techniques to detect CTC. These are much more sensitive, and it is now possible to detect one tumour cell in a sample of 10This paper reviews the evidence for the no-touch isolation technique for the resection of a CRC in light of the recent developments in molecular biological techniques for CTC detection.In performing this review, the studies looking at the effect of CRC surgery on CTC were identified by a Medline search using the subject headings colorectal neoplasms and neoplasm circulating cells together with the map term 'no-touch isolation technique' -16. FurtWe decided to review this topic by addressing three areas of uncertainty. Firstly, does the surgical manipulation of a CRC increase the level of tumour cells within the blood? Secondly, what is the biological significance of CTC in CRC? Thirdly, is the no-touch isolation technique of CRC resection associated with an improved patient survival?To investigate the effect of tumour manipulation on CTC, we have reported the conversion, for each reviewed article, of a negative preoperative blood sample (for CTC) to a positive intra- or post-operative sample within the same patient. We have only noted conversions within the same sample source (systemic venous (SV) or portal venous (PV) blood). Where conversion rates cannot be determined, as data for individual patients are not provided, a comparison between overall preoperative and intra/post-operative positivity for CTC is given. Unless otherwise stated in the reviewed article, we have presumed the conventional method was utilised (tumour manipulation before lymphovascular ligation).A number of experimental models have been used to investigate the effect of surgical manipulation on CTC. Nishitaki et al  studied Romsdahl et al  measuredIn order for the no-touch technique to be effective in humans, early ligation of the main pedicle must eliminate passage of liberated tumour cells into the portal and systemic circulations. However, Salsbury et al  found thOn theoretical grounds, the no-touch technique would appear unsuitable for low rectal cancers, as it is necessary to mobilise tumours in the rectum before all the draining veins are controlled. In addition, a large proportion of the venous drainage occurs into the iliac system, thereby negating the effect of mesenteric pedicle ligation.There have been numerous studies investigating the effect of tumour manipulation on CTC in human tumours. This review focuses on studies involving CRC. The overall conversion rates for each study  are listed in Additional Files The only study to compare directly the conventional and no-touch techniques for the resection of a CRC involved the non-random assignment of 27 patients into conventional and no-touch groups . The tecThe other studies involving CRC have used either the conventional or no-touch surgical techniques, but have not directly compared both. Weitz et al  and SaleStudies employing the conventional technique of CRC resection have found overall conversion rates of 0 – 80% in SV samples -15,18,19As a number of patients were positive for CTC before surgery, a more direct assessment of the effect of tumour manipulation might be to analyse the conversion rates only for those patients negative for CTC preoperatively. This reveals a much greater conversion rate for most studies  involves detection and amplification of certain DNA mutations. A copy of the DNA containing the target sequence is made and the process is repeated many times, producing multiple copies and thereby increasing the sensitivity of detection. Mutations in the k-ras gene have often been used for detection of CTC in CRC.However, the detection of these sequences within the blood does not necessarily imply there are circulating tumour cells, as DNA is relatively stable and may represent fragments of tumour DNA released by cell necrosis or apoptosis and persisting in the blood for some time . Also, t7 normal cells [An alternative technique, now more commonly employed, is reverse transcriptase-PCR (RT-PCR). This detects messenger RNA (mRNA), which is used as an indicator of tissue-specific gene transcription. The technique is rapid, more easily automated than immunocytochemistry, and is capable of detecting one tumour cell in 10al cells . RNA is al cells .in-vitro sensitivity reported in the reviewed articles will be higher than the true in-vivo sensitivity, as the cell lines used to determine the sensitivity are known to express strongly the marker of interest and are not affected by the presence of in-vivo PCR inhibitors.However, there is a lack of standardisation of RT-PCR techniques, resulting in different sensitivities and specificities between centres . IllegitMost of the reviewed articles that state the specificity of their technique claim a rate of 100%, indicating all the tumour samples were positive for the marker of interest, whereas none of the control blood samples  were positive. However, Patel et al  examinedThere are no tumour-specific genes for CRC, and it is known malignant cells continue to express markers that are characteristic of their tissue of origin. Therefore, a range of epithelial cell markers, which are normally absent from the blood, have been used as RT-PCR targets for cancer cells derived from epithelial tissues.a and sialyl Lex, are associated with CRC formation and progression [The cytokeratin (CK) polypeptides are found within the cytoplasm of epithelial cells, and several CK markers have been used to detect CTC. The most common of these is CK 20, which is expressed in gastrointestinal epithelia, urothelium, Merkel cells, and tumours derived from these tissues . Carcinogression , and havConcerns regarding marker specificity have been raised. CK 8, 18 and 19 have all been shown to be expressed in normal blood . CK 20 aThe source of blood for analysis appears to be important. Most studies have investigated systemic venous samples for the presence of CTC. Animal studies suggest tumour cells become trapped in the capillary bed of the first organ encountered ,40, and Due to the discrepancy in sample sources, we have only noted patients who converted within the same venous compartment. Several studies detected CTC in draining vein blood intra-operatively, and compared it against a reference SV sample taken before manipulation. It is difficult to be certain of conversion in these patients, however, as it is possible the PV samples were positive preoperatively. It is important for subsequent studies to measure CTC in both systemic venous and draining vein blood, before, during and after tumour manipulation to investigate further the discrepancy in CTC detection between the venous compartments.The importance of multiple sampling should be considered. Glaves et al  suggestsWeitz et al  suggest The detachment of malignant cells from the primary tumour is an early step in the formation of metastases . The relEarly studies suggested fewer than 0.1% of circulating tumour cells survive in the circulation , and onlThe metastatic process may be enhanced by the surgical procedure itself. It is known the entrapment of tumour cells in the microcirculation of a target organ is facilitated by the presence of fibrin and platelets ,49. The The prognostic value of CTC in CRC has yet to be fully determined. Fujita et al  found paThere are few studies directly comparing the outcomes following conventional and no-touch techniques. Turnbull et al  retrospeWiggers et al  randomlyThe largest series was reported recently by Slanetz , who retAnother component of the no-touch isolation technique investigated by Slanetz is the control of intraluminal spread of malignant cells by applying bowel clamps or ligatures before tumour manipulation. He reviewed the results of 599 CRC resections in which bowel ligation prior to tumour mobilisation was used, and compared the data against 1416 resections in which bowel ligation was not performed. He found the application of bowel ligatures before tumour mobilisation significantly improved the 5-year cancer-related death rate for colon cancer , but not for rectal cancer. When considering colon and rectal cancer combined, bowel ligation prior to mobilisation significantly reduced the local  and distant  recurrence rates compared to resection without prior bowel ligation. These findings support the earlier work by Cole et al , who shoIt is difficult to draw any firm conclusions from the articles studied due to the lack of standardisation of sample source, CTC detection method and the small sample sizes. However, the only study directly comparing conventional and no-touch surgical techniques found a conversion rate of 73% for conventional surgery and 14% for the no-touch technique, suggesting a benefit of vascular clamping before tumour mobilisation. The overall conversion rates for the other studies employing the no-touch technique were 0–16% see , compareDue to the lack of consensus regarding the best technique for detection, the biological importance of CTC has not been fully determined. With the introduction of molecular biological techniques, the sensitivity for detection has improved considerably. The hope is that accurate detection of occult circulating malignant cells would help to stage the disease and predict prognosis, as well as monitor the response to therapy and highlight early the possibility of recurrence. However due to the differences in methodology and conclusions of studies investigating this area, the detection of CTC cannot, at present, be used to dictate therapeutic strategy.Despite the methodological heterogeneity of the articles reviewed, we believe the introduction of highly sensitive methods of CTC detection has forced a re-analysis of the role of the no-touch isolation technique in CRC surgery, and the stages of CRC resection using the no-touch technique would appear to offer a sensible, systematic approach to the surgical management of large bowel tumours. However, further work needs to be done to investigate the remaining areas of uncertainty. In particular, future developments in CTC detection must ensure more automation and greater standardisation of techniques between centres. RT-PCR appears to offer the greatest sensitivity, and techniques detecting multiple markers that are more tumour-specific should be investigated ,58. The The author(s) declare that they have no competing interests.GA researched the topic and prepared the manuscript, IM conceived the article and AC critically analysed and formatted the manuscript.Conversion rates for studies employing the no-touch isolation technique of CRC resectionClick here for fileConversion rates for studies employing the conventional technique of CRC resectionClick here for file


