Pain responses of hospitalized infants and children to venipuncture and intravenous cannulation

The purpose of this study was to describe the experience of pain in infants and children in response to venipuncture and intravenous cannulation. Data on physiological, behavioral, and subjective responses were collected from 90 infants and children, in subgroups of 1 to 12 months, 1 to 3 years, 4 to 6 years, and 7 to 12 years. Changes in behavior were significant in all four groups, although the toddler group was the only group that showed a significant physiological change. The subjective measures showed that the children were able to identify their pain sites and intensity.

Disparities in clinical laboratory performance for blood lead analysis

OBJECTIVE

To evaluate the validity of blood lead analysis for clinical specimens.

DESIGN

We submitted blood lead samples with a known lead concentration, in a blinded fashion, as clinical specimens to 18 laboratories. These laboratories were surveyed for the following characteristics that were hypothesized to be related to assay validity: laboratory ownership (state vs private), participation in the Centers for Disease Control Blood Lead Proficiency Program, assay method, and price. Each laboratory received 6 specimens with an actual blood lead (ABPb) concentration of 0.43 mumol/L (9 micrograms/dL) and 3 additional specimens--each with an ABPb concentration of 0.33, 0.89, and 1.59 mumol/L (6.9, 18.4, and 32.9 micrograms/dL, respectively).

OUTCOME MEASURES

Misclassification error rates for reporting an elevation ( > or = 0.48 mumol/L [ > or = 10 micrograms/dL) in the blood lead concentration, the within-laboratory mean and coefficient of variation (CV) (for multiple specimens with an ABPb concentration of 0.43 mumol/L [9 micrograms/dL]), and the adjusted odds of a reported blood lead concentration differing from those of an ABPb concentration by more than 0.14 mumol/L (3 micrograms/dL).

RESULTS

Blood lead results were obtained for 157 of 162 submissions. One laboratory reported all blood lead specimens as "below 0.48 mumol/L (10 micrograms/dL)." Two (11%) of 18 specimens with an ABPb concentration of 0.89 mumol/L (18.4 micrograms/dL) and 1 (6%) of 17 with an ABPb concentration of 1.59 mumol/L (32.9 micrograms/dL) were classified as below 0.48 mumol/L (10 micrograms/dL); 2 (11%) of 18 with an ABPb concentration of 0.33 mumol/L (6.9 micrograms/dL) and 44 (42%) of 104 with an ABPb concentration of 0.43 mumol/L (9 micrograms/dL) were classified as 0.48 mumol/L or greater ( > or = 10 micrograms/dL). For specimens with an ABPb concentration of 0.43 mumol/L (9 micrograms/dL), the within-laboratory mean ranged from 0.23 to 0.52 mumol/L (4.8-10.7 micrograms/dL); the CV ranged from 3% to 37%. Laboratories that used anodic stripping voltammetry were 6.3 (95% confidence interval, 1.4-28.6) times more likely to report a specimen that differed from the ABPb concentration by more than 0.14 mumol/L (3 micrograms/dL) than those that used atomic absorption methods. No other laboratory characteristic predicted discordance between the reported blood lead and ABPb concentrations.

CONCLUSIONS

This study documents wide variation in the validity of the blood lead measurement among clinical laboratories. While the performance of some laboratories far exceeded the criteria of the Centers for Disease Control Blood Lead Proficiency Program, others made large errors that could have resulted in the false-negative misclassification of children with significant lead exposure. Given these differences, the purchasers of laboratory services may require access to laboratory proficiency data to make rational choices among clinical laboratories. Further study of laboratory performance on clinical specimens is required to determine if order-of-magnitude errors occur with sufficient frequency to warrant routine submission of blinded quality control specimens by proficiency programs and to determine the cause of the poor performance of laboratories that used the anodic stripping voltammetry methodology.

A phase II study of cyclophosphamide followed by PIXY321 as a means of mobilizing peripheral blood hematopoietic progenitor cells

Fourteen patients with stage II-IV breast cancer were enrolled in a phase II study of cyclophosphamide followed by PIXY321 as a means of mobilizing peripheral blood progenitor cells (PBPC). All 14 women tolerated PIXY321 well, with the predominant toxicities being erythema at the injection site, fever, and arthralgias. A median of two aphereses yielded a mean of 1.3 x 10(8) mononuclear cells/kg, 8.9 x 10(4) colony-forming units-granulocyte/macrophage (CFU-GM)/kg, and 4.5 x 10(6) CD34+ cells/kg. All 14 patients underwent high-dose chemotherapy with PBPC support, the median day to ANC >500 cells/microliter was 10.6, and the median day to platelets >20,000 cells/microliter was 13. The day of 90th percentile platelet recovery was 15. When compared to PBPCs mobilized by cyclophosphamide followed by GM-CSF, the use of PIXY321 may confer an advantage of enhanced platelet recovery.

