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We report the case of a middle-aged patient with repeated attacks of regional migratory osteoporosis of the lower limbs, manifesting as severe pain and swelling of both joint and periarticular areas, and marked physical disability during a period of 2 1/2 years. After the therapeutic failure of conservative therapy (physical therapy, rehabilitation therapy, analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs)) and after the correct diagnosis was reached, pamidronate treatment was instituted. The results were a rapid, complete, and long-lasting remission of the symptoms and the renewal of the patient's previous activities. Intravenous biphosphates are proposed as a safe and promising therapy for regional migratory osteoporosis. To our knowledge, this is the first report of pamidronate treatment for this condition.

Ticlopidine is a widely used drug for prevention of stroke and other serious vascular events with a multitude of possible side effects. An increasing number of drugs are being recognized as the triggering agents of drug-induced lupus. We describe three patients in whom the etiologic connection between ticlopidine and lupus was supported by the appearance of lupus-like features (fever, rash, arthritis, renal involvement, positive antinuclear and antihistone antibodies), shortly after drug initiation, and their gradual resolution after its discontinuation. If suggested by clinical or/and laboratory findings (fever of unknown cause, musculoskeletal involvement, hematologic abnormalities), the possibility of ticlopidine-induced lupus should be taken into consideration and appropriate investigations should be performed. Patients should resolve slowly but completely after withdrawal of ticlopidine.

Objective: To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC)., Methods: The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch-pouchitis-is discussed., Results: The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. Steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true., Conclusions: Arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies.

Background: Thyroid hormones are endocrine modulators of several vital processes that are crucial to tumor growth and differentiation. Several anecdotal reports in the literature suggest that some histologic types of carcinoma may remain in a dormant state for prolonged periods of time in patients with hypothyroidism, with eventual progression of the disease once the decreased thyroid function is identified and corrected., Methods: Oral propylthiouracil (PTU) was used to induce hypothyroidism in athymic nude mice that were subsequently inoculated with lung adenocarcinoma and prostate adenocarcinoma cells. Mice were also treated with a combination of PTU and thyroxine, which resulted in hyperthyroid levels of T(4)., Results: Subcutaneous lung and prostate xenografts grew significantly more slowly in hypothyroid mice treated with PTU than in euthyroid or hyperthyroid mice, regardless of treatment with PTU. Tumors grew well in groups of mice that were changed from a hypothyroid state to a euthyroid state by withdrawal of oral PTU. Administration of PTU 3 weeks after tumor inoculation also caused the tumor growth to slow significantly compared with tumors in mice that did not receive PTU. Mice that received PTU and thyroxine had tumors that grew as well as the tumors in euthyroid control animals., Conclusions: Our study indicates that human lung and prostate tumors do not grow well in hypothyroid nude mice, and that rendering these animals euthyroid has a significant impact on the growth rate of these tumors. Furthermore, in vitro and in vivo data indicated that this was not a result of an interaction of the tumor cells with PTU, but rather a result of the hypothyroid state., (Copyright 1999 American Cancer Society.)

Objectives: To analyze the factors which differentiate chronic tophaceous arthritis from rheumatoid arthritis., Methods: We describe two cases of chronic gouty arthritis masquerading as rheumatoid arthritis. The characteristic features of each of these two conditions and the diagnostic approach are discussed in light of relevant literature., Results: The correct diagnosis was reached by the combination of accurate history taking (family history of gout, alcoholism, previous diuretic therapy and renal stones), guiding clinical features (subcutaneous tophaceous deposits) and specific radiological (assymetrical erosions with sclerotic margins and overlying edges) and laboratory findings (hyperuricemia and hyperuricosuria). It was confirmed by the identification of monosodium urate (MSU) crystals in the synovial and subcutaneous tissues., Conclusions: Gout and rheumatoid arthritis rarely coexist. Chronic gouty arthritis may mimic rheumatoid arthritis, and vice-versa. Clinical suspicion supplemented by characteristic laboratory, radiological and histologic findings help at reaching an accurate diagnosis.

