A phase II evaluation of all-trans-retinoic acid plus interferon alfa-2a in stage IV melanoma: a Southwest Oncology Group study

BACKGROUND

Interferon alfa has modest but definite activity in the treatment of metastatic melanoma and is the only agent currently available for adjuvant therapy of high-risk resected disease. A variety of retinoic acid derivatives have been shown to be synergistic with interferon alfa in vitro and in vivo, with nonoverlapping toxicities. If promising combinations of interferon alfa and retinoids could be developed for melanoma patients, they would have clinical relevance for the treatment of advanced as well as localized disease.

PURPOSE

To determine the efficacy and toxicity of a combination of interferon alfa-2a and all-trans-retinoic acid in patients with measurable metastatic melanoma, the South-west Oncology Group conducted a phase II clinical trial.

PATIENTS AND METHODS

Fifty-seven patients with measurable metastatic melanoma (American Joint Committee on Cancer stage IV) were entered; five patients were unevaluable. Treatment consisted of oral all-trans-retinoic acid (37.5 to 75 mg/m2 orally twice daily for 21 days followed by 7 days' rest) plus subcutaneously administered interferon alfa-2a (6 MU/m2 three times a week).

RESULTS

Two complete and three partial responses were observed among 52 evaluable patients, for an objective response rate of 10% (95% confidence interval 3% to 21%). Responses were seen only in patients with pulmonary, nodal, or subcutaneous metastases, and lasted from 4 to 23+ months. Median survival for the 52 patients was 8 months. Side effects were tolerable but significant, with one case of grade IV anemia and 92% of patients experiencing at least grade II toxicity. Flu-like symptoms were the most commonly reported side effects. There was one case of grade III hyperlipidemia.

CONCLUSION

The combination of recombinant human interferon alfa-2a with all-trans-retinoic acid did not result in a greater percentage of objective responses or a longer overall survival than that associated with interferon alfa alone. This combination cannot be recommended for further evaluation in melanoma in either the advanced disease or the adjuvant settings.

Pulse-read on erasable thermal phase-change superresolution disks

New erasable thermal phase-change superresolution (EPSR) disks composed of mask and recording layers can increase recording density by the detection of the below-diffraction-limited marks within the readout spot. The formation of the aperture and the readout signal on the EPSR disk were analyzed. The feasibility of optically designed EPSR disks was evaluated by thermal simulation. A carrier-to-noise ratio of 32 dB at a mark size of 0.4 mum, 8 dB higher than that of a conventional disk, was obtained by application of a pulse-read method to the EPSR disks at a wavelength of 780 nm and a numerical aperture of 0.55.

Metastatic melanoma from intraocular primary tumors: the Southwest Oncology Group experience in phase II advanced melanoma clinical trials

Ocular melanoma is an uncommon malignancy that, in the presence of metastatic disease, has a poor prognosis for response to treatment and survival. Patients with ocular melanoma are often excluded from clinical trials because of the impression that these patients have a poorer response rate to treatment with anticancer agents and poorer survival, possibly related to the predominance of the liver as a site of metastasis. Sixty-four eligible patients with advanced melanoma arising from ocular primary tumors were entered into seven phase II clinical trials of anticancer therapy activated by the Southwest Oncology Group (SWOG) during the 1980s. Eligible patients with nonocular primaries entered into these trials (420 patients) served as a comparison group for survival, pretreatment characteristics, and response rates. Multivariate Cox model analysis of survival data (with survival from the time of study registration as the primary end-point) was conducted. Among the 484 patients observed, patients with ocular melanoma were older than those with nonocular primary tumors and were more likely to have visceral metastasis, metastasis to the liver, and only one metastatic site at registration, primarily to viscera and liver. The median overall survival after registration to study for both groups was 5 months. There was no significant difference in overall survival between patients with ocular melanoma and those with nonocular melanoma after adjusting for a number of prognostic factor (p = 0.43). Furthermore, the overall objective response rate of patients with ocular melanoma in these studies was not significantly different from that achieved in the nonocular group (9% vs. 11%; p = 1.00). Patients with advanced ocular or nonocular melanoma have similar response rates and survival in this series of cooperative group phase II trials. Patients with ocular primaries should not be excluded from investigational studies in advanced melanoma.

13-cis-retinoic acid or all-trans-retinoic acid plus interferon-alpha in recurrent cervical cancer: a Southwest Oncology Group phase II randomized trial

PURPOSE

Preclinical and clinical data support the study of retinoids and interferon-alpha (IFN-alpha) in advanced squamous cell carcinoma of the uterine cervix (SCC). This phase II randomized trial of the Southwest Oncology Group sought to estimate the response rate for IFN-alpha plus either 13-cis-retinoic acid (13cRA) or all-trans-retinoic acid (ATRA) in women with recurrent cervical SCC.

PATIENTS AND METHODS

Eligibility for this trial required bidimensionally measurable locally recurrent or metastatic squamous or adenosquamous carcinoma of the uterine cervix; SWOG performance status of </=2; no prior interferon, retinoids, or chemotherapy (except as radiation sensitization). All but two patients were previously treated with surgery, radiation therapy, or both. After randomization, patients received IFN-alpha-2A (subcutaneous injection; 3 x 10(6) units/m2/day) plus either 13cRA (1 mg/kg/day orally) or ATRA (150 mg/m2/day orally) in two equally divided doses.

RESULTS

Total enrollment was 63 patients, 21 in the ATRA arm, 42 in the 13cRA arm. Three patients were ineligible, 1 in the ATRA arm, 2 in the 13cRA arm. Each arm had 1 patient who received no assigned treatment and was not evaluated for response or toxicity. The ATRA/IFN-alpha response rate was 5% (1/19; 95% confidence interval = 0.1-26%), consisting of 1 partial response lasting 4 weeks. The 13cRA/IFN-alpha response rate was 8% (3/39; 95% confidence interval = 2-21%), consisting of 3 partial responses lasting 17, 22, and 24 weeks, respectively. All confirmed responses were partial. One additional unconfirmed partial response occurred in the 13cRA arm. Both regimens were generally well-tolerated and produced toxicities (principally malaise and fatigue) associated with each constituent agent's known single-agent side effects.

CONCLUSION

Based upon the results of this study, neither regimen can be recommended for further study in patients previously treated with radiation therapy.

A serotonin-like immunoreactivity is present in human cutaneous melanocytes

Immunohistochemistry was applied in the investigation of the possible existence of serotonin in human skin. It was found that epidermal melanocytes express a serotonin-like immunoreactivity. The immunoreactivity was associated with both the cytoplasm and the cellular membrane, though the latter was only found in certain cells. The serotonin anti-serum labeled the same cells as NKI-beteb, which is known as a reliable marker of melanocytes. Blocking experiments showed that both serotonin and NKI-beteb have different epitopes in the melanocytes. In in vitro studies, serotonin-like immunoreactivity appeared in approximately 90% of cultured human melanocytes, and was found both in the cytoplasm and also in the nuclei. Thus, we believe the melanocytes to be the origin of serotonin (or a serotonin-like molecule) in the skin.

