Ungewöhnlicher Suizid durch Verbluten aus einer Hautvene

Ein 90-jähriger Mann verstarb durch protrahiertes Verbluten aus einer, mittels Rasierklinge minimal eröffneten, oberflächlichen Beinvene über der Patella und nachfolgender Manipulation. Dabei handelte es sich wahrscheinlich um einen Ast der V. saphena accessoria anterior. Es lag zunächst eine Fehleinschätzung durch den leichenschauhaltenden Arzt vor, der von einer gastrointestinalen Blutung als Todesursache ausging. Diese Einschätzung teilten die Kriminalbeamten aufgrund der Auffindesituation nicht. Begünstigend war eine vorbestehende Varikosis. Die Einnahme von Antikoagulanzien oder eine vorbestehende oder erworbene Gerinnungsstörung konnte nicht nachgewiesen bzw. eruiert werden. Bei Vorlage eines Abschiedsbriefes und Ausschluss fremder Gewalteinwirkungen oder einer Vergiftung kann plausibel von einem ungewöhnlichen suizidalen Ereignis ausgegangen werden. Es wird über die Auffindung sowie die Ergebnisse der Sektion und umfangreicher Zusatzuntersuchungen berichtet.

Tuberculosis surveillance and its discontents: the ethical paradox

In June 2017, the World Health Organization issued the Guidelines on Ethical Issues in Public Health Surveillance. Using the frame of public health ethics, the guidance declared that countries have an affirmative duty to undertake surveillance and that the global community had an obligation to support those countries whose resources limited their capacity. The centrality of TB surveillance has long been recognized as a matter of public health practice and ethics. Nevertheless, contemporary global realities make clear that TB surveillance falls far short of the goal of uniform notification. It is this reality that necessitated the paradoxical turn to research studies that require informed consent and human subjects' ethical review, the very burdens that mandated notification were designed to overcome.

Suicide by the intraoral blast of firecrackers - experimental simulation using a skull simulant model

Suicides committed by intraorally placed firecrackers are rare events. Given to the use of more powerful components such as flash powder recently, some firecrackers may cause massive life-threatening injuries in case of such misuse. Innocuous black powder firecrackers are subject to national explosives legislation and only have the potential to cause harmless injuries restricted to the soft tissue. We here report two cases of suicide committed by an intraoral placement of firecrackers, resulting in similar patterns of skull injury. As it was first unknown whether black powder firecrackers can potentially cause serious skull injury, we compared the potential of destruction using black powder and flash powder firecrackers in a standardized skull simulant model (Synbone, Malans, Switzerland). This was the first experiment to date simulating the impacts resulting from an intraoral burst in a skull simulant model. The intraoral burst of a "D-Böller" (an example of one of the most powerful black powder firecrackers in Germany) did not lead to any injuries of the osseous skull. In contrast, the "La Bomba" (an example of the weakest known flash powder firecrackers) caused complex fractures of both the viscero- and neurocranium. The results obtained from this experimental study indicate that black powder firecrackers are less likely to cause severe injuries as a consequence of intraoral explosions, whereas flash powder-based crackers may lead to massive life-threatening craniofacial destructions and potentially death.

Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

Rare cause of natural death in forensic setting: hemophagocytic syndrome

We report about the case of a sudden unexpected death of a 25-year-old male suffering from infectious disease. An autopsy was ordered with no final premortem diagnosis. Microscopic and microbiological examination revealed a pneumococcal bronchopneumonia and hemophagocytic lesions in the bone marrow. After integrating clinical and autopsy reports as well as additional postmortem investigations, the cause of death was found to be infectious-triggered hemophagocytic syndrome (HPS) with a final cytokine storm. This seems to be the first reported fatal case of a reactive form of HPS associated to Streptococcus pneumoniae to the best of our knowledge. HPS is a dangerous hyperinflammation with highly characteristic, but nonspecific, laboratory findings and symptoms. Autopsies in such cases must be carefully performed and include systematic tissue sampling done by an experienced pathologist.

Partial amputation of the tongue--self-inflicted or physical assault?

Injuries of the tongue are generally self-inflicted lesions and occur during different diseases or external incidents. The amputation of the tongue is a rare event. In this article, we report about a woman presenting with a complete amputation of the anterior third of the tongue. The morphological findings, which are essential for the differentiation of self-inflicted injuries and injuries caused by a third party, are demonstrated.

