A digital health algorithm to guide antibiotic prescription in pediatric outpatient care: a cluster randomized controlled trial

Excessive antibiotic use and antimicrobial resistance are major global public health threats. We developed ePOCT+, a digital clinical decision support algorithm in combination with C-reactive protein test, hemoglobin test, pulse oximeter and mentorship, to guide health-care providers in managing acutely sick children under 15 years old. To evaluate the impact of ePOCT+ compared to usual care, we conducted a cluster randomized controlled trial in Tanzanian primary care facilities. Over 11 months, 23,593 consultations were included from 20 ePOCT+ health facilities and 20,713 from 20 usual care facilities. The use of ePOCT+ in intervention facilities resulted in a reduction in the coprimary outcome of antibiotic prescription compared to usual care (23.2% versus 70.1%, adjusted difference -46.4%, 95% confidence interval (CI) -57.6 to -35.2). The coprimary outcome of day 7 clinical failure was noninferior in ePOCT+ facilities compared to usual care facilities (adjusted relative risk 0.97, 95% CI 0.85 to 1.10). There was no difference in the secondary safety outcomes of death and nonreferred secondary hospitalizations by day 7. Using ePOCT+ could help address the urgent problem of antimicrobial resistance by safely reducing antibiotic prescribing. Clinicaltrials.gov Identifier: NCT05144763.

Cumulative Antibiotic Exposure in the First Five Years of Life: Estimates for 45 Low- and Middle-income Countries from Demographic and Health Survey Data

BACKGROUND

Estimates of the total cumulative exposure to antibiotics of children in low-resource settings, and the source of these treatments, are limited.

METHODS

We estimated the average number of antibiotic treatments children received in the first five years of life in 45 low- and middle-income countries (LMICs) using Demographic and Health Survey (DHS) data. The two-week point prevalence of fever, diarrhea or cough and antibiotic treatment for these illnesses were estimated for ages 0-59 months and aggregated to estimate cumulative illness and antibiotic treatment for each country. We estimated treatment rates and contribution to total antibiotic use attributable to medical care, informal care, and self-medication.

RESULTS

Forty-five countries contributed 438,140 child-observations. The proportion of illness episodes treated with antibiotics ranged from 10% (95% CI: 9-12) (Niger) to 72% (95% CI: 69-75) (Jordan). A mean of 42·7% (95% CI: 42.1-43.3) of febrile and 32.9% of non-febrile illness (95% CI: 32.4-33.5) episodes received antibiotics. In their first five years, we estimate children received 18.5 antibiotics treatments on average (IQR: 11.6-24.6) in LMICs. Cumulative antibiotic exposure ranged from 3.7 treatments in Niger (95% CI: 2.8-4.6) to 38·6 treatments in DR Congo (95% CI: 34.7-42.4). A median of 9.0% of antibiotic treatment was attributable to informal care (IQR: 5.9-21.2), and 16.9% to self-medication (IQR: 9.5-26.2).

CONCLUSIONS

Childhood antibiotic exposure is high in some LMICs, with considerable variability. While access to antibiotics for children is still not universal, important opportunities for reducing excess use also exist, particularly with respect to the informal care sector and self-medication.

Mobile nudges and financial incentives to improve coverage of timely neonatal vaccination in rural areas (GEVaP trial): A 3-armed cluster randomized controlled trial in Northern Ghana

Background

Despite progress in vaccination coverage, timeliness of childhood vaccination remains a challenge in many settings. We aimed to assess if mobile phone-based reminders and incentives to health workers and caregivers could increase timely neonatal vaccination in a rural, low-resource setting.

Methods

We conducted an open-label cluster randomized controlled 1:1:1 trial with three arms in 15 communities in Northern Ghana. Communities were randomized to 1) a voice call reminder intervention; 2) a community health volunteer (CHV) intervention with incentivized rewards; 3) control. In the voice call reminder arm, a study staff member made voice calls to mothers shortly after birth to encourage vaccination and provide personalized information about available vaccination services. In the incentive arm, CHVs promoted infant vaccination and informed women with recent births about available vaccination opportunities. Both CHVs and women were provided small monetary incentives for on-time early infant vaccination in this arm, delivered using mobile phone-based banking applications. No study activities were conducted in control communities. A population-based survey compared vaccination coverage across arms in the pre-intervention and intervention periods. The primary endpoint was completion of at least one dose of Polio vaccine within 14 days of life and BCG vaccination within 28 days of life.

Results

Six-hundred ninety births were identified; 106, 88, and 88 from pre-intervention and 150, 135, and 123 in the intervention period, in the control, voice call reminder and CHV incentive arms, respectively. In adjusted intent-to-treat analysis, voice call reminders were associated with 10.5 percentage point (95% CI: 4.0, 17.1) higher coverage of on-time vaccination, while mobile phone-based incentives were associated with 49.5 percentage point (95% CI: 26.4, 72.5) higher coverage.

Conclusion

Community-based interventions using mobile phone technologies can improve timely early vaccination coverage. A CHV approach with incentives to community workers and caregivers was a more effective strategy than voice call reminders. The impact of vaccination “nudges” via voice calls may be constrained in settings where network coverage and phone ownership are limited.

