Effects of live-online, group mindfulness training on opioid use and anxiety during buprenorphine treatment: A comparative effectiveness RCT

BACKGROUND

Office-based opioid treatment with buprenorphine has emerged as a popular evidence-based treatment for opioid use disorder. Unfortunately, psychosocial stress, anxiety, pain, and co-morbid substance use increase patients' risk for relapse. We designed this study to compare the effects of complementing buprenorphine treatment with 24 weeks of a live-online Mindful Recovery Opioid Care Continuum (M-ROCC) group to a time and attention-matched, live-online Recovery Support Group (RSG) active control condition.

METHODS

We plan to enroll a maximum of N = 280 and randomize at least N = 192 patients prescribed buprenorphine through referrals from office-based and telemedicine buprenorphine treatment providers and social media advertisements. Participants will be randomly assigned to M-ROCC or RSG and will be blinded to their treatment condition. The primary outcome for this study will be biochemically confirmed periods of abstinence from illicit opioids, as measured by self-reported use and randomly collected, video-observed oral fluid toxicology testing during the final 12 weeks of study participation. Secondary outcomes include changes in Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and pain interference scores between baseline and week 24.

RESULTS

The trial was funded by the National Institutes of Health, HEAL Initiative through NCCIH (R33AT010125). Data collection is projected to end by September 2023, and we expect publication of results in 2024.

CONCLUSION

If the M-ROCC intervention is found to be effective in this format, it will demonstrate that live-online mindfulness groups can improve outcomes and address common co-morbidities like anxiety and pain during buprenorphine treatment.

Preference for Male Risk Takers Varies with Relationship Context and Health Status but not COVID Risk

Risk taking is more commonly shown by males than females and has a signalling function, serving to advertise one's intrinsic quality to prospective mates. Previous research has established that male risk takers are judged as more attractive for short-term flings than long-term relationships, but the environmental and socioeconomic context surrounding female preferences for male risk takers has been overlooked. Using a survey instrument, we examined female preferences for male risk takers across 1304 females from 47 countries. We found preferences for physical risk takers to be more pronounced in females with a bisexual orientation and females who scored high on risk proneness. Self-reported health was positively associated with preferences for high risk takers as short-term mates, but the effect was moderated by country-level health, i.e. the association was stronger in countries with poorer health. The security provided by better health and access to health care may allow females to capitalise on the genetic quality afforded by selecting a risk-prone male whilst concurrently buffering the potential costs associated with the risk taker's lower paternal investment. The risk of contracting COVID-19 did not predict avoidance of risk takers, perhaps because this environmental cue is too novel to have moulded our behavioural preferences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40806-023-00354-3.

Evaluation of repeated or acute treatment with cannabidiol (CBD), cannabidiolic acid (CBDA) or CBDA methyl ester (HU-580) on nausea and/or vomiting in rats and shrews

RATIONALE

When acutely administered intraperitoneally, the non-psychoactive cannabinoid cannabidiol (CBD), its acidic precursor cannabidiolic acid (CBDA) and a stable methyl ester of CBDA (HU-580) reduce lithium chloride (LiCl)-induced conditioned gaping in male rats (a selective preclinical model of acute nausea) via activation of the serotonin 1A (5-HT_1A) receptor.

OBJECTIVES

To utilise these compounds to manage nausea in the clinic, we must determine if their effectiveness is maintained when injected subcutaneously (s.c) and when repeatedly administered. First, we compared the effectiveness of each of these compounds to reduce conditioned gaping following repeated (7-day) and acute (1-day) pretreatments and whether these anti-nausea effects were mediated by the 5-HT_1A receptor. Next, we assessed whether the effectiveness of these compounds can be maintained when administered prior to each of 4 conditioning trials (once per week). We also evaluated the ability of repeated CBD (7 days) to reduce LiCl-induced vomiting in Suncus murinus. Finally, we examined whether acute CBD was equally effective in male and female rats.

RESULTS

Both acute and repeated (7 day) s.c. administrations of CBD (5 mg/kg), CBDA (1 μg/kg) and HU-580 (1 μg/kg) similarly reduced LiCl-induced conditioned gaping, and these effects were blocked by 5HT_1A receptor antagonism. When administered over 4 weekly conditioning trials, the anti-nausea effectiveness of each of these compounds was also maintained. Repeated CBD (5 mg/kg, s.c.) maintained its anti-emetic efficacy in S. murinus. Acute CBD (5 and 20 mg/kg, s.c.) administration reduced LiCl-induced conditioned gaping similarly in male and female rats.

CONCLUSION

When administered repeatedly (7 days), CBD, CBDA and HU-580 did not lose efficacy in reducing nausea and continued to act via agonism of the 5-HT_1A receptor. When administered across 4 weekly conditioning trials, they maintained their effectiveness in reducing LiCl-induced nausea. Repeated CBD also reduced vomiting in shrews. Finally, CBD's anti-nausea effects were similar in male and female rats. This suggests that these cannabinoids may be useful anti-nausea and anti-emetic treatments for chronic conditions, without the development of tolerance.