Effect of developmental age or time after transplantation on Sertoli cell number and testicular size in inbred Fischer rats

The objectives were to establish the developmental age of Fischer rats at which the Sertoli cell number is stabilized, to establish the normal reference plateau number of Sertoli cells for evaluation of testes after transplantation, and to determine whether the developmental pattern establishing Sertoli cell proliferation and stability are similar between intact and transplanted testes. Sertoli cell number was determined at ages 1--120 days in intact rats and at various times (10-90 days) after transplantation of prenatal or neonatal tests. Tests were fixed by vascular perfusion or by immersion with 2% glutaraldehyde and and immersion in 1% osmium and were embedded in Epon 812. Sections and serial sections were cut at 0.5 micrometer to determine the Sertoli cell nuclei volume density and the volume of an individual Sertoli cell nucleus by brightfield microscopy or at 20 micrometers to determine the maximum height and width of nuclei. A correction factor was calculated for intact (0.663 +/- 0.025) or for transplanted (0.558 +/- 0.029) testes to determine the volume of a single Sertoli cell nucleus from height and width measurements. In intact testes, Sertoli cell numbers significantly increased to Day 20 but were not different between 15 and 90 days. Sertoli cell number in prenatal or neonatal transplanted testes increased to 20 or 30 days posttransplantation and then stabilized to Day 60 or 90. There was no difference in the plateau number of Sertoli cells per rat between prenatal and neonatal testes. Sertoli cells in 10-day- and 30-day-transplanted testes incorporated 3H-thymidine when placed in culture. A few tubules had complete spermatogenesis at 90 days posttransplantation, indicating that Sertoli cells in some of these tubules were functional. Leydig cell structure appeared to be normal. Leukocytic infiltration of testes was not observed in intact rats or in rats receiving neonatal testes. Although transplanted testes showed a delay in reaching the plateau value for Sertoli cell number per testis and although the value reached was lower, the developmental pattern of Sertoli cell proliferation in transplanted testes was similar to that in intact rats.

Testicular composition, number of A spermatogonia, germ cell ratios, and number of spermatids in three different breeds of boars

Seminal quality, including the number of spermatozoa in the ejaculate, varies among breeds of boars. Variation in seminal quality may be explained by breed differences in testicular size and composition. The objective of this study was to characterize testicular composition and population sizes of germ cells and somatic cells in three different breeds of boars. Testes from mature and normal Meishan (M, n = 5; age 225 days), Whitecross (WC, n = 5; age 346 days), and West African (WA, n = 5; age 322 days) boars were either fixed in Zenker-formol or perfused with glutaraldehyde, embedded in Epon, sectioned at 0.5 microns or 20 microns and evaluated stereologically for germ cells, Leydig cells, Sertoli cells, and other testicular structures. The paired parenchymal weight was higher (P < 0.05) in the WC (498 +/- 35 g) than in the M (247 +/- 17 g) or WA (133 +/- 10 g). The nuclear volumes per boar of Sertoli cells, type A spermatogonia, leptotene, zygotene, pachytene, secondary spermatocytes, spermatids with spherical nuclei, and spermatids with elongated nuclei were higher (P < 0.05) in the WC than in the M or WA. The nuclear volumes per boar of blood vessels and Leydig cells were exceptionally higher (P < 0.05) in the M than in the WC or WA. The average germ cell nuclear diameters were similar (P > 0.05) for the M and WC but least (P < 0.05) in the WA breed. Also, the nuclear diameters of Leydig cells and Sertoli cells were higher (P < 0.05) in the M than in the WC or WA. The population sizes of all the intratubular components were positively correlated (P < 0.05) with testicular size (weight). Volume density of seminiferous tubules was similar in the WA and WC, but was lowest in the M, who had the highest density of Leydig cells. However, due to the larger testes, all germ cell types and Sertoli cells were higher in the WC than in the WA or M. The M and WA had similar low numbers of type A spermatogonia, but there was less term cell degeneration in M than in Wa, such that M spermatids were intermediate in number between WA and WC.