Trial registration

This trial was registered at ClinicalTrials.gov; NCT03797950.

Response to 'On the importance of understanding physiology when estimating energetics in cetaceans'

Summary: Our paper highlights how temporal changes in tidal volume and the oxygen exchange ratio significantly affect the accuracy of models that use only breathing frequency to estimate metabolic rate.

Estimating energetics in cetaceans from respiratory frequency: why we need to understand physiology

The accurate estimation of field metabolic rates (FMR) in wild animals is a key component of bioenergetic models, and is important for understanding the routine limitations for survival as well as individual responses to disturbances or environmental changes. Several methods have been used to estimate FMR, including accelerometer-derived activity budgets, isotope dilution techniques, and proxies from heart rate. Counting the number of breaths is another method used to assess FMR in cetaceans, which is attractive in its simplicity and the ability to measure respiration frequency from visual cues or data loggers. This method hinges on the assumption that over time a constant tidal volume (VT) and O₂ exchange fraction (ΔO₂) can be used to predict FMR. To test whether this method of estimating FMR is valid, we measured breath-by-breath tidal volumes and expired O₂ levels of bottlenose dolphins, and computed the O₂ consumption rate (V̇_O2) before and after a pre-determined duration of exercise. The measured V̇_O2 was compared with three methods to estimate FMR. Each method to estimate V̇_O2 included variable VT and/or ΔO₂. Two assumption-based methods overestimated V̇_O2 by 216-501%. Once the temporal changes in cardio-respiratory physiology, such as variation in VT and ΔO₂, were taken into account, pre-exercise resting V̇_O2 was predicted to within 2%, and post-exercise V̇_O2 was overestimated by 12%. Our data show that a better understanding of cardiorespiratory physiology significantly improves the ability to estimate metabolic rate from respiratory frequency, and further emphasizes the importance of eco-physiology for conservation management efforts.

Summary: Accounting for changes in tidal volume and gas exchange improves the ability to estimate field metabolic rate from respiratory frequency in cetaceans.

Helicobacter cetorum sp. nov., a urease-positive Helicobacter species isolated from dolphins and whales

A novel helicobacter with the proposed name Helicobacter cetorum, sp. nov. (type strain MIT 99-5656; GenBank accession number AF 292378), was cultured from the main stomach of two wild, stranded Atlantic white-sided dolphins (Lagenorhynchus acutus) and from the feces of three captive cetaceans (a Pacific white-sided dolphin [Lagenorhynchus obliquidens]; an Atlantic bottlenose dolphin [Tursiops truncatus]; and a beluga whale [Delphinapterus leucas]). The infected captive cetaceans were either subclinical, or clinical signs included intermittent regurgitation, inappetance, weight loss, and lethargy. Ulcers were observed in the esophagus and forestomach during endoscopic examination in two of the three captive animals. In the third animal, esophageal linear erosions were visualized endoscopically, and histopathological evaluation of the main stomach revealed multifocal lymphoplasmacytic gastritis with silver-stained spiral-shaped bacteria. Helicobacter cetorum is a fusiform gram-negative bacterium with a single bipolar flagellum. The isolates grow under microaerobic conditions at 37 and 42 degrees C but not at 25 degrees C. H. cetorum is urease, catalase, and oxidase positive, and it is sensitive to cephalothin. The isolates from the wild, stranded dolphins were sensitive to nalidixic acid, whereas the isolates from the collection animals were resistant. By 16S rRNA sequencing it was determined that H. cetorum represented a distinct taxon that clusters most closely with H. pylori. Further studies are necessary to determine the role of H. cetorum in the development of gastric ulcers and gastritis of cetaceans. This is the first description and formal naming of a novel Helicobacter species from a marine mammal.

Infection control programs at children's hospitals: a description of structures and processes

BACKGROUND

Infection control (IC) structures and processes determine the effectiveness of surveillance efforts to prevent infections in health care settings.

METHODS

A survey was sent to 56 children's hospitals collaborating in the Pediatric Prevention Network (PPN).

RESULTS

Completed surveys were returned from 48 hospitals. Responsibility for the IC program resided with the medical director (21%); vice president for patient care (18%); quality improvement director (17%); other senior hospital administrator (15%); or other hospital personnel (18%). Forty-two hospitals had an IC committee; 32 had antimicrobial restriction/control policies; and 21 had an antimicrobial restriction/control task force or committee. Components of antimicrobial restriction programs included infectious disease specialist approval, restricted formularies, selective susceptibility test reporting, and staff education programs. Many methods were used to detect infections, including microbiology laboratory reports (100%); record reviews (98%); informal reports from providers (90%); and readmission reviews (77%).

CONCLUSIONS

Children's hospitals vary widely in how they design and implement their IC functions. These variations influence adverse event detection and nosocomial infection rate calculations. If medical errors, including nosocomial infections, are to be detected and hospital rates compared, standardized methods to collect, analyze, and report data are needed. The PPN has initiated activities to standardize surveillance and IC practices in participating hospitals.

