Mechanical bridge to recovery in fulminant myocarditis

A patient with acute fulminant lymphocytic myocarditis and cardiogenic shock was successfully treated by mechanical off loading of the left ventricle. A nonpulsatile left-heart bypass was undertaken with an implantable centrifugal blood pump. Careful weaning resulted in device removal on the seventh day. Left and right ventricular function is sustained at 7 months. Widespread application of this method depends on the availability of an inexpensive user friendly blood pump, appropriate weaning protocols and emerging strategies to promote sustainable myocardial recovery.

Future devices and directions

This article summarizes the status of left ventricular assist devices currently in the stages of bench testing, animal experiments, and pilot clinical trials. The major design features and estimate of costs for 17 devices are described under 3 major categories of indications for use: destination therapy, bridge to transplant, and bridge to recovery. A sleeved piston pump located in the aorta and a unique, magnetically suspended centrifugal pump are described in the destination therapy section. Eight centrifugal and 4 axial flow devices are listed in the bridge to transplant category, and an external cup and a very low-cost centrifugal pump with a left atrium-to-aorta circuit are described in the bridge to recovery section. The key design features of the future, which will be required for success in both the clinical and marketplace arenas, will be simplicity, safety, low-power requirements, and low cost.

b3a2 BCR-ABL fusion peptides as targets for cytotoxic T cells in chronic myeloid leukaemia

Peptide sequences spanning the BCR-ABL protein junction potentially constitute novel leukaemia-specific antigens. 9-mer b3a2 fusion peptides have been reported to bind with high affinity to HLA-A3, -A11 and -B8. We have studied the effect of b3a2 BCR-ABL junctional peptides on the cytotoxic T-cell (CTL) response against normal and chronic myeloid leukaemia (CML) cells. Antigen-presenting cells (APCs) were prepared from HLA-A3- or -B8-positive peripheral blood mononuclear cells (PBMCs) by incubation with phytohaemagglutinin (PHA) and interleukin (IL)-2 for 7 d. These APCs were pulsed with the respective b3a2 junctional peptide in the presence of beta2-microglobulin and were then used to challenge autologous PBMCs at 7-d intervals in the presence of IL-2, IL-6, IL-7 and IL-12. On subsequent exposure to target cells (either further pulsed normal APCs or unpulsed CML cells), specific HLA-restricted CTL responses were observed against all HLA-A3/-B8 matched normal target cells tested, but not to targets that were HLA mismatched. Cytotoxicity was also induced against HLA-A3/-B8 unpulsed CML cells, but not against unmatched CML cells. These data indicate (i) that endogenous BCR-ABL junctional peptides may be presented by CML cells and (ii) that exogenous peptides are potential stimulators of autologous antileukaemic CTLs.

Oligodeoxynucleotide 5mers containing a 5'-CpG induce apoptosis through a mitochondrial mechanism in T lymphocytic leukaemia cells

A chimeric methylphosphonodiester/phosphodiester 15mer oligodeoxynucleotide of randomly selected sequence was observed to rapidly induce apoptosis in MOLT-4 and Jurkat E6 T lymphocytic leukaemia cells following intracytoplasmic delivery. A series of further methylphosphonate substitutions and mutations and truncations of the oligodeoxynucleotide served to establish that the phosphodiester-linked sequence CGGTA present in the 15mer was responsible for this biological activity. End-protected CpG oligodeoxy-nucleotide 5mers of sequence type CGNNN exhibited a range of apoptosis-inducing potencies, with CGTTA being the most active. The latter was shown to significantly reduce the rate of RNA synthesis in MOLT-4 cells within 1 h; DNA laddering and redistribution of phosphatidylserine to the outer surface of the plasma membrane were marked by 160 min and mitochondrial transmembrane potential collapsed over roughly the same time scale. Pro-caspase 8 was reduced within 130 min and the proteolytically activated caspase 8 substrate Bid was also down by this time, implicating release of cytochrome c from mitochondria by the active 15 kDa fragment of Bid. Substantial proteolytic activation of pro-caspase 3 was relatively delayed. These findings support a mitochondrial amplification mechanism for apoptosis triggered by CpG 5mers.

Antisense therapeutics in chronic myeloid leukaemia: the promise, the progress and the problems

DNA sequences which are complementary or 'antisense' to a target mRNA can inhibit expression of that mRNA's protein product. Antisense therapeutics has therefore received attention for inhibiting oncogenes in haematological malignancy, in particular in chronic myeloid leukaemia. However, it is now becoming clear that antisense therapeutics is considerably more problematic than was naively initially assumed. In this article, some of these difficulties are discussed, together with the achievements in CML so far. Considerable further research is required in order to define an optimal antisense therapeutics strategy for clinical use.

Impaired recognition memory in monkeys after damage limited to the hippocampal region

Monkeys with lesions limited to the hippocampal region (the hippocampus proper, the dentate gyrus, and the subiculum) were impaired on two tasks of recognition memory: delayed nonmatching to sample and the visual paired-comparison task. Recognition memory was impaired in five different groups of monkeys, whether the lesions were made by an ischemic procedure, by radio frequency, or by ibotenic acid. The finding that the hippocampal region is essential for normal recognition memory performance is considered in the context of current ideas about the role of the hippocampus in declarative memory.

Dissociation between the effects of damage to perirhinal cortex and area TE

Perirhinal cortex and area TE are immediately adjacent to each other in the temporal lobe and reciprocally interconnected. These areas are thought to lie at the interface between visual perception and visual memory, but it has been unclear what their separate contributions might be. In three experiments, monkeys with bilateral lesions of the perirhinal cortex exhibited a different pattern of impairment than monkeys with bilateral lesions of area TE. In experiment 1, lesions of the perirhinal cortex produced a multimodal deficit in recognition memory (delayed nonmatching to sample), whereas lesions of area TE impaired performance only in the visual modality. In experiment 2, on a test of visual recognition memory (the visual paired comparison task) lesions of the perirhinal cortex impaired performance at long delays but spared performance at a very short delay. In contrast, lesions of area TE impaired performance even at the short delay. In experiment 3, lesions of the perirhinal cortex and lesions of area TE produced an opposite pattern of impairment on two visual discrimination tasks, simple object discrimination learning (impaired only by perirhinal lesions), and concurrent discrimination learning (impaired only by TE lesions). Taken together, the findings suggest that the perirhinal cortex, like other medial temporal lobe structures, is important for the formation of memory, whereas area TE is important for visual perceptual processing.

