Anticoagulation vs. vena caval filters in cancer patients with venous thromboembolism: Improved survival with anticoagulation

8553

Background: Cancer patients (pts) have an increased incidence of venous thromboembolism (VTE). Inferior vena caval (IVC) filters are used extensively in the US; over 40,000 are inserted annually. The impact on survival of cancer pts receiving IVC filters has not been studied. Methods: A retrospective study examined 154 consecutive cancer pts with VTE in order to compare the effects of IVC filter placement with anticoagulation (AC) therapy on overall survival (OS), as measured from the time of VTE. Pts were classified into three treatment groups: AC (n=58), IVC filter (73), or combination IVC filter+AC (23). OS was analyzed using survival analysis methods (e.g., Kaplan-Meier Product-Limit Method, logrank test). Multivariate Cox regression was used to account for the possible confounders: ECOG performance status (PS) and type of thrombus. Results: Treatment groups did not differ with respect to age, gender, or albumin levels. Groups did differ for PS (P<0.033 chi-square test, better PS was associated with AC only) and for type of thrombus (P<0.007 chi-square, DVT was associated with AC, PE with IVC, and DVT/PE with AC+IVC). Median OS was significantly greater in pts treated with AC (11 mos) compared to IVC filters (3 mos) or IVC+AC (3.5 mos) (p<0.0046). IVC pts were 1.73 times more at risk of death than AC only (hazard ratio; 95%CI 1.18–2.52). Multivariate analysis revealed that PS and type of thrombus were not confounders and had no effect on OS. Conclusion: AC should be considered primary therapy for cancer pts with VTE. IVC filters should be considered a therapeutic option only when AC is strictly contraindicated. Prospective randomized trials are needed to address this issue.

No significant financial relationships to disclose.

Neutrophil and monocyte adhesion molecules in bronchopulmonary dysplasia, and effects of corticosteroids

AIMS

To study a longitudinal change in the expression of adhesion molecules CD11b, CD18, and CD62L on neutrophils and monocytes in very low birth weight babies who develop respiratory distress syndrome, to compare these levels between bronchopulmonary dysplasia (BPD) and non-BPD infants, and to assess the effect of corticosteroid treatment on these adhesion molecules.

METHODS

Of 40 eligible neonates, 11 neonates were oxygen dependent at 36 weeks (BPD 36 weeks), 16 infants were oxygen dependent at 28 days, but not at 36 weeks (BPD d28), and 13 infants did not develop BPD. Seventeen neonates received a six day course of steroid treatment. Expression of CD11b, CD18, and CD62L was measured on neutrophils and monocytes in arterial blood on days 1, 3, 7, 14, 21, and 28, and before and 2-3 days after initiation of dexamethasone treatment by flow cytometry.

RESULTS

CD18 expression on neutrophils and monocytes and CD62L on neutrophils, measured as mean fluorescent intensity, was significantly decreased in BPD neonates compared to non-BPD neonates on days 1-28. Dexamethasone treatment significantly decreased CD11b, CD18, and CD62L expression on neutrophils, and CD11b and CD18L expression on monocytes.

CONCLUSIONS

Decreased CD18 expression on neutrophils and monocytes, and decreased CD62L expression on neutrophils, measured as mean fluorescent intensity during the first four weeks of life in micropremies may be risk factors and early predictors of BPD. Dexamethasone use was associated with decreased expression of CD11b, CD18, and CD62L.

Assessment of a bronchoscopy simulator

The study objective was to validate a flexible bronchoscopy simulator by determining if it could differentiate between expert and novice bronchoscopists. A subsequent evaluation phase was then done to determine whether use of the simulator would improve the rate of bronchoscopy skill acquisition for new pulmonary fellows. A multicenter prospective cohort study was performed using a bronchoscopy simulator. Three cohorts were evaluated based on the number of bronchoscopies previously performed: "experts" (> 500, n = 9), "intermediates" (25 to 500, n = 8), and "novices" (none, n = 11). Each participant performed two simulated cases with performance measures being recorded by the simulator. Performance measures that distinguished between groups were then used to evaluate the learning curve for new fellows training on the simulator. A randomized-controlled trial was then conducted comparing the quality of bronchoscopy performance for new pulmonary fellows who were trained either with conventional methods or with the simulator. Expert bronchoscopists performed better on the simulator than intermediates who performed better than novices in terms of procedure time, percentage of segments visualized, time in red-out, and wall collisions. Training of new fellows demonstrated that after performing 20 bronchoscopic simulations, the skill level acquired with the simulator significantly improved in terms of speed, percentage of segments visualized, time in red-out, and collisions. Fellows trained on the simulator performed better than fellows trained using conventional methods during their first actual bronchoscopies as assessed by procedure time (815 versus 1,168 s, p = 0.001), a bronchoscopy nurse's subjective quality assessment score (7.7 +/- 0.3 versus 3.7 +/- 2.5, p = 0.05), and by a quantitative bronchoscopy quality score (percentage of segments correctly identified/procedure time, 0.119 +/- 0.015 versus 0.046 +/- 034, p = 0.03). In conclusion, the bronchoscopy simulator was able to accurately assess bronchoscopy experience level. Training new fellows on the bronchoscopy simulator leads to more rapid acquisition of bronchoscopy expertise compared with conventional training methods. This technology has the potential to facilitate bronchoscopy training and to improve objective evaluations of bronchoscopy skills.

Comparison of the auditory and visual privacy of emergency department treatment areas with curtains versus those with solid walls

STUDY OBJECTIVE

The design and function of emergency departments may allow breaches of privacy that could adversely affect patient satisfaction and medical care. We sought to determine whether patients perceive less privacy in ED treatment areas with curtains than in rooms with solid walls.

METHODS

Patients 18 years and older at a university hospital ED who received care in a room with solid walls and a door, a curtained area next to the nurses' station, or a curtained area away from the nurses' station were surveyed. Patients responded on a 5-point Likert scale to 11 questions regarding privacy. Differences between areas were determined by using the Kruskal-Wallis and Mann-Whitney tests and were considered significant at P values of less than.05.

RESULTS

Structured interviews were conducted with 108 ED patients. Responses from those in the curtained areas were similar. Compared with those in the rooms with walls, these patients more often believed that they could overhear others and that others could hear them, view them, hear personal information, and view personal parts of their bodies (P < or =.04 for all). They also perceived a lower overall sense of privacy (P <.01). Of all those surveyed, 85.2% reported "a lot of" or "complete" respect for privacy by the staff, and 92.6% experienced at least as much privacy as they expected, with no difference between areas.

CONCLUSION

Patients perceive significantly less auditory and visual privacy in ED treatment areas with curtains compared with a room with solid walls. Consideration of these findings in current practice and in future ED design and construction is suggested.

A dose of 75 microg/kg/d of i.v. anti-D increases the platelet count more rapidly and for a longer period of time than 50 microg/kg/d in adults with immune thrombocytopenic purpura

Treatment with 75 microg/kg/d intravenous (i.v.) anti-D was compared with 50 microg/kg/d in a prospective randomized study of 27 RhD-positive, human immunodeficiency virus-negative, adult, acute, non-splenectomized patients with immune thrombocytopenic purpura (ITP) and platelet counts < or = 30 x 109/l. The higher dose resulted in greater median d 1 (43 x 109/l vs. 7.5 x 109/l; P = 0.012) and d 7 (153 x 109/l vs. 64.5 x 109/l; P = 0.001) platelet increases despite no greater haemoglobin decrease. Children with acute ITP receiving 75 microg/kg/d had overnight platelet increases in seven out of nine cases. The duration of effect at the 75 microg/kg/d dose was 46 d vs. 21 d (P = 0.03). Adverse events were mild to moderate and ameliorated with prednisone and acetaminophen premedication.

Effect of antenatal steroid administration on the fetal biophysical profile

PURPOSE

Our objective was to determine whether antenatal steroid administration affects the biophysical profile score in fetuses.

