A demographic study of the clinical significance of minimal residual disease in children with acute lymphoblastic leukemia

BACKGROUND

Minimal residual disease (MRD) detected during remission might predict outcome in children with acute lymphoblastic leukemia. No population-based studies have been carried out. We studied all children with ALL presenting over 5 years within a defined population to determine its clinical importance.

PROCEDURE

Patients were investigated for the presence of unique clonal rearrangements of IgH and T-cell receptor genes. Unique patient specific probes were used to detect, by polymerase chain reaction, the presence of clonal markers indicating MRD in mononuclear cells obtained from marrow samples at 1, 3, 5, and 24 months. The effect of MRD on event-free survival was determined.

RESULTS

Seventy-seven of 120 children with ALL had informative markers and samples of remission marrow suitable for testing. Presence or absence of MRD did not significantly affect outcome. Gender (P < 0.04) and white cell count (P < 0.04) were independent prognostic factors. Analysis of only those cases with detectable MRD showed that cases with one blast per 100 mononuclear cells, or more, 28 days after starting treatment did worse than those with lower levels (hazard ratio 7.77, P < 0.02).

CONCLUSIONS

Mere presence or absence of MRD is probably too crude a measure to be useful and worse than other standard prognostic indicators. A threshold of 10(-2) blasts at 28 days might be discriminatory, but should not be over-interpreted. The number of patients available for this analysis (31) was small, the threshold and sampling points were arbitrary and any effects could be treatment regimen-specific. Large prospective studies are needed.

OPEC/OJEC for stage 4 neuroblastoma in children over 1 year of age

BACKGROUND

This paper reports the toxicity of OPEC/OJEC chemotherapy in stage 4 neuroblastoma patients over 1 year of age.

PROCEDURE

Ninety-five patients with stage 4 neuroblastoma received alternating courses of OPEC/OJEC--vincristine 1.5 mg/m2 (O), cisplatin 80 mg/m2 (P), etoposide 200 mg/m2 (E), cyclophosphamide 600 mg/m2 (C), and carboplatin 500 mg/m2 (J), every 21 days if there was haematological recovery.

RESULTS

Seventy out of ninety-five (74%) patients completed seven or more courses and were evaluable for toxicity. Of these 70 patients, 33% had more than three episodes of fever and sepsis, 35% required more than five blood or platelet transfusions, 36% had grade 2 or more gastrointestinal toxicity and 9% had neurotoxicity. There was a median reduction in GFR of 32 ml/min/1.73 m2 (-46 to 134) and there was one toxic death.

CONCLUSIONS

OPEC/OJEC is a well-tolerated therapy for stage 4 neuroblastoma over 1 year of age.

Oral immunoglobulin for preventing necrotizing enterocolitis in preterm and low birth-weight neonates

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common emergency of the gastrointestinal tract occurring in the neonatal period. There have been published reports which suggest that oral immunoglobulins IgA and IgG produce an immunoprotective effect in the gastrointestinal mucosa. This systematic review was undertaken to clarify the issue.

OBJECTIVES

To assess whether oral immunoglobulin administered to preterm and low birth-weight neonates reduces the incidence of necrotizing enterocolitis without adverse effects.

SEARCH STRATEGY

The databases MEDLINE, CINAHL, Embase and the Cochrane Controlled Trials Register were searched. The text words 'necrotising enterocolitis OR necrotizing enterocolitis' AND 'immunoglobulin' with constraints 'neonate OR infant' were used. Proceedings of the Perinatal Society of Australia and New Zealand were hand searched. The computer neonatal discussion site 'Nicu Net' was also used. Additionally, all references in the identified trials were checked and authors were contacted to request any additional published or unpublished data.

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials where oral immunoglobulins were used as prophylaxis against necrotizing enterocolitis in preterm (<37 weeks gestation) and/or low birth-weight (<2500 gms) neonates.

DATA COLLECTION AND ANALYSIS

The procedures of the Cochrane Neonatal Review Group (CNRG) were used. The two reviewers independently assessed the trials for their methodological quality and subsequent inclusion in the review. Relative risk (RR), risk difference (RD), and number needed to treat (NNT) were used in the analysis.

