Computed Tomography Imaging Patterns of Sinonasal Inverted Papillomas: Comparison of Primary and Recurrent Disease

OBJECTIVE

To analyze clinical and radiographic features that may impact the rate of focal hyperostosis (FH) on computed tomography (CT) for primary and recurrent sinonasal inverted papillomas (IPs) as well as highlight factors that may affect concordance between FH and IP true attachment point (TAP).

METHODS

All IPs resected between 2006 and 2022 were retrospectively reviewed. CTs were read by a neuroradiologist blinded to operative details. IP with malignancy was excluded. Operative reports and long-term follow-up data were evaluated.

RESULTS

Of 92 IPs, 60.1% had FH, 25% had no CT bony changes, and 20.7% were revision cases. The recurrence rate for rhinologists was 10.5% overall and 7.3% for primary IPs. Primary and revision IPs had a similar rate of FH (63% vs. 52.6%; p = 0.646) and FH-TAP agreement (71.7% vs. 90%; p = 0.664). Nasal cavity IPs, especially with septal attachment, were more likely to lack bony changes on CT (57.1%) compared to other subsites (p = 0.018). Recurrent tumors were 16 mm larger on average (55 mm vs. 39 mm; p = 0.008). FH (75.0% vs. 60.9%; p = 0.295), FH-TAP concordance (91.7% vs. 74.4%; p = 0.094), and secondary IP (18.8% vs. 20.3%; p = 0.889) rates were similar between recurrent and nonrecurrent tumors.

CONCLUSION

Primary and revision IPs have a similar rate of FH and FH-TAP agreement. Nasal cavity IPs are less likely to exhibit bony CT changes. Lower recurrence was associated with smaller size and fellowship training but not multiple TAPs, revision, FH absence, or FH-TAP discordance.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1591-1596, 2024.

A prime editor mouse to model a broad spectrum of somatic mutations in vivo

Genetically engineered mouse models only capture a small fraction of the genetic lesions that drive human cancer. Current CRISPR-Cas9 models can expand this fraction but are limited by their reliance on error-prone DNA repair. Here we develop a system for in vivo prime editing by encoding a Cre-inducible prime editor in the mouse germline. This model allows rapid, precise engineering of a wide range of mutations in cell lines and organoids derived from primary tissues, including a clinically relevant Kras mutation associated with drug resistance and Trp53 hotspot mutations commonly observed in pancreatic cancer. With this system, we demonstrate somatic prime editing in vivo using lipid nanoparticles, and we model lung and pancreatic cancer through viral delivery of prime editing guide RNAs or orthotopic transplantation of prime-edited organoids. We believe that this approach will accelerate functional studies of cancer-associated mutations and complex genetic combinations that are challenging to construct with traditional models.

A nationwide analysis of salvage surgery for laryngeal cancer in the elderly

BACKGROUND

We aim to describe outcomes of elderly patients undergoing salvage surgery for laryngeal cancer and to characterize the interplay of age with various other factors in this growing population.

METHODS

Using the National Cancer Database, we identified cases of salvage laryngectomy in patients who failed chemoradiation. An age cutoff of 70 years was used to separate subjects into two groups. Various factors were compared.

RESULTS

Of the 825 patients included, 166 (20.1%) were elderly. Elderly patients had worse overall survival (p = 0.001), higher 30-day and 90-day mortality (p = 0.006, p < 0.001), and a longer length of stay (LOS) (p = 0.015). LOS over 1 week was associated with worse survival (p = 0.032).

CONCLUSION

Elderly patients had worse overall perioperative survival than their younger counterparts. LOS and 30-day readmissions were associated with higher risk of mortality in this group. We provide a contemporary set of relevant information for head and neck cancer providers to consider in this growing population.

An audit of endoscopic third ventriculostomy (ETV) in a regional paediatric neurosurgical centre assessing the accuracy and feasibility of the ETV success score

BACKGROUND

Endoscopic third ventriculostomy success score (ETVss) is widely utilised to predict outcomes for ETV. Accurate prediction of success for a procedure is of vital importance both for selecting the optimal management plan and for obtaining informed consent. Existing literature demonstrates a variety of opinions on the accuracy of the currently utilised ETVss and recommends a range of techniques to reduce the number of subsequent ventriculo-peritoneal (VP)-shunt insertions, prompting the present study.

METHODS

We retrospectively analysed data for ETV cases since 2007 to review success rate in our regional paediatric neurosurgical centre and if the currently utilised ETVss successfully predicted outcomes. Failed ETV cases were defined as any patient who received a VP-shunt at any time following ETV. Data was analysed with MS Excel^R and RStudio^R.