Number and function of Sertoli cells, number and yield of spermatogonia, and daily sperm production in three breeds of boar

The objective of this study was to determine the number of Sertoli cells per boar, daily sperm production, and germ cell yield per type A spermatogonium in mature Whitecross, Meishan, and West African boars. The paired parenchymal mass was greatest in the Whitecross boars and greater in Meishan than in West African boars. Daily sperm production per boar (x 10(9)) differed significantly (P < 0.05) among breeds (Whitecross: 12.5 +/- 1.5; Meishan: 6.0 +/- 0.5; West African: 2.9 +/- 0.3). Daily sperm production per boar was positively (P < 0.01) correlated with parenchymal mass (r = 0.97), number of A spermatogonia per testis (r = 0.88), and Sertoli cells per testis (r = 0.87). Daily sperm production per gram of testis was similar among breeds. Number of Sertoli cells and number of type A spermatogonia per boar were greater for the Whitecross but similar in the Meishan and West African boars. The number of Stage VII germ cells per Sertoli cell was greater (P < 0.05) in the Meishan (39.08 +/- 5.07), but similar in the Whitecross (19.91 +/- 1.62) and West African boars (15.81 +/- 2.43). The number of type A spermatogonia per testis was highly and positively (P < 0.01) correlated with number of Sertoli cells per testis (r = 0.95), and parenchymal mass (r = 0.88). There was a trend for the spermatid yield per type A spermatogonium to be greater in the Meishan boars, and this ratio was positively correlated with spermatid:Sertoli cell ratio (r = 0.62) but not with daily sperm production per boar or Sertoli cells per testis. No significant germ cell degeneration occurred during the long meiotic prophase, but the loss of progeny during postprophase of meiosis averaged 32.62% across all breeds. Germ cell degeneration was similar (P > 0.05) across breeds during spermiogenesis, and on average amounted to 8.6%. The increased number of type A spermatogonia and of Sertoli cells associated with larger testes for the Whitecross over West African or Meishan boars is sufficient to explain the higher sperm production in the Whitecross. However, the lower index of degeneration and more efficient Sertoli cell function in Meishan boars results in the daily sperm production being intermediate between that of the Whitecross and West African boars.

Effect of hypophysectomy, sex of host, and/or number of transplanted testes on Sertoli cell number and testicular size of syngeneic testicular grafts in Fischer rats

One or more neonatal testicular grafts were transplanted for 60-65 days into young adult inbred Fischer rats to determine the effect of hypophysectomy, sex of host, and/or the number of transplanted testes on testicular size and Sertoli cell number. All host rats had been castrated or ovariectomized and some were hypophysectomized as well. At the end of the treatment, testes were fixed and embedded in Epon before histologic sections (0.5 micrometer or 20 micrometers) were evaluated by stereology. Testicular grafts placed in castrated adult male rats with intact pituitaries weighed more (p < 0.01) and had more (p < 0.01) Sertoli cells than those placed in hypophysectomized hosts. Testicular grafts that were recovered from hypophysectomized rats 34 days posttransplantation and placed in pituitary-intact males for 30 day had larger (p < 0.05) parenchymal weights and more Sertoli cells than did testes re-transplanted into hypophysectomized rats. However, this delayed period of Sertoli cell proliferation id not extend to 65 days of hypophysectomy. When two or four testes were transplanted into castrated males or ovariectomized female hosts for 65 days, there was no difference in the graft weights or Sertoli cell numbers between sexes. Four transplanted testes per rat produced more (p < 0.01) total testicular parenchyma and a greater (p < 0.01) number of Sertoli cells per testis than did two tests regardless of sex of the host. This model has shown that the period of Sertoli cell proliferation can be delayed by hypophysectomy, that Sertoli cell number can be influenced by endogenous hormones, and that a major component in regulation of testicular size is at the level of the testis in this model. Hence, this model should facilitate study of experimental endocrine manipulation control and potential experimental intervention to increase Sertoli cell number and testicular size.

