The right tool for the right question: contrasting biogeographic patterns in the notothenioid fish Harpagifer spp. along the Magellan Province

Molecular-based analysis has become a fundamental tool to understand the role of Quaternary glacial episodes. In the Magellan Province in southern South America, ice covering during the last glacial maximum (20 ka) radically altered the landscape/seascape, speciation rates and distribution of species. For the notothenioid fishes of the genus Harpagifer, in the area are described two nominal species. Nevertheless, this genus recently colonized South America from Antarctica, providing a short time for speciation processes. Combining DNA sequences and genotyping-by-sequencing SNPs, we evaluated the role of Quaternary glaciations over the patterns of genetic structure in Harpagifer across its distribution in the Magellan Province. DNA sequences showed low phylogeographic structure, with shared and dominant haplotypes between nominal species, suggesting a single evolutionary unit. SNPs identified contrastingly two groups in Patagonia and a third well-differentiated group in the Falkland/Malvinas Islands with limited and asymmetric gene flow. Linking the information of different markers allowed us to infer the relevance of postglacial colonization mediated by the general oceanographic circulation patterns. Contrasting rough- and fine-scale genetic patterns highlights the relevance of combined methodologies for species delimitation, which, depending on the question to be addressed, allows discrimination among phylogeographic structure, discarding incipient speciation, and contemporary spatial differentiation processes.

Contrasting biogeographical patterns in Margarella (Gastropoda: Calliostomatidae: Margarellinae) across the Antarctic Polar Front

Members of the trochoidean genus Margarella (Calliostomatidae) are broadly distributed across Antarctic and sub-Antarctic ecosystems. Here we used novel mitochondrial and nuclear gene sequences to clarify species boundaries and phylogenetic relationships among seven nominal species distributed on either side of the Antarctic Polar Front (APF). Molecular reconstructions and species-delimitation analyses recognized only four species: M. antarctica (the Antarctic Peninsula), M. achilles (endemic to South Georgia), M. steineni (South Georgia and Crozet Island) and the morphologically variable M. violacea (=M. expansa, M. porcellana and M. pruinosa), with populations in southern South America, the Falkland/Malvinas, Crozet and Kerguelen Islands. Margarella violacea and M. achilles are sister species, closely related to M. steineni, with M. antarctica sister to all these. This taxonomy reflects contrasting biogeographic patterns on either side of the APF in the Southern Ocean. Populations of Margarella north of the APF (M. violacea) showed significant genetic variation but with many shared haplotypes between geographically distant populations. By contrast, populations south of the APF (M. antarctica, M. steineni and M. achilles) exhibited fewer haplotypes and comprised three distinct species, each occurring across a separate geographical range. We hypothesize that the biogeographical differences may be the consequence of the presence north of the APF of buoyant kelps - potential long-distance dispersal vectors for these vetigastropods with benthic-protected development - and their near-absence to the south. Finally, we suggest that the low levels of genetic diversity within higher-latitude Margarella reflect the impact of Quaternary glacial cycles that exterminated local populations during their maxima.

Quaternary ice sheets and sea level regression drove divergence in a marine gastropod along Eastern and Western coasts of South America

The southern coastline of South America is a remarkable area to evaluate how Quaternary glacial processes impacted the demography of the near-shore marine biota. Here we present new phylogeographic analyses in the pulmonate Siphonaria lessonii across its distribution, from northern Chile in the Pacific to Uruguay in the Atlantic. Contrary to our expectations, populations from the southwestern Atlantic, an area that was less impacted by ice during glacial maxima, showed low genetic diversity and evidence of recent expansion, similar to the patterns recorded in this study across heavily ice-impacted areas in the Pacific Magellan margin. We propose that Atlantic and Pacific shallow marine hard-substrate benthic species were both affected during the Quaternary in South America, but by different processes. At higher latitudes of the southeast Pacific, ice-scouring drastically affected S. lessonii populations compared to non-glaciated areas along the Chile-Peru province where the species was resilient. In the southwest Atlantic, S. lessonii populations would have been dramatically impacted by the reduction of near-shore rocky habitat availability as a consequence of glacio-eustatic movements. The increase of gravelly and rocky shore substrates in the southwest Atlantic supports a hypothesis of glacial refugia from where the species recolonized lower latitudes across the Atlantic and Pacific margins. Our results suggest that current patterns of genetic diversity and structure in near-shore marine benthic species do not solely depend on the impact of Quaternary glacial ice expansions but also on the availability of suitable habitats and life-history traits, including developmental mode, bathymetry and the likelihood of dispersal by rafting.

