Acute intravenous exposure to silver nanoparticles during pregnancy induces particle size and vehicle dependent changes in vascular tissue contractility in Sprague Dawley rats

The use of silver nanoparticles (AgNP) raises safety concerns during susceptible life stages such as pregnancy. We hypothesized that acute intravenous exposure to AgNP during late stages of pregnancy will increase vascular tissue contractility, potentially contributing to alterations in fetal growth. Sprague Dawley rats were exposed to a single dose of PVP or Citrate stabilized 20 or 110nm AgNP (700μg/kg). Differential vascular responses and EC50 values were observed in myographic studies in uterine, mesenteric arteries and thoracic aortic segments, 24h post-exposure. Reciprocal responses were observed in aortic and uterine vessels following PVP stabilized AgNP with an increased force of contraction in uterine artery and increased relaxation responses in aorta. Citrate stabilized AgNP exposure increased contractile force in both uterine and aortic vessels. Intravenous AgNP exposure during pregnancy displayed particle size and vehicle dependent moderate changes in vascular tissue contractility, potentially influencing fetal blood supply.

The FIELDS Instrument Suite for Solar Probe Plus: Measuring the Coronal Plasma and Magnetic Field, Plasma Waves and Turbulence, and Radio Signatures of Solar Transients

NASA's Solar Probe Plus (SPP) mission will make the first in situ measurements of the solar corona and the birthplace of the solar wind. The FIELDS instrument suite on SPP will make direct measurements of electric and magnetic fields, the properties of in situ plasma waves, electron density and temperature profiles, and interplanetary radio emissions, amongst other things. Here, we describe the scientific objectives targeted by the SPP/FIELDS instrument, the instrument design itself, and the instrument concept of operations and planned data products.

Vascular Tissue Contractility Changes Following Late Gestational Exposure to Multi-Walled Carbon Nanotubes or their Dispersing Vehicle in Sprague Dawley Rats

Multi-walled carbon nanotubes (MWCNTs) are increasingly used in industry and in nanomedicine raising safety concerns, especially during unique life-stages such as pregnancy. We hypothesized that MWCNT exposure during pregnancy will increase vascular tissue contractile responses by increasing Rho kinase signaling. Pregnant (17-19 gestational days) and non-pregnant Sprague Dawley rats were exposed to 100 μg/kg of MWCNTs by intratracheal instillation or intravenous administration. Vasoactive responses of uterine, mesenteric, aortic and umbilical vessels were studied 24 hours post-exposure by wire myography. The contractile responses of the vessel segments were different between the pregnant and non-pregnant rats, following MWCNT exposure. Maximum stress generation in the uterine artery segments from the pregnant rats following pulmonary MWCNT exposure was increased in response to angiotensin II by 4.9 mN/mm² (+118%), as compared to the naïve response and by 2.6 mN/mm² (+40.7%) as compared to the vehicle exposed group. Following MWCNT exposure, serotonin induced approximately 4 mN/mm² increase in stress generation of the mesenteric artery from both pregnant and non-pregnant rats as compared to the vehicle response. A significant contribution of the dispersion medium was identified as inducing changes in the contractile properties following both pulmonary and intravenous exposure to MWCNTs. Wire myographic studies in the presence of a Rho kinase inhibitor and RhoA and Rho kinase mRNA/protein expression of rat aortic endothelial cells were unaltered following exposure to MWCNTs, suggesting absent/minimal contribution of Rho kinase to the enhanced contractile responses following MWCNT exposure. The reactivity of the umbilical vein was not changed; however, mean fetal weight gain was reduced with dispersion media and MWCNT exposure by both routes. These results suggest a susceptibility of the vasculature during gestation to MWCNT and their dispersion media-induced vasoconstriction, predisposing reduced fetal growth during pregnancy.

EPOCH-F: a novel salvage regimen for multiple myeloma before reduced-intensity allogeneic hematopoietic SCT

There exists a need for effective salvage regimens for multiple myeloma patients being considered for reduced-intensity allogeneic hematopoietic SCT (RI-alloHSCT). We developed EPOCH-F, a regimen consisting of infusional etoposide, VCR and adriamycin with prednisone, CY and fludarabine to achieve both tumor control and host lymphocyte depletion to facilitate engraftment before RI-alloHSCT. In all, 22 multiple myeloma patients were treated with EPOCH-F before RI-alloHSCT. The median age was 53 years (range 36-65), and the median number of previous therapies was 2 (range 1-8). Patients received a median of three cycles (range 1-5) of EPOCH-F. Toxicities were primarily hematologic and manageable. Median lymphocyte counts decreased from 1423/μL (range 335-2788) to 519/μL (range 102-1420; P=0.0002). The overall response (≥PR) to EPOCH-F was 22 with 13% achieving a CR/near-complete response (nCR); only 1 patient progressed while on therapy. A total of 20 patients underwent RI-alloHSCT. Median day +100 donor chimerism was 100% (range 60-100). In all, 70% of patients achieved very good partial response or better response after transplant; 40% of patients achieved CR/nCR. TRM at 100 days and 5 years was 5 and 30%, respectively. Median OS after RI-alloHSCT was 46.1 months. EPOCH-F provides disease control and host lymphocyte depletion with consistent full donor engraftment in multiple myeloma patients undergoing RI-alloHSCT.

