PTEN methylation is associated with advanced stage and microsatellite instability in endometrial carcinoma

Loss of heterozygosity and mutations in the PTEN (MMAC1) tumor suppressor gene are frequent in endometrial carcinoma. Promoter hypermethylation has recently been identified as an alternative mechanism of tumor suppressor gene inactivation in cancer, but its importance in the PTEN gene in endometrial carcinoma is unknown. The purpose of our study was to assess the frequency of promoter methylation of the PTEN gene and to determine its correlation with clinicopathologic variables in a prospective and population-based series of endometrial carcinomas with complete follow-up. Presence of PTEN promoter methylation was seen in 26 of 138 patients (19%). Methylation was significantly associated with metastatic disease (p = 0.01) and a microsatellite unstable phenotype (p = 0.006). In conclusion, we find that PTEN promoter methylation is relatively frequent in endometrial carcinoma. Its association with metastatic disease and microsatellite instability implicates its importance in the development of this tumor type.

PTEN methylation is associated with advanced stage and microsatellite instability in endometrial carcinoma

Loss of heterozygosity and mutations in the PTEN (MMAC1) tumor suppressor gene are frequent in endometrial carcinoma. Promoter hypermethylation has recently been identified as an alternative mechanism of tumor suppressor gene inactivation in cancer, but its importance in the PTEN gene in endometrial carcinoma is unknown. The purpose of our study was to assess the frequency of promoter methylation of the PTEN gene and to determine its correlation with clinicopathologic variables in a prospective and population-based series of endometrial carcinomas with complete follow-up. Presence of PTEN promoter methylation was seen in 26 of 138 patients (19%). Methylation was significantly associated with metastatic disease (p = 0.01) and a microsatellite unstable phenotype (p = 0.006). In conclusion, we find that PTEN promoter methylation is relatively frequent in endometrial carcinoma. Its association with metastatic disease and microsatellite instability implicates its importance in the development of this tumor type.

The Immunization Monitoring Program Active (IMPACT) prospective five year study of Canadian children hospitalized for chickenpox or an associated complication

BACKGROUND

Varicella vaccine was approved for use in Canada in 1998. A major goal of universal varicella vaccine programs is to reduce severe infection and associated complications. Baseline data are essential against which to judge the effectiveness of routine childhood immunization.

OBJECTIVE

To describe morbidity and mortality among children hospitalized for chickenpox. Methods. From January 1, 1991, to March 31, 1996, chickenpox admissions to 11 pediatric referral centers were actively identified. Patient and illness characteristics were compared for 3 subgroups defined by prior health: healthy; unhealthy but immunocompetent; immunocompromised.

RESULTS

Of 861 cases 488 (56.7%) were healthy, 75(8.7%) were unhealthy and 298 (34.6%) were immunocompromised. The immunocompromised children differed from healthy/unhealthy cases in mean age (6.4 vs. 4.0/4.6 years, respectively, P < 0.0001); median interval from rash onset to admission (2 vs. 5/5 days, P < 0.0001); complication rate (20% vs. 90%/79%; P = 0.001); and rate of acyclovir therapy (98% vs. 24%/39%; P = 0.001). Unhealthy vs. healthy cases had a higher frequency (P < 0.01) of intensive care (13.3% vs. 4.7%), ventilation (9.3% vs. 2.0%) and death (4% vs. 0.2%).

CONCLUSION

These data provide a baseline for morbidity/mortality resulting from chickenpox before varicella vaccine use in Canada.

American Academy of Pediatrics. Technical report: transmissible spongiform encephalopathies: A review for pediatricians. Committee on Infectious Diseases

Transmissible spongiform encephalopathies (TSEs) are a family of rare, slowly progressive, and universally fatal neurodegenerative syndromes affecting animals and humans. Until recently, TSEs were of little interest to pediatricians. However, since the outbreak in adolescents and the association of TSEs with new-variant Creutzfeldt-Jakob disease (nvCJD), interest among pediatricians and the general public has increased. Even before bovine spongiform encephalopathy and nvCJD were linked, the recognition that iatrogenic Creutzfeldt-Jakob disease (CJD) had been acquired from administration of cadaveric human growth and gonadotropic hormones and from corneal and dura mater transplants prompted medical vigilance. Furthermore, recent concern about the potential for transmission of CJD by blood and blood products has raised awareness among public health and regulatory agencies, pediatricians, and the public, although no epidemiologic data support this concern. Because of worldwide concern (although no cases have been reported in North America), this review focuses on the potential impact of TSEs, particularly CJD and nvCJD, on the pediatric population.