Molecular Orbital Insights of Transition Metal-Stabilized Carbocations

Transition metal-stabilized carbocations are characterized by synthetically valuable interactions, yet, to date there are no comprehensive reports of the many bonding modes that can exist between a metal and carbocation. This review summarizes developments in these complexes to provide a clear picture of their properties and reactivities. In order to strategically exploit them, we propose this summary of the different bonding modes for transition metal-carbocation complexes. These models will help chemists understand the orbital interactions involved in these compounds so that they can approach their synthetic goals most effectively. Multiple transition metals and carbocations will be discussed.

Atypical femur fractures in a patient with pycnodysostosis: a case report

Pycnodysostosis is a rare autosomal recessive disease due to a mutation in the gene for the enzyme Cathepsin K. It is characterized by short stature, craniofacial dysmorphias, osteosclerosis, and brittle bones. There are only a few reports in the literature describing surgical interventions for long bone fractures in pycnodysostosis patients, most of which describe intramedullary nail treatment of isolated long bone fractures. We describe a case in which a pregnant female with pycnodysostosis presented with a shaft fracture of the left femur following minor trauma and a history of increasing thigh pain. Radiographs obtained in the emergency room also revealed an impending subtrochanteric fracture of the contralateral side. The acute left femoral shaft fracture was treated with an adolescent-sized intramedullary nail; it was decided to defer surgery on the contralateral side until after pregnancy. Three months later, the patient had the contralateral femur prophylactically fixated with a plate and screws. One year after the index surgery, both methods demonstrated satisfactory healing both clinically and radiographically. Although we recommend use of an intramedullary nail for long bone fractures in patients with pycnodysostosis, a plate can be utilized if health conditions or skeletal morphology precludes use of a nail.

How to diagnose amyloidosis

Amyloidosis is a rare but devastating condition caused by deposition of misfolded proteins as aggregates in the extracellular tissues of the body, leading to impairment of organ function. High clinical suspicion is required to facilitate early diagnosis. Correct identification of the causal amyloid protein is absolutely crucial for clinical management in order to avoid misdiagnosis and inappropriate, potentially harmful treatment, to assess prognosis, and to offer genetic counselling if relevant. This review summarises the current evidence on which the diagnosis and subtyping of amyloidosis is based, outlines the limitations of various diagnostic techniques, particularly in an Australian and New Zealand context, and discusses optimal strategies for the diagnostic approach to these patients. Recommendations are provided for when particularly to suspect amyloidosis, what investigations are required, as well as an approach to accurate subtyping of amyloidosis.

Identification of the primary mechanism of complement evasion by the periodontal pathogen, Treponema denticola

Treponema denticola, a periodontal pathogen, binds the complement regulatory protein Factor H (FH). Factor H binding protein B (FhbB) is the sole FH binding protein produced by T. denticola. The interaction of FhbB with FH is unique in that FH is bound to the cell and then cleaved by the T. denticola protease, dentilisin. A ∼ 50-kDa product generated by dentilisin cleavage is retained at the cell surface. Until this study, a direct role for the FhbB-FH interaction in complement evasion and serum sensitivity had not been demonstrated. Here we assess the serum resistance of T. denticola strain 35405 (Td35405wt) and isogenic mutants deficient in dentilisin (Td35405-CCE) and FhbB production (Td35405ΔfhbB), respectively. Both dentilisin and FhbB have been postulated to be key virulence factors that mediate complement evasion. Consistent with conditions in the subgingival crevice, an environment with a significant concentration of complement, Td35405wt was resistant to serum concentrations as high as 25%. Deletion of fhbB (Td35405ΔfhbB), which resulted in the complete loss of FH binding ability, but not inactivation of dentilisin activity (Td35405-CCE), rendered T. denticola highly sensitive to 25% human serum with 80% of the cells being disrupted after 4 h of incubation. Heat treatment of the serum to inactivate complement confirmed that killing was mediated by complement. These results indicate that the FH-FhbB interaction is required for serum resistance whereas dentilisin is not. This report provides new insight into the novel complement evasion mechanisms of T. denticola.

Waiting for surgery after orthopaedic trauma

Nursing staff on a paediatric surgical ward were concerned about delays experienced by children waiting to go to theatre following orthopaedic trauma, and their families. A facilitated action research approach was used which involved describing the issue, gathering information from a range of sources and introducing changes to the process of care. A flowchart was developed to clarify the stages and the staff involved in admitting a child with orthopaedic trauma for surgery. A white board was introduced to record information on 'trauma' patients. A facilitated action research process offers a flexible and accessible way for staff to develop a range of transferable research and change management skills.

