Identifying predictors of ventral hernia recurrence: systematic review and meta-analysis

BACKGROUND

Ventra hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence.

METHODS

PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool).

RESULTS

Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III-IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence.

CONCLUSION

This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research.

Evaluation of two minimal-preparation regimes for CT colonography: optimising image quality and patient acceptability

OBJECTIVE

To compare a 2 day bowel preparation regime of barium, iodine and a mild stimulant laxative with a 1 day iodine-only regime for CT colonography (CTC).

METHODS

100 consecutive patients underwent CTC. The first 50 patients (Regime 1) ingested 1 bisacodyl tablet twice a day 3 days before CTC and 1 dose each of 50 ml of barium and 20 ml of iodinated contrast per day starting 2 days before CTC. The second 50 patients (Regime 2) ingested 3 doses of iodinated contrast over 24 h prior to CTC. Volumes of residual stool and fluid, and the effectiveness of stool and fluid tagging, were graded according to methods established by Taylor et al (Taylor S, Slaker A, Burling D, Tam E, Greenhalgh R, Gartner L, et al. CT colonography: optimisation, diagnostic performance and patient acceptability of reduced-laxative regimens using barium-based faecal tagging. Eur Radiol 2008; 18: 32-42). A 3 day low-residue diet was taken by both cohorts. Questionnaires rating the side-effects and burden of the bowel preparation were compared to a control cohort of patients undergoing barium enema.

RESULTS

The proportion of colons producing none/scattered stool (score 1) was 90.3% with Regime 1 and 65.0% with Regime 2 (p<0.005). Any residual stool was significantly better tagged with Regime 1 (score 5), with 91.7% of Regime 1 exhibiting optimum tagging vs 71.3% of Regime 2 (p<0.05). No significant differences in side-effects between the bowel preparation regimes for CTC were elicited. Bowel preparation for barium enema was tolerated significantly worse than both of the CTC bowel preparation regimes.

CONCLUSION

Regime 1, containing a 3 day preparation of a mild laxative, barium and iodine, produced a significantly better prepared colon, with no difference in patient acceptability.

Quality of Life of Early Stage Breast Cancer Patients 65 Years Old or Older Randomized to Standard Chemotherapy or Capecitabine: A Cancer and Leukemia Group B Study (CALGB 49907)

Background: CALGB conducted a randomized Phase III trial (49907) to test whether older cancer patients receiving capecitabine would have a similar clinical outcome as those receiving standard chemotherapy, but less toxicity. This represented an important quality of life (QoL) paradigm in which treatment recommendations might be based on QoL findings if there was less toxicity for capecitabine with similar clinical outcomes as those achieved with standard chemotherapy. Materials and Methods: A preplanned QoL assessment was preformed in 350 patients randomized to either standard chemotherapy (CMF or AC) (n= 182) or capecitabine (n=168). All patients were interviewed by telephone using standardized questionnaires conducted at baseline, mid-treatment, at 1 month post-treatment, and at 12, 18 and 24 months. Data were analyzed using pattern mixture models and analysis of covariance with repeated measures, in which the sample was divided into groups based on the period of time they had completed assessments. Results: Patients in the capecitabine arm reported a better overall QoL (EORTC p&lt; 0.0001), less fatigue (EORTC p&lt; 0.0001), less nausea and vomiting (EORTC, p&lt; 0.0001), less constipation (EORTC, p&lt; 0.0001), less systemic side effects (EORTC, p&lt; 0.0001), better appetite (EORTC, p&lt; 0.0001), better body image (EORTC, p&lt; 0.0001), less psychological distress (Hospital Anxiety and Depression scale, p&lt; 0.0001), better role (EORTC, p&lt; 0.0001) and social functioning (EORTC, p&lt; 0.0001) than did those in the standard chemotherapy arm at either mid-treatment and/or the end of treatment for those assessed through 24 months. Capecitabine patients reported worse diarrhea (EORTC, p&lt; 0.0001) at mid-treatment, and worse hand–foot symptoms (p&lt; 0.0001) at mid and end of treatment than did those receiving standard chemotherapy. There were no significant differences in most of these measures by 12 months. Discussion: With clinical results showing a significantly improved relapse-free and overall survival for patients who received standard chemotherapy vs. capecitabine (Muss et al., NEJM 2009; 360: 2118), the QoL results will not guide treatment recommendations. However, the QoL results largely confirmed that patients treated with capecitabine experience significantly better QoL vs. those treated with standard chemotherapy due to less toxicity during and at the end of treatment for the sizable group of patients who had completed interviews through 24 months (n=245). These results indicate that despite the worse clinical outcome of patients who receive capecitabine treatment, the majority of capecitabine patients did not experience a worsening QoL from 12 months through 24 months compared to patients receiving standard chemotherapy. Further, these findings are relevant in selecting treatments in the metastatic setting where QoL endpoints often drive decision-making and the goal is to achieve a reasonable level of efficacy while minimizing toxicity.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5035.