The role of sclerotherapy in abnormal varicose hand veins

Large, tortuous veins involving the dorsa of the hands often become more prominent with the passage of time and are a common source of patient dissatisfaction. The objective was to evaluate the results of sclerotherapy in the management of unsightly varicose veins of the dorsum of the hand. From January of 1987 to August of 1998, 100 healthy, ambulatory female patients with a mean age of 56.5 years (range, 35 to 78 years) underwent sclerotherapy treatment for abnormally dilated veins on the dorsum of the hands. Patients were divided into two groups: group A consisted of 20 patients treated with 0.5% sodium tetradecyl sulfate (Sotradecol Elkins-Sin, Inc., Cherry Hill, N.J.) or 1.5% polidocanol (Aethoxysklerol Kreussler, Chemische-Fabrik, Wiesbaden, Germany). Group B consisted of 80 patients treated with 3% polidocanol. Postsclerotherapy compression was utilized in all cases. Failure was observed in 16 patients (80 percent) in group A. Successful elimination of varicose veins was obtained in 76 of 80 patients (95 percent) in group B. The diameter of treated vessels ranged from 1 to 6 mm (mean, 3 mm). Adverse events observed included pain, ecchymosis, various degrees of edema, and thrombosis of the treated veins. One patient (1 percent) developed transient neuropraxia of the superficial branch of the radial nerve following treatment of vessels located on the thenar web. Eleven of the 76 patients (14.5 percent) treated successfully with higher concentration developed microscopic neovascularization (matting). In conclusion, (1) low concentrations of sclerosing agents were associated with a high incidence of failure (80 percent); (2) the use of higher concentrations of polidocanol (3%) produced good results in 95 percent of treated patients; (3) adverse events common to sclerotherapy were observed in 90 percent of the treated patients-there were no serious adverse events; and (4) when appropriate sclerosant concentrations were employed, compression sclerotherapy proved to be an effective method of treatment for varicose veins involving the dorsum of the hand.

Identification of a good c-myc antisense oligodeoxynucleotide target site and the inactivity at this site of novel NCH triplet--targeting ribozymes

A region of c-myc mRNA was identified which permitted very efficient antisense effects to be achieved in living cells using chimeric methylphosphonate--phosphodiester antisense effectors. Novel inosine--containing ribozymes (which cleave after NCH triplets) were directed to an ACA triplet within this region and delivered into living cells. No ribozyme intracellular activity could be identified. Very low ribozyme function was also observed in in vitro assays using a 1700nt substrate RNA.

The AB-180 circulatory support system: summary of development and plans for phase I clinical trial

BACKGROUND

The AB-180 circulatory support system is a small, durable, efficient centrifugal pump with low thrombogenic potential. The device was designed to provide a fully implantable, left ventricular assist system for short-term support to address the issues of systemic anticoagulation, thrombus formation, infection, and cost.

METHODS

Extensive bench and animal studies were performed to validate the mechanical integrity of the device and its functionality as an implant.

RESULTS

These studies demonstrated anticoagulation requirements, established operating guidelines, incorporated safety systems, and demonstrated safety and efficacy.

CONCLUSIONS

The AB-180 fulfills the stated goals on initial evaluation. A phase I human trial is underway.

Clinical use of streptolysin-O to facilitate antisense oligodeoxyribonucleotide delivery for purging autografts in chronic myeloid leukaemia

Antisense oligodeoxyribonucleotides (ODN) targeted against the breakpoint in BCR-ABL mRNA will specifically decrease BCR-ABL mRNA, provided cells are first permeabilised with streptolysin-O (SL-O). We used 18-mer chimeric methylphosphonodiester: phosphodiester linked (4-9-4) ODN complementary to 9 bases either side of the BCR-ABL junction to purge harvests ex vivo in three CML patients who remained completely Ph positive after multiple chemotherapy courses. After CD34+ cell selection and SL-O permeabilisation, harvests were purged with 20 microM ODN. After purging, all individual CFU-GM colonies grown from the two b3a2 breakpoint cases remained positive for BCR-ABL mRNA. In contrast, all 24 colonies grown from the b2a2 breakpoint case were BCR-ABL mRNA negative. Patients were conditioned with busulphan 16 mg/kg. The initial post-transplant course was uneventful, although the time to return to 0.5 x 10(9)/l neutrophils was slow at 25-51 days. Both chronic phase patients remain in haematological remission at +724 and +610 days, although each has cytogenetic evidence of relapse. The b2a2 accelerated phase patient died of myeloid blast transformation at day +91. The present SL-O-facilitated ODN purging strategy appears to be without significant toxicity, and offers considerable improvements in ODN delivery to the cytosol.

Labor market conditions and employment of the mentally ill

BACKGROUND: The mental health services literature includes assertions that workers with mental illness are at earlier risk of unemployment than other workers when the economy contracts. This possibility is important for several reasons. One is that such a phenomenon would support the argument that the lives of mentally ill persons are made unnecessarily stressful by the stigma of mental illness. Another is that the phenomenon could distort comparisons of the effectiveness of programs designed to prepare persons with severe mental illness for work. Despite its importance, the assertion that severely mentally ill workers are at early risk of unemployment has never been empirically tested. AIMS OF THE STUDY: We aim to test the hypothesis that unemployment among persons with severe mental illness (SMI) increases before job loss among other workers. METHODS: We test the hypothesis by applying Granger causality methods to time-series data collected in two communities in the United States (i.e., Concord and Manchester, NH) over 131 weeks beginning on 12 May 1991. RESULTS: We find no relationship between job loss in the labor market and the likelihood that persons with SMI will be unemployed. DISCUSSION: We speculate that persons with SMI participate in the secondary labor market and that their employment status is unlikely to be well described by data gathered in the primary labor market. This implies that widely available measures of labor market status, which are designed to describe the primary labor market, cannot be used to improve the evaluation of programs intended to prepare the mentally ill for work. We also discuss the possibility that persons with SMI may have needs that are better met by the secondary than by the primary labor market. CONCLUSIONS: The intuition that workers with severe mental illness are affected earlier than other workers by labor market contraction may not be correct. We infer that persons with severe mental illness may participate in the secondary labor market about which we know relatively little. We cannot, therefore, easily adjust program evaluations to disentangle intervention effects from those, if any, of the labor market.

Legal system involvement and costs for persons in treatment for severe mental illness and substance use disorders

OBJECTIVE

Persons with co-occurring severe mental illness and substance use disorders were followed for three years to better understand how they are involved with the legal system and to identify factors associated with different kinds of involvement.

METHODS

Data came from a three-year study of 203 persons enrolled in specialized treatment for dual disorders. Cost and utilization data were collected from multiple data sources, including police, sheriffs and deputies, officers of the court, public defenders, prosecutors, private attorneys, local and county jails, state prisons, and paid legal guardians.

RESULTS

Over three years 169 participants (83 percent) had contact with the legal system, and 90 (44 percent) were arrested at least once. Participants were four times more likely to have encounters with the legal system that did not result in arrest than they were to be arrested. Costs associated with nonarrest encounters were significantly less than costs associated with arrests. Mean costs per person associated with an arrest were $2,295, and mean costs associated with a nonarrest encounter were $385. Combined three-year costs averaged $2,680 per person. Arrests and incarcerations declined over time. Continued substance use and unstable housing were associated with a greater likelihood of arrest. Poor treatment engagement was associated with multiple arrests. Men were more likely to be arrested, and women were more likely to be the victims of crime.

CONCLUSIONS

Effective treatment of substance use among persons with mental illness appears to reduce arrests and incarcerations but not the frequency of nonarrest encounters. Stable housing may also reduce the likelihood and number of arrests.

Measuring resource use in economic evaluations: determining the social costs of mental illness

Concern over costs associated with mental disorders has led to an increase in the number of economic evaluations of treatment interventions; unfortunately, methods for measuring resource use have not kept pace with this concern. Although it is well-known that a significant proportion of the costs associated with mental illness are for resources other than treatment, program evaluators and researchers often count only treatment costs in cost-effectiveness comparisons. Further, existing methods for measuring resource use are plagued by faulty assumptions about resource use, poor validity and reliability, and difficulties quantifying resource use. The authors discuss these problems and suggest five ways of improving measurement of nontreatment resources: clarifying assumptions, using multiple data sources, flexible data collection strategies, methods for improving the accuracy of recall, and an episodic approach to measurement.

