Carboplatin AUC8 in combination with etoposide and bleomycin in the treatment of intermediate and poor-risk metastatic germ cell tumours: a phase II study

PURPOSE

Carboplatin has demonstrated significantly poorer response rates in non-seminomatous germ cell tumours. A phase II study of higher than standard doses of carboplatin was conducted because of suspicion that the poorer response might have been due to suboptimal dosing.

PATIENTS AND METHODS

A group of 19 patients with advanced germ cell tumours (International Germ Cell Cancer Collaborative Group intermediate and poor prognosis) were treated with carboplatin at an AUC of 8 mg/ml.min (using Calvert's formula) on day 1, etoposide 120 mg/m2 days 1-3 and bleomycin 60,000 U over 2 days (EBCa). Treatment was repeated every 3 weeks and a maximum of four courses was given.

RESULTS

Of the 19 patients, 7 (37%) achieved complete remission, of whom 6 (32%) remained long-term progression-free. Post-chemotherapy surgery and further chemotherapy salvaged an additional 26%, leading to an overall disease-free survival rate of 58%. No relationship between outcome and degree of myelosuppression could be established.

CONCLUSION

Dose-escalated carboplatin in combination, although feasible, did not improve the results and led to poorer results than those expected with cisplatin-based therapy. There is no evidence that the patients relapsing following this were easier to salvage. Further investigation of this regimen cannot be recommended.

General case quasi-pyramidal staff training to promote generalization of teaching skills in supervisory and direct-care staff

The authors employed staff training strategies designed to enhance generalization of teaching skills in staff working with persons with developmental disabilities. Staff training consultants initially employed a general case training approach involving the use of specially selected client program exemplars to provide three supervisory staff with generalized teaching skills. Subsequently, supervisory staff used the general case approach to train teaching skills to direct-care staff, with staff training support from the consultants (quasi-pyramidal training). Supervisors showed improvement in teaching skills after supervisory staff training, but only one of the three supervisors exceeded 70% correct skill use. After participating in the training of their own staff, however, supervisors demonstrated further improvements in skill use. All direct-care staff showed improvement after quasi-pyramidal training, with seven of the nine staff exceeding 70% correct skill use. General case quasi-pyramidal training appears to have potential as a strategy for promoting generalization of staff teaching skills in both trainees and trainers.

Regulation of the differentiation and behaviour of extra-embryonic endodermal cells by basement membranes

Both the extracellular matrix and parathyroid hormone-related peptide (PTHrP) have been implicated in the differentiation and migration of extra-embryonic endodermal cells in the pre-implantation mammalian blastocyst. In order to define the individual roles and interactions between these factors in endodermal differentiation, we have used embryoid bodies derived from Lamc1(-/-) embryonic stem cells that lack basement membranes. The results show that in the absence of basement membranes, increased numbers of both visceral and parietal endodermal cells differentiate, but they fail to form organised epithelia. Furthermore, although parietal endodermal cells only migrate away from control embryoid bodies in the presence of PTHrP, they readily migrate from Lamc1(-/-) embryoid bodies in the absence of PTHrP, and this migration is unaffected by PTHrP. Thus, the basement membrane between epiblast and extra-embryonic endoderm is required for the proper organisation of visceral and parietal endodermal cells and also restricts their differentiation to maintain the population of primitive endodermal stem cells. Moreover, this basement membrane inhibits migration of parietal endodermal cells, the role of PTHrP being to stimulate delamination of parietal endodermal cells from the basement membrane rather than promoting migration per se.

Regulation of laminin and COUP-TF expression in extraembryonic endodermal cells

Laminin expression and the subsequent deposition of a basement membrane by primitive endoderm cells is necessary for early mammalian development. We demonstrate that the transcription factors COUP-TF I and II are up-regulated in primitive endoderm cells faster than LAMB1 and LAMC1, and that either COUP-TF is sufficient to induce expression of these laminin genes.

