Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Mechanical endonasal dacryocystorhinostomy--a reproducible technique

BACKGROUND

A study to assess the efficacy and patient acceptability of Mechanical Endonasal Dacryocystorhinostomy (MENDCR) in patients with acquired nasolacrimal duct obstruction.

METHODS

A retrospective series of 38 patients undergoing 37 primary and 7 revision MENDCR's between March 2003 and October 2007. Patients included had symptomatic epiphora with anatomical obstruction on syringing or functional obstruction on scintillography. Short-term follow up was assessed subjectively and objectively by anatomical patency on nasoendoscopy and free flow of fluorescein from eye to nose. Medium term follow up was assessed subjectively by telephone conversation with the patient. The average follow up period was 25.2 months (range 7-50).

RESULTS

There were 44 DCR's performed on 38 patients (12 male, 26female). Average patient age was 67.0years (range 16.6-97.5). Almost all patients (95%) presented with epiphora, and a further 34% with dacryocystitis and/or mucocele. At short term follow up 40/44 (91%) were successful objectively. Of two that failed, neither had a patent ostium and one had recurrent mucocele. Both went on to revision surgery, which was successful at later review. A further two had visible ostia but no free flow of fluorescein. At long term follow up 90% were happy with the procedure and would undergo surgery again. All failures occurred by 3-month follow up.

CONCLUSION

The technique of nMENDCR is a reproducible technique with results comparable to the original authors. MENDCR is an acceptable alternative to external DCR. It is well tolerated by patients most of whom were satisfied and would undergo the same procedure again.

Temporary elevation of serum transaminases after pediatric intestinal transplantation: incidence and clinical correlation in multivisceral transplant vs isolated intestinal transplant

Data were gathered from the records of 51 children of median age 1.5 years who survived more than 6 months after intestinal transplantation. Abnormal liver function tests (LFTs) were defined as serum aspartate aminotransferase (AST) greater than 100 IU/L or total bilirubin greater than 2.0 g/dL lasting more than 3 days. Temporary elevation was defined when LFTs returned to normal without graft loss or death. LFT elevation at the time of transplantation was not included as a temporary LFT elevation. Median follow-up was 36 months. In multivisceral transplant recipients, all patients (n = 34) showed abnormal LFTs at transplantation that normalized within a median period of 2 days. Temporary LFT elevations were seen in 20 of 34 (59%) in multivisceral transplantation and 5 of 17 (29%) in isolated intestinal transplantation. Median length of elevation was 14 days in multivisceral transplantation and 12 days in isolated intestinal transplantation. Peak AST was 353 +/- 190 IU/dL in multivisceral transplantation and 839 +/- 605 IU/dL in isolated intestinal transplantation (P = .0059). Events associated with temporary LFT elevations in multivisceral transplantation were total parental nutrition (TPN) (n = 8), dehydration (n = 2), viral infection (n = 2), others (n = 3), and nonspecific (n = 5). Events in isolated intestinal transplantation were posttransplant lymphoproliferative disorder (n = 2), TPN (n = 1), and nonspecific (n = 2). Temporary LFT elevations were commonly seen among pediatric intestinal recipients, which correlated with events other than rejection. Approximately half of the temporary LFT elevations were associated with no significant clinical events. They resolved spontaneously. Interestingly, the peak AST value was higher in isolated intestinal transplantation compared to multivisceral transplantation.

Expanded use of multivisceral transplantation for small children with concurrent liver and intestinal failure

Fifty-five children with liver and intestinal failure have been transplanted at our center under daclizumab induction therapy since 1998. Of those, 19 received five multiviceral transplantation (MVT), 12 liver-intestine-pancreas transplants, and 2 noncomposite liver and intestine transplants (NCLIT) before 2001 (group 1). During this period, MVT was only used in children with gastric dysmotility. After 2001, we expanded the use of MVT. Therefore, 36 children in this period (group 2) received MVT except for two who received NCLIT. Median age was 1.08 in group 1 and 1.06 in group 2. Median recipient weight was 8.2 kg in group 1 and 7.5 kg in group 2. Six-month, 1-, and 2-year patient survivals were 54%, 37%, and 32% in group 1 and 94%, 91%, and 71% in group 2 (P = .00037). A statistically significant difference was observed in freedom from rejection between the two groups with group 2 being favorable (P = .0019). A statistically significant difference was observed in freedom from rejection between the two groups with group 2 being favorable (P = .0019) Four died of rejection in group 1 (21%); none died of rejection in group 2. There have been two esophago-gastrostomy strictures (one in each group) and a serious reflux of this anastomosis (group 2). Strictures were treated with balloon dilatation, and the reflux was surgically corrected. In 24 recent cases, gastro-gastric anastomosis was used in MVT with no complications to date. No pancreatic rejection was seen. Small children tolerated MVT with improved survival rates and reduced rates of rejection. Use of MVT may be considered as an alternative to liver-intestine-pancreas transplant.

