Impact-induced muscle damage and urinary pterins in professional rugby: 7,8-dihydroneopterin oxidation by myoglobin

Muscle damage caused through impacts in rugby union is known to increase oxidative stress and inflammation. Pterins have been used clinically as markers of oxidative stress, inflammation, and neurotransmitter synthesis. This study investigates the release of myoglobin from muscle tissue due to force-related impacts and how it is related to the subsequent oxidation of 7,8-dihydroneopterin to specific pterins. Effects of iron and myoglobin on 7,8-dihydroneopterin oxidation were examined in vitro via strong cation-exchange high-performance liquid chromatography (SCX-HPLC) analysis of neopterin, xanthopterin, and 7,8-dihydroxanthopterin. Urine samples were collected from 25 professional rugby players pre and post four games and analyzed for myoglobin by enzyme-linked immunosorbent assay, and 7,8-dihydroneopterin oxidation products by HPLC. Iron and myoglobin oxidized 7,8-dihydroneopterin to neopterin, xanthopterin, and 7,8-dihydroxanthopterin at concentrations at or above 10 μM and 50 μg/mL, respectively. All four games showed significant increases in myoglobin, neopterin, total neopterin, biopterin, and total biopterin, which correlated between each variable (P < 0.05). Myoglobin and iron facilitate 7,8-dihydroneopterin oxidation to neopterin and xanthopterin. In vivo delocalization of myoglobin due to muscle damage may contribute to oxidative stress and inflammation after rugby. Increased concentrations of biopterin and total biopterin may indicate production of nitric oxide and monoamine neurotransmitters in response to the physical stress.

The risk of antimalarials in patients with renal failure

We present here a patient with end stage renal failure who received two weeks antimalarial prophylaxis at full dose leading to life threatening toxicity with severe acute megaloblastic anaemia, symptomatic pancytopenia and exfoliative dermatitis. Prompt recognition and treatment can rapidly reverse these fatal effects but more importantly, education of patients before travel is imperative in preventing such events.

Measurement of the two-halo neutron transfer reaction (1)H((11)Li, (9)Li)(3)H at 3A MeV

The p((11)Li, (9)Li)t reaction has been studied for the first time at an incident energy of 3A MeV at the new ISAC-2 facility at TRIUMF. An active target detector MAYA, built at GANIL, was used for the measurement. The differential cross sections have been determined for transitions to the (9)Li ground and first excited states in a wide range of scattering angles. Multistep transfer calculations using different (11)Li model wave functions show that wave functions with strong correlations between the halo neutrons are the most successful in reproducing the observation.

An exploratory study of parents' approaches to health promotion in families of adolescents with physical disabilities

BACKGROUND

The life expectancy of children with physical disabilities now extends into adulthood and has been accompanied by the transfer of rehabilitation services from institutions to the home. Thus, families must increasingly partner with health service providers to promote their child's health and prevent the development of secondary conditions that may contribute to heart disease, stroke, respiratory diseases, low endurance and emotional difficulties.

AIM

To investigate within a family context the health promotion efforts of parents on behalf of a child with a physical disability.

METHOD

The Long Interview Method was used to interview 15 families (11 two-parent and 4 single-parent) having a child 11-16 years of age with a physical disability including cerebral palsy (7), spina bifida (3), muscular dystrophy (3) and other conditions (2).

RESULTS

Parents' health promotion efforts were characterized by three main themes. First, parents emphasized traditional lifestyle health behaviours including nutrition, physical activity, tobacco, alcohol and drug use, and personal hygiene. Second, parents tried to foster their adolescent's social life and friendships. They expressed particular concern about how, and if, their child would develop a sense of purpose and have a productive future. Third, parents invested a great deal of effort into observing daily routines, making arrangements for their child's social inclusion and supporting their child in a way that balanced independence with safety and energy conservation.

CONCLUSIONS

Parents recognize that their child with a physical disability faces greater obstacles, and work hard at health promotion. Healthcare workers need to work with parents to: (1) provide information about specific lifestyle health behaviours including nutrition, physical activity and sexuality; (2) advocate for resources to foster social inclusion; and (3) discuss family strategies that balance parental involvement with their child's need for independence and energy conservation for daily activities.

