Submersion Injuries and the Cost of Injury Associated with Drowning Events in the United States, 2006-2015

INTRODUCTION

The World Health Organization has reported submersion injuries as the third most common cause of death due to unintentional injury in the world. Greater detail in the rates, risk factors, and healthcare associated costs of submersion injuries could be instrumental in demonstrating the need for further funding and intervention.

METHODS

The study was a cross-sectional analysis of a nationally representative dataset of inpatient and emergency department (ED) encounters between 2006 and 2015 in the United States (US). Healthcare utilization costs were provided within the datasets and adjusted to reflect actual charges and provider fees. Lastly, the final cost values were adjusted to the 2020 US dollar (USD) and summarized using a log adjusted mean.

RESULTS

On average, there were 11,873 submersion injuries per year that presented to the ED in the US. Resulting in a rate where approximately 9 out of every 100,000 ED visits were associated with a submersion injury. Slightly more than 6% died in the ED, 24.2% were admitted, and 69.3% were discharged from the ED. In total, annual cost of submersion injuries in the US for ED care is approximately $12.5 million, inpatient care is approximately $27.5 million, and total annual healthcare cost exceeds $40 million.

DISCUSSION

While these results only represent a fraction of the total cost associated with submersion injuries, it remains substantial and unchanged over the 10-year study period. Certain demographic groups showed higher rates of injury and disease burden, thus bearing a greater amount of the cost.

COVID-19 severity scale for claims data research

OBJECTIVE

To create and validate a methodology to assign a severity level to an episode of COVID-19 for retrospective analysis in claims data.

DATA SOURCE

Secondary data obtained by license agreement from Optum provided claims records nationally for 19,761,754 persons, of which, 692,094 persons had COVID-19 in 2020.

STUDY DESIGN

The World Health Organization (WHO) COVID-19 Progression Scale was used as a model to identify endpoints as measures of episode severity within claims data. Endpoints used included symptoms, respiratory status, progression to levels of treatment and mortality.

DATA COLLECTION/EXTRACTION METHODS

The strategy for identification of cases relied upon the February 2020 guidance from the Centers for Disease Control and Prevention (CDC).

PRINCIPAL FINDINGS

A total of 709,846 persons (3.6%) met the criteria for one of the nine severity levels based on diagnosis codes with 692,094 having confirmatory diagnoses. The rates for each level varied considerably by age groups, with the older age groups reaching higher severity levels at a higher rate. Mean and median costs increased as severity level increased. Statistical validation of the severity scales revealed that the rates for each level varied considerably by age group, with the older ages reaching higher severity levels (p < 0.001). Other demographic factors such as race and ethnicity, geographic region, and comorbidity count had statistically significant associations with severity level of COVID-19.

CONCLUSION

A standardized severity scale for use with claims data will allow researchers to evaluate episodes so that analyses can be conducted on the processes of intervention, effectiveness, efficiencies, costs and outcomes related to COVID-19.

Incidence rate of psychiatric disorders in 2020: The pivotal role played by SARS-CoV-2 infection

Importance

The Coronavirus Disease (COVID-19) pandemic has significantly impacted mental health outcomes. While the frequency of anxiety and depressive symptoms has increased in the whole population, the relationship between COVID-19 and new psychiatric diagnoses remains unclear.

Objective

To compare the population incidence rate of emergence of de novo psychiatric disorders in 2020 compared to the previous years, and to compare the incidence rate of new psychiatric disorder diagnoses between people with vs without COVID-19.

Design, setting, and participants

This study utilized administrative claims data from the Clinformatics® Data Mart database, licensed from Optum®. The study is a cross-sectional analysis that compared the incidence rate of new psychiatric disorders in 2020 vs. 2018 and 2019 in the entire insured population database. Subsequently, the incidence of new psychiatric disorders in people with vs. without COVID-19 during 2020 was analyzed.

Exposure

The exposures included diagnosis and severity of COVID-19 infection.

Main outcomes measures

The dependent variables of interest were the incidence rates of new psychiatric disorders, specifically schizophrenia spectrum disorders, mood disorders, anxiety disorders, and obsessive-compulsive disorder.

Results

The population studied included 10,463,672 US adults (mean age 52.83, 52% female) who were unique people for the year of 2020. Incidence of newly diagnosed psychiatric disorders per 1,000 individuals in the 2020 whole population were 28.81 (CI: 28.71, 28.92) for anxiety disorders, 1.04 (CI: 1.02, 1.06) for schizophrenia disorders, 0.42 (CI: 0.41, 0.43) for OCD and 28.85 (CI: 28.75, 28.95) for mood disorders. These rates were not significantly higher than 2018 or 2019. When comparing incidence rates between COVID-19 vs. non-COVID-19 populations in 2020, the rates were significantly higher in the COVID-19 population: 46.89 (CI: 46.24, 47.53) for anxiety, 49.31 (CI: 48.66, 49.97) for mood disorders, 0.57 (CI: 0.50, 0.65) for OCD, and 3.52 (CI: 3.34, 3.70) for schizophrenia. COVID-19 severity was significantly associated with new diagnoses of schizophrenia, anxiety and mood disorders in multivariate analyses.

Conclusions

Compared to 2018 and 2019, in 2020 there was no increased incidence of new psychiatric disorders in the general population based on insurance claims data. Importantly, people with COVID-19 were more likely to be diagnosed with a new psychiatric disorder, most notably disorders with psychosis, indicating a potential association between COVID-19 and mental/brain health.

Phase II randomized trial of carboplatin, paclitaxel, bevacizumab with or without cixutumumab (IMC-A12) in patients with advanced non-squamous, non-small-cell lung cancer: a trial of the ECOG-ACRIN Cancer Research Group (E3508)

Background

Cixutumumab is a fully human IgG1 monoclonal antibody to the insulin-like growth factor type I receptor that can potentially reverse resistance and enhance the efficacy of chemotherapy.

Methods

Bevacizumab-eligible patients with stage IV or recurrent non-squamous, non-small-cell lung cancer and good performance status were randomized to receive standard doses of paclitaxel, carboplatin, and bevacizumab to a maximum of six cycles followed by bevacizumab maintenance (CPB) until progression (arm A) or CPB plus cixutumumab 6 mg/kg i.v. weekly (arm B).

Results

Of 175 patients randomized, 153 were eligible and treated (78 in arm A; 75 in arm B). The median progression-free survival was 5.8 months (95% CI 5.4-7.1) in arm A versus 7 months (95% CI 5.7-7.6) in arm B (P = 0.33); hazard ratio 0.92 (95% CI 0.65-1.31). Objective response was 46.2% versus 58.7% in arm A versus arm B (P = 0.15). The median overall survival was 16.2 months in arm A versus 16.1 months in arm B (P = 0.95). Grade 3/4 neutropenia and febrile neutropenia, thrombocytopenia, fatigue, and hyperglycemia were increased with cixutumumab.

Conclusions

The addition of cixutumumab to CPB increased toxicity without improving efficacy and is not recommended for further development in non-small-cell lung cancer. Both treatment groups had longer OS than historical controls which may be attributed to several factors, and emphasizes the value of a comparator arm in phase II trials.

ClinicalTrials.gov Identifier

NCT00955305.