[Immunoglobulin light chain amyloidosis: recent molecular, clinical and therapeutic approach]

AL amyloidosis is a rare disorder characterised by tissue deposition of a fibrillary proteinaceous material, formed from monoclonal immunoglobulin light (or exceptionally heavy) chains. Although it may complicate multiple myeloma or B-cell lymphomas, AL amyloidosis is often associated with a low burden of clonal plasma cells ("primitive" AL amyloidosis). The mechanisms involved in the formation of AL amyloid deposits remain unclear, but are probably related to structural peculiarities of monoclonal immunoglobulin light chains. AL amyloidosis is usually a systemic disease, often revealed by renal involvement, the most common complication of the disease. The longterm prognosis of AL amyloidosis is poor, mainly related to amyloid restrictive cardiomyopathy leading to congestive heart failure. Oral melphalan and prednisone is considered the standard treatment for AL amyloidosis, but with limited increase in the median survival. High-dose intra-venous melphalan with autologous stem cell transplantation is an effective treatment, aimed at eliminating the clonaly expanded plasma cells, which has been shown to induce complete hematologic remissions and to prolong survival. However, the tolerability of such treatment is low, limiting its use to selected patients. The development of new drugs, able to interfere with amyloid fibril deposition, may provide a new therapeutic approach.

The impact of pre-operative education on recovery following coronary artery bypass surgery. A randomized controlled clinical trial

AIMS

Research has demonstrated the beneficial impact that pre-operative education exerts on the postoperative recovery of patients having surgery but little work has focused specifically on cardiac surgery. Therefore a randomized controlled trial was designed to elucidate the consequences of pre-operative education, given before admission, on postoperative pain, anxiety, depression and wellbeing in the 6 months following a first episode of coronary artery surgery.

METHOD AND RESULTS

Three hundred and fifty-six people were randomized into the study, with 188 in the experimental and 168 in the control arms. Patients in the experimental group received the intervention, a day of education by members of the multidisciplinary team, prior to admission for surgery. Experimental and control subjects had the usual care, which involved education on admission and throughout their stay in hospital. Measurement was conducted on entry to the study, before randomization, and at 3 days, 6 weeks, 3 months and 6 months following operation. A variety of tools were used: the SF-36 Health Status questionnaire, the Hospital Anxiety and Depression scale, the General Well-Being questionnaire and a pain measurement tool. Analysis was done using the intention-totreat principle and non-parametric statistics. There were no significant differences between groups in the primary outcomes namely anxiety (P=0.09) and pain (P=0.48), or in depression (P=0.62) and wellbeing ('worn out' P=0.11; 'tense and uptight' P=0.29) 6 months after operation. This was also the case 3 days after coronary artery surgery. There was a significant difference in length of hospital stay (P=0.01) with the experimental group having the longer stay. These findings contrast with much of the existing evidence.

CONCLUSION

The findings demonstrate that there is no benefit to be gained from this form of pre-operative education and that there is an associated increase in length of hospital stay. Future research could examine an ongoing programme of education and support, and might use alternative methods such as CD-ROM or the Internet.

Depression and posttraumatic stress disorder at three months after mild to moderate traumatic brain injury

To investigate the frequency and risk factors of major depressive disorder (MDD) after mild to moderate traumatic brain injury (TBI), 69 TBI and 52 general trauma (GT) patients were prospectively recruited and studied at 3-months postinjury. There was a nonsignificant difference in the proportion of MDD patients in the TBI and GT groups. Therefore, a composite MDD group (TBI and GT patients) was compared to patients who were nondepressed. Female gender was related to MDD, but no other risk factors were identified. MDD was associated with disability (Glasgow Outcome Scale, Community Integration Questionnaire) and cognitive impairment. MDD was comorbid with posttraumatic stress disorder. Implications for postacute management of mild to moderate TBI are discussed.

Anxiety, depression and functional capacity in older women with mitral valve stenosis

Mitral valve stenosis can lead to a range of symptoms that affect daily life. As many of the people with this problem are elderly, the difficulties resulting from age can be exacerbated by illness. A pilot descriptive study was designed to examine the differences in anxiety, depression and functional capacity in women with mitral valve stenosis who were aged over 60 years when compared to a similar group of volunteers who did not have any cardiac disease. Measurement was undertaken using the Hospital Anxiety and Depression scale, the SF-36 Health Status questionnaire and the Functional Limitations Profile. Forty women were recruited to the study: 20 women with mitral valve stenosis and 20 volunteers. Each person was asked to complete the three questionnaires on one occasion only. Non-parametric statistics were used for analysis. Patients fared worse than volunteers with significant differences between groups in respect of anxiety (P = 0.03), depression (P = 0.02) and overall function (P < 0.001), but not in physical (P = 0.52) or mental health (P = 0.32). Future research could focus on strategies that would help alleviate anxiety and depression and improve functional capacity in older women with mitral valve stenosis.