Methylation of hMLH1 in a population-based series of endometrial carcinomas

Microsatellite instability (MSI) is a characteristic feature of hereditary nonpolyposis colorectal cancer and is also observed in sporadic colorectal and endometrial cancers. Alterations in the mismatch repair genes hMLH1 and hMSH2 are important for the development of MSI. It has recently been demonstrated that hypermethylation of the hMLH1 promoter region is associated with MSI and appears to be a common mechanism for gene inactivation. For endometrial carcinoma, however, previous studies have been relatively small and have not been population based. We therefore wanted to assess the frequency and prognostic significance of hypermethylation of the hMLH1 and hMSH2 genes in conjunction with hMLH1 protein expression in a prospective and population-based series of endometrial carcinoma patients with known MSI status and complete follow-up. A total of 138 patients were studied, and methylation of hMLH1 was found in 23% of tumors with conclusive results, whereas methylation of hMSH2 was seen in only 1% of tumors. Methylation of hMLH1 was significantly correlated with MSI (P < 0.001). Loss of nuclear staining of hMLH1 protein was seen in 14% of the cases and was significantly correlated with hMLH1 methylation and MSI (P < 0.001). Normal expression of hMLH1 was seen in all of the unmethylated tumors (100%). Of the 14 MSI-positive tumors that were also methylated, all but 1 (93%) showed a loss of nuclear expression of hMLH1. None of the tumors with loss of hMLH1 expression or hMLH1 methylation were aneuploid (P for both < or = 0.05), and loss of hMLH1 expression and hMLH1 methylation was significantly correlated with lack of p53 overexpression (P for both < or = 0.05). Nuclear hMLH1 staining and hMLH1 methylation did not significantly influence survival. In conclusion, hMLH1 methylation was common and was significantly correlated with loss of hMLH1 protein expression, MSI, diploid tumors, and lack of p53 overexpression. In contrast, hMSH2 methylation was infrequent in this prospective and population-based series of endometrial carcinomas.

Monitoring signals for vaccine safety: the assessment of individual adverse event reports by an expert advisory committee. Advisory Committee on Causality Assessment

Monitoring vaccine safety is a complex and shared responsibility. It can be carried out in many ways, one of which is the reporting of individual cases of adverse reactions thought to be due to vaccination. The task is difficult because ascribing causality to an individual case report is fraught with challenges. A standardized evaluation instrument--known as the causality assessment form--was therefore developed for use by an expert advisory committee to facilitate the process. By following the several sections in this form, the members of the committee are taken through a series of points to establish causality. These points include the basic criteria for causation such as biological plausibility, the time elapsed between the vaccine administration and the onset of the adverse event, and whether other factors (drugs, chemicals or underlying disease) could account for the adverse symptoms. The form concludes with a consensus assessment of causality, a commentary about the assessment, and advice for further study or follow-up. This method of assessing the more serious cases of adverse reaction reported to vaccination has proven useful in evaluating ongoing safety of vaccines in Canada. Through analyses such as this, new signals can be identified and investigated further.

Alopecia areata: identification and current treatment approaches

Alopecia areata is a disease which occurs in 1.7% of the population (Safavi et al., 1995), often with devastating effects to patients and their families. In the past, this condition has been misunderstood and treated inadequately. New treatment modalities and support systems are offering hope to patients with alopecia areata.

A comparison of national cancer registry and direct follow-up in the ascertainment of ovarian cancer

The National Health Service Central Register (NHSCR) and direct follow-up were used to document ovarian and fallopian tube cancers in 22000 women from 1986 to 1993. Direct follow-up identified 47/49 cases (96%) and the NHSCR 38/49 (78%). NHSCR ascertainment was incomplete and direct follow-up provided additional information. These findings have implications for interpretation of national cancer statistics and for use of the NHSCR in research trials.

Cost of chickenpox in Canada: part I. Cost of uncomplicated cases

OBJECTIVE

The purpose of this study was to assess the direct medical costs and productivity losses associated with uncomplicated chickenpox (no hospitalization) in Canada.