Risk stratification for cardiac valve replacement. National Cardiac Surgery Database. Database Committee of The Society of Thoracic Surgeons

BACKGROUND

The Society of Thoracic Surgeons National Database Committee is committed to risk stratification and assessment as integral elements in the practice of cardiac operations. The National Cardiac Surgery Database was created to analyze data from subscribing institutions across the country. We analyzed the database for valve replacement procedures with and without coronary artery bypass grafting to determine trends in risk stratification.

METHODS

The database contains complete records of 86,580 patients who had valve replacement procedures at the participating institutions between 1986 and 1995, inclusive. The 1995 harvest of data was conducted in late 1996 and available for evaluation in 1997. These records were used to conduct an in-depth analysis of risk factors associated with valve replacement and to provide prediction of operative death by using regression analysis. Regression models were made for six subgroups.

RESULTS

Adverse patient risk factors, including diabetes, hypertension and reoperation, but not ventricular function, increased over time. There were trends with regard to increasing age of the various population subsets. The types of prostheses used remained similar over time, with more mechanical prostheses than bioprostheses used for both aortic and mitral valve replacement. There was a trend toward increased use of bioprostheses in aortic replacements and decreased use in mitral replacements between 1991 and 1995 than between 1986 and 1990. The mortality rate was determined by patient subset for primary operation and reoperation and by urgency status. The modeling showed that the predicted and observed mortality correlated for all age groups and within patient subsets.

CONCLUSIONS

Risk modeling is a valuable tool for predicting the probability of operative death in any individual patient. This large, multiinstitutional database is capable of determining modern operative risk and should provide standards for acceptable care. The study illustrates the importance of risk stratification for early death both for the patient and the surgeon.

Antisense morpholino oligonucleotide analog induces missplicing of C-myc mRNA

A 28-mer morpholino oligonucleotide analog was designed to hybridize to 8 bases of intron 1 and extend 2 bases beyond the translation initiation codon in exon 2 of the unspliced c-myc RNA transcript. Delivery of this compound into human chronic myeloid leukemia KYO1 cells, by streptolysin O permeabilization, resulted in almost total ablation of the 65 kDa c-MYC protein expression for at least 24 hours after treatment. An unexpected band with SDS-PAGE electrophoretic mobility indicating a protein of about 47 kDa was apparent on the 24-hour western blots that were developed using antibodies that recognize MYC protein C terminal epitopes. No inhibition of the approximately 2400 nt c-myc mRNA expression was observed by northern hybridization, a result of the inability of morpholino analogs to direct the activity of ribonuclease H. In fact, high molecular weight c-myc RNA species were found to have accumulated in antisense-treated KYO1 cells. Control sense and scrambled antisense morpholino analogs did not inhibit MYC protein expression or induce the appearance of the anomalous RNA and protein bands. Molecular analyses by RT-PCR and sequencing revealed that the morpholino antisense effector had (1) inhibited splicing of the c-myc pre-mRNA, (2) induced missplicing of the pre-mRNA, and (3) inhibited translation of normal spliced c-myc mRNA. Identical results were obtained with acute promyelocytic leukemia, acute lymphoblastic leukemia, and histiocytic lymphoma cell lines.

The effect of vertical dimension and mandibular position on isometric strength of the cervical flexors

This study compared the peak isometric strength of the cervical flexors in deep bite temporomandibular dysfunction (TMD) patients while biting in four bite positions: habitual occlusion, edge-to-edge, lateral shift and retruded. These values were then compared to those of the same subjects' bite positions elevated to a functional criterion (maximum isometric strength of the deltoid muscles). The mean height increase was 2.4 mm with a range of 1.5-3.8 mm. Fifteen of eighteen deep bite subjects met an inclusionary criterion, at least 13.3 Newtons (N) stronger cervical muscle strength with mandible relaxed open than habitual bite. Peak strength biting edge-to-edge was significantly greater than biting in habitual occlusion. Strength was found to increase significantly when biting in each of four mandibular positions when the bite was elevated to the functional criterion. The greatest strength was obtained from elevated habitual and edge-to-edge positions. The findings are of clinical significance, suggesting that cervical muscle isometric strength is affected by bite position and vertical dimension of occlusion. The results suggest that when biting, individuals with deep bite may be functioning at about 60% of their potential cervical flexor, isometric strength. The interaction between occlusal position, vertical dimension and cervical muscle function suggests a craniomandibular-cervical masticatory system.

Chemotherapy-induced acral erythema (CIAE) with bullous reaction

Chemotherapy-induced acral erythema (CIAE) is a cutaneous response to a number of different chemotherapeutic agents. It causes a symmetrical, painful erythema of both the palms and soles which is self-limiting. CIAE with bullous reaction has been reported in relation to methotrexate, but it has been more commonly associated with cytosine arabinoside. We describe a case of CIAE with bullous reaction in a patient treated for Hodgkin's disease with a number of chemotherapeutic agents. We discuss the differential diagnosis of this condition which includes eccrine squamous syringometaplasia and acute graft vs. host disease

Trace eyeblink classical conditioning in the monkey: a nonsurgical method and behavioral analysis

Classical eyeblink conditioning has been used extensively to study the neurobiology of associative learning and memory in rabbits and in humans. During the last several years, new developments have renewed interest in the possibility of studying classical conditioning in monkeys. Specifically, it is now known that impaired conditioning can be observed in humans with various neurologic problems, including amnesia, and thus there is now considerable interest in the neurobiology of human eyeblink conditioning. Research involving monkeys, in which discrete lesions of anatomically defined neural structures can be produced, has the potential to provide information that might not be readily available from work in humans. Here, the authors present a simple, nonsurgical method for classically conditioning the eyeblink response in monkeys and report behavioral results using a trace conditioning paradigm that is sensitive to hippocampal damage in both rabbits and humans. This method is reliable and effective for recording eyeblinks and shows that robust eyeblink classical conditioning can be readily established in the monkey.

Research on the individual placement and support model of supported employment

This paper reviews research on the Individual Placement and Support (IPS) model of supported employment for people with severe mental illness. Current evidence indicates that IPS supported employment is a more effective approach for helping people with psychiatric disabilities to find and maintain competitive employment than rehabilitative day programs or than traditional, stepwise approaches to vocational rehabilitation. There is no evidence that the rapid-job-search, high-expectations approach of IPS produces untoward side effects. IPS positively affects satisfaction with finances and vocational services, but probably has minimal impact on clinical adjustment. The cost of IPS is similar to the costs of other vocational services, and cost reductions may occur when IPS displaces traditional day treatment programs. Future research should be directed at efforts to enhance job tenure and long-term vocational careers.

Cost-effectiveness of assertive community treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders

OBJECTIVE

To determine the cost-effectiveness of Assertive Community Treatment (ACT) in comparison to Standard Case Management (SCM) for persons with severe mental illness and substance use disorders.