Validity and sensitivity to change of the extended Glasgow Outcome Scale in mild to moderate traumatic brain injury

Using a structured outcome interview, this study addressed the validity and sensitivity to change of the Glasgow Outcome Scale (GOS) and the Extended GOS (GOSE) in a prospective study of patients who sustained mild (n = 30) to moderate (n = 13) traumatic brain injury (TBI) or general trauma (n = 44). The patients were recruited from the emergency center or inpatient units of Ben Taub General Hospital and invited to participate in follow-up examinations at 3 and 6 months. Using a series of functional outcome measures, assessment of affective status, and neuropsychological tests as criteria, the validity of the GOSE generally exceeded the GOS. Analysis of the outcome data for the patients who completed both the 3-month and 6-month assessments disclosed that the GOSE was more sensitive to change than the GOS. Comparison of the 3-month outcome data disclosed that the GOSE and GOS scores did not differ for the TBI and general trauma groups. These findings lend further support for utilization of the GOSE in clinical trials when it is based on a structured interview.

FIN219, an auxin-regulated gene, defines a link between phytochrome A and the downstream regulator COP1 in light control of Arabidopsis development

Light signals perceived by photoreceptors are transduced to negatively regulate COP1, a key repressor of photomorphogenic development. To identify genes involved in light inactivation of COP1, a genetic screen was employed to identify extragenic modifier mutations of a temperature-sensitive cop1 allele. One suppressor mutation isolated also exhibited a far-red-specific long hypocotyl phenotype in a wild-type background. Further phenotypic analyses of this new mutation, named fin219, suggested that it defines a novel phytochrome A signaling component. Genetic analysis indicated that FIN219 interacts closely with another phytochrome A signaling component, FHY1. Molecular characterization of FIN219 indicated that it encodes a cytoplasmic localized protein highly similar to the GH3 family of proteins and its expression is rapidly induced by auxin. In contrast to its loss-of-function mutant phenotype, overexpression of FIN219 results in a far-red-specific hyperphotomorphogenic response. Our data suggest that FIN219 may define a critical link for phytochrome A-mediated far-red inactivation of COP1 and a possible cross-talk juncture between auxin regulation and phytochrome signaling.

Enhanced lymphoproliferation and diminished autoimmunity in CD4-deficient MRL/lpr mice

MRL/lpr mice spontaneously develop an autoimmune disease with features of systemic lupus erythematosus. They also develop a lymphoproliferative disorder characterized by a massive accumulation of double-negative (DN) T cells that lack both CD4 and CD8. To clarify the role of CD4 in autoimmunity and lymphoproliferation in these mice, CD4-deficient MRL/lpr mice were generated. CD4-deficient MRL/lpr mice developed massive expansion of DN T cells in the blood, spleen, and lymph nodes, which significantly exceeded the degree of lymphoproliferation in CD4-expressing control MRL/lpr mice. Despite this lymphoproliferation, CD4-deficient MRL/lpr mice produced little, if any, antibodies to double-stranded DNA, and they had prolonged survival relative to CD4-expressing littermates. However, they eventually developed moderately severe nephritis, characterized by immunoglobulin and complement deposition in glomeruli, vasculitis, and renal infiltration by CD8+ T cells. These findings indicate that (1) lymphoproliferation in MRL/lpr mice does not require the expression of CD4; (2) autoantibody production in MRL/lpr mice is dependent on the expression of CD4 and not on the accumulation of DN T cells; and (3) the development of nephritis in MRL/lpr mice involves both CD4-dependent and CD4-independent mechanisms.

Analysis of 1.9 Mb of contiguous sequence from chromosome 4 of Arabidopsis thaliana

The plant Arabidopsis thaliana (Arabidopsis) has become an important model species for the study of many aspects of plant biology. The relatively small size of the nuclear genome and the availability of extensive physical maps of the five chromosomes provide a feasible basis for initiating sequencing of the five chromosomes. The YAC (yeast artificial chromosome)-based physical map of chromosome 4 was used to construct a sequence-ready map of cosmid and BAC (bacterial artificial chromosome) clones covering a 1.9-megabase (Mb) contiguous region, and the sequence of this region is reported here. Analysis of the sequence revealed an average gene density of one gene every 4.8 kilobases (kb), and 54% of the predicted genes had significant similarity to known genes. Other interesting features were found, such as the sequence of a disease-resistance gene locus, the distribution of retroelements, the frequent occurrence of clustered gene families, and the sequence of several classes of genes not previously encountered in plants.

Geriatric rehabilitation

The United States population is aging, and the number of people over age 85 is expected to quadruple early in the next century. Advancing age increases the likihood of aquiring a disabling condition. By the next century, every other visit to a health provider will be made by an elderly person. Nurse practitioners will see increasing numbers of older patients. They will be called on to differentiate normal aging states from pathological conditions. A focus on promoting vigorous aging, minimizing disabling conditions, and restoring or preserving function and independence will assist the practitioner in appropriate evaluation and treatment of the elderly.