METHODS

A prospective study was conducted in 84 fetuses between 28 and 34 weeks' menstrual age at risk of preterm delivery. Two intramuscular injections of 12 mg of betamethasone were given to the mother 24 hours apart. All fetuses underwent biophysical profile testing prior to and between 24 and 48 hours after steroid administration. Biophysical profiles (including nonstress tests) were evaluated by two maternal-fetal medicine specialists blinded to the timing of steroid administration. Neonatal outcome, including Apgar score, menstrual age at delivery, admission to and length of stay in the neonatal intensive care unit, and mortality, was analyzed in all subjects.

RESULTS

In 31 (37%; 95 confidence interval, 26.6-47.2%) of 84 cases, the biophysical profile score decreased at least 2 points after steroid administration. The most commonly affected variables were fetal breathing and the nonstress test. There was no significant difference in the neonatal outcome between the fetuses whose biophysical profile decreased and those whose did not.

CONCLUSIONS

Biophysical profile scores were decreased in more than one third of fetuses within 48 hours of antenatal steroid administration, but neonatal outcome was not affected. Knowledge of this occurrence could avoid incorrect decision making regarding fetal well-being.

Angiogenesis gene therapy: phase I assessment of direct intramyocardial administration of an adenovirus vector expressing VEGF121 cDNA to individuals with clinically significant severe coronary artery disease

BACKGROUND

Therapeutic angiogenesis, a new experimental strategy for the treatment of vascular insufficiency, uses the administration of mediators known to induce vascular development in embryogenesis to induce neovascularization of ischemic adult tissues. This report summarizes a phase I clinical experience with a gene-therapy strategy that used an E1(-)E3(-) adenovirus (Ad) gene-transfer vector expressing human vascular endothelial growth factor (VEGF) 121 cDNA (Ad(GV)VEGF121.10) to induce therapeutic angiogenesis in the myocardium of individuals with clinically significant coronary artery disease.

METHODS AND RESULTS

Ad(GV)VEGF121.10 was administered to 21 individuals by direct myocardial injection into an area of reversible ischemia either as an adjunct to conventional coronary artery bypass grafting (group A, n=15) or as sole therapy via a minithoracotomy (group B, n=6). There was no evidence of systemic or cardiac-related adverse events related to vector administration. In both groups, coronary angiography and stress sestamibi scan assessment of wall motion 30 days after therapy suggested improvement in the area of vector administration. All patients reported improvement in angina class after therapy. In group B, in which gene transfer was the only therapy, treadmill exercise assessment suggested improvement in most individuals.

CONCLUSIONS

The data are consistent with the concept that direct myocardial administration of Ad(GV)VEGF121.10 to individuals with clinically significant coronary artery disease appears to be well tolerated, and initiation of phase II evaluation of this therapy is warranted.

Variability of human systemic humoral immune responses to adenovirus gene transfer vectors administered to different organs

Administration of adenovirus (Ad) vectors to immunologically naive experimental animals almost invariably results in the induction of systemic anti-Ad neutralizing antibodies. To determine if the human systemic humoral host responses to Ad vectors follow a similar pattern, we evaluated the systemic (serum) anti-Ad serotype 5 (Ad5) neutralizing antibodies in humans after administration of first generation (E1(-) E3(-)) Ad5-based gene transfer vectors to different hosts. AdGVCFTR.10 (carrying the normal human cystic fibrosis [CF] transmembrane regulator cDNA) was sprayed (8 x 10(7) to 2 x 10(10) particle units [PU]) repetitively (every 3 months or every 2 weeks) to the airway epithelium of 15 individuals with CF. AdGVCD.10 (carrying the Escherichia coli cytosine deaminase gene) was administered (8 x 10(8) to 8 x 10(9) PU; once a week, twice) directly to liver metastasis of five individuals with colon cancer and by the intradermal route (8 x 10(7) to 8 x 10(9) PU, single administration) to six healthy individuals. AdGVVEGF121.10 (carrying the human vascular endothelial growth factor 121 cDNA) was administered (4 x 10(8) to 4 x 10(9.5) PU, single administration) directly to the myocardium of 11 individuals with ischemic heart disease. Ad vector administration to the airways of individuals with CF evoked no or minimal serum neutralizing antibodies, even with repetitive administration. In contrast, intratumor administration of an Ad vector to individuals with metastatic colon cancer resulted in a robust antibody response, with anti-Ad neutralizing antibody titers of 10(2) to >10(4). Healthy individuals responded to single intradermal Ad vector variably, from induction of no neutralizing anti-Ad antibodies to titers of 5 x 10(3). Likewise, individuals with ischemic heart disease had a variable response to single intramyocardial vector administration, ranging from minimal neutralizing antibody levels to titers of 10(4). Evaluation of the data from all trials showed no correlation between the peak serum neutralizing anti-Ad response and the dose of Ad vector administered (P > 0.1, all comparisons). In contrast, there was a striking correlation between the peak anti-Ad5 neutralizing antibody levels evoked by vector administration and the level of preexisting anti-Ad5 antibodies (P = 0.0001). Thus, unlike the case for experimental animals, administration of Ad vectors to humans does not invariably evoke a systemic anti-Ad neutralizing antibody response. In humans, the extent of the response is dictated by preexisting antibody titers and modified by route of administration but is not dose dependent. Since the extent of anti-Ad neutralizing antibodies will likely modify the efficacy of administration of Ad vectors, these observations are of fundamental importance in designing human gene therapy trials and in interpreting the efficacy of Ad vector-mediated gene transfer.

Adolescent physical abuse: risk for adolescent psychiatric disorders

OBJECTIVE

The present study examined whether physical abuse functions as an additional risk factor for adolescent psychopathology after other important known risk factors are controlled for.

METHOD

The authors recruited 99 adolescents aged 12 to 18 years directly from the New York State Department of Social Services after official documentation of physical abuse. The abused adolescents were compared to 99 nonabused adolescents matched for age, gender, race, and community income. Diagnostic interviews and measures of selected risk factors for psychopathology were administered to the adolescents and their parents and then entered into a multiple logistic regression model testing the added risk contributed by physical abuse to adolescent psychopathology.

RESULTS

Physical abuse added significantly to other risk factors in accounting for lifetime diagnoses of major depression, dysthymia, conduct disorder, drug abuse, and cigarette smoking. Physical abuse also contributed significantly to prediction of current adolescent unipolar depressive disorders, disruptive disorders, and cigarette smoking.

CONCLUSIONS

Since physically abused adolescents are at greater risk for the development of psychiatric disorders, recognition of adolescent abuse and the provision of psychiatric and substance abuse services may reduce morbidity.

BRCA-associated breast cancer in young women

PURPOSE

To delineate the clinical characteristics and outcomes of breast cancer that arises in the setting of a germline BRCA mutation and to compare BRCA-associated breast cancers (BABC) with those that arise in women without mutations.

PATIENTS AND METHODS

We reviewed the clinical records of 91 Ashkenazi Jewish women ascertained during studies of the genetics of early-onset breast cancer. All women underwent testing for the BRCA1 mutations 185delAG and 5382insC. After the discovery of BRCA2, 79 women were also tested for the BRCA2 mutation 6174delT.

RESULTS

Mutations were identified in 30 women (33%). BABC were less likely to present with stage I disease than cases in women without mutations (27% v 46%), more likely to have axillary nodal involvement (54% v46%), and more likely to have extensive axillary involvement (25% v 17%). These differences were not statistically significant. BABC were significantly more likely to be histologic grade III (100% v 59%, P=.04) and to be estrogen receptor-negative (70% v 34%, P=.04). In the entire cohort, there were no significant differences between BABC and non-BRCA-associated cancers in 5-year relapse-free survival (65% v 69%, P=not significant [NS]), 5-year event-free survival (57% v 68%, P=NS), or 5-year overall survival. However, among cases diagnosed within 2 years of study entry, there was a trend toward shorter event-free survival in BRCA heterozygotes, but not relapse-free survival. Women with germline BRCA mutations were significantly more likely to develop contralateral breast cancer at 5 years (31% v 4%, P=.0007).