Tuberculosis continues to be an important health problem in the world. Besides pulmonary involvement extrapulmonary involvement becomes an affair in developing countries, even in developed countries.A thirty-six year old male patient was admitted with abdominal pain, diarrhea, nausea, vomiting and fever which had started one week before. The patient had been followed up with predialisis Chronic Renal Failure(CRF) diagnosis for 4 years and receiving continuous ambulatory peritoneal dialysis (CAPD) treatment for 4 months. In peritoneal fluid, 1600/mm3 cells were detected and 70% of them were polymorphonuclear leukocytosis. The patient begun nonspesific antibiotherapy but no benefit was obtained after 12 days and peritoneal fluid bacterial cultures remained negative. Peritoneal smear was positive for Asid-fast basilli (AFB), and antituberculosis therapy was started with isoniazid, rifampicine, ethambutol and pyrazinamide. After 15 days his peritoneal fluid cell count was decreased and his symptoms were relieved. Peritoneal fluid tuberculosis culture was found positive.Considering this case, we think that in patients with CAPD catheter and peritonitis; when peritoneal fluid leukocytes are high and PMNL are dominant, AFB and tuberculosis culture must be investigated besides bacterial culture routinely. Serum sodium, potassium, glucose, bilirubin, alkaline phosphatase, aspartate and alanine aminotransferase, gamma-glutamyl transpeptidase, amylase, triglyseride, and cholesterol were normal. A coagulation factor protrombin time was found to be 18.7 sn. C-reactive protein was 9.54 mgr/dl. Bilateral costofrenic angles were blunted in posteroanterior pulmonary graphy.In a laboratory investigation Hg was at 9.1gr/dl, Htc was at %27.6, WBC was at 5200/mm3 cell were detected and it was seen that 70 percent of these cells were polymorphonuclear leukocytosis (PMNL). The patient was given ceftazidime (IV), cephazol, and amikacin , but no benefit was noticed after 12 days of antibiotherapy and there was no growth in peritoneal fluid cultures. There were PMNL present but no microorganism could be detected. Acid-fast basilli (AFB) was found to be positive in the gram staining of peritoneal fluid in the remaining follow up periods, and the patient had begun antituberculosis therapy in fours. Tuberculin skin test was anergical. On the 15th day of anti tbc therapy, peritoneal fluid cell count decreased to 300/mm3 . Peritoneal fluid bacterial culture, blood cultures, throat culture and urine culture were negative but peritoneal fluid tbc culture was found to be positive, in Lowenstein- Jensen medium in 24 days. The patient was followed up with the treatment for recovery with an anti-tbc treatment.No parasites and cystes were found in fecal examination due to diarrhea. No pathogenic agent was detected in stool cultures. In peritoneal cell counting, 1600/mmThe peritoneal fluid of the patient was sent to be examined with Gram staining and Ziehl Neelsen staining. The peritoneal fluid was centrifuged at 3,000 × g for 15 minutes and the sediment was stained by Gram and Ziehl-Neelsen staining. The Gram staining showed PMNL presence but no microorganisms. The Ziehl-Neelsen staining(AFB) was positive.The peritoneal fluid was transferred to 10 ml sterile glass tube and centrifuged at 3,000 × g for 15 minutes. The concentrated sediment was inoculated onto Lowenstein Jensen (LJ) medium without prior decontamination. LJ medium was incubated at 37°C. Two specimens were later sent to be examined with Ziehl Neelsen staining on two different days. Both of them were detected to be positive for Ziehl Neelsen staining.LJ medium was examined for growth twice weekly for the first two weeks and once a week thereafter until the eighth week. After 24 days, the colonies were able to be seen on LJ medium. Positive growth was confirmed by Ziehl Neelsen staining.CRF increases the risk of tuberculosis. In patients receiving hemodialisis, the risk of tbc increases within twelve months after the occurrence of extrapulmonary tbc. The risk in these patients is ten times more for extrapulmonary tbc than in any other population. Peritoneal tuberculosis is rarely seen but remains a very important complication in CAPD patients,6. MortaIn English literature the most common complaints of tbc peritonit are as follows: fever 78 percent), stomachache (92 percent), misty dialisat (90 percent) and PMNL are dominant in peritoneal fluids in 76 percent of the cases and in 73 percent of the cases AFB and culture are positive [ percent,th–57th days of antituberculosis treatment (on average 30 day) [Abraham et al. have reported tbc peritonit in 4 of 155 CAPD patients and tuberculin test were found anergical in all patients . In our  30 day) . We had It was reported in the literature; that in tbc peritonitis treatment, removing peritoneal catheter has no apparent benefit and does not increase efficacy of the treatment ,6,9.Considering this case, we think that in patients with CAPD catheter and peritonitis; when peritoneal fluid leukocytes are high and PMNL are dominant, AFB and tuberculosis culture must be routinely investigated along with bacterial culture.