MAIN RESULTS

Five studies on oral immunoglobulin for the prevention of necrotizing enterocolitis were identified of which three met the inclusion criteria. In this review of the three eligible trials (including a total of 2095 neonates) the oral administration of IgG or an IgG/IgA combination did not result in a significant reduction in the incidence of definite NEC [RR 0.84 (95% CI 0.57, 1.25), RD -0.01 (95% CI -0.03, 0.01)], suspected NEC [RR 0.69 (95% CI 0.42, 1.13), RD -0.01 (95% CI -0.03, 0.00)], need for surgery [RR 0.21 (95% CI 0.02, 1.75), RD -0.03 (95% CI -0.06, 0.00)] or death from NEC [RR 1.10 (95% CI 0.47, 2.59), RD 0.00 (95% CI -0.01, 0.01)].

REVIEWER'S CONCLUSIONS

Based on the available trials, the evidence does not support the administration of oral immunoglobulin for the prevention of NEC. There are no randomised controlled trials of oral IgA alone for the prevention of NEC.

Prevalence and detection of delirium in elderly emergency department patients

BACKGROUND

Delirium is a complex medical disorder associated with high morbidity and mortality among elderly patients. The goals of our study were to determine the prevalence of delirium in emergency department (ED) patients aged 65 years and over and to determine the sensitivity and specificity of a conventional clinical assessment by an ED physician for the detection of delirium in the same population.

METHODS

All elderly patients presenting to the ED in a primary acute care, university-affiliated hospital who were triaged to the observation room on a stretcher because of the severity of their illness were screened for delirium by a research psychiatrist using the Mini-Mental State Examination and the Confusion Assessment Method. The diagnosis of "delirium" or an equivalent term by the ED physician was determined by 2 methods: completion of a mental status checklist by the ED physician and chart review. The prevalence of delirium and the sensitivity and specificity of the ED physician's clinical assessment were calculated with their 95% confidence intervals. The demographic and clinical characteristics of patients with detected delirium and those with undetected delirium were compared.

RESULTS

A sample of 447 patients was screened. The prevalence of delirium was 9.6% (95% confidence interval 6.9%-12.4%). The sensitivity of the detection of delirium by the ED physician was 35.3% and the specificity, 98.5%. Most patients with delirium had neurologic or pulmonary diseases, and most patients with detected delirium had neurologic diseases.

INTERPRETATION

Despite the relatively high prevalence of delirium in elderly ED patients, the sensitivity of a conventional clinical assessment for this condition is low. There is a need to improve the detection of delirium by ED physicians.

A long-term study of Rattus norvegicus in the London borough of Enfield using baiting returns as an indicator of sewer population levels

This is a long-term study that investigates the dynamics of a population of Rattus norvegicus (Berk) inhabiting a sewerage system in London. Thirteen years (1986/7-1998/9) of data from sewer baiting records were analysed (a total of 35,478 records). Manholes were baited with the anticoagulant Brodifacoum (0.005%) on a pinhead oatmeal bait base. Time series analysis was conducted on the data set to determine the underlying trend of the data and the population fluctuations about this trend. An exponential curve was found to give an accurate and realistic fit to the data and indicated that the rat population had decreased over the study period. Decomposition analysis indicated a 5-year cycle best described fluctuations around this trend.

Surgery in the nineties

The population of the United States is aging, and by 2020 it is estimated that 16 per cent of U.S. citizens will be over 65 years of age. Little has been published about the results of surgery in nonagenarians but mortality rates of 45 per cent are reported. Given recent improvements in perioperative care we reviewed the experience with major general surgical operative procedures in nonagenarians. We reviewed the charts of patients greater than or equal to 90 years of age who underwent general surgical procedures at UCLA Medical Center since 1986. No patients were excluded. Thirty-two patients were identified. Most (87.5%) patients had significant premorbid conditions. The most common diagnoses were cancer (12), incarcerated hernia (seven), trauma (three), colonic volvulus (two), and cholecystitis (two). Overall perioperative mortality was 9.4 per cent (3 of 32). Twenty-two surgeries (69%) were performed on an emergency basis, and all three deaths were in this group (13.6%). Overall morbidity rate was 57 per cent. Mean intensive care unit stay was 4.8 days. Most patients were discharged home. Our findings support the perioperative safety of elective general surgery in nonagenarians (0% mortality and 20% morbidity). We also found an acceptable risk (13.6% mortality and 68% morbidity) for emergency procedures despite significant comorbid conditions. Most of the patients had acceptable functional outcomes.

