The combination of Raman Spectroscopy and Mass Spectrometry to investigate cutaneous metallosis

Skin is uniquely accessible to investigation by modern scientific methods. Raman spectroscopy is a non-invasive technology for in-vivo analysis of molecular composition. Furthermore, a skin biopsy examined with Laser ablation - Inductively Coupled Plasma - Mass Spectrometry (LA-ICP-MS) provides high resolution multi-element mapping with high sensitivity and precision for exogenous metals in biological tissue which have no intrinsic abundance. This technique has been successfully applied to identify a variety of metals including gadolinium in cerebral vessel walls after contrast studies (1) . These two techniques were used to investigate metallosis from a shoulder joint replacement.

Ethnic differences in the epidemiology of cutaneous lupus erythematosus in New Zealand

Background The prevalence and variation by ethnicity of cutaneous lupus in New Zealand is not known. Therefore, a cross-sectional study to determine the prevalence and variation by ethnicity of cutaneous lupus in the ethnically diverse community of South Auckland, New Zealand, was undertaken. Methods Multiple sources were examined to determine the prevalence of acute cutaneous lupus erythematosus, subacute cutaneous erythematosus and discoid lupus erythematosus. Ethnicities examined were European, Māori/Pacific and Indian/Asian. Capture-recapture was used to determine the overall population prevalence of cutaneous lupus. Results A total of 145 cases of cutaneous lupus were identified. There were 22 men and 123 women, with an average age (standard deviation), respectively, of 46.4 (±21.5) and 43.1 (±14.8) years. There were 53 cases of acute cutaneous lupus erythematosus, 19 cases of subacute cutaneous erythematosus and 66 cases of discoid lupus erythematosus. The age and sex adjusted relative risk (95% confidence interval; CI) of Māori/Pacific compared to the European population was 2.47 (95% CI 1.67-3.67) for all types of cutaneous lupus, 1.60 (95% CI 0.84-3.18) for acute cutaneous lupus erythematosus, 0.09 (95% CI 0.01-1.1) for subacute cutaneous erythematosus and 5.96 (95% CI 3.06-11.6) for discoid lupus erythematosus. The overall prevalence of cutaneous lupus was 30.1 (95% CI 25.5-35.4) per 100,000. However, capture-recapture estimated the unadjusted prevalence of cutaneous lupus to be 86.0 (95% CI 78.1-94.7) per 100,000. Conclusion Māori and Pacific people in Auckland, New Zealand, have a greater relative risk of all types of cutaneous lupus compared to the European population and a particularly high risk of discoid lupus erythematosus.

Phenytoin loading doses in adult critical care patients: does current practice achieve adequate drug levels?

Phenytoin is regularly employed in the critically ill for prophylaxis against or treatment of seizure disorders. No prior studies have examined current dosing practices in an Australasian intensive care unit (ICU) setting. The aims of this study were to: a) describe the adequacy of contemporary dosing in respect to free and total serum phenytoin concentrations; b) identify factors associated with therapeutic drug concentrations; and c) examine the accuracy of predictive equations that estimate free concentrations in this setting. All patients receiving a loading dose of phenytoin in a tertiary-level ICU were eligible for enrolment; 53 patients were enrolled in the study. Serum samples to determine free and total phenytoin concentrations (measured by high performance liquid chromatography) were then drawn prior to the following dose. Free concentrations below the recommended target (<1 mg/l) were considered as suboptimal. The most common indication for phenytoin loading was traumatic brain injury (49%) and the mean administered dose was 14.5 (3.66) mg/kg. Twenty-six patients (49%) had suboptimal trough free concentrations, although this subgroup was significantly heavier and therefore received a lower per kilogram dose (12.8 [3.1] vs 16.3 [3.4] mg/kg, P=0.001). In multivariate analysis, larger weight adjusted doses (P=0.018), higher albumin concentration (P=0.034) and receiving phenytoin for an indication other than seizure (P=0.035), were associated with a greater likelihood of adequate concentrations. In conclusion, phenytoin dosing remains complex in critically ill patients, although lower per kilogram loading doses are strongly associated with free concentrations below the desired target.