Clinical trial participants’ strategies for coping with prescription drug costs: A companion study to CALGB 80405

9503

Background: The strategies used by clinical trial participants to cope with the high costs of prescription drugs are poorly characterized. Methods: We identified a cohort of newly metastatic CRC patients participating in CALGB 80405, a phase III trial comparing first-line systemic chemotherapy with Bevacizumab, Cetuximab or both agents. We surveyed trial participants about their prescription drug insurance status and strategies they used to cope with out-of-pocket prescription drug costs. We surveyed patients before trial initiation and again 3 months later to assess the extent to which embarking on chemotherapy imposes additional financial burden requiring use of coping strategies. Results: Out of 1422 trial participants, 806 (57%) completed the baseline survey. The 515 enrolled before 09/01/2007 were asked to repeat the survey by phone at 3 months; 409/505 alive at 3 months (81%) did so. The 409 patients in the analytic cohort had similar clinical and demographic features to those not surveyed. 60/409 (15%) lacked prescription drug coverage and only 48/409 (12%) discussed prescription drug costs with their physicians. Conclusions: In the context of a trial in which costs of chemotherapy are covered and most participants had prescription drug insurance, patients rarely discuss prescription drug costs with their physicians. Although a considerable minority report having used coping strategies to lessen the cost burden, only a very small minority newly adopt such strategies after starting chemotherapy on trial.

[Table: see text]

[Table: see text]

Does health-related quality of life (HRQL) improve for patients who respond to chemotherapy? Analysis of patients with advanced pancreas cancer (APC) receiving gemcitabine on Cancer and Leukemia Group B (CALGB) study #80303

9008

Background: Gemcitabine chemotherapy for APC is palliative and confers only modest survival advantage. Therefore HRQL concerns are of paramount importance. Methods: We compared HRQL scores based on response to chemotherapy at the first interval restaging (8 weeks). We evaluated HRQL at baseline on paper, and then q8 weeks by phone using the EQ5D instrument in patients with APC participating in a double-blind, randomized trial comparing overall survival for gemcitabine with bevacizumab (GB) or placebo (GP). The EQ5D is a HRQL measure whose composite (C) and visual analog scale (VAS) scores respectively reflect societal and patient valuations. Results: Among 552 patients starting protocol treatment, characteristics did not differ between 359 who did and 193 who didn’t complete baseline assessments. Patients who didn’t complete 8 week assessments were more likely to have died, progressed or discontinued protocol therapy. Changes in EQ5D scores from baseline to 8 weeks did not differ by treatment arm (p-values=0.84, 0.79 for C and VAS scales, Wilcoxon rank sum test). At 8 weeks, all patients and those with progressive disease had a modest decline in VAS scores (p-values≤0.02, Wilcoxon signed rank test). Comparisons of changes from baseline in C scores at 8 week follow-up revealed no differences within other response group strata (all p-values > 0.05). Conclusions: Based on this preliminary analysis, gemcitabine therapy was not associated with higher HRQL scores, nor was there any strong association between tumor response and HRQL. To increase data representativeness, future APC trials should assess HRQL more often than every 8 weeks. HRQL Scores Based on Gemcitabine Response Strata. Values are Mean (SD)