Abstract P1-12-04: Carboplatin, nab-paclitaxel and bevacizumab as first-line treatment for metastatic breast cancer

Background: Bevacizumab added to weekly paclitaxel resulted in improved progression free survival (PFS) and objective response rates (ORR) compared to weekly paclitaxel alone. Nab-paclitaxel and the platins are active in MBC. We conducted an efficacy and safety study of carboplatin, nab-paclitaxel and bevacizumab.

Methods: A phase II open label prospective multi-site study enrolled patients (pts) who had measurable MBC according to RECIST 1.1 criteria and no prior chemotherapy for advanced disease. The primary endpoint was PFS with secondary endpoints of overall survival (OS), ORR, and safety. Pts initially received carboplatin AUC 6 day 1, 22,43, plus weekly nab-paclitaxel 100mg/m2 and bevacizumab 15mg/m2 day 1,22,43 of a 56 day cycle. This was later changed to carboplatin AUC 6 day 1, nab-paclitaxel 100mg/m2 day 1,8,15, and bevacizumab 10mg/m2 day 1,15 of a 28 day cycle. Thirty-two pts were required to detect an increase in median PFS from 6.7 to 10.5 mo with 80% power based on a one-sided p = 0.05. Kaplan–Meier analyses estimated PFS and OS. The log rank test was used for the comparison of survival curves between pts with triple negative MBC (TNBC) and pts with non-TNBC.

Results: Thirty-two pts were enrolled between 2/2008 and 11/2011 by 1 academic and 5 community oncology practices. Two pts were ineligible due to non-measurable disease and not included in the response analyses. The median age was 58 years (range 35–81), 22 pts (69%) had an ECOG PS 0, 9 (28%) had a PS 1, 1 (3%) PS 2. Twenty-four (75%) pts had ER+ disease, 7 (22%) had TNBC, 1 (3%) had ER-HER2+ disease not eligible for trastuzumab-based therapy. Metastatic sites were bone (26%), liver (18%), loco-regional (16%), and lung (12%). One pt (3%) had bone and loco-regional disease only, 19 (59%) had visceral dominant disease. The median number of weeks on treatment was 28.9 (range 5–131). The median PFS in all pts was 13.6 months (mo) (95% CI 11.2–21.9), with a median OS of 26.8 mo (95% CI 13.3–41.2). The ORR (2 CR and 18 PR) was 66.7% (CI 47.2–82.7). There also were 6 (20%) unconfirmed PR and 3 (10%) stable disease, resulting in a clinical benefit rate of 96.7% (CI 82.78–99.92). There was no significant difference in PFS (median 13.6 vs 16.1mo, p = 0.37) or OS (median 13.6 vs 26.8mo, p = 0.32) in pts with TNBC versus non-TNBC disease. The most common toxicities of any grade (gr) include neutropenia and thrombocytopenia in 24 pts (75%) each, leukopenia and fatigue in 17 pts (53%) each, anemia in 15 (47%), and neuropathy in 10 (31%). Gr 4 neutropenia was seen in 7 pts (22%) without febrile neutropenia, and gr 4 thrombocytopenia occurred in 6 (19%). There were no pts with gr 4 sensory neuropathy. All pts required chemotherapy dose delays, 15 (47%) had chemotherapy dose reductions.

Conclusions: The carboplatin, nab-paclitaxel and bevacizumab combination is highly effective with good tolerance in first line MBC. As the role of anti-angiogenic therapy in first line metastatic breast cancer is being clarified, this would be an attractive regimen to test in the (neo)adjuvant setting and together with novel molecular targeted agents.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-12-04.

The ethics of clinical and epidemiological research

The global burden of tuberculosis (TB) demands that research be undertaken. The vulnerability of the populations most at risk for TB demands that such research be subject to ethical review to protect their rights and interests. In this brief article we cannot review the vast and important literature bearing on the ethics of clinical and epidemiological research and public health surveillance. Instead, we have focused on three questions that have been at the center of discussion and debate and which have special relevance for TB. First, we examine a question that has special bearing when wealthy nations or international organizations carry out research in poor countries: what does justice require in the post trial period? Second, we examine the question of how the principles of consent and confidentiality may require modification in record-based epidemiological research. Third, we look at the challenges posed by public health surveillance, which in many cases requires case reporting by clinicians to public health agencies. By way of conclusion, we take note of the centrality of enhancing the institutional capacities for ethical review of research in poor nations.