Despite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted.To survey physicians currently using e-mail with their patients daily to understand their experiences.In-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus.Almost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear.These physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices. Effective patient-provider communication is essential to comprehensive, quality health care ,2. ImproE-mail is a rapidly-growing communication medium, particularly as time limitations on the part of both providers and patients increase. Technically-minded, electronically-equipped, health care consumers have accelerated the demand for e-mail access to their providers . AlthougThere are several unanswered questions regarding this method of communication that must be answered before widespread use can be expected. How does this new technology impact the patient-physician relationship? For what problems can e-mail be used most effectively? How do physicians respond to patients' desire for electronic communication? How do they integrate this new technology into their practice? There is little research that documents how clinicians who use e-mail daily view and use e-mail communication, or documents its impact on medical practice. Some of these questions may not be fully answered until the diffusion of this technology becomes widespread. To begin to understand and generate hypotheses regarding the potential benefits and limitations of e-mail communication with patients, we explored the experiences of physicians who are currently frequent users of e-mail communication in their clinical practice. By identifying early adopters of this innovation in physician-patient communication and using methods akin to appreciative inquiry  we hoped to better understand how and why electronic mail is currently being used in "real-world" practices, and to perceive how the technology may be successfully used in the future.frequent users, defined as physicians who "receive one or more e-mails from patients in a typical day," were included  have a simple question that is not urgent then they don't have to wait on the phone, for example "Can I take my meds at bedtime with milk?"The comments reflected a belief that e-mail increases physician's accessibility to patients, both by providing a direct route to the physician and by allowing continuous communication when patients are traveling. Some believed that direct access to the physician is a benefit to the patients. A few stated that this could become a potential burden for the physician if there is no triage system with nurses or other office personnel. Others expressed concern about e-mails not reaching them at all or in an untimely manner. For example:Sometimes [the nurses] filter questions [received by phone] appropriately but sometimes they don't. With e-mail, when patients mail me a concern I get it.I had a patient e-mail me with questions about whether he needed a tetanus shot [after an acute event] and I got the message [several days later]There were mixed opinions regarding the potential scope of topics covered by e-mail. Most felt that e-mail provided a somewhat-anonymous medium through which many patients could discuss "sensitive" topics that they may not have otherwise discussed. Patient surrogates, ie, family members or caretakers, have also used e-mail to introduce issues the patient had been reluctant to discuss with the physician. However, some physicians stated that there are some inherent limitations to using e-mail for communicating complex issues and that using e-mail cannot be done as casually as talking on the phone or in person.There was also divergence on the issues of urgencies or emergencies. A few physicians gave examples of when e-mail actually helped in these situations and thought that e-mail could and should be used for emergencies. However, the majority believed e-mail should be utilized for nonemergency matters. Almost all the physicians felt that e-mail is a great medium for exchange of general information, such as scheduling and general clinical questions. When confronted with difficult, vague, or inappropriate questions, physicians generally asked the patients to call the office. Physicians in favor of e-mail told us:There are some patients who are unable to communicate verbally but who are able to put information on paper or who have become accustomed to chat rooms. With those people, I have been able to communicate much more effectively. I had one patient who e-mailed me that she had another issue to discuss with me but she hadn't brought it up earlier because she was too embarrassed to do so in front of the medical student.Wives e-mail and tell me that their husbands are coming in and they are not going to say this but they are passing blood, etc.Those with concerns reported:The only thing that I am scared of honestly is when patients e-mail me with problems like "shortness of breath" or with 20 questions which they feel like I should be able to answer right away.For me, e-mail or phone — I limit it. I use it only for getting some information. I don't even like using the phone for long communication, I ask the patient to come in.There is a difference between seeing someone in the office and seeing them via e-mail with nothing but a name.These physicians seemed to have mixed views regarding confidentiality and e-mail. Some physicians were not concerned about confidentiality as long as the patients were "comfortable" using e-mail, while others were concerned and did not include personal information in e-mails. An example of these concerns is:The biggest snafu that I committed was with a patient's husband, who was having an affair, I breeched patient confidentiality, by sending information to one spouse who I thought was then giving it to the other spouse.There was concern, among these physicians, of potential loss of trust and a negative impact on the doctor-patient relationship. When there is a loss of trust, it is difficult and takes a long time to regain. At the same time, physicians told us that e-mail communication has a positive effect on the doctor-patient relationship by increasing rapport and keeping lines of communication open. For example:I look at e-mail as a fabulous way to establish a rapport with my patients.With e-mail we are able to keep the lines of communication open.Patients feel more of a one to one relationshipChronic disease management is one area of consistent agreement for our respondents. These physicians felt that e-mail is a very effective way of managing patients whom they know well. Many cited examples of using e-mail to manage conditions, such as diabetes, hypertension, psoriasis, and even congestive heart failure.Many of these physicians also felt that there is great potential for exchange of educational information via e-mail, and, therefore, subsequent improvement in clinical management. They felt that e-mail is a useful educational tool. A representative comment is:I have had a few patients [who] you don't have time in the office to give them specific details about their disease. I have compiled a list of articles or Internet sites, and I can e-mail those lists to them. It is not complete yet, it has to be categorized and organized more. But the patients love it.One very-specific use for e-mail, stated by most physicians, is for prescription refills. There were comments, primarily from physicians who do not currently prescribe medications online, concerning the appropriateness of this, the medicolegal concerns, and the difficulty of doing this online. A few physicians who currently provide refills online also expressed these concerns. A separate site designed to deal specifically with medications was suggested as a helpful alternative. Physicians told us that they have realized that e-mail can be very effective for this aspect of patient care. For example:A few patients have got hold of my e-mail address and have started to send me information about prescription renewal or questions. At first, I thought it was an intrusion but I realized what a time saver it was. So yes, I now use it for my regular practice as well; it has helped efficiency.Most physicians' comments seem to reflect the idea that e-mail can improve the continuity of patient care if used for previsit information gathering and followup, particularly with test results and scheduling of tests previsit; this is primarily useful for patients with chronic diseases and for those with whom they had an ongoing relationship. Some stated that receiving preliminary information — such as basic past medical history, allergies to medications, and current medications and doses — prior to the visit saves time during the visit and allows more time to be spent on management. Physicians also felt that e-mail allows patients to communicate with them after leaving the office, particularly for clarification or asking questions they forgot during the visit.There were numerous concerns regarding the technical and day-to-day aspects of actually integrating e-mail communication into daily practice. Comments ranged from the general acceptance of e-mail by patients and providers to broad policy issues and technical implementation into the daily schedule. For the most part, physicians seemed to accept e-mail and felt that it is going to increase in the future. Most physicians felt that their patients who use e-mail love it. There was some ambivalence though, particularly regarding how and for what purposes it should be used. One comment described e-mail as a "double edged sword." There was also some concern regarding the potential substitution of e-mail for visits. For example:A policy needs to be in place regarding expectations about response time, what can be asked, the types of things that would be appropriate or inappropriate, and how my e-mail would be handled if I were to go out of town.Selection of patients for e-mail communication appears to be an issue with which physicians are grappling. Physicians appear to be selective in choosing patients whom they will communicate with via e-mail, but it is not clear, other than patient access to the Internet, what criteria they use. For example:I have chosen my patients impromptu, people who I think can handle the task [of using e-mail].There are a few patients who I do not know well, and e-mail in those instances, is logistically more difficult. I only give it to selected patients. I kind of pick the ones that I know won't abuse it.Promoting and initiating e-mail with patients was also an area of confusion for these physicians. While some physicians were offering the use of e-mail to their patients, a number of physicians commented that patients initially approached them with the idea of using e-mail. A few had advertised the use of e-mail on their Web pages and business cards. There were reservations regarding getting inundated with e-mail, with current methods of advertisement, and these concerns deterred some physicians from putting their e-mail on the business card. On the other hand, there was a fear of disenfranchising patients if they did not offer e-mail.With regard to general and medicolegal issues, the responses indicated that physicians do not have formal policies in place regarding how e-mail should be used with patients. Those who did have formal policies in place generally had a consent sheet or had their patients sign a waiver; a few physicians followed American Medical Association (AMA) guidelines . Many haPhysicians felt that they should be reimbursed for e-mail exchanges, but were skeptical that this would happen in the near future, as they had difficulty getting reimbursed for phone consultations. Again, opinions varied. Some of the physicians did not seem to be too concerned regarding reimbursement, while others feared that this is a potential deterrent to widespread use of e-mail. The following comments are a few examples:If no one is going to pay you for the time, it is not cost effective to use e-mail.Unless reimbursement changes, e-mail consultation won't work.For physicians time is money.There were diverging comments on the impact of e-mail on volume of patient care. Some physicians reported that they were able to address more issues and take care of more patients since some of the preliminary, noncritical topics were handled by e-mail. Others reported concerns that e-mail can be redundant, overused by patients, time-consuming, and can potentially overburden physicians as e-mail use increases. This is an anticipated fear.There were also conflicting opinions and experiences regarding the impact of e-mail on efficiency. Some stated that e-mail was more convenient, offered more flexibility and saved time. Others felt that e-mail could become an added burden, particularly if the physician is solely responsible for handing the e-mails. Most physicians felt that e-mail is more convenient and increases the flexibility of both physicians and patients in terms of addressing medical questions. The ability to communicate via e-mail outside office hours and on their schedule is viewed as an important benefit. Some examples included:E-mail is so much more efficient, you end up knowing the patients so well by the time they come for followup, that you can ask more direct questions about what has been going on with their lives, why their blood pressure is consistently up, etc.No matter what you do there is always limited time in the office. With e-mail the patients are unlimited with their time. They can ask me questions that they forgot to ask while they were in the office.It is more work for the physicians. On the other hand, I can answer e-mails when I am at home, when I am eating, or whenever.There did not appear to be a clear method of documentation. Some respondents felt that documentation by e-mail was much better and easier than by phone; others, who were struggling with how to do this efficiently and incorporate it into office flow, felt that documentation was worse with e-mail. For example:There is much better documentation. I write my response, copy it, and put it in the medical records. In terms of efficiency, it is a wash because it takes me as much time to write an e-mail as to make a phone call.Things are not documented as well as when patients use the phone. We have a formal system of phone calls, but not for e-mails.Physicians were concerned about the technical aspects of using e-mail — particularly with servers malfunctioning and systems failing, inadvertently leading to missed e-mails. This appeared to be more of an anticipated concern than one frequently experienced.Finally, there was a wide spectrum of opinions and experiences in reference to use of office personnel and colleagues using e-mail to communicate with patients. Most physicians had not fully broached the subject with their staff. Many who did felt that their staff was not prepared or interested in using e-mail. The few who had incorporated office personnel into e-mail communication met with success. Most physicians seemed to be responsible for accessing their own e-mail, even when out of town, although some respondents told us about colleagues accessing their e-mail.We attempted to search for what is currently working in electronic patient-centered communication, and through that, to identify "what might be" in the future. We talked with 45 physicians who were frequently using e-mail with patients and found that most opinions regarding electronic patient-physician communication were positive. These physicians did see a benefit to using e-mail in specific situations with specific patients. Physicians reported better and more-consistent communication with patients who have chronic diseases and require frequent, small changes in management. Respondents noted several other benefits including continuity of communication with patients (particularly patients who travel), ability to respond to nonurgent issues on their own time, avoidance of phone tag with patients, and improved efficiency in certain scenarios. Drug-refill requests and dissemination of educational information, including links to reliable Internet sources, were also cited as examples of the effective use of e-mail with patients.Despite the positive experiences, e-mail communication is not yet widespread in clinical care. We heard about a number of barriers that may be influencing this, such as uncertainty of involving office staff, potential of increased demand on physician time (particularly with overuse of e-mail by patients), difficulty incorporating e-mail into daily office work flow, generating timely responses, inappropriate or urgent content in the messages, confidentiality issues, and lack of reimbursement for this service. In previous research by Moyer et al, almost half of a sample of physicians at 2 university-based primary care clinics indicated concerns about being overwhelmed by patients' e-mails and felt that e-mail with patients would add to their workload if they used it in their clinical practice . The onlThe respondents anticipated other problems with e-mail communication, such as reimbursement problems, logistic and technical problems , and medicolegal consequences of e-mail used for urgent issues, but had not frequently experienced them. The physicians in this study appeared quite concerned about the "nuts and bolts" of integrating the technology into the workflow of their clinical practice. Technology for secure communication between physician and patient has not been widely integrated with the medical record system or other office systems for scheduling or triage. Future development in this area may increase e-mail adoption. Expert opinions from prior literature have highlighted additional limitations of e-mail physician-patient communication . SpecifiAn important aspect of e-mail communication involves how physicians select patients for whom they will start e-mail communication. Criteria used to select patients for e-mail communication, such as a patient's "ability to handle it" (verbatim comment from one of the physicians), were not well defined or objective, and do not depend only on access to the Internet. Whether selection depends on the length of the doctor-patient relationship, the nature of the medical issue, educational achievement of the patient, or other factors is not clear and requires further research. E-mail communication may lead to greater, not less, inequality in access to care for certain patient groups.Our study is limited by a relatively-small sample size. The sample was recruited from an online physician organization and is probably more Internet savvy than most physicians. However, these physicians represent several specialties and were from a wide geographic region. Because the use of electronic patient-centered communication is largely unstudied, we feel that the qualitative nature of this study has particular strengths. Our results included 642 comments from physicians across the United States who are frequent users of this technology and reflected a wide range of opinions. Many outcomes, including the selection of specific patients, the lack of concerns related to confidentiality, and the large number of anticipated but unrealized technical problems, were not perceived as potential major themes prior to collecting these data. We believe these qualitative methods have provided useful pilot data for future studies of the feasibility of dissemination and potential impact of this technology.These physician respondents did perceive benefits to e-mail with a select group of patients. Through this study we identified several areas of future research. These include: developing criteria for selecting patients to use e-mail; increasing dissemination of formal guidelines regarding e-mail use; improving incorporation into office flow; use of office personnel to manage e-mail; clarifying medicolegal consequences; and mechanisms for reimbursing online medical care/communication.