RESULTS

44 ETVs were performed over 13 years with approximately equal distribution between male and female patients; median age 7 years (IQR 4-13 years). Overall, mean ETVss for these 44 procedures was 78%; actual success rate was 70% with no statistically significant difference between them (p = 0.286; Welch two sample t-test). Accuracy of ETVss varied with pathology: tectal gliomas (mean ETVss 75% and actual success 78%); cerebellar tumours (mean ETVss 85% and actual success 81%); other tumours (mean ETVss 75% and actual success 81%); aqueduct stenosis (mean ETVss 71% and actual success 69%); and other pathologies (mean ETVss 70% and actual success 60%). < 1 month and 1-6 months and 1-10 years and > 10 years contributed equally to the accuracy of ETVss.

CONCLUSION

Non-telencephalon tumours and obstruction at the level of the mid-brain are most strongly associated with successful ETV outcome. These findings can be used to modify the currently utilised ETVss to further improve accuracy of outcome prediction. We recommend a modified-ETVss (m-ETVss) and a future larger adequately powered prospective study to validate this.

Causes of Cancer Re-Admissions: A Patient-Centered Approach

PURPOSE

Patients with a cancer diagnosis have a high risk of re-admission during the 30 days after discharge. Clinicians, payers, and patients consider this to be an indicator of care quality. The causes of re-admission remain poorly understood. Retrospective chart reviews, used in most re-admission research, provide limited information regarding the causes of, and methods to reduce, re-admissions. This project sought to elicit the insights of those most affected by re-admission: the patients themselves.

METHODS

We interviewed patients with cancer who were re-admitted to 2 urban teaching hospitals when they were hospitalized during their second admission. Trained interviewers used a semistructured interview guide to gather information on events just before the second admission, the patients' understanding of the cause of re-admission, and the patients' views about their readiness for discharge at the previous admission. Interviews were transcribed and analyzed, and themes were identified and explored.

RESULTS

Three major themes were identified. First, most patients saw their re-admission as caused by problems that could not be treated in an outpatient setting. Second, the patients felt that they did not have sufficient resources at home to manage their care. Furthermore, the patients did not see the outpatient care team as a resource that they could call on for assistance. As a result, most of the decisions to return to the hospital were made by the patients themselves.

CONCLUSION

The decision that leads to re-admission often happens at home, in response to unmanageable needs. Strengthening the bond between the care team and the patient, with the aim of providing care in the most appropriate setting, could decrease re-admissions in patients with cancer. Possible interventions include home visits, enhanced discharge planning, and telehealth services.

A unique schedule of palonosetron, ondansetron, and dexamethasone for the prevention of delayed nausea and vomiting in patients receiving myeloablative chemotherapy

Myeloablative chemotherapy administered prior to autologous stem cell transplantation (auto-SCT) is associated with a significant amount of chemotherapy-induced nausea and vomiting (CINV). We conducted a phase II trial to assess the safety, efficacy, and impact on quality of life when palonosetron (PAL) 0.25 mg combined with dexamethasone were given on the final or only day of myeloablative chemotherapy for auto-SCT. The primary end point of this study was the incidence of achieving a delayed CINV complete response defined as no emetic episode and no use of rescue medications during the 24-120 h period post chemotherapy. Eighty-five patients were enrolled in the study and received PAL. A delayed CINV complete response was achieved in 15% of patients. A multivariate analysis demonstrated no associated differences between age, gender, diagnosis, or regimen. By day 5 after PAL, the mean nausea severity was 0.91 ± 2.45 vs. 0.09 ± 1.58 at baseline (p = 0.012). Quality of life measurements demonstrated similar quality of life between baseline and day 3. By day 6 however, nausea alone had a statistically significant impact on quality of life. In our study, PAL controlled nausea severity and sustained quality of life, but further strategies are needed to control delayed CINV associated with the auto-SCT process.