Sublaminar polyester band fixation construct in the treatment of neuromuscular scoliosis

PURPOSE

Multiple fixation techniques exist for treating progressive neuromuscular scoliosis including pedicle screws, sublaminar bands/wires, hooks or a combination of instruments. Most sublaminar band constructs are supplemented with pedicle screws, hooks and/or sublaminar wires particularly at the top of the construct. There are no studies to date that describe an all/predominant sublaminar band construct. The purpose of this study was to investigate the outcomes of a sublaminar polyester band construct to treat neuromuscular scoliosis.

METHODS

A retrospective review was conducted of 32 cases of neuromuscular scoliosis treated with posterior spinal fusion using a sublaminar band construct between 2013 and 2016 by a single surgeon at a single centre. Preoperative, immediate postoperative and two-year follow-up radiographs and clinical records were reviewed. Sagittal, coronal and pelvic obliquity correction was measured. Blood loss, length of surgery and complications were recorded.

RESULTS

In all, 29 patients were included. Mean postoperative coronal plane correction was 57% (0% to 92%) and maintained at two-year follow-up. Mean sagittal balance was 2.3 cm (-2.5 to 6.4). Mean lumbar lordosis angle decreased by 7° (44° to 37°). Mean thoracic kyphosis angle increased by 9° (23° to 32°). Mean pelvic obliquity decreased by 50% (from 15° to 7°). There were four major complications (14%) and eight minor complications (21%). Mean blood loss was 1304 cc (250 cc to 2450 cc).

CONCLUSION

Sublaminar polyester band fixation constructs provide a viable option in correction of deformity in patients with neuromuscular scoliosis with comparable outcomes with what is reported with other constructs.

LEVEL OF EVIDENCE

V.

Human Plasminogen Variant Chicago III

A new abnormal, variant, plasminogen Chicago III has been isolated from a patient with recurring deep vein thrombosis. Studies on the plasma fibrinolytic system of four family members showed no inheritance pattern. Kinetics of activation parameters of Chicago III plasminogen with different activators showed lowered catalytic rate constants from 159fold with urokinase, to 3fold with light (B) chain ‧ streptokinase complex, to 1.3fold with streptokinase. The Michaelis constants of activation of Chicago III plasminogen were 16fold higher with streptokinase, 6fold higher with light (B) chain ‧ streptokinase complex, and similar with urokinase. Each of the three activators exhibited different interaction characteristics with this variant zymogen, as they did with variant Chicago I and Chicago II plasminogens (previously reported). However, the latter variants were characterized by having normal catalytic rate constants of activation, with higher than normal apparent Michaelis constants of activation. Chicago III plasminogen, as well as Chicago I and II plasminogens, has a homogeneous population of molecules; the interpretation of the kinetic data was possible only in terms of a single population of molecules. The plasmins derived from Chicago I plasminogen, and also Chicago II and Chicago III plasminogens, have 100% active sites with normal amidase parameters. Basically, a single population of normal isoelectric forms were found in the Chicago III plasma, with three minor forms, about 11% of the total.