[Table: see text] [Table: see text]

A patterns-of-care study of post-progression treatment (Rx) among patients (pts) with advanced pancreas cancer (APC) after gemcitabine therapy on Cancer and Leukemia Group B (CALGB) study #80303

4524

Background: Gemcitabine is the mainstay of Rx for pts with APC. Practice guidelines encourage participation in trials after disease progression. We evaluated Rx after APC progression for pts in CALGB 80303 a randomized trial of gemcitabine + bevacizumab (GB) or placebo (GP). Methods: Of the 552 pts who began GP or GB Rx, 457 had comprehensive medical record review. Of these 355 progressed on protocol Rx. We evaluated post-progression Rx for these 355 pts - the record review (RecR) group. We also phoned a subgroup of 126 pts to inquire about Rx delivered at sites other than the accruing center - the record review & interview group (RecR + I) to determine whether any Rx had been administered and the specific agents used. Results: ChemoRx after progression on gemcitabine was distinctly uncommon. Based on RecR 239/355=67.3% and on RecR + I, 70/126=55.6% of pts received no chemoRx after progression on the study Rx. These proportions did not vary based on Rx assignment. Worse ECOG performance status at baseline and older age were associated with lower likelihood of post progression Rx. Notably, 99/355=27.9% of pts died within 4 weeks of progression. Conclusions: After progression on a clinical trial of gemcitabine Rx, <half of pts receive 2nd line Rx and remarkably few (<2%) receive further experimental Rx. Given the lack of well established Rx options, there appear to be lost opportunities for participation in early phase clinical trials. Coordinated strategies for second line Rx options might increase the evidence base for this challenging malignancy. Patterns of Post-Progression ChemoRx after Progression on Gemcitabine ± Bevacizumab in APC.

[Table: see text] [Table: see text]

Primary airway epithelial cell culture from lung transplant recipients

Long-term survival in lung transplantation is limited by the development of obliterative bronchiolitis, a condition characterised by inflammation, epithelial injury, fibroproliferation and obliteration of bronchioles leading to airflow obstruction. To investigate the role of the bronchial epithelium in the pathogenesis of obliterative bronchiolitis the current study aimed to establish primary bronchial epithelial cell cultures (PBEC) from lung allografts. Four to six bronchial brushings were obtained from sub-segmental bronchi of lung allografts. Cells were seeded onto collagen-coated plates and grown to confluence in bronchial epithelial growth medium. Bronchial brushings (n=33) were obtained from 27 patients. PBECs were grown to confluence from 12 out of 33 (39%) brushings. Failure to reach confluence was due to early innate infection. Bacteria were usually isolated from both bronchoalveolar lavage and culture media, but a separate population was identified in culture media only. Primary culture of bronchial epithelial cells from lung transplant recipients is feasible, despite a high rate of early, patient-derived infection. Latent infection of the allograft, identified only by bronchial brushings, may itself be a persistent stimulus for epithelial injury. This technique facilitates future mechanistic studies of airway epithelial responses in the pathogenesis of obliterative bronchiolitis.

Case report of a Wilms' tumor and a left-sided inferior vena cava. A common tumor with a normal variant of surgical significance

We report a case of a successful surgical resection of a Wilms' tumor in the right kidney with a coincidental preoperative imaging finding of a left-sided inferior vena cava. To our knowledge, these 2 conditions occurring together has not been previously reported in literature. Diagnostic features and the value of magnetic resonance imaging are emphasized. We also review the literature of major venous anomalies and their influence on surgical procedures carried out on such patients.

Prevalence and clonality of Burkholderia cepacia complex genomovars in UK patients with cystic fibrosis referred for lung transplantation

BACKGROUND

It has previously been reported that patients infected with Burkholderia cenocepacia (genomovar III) before lung transplantation have a poorer outcome than those with other B. cepacia complex infections.