Identification of members of the genera Panaeolus and Psilocybe by a DNA test. A preliminary test for hallucinogenic fungi

Abuse of hallucinogens produced by the fungal genera Psilocybe and Panaeolus are a growing problem. Five species from each of the two genera were examined in this preliminary research and a method that will unambiguously identify fungal samples as being of one of these two genera has been developed. The method uses genus specific DNA sequences within the Internal Transcribed Spacer of the ribosomal gene complex. Amplification of a common DNA product and a genus specific product results in two identifiable products, which facilitates the unambiguous identification of material from these two fungi to generic level.

Expression and proteolysis of vascular endothelial growth factor is increased in chronic wounds

Degradation of angiogenic mediators might be an underlying cause of chronic wounds. To test this hypothesis, we evaluated the expression and integrity of vascular endothelial growth factor, a potent angiogenic mediator, and its receptors, Flt-1 and KDR, in chronic venous leg ulcerations. Immunohisto- chemical, in situ hybridization, and semiquantitative reverse transcriptase polymerase chain reaction analyses all indicate that expression of vascular endothelial growth factor is elevated in ulcerative tissue, with vascular endothelial growth factor mRNA being especially pronounced in the hyperplastic epithelium of the wound margin. Flt-1 and KDR protein and mRNA were detected in the papillary vessels in close vicinity to the lesional epithelium of chronic wounds. Although increased expression of vascular endothelial growth factor protein was detected in the epidermis, the intensity of this staining was weak compared with the epidermal staining in psoriatic lesions and compared with the strong vascular endothelial growth factor mRNA signal in chronic wounds and psoriasis. To analyze whether this apparent decrease in immunoreactivity could be the result of degradation of vascular endothelial growth factor by proteolytic activities from the wound environment, we examined the stability of recombinant vascular endothelial growth factor in wound fluid from chronic leg ulcers. As demonstrated by sodium dodecyl sulfate polyacrylamide gel electrophoresis, incubation of rVEGF165 with chronic, but not acute, wound fluid resulted in rapid proteolytic degradation of rVEGF165. Protease inhibitor studies indicate that serine proteases, such as plasmin, are involved in this degradation. Together, our data show that, although vascular endothelial growth factor expression is elevated in chronic wounds, increased proteolytic activity in this environment results in its degradation, which may contribute to an impaired wound healing response.

Tracking cognitive decline in Alzheimer's disease using the mini-mental state examination: a meta-analysis

OBJECTIVES

To estimate the annual rate of change scores (ARC) on the Mini-Mental State Examination (MMSE) in Alzheimer's disease (AD) and to identify study or population characteristics that may affect the ARC estimation.

METHODS

MEDLINE was searched for articles published from January 1981 to November 1997 using the following keywords: AD and longitudinal study or prognosis or cognitive decline. The bibliographies of review articles and relevant papers were searched for additional references. All retrieved articles were screened to meet the following inclusion criteria: (a) original study; (b) addressed cognitive decline or prognosis or course of AD; (c) published in English; (d) study population included AD patients with ascertainable sample size; (e) used either clinical or pathological diagnostic criteria; (f) longitudinal study design; and (g) used the MMSE as one of the outcome measures. Data were systematically abstracted from the included studies, and a random effects regression model was employed to synthesize relevant data across studies and to evaluate the effects of study methodology on ARC estimation and its effect size.

