Obstruction of Valid Race/Ethnicity Data Acquisition by Current Data Collection Instruments

Methods of collecting race/ethnicity data affect the validity of conclusions based on them as do other factors such as lack of consensus and inadequate definitions for terminology; and misclassification or miscounting of patients. Current data collection instruments do not identify mixed heritage. We propose improving data measurement and collection by including a quantified multiracial/multiethnic heritage category for persons of mixed heritage; a don't know category; and a refuse to reveal category. The resulting problems affect all uses of racial and ethnic data, including health care provision, research, and health planning. More precise race/ ethnicity categories should be encouraged by such means as a 16-category checklist (with instructions to check all which apply) currently in development. The Methods section of all clinical, epidemiologic, and pharmacologic reports should include descriptions of racial measurement and reasons for including or excluding clearly defined populations.

Design of a Mobile Application for Transfusion Medicine

One of the most frequent error in transfusion medicine is the failure in verifying the patient's identity prior to transfusion. This paper describes the design and development of a Mobile Application (MA) for transfusion medicine. The app uses barcode and QR reading technology for the verification of the patient's identity and the administration of blood components when making a blood transfusion. Physicians, developers, technicians of transfusion medicine and a User Centered Design team participated in the design. The inclusion of end users was fundamental to get full representativeness of their workflow. The project was based on agile methodologies of project management and software development.

Understanding normality: a qualitative analysis of breast cancer patients concepts of normality after mastectomy and reconstructive surgery

BACKGROUND

As survival rates increase, many people have to adjust to life after cancer. This includes adjusting to life after surgery. While previous research suggests that patients commonly strive to be 'normal' after mastectomy and reconstructive surgery, research surrounding individual perceptions of normality is lacking.

AIM

The aim of this study was to explore concepts of normality within a sample of breast cancer patients eligible for reconstructive surgery following mastectomy.

METHODS

A total of 35 semi structured interviews, with women who had undergone or were about to undergo breast reconstructive surgery following breast cancer, were analysed using thematic analysis.

RESULTS

Four main themes emerged from the data. Women referred to looking normal (appearance); being able to fulfil everyday activities (behaviour); adapting to a new normal (reconstructing normality); and not being ill (health). The importance placed on each area of normality differed between patients. Additionally, patients used different standards to anchor concepts of normality. These included individual standards, social standards and clinical standards.

DISCUSSION

The results indicate that although there are commonalities between patients' concepts of normality, it is important for health care professionals to recognise potential individual differences. This may usefully aid communication and help to manage expectations among patients considering surgical options.

An evaluation of the efficacy of the national immunization programme for hepatitis B

We report an evaluation of the Israeli national immunization programme for hepatitis B in the Haifa subdistrict. We used a convenience sample of blood tests reported positive for HBsAg over a 6-year period from children who were born after routine immunization began in 1992. We identified 11 children with presumed chronic hepatitis B virus infection who were residents of the Haifa subdistrict, three of whom were born in Israel. All three were immunized at the appropriate age and are thus considered vaccination failures rather than failure to vaccinate. The remaining eight were born abroad, had emigrated to Israel as children and were not immunized at birth. We estimate the rate of chronic hepatitis B virus infection for children born since 1998 to be 0.24/10,000 births. For all children resident in the subdistrict under the age of 12 years, the period prevalence is estimated to be 1.26/10,000. The rate of chronic infection in children younger than 12 years was significantly less than that of older cohorts and less than that of historical controls before the start of immunization. Although the reported rates are probable underestimates of actual rates, the fact that they are based on testing carried out in clinical settings increases the likelihood of positive findings and thus reduces the degree of error. The fact that most young carriers are foreign born points to the importance of timely catch-up programmes. In countries with low and intermediate rates of chronic infection, serosurveys of immunized children need to be large and are therefore costly. Monitoring HBsAg positive tests from routine testing carried out in clinical settings is an inexpensive way to monitor chronic infection rates.