Ecohydrological and socioeconomic integration for the operational management of environmental flows

Investment in and operation of flow control infrastructure such as dams, weirs, and regulators can help increase both the health of regulated river ecosystems and the social values derived from them. This requires high-quality and high-resolution spatiotemporal ecohydrological and socioeconomic information. We developed such an information base for integrated environmental flow management in the River Murray in South Australia (SA). A hydrological model was used to identify spatiotemporal inundation dynamics. River ecosystems were classified and mapped as ecohydrological units. Ecological response models were developed to link three aspects of environmental flows (flood duration, timing, and inter-flood period) to the health responses of 16 ecological components at various life stages. Potential infrastructure investments (flow control regulators and irrigation pump relocation) were located by interpreting LiDAR elevation data, digital orthophotography, and wetland mapping information; and infrastructure costs were quantified using engineering cost models. Social values were quantified at a coarse scale as total economic value based on a national survey of willingness-to-pay for four key ecological assets; and at a local scale using mapped ecosystem service values. This information was integrated using a constrained, nonlinear, mixed-integer, compromise programming optimization model and solved using a stochastic Tabu search algorithm. We tested the model uncertainty and sensitivity using 390 Monte Carlo model runs at varying weights of ecological health vs. social values. Integrating ecohydrological and socioeconomic information identified environmental flow management regimes that efficiently achieved both ecological and social objectives. Using an ecologically weighted efficient and socially weighted efficient scenario, we illustrated model outputs including a suite of cost-effective infrastructure investments and an operational plan for new and existing flow control structures including dam releases, weir height manipulation, and regulator operation on a monthly time step. Both the investments and management regimes differed substantially between the two scenarios, suggesting that the choice of weightings on ecological and social objectives is important. This demonstrates the benefit of integrating high-quality and high-resolution spatiotemporal ecohydrological and socioeconomic information for guiding the investment in and operational management of environmental flows.

What do I do now? An electroencephalographic investigation of the explore/exploit dilemma

To maximize reward, we are faced with the dilemma of having to balance the exploration of new response options and the exploitation of previous choices. Here, we sought to determine if the event-related brain potential (ERP) in the P300 time range is sensitive to decisions to explore or exploit within the context of a sequential risk-taking task. Specifically, the task we used required participants to continually explore their options-whether they should "push their luck" and keep gambling or "take the money and run" and collect their winnings. Our behavioral analysis yielded two distinct distributions of response times: a larger group of short-decision times and a smaller group of long-decision times. Interestingly, these data suggest that participants adopted one of two modes of control on any given trial: a mode where they quickly decided to keep gambling (i.e. exploit), and a mode where they deliberated whether to the take the money they had already won or continue gambling (i.e. explore). Importantly, we found that the amplitude of the ERP in the P300 time range was larger for explorative decisions than for exploitative decisions and, further, was correlated with decision time. Our results are consistent with a recent theoretical account that links changes in ERP amplitude in the P300 time range with phasic activity of the locus coeruleus-norepinephrine system and decisions to engage in exploratory behavior.

Mechanisms of resistance off NSCLC to interferons

Interferons (IFNs) are naturally occurring cytokines which have pleiotropic actions including regulation of cell growth and differentiation, important for control of tumour growth and development. In this study we investigated the association between the presence of IFN genes in NSCLC cell lines, receptor expression and function, and sensitivity to IFNs. Some of the NSCLC lines had partial or complete IFN gene deletion but others contained all genes. However, all NSCLC lines were resistant to the antiproliferative effects of IFN alpha 2 and IFN beta ser. While the lack of sensitivity to IFNs did not appear to be associated with the presence of IFN genes, numbers of receptors or with low binding affinities it did correlate with abnormal regulation of receptor expression. When analyzed by Northern blotting it was notable that IFNA receptor expression on a sensitive cell line, Daudi, was upregulated following IFN exposure however, in the insensitive NSCLC lines IFN mediated upregulation of receptors did not occur. This defect in the regulation of receptor expression in NSCLC lines could contribute to the insensitivity of the antiproliferative effects of IFN's and thus potentiate tumour development or progression.

Sinks for nitrogen inputs in terrestrial ecosystems: a meta-analysis of 15N tracer field studies