A complication of steroid therapy in acute leukaemia--a case report

Common complications associated with steroid therapy are well documented. We report a rare and fatal complication, in which oesophageal erosion secondary to the use of steroids was associated with pneumopericardium.

Evolution of mammalian X chromosome-linked imprinting

We analyse the evolution of X chromosome-linked imprinting by modifying our previous model of imprinting of autosomal genes that influence the trade-off between maternal fecundity and offspring viability through alterations in maternal investment (Mills and Moore, 2004). Unlike previous genetic models, we analyse X-linked imprinting in the context of populations at equilibrium for either autosomal or X-linked biallelically expressed alleles at loci that influence the fecundity/viability trade-off. We show that selection under parental conflict over maternal investment in offspring can parsimoniously explain the occurrence of sex-specific gene expression patterns, without a requirement to postulate direct selection for sexual dimorphism mediated through imprinting. We note that sex chromosome imprinting causes a small distortion of the post-weaning sex ratio, providing a possible selection pressure against the evolution of X-linked imprints. We discuss our conclusions in the context of recent reports of imprinting of mouse X-linked Xlr genes.

Congenital syphilis surveillance and newborn evaluation in a low-incidence state

OBJECTIVES

To evaluate congenital syphilis surveillance in Minnesota, to assess the evaluation and management of newborns at risk for congenital syphilis, and to assess prenatal syphilis screening.

DESIGN

Case ascertainment and medical record review.

SETTING

The 7-county Minneapolis-St Paul metropolitan area.

PATIENTS

Newborns at risk for congenital syphilis during a 3-year period (1992-1994).

MAIN OUTCOME MEASURES

The completeness of congenital syphilis case ascertainment, maternal demographic data, maternal syphilis management, newborn evaluation for and management of congenital syphilis, and hospital syphilis screening practices at delivery.

RESULTS

Eighty mother-infant pairs who were at risk for congenital syphilis were identified from 3 sources. Using the Centers for Disease Control and Prevention's congenital syphilis case definition, 36 infants (45%) were classified as probable cases, 42 (53%) were classified as noncases, and 2 (3%) were syphilitic stillbirths. Forty-seven women (59%) had syphilis serologic tests performed in the third trimester; only 37 (46%) had syphilis screening at delivery. Conditions of the mothers of 8 probable cases (22%) were diagnosed at delivery. Most probable cases (86%) were evaluated; only 56% were evaluated adequately. Twenty-five probable cases (69%) were treated. Most hospitals did not have formal policies for syphilis screening at delivery. The Minnesota Department of Health's congenital syphilis registry lacked sensitivity (39%) as a case ascertainment method.

CONCLUSIONS

Clinicians should adhere to standardized protocols in the evaluation and management of at-risk newborns. Vigilant screening prenatally and at delivery and adequate follow-up are critical to reduce congenital syphilis. Improved surveillance data and resources are needed for the identification and follow-up of newborns at risk for congenital syphilis.

Distribution of gamma satellite DNA on the human X and Y chromosomes suggests that it is not required for mitotic centromere function

The bulk of the DNA found at human centromeres is composed of tandemly arranged repeats, the most abundant of which is alpha satellite. Other human centromeric repetitive families have been identified, one of the more recent being gamma satellite. To date, gamma satellite DNAs have been reported at the centromeres of human chromosomes 8 and X. Here, we show that gamma-X satellite DNA is not interspersed with the major DZX1 alpha-X block, but rather is organised as a single array of approximately 40-50 kb on the short-arm side of the alpha satellite domain. This repeat array is absent on two mitotically stable Xq isochromosomes. Furthermore, a related repeat DNA has been identified on the human Y chromosome. Fluorescence in situ hybridisation has localised this satellite DNA to the long arm side of the major DYZ3 alpha-Y domain, outside the region previously defined as that required for mitotic centromere function. Together, these data suggest that while blocks of highly related gamma satellite DNAs are present in the pericentromeric regions of both human sex chromosomes, this repeated DNA is not required for mitotic centromere function.