Peri-tumour fibrin is a consistent feature of tumour stroma and is deposited shortly after tumour cell inoculation. Since there are several ways in which fibrin may be beneficial to tumour growth, it is possible that the ability of normal or malignant tissue to generate fibrin may influence metastasis. Many normal tissues and tumour cells possess a procoagulant activity that is due to a complex of tissue factor and factor VII. We have measured this tissue procoagulant activity in normal rats, rats stabilised on Warfarin and similarly anticoagulated animals injected with factor VII. The effect of Warfarin and factor VII administration on pulmonary seeding following injection of MC28 fibrosarcoma cells was also assessed. Procoagulant activity in adrenal, lung and colon was significantly reduced by Warfarin (P less than 0.001). Administration of factor VII significantly increased lung and adrenal tissue procoagulant activity in anticoagulated rats (P less than 0.02). Warfarinised rats had significantly slower primary tumour growth (P less than 0.001) and fewer lung deposits than control animals (P less than 0.001). Injection of factor VII restored pulmonary seeding to control levels (P less than 0.001). Warfarin did not affect the ability of the cells to adhere in vitro and did not reduce the number of tumour cells physically trapped in the lungs after intravenous injection. It is concluded that the procoagulant activity of normal tissues may influence their ability to support tumour growth and that the antimetastatic effect of Warfarin may be at least partly due to a reduction in the availability of the factor VII required for this activity.


A human ovarian carcinoma, IGROV-1, was xenografted into different sites  in nude athymic female mice to investigate the pattern of antitumour efficacy of FAA and compare it to that of doxorubicin and cisplatin, two established cytotoxic drugs. Ascitic and lung-growing tumours totally failed to respond to FAA, whereas s.c. and liver-growing tumours were significantly growth inhibited. This pattern of activity differs from that achieved by the two conventional cytotoxic drugs, which were active against the IGROV-1 tumour growing in all of the tested sites. These studies indicate that cytotoxicity is not the major determinant of FAA antitumour efficacy even against human tumour xenografts. Moreover, the dramatic difference between the sensitivity of lung and liver tumour colonies demonstrates the great importance of the site of tumour growth for FAA efficacy.


A twelve year series of 375 patients with gastric carcinoma has been studied. Patients were divided into TNM Groups. Tumours were classified as intestinal-type and diffuse. The patients with T1-3NOMO diffuse tumour were ten years younger than the patients with T1-3NOMO intestinal-type tumour. The mean age increased from T1 through T2 to those with T3 tumour. The age differences between the T-stages were the same in both groups, which indicate that once started, the diffuse and the intestinal-type tumours infiltrate the gastric wall at about the same rate. Among the patients with intestinal-type tumour, those with lymph node or distant metastases were three to seven years younger than the patients without metastases. On the other hand, the patients with diffuse tumour and metastases were as many years older than the patients without metastases. Apparently, tumour spread is age dependent and different between the two types of gastric carcinoma. The ill repute of the diffuse gastric carcinoma may therefore be explained by the advanced stage of that tumour at the time of treatment as compared to the intestinal-type tumour. The diffuse tumour seems to be clinically more silent and to give symptoms at a later stage than the intestinal-type tumour.