The kinetic parameters have permitted us to classify the four known plasminogen variants into three different classes. The Class A homozygote (Tochigi) has both an active center defect and a charge mutation difference with normal cleavage of the Arg560-Val peptide bond; the Class B homozygote (Chicago I and Chicago II) has a Km of activation defect with impaired activator binding and normal cleavage of the Arg560-Val peptide bond; and, the Class C homozygote (Chicago III) has both a Km of activation defect with impaired activator binding and a kcat of activation defect, and impaired Arg560-Val peptide bond cleavage.

[Patients suffering from atrial fibrillation in Germany. Characteristics, resource consumption and costs]

INTRODUCTION

Atrial fibrillation (Afib) is considered to be the most frequent form of cardiac dysrhythmia and is well known as a key risk factor for arterial thromboembolism. The incidence of Afib will increase in the future due to demographic changes as well as improved treatment options for acute and chronic heart diseases.

OBJECTIVE

The primary objectives of this analysis were to describe patient characteristics, to assess the resource consumption associated with Afib and to measure costs of direct treatment as well as consequential costs. A secondary objective was to identify factors that influence the costs or the type of Afib.

METHODS

The analysis is based on the representative ATRIUM register (Ambulantes Register zur Morbidität des Vorhofflimmerns, Ambulatory register on morbidity of atrial fibrillation), a prospective, multicenter cohort study in which general practitioners and family doctors documented the characteristics and resource utilization of consecutively enrolled patients. The documented resource consumption use was subsequently valued with unit costs. The presented results are focused on the baseline documentation and refer to the period 12 months before enrollment.

RESULTS

A total of 3,667 patients (mean age 72.1±9.2 years, 58% men) fulfilled all inclusion criteria and were included by a total of 730 doctors. The patients had an average of 2.4±1.0 risk factors and the most common was hypertension (84% of patients). The most commonly observed comorbidities were heart failure (43%) and coronary heart disease (CHD, 35%). Medicines for oral anticoagulation (86%) and beta blockers (75%) were the most frequently prescribed drugs. A total of 1/3 of all patients received a specific kind of Afib therapy (e. g. drug conversion, cardioversion) during the past 12 months. The disease-specific mean costs of the patients were 3,274±5,134 Euro, while the acute (inpatient) treatment represented the largest proportion of these total costs (1,639±3,623 Euro). Patients with high treatment costs were significantly younger and suffered from more concomitant diseases.

CONCLUSION

Atrial fibrillation is associated with significant patient-related attributable costs that are caused particularly by expenditures of inpatient stay. New, innovative treatment strategies seem to offer particular potential savings if they are able to reduce the number of hospitalizations due to Afib itself or subsequent cardiac events.

Treatment with temozolomide for malignant gliomas: Is rechallenge with alternative dosing regimens successful?

11514

Background: Temozolomide (TMZ) is an alkylating agent with activity against malignant gliomas. A variety of dosing schedules has been used including: 5 days on/21 days off (200 mg/m2/d), bid dosing (initial bolus of 200 mg/m2 followed by bid dosing of 90 mg/m2 × 9 doses), and 7 days on/7 days off (150 mg/m2/d). It is not known which regimens are the most effective. Furthermore, it is not known whether patients failing one schedule will respond to alternative ones. Materials and Methods: We report on a retrospective series of 8 patients (7 M, 1 F), who were treated with TMZ at least twice. Mean age at recurrence was 48 (26–58). Pathology revealed GBM (3), AA (4), and AO (1). 7 patients had received prior XRT. 7 patients had a local (L) recurrence at the time of retreatment with TMZ, and one patient had leptomeningeal (LM) and L recurrence. 7 pts received TMZ alone both at the time of the first recurrence and at the time of rechallenge. One patient had received TMZ concommitant with XRT and TMZ alone at the time of rechallenge. Results: See Table . Toxicity was mild and not different than that seen in patients treated with the first course of TMZ. Conclusions: While the number of patients is limited, some observations can be made: 1) patients can respond to TMZ at rechallenge, particularly if a prior response to TMZ had been observed. 2) Some patients who fail or respond modestly to one regimen may achieve a better response to alternative dosing schedules. Further studies need to address whether one regimen of TMZ given at rechallenge allows an improved survival as compared with other regimens without sacrificing safety.