Importance of positioning and technical factors in anatomic localization of sporting injuries in scintigraphic imaging

Sports medicine is becoming increasingly important as more people take up exercise for health and well-being. It is adding to the spectrum of acute and chronic injuries that have traditionally been seen in elite or professional athletes. Because of its high sensitivity and lesion contrast, bone scintigraphy has traditionally played a key role in the detection of such injuries. This role has been reduced in recent times by the increased use of magnetic resonance imaging (MRI), which has functional capability, high-contrast resolution, and high-spatial resolution. Bone scintigraphy has the capability of detecting early cortical ligament avulsion and enthesopathic disease before the onset of edema or changes in bone marrow that are detected by MRI. If this capability is added to more precise anatomic localization of lesions, we may see a resurgence in its use in sports medicine. A number of techniques are presented in this article, encompassing positioning, special views, and tomographic reconstructions, that can significantly improve the accuracy of localization of scintigraphic abnormalities with reference to anatomic models or sources of cross-sectional anatomy.

Regulation of programmed cell death by basement membranes in embryonic development

The formation of the proamniotic cavity in the mammalian embryo is the earliest of many instances throughout development in which programmed cell death and the formation of epithelia play fundamental roles (Coucouvanis, E., and G.R. Martin. 1995. Cell. 83:279-287). To determine the role of the basement membrane (BM) in cavitation, we use embryoid bodies derived from mouse embryonic stem cells in which the LAMC1 genes have been inactivated to prevent BM deposition (Smyth, N., H.S. Vatansever, P. Murray, M. Meyer, C. Frie, M. Paulsson, and D. Edgar. 1999. J. Cell Biol. 144:151-610). We demonstrate here that LAMC1-/- embryoid bodies are unable to cavitate, and do not form an epiblast epithelium in the absence of a BM, although both embryonic ectodermal cells and extraembryonic endodermal cells do differentiate, as evidenced by the expression of cell-specific markers. Acceleration or rescue of BM deposition by exogenous laminin in wild-type or LAMC1-/- embryoid bodies, respectively, results in cavitation that is temporally and spatially associated with restoration of epiblast epithelial development. We conclude that the BM not only directly regulates development of epiblast epithelial cells, but also indirectly regulates the programmed cell death necessary for cavity formation.

The role of coagulation abnormalities in the development of Perthes’ disease

Recent reports have suggested an association between Perthes’ disease and an underlying thrombophilic or hypofibrinolytic tendency. In Northern Ireland there is a high incidence of Perthes’ disease (11.7 per 100 000 or 1 in 607 children) in a stable paediatric population.

We reviewed 139 children with Perthes’ disease and compared them with a control group of 220 aged- and gender-matched healthy primary schoolchildren with similar racial and ethnic backgrounds.

There were no significant deficiencies of antithrombotic factors protein C, protein S, antithrombin III or resistance to activated protein C. A total of 53 (38.1%) of the children with Perthes’ disease had a prolonged activated partial thromboplastin time (> 38) compared with 13 (5.9%) of the control group (p < 0.001). Our findings have shown that using standard assays, thrombophilia secondary to antithrombotic factor deficiency or resistance to activated protein does not appear to be an aetiological factor for Perthes’ disease. The cause of the prolonged activated partial thromboplastin time, usually associated with a clotting factor deficiency, is under further investigation.

The role of coagulation abnormalities in the development of Perthes' disease

Recent reports have suggested an association between Perthes' disease and an underlying thrombophilic or hypofibrinolytic tendency. In Northern Ireland there is a high incidence of Perthes' disease (11.7 per 100,000 or 1 in 607 children) in a stable paediatric population. We reviewed 139 children with Perthes' disease and compared them with a control group of 220 aged- and gender-matched healthy primary schoolchildren with similar racial and ethnic backgrounds. There were no significant deficiencies of antithrombotic factors protein C, protein S, antithrombin III or resistance to activated protein C. A total of 53 (38.1%) of the children with Perthes' disease had a prolonged activated partial thromboplastin time (>38) compared with 13 (5.9%) of the control group (p < 0.001). Our findings have shown that using standard assays, thrombophilia secondary to antithrombotic factor deficiency or resistance to activated protein does not appear to be an aetiological factor for Perthes' disease. The cause of the prolonged activated partial thromboplastin time, usually associated with a clotting factor deficiency, is under further investigation.