Estimating the glomerular filtration rate using serum cystatin C levels in patients with spinal cord injuries

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To investigate the relationship between (51)chromium-ethylene-diamine-tetra-acetate ((51)Cr-EDTA) clearance, serum cystatin C (CysC), serum creatinine, creatinine clearance and estimated glomerular filtration rate (eGFR(MDRD), MDRD stands for modification of diet in renal disease) based on the serum creatinine in patients with complete or incomplete spinal cord injury (SCI) and to develop and evaluate a GFR-estimating equation using serum CysC.

SETTINGS

Spinal Cord Injury Unit, Viborg Regional Hospital, Viborg, Denmark.

METHODS

Ninety-eight men and 47 women with SCI were included in the study. Serum CysC levels were measured by an automated particle-enhanced nephelometric immunoassay, serum and urine creatinine levels were measured by an enzymatic method traceable to the IDMS creatinine reference method, and (51)Cr-EDTA clearance was measured by a multiple plasma sample method.

RESULTS

The area under the curves (AUCs) in the non-parametric receiver operating characteristics (ROC) plots for serum CysC were compared with serum creatinine and to eGFR(MDRD) and revealed a significant difference (P-value < 0.05) for all SCI patients. There was no significant difference between the AUC for serum CysC compared with the AUC for creatinine clearance. GFR (ml min(-1) per 1.73 m(2)) can be calculated from serum CysC values (mg l(-1)) using the equation eGFR(CysC) = 212·exp(0.914·CysC). The model accurately predicted the GFR of 88% of patients within ± 30% of the measured GFR, and it was able to predict the GFR of 50% of patients within ± 10% of the measured GFR.

CONCLUSION

In patients with SCI, GFR can be estimated independent of age, sex and muscle mass by a newly developed equation based on a single serum CysC value.

Cycloplegic refractions in healthy children aged 1 through 48 months

OBJECTIVES

To provide a description of refractive errors in healthy, term-born children, aged 1 through 48 months, and to test the hypotheses that spherical equivalent becomes significantly less hyperopic and less variable with increasing age.

METHODS

Following a prospective, cross-sectional design, cycloplegic retinoscopy was used to measure the refractive error in both eyes of 514 healthy, term-born children in 12 age groups. Three hundred were aged 12 months or younger. Spherical equivalent and cylindrical power and axis were analyzed as a function of age. Prediction limits for spherical equivalent were calculated.

RESULTS

Spherical equivalents of right and left eyes did not differ at any age. Hyperopia declined significantly with increasing age. The variability in spherical equivalent also decreased significantly with age. Cylindrical error of 1 diopter or more was found in 25% of the children; the proportion with astigmatism was highest in infancy and then waned. Myopia and anisometropia were rare, occurring in 3% and 1% of the sample, respectively.

CONCLUSIONS

Significant declines in hyperopia and variability of spherical equivalent appear to be features of emmetropization. The normal prediction limits provide guidelines against which data from individual patients can be compared.

The rod photoreceptors in retinopathy of prematurity: an electroretinographic study

OBJECTIVE

To test the hypothesis that the more severe the acute phase retinopathy of prematurity (ROP) was in the preterm weeks, the more severely compromised is rod photoreceptor function after the ROP has resolved.

METHODS

Electroretinographic (ERG) responses were recorded from 25 dark-adapted children (ages 2.5 months' postterm to 14 years) categorized by maximum, acute phase ROP (None to Very Severe). From the ERG a-wave "S," a sensitivity parameter for the rod photoreceptor response, and R(mp3), the saturated amplitude of the rod photoreceptor response were calculated using a model of the activation of rod phototransduction. The patients' results were compared with those of healthy controls (n = 71).

RESULTS

Among those in the None, Mild, Moderate, and Severe categories, both S and R(mp3) varied significantly with severity of acute phase ROP. In the Very Severe category, ERG responses were too attenuated to calculate S and R(mp3).

CONCLUSIONS

The rod photoreceptors must be involved in ROP. The more severe the acute phase ROP, the more severe is the compromise of the processes involved in the activation of phototransduction in the rods.

Rod-mediated increment threshold functions in infants

PURPOSE

To obtain and analyze scotopic increment threshold functions to test the hypothesis that rod photoreceptor immaturity accounts for the elevation of infants' over controls' dark-adapted thresholds and elevation of parafoveal over peripheral thresholds in infants.

METHODS

Using a preferential looking method, thresholds for detection of 2(o), 50 msec, blue stimuli presented 10(o) (parafoveal) or 30(o) (peripheral) eccentric were measured in the dark and in the presence of steady red backgrounds. Ten 10-week-old infants and four control subjects (8-35 years) were tested. To evaluate pre- and postadaptation site determinants of threshold, a model of the increment threshold function was fit to the data, and the dark-adapted threshold (T(D)) and eigengrau (A(O)) were calculated. The values of T(D) and A(O) were compared between infants and controls and between parafoveal and peripheral eccentricities.

RESULTS

At both parafoveal and peripheral eccentricities, infants' values of T(D) and A(O) were significantly higher than those of controls. The locus of the coordinates (A(O), T(D)) differed significantly between parafoveal and peripheral eccentricities. In every infant, the parafoveal value of T(D) was higher (by 0.3-0.6 log unit) and A(O) lower (by 0.2-0.5 log unit) than the peripheral value, whereas controls had no difference in T(D) and A(O) at the two eccentricities.

CONCLUSIONS

The results indicate that both receptoral and postreceptoral immaturities have a role in the elevation of infants' over controls' thresholds. In infants, rod photoreceptor immaturity before the site of adaptation accounts for elevation of parafoveal over peripheral thresholds.

Rod and rod mediated function in patients with beta-thalassemia major

An electroretinographic (ERG) study was undertaken to test the hypothesis that scotopic retinal function is altered in transfused thalassemics on chronic Deferoxamine (DFO). ERG a- and b-wave responses and dark adapted visual thresholds were obtained from 11 patients with beta-thalassemia major, ages 7 to 38 (median 17) years. A quantitative model of the activation of phototransduction was fitted to the a-waves to estimate the gain of the transduction processes and the saturated amplitude of the rod photoresponse. From b-wave stimulus/response functions. the saturated b-wave amplitude and an index of b-wave sensitivity (log sigma ) were calculated. The patients' data were compared to those of normal subjects. The relations of the ERG parameters to age. average ferritin level, and duration of transfusion without DFO as well as other clinical parameters were examined. Longitudinal measures of b-wave responses and dark adapted visual thresholds. available for nine of the patients, were examined for significant change over time. For all patients both the gain and saturated amplitude of the rod response are normal. In two patients log sigma is below the 99% prediction interval for normal. One has low scotopic visual sensitivity. The duration of transfusion therapy unprotected by DFO chelation therapy was correlated with log a. These results suggest iron accumulation rather than DFO toxicity underlies scotopic dysfunction in older thalassemics. some of whom may have had extended periods of transfusion without the protection of chelation. Thus, monitoring of retinal function is recommended in such patients.

The development of scotopic sensitivity

PURPOSE. Test the hypothesis that the developmental increases in rod photoreceptor sensitivity and rod-mediated visual sensitivity at 10 degrees, 20 degrees , and 30 degrees eccentric are concurrent. It is known that maturation of the parafoveal (10 degrees eccentric) rod outer segments and visual sensitivity is delayed compared to that at 30 degrees eccentric.