This piece follows an earlier Editorial, “Ten Simple Rules for Getting Published” , which hAt the present time, US funding is frequently below 10% for a given grant program. Today, more than ever, we need all the help we can get in writing successful grant proposals. We hope you find these rules useful in reaching your research career goals.Good science begins with new and fresh ideas. The grant writing process should be a pleasure , for it allows you to articulate those ideas to peers who have to read your grants but not necessarily your papers. Look at grant writing as an opportunity to have an impact. Feel passionate about what you are writing—if you are not passionate about the work, it is probably not a good grant and is unlikely to get funded. “Me-too” science will not get funded when funding levels are low. On the other hand, science that is too speculative will not be supported either, particularly when funds are tight—sad but true.You need to convince reviewers that the work you propose needs to be done and that you are the best person to do it. Different granting programs require differing amounts of preliminary data. For certain programs, it can be said that the work must be essentially done before the grant is awarded, and that the funds are then used for the next phase of the research program. There is some truth in this. So where appropriate, do provide some tantalizing preliminary result, making sure to tell the reviewers what these results imply with respect to the specific aims of your proposal. In formulating the motivation for your proposal, make sure to cite all relevant work—there is nothing worse than not appropriately citing the work of a reviewer! Finally, convince the reviewer that you have the technical and scientific background to perform the work as proposed.Most funding organizations have specific staff to assist in finding funding opportunities, and most funding agencies have components of their Web sites designed to help investigators find the appropriate programs. Remember, programs want to give away money—the jobs of the program's staff depend on it. The program staff can help you identify the best opportunities. If your grant does not fit a particular program, save your time and energy, and apply elsewhere, where there is a better programmatic fit.Many funding bodies will immediately triage grants that do not comply with the guidelines—it saves the program time and money. This extends to all the onerous supporting material—budget justification, bibliographies, etc. Get them right and keep them updated for future applications. Even if it goes to review, an inappropriately formulated application may aggravate the reviewers, and will have a negative impact even if the science is sound. Length and format are the most frequent offenders.The grant does not have to fill the allotted page count. Your goal should be to provide a complete reckoning of what is to be done, as briefly as possible. Do not rely on supplements  or on Web sites . Specify the scope up-front and make sure it is realistic with respect to the funds requested. A common temptation for inexperienced grant writers is to propose to do too much. Such applications are usually judged as overly ambitious and consequently poorly rated.Typically, reviewers will have a large number of grants to review in a short period. They will easily lose concentration and miss key points of your proposal if these are buried in an overly lengthy or difficult-to-read document. Also, more than likely, not all the reviewers will be experts in your discipline. It is a skill to capture the interest of experts and nonexperts alike. Develop that skill. Unlike a paper, a grant provides more opportunity to apply literary skills. Historical perspectives, human interest, and humor can all be used judiciously in grants to good effect. Use formatting tricks (without disobeying rule 4), for example, underlining, bolding, etc., and restate your key points as appropriate. Each section can start with a summary of the key points.Give yourself the appropriate lead time. We all have different approaches to deadlines. Ideally, you should complete a draft, leave sufficient time to get feedback from colleagues, and then look at the grant again yourself with a fresh eye. Having a spectrum of scientific colleagues who are similar to the likely reviewer pool critique your grant is very valuable.At the end of the day, this person is your best advocate. How well you understand each other can make a difference. Many grant administrators have some measure (limited to complete) discretionary control over what they fund. The more they know and understand you and your work, the better your chances of success. Do not rely just on E-mail to get to know the grant administrator. Do not be intimidated. Talk to them on the telephone and at meetings where possible—they want to help.Being on review panels will help you write better grants. Understanding why grants get triaged before complete review, how a panel reacts to a grant, what the discretionary role of program officers is, and what the role of oversight councils is provide valuable lessons for writing successful grants of your own and for giving others advice about this process.Rejection is inevitable, even for very good grants when funding levels are low. Learn to live with rejection and to respond appropriately. Do not be defensive; address each criticism head on and respond with facts and not emotional arguments. When resubmission is necessary, make it very clear to the reviewer that you understand what was wrong the first time. Indicate precisely how you have fixed the problems. In the resubmitted application, never argue with the validity of the prior review. If the grant was close to being funded the first time around, remind the reviewers of that fact by including the previous score if appropriate, and make it crystal clear why this version is much improved.There are no previously unrevealed secrets to grant writing presented here. Rather, it is a concise picture intended to help our early career readers take the next step. If you feel like you need more detail, take a look at Kraicer's article . Good lu


The route of local and metastatic spread of testicular seminoma is well recognised and accepted. The spread is via lymphatics to the paraaortic nodes.We present a case report of testicular seminoma in a 56 year old man with previously unreported histological findings. In this case seminoma tumour cells did not appear to have spread by the expected lymphatic route. There was no involvement of retro-peritoneal para-aortic lymph nodes. The tumour appeared to have spread directly along the vas deferans in the sub epithelial plane to the mesenteric lymph nodes.This type of seminoma tumour spread has not previously been described and it is not a recognised route for metastasis by seminoma tumour. In this case the macroscopic clinical appearance was of a stage I tumour with normal tumour markers. However, the pathological stage of the tumour was surprisingly increased to stage III on the basis of histology and CT radiological findings. We present the unusual histological findings. In view of this unusual histological finding we reinforce the need for accurate staging and for resection of the spermatic cord close to the deep inguinal ring. Accurate staging is crucial in planning the treatment and follow up of seminoma and determines the prognosis. We present a case report of testicular seminoma in a 56 year old man where the histological findings were unusual and the route of spread has not previously been reported. Accurate staging is crucial in planning the treatment and follow up of seminoma and determines the prognosis. The American Joint Committee on Cancer (AJCC) tumour node metastasis (TNM) staging system is widely used to stage testicular tumours and includes tumour markers in the staging system. Stage I disease is subdivided according to the T stage and Tumour marker levels. Stage II disease is subdivided according to the volume of retroperitoneal lymph node involvement and stage III disease according to the degree of metastatic involvement and serum tumour markers . In thisA 56 year old male presented with a non tender hard atrophic left testicle. The rest of the examination was normal. There had been no previous scrotal surgery or trauma.Tumour markers including lactate dehydrogenase (LDH), human chorionic gonadotrophin (HCG), alpha fetoprotein (AFP) and prostate specific antigen (PSA) were normal. His total white cell count was normal. An ultrasound of the scrotum demonstrated a localised tumour of the testis. Chest x-ray was normal. A standard left radical orchidectomy was performed by the inguinal approach. The tumour appeared to be confined to the upper pole of the testis and was clinically described as T1 or T2. Macroscopic histological examination suggested no involvement of the tunica albuginea, epididymis or spermatic cord. Microscopic examination demonstrated infiltration of the testis by uniform ovoid cells with clear cytoplasm, vesicular nuclei and prominent nucleoli consistent with seminoma , early orchidectomy and early chemotherapy. Patients who develop a germ cell tumour before the age of 50 years have better 10 year relative survival (91%) than those who develop disease after the age of 50 years (84%) . A pre oThe prognosis and period of remission remains uncertain in this case. This case reinforces the need for high spermatic cord ligation and excision at the deep inguinal ring and immediate CT staging. This should be performed even in patients who are thought to have low stage disease and when tumour markers are normal. The histological and radiological findings may be quite unexpected.CT – computed tomography, TNM – tumour, node metastais staging system, AJCC – American Joint Committee on CancerThe author(s) declare that they have no competing interests.All three authors have been involved in completing this publicationThe pre-publication history for this paper can be accessed here:


A variety of experimental endpoints including excision cell survival, lung colony curability, tumour regrowth delay and i.m. tumour curability following MeCCNU alone and combined with gamma-radiation, were used to define the MeCCNU cell survival curve down to "tumour cure" level in previously untreated i.m. Lewis lung tumours. The survival curve was found to be biphasic, the tumour cells being markedly resistant to MeCCNU at high doses of the drug. Below 10 mg kg-1 the survival curve was exponential through the origin with a D10 of approximately 2 mg kg-1, while above 15 mg kg-1 the D10 was approximately 25 mg kg-1. From linear extrapolation of the terminal part of the cell survival curve to zero drug dose, it appeared that about 1 in 10(5) (or 0.001%) of tumour cells were resistant to MeCCNU.