Partial wave in human seminiferous tubules appears to be a random occurrence

Serial cross sections were evaluated to determine the architectural arrangement of stages among men with varied spermatogenic efficiencies. Using autopsy specimens, glutaraldehyde-perfused testes from men with low or high daily sperm production per g parenchyma were compared. Lobes of testicular parenchyma were teased from connective tissue septa, further fixed in osmium, and embedded such that the straight portions of tubules could be sectioned perpendicularly. Unstained 22 microns serial sections were sectioned optically with Nomarski optics. Paired photomicrographs of each tubular cross section were taken under a 40 x objective, and stages of the spermatogenic cycle were mapped by two observers using Clermont's criteria (Clermont, 1963). For comparison, numbers (1-6) were assigned randomly to the stages, the stages were plotted in two dimensions (length and circumference of tubule) as if the tubule were cut down its length and laid flat, and geometric centers were plotted for each stage. Geometric centers consecutive and/or non-consecutive stages appeared to form an angle down the length of the tubule. When considering helical patterns along the tubule, men with neither low nor high spermatogenic efficiency had a complete wave composed of all six consecutive stages. The helical pattern of geometric centers indicated only 2-4 consecutive stages when the actual values of stages were used or when random numbers were substituted for actual numerical value of stages. The number of consecutive stages in tubules from these men was not different from consecutiveness found when stages were assigned random numbers. Given that no complete wave was found, regardless of spermatogenic efficiency, and that the degree of consecutiveness of stages down a helical pattern in human seminiferous tubules could be generated from random numbers, the arrangement of stages in human seminiferous tubules may simply be a random occurrence.

Isolated pancreas rejection in combined kidney pancreas tranplantation

The clinical success of pancreas transplantation is limited by the difficulty in diagnosing rejection. In simultaneous pancreas kidney (SPK) transplantation, the diagnosis of pancreatic rejection is particularly difficult in the absence of clinical evidence of kidney rejection. Moreover, patients receiving only pancreas grafts will not have a concomitantly grafted kidney to serve as a "sentinel" for rejection. Percutaneous pancreas graft biopsy has been reported in a few small series but has not been adopted for broad clinical use. We describe the evaluation of 69 consecutive episodes of suspected isolated pancreas allograft rejection by percutaneous pancreas allograft biopsy. These rejection episodes occurred in 41 patients with bladder-drained pancreas transplants (25 SPK, 14 pancrease after kidney transplants [PAK], amd two pancreas transplant alone [PTA]). The indications for percutaneous pancreas biopsy were a twofold or greater increase in serum amylase or lipase, or a sustained 40% to 50% drop in urine amylase in the setting of no evidence of renal allograft dysfunction in SPK transplants. Biopsies were performed with color-flow Doppler ultrasound localization using an 18-gauge automated biopsy needle. Pancreatic tissue adequate for histologic evaluation was obtained in 61 of 69 cases (88%). There were two cases of intraabdominal bleeding, one of which required surgical intervention; the other resolved spontaneously. Histologic assessment of the biopsies demonstrated varying degrees of acute cellular rejection in 48 of 61 specimens (79%). Twelve specimens (20%) were free of histologic evidence of rejection, and one specimen (2%) showed acute pancreatitis. At the time of suspected rejection mean serum amylase and lipase values were increased 3.6 and 8.3-fold, respectively, and urine amylase was decreased by a mean of 45%. We conclude that the commonly used markers for pancreas allograft rejection are only about 80% specific for acute rejection. Percutaneous pancreas allograft biopsy is safe and allows the avoidance of unnecessary antirejection therapy with its attendant side effects and cost.

Body fat distribution and non-insulin-dependent diabetes: comparison of a fiber-rich, high-carbohydrate, low-fat (23%) diet and a 35% fat diet high in monounsaturated fat

The effects of a fiber-rich, high-carbohydrate, low-fat (HCLF) diet and a modified-fat (MF) diet high in monounsaturated fat on body fat distribution were examined by dual-energy X-ray absorptiometry (DXA) in 16 subjects with non-insulin-dependent diabetes (NIDDM) during a randomized crossover study. Subjects lost similar amounts of body fat consuming the HCLF and MF diets (-0.83 +/- 0.37 and -0.87 +/- 0.40 kg, respectively) despite a marked difference in total fat consumption. With the MF diet, the ratio of upper- to lower-body fat (UF:LF) remained unchanged because fat was lost proportionately from the upper and lower body. In contrast, with the HCLF diet, a disproportionate loss of lower-body fat caused the UF:LF to increase. The effects of diet on regional body fat loss were significant (P < 0.05, two-factor repeated-measures ANOVA).

Tandem high-dose chemotherapy supported by hematopoietic progenitor cells yields prolonged survival in stage IV breast cancer