EPOCH-F: A salvage regimen for multiple myeloma prior to reduced intensity allogenic hematopoietic stem cell transplantation

8592

Background: Variation in baseline host immune status contributes to inconsistent donor engraftment and may impede maximal graft-versus-myeloma effects after reduced intensity allogenic hematopoietic stem cell transplantation (RIHSCT) for advanced multiple myeloma (MM). As no specific salvage regimen has been designed for MM patients being considered for RIHSCT, we evaluated EPOCH-F a novel salvage regimen designed to provide disease control and immune depletion. Methods: EPOCH-F is an infusional chemotherapeutic regimen consisting of etoposide, vincristine and adriamycin, with prednisone, cyclophosphamide and fludarabine given in 21 day cycles prior to RIHSCT. Targeting a CD4+ T cell count, 22 pts were treated <5 cycles of EPOCH-F. Pts proceeded to RIHSCT after adequate lymphodepletion or if there was disease progression during EPOCH-F, regardless of CD4 count. Results: Median age was 53 years (range 36–65); median time from initial therapy to transplant was 12 months (range 2–168). Median number of prior therapies was 2 (range 1–8), 63% had chemotherapy sensitive disease and 68% had received a novel agent. Pts received a median of 3 cycles (range 1–5), with manageable toxicities, mostly hematologic. Grade IV Neutropenia was seen in 77% of the administered cycles with only 6 episodes of neutropenic fever. Median lymphocyte count decreased from 1423/μL (range 335–2788) to 519/μL (range 102–1420); CD4 count decreased from 320/μL (range 130–1366) to 115/μL (30–309). In 21 evaluable pts, the ≥PR rate to EPOCH-F was 22% with 13% CR/nCR. 68% had SD and only 1 pt progressed. 20 pts underwent RIHSCT from HLA matched sibling. Median Day 100 chimerism was 100% (range 60–100, mean 95). 70% of patients achieved ≥VGPR and CR/nCR was seen in 40%. Acute GVHD (grade II-IV) was seen in 47% and chronic GVHD (grade III-IV) was seen in 52% of the pts. TRM at 100 days was 5% and 30% at 60 months. Median overall survival of patients after RIHSCT was 46.1 months. Conclusions: EPOCH-F is an active regimen which provides pre-transplantation lympho-depletion, disease control and allows consistent engraftment in multiple myeloma patients undergoing RIHSCT.

No significant financial relationships to disclose.

Clinical evidence of a graft-versus-lymphoma effect against relapsed diffuse large B-cell lymphoma after allogeneic hematopoietic stem-cell transplantation

BACKGROUND

A graft-versus-lymphoma effect against diffuse large B-cell lymphoma (DLBCL) is inferred by sustained relapse-free survival after allogeneic stem-cell transplantation; however, there are limited data on a direct graft-versus-lymphoma effect against DLBCL following immunotherapeutic intervention by either withdrawal of immunosuppression or donor lymphocyte infusion (DLI).

MATERIALS AND METHODS

An analysis was carried out to determine whether a direct graft-versus-lymphoma effect exists against DLBCL. The analysis was restricted to patients with DLBCL, who were either not in complete remission at day +100 after allogeneic stem-cell transplantation or subsequently relapsed beyond this time point.

RESULTS

Fifteen patients were identified as either not in complete remission (n = 13) at their day +100 evaluation or subsequently relapsed (n = 2) and were assessed for subsequent responses after withdrawal of immunosuppression or DLI. Eleven patients were treated with either withdrawal of immunosuppression (n = 10) or a DLI (n = 1) alone; four patients received chemotherapy with DLI to reduce tumor bulk. Nine (60%) patients subsequently responded (complete = 8, partial = 1). Six responses occurred after withdrawal of immunosuppression alone. Six patients are alive (range 42-83+ months) in complete remission without further treatment.

CONCLUSION

The demonstration of sustained complete remission following immunotherapeutic intervention provides direct evidence of a graft-versus-lymphoma effect against DLBCL.