A preliminary evaluation of plasma b-type natriuretic peptide as a screening test for left ventricular diastolic dysfunction in non-cardiac intensive care

Left ventricular filling and thus diastolic function are frequently monitored and managed in critical care. However, scant data exist regarding possible screening tests for diastolic dysfunction in the intensive care unit (ICU). The present study aimed to evaluate plasma b-type natriuretic peptide (BNP) as a marker of diastolic dysfunction in a single-centre cohort of 'non-cardiac' ICU patients. The ICU is non-cardiac in that it provides mixed medical/surgical services with the exception of cardiology, cardiac surgery and solid organ transplantation. Clinical data were recorded over the first 24 hours of ICU stay for 32 consecutive patients. Transthoracic echocardiogram and blood collection for BNP assay were then performed. Diastolic dysfunction was demonstrated in 34% (n=11). Mean ± standard deviation BNP values were higher with diastolic dysfunction (238 ± 195 vs 72 ± 78 pg/ml; P=0.003). A BNP threshold of >43 pg/ml yielded a sensitivity of 80% and a specificity of 59%; area under the receiver operating characteristic curve was 0.82. BNP correlated independently with E/e' (R=0.425; P=0.015) (E/e': peak early transmitral velocity [E]/early diastolic mitral annular velocity [e']) but not left ventricular ejection fraction (P=0.8), illness severity (Acute Physiological and Chronic Health Evaluation II; P=0.3) or fluid balance (P=0.4). Diastolic dysfunction was common in this cohort of non-cardiac ICU patients and was independently associated with a significantly higher BNP. The potential application as a screening test for diastolic dysfunction is likely to require a threshold lower than previously proposed for heart failure.

Curettage and diathermy: a treatment for feline nasal planum actinic dysplasia and superficial squamous cell carcinoma

OBJECTIVE

To evaluate curettage and diathermy as a treatment for actinic dysplasia and superficial squamous cell carcinoma of the feline nasal planum.

METHODS

Thirty-four cats clinically assessed to have actinic dysplasia and superficial squamous cell carcinoma involving less than 50% of the nasal planum were treated with a three-cycle curettage and diathermy procedure. Degree of dysplasia, response to treatment, adverse effects, owner perceptions, time to recurrence and proportion disease free at 1 year were evaluated.

RESULTS

Lesions ranged from actinic keratoses to invasive squamous cell carcinoma. A complete response to treatment was obtained in all cats. The median follow-up time was 18 · 2 (IQR: 12 · 0-22 · 8) months. Two cats had a clinical recurrence of lesions at 161 and 192 days after treatment. The probability of remaining disease free after 12 months was 0 · 94 (95% CI: 0 · 85-1 · 0). Median time to recurrence was not reached. The procedure was well tolerated with a good cosmetic outcome and no significant post-operative complications.

CLINICAL SIGNIFICANCE

This study suggests that curettage and diathermy is an effective treatment for feline actinic dysplasia and for superficial squamous cell carcinoma involving less than 50% of the nasal planum. Curettage and diathermy is an easily mastered technique, requiring minimal equipment.

A comparison of pulse contour wave analysis and ultrasonic cardiac output monitoring in the critically ill

Cardiac output (CO) is a key determinant of major organ blood flow and solute delivery to drug eliminating organs. As such, CO assessment is a key covariate in understanding altered drug handling in the critically ill. Newer minimally-invasive devices are providing unique platforms for such an application, although comparison data are currently lacking. In this study we evaluated the Vigileo (Edwards Lifesciences, Irvine, CA, USA) and USCOM (USCOM Ltd, Sydney, NSW) devices in 62 critically ill patients requiring antibacterial therapy. The mean COVigileo and COUSCOM for the first paired measurements were 8.20±2.65 l/minute and 6.84±2.57 l/minute respectively (P <0.001). A significant correlation was evident in all patients (r=0.537, P <0.001) although the recorded bias was large (1.36±2.51 l/minute, limits of agreement -3.6 to±6.3 l/minute). The overall percentage error was 65%. There was an improved correlation in those admitted with sepsis (r=0.639, P <0.001), compared to trauma (r=0.373, P=0.066), although bias, precision and percentage error were similar in both subgroups. In 54 patients a second paired assessment was obtained at three hours. A weak, although significant correlation (r=0.377, P=0.005) was observed suggesting that gross trends over time were similar. In conclusion, our findings demonstrate poor agreement between these techniques suggesting that these devices are not simply interchangeable when assessing CO in a research or clinical setting.

Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of -13.3 degrees was converted to +13.4 degrees . The ranges of motion of the proximal and DIP joints were significantly different (Student's t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.

Rheumatoid papules treated with dapsone

A patient with a long history of seropositive rheumatoid arthritis presented with a progressive papular eruption on the trunk. A skin biopsy showed a neutrophilic and palisaded granulomatous dermatitis compatible with rheumatoid papules. The eruption failed to respond to topical and systemic corticosteroids and the patient was treated with dapsone with complete resolution of the rash. Rheumatoid papules are a rare disorder seen in a variety of collagen vascular diseases. The literature concerning the treatment of rheumatoid papules is scanty. In this patient, dapsone was an effective treatment.

The use of the dermatoscope to identify early melanoma using the three-colour test

BACKGROUND

There is continuing interest in pre-operative evaluation of cutaneous pigmented lesions with the aim of differentiating early melanoma, which requires excision from non-melanomatous pigmented lesions that may safely be left untreated.

OBJECTIVES

To establish, in the setting of a specialist pigmented lesion clinic, if use of the hand-held dermatoscope can prevent unnecessary excision of benign melanocytic pigmented lesions.

METHODS

The study was carried out by three dermatologists experienced in the use of the dermatoscope. Patients had been referred by primary care physicians to the pigmented lesion clinic and had melanocytic lesions considered by dermatologists to merit excision on clinical grounds. A set of 74 sequentially observed lesions referred for excision, 37 melanomas and 37 melanocytic naevi, was used as the initial set and, thereafter, a second set of 52 lesions comprising 32 melanomas and 20 melanocytic naevi was used to validate conclusions drawn from the original set. Clinical features such as appearance and history, and also dermatoscope features were included in the assessment.

RESULTS

In both sets of lesions, the most powerful identifying feature of lesions subsequently shown on pathological examination to be melanoma was the presence of three or more colours seen in the lesion on dermatoscopy. In the initial set of lesions, the age of the patient, an irregular edge and largest diameter of the lesion also contributed to diagnosis; however, in the second set of lesions these variables contributed little additional discriminatory value. The sensitivity and specificity of the three-colour dermatoscopy test for melanoma vs. naevus were 92% and 51%, respectively.

CONCLUSIONS

The use of the dermatoscope three-colour test could reduce excision of benign melanocytic naevi by 50%, and thus prevent both unnecessary minor surgical workload and patient morbidity.

Subcutaneous panniculitic T-cell lymphoma and cytophagic histiocytic panniculitis

A 43-year-old Maori man presented with a 1 month history of malaise, weight loss, anorexia, arthralgia, recurrent fever and tender erythematous subcutaneous skin lesions. Histological examination of an incisional biopsy of a lesion revealed a lobular panniculitis with an inflammatory infiltrate of atypical lymphocytes and evidence of cytophagocytosis consistent with a diagnosis of subcutaneous T-cell lymphoma. The systemic symptoms and skin lesions resolved spontaneously within 3 weeks, only to recur 2 months later, requiring treatment with oral prednisolone. T-cell gene rearrangement studies demonstrated a monoclonal T-cell receptor (gamma-chain) gene rearrangement, further supporting the diagnosis of subcutaneous panniculitic T-cell lymphoma. Treatment with chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone) led to remission of symptoms. Four months after completing chemotherapy, the patient remained asymptomatic with a few indurated subcutaneous plaques on the chest. Biopsy of these areas revealed lobular panniculitis, lymphocytic infiltrate without cytological atypia, abundant lipophages and fibrosis and sclerosis consistent with a healing response. He remains well 24 months following chemotherapy.