Growth After Intestinal Transplant in Children

Intestinal transplantation has been more frequent in children with intestinal failure. However, the growth after intestinal transplantation has not been well documented. The demographics, transplant information, postoperative complications, heights, and weights were obtained retrospectively from medical records on 23 children who underwent intestinal transplantation. Z-scores were calculated from the STAT Growth-BP, based on Centers for Disease Control and Prevention growth chart (2000). Transplantations were performed between 1999 and 2004. Patient median age was 1.1 years (range 0.5 to 6.9 years). Twelve were boys and 11 girls. Seventeen children received multivisceral transplantations, one modified multivisceral transplantation, and five isolated intestinal transplantations. Baseline immunosuppression consisted of tacrolimus and corticosteroids. Daclizumab was used as induction agent in 18 patients; alemtuzumab, in five patients. Median pretransplant Z-scores were median -1.67 (n = 23) in weight, and median -3.36 (n = 21) in height. Pretransplant growth was significantly retarded. We analyzed significantly retarded patients with Z-score <-2.0. The change of weight Z-score from pretransplant was: 1.25 at 6 months (n = 11), 1.46 at 12 months (n = 10), and 2.21 at 24 months (n = 7). The change of height Z-score: 1.9 at 6 months (n = 16), 1.42 at 12 months (n = 13), and 1.51 at 24 months (n = 10). Z-score significantly improved (P < .002, ANOVA). Among the analyzed factors sex, age at transplant, length of stay, and rejection within 6 months, were not associated with catch-up growth. Children with retarded growth showed significant catch-up after successful intestinal transplantation.

Renal Function After Pediatric Intestinal Transplant

Data were analyzed from 44 patients who survived more than 2 years after intestinal transplantation performed between 1994 and 2002. Median age was 1.7 years. Tacrolimus level was defined as average tacrolimus level over 6 months. Kidney function was evaluated using a 6-month average serum creatinine. Glomerular filtration rate (GFR) was calculated with the Schwartz formula. The procedures were: isolated intestinal transplantation (n = 11), liver and intestinal transplantation (n = 9), multivisceral transplantation (n = 22), and modified multivisceral transplantation (n = 2). Forty-four patients were followed for a mean of 3.6 years on tacrolimus. Tacrolimus levels ranged between 3.5 and 19.9 ng/mL (median 14.6 ng/mL) at 0 to 6 months and 6.0 to 18.9 ng/mL (median 13.2 ng/mL) at 0 to 12 months. Pretransplant kidney function as mean GFR was 138 +/- 42 mL/min/1.73 m(2) (n = 44), posttransplant kidney function at 18 to 24 month as mean GFR was 102+/-35 mL/min/1.73 m(2) (n = 44), a value that was 81% of the pretransplant GFR (P < .0001). In an analysis of tacrolimus level versus renal function, a value greater than 13.5 ng/mL during the first 12 months was a significant predictor for impaired renal function at 2 years after transplantation (defined as average GFR less than 90 mL/min/1.73 m(2) at 18 to 24 months; P = .001). Only age among age, sex, diagnosis, transplant type, and rejection episodes showed a correlation with renal function. Renal function dropped significantly at 2 years after pediatric intestinal transplantation to 81% of the pretransplantation value. Tacrolimus level for the first 12 months seemed to predict subsequent development of renal impairment at 2 years.

Renal Dysfunction Following Adult Intestinal Transplant Under Tacrolimus-Based Immunosuppression

We analyzed data from the records of 24 adult patients who survived more than 2 years after intestinal transplantation performed between 1995 and 2002 under tacrolimus-based immunosuppression. Ages ranged from 19.3 to 59.2 years old (median 32.1 years). Tacrolimus cumulative level was defined as a sum of weekly average tacrolimus level over time. Kidney function was evaluated by the 6-month average serum creatinine level. Estimated creatinine clearance was calculated with the Cockcroft-Gault formula. Student's t test was used for analysis. Primary diseases were mesenteric thrombosis (n = 7), trauma (n = 4), Crohn's (n = 3), Gardner's (n = 5), and others (n = 7). Procedures were isolated intestinal transplant (n = 10), liver and intestine (n = 1), multivisceral transplant (n = 9), or modified multivisceral transplant (n = 4). Cumulative tacrolimus levels ranged between 1161 and 8623 ng*day/mL (median 4132 ng*day/mL) at 0 to 12 months. Pretransplant kidney function as mean creatinine clearance was 114 mL/min per 1.73 m(2) (n = 24). Creatinine clearance decreased to a mean of 49.6 mL/min per 1.73 m(2) (43.5% of pretransplant) at 2 years (P < .0001). The average creatinine clearance at 18 to 24 months in each patient with a cumulative tacrolimus level <4500 ng*day/mL was 63% +/- 25% of preoperative creatinine clearance. In patients with a cumulative tacrolimus level >4500 ng*day/mL, it was 34% +/- 17%. Cumulative tacrolimus level >4500 ng ng*day/mL was significantly associated with a decreased creatinine clearance at 2 years (P = .006). Renal function decreased significantly after intestinal transplantation in adults. Cumulative tacrolimus level in the first year affected renal function at 2 years.

Intestinal Transplantation With Alemtuzumab (Campath-1H) Induction for Adult Patients

BACKGROUND

Alemtuzumab (Campath-1H [C1H]) is a humanized monoclonal antibody directed against the CD 52 antigen that is present on the surface of T cells, B cells, natural killer cells and monocytes. We studied its application in intestinal transplantation.