RESULTS

Of the 439 studies screened, 43 met all the inclusion criteria. After 6 studies with inadequate or overlapping data were excluded, 37 studies involving 3,492 AD patients followed over an average of 2 years were included in the meta-analysis. The pooled estimate of ARC was 3.3 (95% confidence interval [CI]: 2.9-3.7). The observed variability in ARC across studies could not be explained with the covariates we studied, whereas part of the variability in the effect size of ARC could be explained by the minimum MMSE score at entry and number of assessments.

CONCLUSIONS

A pooled average estimate of ARC in AD patients was 3.3 points (95% CI: 2.9-3.7) on the MMSE. Significant heterogeneity of ARC estimates existed across the studies and cannot be explained by the study or population characteristics investigated. Effect size of ARC was related to the initial MMSE score of the study population and the number of assessments.

Excessive ethanol drinking following a history of dependence: animal model of allostasis

Alcohol withdrawal symptoms, particularly negative emotional states, can persist for months following the removal of alcohol. These protracted withdrawal symptoms have been implicated as an important trigger of relapse to excessive drinking in alcoholics and may represent a long lasting shift in affective tone as a result of chronic alcohol exposure. It was shown previously that ethanol-dependent rats increased their operant responding for ethanol when tested during the first 12 hr after withdrawal. The purpose of the present experiments was to determine the persistence of this finding by examining operant oral ethanol self-administration in rats with a history of physical dependence upon ethanol, detoxified and then allowed a two week period of protracted abstinence. The results of these experiments indicate that operant responding for ethanol was enhanced during protracted abstinence by 30-100% and remained elevated for 4-8 weeks post acute withdrawal. These results have important implications for understanding the characteristics and mechanisms underlying vulnerability to relapse.

Identification of hallucinogenic fungi from the genera Psilocybe and Panaeolus by amplified fragment length polymorphism

Unambiguous identification of the hallucinogenic fungi of the genera Psilocybe and Panaeolus is required by national and international drug control legislation. We report on a DNA-based test using the technique of amplified fragment length polymorphism (AFLP). AFLP can differentiate species of the two genera Psilocybe and Panaeolus by using different primer sets. The identification of hallucinogenic fungi using a DNA-based test, which can be used in conjunction with morphological features, will assist in forensic investigations.

A World Wide Web-based health resource. Survey of Missouri school nurses to determine priority health information resources for SchoolhealthLink

Two hundred ninety-two school nurses in Missouri participated in a mailed survey to aid in the design of SchoolhealthLink, a World Wide Web (WWW)-based information service for Missouri school nurses and children. The nurses identified specific health information resources likely to benefit school nurses and school children and prioritized these resources. The school nurses assigned high priority to 11 types of health information resources: individualized health care plans, emergency care plans, communicable disease control plans, acute illness, injuries, communicable diseases, hotline numbers, medications in schools, immunization protocols and standards, community-based health care resources, and Department of Elementary and Secondary Education regulations that affect school nurse practice. The four most common health problems school nurses identified were asthma, attention deficit disorder, diabetes, and head lice. SchoolhealthLink will provide a one-stop WWW-based resource for school nurses and school children.

Prolonged exposure to intermittent alcohol vapors blunts hypothalamic responsiveness to immune and non-immune signals

BACKGROUND

We have previously shown that long-term alcohol treatment blunts the ACTH response to alcohol itself, as well as to other stresses, and is accompanied by decreased pituitary responsiveness to vasopressin (VP), but not corticotropin-releasing factor (CRF). The present work aims to determine the relevance of changes in CRF and VP receptors in the pituitary gland and/or peptide stores of CRF neurons in the paraventricular nucleus (PVN) of the hypothalamus, the areas that are most directly involved in ACTH release.