[Table: see text]

[Table: see text]

[Outpatient treatment of patients suffering from Alzheimer dementia. Two exploratory studies on the characteristics of therapy in medical practice]

In two exploratory studies on the outpatient treatment of patients suffering from Alzheimer dementia research was done into the characteristics of therapy in medical practice on the basis of exemplary interviews of 100 doctors in 2000 and 2002. The interviewers discern the burden of the disease for the patients and their relatives. However, medical treatment is still too scarce and inappropriate as the prescribing of antidementia drugs shows, among which especially acetylcholinesterase inhibitors as drugs of first choice. The spectrum of non-pharmacological interventions is applied but psychosocial measures are under-represented. To maintain the Alzheimer patient's functional level and to thus relieve the caring relatives a multimodal therapy should be intensified preferably by comprehensive co-operations.

Comparative validation of the Block, Willett, and National Cancer Institute food frequency questionnaires : the Eating at America's Table Study

Researchers at the National Cancer Institute developed a new cognitively based food frequency questionnaire (FFQ), the Diet History Questionnaire (DHQ). The Eating at America's Table Study sought to validate and compare the DHQ with the Block and Willett FFQs. Of 1,640 men and women recruited to participate from a nationally representative sample in 1997, 1,301 completed four telephone 24-hour recalls, one in each season. Participants were randomized to receive either a DHQ and Block FFQ or a DHQ and Willett FFQ. With a standard measurement error model, correlations for energy between estimated truth and the DHQ, Block FFQ, and Willett FFQ, respectively, were 0.48, 0.45, and 0.18 for women and 0.49, 0.45, and 0.21 for men. For 26 nutrients, correlations and attenuation coefficients were somewhat higher for the DHQ versus the Block FFQ, and both were better than the Willett FFQ in models unadjusted for energy. Energy adjustment increased correlations and attenuation coefficients for the Willett FFQ dramatically and for the DHQ and Block FFQ instruments modestly. The DHQ performed best overall. These data show that the DHQ and the Block FFQ are better at estimating absolute intakes than is the Willett FFQ but that, after energy adjustment, all three are more comparable for purposes of assessing diet-disease risk.

Botulinum toxin type a neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: a multicenter, open-label clinical trial

BACKGROUND

Focal spasticity of the gastrocnemius-soleus muscles causes equinus gait in children with cerebral palsy (CP). Botulinum toxin type A (BTX-A), a neuromuscular blocking agent, reduces muscle tone/overactivity in dystonia, stroke, and CP.

OBJECTIVE

A prospective, open-label, multicenter clinical trial evaluated the long-term safety and efficacy of repeated intramuscular injections of BTX-A on equinus gait in CP children.

METHODS

Nine centers enrolled 207 children. BTX-A injections (4 U/Kg) were given approximately every 3 months (maximum dose 200 U per treatment). Outcome measures included a Physician Rating Scale of gait, ankle range of motion measurements, and the incidence and profile of adverse events.

RESULTS

One hundred fifty-five (75%) of 207 children completed at least 1 year with a total of 302 patient years of BTX-A treatment. The mean duration of BTX-A exposure was 1.46 years per patient. Dynamic gait pattern on the Physician Rating Scale improved in 46% of patients (86/185) at first follow-up. The response was maintained in 41% to 58% of patients for 2 years. Both gait pattern and ankle position improved at every visit. The most common treatment-related adverse events included increased stumbling, leg cramps, leg weakness, and calf atrophy in 1% to 11% of patients. No treatment-related serious adverse events were reported. Only 6% (7/117) of patients with pre- and postantibody samples had both detectable antibodies and a subsequent treatment failure.

CONCLUSION

BTX-A proved both safe and effective in the chronic management of focal muscle spasticity in children with equinus gait.