Effects of anthropogenic nitrogen (N) deposition and the ability of terrestrial ecosystems to store carbon (C) depend in part on the amount of N retained in the system and its partitioning among plant and soil pools. We conducted a meta-analysis of studies at 48 sites across four continents that used enriched 15N isotope tracers in order to synthesize information about total ecosystem N retention (i.e., total ecosystem 15N recovery in plant and soil pools) across natural systems and N partitioning among ecosystem pools. The greatest recoveries of ecosystem 15N tracer occurred in shrublands (mean, 89.5%) and wetlands (84.8%) followed by forests (74.9%) and grasslands (51.8%). In the short term (< 1 week after 15N tracer application), total ecosystem 15N recovery was negatively correlated with fine-root and soil 15N natural abundance, and organic soil C and N concentration but was positively correlated with mean annual temperature and mineral soil C:N. In the longer term (3-18 months after 15N tracer application), total ecosystem 15N retention was negatively correlated with foliar natural-abundance 15N but was positively correlated with mineral soil C and N concentration and C:N, showing that plant and soil natural-abundance 15N and soil C:N are good indicators of total ecosystem N retention. Foliar N concentration was not significantly related to ecosystem 15N tracer recovery, suggesting that plant N status is not a good predictor of total ecosystem N retention. Because the largest ecosystem sinks for 15N tracer were below ground in forests, shrublands, and grasslands, we conclude that growth enhancement and potential for increased C storage in aboveground biomass from atmospheric N deposition is likely to be modest in these ecosystems. Total ecosystem 15N recovery decreased with N fertilization, with an apparent threshold fertilization rate of 46 kg N x ha(-1) x yr(-1) above which most ecosystems showed net losses of applied 15N tracer in response to N fertilizer addition.

Multimodality imaging in the surgical treatment of children with nonlesional epilepsy

OBJECTIVES

To evaluate the diagnostic value of individual noninvasive presurgical modalities and to study their role in surgical management of nonlesional pediatric epilepsy patients.

METHODS

We retrospectively studied 14 children (3-18 years) with nonlesional intractable focal epilepsy. Clinical characteristics, surgical outcome, localizing features on 3 presurgical diagnostic tests (subtraction peri-ictal SPECT coregistered to MRI [SISCOM], statistical parametric mapping [SPM] analysis of [18F] FDG-PET, magnetoencephalography [MEG]), and intracranial EEG (iEEG) were reviewed. The localization of each individual test was determined for lobar location by visual inspection. Concordance of localization between each test and iEEG was scored as follows: 2=lobar concordance; 1=hemispheric concordance; 0=discordance or nonlocalization. Total concordance score in each patient was measured by the summation of concordance scores for all 3 tests.

RESULTS

Seven (50%) of 14 patients were seizure-free for at least 12 months after surgery. One (7%) had only rare seizures and 6 (43%) had persistent seizures. MEG (79%, 11/14) and SISCOM (79%, 11/14) showed greater lobar concordance with iEEG than SPM-PET (13%, 3/14) (p<0.05). SPM-PET provided hemispheric lateralization (71%, 10/14) more often than lobar localization. Total concordance score tended to be greater for seizure-free patients (4.7) than for non-seizure-free patients (3.9).

CONCLUSIONS

Our data suggest that MEG and SISCOM are better tools for lobar localization than SPM analysis of FDG-PET in children with nonlesional epilepsy. A multimodality approach may improve surgical outcome as well as selection of surgical candidates in patients without MRI abnormalities.

Learning to listen to the organisational rhetoric of primary health and social care integration

The sustained modernisation of the UK primary health care service has resulted in individuals and organisations having to develop more integrated ways of working. This has resulted in changes to the structure and functioning of primary care organisations, changes to the traditional workforce, and an increase in scope of primary care practice. These changes have contributed to what for many staff has become a constantly turbulent organisational and practice environment. Data from a three-year project, commissioned by the North West Development Agency is used to explore how staff involved in these changes dealt with this turbulence. Three hundred and fifty staff working within primary care participated in the study. A multimethods approach was used which facilitated an iterative analysis and data collection process. Thematic analysis revealed a high degree of congruence between the perceptions of all staff groups with evidence of a generally well-articulated, but often rhetorical view of the organisational and professional factors involved in how these changes were experienced. This rhetoric was used by individuals as a way of containing both the good and bad elements of their experience. This paper discusses how these defense mechanisms need to be recognised and understood by managers so that a more supportive organisational culture is developed.

Functional mapping of Toll/interleukin-1 signalling networks by expression cloning

Multiple cellular proteins have been identified as participating in Toll/interleukin-1 receptor-mediated inflammatory gene expression. The continuing isolation of novel components, based on sequence similarities, protein-protein interactions and protein purification, suggests that many elements of this signalling network remain to be identified. We report here the development of a high-throughput functional screening platform and its application for the identification of components of inflammatory signalling networks. Our results enable us to estimate that 100-150 gene products are involved in controlling the transcription of the human interleukin 8 gene. The approach, which is simple and robust, constitutes a general method for mapping signal transduction systems and for rapid isolation of a large number of signalling components based on the control of pathways leading to regulation of gene expression.

The visual field in toxoplasmic retinochoroiditis

AIMS

To document loss of central field in patients with scars from toxoplasmic retinochoroiditis close to the disc after resolution of disease.