Sequence analysis of insecticidal genes from Xenorhabdus nematophilus PMFI296

Three strains of Xenorhabdus nematophilus showed insecticidal activity when fed to Pieris brassicae (cabbage white butterfly) larvae. From one of these strains (X. nematophilus PMFI296) a cosmid genome library was prepared in Escherichia coli and screened for oral insecticidal activity. Two overlapping cosmid clones were shown to encode insecticidal proteins, which had activity when expressed in E. coli (50% lethal concentration [LC(50)] of 2 to 6 microg of total protein/g of diet). The complete sequence of one cosmid (cHRIM1) was obtained. On cHRIM1, five genes (xptA1, -A2, -B1, -C1, and -D1) showed homology with up to 49% identity to insecticidal toxins identified in Photorhabdus luminescens, and also a smaller gene (chi) showed homology to a putative chitinase gene (38% identity). Transposon mutagenesis of the cosmid insert indicated that the genes xptA2, xptD1, and chi were not important for the expression of insecticidal activity toward P. brassicae. One gene (xptA1) was found to be central for the expression of activity, and the genes xptB1 and xptC1 were needed for full activity. The location of these genes together on the chromosome and therefore present on a single cosmid insert probably accounted for the detection of insecticidal activity in this E. coli clone. Although multiple genes may be needed for full activity, E. coli cells expressing the xptA1 gene from the bacteriophage lambda P(L) promoter were shown to have insecticidal activity (LC(50) of 112 microg of total protein/g of diet). This is contrary to the toxin genes identified in P. luminescens, which were not insecticidal when expressed individually in E. coli. High-level gene expression and the use of a sensitive insect may have aided in the detection of insecticidal activity in the E. coli clone expressing xptA1. The location of these toxin genes and the chitinase gene and the presence of mobile elements (insertion sequence) and tRNA genes on cHRIM1 indicates that this region of DNA represents a pathogenicity island on the genome of X. nematophilus PMFI296.

Role of proteolysis in determining potency of Bacillus thuringiensis Cry1Ac delta-endotoxin

Bacillus thuringiensis protein delta-endotoxins are toxic to a variety of different insect species. Larvicidal potency depends on the completion of a number of steps in the mode of action of the toxin. Here, we investigated the role of proteolytic processing in determining the potency of the B. thuringiensis Cry1Ac delta-endotoxin towards Pieris brassicae (family: Pieridae) and Mamestra brassicae (family: Noctuidae). In bioassays, Cry1Ac was over 2,000 times more active against P. brassicae than against M. brassicae larvae. Using gut juice purified from both insects, we processed Cry1Ac to soluble forms that had the same N terminus and the same apparent molecular weight. However, extended proteolysis of Cry1Ac in vitro with proteases from both insects resulted in the formation of an insoluble aggregate. With proteases from P. brassicae, the Cry1Ac-susceptible insect, Cry1Ac was processed to an insoluble product with a molecular mass of approximately 56 kDa, whereas proteases from M. brassicae, the non-susceptible insect, generated products with molecular masses of approximately 58, approximately 40, and approximately 20 kDa. N-terminal sequencing of the insoluble products revealed that both insects cleaved Cry1Ac within domain I, but M. brassicae proteases also cleaved the toxin at Arg423 in domain II. A similar pattern of processing was observed in vivo. When Arg423 was replaced with Gln or Ser, the resulting mutant toxins resisted degradation by M. brassicae proteases. However, this mutation had little effect on toxicity to M. brassicae. Differential processing of membrane-bound Cry1Ac was also observed in qualitative binding experiments performed with brush border membrane vesicles from the two insects and in midguts isolated from toxin-treated insects.

The risk of dementia and death after delirium

BACKGROUND

delirium is common and is associated with many adverse short-term consequences.

OBJECTIVES

to examine the relationship between an episode of delirium and subsequent dementia and death over 3 years.

DESIGN

prospective cohort study.

SETTING

patients (n = 203) were aged 65 years or older at baseline and survivors of the index admission.

METHODS

Using a standard assessment of cognitive function, we followed 38 inpatients diagnosed with delirium (22 with delirium and dementia, 16 with delirium only) and 148 patients with no delirium or dementia, for a median of 32.5 months. Follow-up was by personal interviews, supplemented by standardized clinical examinations. We calculated the incidence and odds of dementia and the incidence and hazard ratio for death, with adjustment for potential confounders.

RESULTS

The incidence of dementia was 5.6% per year over 3 years for those without delirium and 18.1% per year for those with delirium. The unadjusted relative risk of dementia for those with delirium was 3.23 (95% confidence interval 1.86-5.63). The adjusted relative risk of death also increased (1.80; 1.11-2.92), while the median survival time was significantly shorter in those with (510 days; 433-587) than in those without delirium (1122 days; 922-1322).

CONCLUSION

delirium appears to be an important marker of risk for dementia and death, even in older people without prior cognitive or functional impairment.