The Cornwall dermatology electronic referral and image-transfer project

An evaluation of a store-and-forward electronic referral system was carried out in Cornwall to gauge its effectiveness in prioritizing dermatological patients needing secondary care. A dermatologist classified patients to be seen according to need based on information on the electronic referral form along with an image of the skin condition. Initial findings indicated that patients were more accurately triaged in at least 50% of cases and that 25% of patients did not require an outpatient dermatological appointment. Dermatologists rated image quality at 7.5 on a 10-point scale. This low-cost system has potential for more appropriate clinical management of dermatological patients in both primary and secondary care.

Cloning and characterisation of the chicken gene encoding the telomeric protein TRF2

The telomere-associated protein TRF2 binds as a homodimer to double-stranded (TTAGGG)n arrays in vitro and localises to chromosome ends in vivo. Inhibition of TRF2 in human cell lines and recent electron microscopy analyses suggest that TRF2 plays a crucial role in the maintenance of telomere integrity. To study the role of TRF2 in vertebrate telomere biology using an alternative model system, we report the isolation and characterisation of the chicken TRF2 locus. The TRF2 protein is highly conserved between mammals and birds, particularly within the dimerisation and myb-type DNA binding domains. However, the chicken ORF predicts an additional protein domain consisting of 15 copies of a degenerate 13 amino acid repeat. Indirect immunofluorescence reveals the localisation of a FLAG-tagged version of the chicken TRF2 protein at chromosome ends in both chicken and human cells suggesting that the protein is functionally conserved.

Practice variation in the diagnosis and treatment of osteoporosis: a case for more effective physician education in primary care

Bone mineral density (BMD) performed by dual energy x-ray absorptiometry (DEXA) has been used at our institution as a screening test for osteoporosis since 1986. Of 2789 bone densitometry tests done between 1992 and 1996 on women aged 51-75 years, 1743 (62.5%) were ordered by general internists (GIM), endocrinologists (ENDO), rheumatologists (RHEUM), and a metabolic bone disease specialist (MBDS). We compared the percentage of densitometry tests ordered by GIM, ENDO, RHEUM, and MBDS resulting in one of three possible diagnoses (normal, osteopenia, or osteoporosis). Applying the World Health Organization's (WHO) definition of normal (< 1 standard deviation [SD] below the mean for young, adult women), osteopenia (> or = 1 SD-< 2.5 SD below the mean), and osteoporosis (> or = 2.5 SD below the mean), we found that 34% of patients tested between 1992 and 1996 were osteoporotic, 42% were osteopenic, and 24% had normal bone density results. The rate of osteoporosis diagnosis was highest in the MBDS cohort (chi 2 = 9.19, p = 0.002) compared with patients in the other cohorts. To explore trends in management of this condition, a random sample of osteoporotic women aged 51-75 who had densitometry in 1996 (n = 82) was obtained. Review of medical records revealed that 73% were on some form of osteoporosis treatment (bisphosphonate, estrogen, or calcitonin, with or without calcium and vitamin D supplementation). Treatment rates differed significantly, however, by the ordering physician specialty (96% for MBDS, 63% for ENDO, 75% for RHEUM, and 53% for GIM, chi (2)3df = 11.37, p = 0.01). There were no significant differences in selected clinical or demographic characteristics between patients treated by GIM and MBDS. This variation in treatment rates suggests that an opportunity to enhance primary care physicians' recognition and treatment of osteoporosis exists. Making osteoporosis management an educational focus may help narrow differences in practice and improve the effectiveness of a larger number of physicians treating patients with this problem.

Generation of an approximately 2.4 Mb human X centromere-based minichromosome by targeted telomere-associated chromosome fragmentation in DT40