CONCLUSION

BABC present with adverse clinical and histopathologic features when compared with cases not associated with BRCA mutations. However, the prognosis of BABC appears to be similar to that of nonassociated cancer. Further studies of incident cases are necessary to define the independent prognostic significance of germline BRCA mutations.

Impact of minimum hematocrit during cardiopulmonary bypass on mortality in patients undergoing coronary artery surgery

BACKGROUND

The hematocrit on cardiopulmonary bypass (CPB) frequently falls to a low level during many cardiac surgical procedures. This study was designed to explore the impact on mortality of minimum hematocrit level achieved during the CPB after coronary artery surgery.

METHODS AND RESULTS

Two thousand seven hundred thirty-eight sequential isolated coronary artery surgery patients during a 42-month period at a tertiary academic center were included in this study. Thirty-one standardized preoperative risk factors used in a multiple logistic regression revealed eight statistically significant independent predictors for postoperative mortality. Minimum hematocrit level during CPB was then added to the regression model and was found to be an independent risk factor for mortality. The entire patient population was divided into dichotomous groups using different minimum hematocrit levels on CPB for the determination of cutoff points by multiple logistic regression. After adjusting for other risk factors, the minimum hematocrit level of 14% was found to be a statistically significant cutoff point. Patients with minimum hematocrit levels < or =14% were found to have an increased probability of risk-adjusted mortality (odds ratio, 2.70; P=.002). A subgroup analysis revealed that high-risk patients with minimum hematocrit levels < or =17% were found to have a significantly increased probability of postoperative mortality (odds ratio, 2.20; P=.017).

CONCLUSIONS

Minimum hematocrit level during CPB is an independent risk factor for mortality after coronary artery surgery. There is a significantly increased risk of mortality for hematocrit levels < or =14%. For high-risk patients, there is a significantly increased risk of mortality for hematocrit levels < or =17%.

Statistical and methodological issues in the evaluation of case management studies

For the past 3 years, the nursing case management team at North Shore University Hospital in Manhasset, NY, has been involved in a project to implement more than 50 clinical pathways, which provide a written "time line" for clinical events that should occur during a patient's hospital stay. A major objective of this project was to evaluate the efficacy of these pathways with respect to a number of important outcomes, such as length of stay, hospital costs, quality of patient care, and nursing and patient satisfaction. This article discusses several statistics-related issues in the design and evaluation of such case management studies. In particular, the role of a research approach in implementing and evaluating hospital programs, the choice of a comparison (control) group, the exclusion of selected patients from analysis, and the problems of equating pathways with diagnosis-related groups are addressed.

Guidelines for budgeting biostatistics involvement in research projects

This paper seeks to help biostatisticians develop realistic budgets for their involvement in research projects. The approach is to list categories of expenses and associated questions about the types and levels of projected costs that the budget planner needs to consider. I subdivide the expense categories into smaller subcomponents that should provide for better planning. I also propose an algorithm for determining hourly rates.

Antenatal management of alloimmune thrombocytopenia with intravenous gamma-globulin: a randomized trial of the addition of low-dose steroid to intravenous gamma-globulin

OBJECTIVES

Our purposes were to investigate maternal infusions of intravenous gamma-globulin, to prevent intracranial hemorrhage, and to determine whether 1.5 mg dexamethasone and 60 mg prednisone per day add to the effect of intravenous gamma-globulin.

STUDY DESIGN

Fifty-four women with alloimmune thrombocytopenia and thrombocytopenic fetuses were randomized to intravenous gamma-globulin 1 gm/kg per week with or without dexamethasone. Nonresponders after 4 to 6 weeks received continued intravenous gamma-globulin plus 60 mg of prednisone per day ("salvage").

RESULTS

Dexamethasone did not add to the effect of intravenous gamma-globulin. Overall, there was a mean platelet increase from the first to the second fetal blood sampling of 36,000/microliters (n = 47) and from the first fetal blood sampling to birth of 69,000/microliters (n = 54). A total of 62% to 85% of fetuses responded. There were no intracranial hemorrhages. "Salvage" increased the platelet count in 5 of 10 nonresponders to intravenous gamma-globulin.

CONCLUSION

Intravenous gamma-globulin treatment is appropriate for thrombocytopenic fetuses with alloimmune thrombocytopenia before use of weekly in utero platelet transfusions, even in severe thrombocytopenia.

Antiplatelet antibody testing in thrombocytopenic pregnant women

OBJECTIVE

The purpose of the study was to attempt to distinguish pregnant women with gestational thrombocytopenia from those with idiopathic immune thrombocytopenia by eight different platelet antibody assays.

STUDY DESIGN

Sera from pregnant women with presumed gestational thrombocytopenia (n = 160) and idiopathic immune thrombocytopenia (n=90) were prospectively tested for indirect and platelet-associated immunoglobulins G and M and complement C3, as well as for serotonin release. After the results were analyzed, a subset of patients were subsequently analyzed for circulating antiplatelet antibody directed against platelet membrane glycoprotein GPIIb/IIIa.

RESULTS

Indirect immunoglobulin G was significantly greater in the 85 women with idiopathic immune thrombocytopenia than in the 129 women with gestational thrombocytopenia (p<0.001). Platelet-associated immunoglobulin G was elevated in the majority of women, both those with gestational thrombocytopenia and those with idiopathic immune thrombocytopenia. There were also no statistically significant difference in the values for platelet-associated C3 or indirect immunoglobulin M and C3. Levels of platelet-associated immunoglobulin M showed a tendency to be higher in women with gestational thrombocytopenia (p=0.04), as did the values in the serotonin release assay (p=0.06).

CONCLUSION

Our data demonstrate that patients with gestational thrombocytopenia had surprisingly high levels of platelet-associated immunoglobulin despite mild thrombocytopenia. Comparison of a relatively large number of patients with idiopathic immune thrombocytopenia and gestational thrombocytopenia indicates that women with idiopathic immune thrombocytopenia cannot be distinguished from those with gestational thrombocytopenia by means of one or more of the prototypic platelet antiglobulin tests currently in use. Our preliminary data with glycoprotein-specific assays indicate that they may be more useful.

Immunophenotype of intraductal carcinoma

OBJECTIVE

Mammography and breast-conserving therapy have focused attention on the classification of intraductal carcinoma (IDC) and emphasized the prognostic importance of comedo versus noncomedo variants. We used histochemical markers to define the immunophenotype of 43 IDCs with respect to comedo versus noncomedo status and patterns of angiogenesis.

RESULTS

Reactions in comedo carcinomas were significantly negative for estrogen receptor and progesterone receptor, and positive for p53 and HER-2/neu more often than the noncomedo variant. All seven IDCs associated with Paget's disease showed positive reactions for HER-2/neu. Basement membrane immunoreactivity for type IV collagen and laminin was discontinuous in most examples of IDC regardless of type, with a trend toward more intense staining in comedo than in noncomedo carcinomas. Periductal angiogenesis was not significantly related to the type of IDC but was more pronounced with comedo carcinomas.

CONCLUSIONS

These observations indicate that there are immunophenotypic correlates to the current structural classification of IDC. The immunophenotype of IDC is helpful in subclassifying an IDC and could prove useful as a prognostic indicator for local control in patients treated by breast-conserving therapy.

Laboratory diagnosis of infection status in infants perinatally exposed to human immunodeficiency virus type 1

Accurate and timely diagnosis of infection status in infants born to women infected with human immunodeficiency virus (HIV) is of paramount importance. The comparative accuracy of five diagnostic decision rules was evaluated in 208 HIV-exposed infants (32 infected, 176 uninfected) based on laboratory testing during the first 6 months of life. Diagnostic rules A and B, which required single blood samples analyzed by culture and polymerase chain reaction (PCR) (rule A) or culture, PCR, and p24 antigen detection (rule B) were more prone to incorrect diagnoses than were rules requiring 2 blood samples analyzed by a single assay (rule C) or combinations of culture and PCR (rules D and E). Rule D, which used PCR as the initial test, established the most useful algorithm: a positive PCR result followed by a positive culture in the second sample confirmed infected status, while two consecutive negative PCR results reconfirmed as negative at 6 months of age established uninfected status.