Androgen therapy in chronic renal failure

Chronic renal failure, dialysis and transplantation have major effects on male reproductive health because of the impairment of spermatogenesis, steroidogenesis and sexual function. Hypothalamo-pituitary testicular dysfunction in uraemia is manifest clinically as delayed growth and puberty, sexual dysfunction, androgen deficiency, impaired spermatogenesis and infertility. Apart from renal anaemia, there are at present no proven indications for androgen therapy in chronic renal failure. This chapter reviews the basis and scope for various clinical applications of gonadotropin and androgen therapy as an adjunct to the standard medical care of chronic renal failure. The therapeutic possibilities implied by experimental and clinical findings suggesting that uraemic hypogonadism may be a functional state of gonadotropin deficiency are emphasized.

Molecular epidemiology of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae isolates in a district hospital in Taiwan

Thirty-one of 104 clinical isolates of Klebsiella pneumoniae collected over a period of 8 months were found to be putative extended-spectrum beta-lactamase (ESBL) producers. Isoelectric focusing and an iodine overlay agar method were used for preliminary identification of the ESBLs. They were further identified by DNA sequencing. Seventy-one percent of the isolates were found to produce SHV-5. The variation in the ESBL patterns of these isolates was slight, with only five patterns being identified. The strains were typed by pulsed-field gel electrophoresis (PFGE), and 16 different genotypes were identified. When the PFGE patterns were analyzed by the algorithmic clustering method called the unweighted-pair group method using arithmetic averages, five clusters were found. However, significant genetic variations were found among 11 isolates and between each cluster. A plasmid of 36 kb was found in all clinical isolates and in the transconjugants. Our results indicate that the increase in the number of ESBL-producing K. pneumoniae isolates in this hospital is due mainly to the dissemination of a resistance plasmid rather than to the clonal spread of a few epidemic strains.

Molecular epidemiology of penicillin-resistant Streptococcus pneumoniae isolated in central Taiwan

Previous studies have suggested that penicillin-resistant pneumococcal isolates (especially those with MIC > 1 microgram/mL) usually are clonally related. To test this hypothesis, the molecular epidemiology of 29 clinical isolates of penicillin-resistant pneumococci (of which 83% were also resistant to either cefotaxime or ceftriaxone) collected in central Taiwan was investigated by pulsed field gel electrophoresis. Twenty-seven distinct patterns were identified. Our results indicate that an increase in penicillin-resistant S. pneumoniae between April 1993 and June 1994 in central Taiwan is not due to the clonal dissemination of a limited number of epidemic strains.

Design and analysis for survival data under order restrictions with a modified logrank test

We previously proposed a class of ordered weighted logrank tests for analysing censored survival data under order restrictions. However, the power of these tests is asymmetrical with respect to possible alternative configurations. While it is superior in most cases, the power can be inferior to the non-ordered logrank test in extreme cases. We propose a modified ordered logrank test which performs uniformly better than the non-ordered test. The power of the modified test is equivalent to the generalized Jonckheere's test but its computation is much simpler. We give sample size requirements for sufficient power to reject the global null hypothesis at specified hazard ratios between the control group and the best group. Following Fisher's least significant difference (LSD) strategy for multiple comparisons, power investigations indicate that the nominal power for the global test carries over to the control versus best comparison during pairwise testing. The power for detecting intermediate survival differences is inadequate but the sample sizes required to detect such differences may be impractical in most applications.

beta-Lactam resistance and beta-lactamase isoforms of Moraxella catarrhalis isolates in Taiwan

Moraxella catarrhalis is an important pathogen in both upper and lower respiratory tract infections. More than 90% of isolates worldwide produce beta-lactamase. The beta-lactamases produced by M. catarrhalis can be differentiated by isoelectric focusing (IEF) into BRO-1 and BRO-2 patterns. In this study, we investigated the prevalence of various beta-lactamase isoforms in clinical isolates of M. catarrhalis in Taiwan, as well as the relationships of these isoforms with antibiotic resistance. A total of 271 clinical isolates of M. catarrhalis were collected from 12 large medical laboratories in Taiwan from 1 August 1993 to 31 July 1995. The overall prevalence of beta-lactamase production was 98.2% (266 of 271 isolates). Analytical IEF revealed BRO-1 was the most common beta-lactamase pattern among the isolates (238 isolates, 88%); BRO-2 was the only other pattern found, with 32 (12%) isolates. The geometric mean minimum inhibitory concentration of ampicillin for BRO-1 producers was 63-fold higher than that for beta-lactamase-negative isolates, and 6.5-fold higher than that for BRO-2 producers. beta-Lactam antibiotics, such as amoxicillin + clavulanate and the cephalosporins, tested were very active against this species, regardless of whether the isolate produced beta-lactamase or not. In conclusion, beta-lactamase is common among clinical isolates of M. catarrhalis in Taiwan, with BRO-1 being the most common isoform. However, because most isolates tested were still sensitive to amoxicillin + clavulanate and cephalosporins, these agents appear to be reliable alternatives to first-line therapy when M. catarrhalis is contributing to a clinical infection.

Comparison of detection of extended-spectrum beta-lactamases by agar dilution method, E-test ESBL screen and double disk test

The extended-spectrum beta-lactamases (ESBL) are derived from TEM-or SHV-enzymes. They mediate resistance to broad-spectrum beta-lactams and can cause infectious outbreaks in hospitals. Rapid recognition and diagnosis are important for the clinician to prescribe more effective treatment. In the present study, a group of 52 probable ESBL-producing Klebsiella pneumoniae and Escherichia coli having a suspected resistant antibiogram phenotype were included. The E-test ESBL screen and the double disk test were performed for these isolates for detection of ESBL-producing strains, as compared with the conventional agar dilution method. The agreement between the E-test ESBL screen or the double disk test and the conventional agar dilution method was good and the degree of agreement were 86.5% and 92.3% respectively. The results showed that both the E-test ESBL screen and the double disk test were useful and convenient for detection of ESBLs.

Neonatal withdrawal following pre- and postnatal exposure to methadone in the rat

Recent evidence has shown that infant rats undergo precipitated withdrawal following chronic postnatal injection of morphine. In this study we examined whether or not infants exposed to methadone prenatally via the placental blood supply and postnatally via the dam's milk would also experience precipitated withdrawal. Dam's were implanted on gestational day 14 with osmotic minipumps containing one of two concentrations of methadone to supply the opiate throughout gestation and the first postnatal week. Nontreated and pair-fed controls were used. On postnatal day 7, pups were injected with naltrexone and their locomotor activity and ultrasonic vocalizations measured. Methadone exposed pups were more active and vocalized more when injected with naltrexone than with saline. The controls did not show these behavioral changes. The milk of methadone-exposed dams apparently contains sufficient quantities of the opiate for dependence to develop. The results are consistent with other data that demonstrate that very young rat pups can experience an opiate abstinence syndrome that includes increased behavioral activation.

Phase II study of carmustine, dacarbazine, cisplatin, and tamoxifen in advanced melanoma: a Southwest Oncology Group study

PURPOSE

The combination of carmustine (BCNU), dacarbazine (DTIC), cisplatin (DDP), and tamoxifen (Tam) has been reported in small series to provide a response rate of 50%, but with significant myelosuppression and risk of thromboembolic complications. We performed this phase II study to assess the antitumor activity and important toxicities of this combination in the cooperative group setting.

PATIENTS AND METHODS

Seventy-nine eligible patients were treated with BCNU 150 mg/m2/d, every 6 weeks, DTIC 220 mg/m2/d on days 1 to 3 every 3 weeks, DDP 25 mg/m2/d on days 1 to 3 every 3 weeks, and Tam 20 mg orally daily throughout treatment. Treatment cycles were repeated every 6 weeks in responding or stable patients for a maximum duration of 1 year.