Scabies presenting as a necrotizing vasculitis in the presence of lupus anticoagulant

A 75-year-old man presented with a progressive eruption of 6 weeks' duration. Purpura and focal areas of cutaneous infarction were present on the legs. There were scabies burrows on the wrists and hands, and a mite was extracted. Histology of a skin biopsy showed a necrotizing leucocytoclastic vasculitis. Circulating lupus anticoagulant was detected. Treatment consisted of topical 5% permethrin cream and systemic steroids.

Necrotizing fasciitis complicating disseminated cutaneous herpes zoster

The association of necrotizing fasciitis, often due to group A streptococcus and primary varicella (chicken pox), is unusual but recognized in children. The association in adults is rare but one report in the literature describes a previously healthy man with the two disorders. We now describe a case of disseminated cutaneous herpes zoster complicated by subacute necrotizing fasciitis in an elderly woman taking low dose methotrexate and prednisone for rheumatoid arthritis. Staphylococcus aureus was isolated. Localized debridement and split skin grafting were required.

Toxic epidermal necrolysis treated with cyclosporin and granulocyte colony stimulating factor

A patient developed toxic epidermal necrolysis while on carbamazepine, 80% of her skin surface being involved. She also developed a pancytopenia with a neutropenia of 0.77 x 10(9)/l (normal range 2-7.5 x 10(9)/l), but was treated with cyclosporin and granulocyte colony stimulating factor and made a full recovery.

The clinical spectrum of necrotising fasciitis. A review of 15 cases

BACKGROUND

Necrotising fasciitis represents a spectrum of disease which ranges from fulminant through acute to subacute varieties. While fulminating necrotising fasciitis is a well recognised entity the subacute variety is not.

AIM

To assess six years' experience of necrotising fasciitis at Waikato Hospital.

METHOD

Cases of necrotising fasciitis were identified from discharge statistics for the period 1990-1995. Records were reviewed for clinical features, predisposing factors, microbiology, histology, treatment and outcome.

RESULTS

Fifteen cases were identified of which ten were female. The average age was 55 years (range of 15-92 years). One patient presented with fulminant, eight with acute and six with subacute necrotising fasciitis. Significant blister formation was noted in eight cases. Risk factors were identified in 14 patients including trauma, renal impairment, diabetes mellitus, and various drugs including diclofenac (four patients), naproxen (one patient) and prednisone (two patients). Group A beta haemolytic streptococcus (GABHS) was identified in ten cases. Swab or tissue cultures had the highest yield for isolating the organism. Blood cultures grew GABHS in only three of 12 cases. Eight patients (53%) died. Of the survivors all but one patient required debridement and skin grafting.

CONCLUSIONS

Necrotising fasciitis is a clinical spectrum of disease. It affects a wide age group and can have associated morbidities. It is often a fatal disease. Early recognition, high dose antibiotics and surgical debridement are important in the management of the entire spectrum of necrotising fasciitis.

Mycobacterium kansasii infection in a patient presenting with porphyria cutanea tarda

Mycobacterium kansasii, an atypical mycobacterium, is an uncommon cause of cutaneous and joint disease in immunocompetent patients. We report an unusual case of infection with this organism in a patient who initially presented with porphyria cutanea tarda (PCT), and who was noted also to have a crusted ulcer over the middle phalanx and swelling of the proximal interphalangeal joint of the right middle finger. The cutaneous ulcer healed with minocycline, but the joint disease required a combination of rifampicin and ethambutol before a therapeutic response was obtained.

Increasing the recognition of delirium in elderly patients

OBJECTIVE

To determine if an educational intervention aimed at house staff will increase knowledge about and recognition of delirium.

DESIGN

Before/after study, with blinding of participants to the intent of the study.

SETTING

University hospital in Halifax, Nova Scotia.

PATIENTS

One hundred eighty-seven control patients, seen as consecutive admissions of elderly patients (65 + years) to the General Medicine services of the Victoria General Hospital prior to the educational intervention, and 247 patients seen thereafter.

INTERVENTION

Educational intervention at grand rounds, housestaff rounds, sign-in rounds, and bedside teaching.

MEASUREMENTS

Recognition of delirium in the admitting history or progress notes, Confusion Assessment Method (CAM) as recorded by nurses, diagnosis of delirium by independent study physicians using DSM-IIIR criteria and the Trzepacz Delirium Symptom Rating Scale.