The aim of the study was to evaluate the ability of different static and dynamic measurements of preload to predict fluid responsiveness in patients with spontaneous respiratory movements.n = 9) or breathing through a face mask (n = 12), and who required a fluid challenge. Complete hemodynamic measurements, including pulmonary artery occluded pressure (PAOP), right atrial pressure (RAP), pulse pressure variation (ΔPP) and inspiratory variation in RAP were obtained before and after fluid challenge. Fluid challenge consisted of boluses of either crystalloid or colloid until cardiac output reached a plateau. Receiver operating characteristics (ROC) curve analysis was used to evaluate the predictive value of the indices to the response to fluids, as defined by an increase in cardiac index of 15% or more.The subjects were 21 critically ill patients with spontaneous breathing movements receiving mechanical ventilation with pressure support mode (-1 m-2 (medians and 25th and 75th centiles), p < 0.05. At baseline, ΔPP varied between 0% and 49%. There were no significant differences in ΔPP, PAOP, RAP and inspiratory variation in RAP between fluid responders and non-responders. Fluid responsiveness was predicted better with static indices  than with dynamic indices of preload .Cardiac index increased from 3.0 (2.3 to 3.5) to 3.5 (3.0 to 3.9) l minuteIn patients with spontaneous respiratory movements, ΔPP and inspiratory changes in RAP failed to predict the response to volume expansion. Fluid challenge is commonly performed in critically ill patients but the response is quite variable . InapproRecently, dynamic evaluation of preload indexes has been introduced, on the basis of the observation that cyclic changes in intrathoracic pressure induced by mechanical ventilation can result in concurrent changes in stroke volume in preload-dependent, but not in preload-independent, patients. These dynamic indices of preload can better predict the individual response to fluid loading than static indices -5.However, all these studies have been performed in patients receiving mechanical ventilation, well sedated and even paralyzed to avoid any spontaneous respiratory movements. But spontaneous respiratory movements, inspiratory as well as expiratory, can also influence venous flow, preload, and afterload ,7. RookeWe therefore designed this study to assess the value of several dynamic and static indices of preload as predictors of fluid responsiveness in spontaneously breathing patients, receiving mechanical ventilation in pressure support mode or breathing through a face mask.This study was approved by the local Ethical Committee, and informed consent was obtained from the patients or their relatives.This prospective study included 21 patients over a six month period. Inclusion criteria consisted of the need for fluid loading  in a patient equipped with a central venous catheter and an arterial catheter, in whom cardiac output was determined by the thermodilution technique either with a pulmonary artery catheter  or by a modified arterial catheter . For inclusion, each patient had to show spontaneous breathing movements. Exclusion criteria were the following: age less than 18 years, pregnancy, and any significant cardiac arrhythmia. Fourteen patients were treated with vasoactive agents; no change in vasoactive treatment was allowed during the study period.ee) and end-inspiration (RAPei). When available, pulmonary arterial pressures and pulmonary artery occluded pressure (PAOP) were also measured at end-expiration. The arterial pressure waveforms were measured on the computer system, and variation in pulse pressure (ΔPP) was calculated. The respiratory variation in RAP was calculated as RAPee - RAPei.Arterial pressure was measured with either radial or femoral arterial catheters. Cardiac output was measured with a pulmonary artery catheter  in 20 patients and by transpulmonary thermodilution  in one patient. After calibration, all pressures were recorded on a computer system. We looked carefully at patient respiratory efforts and manually noted each breath initiation. Right atrial pressure was measured both at end-expiration  or 1,000 ml of crystalloid  infused over 30 minutes. Hemodynamic measurements were obtained after each 250 ml aliquot. The VE was interrupted when the cardiac output did not increase further and PAOP or RAP increased by more than 3 mmHg. At the end of VE, another complete set of hemodynamic measurements, including venous and arterial blood gases, was obtained. A rise of 15% or more in cardiac output between baseline and final measurements defined the responders.A complete set of hemodynamic measurements as well as blood sampling for arterial and mixed venous blood gases were obtained at baseline and before each volume expansion (VE). VE consisted of 500 ml of synthetic colloid . Receiver operating characteristics (ROC) curves were used to evaluate the predictive value of the various indices on fluid responsiveness. ROC curve area are presented as area ± SD. A n = 2) or because it reached a plateau (n = 19), in the presence of an increase in RAP or PAOP by at least 3 mmHg. Fluid infusion was stopped after one aliquot in two patients, two aliquots in six, three aliquots in three, and four aliquots in ten. None of the patients required more than four aliquots. Seventeen patients survived. The effects of VE are shown in Table -1 m-2 (p < 0.05), but it increased by more than 15% in only nine patients.Patient characteristics are shown in Table ee and inspiratory variation in RAP between responders and non-responders . There was no relationship between the inspiratory variation in RAP at baseline and ΔCI  during VE and ΔPP baseline for the entire group or for the subgroups  than for dynamic indices of preload . The likelihood of a response to fluids was highest at low values of RAP . For inspiratory variation in RAP, only three patients had no decrease in CVP during inspiration, and one of these responded to fluid challenge . In comparison, 8 of the 18 patients with a 1 mmHg inspiratory decrease in RAP responded to fluids . Four patients presented respiratory efforts insufficient to generate an inspiratory decrease in PAOP of more than 2 mmHg, and excluding these patients from the analysis did not alter our results (data not shown).Several subgroup analyses were conducted to provide a better definition of the potential factors influencing ΔPP and inspiratory variation in RAP. No patient had evidence of right ventricular dysfunction, either before or after fluid challenge. We noticed active expiratory efforts in four patients, but excluding these patients did not alter the results (data not shown). The ROC curve area of ΔPP was 0.64 ± 0.26 in patients receiving mechanical ventilation, and 0.29 ± 0.17 in patients breathing through a face mask (Important questions are the following. Which indices can be used to predict fluid responsiveness in patients with respiratory movements ? In partIt has indeed been proposed that ΔPP (and other indices of ventilation-induced stroke volume variations) may not apply in patients breathing spontaneously ,7, but tSpontaneous respiratory movements can affect ΔPP through different pathways. First, respiratory changes in alveolar and pleural pressure are lower during spontaneous breaths than during mechanically assisted breaths. However, this factor may only account for patients breathing spontaneously through a face mask. Patients ventilated with pressure support ventilation experienced a range of driving pressures similar to those observed in other studies . Second,In contrast to our expectations, respiratory variations in RAP were also not predictive of the response to fluid loading. Several factors may explain this finding. First, Magder and colleagues ,16 demonInterestingly, the static variables were slightly better predictors of the response to a VE. This is also reflected by the inverse relationship between filling pressures and changes in CI, but this relationship was quite loose. As expected, no cut off value could be found and the differences in these indices between responders and non-responders were not significant.We did not evaluate volumetric indices of preload, and these indices may perform better than pressure measurements, especially in the presence of diastolic dysfunction. These should be evaluated in further studies.In the absence of a clear cut off value allowing reliable prediction of fluid responsiveness in the individual patient, the physician is left with the option of performing a fluid challenge; that is, testing the system. A possible alternative would be to perform a passive leg-raising test but this would require using a fast response methodology for cardiac output measurements. Of course, fluid challenge may fail to increase cardiac output, but the risks of performing a fluid challenge are basically the same whether or not cardiac index increases, because ventricular volumes and pressures increase in response to fluid . One might expect cardiac filling pressures to increase more in non-responders, but it would be limited as an increase in RAP or PAOP (or a volumetric index) is used as a safety limit. So the basic difference between a successful and a failed fluid challenge is that in responders the benefit is supposed to outweigh the risks, but the risks are similar. These risks are probably limited when fluid challenge is performed cautiously, using repeated aliquots of fluids over a short period and re-evaluating the hemodynamic situation before administration of the next bolus. Matejovic and colleagues  reportedThe fluid challenge technique we used is standardized, but it included various amounts of either colloid or crystalloid as recommended clinically. Even though colloids and crystalloids may have different volume expansion properties, fluid challenge was adapted to the hemodynamic response . Thus, iIn patients with spontaneous respiratory movements, ΔPP and inspiratory variations in RAP failed to predict the response to volume expansion.• 	Pulse pressure variation and inspiratory variation in RAP failed to predict the response to fluid challenge in patients with spontaneous respiratory movements.• 	Filling pressures are a slightly better predictor of fluid responsiveness than dynamic indices of preload, but no cutoff value was detected.• 	Fluid challenge should be performed carefully when clinically indicated.ee = RAP at end-expiration; RAPei = RAP at end-inspiration; ROC = receiver operating characteristics; VE = volume expansion.CI = cardiac index; ΔCI = change in cardiac index; ΔPP = pulse pressure variation; PAOP = pulmonary artery occluded pressure; RAP = right atrial pressure; RAPSH declares no conflict of interest related to the current work; DDB and JLV have received research grants and/or material from Edwards Healthcare, LiDCO, and Pulsion.SH collected the data and contributed to the analysis of the data and writing of the manuscript. DDB designed the study collected the data and contributed to the analysis of the data and writing of the manuscript. JLV contributed to the analysis of the data and writing of the manuscript. All authors read and approved the final manuscript.