METHODS

Intact male rats were exposed to alcohol using a new vapor delivery system which enables individual rat housing in boxes. Alcohol treatment was delivered for 6 hr once daily (0700-1300), after which the rats were returned to their home cages where they had free access to food and water. Control rats were kept in similar boxes, but not exposed to alcohol. Total treatment time was 8 days. All animals were equipped with indwelling jugular cannulae that were used to monitor blood alcohol levels (BALs) as well as ACTH and corticosterone release throughout drug exposure. Due to the presence of a swivel, the animals' movements were not restricted or hindered by the presence of these cannulae. On the morning of day 9, the animals were decapitated under basal conditions or exposed to a neurogenic (mild electrofootshocks) or systemic [i.v. lipopolysaccharide (LPS)] stimulus. PVN neuronal responses, indicated by changes in mRNA concentrations of the immediate early genes (IEGs) c-fos and NGFI-B, and plasma ACTH levels were measured before and during endotoxemia or electrofootshocks.

RESULTS

In the absence of alcohol, plasma ACTH and corticosterone remained at basal levels, indicating the absence of environment-induced stress. In rats exposed to alcohol, BALs were consistent and predictable, and we targeted peak values of about 200 mg%. At the end of the drug treatment period, there were no significant differences between CRF and VP receptor mRNA levels in the anterior pituitary of control and alcohol-treated rats. In contrast, alcohol treatment respectively decreased CRF and increased VP stores in the external zone of the median eminence. It also increased NGFI-B and c-fos transcripts in the magnocellular (m) portion of the PVN, but not the parvicellular (p) division of this nucleus under basal conditions (i.e., in the absence of shocks or LPS). After exposure to these stressors, on the other hand, all groups of rats showed significant increases in plasma ACTH levels as well as up-regulation of their PVN neuronal response, as indicated by changes in pPVN IEGs transcripts. However, these hormonal and neuronal responses were significantly blunted in animals pretreated with alcohol.

CONCLUSIONS

Collectively, our results suggest that decreased PVN neuronal activation represents an important mechanism of the ability of long-term alcohol treatment to blunt the ACTH response to shocks or endotoxemia. In addition, the new system of alcohol delivery that we developed is practical and reliable, and has the significant advantage that it enables measurement of circulating hormone levels during drug exposure of the animals.

Out of sight, out of mind: Female sexuality and the care plan approach in psychiatric inpatients

INTRODUCTION

This study examines how often issues surrounding sexuality were taken into account when managing 56 women inpatients of reproductive age.

METHOD

Examination of the records of women discharged from the psychiatric wards of a hospital.

RESULTS

80% for whom there was no mention of contraceptive usage were taking at least one drug that is inadvisable in pregnancy, and 53% of this group had an identified sexual partner. There was a lack of recorded data on other aspects of sexual health. When children were mentioned in the admitting history, details were incomplete.

CONCLUSION

It is argued that a thorough approach to assessment and care planning is needed in this population.

B-cell leukemia protein-2 and peptide YY chemotherapy resistance in colon cancer

BACKGROUND

Inhibition of apoptosis may allow cells with drug-induced damage to escape programmed cell death. The bcl-2 protein inhibits apoptosis and bcl-2 overexpression has been associated with drug resistance. It is our hypothesis that higher levels of bcl-2 expression will be seen in colon cancer cells resistant to PYY treatment.

METHODS

Caco2 and HCT116 colon cancer cells were treated with 2 microM PYY for 24 hours. Protein was extracted from cells surviving PYY treatment; bcl-2 expression was measured by enzyme-linked immunosorbent assay (ELISA) and confirmed by Western blotting.

RESULTS

Caco2 and HCT116 cells surviving PYY treatment demonstrated increased bcl-2 from 20.54+/-2.7 to 28.63+/-2.20 units/mL (P <0.05) and 21.98+/-1.28 to 29.32*+/-2.26 units/mL, respectively.

CONCLUSIONS

Increased expression of bcl-2 is seen in a population of colon cancer cells resistant to PYY. Hence, bcl-2 may protect neoplastic cells from apoptosis; its levels may be useful in predicting chemotherapy response and in selecting appropriate drug regimens.

When the left brain is not right the right brain may be left: report of personal experience of occipital hemianopia

OBJECTIVES

To make a personal report of a hemianopia due to an occipital infarct, sustained by a professor of neurology.

METHODS

Verbatim observation of neurological phenomena recorded during the acute illness.