METHODS

This is a retrospective review of adult patients who underwent intestinal transplantation between December 1994 and May 2005. Group 1: non-C1H group (n = 39); group 2: C1H group (n = 37). C1H was administered as an induction immunosuppression in four doses (0.3 mg/kg), or in two doses (30 mg/kg). Tacrolimus levels were maintained at low level (5-10 ng/dL). No maintenance steroids were given.

RESULTS

One-year survival of group 1 and group 2 patients were 57% and 70%, respectively. This difference is not statistically significant. Of 37 patients in group 2, 21 are alive. The incidence of rejection was lower in group 2 (P < .005). Average current tacrolimus level is 6.97 +/- 3.98 ng/dL. Seventeen patients (81%) are steroid free, and 15 (71%) are maintained solely on tacrolimus. There was no graft versus host disease in group 2.

CONCLUSIONS

Our preliminary data suggest that C1H can provide effective immunosuppression for intestinal transplantation. Incidence of rejection was less with this regimen using low maintenance tacrolimus and minimal steroids.

Modulation of A(beta) peptides by estrogen in mouse models

Clinical studies have shown that estrogen deprivation through menopause is a risk factor in both the initiation and progression of Alzheimer's disease (AD) and that estrogen replacement therapy may be protective. One of the major pathological features in the human AD brain is the senile plaque, a proteinaceous structure composed mainly of heterogeneous peptides collectively known as A-beta (A(beta)). In vitro studies have linked estrogen with A(beta) modulation, suggesting that one-way that estrogen depletion at menopause may exacerbate the features of AD is through A(beta) accumulation. To test this, two studies were performed on transgenic models of amyloidosis. Firstly, transgenic mice without detectable amyloid aggregates were subjected to ovariectomy and estradiol supplementation, and A(beta) levels were assessed. Secondly, the effects of estrogen modulation were assessed in mice at an age when plaques would be forming initially. Overall, A(beta) levels were higher in estrogen-deprived mice than intact mice, and this effect could be reversed through the administration of estradiol. These data suggest that, in vivo, estrogen depletion leads to the accumulation of A(beta) in the CNS, which can be reversed through replacement of estradiol. These results provide evidence that post-menopausal estrogen depletion may be linked to an increased risk of AD through A(beta) modulation.

SF-36 health status of workers compensation cases with spinal disorders

BACKGROUND CONTEXT

Poorer outcomes of treatment are reported in patients with spinal disorders who receive workers compensation. The reason for their suboptimal outcomes is unclear. No study has examined the relationship between workers compensation and the Short Form Health Survey (SF-36) health status of patients with spinal disorders.

PURPOSE

To compare the self-perceived health status of spinal disorder patients receiving workers compensation with those not receiving workers compensation.

STUDY DESIGN/SETTING

A cross-sectional study on 18,389 patients who were evaluated in the 28 centers comprising the National Spine Network.

PATIENT SAMPLE

The study data were derived from patients when first evaluated for back or neck pain between January 1998 and April 2000.

OUTCOME MEASURES

The outcome measures used were the eight individual and two component scores of the SF-36.

METHODS

All first-visit patients enrolled in the National Spine Network from January 1998 to April 2000 were reviewed. Eight individual scores and two component scores of the SF-36 were compared.

RESULTS

Of the 18,389 patients, 1,535 (8%) were receiving workers compensation. Bivariate analyses showed all eight individual scores, and two summary scores of the SF-36 were significantly lower (p<.0001) in patients receiving workers compensation. After controlling for confounding covariates, workers compensation status was a significant predictor of lower SF-36 scores for General Health (p<.0001), Physical Functioning (p<.0001), Role Physical (p<.01), Social Functioning (p<.05), and Mental Health (p<.05).

CONCLUSIONS

Workers compensation status is associated with poorer physical and mental health of patients with spinal disorders. Because the workers compensation group is younger, has a shorter duration of symptoms, and fewer comorbid medical problems, the lower SF-36 scores most likely reflect psychological factors and not ill health per se. The lower SF-36 scores may also reflect premorbid personality differences in the workers compensation patients, compared with those not receiving workers compensation. SF-36 is a validated tool that can be used to objectively identify the patient at risk for delayed recovery. Future treatment protocols should pay special attention to improve the health-related quality of life, especially general health and physical functioning of spinal patients receiving workers compensation.