We examined bone marrow aspirates from 100 metastasis-free primary breast cancer patients. In 38/100 patients (38%), tumour cells were detected in the marrow using an immunocytochemical technique with a cocktail of two monoclonal antibodies: anti-EMA and anti-cytokeratin. Median follow-up was 34 months: 15/38 (39%) tumour cell-positive patients have since relapsed, but only 9/62 (15%) tumour cell-negative patients. The median interval between tumour cell detection and relapse was 11.4 months. No statistically significant correlation existed between tumour cell presence and 'established' prognostic factors. However, relapse-free survival was significantly shorter in tumour cell-positive patients. Multivariate analysis showed tumour cell presence as a strong, significant prognostic factor for relapse-free as well as overall survival. We conclude that screening for tumour cells in bone marrow of primary breast cancer patients identifies high-risk patients for early relapse. In particular, patients with node-negative tumours who have tumour cells in their bone marrow may require subsequent systemic therapy.


The interaction between tumour and bone with respect to the proliferative activity of transplanted tumour cells was studied using five transplantable human urogenital tumours in nude mice. Cells from those tumours were injected subcutaneously over the calvaria of nude mice following disruption of the periosteum. The extent of tumour-bone interaction varied with the type of implanted tumour as shown on X-ray and by histologic examinations of the calvaria. The classic histologic pattern of bone remodelling including the destruction of bone with proliferation of osteoclasts and reactive new bone formation was seen with all five tumours. Tumour proliferative activity determined from the tumour doubling time and the S-phase fraction using bromodeoxyuridine labelling showed that the rate of reactive bone formation appeared to be inversely proportional to the rate of tumour cell proliferation.


We measured the clonogenic growth of 110 breast cancer samples obtained from 107 patients with advanced disease. We determined clonogenicity under conventional conditions and under conditions supplemented with growth factors and hormones that target breast tissue. After a median follow-up period of 6 years we analyzed our data to determine if and to what degree clonogenic growth of metastatic breast tumours was related to the survival of patients. We found that tumour clonogenicity and patient survival correlated weakly, particularly if compared to the strong correlations of patient survival with either performance status or tumour bulk. Furthermore, an association between tumour clonogenicity and patient survival was visible only for clonogenicity that was determined under hormone-supplemented conditions, and only for tumour lesions that formed 50 or more colonies per 500,000 cells cultured. Thus, we conclude that clonogenic growth of breast tumour samples incompletely reflects the tumour features that determine the course of advanced disease.


The effects of tumour cells (Colon 26) on the development and response of new blood vessels to different vasoconstrictors  have been investigated. Sponge implants in mice were used to host tumour cells while washout of 133Xe was employed to assess local blood flow in the implanted sponges. By 14 days after implantation the response of vessels in tumour-bearing implants to the various vasoconstrictors generally was decreased compared to that obtained in control sponge implants or adjacent normal skin. Thus at this time point the t1/2 for 133Xe washout from control sponges treated with adrenalin (0.5 micrograms) was 30 +/- 4 min whereas in tumour-bearing sponges it was 5 +/- 1 min. This decreased sensitivity in tumour vessels was probably not due to a complete lack of contractile elements since actin was demonstrated by immunohistochemistry around blood vessels in both types of implant. The results of the present study have shown that the pharmacological responses of blood vessels in a growing tumour, Colon 26, differed from the responses of vessels of a similar age in non-neoplastic tissue. These results appear to suggest that the different angiogenic stimuli released from tumour tissue may markedly influence pharmacological reactivity of newly formed blood vessels.


The growth promoting properties of ascitic fluids, cyst fluids and peritoneal fluids from patients with ovarian malignancy, benign ovarian tumours and non-tumour related gynaecological conditions have been investigated using an ovarian carcinoma cell line (OAW 42), mesothelial cells (58MC) and rat kidney cells (NRK-49F). Colony stimulating activity (CSA) for tumour cells and transforming activity (TA) for mesothelial cells were weakly correlated, but whereas elevated TA was tumour-associated, CSA was not. However, TA was not cancer-associated and, although the difference between the mean TA values of benign and malignant cyst fluids was of borderline significance, some benign cyst fluids from cystadenomas showed high TA values. Higher levels of TA in the cystadenomas showed a significant correlation with the menopausal status of the patient and higher levels of TA in the malignant cyst fluid/peritoneal fluid groups were associated with more advanced disease. Results indicated that some fluids contained TGF-beta-like activity, but there was no direct evidence for the presence of TGF-alpha/EGF-like activity in the fluids. Heparin inhibited clonogenic growth of tumour cells but not mesothelial cells. The reduced CSA which was observed after treatment of fluids with both heparin and thrombin implicated coagulation factors in the manifestation of CSA. It was concluded that CSA in the fluids was due, at least partly, to fibrin coagulation, and TA was due to unknown growth factor(s) which may include TGF-beta-like activity. The results are discussed in the context of the aetiology of ovarian carcinoma, and the possible clinical significance of TA.


The GI-101 human breast tumour xenograft line is unique in that it spontaneously metastasizes to the lungs of athymic murine hosts from subcutaneous trochar implants. Both tumour and lung metastases are positive for normal human breast tissue markers. GI-101 also is positive for the p53 antigen but negative for the c-erbB-2 oncogene.


Detailed flow cytometric analysis of cellular DNA content was performed on neoplastic tissue from 33 patients with malignant common epithelial ovarian tumours in order to investigate the intratumoral stability of ploidy and proliferative fraction. There was a remarkable stability, both spatial and temporal, in the DNA pattern for any particular tumour. Of 24 tumours that were analysed in multiple areas tumour ploidy was found to be a stable marker in all but 3 cases where regional variations were evident. In 9 patients serial analyses were performed on tumour obtained either at initial diagnosis (6 patients) or second look laparotomy (3 patients) and then some time later (7-17 months) at relapse or death and in all cases the tumour ploidy remained unchanged. In addition, 10 ovarian carcinomas established in nude mice have maintained a DNA content during serial passage similar to that of the original implanted tumour. In contrast in 50% of tumours that were evaluable for S-phase analysis we demonstrated a considerable intratumoral variability in the S-phase fraction. We conclude that cellular DNA content is a stable feature of ovarian carcinoma while S-phase fraction is commonly subject to intratumoral variation.


The metabolism of 1-naphthol, a model phenolic substrate, to its glucuronic acid and sulphate ester conjugates has been studied in short-term organ cultures of normal human colon and tumour tissue, subcellular fractions of these tissues, human colonic tumour cell lines and human colonic tumour xenografts. Normal colonic tissue, in short-term organ culture, formed more 1-naphthyl sulphate than glucuronic acid conjugates. In contrast the colonic tumours, under the same conditions, produced more 1-naphthyl beta-D-glucuronide than 1-naphthyl sulphate. A marked interindividual variation in sulphate ester and glucuronic acid conjugation was noted in both normal and tumorous colon. The conjugation of 1-naphthol was also investigated, using subcellular fractions, where the metabolism found with normal colon reflected that observed utilizing short-term organ culture, but that from colonic tumour samples did not. Cell lines derived from human colonic adenocarcinomas metabolised 1-naphthol almost exclusively to its glucuronic acid conjugate. Xenografts derived from human colonic tumours formed similar conjugates to surgical samples in culture. Thus somewhat different results were obtained dependent on the experimental model chosen. However, in all colonic tumour systems studied, when the cells remained intact and where tissue architecture was maintained, 1-naphthol was metabolised predominantly to its glucuronic acid conjugate.