Objective: To determine an effective, evidence-based, postoperative surveillance strategy for the detection and treatment of recurrent breast cancer. Tests are recommended only if they have an impact on the outcomes specified by American Society of Clinical Oncology (ASCO) for clinical practice guidelines., Potential Intervention: All tests described in the literature for postoperative monitoring were considered. In addition, the data were critically evaluated to determine the optimal frequency of monitoring., Outcome: Outcomes of interest include overall and disease-free survival, quality of life, toxicity reduction, and secondarily cost-effectiveness., Evidence: A search was performed to determine all relevant articles published over the past 20 years on the efficacy of surveillance testing for breast cancer recurrence. These publications comprised both retrospective and prospective studies., Values: Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design., Benefits, Harms, and Costs: The possible consequences of false-positive and -negative tests were considered in evaluating a preference for one of two tests providing similar information. Cost alone was not a determining factor., Recommendations: The attached guidelines and text summarize the updated recommendations of the ASCO breast cancer expert panel. Data are sufficient to recommend monthly breast self-examination, annual mammography of the preserved and contralateral breast, and a careful history and physical examination every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, then annually. Data are not sufficient to recommend routine bone scans, chest radiographs, hematologic blood counts, tumor markers (carcinoembryonic antigen, cancer antigen [CA] 15-5, and CA 27.29), liver ultrasonograms, or computed tomography scans., Validation: The recommendations of the breast cancer expert panel were evaluated and supported by the ASCO Health Services Research Committee reviewers and the ASCO Board of Directors.

Substantial weight loss in individuals with AIDS or cancer is associated with a poor prognosis and increased mortality. We have isolated and partially characterized a proteoglycan (named azaftig) from the urine of a cancer patient experiencing weight loss. Furthermore, we have raised a polyclonal antibody to azaftig in rabbits and developed a procedure to measure the level of this proteoglycan in urine by Western blot. We report the presence of azaftig in the urine of cancer and AIDS patients experiencing weight loss, but not in the control or weight-stable subjects. The azaftig-like immunoreactivity was present in 69.2% (9/13) of patients with weight loss, but only in 27.0% (3/11) of weight-stable cancer or AIDS patients and none of the control subjects (n = 8)., (Copyright 1999 Academic Press.)

Objective: To assess bone mineral status in a group of children with systemic type juvenile chronic arthritis (JCA), which places them at high risk to develop osteoporosis., Methods: Bone mineral density (BMD) was measured in 17 children aged 6-18 yrs (mean 14.9 +/- 4.5) with systemic JCA and in 18 matched controls by dual energy x-ray absorptiometry. Bone turnover was determined by quantitative bone scintigraphy, using quantitative single photon emission computed tomography based on skeletal uptake of methylene diphosphonates (MDP uptake). Serum concentrations of minerals, osteocalcin, and bone alkaline phosphatase were determined. Nutrient intake was assessed by a 24 hour dietary recall., Results: Patients with systemic JCA who received corticosteroid therapy had significantly reduced BMD in both the lumbar spine (p < 0.05) and the femoral neck (p < 0.05) compared to controls, whereas BMD values of the non-steroid systemic JCA patients were not different from controls. Bone turnover measurement by MDP uptake showed no difference between patients with JCA and controls. Levels of calcium, phosphorus, alkaline phosphatase. and osteocalcin were within normal limits in all patients., Conclusion: Patients with systemic JCA receiving longterm steroid treatment may develop a significant decrease in BMD. The normal MDP uptake values together with normal osteocalcin levels that we observed in our patients indicate that their disease is not associated with enhancement of bone turnover rates. These observations might have therapeutic implications for prevention and management of osteoporosis in JCA.