Patients' perceptions of their education needs in the first six weeks following discharge after cardiac surgery

The aim of this study was to discover what information and support patients feel they need in the 6-week rehabilitation period following discharge after cardiac surgery. It was undertaken at the request of the hospital multidisciplinary cardiac rehabilitation team to enable them to plan a package of information to meet those needs. It was a local study aiming to gain insight into the patients' own views by asking them to keep a diary over the 6-week period and then take part in an unstructured interview when they returned for their 6-week out-patient appointment. The analysis of the respondents' comments gave an insight into their whole experience of the first 6 weeks following discharge. The themes which emerged were wide-ranging and were grouped under the headings of the early discharge needs of pain relief and sleep promotion, psychological needs, practical needs and community support. To take the study forward, several recommendations were made to improve the rehabilitation experience. These included additions to the literature and patient education sessions, and changes to ensure a smoother transition into the community. The findings also suggest the need for improvements in and further research into the whole area of the psychological preparation for discharge after cardiac surgery.

Acute-phase response and the hypercoagulable state in pulmonary tuberculosis

In our experience, severe pulmonary tuberculosis (PTB) is often complicated by deep venous thrombosis (DVT). Because of the association between inflammation and haemostatic changes that can result in a hypercoagulable state, we have prospectively examined such predisposing factors in representative patients. Sequential analyses in a control group with active PTB showed anaemia, thrombocytosis, elevations in plasma fibrinogen, fibrin(ogen) degradation products (FDP), tissue plasminogen activator (t-PA) and inhibitor (PAI-1) with depressed antithrombin III levels. Age, sex and disease matched individuals with venographically proven DVT had higher FDP (15.8 +/- 14.3 v 3.2 +/- 1.7 micrograms/ml:P < 0.01), t-PA (19.4 +/- 14.9 v 11.3 +/- 0.8 ng/ml:P < 0.01), and functional PAI-1 activity (11.6 +/- 6.3 v 4.2 +/- 4.1:P < 0.01) with lower platelet counts (347 +/- 110 v 563 +/- 230 x 10(9)/1:P < 0.01). Fibrinogen levels in all patients rose during the first 2 weeks of therapy and, together with related disturbances, corrected within 12 weeks. In conclusion, elevated plasma fibrinogen with impaired fibrinolysis coupled with a decrease in antithrombin III and reactive thrombocytosis would appear to favour the development of DVT in PTB.

Haemostatic Abnormalities in Patients with a Clinical Predisposition to Venous Thromboembolism

Although a number of clinical risk factors for deep vein thrombosis (DVT) and embolism are recognised, the precise pathogenetic mechanism operating in the majority of cases is never established. Whilst it is important to recognise congenital deficiencies of naturally occurring anticoagulant proteins, their incidence is often unknown in any given hospitalized population. To examine this controversy, a case controlled study was undertaken to correlate venous thromboembolism at our institution with laboratory tests of haemostasis and to define those having predictive value for this event. Patients with the clinical diagnosis of DVT were divided into those having venographic confirmation (Group 1; n = 106) and a matching series where these studies were negative (Group 2: n = 74). The most frequent associations with DVT were the confirmed diagnosis of severe pulmonary tuberculosis (n = 30), carcinoma (n = 13) and surgery (n = 6); no proven case of a congenital factor deficiency was documented. Comparison of laboratory data from groups 1 and 2 showed, respectively, higher levels of fibrinogen, being 4.6 ± 0.8 g/L versus 3.16 ± 1.12 g/L (p < 0.05), fibrin(ogen) degradation products (FDP) of 11.5 ± 8.3 μg/ml versus 1.4 ± 1.63 (p < 0.01), and tissue plasminogen activator antigen (tPA) 26.5 ± 14.5 versus 12.1 ± 11.2 (p < 0.01). Decreased levels of several coagulation inhibitory proteins were seen only in association with clinical and haematologic evidence of multisystem disease with coagulopathy. No isolated deficiencies of these proteins were observed, even in the small group of idiopathic recurrent venous thrombosis in this series. Increased plasma fibrinogen, FDP, and plasminogen activator antigen levels may indicate the presence of DVT in individuals at risk, and in the case of pulmonary tuberculosis may be associated with a potential hypercoagulable state.

Geriatric rehabilitation

The United States population is aging, and the number of people over age 85 is expected to quadruple early in the next century. Advancing age increases the likelihood of acquiring a disabling condition. By the next century, every other visit to a health provider will be made by an elderly person. Nurse practitioners will see increasing numbers of older patients. They will be called on to differentiate normal aging states from pathological conditions. A focus on promoting vigorous aging, minimizing disabling conditions, and restoring or preserving function and independence will assist the practitioner in appropriate evaluation and treatment of the elderly.