Correlations among vitality, physical competence, lipid profile and measures of inflammation in transplant survivors with chronic graft versus host disease

7108

Background: Chronic graft vs. host disease (cGVHD) is a multi-system disorder and a late complication of cancer therapy experienced by more than 50% of survivors after allogeneic hematopoietic stem cell transplantation. An improved understanding of the underlying biology and its relation to clinical symptoms may guide the development of better treatments for cGVHD. Methods: In a prospective, cross-sectional natural history protocol we examined the associations among organ/system dysfunction, measures of physical performance and health status with clinical measures of inflammation and fat metabolism. Variables included: 1. a composite severity score (CAS) rated by clinician-specialists (skin, eyes, mouth, gastrointestinal/liver, hematological, gynecological, pulmonary function evaluations); 2.functional measures [2 minute walk time (WT), grip strength (GS), SF-36 physical component summary score (PCS), vitality (VT) subscale, maximal activity score (MAS) of the Human Activity Profile]; 3.Laboratory tests (glucose, LDH, hemoglobin, ferritin, platelets, lymphocytes, pre-albumin, cholesterol, lipoproteins (HDL, LDL), triglycerides (TG), beta-2microglobulin (B2), and CRP. Results: 43 pts (mean age 47 yrs) with prior hematologic malignancy participated (mean 3 yrs post transplant). An average of 3.5 organ systems were affected, 77% were on systemic treatment for cGVHD, and 67% had prior acute GVHD. The mean body mass index (BMI) was 25, TG 255, cholesterol 222, LDL 132. They were moderately disabled by self-report (MAS), had slower than normal WT (540 ft/min), lower than normal GS (63 pounds), PCS (36) and VT (46) than a healthy population. Using a backward selection model with a significance of 0.1, low lung diffusing capacity (p<.001) and low PCS (p=0.01) correlated with high CAS. VT correlated negatively with LDH, platelets, B2 and LDL (all p<0.01). Low GS correlated with high LDH and B2 (p=0.01). Conclusions: Reported physical function and vitality in cGVHD patients are associated with abnormal lipid profiles and markers of inflammation. Establishment of such profiles is a critical step in the development of testable and validated outcome measures and for evaluation of new therapies in cGVHD.

No significant financial relationships to disclose.

Assessment of the hematopoietic cell transplantation comorbidity index in non-Hodgkin lymphoma patients receiving reduced intensity allogeneic hematopoietic cell transplantation

7096

Background: Several patient-related factors influence outcomes after allogeneic hematopoietic cell transplantation (HCT). The Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI), a weighted index of 17 pre-transplant comorbidities, has been validated in non- myeloablative HCT studies, but it has not been tested in non-Hodgkin's lymphoma (NHL) patients receiving reduced-intensity conditioning (RIC) HCT nor has it been compared with a number of other pre-transplant factors. Methods: We performed an analysis of 63 NHL patients treated with RIC HCT to assess the HCT-CI's impact on overall survival (OS), treatment-related mortality (TRM) and disease-related mortality (DRM). Individual factors, including performance status, single comorbidities, CD34 dose, prior chemotherapy number, pre-transplant induction chemotherapy response, and NHL histology, were also analyzed relative to their impact on OS. Prior to transplant, all patients received an identical induction regimen (EPOCH-fludarabine). All patients received identical RIC (Cy/Flu) and were transplanted from HLA-matched siblings. Results: In univariate analysis, each of the above factors, except for histology and CD34 dose, exhibited a trend toward an association with OS (adjusted p<0.10). The HCT-CI (0–2 comorbidities vs. 3+ comorbidities) demonstrated an association with TRM at 100 days (4.5% vs. 26.3%) and 1 year (13.6% vs. 36.8%) post-transplant, but not DRM. The factor most strongly associated with OS was response to induction chemotherapy (CR/PR/SD vs. PD; p=0.0025). In a Cox model for OS, induction chemotherapy response remained the sole important factor, while the HCT-CI and other pre-transplant factors added little predictive value to the induction chemotherapy response. The HCT-CI was more strongly associated with OS and TRM in a subset analysis restricted to patients in CR/PR following induction chemotherapy. Conclusions: These findings suggest that the HCT-CI may be useful for estimating probabilities of TRM and OS in NHL patients being considered for RIC HCT. The data further suggest that chemotherapy response at transplant may have significant impact on transplant outcomes.

No significant financial relationships to disclose.