Objective: To study zinc absorption in patients with active rheumatoid arthritis (RA)., Methods: We studied zinc tolerance tests and 24 hour urinary zinc excretion before and after ingestion of 50 mg elemental zinc in 8 healthy volunteers (Group 1) and 13 patients with low RA activity (Group 2) and 16 patients with high RA activity (Group 3)., Results: In Group 1, plasma zinc rose from 111 +/- 7 micrograms/dl to a peak of 200 +/- 24 micrograms/dl (mean +/- SEM) in 2 h. In Groups 2 and 3, plasma zinc before zinc ingestion was significantly lower than that of the control group (p < 0.00001 for both groups) and showed no significant increase in plasma after ingestion. Twenty-four hour urinary zinc excretions before and after zinc ingestion were significantly lower (p < 0.01, p < 0.0001 for Group 2; p < 0.05, p < 0.01 for Group 3, respectively) than those in the control group., Conclusion: These results are compatible with zinc malabsorption and consequent zinc deficiency in patients with RA. Whether zinc deficiency contributes to perpetuation of disease activity by compromising cellular immune function needs further investigation.

Seven elderly women with insufficiency fractures of the pubic ramus are described. The predisposing factors for this condition were osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. The clinical presentation included progressive inguinal pain, limping, and inability to walk. Because initial radiographs were diagnostic only in four cases, bone scintigraphy and computed tomography were necessary to confirm the diagnosis and detect additional fractures. In most patients, bed rest, non-weight-bearing ambulation, symptomatic treatment, and therapy for osteoporosis resulted in rapid improvement, and long-term follow-up showed complete or partial recovery. In one case, no recovery was achieved because of noncompliance with treatment. Insufficiency fracture of the pubic ramus should be suspected in cases of unexplained inguinal or hip-area pain and inability to walk in the elderly. The clinical suspicion should be supplemented by radiological investigation. Bone scintigraphy and computed tomography are useful means for early and accurate diagnosis. The risk factors for this condition should be identified and treated. If therapy is initiated early and pursued, this type of fracture has a benign outcome.

It appears that screening mammography certainly is of value in women over age 50, and although controversy exists regarding screening of women under 50 years of age for breast cancer, the authors believe that this strategy is the most reasonable one for women 40 to 64 years of age at this time. Additionally, it is important for physicians to remember to encourage their patients to undergo cancer screening evaluation. Encouragement by physicians is an important factor in increasing cancer screening rates.

Tumor-induced (oncogenic) osteomalacia is a rare clinicopathologic entity in which the clinical signs and symptoms of osteomalacia and the specific laboratory abnormalities of hypophosphatemia, hyperphosphaturia, and low serum levels of 1,25(OH)2 vitamin D are associated with the finding of a neoplastic process in the patient. To date, less than 100 cases of oncogenic osteomalacia have been described. We report a new case of adult-onset hypophosphatemic osteomalacia leading to the discovery of an asymptomatic phosphaturic mesenchymal lung tumor. Complete resection of the pulmonary neoplasia was followed by rapid normalization of the laboratory findings and clinical remission. The clinical, laboratory, and histopathologic spectrum of tumor-induced osteomalacia is presented, and the postulated mechanism of this condition is discussed in light of the relevant literature. The presence of occult neoplasms should be considered in cases of unexplained adult osteomalacia, with the physician's efforts being rewarded by the dramatic cure that follows excision of the tumor.

The effect of 17 beta-estradiol and progesterone on ocular lens in rats and untreated controls was studied. In the treated lenses, the activity of hexokinase and glucose-6-phosphate dehydrogenase remained unchanged. The activity of aldolase was increased in 18- and 20-month-old lenses as compared to controls. Aldose reductase activity was decreased at the age of 20 months (p < 0.001). Structural lens proteins studies by SDS polyacrylamide gel electrophoresis and immunodecoration with specific antibodies for crystallines alpha A + alpha B and beta + gamma suggest some protective effect in treated animals.