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.

Recurrent urinary tract infections in postmenopausal women

To evaluate factors associated with recurrent urinary tract infection (UTI) in postmenopausal women, we conducted a case-control study comparing 149 postmenopausal women referred to an infectious diseases outpatient clinic who had a history of recurrent UTI (case patients) with 53 age-matched women without a history of UTI (control patients). Each woman completed a questionnaire providing demographic data, history and clinical characteristics of prior infections, and information regarding risk factors for UTI. In addition, each patient underwent a gynecologic evaluation, renal ultrasound and urine flow studies, and blood group and secretor status testing. Three urologic factors-namely, incontinence (41% of case patients vs. 9.0% of control patients; P<.001), presence of a cystocele (19% vs. 0%; P<.001), and postvoiding residual urine (28% vs. 2.0%; P=.00008)-were all strongly associated with recurrent UTI. Multivariate analysis showed that urinary incontinence (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.05-16.42; P=.0009), a history of UTI before menopause (OR, 4.85; 95% CI, 1.7-13.84; P=. 003), and nonsecretor status (OR, 2.9; 95% CI, 1.28-6.25; P=.005) were most strongly associated with recurrent UTI in postmenopausal women. Prospective studies are needed to confirm these observations and to develop approaches for prevention.

Late clonal diseases of treated aplastic anemia

Recent progress in the treatment of aplastic anemia has dramatically changed the previously grim prognosis for these patients. Improvements in bone marrow transplantation and immunosuppression have increased the number of long-term survivors so that immediate survival is no longer the sole concern. Here, we review the major clinical studies and summarize recent analyses of risk factors for developing paroxysmal nocturnal hemoglobinuria (PNH), myelodysplastic syndrome (MDS), acute leukemia, or solid tumor after treatment for aplastic anemia. We also examine biologic clues that may shed light on the interrelationship between aplastic anemia and clonal diseases.

Joint effects of an aldosterone synthase (CYP11B2) gene polymorphism and classic risk factors on risk of myocardial infarction

BACKGROUND

The -344C allele of a 2-allele (C or T) polymorphism in the promoter of the gene encoding aldosterone synthase (CYP11B2) is associated with increased left ventricular size and mass and with decreased baroreflex sensitivity, known risk factors for morbidity and mortality associated with myocardial infarction (MI). We hypothesized that this polymorphism was a risk factor for MI.

METHODS AND RESULTS

We used a nested case-control design to investigate the relationships between this polymorphism and the risk of nonfatal MI in 141 cases and 270 matched controls from the Helsinki Heart Study, a coronary primary prevention trial in dyslipidemic, middle-aged men. There was a nonsignificant trend of increasing risk of MI with number of copies of the -344C allele. However, this allele was associated in a gene dosage-dependent manner with markedly increased MI risk conferred by classic risk factors. Whereas smoking conferred a relative risk of MI of 2.50 (P=0.0001) compared with nonsmokers in the entire study population, the relative risk increased to 4.67 in -344CC homozygous smokers (relative to nonsmokers with the same genotype, P=0.003) and decreased to 1.09 in -344TT homozygotes relative to nonsmokers with this genotype. Similar joint effects were noted with genotype and decreased HDL cholesterol level as combined risk factors.

CONCLUSIONS

Smoking and dyslipidemia are more potent risk factors for nonfatal MI in males who have the -344C allele of CYP11B2.

Paroxysmal nocturnal hemoglobinuria cells in patients with bone marrow failure syndromes

BACKGROUND

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hematopoietic stem-cell disorder in which the affected cells are deficient in glycosylphosphatidylinositol (GPI)-anchored proteins. Paroxysmal nocturnal hemoglobinuria is frequently associated with aplastic anemia, although the basis of this relation is unknown.

OBJECTIVE

To assess the PNH status of patients with diverse marrow failure syndromes.

DESIGN

Correlation of cytofluorometric data with clinical features.

SETTING

Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland.