RESULTS

Twelve objective responses were achieved (response rate 15%, 95% confidence interval 8%-25%). Five responses were complete (CR) and seven were partial (PR). The median response duration was 8+ (range, 4-19+) months, (16+ [4-19+] for CR and 8+ [4-11] for PR), and the median survival of the entire group was 9 months. The toxicities were predominantly neutropenia and thrombocytopenia. Four patients developed thromboembolic events. Two patients died while on protocol therapy, one with complications of neutropenia, and the other with disease progression.

CONCLUSION

The activity of this regimen is in the range reported for single agents or DTIC plus DDP, and the addition of BCNU and Tam appears to increase toxicity. We do not recommend this combination for routine treatment of advanced melanoma or as the control arm in randomized studies of combination therapy.

Cryptococcal osteomyelitis: case report and review

Cryptococcosis is a disseminated infection of man and animals caused by Cryptococcus neoformans. The most commonly involved sites are the lungs and the central nervous system. Isolated osteomyelitis due to C. neoformans is a rare complication of disseminated cryptococcosis. Herein we report a case of isolated osteomyelitis due to C. neoformans. A review of the English-language literature has been made and shows 40 cases (including this present report) with detailed data available since 1956. Most of the cases occurred between the ages of 21 and 59. Seventy-five percent of cases involved only one single site of bone infection, with vertebrae being the most common site. Sarcoidosis is the most common underlying disease, followed by tuberculosis and previous steroid therapy. Most of the cases (> 60%) reported were treated successfully with medical treatment alone or the combination of medical treatment and surgical curettage.

Comparison of patient characteristics and outcome between a single-institution phase II trial and a cooperative-group phase II trial with identical eligibility in metastatic melanoma

Differences in overall survival and response rates are often noted when promising single-institution phase II treatment regimens are evaluated in a cooperative group setting. One reason for this discrepancy may be the differences in patient characteristics at the time of registration. In the metastatic melanoma literature, the prognostic factors for survival that are most frequently identified are the number of metastatic sites, visceral involvement, performance status, liver involvement, and possibly the disease-free interval and gender. A prognostic factor for response appears to be sites of involvement. A comparison of patient characteristics and outcome was conducted for patients entered in similar phase II melanoma trials at a single institution versus those in a cooperative group. Sixty-four patients at Wayne State University (WSU) were compared with 96 patients who had nearly identical eligibility criteria and were registered in the Southwest Oncology Group (SWOG). All patients were receiving comparable phase II treatments for metastatic melanoma. Southwest Oncology Group patients were significantly older (p < 0.001), had worse performance status (p = 0.03), had more visceral involvement (p = 0.001), and were more likely to have two or more metastatic sites (p = 0.02). No significant differences in gender (p = 0.55), absence or presence of liver involvement (p = 0.12), or disease-free interval were noted. These disparities, despite similar eligibility, may partly explain the observed differences in survival (WSU median = 10 months, SWOG median = 7 months; p = 0.13) and response rates (WSU = 31%, SWOG = 15%; p = 0.02) between the two groups of patients. Investigators should report these important patient characteristics in treatment reports. These differences highlight the difficulty in comparing single-institution and cooperative-group phase II trials, even with comparable patient eligibility. This serves to emphasize the need for well-designed phase III trials when comparing treatment approaches and stratification for the prognostic factors identified.

In vitro antimicrobial activity of levofloxacin against Streptococcus pneumoniae

BACKGROUND

Infections caused by Streptococcus pneumoniae continue to be a significant cause of mortality and morbidity in humans. Diseases caused by multi-resistant pneumococci are increasing rapidly worldwide. The fluoroquinolones have been widely used clinically to treat infectious diseases. The results of a study here on the five fluoroquinolones susceptibilities of S. pneumoniae are reported from the Taichung Veterans General Hospital.

METHODS

Minimum inhibitory concentrations (MICs) of five quinolones (enoxacin, norfloxacin, ofloxacin, levofloxacin and ciprofloxacin) were determined for 106 strains of S. pneumoniae. All MICs were determined by the agar dilution method utilizing Mueller-Hinton agar supplemented with 5% sheep blood.

RESULTS

MIC90 of levofloxacin was 1 microgram/ ml, and was unaffected by penicillin-susceptibility. MIC90 of ofloxacin and that of ciprofloxacin were 2 and 4 micrograms/ml, respectively, with 90.6% sensitive to ofloxacin. MIC90 of enoxacin and that of norfloxacin were higher than other compounds.

CONCLUSIONS

The in vitro activity of levofloxacin is twice that of ofloxacin, 4-fold of ciprofloxacin, 16-fold of norfloxacin, and 64-fold of enoxacin. MICs of these five quinolones were unaffected by penicillin-susceptibility. The antibacterial activity of levofloxacin was better than that of ofloxacin and ciprofloxacin, norfloxacin, or enoxacin against S. pneumoniae.

Use of different PCR-based DNA fingerprinting techniques and pulsed-field gel electrophoresis to investigate the epidemiology of Acinetobacter calcoaceticus-Acinetobacter baumannii complex

Acinetobacter calcoaceticus-Acinetobacter baumannii complex is an important nosocomial pathogen for which optimal typing methods in epidemiologic investigations have not been defined. We compared DNA macrorestriction analysis by pulsed-field gel electrophoresis (PFGE) with different PCR-based DNA fingerprinting techniques, including enterobacterial repetitive intergenic consensus (ERIC) polymerase chain reaction (PCR), repetitive extragenic palindromic (REP) PCR, arbitrary-primed PCR with primer M13, and multiplex PCR with primers REP-1, REP-2 and M13, for characterization of 98 clinical isolates (including 10 apparent outbreak-related isolates and 68 presumed epidemiologically unrelated isolates) in a tertiary-care hospital over a 4-year period. The PFGE patterns after Smal restriction of the bacterial DNA were analyzed by computer software (Gelcompar) using the unweighted pair group method with arithmetic averages clustering and the Dice coefficient. A cluster of 48 isolates (cluster A), including 9 outbreak isolates, linked at a level of 83.4% similarity was observed. This epidemic strain and its variants were also found among the 68 presumed epidemiologically unrelated isolates, and this may represent ongoing endemic infection in this institution. The discrimination index for the PCR-based DNA fingerprinting techniques was 0.75 for enterobacterial repetitive intergenic consensus 1, 0.71 for M13, 0.77 for REP-1, 0.77 for REP-2, and 0.87 for multiplex PCR. The discriminatory power of PFGE was found to be higher than those of PCR-based techniques. It was concluded that both PFGE and PCR-based fingerprinting are useful for typing of A. calcoaceticus-A. baumannii complex. However, PFGE can detect minor mutations among outbreak strains, and this is important for epidemiological study of this species in a complex endemic setting.

Growth factors in the repair of partial thickness porcine skin wounds

In 28 porcine partial thickness excisional wounds, the presence of several growth factors was first studied by enzyme-linked immunoadsorbent assay on wound fluid collected in sealed wound chambers. Basic fibroblast growth factor (bFGF) peaked on day 1 at 31.4 pg/ml; platelet derived growth factor (PDGF)-AB on day 3 reached 45.2 pg/ml, and transforming growth factor-beta (TGF-beta) on day 7 was 726.1 pg/ml. The same chamber system was used in 48 partial thickness excisional wounds for delivery of nanogram doses of bFGF, PDGF-AB, insulin-like growth factor (IGF)-1, epidermal growth factor (EGF), and cholera toxin. PDGF and EGF accelerated healing (1.1 days and 0.3 days, respectively), whereas bFGF and IGF-1 had no effect. Cholera toxin retarded healing by 1.9 days. Furthermore, in 100 excisional wounds EGF in the concentration range of 10 to 1,000 ng/ml had the same stimulating effect on healing. EGF at 10,000 ng/ml significantly delayed healing. The wound chamber model is useful for detecting of endogenous growth factors as well as for delivering exogenous factors.