Hospice care is a reasonable treatment strategy for those cancer patients whose disease process is no longer responsive to standard treatment regimens or who are unable to tolerate the adverse side effects of continued aggressive therapy. A 1:1 matched case-control study design that designated those patients selecting the hospice model of care as controls and those receiving acute care as cases was utilized. Data was abstracted from medical records and financial billing statements. The difference between total hospital charges plus hospice charges during the last 6 months of life for the hospice patients ($35,625) compared to the non-hospice patients ($50,152) was statistically significant. The hospice model of care may be a less costly option for those cancer patients where palliation is the objective.

The effect of weight loss on estimated breast cancer risk, sex hormone binding globulin (SHBG), total and free estradiol levels was evaluated. Increasing weight loss reduced upper body fat distribution progressively. Women with a family history of breast cancer who lost more than 7.0 kilograms decreased their estimated breast cancer risk by 25.7% while women without such a family history decreased their risk by 42.8%. A significant (P<0.001) increase in SHBG with a 4.0 to 7.4 kg weight loss was seen in both pre and postmenopausal women (P<0.05). No significant change in total or free estradiol levels was observed.

The survival of patients with hematologic malignancies who require admission to the intensive care unit (I.C.U.) is poor. The potential for cure in this group of patients necessitates aggressive treatment that can result in life-threatening complications. A medical, ethical and financial dilemma arises when aggressive therapy and intensive support is balanced with actual survival, meaningful survival and the financial burden to society and the patient's family. We collected complete financial information on 64 leukemia and lymphoma patients admitted for the first time to the intensive care unit (I.C.U.) at the H. Lee Moffitt Cancer Center and Research Institute between 7/1/88 and 6/30/90. The charges were calculated from actual itemized statements and included all inpatient and out-patient charges. Survival was addressed by individually evaluating candidate variables with parametric and non-parametric analysis. Survival after I.C.U. admission and hospital discharge were studied as dependent variables in a stepwise multiple regression analysis. The nadir of the platelet count and albumin level prior to and during the I.C.U. admission significantly affected survival. During the I.C.U. admission, the BUN, serum creatinine and the need for mechanical ventilation significantly affected survival. Seventy-eight percent of patients survived less than five months and spent less than two and one half months at home. Fifty percent of patients expired during the I.C.U. admission. Only 3.2% of patients who had received two or more chemotherapeutic regimens had survived more than one year. The cost per year of life gained for the entire group of patients was $189,339. The results of this study show that the majority of leukemia and lymphoma patients who are admitted to the I.C.U. expire prior to discharge or spend a minimal amount of time at home prior to expiring. This study suggests that the cost of meaningful survival must be borne in mind by physicians and should encourage them to discuss treatment options, potential outcomes, risks and benefits so that a reasonable strategy can be planned by the physician, patient and family prior to treatment.

Ninety-two undergraduates were assigned into groups to evaluate the effectiveness of interactive, computer-delivered programmed instruction for nutrition education on the topic of diet and cancer compared to traditional passive modes of instruction. Students were monitored for knowledge gains by means of a single 50-item test and an application task, using a 4-day diet record, administered 4 weeks prior to and 3 weeks after intervention. Results indicated that although subjects in the interactive group took nearly twice as long to complete the program, having the opportunity to respond to program blanks, this group produced significantly greater knowledge gains and lowered their fat intake by 41.8% compared to 26.1% reduction in fat intake in the noninteractive computer group and 18.6% in the passive prose text groups. Results suggest that interactive, computer-delivered, programmed instruction can be a very important adjunct to health care and cancer prevention programs at high schools and university settings.