Association of serum interleukin-7 and interleukin-15 levels with immune reconstitution (IR), graft-versus-host disease (GVHD), and survival after reduced-intensity allogeneic stem cell transplantation (RIST)

7107

Background: In laboratory models, interleukin-7 (IL-7) and IL-15 significantly influence IR after allogeneic stem cell transplantation (SCT), thereby affecting immunity, graft-versus-malignancy (GVM) effects, and GVHD. Interleukin-7 (IL-7) is the main homeostatic regulator of naïve CD4+ and CD8+ T cells, and IL-15 is homeostatic for CD8+ memory and effector T cells and NK cells. The contributions of these cytokines to IR after allogeneic SCT are not well characterized in a clinical setting. Methods: We studied serum IL-7 and IL-15 levels in 31 pts with hematologic malignancies undergoing RIST from HLA-matched siblings in a prospective trial. Pts received identical transplant conditioning (fludarabine/cyclophosphamide) and GVHD prophylaxis (CSA/MTX). IL-7 and IL-15 levels and peripheral blood lymphocyte subpopulations (ALC, CD3, CD4, CD8, B, NK, and NKT) were measured before RIST, and post RIST at 1 and 2 weeks; 1, 2, 3, 6, 9, and 12 months. Results: Consistent with their homeostatic effects, IL-7 and IL-15 levels rose from baseline as transplant conditioning induced lymphopenia, and then decreased with lymphocyte recovery. These inverse correlations were strongest within 1 month post RIST. In an exploratory analysis, IL-15 levels at day 0 were correlated with baseline age (r=0.49; p=0.0058) and were higher among patients with CMV reactivation after RIST (p=0.048). At 2 weeks post RIST, higher IL-7 levels were strongly associated with subsequent acute GVHD (p=0.000033), and higher IL-15 levels were associated with inferior survival (p=0.007), mainly from relapse. At 3 months post RIST, superior survival was associated with higher NK cell counts (p=0.0008), and to a lesser extent with higher CD4 counts (p=0.036). Conclusions: These data support preclinical observations that IL-7 promotes GVHD after allogeneic SCT. The association of higher post-RIST IL-15 levels with death from relapse may identify pts with impaired IR leading to inadequate GVM effects. This hypothesis is consistent with the finding that higher NK cell counts after RIST were associated with better survival. Further studies must confirm the hypotheses generated in this setting.

No significant financial relationships to disclose.

Oral chronic graft-versus-host disease symptom experience and cytokine correlates in survivors after transplantation for hematologic malignancies

19510

Background: Oral chronic graft-versus-host-disease (cGVHD) is a frequent, clinically significant sequela of hematopoietic stem cell transplant (HSCT). No optimal treatment exists; molecular pathogenesis remains unclear. This descriptive study assessed stomatitis, oral pain, and dry mouth severity, and correlations with proinflammatory cytokine levels in stimulated submandibular saliva samples from cGVHD patients. Methods: Subjects were enrolled in the NCI sponsored cGVHD natural history protocol. Stomatitis severity was assessed with the Oral Mucositis Rating Scale (OMRS) (0–103); oral pain and dryness were self-reported via VAS (0–10). Saliva samples were collected on ice, stored at -80°C, centrifuged at 4000xg for 10 minutes at 4°C, and supernatant retained. Salivary TNFa, IL1a, and IL6 concentrations were measured by enzyme-linked immunosorbent assay (ELISA) (R & D Systems, Minneapolis, MN). Results: Adult male and female subjects (N = 42) with cGVHD after HSCT primarily for hematologic malignancies were prescribed systemic (n = 34) and/or topical (n = 4) immunosuppressive agents, and opioids (n = 19). All subjects had mild to moderate stomatitis (OMRS mean = 18.38; range = 2.0 to 46) with erythema (n = 40), lichenoid (n = 32), and ulceration (n = 25). Mild to severe oral dryness (43%) (mean = 2.56; range 0 to 10) was more clinically significant than oral pain (8%) (mean = .13). Salivary cytokine concentrations were: TNFa (n = 32; mean = .31 pg/mL; range 0 to 2.8); IL1a (n = 29; mean = 85.23 pg/mL; range = 13 to 250), and IL6 (n = 29; mean = 2.48 pg/mL; range 0.100 to 10.00). Significant associations by Pearson Product Moment correlation were: TNFa and erythema (r = .34; p < .05); IL1a and oral dryness (r = .40; p < .05); IL6 and OMRS (r = .49; p < .01), erythema (r = .63; p < .001), and ulceration (r = .38; p < .05). Conclusions: Paucity of oral pain may be related to appropriate management. Moderate to strong correlations between salivary TNFa and IL6 and oral cGVHD severity, and IL1a and oral dryness suggest utility as correlates of disease severity and symptom, and monitors of therapeutic response to investigational agents.