Comparison of polymerase chain reaction and pulsed-field gel electrophoresis for the epidemiological typing of Alcaligenes xylosoxidans subsp. xylosoxidans in a burn unit

Eighteen isolates of Alcaligenes xylosoxidans subsp. xylosoxidans were collected from clinical specimens of 15 patients in a burn unit and a plastic surgery ward over a 16-month period. Pulsed-field gel electrophoresis and polymerase chain reaction (PCR) were compared for the epidemiologic typing of these 18 isolates and fifteen epidemiologically unrelated strains. These 18 isolates demonstrated an identical fingerprint pattern and were easily distinguished from the 15 epidemiologically unrelated strains by pulsed-field gel electrophoresis typing and both enterobacterial repetitive intergenic concensus and repetitive extragenic palindrome-primed PCR fingerprinting. We conclude that pulsed-field gel electrophoresis analysis of XbaI-digested genomic DNA is a highly discriminatory and reproducible method for epidemiological typing of A. xylosoxidans subsp. xylosoxidans isolates. However, poor resolution due to frequent cutting in the smaller fragments (< 145.5 Kb) may lead to difficulty in interpretation. PCR is a rapid and highly discriminatory, but less reproducible, technique with occasional loss of major bands. The fingerprints produced by repetitive extragenic palindrome primed PCR had more intense bands and were easier to read than those produced by enterobacterial repetitive intergenic concensus-primed PCR in this study.

Use of pulsed-field gel electrophoresis to investigate a pseudo-outbreak of Bacillus cereus in a pediatric unit

Bacillus cereus is a well-known cause of food poisoning. It also causes rare systemic infections, usually in immunocompromised patients. Dissemination of this species in hospitals had been reported. Most of these episodes were pseudo-outbreaks and were usually secondary to equipment or environmental contamination. We report here on the use of pulsed-field gel electrophoresis (PFGE) to analyze a pseudo-outbreak of B. cereus in a pediatric unit. Different restriction endonucleases had been tested, and SmaI was found to give the best result for PFGE. Among the 26 clinical isolates of B. cereus and the type strain of the species, 15 distinct PFGE patterns were distinguished. PFGE after DNA macrorestriction with SmaI could clearly differentiate between the epidemiologically related isolates and the unrelated isolates. Because the same epidemic strain of B. cereus was isolated from the settle plates which were exposed near the outlet of the ventilation system, the source of this pseudo-outbreak was suspected to be the unit's air filtration system. This is one of the first reports of the application of PFGE to the study of B. cereus, and this method is useful for epidemiological investigation.

Effectiveness of a violence prevention curriculum among children in elementary school. A randomized controlled trial

OBJECTIVE

To determine if a commonly used violence prevention curriculum, Second Step: A Violence Prevention Curriculum, leads to a reduction in aggressive behavior and an increase in prosocial behavior among elementary school students.

DESIGN

Randomized controlled trial.

SETTING

Urban and suburban elementary schools in the state of Washington.

PARTICIPANTS

Six matched pairs of schools with 790 second-grade and third-grade students. The students were 53% male and 79% white.

INTERVENTION

The curriculum uses 30 specific lessons to teach social skills related to anger management, impulse control, and empathy.

MAIN OUTCOME MEASURES

Aggressive and prosocial behavior changes were measured 2 weeks and 6 months after participation in the curriculum by parent and teacher reports (Achenbach Child Behavior Checklist and Teacher Report Form, the School Social Behavior Scale, and the Parent-Child Rating Scale) and by observation of a random subsample of 588 students in the classroom and playground/cafeteria settings.

RESULTS

After adjusting for sex, age, socioeconomic status, race, academic performance, household size, and class size, change scores did not differ significantly between the intervention and control schools for any of the parent-reported or teacher-reported behavior scales. However, the behavior observations did reveal an overall decrease 2 weeks after the curriculum in physical aggression (P=.03) and an increase in neutral/prosocial behavior (P=.04) in the intervention group compared with the control group. Most effects persisted 6 months later.

CONCLUSIONS

The Second Step violence prevention curriculum appears to lead to a moderate observed decrease in physically aggressive behavior and an increase in neutral and prosocial behavior in school.

Use of pulsed-field gel electrophoresis to investigate an outbreak of Serratia marcescens

Pulsed-field gel electrophoresis (PFGE) typing was applied to the epidemiological investigation of 20 Serratia marcescens isolates collected from urine specimens of 17 patients and three urinals over a 2-month period. Twenty-five epidemiologically unrelated strains were also tested to determine the discriminatory power of PFGE. The PFGE fingerprints of each isolate were consistent in three different tests. The 20 outbreak isolates had an identical PFGE fingerprint pattern, while the epidemiologically unrelated strains demonstrated unique PFGE fingerprint patterns. The source of the outbreak was inadequately disinfected urinals. We conclude that PFGE served as a highly discriminatory and reproducible method for the epidemiological investigation of the outbreak of S. marcescens infection addressed by this study.

Intraperitoneal cisplatin plus intravenous cyclophosphamide versus intravenous cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer

BACKGROUND

Intravenous platinum-based chemotherapy is the standard primary therapy for advanced ovarian cancer. We conducted a phase 3 trial to compare the effects of intraperitoneal and intravenous cisplatin on the survival of women with previously untreated, stage III, epithelial ovarian cancer.

METHODS

The patients underwent an initial exploratory laparotomy and resection of all tumor masses larger than 2 cm. Within four weeks after surgery, six courses of intravenous cyclophosphamide (600 mg per square meter of body-surface area per course) plus either intraperitoneal cisplatin (100 mg per square meter) or intravenous cisplatin (100 mg per square meter) were administered at three-week intervals.

RESULTS

Of 654 randomized patients, 546 were eligible for the study. The estimated median survival was significantly longer in the group receiving intraperitoneal cisplatin (49 months; 95 percent confidence interval, 42 to 56) than in the group receiving intravenous cisplatin (41 months; 95 percent confidence interval, 34 to 47). The risk of death was lower in the intraperitoneal group than in the intravenous group (hazard ratio, 0.76; 95 percent confidence interval, 0.61 to 0.96; P = 0.02). Moderate-to-severe tinnitus, clinical hearing loss, and neuromuscular toxic effects were significantly more frequent in the intravenous group.

CONCLUSIONS

As compared with intravenous cisplatin, intraperitoneal cisplatin significantly improves survival and has significantly fewer toxic effects in patients with stage III ovarian cancer and residual tumor masses of 2 cm or less.