Case report: rectal stenosis due to extramedullary haemopoiesis--radiological features

Although extramedullary haemopoiesis (EMH) is relatively common in myelofibrosis, it is seldom symptomatic and rarely involves the intestinal tract. We report a case in which perirectal infiltrate resulted in clinically symptomatic constipation. The barium enema showed tubular rectal narrowing with mucosal pleating. On computed tomography a poorly marginated soft tissue mass was shown to be replacing the perirectal fat.

Phase I pharmacokinetic study of the hypoxic cell sensitizer etanidazole with carboplatin and cyclophosphamide in the treatment of advanced ovarian cancer

PURPOSE

A Phase I study was undertaken to determine the maximum tolerated dose of the hypoxic cell sensitizer etanidazole which could be administered with carboplatin and cyclophosphamide, to determine whether adequate serum levels of etanidazole were achieved to allow for alkylating agent sensitization, and whether pretreatment with etanidazole altered carboplatin pharmacokinetics.

METHODS AND MATERIALS

Patients received 2 g/m2 of intravenous etanidazole followed by a second dose of 4 g/m2 90 min later, followed by intravenous carboplatin (300 mg/m2) and cyclophosphamide (600 mg/m2) for four treatment cycles. Patients received an additional two cycles of carboplatin and cyclophosphamide without etanidazole.

RESULTS

Two patients who received a total of 24 g/m2 of etanidazole developed Grade 1 neurotoxicity, and therefore etanidazole doses were not escalated further. The grade of granulocytopenia was worse after cycles with etanidazole than after those without (p = 0.03), but clinical outcome was not different. Etanidazole levels were adequate for alkylating agent sensitization (> 70 ug/ml) in all patients for the majority of the 7 h of testing. Pharmacokinetic data suggested t1/2 alpha and t1/2 beta for carboplatin were prolonged after pretreatment with etanidazole.

CONCLUSION

Etanidazole, 2 g/m2 followed by 4 g/m2 90 min later, is safe and results in adequate serum levels for alkylating agent sensitization. Neurotoxicity appears to prevent dose escalation of etanidazole, and an interaction between etanidazole and carboplatin may have enhanced neurotoxicity in these patients.

Analysis of HPV-positive and -negative vulvar carcinomas for alterations in c-myc, Ha-, Ki-, and N-ras genes

Mutation or overexpression of certain host genes, including c-myc, Ha-ras, and Ki-ras, have been associated with genital squamous neoplasia, specifically in the cervix, and have been implicated in the natural history of these tumors. The relationship of these host gene alterations to vulvar squamous cell carcinomas has not been previously studied. We analyzed archival material from 13 human papillomavirus-positive and -negative vulvar squamous cell carcinomas for mutations in Ha-, Ki-, and N-ras genes, and a smaller number of fresh samples for c-myc amplification, using PCR-based assays. For comparison, eight cervical squamous cell carcinomas (three fixed and five fresh) were also analyzed. Analysis for ras mutations revealed a previously reported silent allelic variant at nucleotide 1744 in the Ha-ras gene, but no mutations in codons 12, 13, or 61. Similarly, genomic amplification of c-myc beyond a maximum of three haploid copies was not identified in the cases. These findings indicate that alterations in myc or ras sequences are not linked to vulvar squamous cell carcinomas or to the presence or absence of HPV nucleic acids. Moreover, they apparently will not distinguish vulvar from cervical carcinomas, both groups appearing to be unlikely to harbor these sequence alterations.

Comparison between sonographic morphology and Doppler waveform for the diagnosis of ovarian malignancy

OBJECTIVE

To assess the accuracy of pelvic sonography in distinguishing benign from malignant lesions in postmenopausal women, using morphologic criteria and Doppler flow characteristics.

METHODS

All postmenopausal patients scanned from March 1992 to April 1993 with sonographically identified and pathologically confirmed adnexal masses formed the study group. The adnexal lesions were morphologically categorized prospectively as benign or malignant, and pulsed Doppler flow studies were measured using the lowest resistance index obtained from each mass. The sensitivity and specificity were determined for morphologic and Doppler flow assessments, as well as for a combination of these methods, for predicting the presence of malignancy.

RESULTS

Thirty-three postmenopausal patients formed the study group; 12 lesions were malignant and 21 were benign pathologically. Using morphologic criteria alone, the sensitivity in detecting malignancy was 91% and specificity was 52%. Using pulsed Doppler alone with a resistance index limit of 0.6, the sensitivity in predicting malignancy was 66%, with a specificity of 81%. If a resistance index limit of 0.8 were used, the sensitivity and specificity would be the same as those for morphology alone. Combining morphology and resistance index, a single malignancy would still have been missed (sensitivity 91%).

CONCLUSION

In our experience, Doppler flow studies did not add substantially to the prediction of malignancy using morphologic assessment alone.