DATA SOURCES AND STUDY SETTING

Original data on the effectiveness and social costs of ACT and SCM that were collected between 1989 and 1995. Seven community mental health centers in New Hampshire provided both types of treatment.

STUDY DESIGN

Persons with schizophrenia, schizoaffective disorder, or bipolar disorder and a concurrent substance use disorder were randomly assigned to ACT or SCM and followed for three years. The primary variables assessed were substance use, psychiatric symptoms, functioning, quality of life, and social costs.

DATA COLLECTION METHODS

Effectiveness data were obtained from interviews at six-month intervals with persons enrolled in treatment and with their service providers. Social cost and service utilization data came from client reports; interviews with informal caregivers; provider information systems and Medicaid claims; law enforcement agencies; courts; and community service providers.

PRINCIPAL FINDINGS

Participants in both groups showed significant reductions in substance use over time. Focusing on quality of life and substance use outcomes, ACT and SCM were not significantly different in cost-effectiveness over the entire three-year study period. Longitudinal analyses showed that SCM tended to be more efficient during the first two years but that ACT was significantly more efficient than SCM during the final year of the study.

CONCLUSIONS

In an adequately funded system, ACT is not more cost-effective than SCM. However, ACT efficiency appears to improve over time.

Previous treatment predicts the efficiency of blood progenitor cell mobilisation: validation of a chemotherapy scoring system

Following mobilising chemotherapy and myeloid growth factors, some heavily pretreated patients do not mobilise adequate numbers of peripheral blood progenitor cells (PBPC). It would be clinically useful to identify such patients in advance. A recent scoring system based on previous therapy may be useful in predicting CD34-positive cell yield. In this study we validated this scoring system on an independent group of 99 patients undergoing 103 harvesting episodes. In 61 patients mobilised with cyclophosphamide 1.5 g/m2 and G-CSF, those with treatment scores less than 21 yielded significantly more CD34-positive cells than patients with scores greater than 63 (P = 0.0012). Previous treatment with melphalan or carmustine was associated with a significantly lower yield of CD34-positive cells (P= 0.0001). No relationship was seen between the time from previous chemoradiotherapy and harvest outcome. Patients with treatment scores less than 21 required a shorter duration of G-CSF therapy (P = 0.05). Similar findings were seen in 42 further mobilisation cycles undertaken with alternative mobilisation schedules. The present data suggest that a score summarising previous treatment can be used to predict CD34 yields, and could be of clinical use to identify poor PBPC mobilisers in advance.

Left ventricular support with the implantable AB-180 centrifugal pump in sheep with acute myocardial infarction

A small, 257 g centrifugal pump was tested as a left ventricular assist device (LVAD) in sheep given a myocardial infarction. Pump performance, hemolysis, end organ function, weaning, explant procedure, and the incidence of thromboemboli at autopsy were studied over intervals of 1 to 44 days. Twelve sheep were given acute myocardial infarction by ligation of the anterior descending coronary artery and 11 had insertion of the AB-180 Circulatory Support System (CSS). One sheep served as a control for the space occupying effects of the pump in the left chest. Inflow was from the left atrium and outflow was to the descending thoracic aorta. Heparin (57-83 U/ml) in sterile water was infused into the pump at a rate of 10 ml/hr. Pump flows of 1-5.7 L/min were tested. The AB-180 CSS supported 73.5% of the total cardiac output (pump + heart) of 3.89 L/min, with a mean arterial pressure of 86 +/- 7 mmHg at a pump speed of 4,162 +/- 276 rpm immediately after implant. Hemolysis was <10 mg/dl and activated partial thromboplastin time (aPTT) values were in the normal range for sheep (<52 sec) after 48 hr of pumping. Liver enzyme concentrations returned to normal within 2 weeks. There was no evidence of thrombocytopenia. No signs of infection were present during assist and none was found at autopsy. The device was successfully removed three times without the use of pressor agents or blood transfusion. Alarm systems performed appropriately. During the 106 days of cumulative pumping, two sheep showed small (<1.5 cm) renal infarcts. Both were associated with intervals of pump stasis. The AB-180 CSS pump was easily implanted into the left chest without the use of cardiopulmonary bypass. It appears to have a low thromboembolic potential in sheep, without the need for large doses of heparin to elevate aPTT values. This characteristic may ameliorate the excessive bleeding seen clinically with current LVAD systems used for post cardiotomy cardiogenic shock, which require anticoagulation with heparin. The small size and weight of the device permit implantation within the chest and allow chest closure. This may reduce the incidence of infection associated with temporary left ventricular assist and an open sternum.

Trace eyeblink classical conditioning in the monkey: a nonsurgical method and behavioral analysis

Classical eyeblink conditioning has been used extensively to study the neurobiology of associative learning and memory in rabbits and in humans. During the last several years, new developments have renewed interest in the possibility of studying classical conditioning in monkeys. Specifically, it is now known that impaired conditioning can be observed in humans with various neurologic problems, including amnesia, and thus there is now considerable interest in the neurobiology of human eyeblink conditioning. Research involving monkeys, in which discrete lesions of anatomically defined neural structures can be produced, has the potential to provide information that might not be readily available from work in humans. Here, the authors present a simple, nonsurgical method for classically conditioning the eyeblink response in monkeys and report behavioral results using a trace conditioning paradigm that is sensitive to hippocampal damage in both rabbits and humans. This method is reliable and effective for recording eyeblinks and shows that robust eyeblink classical conditioning can be readily established in the monkey.

Autologous transplantation in chronic myeloid leukaemia using peripheral blood stem cells

Forty-three patients with chronic myeloid leukaemia in first chronic phase were recruited to study intensive chemotherapy (idarubicin plus cytarabine; IdAC) followed by collection of peripheral blood stem cells (PBSC) in the recovery phase. PBSC autografting was performed on 32 patients. One patient died during mobilization and three died following autograft. All procedural deaths occurred in patients who received IdAc more than a year from diagnosis. Nine further patients died, eight following progression of CML. 72% of transplanted patients showed a major cytogenetic response but most cases have returned to Philadelphia-positive haemopoiesis. 62% of autografted patients remain alive (median survival from diagnosis 52 months). Four of the 11 patients who did not receive a transplant remain in chronic phase.

AB-180 circulatory support system: summary of development and phase I clinical trial

The AB-180 Circulatory Support System (AB-180 CSS; Cardiac Assist Technologies, Pittsburgh, PA) is a left ventricular assist system for investigational use in patients with postcardiotomy cardiogenic shock who are refractory to standard treatment with an intra-aortic balloon pump, pharmacologic treatment, or both. The intent of the AB-180 CSS is to provide temporary (up to 14 days) mechanical circulatory support until the heart recovers adequate mechanical function. The system consists of a small implantable centrifugal pump and a controller. A unique infusion system produces a hydrodynamic bearing between rotational and stationary components of the AB-180 CSS pump. This infusion system also provides a source of heparin for localized anticoagulation. Extensive bench and animal work has illustrated anticoagulation requirements, established operating guidelines, and demonstrated safety and efficacy. An investigational device exemption has been granted for a Phase I, five patient feasibility study at Allegheny General Hospital in Pittsburgh, Pennsylvania. To date, the pump has been implanted in one patient. The results from this first case are presented here.