Pediatric Prevention Network: a multicenter collaboration to improve health care outcomes

Nosocomial infections and antimicrobial resistance are major causes of mortality and morbidity and have become a major public health focus. To date, most national and international nosocomial infection surveillance and prevention activities have been focused on adults, despite the fact that pediatric patients are at high risk for nosocomial infections because of their immature immune systems and prevalent device usage. In 1997 the Hospital Infections Program at the Centers for Disease Control and Prevention and the National Association of Children's Hospitals and Related Institutions partnered to establish a Pediatric Prevention Network. Infection control professionals and their hospital administrators at all children's hospitals were invited to participate. The objectives of the network are to establish baseline infection rates; design, implement, and evaluate prevention interventions; establish benchmark rates and best practices; and serve as a site for multicenter studies to improve outcomes for hospitalized children. This network serves as a model for quality improvement systems in health care.

Expression of the telomerase catalytic subunit, hTERT, induces resistance to transforming growth factor beta growth inhibition in p16INK4A(-) human mammary epithelial cells

Failures to arrest growth in response to senescence or transforming growth factor beta (TGF-beta) are key derangements associated with carcinoma progression. We report that activation of telomerase activity may overcome both inhibitory pathways. Ectopic expression of the human telomerase catalytic subunit, hTERT, in cultured human mammary epithelial cells (HMEC) lacking both telomerase activity and p16(INK4A) resulted in gaining the ability to maintain indefinite growth in the absence and presence of TGF-beta. The ability to maintain growth in TGF-beta was independent of telomere length and required catalytically active telomerase capable of telomere maintenance in vivo. The capacity of ectopic hTERT to induce TGF-beta resistance may explain our previously described gain of TGF-beta resistance after reactivation of endogenous telomerase activity in rare carcinogen-treated HMEC. In those HMEC that overcame senescence, both telomerase activity and TGF-beta resistance were acquired gradually during a process we have termed conversion. This effect of hTERT may model a key change occurring during in vivo human breast carcinogenesis.

Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases

BACKGROUND

Puerperal hematomas can become a life-threatening obstetric emergency. Their incidence is 1 or 2/1,000 deliveries. When mainstay methods of suture and packing fail, arterial embolization becomes an excellent alternative to definitive treatment, laparotomy.

CASES

A 32-year-old woman, para 2-0-2-2, developed extreme rectal and vulvar pain one hour postpartum. A 12 x 10-cm vulvovaginal hematoma was identified, drained, sutured and packed. Bleeding continued, blood products were administered, and selective angiographic embolization of the pudendal and inferior gluteal arteries was successfully performed. A 31-year-old woman, para 1-0-1-1, developed a left vaginal hematoma immediately postpartum. She failed vaginal packing and underwent angiographic arterial embolization successfully. The patient was discharged on the fourth postpartum day. At six weeks postpartum, neither patient had evidence of hematoma formation.

CONCLUSION

In the setting of a puerperal hematoma refractory to conventional first-line therapy, arterial embolization provides a rational, effective alternative for achieving hemostasis with minimal morbidity.

Acute local inflammation potentiates tumor growth in mice

Chronic inflammation in humans has been implicated in the pathogenesis of several types of cancer. In animals, experimentally-induced tumor growth was found to be enhanced at sites of injury. However, a direct demonstration in vivo that an inflammatory agent applied locally at the tumor site can promote a switch into a highly proliferative state of tumor growth, has not yet been documented. The present work was designed to test, in a syngeneic primary tumor model in mice, whether a commonly used inflammatory agent, carrageenan, could cause acceleration of tumor growth and to investigate the cellular mechanisms mediating such a process. Local injection of carrageenan into a tissue site containing tumor cells produced an accelerated rate of tumor growth at that site which was characterized by a decreased percentage of apoptotic cells and an increased proportion of cells at the S and G2/M phases of the cell cycle. The pro-tumorigenic effect of carrageenan is dose-dependent and can be exerted at any time throughout the course of the tumor growth. Furthermore, the effect is prostaglandin-mediated since the cyclooxygenase inhibitor indomethacin totally abrogated it. Experiments with tumors cells in culture have shown that carrageenan actually inhibits cell proliferation as well as increases apoptosis. Thus, the tumor promoting effects of carrageenan in vivo appear to arise not from a direct effect on the tumor cells per se but rather through induction of host-dependent humoral/cellular responses that generate increased levels of prostanoids and pro-inflammatory cytokines that accelerate tumor growth. These data demonstrate for the first time that an acute, local inflammatory stimuli can induce accelerated tumor growth at the affected site and provide further support for a mechanism-based, anti-tumorigenic action of anti-inflammatory drugs.

Sevoflurane anesthesia in desert tortoises (Gopherus agassizii)