Use of peripheral-blood progenitor cells abrogates the myelotoxicity of repetitive outpatient high-dose carboplatin and cyclophosphamide chemotherapy

PURPOSE

Attempts to increase dose-intensity in clinical practice have been limited by cumulative hematologic toxicity despite the use of hematopoietic growth factors. To address this problem, we designed a study to determine whether four cycles of dose-intensive chemotherapy with carboplatin could be administered in the outpatient setting using granulocyte-macrophage colony-stimulating factor (GM-CSF) and peripheral-blood progenitor cells (PBPCs) that had been harvested before initiation of treatment.

PATIENTS AND METHODS

An initial cycle (cycle no. 0) of cyclophosphamide 4 g/m2 followed by GM-CSF was used to mobilize PBPCs harvested by leukapheresis for 6 consecutive days. Cycles no. 1 through 4 consisted of outpatient carboplatin 600 mg/m2 and cyclophosphamide 600 mg/m2 followed by GM-CSF 5 micrograms/kg subcutaneously (SC) twice per day every 28 days. In cycle no. 1, PBPC were not reinfused to assess the effects of GM-CSF alone. In cycles no. 2 through 4, PBPCs were reinfused on day 3 in an outpatient setting.

RESULTS

In eight assessable patients, the addition of PBPCs in cycle no. 2 resulted in a significant reduction in the median duration of thrombocytopenia less than 20,000/microL (6.5 v 1 day; P = .016), days to platelets more than 50,000/microL (20.5 v 15 days; P = .020), number of platelet transfusions (five v 1.5; P = .016), and duration of neutropenia (absolute neutrophil count [ANC] < 1,000/microL (7 v 2.5 days; P = .008) when compared with cycle no. 1. Dose-limiting hematologic toxicity, defined as more than 7 days of platelets less than 20,000/microL or ANC less than 500/microL, was observed in four of eight patients during cycle no. 1, but not during cycles no. 2, 3, and 4 of chemotherapy supported by PBPCs (a total of 19 cycles in eight patients). Five of eight patients completed all four cycles of high-dose therapy. Three patients did not complete four cycles due to late thrombocytopenia (n = 2) or tumor progression (n = 1).

CONCLUSION

These results indicate a benefit of PBPCs in addition to GM-CSF in alleviating myelosuppression of dose-intensive chemotherapy. Initial collection of PBPCs may allow administration of repetitive cycles of high-dose chemotherapy with acceptable toxicity to outpatients at disease onset.

In-use evaluation of surgical gowns

Surgical gowns must protect patients from the bacteria of operating room personnel and also protect staff members from the lethal viruses in the blood of patients. The current study was done to evaluate the barrier function of several surgical types of gowns during use in surgical procedures and identify the frequency of failure of the gowns and some causes for this failure. We performed direct observation of 234 operations during which the surgeon and the first assistant wore 535 gowns. Blood strikethrough occurred most often when contamination on the outside of the gown was heavy (20 per cent), but still occurred after medium (7 per cent) and small (1 per cent) contamination. We found significant differences between gowns based on the material used and the design of the gowns. Gowns reinforced with a second layer of material or a layer of plastic material were more effective at preventing strikethrough than a single layer of material. One gown was identified that was unacceptable for any use in the operating room. Gowns of different designs and degrees of protection should be chosen based on the body area likely to be exposed to blood and the amount of predicted blood contamination. Further improvement in gown materials and design are required, since surgeons cannot consider any of these gowns protective during strenuous use.

Double gloving. Protecting surgeons from blood contamination in the operating room

Health care workers, particularly surgeons, understand the importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination.

Risk of blood contamination and injury to operating room personnel

The potential for transmission of deadly viral diseases to health care workers exists when contaminated blood is inoculated through injury or when blood comes in contact with nonintact skin. Operating room personnel are at particularly high risk for injury and blood contamination, but data on the specifics of which personnel are at greater risk and which practices change risk in this environment are almost nonexistent. To define these risk factors, experienced operating room nurses were employed solely to observe and record the injuries and blood contaminations that occurred during 234 operations involving 1763 personnel. Overall 118 of the operations (50%) resulted in at least one person becoming contaminated with blood. Cuts or needlestick injuries occurred in 15% of the operations. Several factors were found to significantly alter the risk of blood contamination or injury: surgical specialty, role of each person, duration of the procedure, amount of blood loss, number of needles used, and volume of irrigation fluid used. Risk calculations that use average values to include all personnel in the operating room or all operations performed substantially underestimate risk for surgeons and first assistants, who accounted for 81% of all body contamination and 65% of the injuries. The area of the body contaminated also changed with the surgical specialty. These data should help define more appropriate protection for individuals in the operating room and should allow refinements of practices and techniques to decrease injury.

Well-differentiated hepatocellular carcinoma associated with long-term survival. Report of two cases

Two cases of well-differentiated hepatocellular carcinoma (HCC) with focal biliary differentiation are presented. The distinct histological features of these neoplasms and the unusually protracted clinical course of 8 and 10 years distinguish them from previously described pathological categories of primary hepatic tumors. Electron microscopic and immunohistochemical findings support a dual hepatic and bile duct differentiation of the tumor cells. If additional examples of this tumor are found to be associated with a similarly prolonged symptom-free survival, the distinction of this entity from traditional, rapidly fatal HCC becomes important. Less aggressive therapeutic options may be entertained.