Sedative and cardiopulmonary effects of medetomidine and reversal with atipamezole in desert tortoises (Gopherus agassizii)

Ten desert tortoises (Gopherus agassizii) were given i.m. injections of 150 microg/kg of medetomidine. Sedation was achieved in all tortoises by 20 min postinjection and was accompanied by a significant decrease in mean heart and respiratory rates, systolic, diastolic, and mean ventricular pressures, and mean ventricular partial pressure of oxygen (PO2). There was no change in mean blood pH, HCO3, Na+, K+, ionized calcium values, and mean ventricular partial pressure of carbon dioxide (PCO2). There were statistically significant but clinically insignificant changes in mean base excess and pH-corrected ionized calcium values. Atipamezole given to five of the tortoises at 0.75 mg/kg i.m. significantly reversed the sedative effects of the medetomidine, with all tortoises returning to a normal state by 30 min after administration of the reversal agent. In comparison, the other five tortoises given an equal volume of physiologic saline in place of atipamezole (control group) remained significantly sedated for the duration of the study. In addition, the heart rate and ventricular PO2 returned to baseline, but the respiratory rate and ventricular blood pressures were not significantly altered by the atipamezole as compared with those of the control group. These cardiopulmonary and physiologic effects are similar to those seen in some domestic mammals. Medetomidine can be used to safely induce sedation in desert tortoises. For procedures lasting greater than 120 min, supplemental oxygen should be provided. Atipamezole will reverse the sedation but not all of the cardiopulmonary effects, thus necessitating continued monitoring after reversal. Future studies should address the anesthetic and cardiopulmonary effects of medetomidine in combination with other agents such as ketamine and/or butorphanol.

Sevoflurane anesthesia in desert tortoises (Gopherus agassizii)

The effects of sevoflurane on anesthesia induction, recovery, ventricular pressures, heart rate, ventricular pH, blood gas values, and electrolytes were evaluated in desert tortoises (Gopherus agassizii). Tortoises were orotracheally intubated while awake and ventilated manually with 3-7% sevoflurane in oxygen (1 L/min) to achieve desired expired sevoflurane concentrations. Data, consisting of induction time, recovery time, systolic, diastolic, and mean ventricular pressures, heart rate, ventricular pH, blood gas values, and electrolytes, were collected prior to anesthesia and sequentially at 2.50% and 3.75% expired sevoflurane as measured at the junction of the endotracheal tube and the breathing circuit. Blood pressure was measured and blood samples were collected through a 25-ga needle passed through a cardiac access port that was placed while the tortoises were in dorsal recumbency. Mean (+/-SE) induction time was 2.55+/-0.55 min, recovery time was 27.58+/-7.55 min, and duration of anesthesia was 105+/-12 min. Mean (+/-SD) values for systolic, diastolic, and mean ventricular pressures in awake tortoises were 28+/-3 mm Hg, 22+/-2 mm Hg, and 24+/-2 mm Hg, respectively. Sevoflurane (2.5% expired) significantly decreased systolic (14+/-3 mm Hg), diastolic (12+/-1 mm Hg), and mean (13+/-1 mm Hg) ventricular pressures compared with those of awake tortoises. Ventricular pressures did not decrease further with increasing depth of anesthesia. Heart rate (32+/-4 beats/min) did not change significantly under sevoflurane anesthesia. Sevoflurane administration increased ventricular PO2 but did not change Na+, K+, or iCa++ concentrations. Sevoflurane appears to provide safe and effective anesthesia with rapid induction and recovery.

Diagnosis and surgical repair of partial atrioventricular septal defects in two dogs

Partial atrioventricular (AV) septal defects consist of an ostium primum defect and malformation of the septal cusp of the mitral valve. A partial AV septal defect was diagnosed by means of echo-cardiography in 2 dogs. Transatrial septal blood flow was high enough in both dogs to warrant surgical correction. Defects were repaired through right fifth intercostal thoracotomies, with the aid of cardiopulmonary bypass. An incision was made in the right atrium to expose the AV septal defect, and the mitral valve was inspected through the septal defect. The cleft in the septal cusp of the mitral valve was repaired with mattress sutures of 6-0 polypropylene. The septal defect was closed with autogenous pericardium harvested from the right aspect of the pericardial sac. Both dogs survived surgery and were alive 15 and 42 months, respectively, after surgery, however, 1 dog developed progressive mitral regurgitation after surgery. Partial AV septal defects can be successfully repaired in dogs. Long-term prognosis probably depends on the adequacy of the mitral valve repair.

Brief hypoxic stress downregulates E. coli-induced IL-1 alpha and IL-1 beta gene expression in perfused liver

Hepatic cytokine gene expression is independently stimulated by circulating microbial products and reductions in the cellular O2 supply. Although these stimuli occur sequentially after gram-negative bacteremia, it is unknown whether their interplay augments production of interleukin (IL)-1 by the liver. We studied the effects of intraportal Escherichia coli (EC) bacteremia and secondary constant-flow hypoxia (Po2, approximately 46 Torr for 30 min) on IL-1 alpha and IL-1 beta gene expression in ex situ buffer-perfused rat livers over 180 min (n = 67). At t = 0, normoxic EC and normal saline (NS) controls received 10(9) live EC serotype 055:B5 and 0.9% NaCl, respectively; in livers subjected to EC+hypoxia-reoxygenation (H/R) and NS+H/R, hypoxia began 0.5 h after EC or NS and was followed by 120 min of reoxygenation. Portal and hepatic venous perfusates were serially analyzed for bacterial colony-forming units, O2 uptake, and aspartate aminotransferase. At 60 min (peak hypoxia) and 180 min, cDNAs for IL-1 alpha and IL-1 beta were hybridized to whole liver RNA, and IL-1 beta protein levels in venous perfusates were assessed. Intrahepatic levels of reduced glutathione (GSH) were measured as an index of oxidative stress. Compared with normoxic EC, IL-1 alpha transcripts decreased at 180 min in EC+H/R livers (P < 0.0001) as did IL-1 beta mRNA (P < 0.05), despite similar EC clearance, GSH levels, posthypoxic O2 uptake, and aspartate aminotransferase release. Hepatic secretion of IL-1 beta likewise fell in EC+H/R vs. EC controls (P < 0.005). Prostaglandin H synthase-2 (COX-2) message accumulation was not enhanced by H/R, and indomethacin did not reverse H/R-mediated suppression of IL-1 production. In contrast, H/R-related falls in EC-induced IL-1S expression were reversed by allopurinol or catalase. Thus brief hypoxic stress of the liver causing neither GSH depletion nor functional impairment downregulates postbacteremic IL-1 expression by a mechanism involving O2 radicals but not cyclooxygenase metabolites.