Between May 1987 and December 1991 sixty four patients with Stage I Endometrial carcinoma were treated primarily with surgery at the University of Colorado Health Sciences Center, Denver and at hospitals in the Tampa Bay Metropolitan region. A frozen section protocol on the hysterectomy specimen was utilized in a uniform manner at all institutes. The aim of the study was to determine the speed and accuracy of this protocol in determining the dominant grade of the tumor and depth of invasion of the myometrium. The accuracy rate for reporting dominant tumor grade when compared to permanent histology was 100% for 33 specimens and 93.6% for the remaining 31 specimens. The overall accuracy for depth of myometrial invasion was expressed as a comparison of the average ratio of myometrial invasion to adjacent uninvolved myometrial thickness between frozen and permanent histology specimens. The correlation was 97.7% in this study. The average time taken was 12.6 minutes for 16 specimens, 18.8 minutes for 33, and 32.4 minutes for 17. A case is made in this paper for the value of such intraoperative information being made available to the surgeon on a routine basis.

The intention of a surveillance program to monitor prostate cancer patients is to detect recurrence of disease as soon as possible and institute therapy at the time of recurrence in order to improve the chance of cure or extend survival. We analyzed the cost of four surveillance programs for prostate cancer. As PSA levels are more sensitive than the bone scan, prostatic acid phosphatase and alkaline phosphatase, a surveillance program which utilizes these latter tests provides no additional clinically useful information beyond a PSA level and is costly. Adopting a strategy of eliminating these tests from a surveillance program would reduce national annual expense by approximately $1.5 billion in the year 2000.

The effectiveness of a surveillance program for breast cancer recurrence in extending survival is predicated on two assumptions: 1) most recurrences are detected at an early stage at surveillance visits; and 2) the early treatment of recurrence offers a better chance of cure or longer survival. However, the data suggest that neither of these two assumptions is correct, and that postoperative follow-up of patients with breast cancer is expensive and does not significantly extend survival.

Transient osteoporosis of the hip (TOH) is an uncommon but possibly underdiagnosed condition. This pattern of regional osteoporosis affects previously healthy middle-aged men, and women in the third trimester of pregnancy. Its etiology is still unclear, yet in view of similarities to regional migratory osteoporosis and reflex sympathetic dystrophy, vascular and neurologic disturbances have been proposed as the possible pathogenetic mechanisms. Pain in the hip area and functional disability of the affected limb are the main clinical signs. Diagnosis is supported by local radiological osteopenia whose gradual disappearance parallels the spontaneous recovery. Bone scintigraphy, magnetic resonance imaging, computed tomography, and other imaging methods are supplementary diagnostic tools. Exclusion of more common entities is required. The purpose of this report is to elucidate the diagnostic and therapeutic aspects of TOH and to stimulate the physician's awareness of this condition, recognition of which may prevent unnecessary invasive procedures and inadequate treatment.

Of all cancers in the United States, 35% are estimated to be caused by dietary factors and may be preventable. Diets high in fat or calories, for example, are said to be associated with five of the six most common cancers: breast, colorectal, pancreatic, prostatic, and uterine. Conversely, some dietary components such as vitamin A, in fruits and vegetables, and fiber may help protect against certain cancers. Obesity may confer a small risk of breast cancer on a woman, but women with upper body fat localization are at significantly higher risk of developing breast cancer and endometrial cancer.

Coined in French in the early 1820s as a mere description of a pathological state of the bone, the term 'osteoporosis' made its way into the English medical vocabulary only in the twentieth century. Unlike other medical concepts, which have not been substantially altered by progress in medical research, the definition of osteoporosis has constantly reflected the state of knowledge on the phenomenon itself. Over its 170 years of evolution, this definition has continuously sought to maintain a difficult balance between physiological and clinical criteria. Even at present, while the 1990 Consensus Conference definition (centering mainly on physiological deterioration) merely implies the clinical aspect through the notions of fragility and fracture risk, others advocate restriction of the term to the clinical consequences of osteopenia. How will the concept of osteoporosis develop in the future? This article, which deals with the origin of the term and its successive definitions, is offered as a basis for further discussion on this subject of high topicality.