The aim of this phase II study was to determine the feasibility of using two (tandem) courses of high-dose alkylating agents with bone marrow or peripheral blood progenitor cell support in women with stage IV breast cancer. Women with stage IV breast cancer who had achieved a CR or PR during conventional chemotherapy were enrolled in a phase II trial of high-dose cyclophosphamide 7500 mg/m2 and thiotepa 675 mg/m2 (C+T) followed within 180 days by high-dose melphalan (M) 140 mg/m2. Bone marrow and/or GM-CSF mobilized peripheral blood hematopoietic progenitor cells were used to support high-dose C+T and high-dose M. Twenty-seven women were enrolled in this trial. The median age was 45 years (range 32-56). The median PS was 0 and all patients had achieved either a CR (4/27, 15%) or PR (23/27, 85%) to conventional chemotherapy. All 27 women underwent high dose C+T. The predominant toxicities were mucositis (81%), and diarrhea (81%); two patients (7%) died from infectious complications. Following C+T, the median time to hematologic recovery for neutrophils (ANC > 500 cells/mu 1) was 12 days and for platelets (>20 000 cell/mu 1), 23 days. Following C+T, 18 of 22 patients received high dose M; the predominant toxicities were nausea, vomiting (70%), and mucositis (91%). The median time to hematologic recovery for the ANC was 13 days and for platelets, 18 days. The overall response after high dose C+T and high dose M was 67% (CR, 15/27 patients (56%) and PR* (complete resolution of all measurable disease but persistent lytic disease or positive bone scan) 3/27 patients (11%). With median follow-up of 24 months, the actuarial freedom from relapse or treatment failure is 56% at 24 months. At 30 months 56% of patients are alive. For patients who achieve a CR or PR* the actuarial freedom from relapse or treatment failure at 24 months is 88%. In women with stage IV breast cancer who attain a CR or PR to conventional chemotherapy, tandem high-dose chemotherapy with ABMT can lead to prolonged relapse-free survival.

MAG3 renal transplant tomography SPECT with a non-SPECT agent

The authors encountered a renal transplant patient in whom tubular stasis permitted sufficient time to perform SPECT using Tc-99m MAG3. SPECT revealed a defect that was not apparent on the planar study. Renal biopsy showed acute vascular rejection. On a subsequent Tc-99m MAG3 SPECT study the defect had resolved.

In vivo MRI visualization of acute myocardial ischemia and reperfusion in ferrets by the persistent action of the contrast agent Gd (BME-DTTA)

BACKGROUND

Contrast agent-enhanced magnetic resonance imaging (MRI) has the potential to visualize myocardial ischemia. To date, however, no agent has been found that has a sustained effect that allows MRI detection for the entire duration of ischemia and reperfusion and thus is useful in conjunction with stress test MRI. In this article, we introduce the gadolinium complex of N3,N6-bis(2'-myrisotyloxyethyl)-1,8-dioxo-triethylene- tetraamine-N,N,N1,N1-tetraacetic acid [Gd(BME-DTTA)], an agent potentially useful for such a purpose.

METHODS AND RESULTS

Four protocols were carried out. ECG-triggered, partially T1-weighted, spin-echo MRI was used in protocols A through C. In protocol A, in nonischemic ferrets, 50 mumol/kg Gd(BME-DTTA) induced a 70 +/- 5% intensity enhancement lasting 3 hours. In protocol B, the left anterior descending coronary artery was occluded, and a 99mTc-sestamibi-induced autoradiographic contrast verified (r = .87, P < .01) a Gd(BME-DTTA)-induced (n = 5) or Gd(DTPA)-induced (n = 4) MRI contrast. In the Gd(BME-DTTA) group a sustained contrast and in the Gd(DTPA) group a short-lived contrast were observed. In protocol C (n = 11), during ischemia, a 31 +/- 3.3% (P < .02) contrast was evident between the ischemic and nonischemic myocardial regions. Upon reperfusion, a contrast of 19 +/- 3% (P < .05) and 13 +/- 4.5% (P < .05) persisted for 5 and 15 minutes, respectively. Beyond 15 minutes, the contrast continued to diminish gradually. Nonradioactive microspheres verified (r = .87, P < .05) ischemia and reperfusion in this model. In protocol D (n = 4), blood delta R1 data showed that the blood pool retained Gd(BME-DTTA) for the entire time frame of the experiment at high enough concentration to provide an appropriate wash-in effect during the initial contrast enhancement and during reperfusion.

CONCLUSIONS

This study demonstrates that Gd(BME-DTTA) induces a sustained MRI contrast between regions of normal versus ischemic myocardium, showing the potential of this agent for the diagnosis of ischemic heart disease in conjunction with stress tests.