Long-term subjective functional outcome of surgery plus postoperative radiotheraphy for advanced stage oral cavity and oropharyngeal carcinoma

BACKGROUND

Although long-term cures have been achieved for locally advanced squamous cell carcinomas of the head and neck, there is a paucity of information available regarding patients' perspectives of their functional outcome.

PATIENTS AND METHODS

Thirty-five long-term survivors free of disease following surgery and postoperative radiotherapy for advanced cancers of the oral cavity and oropharynx were sent questionnaires to evaluate their long-term functional outcome after therapy. The questionnaires included a subjective performance status scale that assessed the patient perceived (1) ability to eat in public, (2) understandability of speech, and (3) normalcy of diet. Twenty-nine of 35 patients participated in this function assessment and are the subjects of this report.

RESULTS

The mean function scores for all patients were as follows: 72 for eating in public, 69 for understandability of speech, and 58 for normalcy of diet. Functional results were further analyzed by T stage and anatomic subsite. Inferior results were noted with increasing T stage. A two-way analysis of variance showed that this difference was significant even after adjusting for the effect of anatomic subsite (P = 0.0002, P = 0.018, and P = 0.0018 for the three outcome variables). In addition, patients with base of tongue lesions had a worse functional outcome for both early T state (T1/T2) and advanced T stage (T3/T4) when compared to other subsites. This difference averaged across T stage was statistically significant for understandability of speech (P = 0.0019) and normalcy of diet (P = 0.013), but was not significant for eating in public (P = 0.16).

CONCLUSIONS

This performance status scale was found to be a useful tool for functional assessment following definitive therapy for advanced stage head and neck carcinomas. These subjective functional scores deteriorated with increasing T stage. In addition, functional scores for oral tongue, floor of mouth, and tonsillar primaries were superior to those for base of tongue lesions. These functional outcome scores are consistent with the extent of surgery required for the base of tongue subsite and are in direct relation to the patients' T stage in this study population.

The effect of diagnosis and treatment delay on prognostic factors and survival in endometrial carcinoma

OBJECTIVE

The aim of this study was to assess the association of diagnosis and treatment delay with established prognostic factors and survival.

STUDY DESIGN

The study group comprised 181 consecutive patients with endometrial carcinoma diagnosed between 1970 and 1986, whose records contained details with regard to diagnosis delay; 174 of them also contained details with regard to treatment delay.

RESULTS

The significant prognostic factors that we found, namely, age, clinical stage, grade, depth of myometrial invasion, and histologic type, are in line with those of other studies. However, no significant correlation was found between the duration of delay and these prognostic factors or with survival.

CONCLUSION

We conclude that delay of diagnosis (< 1 year) and of treatment of < 4 months do not compromise survival of patients with endometrial cancer.

Carcinoma of the ampulla of Vater

We reviewed our experience with 69 patients with carcinoma of the ampulla of Vater admitted to the Memorial Sloan-Kettering Cancer Center, New York, from October 1983 to October 1990. Of the 69 patients, 66 were explored and 55 underwent resection (83 percent resectability). The median length of survival for the 55 patients who underwent resection was 51 months, compared with eight months for the 14 patients who did not undergo resection (p = 0.000004). Of the variables evaluated, only resectability was a statistically significant predictor of survival. Positive lymph nodes in 17 of 55 patients who underwent resection were not predictive of long term survival.

Severe toxicity limits intensification of induction therapy for acute lymphoblastic leukemia

Fourteen adult patients with newly-diagnosed acute lymphoblastic, leukemia (ALL), and lymphoblastic lymphoma, were treated with a dose-intense induction regimen. This regimen was designed to increase the fraction of patients achieving an early complete remission, in an attempt to increase the fraction of patients who are long-term disease-free survivors. The induction regimen included vincristine, prednisone, intermediate-dose cytarabine (Ara-C), and idarubicin, all given during the first week of therapy. This combination led to significant hepatic, gastro-intestinal, infectious, and neurologic toxicity. There was unacceptable treatment-related mortality (29%). After the first eight patients, the study was modified, omitting the Ara-C from the induction phase. Gastrointestinal morbidity was less in the cohort treated without Ara-C; however, infectious morbidity persisted at unacceptable levels and this program was terminated as too toxic to administer. There were nine complete remissions, three early deaths, and two patients with resistant disease. There have been six relapses, three of which occurred in patients who, because of protracted grade III/IV toxicity, were no longer receiving chemotherapy. With a minimum follow-up of 20 months, only three patients are still alive. We conclude that this combination of vincristine, prednisone, Ara-C, and idarubicin, is too toxic to be used as induction therapy for adult patients with ALL and lymphoblastic lymphoma.