METHODS

Patients with a clinical diagnosis of toxoplasmic retinochoroiditis were enrolled from four centres. Automated central visual field testing was performed when their disease had settled and retinal photographs of the lesions were taken. The type of central field defect (whether absolute or relative) and whether it broke out to the periphery were correlated with the size of the retinochoroidal scar and its proximity to the optic nerve head.

RESULTS

69 eyes were enrolled; 16 (26%) were discarded because of poor field performance. Of the 53 remaining eyes, 31 showed absolute defects and 20 relative defects. Scars within one disc diameter of the disc were more likely to be associated with absolute defects breaking out to the periphery.

CONCLUSION

The scarring induced by toxoplasmic retinochoroiditis is associated with considerable field loss when it occurs close to the optic nerve head. Current treatment is unlikely to ameliorate this situation. The degree of visual field loss should be an outcome measure for future trials of the efficacy of treatment trials for the disease.

The effect of anti-integrin monoclonal antibodies on antigen-induced pulmonary inflammation in allergic rabbits

The integrin adhesion molecules are involved in the recruitment and activation of inflammatory cells at sites of inflammation in a variety of diseases. In the present study, we have investigated the effects of blocking monoclonal antibodies (mAbs) directed against CD49d (alpha(4) integrin), CD18 (beta(2) integrin) and the alpha sub-units of beta(2) integrin CD11a (LFA-1 integrin) and CD11b (Mac-1 integrin), on antigen (Ag)-induced acute bronchoconstriction and cellular recruitment in allergic rabbits in vivo. Inhaled Ag (Alternaria tenuis) challenge of neonatally sensitised rabbits caused an acute bronchoconstriction demonstrated by an increase in lung resistance (R(L)) and decrease in dynamic compliance (C(dyn)) and pulmonary inflammation characterised by an increase in bronchoalveolar lavage (BAL) inflammatory cells, particularly eosinophils, 24 h after challenge. Pre-treatment with the anti-CD49d mAb (Max-68P), significantly inhibited the Ag-induced acute bronchoconstriction in terms of R(L) and (C(dyn)). Treatment with the other anti-integrin mAbs had no effect on the acute bronchoconstriction after inhaled Ag challenge.Pre-treatment with the anti-integrin mAbs had differential effects in blocking the recruitment of inflammatory cells 24 h after inhaled Ag in the allergic rabbits. The data show that in the allergic rabbit model of asthma, VLA-4 (CD49d/CD29) only, is involved in the acute bronchoconstriction, suggesting an involvement of mast cell degranulation. Furthermore, eosinophil recruitment and activation appears to be mediated by a combination of VLA-4 (CD49d/CD29) and LFA-1 (CD18/CD11a). However in contrast, lymphocyte recruitment appears to be mediated by a combination of LFA-1 (CD18/CD11a) and Mac-1 (CD18/CD11b).

Clinical governance is "ACE"--using the EFQM excellence model to support baseline assessment

The introduction of clinical governance in the "new NHS" means that National Health Service (NHS) organisations are now accountable for the quality of the services they provide to their local communities. As part of the implementation of clinical governance in the NHS, Trusts and health authorities had to complete a baseline assessment of their capability and capacity by September 1999. Describes one Trust's approach to developing and implementing its baseline assessment tool, based upon its existing use of the European Foundation for Quality Management (EFQM) Excellence Model. An initial review of the process suggests that the model provides an adaptable framework for the development of a comprehensive and practical assessment tool and that self-assessment ensures ownership of action plans at service level.

A journey to becoming: the student nurse in transition

The study reported in this paper explored the nature of the transition experienced by student nurses in their journey to becoming qualified nurses. In keeping with the developing relationship between the disciplines of anthropology and nursing, the methodology of choice was ethnography. Data were collected by open-ended questionnaires and interviews with key informants from one English College of Nursing undertaking Diploma level Project 2000 Adult Branch Studies. Thematic analysis of the data revealed an ill-defined transition for the student nurse and this lack of clarity was being perpetuated for many by their dual role as both student nurse and worker. This was also creating a potential role conflict and a blurring of the boundaries between professional nursing and skilled health care work. The data also revealed two 'in limbo' states, a ritualized transition phase, and that the rationale for 'learning to become a nurse' retains the idealized and vocational imagery of nursing as helping and caring for sick people.

Alternatives to traditional illness models. Interview by Cheryl Slagle King

The Center for Human Caring at the School of Nursing, University of Colorado Health Sciences Center embraces complementary care modalities. The author interviews Karen Holland, Executive Director for the Center.