RESULTS

Prior to the intervention, delirium or acute confusion was diagnosed in 3% of patients; after the intervention, delirium or acute confusion was diagnosed in 9% of patients (P < 0.01). Other abnormalities in mental state were noted in 8.5% of admissions prior to the intervention, and 15.6% of admissions after the intervention. After the intervention there was a significant difference in the proportion of patients in whom a mental status questionnaire had been carried out and in whom there was formal comment on various aspects of the mental state. The nursing CAM had a sensitivity of 0.68 and a specificity of 0.97.

CONCLUSIONS

A simple educational intervention aimed at house staff appears to be effective in changing house staff behavior. Improved recognition of delirium may lead to better patient outcomes.

Distribution, Frequency, and Diversity of Bacillus thuringiensis in an Animal Feed Mill

Bacillus thuringiensis was isolated from 36 of 50 residue samples obtained from an animal feed mill (a stored-product environment). Of 710 selected colonies having Bacillus cereus-B. thuringiensis morphology isolated from the samples, 477 were classified as B. thuringiensis because of production of parasporal δ-endotoxin crystals. There was a diverse population of B. thuringiensis , as revealed by differentiation of the isolates into 36 subgroups by using (i) their spectra of toxicity to the lepidopterans Heliothis virescens, Pieris brassicae , and Spodoptera littoralis and the dipteran Aedes aegypti and (ii) their parasporal crystal morphology. A total of 55% of the isolates were not toxic to any of these insects at the concentrations used in the bioassays; 40% of all isolates were toxic to one or more of the Lepidoptera; and 20, 1, and 1% of the isolates were toxic to only P. brassicae, H. virescens , and S. littoralis , respectively. The most frequent toxicity was toxicity to P. brassicae (36% of all isolates); 18% of the isolates were toxic to A. aegypti (5% exclusively), 10% were toxic to H. virescens , and 4% were toxic to S. littoralis . Toxicity to P. brassicae was more often linked with toxicity to H. virescens than with toxicity to S. littoralis . The frequency of toxicity was significantly greater in isolates that produced bipyramidal crystals than in isolates that produced irregular pointed, irregular spherical, rectangular, or spherical crystals.

Which dogs bite?

Young children (less than 11 years old) are a particular risk group for dog bites. Dog bites commonly occur from the family pet. Alsatian or alsatian mixes are the biggest group in the study causing dog bites. Alsations are a popular breed. By comparison Retrievers (Labrador and Golden), also a popular breed, caused few bites.

Plasmid transfer between strains of Bacillus thuringiensis infecting Galleria mellonella and Spodoptera littoralis

To determine the possibility of plasmid transfer occurring between strains of Bacillus thuringiensis in infected lepidopterous larvae, Galleria mellonella and Spodoptera littoralis were infected with two or more strains of B. thuringiensis and the resulting bacteria from the dead insects were examined for plasmid transfer. Transfer rates of plasmids coding for crystal production and tetracycline resistance were high, reaching levels similar to those obtained in laboratory broth cultures. Transfer was higher in G. mellonella than S. littoralis, probably due to the greater ability of B. thuringiensis to colonize the larvae. In broth cultures, B. thuringiensis was also able to transfer plasmids into sporeforming bacteria present in soil samples. The results suggest that plasmid transfer between strains of B. thuringiensis occurs in nature, resulting in the production of new combinations of delta-endotoxins within populations of the bacteria.

Psychiatric nursing management of medication-free psychotic patients

This article discusses how a team of psychiatric nurses manages acutely psychotic patients on a clinical research unit without the use of psychotropic medications. The article describes a schizophrenia research unit, identifies the behaviors of acutely psychotic patients, and provides examples of effective nursing interventions used on the unit. These interventions are grounded in principles of interpersonal psychiatric nursing practice and milieu therapy. The discussion is directed to psychiatric nurses and other health care professionals who are employed on research units.