The effects of sevoflurane on anesthesia induction, recovery, ventricular pressures, heart rate, ventricular pH, blood gas values, and electrolytes were evaluated in desert tortoises (Gopherus agassizii). Tortoises were orotracheally intubated while awake and ventilated manually with 3-7% sevoflurane in oxygen (1 L/min) to achieve desired expired sevoflurane concentrations. Data, consisting of induction time, recovery time, systolic, diastolic, and mean ventricular pressures, heart rate, ventricular pH, blood gas values, and electrolytes, were collected prior to anesthesia and sequentially at 2.50% and 3.75% expired sevoflurane as measured at the junction of the endotracheal tube and the breathing circuit. Blood pressure was measured and blood samples were collected through a 25-ga needle passed through a cardiac access port that was placed while the tortoises were in dorsal recumbency. Mean (+/-SE) induction time was 2.55+/-0.55 min, recovery time was 27.58+/-7.55 min, and duration of anesthesia was 105+/-12 min. Mean (+/-SD) values for systolic, diastolic, and mean ventricular pressures in awake tortoises were 28+/-3 mm Hg, 22+/-2 mm Hg, and 24+/-2 mm Hg, respectively. Sevoflurane (2.5% expired) significantly decreased systolic (14+/-3 mm Hg), diastolic (12+/-1 mm Hg), and mean (13+/-1 mm Hg) ventricular pressures compared with those of awake tortoises. Ventricular pressures did not decrease further with increasing depth of anesthesia. Heart rate (32+/-4 beats/min) did not change significantly under sevoflurane anesthesia. Sevoflurane administration increased ventricular PO2 but did not change Na+, K+, or iCa++ concentrations. Sevoflurane appears to provide safe and effective anesthesia with rapid induction and recovery.

Accuracy and clinical utility of the mini-dose 14C-urea breath test in the evaluation of Helicobacter pylori infection

The aim of this study was to evaluate the accuracy of the 14C-urea breath test by comparing the results to those obtained by endoscopy with mucosal biopsy. We also examined the value of the breath test result obtained prior to endoscopy in predicting peptic ulcer disease. Forty-two individuals underwent the 14C-urea breath test. Collections of expired C02 were analysed using a liquid scintillation counter. All individuals then underwent endoscopy with biopsy. Biopsy material was evaluated by the rapid urease method and by histology for the presence of H. pylori. Our results demonstrated that the 14C-urea breath test was 100% sensitive and specific when compared to the rapid urease test as the 'gold standard' for the detection of H. pylori. In comparison to pathology, the sensitivity remained 100% and the specificity was 89%. The results of the 14C-urea breath test had a poor predictive value for the determination of peptic ulcer disease. We conclude that the 14C-urea breath test can be easily performed at any medical facility equipped with a liquid scintillation counter and can accurately detect H. pylori. A negative breath test result could not exclude the presence of peptic ulcer disease.

An analysis of risk factors for withdrawal from dialysis before death

Withdrawal from dialysis has been a significant cause of mortality among dialysis patients, accounting for 6 to 22% of deaths. Since 1990, a new death notification form has allowed more detailed analyses of withdrawal from dialysis separate from causes of death. Using the U.S. Renal Data System data base, this study examined 116,829 deaths in adult patients from 1990 to 1995. Adjusted odds ratios were calculated for the risk of withdrawal using logistic regression. Adjustments included age at death, ethnicity, gender, cause of death, primary cause of end-stage renal disease, time on dialysis, and dialysis modality. In addition, odds ratios of withdrawal were calculated for deaths in patients who started dialysis after age 65. Death was preceded by withdrawal significantly more frequently in women than in men, more than twice as frequently in Caucasians than in African-Americans or Asians, and more frequently in older than in younger age groups. Patients who died of chronic diseases (e.g., dementia, malignancy) were much more likely to withdraw before death, whereas patients who died from more acute causes (e.g., coronary artery disease) were less likely to withdraw before death. It is concluded that patients who are Caucasian, female, older, or die of chronic or progressive diseases are more likely to withdraw from dialysis before death. The ethnic and gender differences in withdrawal do not appear to have a medical explanation from this analysis. Further research along sociologic lines is needed to better explain the differences in withdrawal from chronic dialysis.

Use of bare-mounted Palmaz-Schatz stents employing the stent saddle technique on the delivery balloon: a single center experience

The major limitations of the Palmaz-Schatz stent stem from the design of its stent delivery system (SDS). The SDS is bulky and has poor trackability in lesions with proximal tortuosity and/or vessel calcification. The use of bare-mounted Palmaz-Schatz stents on low profile balloons represents an alternate approach for lesions that are not accessible for stenting with the SDS. Thus we evaluated the indications, procedural success rate, and in-hospital complications of patients undergoing bare stenting at a single center between 1 October 1995 through 30 September 1996. A total of 363 coronary interventions were performed during this period, including coronary stenting in 194 vessels. In 18 of these 194 vessels, bare-mounted Palmaz-Schatz stents were used. The indications for bare stenting were: inability to deliver the Palmaz-Schatz stent on SDS for suboptimal angioplasty results or acute/threatened abrupt closure; use of half stents; stenting in vessels < 3.0 mm; intermediate disease in the proximal segment that would have precluded optimal visualization of stent placement; and use of guides 7 French or smaller. Bare stenting was successful in 15 of the 18 patients (vessels) in whom it was attempted. There were no deaths, myocardial infarctions, stent thrombosis, repeat interventions, or significant bleeding in patients with successful bare stent delivery. The stents were successfully retrieved in the three patients in whom the stent could not be advanced into the target coronary segment. One of these patients had a propagated spiral dissection prior to attempts at bare stenting and required emergent bypass surgery. The remaining two patients with failed deployment had suboptimal angioplasty results but had an uncomplicated hospital course. Thus bare stenting represents an alternate percutaneous approach to tackle suboptimal procedural results and/or complications in patients who have failed stent deployment with the standard sheathed stent delivery system currently available in the United States.