METHODS

Rod isolated electroretinographic (ERG) responses to full-field stimuli were obtained from dark-adapted subjects (n = 71), ranging in age from early infancy through middle age. Rod photoreceptor sensitivity was calculated by fitting a model of the activation of phototransduction to the a-wave response. Rod driven b-wave sensitivity was calculated from stimulus-response functions. A logistic growth model was used to summarize the developmental increases in sensitivity of the rod photoreceptors and the b-wave. Previously reported dark-adapted, rod-mediated visual sensitivities at 10 degrees , 20 degrees, and 30 degrees eccentric, obtained using preferential looking procedures, were reanalyzed using the logistic growth model.

RESULTS

The logistic growth model accounted for 57% to 85% of the variance of each sensitivity parameter with age in normal subjects. The shape of the growth curve and the age at which sensitivity reaches 50% of the adult value is similar (10.0-13.5 weeks) for the rods, the b-wave, and peripheral visual sensitivity, but is significantly older, 19.5 weeks, for rod-mediated parafoveal visual sensitivity.

CONCLUSIONS

Rod photoreceptor sensitivity and peripheral, rod-mediated visual sensitivity develop concurrently. A parsimonious explanation is that rod photoreceptor sensitivity determines dark-adapted, rod-mediated visual sensitivity during development.

Background adaptation in children with a history of mild retinopathy of prematurity

PURPOSE

In children with a history of mild retinopathy of prematurity (ROP), test the hypothesis that elevation of the parafoveal over peripheral dark-adapted threshold is due to photoreceptor rather than postreceptor dysfunction.

METHODS

A forced choice procedure was used to measure thresholds, for detection of 2 degrees diameter, 50 msec, blue stimuli presented 10 degrees (parafoveal) or 30 degrees (peripheral) eccentric in the dark and in the presence of steady red backgrounds (-4 to +2 log scot td). Four ROP and four control subjects were tested at both eccentricities. A model of the increment threshold function was fit to the data to calculate the eigengrau and dark-adapted threshold.

RESULTS

Both ROP subjects with elevated parafoveal thresholds also have elevated parafoveal eigengraus. On the other hand, parafoveal and peripheral eigengraus are equal in ROP subjects without parafoveal threshold elevation. Nevertheless, the dark-adapted thresholds of all ROP subjects are higher than those of any control subject at both sites.

CONCLUSIONS

The parafoveal threshold elevation is due to rod dysfunction. There is also evidence of peripheral rod photoreceptor involvement in the subjects with ROP.

The course of maturation of rod-mediated visual thresholds in infants

PURPOSE

To measure the developmental course of infants' rod-mediated thresholds.

METHODS

Thresholds for detecting stimuli (2 degrees diameter, 50 msec duration) presented at 10 degrees (parafoveal site) or 30 degrees (peripheral site) from a central fixation target were estimated using a preferential-looking method. Nine infants were tested at both stimulus positions at ages 10, 18, and 26 weeks.

RESULTS

At 10 weeks, infants' thresholds at both sites were significantly higher than those of adults. The infants' average threshold at 10 degrees was 0.5 log unit higher than the infants' average threshold at 30 degrees. Adults' thresholds at the two sites were equal. Thresholds of all infants decreased with age until by age 26 weeks the parafoveal and peripheral thresholds were equal and were the same as those of adults. The rate of change of parafoveal thresholds was significantly faster than the rate of change of peripheral thresholds.

CONCLUSIONS

Although postreceptoral factors cannot be ruled out, the results suggest that developmental increases in rod outer segment length and rhodopsin density account for most of the threshold changes during infancy.

The rhodopsin content of human eyes

PURPOSE

To measure the total amount of rhodopsin in human eyes across the life span and to test the hypothesis that the rhodopsin content of infants' and the elderly's eyes is lower than at other ages.

METHODS

Rhodopsin was extracted from retinal and pigment epithelial fractions of 196 eyes of 102 donors, ages 27 weeks' gestation through 94 years, using quantitative procedures. To recover photopigment bleached by unavoidable light exposure, the fractions from 78 eyes were incubated with 9-cis retinal. The total photopigment (retinal plus pigment epithelial fractions) per eye was examined for significant changes with age, using the higher value from pairs of eyes.

RESULTS

The median rhodopsin content of the higher eye of adults is 6.45 nmoles (range, 3.33-10.84 nmoles) with 8 nmoles or more recovered from 28% of all adult eyes. The rhodopsin content of infants' eyes (< 12 months post-term) is significantly lower than that of older individuals and increases with age. After infancy, no change with age is found. For both infants and adults, 9-cis retinal significantly increases the amount of photopigment recovered without reducing the variance in the amount of photopigment recovered. The rhodopsin content is estimated to be 50% of the median adult amount early in infancy, approximately 5 weeks postterm (95% confidence interval, 0-10 weeks postterm).

CONCLUSIONS

A developmental increase in rhodopsin content occurs during infancy. Thereafter rhodopsin content remains constant. The amount of rhodopsin recovered from human eyes is quite variable. Bleaching alone cannot explain the variability.

Rod photoreceptor maturation does not vary with retinal eccentricity in mammalian retina

PURPOSE

Test the hypothesis that the development of mammalian rod outer segments (ROS) varies with retinal eccentricity.

METHODS

During the period of photoreceptor cell development, ROS lengths, opsin mRNA and (rhod)opsin were measured in central and peripheral retina of cows and pigmented rats. Published ROS length and/or rhodopsin data from albino rats, cows and monkeys were re-analyzed. Logistic growth curves were fitted to the newly obtained and published data. Within a species, growth in central and peripheral regions was compared.

RESULTS

The logistic growth curves fit all the data well and provide an excellent view of the developmental increases in ROS length, opsin mRNA and (rhod)opsin in each retinal region. Within a species, the growth curves for ROS length, opsin mRNA and (rhod)opsin concentration are superimposable. The age at which ROS length reaches 50% of its adult value is invariant with eccentricity. An exception to this pattern is the simian parafoveal ROS, which appears to have a delayed course of development.

CONCLUSIONS

The hypothesis is disproved. Unlike rod photoreceptor cell genesis, ROS development is invariant with retinal eccentricity. Primate parafoveal ROS appear to have a different pattern of development.

Rod photoreceptors in infant rats with a history of oxygen exposure

PURPOSE

To study in an infant rat model of retinopathy of prematurity, the rod photoreceptors, which are known to have attenuated photoresponses.

METHODS

Rhodopsin was extracted from whole retinas, the thickness of the rod outer segment (ROS) layer was measured, large phagosomes were counted, and the ROS ultrastructure was examined in the retinas of oxygen-exposed and control rats, ages 13 and 18 days. Rhodopsin absorbances in the ROS were measured by microspectrophotometry at age 20 days.

RESULTS

The rhodopsin content did not differ significantly between the oxygen-exposed and control rats at either 13 or 18 days. The thickness of the ROS layer was equal in 13-day-old oxygen-exposed and control rats; however, at 18 days, the ROS layer was significantly thinner in the oxygen-exposed rats than in the control rats. The number of phagosomes did not vary significantly among the oxygen-exposed and control groups. Opsin immunoreactivity was seen only in the ROS layer in oxygen-exposed and control rats. The ROS were disorganized in oxygen-exposed rats. The rhodopsin absorbances of the oxygen-exposed ROS were significantly more variable and higher than in the control rats.