METHODS

A total of 179 otherwise healthy 1- to 9-year-old children with active chickenpox were recruited from schools, day care centers, and physician offices in 5 provinces. Direct medical (physician contacts, medication, and diagnostic tests) and nonmedical (personal expenses including child care) resources expended during the illness were determined by caregiver interview. Productivity losses attributable to the disease were determined by assessing caregiver time lost from work and daily activities. Unit costs for all resources were obtained from sources in 2 provinces, and per-patient treatment costs were determined from the patient, Ministry of Health, and societal perspectives.

RESULTS

From a societal perspective, the per-case cost for children from 1 to 4 years of age and from 5 to 9 years of age was $370.2 and $236.5, respectively. Direct medical costs accounted for 10% of the total costs in both groups. The largest cost driver in patient care was caregiver productivity losses, which amounted to $316.5 in the younger age group and to $182.7 in the older age group. Based on an estimated yearly incidence of 344 656 cases of uncomplicated chickenpox in Canada, the total annual societal burden of the disease can be estimated at $109.2 million, with a cost to the Ministry of Health of $11.2 million.

CONCLUSION

Chickenpox is one of the last common childhood diseases prevalent in Canada, and the uncomplicated disease, despite its rather benign course, imparts a large annual economic burden.

Epidemiological features of pertussis in hospitalized patients in Canada, 1991-1997: report of the Immunization Monitoring Program--Active (IMPACT)

To assess the morbidity associated with the continued high levels of pertussis, we studied all children <2 years of age who were admitted to the 11 Immunization Monitoring Program--Active (IMPACT) centers, which constitute 85% of Canada's tertiary care pediatric beds. In the 7 years preceding implementation of acellular pertussis vaccine, a total of 1,082 pertussis cases were reported, of which 49.1% were culture-confirmed. The median age of the patients was 12.4 weeks; 78.9% of cases were in children <6 months of age. Complications of pertussis were common: pneumonia was reported in 9.4% of cases, new seizures in 2.3%, and encephalopathy in 0.5%. There were 10 deaths (0.9%), all in children < or =6 months of age. Duration of hospitalization was longer (9.3 days vs. 4.9 days; P = .001) and intensive care was required more frequently (19.2% vs. 4.9%; P = .001) in infants under <6 months of age than in those > or =6 months. Pertussis continues to cause significant morbidity and occasional mortality in Canada, particularly in young infants.

Risk factors for resistance to "first-line" antimicrobials among urinary tract isolates of Escherichia coli in children

BACKGROUND

There are increasing concerns regarding antimicrobial resistance in Canada. Data are limited on the prevalence, patterns of resistance and risk factors associated with resistant organisms, including coliforms, in children. This study was done to address these issues as they relate to urinary tract isolates of Escherichia coli in a tertiary care pediatric centre in Ottawa.

METHODS

A surveillance study was conducted from December 1992 to December 1994. Susceptibility testing of urinary tract isolates of E. coli was performed using a panel of antimicrobial agents. A case-control study was also conducted for subjects with isolates resistant to trimethoprim-sulfamethoxazole (T-S), this drug being used a representative "first-line" agent.

RESULTS

A total of 1636 consecutive isolates were obtained from 967 subjects. Of the 1636 isolates, 736 (45.0%) were resistant to ampicillin, 514 (31.4%) were resistant to T-S, 363 (22.2%) were resistant to both ampicillin and T-S, and 27 (1.7%) were resistant to both ampicillin and gentamicin. In the case-control study 274 children with isolates resistant to T-S were matched with 274 children who had T-S-sensitive isolates obtained during the study period or the preceding or subsequent 6 months. Multivariate analyses indicated that subjects who had received antimicrobials for more than 4 weeks in the previous 6 months were about 23 times more likely to have isolates resistant to T-S than were subjects without this risk factor (odds ratio [OR] 23.4, 95% confidence interval [CI] 12.0-47.6). Children with genitourinary tract abnormalities were 2.4 times more likely to have resistant isolates than those without such abnormalities (95% CI 1.2-4.5). Compared with children who had no hospital admissions in the previous year, those with 1 admission in that period were more likely to have resistant isolates (OR 2.3, 95% CI 1.4-7.5), as were those with 2 or more admissions in that period (OR 3.2, 95% CI 1.1-4.8). Compared with children aged 2-6 years, children under 2 years of age were less likely to have resistant isolates (OR 0.3, 95% CI 0.2-0.8).