Bosentan treatment for pulmonary arterial hypertension related to connective tissue disease: a subgroup analysis of the pivotal clinical trials and their open-label extensions

BACKGROUND

Endothelin-1 is considered to be a central pathogenic factor in connective tissue diseases (CTDs) such as systemic sclerosis (SSc), leading to vasoconstriction, fibrosis, hypertrophy and inflammation. A frequent complication of CTD is pulmonary arterial hypertension (PAH), which has a major effect on functioning and quality of life, and is associated with a particularly poor prognosis.

OBJECTIVE

To present a subgroup analysis that summarises experiences from the pivotal studies and their open-label extensions with the oral dual endothelin-1 receptor antagonist bosentan in patients with PAH and CTD, mostly SSc and lupus erythematosus.

METHODS

66 patients with PAH secondary to CTD, in World Health Organization functional class III or IV, were randomised to two double-blind, placebo-controlled studies and followed up for 12 and 16 weeks, respectively. The primary end point was change in exercise capacity, assessed using the 6-min walk test. In both studies and their extensions, survival was assessed from start of treatment to death or data cut-off and analysed as Kaplan-Meier estimates.

RESULTS

44 patients with PAH secondary to CTD who were treated with bosentan were stable in 6-min walk distance at the end of the study (+19.5 m, 95% confidence interval (CI) -3.2 to 42.2), whereas patients treated with placebo deteriorated (-2.6 m, 95% CI -54.0 to 48.7). 64 patients subsequently received bosentan in an open-label long-term extension study. Mean (standard deviation (SD)) exposure to bosentan was 1.6 (0.9) years, and duration of observation was 1.8 (0.8) years. 8 (16%) patients received epoprostenol as add-on treatment and 7 (14%) after discontinuation of bosentan. Survival in those receiving bosentan was 85.9% after 1 year and 73.4% after 2 years.

CONCLUSION

Short-term bosentan treatment in a subgroup of patients with PAH secondary to CTD seems to have a favourable effect compared with placebo. The long-term follow-up of these patients suggests that first-line bosentan, with the subsequent addition of other PAH treatments if required, is safe for long-term treatment and may have a positive effect on outcome.

Progression of lung disease on computed tomography and pulmonary function tests in children and adults with cystic fibrosis

BACKGROUND

A study was undertaken to compare the ability of computed tomographic (CT) scores and pulmonary function tests to detect changes in lung disease in children and adults with cystic fibrosis (CF).

METHODS

CT scans and pulmonary function tests were retrospectively studied in a cohort of patients with CF aged 5-52 years for whom two or three CT scans at 3 year intervals were available, together with pulmonary function test results. All CT scans were scored by two observers. Pulmonary function results were expressed as percentage predicted and Z scores.

RESULTS

Of 119 patients studied, two CT scans were available in 92 patients and three in 24. CT (composite and component) scores and lung function both deteriorated significantly (p<0.02). Peripheral bronchiectasis worsened by 1.7% per year in children (p<0.0001) and by 1.5% per year in adults (p<0.0001). Bronchiectasis worsened in 68 of 92 patients while forced expiratory volume in 1 second (FEV1) worsened in 54 of 92 patients; bronchiectasis also deteriorated in 27 patients with stable or improving FEV1. The CT score (and its components) and pulmonary function tests showed similar rates of deterioration in adults and children (p>0.09).

CONCLUSION

The peripheral bronchiectasis CT score deteriorates faster and more frequently than lung function parameters in children and adults with CF, which indicates that pulmonary function tests and CT scans measure different aspects of CF lung disease. Our data support previous findings that the peripheral bronchiectasis CT score has an added value to pulmonary function tests in monitoring CF lung disease.