No significant financial relationships to disclose.

Targeted immune depletion prior to reduced-intensity allogeneic stem cell transplantation results in rapid and complete donor chimerism with low treatment-related mortality

6540

Background: Significant variation in host immune status may influence outcomes after reduced-intensity (RI) allogeneic stem cell transplantation (alloSCT). We have investigated a strategy of targeted immune depletion (TID) with conventional chemotherapy to deplete host T cells and achieve a minimal disease state prior to RI alloSCT. The aim of TID is to rapidly establish complete donor chimerism after RI alloSCT in order to potentiate a graft-versus-tumor (GVT) effect. In a prospective phase II trial (NIH 03-C-0077), we evaluated the effect of TID on donor chimerism, acute graft-versus-host disease (GVHD), and clinical outcome. Methods: Thirty-one patients (pts) with relapsed and refractory hematologic malignancies (NHL = 16; HL = 4; CLL/PLL = 4; MDS/AML = 3; other = 4) were enrolled. Median age was 57 years (range: 31–71). All pts received EPOCH-F (etoposide, prednisone, vincristine, cyclophosphamide, adriamycin, fludarabine) ± rituximab (R) as TID to deplete host CD4+ cells <100/μL. All pts then received a RI conditioning regimen consisting of fludarabine and cyclophosphamide followed by a T-cell replete allograft from HLA-matched siblings. GVHD prophylaxis consisted of cyclosporine plus short-course mini-methotrexate. Results: EPOCH-F(R) achieved the target host T-cell level in 74% of pts. All 31 pts engrafted after RI alloSCT. Complete donor chimerism (> 95%) was observed in 74% and 81% of pts at day +14 and +28 post-transplant, respectively. The incidence of grade II-III acute GVHD was 42% with no cases of grade IV acute GVHD. The median potential follow-up from transplant is 25 months. Actuarial treatment-related mortality at 1 and 2 years was 3% and 8%, respectively. Event-free survival probabilities at 1 and 2 years post-transplant are 65% and 49%, respectively. Ten pts are alive and event-free >24 months post-transplant. The overall survival probabilities at 1 and 2 years are 84% and 64%, respectively. Conclusions: TID prior to RI alloSCT results in rapid, complete donor engraftment and may potentiate GVT effects. This treatment strategy was associated with very low TRM and favorable outcomes in an older patient population with advanced hematologic malignancies.

No significant financial relationships to disclose.

Reduced-intensity allogeneic stem cell transplantation for diffuse large B-cell lymphoma: Clinical evidence of a graft-versus-lymphoma effect

6546

Background: Despite being the most common non-Hodgkin’s lymphoma, there have been no specific reports on the use of reduced-intensity (RI) allogeneic stem cell transplantation (alloSCT) to treat patients (pts) with diffuse large B-cell lymphomas (DBCL). This may be due to a lack of definitive evidence for a therapeutic graft-versus-lymphoma (GVL) effect against DLBC. We undertook a retrospective analysis to assess clinical outcomes and evidence of a GVL effect in DLBC pts undergoing RI alloSCT. Methods: The analysis was limited to 18 pts with primary refractory (n = 6) or relapsed (n = 12) DLBC. The median age was 43 years (range: 31–61); median number of previous treatments was 3 (range: 2–9). Nine (50%) pts had undergone autologous transplantation. Three (16%) pts were determined to have chemo-sensitive disease to last treatment prior to RI alloSCT. All pts received a RI conditioning regimen consisting of fludarabine (30 mg/m2/d × 4d) and cyclophosphamide (1200 mg/m2/d × 4d) followed by a T-cell replete allograft from HLA-matched siblings. Results: Median potential follow-up from transplant is 43 months. Seven (39%) pts developed grade II-IV acute GVHD. Response at day +100 post-transplant was as follows: complete response (CR/CRu) = 5; partial response = 5; progressive disease = 8. Nine of 17 (53%) evaluable pts developed chronic GVHD. Median progression-free survival (PFS) was 4.8 months; however, PFS after 9 months post-transplant was 31% with 5 pts in continuous CR/CRu > 12 months post-transplant. Among 14 pts who were not in CR/CRu (n = 12) or progressed after achieving a CR/CRu (n = 2) at day +100 post-transplant, 8 (57%) subsequently achieved a CR/CRu after removal of immune suppression and/or donor lymphocyte infusion (DLI) ± chemotherapy. Seven of these 8 pts remain in continuous (median = 34 months; range: 6–55+) CR/CRu without further treatment. Median survival for all 18 pts was 19 months with survival probability of 40% plateauing at 25 months post-transplant. Conclusions: The clinical observations of sustained CR/CRu after withdrawal of immune suppression and DLI suggest that a GVL effect exists against DLBC. RI alloSCT should be considered as a treatment option for pts with primary refractory and relapsed DLBC.