Epidemiological typing of isolates from an outbreak of infection with multidrug-resistant Enterobacter cloacae by repetitive extragenic palindromic unit b1-primed PCR and pulsed-field gel electrophoresis

An outbreak of multidrug-resistant Enterobacter cloacae infection lasted for 4 months in a neonatal intensive care unit (NICU). Forty-six isolates from the NICU and 20 epidemiologically unrelated strains were characterized by pulsed-field gel electrophoresis (PFGE) and repetitive extragenic palindromic unit b1-primed PCR (REPUb1-PCR) typing. The PFGE patterns after XbaI restriction of the bacterial DNA were analyzed by computer software (Gelcompar) using the UPGMA (unweighted pair group method with arithmetic averages) clustering method and the Dice coefficient. The 46 isolates from the NICU were classified by PFGE typing into five clusters: A (further classified into 7 subtypes, A1 to A7), B, C, D, and E. This outbreak was attributed to multiple genetically related strains of cluster A which had a similarity of 85.8% +/- 4.6%. The minor band differences among strains of cluster A were probably due to minor genetic mutations. The type A1 and A3 strains were isolated from the clinical specimens of patients and hands of nurses. It was probable that these outbreak strains were transmitted among patients via the hands of personnel. REPUb1-PCR typing of the 46 isolates also demonstrated five types, in agreement with results obtained by the PFGE technique, but could not detect the minor mutations among the cluster A strains. Twenty epidemiologically unrelated strains were well distinguished by both PFGE and REPUb1-PCR typing. We conclude that PFGE is a highly discriminatory but time-consuming method for epidemiological typing of E. cloacae and that REPUb1-PCR is a more rapid method with good reproducibility and discriminatory power comparable to that of PFGE.

Comparison of polymerase chain reaction and pulsed-field gel electrophoresis for the epidemiological typing of Campylobacter jejuni

Seventeen sporadic Campylobacter jejuni enteritis cases occurred in Taichung City, Taiwan between July 1995 and September 1995. Pulsed-field gel electrophoresis (PFGE) and enterobacterial repetitive intergenic consensus (ERIC-1) primed polymerase chain reaction (PCR) techniques were compared for the epidemiological typing of the 17 C. jejuni isolates. Fourteen distinct PFGE fingerprint patterns were observed. Fifteen distinct PCR fingerprint patterns were demonstrated. Two clusters of isolates (isolates 5 and 6; isolates 10, 11 respectively) were found to be genetically indistinguishable by both methods. In conclusion, we consider that PFGE is a highly reproducible method for determining the relatedness among the C. jejuni isolates in this study, although their limited numbers of restriction fragments may reduce the discriminatory power. Although less reproducible than PFGE typing, ERIC-1 primed PCR can be used as a simple and rapid tool to discriminate different strains of C. jejuni.

The occurrence of cutaneous nerve endings and neuropeptides in vitiligo vulgaris: a case-control study

Pioneering studies both in humans and animals have demonstrated an association between the peripheral nervous system and epidermal melanocyte destruction. The presence of certain neuropeptides and neuronal structural markers in peripheral nerve fibres was investigated in involved and uninvolved vitiligo skin and compared with normal healthy skin. A group of 18 vitiligo vulgaris patients and matched healthy volunteers participated in the investigation. The indirect immunofluorescence technique was employed. There was a tendency for a reduction in the number and intensity of low affinity (p75) nerve growth factor receptor immunoreactive (NGFr-IR) basal keratinocytes in involved vitiliginous skin (P < 0.06) compared with control skin, while the number of NGFr-IR nerve fibres was significantly increased (P < 0.01). The number of calcitonin gene-related peptide (CGRP)-IR nerve fibres in the epidermis and papillary dermis was dramatically increased in involved skin as compared with control skin (P < 0.01) and with uninvolved skin (P < 0.05). No clear difference could be found in the distribution of vasoactive intestinal polypeptide (VIP)- and neuropeptide tyrosine (NPY)-IR nerve fibres. A different structural appearance of the peripheral nervous system as well as a changed balance of neuropeptides in vitiliginous skin point to a critical role of the nervous system in the pathogenesis of vitiligo.

The effectiveness of weekly iron supplementation regimen in improving the iron status of Chinese children and pregnant women

It is evident that intermittent iron supplementation is better than daily supplementation in two aspects: iron absorption is more efficient and has insignificant side effects in contrast to the daily dose. The significantly higher daily iron loss observed in the daily iron supplemented groups rats also suggests alterations in total body iron metabolism. Based on serum ferritin distribution patterns, intermittent iron supplementation avoids temporary iron overload with daily iron supplemented. We conclude that weekly iron supplementation scheme is safer and easier to administer. This feasible strategy for the control of iron deficient anemia in pregnant women and children would be an effective iron-supplementation program (Baily et al., 1993).

A phase II trial of piroxantrone in endometrial cancer: Southwest Oncology Group study 8918

A phase II trial of the new anthrapyrazole piroxantrone was carried out by the Southwest Oncology Group in patients with advanced metastatic or recurrent endometrial cancer. A two-stage statistical design targeted accrual of 20 eligible patients. The starting dose of piroxantrone was 150 mg/m2 in patients without prior radiation therapy (RT) and 120 mg/m2 in patients with prior RT. There were 15 eligible patients, six of whom had received prior hormonal therapy while nine patients had not received prior hormonal therapy. Eight patients had received prior RT while seven patients had not received any prior RT. One to seven cycles of piroxantrone were administered. Dose escalation was feasible in four patients. No grade 5 toxicity was experienced by any patients. Most of the grade 4 (granulocytopenia in one) and grade 3 (leukopenia in three, granulocytopenia in three, anemia in two and thrombocytopenia in one) toxicity was related to myelosuppression. Grade 3 non-hematologic toxicities were nausea, fatigue and SGOT elevation. There was one partial response for a response rate of 7% (95% CI 0.2-32%) and median survival was 11 months (95% CI 3-13 months). The study was prematurely terminated due to lack of patient accrual.

Debridement of porcine burns with a highly purified, ananain-based cysteine protease preparation

A novel enzymatic debriding agent was evaluated on experimental full-thickness porcine contact burns. This agent consists of a highly purified, ananain-based, cysteine protease preparation formulated in a hydrophilic cream vehicle. Debridement of full-thickness burns was found to be dependent on several factors including the concentration of enzyme in the vehicle, the duration of treatment, and the hydration status of the burn wound before treatment. With an optimized debridement regimen, burns were consistently debrided of all gelatinized tissue with two 5-hour treatments. Histologic evaluation of the debrided wounds revealed an acellular deeper dermis that was debrided of necrotic cellular debris; however, the collagen matrix of the deeper dermis remained intact. This observation was consistent with a demonstrated in vitro specificity of the ananain-based protease for gelatin over collagen. A direct comparison of debridement efficacy with sutilains ointment, showed the ananain-based, debriding enzyme preparation to provide more rapid debridement of gelatinized tissue. Enzymatically debrided wounds exhibited graft take only after surgical excision of approximately 1 mm of the remaining acellular, avascular dermis. This highly purified enzyme preparation offers the potential for rapid nonsurgical debridement of gelatinized burn tissue, but required additional surgical debridement for graft take in this porcine model.