Scientific evidence supports a relationship between diet and the incidence of cancer. This finding has resulted in dietary recommendations that have been disseminated to the public. To reduce actual cancer incidence, these recommendations must lead to dietary changes among the population. We compared two brief dietary interventions with a longer term intervention and found that all three interventions produced significant reductions of calories, fat, fiber intake, and weight. The duration of the intervention did not significantly affect the magnitude of these reductions. We also found that health locus of control did not affect dietary change. Participants who initially were found to have an internal locus of control, or who subsequently internalized their locus of control during the period of observation, did not demonstrate a significant change in their intake of any of the nutrients measured when compared to participants with an external locus of control. Thus, we suggest a brief dietary intervention as a feasible and effective mechanism to produce progressive incremental dietary changes in a large population.

Thirty-five percent of all cancers in the United States are estimated to be caused by dietary factors and may be preventable. Diets high in fat or calories, for example, are said to be associated with five of the six most common cancers: breast, colorectal, pancreatic, prostatic, and uterine. Conversely, some dietary components such as vitamin A in fruits and vegetables and fiber may help protect against certain cancers. Although some of these findings are controversial, the dietary guidelines they engender are not, as the recommendations are healthy for other reasons as well. Obesity may confer a small risk of breast cancer on a woman, but women with upper body fat localization are at significantly higher risk of developing breast cancer. This risk appears to be reduced with weight loss.

A group of 531 participants age 50 years or older were evaluated for colonic polyps and malignancy with stool occult blood testing, hemoglobin, hematocrit, serum ferritin, flexible fiberoptic sigmoidoscopy, and colonoscopy. Screening revealed 1 colorectal cancer, 2 malignant polyps, 30 hyperplastic polyps, 69 adenomatous polyps, 4 villous adenomas, and 2 villous components. Low serum ferritin, an indicator of iron deficiency without anemia, improved the detection of colonic malignancies and polyps when used in combination with stool occult blood testing. The program was acceptable to participants and attrition was low; the attrition rate for the screening program at 1 year was 14.5%.

The serum cholesterol levels of 123 consecutively and newly diagnosed women with Stage I and II breast cancer taking tamoxifen were compared with a control group of 81 consecutively newly diagnosed women with Stage I and II breast cancer who were not taking a hormonal treatment or supplement. Other factors that were evaluated were age, menopausal status, tumor size, weight, height, Quetelet index, and smoking and alcohol intake history. The mean cholesterol change in patients on tamoxifen (34.2 +/- 3.6 mg/dl) was significantly greater than controls (1.0 +/- 4.1 mg/dl) (P less than 0.001). Serum cholesterol fell by more than 10 mg/dl in 72.9% of women on tamoxifen vs. 35.1% of controls and by more than 40 mg/dl in 39.9% of women on tamoxifen vs. 12.6% of controls. Multivariate analysis revealed that tamoxifen administration (P less than 0.0001), initial cholesterol level (P = 0.001), and age (P = 0.04) were significant factors in producing a decrease in serum cholesterol. The administration of tamoxifen as adjuvant therapy to women with newly diagnosed breast cancer resulted in a significant fall in serum cholesterol. This effect of tamoxifen on the serum cholesterol may prove to be an additional benefit in the form of reduced cardiovascular risk in these women.

To prevent or delay the occurrence of chronic diseases, scientific bodies from the cardiologic and oncologic disciplines have made recommendations regarding the daily dietary intake of certain macro- and micronutrients. This study assessed the knowledge of a random population of 2,305 individuals comprising members of the public, health care workers, university graduate students, and health club attendees. Segments of this population might be expected to have a greater understanding and ability to implement these dietary recommendations. We found that over 90% of the participants were unaware of the recommendations for calcium, salt, vitamin A, and fiber, and the fiber content in a high fiber cereal. Approximately 80% of the participants were unaware of the recommendations regarding fat intake and could not calculate the fat content of a food product. Almost half of the study population took a vitamin pill daily. Of the subjects who were aware of the correct unit measurement for vitamin A (IU), almost 25% of gave a response that exceeded the recommended daily intake. A majority of this study population were unaware of the dietary recommendations regarding the prevention of cardiovascular events and cancer. Subgroups of this study population that might be expected to have more information regarding these recommendations (i.e., having higher education or being a health care professional) did not display a satisfactory level of knowledge. To further compound the problems of adhering to the recommended guidelines, the labeling of many food products is misleading. The recommendations on dietary intake and the information on food product content must be transmitted to the public in a form that allows for ready application when purchasing and consuming food.