No significant financial relationships to disclose.

Nursing shortage: impending doom or challenging opportunity?

A nursing shortage currently exists and is expected to worsen. This shortage is different from shortages of the past with no easy solutions. The reasons for the shortage are multifaceted and require short-term and long-term answers. The aging of the RN workforce, a decrease in the number of persons entering nursing, managed care, and increasing acuity of patients in the hospital setting have contributed to this situation. Perianesthesia nurses can expect to feel the impact of the shortage quickly because this shortage is affecting specialty areas such as PACU, the OR, and ICU in particular. We need to become proactive in the search for solutions and view this time as a challenging opportunity.

Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs

The present study used a meta-analysis to examine 4 questions about intraoperative hypothermia. The questions addressed were as follows: (1) Is the difference in adverse patient outcomes between normothermic and mildly hypothermic patient groups significant across studies and within studies? (2) What is the magnitude of the difference in adverse patient outcomes across studies? (3) What are the costs resulting from the difference in adverse patient outcomes? (4) Does a significant difference exist in effectiveness of modality for maintaining intraoperative normothermia? The results of this meta-analytic study provide evidence that the difference in adverse patient outcomes between the normothermic and mildly hypothermic patients is significant across studies for all adverse outcomes examined. The magnitude of this difference and the costs resulting from these adverse outcomes are presented. In addition, a significant difference in effectiveness between warming modalities for maintaining intraoperative normothermia was found. A significant increase in the risk of costly complications occurred when patient temperatures dropped a mean of 1.5 degrees C. For example, patients who become mildly hypothermic are much more likely to receive blood transfusions and to develop infections; both of these outcomes result in increased costs. Minimizing adverse outcomes is critical to cost-effective patient care in today's competitive healthcare environment. The cost of preventing intraoperative hypothermia is much less than the cost of treating the adverse outcomes that affect patients experiencing intraoperative hypothermia. Meta-analytic results allowed us to conclude that hypothermia averaging only 1.5 degrees C less than normal resulted in cumulative adverse outcomes adding between $2,500 and $7,000 per surgical patient to hospitalization costs across a variety of surgical procedures. In conclusion, patients whose temperatures have been maintained at normal levels during the intraoperative period experience fewer adverse outcomes, and their overall hospital costs are lower. Intraoperative normothermia is maintained more effectively with the use of forced air warming.

Phase II trial with dose titration of paclitaxel for the therapy of human immunodeficiency virus-associated Kaposi's sarcoma

PURPOSE

To investigate the antitumor activity and safety of paclitaxel in patients with advanced human immunodeficiency virus (HIV)-associated Kaposi's sarcoma (KS).

PATIENTS AND METHODS

Twenty-nine patients with advanced HIV-associated KS were enrolled. The patients were overall quite immunosuppressed (median CD4 count, 15 cells/microL). Paclitaxel was initially administered at 135 mg/m2 over 3 hours every 3 weeks without filgrastim support; the dose was increased as tolerated to a maximum of 175 mg/m2. Patients who failed to respond or progressed could then receive filgrastim support or paclitaxel administered over 96 hours.

RESULTS

Of 28 assessable patients, 20 had major responses (18 partial responses [PRs], one clinical complete response [CR], and one CR), for a major response rate of 71.4% (95% confidence interval [CI], 51.3% to 86.8%). Each of the five patients with pulmonary KS responded, as did all four assessable patients who had previously received anthracycline therapy for KS. Of six patients who went on to receive a 96-hour infusion of paclitaxel, five had major responses. Neutropenia was the most frequent dose-limiting toxicity; possible novel toxicities included late fevers, late rash, and eosinophilia. Two patients developed an elevated creatinine concentration and one cardiomyopathy.

CONCLUSION

Paclitaxel has substantial activity against advanced HIV-associated KS as a single agent, even in patients with pulmonary involvement or who had previously received anthracyclines. Further research is needed to define the optimal treatment schedule and its role vis-a-vis the other available therapies for this disease.

Systemic hemodynamic, neurohormonal, and renal effects of a steady-state infusion of human brain natriuretic peptide in patients with hemodynamically decompensated heart failure

BACKGROUND

Human brain natriuretic peptide (hBNP) is a promising agent for the treatment of decompensated cardiac failure. However, the systemic hemodynamic, neurohormonal, and renal effects of hBNP have been incompletely studied in human heart failure.