Intraperitoneal mitoxantrone or floxuridine: effects on time-to-failure and survival in patients with minimal residual ovarian cancer after second-look laparotomy--a randomized phase II study by theSouthwest Oncology Group

A randomized phase II study of intraperitoneal (ip) mitoxantrone or floxuridine (FUDR) was performed for the treatment of minimal residual epithelial ovarian cancer found at second-look laparotomy after initial platinum-based chemotherapy. Entry was to take place within 30 days of reassessment laparotomies, with documentation of peritoneal metastases either microscopic or gross with cytoreduction to less than or equal to 1 cm in largest diameter. Patients were stratified by the site of the largest disease present (microscopic to 0.5 cm maximum diameter versus greater than 0.5 to 1 cm maximum diameter), by time of registration (< 14 days versus up to 30), and by serum CA-125 (< or = 35 versus >35 units/ml) prior to randomization to either ip mitoxantrone 10 mg/m2 every 2 weeks X 9 or ip floxuridine (FUDR) 3 g (total dose)/ day X 3 days every 3 weeks X 6 cycles. Implantable ip systems and 1.5-2 liters of normal saline were used to deliver the drugs of 83 patients registered between December 1988 and January 1994; there were 6 pathology exclusions and 9 surgical exclusions, and 1 nonevaluable patient for a total of 39 evaluable on mitoxantrone and 28 on FUDR being evaluable. FUDR is the choice for further study because of a progression-free survival exceeding 15% at 1 year over mitoxantrone and a median overall survival of 38 months. It should be emphasized again that the goal of a randomized phase II selection design is to select a winner for phase III testing should there be a substantial difference between the treatments with respect to the primary endpoint. Comparative conclusions between the treatment arms should not be attempted due to the inherently much smaller sample sizes. This should reemphasize the limitations in a comparison of efficacy; however, the toxicologic differences still emerge quite clearly.

The addition of tamoxifen to dacarbazine and cisplatin in metastatic malignant melanoma. A phase II trial of the Southwest Oncology Group, (SWOG-8921)

Based on the reports of substantial improvement in the response rate w ith the addition of tamoxifen to a multiagent chemotherapy regimen for metastatic melanoma, Southwest Oncology Group (SWOG)-8921 was initiated. A prior regimen (SWOG-8804) of dacarbazine (DTIC) 750 mg/m(2) i.v. day 1 and cisplatin 100 mg/m(2) day 1 repeated every 3 weeks produced a 13% response rate in patients with metastatic melanoma without brain metastasis. SWOG-8921 using identical chemotherapy and schedule added tamoxifen 10 mg twice daily. There were 55 eligible patients registered, median age 52, with 37 men and 18 women. Fifty (91%) patients had evidence of visceral metastasis at registration. There were 10 responders (2 complete and 8 partial responses) for an 18% response rate (95% CI, 9-31%). The response rate in women was 28% (95% CI, 10-53%; in men, 14% (95% CI, 5-29%). Tamoxifen has produced a small increase in the response rate when added to the present combination and schedule of chemotherapy. Further Phase III trials will be necessary to assess whether there is a statistical advantage to the use of tamoxifen when combined with chemotherapy and whether there are statistical differences between men and women.

Antimicrobial susceptibility of clinical isolates of Acinetobacter baumannii

The in-vitro activity of 18 antimicrobial agents alone or in combination against 248 clinical isolates of Acinetobacter baumannii from Taiwan were tested by agar dilution. The MIC90S of ampicillin, amoxicillin, piperacillin, cefuroxime, cefotaxime, ceftriaxone, gentamicin, and amikacin were at least 128 mu g/ml. Ceftazidime, cefepime, sulbactam, clavulanic acid, and tazobactam presented moderate activity with MIC90S of 32, 16, 16, 32, and 32 mu g/ml, respectively. The increased activity of ampicillin/sulbactam, amoxicillin/clavulanic acid, and piperacillin/tazobactam was due to the intrinsic effect of sulbactam, clavulanic acid, and tazobactam, respectively. Imipenem, meropenem, and ciprofloxacin were the most active antimicrobial agents with MIC90S of 1, 1, and 0.5 mu g/ml, respectively. Nineteen isolates (7.7%) were resistant to all aminoglycosides and beta-lactam antibiotics, except carbapenems and ciprofloxacin. We are concerned about the multidrug resistance of A. baumannii in this study.

Use of restriction endonuclease analysis of plasmids and pulsed-field gel electrophoresis to investigate outbreaks of methicillin-resistant Staphylococcus aureus infection

We used restriction endonuclease analysis of plasmids (REAP) and pulsed-field gel electrophoresis (PFGE) to investigate clusterings of methicillin-resistant Staphylococcus aureus (MRSA) infections in our orthopedic unit, neurosurgery unit, intensive care unit, and burn unit. Fourteen different strain types were identified by REAP and 10 different strain types were identified by PFGE among 25 MRSA isolates collected during these incidents of infection. Though neither technique was clearly superior to the other for typing MRSA isolates, REAP is recommended as a relatively simple and reproducible technique for the preliminary investigation of MRSA infection outbreaks in clinical settings.

Epidemiological typing of Flavimonas oryzihabitans by PCR and pulsed-field gel electrophoresis

Flavimonas oryzihabitans has emerged as a potential nosocomial pathogen in recent years. The typing method for characterization of this species has never been reported before. Pulsed-field gel electrophoresis (PFGE) and enterobacterial repetitive intergenic consensus (ERIC)-based PCR were used to generate DNA fingerprints for 14F. oryzihabitans isolates obtained from eight episodes of nosocomial infections during a 2-year period. Both techniques successfully classified these clinical isolates into eight distinct genotypes, thus indicating that all of these episodes of infections were independent. In contrast, repeated isolates from the same patient were assigned to identical genotypes. The reproducibility of both techniques was good. Therefore, we conclude that both PFGE and ERIC-PCR have comparable reproducible and discriminatory powers for the typing of F. oryzihabitans and may be useful for clarifying the epidemiology of this species; however, ERIC-PCR has the advantages of both speed and simplicity.

Comparison of different PCR approaches for characterization of Burkholderia (Pseudomonas) cepacia isolates

In this study, we evaluated three PCR methods for epidemiological typing of Burkholderia (Pseudomonas) cepacia--PCR-ribotyping, arbitrarily primed PCR (AP-PCR) and enterobacterial repetitive intergenic consensus sequence PCR (ERIC-PCR)--and compared them with pulsed-field gel electrophoresis. The analysis was performed with 31 isolates of B. cepacia, comprising 23 epidemiologically unrelated isolates and 8 isolates collected from the same patient during two episodes of bacteremia. Pulsed-field gel electrophoresis, ERIC-PCR, and AP-PCR identified 23 distinct types among the 23 unrelated isolates, while PCR-ribotyping only identified 12 strain types, even after AluI digestion of the amplification products. Among the eight isolates collected from the same patient, all typing techniques revealed two clones of strains. The day-to-day reproducibilities of PCR-ribotyping and ERIC-PCR were good, while greater day-to-day variations were noted in the fingerprints obtained by AP-PCR. We conclude that all three PCR techniques are useful for rapid epidemiological typing of B. cepacia, but ERIC-PCR seems to be more reproducible and discriminative.