Whole-genome screening in ankylosing spondylitis: evidence of non-MHC genetic-susceptibility loci

Ankylosing spondylitis (AS) is a common inflammatory arthritis predominantly affecting the axial skeleton. Susceptibility to the disease is thought to be oligogenic. To identify the genes involved, we have performed a genomewide scan in 185 families containing 255 affected sibling pairs. Two-point and multipoint nonparametric linkage analysis was performed. Regions were identified showing "suggestive" or stronger linkage with the disease on chromosomes 1p, 2q, 6p, 9q, 10q, 16q, and 19q. The MHC locus was identified as encoding the greatest component of susceptibility, with an overall LOD score of 15.6. The strongest non-MHC linkage lies on chromosome 16q (overall LOD score 4.7). These results strongly support the presence of non-MHC genetic-susceptibility factors in AS and point to their likely locations.

Five decades of trends in anemia in Israeli infants: implications for food fortification policy

OBJECTIVE

To describe the secular trends in the prevalence rates of iron-deficiency anemia (IDA) in infants in Israel, identify population group differences and assess the effectiveness of the 1985 Public Health directives on iron supplementation and avoidance of cow's milk in the first year of life.

DESIGN

A systematic analysis of published and unpublished cross-sectional studies.

METHODS

IDA rates in 1-y-old infants between 1946 and 1997 were assessed from published papers and reports. Rates for Arab infants were available from 1984. Data on routine hemoglobin tests on 1-y-old infants for Arabs and Jews separately were obtained from four health districts for the period 1987 to 1997. Analyses were done for the periods prior to and following the Public Health directives.

RESULTS

The prevalence of IDA in Jewish infants declined from 68% in 1946 to 50% in 1985 at an average annual rate of -1.43%. Following the iron supplementation directives, the average annual rate of decline increased to -4.0% and reached a prevalence of about 11% in 1996. IDA rates in Arab infants declined by an annual average of -3.7%, and were consistently almost twice as high as for Jewish infants.

CONCLUSIONS

Despite the contribution of the iron supplementation program to the reduction in TDA, the persistently high rates indicate inadequate iron content in the diet. This emphasizes the important role of a national food fortification program, using staple foods commonly consumed.

Influenza vaccination among healthcare workers

OBJECTIVE

To determine the vaccination rates among healthcare workers in the Haifa subdistrict and to assess factors associated with vaccination uptake among them.

METHODS

The study was conducted in the three general hospitals in Haifa City, and in five nursing homes in the Haifa subdistrict. Self-administered questionnaires were distributed to 1,014 employees of whom 71% were females, 34% were nurses, 27% were physicians and 28% were non-professional workers.

RESULTS

The crude response rate was 66%. Response rates were higher in females (71%) than in males (49%), in nurses (70%) than in physicians (43%), and in staff of internal and pediatric departments than in workers of surgery departments and emergency rooms. The overall vaccination rate among the respondents was 11%, which was higher among males (15%) than among females (10%). No significant relationship between vaccination rate and age, occupation and department was found. The vaccination rate among employees with chronic illness was very low (7%). Influenza vaccine was actively recommended to 29% of the employees. The main reasons for non-compliance were low awareness of the severity of the disease and of the vaccine's efficacy and safety, and unavailability of the vaccine within the workplace.

CONCLUSIONS

Educational efforts and offering the vaccine at the workplace at no cost are the most important measures for raising influenza vaccination rates.

Programmed cell death in zebrafish rohon beard neurons is influenced by TrkC1/NT-3 signaling

Rohon Beard (RB) cells are embryonic primary sensory neurons that are removed by programmed cell death during larval development in zebrafish. RB somatosensory functions are taken over by neurons of the dorsal root ganglia (DRG), suggesting that RB cell death may be triggered by the differentiation of these ganglia, as has been proposed to be the case in Xenopus. However, here we show that the timing of RB cell death correlates with reduced expression of trkC1, the receptor for neurotrophin NT-3, but not with the appearance of DRG, which differentiate only after most RB cells die. trkC1 is expressed in subpopulations of RB neurons during development, and cell death is initiated only in trkC1-negative neurons, suggesting a role for TrkC1 and its ligand, NT-3, in RB cell survival. In support of this, antibodies that deplete NT-3 induce RB cell death while exogenous application of NT-3 reduces death. In addition, we show that RB cell death can be prevented using a caspase inhibitor, zVADfmk, showing that during normal development, RB cells die by a caspase-dependent programmed cell death pathway possibly triggered by reduced signaling via TrkC1.