Treatment of children with neurogenic sarcoma. Experience at the Children's Hospital of Philadelphia, 1958-1984

Twenty-four children aged 3 months to 18 years (median, 12 years) were treated for neurogenic sarcoma at the Children's Hospital of Philadelphia Cancer Research Center from 1958 through 1984. Sixteen patients had neurofibromatosis (NF). The tumors arose in an extremity or in the trunk (15 patients), the retroperitoneum-pelvis (6), or other sites (3). Twelve children underwent grossly complete excision of localized sarcoma; of them, five had no known residual tumor and seven had proven microscopic residual disease. Ten of the remaining 12 patients had grossly visible, residual localized disease, and two had lung metastases. After operation, nine were treated on a protocol with local radiation therapy (4000-6000 rad) plus vincristine, actinomycin D, and cyclophosphamide with or without Adriamycin (doxorubicin). The other 15 were treated variably. At 3 years, the proportion of tumor-free survivors was 9 of 24 (37.5%). The significant favorable factors were the initial surgical removal of all gross tumor (9 of 12 with tumor excision were tumor-free survivors at 3 years compared to none of 12 with gross residual sarcoma; P less than 0.01), and a tumor mitotic rate under one per high-power field. No significant correlation was found between tumor-free survival expectancy and age, race, sex, the presence of NF, the site and size of the primary tumor, or use of the chemoradiotherapy regimen. More effective treatment programs are needed for children with neurogenic sarcoma, especially for those with unresectable tumors.

Properties of a novel DNA virus from the tsetse fly, Glossina pallidipes

Virus particles were isolated from hypertrophied salivary glands of the tsetse fly, Glossina pallidipes collected near Mombasa, Kenya. Purified virus particles were rod-shaped, 57 nm wide by 700 to 1300 nm long. Particle lengths fell into two size classes, with 'short' particles averaging 869 nm and 'long' particles 1175 nm. The virus particles morphologically resembled elongated baculovirus nucleocapsids although, unlike baculoviruses, no fully enveloped virions were found in purified preparations. The particles contained double-stranded DNA which appeared to be linear when analysed by electrophoresis in agarose gels, ethidium bromide-caesium chloride gradient centrifugation or electron microscopy (EM). There was some evidence for the DNA being heterogeneous in size from EM studies and from the observation that restriction enzyme analysis failed to provide a clear profile of DNA fragments. Protein from purified virions contained at least 12 polypeptides with a major component of 39 000 mol. wt. These results suggest that the virus cannot be placed in any of the existing taxonomic groupings of DNA viruses.

Influence of place of treatment on diagnosis, treatment, and survival in three pediatric solid tumors

This study examines differences between cancer centers (CC) and noncancer centers (NCC) in terms of management procedures and outcomes for three pediatric solid tumors: Wilms' tumor (N = 147), rhabdomyosarcoma (N = 87), and medulloblastoma (N = 76). Data were derived for the period 1970-1979 from the population-based Greater Delaware Valley Pediatric Tumor Registry maintained at the Children's Cancer Research Center, which routinely collects data on all childhood neoplasms that occur in a 31-county region. Management measures reviewed included the degree to which important pretreatment evaluations were performed, types of therapy used, and extent of follow-up examinations conducted. Outcome variables were three-year disease-free survival and frequency of deaths related to complications of therapy. Differences in three-year disease-free survival between CC and NCC were noted for medulloblastoma (52% v 24%) and rhabdomyosarcoma (48% v 10%), but not for Wilms' tumor (79% v 68%). Among medulloblastoma patients, differences were detected in the frequency of pretreatment evaluations and in the therapy used. The principal management contrast found in rhabdomyosarcoma was that multiagent chemotherapy was used less often in NCC. Wilms' tumor patients were evaluated and treated similarly in the community versus the CC, except for some contrasts in the surgical approach and the frequency of follow-up for the detection of late complications.

Racial variation in incidence of Wilms' tumor: relationship to congenital anomalies

This is a study of the occurrence of Wilms' tumor and associated anomalies in all incident cases in the Greater Delaware Valley by race. The average annual incidence of Wilms' tumor in this population of 2 million children is significantly higher among nonwhites than whites. A significantly larger proportion of black cases has a Wilms' tumor-associated condition including aniridia, genito-urinary anomalies, the Beckwith-Wiedemann Syndrome, and hemihypertrophy. For very young patients, there was a greater tendency for blacks to have bilateral tumors or a tumor-associated anomaly, features characteristic of the hereditary form of Wilms' tumor. The excess risk of Wilms' tumor among blacks may be a result of a higher proportion having a hereditary predisposition or more common exposure to agents capable of inducing germinal mutations.