Laser-induced fluorescence to discriminate between a dental composite resin and tooth

PURPOSE

Investigation of laser-induced fluorescence of an experimental pigment (Flu) to discriminate between a filling and the tooth and its influence on the material properties of experimental dental composites.

MATERIALS AND METHODS

Three experimental composites (EC) were manufactured. The standard contained no Flu, Flu-0.5 contained 0.5%, Flu-1.0 contained 1%. To judge the extent of fluorescence, specimens and fillings placed in natural teeth were irradiated with an infrared laser (980 nm, 120 mW). Flexural strength, modulus of elasticity, depth of cure, water sorption, solubility, and color (CIE-L(*)a(*)b(*)-values) were measured to investigate the influence of Flu on EC. ANOVA was calculated and the statistical significance was p < 0.05.

RESULTS

Strong laser-induced green fluorescence was observed so that fillings and tooth structures were clearly discriminated. No influence of Flu on flexural strength and modulus of elasticity occurred. Water sorption and solubility were far below the limits of EN ISO 4049. Increasing Flu concentrations revealed minor but significant reduction of depth of cure, shifts to more white and red and less yellow.

SIGNIFICANCE

Flu provides laser-induced fluorescence allowing an easy discrimination between fillings and teeth. Flu did not severely influence the material properties.

The laser diffractoscope - a new and fast system to analyse red blood cell flexibility with high accuracy

Red blood cell (RBC) flexibility is one of the determining parameters of the microcirculation. As capillaries are smaller in diameter than RBC, RBC can only pass through by deformation. Reduced flexibility is associated with a reduced microcirculation. In obstetrics, pre-eclampsia and intrauterine growth retardation are regarded as diseases exhibiting a reduced microcirculation. With this new system it might be possible to achieve new data concerning the microcirculation in these diseases. The laser diffractoscope is based on laser light diffraction and computer-assisted image analysis. It offers the ability to determine the flexibility of RBC in whole blood with high accuracy between 0 and 30 Pa. Two hundred microlitres of whole blood are required, and the analysis is carried out in less than 5 min, with a standard deviation < or =1%. The laser diffractoscope is a new system which offers the ability to measure RBC deformability with high accuracy in a short time. Evaluation of reproducibility and validity, as well as comparison with data from other measuring systems, proves the excellence of the laser diffractoscope. An example of its application is shown by analysing the deformability of RBC in 10 uncomplicated pregnancies at term.

A phase II trial evaluating the safety and effectiveness of the AastromReplicell system for augmentation of low-dose blood stem cell transplantation

To reduce the number of apheresis procedures and maintain the usual rate of hematopoietic recovery in patients treated with high-dose chemotherapy, we studied the effect of adding a small volume of ex vivo expanded bone marrow to low doses of CD34(+) blood stem cells. Thirty-four patients with breast cancer received G-CSF (10 microg/kg/day) priming followed by a limited volume (50-100 ml) bone marrow aspiration and standard 10-liter aphereses. Marrow was expanded ex vivo using the AastromReplicell system and infused along with low doses of blood-derived CD34(+) cells, collected in one apheresis. Thirty-one evaluable patients received a median CD34(+) blood stem cell dose of 0.7 x 10(6)/kg (range, 0.2-2.5) and 4.7 x 10(7) nucleated cells/kg (range, 1.98-8.7) of ex vivo expanded marrow. All patients recovered with normal blood counts and engrafted 500 neutrophils/microl and 20 000 platelets/microl in a median of 10 and 13 days, respectively. Multivariate analysis revealed that, in addition to CD34(+) lineage negative cell quantity, the quantity of stromal progenitors contained in the ex vivo expanded product correlated with engraftment outcome (r = 0.551, P = 0.004). Our results indicate that ex vivo expanded bone marrow is capable of facilitating engraftment when combined with low doses of mobilized blood derived CD34(+) cells.

Pilot trial of interleukin-2 with granulocyte colony-stimulating factor for the mobilization of progenitor cells in advanced breast cancer patients undergoing high-dose chemotherapy: expansion of immune effectors within the stem-cell graft and post-stem-cell infusion

PURPOSE

To evaluate whether administration of interleukin-2 (IL-2) with granulocyte colony-stimulating factor (G-CSF) improves mobilization of immune effector cells into the stem-cell graft of patients undergoing high-dose chemotherapy and autografting.