Young men's experience with condom breakage

In a nationally representative sample of men aged 17-22, 23% of those using condoms reported experiencing at least one condom break during the previous 12 months. Of all condoms used, 2.5% had broken. In multivariate analyses, increased experience with condoms reduced the likelihood of experiencing condom breakage. Recent sex education was associated with an almost 80% decrease in the risk of breakage among young men who used condoms infrequently. Young males who had ever had a sexually transmitted disease (STD), or whose sexual partner had had an STD, were almost three times as likely as other respondents to have experienced condom breakage. In addition, young men with a household income of less than $60,000 were 2-3 times as likely to have broken a condom as were those with a higher household income.

Lansoprazole heals erosive reflux oesophagitis in patients with Barrett's oesophagus

BACKGROUND

Barrett's oesophagus is thought to be a complication of severe gastro-oesophageal reflux.

AIM

To determine whether the proton pump inhibitor, lansoprazole, is effective in healing erosive reflux oesophagitis in patients with Barrett's oesophagus.

METHODS

An 8-week, randomized, double-blind study was conducted using patients with both erosive reflux oesophagitis and Barrett's oesophagus. Erosive reflux oesophagitis was defined as grades 2-4 oesophagitis; Barrett's oesophagus, as specialized columnar epithelium obtained by biopsy from the tubular oesophagus; and healing, as a return to grade 0 or 1 oesophageal mucosa (complete re-epithelialization). One-hundred and five (105) patients from one centre were randomized to receive either lansoprazole 30 mg daily or ranitidine 150 mg twice daily. Unhealed or symptomatic lansoprazole patients at week 4 were randomized to receive the same 30 mg dose daily or an increased dose of 60 mg daily. Endoscopy was performed at baseline and at weeks 2, 4, 6 and 8.

RESULTS

The treatment groups were similar in regards to baseline characteristics, erosive reflux oesophagitis grades and length of Barrett's oesophagus. At each 2-week interval, lansoprazole patients had significantly greater healing rates and less day and night heartburn and regurgitation than ranitidine patients. There were no significant differences between treatment groups in antacid use, quality of life parameters, or rate of reported adverse events. Median values for fasting serum gastrin levels remained within the normal range for both groups.

CONCLUSION

In patients with both Barrett's oesophagus and erosive reflux oesophagitis, lansoprazole is significantly more effective than ranitidine in relieving reflux symptoms and healing erosive reflux oesophagitis.

Using USRDS generated hospitalization tables to compare local dialysis patient hospitalization rates to national rates

Hospitalization tables of the U.S. Renal Data System allow description of national hospitalization rates among incident and prevalent dialysis patients in five-year age groups. These rates are further stratified by sex, race, and four primary disease categories. Based on these tables derived from the data on over 250,000 incident and prevalent patients during 1991 to 1993, a methodology is described that allows comparison of local (for example, dialysis facility) or regional "first admission" rates among incident and prevalent dialysis patients to the national rates. A standardized hospitalization ratio is introduced to facilitate such comparisons, and methods for assessing statistical significance are discussed. Since this methodology allows adjustment for age, race, sex, and primary disease, it can serve as useful tool for dialysis research. It can also be used at the dialysis facility level, alone or in conjunction with the standardized mortality ratio, to facilitate local quality assurance.

Radiopharmaceutical regulation and Food and Drug Administration policy

The regulatory policy of the Food and Drug Administration (FDA) on radiopharmaceuticals flows from a rigid, traditional, drug-like interpretation of the FDC Act on the licensing of radiopharmaceuticals. This contributes to significant delays in the drug-approval process for radiopharmaceuticals, which are very costly to the nuclear medicine community and the American public. It seems that radiopharmaceuticals would be better characterized as molecular devices. Good generic rule-making principles include: use of a risk/benefit/cost analysis; intent based on sound science; performance standards prepared by outside experts; a definite need shown by the regulatory agency; to live with the consequences of any erroneous cost estimates; and design individual credential requirements so that additional training results in enhanced professional responsibility. When these common elements are applied to current FDA policy, it seems that the agency is out of sync with the stated goals for revitalizing federal regulatory policies as deemed necessary by the Clinton administration. Recent FDA rulings on positron-emission tomography, Patient Package inserts, and on medical device service accentuate the degree of such asynchronization. Radiopharmaceutical review and licensing flexibility could be dramatically improved by excluding radiopharmaceuticals from the drug category and reviewing them as separate entities. This new category would take into account their excellent record of safety and their lack of pharmacological action. Additionally, their evaluation of efficacy should be based on their ability to provide useful scintiphotos, data, or responses of the physiological system it portends to image, quantitate, or describe. To accomplish the goal of transforming the FDA's rigid, prescriptive policy into a streamlined flexible performance-based policy, the Council on Radionuclides and Radiopharmaceuticals proposal has been presented. In addition, it is suggested that the United States Pharmacopeia write radiopharmaceutical review standards, that an independent scientific body review the data submitted, and that the FDA either accept or reject the recommendation.