Efficiency of spermatogenesis

Spermatogenesis is a process of division and differentiation by which spermatozoa are produced in seminiferous tubules. A measure of efficiency of spermatogenesis is the estimated number of spermatozoa produced per day per gram of testicular parenchyma. This measure is not influenced by species differences in testicular size; however, it is influenced by species differences in the numerical density of germ cells and in the life spans of these cells. Seminiferous tubules are composed of somatic cells (myoid cells and Sertoli cells), and germ cells (spermatogonia, spermatocytes, and spermatids). Activity of these three germ cells divide spermatogenesis into spermatocytogenesis, meiosis, and spermiogenesis, respectively. Spermatocytegenesis involves mitotic cell division to increase the yield of spermatogenesis and to produce stem cells and primary spermatocytes. Meiosis involves duplication and exchange of genetic material and two cell divisions that reduce the chromosome number and yield four spermatids. Spermiogenesis is the differentiation of spherical spermatids into mature spermatids which are released at the luminal free surface as spermatozoa. The spermatogenic cycle is superimposed on the three major divisions of spermatogenesis. Spermatogenesis and germ cell degeneration can be quantified from numbers of germ cells in various steps of development throughout spermatogenesis, and quantitative measures are related to number of spermatozoa in the ejaculate. Germ cell degeneration occurs throughout spermatogenesis; however, the greatest impact occurs during spermatocytogenesis and meiosis. Efficiency of spermatogenesis is related to the amount of germ cell degeneration, pubertal development, season of the year, and aging of humans and animals. Number of Sertoli cells and amount of smooth endoplasmic reticulum of Leydig cells (but not Leydig cell number) are related to efficiency of spermatogenesis. In humans, efficiency of spermatogenesis is reflected in number of spermatogenic stages per cross-section and number of missing generations within each stage; however, the arrangement of stages along the tubular length does not reflect differences in the efficiency of spermatogenesis. In short, spermatogenesis involves both mitotic and meiotic cell divisions and an unsurpassed example of cell differentiation in the production of the spermatozoon, and daily sperm production per g parenchyma is a measure of its efficiency.

Severe retinopathy of prematurity in infants with birth weights less than 1250 grams: incidence and outcome of treatment with pharmacologic serum levels of vitamin E in addition to cryotherapy from 1985 to 1991

OBJECTIVE

To determine the effect of vitamin E prophylaxis and treatment on the sequelae of severe (threshold) retinopathy of prematurity (ROP) in infants treated with cryotherapy at Pennsylvania Hospital from 1985 to 1991.

STUDY DESIGN

Beginning on day 0, all infants with birth weights < or = 1250 gm received supplements of vitamin E using standard preparations. Serum E levels of 23 to 58 mumol/L (1 to 2.5 mg/dl) were targeted for infants with immature retinal vasculature or ROP of stage 2 or less in severity, and levels of 58 to 81 mumol/L (2.5 to 3.5 mg/dl) for infants with prethreshold ROP. At diagnosis of threshold ROP, treatment with a parenteral investigational new drug preparation of alpha-tocopherol was begun to raise serum levels to the pharmacologic range (93 to 116 mumol/L or 4 to 5 mg/dl). Within 3 days of diagnosis, and at the discretion of the retinal specialist, one or both eyes were treated with cryotherapy. Visual outcome at 4 years was compared with the 42-month outcome reported for eyes in the infants randomly assigned to treatment in the 1986-1987 Multicenter Trial of Cryotherapy for ROP (CRYO-ROP).

RESULTS

Threshold ROP developed in 22 of 450 surviving infants (age 3 months). All were treated with pharmacologic serum levels of vitamin E; 17 infants were also treated with cryotherapy (10 in one eye and 7 in both eyes). These 17 infants, in comparison with infants in the CRYO-ROP trial (n = 187), were at least at equal risk for poor visual outcome on the basis of birth weight, gestational age, the percentage of zone 1 ROP, and mean interval from appearance of ROP to diagnosis of prethreshold ROP, which was shorter at Pennsylvania Hospital (4.1 days for the Pennsylvania Hospital group, 10.3 days for the CRYO-ROP group). However, on the basis of the mean number of days from diagnosis of prethreshold to threshold ROP (12.5 days for Pennsylvania Hospital, 10.5 days for CRYO-ROP) and the extent of extraretinal neovascularization at threshold (mean 7.9 sectors for Pennsylvania Hospital, 9.7 for CRYO-ROP), progression of retinopathy beyond the prethreshold stage had slowed and visual outcome in the eyes of infants at Pennsylvania Hospital treated with both cryotherapy and vitamin E (worse eye used for those treated with bilateral cryotherapy) was better than that reported for the treated eye of infants in the CRYO-ROP group (percentage of favorable visual acuity, 76% vs 48%, p = 0.04; percentage of normal structure posterior retinal pole, 71% vs 38%, p < or = 0.02).

CONCLUSIONS

In this small case series, the combination of cryotherapy with anti-oxidant prophylaxis and treatment appeared to decrease the severity and sequelae of threshold ROP. This hypothesis deserves testing in a large, randomized clinical trial.