PATIENTS AND METHODS

We performed a trial of stem-cell mobilization with IL-2 and G-CSF in advanced breast cancer patients receiving high-dose chemotherapy with cyclophosphamide, thiotepa, and carboplatin and stem cells followed by IL-2. The trial defined immune, hematologic, and clinical effects of IL-2 in this setting.

RESULTS

Of 32 patients enrolled, nine received G-CSF alone for mobilization. Twenty-one of 23 patients mobilized with IL-2 plus G-CSF had stem cells collected with more mononuclear cells than those receiving G-CSF (19.3 v 10.4 x 10(8)/kg; P =.006), but fewer CD34(+) progenitor cells (6.9 v 22.0 x 10(6)/kg; P =.049). The IL-2 plus G-CSF-mobilized patients had greater numbers of activated T (CD3(+)/CD25(+)) cells (P =.009), natural killer (NK; CD56(+)) cells (P =.007), and activated NK (CD56 bright(+)) cells (P: =.039) than those patients mobilized with G-CSF. NK (P =.042) and lymphokine-activated killer (LAK) (P =.016) activity was increased in those mobilized with IL-2 + G-CSF, whereas G-CSF-mobilized patients had a decline in cytolytic activity. In the third week posttransplantation, immune reconstitution was superior in those mobilized with IL-2 plus G-CSF based on greater numbers of activated T cells (P =.003), activated NK cells (P =.04), and greater LAK activity (P =.003). The 16 of 21 IL-2 + G-CSF-mobilized patients with adequate numbers of stem cells (> 1.5 x 10(6) CD34(+) cells/kg) collected engrafted rapidly posttransplantation.

CONCLUSION

The results demonstrate that G-CSF + IL-2 can enhance the number and function of antitumor effector cells in a mobilized autograft without impairing the hematologic engraftment, provided that CD34 cell counts are more than 1.5 x 10(6) cells/kg. Mobilization of CD34(+) stem cells does seem to be adversely affected. In those mobilized with IL-2 and G-CSF, post-stem-cell immune reconstitution of antitumor immune effector cells was enhanced.

Public health. Surveillance and privacy

Surveillance is the radar of public health. It has provided the foundation for public health planning, intervention, and prevention. Important ethical issues regarding privacy--the extent to which name-based reporting violates the trust and assumptions made about how personal medical information will be treated--are raised by public health surveillance. This policy forum looks at the contexts of differing responses from the public health communities and general public to surveillance efforts.

Myeloablative chemotherapy for recurrent aggressive oligodendroglioma

The objective of this study was to ascertain the duration of tumor control and the toxicities of dose-intense myeloablative chemotherapy for patients with recurrent oligodendrogliomas. Patients with previously irradiated oligodendrogliomas, either pure or mixed, that were contrast enhancing, measurable, and behaving aggressively at recurrence were eligible for this study. Only complete responders or major partial responders (75 % reduction in tumor size) to induction chemotherapy--either intensive-dose procarbazine, lomustine, and vincristine or cisplatin plus etoposide-could receive high-dose thiotepa (300 mg/m2/day for 3 days) followed by hematopoietic reconstitution using either bone marrow or peripheral blood stem cells. Thirty-eight patients began induction chemotherapy and 20 (10 men, 10 women; median age 46 years; median Karnofsky score 80) received high-dose thiotepa. For the high-dose group, the median event-free, progression-free, and overall survival times from recurrence were 17, 20, and 49 months, respectively. Tumor control in excess of 2 years was observed in 6 patients (30%). Four patients (20%) are alive and tumor free 27 to 77 months (median, 42 months) from the start of induction therapy; however, fatal treatment-related toxicities also occurred in 4 patients (20%). Three patients died as a result of a progressive encephalopathy which, in 2 instances, was accompanied by a wasting syndrome; 1 patient died as a consequence of an intracerebral (intratumoral) hemorrhage. Fatal toxicities occurred in patients with pretreatment Karnofsky scores of 60 or 70. High-dose thiotepa to consolidate response was a disappointing treatment strategy for patients with recurrent aggressive oligodendroglial neoplasms, although several patients had durable responses. Moreover, as prescribed, high-dose thiotepa had significant toxic effects in previously irradiated patients, especially those with poorer performance status.