METHODS AND RESULTS

The effects of a continuous 4-hour infusion of hBNP were determined in 16 decompensated heart failure patients in an invasive, randomized, double-blind, placebo-controlled study. Patients were evaluated during three 4-hour study periods: baseline, treatment (placebo [n = 4] versus hBNP 0.025 or 0.05 microgram/kg/min [n = 12]), and post-treatment. Urinary volume losses were replaced hourly to separate the vasodilatory and diuretic effects of hBNP. Two patients in the hBNP group were excluded from the analysis because of adverse events. hBNP significantly (P < .001) reduced right atrial pressure and pulmonary capillary wedge pressure by approximately 30% and 40%, respectively. hBNP also significantly lowered systemic vascular resistance from 1722 +/- 139 to 1101 +/- 83 dynes.s.cm-5 (P < .05). These unloading effects of hBNP produced a 28% increase in cardiac index (P < .05) with no change in heart rate. Compared to placebo, hBNP decreased plasma norepinephrine and aldosterone. Renal hemodynamics were unaffected by hBNP; however, most patients were resistant to its natriuretic effect.

CONCLUSIONS

1) The predominant hemodynamic effects of hBNP were a decrease in cardiac preload and systemic vascular resistance. 2) hBNP also improved cardiac output without increasing heart rate. 3) Plasma norepinephrine and aldosterone levels decreased during hBNP infusion. 4) hBNP is pharmacologically active and has potential in the therapy for decompensated heart failure.

Conscious sedation in the ambulatory setting

Conscious sedation has become an important component of practice for many ambulatory procedures. Important factors to maintain the safety of this technique are proper patient selection, slow titration of the medication, continuous patient monitoring, proper education of the individuals administering the medication and monitoring the patient, and appropriate policies and guidelines in place in the ambulatory setting. When patient safety is the number one priority, conscious sedation can be a very effective, practical, and safe technique used in the ambulatory setting.

Tips for RN-administered conscious sedation

The RN should know his or her state Board of Nursing position, national standards, hospital policy, and procedure before assuming this role. The RN delivering conscious sedation must focus on patient education, assessment, and monitoring. The successful practice requires consistency of care in all departments and continuity of care at all costs.

Treatment of HIV-associated Kaposi's sarcoma with paclitaxel

We investigated whether paclitaxel was active in AIDS-associated Kaposi's sarcoma. We gave 135 mg/m2 intravenously over 3 hours every 21 days. Follow-up is available on the first 20 patients, most of whom had advanced Kaposi's sarcoma and severe immunocompromise. Neutropenia was the most frequent dose-limiting toxic effect; novel toxic effects included late fevers, rash, and eosinophilia. Creatinine increased in 2 patients and 1 patient had cardiomyopathy. There were 13 partial responses (65%, 95% CI 41-85%). All 5 patients with pulmonary involvement responded. Paclitaxel appears to be active against Kaposi's sarcoma as a single agent. Further studies, including a randomised trial, are warranted.

The role of sigmoidoscopy in the management of gunshot wounds to the buttocks

The charts of all patients (n = 70) admitted over 26 months after sustaining a gunshot wound to the buttocks were reviewed to assess the role of physical examination, routine radiologic studies, and sigmoidoscopy in the evaluation of these patients. There were 68 men and 2 women. Sixteen patients underwent sigmoidoscopy, which demonstrated a rectal injury in 7. Six of these patients had other abnormalities on either physical examination or plain pelvic radiographs that would have otherwise led to operation. There were no missed injuries and no morbidity in the remaining patients that were managed without sigmoidoscopy. Indications for sigmoidoscopy were gross blood on rectal examination in 2, bullet path with proximity to the rectum in 13, and persistent abdominal pain in 1. All patients with gross blood on rectal examination (n = 5) and blood at the urethral meatus (n = 2) had visceral injuries. One patient underwent celiotomy for an injury at 15 cm that was noted on sigmoidoscopy performed because the bullet trajectory was in proximity to the rectum. Sigmoidoscopy can be performed selectively in patients sustaining a gunshot wound to the buttocks when the proximity of the wound to the rectum is in doubt.