Phosphorus-32 intracavitary irradiation of cystic craniopharyngiomas: current technique and long-term results

PURPOSE

The management of patients with craniopharyngiomas is often multifaceted and multidisciplinary. The purpose of this study was to examine the results of phosphorus-32 intracavitary irradiation in the treatment of patients with predominately cystic craniopharyngiomas.

METHODS AND MATERIALS

Thirty patients with cystic craniopharyngiomas underwent phosphorus-32 intracavitary irradiation at our center between 1981 and 1993. The median patient age was 26 years (range, 3-70 years). Thirteen patients had intracavitary irradiation as the primary surgery for their cystic tumors, whereas 17 patients had adjuvant intracavitary irradiation after microsurgical resection, fractionated radiotherapy, or both. Patients in the adjuvant treatment group were more likely to have preoperative anterior pituitary insufficiency (p = 0.008 Fischer exact test) and diabetes insipidus (p = 0.003 Fischer exact test). The median follow-up was 37 months (mean, 46 months, range, 7-116 months).

RESULTS

Phosphorus-32 intracavitary irradiation resulted in cyst regression in 28 of 32 treated cysts (88%). Ten patients (33%) have had tumor progression requiring further surgical intervention. Three patients (10%) died: two of tumor progression, and one of unrelated causes. Visual acuity and fields improved or remained stable in 63% of the patients. Fifteen patients had residual anterior pituitary function before intracavitary irradiation and 10 (67%) retained their preoperative endocrine status. New-onset diabetes insipidus occurred in 3 of 17 patients (18%) who had normal posterior pituitary function preoperatively. Fourteen of 20 adult patients (70%) continued to perform at their preoperative functional level; 3 of 5 pediatric patients who were age appropriate at the time of treatment continued to develop normally. No difference was noted between primary and adjuvant treatment patients with respect to cyst control, visual deterioration, or endocrine preservation after phosphorus-32 intracavitary irradiation.

CONCLUSION

The goals of craniopharyngioma management should be tumor control with preservation of visual, endocrine, and cognitive function. Phosphorus-32 intracavitary irradiation is an important option that enhances the likelihood of achieving these goals in patients with primarily cystic craniopharyngiomas.

Fecal occult blood testing: a false sense of security?

BACKGROUND

Recent screening studies with fecal occult blood testing (FOBT) report that one of three patients with colorectal cancer (CRC) can be cured of the disease; minimal attention has been given to the two of three patients who despite repeated screening go on to die of silent CRC. We report the known "miss rate" (known false negatives) of our 14-year ongoing program of FOBT that was organized in 1979 to detect early CRC.

METHODS

From October 1979 through December 1993, 36,034 FOBT kits were distributed to patients who were without gastrointestinal complaints at Hines Veterans Affairs Hospital. The test was considered positive if at least one result of the six tests was positive and negative if the test result was equivocal. Patients with negative FOBT received a new test kit each year by mail. A positive test was followed by full colonoscopy or an air contrast barium enema if a full colonoscopy was not possible.

RESULTS

The overall return rate was 47.8%. CRC was detected in 115 patients: 94 had a favorable and 21 had an unfavorable Duke's C or D or lymphoma prognosis. Of 21 patients 13 (62%) had initially tested FOBT negative (missed lesion). Of the 21 cases of advanced CRC 15 (71.43%) were in the descending, sigmoid, or rectosigmoid colon or rectum.

CONCLUSIONS

(1) The majority (82%) of all CRC detected by FOBT screening are diagnosed at a favorable stage. (2) The majority of known advanced CRC (62%) escape early detection with FOBT. (3) Five (62.5%) of eight of the advanced CRC cases discovered on initial FOBT and 10 (76.9%) of 13 of advanced CRC cases missed on initial FOBT but detected in subsequent years were in the left colon and most likely in the range of the flexible sigmoidoscope. (4) FOBT as a sole screening test may provide a false sense of security, especially in patients with advanced left-side CRC.

In-111 monoclonal antibody versus Ga-67 citrate and Tc-99m SC subtraction in a patient with malignant melanoma

Gallium-67 is routinely used for follow-up of patients with malignant melanoma. However, its nonspecificity for melanoma and its high rate of false-positive results have always been a matter of concern. The authors describe a patient who encountered serious problems with the use of gallium. Because gallium is taken up well by the liver and by melanoma, results of gallium scintigraphy of the liver may appear normal even if there is metastatic disease. In this patient, results of gallium scintigraphy of the liver were negative for metastasis but revealed extrahepatic foci detected by the monoclonal antibody. Computed tomography showed areas of attenuation, revealing only a few intrahepatic tumors and no extrahepatic disease. Tc-99m SC revealed intrahepatic metastases, but no extra-hepatic metastases were seen. A monoclonal antibody (ZME-018) scintigram did reveal hepatic metastases along with probable small, extrahepatic, metastatic foci. Overall hepatic uptake of the monoclonal antibody was relatively low. An image subtraction algorithm was devised whereby the sulfur colloid image was subtracted from the gallium scintigram. The resultant image revealed both the intrahepatic and extrahepatic metastases seen on the ZME-018 images. It is likely that in the past many hepatic metastases have been missed because Tc-99m SC images have not been routinely used as part of melanoma management protocols. The uptake of the ZME-018 by the tumor was significantly higher than that of the normal liver, suggesting that ZME-018 labeled with the appropriate emitter may be an effective specific therapeutic tool in selected patients.