METHODS

An extensive study was conducted to determine the prevalence and clonality of B. cepacia complex genomovars isolated from patients referred for transplant assessment between 1989 to the present and, where appropriate, whether strain type was related to transplant outcome.

RESULTS

Isolates from 29 patients were identified as B. cepacia complex organisms by molecular analysis. Thirteen patients (45%) were infected with the highly transmissible ET-12 strain of B. cenocepacia recA lineage III-A, while all remaining patients were infected with genetically unique B. cenocepacia, B. multivorans, and B. vietnamiensis strains. All previously reported deaths following transplantation were associated with ET-12 infection.

CONCLUSIONS

The ET-12 strain is the predominant cause of B. cenocepacia infections in patients with cystic fibrosis referred to our pulmonary transplant centre and is associated with poor transplant outcomes using standard treatment regimens.

The impact of the introduction of treated water on aspects of community health in a rural community in Kwazulu-Natal, South Africa

A project was designed by Umgeni Water (funded by the Water Research Commission of South Africa) to monitor the implementation of water reticulation in Vulindlela and evaluate the Water Supply Scheme from a community and environmental health perspective. The findings would hopefully contribute toward the development of criteria for Health Impact Assessment on Water Reticulation Projects. One objective of this study was to evaluate the usefulness of diarrhoeal disease as opposed to other health indicators for water-associated diseases. The innovative methodology followed in the study, a "stepped wedge design", compared four discrete areas of water reticulation implementation in Vulindlela over a 15-month period. Five surveys, including a baseline and four follow-ups at each household, were carried out. Analysis (microbiological, chemical) was carried out of samples from the household drinking water and from the source of the water. Each survey included health questionnaires, the respondent being the head of the household in each case. Overall, there was no direct correlation proved between water quality and diarrhoea per se. However, there was a marked decrease in diarrhoea with the introduction of the new water supply. There was definite correlation between hygiene behaviours and diarrhoea. Diarrhoea would seem to be the health impact associated with water, of choice.

Effects of echistatin and an RGD peptide on orthodontic tooth movement

We tested whether orthodontic tooth movement (OTM) could be blocked by local administration of echistatin or an arginine-glycine-aspartic acid (RGD) peptide, agents known to perturb bone remodeling, adjacent to maxillary molars in rats. These molecules were incorporated into ethylene-vinyl acetate (ELVAX), a non-biodegradable, sustained-release polymer. In vitro experiments showed that the echistatin and RGD peptide were released from ELVAX in active forms at levels sufficient to disrupt osteoclasts. Biotinylated RGD peptide was released from ELVAX into the PDL after surgical implantation. ELVAX loaded with either RGD peptide or echistatin and surgically implanted next to the maxillary molars inhibited orthodontic tooth movement (p < 0.01). The RGD peptide also reduced molar drift (p < 0.05). This study shows the feasibility of using ELVAX to deliver integrin inhibitors adjacent to teeth to limit local tooth movement in response to orthodontic forces.

Effects of matrix metalloproteinase inhibitors on bone resorption and orthodontic tooth movement

Matrix metalloproteinases are involved in the regulation of bone remodeling. The hypothesis that matrix metalloproteinase inhibitors may be useful for experimentally limiting orthodontic tooth movement, a process involving perturbations of normal bone remodeling, was tested. General matrix metalloproteinase inhibitors limited the resorption of bone slices by mouse marrow cultures stimulated by calcitriol, parathyroid hormone, and basic-fibroblast growth factor. Pre-coating dentin slices with short arginine-glycine aspartic acid (RGD) peptides, but not arginine-glycine-glutamic acid (RGE) controls, restored bone resorption in the presence of matrix metalloproteinase inhibitors. Orthodontic tooth movement was inhibited by local delivery of Ilomastat, a general matrix metalloproteinase inhibitor, with the use of ethylene-vinyl-acetate (ELVAX) 40, a non-biodegradable, non-inflammatory sustained-release polymer. This study shows that orthodontic tooth movement can be inhibited with the use of matrix metalloproteinase inhibitors, and suggests a mechanistic link between matrix metalloproteinase activity and the production of RGD peptides.