Survival in childhood acute lymphocytic leukemia: effect of protocol and place of treatment

The objective of this study was to determine the effect of place and type of initial treatment on survival from acute lymphocytic leukemia (ALL). Every one of the 327 children under 15 years of age diagnosed with ALL from 1970 to 1975 in a 31-county area designated the Greater Delaware Valley, were studied. Treatment according to protocol was associated with improved survival, yielding a 4 year survival of 60% vs 19% for nonprotocol treated patients (p less than 0.001). There was also a significantly improved survival rate among patients treated in a cancer center, especially for those with a low white blood count (WBC) at diagnosis. The prognostic importance of WBC, age, and sex was confirmed.

Incidence of childhood cancer: experience of a decade in a population-based registry

Incidence rates of cancer among children aged 0-14 for the period 1970-79 have been generated with the use of data from the Greater Delaware Valley (GDV) Pediatric Tumor Registry. This population-based registry covers a 31-county area and has a pediatric base population of 2 million. During the period, approximately 2,300 cases of childhood cancer were diagnosed in the region. Incidence rates for all histologic types combined are similar to rates from other large surveys conducted in the United States and Western Europe. However, certain histology-specific rates in the GDV vary by race. In the GDV nonwhites relative to whites have higher rates of Wilms' tumor, soft tissue sarcomas other than rhabdomyosarcoma, and retinoblastoma. These contrasts are supported by surveys in African populations showing relatively higher rates of these tumors among African black children. GDV whites exceed nonwhites in incidence of acute leukemia, neuroblastoma, and Ewing's sarcoma. African black children also experience low rates of these tumors. The frequency of central nervous system tumors is similar for GDV whites and nonwhites, despite reports of a rarity of these neoplasms in African blacks. Variations in incidence rates reveal population subgroups with particular tumor susceptibilities and may provide clues as to the relative influence of heredity and environment on patterns observed.

Treatment strategies for infants with malignant sacrococcygeal teratoma

Twelve children with malignant sacrococcygeal teratoma containing embryonal carcinoma, were treated at the Children's Hospital of Philadelphia between 1971 and 1980. Their ages at diagnosis ranged from 2 days to 23 mo; 8 of the 12 (67%) were girls. Five of the 12 patients presented with localized tumors which were grossly completely excised. Four received no further therapy, and all 4 recurred with histologically documented embryonal carcinoma. Despite subsequent treatment with radiation therapy (RT) and chemotherapy (vincristine, actinomycin D, and cyclophosphamide, collectively called VAC, in all 4 plus adriamycin in 3, only 1 has survived free of disease, 8 yr from diagnosis. The other 3 died of tumor (2) or pneumonia after pulmonary RT (1). The fifth patient in this group received VAC with adriamycin (total dose, 350 mg/sq m) and died of autopsy-proven cardiotoxicity without tumor. The remaining 7 patients presented with either unresectable local tumor (3) or distant metastases (4). One of these 7 died 6 days after biopsy with massive liver metastases. The other 6 children were treated after operation with VAC (5) or vincristine and actinomycin D (1) chemotherapy, and 5 also received RT to the pelvis. One has survived free of disease at 6 yr after treatment with VAC and adriamycin and pelvic RT, but the other 5 died of tumor (2) or of pneumonia after pulmonary RT (3). Surgery alone is inadequate for successful management of children with malignant sacrococcygeal teratoma. Chemotherapy with VAC, with or without adriamycin, can be effective when combined with radiation, but fatal pulmonary toxicity can result from such combined therapy. The optimal therapeutic program for children with malignant sacrococcygeal teratoma is still evolving.

Pediatric brain stem gliomas

Sixty-two pediatric patients with brain stem glioma diagnosed between 1964 and 1978 have been reviewed. Posterior fossa eploration was performed on 53% of the patients. Pathology was obtained by biopsy in 58% of those explored. Fifty-four patients had definitive radiation therapy with a median dose of 5000 rads. The actuarial five-year survival for the entire group is 30%. A pathologic diagnosis was available from necropsy or biopsy on 36 of the 62 patients. One-half had malignant tumors, and none survived more than 16 months. The remaining patients with well-differentiated gliomas had five-year actuarial survival of 55%. The use of computed tomography (CT) has been found to be valuable in diagnosis and follow-up, as well as in the design of radiation therapy portals. The data demonstrate no dose response curve. We recommend local radiation therapy of 5000 to 5500 rads to the tumor area as defined by CT.