PATIENTS

115 patients with aplastic anemia, 39 patients with myelodysplasia, 28 patients who had recently undergone bone marrow transplantation, 18 patients with cancer that was treated with chemotherapy, 13 patients with large granular lymphocytosis, 20 controls who had received renal allografts, and 21 healthy participants.

INTERVENTION

Patients with aplastic anemia, myelodysplasia, or renal allografts received antithymocyte globulin.

MEASUREMENTS

Flow cytometry was used to assess expression of GPI-anchored proteins on granulocytes.

RESULTS

Evidence of PNH was found in 25 of 115 (22%) patients with aplastic anemia. No patient with normal GPI-anchored protein expression at presentation developed PNH after therapy (n = 16). Nine of 39 (23%) patients with myelodysplasia had GPI-anchored protein-deficient cells. Abnormal cells were not detected in patients with constitutional or other forms of bone marrow failure or in renal allograft recipients who had received antithymocyte globulin. Aplastic anemia is known to respond to immunosuppressive therapy; in myelodysplasia, the presence of a PNH population was strongly correlated with hematologic improvement after administration of antithymocyte globulin (P = 0.0015).

CONCLUSIONS

Flow cytometric analysis is superior to the Ham test and permits concomitant diagnosis of PNH in about 20% of patients with myelodysplasia (a rate similar to that seen in patients with aplastic anemia). The presence of GPI-anchored protein-deficient cells in myelodysplasia predicts responsiveness to immunosuppressive therapy. Early emergence of GPI-anchored protein-deficient hematopoiesis in a patient with marrow failure may point to an underlying immune pathogenesis.

High incidence of adeno- and polyomavirus-induced hemorrhagic cystitis in bone marrow allotransplantation for hematological malignancy following T cell depletion and cyclosporine

Nine of 56 (20% actuarial) patients receiving a T cell-depleted, HLA-identical sibling BMT for hematological malignancy developed hemorrhagic cystitis (HC) 15-368 days post BMT. Hematuria was severe and prolonged (median duration 18 days). In eight patients (89%), a viral etiology was confirmed (four adenovirus, four polyomavirus). HC was associated with significant morbidity, with all patients requiring continuous bladder irrigation and transfusion support for blood loss and thrombocytopenia. HC occurring before day 100 was significantly associated with a reduction in long-term survival: 1/7 (14.3%) patients developing HC before day 100 became long-term survivors vs 21/49 (42.8%) without HC by day 100 (P = 0.034). In univariate analysis, HC was associated with a diagnosis of multiple myeloma (P = 0.02). There was a trend towards a higher incidence of HC in patients reactivating cytomegalovirus (CMV) compared with those remaining CMV negative (18.4 vs 5.5% respectively, P = 0.17). HC was not associated with graft-versus-host disease, or with the transplant dose of CD34+ progenitors or CD3+ cells, patient age or sex. Life-threatening, viral-induced HC and the unusually high incidence of adenovirus-induced HC may have been caused by immune deficiency associated with T cell depletion in this series.

Identification of a recombination event narrowing the Lafora disease gene region

Patients affected with progressive myoclonus epilepsy of the Lafora type present during late adolescence with a characteristic EEG pattern and Lafora bodies seen on skin biopsy. The critical region for the Lafora gene has been localised to chromosome 6q24 flanked by the dinucleotide repeat markers D6S292 and D6S420. This study for linkage of markers from the candidate gene region was performed in a previously unpublished family affected with Lafora disease. EEG and skin biopsy evaluation for Lafora bodies were performed on five of eight family members followed for seizure activity. Haplotype and linkage analysis of DNA from five family members were carried out using the nine dinucleotide repeat markers reported in the common region of homozygosity by Serratosa et al in 1995. The present study of an additional family affected by Lafora disease has narrowed the 17 cM critical region for the Lafora disease gene on chromosome 6q24 to a 4 cM region flanked by markers D6S308 and D6S311.