Autologous transplantation of ex vivo expanded bone marrow cells grown from small aliquots after high-dose chemotherapy for breast cancer

The collection of small aliquots of bone marrow (BM), followed by ex vivo expansion for autologous transplantation may be less morbid, and more cost-effective, than typical BM or blood stem cell harvesting. Passive elimination of contaminating tumor cells during expansion could reduce reinoculation risks. Nineteen breast cancer patients underwent autotransplants exclusively using ex vivo expanded small aliquot BM cells (900-1200 x 10(6)). BM was expanded in media containing recombinant flt3 ligand, erythropoietin, and PIXY321, using stromal-based perfusion bioreactors for 12 days, and infused after high-dose chemotherapy. Correlations between cell dose and engraftment times were determined, and immunocytochemical tumor cell assays were performed before and after expansion. The median volume of BM expanded was 36.7 mL (range 15.8-87.0). Engraftment of neutrophils greater than 500/microL and platelets greater than 20,000/microL were 16 (13-24) and 24 (19-45) days, respectively; 1 patient had delayed platelet engraftment, even after infusion of back-up BM. Hematopoiesis is maintained at 24 months, despite posttransplant radiotherapy in 18 of the 19 patients. Transplanted CD34(+)/Lin(-) (lineage negative) cell dose correlated with neutrophil and platelet engraftment, with patients receiving greater than 2.0 x 10(5) CD34(+)/Lin(-) cells per kilogram, engrafting by day 28. Tumor cells were observed in 1 of the 19 patients before expansion, and in none of the 19 patients after expansion. It is feasible to perform autotransplants solely with BM cells grown ex vivo in perfusion bioreactors from a small aliquot. Engraftment times are similar to those of a typical 1000 to 1500 mL BM autotransplant. If verified, this procedure could reduce the risk of tumor cell reinoculation with autotransplants and may be valuable in settings in which small stem cell doses are available, eg, cord blood transplants. (Blood. 2000;95:2169-2174)

Clinical progress and the future of HIV exceptionalism

In the 18 years since the first cases of the acquired immunodeficiency syndrome (AIDS) were reported by the Centers for Disease Control and Prevention (CDC), the epidemic has undergone profound transformations, and so, too, has the sociomedical context within which public health policy is fashioned and implemented. The early years of neglect and panic were also characterized by relative therapeutic impotence and deep uncertainty about the epidemiological course the new threat would take. In the United States and in other economically advanced nations, the threat of contracting the human immunodeficiency virus (HIV) has abated. The incidence of infection has declined, and the prevalence of infection has stabilized and, in some instances, begun to fall. The pattern of HIV spread, where it has continued, has been dramatically circumscribed to marginalized populations. The panic of the mid-1980s has passed, and in many nations, AIDS has lost its salience as a public issue. A sense of therapeutic impotence no longer prevails, and a new mood of triumphalism has taken hold. How have these crucial changes affected AIDS policies in America?

The synthesis of sialylated oligosaccharides using a CMP-Neu5Ac synthetase/sialyltransferase fusion

Large-scale enzymatic synthesis of oligosaccharides, which contain terminal N-acetyl-neuraminic acid residues requires large amounts of the sialyltransferase and the corresponding sugar-nucleotide synthetase, which is required for the synthesis of the sugar-nucleotide donor, CMP-Neu5Ac. Using genes cloned from Neisseria meningitidis, we constructed a fusion protein that has both CMP-Neu5Ac synthetase and alpha-2,3-sialyltransferase activities. The fusion protein was produced in high yields (over 1200 U/L, measured using an alpha-2,3-sialyltransferase assay) in Escherichia coli and functionally pure enzyme could be obtained using a simple protocol. In small-scale enzymatic syntheses, the fusion protein could sialylate various oligosaccharide acceptors (branched and linear) with N-acetyl-neuraminic acid as well as N-glycolyl- and N-propionyl-neuraminic acid in high conversion yield. The fusion protein was also used to produce alpha-2,3-sialyllactose at the 100 g scale using a sugar nucleotide cycle reaction, starting from lactose, sialic acid, phosphoenolpyruvate, and catalytic amounts of ATP and CMP.

Directly observed therapy and treatment completion for tuberculosis in the United States: is universal supervised therapy necessary?

OBJECTIVES

This study examined the relationship between directly observed therapy and treatment completion rates in the years before and after infusion of federal funding for tuberculosis (TB) control in 1993.