Four cycles of chemotherapy and regional radiation therapy for clinical early-stage and intermediate-stage Hodgkin's disease

To achieve a high percentage of durable complete remissions (CR) and prolonged survivals and reduce toxicity in patients with early-stage and intermediate-stage Hodgkin's disease, a randomized trial of four cycles of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) versus four cycles of thiotepa, bleomycin, and vinblastine (TBV) combined with regional radiation therapy (RT) was conducted. For MOPP and RT, the CR percentage was 98% (60 of 61), and at 5 years, the percentage of patients in CR was 90%, with freedom from progression of 89% and overall survival of 91%. For TBV and RT, the CR percentage was 93% (55 of 59), with a 5-year duration of CR of 83%, freedom from progression of 81%, and overall survival of 91% (P greater than 0.15). The median follow-up was 65 months (range, 7 to 96 months). For 27 patients with clinical Stage IIIA, the CR percentage for MOPP and RT was 75% (12 of 16), with 1 relapse and 4 deaths. For TBV and RT, the CR percentage for clinical Stage IIIA was 73% (8 of 11) with 2 relapses and 2 deaths. Short-term toxicity except for transient leukopenia was less for TBV and RT than for MOPP and RT. Good results are achievable with combined treatment without excessive toxicity.

The role of multimodality therapy in soft-tissue sarcoma

Soft-tissue sarcomas are uncommon malignancies. The development during a period of 8 years, in one institution, of a prospective data base incorporating more than 1600 patients with these tumors is described. The most common sites for occurrence are the extremities, but they can occur in any of the soft tissues of the body. Liposarcoma and leiomyosarcoma are the most common histopathologic conditions identified. Prognostic factors for both recurrence and survival include site, histopathology, size, grade, and adequacy of resection. A prospective randomized trial of the use of adjuvant radiation by the brachytherapy technique in extremity lesions has shown a decrease in local recurrence, but no impact on survival. Eligible patients not randomized to the trial show no difference in local recurrence or survival, regardless of whether they received adjuvant radiation.

Regulation of a chitinase gene promoter by ethylene and elicitors in bean protoplasts

Chitinase gene expression has been shown to be transcriptionally regulated by a number of inducers, including ethylene, elicitors, and pathogen attack. To investigate the mechanism(s) responsible for induction of chitinase gene expression in response to various stimuli, we have developed a transient gene expression system in bean (Phaseolus vulgaris) protoplasts that is responsive to ethylene and elicitor treatment. This system was used to study the expression of a chimeric gene composed of the 5' flanking sequences of a bean endochitinase gene fused to the reporter gene beta-glucuronidase linked to a 3' fragment from nopaline synthase. Addition of 1-aminocyclopropane-1-carboxylic acid, the direct precursor of ethylene, or elicitors such as chitin oligosaccharides or cell wall fragments derived from Colletotrichum lagenarium, to transformed protoplasts resulted in a rapid and marked increase in the expression of the chimeric gene. The kinetics and dose response for these treatments were similar to those observed for the native gene in vivo. Analyses of 5' deletion mutants in the protoplast system indicated that DNA sequences located between -305 and -236 are important for both ethylene and elicitor induction of the reporter gene.

Limited small-cell lung cancer: do favorable short-term results predict ultimate outcome?

Advances in the treatment of limited small-cell lung cancer (L-SCLC) have led to improved short-term outcome. However, it is not clear how well this predicts the ultimate fate of the patients. This may be affected by late relapse of SCLC, the development of second malignancies, and the long-term toxicity of therapy. To address this issue we report follow-up in excess of 5 years on a cohort of 36 patients who had high short-term survival resulting from treatment with chemotherapy combined with cranial and thoracic irradiation. All patients were followed until death or the time of analysis. The initially promising result of 31% survival at 3 years, was reflected in survival from SCLC of 27% at 5 years, and 23% at 9 years. However, when death from all causes was analyzed, survival was only 19% at 5 years and 7% at 9 years. There were 2 survivors disease-free at 7 and 8 years; 7 patients died of other causes without any evidence of SCLC. Among those not dying of SCLC, 4 patients developed second malignancies with a risk of 22% at 3.2 years and 50% at 8 years. Clinical neurotoxicity developed in 3 patients. These data suggest that cure of SCLC is possible in a modest proportion of patients with limited disease, but that the survivors are at significant risk of developing second malignancies which emerge as the most common cause of death during prolonged follow-up. Successful outcome of treatment is further hampered by the occurrence of neurotoxicity. Clinical strategies to prevent these sequelae of therapy are discussed.