INTERPRETATION

Selective antimicrobial pressure and multiple admissions to hospital were among the risk factors associated with antimicrobial resistance. The finding of a low but definite level of resistance to both ampicillin and gentamicin is important for the selection of empiric therapy for sepsis in neonates. The role of inexpensive first-line agents in the outpatient treatment and prevention of urinary tract infections requires re-examination, particularly in children who have recently received antimicrobial therapy.

Increased mortality in postmenopausal women with serum CA125 elevation

OBJECTIVES

Serum CA125 is used in monitoring treatment and detecting recurrence in ovarian cancer (OC). We have also shown that CA125 can be used with ultrasound for the early detection of OC. However, physiological, benign, and malignant conditions are also associated with CA125 elevation. The aim of the study was to determine the prognostic implications of CA125 elevation in asymptomatic postmenopausal women.

METHODS

The study involved 771 volunteers in an OC screening trial of 22,000 women who had elevated serum CA125 levels (>/=30 U/ml). The control group consisted of an equal number of volunteers with normal levels. Survival was analyzed from the first point of CA125 elevation. Univariate analyses utilized the log-rank chi2 test. A logistic model was constructed for the multivariate analyses.

RESULTS

The mean duration of follow-up was 1614 days (SD 897 days). Eighty-four women died (elevated CA125 group-62, control group-22). Univariate analyses showed that mortality in the elevated CA125 group was significantly greater (log-rank chi2 = 23.556, P < 0.0001, RR = 2.76), even when preexisting morbid conditions were excluded (log-rank chi2 = 14.644, P = 0.0001, RR = 2.4). Multivariate analysis showed that CA125 elevation, age (>60 years), and a prior history of cancer were associated with a poor prognosis.

CONCLUSIONS

Serum CA125 elevation is associated with a significantly increased risk of death from all causes in the next 5 years. These findings may have implications for asymptomatic postmenopausal women with CA125 elevation.

Screening for ovarian cancer: a pilot randomised controlled trial

BACKGROUND

The value of screening for ovarian cancer is uncertain. We did a pilot randomised trial to assess multimodal screening with sequential CA 125 antigen and ultrasonography.

METHODS

Postmenopausal women aged 45 years or older were randomised to a control group (n=10,977) or screened group (n=10,958). Women randomised to screening were offered three annual screens that involved measurement of serum CA 125, pelvic ultrasonography if CA 125 was 30 U/mL or more, and referral for gynaecological opinion if ovarian volume was 8.8 mL or more on ultrasonography. All women were followed up to see whether they developed invasive epithelial cancers of the ovary or fallopian tube (index cancers).

FINDINGS

Of 468 women in the screened group with a raised CA 125, 29 were referred for a gynaecological opinion; screening detected an index cancer in six and 23 had false-positive screening results. The positive predictive value was 20.7%. During 7-year follow-up, ten further women with index cancers were identified in the screened group and 20 in the control group. Median survival of women with index cancers in the screened group was 72.9 months and in the control group was 41.8 months (p=0.0112). The number of deaths from an index cancer did not differ significantly between the control and screened groups (18 of 10,977 vs nine of 10,958, relative risk 2.0 [95% CI 0.78-5.13]).

INTERPRETATION

These results show that a multimodal approach to ovarian cancer screening in a randomised trial is feasible and justify a larger randomised trial to see whether screening affects mortality.

Analysis of antibiotic use and misuse in children hospitalized with RSV infection

OBJECTIVE

To determine the extent of, rationale for and acquisition cost of antibiotic use in a cohort of children with lower respiratory tract infection (LRI) secondary to the respiratory syncytial virus (RSV).

DESIGN

Prospective, observational cohort study.

SUBJECTS

Patients younger than two years of age admitted to a tertiary care paediatric hospital with a clinical diagnosis of LRI and positive direct immunoflourescence microscopy and/or viral culture for RSV were eligible. Patients older than two years with underlying cardiac abnormalities, respiratory disease or immunosuppression were also eligible. Patients were enrolled as part of the Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of RSV-related LRI.