METHODS

An ecological study of estimated directly observed therapy rates and 12-month treatment completion rates from 1990 through 1994 was undertaken for TB control programs in all 25 cities and counties across the nation with 100 or more incident TB cases in any year from 1990 to 1993. Three cohorts were formed: high treatment completion, intermediate completion, and low completion.

RESULTS

In 1990, the median 12-month treatment completion rate was 80% for the entire study population, with a median estimated directly observed therapy rate of 16.8%. By 1994, those rates had increased to 87% and 49.4%, respectively, and increases were shown in all 3 cohorts.

CONCLUSIONS

Directly observed therapy has had a marked impact on treatment completion rates in jurisdictions with historically low rates. But TB treatment completion rates of more than 90% can be attained with directly observed therapy rates far lower than those proposed by advocates of universal supervised therapy.

Recombinant methionyl human stem cell factor and filgrastim for peripheral blood progenitor cell mobilization and transplantation in non-Hodgkin's lymphoma patients--results of a phase I/II trial

To examine the safety and efficacy of recombinant-methionyl human stem cell factor (r-metHuSCF), 38 patients with intermediate-grade or immunoblastic high-grade non-Hodgkin's lymphoma who were eligible for autologous transplantation were randomized to receive r-metHuSCF (5, 10, 15, or 20 microg/kg/d) plus Filgrastim (10 microg/kg/d) or Filgrastim (10 microg/kg/d) alone to mobilize peripheral blood progenitor cells. Subcutaneous administration of r-metHuSCF was well tolerated in conjunction with a multi-agent pre-medication regimen; local injection site reactions were the most commonly seen adverse event. The total mononuclear cell count, CD34+ cell content, granulocyte-macrophage colony-forming cells (GM-CFC), and burst-forming units-erythroid (BFU-E) per kilogram in the apheresis product was similar when all patients were analyzed by treatment cohort and mobilization regimen (Filgrastim or r-metHuSCF in combination with Filgrastim); however, when prior chemotherapy was taken into account in a supplementary analysis, clinically important differences were observed. Extensive prior therapy was defined as the amount of exposure to specific stem cell toxic chemotherapeutic agents that patients received. These agents include procarbazine, nitrogen mustard, melphalan, nitrosoureas (> or = 2 cycles of any of these drugs) or greater than 7.5 g of cytosine arabinoside. In these patients, there was an increased number of CD34+ cells (1.76 v 0.28 x 10(6)/kg), GM-CFC (20.5 v 5.0 x 10(4)/kg), and BFU-E (36.9 v 8.9 x 10(4)/kg) in patients receiving r-metHuSCF and Filgrastim (N = 18) compared with Filgrastim alone (N = 5). These patients also had a decreased time to an untransfused platelet count of 20 x 10(9)/L that was 10.5 days shorter in the patients who received r-metHuSCF and Filgrastim (12.5 v 23 days). These differences were not found to be statistically significant, possibly because of small size, but are clinically important.

High-dose chemotherapy with autologous transplantation for persistent/relapsed ovarian cancer: a multivariate analysis of survival for 100 consecutively treated patients

PURPOSE

To examine the prognostic factors associated with prolonged progression-free survival (PFS) and overall survival (OS) in 100 consecutively treated women undergoing autologous stem-cell transplant for advanced ovarian cancer.

PATIENTS AND METHODS

From October 1989 to February 1996, we transplanted 100 patients with ovarian cancer following chemotherapy with high-dose carboplatin, mitoxantrone, and cyclophosphamide with or without cyclosporine (n = 70); melphalan and mitoxantrone with or without paclitaxel (n = 25); or other regimens (n = 5). Their median age was 48 years (range, 23 to 65), 70% had papillary serous histology, 72% had grade III tumors, 66% were platinum-resistant, and 61% had > or = 1 cm bulk. The median number of prior regimens was two (range, one to six). Univariate and multivariate analyses were performed to examine age (< v > or = mean), stage, initial bulk, histology, grade, response to initial therapy, number of prior regimens, time from diagnosis to transplant, transplant regimen, platinum sensitivity, and bulk (< v > or = 1 cm) at transplant.