CONCLUSIONS

Attenuation of the rod photoresponse parameters does not result simply from shortening of the outer segments and consequent low rhodopsin content. Rather, the structure of the outer segments is altered. A fault in the synthesis of the outer segments, rather than disposal of outer segment discs, is suspected.

Dark-adapted thresholds in children with histories of mild retinopathy of prematurity

PURPOSE

To test the hypothesis that rod-mediated visual thresholds at 10 degrees eccentricity are elevated in children with histories of mild retinopathy of prematurity (ROP).

METHODS

Dark-adapted thresholds for detection of 50 msec, 2 degrees diameter spots at a 10 degrees eccentric site, and at a peripheral reference site, 30 degrees eccentric, were measured in 20 children with a history of mild ROP and known courses of refractive development. Ten myopic control subjects also were tested. The thresholds of the ROP and control subjects were compared.

RESULTS

Six of the subjects with ROP had elevated thresholds at the 10 degrees site. High myopia had been present since age 18 months or younger in each of the six. The thresholds of all other subjects with ROP, whose courses of refractive development had been toward emmetropia, and the control subjects with myopia were normal. In subjects with ROP, the association of early, persistent high myopia and an elevated threshold at 10 degrees was significant (chi 2 = 20; P < 0.01). Among the subjects with ROP, refractive error and axial length were correlated.

CONCLUSIONS

ROP or factors causing ROP appear to alter rod-mediated retinal function. The association of abnormal rod-mediated sensitivity and refractive development suggests that rod-mediated retinal function is involved in the regulation of eye growth in children with a history of mild ROP.

Rhodopsin in immature rod outer segments

PURPOSE

To test the hypothesis that rhodopsin concentration is low in immature rat rod outer segments (ROS).

METHODS

Microspectrophotometry (MSP) was used to assess rhodopsin absorbances in localized regions of isolated ROS from dark-adapted 13-, 19-, and 34-day-old and adult rats. Photopigment was extracted from the retinas of paired eyes in dark-adapted and light-adapted rats. One retina of each pair was treated with 9-cis retinal before extraction of photopigment. Rhodopsin with native 11-cis retinal was extracted from the fellow retina.

RESULTS

By MSP, rhodopsin absorbance was low in the short ROS of 13-day-old rats. In 19-day-old rats with ROS lengths approximately equal to those of adults, absorbance was low at the tip, but at the base, it was equal to the high absorbance at both the tip and the base in adults. The 9-cis retinal did not add absorbance to the photopigment extracts of dark-adapted retinas at any age, but it did add absorbance to extracts of the light-adapted retinas at every age.

CONCLUSIONS

The MSP results show that the accumulation of rhodopsin in developing rat rods depends on increasing concentrations in localized regions. No evidence of apo-opsin is found in immature rat rods. Thus, in immature ROS regions, the low rhodopsin absorbances suggest that the amount of opsin is also low. Greater disk-to-disk spacing in immature ROS regions than in mature regions could account for these findings.

Vision in Leber congenital amaurosis

OBJECTIVE

To determine if vision changed with age in infants and children with Leber congenital amaurosis.

PATIENTS

Grating acuity and dark-adapted visual thresholds were tested in 36 patients with Leber congenital amaurosis. Longitudinal assessments were obtained for 24 patients and analyzed for significant changes over time. Visual acuity and threshold and the courses of visual acuity and threshold were examined for significant associations with hyperopia, fundus appearance, and complicated vs uncomplicated status.

RESULTS

Measurable grating acuities ranged from 0.16 to 6 cycles per degree (median, 1.27 cycles per degree or about 20/500), and dark-adapted visual thresholds were elevated 1.0 to 5.6 log units (median, 2.33 log units). Eighteen patients never had demonstrable grating acuity, and 12 had no light perception. Among those with serial tests, visual acuity improved or remained stable in 10 patients and declined in 4. Dark-adapted visual thresholds were stable in those with improving or stable visual acuities but worsened in 5 patients, including the 4 whose visual acuity worsened. No significant associations of visual acuity, dark-adapted visual threshold, the course of visual acuity, or the course of dark-adapted visual threshold with hyperopia, fundus appearance, or complicated vs uncomplicated status were found.

CONCLUSIONS

Visual capabilities varied widely. Vision was stable in the majority by longitudinal measures but increased in a few and deteriorated in others. Neither ocular characteristics nor complicated vs uncomplicated status predicted visual function. Thus, if vision and its course are to be known in a patient with Leber congenital amaurosis, it must be tested.

Phase III study of bolus versus infusion fluorouracil with or without cisplatin in advanced colorectal cancer

BACKGROUND

Phase II studies of fluorouracil (5-FU) administered by protracted intravenous infusion have suggested an improved response rate and decreased toxicity profile when compared with 5-FU given by bolus injection in patients with metastatic colorectal cancer. Additional studies have suggested further enhancement of infusion 5-FU activity when it is combined with low-dose weekly cisplatin administration.

PURPOSE

This phase III study in adults with metastatic colorectal cancer was planned as a comparison of objective response rates, toxicity, and survival in patients receiving bolus versus protracted-infusion 5-FU with or without cisplatin.

METHODS

Four hundred ninety-seven previously untreated patients with advanced, measurable metastatic colorectal cancer were randomly assigned to receive treatment A (bolus 5-FU at 500 mg/m2 for 5 days followed in 2 weeks by weekly bolus 5-FU at 600 mg/m2), treatment B (bolus 5-FU at 500 mg/m2 for 5 days followed in 2 weeks by weekly bolus 5-FU at 600 mg/m2, plus weekly cisplatin at 20 mg/m2), treatment C (5-FU at 300 mg/m2 per day by continuous infusion), or treatment D (5-FU at 300 mg/m2 per day by continuous infusion plus weekly cisplatin at 20 mg/m2). All drugs were administered intravenously. Enrollment in the trial occurred from August 1987 through December 1990, and follow-up was through September 1995. The Kaplan-Meier method was used to estimate overall and disease-free survival, and Cox regression models were used to assess the effects of patient characteristics on survival. All P values resulted from two-sided tests.

RESULTS

Objective tumor response was observed in 28 (18%) of 153 patients receiving treatment A, in 45 (28%) of 159 patients receiving treatment C (C versus A; P = .045), and in 47 (31%) of 153 patients receiving treatment D (D versus A; P = .016). Because of excessive toxicity, treatment B was discontinued after only 12 patients had begun treatment. Median time to disease progression was 5.1 months for patients in arm A compared with 6.2 and 6.5 months for patients in arms C and D, respectively (C versus A, P = .007; D versus A, P = .017). Patterns of toxic effects differed substantially among the treatment arms. Forty-five percent of the patients receiving bolus 5-FU alone (A) experienced grade 3-4 leukopenia, with two sepsis-related deaths. Hand-foot syndrome and mucositis were the major treatment-limiting toxic effects for patients in the two treatment arms involving infusion. Despite the improvement in response rates and time to disease progression with infusion 5-FU with or without cisplatin (C and D, respectively) (P = .003), the overall survival for the three groups (A, C, and D) was similar (P = .307). This may have been due in part to a longer median survival time of 10.4 months for patients in arm A, compared with an anticipated survival of 7 months.

CONCLUSION

5-FU given as a continuous infusion produced a higher objective response rate, a modest prolongation in time to disease progression, and less life-threatening myelosuppression in patients than bolus 5-FU. Concomitant treatment with low-dose cisplatin caused added toxicity and complexity of treatment and did not provide a major clinical benefit. No statistically significant survival differences were observed among the three treatment groups.