The association between carpal tunnel syndrome and Polymyalgia Rheumatica has already been described. As in other systemic diseases the bilaterality of the syndrome is a common finding. Surgical treatment is usually necessary in carpal tunnel syndrome. Three cases of the syndrome associated with polymyalgia rheumatica are presented. Clinical remission and normalization of the electromyographic tracing were achieved by systemic corticosteroid treatment. The relationship between these two conditions is once more confirmed. A "wait and see" period which might eventually avoid unnecessary surgical intervention is strongly recommended.

Diabetes mellitus and peripheral neuropathies are considered to be unusual causes of the reflex sympathetic dystrophy syndrome. Their coexistence in a patient with this syndrome is rare and considered to be incidental. We report a case in which remission of the syndrome accompanied the resolution of the diabetic neuropathy. A possible pathophysiologic mechanism connecting these conditions is discussed.

Ceruloplasmin (CP), an acute phase reactant, has been found to be elevated in patients with various tumors including breast cancer. We found that the CP level was elevated in 89% of 103 patients with metastatic breast cancer. In 27 patients with measurable metastatic disease that responded to treatment the mean CP level fell by 35% (p less than 0.001) and in 22 patients whose disease progressed on treatment, the mean CP level rose by 44% (p less than 0.001). Of those patients with Stage II breast cancer that were treated with adjuvant chemotherapy, only 6% of patients with a normal post mastectomy CP level have recurred, whereas 44% of patients with an elevated post mastectomy CP level have recurred (p less than 0.01). In following patients with breast cancer, we noted that in those patients that recurred, the CP level became elevated 16-34 weeks prior to any clinical evidence of metastases. We also noted that the CP level became elevated after initially falling in patients receiving adjuvant chemotherapy and on occasion, the initially elevated CP level did not even fall. These circumstances may represent resistant microscopic disease, so that changing to a noncross-resistant chemotherapeutic regimen might be appropriate.

Changes in vertebral bone mineral content and density during aging were quantified in female Wistar rats. This study represents a longitudinal follow up utilizing single photon absorptiometry for the measurement of bone mineral content (BMC), quantitative computed tomography (QCT) for the measurement of bone mineral density (BMD), and image analysis histomorphometry for the measurement of trabecular bone volume (TBV) and bone cortical area (BCA). The above measurements were accompanied by biochemical assays of calcium concentrations in the respective bones. All aging animals experienced significant decreases in BMC, BMD, TBV, BCA and in the calcium content of their bones. The above features have been further emphasized through the use of scanning electron micrographs showing the age-related structural changes in a three-dimensional fashion. New, advanced technologies will enable the quantitation of 3-dimensional images that are currently obtained from the scanning electron micrograph; thus will provide new consideration as related to trabecular bone compactness (density). Energy dispersive x-ray spectroscopy indicated that the nature of crystals in aging bones does not differ markedly from that encountered in young specimens. Data are also provided with regard to the health of the animals, and it became apparent that aging rats undergo changes in their kidneys yet do not show any significant change in renal functional parameters as measured in both the serum and the urine. Hence, new noninvasive methodologies are currently available for longitudinal studies related to the skeleton in laboratory animals enabling reliable monitoring of age-related and hormonally induced changes in bones (spine and hip) of well defined experimental models.

Hepatotoxicity is a rare complication of treatment with gold salts. The clinical and laboratory features are those of cholestatic jaundice and other diagnostic possibilities must be ruled out. Gradual recovery after withdrawal of the drug is the rule. We report a case and review previous literature with emphasis on the diagnostic value of the lymphocyte transformation test.