Interaction of thyroxine and estrogen on the expression of estrogen receptor alpha, cholecystokinin, and preproenkephalin messenger ribonucleic acid in the limbic-hypothalamic circuit

To study thyroid hormone and estrogen interactions in the central nervous system (CNS), the expression of estrogen sensitive genes was examined within the limbic-hypothalamic circuit. Estrogen up-regulates the expression of reproductively relevant neuropeptide messenger RNAs (mRNAs) encoding cholecystokinin (CCK) and enkephalin, peptides that stimulate lordosis. Estrogen down-regulates the expression of the estrogen receptor alpha (ER alpha) mRNA in the nuclei of the circuit. We examined the possibility that thyroid hormone treatment would block the estrogen modulation of these messages. Estradiol benzoate (EB), EB + thyroxine (T4), T4, or oil were administered to ovariectomized, adult female rats for 10 days. Isotopic in situ hybridization histochemistry revealed that within the limbic-hypothalamic nuclei, levels of CCK and preproenkephalin (PPE) mRNA levels were significantly higher in EB and EB + T4-treated animals compared with T4 or oil-treated animals. ER alpha mRNA levels were low in EB treated animals, elevated in T4 or oil-treated animals and further elevated in EB + T4-treated animals. In summary, T4 treatment had neither an independent nor an antagonistic effect on estrogen induced expression of CCK or PPE mRNA in the circuit. However, T4 did prevent the normal estrogenic decrease of ER alpha mRNA levels in the nuclei of the limbic-hypothalamic circuit.

A prospective randomized trial of buffy coat versus CD34-selected autologous bone marrow support in high-risk breast cancer patients receiving high-dose chemotherapy

High-dose chemotherapy with hematopoietic progenitor cell support is administered increasingly to selected categories of patients with high-risk malignancies. Bone marrow and/or peripheral blood progenitor cells (PBPCs) are commonly cryopreserved with the cryoprotectant dimethyl sulfoxide (DMSO), which can cause a variety of systemic side effects when the graft is thawed and infused. The progenitor cells thought to be responsible for hematopoietic recovery express the CD34 antigen and constitute 1% to 3% of the marrow cells and 0.5% of the PBPC fraction. Transplantation of a CD34(+) graft would markedly reduce the volume and thus the amount of DMSO required, thereby decreasing the infusion-related toxicities. In this study, 89 high-risk breast cancer patients received high-dose therapy and were randomized to receive an autologous CD34(+) marrow graft (Arm A) versus a standard buffy coat fraction (Arm B). After marrow infusion, significant increases in diastolic and systolic blood pressure, as well as significant decreases in heart rate, were documented in Arm B compared to Arm A patients (P < .001). None of the patients in Arm A experienced any clinically serious adverse events associated with the marrow infusion compared to 6% of the Arm B patients. The median time to neutrophil engraftment was 13 days for Arm A and 11 days for Arm B patients (P = .218). The median time to platelet engraftment was 27 days for Arm A and 20 days for Arm B patients (0.051). There were no other significant differences between the two arms of the study with respect to thrombocytopenia-related complications or immune function reconstitution. Additionally, patients on Arm A who received >/=1.2 x 10(6) CD34(+) cells/kg had no delay in platelet recovery (22 days), compared to patients on Arm B, who also received greater than 1.2 x 10(6) CD34(+) cells/kg (20 days) (P = .604). In conclusion, this prospective randomized study demonstrates that breast cancer patients who receive high-dose therapy with autologous CD34(+) marrow support have reduced marrow infusion-related toxicity, comparable time to neutrophil engraftment and immune function recovery posttransplant, and for those who receive <1.2 x 10(6) CD34(+) cells/kg, comparable time to platelet engraftment compared to women who receive buffy coat fractions of marrow.

The effect of noncontingent sensory reinforcement, contingent sensory reinforcement, and response interruption on stereotypical and self-injurious behavior

Three analyses were conducted to assess the effects of different consequent stimuli on the rate of stereotypical and self-injurious behavior performed by two individuals with severe developmental disabilities and dual sensory impairments. An analogue functional analysis documented an undifferentiated pattern of problem behavior across all conditions for Participant 1. Data for Participant 2 indicated an undifferentiated pattern with lower frequencies in the demand condition. Stimuli chosen to compete with the type of sensory stimulation produced by the stereotypy and self-injurious behavior were presented noncontingently during play conditions. Noncontingent presentation of the specially selected stimuli resulted in reductions in stereotypy and self-injurious behavior. Finally, contingent presentation of the same stimuli with and without response interruption was assessed in a demand context. Contingent presentation of the specially selected stimuli plus response interruption resulted in more suppression than contingent sensory stimulus presentation alone. Results are discussed as to competing and concurrent schedules of reinforcement.