Immunohistochemical evidence of alpha-, beta- and gamma 3-melanocyte stimulating hormone expression in cutaneous malignant melanoma of nodular type

Opiomelanocortins are formed after cleavage of the larger precursor molecule, proopiomelanocortin (POMC), which contains several peptide residues, sharing certain amino acid homology, including adrenocorticotrophic hormone (ACTH) and alpha-, beta- and gamma-melanocyte stimulating hormone (MSH). The expressions of alpha-, beta- and gamma 3-MSH in human cutaneous malignant melanoma of nodular type are demonstrated. For the MSHs, the immunolabelling was concentrated mostly in the tumour cellular cytoplasm, with occasional cells displaying a nuclear staining. Labelled tumour cells were dispersed throughout the epidermis and dermis as individual cells or in so-called 'pearl-like nests', most of which consisted mainly of round or oval shaped cells as well as a few pleomorphic or spindle-shaped cells. The fluorescence intensity seemed to increase in accordance with the development of the tumours. All cases examined were clearly stained with protein S-100, which provided us with a definite diagnosis. Considering the overall MSHs-related staining intensity of each section, the general perception we got was that the closer to the centre of the tumour parenchyma, the stronger was the staining and, furthermore the larger/more poorly differentiated the cells, the stronger was the staining. We also found the MSHs expressions to appear in the peripheral part of the tumour and the perilesional tissues including epidermis, sweat glands, sebaceous glands as well as hair follicles. Neurohypertrophic features were encountered including increases in both the number of nerve fibres and their diameter. Our results presented here strongly support the viewpoint earlier proposed that MSH peptides, by an autocrine and/or paracrine production from melanoma cells, are engaged in the regulation of melanogenesis, growth and proliferation of the tumour cells. We also conclude that, although alpha-, beta- and gamma 3-MSH peptides do not provide as high a sensitivity for diagnosis as protein S-100, they appear as useful markers for supportive diagnosis and assessment of malignant melanoma.

DNA fingerprinting of Pseudomonas aeruginosa serotype O11 by enterobacterial repetitive intergenic consensus-polymerase chain reaction and pulsed-field gel electrophoresis

We report the use of pulsed-field gel electrophoresis (PFGE) and enterobacterial repetitive intergenic consensus (ERIC)-based polymerase chain reaction (PCR) to characterize clinical isolates of Pseudomonas aeruginosa serotype O11 collected from an incident of hospital-acquired infection. Both typing techniques differentiated 20 different strain types among seven epidemiologically related isolates and 22 epidemiologically unrelated isolates. There was complete concordance between these two techniques. Our results indicate that the ERIC-based PCR technique represents a rapid and simple means for typing P. aeruginosa serotype O11 with a level of discrimination equivalent to that of PFGE.

Comparison of susceptibility to extended-spectrum beta-lactam antibiotics and ciprofloxacin among gram-negative bacilli isolated from intensive care units

The in vitro activities of extended-spectrum beta-lactam antibiotics (including piperacillin, cefotaxime, ceftriaxone, ceftazidime, cefepime, imipenem, and meropenems) were assessed and compared with the activity of ciprofloxacin against 366 clinical Gram-negative bacilli isolates from the intensive care units of Taichung Veterans General Hospital. The most prevalent species isolated were Pseudomonas aeruginosa and Acinetobacter baumannii. The activities of ceftazidime, cefepime, imipenem, and meropenem against these isolates were comparable to that of ciprofloxacin. Meropenem was found to be the most potent extended-spectrum beta-lactam antibiotic tested and the MIC50s and MIC90s for most of these multiresistant strains were lower than those of imipenem, ceftazidime, and cefepime, except for Stenotrophomonas maltophilia. The extended-spectrum beta-lactam antibiotics that were still active against S. maltophilia were piperacillin and ceftazidime. More than 50% of Enterobacter spp. were resistant to third-generation cephalosporins and piperacillin, but they remained susceptible to carbapenems and cefepime.

Prenatal administration of buprenorphine using the osmotic minipump: a preliminary study of maternal and offspring toxicity and growth in the rat

Buprenorphine, an opioid with mixed agonist-antagonist properties, is gaining new attention as an effective pharmacotherapy for opioid and possibly cocaine abuse. With a view to its consideration for use with pregnant clients and because so little is know of its potential developmental toxicity, we have carried out this preliminary study. Three doses of buprenorphine (BUP) were administered by osmotic minipump from day 8 of gestation through parturition. In addition to 0.3, 1.0, and 3.0 mg/kg/day of BUP, a vehicle control group received sterile water via minipump and a nontreated control group was left undisturbed during pregnancy. All treated and control litters were fostered at birth to untreated dams. BUP produced a dose response reduction in maternal water intake but had no effect on maternal weight gain, the frequency of resorptions, or birthweight. BUP had no effect on perinatal mortality and produced inconsistent effects on postnatal growth. The unique chemical and pharmacological properties of this compound, especially its bell-shaped or asymptotic dose response effects, are discussed with respect to the development of an adequate animal model to evaluate neurobehavioral effects and assess its safety for use during pregnancy.

Analysis of clonal relationships among isolates of Shigella sonnei by different molecular typing methods

Shigella sonnei is a major cause of diarrheal disease in developed as well as in developing countries. Epidemiologic studies of this organism have been limited by the lack of a simple and effective method for comparing strains. In this study, we have compared different molecular typing methods, i.e., plasmid profile analysis, restriction endonuclease analysis of plasmids, rRNA gene restriction analysis (ribotyping), pulsed-field gel electrophoresis (PFGE), and enterobacterial repetitive intergenic consensus (ERIC) sequence-based PCR (ERIC-PCR) for typing 20 clinical isolates of S. sonnei collected from six incidents of infection. PFGE and ERIC-PCR fingerprintings had the highest discriminatory power for discrimination of epidemiologically related isolates from epidemiologically unrelated strains of S. sonnei, and both gave seven distinct strain types among these isolates and the type strain of the species. Plasmid study and ribotyping produced only six and typing techniques demonstrated two distinct patterns, respectively, among these strains. All of these molecular an identical fingerprint for eight temporally related sporadic isolates. It is possible that these temporally related isolates belonged to a single bacterial clone and circulated obscurely through the community. Our results indicate that the ERIC-PCR technique represents a rapid and simple means for typing S. sonnei with a level of discrimination equivalent to that of PFGE but greater than those of plasmid profile analysis, restriction endonuclease analysis of plasmids, and ribotyping.

A phase II trial of piroxantrone in advanced ovarian carcinoma after failure of platinum-based chemotherapy: Southwest Oncology Group Study 8904

A phase II trial of the new anthrapyrazole piroxantrone was conducted by the Southwest Oncology Group in advanced ovarian carcinoma. The objective were to evaluate its response rate and toxicity in patients who had disease persistence, progression, or recurrence either during or after platinum-containing chemotherapy. A two-stage statistical design targeted accrual to 15 eligible patients if no responses were observed. The piroxantrone starting dose was 120 mg/m2, with the provision to escalate to 150 and 180 mg/m2. There were 16 eligible patients, all of whom had received either one (12 patients) or two (4 patients) prior platinum-containing regimens; one patient had received doxorubicin. Fourteen of the 16 patients were enrolled either at the time of disease persistence/progression during initial chemotherapy or with recurrence or progression within 6 months of the previous platinum-based remain. One to 5 cycles of piroxantrone were given. Dose escalation was feasible in 7 patients but was prevented in the other 9 by neutropenia. Maximum toxicity for all cycles was none or grade 1 in 2 patients; grade 2, 5; grade 3, 8; and grade 4, 1. All but one of the grade 3 or 4 events was from myelosuppression; there were no adverse cardiac events. No responses were observed. Thus, piroxantrone appears inactive in patients with persistent, progressive, or recurrent ovarian cancer who recently had received a platinum-based regimen.