The effect of the position of the limb on venous impulse foot pumps

Compression foot pumps are widely used for the prevention of postoperative venous thrombosis. We tested the efficiency of the pump in ten healthy subjects; the velocity of venous blood flow in the common femoral vein was measured in the horizontal, Trendelenberg (foot-up) and reverse-Trendelenberg (foot-down) positions. Application of the foot pump produced an increase in the venous velocity in all subjects. The mean increase in the horizontal position was 27.2% and in the Trendelenberg position 15.4%. In the reverse-Trendelenberg position, the foot pump produced a mean increase of 102.8%. The efficiency of the compression foot pump in increasing venous return is improved by adopting the reverse-Trendelenberg position. This may increase its thromboprophylactic effect.

The effect of the position of the limb on venous impulse foot pumps

Compression foot pumps are widely used for the prevention of postoperative venous thrombosis. We tested the efficiency of the pump in ten healthy subjects; the velocity of venous blood flow in the common femoral vein was measured in the horizontal, Trendelenberg (foot-up) and reverse-Trendelenberg (foot-down) positions.

Application of the foot pump produced an increase in the venous velocity in all subjects. The mean increase in the horizontal position was 27.2% and in the Trendelenberg position 15.4%. In the reverse-Trendelenberg position, the foot pump produced a mean increase of 102.8%.

The efficiency of the compression foot pump in increasing venous return is improved by adopting the reverse-Trendelenberg position. This may increase its thromboprophylactic effect.

Whiplash injury--are current head restraints doing their job?

It is generally accepted that the incidence of whiplash associated disorders is increasing in all industrialised countries, despite the almost universal fitment of head restraints in at least the front seats of cars. This is usually attributed to the fact that few people can be observed to follow the standard recommendations as regards head restraint positioning, that is, level with the head vertically and as close to the head as possible horizontally. This study set out to determine whether any other factors, in addition to head restraint adjustment, could be found which would influence the severity of whiplash injury. This was done by linking medical assessment of real-world accident victims with engineering assessment of the accident vehicles. A random sample of road accident victims suffering from whiplash associated disorder was studied. The vehicles they had been travelling in were examined to assess impact severity and, where possible, measurements were made of seat and head restraint adjustment with the subject sitting in the vehicle. All subjects were interviewed to assess the disability resulting from their injuries, and their progress was followed for 12 months. The results were subjected to statistical analysis to try to determine relationships between severity of injury (as measured by resultant disability) and a number of occupant- and vehicle-related factors. A significant proportion of the sample had suffered lumbar strain injury in addition to whiplash, and these were excluded from the present analysis. Frontal impact victims suffered symptoms indistinguishable from those of rear impact victims. The beneficial effects of good head restraint adjustment could not be clearly demonstrated, and some trends, especially in rear impacts, where the benefits of a well-adjusted restraint should have been very clear, indicated that larger distances from head to restraint were associated with lower disability. The paper discusses these counter-intuitive results and their implications.

Trace metal speciation and bioavailability in urban soils

Urban soils often contain concentrations of trace metals that exceed regulatory levels. However, the threat posed by trace metals to human health and the environment is thought to be dependent on their speciation in the soil solution rather than the total concentration. Three inactive railway yards in Montréal, Québec, were sampled to investigate the speciation and bioavailability of Cd, Cu, Ni, Pb and Zn. Soil solutions were obtained by centrifuging saturated soil pastes. In the soil solutions, up to 59% of the dissolved Cd was in its free ionic form. For Cu, Pb and Zn, organic complexes were the predominant species. Over 40% of Ni was present as inorganic complexes if the solution pH exceeded 8.1. Multiple regression analyses showed that pH and total metals in soil were significantly correlated with the activities of free metal ions, except for Cd(2+), which only had a weak correlation with soil pH. Free, dissolved and total soil metals were tested for their ability to predict metal uptake by plants in the field. However, none of these metal pools were satisfactory predictors. The results indicated that in these urban soils, trace metals were mainly in stable forms and bioavailability was extremely low.