Anorexigens and pulmonary hypertension in the United States: results from the surveillance of North American pulmonary hypertension

BACKGROUND

The use of appetite suppressants in Europe has been associated with the development of primary pulmonary hypertension (PPH). Recently, fenfluramine appetite suppressants became widely used in the United States but were withdrawn in September 1997 because of concerns over adverse effects.

MATERIALS AND METHODS

We conducted a prospective surveillance study on patients diagnosed with pulmonary hypertension at 12 large referral centers in North America. Data collected on patients seen from September 1, 1996, to December 31, 1997, included the cause of the pulmonary hypertension and its severity. Patients with no identifiable cause of pulmonary hypertension were classed as PPH. A history of drug exposure also was taken with special attention on the use of antidepressants, anorexigens, and amphetamines.

RESULTS

Five hundred seventy-nine patients were studied, 205 with PPH and 374 with pulmonary hypertension from other causes (secondary pulmonary hypertension [SPH]). The use of anorexigens was common in both groups. However, of the medications surveyed, only the fenfluramines had a significant preferential association with PPH as compared with SPH (adjusted odds ratio for use > 6 months, 7.5; 95% confidence interval, 1.7 to 32.4). The association was stronger with longer duration of use when compared to shorter duration of use and was more pronounced in recent users than in remote users. An unexpectedly high (11.4%) number of patients with SPH had used anorexigens.

CONCLUSION

The magnitude of the association with PPH, the increase of association with increasing duration of use, and the specificity for fenfluramines are consistent with previous studies indicating that fenfluramines are causally related to PPH. The high prevalence of anorexigen use in patients with SPH also raises the possibility that these drugs precipitate pulmonary hypertension in patients with underlying conditions associated with SPH.

Laminectomy versus percutaneous electrode placement for spinal cord stimulation

OBJECTIVE

The purpose of this study was to compare the long-term effectiveness of spinal cord stimulation using laminectomy-style electrodes versus that using percutaneously implanted electrodes.

METHODS

Forty-one patients underwent an initial trial period of spinal cord stimulation with temporary electrodes at Duke Medical Center between December 1992 and January 1998. A permanent system was implanted if trial stimulation reduced the patient's pain by more than 50%. Median long-term follow-up after permanent electrode placement was 34 months (range, 6-66 mo). Severity of pain was determined postoperatively by a disinterested third party using a visual analog scale and a modified outcome scale.

RESULTS

Twenty-seven (66%) of the 41 patients participating in the trial had permanent electrodes placed. Visual analog scores decreased an average of 4.6 among patients in whom electrodes were placed via laminectomy in the thoracic region (two-tailed t test, P < 0.0001). Patients who underwent percutaneous placement of thoracic electrodes had an average decrease of 3.1 in their visual analog scores (two-tailed t test, P < 0.001). Electrodes placed through laminectomy furnished significantly greater long-term pain relief than did those placed percutaneously, as measured by a four-tier outcome grading scale (P = 0.02).

CONCLUSION

Spinal cord stimulation is an effective treatment for chronic pain in the lower back and lower extremities that is refractory to conservative therapy. Electrodes placed via laminectomy in the thoracic region appear to be associated with significantly better long-term effectiveness than are electrodes placed percutaneously.