RESULTS

One hundred and fifty-two patients were enrolled between January 1 and April 30, 1993. Median age was 5.6 months (range 0.2 to 151 months); the male to female ratio was 1.6:1. Morbidity was comparable with that of previously reported cohorts, and no patients died. Sixty-seven (44%) patients received an antibiotic before hospitalization, and ninety-two (60.5%) received at least one antibiotic during hospitalization. Of those receiving antibiotics in hospital, 65 were given oral and 44 intravenous preparations. Reasons for antibiotic prescription during hospitalization were otitis media (37%), 'pneumonia' (31%) and suspected sepsis (9%). Twenty-three per cent had no documented reason. In patients started on intravenous antibiotics, only 32% (14) had the medication discontinued once RSV infection was confirmed. Of the remaining 30 patients, 10 had positive blood (16.6%) or urine (16.6%) cultures, and 15 (50%) had no clearly defined bacterial etiology or rationale documented. Eighty-eight per cent of patients who received ribavirin also received an antibiotic compared with 55% of patients who did not receive ribavirin (P<0.005). The total medication cost of the administered antibiotics was CDN$4,578.16. Eleven adverse events were recorded in children given antibiotics, of which 10 (91%) were in those receiving intravenous preparations.

CONCLUSION

This study demonstrated that a high percentage of children admitted to hospital with LRI secondary to RSV received antibiotics in the absence of a clearly defined bacterial coinfection. Physician education strategies should stress discontinuation of antibiotic therapy once RSV infection is diagnosed. This may diminish the development of resistant bacteria, reduce health care costs and minimize the potential for adverse events associated with inappropriate antibiotic use.

Bioethics for clinicians: 15. Quality end-of-life care

A physician who receives a call from the emergency department to see a patient with heart failure will have a clear framework within which to approach this problem. The thesis of this article is that physicians do not have an analogous conceptual framework for approaching end-of-life care. The authors present and describe a framework for end-of-life care with 3 main elements: control of pain and other symptoms, the use of life-sustaining treatments and support of those who are dying and their families. This 3-part framework can be used by clinicians at the bedside to focus their effort in improving the quality of end-of-life care.

Palliative care--an essential component of cancer control

Unlike in other nations, in Canada palliative care has its origins in university hospitals. It has subsequently developed in a few Canadian schools as an academic discipline closely linked with oncology programs. Although this model is successful, other faculties of medicine and cancer centres have been slow to emulate it. Today, the situation is rapidly changing, and both palliative care and oncology professionals are re-examining the manifest need for collaborative efforts in patient care, research and education. Palliative care must be regarded as an essential component of cancer care, its principles must be applied throughout the course of the illness and, as in other phases of cancer control, palliative care should be regarded as an exercise in prevention--prevention of suffering. This article discusses practical applications that flow from acceptance of these concepts.

Acute-phase neurologic complications of Haemophilus influenzae type b meningitis: association with developmental problems at school age

The purposes of this study were to describe the incidence of acute-phase neurologic complications in a sample of 126 children with Haemophilus influenzae type b meningitis, and to determine if these complications were associated with higher rates of learning and behavior problems at school age. Risks were assessed by comparing rates of adverse psychoeducational outcomes in the 53 children in the sample with complications to corresponding outcome rates in the 67 children who were free of neurologic complications and who did not have abnormal electroencephalograms (EEGs) or computed tomographic (CT) scans. Comparisons were made by means of logistic regression analysis. Twenty-nine children (23% of the sample) had seizures, 16 (13%) were comatose or obtunded, 15 (12%) had sensorineural hearing loss, 8 (6%) had hemiparesis, and 7 (6%) had cranial nerve deficits other than hearing loss. Relative to children without complications, those with complications had higher rates of grade repetition and substandard performance on neuropsychological and achievement testing. Adverse outcomes, however, consisted primarily of more subtle cognitive and learning problems; only two of the children in the sample obtained prorated IQ scores below 70. Sequelae were associated with persistent neurologic deficits and bilateral hearing loss, as well as with transient symptoms including seizures, coma, and hemiparesis. While study findings argue against adverse consequences for the vast majority of children treated for this disease, the results clarify learning and behavior outcomes and indicate which children are at greatest risk.