Evaluating participatory extension programs: challenges and problems

Extension in Australia, in common with other parts of the world, is increasingly including participatory and process oriented approaches. At the same time there is an increasing requirement for accountability by government and other funding agencies. The credibility and acceptance of emergent participatory extension approaches to funding bodies can be improved by appropriate evaluation. Models for evaluation of extension have developed that are well suited to ‘transfer of technology’; however, these outcome-oriented evaluations are not appropriate for participatory extension approaches. Outcome focused evaluation, particularly where the focus is on predetermined, externally imposed criteria can be stifling to genuinely participatory extension approaches. While ‘Participatory Monitoring and Evaluation’ offers an alternative approach, the differentials between stakeholders, which are essentially differences in power, mean that this approach will not provide a complete answer. Models of evaluation which meet the requirements of funding agencies and other stakeholders need to be further developed.

Evaluating three trace metal contaminated sites: a field and laboratory investigation

Selecting guidelines to evaluate elevated metals in urban brownfields is hindered by the lack of information for these sites on ecosystem structure and function. A study was performed to compare three trace metal-contaminated sites in the metropolitan Montreal area. The goal was to obtain an idea of the organisms that may be present on urban brownfields and to measure if elevated metals alter the presence and activity of the indigenous biota. Field and laboratory studies were conducted using simple methodologies to determine the extent to which microbial activity affected by trace metal content, to assess diversity of plant and soil invertebrate communities and to measure phytoaccumulation of trace metals. It was found that microbial activity, as measured by substrate-induced respiration (SIR) and nitrification, was not affected by the levels of soil Cd, Cu, Ni, Pb and Zn recorded on the sites. Seven of the 12 invertebrate groups collected were sampled on soils with similar Cd, Cu, Ni, Pb and Zn concentrations. Diversity of plant species increased as a function of the length of time the sites had been inactive. Levels of metals in plant tissue were influenced by soil characteristics and not by total soil Cd, Cu, Ni, Pb and Zn.

Molecular investigations implicate human endogenous retroviruses as mediators of anti-retroviral antibodies in autoimmune rheumatic disease

Polymerase chain reaction using specific primers, failed to detect HTLV-I amplicons in patients with rheumatic diseases previously shown to possess antibodies to retroviral products. However, by employing broad spectrum oligonucleotide primers, 135 bp amplicons were generated from peripheral blood mononuclear cells and synovial fluid cells. Subsequent cloning and DNA sequencing revealed homology to a number of exogenous and human endogenous retroviruses (HERVs). Furthermore, in combining the presence of type B and C related endogenous retroviruses, a significant association (p=0.014) was apparent for chronic autoimmune rheumatic diseases as compared to controls. Reverse transcription polymerase chain reaction of RNA derived from patients, healthy controls and cell lines (U937, BJAB, human endothelial lung fibroblasts) demonstrated ubiquitous expression of HERV-K10 and RTVL-H2. Furthermore messenger RNA expression of HERV-K10 was enhanced in fibroblasts infected with human cytomegalovirus. It is plausible that subsequent production of HERV peptides could explain the presence of anti-retroviral antibodies in cohorts of patients with autoimmune rheumatic diseases.

Fundamental issues in questionnaire design

The questionnaire is probably the most common form of data collection tool used in nursing research. There is a misconception that anyone with a clear grasp of English and a modicum of common sense can design an effective questionnaire. Contrary to such common belief, this article will demonstrate that questionnaire design is a complex and time consuming process, but a necessary labour to ensure valid and reliable data is collected. In addition, meticulous construction is more likely to yield data that can be utilized in the pursuit of objective, quantitative and generalizable truths, upon which practice and policy decisions can be formulated. This article examines a myriad of fundamental issues surrounding questionnaire design, which encompass question wording, question order, presentation, administration and data collection, amongst other issues.