A linear mammalian artificial chromosome (MAC) will require at least three types of functional element: a centromere, two telomeres and origins of replication. As yet, our understanding of these elements, as well as many other aspects of structure and organization which may be critical for a fully functional mammalian chromosome, remains poor. As a way of defining these various requirements, minichromosome reagents are being developed and analysed. Approaches for minichromosome generation fall into two broad categories: de novo assembly from candidate DNA sequences, or the fragmentation of an existing chromosome to reduce it to a minimal size. Here we describe the generation of a human minichromosome using the latter, top-down, approach. A human X chromosome, present in a DT40-human microcell hybrid, has been manipulated using homologous recombination and the targeted seeding of a de novo telomere. This strategy has generated a linear approximately 2.4 Mb human X centromere-based minichromosome capped by two artificially seeded telomeres: one immediately flanking the centromeric alpha-satellite DNA and the other targeted to the zinc finger gene ZXDA in Xp11.21. The chromosome retains an alpha-satellite domain of approximately 1. 8 Mb, a small array of gamma-satellite repeat ( approximately 40 kb) and approximately 400 kb of Xp proximal DNA sequence. The mitotic stability of this minichromosome has been examined, both in DT40 and following transfer into hamster and human cell lines. In all three backgrounds, the minichromosome is retained efficiently, but in the human and hamster microcell hybrids its copy number is poorly regulated. This approach of engineering well-defined chromosome reagents will allow key questions in MAC development (such as whether a lower size limit exists) to be addressed. In addition, the 2.4 Mb minichromosome described here has potential to be developed as a vector for gene delivery.

Generation of a human X-derived minichromosome using telomere-associated chromosome fragmentation

A linear mammalian artificial chromosome vector will require at least three functional elements: a centromere, two telomeres and replication origins. One route to generate such a vector is by the fragmentation of an existing chromosome. We have previously described the use of cloned telomeric DNA to generate and stably rescue truncated derivatives of a human X chromosome in a somatic cell hybrid. Further rounds of telomere-associated chromosome fragmentation have now been used to engineer a human X-derived minichromosome. This minichromosome is estimated to be < 10 Mb in size. In situ hybridization and molecular analysis reveal that the minichromosome has a linear structure, with two introduced telomere constructs flanking a 2.5 Mb alpha-satellite array. The highly truncated chromosome also retains some chromosome-specific DNA, originating from Xp11.21. There is no significant change in the mitotic stability of the minichromosome as compared with the X chromosome from which it was derived.

Dose intensification of etoposide in the BEAM ABMT protocol for malignant lymphoma

We have previously demonstrated a dose response relationship in Hodgkin's disease for the combination of BCNU, VP16, Ara C and Melphalan, with the superior efficacy of the BEAM regimen requiring haemopoietic support, compared with miniBEAM. To further exploit this, we have attempted to escalate the VP16 dose in BEAM. The standard etoposide dose is 200 mg/m2 IV for four days. Thirty seven patients with refractory lymphoma received 400 mg/m2/day of etoposide, and 13 patients 600 mg/m2/day, in addition to BCNU, cytarabine, and melphalan. Toxicity and outcome parameters were compared in the preceding 40 patients, who received 200 mg/m2/day etoposide. The toxic mortality with 400 mg/m2/day of etoposide (3%) was identical to that for the standard BEAM regimen (5%). Two procedure related deaths occurred in the highest VP16 dose group (15%). The morbidity of the lower etoposide dose regimens was comparable, but 600 mg/m2/day induced significantly greater gastrointestinal toxicity. Twelve of the 13 patients receiving this dose suffered grade II-IV mucositis, with stomatitis, dysphagia and prolonged diarrhoea; 5 haemodynamically significant gastrointestinal haemorrhage, and 1 fatal toxic colitis. Granulocyte colony stimulating factor did not influence the nonhaematological toxicity. The three month response rates were similar (91%) in all dose cohorts. The maximum tolerable etoposide dose within the BEAM regimen is thus 400 mg/m2 for four days.

BEAM chemotherapy and autologous bone marrow transplantation for patients with relapsed or refractory non-Hodgkin's lymphoma

PURPOSE

To evaluate the outcome of patients with relapsed or resistant non-Hodgkin's lymphoma (NHL) undergoing high-dose chemotherapy and autologous bone marrow transplantation (ABMT) and to determine the main prognostic factors.

PATIENTS AND METHODS

One hundred seven patients with relapsed or resistant intermediate-/high-grade NHL underwent high-dose carmustine, etoposide, cytarabine, and melphalan (BEAM) chemotherapy and ABMT at University College Hospitals between September 1981 and February 1993. The minimum follow-up duration of all patients is 6 months.