A Canadian survey of issues in cancer pain management

We report the analysis of a cancer management survey mailed to a representative group of health professionals in 1994. The goals of the study were to gather information on cancer pain treatment practices, and to obtain health professional views on obstacles to ideal pain management. The survey, designed by a working party of pharmacists, nurses and physicians, was distributed to 14,628 physicians. A total of 2,686 physicians responded to the survey, including 39% of medical or radiation oncologists, and 18.19% of physicians who listed their primary interest as Family Medicine. Reflecting the modest emphasis placed on palliative care and cancer pain management in the current Canadian milieu, 67% of physicians rated their past teaching experience as only "fair" or "poor." Lack of exposure to pain education was reflected in the response to a series of hypothetical case scenarios exploring physician choices in managing severe cancer pain. For example, in the initial management of a cancer patient with severe pain, 50% of physicians would not use a strong opioid in the absence of other contraindications to opioid use. A wide variety of analgesics and non-pharmacologic techniques is available to Canadian physicians to assist patients with pain. Few physicians identified the unavailability of analgesics or analgesic techniques as limiting factors in pain management. We conclude that greater emphasis should be placed on pain education in our training programmes. We suggest that further surveys of this type, sponsored by our provincial colleges and medical organizations, can provide feedback which will enhance the adherence by Canadian physicians to published guidelines for pain management.

School-based hepatitis B immunization program: follow-up of non-participants at first school clinic

This research project was conducted in the Ottawa-Carleton region of Ontario to provide information on reasons why students did not participate in a Grade 7 hepatitis B school immunization project, and to determine whether telephone contact increased attendance at the community catch-up clinics above that achieved by a notice sent home with the child from school. A matched comparison group design was used. The overall uptake of the first dose of the vaccine in the region was 94% of 8,560 eligible students; 90% were immunized at the school clinic and 4% at the community catch-up clinic. About 4% of the parents refused to have their child immunized at the school or catch-up clinics. Of parents in the intervention group 198 (95%) were contacted by phone. The major reasons for non-participation at the school clinics were: (1) the child was not at school on the clinic day, or the child was sick (51%), (2) there were problems with the consent form (21%), and (3) the parents did not know of the program (10%). More students from the intervention group (72%) came for vaccination than did those of the control group (50%) (p < 0.01).

School-based hepatitis B immunization program: follow-up of non-participants at first school clinic

This research project was conducted in the Ottawa-Carleton region of Ontario to provide information on reasons why students did not participate in a Grade 7 hepatitis B school immunization project, and to determine whether telephone contact increased attendance at the community catch-up clinics above that achieved by a notice sent home with the child from school. A matched comparison group design was used. The overall uptake of the first dose of the vaccine in the region was 94% of 8,560 eligible students; 90% were immunized at the school clinic and 4% at the community catch-up clinic. About 4% of the parents refused to have their child immunized at the school or catch-up clinics. Of parents in the intervention group 198 (95%) were contacted by phone. The major reasons for non-participation at the school clinics were: (1) the child was not at school on the clinic day, or the child was sick (51%), (2) there were problems with the consent form (21%), and (3) the parents did not know of the program (10%). More students from the intervention group (72%) came for vaccination than did those of the control group (50%) (p < 0.01).

Does ribavirin impact on the hospital course of children with respiratory syncytial virus (RSV) infection? An analysis using the pediatric investigators collaborative network on infections in Canada (PICNIC) RSV database

OBJECTIVES

To determine the relationship between receipt of aerosolized ribavirin and the hospital course of high-risk infants and children with respiratory syncytial virus (RSV) lower respiratory infection (LRI).

METHODS

The 1993-1994 Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) RSV database consists of prospectively enrolled children with acute RSV LRI, admitted to nine Canadian pediatric tertiary care centers. After excluding cases with compromised immunity and/or nosocomial infection, subsets with any congenital heart disease (CHD), chronic lung disease (CLD), age </=6 weeks (INFANT), gestation </=36 weeks (PREM), or severe disease within 48 hours of admission as shown by an oxygen saturation </=90% or an FiO2 requirement of >.35 (EARLY HYPOXIA) were studied in two ways. First, each risk group subset was analyzed separately to assess the association between ribavirin receipt and measures of disease severity including duration of intensive care, mechanical ventilation, hypoxia and RSV-attributable hospital stay. Secondly, ribavirin was added as an independent variable to a previously described multiple regression model for RSV-attributable length of hospital stay and two mutually exclusive subsets were analyzed: 1) previously healthy patients with >/=1 of: INFANT, PREM, or EARLY HYPOXIA; 2) patients with CHD and/or CLD.