The influence of social status and prior explanation on parental attitudes toward behavior management techniques

The purpose of this study was to determine whether parental social status influences preference toward behavior management techniques used during dental treatment of children. One hundred and twenty-two parents from two private practices and one institutional site completed a questionnaire and rated eight commonly used behavior management techniques. These techniques were tell-show-do, nitrous oxide/oxygen, Papoose Board (Olympic Medical Group, Seattle, WA), voice control, hand-over-mouth (HOM), oral premedication, active restraint, and general anesthesia (GA). Half the parents viewed these eight techniques on a videotape which contained prior explanation for each technique (experimental group). The other half (control group) viewed the same techniques on videotape, but without prior explanations. Parents indicated their degree of acceptability by marking a line on a visual analogue scale (VAS, scored from 1 to 99). A score below 50 was considered acceptable. The parents were divided into "high" and "low" social status groups. Significant differences for HOM and GA were noted between mean scores of the experimental and control groups for both "high" and "low" social status groups; the control groups were less accepting except for GA in the "low" group where the reverse was true (P < 0.05). Techniques judged least acceptable were HOM, GA, Papoose Board and oral premedication. Parental acceptance of individual techniques varied greatly, suggesting the importance of informed consent irrespective of social status.

A prospective randomized study of pregnancy rates following intrauterine and intracervical insemination using frozen donor sperm

Cryopreserved sperm have lowered fertility when compared with fresh sperm in artificial insemination by donor programs. The purpose of this study was to compare pregnancy rates following intrauterine insemination (IUI) and intracervical insemination (ICI) with cryopreserved sperm in a prospective trial using the patient as her own control. A total of 154 patients were randomized into alternating treatment cycles and underwent 238 cycles of IUI and 229 cycles of ICI. The pregnancy rate per treatment cycle was 9.7% following IUI and 3.9% following ICI. Treatment outcome was influenced by patient age, ovulatory status, and endometriosis. Pregnancy success correlated well with the post-thaw survival of sperm and the number of motile cells inseminated. In spite of having normal semen parameters, some donors were found to have markedly reduced sperm fecundity. We conclude that IUI with cryopreserved sperm can be an effective treatment for couples with infertility, genetic indications, or other reasons.

Effect of calcium lactate in erosion and S. mutans in rats when added to Coca-Cola

Thirty-six Sprague Dawley rats, 22 days of age, were divided randomly into three groups of 12 each and housed in a programmable feeder. The three experimental groups received either Coca-Cola (CC), Coca-Cola with calcium lactate (CC-CaL), or distilled water. The programmable feeder was set to deliver 17 equal volumes of fluid per day with each feeding period lasting between 80-90 min. All groups were given Diet MIT 305 in one premeasured amount per 24 hr period (ad libitum). The pH of the CC with calcium lactate was adjusted to match the CC without calcium lactate by the addition of citric and phosphoric acids. The test period lasted five weeks. Each week, the food and fluid consumed and the weight gain were measured. Erosion of the teeth was scored by the method of Restarski et al. (1945). ANOVA indicated that there was a significant difference in the amount of erosion among groups. A Newman-Keuls analysis showed that the mean erosion score of the CC group was significantly greater (P less than 0.05) than that of the CC-CaL and distilled water groups (54.2 +/- 0.12; 0.0275 +/- 0.0123; 0.132 +/- 0.070, respectively). There was no significant difference in erosion between the CC-CaL and distilled water groups. There was no difference in the amount of food and fluid consumed among the group of rats. In conclusion, calcium lactate added to CC resulted in significantly reduced tooth erosion in rats.

Orally and parenterally administered ibuprofen for postoperative adhesion prevention

Adhesion formation was examined in 45 rats that were divided into five groups of 9 animals each: control, oral ibuprofen, intramuscular ibuprofen, intraperitoneal 32% dextran 70, and oral ibuprofen plus intraperitoneal 32% dextran 70. Four weeks after receiving a standard injury, all the animals were killed and the adhesions scored blindly. Both the oral and intramuscular ibuprofen groups had significantly less severe adhesion formation (P less than .01) when compared to the control group. Although 32% dextran 70 alone showed no beneficial effect in reducing adhesions, the combination of oral ibuprofen and 32% dextran 70 had the least adhesion formation (P less than .002) when compared to the control group. Oral and intramuscular ibuprofen seem to be equally efficient in reducing postoperative adhesions. Furthermore, the combination of oral ibuprofen and 32% dextran 70 appears to have a synergistic effect.

Anterior approach to the thoracolumbar spine: technical considerations

Forty-five patients, of whom most were children, underwent extensive exposure of the thoracolumbar spine to correct serious orthopedic abnormalities. The spine was exposed through a combined thoracotomy and retroperitoneal approach that gave excellent access with minimal morbidity. The diaphragm was opened circumferentially after the peritoneum had been dissected from its muscular portion. This permitted repair of the diaphragm with no detectable loss of function. Although this approach was developed for exposure of the spine, it can also be utilized to expose the entire aorta, both kidneys and their blood supply, and the retroperitoneal area for possible excision of large tumors.