RESULTS

At 3 months, the overall response rate to BEAM and ABMT was 73% (41% complete response and 32% partial response). The 5-year actuarial overall survival and progression-free survival rates were 41% and 35%, respectively. The early procedure-related mortality rate was 7% (eight of 107 patients). On multivariate analysis, the main prognostic factor was disease status at the time of ABMT. Patients with chemosensitive disease had an actuarial 5-year survival rate of 49% at 5 years compared with 13% for those with chemoresistant disease (P < .001). For patients considered to have chemosensitive disease at the time of transplantation, there is a significant difference in the actuarial progression-free survival rates for those who received high-dose therapy after attaining a partial response to first-line therapy (69% at 5 years) as compared with those with sensitive but relapsed disease (32% at 5 years) (P = .003).

CONCLUSION

Patients with chemosensitive disease benefit most from high-dose chemotherapy, and those who receive such therapy early after achieving a partial response to first-line therapy have a high rate of cure.

Hepatic artery chemoembolization therapy for hepatic tumors

Patients with hepatocellular carcinomas who undergo chemoembolization therapies require skilled perioperative nursing care that addresses their knowledge deficits about chemoembolization techniques, their anxieties related to chemoembolization procedures and adverse effects, and their impaired mobility resulting from the presence of arterial lines and the progression of the cancer. Perioperative nursing participation in chemoembolization procedures is an example of the expanded role of today's OR nurse.

Autologous bone marrow transplantation in multiple myeloma: a single centre experience of 23 patients

We report the complications and outcome of high-dose melphalan and TBI combined with ABMT used in the treatment of multiple myeloma at a single centre. Twenty-three patients, aged 65 years or less, who underwent the procedure are reviewed. All had chemosensitive disease. Response to ABMT assessed at 3 months showed 75% of evaluable patients to have further tumour cytoreduction of at least 50%, with 24% of patients who entered ABMT with residual disease eventually achieving CR. There was one toxic death. The overall survival is 60% and the progression-free survival is 49.8% at a median follow-up time of 17 months. Relapse or disease progression has occurred in 27% of patients, of whom half have died. No significant prognostic factors affecting survival were found although those patients with IgG myeloma had a better outcome. Patients transplanted in first plateau appeared to do significantly better if they had been resistant to their first-line chemotherapy but had then responded to further conventional chemotherapy (p = 0.029).

Partial hypopituitarism following total body irradiation in adult patients with haematological malignancy

We present the endocrine parameters of two adult patients with partial hypopituitarism documented at 6 and 8 months after chemotherapy, single fraction total body irradiation (10.5 Gy) and autologous bone marrow transplantation. The hormone profiles demonstrate severe somatotroph insufficiency and impaired adrenocorticotroph secretory capacity, despite sparing of the gonadotroph compartment. We recommend stimulatory testing of hypothalamic-pituitary function from 3 months post-transplant, as basal hormonal concentrations may be equivocal, and supplementation may significantly improve quality of life.

Development of a simplified single-apheresis approach for peripheral-blood progenitor-cell transplantation in previously treated patients with lymphoma

PURPOSE

The aims of this study were to develop a simplified, safe, and cost-effective peripheral-blood progenitor-cell (PBPC) mobilization protocol.

PATIENTS AND METHODS

Twenty-six patients with relapsed or resistant lymphomas were entered onto a sequential cohort study in which schedules of various granulocyte colony-stimulating factor (G-CSF) were administered after cyclophosphamide 1.5 g/m2. Hematologic recovery after high-dose carmustine (BCNU) etoposide, cytarabine, and melphalan (BEAM) chemotherapy was compared with that of 46 patients who received autologous bone marrow transplantation (ABMT) without growth factors and 28 patients who received ABMT followed by G-CSF.

RESULTS

When G-CSF (10 micrograms/kg/d) was administered from the day after the cyclophosphamide, neutropenia developed on day 8 followed by an abrupt increase in the WBC count. The optimal time for PBPC harvesting was the day on which the postnadir WBC count was greater than 8.0 x 10(9)/L, as shown by CD34+ cell counts and granulocytic-macrophage colony-forming cell (GM-CFC) assays. The reproducibility of the response was such that routine monitoring of CD34+ cell counts and GM-CFC was not necessary. A single leukapheresis on this day was adequate for prompt hematologic engraftment, and posttransplant G-CSF made little further impact on the rapid recovery. Compared with both control groups, the use of PBPC led to more rapid neutrophil recovery, markedly accelerated platelet recovery, less use of antimicrobial agents and parenteral nutrition, and more than 10 days earlier discharge from hospital. All of these differences were highly significant (P < .01).