Comparison of a patient-controlled analgesia system with continuous infusion for administration of diamorphine for mucositis

Mucositis remains an important problem following BMT and may delay discharge from hospital. Patient-controlled analgesia (PCA) systems have been reported to be of benefit in controlling BMT-associated mucositis. The present study comprised 65 patients (age range 16-68 years; 19 allografts, 29 peripheral blood stem cell autografts and 17 autologous bone marrow). Subjects were prospectively randomised to receive intravenous diamorphine for pain relief either by conventional continuous infusion (CI) or by PCA, using a Medex Walkman 440 delivery system. Each patient assessed his/her pain control and nausea daily by a visual analogue scale. Twenty-two patients did not require any diamorphine. Four patients required diamorphine for pain other than mucositis, and four patients failed PCA control. Of 35 assessable cases, no difference in pain control was noted between CI and PCA. However, PCA-controlled patients required significantly less diamorphine than CI controlled patients (mean, 131 +/- 23 mg for PCA vs 296 +/- 40 mg for CI; P = 0.001), and PCA required fewer days of diamorphine than CI (mean, 7.17 +/- 0.66 days for PCA, 9.00 +/- 0.65 days for CI; P = 0.03). Side-effects were minimal and equivalent in the two arms. The findings suggest that PCA and CI offer equivalent control of the pain of BMT-associated mucositis, but PCA requires less total consumption and duration of diamorphine therapy.

The influence of target protein half-life on the effectiveness of antisense oligonucleotide analog-mediated biologic responses

During the course of a study aimed at improving antisense oligodeoxynucleotide-mediated ex vivo bone marrow purging of patients suffering from chronic myeloid leukemia (CML), the properties of a number of antisense structures intended to reduce the expression of c-myc, mutant p53, and bcr-abl mRNAs and proteins were examined. The majority of the antisense oligodeoxynucleotides were designed to be capable of directing ribonuclease H (RNase H) cleavage of their target mRNAs. Streptolysin O (SLO) reversible permeabilization was used to deliver the oligodeoxynucleotides into the CML line KYO-1. We found that the efficiency and specificity of antisense oligonucleotide-induced reductions of target protein expression depended on target protein half-life, the oligonucleotide structure, and the specific sequence within the target mRNA. Transient reductions of c-myc mRNA and protein were achieved with a chimeric methylphosphonate-phosphodiester oligodeoxynucleotide antisense to the initiation codon, but cell proliferation was unaffected. In contrast, a chimeric oligodeoxynucleotide of similar structure targeted to an alternative site in the coding region of c-myc mRNA reduced target mRNA and protein levels for over 24 hours and halted cell proliferation. Chimeric methylphosphonate-phosphodiester oligodeoxynucleotide antisense to a point mutation in KYO-1 p53 mRNA efficiently reduced target mRNA expression, but only small, transient reductions in p53 protein expression were observed. However, a chimeric methylphosphonate-phosphorothioate oligodeoxynucleotide targeted to the same site reduced p53 protein to 30% of control levels over a 48-hour period. BCR-ABL protein expression was unaffected by chimeric oligodeoxynucleotides targeted to the breakpoint in bcr-abl mRNA, even when mRNA levels at early times were substantially reduced.

The economic benefits of supported employment for persons with mental illness

BACKGROUND: Policies and programs that emphasize employment for persons with mental illness are often promoted with the goals of improving economic self-sufficiency and reducing dependence on public welfare programs. At present, there is little empirical evidence about the actual effect of vocational interventions on economic self-sufficiency or on use of public benefits by persons with mental illness. STUDY AIMS: This study provides a preliminary look at how participating in supported employment, a form of vocational rehabilitation emphasizing ongoing support in competitive jobs, affects the amount that participants earn from work and the total amount of income they receive from all sources. Further, we examine the extent to which receiving public benefits affects the amount earned from private employment, taking into consideration other factors that might be associated with benefit status. METHODS: Data are from a randomized trial of supported employment interventions. This analysis followed 137 of those study participants with severe mental illness for 18 months after they enrolled in either of two supported employment programs. Income from various sources was estimated based on interviews with study participants upon study entry and at six-month intervals thereafter. Changes in income from work, government and other sources were analyzed using paired Wilcoxon matched-pairs signed-ranks tests and t-tests. Using ordinary least-squares regression, we analyzed the effect of benefit status on changes in earnings, taking into account diagnosis, work history, education, program type, site of program, psychiatric symptoms, global functioning and previous earnings. RESULTS: Estimated total income increased by an average of $134 (US) per month after enrolling in supported employment. More than three-quarters of this increase was from government sources, such as Social Security and educational grants. The increase in government income was largely due to participants applying for and getting cash benefits for the first time. Social Security payments for those receiving benefits before enrollment did not change significantly. A small group of persons (n = 22) who did not receive Social Security benefits before or after enrolment earned significantly more from competitive employment after enrolling than did those who received benefits. This finding persisted after taking into acount differences in work history, clinical and functional variables and education. LIMITATIONS: Because of the relatively small sample size and the lack of continuous measures of income these results should be considered preliminary. CONCLUSIONS: Supported employment, one of the more effective forms of vocational rehabilitation for persons with mental illness, did not reduce dependence on government support. Receiving government benefits was associated with lower earnings from work. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These findings suggest that most persons in treatment for severe mental illness need continued public financial support even after enrolling in vocational rehabilitation programs. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Undoubtedly increased labor force participation can benefit persons with mental illness in a number of ways. However, policy makers should be careful about justifying increased access to vocational programs on the basis of reduced spending for income support. Further, targeting such programs only to persons receiving income support may overlook the clients who can benefit most: those who are not currently receiving benefits. IMPLICATIONS FOR FURTHER RESEARCH: Policy makers need a better understanding of how vocational interventions and income support programs affect the income and well-being of persons with mental illness. Studies similar to this one should be repeated with larger, more diverse samples that will allow use of instrumental variables statistical techniques.

Improving the intracellular delivery and molecular efficacy of antisense oligonucleotides in chronic myeloid leukemia cells: a comparison of streptolysin-O permeabilization, electroporation, and lipophilic conjugation