The biostatistician in medical research: allocating time and effort

Biostatisticians in research juggle many responsibilities: short-term consulting; long-term collaboration; teaching/training, and statistical research. In an institutionally-supported service group, the biostatistician frequently faces allocation of limited resources (time and effort) over multiple projects, none of which individually supports the biostatistician. In addition to the level of support provided by a specific project, there are several major issues with resource allocation: the quality of the science and data in the project; the possibility that long-term support develops from the work; personal and institutional considerations that involve the specific investigator or project. In this paper, we discuss these considerations along with some examples. We present guidelines for making decisions about allocation of time and effort and the possible implications of setting such priorities.

Pathological gambling among methadone patients

This paper examines the correlates of problem gambling among a population of 220 methadone patients receiving treatment in the New York metropolitan area. Like most methadone patients, respondents were primarily adult males, ethnically mixed, of limited educational accomplishment and had long experiences with intravenous drug use. More than two-thirds of subjects had been convicted of one or more criminal offences. Analysis of the data showed seven percent of respondents to be probable pathological gamblers according to the South Oaks Gambling Screen (SOGS), indicating a high rate of gambling problems among this treatment population. Consistent with past studies, problem gamblers are more likely to be men, with histories of alcohol abuse, and with extensive criminal participation dating back to their teenage years. The data also suggested that problem gamblers who were also drug dependent were more likely to show greater evidence of social dysfunctionality compared to those who were exclusively substance abusers. More dually addicted respondents reported higher levels of recent heroin use, greater unemployment, and more reported hallucinations. Probable pathological gamblers who were substance abusers were also more likely to report being in conflict with their close friends. A multiple regression analysis suggested this to be the closest linked correlate to being a pathological gambler. Evidently, pathological gamblers create antipathy towards themselves as their compulsion to gamble is expressed; this in turn, may drive them toward further gambling, as they respond to this perceived opposition. These last preliminary findings will require further confirmation in future research.

p53 in node-negative breast carcinoma: an immunohistochemical study of epidemiologic risk factors, histologic features, and prognosis

PURPOSE

The present study explores p53 in relation to the following four aspects of node-negative breast carcinoma: epidemiologic risk factors, tumor histopathology, prognosis, and HER2/neu (HER) expression.

MATERIALS AND METHODS

Immunohistochemical (IH) staining for p53 was performed on formaldehyde-fixed, paraffin-embedded primary invasive carcinomas from 440 node-negative patients with a median follow-up duration of 119 months.

RESULTS

The IH expression, or lack thereof, of p53 separately or in combination with HER did not prove to be prognostically significant and there was no consistent association of p53 with epidemiologic risk factors. p53 was expressed in 68% of medullary carcinomas (MEDs), which is a significantly higher frequency (P < .001) than in lobular (9%) and duct (23%) carcinomas. p53 was not found in some types of low-grade carcinomas (tubular and papillary), and was observed in a minority of mucinous carcinomas. p53 was present significantly more often in carcinomas with high-grade or poorly differentiated nuclear grade than in low- or intermediate-grade tumors. There was an inverse statistically significant relationship between estrogen receptor (ER) positivity and p53 expression. Tumors with the p53(+)/HER(-) immunophenotype tended to be MEDs or duct carcinomas with a marked lymphoplasmacytic reaction. Infiltrating lobular carcinomas (IFLCs) were largely p53(-)/HER(-). p53(+)/HER(+) carcinomas had the best prognosis. The poorest outcome was associated with the p53(-)/HER(+) immunophenotype. This trend was statistically significant for recurrence-free and overall survival in patients with T1NOMO infiltrating duct carcinoma (IFDC).

CONCLUSION

The IH demonstration of p53 was not a reliable prognostic indicator in the node-negative breast carcinoma patients studied and it was not associated with major epidemiologic risk factors. The combined immunophenotypic expression of p53 and HER was significantly associated with some histologic types of breast carcinoma and with prognosis in T1NOMO breast carcinoma.

Immunochemotherapy for a systemic intracellular infection: accelerated response using interferon-gamma in visceral leishmaniasis

To determine if cytokine immunotherapy accelerates the response to conventional treatment in visceral leishmaniasis (kala-azar), previously untreated Indian patients were given antimony for 30 days (n = 15) or antimony plus interferon-gamma (IFN-gamma; n = 16). After 10 days, 10 (63%) of 16 patients treated with antimony plus IFN-gamma versus 1 (7%) of 15 randomized to antimony alone were considered cured of parasites (P < .005). On day 20, 14 (93%) of 15 versus 6 (40%) of 15 patients, respectively, were apparent clinical cures (P < .006), and treatment was discontinued early in the 14 IFN-gamma treated responders. Day 30 apparent cure rates (100% vs. 73%) and 6-month ultimate cure responses (87% vs. 60%) were higher in IFN-gamma-treated patients but not statistically different from controls (P > .05). All 13 IFN-gamma-treated subjects who were cured (12 of whom received therapy for 20 days) have remained healthy with follow-up of 14-24 months (mean, 18.9). These results indicate that IFN-gamma successfully accelerates the parasitologic and clinical response to antimony treatment, an effect that should permit shortening the duration of conventional therapy in previously untreated kala-azar.

Immunohistochemical detection of HER2/neu in patients with axillary lymph node negative breast carcinoma. A study of epidemiologic risk factors, histologic features, and prognosis

BACKGROUND

Numerous studies have examined the prognostic significance of HER2/neu (HER) expression in patients with axillary lymph node negative breast carcinoma. Although some investigations suggest that the presence of the altered expression of HER is prognostically unfavorable, the subject remains controversial. This study explores the interaction of HER with three aspects of axillary lymph node negative breast carcinoma: epidemiologic risk factors, tumor histopathology, and prognosis.

METHODS

Immunohistochemical staining for HER was performed on 10% formalin fixed paraffin embedded primary carcinomas from 440 patients with negative axillary lymph nodes with a median follow-up of 119 months.

RESULTS

The immunohistochemical expression, or lack thereof, of HER did not prove to be prognostically significant in this group of patients with axillary lymph node negative breast carcinoma. There was also no consistent association with epidemiologic risk factors. The most striking results concerned the relationship of HER to histopathologic features of the carcinomas. Medullary carcinoma differed from other tumor types because it was HER(+) substantially less often (10%) than were other ductal (49%) or lobular (43%) carcinomas.

CONCLUSION

The results obtained in this study suggest that the immunohistochemical demonstration of HER is not a reliable prognostic indicator for patients with axillary lymph node negative breast carcinoma. This marker was not associated with major epidemiologic risk factors; however, there was a significant correlation between HER and the phenotypic features of breast carcinoma because medullary carcinoma is rarely HER(+). Although the associations may not be a strong enough basis for refining the classification of breast carcinoma, they could be useful for diagnosing individual patients. The changes in HER that are detectable by the immunohistochemical methods used in this study probably do not occur in the earliest stages of mammary carcinogenesis.

Late effects of bone marrow transplantation on pulmonary function in children

This study was undertaken to evaluate in a primarily pediatric population whether the late effects of bone marrow transplantation (BMT) on pulmonary function in patients having undergone the procedure for treatment of acute leukemia or lymphoma are worse than that of patients having undergone transplant for treatment of aplastic anemia. Forty-six patients were studied. We did not demonstrate statistically significant differences in group mean forced expiratory flow in one second/forced vital capacity (FEV1/FVC) and percentage predicted forced expiratory volume in one second (FEV1), forced vital capacity (FVC), forced expiratory flow at 25-75% of the forced vital capacity (FEF25-75) and total lung capacity (TLC) values between the two groups of patients before BMT and to 7 years post-transplant. Individual patients with pulmonary function abnormalities were identified. Furthermore, there were no significant differences between the two study groups or within the group of patients with aplastic anemia from pre-transplant to 9-12 months and from pre-transplant to 18-24 months after BMT. However, within the group of patients treated for acute leukemia or lymphoma, there was a significant decline in the group mean percentage predicted FVC (p = 0.0001), FEV1 (p = 0.0006) and FEF25-75 (p = 0.0063) from pre-transplant to 9-12 months and in the FVC (p = 0.004) and FEV1 (p = 0.0006) from pre-transplant to 18-24 months after BMT. The greater decline in the FVC relative to the FEV1 suggests the development of a restrictive process in this group of patients.