Structural analysis of human and murine flt3 ligand genomic loci

Both the murine and human genomic loci that encode flt3 ligand have been cloned. flt3 ligand is a hematopoietic growth factor that stimulates the proliferation of stem and progenitor cells. The portions of the murine and human flt3 ligand genomic loci encompassing the coding region of the protein are approximately 4.0 kb and 5.9 kb, respectively. The human genomic locus is larger as a result of the presence of repeated sequences within introns I, II, IV, V and VI. The transmembrane isoform of the murine and human flt3 ligand proteins are each encoded within seven exons (1-5 + 7 and 8). Analyses of flt3 ligand cDNA clones show that alternative splicing of a putative sixth exon results in the generation of a soluble form of the flt3 ligand protein. The sizes of each of the exons are well conserved between species. Murine and human flt3 genomic loci have a similar exon: intron structure compared to the genomic loci encoding Steel factor and colony stimulating factor 1. These proteins, which appear to be ancestrally related, are hematopoietic growth factors that stimulate cells via specific and structurally related tyrosine kinase receptors on the cell surface.

Pain responses of hospitalized neonates to venipuncture

Neonates' response to pain after venipuncture was studied by observing, recording, and measuring physiological and behavioral responses. The measurement used was the National Individualized Developmental Care Assessment Program (NIDCAP). Data were recorded from a convenience sample of 30 neonates required to have a venipuncture as part of their routine treatment for 20 minutes before and 20 minutes following the procedure by a person certified as reliable in administering the NIDCAP. Both behavioral and physiologic changes were observed. Most of the infants (93 percent) moved abruptly into a hyperalert or crying state in response to venipuncture, skipping several states without transition and showing disorganized behavior. The heart rate, oxygen saturation, and skin color showed significant changes when data recorded just prior to venipuncture were compared to data recorded immediately following the procedure. Nursing implications, including the unit environmental elements, are discussed.

Administrative databases' complication coding in anterior spinal fusion procedures. What does it mean?

STUDY DESIGN

A review of a cohort of 310 consecutive patients who underwent anterior spinal fusion was performed to evaluate the accuracy of hospital ICD-9-CM complication coding.

OBJECTIVES

To better understand the clinical significance of conclusions suggested by studies that rely on electronic administrative databases for their data source.

SUMMARY OF BACKGROUND DATA

Despite their availability, there have been no studies to date that have evaluated the accuracy of ICD-9-CM administrative databases as they relate to the actual clinical experience in spinal procedures.

METHODS

A physician and a research technician independently reviewed the primary medical records for the occurrence of complications. This data was compared with the hospital-acquired ICD-9-CM coded complications.

RESULTS

The physician reviewer identified 152 complications in 119 patients, with 32 different types of complications. The research abstracter identified 175 complications in 130 patients, with 34 different types of complications identified. Hospital ICD-9-CM coding identified 105 complications in 80 patients, including only 11 different ICD-9-CM codes. Overall, 27% of ICD-9-CM complication codes were listed as "unspecified or unclassified complications, reactions, or misadventures," and contained no meaningful clinical information. Cardiac and pulmonary complications were over-estimated and wound infections and genitourinary and gastrointestinal complications were underestimated by ICD-9-CM coding.

CONCLUSIONS

Studies of complications of spinal procedures using data derived from hospital ICD-9-CM complication codes may be intrinsically flawed because the data available to researchers from these electronic databases may be inaccurate.

Progress in a Moscow children's burn unit: a joint Russian-American collaboration

A joint Russian-American paediatric burn programme involving Childrens Hospital No. 9 in Moscow and Project HOPE in Millwood, Virginia emerged from the efforts of burn professionals from both countries in caring for a group of children seriously burned as a result of the train-pipeline catastrophe that occurred in June 1989 in the Ural Mountains. This paper describes the burn unit and its activities during the years 1985-93 and includes: (1) a general description of the physical and administrative structure of the unit; (2) the demography of burn admissions; (3) clinical activities; (4) a comparison of the clinical results of the years before the institution of the combined programme (1985-89) with those achieved during the first 4 years of the combined collaboration (1990-93). Among the important changes that have occurred since the onset of the combined programme are: (1) overall reduction in the crude burn mortality rate; (2) decrease in burn deaths in all burn size groups; (3) dramatic reduction in the length of stay of children with the deepest burns; (4) marked improvement in the take of skin grafts applied to burn wounds and an almost total elimination of complete skin graft failures.