Photoreceptor function in infants and children with a history of mild retinopathy of prematurity

Five infants and children with a history of mild retinopathy of prematurity (ROP) were tested for postulated alterations in rod photoreceptor function. The photoreceptor responses were derived from the electroretinographic alpha waves. Postreceptoral components, the beta wave and the oscillatory potentials, were also examined. The saturated amplitude and sensitivity of the rod photoreceptor responses were low, except for the sensitivity in one patient. The beta-wave sensitivity was low, but saturated amplitudes were within the 95% prediction interval for normal. The amplitudes of the oscillatory-potential responses were also attenuated. The results indicate that retinal dysfunction may be present in patients with a history of mild ROP long after the ROP has completely resolved. Additionally, the data suggest that the photoreceptors are the primary site of retinal dysfunction in mild ROP.

Effect of prior oxygen exposure on the electroretinographic responses of infant rats

PURPOSE

To study electroretinographic responses of infant rats with a history of exposure to high-ambient oxygen.

METHODS

Electroretinographic responses to a range of full-field stimuli were recorded from 13-day-old (n = 8) and 18-day-old (n = 10) rats with a history of intermittent exposure to 80% oxygen and age-matched controls. The a-waves were fitted with a model of rod cell sensitivity and saturated response amplitude. The amplitudes and implicit times of the b-wave and oscillatory wavelets were examined as a function of stimulus energy. Response parameters in oxygen-exposed rats were compared to those in controls.

RESULTS

The amplitude of the saturated rod response was reduced in oxygen-exposed 13-day-old but not 18-day-old rats. The sensitivity of the rod response was reduced in both 13- and 18-day-old oxygen-exposed rats. The saturated amplitude and sensitivity of the b-wave did not differ significantly between oxygen-exposed and control rats age 13 days, but both amplitude and sensitivity were significantly decreased in 18-day-old oxygen-exposed rats. Oscillatory potentials, which could be investigated only in 18-day-old rats, showed significant attenuation of OP3 but not OP4 amplitudes in the oxygen-exposed rats. The sensitivity of OP2 did not differ significantly between oxygen-exposed and control rats. The avascular area in the oxygen-exposed rats was not correlated with any of the rod cell, b-wave, or oscillatory potential response parameters.

CONCLUSION

The function of the rod photoreceptors, as well as the inner retina, is altered in infant rats with a history of oxygen exposure.

Electroretinogram responses and refractive errors in patients with a history of retinopathy prematurity

Ametropias, particularly myopia, and mild retinal dysfunction are found in eyes with a history of retinopathy of prematurity. The retina is an important controller of refractive development. The aims of this study were to find out whether altered measures of retinal function and ametropias are associated and to consider mechanisms by which the retina might control refractive development. Nine infants and children with a history of stage 1, 2 or 3 retinopathy of prematurity and known courses of refractive development were studied. Spherical equivalents at the time of the electroretinogram ranged from +5.50 to -9.00 diopters. Rod photoresponse characteristics were derived from the a-wave, and postreceptoral components were also analyzed with calculation of the sensitivity and saturated amplitude of the b-wave, the sensitivity of oscillatory wavelet OP2, and average amplitudes of OP3 and OP4. In hyperopic and myopic patients alike, the saturated amplitude and gain of the rod cell response were attenuated. In all patients, b-wave sensitivity was low, but in most there was little effect on saturated b-wave amplitude. In patients with courses toward myopia, the amplitude of OP4, an 'OFF' signal, is relatively more attenuated than that of OP3, an 'ON' signal. OP4 is relatively larger in patients with courses toward hyperopia. The OP results suggest that an imbalance of 'ON' and 'OFF' activity in the retina is associated with development of ametropias in retinopathy of prematurity.

The development of the rod photoresponse from dark-adapted rats

PURPOSE

To study electroretinographic a- and b-wave responses of rats at the ages during which rod outer segment length (ROS) and rhodopsin content increase.

METHODS

Electroretinographic responses to brief, full-field stimuli were recorded from dark-adapted young (ages 12 to 30 days) and adult rats. The amplitude of the a-wave and the amplitude and implicit time of the b-wave were examined as a function of stimulus intensity. Sensitivity (S), saturated amplitude (RmP3), and delay (td) of the rod cell responses were calculated from the a-waves.

RESULTS

The developmental increase in saturated a-wave amplitude parallels, but lags behind, growth of outer segment length, whereas the saturated b-wave amplitude increases with about the same course as rhodopsin content of the retina. The sensitivity, S, depends on rhodopsin content, and the developmental decrease in the flash energy required to produce a half-maximum b-wave amplitude is inversely proportional to the developmental increase in rhodopsin content. No significant age-dependent variation in td can be detected.

CONCLUSION

During development, ROS length and rhodopsin content of the retina are significant determinants of a- and b-wave response parameters.

Dark-adapted thresholds at 10- and 30-deg eccentricities in 10-week-old infants

We tested the hypothesis that the dark-adapted sensitivity of the near central retina is lower than that of peripheral retina in 10-week-old infants. A spatial two alternative forced-choice psychophysical method was used to estimate the threshold for 2-deg spots presented 10 deg and 30 deg from the center of a screen. Each 10-week-old infant (n = 11) and adult (n = 5) subject was tested at both eccentricities. Every infant's threshold at 10 deg is higher than that at 30 deg. The median difference between the infants' thresholds at 10 deg and 30 deg is about 0.5 log unit. Whereas the scotopic thresholds of adults at 10 deg and 30 deg are virtually identical, the thresholds of infants' near central retina are higher than those in more peripheral retina. Delayed maturation of the near central rod outer segments with consequent lower quantum catch may be the primary determinant of this infantile sensitivity pattern.

The course of myopia in children with mild retinopathy of prematurity

The courses of spherical equivalent in patients (n = 62) who had mild, non-cicatricial retinopathy of prematurity (ROP), and in those without a history of ROP (n = 25) were modeled as a linear function of age; an exponential model was also considered. A few (n = 5) without ROP have abnormal courses characterized by hyperopia in early infancy; none have poor acuity. Although the majority of patients with ROP have courses indistinguishable from those of term born controls, 27 (43.5%) have abnormal courses, most of which are toward myopia. Optotype acuities were significantly poorer among the ROP patients with abnormal than normal refractive courses. Thus abnormal refractive development and acuity deficits are associated in eyes that have had mild ROP.

The effects of acetazolamide on the electroretinographic responses in rats

PURPOSE

To study the mechanisms and sites of action of the carbonic anhydrase inhibitor, acetazolamide (AZM), on the rod- and cone-mediated electroretinogram (ERG) of the dark-adapted rat.

METHODS

After a within-subjects design, ERG responses to brief, full-field flashes were recorded from adult (60 to 90 days old) albino rats, with and without AZM (5 mg/100 g, intraperitoneally). Flickering stimuli (6 and 26 Hz) were used to study rod- and cone-mediated responses. Aspartate-isolated responses of the isolated retina were recorded with and without AZM in the superfusate. The a-wave and PIII responses were fitted with a model of the rod's response by estimating the maximum response (Rmp3), sensitivity (S), and delay td. The b-wave response amplitude and implicit time were examined as a function of stimulus energy. The parameters obtained in the AZM-treated and untreated conditions were compared.