Dysphagia therapy following stroke: a controlled trial

OBJECTIVE

To determine the effect of graded levels of intervention by a dysphagia therapist on the occurrence of pneumonia, dehydration, calorie-nitrogen deficit, recurrent upper airway obstruction, and death following stroke.

DESIGN

A randomized control trial.

SETTING

Inpatient stroke rehabilitation unit.

PATIENTS

All patients met the following eligibility criteria: (1) stroke defined by clinical history and neurologic examination with compatible CT or MRI, (2) ages 20 to 90 years inclusive, (3) no known history of significant oral or pharyngeal anomaly, (4) laboratory values below end point criteria, (5) failure on the Burke Dysphagia Screening Test, and (6) modified barium swallow evaluation evidence of dysphagia (patients who aspirated > or = 50% of all consistencies presented, even using compensatory swallowing techniques, were excluded). Of 123 eligible patients, eight refused study participation. One hundred fifteen patients were randomized.

INTERVENTIONS

Three graded levels of dysphagia therapist control of diet consistency and reinforcement of compensatory swallowing techniques were provided during the inpatient rehabilitation stay.

MAIN OUTCOME MEASURES

Pneumonia, dehydration, calorie-nitrogen deficit, recurrent upper airway obstruction, and death.

RESULTS

The log rank statistic showed no significant difference between the three treatment groups for the distribution of time until end point during the inpatient stay or to 1 year post-stroke.

CONCLUSION

Limited patient and family instruction regarding use of diet modification and compensatory swallowing techniques during inpatient rehabilitation is as effective as therapist control of diet consistency and daily rehearsal of compensatory swallowing techniques for the prevention of medical complications associated with dysphagia following stroke.

Improved body weight status as a result of nutrition intervention in adult, HIV-positive outpatients

OBJECTIVE

Malnutrition is an important consequence of infection with the human immunodeficiency virus (HIV); involuntary weight loss greater than 10% is one criterion that the Centers for Disease Control and Prevention uses for the diagnosis of acquired immunodeficiency syndrome (AIDS). This study was designed to determine whether nutrition intervention in a group of adult, HIV-positive outpatients affected weight maintenance.

METHODS

We undertook a retrospective review of 175 patient charts from the AIDS Reproductive Health Clinic and the Center for Special Studies at The New York Hospital. Forty-nine charts were excluded because the patient expressed a desire to reduce weight, discontinued medical care, or died. Seven charts were eliminated because of missing data. In the remaining patients (n = 119), weights were recorded for the initial clinic contact and for a follow-up visit at least 6 months later. Nutrition intervention completed by a registered dietitian was indicated on 42 patient charts (intervention group); intervention included dietary assessment, intake analysis, appropriate counselling, follow-up, and provision of supplements as needed. The remaining 77 charts did not indicate nutrition intervention; this group was called the nonintervention group. Differences between the intervention and nonintervention groups were analyzed using the two-tailed Fisher exact test and the Mann-Whitney nonparametric test.

RESULTS

Forty-two subjects (35% of the total) recieved nutrition intervention, including all of those with gastrointestinal problems (n = 10) and wasting (n = 11). Individuals in the intervention group gained a significant (P < .02) 1.2 +/- 11.4 lb (mean +/- standard deviation; median = +3 lb) compared with those in the nonintervention group who lost a mean of 3.5 +/- 12.8 lb (median = -4 lb). Twenty-six subjects (63%) in the intervention group maintained or gained weight compared with 32 subjects (42%), in the nonintervention group.

CONCLUSION

The results of this study suggest that nutrition intervention in HIV-infected persons can improve nutritional status and may lead to an enhanced ability to fight infection.

Pulmonary function abnormalities in thalassemia major and the role of iron overload

To determine the predominant abnormality of pulmonary function in patients with thalassemia major (TM), we evaluated 29 patients with TM who were receiving hypertransfusion therapy and chelation with desferrioxamine (DFO), and who ranged in age from 6 to 40 yr (mean 19.8 +/- 8.5 yr). A reduction in the total lung capacity (TLC) was the most striking abnormality, found in 21 of 29 patients (79%). Fourteen of these patients (67%) had a moderate or severe reduction in TLC. Expiratory flow rates, FEV1, and FEF25-75 were decreased below predicted values in 48 and 17% of the patients, respectively, but no patients had pure obstructive disease. Significant hypoxemia (oxygen saturation of less than 95%) was observed in only one patient. There was a significant inverse correlation between TLC and patient age (p < 0.003), transfusional iron burden (p < 0.003) and DFO ratio (p < 0.024). Restrictive disease is the predominant abnormality of pulmonary function in TM, with a mixed restrictive-obstructive pattern in a small number of patients. The restrictive disease becomes more severe with increasing age, and the degree and duration of iron overload appear to be important in its pathogenesis. The role of DFO therapy in preventing the pulmonary complications associated with TM requires further study.

Luteinizing hormone pulsatility in subjects with 5-alpha-reductase deficiency and decreased dihydrotestosterone production

The pattern of LH pulsatility in male pseudohermaphrodites with inherited 5 alpha-reductase-2 deficiency (5 alpha RD) and decreased levels of plasma dihydrotestosterone was compared to that in normal males. Analysis of 10-min plasma LH sampling during either a 10- or 24-h period demonstrated that the subjects with 5 alpha RD had 1) a mean plasma LH level, mean LH pulse amplitude, and mean plasma LH nadir that were approximately twice normal; and 2) a mean LH pulse frequency similar to that in normal males, whether described as pulses per h or pulses per study period. An increased plasma LH response to GnRH administration was also noted. The findings suggest that a deficiency of DHT results in decreased negative feedback at the level of the hypothalamus and/or pituitary, resulting in an increase in mean plasma LH, LH pulse amplitude, and LH responsiveness to GnRH. In response to increased LH, mean plasma testosterone (T), free T, and plasma estradiol (E2) are increased. The pulse amplitude is increased despite elevated plasma T and E2 levels; this underscores the importance of DHT in pulse amplitude regulation. LH pulse frequency is not decreased despite elevated plasma T and E2, raising the possibility that DHT deficiency increased pulse frequency that was normalized by increased T and/or E2. In conclusion, studies of LH pulsatility in subjects with 5 alpha RD suggest a role for DHT in the modulation of LH.

Immunohistochemical detection of cathepsin D in T2N0M0 breast carcinoma

Recent studies have reported significant but inconsistent correlations between tumor cathepsin D (CD) concentration and prognosis in breast carcinoma. To investigate the tissue distribution and a prognostic utility of CD in breast carcinoma, 159 cases of T2N0M0 breast carcinoma with a minimum of 10 years' follow-up were studied for CD expression by immunohistochemistry. This group of patients was chosen for study because of current interest in prognostic markers for stage I breast carcinoma and the likelihood that there would be sufficient recurrences in this group to detect significant differences. Seventy-two carcinomas (45%) showed prominent staining of cells composing the tumor. Neoplastic cell staining for CD correlated with well-differentiated architecture, and lack of neoplastic cell CD expression correlated with high nuclear grade and the medullary carcinoma category. Stromal cell (primarily histiocyte) staining in carcinomas was the major contributor to CD expression in 67 of the 159 cases (42%). Intense intratumoral stromal cell staining correlated with absence of estrogen receptors and the medullary carcinoma subtype. There was no significant correlation between disease-free or overall survival and (a) intensity of overall staining for CD, (b) staining of carcinoma cells alone, or (c) staining of nonneoplastic cells within the region of the carcinoma. These results show that a significant proportion of CD activity detected within a tumor by immunohistochemistry may be contributed by nonneoplastic cells, and there is no significant correlation between survival and immunohistochemical detection of CD in T2N0M0 breast cancer.