Patterns of failure following total body irradiation and bone marrow transplantation with or without a radiotherapy boost for advanced neuroblastoma

PURPOSE

To evaluate the patterns of failure and outcome of patients undergoing high-dose chemotherapy, total body irradiation (TBI), and bone marrow transplantation (BMT) for advanced/relapsed pediatric neuroblastoma, with emphasis on the impact of a radiotherapy boost to primary and metastatic sites.

METHODS AND MATERIALS

Between May 1986 and June 1993, 26 patients with advanced neuroblastoma underwent high-dose chemotherapy and TBI followed by BMT at our institution. The majority of patients were over the age of 2 years (73%) and were Stage IV at diagnosis (81%). Multiple metastatic sites were involved including bone (17), bone marrow (15), distant nodes (11), liver (5), lung (4) and brain (1). Twenty patients (77%) received cyclophosphamide (50 mg/kg x 4 days) and TBI as consolidation therapy. TBI was delivered to a total dose of 12 Gy given in 2 Gy twice daily (b.i.d.) fractions over the 3 days preceding bone marrow infusion. A local radiotherapy boost of 8-24 Gy was given to 13 out of 26 patients (50%) to the primary and/or metastatic sites immediately prior to or following induction chemotherapy according to physician judgement. Sites not amenable to a radiotherapy boost included the bone marrow, diffuse/bilateral lung involvement, and multiple bone metastases (> four sites).

RESULTS

The actuarial overall survival of the 26 patients was 40.4% at 3 and 5 years, with a progression-free survival at 5 years of 38.5%. Six patients died of transplant-related toxicity (23%). The use of cyclophosphamide as high-dose consolidation chemotherapy was significantly better than other multidrug regimens used in terms of overall survival (p < 0.0001) and progression-free survival (p = 0.0004). The presence of liver involvement prior to BMT was a significant adverse prognostic factor by multivariate analysis. Of the 20 patients surviving the transplant, 10 (50%) underwent a local radiotherapy boost. The patterns of failure were as follows: 3 out of 10 "boost" patients failed overall, none in previous (old) sites of disease only, 1 in new sites only, and 2 in old and new sites; 6 out of 10 "no boost" patients failed overall, 4 in old sites only, none in new sites only, and 2 in old and new sites. There was a trend toward improved 5-year progression-free survival in patients surviving the transplant that received a boost (68% vs. 33%, p = 0.24). A failure analysis was also performed for each of the 59 initially involved sites, of which the majority (64%) were amenable to a radiotherapy boost. Overall, there is a trend toward less failure in sites amenable to a radiotherapy boost that were irradiated (1 out of 10) vs. those not irradiated (6 out of 28). Failure in the liver occurred in three out of four of the patients with liver involvement that did not receive boost radiotherapy, whereas all seven patients with distant nodal involvement were controlled without a boost. Long-term sequelae include learning difficulties (2), cataract formation (1), and hearing loss (2). Sequelae attributable to a radiotherapy boost occurred in only one patient who received whole brain radiotherapy and developed a cataract and learning difficulties.

CONCLUSION

We have found an actuarial 5-year survival rate of 40.4% for patients with advanced neuroblastoma treated with BMT, which compares favorably with results of other published series. Disease recurrence following BMT was most common in previous sites of disease. The majority (64%) of these sites were amenable to a radiotherapy boost. An analysis of failure suggests that a low-dose radiotherapy boost improves control of these sites.

The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. A review of 1223 procedures

STUDY DESIGN

A retrospective review of 1223 thoracic and lumbar anterior spinal fusions was performed from 1969 through 1992.

OBJECTIVES

To document the incidence and specific types of perspective complications related to anterior spinal fusions.

SUMMARY OF BACKGROUND DATA

Despite the increased use of anterior spinal surgery, there has been little documentation of the specific types and frequencies of the complications associated with its use.

METHODS

All Minnesota Spine Center patients age 18 years or older who had anterior spinal fusions between the levels of T1 and S1 from August 1969 to June 1992 were reviewed for the occurrence of perioperative complications. Surgical approach and technique and associated comorbidity was recorded.

RESULTS

The risk of a complication was increased for patients over age 60 years, for women, and for patients with multiple preexisting health problems. Serious complications, such as death (0.3%), paraplegia (0.2%), and deep wound infection (0.6%) were rare. The complication rate for complications that were directly attributed to the anterior spinal surgery was 11.5%.

CONCLUSIONS

Anterior spinal fusion surgery is a safe procedure and can be used with confidence when the nature of a patient's spinal disorder dictates its use. Complications are often approach specific.