Uterine leiomyosarcoma--magnetic resonance imaging

Magnetic resonance (MR) scanning shows great promise as an imaging tool to evaluate the pelvis as a result of contrast resolution and lack of ionizing radiation. For these reasons, it is assuming an important role in staging gynecologic neoplasms, and evaluating diseases in the gravid pelvis. A case of uterine leiomyosarcoma is presented in which MR imaging was able to delineate the extent and tissue characteristics of the lesion more precisely than CT scan.

Hydromorphone levels and pain control in patients with severe chronic pain

To better understand the use of narcotic analgesics, the hydromorphone concentration was measured in serum samples from 43 patients with chronic severe pain who were receiving this drug. At the time of blood sampling, pain intensity, mood, and cognitive performance were assessed. There was large individual variation in the dose-drug level relationship. Seven patients with bone or soft tissue pain and drug levels of greater than or equal to 4 ng/ml had good pain control, whereas 10 did not. None of 15 patients with levels less than 4 ng/ml had pain control, despite drug doses similar to those given patients with higher levels. Thus 60% of the patients without control of their pain had hydromorphone levels below the lowest level that produced pain control. No patient with pain from nerve infiltration or compression had good pain control, irrespective of the drug level or dose. Poor mood correlated with high pain intensity and low drug level. Impaired cognitive performance was not related to drug level. Knowing that there is a low concentration of narcotic in the blood of a patient with chronic severe pain who is receiving high drug doses and who shows lack of both efficacy and side effects may reassure health care professionals that further narcotic dosage escalation is appropriate.

Reversible, narcotic-associated mental status impairment in patients with metastatic cancer

Pain and mental status were assessed in a series of 35 consecutive hospitalized patients with metastatic cancer receiving narcotics for pain that was difficult to control. Forty-five episodes of mental status impairment were detected in 27 of these patients. Fifteen patients had dose-related oversedation or organic brain syndrome. In only 4 could the narcotic dose be decreased without exacerbating the pain. Eleven patients had mental status impairment associated with factors other than the narcotic dose. These factors were: concurrent CNS-depressant drugs, presence of fever or infection, or changing from parental to average oral equianalgesic dose of narcotic. When these factors were corrected, mental function improved and remained stable despite resumption of the previous narcotic dose. Delirium occurred more frequently in patients over 65, while oversedation without delirium was more frequent in the younger group. For some patients with advanced metastatic cancer, pain relief and intact mental status cannot coexist. For others, correction of factors other than narcotics which can impair function can often lead to improved mental status without decreasing narcotic dose or decreasing the degree of pain control.

WHO's first research unit: immunology

The Advisory Committee on Medical Research has just celebrated its 25th anniversary. The first research unit concerned itself with immunology and it provides an excellent example of the foresight of ACMR. Immunological tests are now an integral part of all branches of medicine. All nurses need to have an awareness of the rapid growth of immunology, from its roots in microbiology to its present status as a scientific discipline.

Development of an enzyme-linked immunosorbent assay for determination of lysozyme in human parotid and submandibular-sublingual salivas

The specificity of lysozyme determinations in human parotid and submandibular-sublingual salivas of two subjects was assessed by comparison of lysozyme concentrations in native acidified salivas with purified enzyme obtained by immunoadsorbent fractionation of the salivas. Lysozyme concentrations were measured by the turbidimetric catalytic method and by a newly developed enzyme-linked immunosorbent assay (ELISA). The validity of the assays was established by comparing assay results with enzyme concentration values determined from optical density-extinction coefficient calculations of the purified lysozyme peak. Values for purified enzyme were found to be similar, irrespective of the assay used to determine lysozyme concentrations, and were in agreement with extinction coefficient calculations. Based on the ELISA technique, recoveries of lysozyme from both parotid and submandibular-sublingual salivas were greater than 75 and 90%, respectively. Similar recoveries were noted for parotid saliva when determinations were based on the turbidimetric assay. However, the ELISA and turbidimetric assays differed with respect to lysozyme levels in submandibular-sublingual saliva because of the apparent presence of an enhancement factor which gave rise to higher lysozyme values in the catalytic assay and therefore resulted in low recoveries of purified enzyme. This catalytic enhancement factor was present in the nonadsorbed fraction of both subjects, as higher lysozyme activities were noted when nonadsorbed fractions were added to affinity-purified lysozymes. Lysozyme levels were also determined in the parotid and submandibular-sublingual salivas of caries-resistant and -susceptible adults. In general, levels of lysozyme in parotid saliva were lower in comparison to submandibular -sublingual saliva; however, significant differences in enzyme concentration were not evident between the caries-resistant and caries-susceptible subjects.