The hybrid gene BCR-ABL that typifies chronic myeloid leukemia (CML) represents an attractive target for therapy with antisense oligodeoxyribonucleotides (ODN). A central obstacle in the therapeutic application of ODN is their poor cellular uptake. Adding various lipophilic conjugates to the ODN backbone has been reported to improve uptake, and electroporation of target cells has also been shown to enhance intracellular ODN delivery. We have shown that (1) BCR-ABL-directed ODN will specifically decrease the level of BCR-ABL mRNA, provided that cells are first permeabilized with Streptolysin-O (SL-O), and (2) chimeric methylphosphonodiester:phosphodiester ODN directed against 9 bases either side of the BCR-ABL junction are more efficient ODN effectors than structures composed solely of phosphodiester or phosphorothioate linkages. In this study, we compared the efficacy of lipophilic conjugation, SL-O permeabilization and electroporation on the intracellular delivery and molecular effect of BCR-ABL-directed ODN. b2a2- and b3a2-directed chimeric ODN were synthesized either unmodified or with one of the following groups at the 5' end: cholesterol, vitamin E, polyethylene glycol of average molecular weight 2,000 or 5,000, N-octyl-oligo-oxyethylene, or dodecanol. ODN associated with Lipofectin was also studied. Comparison was made in untreated, electroporated, and SL-O permeabilized KYO1 cells. Uptake was examined by fluorescence microscopy and flow cytometry, using ODN structures that were 3' labeled with fluorescein. The effect on target BCR-ABL mRNA expression was analyzed by Northern blotting. Several conjugated structures associated avidly with the cell membrane without achieving significant intracellular uptake or molecular effect. Similarly, ODN:Lipofectin complexes moderately increased cell association, without enhancing intracellular levels of ODN or inducing detectable molecular effect. In SL-O permeabilized or electroporated cells, uptake was approximately 1 to 2 logs greater than in untreated cells, and rapid nuclear localization was seen, especially with unmodified chimeric ODN. In SL-O permeabilized cells treated with ODN directed to the b2a2 and b3a2 junctions respectively, b2a2 BCR-ABL mRNA levels at 4 hours were reduced to 2. 6% +/- 2.1% and 38.4% +/- 1.3% of control values. In cells permeabilized by electroporation, BCR-ABL mRNA levels were decreased to 4.0% +/- 1.4% of control levels by b2a2 directed ODN, although very little nontargeted suppression was seen with b3a2-targeted ODN (93.4% +/- 4.2% of control). Greater cell to cell variation in ODN uptake was seen for SL-O permeabilized cells when compared with electroporated cells, suggesting that, after SL-O permeabilization, relatively unpermeabilized and overpermeabilized populations may coexist. No structure had any effect on the level of irrelevant (p53, MYC, and GADPH) mRNA levels. We conclude that the conjugation of chimeric ODN with one of the above-mentioned lipophilic groups or the complexing of ODN with Liopfectin does not improve either intracellular delivery of ODN or the molecular effect. In contrast, both electroporation and SL-O permeabilization (1) considerably enhanced uptake of chimeric ODN (even for structures without a conjugate group) and (2) achieved significant suppression of target mRNA levels.

Desmoglein in multiple self-healing squamous epithelioma of Ferguson-Smith--comparison of staining patterns with actinic keratoacanthoma and squamous cell carcinoma of the skin

BACKGROUND

Multiple self-healing squamous cell epithelioma of the skin (MSSE) is the most common variant of multiple keratoacanthoma. Although the morphology of the lesions in MSSE is similar to classical actinic keratoacanthoma (KA), several distinctive features in clinical presentation and histology have been emphasized. Desmosomes have been shown to be downregulated in certain types of carcinoma. Desmogleins (Dsg) are transmembrane desmosomal glycoproteins that exist as three isoforms. Dsg markers have been found to be reduced or absent in squamous cell carcinoma (SCC) but preserved in KA.

OBJECTIVE

This study was designed to determine the pattern of Dsg staining in MSSE.

METHODS

Eight tumors from two female patients with MSSE were stained with the antidesmoglein monoclonal antibody 32-2B, which recognizes Dsgl and Dsg3.

RESULTS

All eight tumors showed uniform pericellular Dsg staining throughout the nonkeratinized layers of the neoplastic epithelium. This pattern is entirely similar to that observed in actinic KA, normal epidermis or follicular epithelium.

CONCLUSION

Despite the differences, uniform preservation of Dsg seems to be the invariable feature of both MSSE and KA. Further studies are necessary to evaluate this antibody in routine dermatopathology of MSSE and SCC.

Classical conditioning and brain systems: the role of awareness

Classical conditioning of the eye-blink response, perhaps the best studied example of associative learning in vertebrates, is relatively automatic and reflexive, and with the standard procedure (simple delay conditioning), it is intact in animals with hippocampal lesions. In delay conditioning, a tone [the conditioned stimulus (CS)] is presented just before an air puff to the eye [the unconditioned stimulus (US)]. The US is then presented, and the two stimuli coterminate. In trace conditioning, a variant of the standard paradigm, a short interval (500 to 1000 ms) is interposed between the offset of the CS and the onset of the US. Animals with hippocampal lesions fail to acquire trace conditioning. Amnesic patients with damage to the hippocampal formation and normal volunteers were tested on two versions of delay conditioning and two versions of trace conditioning and then assessed for the extent to which they became aware of the temporal relationship between the CS and the US. Amnesic patients acquired delay conditioning at a normal rate but failed to acquire trace conditioning. For normal volunteers, awareness was unrelated to successful delay conditioning but was a prerequisite for successful trace conditioning. Trace conditioning is hippocampus dependent because, as in other tasks of declarative memory, conscious knowledge must be acquired across the training session. Trace conditioning may provide a means for studying awareness in nonhuman animals, in the context of current ideas about multiple memory systems and the function of the hippocampus.

Methodological issues in assertive community treatment studies

Recent evaluations of ACT programs have produced equivocal findings, often leading to the invocation of methodological problems as responsible for the lack of positive results. This paper discusses issues of theory and methodology as they pertain to improving research of ACT, with particular attention paid to issues of sampling, process evaluation, measurement, and data analysis.

Selecting optimal oligonucleotide composition for maximal antisense effect following streptolysin O-mediated delivery into human leukaemia cells

It is widely accepted that most cell types efficiently exclude oligonucleotides in vitro and require specific delivery systems, such as cationic lipids, to enhance uptake and subsequent antisense effects. Oligonucleotides are not readily transfected into leukaemia cell lines using cationic lipid systems and streptolysin O (SLO) is used to effect their delivery. We wished to investigate the optimal oligonucleotide composition for antisense efficacy and specificity following delivery into leukaemia cells using SLO. For this study the well characterised chronic myeloid leukaemia cell line KYO-1 was selected and oligonucleotides (20mers) were targeted to an empirically identified accessible site of c- myc mRNA. The efficiency and specificity of antisense effect was measured 4 and 24 h after SLO-mediated delivery of the oligonucleotides. C5-propyne phosphodiester and phosphorothioate compounds were found to present substantial non-specific effects at 20 microM but were inactive at 0.2 microM. Indeed, no antisense-specific effect was noted at any concentration at either time. All of the other oligonucleotides tested induced some measurable antisense effect, except 7 (chimeric, all-phosphorothioate, 2'-methoxyethoxy termini) which was essentially inactive at 20 microM. The rank efficiency order of the remaining antisense compounds was 4 = 3 >> 9 >> 10 = 8 = 5 = 6 > 11. The efficient antisense effects induced by the chimeric methylphosphonate-phosphodiester compounds were found to be highly specific. Increased phosphorothioate content in the oligonucleotide backbone correlated with reduced antisense activity (efficacy: 2'-methoxyethoxy series 9 >> 8 >> 7, 2'-methoxytriethoxy series 10 > 11). No consistent evidence was obtained for increased activity correlating with increased oligonucleotide-mRNA heteroduplex thermal stability. In conclusion, the chimeric methylphosphonate-phosphodiester oligodeoxynucleotides present the most favourable characteristics of the compounds tested, for efficient and specific antisense suppression of gene expression following SLO-mediated delivery.