RESULTS

Hemianopia, visual hallucinations, and non-occipital deficits without extraoccipital lesions on MRI, are described and discussed.

CONCLUSIONS

Hemianopia, due to an occipital infarct, without alexia, is not a disability which precludes a normal professional career. Neurorehabilitation has not been necessary.

Cyclophosphamide metabolism in children with Fanconi's anaemia

Although patients with Fanconi's anaemia (FA) exhibit a heightened sensitivity to DNA cross-linking agents, modified doses of CY continue to be used in their conditioning prior to BMT. We measured the pharmacokinetics and metabolism of CY in six children with FA using an established high performance thin layer chromatography technique. CY doses ranged between 5 and 20 mg/kg (median 10 mg/kg). The median CY clearance was 0.6 l/h/m2 (range 0.4-1.1 l/h/m2), t1/2 was 8.1 h (range 6.7-9.5 h) and volume of distribution was 0.19 l/kg (range 0.16-0.34 l/kg), respectively. These results contrast with those previously reported from a comparable group of non-FA children in whom the median CY clearance was 3.2 l/h/m2 (range 2-5 l/h/m2) (P = 0.035), t1/2 was 2.4 h (range 2-3.8 h) (P = 0.035) and volume of distribution 0.5 l/kg (range 0.26-0.95 l/kg) (NS). Unlike the control group in whom the presence of inactive metabolites of CY was common, metabolites could not be found in any FA patient. The enhanced sensitivity of children with FA to CY may in part result from altered drug metabolism.

Ascorbic acid is a potent inhibitor of various forms of T cell apoptosis

This study was designed to examine the effect of ascorbic acid (vitamin C) on various death pathways of mouse T cells. Unlike humans, mice produce their own ascorbic acid and our study tested the effect of additional ascorbic acid on murine T cells. Our data show that three T cell death pathways (growth factor withdrawal-, spontaneous-, and steroid-induced death) were inhibited when T cells were incubated with ascorbic acid. The data show that both activated and resting T cells were responsive to ascorbic acid since both populations were resistant to death stimuli when treated with ascorbic acid. Additionally, effector T cells were more likely to enter S phase if treated with ascorbic acid. Our data implicate ascorbic acid as a potent inhibitor of various forms of T cell death and suggest that vitamin C may function as an immune booster through this mechanism.

T and Tk antigen activation in necrotising enterocolitis: manifestations, severity of illness, and effectiveness of testing

AIMS

To determine if T or Tk antigen activation is associated with different and more severe manifestations of illness in infants with necrotising enterocolitis (NEC); and if a policy of testing infants with suspected sepsis or NEC for T and Tk antigen activation is effective.

METHODS

A case-control study of infants with confirmed NEC, born after the introduction of screening, was undertaken:17 activated infants were compared with 28 non-activated controls, matched for gestation and weight. A historical control study compared the outcome of infants before and after the introduction of testing.

RESULTS

Of 201 infants with confirmed NEC, 27 were T or Tk antigen activated-10 (9%) before and 17 (19%) after the introduction of testing. T or Tk antigen activated infants had a significantly higher mortality (35% vs 7%); more frequent (71% vs 21%) and severe haemolysis, hyperkalaemia, renal impairment, acidosis; and they received more colloid for resuscitation. While only known activated infants in both time periods were managed with the use of low titre T antibody blood products, there was a significant increase in mortality (odds ratios 2.6; 95% CI 1.2, 5.6) and incidence of surgery (OR 2.7; 1.5, 4.9) after the introduction of testing. The increased mortality (OR 2.6; 0.8, 5.2) and incidence of surgery (OR 1.8; 0.9, 3.7) were no longer significant after adjustment for several perinatal risk factors.

CONCLUSIONS

In a retrospective case-control study, routine testing of at risk infants increased the detection rate of T and Tk antigen activation. The use of low titre T plasma products in these patients did not reduce mortality compared with historical controls. A randomised controlled trial of testing in at risk infants, or of the use of low titre T plasma products in babies with NEC and T activation, is warranted.