Burkholderia cepacia complex genomovars and pulmonary transplantation outcomes in patients with cystic fibrosis

Burkholderia cepacia is a group of organisms that comprises seven genotypically distinct species (B cepacia genomovars I-VII), which are collectively known as the B cepacia complex. Preoperative infection with B cepacia is associated with a poor prognosis in lung transplant recipients with cystic fibrosis. Many centres do not, therefore, offer transplants to these individuals. Our aim was to ascertain whether or not post-transplant mortality is affected by pretransplant genomovar status. We studied archived isolates with PCR-based methods, and recorded excessive mortality in patients infected with B cepacia genomovar III, but not in those infected with other genomovars.

Two-year outcome of preschool children with autism or Asperger's syndrome

OBJECTIVE

DSM-IV specifies that Asperger's disorder is a type of pervasive developmental disorder without clinically significant cognitive or language delay. There are no data, however, on the outcome of children with Asperger's disorder or on whether their outcome differs from that of children with autism. The objectives of this study were to compare the outcome of groups of children with these disorders over a period of 2 years on variables independent of the defining criteria and to identify variables that might account for these differences.

METHOD

All children 4-6 years of age who came for assessment or were currently in treatment at a pervasive developmental disorder service of one of several centers in a large geographic region were identified. Children who received a diagnosis of autism (N=46) or Asperger's syndrome (N=20) on the basis of a diagnostic interview and had an IQ in the nonretarded range were given a battery of cognitive, language, and behavioral tests. Families were contacted roughly 2 years after the date of their enrollment in the study, and many of the tests were readministered.

RESULTS

Children with Asperger's syndrome had better social skills and fewer autistic symptoms 2 years after study enrollment than the children with autism. The differences in outcome could not be explained by initial differences in IQ and language abilities. Children with autism who had developed verbal fluency at follow-up were very similar to the children with Asperger's syndrome at study enrollment.

CONCLUSIONS

Although the exact mechanism for the differences in outcome remain to be determined, it appears that Asperger's disorder and autism represent parallel but potentially overlapping developmental trajectories.

Later orthodontic appliance reactivation stimulates immediate appearance of osteoclasts and linear tooth movement

BACKGROUND

Delays in the appearance of osteoclasts at compression sites occur after orthodontic appliance reactivation, when this is done during both the period of osteoclast recruitment and the peak expansion in the osteoclast population. This experiment examines osteoclasts and tooth movement in alveolar bone after appliance reactivation coinciding with alveolar bone formation and the time when reactivation osteoclasts first appear (ie, 10 days after initial appliance activation).

METHODS

Bilateral orthodontic appliances were activated to mesially tip maxillary molars with 40 cN in 144 rats. After 10 days, all rats were randomized into two groups of 72. Group I had appliances reactivated in precisely the same manner as the first activation. Group II had appliances sham-reactivated. Nine to 12 rats were then sacrificed at 1, 3, 5, 7, 10, and 14 days in both groups (eg, day 1 represents an interval of 11 days after the first appliance activation and 1 day after either sham or real reactivation). Orthodontic movement was measured cephalometrically; changes in osteoclasts and root resorption were assessed at both compression and tension sites histomorphometrically.

RESULTS

Teeth in the reactivated group (Group I) displayed linear tooth movement (62.6 micrometers/day), and 0.9 mm tooth movement by day 10. Significant increases in osteoclast numbers, osteoclast surface percentage, and surface per individual osteoclast were evident in these animals by 1 day postreactivation (P <.01). Significant treatment-related increases in root resorption were not evident at compression sites at any time.

CONCLUSIONS

These findings indicate that, after appliance reactivation during the time when reactivation osteoclasts appear, a second cohort of osteoclasts can be recruited immediately, along with immediate and substantial tooth movement and no greater risk of root resorption.