CONCLUSION

A simplified mobilization protocol is described that requires only one apheresis to achieve rapid hematologic engraftment.

Detection and significance of bone marrow infiltration at the time of autologous bone marrow transplantation in Hodgkin's disease

Bilateral iliac crest biopsies were performed at the time of bone marrow (BM) harvest in patients with poor-risk Hodgkin's disease (HD) undergoing autologous bone marrow transplantation (ABMT). 67 consecutive patients with normal trephine biopsies (58 unilateral; nine bilateral) taken 2 weeks prior to harvest were studied. Nine (13%) of patients had BM infiltration with HD on the harvest biopsies. These patients had all previously had only unilateral biopsies. Three patients did not proceed to ABMT because disease progression became clinically apparent, but the remaining six patients were infused with involved marrow. One patient died 6 weeks post ABMT, with no evidence of disease at post-mortem. One patient showed no response to ABMT and four patients either had a partial or complete response to ABMT. Of the responders, three patients are now in complete remission at 53, 39 and 33 months past ABMT.

Prospective study of pituitary-gonadal function to evaluate short-term effects of ablative chemotherapy or total body irradiation with autologous or allogenic marrow transplantation in post-menarcheal female patients

Pituitary-gonadal (P-G) function was evaluated 0-3 months before and 3-4 months after bone marrow transplantation (BMT) in 15 post-menarcheal females aged 17-30 (21.6 +/- 0.34) years with haematological malignancies. All patients had evidence of gonadal insufficiency prior to BMT in that their basal and human menopausal gonadotrophin (HMG)-stimulated oestradiol (E2) levels were significantly lower than those of control subjects. The patients also had markedly higher basal FSH levels and exaggerated responses to 100 micrograms iv gonadotrophin release hormone bolus compared with those of control subjects. However, the conditioning regimens employed prior to BMT, i.e. cytotoxic chemotherapy (CT) and total body irradiation (TBI), acting either singly or in combination, caused further ovarian damage. As a result, their gonadotrophins rose further into the menopausal range. Their oestradiol secretion diminished and ovaries became almost unresponsive 3-4 months after BMT. Pelvic ultrasound undertaken in 5 patients before and after BMT demonstrated a reduction in ovarian size associated with follicular depletion. All patients developed menopausal symptoms and became amenorrhoeic during this period. Contrary to expectation, the hormonal changes occurring acutely were similar in patients undergoing radiation-based regimens and those conditioned with high-dose chemotherapy alone. Also, the severity of ovarian dysfunction appeared independent of age at transplantation, the nature of the conditioning-regimen or the type of transplant. Gonadotrophic, thyrotrophic, lactotrophic and adrenocorticotrophic secretions were unaffected. These data indicate that the ovary suffers an acute insult during short-term chemotherapy but the anterior pituitary gland retains its trophic hormone reserve and secretory capacity.

Germ cell failure and Leydig cell insufficiency in post-pubertal males after autologous bone marrow transplantation with BEAM for lymphoma

Thirteen post-pubertal male patients aged 17-25 years were assessed for pituitary-gonadal function 0-3 months prior to and 2-3 months post-bone marrow transplantation for haematological malignancy. All patients had multiagent cytotoxic treatment prior to transplantation and 30% were found to have germ cell dysfunction with abnormal semen parameters before high-dose therapy indicating damage to the germinal epithelium. They also had evidence of reduced Leydig cell reserve even before transplantation. During transplantation all patients sustained sustained gonadal injury, the effect on their germ cells being more pronounced than on the Leydig cells. Fifty per cent had reduction in testicular volume and all had azoospermia 2-3 months post-transplantation. Our results indicate that short-term chemoradiotherapy causes profound damage to the germ cell compartment of the testis, with less severe damage to the Leydig cells, but no overt injury to the anterior pituitary gland. The changes appeared to be identical in patients conditioned with total body irradiation-based protocols and those who received only high-dose chemotherapy prior to bone marrow transplantation.