Chronic graft-versus-host disease and pulmonary function

Pulmonary complications are a major cause of morbidity and mortality in bone marrow transplant recipients. Earlier series, consisting mainly of adults, have shown evidence of obstructive changes of pulmonary functions in association with chronic graft-versus-host disease (CGVHD). We longitudinally evaluated spirometry in 46 patients who received bone marrow transplants as children or as young adults to determine whether they had similar abnormalities. Group mean FEV1/FVC, and percent predicted FVC, FEV1, and FEF25-75 values did not demonstrate obstructive changes in association with CGVHD in this patient population. Our findings suggest that younger patients with CGVHD, as a group, may fare better than older bone marrow transplant recipients with CGVHD. However, due to small sample sizes, it cannot be conclusively stated that the pulmonary function parameters analyzed do not differ in the two patient groups.

Long-term results of iodine 125 irradiation of uveal melanoma

The authors report on 64 of the first 65 patients treated with iodine 125. The mean follow-up was 64.9 months. After treatment, 29 patients (45.3%) retained visual acuity of 20/100 or better, and 18 patients (28.1%) retained visual acuity within two lines of visual acuity before irradiation. Eleven patients (17.2%) died of metastasis, and 5 patients (7.8%) had local recurrence. Cataract developed in 29 (45.3%) patients; keratitis developed in only 2 (3.1%) patients, and dry eye developed in none. Neovascular glaucoma developed in 7 (10.9%) patients, and 15 (23.4%) patients had radiation retinopathy. Eleven patients (17.2%) required enucleation for either tumor growth or neovascular glaucoma. These results show the increasing number of radiation complications seen with long-term observation and the frequently seen adverse visual outcome.

Obesity at diagnosis of breast carcinoma influences duration of disease-free survival

OBJECTIVE

To study disease-free survival at 10 years in relation to obesity at the time of diagnosis.

DESIGN

A prospective study of consecutively treated patients with primary breast cancer.

SETTING

Memorial Sloan-Kettering Cancer Center, New York.

PATIENTS

Nine hundred twenty-three women treated by mastectomy and axillary dissection.

MAIN RESULTS

Women who were obese (25% or more over optimal weight for height) at the time of primary breast cancer treatment were at significantly greater risk for recurrence (42%) compared with nonobese patients (32%) 10 years after diagnosis (P less than 0.01). In multivariate analyses, obesity remained a statistically significant prognostic factor after controlling for measured tumor size, number of positive axillary lymph nodes, age at diagnosis, and adjuvant chemotherapy with a hazard ratio of 1.29 (95% CI, 1.0 to 1.67). When analyses were restricted to the 557 patients free of lymph node metastases, the hazard ratio of recurrence associated with obesity was 1.59 (CI, 1.06 to 2.39); 32% of obese patients developed recurrent disease compared with 19% of nonobese women.

CONCLUSIONS

Obesity at the time of diagnosis is a significant prognostic factor that may limit the reduction in breast cancer mortality attainable through detection at an early stage of disease. Because obesity and the risk for breast cancer increase with age, interventions that encourage weight control may influence breast cancer survival rates.

Prediction of early relapse in patients with operable breast cancer by detection of occult bone marrow micrometastases

We used monoclonal antibodies to identify occult micrometastases in the bone marrow of 49 patients with operable (stage I and II) breast carcinoma. Follow-up (mean, 29 months; median, 30 months) revealed that 12 patients recurred. The presence of bone marrow micrometastases (BMM) was significantly associated with early recurrence (P less than .04). The estimated 2-year recurrence rate for patients with no BMM detected (BMM-) was 3%; in patients with BMM, the 2-year recurrence rate was 33%. When BMM and axillary lymph node (LN) status were combined, groups of patients at low risk (LN-, BMM-; 2-year recurrence rate, 0%) and high risk (LN+, BMM+; 2-year recurrence rate, 42%) for early recurrence were identified. Bone marrow tumor burden was related to early recurrence. Among patients with BMM, those who did not recur had on average fewer extrinsic cells in their marrow than those who recurred (15 v 43 cells, respectively). Multivariate analysis comparing BMM, LN+ versus LN-, and tumor size (less than or equal to 2 cm v greater than 2 cm) revealed no factor independently associated with early recurrence. Peripheral tumor burden of BMM (0 or less than 10 extrinsic cells v greater than or equal to 10 extrinsic cells) was the only independent predictor of early recurrence (P less than .003). In conjunction with conventional prognostic factors, particularly axillary LN status, evaluation for BMM might be used to stratify patients for adjuvant treatment programs. Because this pilot study involved few patients with short-term follow-up, the results should be interpreted with caution. The examination of bone marrow for micrometastases remains an experimental procedure; the clinical usefulness of the test will be established through larger studies with long-term follow-up.

Timing of breast cancer excision during the menstrual cycle influences duration of disease-free survival

OBJECTIVE

To study disease-free survival at 10 years in relation to timing of breast tumor excision during the menstrual cycle.

DESIGN

A prospective study of consecutively treated patients with primary breast cancer.

SETTING

Memorial Sloan-Kettering Cancer Center, New York.

PATIENTS

Two hundred and eighty-three premenopausal patients treated by mastectomy and axillary dissection.

MAIN RESULTS

When the tumor was excised during the follicular phase, approximated by setting the putative day of ovulation on day 14 after the onset of last menses, a higher recurrence risk (43%) was observed compared with excision later in the menstrual cycle (29%, P = 0.02). The rate peaked among patients treated between days 7 and 14 and was lowest between days 20 and 30. Multivariate analysis using the Cox regression model to control for tumor size, nodal status, estrogen receptor status, adjuvant chemotherapy, and family history indicated that the hazard rate of breast cancer recurrence after excision during the follicular phase was 1.53 (95% Cl, 1.02 to 2.29). Stratification by nodal status indicated that the effect of phase was statistically significant only among patients with positive nodes (hazard ratio, 2.10; Cl, 1.19 to 3.70).

CONCLUSIONS

Our results support the hypothesis that the risk for recurrence may be affected by the hormonal milieu of the menstrual cycle; these findings must be confirmed, however, by a prospective study in which cycle phase at time of tumor excision is biochemically documented.

Prolonged survival in patients with beta-thalassemia major treated with deferoxamine

To determine whether survival of patients with beta-thalassemia major has been prolonged by management that utilizes hypertransfusion and chelation with deferoxamine, we analyzed longevity by the Kaplan-Meier product-limit method. Group 1 patients (n = 71) followed between 1960 and 1976 with a low-transfusion regimen (pretransfusion hemoglobin level 7 to 8 gm/dl) and no chelation had an estimated median age of survival of 17.4 years, whereas it was 31.0 years for group 2 subjects (n = 80), who began hypertransfusion between 1976 and 1978 (pretransfusion hemoglobin level 10.5 to 11.5 gm/dl) and chelation with deferoxamine (20 to 60 mg/kg per day) (p less than 0.0001). For 70 patients who were treated with hypertransfusion and deferoxamine, we had data to calculate the ratio of total milligrams of transfusional iron to cumulative grams of deferoxamine. The 24 patients who died had a total iron burden of greater than 1.05 gm/kg; the ratio for them exceeded 31. These patients were characterized by poor compliance with chelation or by late start of therapy, with inability to receive enough deferoxamine before death. Death was preceded by arrhythmia requiring therapy in all but one, and by cardiac failure in all. Of 41 similarly iron-loaded survivors, 33 had a ratio of less than 31; only three had an arrhythmia, and five had cardiac failure. We conclude that treatment with deferoxamine, when used in amounts proportional to iron burden, delayed cardiac complications and improved longevity.