Detection of carboxypeptidases as taxonomic markers for gram-negative bacteria

The use of seven benzoyl-L-amino acids for the detection of carboxypeptidase activities in strains of Gram-negative aerobic and facultatively anaerobic bacteria is reported. A simple overnight assay was designed using ninhydrin for the demonstration of the amino acid released by hydrolysis. Detection of carboxypeptidase activity was shown to have some taxonomic relevance within the Enterobacteriaceae; it was also useful for differentiation within the genus Acinetobacter and for distinction between Pseudomonas aeruginosa and Pseudomonas fluorescens.

Asperger's syndrome and autism: differences in behavior, cognition, and adaptive functioning

OBJECTIVE

To determine whether subtypes of children with pervasive developmental disorder (PDD) differed on variables that were relatively independent of distinguishing criteria.

METHOD

Higher-functioning children with PDD, 4 through 6 years of age, were differentiated into those with autism (n = 47) and those with Asperger's syndrome (n = 21) on the basis of delayed and deviant language development. The groups were then compared on a wide range of measures including PDD symptoms, adaptive behaviors in communication, socialization, and activities of daily living, and an assessment of verbal and nonverbal cognitive skills.

RESULTS

Significant differences between the groups existed on many PDD symptoms, adaptive behaviors, and cognitive measures of language competence, but not on aspects of nonverbal communication, nonverbal cognition, or motor development.

CONCLUSION

Subtypes of children with PDD can be identified that differ on variables relatively independent of defining characteristics. These findings should provide a firm foundation into research to determine whether children with autism and Asperger's syndrome also differ on outcome, etiology, and response to treatment.

What if Americans drank less? The potential effect on the prevalence of alcohol abuse and dependence

OBJECTIVES

Several advisory committees have recently recommended that alcohol consumption be limited to moderate levels. Moderate drinking has been defined generally as not more than two drinks per day for healthy men and not more than one drink per day for healthy, nonpregnant women. The impact of reducing alcohol consumption to within the recommended guidelines on the prevalence of two serious alcohol-related problems was examined by modeling the relationship between average daily ethanol intake and alcohol abuse and dependence.

METHODS

The recommended drinking guidelines, both in their existing form and modified by a measure of impairment, were applied to the observed distribution of consumption derived from a large representative survey of the US general population.

RESULTS

The results demonstrated that restricting drinking to the maximum allowable levels under the existing and the modified guidelines would reduce the prevalence of alcohol abuse and dependence by 14.2% and 47.1%, respectively, in the adult US general population.

CONCLUSIONS

Implications of these findings are discussed in terms of the validity of the assumptions underlying the models and the nature and direction of future research that would form the basis of newly developed guidelines for safe drinking limits.

Parent and teacher agreement in the assessment of pervasive developmental disorders

Although it is well known that informants often disagree about the degree of psychopathology in children, this issue has not been systematically evaluated in children with autism. The objective of this paper is to estimate the extent of agreement between parents and teachers on the assessment of autistic symptoms and adaptive behavior skills. We assessed 83 children, 4-6 years of age, with a diagnosis of pervasive developmental disorder (PDD), using the Autism Behavior Checklist (ABC) and the Vineland Adaptive Behavior Scales (VABS). Parents and teachers rated each child on each measure. While there was good agreement between informants on the VABS, teachers tended to rate the PDD children higher than parents. In contrast, there was virtually no agreement on the ABC. High levels of stress experienced by parents appeared to be associated with parents reporting more autistic behaviors and less adaptive skills than teachers. As with other child psychiatric disorders, caution must be exercised in combining information from several informants.