Immunohistochemical staining for desmogleins 1 and 2 in keratinocytic neoplasms with squamous phenotype: actinic keratosis, keratoacanthoma and squamous cell carcinoma of the skin

Desmosomes are intercellular junctions that have been shown to be down-regulated in certain types of carcinoma and that may play a role in suppression of invasion and metastasis. This paper describes an immunohistochemical study of three types of epidermal neoplasms with monoclonal antibody to desmoglein in order to determine how desmosomal staining correlates with the clinical, biological and histopathological features of these neoplasms. Actinic keratosis (AK) is the most common keratinocytic premalignant neoplasm that was reported to have a 10-20% rate of malignant transformation into squamous cell carcinoma (SCC). Keratoacanthoma (KA) is a benign neoplasm that involutes spontaneously after a few months of rapid growth. SCC is a malignant tumour capable of metastasis. Electron microscope studies of KA and SCC showed significantly reduced staining for desmosomes in SCC but not in KA. We have examined staining for desmoglein using the monoclonal antibody 33-3D, a mouse IgM monoclonal antibody, that recognizes the cytoplasmic domains of desmoglein (Dsg)1 and Dsg2 on frozen sections. Immunohistochemical staining of normal skin with this antibody revealed strong pericellular localization of the antigen, outlining the cell membranes of the keratinocytes. A series of 30 AKs, 12 KAs and 24 SCCs was stained immunohistochemically with 33-3D monoclonal antibody. All examined KAs showed extensive pericellular staining for Dsg. By contrast, juxtanuclear staining for Dsg was noted in 12 SCCs, and completely negative staining in seven SCCs. The five remaining SCCs showed focal pericellular staining for the Dsg marker. The most common finding in AK was focal pericellular staining for Dsg, with complete absence of staining in dysplastic areas (25 cases). In five cases negative pericellular staining in dysplastic areas was associated with juxtanuclear accumulation of the Dsg marker. A strong negative correlation between Dsg staining and degree of dysplasia was obtained. The Dsg pattern in KA is similar to normal epidermis and shows a clear difference between KA and SCC. AK has a limited loss of Dsg expression in a SCC-like pattern that is congruent with its premalignant nature. As the stain works on frozen tissue, it may be helpful for rapid differentiation in selected cases in cutaneous oncology and Mohs micrographic surgery. This antibody may also have great potential for the detection of the effects of chemopreventive agents in skin cancer.

Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial

Integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach was compared to that within a standard case management approach for 223 patients with dual disorders over three years. ACT patients showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder.

Benefits and costs of supported employment from three perspectives

Administrators, consumers, and policy makers are increasingly interested in supported employment as a way of helping persons with severe mental illness get and keep competitive jobs. However, in an atmosphere of increased expectations for performance and declining public financing, administrators want to know the costs and benefits of different approaches before they reallocate scarce treatment or rehabilitative dollars. This article discusses the net benefits of two approaches to supported employment that were compared in a randomized trial: Individual Placement and Support (IPS) and Group Skills Training (GST). The authors analyze costs and benefits from societal, government, and consumer perspectives. Although a previous analysis showed that IPS participants were significantly more likely to find work, worked more hours, and had higher earnings, net benefits of the two programs were not significantly different. The authors also discuss some of the strengths and weaknesses of cost-benefit analysis in mental health care and suggest future directions for policy and research.

Microscopically controlled surgical excision combined with ultrapulse CO2 vaporization in the management of a patient with the nevoid basal cell carcinoma syndrome

Nevoid basal cell carcinoma syndrome is an autosomal dominant condition characterized by multiple basal cell carcinomas, skeletal abnormalities and sometimes mental retardation. The large number of tumors, which are often disfiguring, presents extreme difficulties in the treatment of these patients. Microscopically controlled excision, compared to other modalities (radiation therapy, photodynamic therapy, intralesional interferon alpha-2b) offers the highest cure rate. However, because of the large size and involvement of wide areas of the skin, this approach is sometimes impractical. The ultrapulse CO2 laser with high energy and short pulses achieves char-free ablation of the tumors, bloodless surgical field, minimal nonspecific thermal damage, rapid healing and diminished postoperative pain. Also, a number of lesions can be removed in a single session. We present a 48-year-old man with a 6.5 x 4.5 cm large basal cell carcinoma involving the anterior abdomen and navel area. The central thick portion of the tumor was resected by microscopically controlled excision with 3 stages, and wide thinner peripheral crescentic plaque vaporized with ultrapulse CO2 laser. The laser settings were 300 mJ energy/pulse and 100 W average power, which corresponds to the fluence of 7.5 J/cm2. Computerized pattern generator (ultrascan handpiece) was adjusted to patterns of 3 (circle) and 1 (square) with sizes varying from 5 to 7, and density of 9 (60% overlapping). The tumor was vaporized with 6 passes, all the way to deep reticular dermis. A fifteen month-follow up disclosed no recurrent disease. Subsequent biopsies revealed only a scar with postinflammatory hyperpigmentation. Our experience indicates that combined treatment with microscopically controlled excision and ultrapulse CO2 laser ablation is a suitable modality for the large tumor plaques involving concave and convex areas of the skin respectively. Microscopically controlled excision of thicker, concave portions of basal cell carcinoma plaques, where CO2 laser surgery is less feasible, presents an effective addition that renders this combined modality a successful method for the treatment of nevoid basal cell carcinoma syndrome.

Nail surgery

Nail deformities may present as wither medical or cosmetic problems, often requiring surgical intervention. These deformities have a number of etiologic factors including infections, inflammatory disease processes, congenital abnormalities, trauma, tumors, and systemic diseases. This article discusses several nail problems and surgery techniques.

Financing assertive community treatment

Assertive community treatment (ACT) is a widely-used intervention for the most severely impaired persons with mental illness. Because it differs from traditional treatment approaches in its philosophy, its organization, and in the clients it serves, financing strategies that are appropriate for standard services may not be optimal for ACT. In developing new payment systems, policymakers must choose between targeted strategies that attempt to influence the treatment process directly and those that establish broad goals for effectiveness, access, and efficiency while allowing providers more latitude in the treatment process. These choices profoundly influence how and to whom ACT is available.

Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor of the skin; its microscopic extent of invasion beyond the grossly visible tumor is frequently difficult to appreciate. Although wide local excision has been the standard treatment of DFSP, recurrence rates range from 11% to 53%. Because Mohs micrographic surgery allows the extent of excision to be tailored to the microscopic extent of tumor, we evaluated this technique for the treatment of primary and recurrent DFSP.

OBJECTIVE

Our purpose was to determine the local recurrence rate and microscopic extent of spread of primary and recurrent DFSP after treatment with Mohs micrographic surgery.

METHODS

The records of 58 patients with primary and recurrent DFSP treated with Mohs micrographic surgery at three institutions were reviewed and the macroscopic and microscopic extents of tumor were recorded.

RESULTS

One patient with a twice-recurrent DFSP had another recurrence after Mohs micrographic surgery, for an overall local recurrence rate of 2% (zero for primary tumors and 4.8% for recurrent tumors). There were no cases of regional or distant metastases. Macroscopic tumor size ranged from 0.3 x 0.6 cm to 30 x 20 cm, whereas microscopic (postoperative) size ranged from 1.8 x 1.0 cm to 35 x 40 cm. We calculated the likelihood that a given width of excision around the macroscopic tumor would clear the entire microscopic extent of tumor. Standard wide excision with a width of 1 cm around the primary tumor would have left microscopic residual tumor in 70.7%; a width of 2 cm, 39.7%; 3 cm, 15.5%; and 5 cm, 5.2%. Even an excision width of 10 cm would not have cleared the microscopic extent of some tumors, despite taking a huge excess of normal tissue.