Transjugular intrahepatic portosystemic shunt for the management of severe venoocclusive disease following bone marrow transplantation

Hepatic venoocclusive disease (VOD) is a common, life-threatening complication of bone marrow transplantation (BMT). Portal hypertension is usually present and accounts for many of the clinical manifestations of this syndrome. We describe the results of transjugular intrahepatic portosystemic shunt (TIPS) for the management of VOD after BMT TIPS was performed in six patients with histologically confirmed VOD who had progressive jaundice and ascites. Portal hypertension was improved by TIPS in all patients (mean portal pressure gradient before TIPS, 20.2 +/- 4.6 vs. 6.7 +/- 1.9 mm Hg post-TIPS, P < .004). Three patients who underwent TIPS late in the course of VOD did not demonstrate any clinical improvement after TIPS and expired within 2 weeks of the procedure. The remaining three patients had less advanced disease and demonstrated decreases in serum bilirubin, improvement in coagulopathy, and decreased ascites after TIPS. Two patients subsequently expired, one with persistent histological changes of VOD. The lone survivor continues to do well with resolution of ascites, jaundice, and coagulopathy as of her last outpatient visit. TIPS was an effective method for portal decompression in patients with VOD after BMT, and was associated with clinical improvement in some patients. However, these effects may be transient and may not improve overall survival.

Induction of CCK mRNA levels in the limbic-hypothalamic circuit: time course and site-specific effects of estrogen

Estrogenic regulation of cholecystokinin (CCK) and its receptors is correlated with the initiation and termination of lordosis behavior. To understand the effect of circulating estrogen concentration on the temporal aspects of CCK mRNA expression in the posterodorsal medial amygdaloid nucleus (MeApd) and the central part of the medial preoptic nucleus (MPNc) of the limbic-hypothalamic circuit, ovariectomized female rats were treated with a 10 mm Silastic capsule filled with estradiol, a bolus injection of 50 micrograms estradiol benzoate or 2 micrograms estradiol benzoate every 4 days for five "cycles." In situ hybridization was used to compare the relative changes of CCK mRNA levels at 0 h to levels measured at 6, 12, 24, 48, 72, or 96 h after estrogen administration. In the MPNc and the MeApd, the 10-mm capsule significantly increased and maintained CCK mRNA levels from 6 to 96 h. The range of the increase was 3.0-5.1-fold in the MPNc and 2.8-5.0 in the MeApd. The 50-micrograms injections significantly increased and maintained CCK mRNA levels in the MPNc from 12 to 96 h (range of the increase 2.4-4.1-fold) and in the MeApd from 24 to 96 h (range of the increase 2.2-2.8-fold). The repeated administration of 2 micrograms estrogen induced a significant increase of message levels in the MPNc at 12 and 24 h that were 4.2- and 4.7-fold, respectively. In the MeApd this estrogen treatment did not significantly increase CCK mRNA. These studies demonstrate that small doses (2 micrograms) of estrogen that mimic the pattern and circulating levels of estrogen dramatically stimulate CCK mRNA levels in the limbic-hypothalamic circuit. To further study this steroid stimulation, ovariectomized female rats were implanted with estradiol-filled cannulae into the bed nucleus of the stria terminalis or MeA. Estrogen elevated CCK mRNA levels locally in each nucleus. Implants in the bed nucleus also elevated CCK mRNA levels in the MeApd indicating that physiologic estrogen stimulation of CCK in the MeApd is the result of both local and distal transsynaptic elevation of CCK mRNA levels. The sitespecific induction of CCK mRNA levels within the limbic-hypothalamic nuclei provides another important facet of estrogenic modulation of CCK induction.

[Prevention of thrombosis with fraxiparin 0.3 after arthroscopic interventions]

METHODS

During a drug monitoring 101 men and women between 13 and 67 years underwent arthroscopic interventions on the knee on an outpatient basis and received the low-molecular-weight heparin, Fraxiparin 0.3, as prophylaxis of thromboembolism. In general the drug was administered the day before operation, two hours prior to operation and for five to six days postoperatively as a single daily s.c. dose.