RESULTS

The median PFS and OS times for the 100 patients were 7 and 13 months. A stepwise Cox proportional hazards model identified tumor bulk (P = .0001), and cisplatin sensitivity (P = .0249) as the best predictors of PFS. Age (P = .0017), bulk at transplant (P = .0175), and platinum sensitivity (P = .0330) provided the best prediction of OS. The median PFS and OS times for the 20 patients with platinum-sensitive, < or = 1-cm disease were 19 and 30 months. No differences in OS were seen when chemotherapy or surgery was used to achieve a minimal disease state.

CONCLUSION

Before consideration of high-dose therapy for recurrent/persistent advanced ovarian cancer, patients should undergo debulking surgery or chemotherapy to achieve a minimal disease state. Patients with platinum-resistant, bulky disease should not be transplanted. The optimal patients for this therapy may be those with minimal disease responsive to initial chemotherapy.

Science, politics, and AIDS prevention policy

The relationships among science, politics, and health care policy have changed dramatically over the years since AIDS was first diagnosed in the United States. Initially politics was viewed as inimical to prevention; now it is viewed as central. The challenge is to ensure that policies facilitate prevention of the spread of HIV and do so in a way that protects those most vulnerable. The policies of the first decade of the epidemic were hostile to research in areas such as needle exchange and sexuality. More recently, the political climate has been more sympathetic, but whether this will result in a more effective health-care policy is not yet clear. Two important debates continue in AIDS prevention policy: (a) the issue of whether prevention efforts should be targeted to high-risk populations and geographic areas or should be more broadly focused, and (b) whether prevention priorities are best established through democratic participation that includes federal government agencies, local health departments, and community-based organizations.

A balancing act: the tension between case-finding and primary prevention strategies in New York State's voluntary HIV counseling and testing program in women's health care settings

This study sought (1) to identify factors that influence women's willingness to accept voluntary HIV counseling and testing at New York State Family Planning Programs (FPPs) and Prenatal Care Assistance Programs (PCAPs) and (2) to evaluate the effectiveness of such a voluntary counseling and testing program. Telephone interviews elicited organizational-level data from 136 agencies; a combination of telephone and face-to-face interviews was used to gather provider data from 98 HIV counselors; and client data were gathered from 354 women in face-to-face interviews at counseling sites. Slightly fewer than 60% of women agreed to be counseled, and, of those, under half consented to an HIV test at the counseling site. Approximately two thirds of the women who were tested returned for their results and posttest counseling. Clients' recall of pretest counseling content was relatively poor. Bivariate and regression analyses suggest that client, provider, and organizational factors are all associated with rates of pretest counseling and testing. The current voluntary counseling and testing program is achieving only moderate success. Although a substantial number of clients accept HIV counseling, many women remain reluctant to consent to HIV testing, and many who accept testing do not return for their results. Moreover, among those who receive pretest counseling, many do not recall important informational content, which suggests variation may exist in the quality of counseling or that one-time HIV counseling interventions are insufficient to communicate complex information. Medical Subject Headings (MeSH): AIDS, HIV serodiagnosis, women's health, patient education.

High-dose chemotherapy combined with escalating doses of cyclosporin A and an autologous bone marrow transplant for the treatment of drug-resistant solid tumors: a phase I clinical trial

High response rates are seen in patients undergoing dose-intensive chemotherapy and autologous marrow transplantation due to the ability of the therapy to overcome inherent or acquired drug resistance. However, relapse rates are also high because this drug resistance reversal is incomplete. Because both P-glycoprotein- and platinum-induced resistance appear to be clinically important and can be reversed in vitro with a short exposure of cyclosporin A (CSA) at 2000 and 5000 ng/ml, respectively, we undertook a trial of high-dose chemotherapy with carboplatin (1500mg/m2), mitoxantrone (75 mg/m2), and cyclophosphamide (120 mg/kg) over a 5-day period combined with escalating doses of CSA. Thirty-seven patients with primarily breast cancer (61% doxorubicin resistant) and ovarian cancer (85% platinum resistant) were treated with CSA given as a bolus 18 h prior to chemotherapy, followed by a 5-day infusion at doses of 5.0-28.2 mg/kg/day and the chemotherapy. The maximum tolerated dose of CSA was a bolus of 5.5 mg/kg and an infusion of 15. 9 mg/kg/day, which gave a mean serum CSA level of 1544 ng/ml. The dose-limiting toxicity was severe mucositis and enteritis, leading to infectious complications. Nephrotoxicity was seen in 42% and, while usually mild and reversible, was fatal in two patients with pretreatment creatinine clearances h80 ml/min. Grade III-IV isolated hyperbilirubinemia was seen in 39%, but appeared to be of no clinical significance. The overall response rate for the 26 patients with measurable/evaluable disease was 73% and 63% for those with doxorubicin- or platinum-resistant disease. The median overall survival and progression-free survival for the group were 18.1 and 8. 0 months. The overall survival for the nine patients with doxorubicin-resistant breast cancer was 19.3 months. Although we did not achieve CSA levels needed to reverse platinum resistance in vivo, levels approaching those needed to reverse P-glycoprotein resistance were reached at the maximum tolerated dose. The strategy of combining dose intensity with drug resistance reversal deserves further study, especially with the advent of potentially less toxic agents available to reverse P-glycoprotein-mediated resistance.