Stereotactic options in the management of craniopharyngioma

Multimodality stereotactic techniques were used in the management of 39 patients with craniopharyngiomas in a 12-year interval. Monocystic craniopharyngiomas were treated successfully by intracavitary beta-irradiation using 32P (96% cyst control rate). Solid tumor progression or secondary cyst formation required repeat irradiation, radiosurgery or microsurgery in selected patients. In the future, wider and earlier application of stereotactic techniques may further reduce the still unacceptable morbidity currently associated with initial radical microsurgical resection of craniopharyngiomas.

186Rhenium-HNK1 monoclonal antibody targets human small cell lung cancer cells in athymic nude mice: rapid screening model for therapy

A model is described by which in vivo tumor-MOAB interactions may be investigated. The method is rapid and may aid in the selection of appropriate MOABS from a panel of MOABS for individualized patient treatment. Groups of athymic nude mice were injected intravenously with small cell lung cancer line SHP-77 cells which are trapped primarily in the lungs. Twenty-four hours post tumor cell inoculation, 186Rhenium tagged HNK1 MOAB (CD57) was injected intravenously. Controls which received no tumor cells were injected with unbound 186Re or radioactive MOAB. Biodistribution studies at 24 hours following MOAB injection showed significantly more radioactivity in lungs of mice inoculated with both SHP-77 cells and 186Re MOAB than did lungs of controls.

A phase 1 study of adoptive transfer of autologous CD8+ T lymphocytes in patients with acquired immunodeficiency syndrome (AIDS)-related complex or AIDS

Based on preclinical studies showing that CD8+ T lymphocytes of human immunodeficiency syndrome (HIV)-infected subjects have anti-HIV activities, a phase 1 study was undertaken to determine the safety and feasibility of infusing in vitro purified, activated, and expanded CD8+ cells as a therapeutic measure in seven patients with acquired immunodeficiency syndrome (AIDS)-related complex (ARC) or AIDS. Autologous CD8+ cells were first selectively isolated in monoclonal antibody-coated flasks from peripheral blood mononuclear cells recovered by leukapheresis. They were then cultured and expanded with phytohemagglutinin and recombinant interleukin-2 (rIL-2) before infusion. Five cycles of isolations and infusions of increasing numbers of CD8+ T cells were achieved in five of seven subjects. Five cycles could not be completed in two subjects with AIDS whose CD4+ cell counts were < or = 48/microliters. Infusions of CD8+ cells alone were well tolerated. Four patients received rIL-2 by continuous infusion for 5 days with their final cycle of CD8+ cells. All developed reversible adverse effects attributable to rIL-2. After infusion, 111In-labeled CD8+ cells quickly accumulated in the lungs, with less than 10% of the labeled cells remaining in the circulation. After 24 hours, labeled CD8+ cells were reduced in the lungs, but increased and persisted in liver, spleen, and bone marrow. Four of five patients who were treated with multiple infusions of CD8+ cells have improved or remained clinically stable, and the fifth developed Pneumocystis carinii pneumonia but recovered. This study demonstrated that infusion of autologous, in vitro expanded and activated CD8+ cells was feasible and clinically well tolerated in five of seven subjects with advanced HIV infections.

Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management

Occult pneumothorax is pneumothorax identified by computed tomography but not seen on conventional chest radiographs. Twenty-seven occult traumatic pneumothoraces in 26 patients were identified retrospectively at the authors' level I trauma center. Of these, 24 patients survived to discharge or transfer; 2 died of brain injury. Eleven patients were treated immediately with tube thoracostomy (TT) and 13 were observed with interval chest radiography. The authors' data support the conclusion that it is safe to withhold immediate TT in patients who are hemodynamically stable. Close clinical observation and interval chest radiography can identify those patients who require subsequent TT. Prospective study of larger numbers of patients is needed to confirm the safety and cost efficacy of this approach.

A survey of community (out-of-hospital) sites used in pediatric training

A survey was completed of US pediatric residency programs about the use of community sites in training. A total of 85% of program directors responded and reported a wide use of the 21 identified survey sites. Further study is needed to determine the appropriate contribution that community sites can make to pediatric training.

Colorectal carcinoma metastases: detection with In-111-labeled monoclonal antibody CCR 086

A phase I/II clinical trial with indium-111-labeled antimucin murine monoclonal antibody (MoAb) CCR 086 was conducted. Seventeen patients with histologically proved colorectal carcinoma and known metastatic disease underwent external scintigraphy after administration of 5.5 mCi (203.5 MBq) of In-111 CCR 086 at doses of 5 and 20 mg. Of 25 known lesions, 17 were detected (sensitivity, 68%). The smallest detected lesion in the lung was 1 cm and in the liver was 1.5 cm. The serum half-life of In-111-labeled CCR 086 MoAb was approximately 64 hours. The formation of human antimouse antibody (HAMA) was detected in the serum of four of five patients who received 20 mg of MoAb. No HAMAs were detected in four patients receiving 5 mg of MoAb. No side effects were encountered. Because of effective detection of liver and lung metastases with lower doses (5-20 mg) of CCR 086 conjugated with In-111, further investigations are warranted to assess clinical and therapeutic potentials of CCR 086 in the management of colorectal cancer.