RESULTS

Acetazolamide causes a significant decrease in saturated rod response, b-wave amplitude, aspartate-isolated PIII, and the rod- and cone-mediated responses to flickering light. The estimated sensitivity of the rod response (S), b-wave sensitivity, and b-wave implicit time are not altered significantly by AZM.

CONCLUSION

Acetazolamide, probably through mechanisms that acidify the retina, attenuates the amplitudes of the retinal responses without significant effect on sensitivity.

The VEP thresholds for full-field stimuli in dark-adapted infants

Dark-adapted adults' electroretinographic b-wave thresholds are approximately 2 log units below a-wave thresholds and approximately 3 log units above the perceptual threshold, and their perceptual and the visually evoked cortical potential (VEP) thresholds are similar. Dark-adapted infants' scotopic a- and b-wave thresholds for full-field stimuli are both about 0.5 log units above those of adults, but their scotopic VEP thresholds for such stimuli have not been studied. We obtained scotopic VEP thresholds for brief, full-field stimuli from dark-adapted, infants and adults to consider the relationships of the cortical responses to the responses of more distal structures, namely the rod photoreceptors (scotopic a-wave) and ON-bipolars (scotopic b-wave). The median VEP threshold of infants is 0.5 log unit above that of adults. Thus, the relationships of a- and b-wave and VEP thresholds in infants are similar to those in adults. These results are consistent with rod cell immaturities being the primary determinant of the difference between infants' and adults' thresholds.

Scotopic center surround organization in 10-week-old infants

The large critical areas for complete spatial summation in infants may be due to immaturities of receptive field organization in both dark and light adapted scotopic conditions. Scotopic lateral excitatory/inhibitory interactions have been previously studied in adults using Westheimer's [(1965) Journal of Physiology, London, 181, 881-894] paradigm. We modified this paradigm to investigate scotopic receptive field organization in infants. Detection thresholds for probe flashes of constant diameter and duration presented on steady backgrounds of various diameters were determined for 10-week-old infants and adults. Infants' thresholds increased up to background diameters of 3 degrees to 3.5 degrees and then decreased at greater background diameters. Adults' thresholds increased for backgrounds up to about 0.75 degrees diameter and then decreased at greater background diameters. These results suggest that the excitatory, central receptive field size is larger in infants than adults, and that a balanced center-surround mechanism is operative.

Scotopic optokinetic nystagmus thresholds in 10-week-old infants

PURPOSE

To compare psychophysical and reflexive optokinetic nystagmus (OKN) estimates of dark-adapted scotopic thresholds mediated by the posterior retina in 10-week-old infants and adults.

METHODS

A staircase procedure was used to determine the stimulus intensity needed to produce an OKN response to a moving 19 degrees x 19 degrees grating. In the same subjects, a two-alternative, forced-choice procedure was used to obtain thresholds for detecting 10 degrees diameter, 50 ms duration stimuli.

RESULTS

Both OKN and psychophysical thresholds of infants are 0.9 log unit higher than those of adults.

CONCLUSION

The infant-adult difference in thresholds mediated by retina at the posterior pole is greater than the infant-adult difference in thresholds for full-field stimuli. It is possible that delayed maturation of the posterior retina is the primary determinant of infants' high OKN and psychophysical thresholds.

Natural course of visual functions in the Bardet-Biedl syndrome

OBJECTIVE

To determine the course of visual functions in patients with Bardet-Biedl syndrome.

PATIENTS AND METHODS

The 21 patients with Bardet-Biedl syndrome seen at Children's Hospital, Boston, Mass, had optotype and grating acuities and dark-adapted thresholds measured over time. Their ages at first visit ranged from 2 weeks to 23 years (median age, 6 years). The courses of the visual functions were analyzed with a random-effects model.

RESULTS

Substantial declines in visual functions were found. On average, grating and optotype acuities declined 0.09 log units (roughly 1 line) per year, and thresholds increased about 0.19 log units per year. The rates at which these visual functions were lost and the predicted level of the visual functions at ages 11 to 12 years (the mean ages of measurement) varied among individuals.

CONCLUSIONS

The visual prognosis for children with Bardet-Biedl syndrome is poor. The course of both central and peripheral visual functions is variable.

[Ambulatory labor--experience from the first 2 years]

A trial arrangement for mandatory early discharge for all normal multiparae in 1990 and 1991 was evaluated. 63.4 percent of 1661 multiparous women were discharged within 24 hours of giving birth. During the period the mean time to discharge rose from 6 1/2 to 10 1/2 hours. Only 2.6 per cent of the children were readmitted to hospital, as were 1.2 percent of the mothers. The purpose of the trial was to save money, but in the trial period no money was saved from the early discharged women, the savings came from deductions in the perinatal service to the non-early discharged women.

[Long-term prognosis for women with chronic pelvic pain without laparoscopically demonstrable cause]

With the object of assessing the long-term prognosis and the frequencies of recurrence and remission in women chronic low abdominal pain without laparoscopically visible cause, questionnaire were sent in 1985 and 1991 to 55 women who had been submitted to laparoscopy in 1982-1984 for this reason. These women had been told that there was no demonstrable explanation of the pain experienced and were then discharged. 65% and 55% respectively had experienced and unfavourable course with considerable and continued symptoms. Only 22% stated in both investigations that they had experienced a favourable course and that they were, by and large, free from pain. 36% changed from an unfavourable to a favourable course or the reverse. The assessment made by the women was confirmed by a series of subordinate questions and this demonstrated a marked difference between the favourable and unfavourable courses of the condition. It is concluded that laparoscopy with exclusion of significant pathology is not, in itself, satisfactory as treatment of this patient group and that no improvement occurs in the course of time. The condition varies greatly with many recurrences and remissions and, for this reason, uncontrolled reports of the therapeutic effects are of no significance. When compared with the literature, it is suggested that this patient group should be referred early in the course of the condition to a therapist with specialist psychological/sexological insight and/or to a physiotherapist with interest in this patient group.

A phase I trial of protracted 5-fluorouracil infusion and oral calcium leucovorin

This phase I study of 36 patients was performed to identify the maximal tolerated dose of oral calcium leucovorin (CLV) that could be concomitantly administered with protracted 5-fluorouracil (5-FU) infusion (greater than 30 days). Administration of CLV in very small doses (5 mg p.o. q8h) with 5-FU, 200-300 mg/m2/day, resulted in excessive toxicity requiring treatment interruption in all patients. Subsequent reduction in the dose of 5-FU to 100 mg/m2/day with simultaneous administration of CLV, 5 mg p.o. q8h, decreased the toxicity and allowed for protracted administration of the combination. In subsequent patients the dose of oral CLV was increased to 22.5 mg p.o. q8h, which resulted in treatment-limiting toxicity in the majority of patients. Toxicity consisted almost exclusively of mucositis. No myelosuppression or significant organ toxicity was observed. We conclude that even low doses of oral CLV potentiate the biological effect of infusion 5-FU. If the combination is to be given on a protracted basis, 5-FU must be administered at a much smaller dosage than has been traditionally utilized.