CONCLUSION

Treatment of primary and recurrent DFSP by Mohs micrographic surgery results in a low recurrence rate because of the ability of the technique to permit the detection and excision of microscopic tumor elements in even the most asymmetric tumors. Whatever type of surgery is chosen to treat DFSP, it is necessary to assess the entire perimeter of the tumor for microscopic extension and to achieve tumor-free margins in all directions.

Preclinical studies of streptolysin-O in enhancing antisense oligonucleotide uptake in harvests from chronic myeloid leukaemia patients

Antisense oligodeoxyribonucleotides (ODN) have been shown to produce a sequence-specific cleavage of BCR-ABL mRNA. They may therefore have clinical potential for purging harvests from chronic myeloid leukaemia (CML) patients, prior to autografting. Whilst ODN are highly effective in cell-free systems, their uptake into intact cells is very poor. We have previously reported that reversible permeabilisation of CML cell lines with Streptolysin-O (SL-O) can dramatically increase intracytoplasmic and nuclear ODN uptake. In this study, we examined whether SL-O permeabilisation could be used to enhance ODN uptake into bone marrow (BM) and peripheral blood stem cell (PBSC) harvests from CML patients, without undue toxicity. All 19 harvests studied were from patients in stable chronic phase of CML. Samples studied were either fresh BM harvests following leucoconcentration, fresh PBSC collections, or from previously cryopreserved harvests. Cells were permeabilised by SL-O to load them with fluorescein-labelled ODN. The proportion of permeabilised and viable cells was assessed by fluorescein uptake and propidium iodide exclusion, respectively, by flow cytometry. The effect of SL-O on ODN uptake and cell toxicity was unpredictable on simple mononuclear fractions of harvests. In contrast, SL-O consistently significantly enhanced ODN uptake in samples which were first selected for CD34-positive cells, and this was achieved without either direct toxicity or inhibition of CFU-GM growth. The SL-O concentration required for optimal permeabilisation varied considerably from case to case, in line with previous data on cell lines. PBSC harvests positively selected for CD34-positive cells tended to achieve superior permeabilisation to CD34 positively selected BM harvests. SL-O can be used to safely enhance the intracellular uptake of antisense ODN. This is best achieved on harvests which are first selected for CD34-positive cells.

European results of matched unrelated donor bone marrow transplantation for chronic myeloid leukemia. Impact of HLA class II matching. Chronic Leukemia Working Party of the European Group for Blood and Marrow Transplantation

We have retrospectively analyzed the impact of prognostic factors on the outcome of serologically HLA-matched unrelated donor (UD) BMT for CML. For this purpose, we have studied a cohort of 366 patients transplanted in Europe between January 1985 and December 1994. The median age of the 211 males and 155 females was 34 years; 238 patients were transplanted in first chronic phase and 116 in advanced phases. The median interval from diagnosis to BMT was 827 days. GVHD prophylaxis consisted of CsA and MTX in 202 patients or of ex vivo or in vivo T cell depletion (TCD) in 129. Recently, DNA-based methods of HLA-class II typing have been used to improve donor selection. We obtained complete data on 300 donor/recipient (D/R) pairs. Among them, we have identified three groups of patients, according to specific HLA-DRB1 D/R compatibility. Two hundred and ten patients received marrow from donors identical for HLA-DRB1 (group 1). Thirty-one patients received BMT from a donor who was HLA-DRB1 mismatched (group 2) and 59 from a donor in whom specific HLA-DRB1 typing was not performed (group 3). The overall survival was 37 +/- 3% at 2 years and leukemia-free survival (LFS) was 31 +/- 3%. In univariate analysis, five variables had a favorable effect on LFS: transplant in first chronic phase (P = 0.0001), time interval from diagnosis to BMT shorter than the median (P = 0.01), prophylaxis of GVHD without TCD (P + 0.001), acute GVHD < grade III (P = 0.0009) and HLA-DRB1 D/R matching (P = 0.0001). Transplant-related mortality (TRM) was 49 +/- 4% in group 1, 79 +/- 8% in group 2 and 80 +/- 6% in group 3 (P = 0.0001). Multivariate analysis confirmed that HLA-DRB1 matching was the most significant factor influencing survival (P = 0.04), LFS (P = 0.013) and TRM (P = 0.0049). From these results, we have defined a 'good risk' group, ie patients transplanted in first chronic phase, from an HLA-DRB1 matched donor, without TCD as prophylaxis against GVHD. The 2 year LFS, TRM and relapse incidence for this group were 51 +/- 5%, 47 +/- 5% and 2 +/- 2%, respectively. This suggests that the long-term outcome of patients with favorable prognostic features can approach that of patients transplanted from geno-identical siblings. In contrast, the TRM for patients transplanted for advanced disease from non HLA-DRB1-identical donors was 94%. Such a high TRM clearly indicates that UD BMT is not justifiable for these individuals.

The use of antidesmoglein stains in Mohs micrographic surgery. A potential aid for the differentiation of basal cell carcinoma from horizontal sections of the hair follicle and folliculocentric basaloid proliferation

BACKGROUND

Histopathologic differentiation between benign and malignant tissue is of utmost importance for the Mohs surgeon. Folliculocentric basaloid proliferation (FBP) shares many histologic features with basal cell carcinoma (BCC). It is most commonly associated with tumors of areas with abundant hair follicles such as nasal and perinasal skin. Residual BCC incorrectly identified as a horizontally sectioned hair follicle undoubtedly increases the risk of tumor recurrence. Excision of additional layers of normal tissue to remove "funny looking follicles" may have profound impacts on tissue conservation, preservation of function, and cosmesis. Electron microscope studies of BCC revealed a significant reduction of desmosomes compared with normal basal cells and hair follicle keratinocytes.

OBJECTIVE

This study has assessed the potential of rapid staining with monoclonal antidesmoglein antibody (33-3D) to discriminate between BCC, horizontally sectioned hair follicles, and FBP.

METHODS

A rapid immunoperoxidase technique with 33-3D antidesmoglein antibody was performed on Mohs frozen sections. We selected 18 patients with BCC of nasal and perinasal locations where histologic discrimination between residual tumor and tumor-free margins with FBP or horizontally sectioned hair follicle was equivocal.

RESULTS

Fourteen sections disclosed the preservation of desmoglein marker delineating the cell membranes ("perimembranous" pattern) consistent with normal hair follicles. The sections were identified as tumor-free and no additional stages were performed. The remaining four sections revealed absent perimembranous pattern but presence of diffuse cytoplasmic staining. These were diagnosed as positive for residual BCC requiring the excision of another layer of tissue to obtain tumor-free margins. A follow-up period ranging from 6 to 24 months revealed no instance of recurrent disease.

CONCLUSION

Rapid detection of desmoglein with 33-3D antibody is a promising tool for discrimination between residual BCC and FBP or horizontally sectioned hair follicles. It may enhance the sensitivity of Mohs surgery by disclosing the hidden foci of BCC, thus preventing tumor recurrence and unnecessary excision of normal tissue.