New monkey model of severe-volume controlled hemorrhagic shock

Three series of experiments were conducted to develop a model of volume-controlled severe hemorrhagic shock in the unanesthetized analgesic cynomolgus monkey. This report concerns the insult without resuscitation. In Series I, seven monkeys were sedated with 75% N2O/25% O2, bled 40% of their measured blood volume over 20 min and observed until death. Mean arterial pressure (MAP) decreased to 21 +/- 6 mmHg, spontaneously increased to 46 +/- 5 mmHg, then gradually decreased to pulselessness at 146 +/- 42 min (range 101-213). Hemodynamic variables, lactate, base excess, electroencephalogram and sagittal sinus PO2 followed the same biphasic pattern. In Series II, eight monkeys were bled 27 ml/kg (43% of estimated blood volume) over 20 min under the same N2O analgesia and with similar responses as in Series I. In Series III 26 monkeys were bled 27 ml/kg over 20 min (time zero) as in Series II. Three developed apnea and pulselessness at end of hemorrhage. In 23 the shock period was prolonged for testing resuscitation therapies. Starting at 0 + 30 min, MAP was controlled with minute blood volume adjustments at 30 mmHg until 0 + 2 h. Three died due to inaccurate (preventable) MAP adjustments. At MAP 30 mmHg, all animals lost consciousness, EEG activity decreased, and brain stem reflexes disappeared. The "volume-pressure controlled" hemorrhagic shock model of Series III retains the initial natural response to bleeding, simulates the clinical picture of severe prolonged shock without anesthesia, and represents a more controllable insult than volume controlled hemorrhage alone.

Radioimmunoimaging of metastatic medullary carcinoma of the thyroid gland using an indium-111-labeled monoclonal antibody to CEA

Elevated levels of carcinoembryonic antigen (CEA) or calcitonin after surgical therapy for medullary carcinoma of the thyroid gland (MCT) indicate the presence of residual or metastatic disease. CEA elevations appear to be prognostically more reliable in patients with metastatic disease and suggest a more virulent tumor. Attempts to stage the disease with use of conventional imaging techniques are usually inadequate, as is the therapy for disseminated or recurrent MCT. An indium-111-labeled anti-CEA monoclonal antibody (ZCE-025) was used to image metastases in a patient with MCT. Potential applications of monoclonal antibody technology in the management of MCT would include (1) preoperative differentiation of unicentric from multicentric thyroid gland involvement, (2) detection of regional or distant metastases or both, (3) measurement of response to systemic therapy, and (4) the facilitation of radionuclide immunoconjugate therapy.

Stereotaxic intracavitary irradiation for cystic craniopharyngiomas

Stereotaxic intracavitary irradiation with instillation of phosphorus-32 (32P) colloidal chromic phosphate was performed in nine patients with cystic craniopharyngiomas. Serial neurological, ophthalmological, neuroendocrinological, and radiological examinations were performed before and after treatment. Dosimetry was determined based on a computerized tomography (CT) estimation of tumor volume, and was calculated to provide a tumoricidal dose (200 to 300 Gy) to the cyst wall. The follow-up period ranged from 14 to 45 months (mean 27 months). After treatment, all nine patients showed improvement of symptoms and radiological evidence of cyst regression. Because of an expanding solid component producing recurrent symptoms, one patient required a craniotomy 14 months after isotope instillation. Three of five patients with impaired visual acuity before surgery had significant improvement in acuity after treatment. Preoperative visual field defects in eight patients improved in four after 32P therapy. Of seven patients with preoperative endocrine abnormalities, one individual showed almost complete normalization and another had improvement in endocrine function. Patients who exhibited residual neuroendocrine function before isotope instillation developed no significant deterioration in endocrine status during the follow-up period. The findings suggest that stereotaxic intracavitary irradiation is a safe and effective treatment which should be considered as the initial surgery for cystic craniopharyngiomas.

Radioimmunolocation of a heterotransplanted human choriocarcinoma (BeWo) using monoclonal anti-SSEA-1: pharmacokinetics

Stage-Specific Embryonic Antigen-1 (SSEA-1), originally discovered on mouse teratocarcinomas, has since been found on some human non-seminomatous germ-cell tumors and adenocarcinomas, as well as on some adult mouse and human tissues. A monoclonal antibody to this antigen (anti-SSEA-1; IgM, kappa) was used for radioimmunolocation. Nude mice bearing the human choriocarcinoma BeWo, which is SSEA-1 positive, were injected using a mixture of [131I]anti-SSEA-1 and [125I]MOPC 104E, an unselected myeloma protein of the same heavy-chain isotype. Animals were sacrificed at 24 hour intervals; the radioactive deposition due to both antibodies was determined for both tumors and normal organs. Accumulation of anti-SSEA-1 in the tumor was consistantly rapid and specific, while little accumulation of the unselected myeloma protein occurred. At five days after injection, an average of 3% of the initial dose of specific antibody was retained per gram of tumor; the tumor/blood ratio was 11, tumor/muscle was 80. Gamma-camera imaging allowed ready location of the tumors. Tumors could also be imaged using F(ab')2 antibody fragments.