RESULTS

Between January 1993 and June 1994, 1425 community-acquired hospitalized cases of RSV LRI were entered into the RSV database. Among these 750 (52.6%) fit into one or more of the defined subsets including 97 CHD, 134 CLD, 213 INFANT, 211 PREM, and 463 EARLY HYPOXIA. The proportion ventilated in each group was 20.6%, 20.9%, 15.5%, 15.2%, and 13.3%, respectively. Across the subsets ribavirin use ranged from 36% to 57% of ventilated patients and 6% to 39% of nonventilated patients. For nonventilated patients in each subset the median RSV-attributable hospital length of stay (RSV-LOS) was 2 to 3 days longer for ribavirin recipients and the duration of hypoxia was significantly increased. Duration of intensive care unit (ICU) stay was also increased for all ribavirin-treated subgroups except those with CHD. In contrast, for ventilated patients, ribavirin therapy was not significantly associated with any of the outcome measures regardless of risk group. In the multiple regression model, ribavirin was significantly associated with a prolonged RSV-LOS both for children with CHD and/or CLD as well as for those whose only risk factors included INFANT, PREM, and/or EARLY HYPOXIA.

CONCLUSIONS

These data raise further doubts about the clinical effectiveness of ribavirin in infants and children with risk factors for severe disease. Selection bias, with ribavirin used for sicker children, may have influenced outcome. Nevertheless the long durations of hospitalization, ICU, ventilation, and oxygen supplementation in nonventilated ribavirin recipients stress the need for further randomized trials to assess its efficacy.

Prevalence of Dientamoeba fragilis antibodies in children and recognition of a 39 kDa immunodominant protein antigen of the organism

Dientamoeba fragilis, a common intestinal protozoan parasite in Canada, has been associated with diarrhoea and abdominal pain in some patients. Seroprevalence of this organism has not been reported previously. In the present study sera from three symptomatic patients, 12 age- and sex-matched controls, and 189 randomly selected healthy individuals (age 6 months to 19 years) were tested for antibodies against Dientamoeba fragilis by an indirect immunofluorescence (IIF) assay. All three symptomatic patients infected with Dientamoeba fragilis had positive IIF titres of 80, and all 12 matched controls had positive titres ranging 20 to 160 (geometric mean titre 48). Of the 189 healthy children, 172 (91%) were positive at a serum dilution of 1:10 or higher. The specificity of the IIF assay was reinforced by immunoblotting 20 representative serum samples against Dientamoeba fragilis. In all 17 IIF-positive serum samples, a 39 kDa protein band of Dientamoeba fragilis was identified, the same band recognized by a mouse monoclonal antibody raised in our laboratory. Findings over a five-year period indicate that Dientamoeba fra-gilis was the most common protozoan, followed closely by Giardia lamblia and more distantly by Cryptosporidium parvum. The high seropositivity of 91% for Dientamoeba fragilis compares reasonably well with serologic data obtained by IIF and reported previously for Giardia lamblia (85.6%) and Cryptosporidium parvum (86%).

A comparison of Culture-Free Self-Esteem Scale means from different child and adolescent groups

The Culture-Free Self-Esteem Inventory (CFSEI-2) was administered to 7 groups of children: 84 White Catholic school students from a New Orleans suburb, 78 White rural public school students from Virginia, 62 Hispanic Migrant student from Florida, 90 Aboriginal and White students from an isolated Canadian community, 199 African American students attending an inner city school, 60 Hispanic and White international students from Venezuela, and 61 Innuit students from isolated community in Labrador. The four elder groups also wrote three words to describe themselves (the Adjective Generation Technique [AGT]). Significant differences in responding between groups were found on all CFSEI-2 scales and for AGT favorability means. Although several possible reasons for these results are discussed, we conclude that the CFSEI-2 is not culture-free. Recommendations are: change the title of the test to avoid misrepresentation, limit test usage to elementary school children, develop an adolescent version with age appropriate language, and construct local norms before using the CFSEI-2 to make decisions about a child's self-esteem. To determine relevance of scores, a team of professionals and lay persons should review items from this or any test given to children who may be different from the normative or standardization group.

Occult infection as a cause of hip pain in a patient with metastatic breast cancer

A 39-year-old woman with breast cancer metastatic to bone presented with acute hip pain marginally responsive to escalating doses of opioid analgesics. Pathologic pelvic fractures were present and there were minimal clinical indicators of infection, but the severity and intractable nature of the pain prompted further investigation. Computed tomography revealed a pelvic abscess. Antibiotic therapy and drainage of the abscess resulted in markedly improved pain control, decreased analgesic requirements, and improved quality of life. We suggest that, in patients with malignancy, the diagnosis of occult infection should be aggressively pursued as a potentially reversible cause of intractable pain.

The Brandes-Friesen case reports: how should we interpret the news?