RESULTS

During the period of treatment, one patient developed a deep venous thrombosis of the leg; on completion of observation time four more cases of venous thrombosis of the leg occurred. In contrast, no pulmonary embolisms were observed. Fraxiparin 0.3 has proved to be very well tolerated, undesired side effects did not occur, and in no case was the preventive treatment interrupted.

Preliminary observations concerning treatment of visual discomfort and associated perceptual distortion

A system for therapeutic precision tinting is described. Some individuals who are subject to perceptual distortion of text no longer perceive the distortion when the text has a particular colour. A simple colorimeter enables an observer to illuminate text with light of a particular chromaticity, varying first CIE 1976 hue angle (huv), then saturation (suv), and then luminance, to obtain a setting that maximizes visual comfort and reduces any perceptual distortion. The colorimeter setting is then matched by a combination of tinted trial lenses. The combination uses only two dyes at a time from a selection of seven, unless a dark lens is required, when a third neutral (grey) dye is added. The subject observes both text and a normal scene when wearing tinted trial lenses. A variety of trial lenses are compared including those that match the colorimeter setting and others with similar hue angle. Spectacle lenses are then tinted so as to have a spectral transmission identical to that of the chosen combination of trial lenses. Certain patients with reading disorders, eye-strain, headaches or photosensitivity epilepsy report benefit when wearing spectacles tinted according to the above techniques. The physiological basis for the therapeutic effects is uncertain, but may involve a selective impairment of luminance or colour-difference channels.

Incidence of numerical chromosome anomalies in human pregnancy estimation from induced and spontaneous abortion data

Induced abortion data provided an estimate of 4.7% numerical chromosome anomalies for women with a clinically recognized pregnancy at the end of the 7th week after the last menstrual period (LMP). This frequency requires that 51.9% of spontaneous abortions occurring after the 7th week should be chromosomally abnormal if the frequency of numerical chromosome anomalies at term (live and stillbirths combined) is 0.53%. Cytogenetic data from surveys of spontaneous abortion suggested a lower incidence of 39.7%. However, this figure is likely to be an underestimate because chromosome anomalies are almost certainly over-represented among the many early abortuses which lack embryonic tissue and hence are not karyotyped. The frequency of numerical chromosome anomalies at conception, arising from meiotic errors, was estimated from sperm karyotype data combined with information on the relative frequencies of maternal and paternal errors in the aetiology of trisomies. This provided a minimum estimate of 20%.

Vancomycin-resistant Corynebacterium species causing prosthetic valve endocarditis successfully treated with imipenem and ciprofloxacin

Endocarditis caused by a Corynebacterium sp. resistant to vancomycin, penicillin G, erythromycin, gentamicin and rifampicin arose in a 44-year-old woman 4 months after replacement of the mitral valve with a prosthesis. She was successfully treated with a 79-day course of intravenous imipenem and ciprofloxacin and replacement of the prosthesis 48 days after treatment began.

XO monosomy is associated with reduced birthweight and lowered weight gain in the mouse

The growth of XO mice and their XX sisters was followed from the day of birth up to 15 weeks post partum. XO mice were underweight at birth, and grew more slowly than XX mice in the preweaning period. Some, but not all, of this decrease in growth rate was attributable to an effect of the reduced birth weight.

Prevention of ventricular fibrillation by bretylium in a conscious canine model of sudden coronary death

In anesthetized dogs, a silver wire electrode was inserted into the lumen of the circumflex coronary artery (LCX) and myocardial infarction was produced by a temporary 90-minute occlusion of the left anterior descending coronary artery (LAD) followed by reperfusion. Four days later while in the ambulatory state, a 150 microA current was applied to the intimal surface of the LCX of saline (n = 10) and bretylium (n = 10) treated animals. Intimal injury and coronary thrombosis produced ST segment changes at 138 +/- 39 minutes (chi +/- SEM), followed by premature ventricular beats (at 142 +/- 37 minutes), ventricular tachycardia (at 156 +/- 49 minutes), and ventricular fibrillation (at 163 +/- 51 minutes) in 9 of 10 saline-treated animals. In bretylium-treated animals, ST segment changes appeared at 128 +/- 35 minutes, with six animals surviving for 24 hours (p less than 0.03 vs saline). LAD infarction was present in both saline (14.1 +/- 2.3%) and bretylium (15.1 +/- 2.1% of left ventricle) treated animals with only bretylium-treated animals developing LCX infarcts (16.1 +/- 2.1%). Bretylium prevents ventricular fibrillation (VF) resulting from ischemia at a site distant to prior myocardial infarction in the conscious dog and deserves further attention as a potential antifibrillatory agent for prevention of sudden coronary death in man.