Dry, moist, and wet skin wound repair

Effects of wet (saline in a vinyl chamber), moist (hydrocolloid dressing), and dry (sterile gauze dressing) environments on wound repair were studied in a porcine partial-thickness wound model. Chambers were exchanged and refilled daily with normal saline containing penicillin G (100 U/ml) and streptomycin (100 micrograms/ml). Hydrocolloid and gauze dressings were kept in place until biopsy of the wound site. Wounds in wet, moist, and dry environments were completely epithelialized on days 6, 7, and 8, respectively. Thickness of the epidermis in wet, moist, and dry wounds was 204 +/- 23, 141 +/- 12, and 129 +/- 18 (mean +/- SEM), respectively. Moist wounds had more subepidermal inflammatory cells than wet wounds. In comparison to dry wounds, the moist or the wet healing environment resulted in less necrosis and faster and better quality of healing in the formation of the newly regenerated epidermis.

Design and analysis of multiarm clinical trials with survival endpoints

The clinical trials literature has paid relatively little attention to the design and analysis of K-sample trials with survival endpoints where K is 3 or greater. Following the least-significant-difference approach proposed by Makuch and Simon [1], we derive sample size formulas by working with the logrank test and proportional hazards model directly. This approach ensures the type I error rate to be the nominal value when the global null hypothesis is true. For power considerations, planning the study based on the least favorable alternative is recommended. The resulting sample size requirements are presented in graphic form for K = 3 and 4. Assuming that there is a control group and considering only the alternative that the survival of the experimental treatments is at least as good as that of the control group, power investigations indicate that the proposed strategy has good power for detecting the difference between the control and the best treatment. The "overall power," defined as the chance of the global test and subsequent pairwise comparisons all being correct, is good when all treatments are similar to either the control or the best treatment. Overall power is poor when the hazards are more evenly spread out between the control and the best group because the sample size is inadequate to detect such differences.

A phase II trial of piroxantrone in disseminated malignant melanoma. A Southwest Oncology Group study

Piroxantrone is one of the anthrapyrazoles developed in an effort to combine the broad antitumor activity of the anthracyclines with decreased myocardial toxicity. It has shown activity in metastatic melanoma during phase I trials. The Southwest Oncology Group (SWOG) conducted a phase II trial in disseminated malignant melanoma with piroxantrone administered at 150 mg/m2 intravenously over 1 h every 21 days, based upon the phase I experience. Forty-six eligible patients were registered to the trial and 44 were evaluable for response. Two partial responses, Wayne of 6 and 9 months duration were observed for an overall response rate of 5% (95% confidence interval 1%-15%). Thirty-six of 46 eligible patients have died with an estimated median survival of 5 months (95% confidence interval 3-8 months). Toxicities were tolerable with granulocytopenia being the predominant toxicity. Based upon the observed response rate, it is concluded that piroxantrone administered at this dose and schedule has detectable but minimal activity, and does not warrant further investigation in this disease.

Evaluation of merbarone (NSC 336628) in disseminated malignant melanoma. A Southwest Oncology Group study

Merbarone, NSC 336628, is an investigational anticancer drug with activity against experimental animal tumors including melanoma. This paper presents results of a Phase II clinical study of merbarone in patients with biopsy proven stage IV malignant melanoma without prior chemotherapy and with no evidence of CNS involvement. Thirty-five patients with median age 58 (range 27-81), with performance status 0-2 were treated with merbarone 1000 mg/m2/day for five days by intravenous continuous infusion repeated every 3 weeks. All patients (21 males and 14 females) were evaluable for toxicity. Two patients were not evaluable for response having been removed from protocol treatment due to toxicity and received other treatment during the first course of chemotherapy. Among the evaluable patients there was one complete response in a supraclavicular lymph node lasting four months and one partial liver response lasting three months. The remaining thirty-one patients were non-responders. Of these one had a stable disease lasting 21 months. The overall objective response rate was 6% (2/35) with a 95% confidence interval of 1%-19%. Twenty-six of the 35 patients have died. The estimated median survival of the entire group was 9 months with a 95% confidence interval six to eleven months. Renal toxicity was dose-limiting and manifested as increasing serum creatinine (54% of patients), proteinuria (51%) and hematuria (9%). One patient experienced grade 4 creatinine increase, proteinuria and acute renal failure. Other toxicities included nausea (71%), vomiting (51%0, malaise (23%), weakness (20%), alopecia (17%), diarrhea (17), anorexia (14%) transaminase (SGOT, SGPT) increase (14%), constipation (14%), alkaline phosphatase or 5'nucleotidase increase (9%), and fever (9%). Hematologic toxicity (granulocytopenia, leukopenia, and anemia) was generally mild and infrequent (29%, only one patient had grade 4 granulocytopenia). Overall 9 patients (26%) had at least one grade 3 toxicity. We conclude that merbarone at this dose and schedule has detectable but minimal activity in the treatment of metastatic malignant melanoma and given the significant renal toxicity this schedule does not merit further evaluation in this disease.

Randomized trial of vitamin A versus observation as adjuvant therapy in high-risk primary malignant melanoma: a Southwest Oncology Group study

PURPOSE

A national cooperative group trial was conducted in patients with early-stage cutaneous malignant melanoma to determine if oral vitamin A can increase disease-free survival or survival.

PATIENTS AND METHODS

Two hundred forty-eight patients with completely resected melanoma of Breslow's thickness greater than 0.75 mm and clinically negative lymph nodes were randomized to oral vitamin A (100,000 IU/d) for 18 months or to observation. Patients were stratified by Breslow's thickness of primary lesion (0.76 to 1.50 mm, 1.51 to 3.00 mm, or > 3.00 mm), sex, and type of therapy (excision, excision plus node dissection, excision plus perfusion, or excision plus both). The median duration of follow-up observation of living patients is greater than 8 years. The relative risk (RR) in disease-free survival and overall survival in the treatment compared with the observation group was calculated using Cox proportional hazards models.

RESULTS

Overall, there was no difference in disease-free survival or overall survival between the two groups. Examination of treatment by stratification interactions and subset analysis did not show any treatment-effect differences based on sex or type of therapy. There was also no difference between groups in disease-free survival based on Breslow's thickness of the primary lesion. Overall, 12% of patients who received vitamin A experienced grade 3 or 4 toxicities.

CONCLUSION

Based on the lack of overall survival benefit, further evaluation of vitamin A as adjuvant therapy for melanoma does not appear warranted.

Use of PCR to study epidemiology of Serratia marcescens isolates in nosocomial infection

A method to characterize strains of Serratia marcescens based on the PCR amplification of enterobacterial repetitive intergenic consensus sequences has been developed. The PCR fingerprints were generated from boiled supernatants prepared directly from bacterial colonies without the need for DNA extraction. The technique was applied to isolates obtained during an outbreak of pneumonia from seven mechanically ventilated patients, and its result indicated that the outbreak was due to the spread of two epidemic strains. This technique was validated by comparison with rRNA gene restriction analysis. There was complete concordance between these two techniques in discriminating the outbreak-related strains from epidemiologically unrelated isolates. Typing with both biochemical profile and antibiogram profile, though simple, was found to be less reliable than genotyping. The results show that this enterobacterial repetitive intergenic consensus PCR provides a rapid and simple means of typing S. marcescens isolates for epidemiologic studies.

Data Monitoring Committees and early stopping guidelines: the Southwest Oncology Group experience

Data Monitoring Committees in the Southwest Oncology Group comprise the study leadership and the leadership of the Group, augmented by some outside representation. The early stopping guidelines used by these committees are explicit in each protocol, and can be characterized as specifying a few interim analyses at conservative statistical levels. We describe our ten years of experience with this system, and give examples of different trials which have stopped either for positive or negative results.