Neutrophil adhesion in leukocyte adhesion deficiency syndrome type 2

We have previously reported a newly discovered congenital disorder of neutrophil adhesion, leukocyte adhesion deficiency syndrome type 2 (LAD II). The clinical manifestations of this syndrome are similar to those seen in the classic leukocyte adhesion deficiency syndrome, now designated type 1 (LAD I), but the two syndromes differ in the molecular basis of their adhesion defects. LAD I is caused by a deficiency in the CD18 integrin adhesion molecules while LAD II patients are deficient in expression of sialyl-Lewis X (SLeX), a carbohydrate ligand for selectins. In this report we demonstrate that neutrophils from a LAD II patient bind minimally or not at all to recombinant E-selectin, purified platelet P-selectin, or P-selectin expressed on histamine-activated human umbilical vein endothelial cells, but have normal levels of L-selectin and CD11b/CD18 integrin, and adhere to and migrate across endothelium when CD11b/CD18 is activated. We compare LAD I and LAD II patient neutrophil function in vitro, demonstrating that integrin and selectin adhesion molecules have distinct but interdependent roles in neutrophil adhesion during an inflammatory response.

A phase I trial of interleukin 3 (IL-3) pre-bone marrow harvest with granulocyte-macrophage colony-stimulating factor (GM-CSF) post-stem cell infusion in patients with solid tumors receiving high-dose combination chemotherapy

In humans, interleukin 3 (IL-3) administration increases the cellularity and cycling of bone marrow progenitor cell populations. Initially, in primates and then in humans, IL-3 in sequence with GM-CSF has been shown to stimulate multilineage hematopoiesis. Based upon these effects, we designed a phase I trial of daily IL-3 administered subcutaneously for 10 days at dose levels of 2.5, 5.0, 10.0, 12.5, and 15.0 micrograms/kg followed within 72 h by bone marrow harvest, high-dose chemotherapy, and following chemotherapy, a fixed dose (5.0 micrograms/kg/day) of GM-CSF and bone marrow rescue. The study was designed to assess the toxicity and biological effects of IL-3 administered alone prior to bone marrow harvest and to determine the safety and clinical effects of IL-3 stimulated bone marrow with GM-CSF following high-dose combination chemotherapy. A total of 19 patients with chemotherapy-sensitive non-hematologic malignancies (13 breast, five ovarian, and one testicular cancer) were enrolled. IL-3 up to 15.0 micrograms/kg/day could be administered without dose-limiting toxicities. Flu-like symptoms and headaches were common and poorly tolerated at the highest IL-3 dose. Significant increases in neutrophil counts (P = 0.018) were observed following IL-3. Overall, IL-3 administration was associated with a modest, but significant increase in CFU-GM within the bone marrow (P = 0.034). IL-3 administration had no consistent effect on CD34+ cell number within bone marrow. For the entire group, engraftment of neutrophils to greater than 0.5 x 10(9)/l occurred at a median of 21 days (range of 13-63 days) and platelet independence occurred at a median of 17 days (range 11-120 days). When IL-3 dose levels were analyzed separately, engraftment of neutrophils and platelets, blood product (platelets and packed RBCs) utilization, and discharge date were not superior in those treated with the higher dose (15.0 micrograms/kg) of IL-3. While higher doses of IL-3 were associated with more toxicity, they did not appear to enhance the stem cell pool or speed engraftment later. The effects of pre-bone marrow harvest IL-3 are modest and likely not as impressive as other approaches aimed at enhancing hematologic recovery following high-dose chemotherapy.