Liposomal amphotericin B in the treatment of fungal infections in neutropenic patients: a single-centre experience of 133 episodes in 116 patients

Liposomal amphotericin B (AmBisome) was used for suspected or confirmed fungal infection complicating 133 neutropenic episodes in 116 patients not tolerating, or not responding to, conventional amphotericin. Adverse effects were infrequent and no significant renal impairment resulted. Acute reactions occurred in five patients, reversible hepatic dysfunction in 23, and hypernatraemia in 17. The putative mycosis resolved with AmBisome treatment in 81 episodes (61%) and progressed with fatal outcome in 25 (19%), but the diagnosis was equivocal in most, and in 27 episodes (20%) evidence indicating nonfungal pathogenesis emerged. Treatment efficacy is, however, evaluable in those with proven aspergillosis. 13/17 patients with confirmed invasive aspergillosis responded to AmBisome (77%), conventional amphotericin having failed in 11. Treatment was successfully discontinued when the neutrophil count was < 1 x 10(9)/l in eight responders (61%). In four further patients treated for suspected aspergillosis, disseminated infection was documented at post-mortem, but the true incidence is unknown. This analysis confirms that AmBisome is well tolerated and effective against invasive mycoses in neutropenic patients, and may salvage patients when conventional amphotericin proves excessively toxic or ineffective.

Induction of ovarian function by using short-term human menopausal gonadotrophin in patients with ovarian failure following cytotoxic chemotherapy for haematological malignancy

Currently no treatment has proved successful in inducing ovarian steroidogenic and/or gametogenic recovery in patients with haematological malignancies treated by cytotoxic chemotherapy once biochemical failure becomes manifest i.e., when FSH levels exceed 40 IU/L. This paper reports two such cases with classical biochemical ovarian failure in which ovarian function was induced by brief stimulation with Human Menopausal Gonadotrophin (HMG).

Efficacy of delayed granulocyte colony-stimulating factor after autologous BMT

Granulocyte colony-stimulating factor (G-CSF) has been shown to be effective in accelerating neutrophil recovery after BMT. In this single centre study, we have examined the effect of delaying the start of treatment with G-CSF (5 micrograms/kg) until 8 days after BM infusion in a cohort of 17 patients with malignant lymphomas undergoing autologous BMT. In comparison with historical controls, neutrophil recovery to > 0.5 x 10(9)/l was shortened from 22 to 14 days (p < 0.01). Patients receiving G-CSF required iv antibiotics for a median 13 days (control 17, p < 0.05) and were discharged a median 28 days post-ABMT (control 32.5, p = NS). Patients received G-CSF for a median of 10 days only. Although these results require confirmation in a randomised trial they suggest that G-CSF administration could be delayed until 8 days after BMT without compromising efficacy and with an accompanying reduction in treatment costs.

Psychological and psychophysiological factors in prevention and treatment of cold injuries

Cold injured patients in Alaska come from many sources. Although sport and work continues to provide large numbers of cold injured, most severe repeat injuries tend to reflect other biopsychosocial consequences. Certain behaviors can increase the probability of injury, however all persons living in cold climates are potential candidates. One can decrease risk by education, knowledge and intelligent behavior. Proper respect for adequate protection and hydration seem to be critical factors. Understanding the psychological, physiological and psychophysiological aspects of the cold environment performer helps refine the prevention and treatment strategies for cold injury. Skill training with bio-behavioral methods, such as thermal biofeedback, and the value of medical psychotherapy appear to offer continued promise by facilitating physiologic recovery from injury, as well as assisting in long term rehabilitation. Both approaches increase the likelihood of a favorable healing response by soliciting active patient participation. Medical Psychotherapy for traumatic injuries can also help identify and manage cognitive emotional issues for families and patients faced with the permanent consequences of severe thermal injuries. Thermal biofeedback therapy has the potential benefit of encouraging greater self-reliance and responsibility for self-regulating overall health by integrating self-management skills regarding physiology, diet and lifestyle. Inpatient and outpatient biofeedback training offers specific influence over vascular responses for healing, as well as providing an effective tool for pain management. Interest in cold region habitation has continued to expand our study of human tolerance to harsh, extreme environments. Biological, psychological, sociological, and anthropological views on adaptation, habituation, acclimatization, and injury in cold environments acknowledges the role of development, learning and educated responses to cold environments. The study of health, performance, and injury prevention in extreme isolated cold environments has important strategic and scientific implications. What is learned from behavioral studies of cold survival provides an opportunity to increase our scientific knowledge and understanding. These cold research findings can assist in our future exploration of cold, underwater farming at great depths, and to far distance space travel to cold planets. The relatively new research frontier "Polar Psychology" has evolved to study how interactions with cold environments can have both positive and/or negative consequences. This research simulates the psychological factors likely to be encountered while exploring isolated cold regions of distant galaxies. The psychological and psychophysiological correlates of cold experience appear to be a function of four interactive issues: the environment, genetic predisposition, learning or experience, and finally perception or cognition. Individual cold tolerance seems to relate heavily on sensation, perception and behavior.(ABSTRACT TRUNCATED AT 400 WORDS)