A phase III randomized prospective trial of external beam radiotherapy, mitomycin C, carmustine, and 6-mercaptopurine for the treatment of adults with anaplastic glioma of the brain. CNS Cancer Consortium

PURPOSE

This study was designed to evaluate strategies to overcome the resistance of anaplastic gliomas of the brain to external beam radiotherapy (ERT) plus carmustine (BCNU). Patients were > or = 15 years of age, had a histologic diagnosis of malignant glioma, and a Karnofsky performance status (KPS) > or = 60%.

METHODS AND MATERIALS

In Randomization 1, patients were assigned to receive either ERT alone (61.2 Gy) or ERT plus mitomycin C (Mito, IV 12.5 mg/m(2)) during the first and fourth week of ERT. After this treatment, patients went on to Randomization 2, where they were assigned to receive either BCNU (i.v. 200 mg/m(2)) given at 6-week intervals or 6-mercaptopurine (6- MP, 750 mg/m(2) IV daily for 3 days every six weeks), with BCNU given on the third day of the 6-MP treatment. Three hundred twenty-seven patients underwent Randomization 1. One hundred sixty-four received ERT alone, and 163 received ERT + Mito [average 52.7 years; 63% male; 69% glioblastoma multiforme (GBM); 66% had a resection; 56% KPS > or = 90%]. Step-wise analysis of survival from Randomization 1 or 2 indicates that survival was significantly diminished by: (a) age > or = 45 years (b) KPS < 90%; (c) GBM/gliosarcoma histology; (d) stereotactic biopsy as opposed to open biopsy or resection. Median survival from Randomization 1 in both arms (ERT + Mito) was 10.8 months. Median survival from Randomization 2 was 9.3 months for BCNU/6MP vs. 11.4 months for the BCNU group (p = 0.35). Carmustine/6-MP showed a possible survival benefit for histologies other than GBM/GS. Two hundred and thirty-three patients underwent Randomization 2. The proportion of patients in the ERT group who terminated study prior to Randomization 2 was significantly less in the ERT group than in the ERT + Mito group (20 vs. 37%, p < 0.001).

CONCLUSIONS

(a) The addition of Mito to ERT had no impact on survival; (b) patients treated with ERT + Mito were at greater risk of terminating therapy prior to Randomization 2; (c) there was not a significant survival benefit to the addition of 6-MP to BCNU.

Percutaneous in situ fixation of slipped capital femoral epiphysis using two threaded Steinmann pins

Twenty-six patients with 34 slipped capital femoral epiphyses were treated by percutaneous in situ pinning with two 5/32-inch threaded Steinmann pins. Twenty-three patients with 31 hips were followed-up until the time of epiphyseal closure and pin removal. The average time to closure was 8.5 months (range, 3-25). The average operative time for pinning was 53 min (range, 18-115). The average operative time for pin removal was 42 min (range, 12-132). Complications included two progressive slips, two poorly placed pins, one pin breakage during removal, and one case of capital necrosis. This technique is a quick, efficient means of stabilizing the slipped capital femoral epiphysis, with case of hardware removal.

Ineffective hip rotation with Pavlik harness. Prospective study of 35 infant dislocations

35 hips in 31 infants diagnosed as unstable were treated with a Pavlik harness and followed by weekly clinical and monthly ultrasound evaluation to determine eventual stability. 26 hips became stable within 3 months, and 9 dislocations required reduction with hip spica placement; 1 of these subsequently required open reduction. Of the 7 infants with 9 hips that failed, 2 children had a late onset of treatment, 2 children had problems with brace fit or family acceptance, and 3 other children had no problem with use of the orthosis. Internal rotation of a degree not possible with the Pavlik harness was required to reduce 4 of these 9 hips. The Pavlik harness is ineffective in some patients because of the need for internal rotation.