Flavone acetic acid (FAA) is a synthetic flavonoid with dramatic pre-clinical anti-tumour activity involving a vascular component in its mechanism but no clinical effects have been seen to date. As FAA also has immunomodulatory activity, immunological factors might explain differences in activity between mouse and man. This study examines the influence of host immune status on the anti-tumour activity of FAA. Two human colon tumour xenografts  fail to respond to FAA in nude mice. The lack of activity of FAA against HT-29 xenografts cannot be explained on the basis of limited drug bioavailability as achievable plasma, and tumour levels of FAA are similar to those seen in sensitive murine colon tumours. The immune status of the host also influences the activity of FAA against two transplantable tumours of the mouse colon. Both these tumours are highly responsive to FAA in their normal NMRI hosts, but neither tumours exhibited significant growth delay in thymectomised NMRI or nude hosts. Histological examination of treated tumours revealed significant areas of haemorrhagic necrosis in all three hosts. These data suggest a clear immunological component in the mechanism of action of FAA which is separate from the previously described haemorrhagic necrosis.


We have examined the anti-tumour activity of liposome-entrapped Adriamycin in a murine metastatic tumour model produced by i.v. inoculation of J-6456 lymphoma cells and affecting predominantly the liver. Sonicated liposomes containing phosphatidylcholine, a negatively-charged phospholipid and cholesterol were used in these experiments. Liposome-entrapped Adriamycin was more effective than free Adriamycin at equivalent doses of the drug. The superior therapeutic effect of the liposome-associated drug was manifest, either with a single i.v. treatment using a dose bordering the toxicity threshold of free Adriamycin or with a multi-injection schedule using smaller doses. Based on the growth kinetics data of the J-6456 lymphoma, our results indicate that tumour cell killing was enhanced by a factor of approximately 100 using the liposome associated form of Adriamycin. Histopathologic studies in mice bearing well-established metastases of the J-6456 lymphoma in liver and spleen indicated that the extent and duration of pathologic remission were significantly improved in mice receiving the liposome-entrapped drug as compared to mice receiving free drug. No significant differences in the anti-tumour effect of liposome entrapped Adriamycin were observed replacing phosphatidylserine by phosphatidylglycerol and reducing the cholesterol:phospholipid molar ratio from 100% to 25%. In contrast to the metastatic tumour model, liposome-entrapped Adriamycin was significantly less effective than free Adriamycin on the local i.m. growth of the J-6456 tumour. Altogether the survival and histopathological data presented suggest that, with regard to a group of neoplastic conditions with a predominant pattern of liver dissemination, a substantial increase in the therapeutic index of Adriamycin can be achieved in a selective manner with the use of liposomes.


Flavone acetic acid (FAA) is extremely active against subcutaneous transplantable tumours in mice, but disappointingly there has been no demonstrable clinical activity. Previous studies have shown that lung tumour deposits are less responsive than the same cells implanted subcutaneously. The aim of this study is to examine the tissue disposition of FAA in an attempt to explain this site-dependent activity. The data show clearly that FAA clearance curves are influenced by the presence of MAC 15A tumours growing either subcutaneously or systemically. The decreased clearance of FAA from MAC 15A tumour bearing animals does not however explain the resistance of lung deposits. Neither can this be explained by differences in metabolism in these different sites. Cytotoxic metabolites have not been detected either in vitro or in vivo and their role in the mechanism of action of FAA is questionable.


Three intraperitoneal human ovarian cancer xenografts  were used to assess the antitumour activity of intraperitoneal therapy with liposome encapsulated MTP-PE. MTP-PE led to significant prolongation of survival in all three xenograft models, but with varying efficacy. In one tumour model (OS), 80% of mice were cured of tumour by twice weekly therapy for 4 weeks, whereas in another xenograft model (LA), the median survival time was approximately doubled compared to PBS injected and placebo liposome injected controls . The antitumor efficacy of MTP-PE did not correlate with the extent of peritoneal neutrophil infiltration after intraperitoneal therapy. Combined therapy with liposome encapsulated MTP-PE and recombinant murine granulocyte-macrophage colony stimulating factor led to increased survival of mice bearing the LA and HU xenografts, compared to tumour bearing mice treated with either agent singly.


Early and severe loss of body weight associated with pronounced tissue changes developed in rats transplanted with a fast-growing ascites hepatoma (Yoshida AH-130). The protein content showed an early and marked fall in the skeletal muscle, while in the liver it transiently increased 4 days after implantation then declined to values lower than in control animals. Protein loss in gastrocnemius muscle and liver resulted mainly from enhancement of protein catabolism . In contrast to the tumour-bearing rats, in the pair-fed animals the initial body weight was maintained, while the protein mass decreased sharply in the liver and moderately in the gastrocnemius muscle. In host animals total plasma protein decreased during the period of tumour growth, while both triglycerides and total cholesterol markedly increased. Glucose remained unchanged even when overt cachexia had developed. The total free amino acid concentration in the plasma of tumour-bearing rats decreased slightly by day 4 and returned to values close to those of controls in the late stages of tumour growth. By contrast, in the pair-fed controls the plasma levels of triglycerides and particularly of total free amino acids and glucose decreased over the whole experimental period, whereas total protein and cholesterol were unchanged. Marked perturbations in the hormonal homeostasis developed early after tumour transplantation. The plasma levels of glucagon, corticosterone and catecholamines rose sharply, while those of insulin and thyroid hormones decreased. Furthermore, high plasma concentrations of prostaglandin E2 (PGE2) and tumour necrosis factor (TNF) were observed over the whole experimental period. IL-1-like activity, TNF and PGE2 were released in vitro from AH-130 cells. These data suggest that the systemic effects of AH-130 tumour on the host rat reflected the interplay of a complex network of factors, including classical hormones and cytokines, all of which likely concur in enhancing tissue protein catabolism.


Although animals bearing the MAC16 colon adenocarcinoma showed progressive weight loss, the average food consumption  did not differ from non tumour-bearing controls , while animals bearing a related colon adenocarcinoma, MAC13, which had no effect on body weight had a significantly (P less than 0.01) elevated food intake  above controls. Weight loss in animals bearing the MAC16 tumour was associated with a significant reduction in the percentage contribution of the kidneys, colon and epididymal fat pads to the total body weight. Although loss of body fat occurred only in the MAC16 model, both tumours were capable of synthesising lipids from glucose both in vitro and in vivo at the same rate. In addition both tumours increased the rate of lipogenesis from glucose in kidney, liver and epididymal fat pads of the host. Lipogenesis from glucose would be expected to result in a loss of utilisable carbohydrate energy and thus would be expected to increase the overall energy requirements in the tumour-bearing state leading to catabolism of host body tissues if the energy intake is not increased.


Suppressor gene loci involved in the development of hepatocellular carcinoma (HCC) have not been fully identified. The aim of this study was to look for consistent allele loss, or loss of heterozygosity (LOH), in HCC which might represent such gene loci. We have prepared DNA from tumour and non-tumour material from 16 patients with HCC (nine with and seven without liver cirrhosis). Tumour DNA was compared with non-tumour DNA by Southern analysis performed with a panel of 22 probes recognising restriction fragment length polymorphisms assigned to chromosomes 1, 4, 5, 7, 9, 11, 12, 13, 14, 16, 17, 18 and 20. Non-tumour DNA from five of the seven patients with HCC without cirrhosis was heterozygous with the probe Lambda MS8 (5q35-qter), and in all five there was LOH in tumour DNA. Probes for other regions of chromosome 5 have as yet shown no LOH in this group of patients. Cirrhotic HCC patients exhibited LOH on chromosomes 1q and 5p but not in the region 5q35-qter. Both groups of HCC showed LOH on chromosome 17p13. Screening with other probes has not shown any consistent LOH in either group as yet. A comparison of LOH on chromosome 5 in seven patients with colorectal metastasis in the liver showed a different pattern, which suggests that the proposed tumour suppressor gene locus for HCC without cirrhosis on chromosome 5 appears to be distinct from the familial adenomatous polyposis coli gene.