Five case reports of high grade non-Hodgkin's lymphoma in human immunodeficiency virus-1 negative homosexual men

High grade non-Hodgkin's lymphoma accounts for only 5%-10% of all non-Hodgkin's lymphoma. Infection with the human immunodeficiency virus increases the risk of developing high grade, usually B-cell, lymphoma, which has been noted to occur more commonly in homosexual men. These lymphomas often have unusual clinical presentations. We report five cases of high grade non-Hodgkin's lymphoma in HIV negative homosexual men who presented to our hospital in a 13-month period. As a major centre for the treatment of the acquired immune deficiency syndrome, there may be a self-selected homosexual population attending for medical care, and thus a bias in the relative incidence of lymphoma seen in this group.

From taxonomy I to taxonomy II

Taxonomic development in nursing, although still in its infancy, is progressing. Taxonomy development has moved beyond subjective placement of diagnoses into categories based on an "expert" opinion alone. The taxonomy of nursing diagnoses is entering a new era whereby the assumptions and classification rules for Taxonomy I--Revised are being investigated. Alternative taxonomic structures require careful scrutiny and comparison to establish whether one structure will meet the needs of the profession or whether multiple structures of nursing diagnoses relative to outcomes are required. As members within the discipline become more sophisticated in approaches to taxonomic development, methods of handling taxonomic problems, such as varying levels of abstraction and taxonomic affinity, will be discerned.

Implementation of unit-based quality assurance projects in a rehabilitation hospital

This article describes a unit-based quality assurance program in a rehabilitation nursing department. Staff selected clinical nursing topics of interest and concern in rehabilitation nursing and developed projects with the aim of improving quality of care.

The effect of indomethacin, aspirin, and ibuprofen on bone ingrowth into a porous-coated implant

Therapeutic doses of indomethacin, aspirin, and ibuprofen were administered to New Zealand White rabbits after implantation of a porous-coated chrome-cobalt implant. Quantitative histomorphometric analysis was used to calculate the amount of bone occupying the pores. There was a statistically significant decrease in bone ingrowth in animals treated with indomethacin, ibuprofen, and high-dose aspirin when compared to a control group. There was a dose-response effect for the indomethacin and aspirin groups, with higher doses having a greater inhibitory effect. Indomethacin, ibuprofen, and high-dose aspirin may be contraindicated during the immediate postoperative period in patients having cementless arthroplasty.

Safety and efficacy of warfarin started early after submassive venous thrombosis or pulmonary embolism

Two anticoagulant regimens, similar except for the timing of warfarin therapy, were compared in patients with clinically submassive venous thromboembolism (VTE). Warfarin was begun after 7 days of continuous intravenous heparin infusion in group L (127 patients) or within 3 days (average 1 day) of starting heparin in group S (139 patients), with similar outcomes. The frequency of symptomatic VTE recurrence during the hospital stay was 4.7% in group L and 3.6% in group S, and that of symptomless new perfusion defects 8.5% in group L and 3.9% in group S. On routine iodine-125-fibrinogen leg scanning of patients presenting with distal thrombosis (in the calf, popliteal, or distal femoral veins) 3.6% of group S but no group L patients had symptomless proximal extension. The incidence of bleeding was similar with both regimens. Outpatient follow-up showed no excess recurrent VTE in either treatment group. Early warfarin treatment significantly shortened hospital stay by an average of 3.9 days (30%) in patients admitted solely because of VTE.