Synergistic effect between intraneoplastic methotrexate and radiation on experimental intracerebral rat gliosarcoma

Methotrexate (MTX) alone has a limited effect against malignant brain tumors, but we previously demonstrated a beneficial synergism between MTX and radiation therapy (XRT) against RT-9 gliosarcoma. Because the beneficial effects of that study were limited by systemic toxicity and poor brain penetration of MTX, we have continued our studies using direct intracerebral MTX therapy. Male CD-Fisher rats with intracerebrally implanted RT-9 gliosarcoma and indwelling brain tumor catheters were treated with intracerebral injections of MTX, whole-brain XRT, or a combination of both. MTX was given either as one of two "high-dose" treatments, on the basis of whole-body doses, or two "low-doses," on the basis of average brain weight. MTX alone at lower doses and XRT alone each prolonged survival moderately. High-dose MTX was highly toxic, but low-dose MTX was well tolerated. Combined MTX and XRT caused a significant prolongation of survival in all animals that survived treatment long enough to die from tumor growth.

Linkage mapping of the spinal muscular atrophy gene

Spinal muscular atrophy (SMA) is a common autosomal recessive disorder resulting in loss of motor neurons. We have performed linkage analysis on a panel of families using nine markers that are closely linked to the SMA gene. The highest lod score was obtained with the marker D5S351 (Zmax = 10.04 at theta = O excluding two unlinked families, and Zmax = 8.77 at theta = 0.007 with all families). One type III family did not show linkage to the 5q13 markers, and in one type I consanguineous family the affected individual did not show homozygosity except for the marker D5S435. Three recombinants were identified with the closet centromeric marker, D5S435, which position the gene telomeric of this marker. These recombinants will facilitate finer mapping of the location of the SMA gene. Lastly, two families provide strong evidence for a remarkable variability in presentation of the SMA phenotype, with the age at onset in one family varying from 17 months to 13 years.

Respiratory findings among millwright and machinery erectors: identification of health hazards from asbestos in place at work

Asbestos-associated diseases are prevalent in the construction trades primarily because of the previously widespread use of asbestos-containing insulation materials. Workers in metal-related trades, employed at construction sites and power facilities, but who do not routinely handle such materials as part of their work, may also be at risk for significant asbestos exposure. In order to evaluate such risk, a clinical field survey was conducted of 110 millwright and machinery erectors from the New York metropolitan area. A high prevalence of chest roentgenologic abnormalities was found. Forty-nine (44.5%) of the examined workers had pleural abnormalities consistent with asbestos-induced effects. Eighteen workers showed evidence of unilateral pleural thickening. Duration from onset of employment was significantly longer for those with pleural abnormalities (mean 32.3 years) as compared to those with normal chest radiographs (mean 18.5 years). Thirteen workers (11.8%) had radiographic signs of interstitial lung disease. The workers with pleural abnormalities had lower mean values of restrictive and obstructive lung function parameters than those with normal pleura. Multivariate and logistic regression analyses demonstrated association between duration of employment in the millwright trade and pleural abnormalities which was independent of smoking status. These findings suggest that millwright and machinery erectors employed in work environments where there is potential for primarily indirect exposure to airborne asbestos-containing dust are at risk for adverse effects from such exposure.

FDG-PET in differentiating lymphoma from nonmalignant central nervous system lesions in patients with AIDS

Structural imaging studies such as CT or MRI are not able to accurately differentiate infectious from malignant cerebral lesions in patients with AIDS. We studied 11 individuals with AIDS and central nervous system (CNS) lesions with 18F-fluoro-2-deoxyglucose (FDG) and positron emission tomography (PET). FDG-PET was able to accurately differentiate between a malignant (lymphoma) and nonmalignant etiology for the CNS lesions. Both qualitative visual inspection of the images as well as semiquantitative analysis using count ratios was performed and revealed similar results. FDG-PET may be useful in the management of AIDS patients with CNS lesions since high FDG uptake most likely represents a malignant process which should be biopsied for confirmation rather than treated presumptively as infectious.