Multifactorial analysis of survival in primary extremity liposarcoma

The treatment of extremity soft tissue sarcoma is now directed at limb preservation with the addition of various adjuvant therapies to improve treatment results. To achieve this goal, a knowledge of prognostic factors for extremity soft tissue sarcoma becomes increasingly critical. The object of this study was to analyze prognostic factors for survival in patients with extremity liposarcoma. Eighty-three patients with primary localized extremity liposarcoma, admitted from 1968 to 1978, were retrospectively reviewed. Surgical resection was the primary mode of treatment. Eleven prognostic factors were analyzed. Tumor factors included: histologic subtype, tumor grade, size, depth, invasion of vital structures, and site; operative factors included: type of operation, and surgical margins; and patient factors included: symptoms, age at diagnosis, and sex. Kaplan-Meier survival curves, and univariate and stratified log-rank tests of association were performed. Independent factors for predicting survival were identified using the Cox model stepwise regression technique. In univariate analysis of the entire group of patients, 5 factors were significant for tumor mortality: tumor grade (p = 0.00005), histologic subtype (p = 0.00025), tumor size greater than or equal to 5 cm (p = 0.005), type of surgery/margin (p = 0.0001), and invasion of vital structures (p = 0.008). When associations among all factors were analyzed, it was found that many factors were interdependent. The independent prognosticators were, therefore, determined according to the Cox model technique. For the multivariate analysis, well-differentiated and lipoblastic liposarcomas were excluded because of lack of survival variation within each group. The former group had no tumor-related deaths and the latter group showed 80% tumor mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Importance of long-term follow-up in evaluating treatment regimens for adults with acute lymphoblastic leukemia

During the past 20 years, we have treated 250 previously untreated adults (greater than age 15 years) with acute lymphoblastic leukemia (ALL) with five successive multidrug protocols: L2, L10, L10M, L17/17M, and L20. The L10 and L10M protocols had the highest percentage of long-term (greater than 5 years) remissions (52% and 40% respectively) compared with the L2 and more recent protocols (24%-32%); this is partly attributable to a greater prevalence of adverse risk factors among the latter protocols. The overall long-term survival of the first 199 patients with minimum 3 years follow-up is now 31%, with 35% of the 163 patients achieving complete remission (CR) remaining free of relapse for greater than 5 years. The disease-free survival of the 163 patients reaches a plateau of 33% after 6 years. The percentages of patients subsequently relapsing after remaining in continuous CR for 1.5, 3, and 5 years are 42%, 28%, and 6%, respectively; no relapses have yet occurred after 6 years in this series. Postrelapse survival improved progressively with longer duration of first remission. The results of treatment in second or later remission with either chemotherapy or bone marrow transplantation (BMT) were unsatisfactory and there were only a few long-term survivors. Recently we have attempted to select patients at highest risk of early relapse for BMT in first remission, but the number of eligible patients actually having BMTs has been low for a variety of reasons, including early death, failure to reach CR, early relapse, patient refusal, or medical contraindications.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative trial of cytarabine and thioguanine in combination with amsacrine or daunorubicin in patients with untreated acute nonlymphocytic leukemia: results of the L-16M protocol

Ninety-six patients with de novo acute nonlymphocytic leukemia (ANLL) were randomized to receive either daunorubicin (50 mg/m2, IV) on days 1-3; cytarabine (Ara-C) (25 mg/m2, IV) bolus, followed by 160 mg/m2 as a continuous IV infusion daily for 5 days and 6-thioguanine (6-TG) (100 mg/m2 po) every 12 hr daily for 5 days (DAT); or amsacrine (190 mg/m2, IV) on days 1-3 with Ara-C and 6-TG at the above doses (AAT). Patients achieving complete remission (CR) then received two courses of consolidation therapy with the same combination that had induced remission but at slightly reduced total doses. Patients less than or equal to age 40 with an HLA-identical sibling donor underwent allogeneic transplantation, usually after consolidation therapy. The remaining patients were then randomized to receive either maintenance therapy (alternating cycles of vincristine/methotrexate, cyclophosphamide/6-TG, daunorubicin/hydroxyurea and Ara-C/6-TG) or no further treatment. Ninety-two patients were evaluable for response. Twenty-five of the 46 patients (54%) who received DAT and 32 of the 46 patients (70%) who received AAT achieved CR (p = 0.13). When patients were stratified by age, however, remission induction advantage with AAT became statistically significant (p = 0.03). Additionally, more patients achieved CR following one course of AAT than following one course of DAT (48% vs 28%, p = 0.03). Overall survival in the AAT group was improved as well (p = 0.01). Too few patients were randomized on the maintenance arm of the protocol to make interpretation meaningful. Non-hematologic toxicity was generally comparable in both arms. In conclusion, patients with de novo ANLL who received AAT had a higher remission incidence and slightly longer survival compared to patients who received DAT. Further investigation of this drug combination in untreated patients with ANLL is warranted.