Safe biotechnology (5). Recommendations for safe work with animal and human cell cultures concerning potential human pathogens

The benefits of using animal or human cell cultures have been clearly demonstrated in diagnostic and therapeutic research and in their application for manufacturing. Cell cultures serve as a tools for the production of vaccines, receptors, enzymes, monoclonal antibodies and recombinant DNA-derived proteins. They represent an integral part of drug development for which corresponding facilities, equipment and manufacturing processes are required. Although the cells themselves offer no particular risk to workers in laboratories and production areas or to the environment, the cell cultures may be contaminated with viruses, mycoplasma, bacteria, yeast and fungi or might contain endogenous viruses. The containment level for animal and human cells is therefore determined by the risk class of these agents. The history of animal and human cell cultures has proved that they can be handled safely. The recommendations in this publication concern the safe handling of cell cultures (tissue explants, primary cell cultures) and permanent cell lines of animal and human origin. A classification system of safety precautions has been elaborated according to the potential for contamination with the pathogenic agents involved.

Safe biotechnology (4). Recommendations for safety levels for biotechnological operations with microorganisms that cause diseases in plants

The Working Party on Safety in Biotechnology of the European Federation of Biotechnology has proposed a classification of microorganisms that cause diseases in plants. In this paper appropriate safety levels are proposed for these classes of microorganisms in order to ensure that research, development and industrial fermentation work with plant pathogens will limit the risk of outbreaks of diseases in crops that could result from work with such microorganisms when they are cultivated in laboratories, glasshouses and biotechnology installations.

[Ethical and social issues on the human genome analysis]

The modern technologies for human genome analysis raise a variety of ethical and social questions. The pre-symptomatic diagnostic of diseases of late expression is becoming possible for a rapidly increasing number of situations. The use of that knowledge by employers, insurance companies, schools, and society in general, could lead to discriminations and stigmatizations, in addition to adverse psychological reactions. DNA fingerprinting raises questions of privacy and personal autonomy in its applications to paternity proof, criminal proceedings, and establishment of data banks. The project of the immediate and complete sequencing of the human genome will lead to questions of economical ethics, as well as of access, commercialization and property rights of scientific information and materials obtained. It also favours a reducionistic mentality and international unbalances. The molecular biology of humans, which will follow the complete sequencing of the genome, may foster a rethinking of the concepts of freedom of self-determination (basic for moral responsibility) and of equality. The gene therapy and its possible extension to the betterment of the human species, pose questions of ethical limits to this technology. All these problems will have to be answered in terms of the application of the principle of ethical freedom for self-fulfillment, as a right of the human person, as well as of science and society. Scientific, economic and social interests have to be subordinated to the dignity of the human person.

Alcohol and the elderly

Moderate drinking for the elderly of both genders is no more than one drink per day, where a drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of spirits. Age does not affect the rate of absorption or elimination of alcohol. Lean body mass decreases and adipose tissue increases with age, however, resulting in a corresponding decrease in the volume of total body water. With a smaller volume of distribution, an alcohol dose identical to that administered to a younger individual of the same size and gender will produce a higher blood alcohol concentration in the elderly. Low-dose alcohol stimulates appetite and promoters regular bowel function. In the well-nourished nonalcoholic elderly, the negative impact of alcohol consumption on nutrition is minimal. Alcohol consumption improves mood by increasing feelings of happiness and freedom from care while lessening inhibitions, stress, tension, and depression. Although in the laboratory low-dose alcohol improves certain types of cognitive function in young men, in other types of task performance, alcohol induces impairment, which worsens with age. The effects of alcohol on sleep are primarily detrimental, worsening both insomnia and breathing disturbances during sleep. Although the role of alcohol consumption in mortality from heart disease has not been investigated in the elderly, moderate drinking appears safe. Under some circumstances low-dose alcohol may produce analgesia whereas in others it may worsen pain. The elderly use a significant proportion of both prescription and over-the-counter medication, a large variety of which interact with alcohol. Alcoholic beverage consumption may exacerbate cognitive impairment and dementias of other etiology. Although some studies suggest that moderate use of alcohol by institutionalized senior citizens appears to produce benefits including improved socialization, separation of the effects of the social situation from those specifically attributable to alcohol remains to be accomplished. Older individuals who want to drink, have no medical contraindications, and take no drugs (prescription or over-the-counter) that interact with alcohol, may consider one drink a day to be a prudent level of alcohol consumption. Patients should be counseled to avoid alcohol consumption immediately prior to going to bed in order to avoid sleep disturbances. They also should be cautioned against potential drug-alcohol interactions and told to avoid alcohol ingestion prior to activities such as driving. The decision to recommend a particular level of alcohol consumption in any given patient must, however, be carefully tailored not only to that individual's specific medical needs but to his or her social and environmental circumstances as well.