Prolonged survival in patients with beta-thalassemia major treated with deferoxamine

To determine whether survival of patients with beta-thalassemia major has been prolonged by management that utilizes hypertransfusion and chelation with deferoxamine, we analyzed longevity by the Kaplan-Meier product-limit method. Group 1 patients (n = 71) followed between 1960 and 1976 with a low-transfusion regimen (pretransfusion hemoglobin level 7 to 8 gm/dl) and no chelation had an estimated median age of survival of 17.4 years, whereas it was 31.0 years for group 2 subjects (n = 80), who began hypertransfusion between 1976 and 1978 (pretransfusion hemoglobin level 10.5 to 11.5 gm/dl) and chelation with deferoxamine (20 to 60 mg/kg per day) (p less than 0.0001). For 70 patients who were treated with hypertransfusion and deferoxamine, we had data to calculate the ratio of total milligrams of transfusional iron to cumulative grams of deferoxamine. The 24 patients who died had a total iron burden of greater than 1.05 gm/kg; the ratio for them exceeded 31. These patients were characterized by poor compliance with chelation or by late start of therapy, with inability to receive enough deferoxamine before death. Death was preceded by arrhythmia requiring therapy in all but one, and by cardiac failure in all. Of 41 similarly iron-loaded survivors, 33 had a ratio of less than 31; only three had an arrhythmia, and five had cardiac failure. We conclude that treatment with deferoxamine, when used in amounts proportional to iron burden, delayed cardiac complications and improved longevity.

The two patterns of reactive astrocytosis in postischemic rat brain

The distribution and time course of postischemic astrocyte hypertrophy and hyperplasia and the relationship to neuronal viability or necrosis was studied in rats subjected to 30 min of carotid and vertebral artery occlusion followed by reperfusion from 3 h to 5 weeks. Intermediate filaments (IFs) were evaluated by electron microscopy, IF proteins by immunohistochemistry, and astrocyte division by [3H]thymidine uptake. Glial fibrillary acidic protein (GFAP) increased in damaged and nondamaged brain regions by 2 days and was associated with cell enlargement, increases in IF, and transformation of GFAP-negative into GFAP-positive glia. Cell hypertrophy and increased GFAP persisted only in regions of neuronal necrosis whereas the number and size of GFAP-positive astrocytes returned to control levels in nondamaged regions by 2 weeks. Astrocyte hyperplasia was not seen until 3 days and was confined to damaged brain regions. Vimentin-positive astrocytes were numerous by 2 days in damaged brain and remained only in those regions at 5 weeks. The data demonstrate that reactive astrocytosis develops in undamaged brain, but is reversible with prolonged survival, whereas reactive astrocytosis that accompanies structural brain damage persists for prolonged periods and is associated with hyperplasia, as well as hypertrophy. In addition, the results show that astrocyte expression of vimentin is more specific than GFAP in identifying regions of permanent ischemic injury during the early postischemic period.

DNA content of rectal scrapings from individuals at low and high risk for the development of colorectal cancer. A feasibility study

Scrapings of superficial rectal mucosa were collected from 31 patients with colorectal carcinoma, 66 patients with sporadic adenoma, and 53 control subjects with no personal or family history of colorectal cancer. The DNA ploidy level and proliferative patterns of each specimen were analyzed by flow cytometry (FCM). A GMS index, calculated as the ratio of G2 + M:S, was found to be significantly lower in control subjects than in any of the high-risk groups studied. Aneuploidy was more prevalent in rectal scrapings from cancer patients and adenoma patients than in those from control subjects. Aneuploid cell populations were detected in apparently normal rectal scrapings from two control subjects. Some high-risk individuals (i.e., cancer patients and patients with adenomas and a family history of cancer) exhibited higher proportions of tetraploid (designated G2/M) cells and a higher G2/M:S phase ratio than control subjects. The results accumulated thus far show that the rectal scraping procedure is safe and easy to perform. Our limited findings give hope that the DNA content analysis of cells obtained by rectal scraping may eventually prove useful in mass screening for colorectal cancer risk. However, definitive evaluation will require further refinement and elaboration of analytic technique and testing on more patients at various levels of predetermined risk.

Clinical trial of single-dose intravenous gamma globulin in acute Kawasaki disease. Preliminary report

Gamma globulin administered in a single dose of 1 g/kg of body weight intravenously caused prompt clinical improvement in 27 of 32 consecutive children with Kawasaki disease treated by the 12th day of illness. Response was equally good for the 20 children treated in the first week and the 12 treated in the second week. Fever and clinical signs abated within the first day after treatment, the mean white blood cell count normalized by 48 hours, and the sedimentation rate continued to be elevated for about 2 weeks, while the platelet count rose during the first 2 weeks after treatment and returned to normal approximately 1 month after treatment. Five children with incomplete relief needed more than the single dose before resolution of signs and symptoms occurred. Coronary aneurysms in 2 patients before treatment regressed by 2 weeks. No patient developed coronary aneurysms. No child had sequelae of Kawasaki disease at a follow-up of 2 to 31 months. We believe that although this was a one-arm, uncontrolled pilot study, the results suggest that this protocol provides a safe, flexible, and effective treatment for acute Kawasaki disease.

Effect of wheat fiber and vitamins C and E on rectal polyps in patients with familial adenomatous polyposis

Over a 4-year period in a chemoprevention trial on large bowel neoplasia, 58 patients with familial adenomatous polyposis were treated with 4 g of ascorbic acid (vitamin C)/day plus 400 mg of alpha-tocopherol (vitamin E)/day alone or with a grain fiber supplement (22.5 g/day). In this randomized, double-blind, placebo-controlled study, we determined the effects of these supplements on rectal polyps in these patients. Analysis by intent to treat suggested that the high-fiber supplement had a limited effect. Analysis adjusted for patient compliance showed a stronger benefit from the high-fiber supplement during the middle 2 years of the trial. The results provide evidence for inhibition of benign large bowel neoplasia by grain fiber supplements in excess of 11 g/day in this study population. The findings are consistent with the hypothesis that dietary grain fiber and total dietary fat act as competing variables in the genesis of large bowel neoplasia.

Epidemiologic aspects of Kawasaki disease in a Manhattan hospital

Epidemiologic and clinical features of Kawasaki disease in 106 patients seen between 1980 and 1986 at The New York Hospital in midtown Manhattan were compared with those in large series from the United States, Canada, and Japan. Dissimilarities in our Kawasaki disease experience included ethnic heterogeneity of our patients (50% white, 18% black, 16% Hispanic, and 16% Oriental) and, in comparison with the Japanese experience, an older mean age (3 1/2 vs 1 1/2 years) with fewer children less than 2 years of age (32% vs 50% to 60%). In comparison with the general population of the geographic urban and suburban referral area for our hospital and in comparison with our general pediatric population, Oriental children with Kawasaki disease were overrepresented (16% vs 2%). More families of children with Kawasaki disease were members of the upper and middle class (73%) than were the population seen in general pediatrics (31.7%) at our hospital. Personal interviews with 63 families of children with Kawasaki disease and 63 control families with children paired for ethnic group, sex, and age revealed no epidemiologic differences except for use of rug shampoo within 1 month of onset in 16 episodes in 15 children with Kawasaki disease in 14 families (22% of families) compared with two families of control children (3%) (P less than .001).

Rug shampoo and Kawasaki disease

Following personal interviews with 63 families of children with Kawasaki disease and with 63 control families with children paired for race, sex, and age, no epidemiologic differences were seen except for use of rug shampoo within 1 month of onset in 16 episodes in 15 children with Kawasaki disease in 14 families (24% of children, 22% of families) compared with two families of control children (3%, P less than .005). Explanations for this strong association of recent rug shampoo and Kawasaki disease include the question of recall bias as well as the possibility that an agent in the shampooing process does cause or does contribute to illness.