The rod sensitivity of dark adapted human infants

The determinants of infants' low scotopic visual sensitivity are controversial. Some interpret infants' scotopic vision as indicative of immature rod photoreceptor function while others attribute infantile sensitivities mainly to post receptoral immaturities. To date the rod photoreceptor sensitivity of human infants has not actually been measured. In the work reported herein, electroretinographic a-wave responses, which represent the rod photoresponse, were recorded from dark adapted 10-week old infants and adult control subjects. Rod isolated a-waves indicate that 10-week-old infants' rods are less sensitive than adults'. Thus, any explanation of infants' scotopic visual sensitivity must take into account this fundamental property of infants' rods, low sensitivity.

Current status of interferons in the treatment of cancer

Interferons produced by recombinant DNA technology began phase I trials little more than a decade ago. Today interferon alfa-2 is a mainstay in the treatment of hairy cell leukemia, and has demonstrated benefit in the more common chronic myelogenous leukemia. Interferon alfa-2 also has activity in other hematologic malignancies, including indolent non-Hodgkin's lymphomas, cutaneous T-cell lymphomas, T-cell lymphoma, and multiple myeloma, and in solid tumors such as disseminated melanoma, renal cell carcinoma, Kaposi's sarcoma, endocrine pancreatic tumors, and malignant carcinoid tumors. Interferon alfa, beta, and gamma remain under investigation to define potential roles in ovarian, breast, bladder, and cervical carcinomas and gliomas. The greatest value of the interferons will be in prolonging the disease-free interval when used in combination with other treatment modalities, including surgery, radiation, chemotherapy, and other biologic agents.

Periocular lymphoproliferative diseases: natural history, prognostic factors, and treatment

A study was undertaken to assess the natural history of periocular lymphoproliferative diseases, identify key prognostic factors, and clarify the role of orbital irradiation. Thirty-four patients with periocular lymphoproliferative disease were treated with orbital irradiation between 1975 and 1990. Eight patients had atypical lymphoid infiltrate, and 26 had malignant lymphoma. Forty-three eyes were irradiated with en-face electrons or 6-MV photons. Five-year disease-free survival for all stages was 65%; it was not significantly affected by bilaterality or site. Stage, distinction between atypical lymphoid infiltrate and malignant lymphoma, and working formulation grade were important prognostic indicators. A complete response during irradiation was achieved in 24 of 43 (56%) eyes at a median dose of 2,400 cGy, and a partial response was achieved in 19 (44%), with resolution at a median of 2.8 months. Patients with periocular reactive lymphoid hyperplasia or atypical lymphoid infiltrate may have or are at significant risk of developing lymphoma and dissemination. Local treatment remains important; orbital irradiation achieves prompt local control with acceptable morbidity.

Effects of halothane on children's electroretinograms

BACKGROUND

At times, anesthesia is necessary to test children's electroretinographic (ERG) responses. Halothane, an anesthetic commonly used for pediatric patients, affects some aspects of ERG responses, but it is unknown if halothane affects ERG parameters evaluated by contemporary clinical protocols.

METHODS

Scotopic and photopic ERG responses were recorded from children when awake and then under halothane.

RESULTS

Halothane has no effect on scotopic b-wave stimulus/response parameters, including amplitude, sensitivity, and implicit time. Scotopic a-wave amplitudes, implicit times, model parameters, and ratio of a- to b-wave amplitudes are unaffected by halothane. The amplitudes and implicit times of photopic responses to red flashes and 30 Hz flickering white light are not altered by halothane. Halothane causes no significant change in amplitudes and implicit times of the oscillatory potential wavelets.

CONCLUSION

These results suggest that significant departures of ERG responses (studied with the protocol described herein) from a laboratory's normal values cannot be attributed to halothane.

Imaging of regional spread of breast cancer by internal mammary lymphoscintigraphy, CT, and MRI

Forty women with breast cancer underwent imaging by internal mammary lymphoscintigraphy (IMLS), which was correlated with the results of CT and MRI of the chest. IMLS was performed and interpreted using the previously described methods of Ege. It identified 22 instances of ipsilateral internal mammary nodal involvement, none of which corresponded to cases of abnormally enlarged (diameter greater than 1.0 cm) internal mammary nodes on CT and/or MRI. Positive IMLS was associated with axillary nodal metastases in 15 out of 22 instances. The authors conclude that IMLS provides information on regional nodal spread of breast cancer that is not available with either CT/MRI imaging or axillary biopsy.

The effect of light adaptation on scotopic spatial summation in 10-week-old infants

Psychophysical area-intensity functions of individual 10-week-old human infants and adults were obtained in the dark adapted state, and in the presence of a steady background that elevated threshold 1 log unit above the dark adapted level. For dark adapted infants, the mean diameter for complete spatial summation (4.42 degrees; SD: 1.67 degrees) was significantly larger than that of adults (2.32 degrees; SD: 0.09 degrees). The background reduced the mean critical diameter to 2.67 degrees for infants (SD: 0.64 degrees) and to 1.16 degrees for adults (SD: 0.08 degrees). Spatial probability summation has similar effects on infant and adult thresholds, and, therefore, does not appear to account for the developmental decrease in critical diameters. Rather, decreases in receptive field size are suspected.

Twice-daily tapering dexamethasone treatment during cranial radiation for newly diagnosed brain metastases

Twenty evaluable patients with newly diagnosed brain metastases underwent treatment with a novel dose/schedule of dexamethasone aimed at reducing steroid toxicity during palliative radiation therapy. All patients received twice daily dexamethasone starting at 8 mg bid for four days then 4 mg bid for four days then 2 mg bid until the last day of radiation therapy. The radiation prescriptions were not standardized varying from 2000 cGy/5 fractions to 5800 cGy/29 fractions. Fourteen patients received dexamethasone for a minimum of 24 hours before their first radiation treatment and 7 (50%) experienced improvement in neurologic symptoms/signs prior to starting radiation treatments. Fourteen patients completed the planned course of radiation and dexamethasone. Only 1 patient needed to restart dexamethasone within 30 days of finishing radiation because of steroid reversible neurologic deficits. Steroid toxicity was mild including hyperglycemia (1), candida esophagitis (1), steroid pseudorheumatism (2), peripheral edema (1) and steroid withdrawal syndrome (1). Only two toxic events were recorded in patients receiving steroids less than 21 days. Twice daily dexamethasone appears to provide good clinical results with minimal morbidity.

The quantity of rhodopsin in young human eyes

The rhodopsin content of 20 eyes of infants and children ages 27 weeks gestation to 8 years (11 donors) was assayed and compared to the rhodopsin content of adults (36 eyes; 19 donors). Infants have significantly lower rhodopsin contents than adults. On average the rhodopsin content of young infants is about a third of adults. Previously reported full-field b-wave sensitivity of young infants is about 0.5 log units, that is about a third, less than adults. Thus, as previously found in infant rats, photon capture by rhodopsin appears to limit the dark adapted sensitivity of young human infants.