Gender differences in alcohol consumption: effects of measurement

Data from a 1988 survey of US drinking habits and related problems revealed differences in male and female patterns of alcohol consumption. Men were more likely than women to be current drinkers (64 v. 41%), and beer accounted for a larger proportion of their overall intake. Men's average daily ethanol intake was about twice as high as that of women, 17.5 v. 8.9 g. Adjustment for differences in body weight and composition substantially reduced the male-to-female ratio of consumption. Men were more likely than women to be classified as heavy drinkers, and the excess proportion of males so categorized increased with the severity of the measure of heavy drinking.

Flow cytometric analysis of megakaryocytes from patients with abnormal platelet counts

Megakaryocytes (MKs) from 40 patients with quantitative platelet disorders and 19 normal volunteers were analyzed by flow cytometry for size, fine cell internal structure and granularity, membrane expression of the glycoprotein (GP) IIb/IIIa complex, and for ploidy distribution. Analysis was performed on unfractionated minimally manipulated marrows obtained from routine bone marrow aspirates. MKs were labeled with a fluorescent lineage-specific monoclonal antibody to the GPIIb/IIIa complex followed by DNA staining with propidium iodide. Eight hundred to 3,000 MKs were analyzed in each sample. The modal ploidy distribution in normals was 16N, comprising about half of the megakaryocytic population, with 22.6% of the cells less than or equal to 8N and 22.0% greater than or equal to 32N. Twelve thrombocytopenic patients with decreased marrow MKs on biopsy (mean platelet count [MPC] 44,600/microliters) showed an increase in low ploidy cells with 53.2% less than or equal to 8N (P less than .01); cell size was reduced in three patients when compared to normal cells of identical ploidy (P less than .05). Eight thrombocytopenic patients with enhanced platelet destruction (with normal or increased MKs on biopsy and shortened platelet survival; MPC 41,400/microliters) showed an increased proportion of high ploidy cells greater than or equal to 32N to 39.2% (P less than .01). Increased cell size and granularity were found in four of these patients (P less than .05). Six patients with thrombocytopenia secondary to multiple mechanisms affecting both platelet production and destruction (MPC 66,700/microliters) showed no shift in ploidy. Four patients with primary thrombocytosis (two with thrombocythemia and two with polycythemia vera; MPC 822,500/microliters) showed a marked shift toward high ploidy cells with 42.3% greater than or equal to 32N and 7.6% greater than or equal to 64N cells (P less than .01). The shift was accompanied by a marked increase in cell size and granularity in the patients with thrombocythemia. Ten patients with thrombocytosis secondary to chronic blood loss, malignant or inflammatory disorders (MPC 714,000/microliters), showed variable distributions with four patients exhibiting a shift in ploidy to the right similar to that found in the patients with increased platelet destruction. Based upon the present data, flow cytometric ploidy distribution may be diagnostically useful in thrombocytopenic patients by discriminating between disorders of platelet production and destruction. (ABSTRACT TRUNCATED AT 400 WORDS)

Restriction analysis of PBS 1-related phages

The Bacillus subtilis bacteriophages AR 9, 3 NT, and I 10 belong to the same group as the widely used bacteriophage PBS 1. These four phages have in common, among other properties, flagellotropic adsorption to host cells and total substitution of thymine by uracil in their DNAs. We tested the action of different restriction endonucleases on the four genomes. Among 14 enzymes, which did cut the DNAs into discrete fragments, six are known as having at least one thymine residue in their recognition sequences. The electrophoretical patterns of the digested DNAs from the four phages show strong similarities. Nevertheless, the differences are sufficient to allow a clear distinction between them.