Nursery privileges of the private attending pediatrician in the care of critically sick neonates in New York state

To determine the role of the private attending pediatrician in caring for newborns who require intensive, intermediate, or continuing care in New York state, a request was sent to New York state institutions to select the statement best describing private attending pediatrician privileges. Privileges were graded from 1 to 6 with category 1 allowing the private attending pediatrician to care for all newborns and category 6 not allowing the private attending pediatrician to care for any newborns. Nurseries were classified (per New York State Department of Health) as regional, nonregional intensive care, intermediate care, and continuing care centers. A total of 97% (88/90) of institutions responded, representing 2,040 private attending pediatricians. In 95% (79/83) of the New York state institutions with staff private attending pediatricians, the pediatricians' privileges were limited. In 18% (15/83), the private attending pediatrician does not supervise any newborns receiving special care, whereas in an additional 77%, pediatricians' privileges have been limited. Despite this, the majority of institutions encourage the private attending pediatrician to continue communication with the family. Limited hospital privileges coupled with continued family communication may be the future trend for private attending pediatricians in the hospital setting.

Early seizures following intracerebral hemorrhage: implications for therapy

Seizures occurred in 19 of 112 patients (17%) with nontraumatic, supratentorial intracerebral hemorrhage (ICH). All seizures occurred at ICH onset; patients without seizures at hemorrhage onset remained seizure-free until the last recorded follow-up. Seizures were significantly associated with extension of blood into the cerebral cortex. We found no association between seizures and hemorrhage size or the presence of subarachnoid or intraventricular blood. These data suggest that (1) seizures, in ICH, occur at hemorrhage onset, (2) patients without seizures at hemorrhage onset are at very low risk for subsequent seizures during their hospitalization, (3) hemorrhage involving the cerebral cortex, regardless of site of origin, predisposes to seizures, and (4) the prophylactic use of anticonvulsants in the acute management of these patients appears unwarranted, especially in patients without cortical extension.

Effect of doxycycline on pre-menstrual syndrome: a double-blind randomized clinical trial

Thirty patients with well-defined symptoms of pre-menstrual syndrome were randomly treated with the antibiotic doxycycline or placebo. The antibiotic-treated group showed a highly significant reduction of symptoms. Subsequent antibiotic treatment of the original placebo group similarly diminished the symptoms in this group. A 6-month follow-up demonstrated that the improvement in symptom scores was permanent and independent from the presence of the antibiotic. Luteal phase endometrial biopsies showed a high incidence of out-of-phase endometrium. An unexpectedly high percentage of endometrial biopsy cultures yielded positive findings for mycoplasma, Chlamydia trachomatis and anaerobic bacteria. There were no characteristic hormonal changes in this study group. An infectious aetiology, possibly a sub-clinical endometrial or ovarian infection, behind certain cases of pre-menstrual syndrome is postulated.

Use of diastolic velocity ratios to predict significant carotid artery stenosis

Duplex scanning of the carotid bifurcation has emerged as an accurate noninvasive means of predicting and quantifying carotid arterial stenoses. Compared with the more widely reported measurements of spectral broadening and peak frequency ratios, measurements of diastolic velocity ratios have theoretical advantages in predicting carotid artery stenosis. The use of diastolic velocity ratios between the internal and common carotid arteries was prospectively studied in 30 consecutive patients to determine its accuracy in predicting significant stenosis of the internal carotid artery when compared with angiography. A total of 55 carotid bifurcations were studied, and the use of diastolic velocity ratios correctly predicted high-grade stenosis (greater than or equal to 75% diameter reduction) in 52 cases (95%). We conclude that diastolic velocity ratios may be used to accurately detect significant internal carotid artery stenosis.

Female external genitalia and müllerian duct derivatives in a 46,XY infant with the smith-lemli-Opitz syndrome

We report on a 46,XY newborn infant with Smith-Lemli-Opitz (SLO) syndrome with female external genitalia, intraabdominal testes with epididymides and deferent ducts and a normally shaped uterus and vagina. Polydactyly, cleft palate, and several internal organ malformations were also present, and the patient died shortly after birth. Data on six reported male infants with SLO syndrome and female external genitalia suggest a correlation between degree of genital involvement and overall degree of severity. Scoring systems to quantify overall degree of severity (SLO score) and degree of genital involvement in males (genital score) were devised and applied to 122 reported cases from the literature. Statistical analyses showed a unimodal distribution of the SLO severity scores, and positive correlations between the SLO score and the genital score in males, the presence of polydactyly, and the presence of cleft palate. In 19 multiplex families the affected sibs were generally similar in their SLO scores. The above analyses suggest that the wide phenotypic variability in the SLO syndrome is determined by variable expressivity of the same entity as opposed to genetic heterogeneity. The observed phenotypic correlations naturally determine that males with complete feminization are among the more severe patients and tend to have polydactyly and cleft palate.

Intracerebral haemorrhage: a model for the prediction of outcome

The hospital charts and CT scans of 112 patients with spontaneous supratentorial haemorrhage were retrospectively reviewed to evaluate factors important to prognosis. A low Glasgow Coma Scale score, coma, ataxic respiration, abnormal pupils, acute hypertension, large haemorrhage size and intraventricular extension of blood were associated with a poor outcome. Multivariate analysis using the technique of logistic regression identified three variables, the Glasgow Coma Scale score, haemorrhage size and intraventricular extension of blood, which were most predictive of outcome. A model was developed from this analysis which accurately estimates the probability of good outcome and the risk of poor outcome based on data available on presentation. With additional validation, this model may be useful in choosing patients for surgical evacuation of haematomas.

Intraoperative outflow resistance as a predictor of late patency of femoropopliteal and infrapopliteal arterial bypasses

To evaluate the efficacy of intraoperative outflow resistance (OR) measurements in predicting late graft patency rates (PR) for femoropopliteal (FP) and femoroinfrapopliteal (FD) bypasses, we have reviewed 134 such cases performed during the past 3 years at our institution. Of these, 64 bypasses were FP (13 autogenous saphenous vein [ASV] and 51 polytetrafluoroethylene [PTFE]) and 70 were FD (43 ASV and 27 PTFE). Total and distal OR measurements (measured in millimeters of mercury per milliliter per minute) were divided into four groups each for all infrainguinal bypasses combined and for FP and FD bypasses separately. The relationship of PR to total and distal OR measurements were analyzed according to the product limit method. Overall 1- and 2-year PRs were 64% and 56%, respectively. For FP bypasses the same PRs were 78% and 67% whereas for FD bypasses, they were 52% and 45%, respectively. The 1-year PRs for FP and FD bypasses within each respective OR group were analyzed. For FP bypasses in the lowest to the highest total OR groups, the 1-year PRs were 86%, 75%, 78%, and 62% (NS), and for FD bypasses they were 72%, 89%, 23%, and 22% (p less than 0.001). Similar trends were observed when distal OR measurements were analyzed. For infrainguinal PTFE bypasses, both total and distal OR measurements were significant predictors of patency, whereas for those with ASV only distal OR measurements were predictive. These data reaffirm our early experience with OR measurements. Although a trend for predicting graft patency was noted for FP bypasses, OR measurements were highly predictive only for FD bypasses.

Lobar vs thalamic and basal ganglion hemorrhage: clinical and radiographic features

One hundred and twelve patients with spontaneous supratentorial intracerebral hemorrhages were reviewed to identify features which distinguish lobar intracerebral hemorrhage (LH; n = 42) from thalamic or basal ganglionic hemorrhage (TGH; n = 70). Chronic hypertension occurred more commonly in TGH (TGH 67%; LH 48%) while bleeding diathesis was more common in LH (LH 19%; TGH 6%). Clinical presentations were extremely variable and not associated with the type of hemorrhage. Bleeding into the ventricles and hydrocephalus occurred more often with TGH. At last follow-up, there were minimal differences between LH and TGH in overall mortality and functional outcome of the survivors. Alertness on admission was associated with a good outcome regardless of the type of hemorrhage, while a low Glasgow Coma Scale score, coma, ataxic respiration, abnormal pupil reactions, acute hypertension, large hemorrhage size and intraventricular blood were associated with a poor outcome. These data confirm etiological distinctions between LH and TGH, but fail to confirm previously reported differences in clinical presentation and outcome.