A cause-specific hazard rate analysis of prognostic factors among 199 adults with acute lymphoblastic leukemia: the Memorial Hospital experience since 1969

Results of a multivariable analysis of prognostic factors are reported for 199 previously untreated adults with acute lymphoblastic leukemia (ALL). These patients have long-term follow-up, and the probability of cure is estimated at approximately 35%. The cause-specific hazard rate analysis found lower rates of achieving complete remission (CR) in patients with WBC greater than 10,000/microL, AUL (undifferentiated) morphology, and older age. Since these patients required additional time to respond, fewer of them actually achieved CR. Characteristics directly associated with a higher rate of death during induction therapy due to severe bone marrow suppression were low serum albumin concentration (less than or equal to 3.5 g/dL), age greater than 50 years, acute undifferentiated leukemia (AUL) morphology, low Karnofsky performance status, and weight loss greater than 5%. Factors associated with a higher rate of relapse were WBC greater than 20,000/microL, non-T cell ALL, age greater than 60 years, Ph' + ALL, and time to achieve CR greater than 5 weeks. These criteria were used to identify patients at high risk of relapse. In addition, the predictive value of high WBC was found to disappear by 18 months of continuous CR. Finally, the rate of death following first relapse was higher in patients with a short first remission duration, high percentage weight loss at initial diagnosis, and older age. In summary, factors associated with a higher rate of death during attempted induction (ie, low albumin, high percent weight loss, and poor performance status) had no association with the patient's ability to remain relapse-free. Conversely, factors correlating with more extensive or resistant disease (ie, high WBC, null or B cell ALL, or Ph' + ALL) showed no association with the ability to tolerate therapy. Thus, a less toxic but more effective induction regimen is needed for patients with a poor clinical status, whereas a more intensive form of therapy appears warranted for patients presenting with more extensive or resistant disease.

Recent advances in the treatment of acute lymphoblastic leukemia in adults and future prospects

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Restrictiveness of care among the severely mentally disabled

Restrictiveness of care was assessed among 286 severely mentally disabled individuals known to an urban community mental health center. By examining clinical records, the authors rated each subject for each month during a period of up to 85 months on four dimensions of restrictiveness: physical freedom, time constraints, legal status, and conservatorship. The maximum restrictiveness experienced by most of the subjects was high, reflecting periodic involuntary hospitalization. The average restrictiveness they experienced, however, was well below the level represented by state hospital care. Thus the authors suggest that the average restrictiveness experienced by this population has been reduced since the initiation of deinstitutionalization.

Measuring case management activity

A method is presented for measuring the activities of case management in the care of the severely mentally disabled in catchmented public community mental health systems. Two variants of the method were compared, interviewing case managers and record abstracting. The methods were tested in two community mental health center (CMHC) sites, and appear to yield comparable results. The record abstract method seems workable for retrospective examination of case management in a CMHC system, and for the comparison of case management in different systems.

Defining the severely mentally disabled

A definition of the "known target population of severely mentally disabled" in community mental health centers is examined. Criteria include intensive treatment contact and persistent, severe disability, but not diagnosis. Feasible and reliable screening procedures are demonstrated. In the identified population, most subjects at some time had received a diagnosis of schizophrenia and had been on public assistance. These criteria apply to catchmented treatment systems and should be useful in services research.

Measuring restrictiveness of psychiatric care

"Restrictiveness" is neither a narrow legal concept nor a clinical concept that encompasses all aspects of a patient and his treatment; it refers to several features of treatment that can infringe on individual freedoms. As part of a study to develop a reliable method to measure restrictiveness, 31 mental health professionals were asked to rate the restrictiveness of six dimensions of treatment, such as legal status, and 33 treatment alternatives. Interrater reliability was high for both the importance of dimensions (alpha = .92) and the restrictiveness of alternatives within dimensions (alpha = .99). The treatment dimension judged most important in assessing restrictiveness was "limitations of physical freedom." The scale resulting from these judgments offers a plausible measurement of the restrictiveness of treatment configurations for use in evaluation research. The authors caution that restrictiveness is not in itself a comprehensive index of the quality of psychiatric care.

Relationships between U.S. Navy carrier landing accidents and flight experience parameters

Carrier arrested landing activity of all aviators flying naval attack and fighter aircraft were analized with aircraft accident data to determine whether statistical relationships exist between lifetime and recent experience variables, and accident liability. The results demonstrate that accident potential, though not statistically related to carrier landings in 30-d periods, is significantly correlated with lifetime experience and with landing activity in 7-d periods. The highest accident rates are associated with minimal amounts of total carrier experience. Moreover, accident liability for inexperience carrier aviators is lowest if number of landings in 7-d periods are high.

"Emergency room" and "mobile response" models of emergency psychiatric services

The present study surveyed federally-funded emergency psychiatric programs in 33 California community mental health centers (CMHCs). Four aspects of service organization were examined: (1) the availability of various response styles (telephone service, walk-in service, follow-up home visits, mobile initial response); (2) the types of staff providing the service; (3) the location of the programs, and (4) the organizational setting of the CMHCs (consortium or single agency centers). From these characteristics of service organization two contrasting types of emergency psychiatric programs were derived--the "emergency room" and "mobile response" models. The relationship between these two models of service delivery and catchment area demographic characteristics was examined and no remarkable trends emerged. The implications of developing a typology of emergency psychiatric programs are discussed with respect to a scheme for evaluating the relative effectiveness of services and for planning future programs.