Correlation of opsonophagocytosis and passive protection assays using human anticapsular antibodies in an infant mouse model of bacteremia for Streptococcus pneumoniae

An infant mouse assay system for assessment of protective concentrations of human serum pneumococcal anticapsular antibodies is described. Passive immunization of anticapsular antibodies was evaluated for protection of infant mice challenged with Streptococcus pneumoniae serotypes 1, 4, 5, 6B, 18C, and 23A, with bacteremia as an end point. Protection was defined as no detectable bacteremia in 70% of mice 48 h after challenge. Type-specific anticapsular concentrations required for protection varied with serotype (</=0.05 to >0.4 microg/mL). Across serotypes, there was no significant correlation between human IgG concentration in mouse serum and protection from bacteremia or between IgG concentration and opsonophagocytic titer. Significant correlation (r=.84, P<.001) was observed between opsonophagocytic titer of human IgG antibody in mouse sera and protection from bacteremia. Thus, protective concentrations of anticapsular antibodies against bacteremia are serotype dependent. Opsonophagocytosis is a better predictor of in vivo protective capacity of pneumococcal anticapsular antibodies than are ELISA IgG antibody concentrations.

Advanced glycation endproducts (AGE) on IgG, a target for circulating antibodies in North American Indians with rheumatoid arthritis (RA)

Several tribes of North American Indians are known to have poor glucose control and are at a high risk of developing type 2 diabetes. Similarly some tribes also exhibit RA at a high frequency. We have recently determined that a subset of Caucasian patients with RA mount an immune response to IgG modified with advanced glycation endproducts (AGE). The AGE modifications on IgG in vivo include N(epsilon)-(carboxymethyl) lysine, imidazolone and pentosidine. The presence of IgG-AGE and the antibody response to the IgG-AGE in the Ojibwe tribe of First Nations native Indians where both NIDDM and RA are prevalent was investigated. AGE modified IgG and albumin were determined using a modified nitroblue tetrazolium assay. Rheumatoid factors (RFs) and IgM and IgA anti-IgG-AGE were detected by ELISA. Of the 108 individuals tested, 21 had RA only, 3 had both RA and type 2 diabetes, 30 had type 2 diabetes only and 51 had no diagnosed disease. AGE modified IgG was significantly elevated in the RA group compared to the diabetic group. IgM and IgA RFs were detected in 83% and 50% of the RA patients, compared to 31-37% and 7-10% of the diabetics or normal individuals. IgM anti-IgG-AGE was detected in 54% of the RA patients, in contrast to 7-14% in the diabetics or normal individuals. IgA anti-IgG-AGE was detected in 42% of the RA patients and only 7 to 8% of the NIDDM or normal individuals. The IgM or IgA anti-IgG-AGE antibodies likely contribute to the accumulation of IgG-AGE, possibly through blocked clearance through AGE receptors. A trend towards more severe disease was seen in those Ojibwe RA patients with circulating anti-AGE antibodies. Non-enzymatic glycation may be an important pathogenic link in the RA seen in North American Indians.

Obstruction of valid race/ethnicity data acquisition by current data collection instruments

Methods of collecting race/ethnicity data affect the validity of conclusions based on them as do other factors such as lack of consensus and inadequate definitions for terminology; and misclassification or miscounting of patients. Current data collection instruments do not identify mixed heritage. We propose improving data measurement and collection by including a quantified multiracial/multiethnic heritage category for persons of mixed heritage; a don't know category; and a refuse to reveal category. The resulting problems affect all uses of racial and ethnic data, including health care provision, research, and health planning. More precise race/ethnicity categories should be encouraged by such means as a 16-category checklist (with instructions to check all which apply) currently in development. The Methods section of all clinical, epidemiologic, and pharmacologic reports should include descriptions of racial measurement and reasons for including or excluding clearly defined populations.

Purification of a multipotent antideath activity from bovine liver and its identification as arginase: nitric oxide-independent inhibition of neuronal apoptosis