In this issue (see pages 561 to 566 two case reports by Lorne J. Brandes and Linda A. Friesen illustrate a temporal relation between the discontinuation or initiation of therapy with certain non-antineoplastic agents (lithium, carbamazepine and an H1-antihistamine) and the clinical course of cancer. Only an accumulation of similar case reports and the results of epidemiologic and controlled clinical studies will show whether the temporal relation observed in these cases is also a causal one. In the absence of strong, let alone conclusive, evidence that antidepressants or antihistamines promote the growth of tumours in human beings, a recommendation to stop using these medications would be premature. The news about these case reports and about animal studies on the tumour-promoting potential of some antidepressants and antihistamines is likely to spread through the media. The realistic and responsible option for physicians and clinical investigators is to help patients and prospective participants in clinical trials to interpret this information in a balanced and reasonable fashion.

Incidence and pathogenicity of Arcanobacterium haemolyticum during a 2-year study in Ottawa

Arcanobacterium haemolyticum has been described as a rare cause of systemic invasive disease and is occasionally isolated from throat swabs. We describe a 2-year study of the incidence and clinical features of A. haemolyticus infection in a pediatric and adolescent population. A total of 11,620 throat swabs were examined for A. haemolyticum with use of a locally developed selective medium. Controls (2,241) were healthy students who were recruited from a separate study. A. haemolyticum was isolated from 42 patients, with the maximum incidence in the 15 to 18-year-old age group; in this subset the incidence was 2.5%. There were no isolates of A. haemolyticum found in the healthy controls, and the difference in incidence between patients and controls in the 15 to 18-year-old age group was highly significant (P < .01). Approximately half of the patients infected with A. haemolyticum had a rash. In 5 patients, A. haemolyticum was associated with a positive monospot test. The organism was highly susceptible to erythromycin and less susceptible to penicillin. The evidence from this study suggests that A. haemolyticum may be a pathogen with maximum incidence in the 15 to 18-year-old age group.

Diffusion of standards of care for cancer pain

The authors report the results of a symposium on improving the standards of care for patients with cancer pain. The symposium was sponsored by the Advisory Committee on Cancer Control of the National Cancer Institute of Canada and was held Apr. 8 to 10, 1994, in Toronto. Participants included experts on control of cancer pain and on diffusion techniques, patients with cancer and representatives of regulatory agencies. They suggested the following strategies to improve outcomes in patients with cancer pain. Processes for accreditation of health care institutions should require documentation of cancer pain, its treatment and its outcome. Tertiary care facilities that provide cancer treatment should have expert, subspecialty, multidisciplinary programs for pain control and should provide adequate psychosocial support to patients suffering cancer pain. The Canadian Cancer Society should conduct a public-education campaign to encourage patients to report pain to health care providers. The National Cancer Institute of Canada should foster research on cancer pain by restructuring its process for review of pain-research protocols. Examinations for professionals who care for patients with cancer should include a defined number of questions concerning pain and symptom control. Provincial programs to monitor prescribing through the use of triplicate prescription pads should have an educational as well as regulatory purpose.

Cachexia-anorexia-asthenia

The National Cancer Institute (Canada) sponsored a workshop on symptom control in Banff, Alberta, in October 1993. This article reports on the workshop recommendations for research on one symptom complex, the cachexia-anorexia-asthenia syndrome. In addition to encouraging study generation, the recommendations provide a baseline for assessing the scope and strength of future Canadian research initiatives on cachexia-anorexia-asthenia.

A proposed matrix for organisational changes to improve quality of life in oncology

Educational and institutional changes are needed to improve the care of dying patients. There are four phases to a cancer control programme, and each phase stresses prevention. The fourth phase of a cancer control programme is concerned with the prevention of suffering, through impeccable management of physical and psychosocial distress. In practice, cancer control is usually addressed primarily as a biological problem, with less emphasis placed on behavioural aspects and the alleviation of suffering. The principles of symptom control and the management of psychosocial issues have been defined by the palliative care movement. However, this body of knowledge tends to be cocooned within palliative care programmes and associated journals and textbooks. As exemplified by recent advances in cancer pain management, symptom control research is a promising area for development. However, the promise is not matched by priority assignment and idea implementation. This article offers proposals for specific changes in the structure of university and cancer programmes, and revision of legislative policies which will enhance the care of patients who depend upon our interest in the fourth phase of cancer control, the prevention and relief of suffering.