Allogeneic bone marrow transplantation for relapsed and refractory lymphoma using genotypically HLA-identical and alternative donors

Twenty-two patients, ages 16.6 to 43.9 years (median age, 30 years), with relapsed or refractory lymphoma were treated by allogeneic bone marrow transplantation after high-dose chemotherapy with or without total body irradiation (TBI). Seven patients had Hodgkin's disease, four had low-grade histology non-Hodgkin's lymphoma (NHL), seven had intermediate-grade NHL, and four had high-grade NHL. Of the 22 patients, 17 received T-cell (CD-3)-depleted marrow after intensive pretransplant chemoradiotherapy, and five received T-cell-replete grafts after chemotherapy-based preparative regimens. Five patients were transplanted from donors other than genotypically HLA-identical siblings: four from partially HLA-matched relatives, and one from a phenotypically HLA-identical unrelated donor. Acute graft-versus-host disease (GVHD) was less than or equal to grade II in all patients, and chronic GVHD was limited or absent in all but one patient. Of the 21 assessable patients, 17 (80.9%) achieved complete remissions. Death due to transplant-associated complications occurred in five patients, and five patients have relapsed. Thirteen patients are alive, and 12 are continuously relapse-free at a median follow-up of longer than 28 months (range, greater than 10 to greater than 58 months) from transplant. The cumulative probability of treatment failure from relapse or progression of lymphoma was 29% (95% confidence interval [CI], 12% to 51%), while the actuarial lymphoma-free (ie, event-free) survival plateau is 54.6% (95% CI, 34% to 76%). For young patients with advanced malignant lymphoma, allogeneic bone marrow transplantation appears superior to salvage chemotherapy for achievement of long-term, lymphoma-free survival and may be preferable to autologous bone marrow transplantation for selected patients.

Gold induced hepatitis and pure red cell aplasia. Complete recovery after corticosteroid and N-acetylcysteine therapy

A 54-year-old man developed severe cholestatic jaundice and pure red cell aplasia shortly after beginning treatment with gold sodium thiomalate. Although the hepatic toxicity began to spontaneously improve, the pure red cell aplasia was progressive. Treatment with prednisone and N-acetylcysteine (NAC) infusions was followed by prompt and complete hematologic recovery. Gold induced pure red cell aplasia should be added to the list of gold induced hematologic toxicities that can be potentially reversed with NAC infusion therapy.

Skeletal size and bone mineral content in Turner's syndrome: relation to karyotype, estrogen treatment, physical fitness, and bone turnover

Bone mineral content (BMC), bone mineral density, and metacarpal dimensions were studied in 50 women with Turner's syndrome aged 21-45 years in relation to karyotype, estrogen treatment, physical fitness, and biochemical markers of bone turnover. No differences were found between the 25 women with karyotype 45.X and women with other karyotypes. Forty-six women had received estrogen. Significant partial correlations were found between bone mineral density of the forearm and duration of estrogen treatment and physical fitness. BMC of the lumbar spine corrected for vertebral height (BMC(C)spine) was directly correlated with duration of estrogen treatment and height, marginally correlated with physical fitness, and inversely correlated with age. Outer metacarpal width was positively correlated with duration of estrogen treatment, age at initiation of therapy, and body weight. The diameter of medullary space showed negative correlation with physical fitness and height, and positive correlation with age at initiation of estrogen treatment. Cortical thickness was positively correlated with duration of estrogen treatment, physical fitness, and height. No convincing effects of estrogen could be demonstrated in women below the age of 30. Above the age of 30, all bone mineral measurements were markedly elevated in women treated for longer than the average of this age group. BMC(C)spine was inversely correlated with biochemical markers of bone formation. Our results demonstrate that estrogen treatment and physical fitness are important determinants of bone mineral status in Turner's syndrome and add to the evidence that estrogen treatment increases BMC in Turner's syndrome.

Continuous 5-fluorouracil infusion and alpha interferon in advanced cancers: a report of initial treatment results

Twenty-four patients with advanced metastatic cancer were treated with continuous intravenous 5-fluorouracil infusion 200-300 mg/m2/day and alpha interferon 3 million units subcutaneously 3 times per week. The average duration of treatment was 87 days (range 22-204 days). 5-fluorouracil could be infused 66% of the planned time on treatment, and patients received an average of 60% of the planned interferon injections. Objective tumor responses were seen in 6 of 17 previously untreated patients (35%). Twenty-two of the 24 patients (92%) experienced toxicity (greater than or equal to ECOG grade II) that required treatment interruption and subsequent dose reduction predominantly for the following reasons: mucositis (67%), hand-foot syndrome (21%), and leukopenia (25%). The incidence of treatment limiting toxicity is higher than previously observed with 5-fluorouracil infusion alone. This suggests true augmentation of 5-fluorouracil effect by interferon. 5-Fluorouracil infusion and alpha interferon is a potentially useful combination that needs further evaluation in future phase II and phase III trials.

5-Fluorouracil by protracted venous infusion: a review of recent clinical studies

The pharmacokinetics of continuous infusion 5-fluorouracil make it an ideal drug to administer as a protracted infusion (continuous infusion more than 30 days). During the last decade numerous clinical studies have been conducted to evaluate the efficacy of 5-fluorouracil (5FU) administered as a protracted venous infusion. Phase II studies in metastatic colorectal cancer in 345 patients have demonstrated an average response rate of 36% (range 15-59%) and a prospective randomized study performed by the Mid-Atlantic Oncology Program (MAOP) has confirmed a higher response rate with 5FU infusion compared with a bolus schedule. Phase II studies in refractory carcinoma of the breast in 177 patients have demonstrated a 30% response rate (range 17-50%); studies in pancreatic, gastric, and refractory prostate cancer have also demonstrated clinical utility. The major toxicities of 5FU infusion are mucositis and hand-foot syndrome; life-threatening myelosuppression is rare and treatment-related deaths have not been reported. 5FU infusion is a useful palliative treatment for many adult patients with advanced malignancies.

Electroretinographic assessment of background adaptation in 10-week-old human infants

Full field, scotopic b-wave stimulus/response functions of 10-week-old infants and adults were measured in the dark-adapted condition, and in the presence of steady backgrounds. Dark adapted b-wave sensitivity (log sigma) differed significantly between infants and adults; the median dark adapted sensitivity of infants was 0.50 log unit less than that of adults. The median eigengraus of infants (-1.32 log scot. td) and adults (-1.55 log scot. td) did not differ significantly. The median slope of the linear portion of the background adaptation function was about 0.9 for infants and adults. These results argue for post-receptoral immaturities, but do not rule out receptoral immaturities.

Dark adapted thresholds in young RCS rats

The dark adapted thresholds of black-eyed RCS rats and cogenic controls were measured using a new psychophysical procedure that permits determination of thresholds at earlier ages than previously possible. Rats were tested longitudinally between about ages 1 and 3 months. At all ages, thresholds of RCS rats were higher than those of controls. Thresholds did not change systematically with age for either RCS rats or controls. At age 3 months, when the RCS rats' b-wave is no longer recordable, RCS thresholds are about 2.2 log units higher than those of controls.

Protracted intravenous infusion of 5-fluorouracil in combination treatments. A review

5-fluorouracil (5-FU) administered by protracted intravenous infusion has been shown to have clinical utility against colorectal cancer and several other advanced tumors. However, additional therapeutic strategies are needed to further improve treatment results. Although the addition of low-dose cisplatin appeared to improve the clinical activity of 5-FU infusion in early phase II studies, subsequent evaluation has failed to substantiate these early reports. In addition, toxicity has been significantly increased. Combinations of cisplatin and other drugs with 5-FU infusion are currently being evaluated. Phase I studies demonstrate that only low doses of concomitant leucovorin are necessary to potentiate 5-FU infusion; phase II studies to evaluate efficacy are underway. Although combinations of 5-FU and biological therapies such as alpha 2a-interferon appear to be very promising, they will require extensive phase II and III testing to define their clinical utility and toxicity.