Catalase is an antioxidant enzyme that has been shown to inhibit apoptotic or necrotic neuronal death induced by hydrogen peroxide. We report the purification of a contaminating antiapoptotic activity from a commercial bovine liver catalase preparation by following its ability to inhibit apoptosis when applied extracellularly in multiple death paradigms. The antiapoptotic activity was identified by protein microsequencing as arginase, a urea cycle and nitric oxide synthase-regulating enzyme, and confirmed by demonstrating the presence of antiapoptotic activity in a >97% pure preparation of recombinant arginase. The pluripotency of recombinant arginase was demonstrated by its ability to inhibit apoptosis in multiple paradigms including rat cortical neurons induced to die by glutathione depletion and oxidative stress, by 100 nM staurosporine treatment, or by Sindbis virus infection. The protective effects of arginase in these apoptotic paradigms, in contrast to previous studies on excitotoxic neuronal necrosis, are independent of nitric oxide synthase inhibition. Rather, arginase-induced depletion of arginine leads to inhibition of protein synthesis, resulting in cell survival. Because inhibitors of nitric oxide synthesis and of protein synthesis have been shown to decrease necrotic and apoptotic death, respectively, in animal models of stroke and spinal cord injury, arginine-depleting enzymes, capable of simultaneously inhibiting protein synthesis and nitric oxide generation, may be propitious therapeutic agents for acute neurological diseases. Furthermore, our results suggest caution in attributing the cytoprotective effects of some catalase preparations to catalase.

The role of germline polymorphisms in the T-cell receptor in susceptibility to ankylosing spondylitis

The role of germline polymorphisms of the T-cell receptor A/D and B loci in susceptibility to ankylosing spondylitis was investigated by linkage studies using microsatellite markers in 215 affected sibling pairs. The presence of a significant susceptibility gene (lambda > or = 1.6) at the TCRA/D locus was excluded (LOD score < -2.0). At the TCRB locus, there was weak evidence of the presence of a susceptibility gene (P = 0.01, LOD score 1.1). Further family studies will be required to determine whether this is a true or false-positive finding. It is unlikely that either the TCRA/D or TCRB loci contain genes responsible for more than a moderate proportion of the non-MHC genetic susceptibility to ankylosing spondylitis.

Distinct location and prevalence of alpha-, beta-catenins and gamma-catenin/plakoglobin in developing and denervated skeletal muscle

We studied the distribution of alpha-catenin, beta-catenin and gamma-catenin/plakoglobin in developing, adult and denervated mouse skeletal muscle. During primary myogenesis, all three catenins present a subsarcolemmal distribution within primary myotubes. During secondary myogenesis they accumulate at myotube-myotube contacts. In contrast to the other catenins, gamma-catenin is strongly expressed in the sarcoplasm. In adult muscle, all three catenins are localized on the presynaptic elements of the neuromuscular junction. In denervated muscles, alpha- and beta-catenins are upregulated like N- and M-cadherin, while the levels of gamma-catenin/plakoglobin remain unchanged. The developmental changes in localization and regulation of alpha- and beta-catenins in muscle compared to gamma-catenin/plakoglobin are suggestive of a privileged association of alpha- and beta-catenins with N- and M-cadherins, while gamma-catenin/plakoglobin appears to be expressed quite independently and must assume a different role during myogenesis.

Protein phosphorylation and the regulation of cell-cell junctions in brain endothelial cells

Endothelial cells lining the capillaries of the brain have two properties that distinguish them from their peripheral counterparts: (1) tight junctions of extremely low permeability; and (2) low rates of fluid-phase endocytosis. In combination, these features limit the nonspecific flux of ions, proteins, and other substances into the central nervous system environment, creating the blood-brain barrier. This barrier is not immutable. Tight junction permeability can be rapidly increased, which may play a role in the development of a variety of brain pathologies. We have therefore been interested in mechanisms regulating junctional permeability and strategies for interfering with this regulation. What is becoming increasingly apparent is that junctions are not passive mechanical entities; rather, they are targets for a variety of signaling pathways.

Posttransplantation lymphoproliferative disorders in bone marrow transplant recipients are aggressive diseases with a high incidence of adverse histologic and immunobiologic features

Posttransplantation lymphoproliferative disorders (PT-LPDs) occurring in T-cell depleted (TCD) allogeneic bone marrow transplant recipients seem to be different from those that arise in solid organ recipients in their early development, the high incidence of extensive dissemination at presentation, and their aggressive course and high fatality rate. We report a series of 10 patients with PT-LPDs after TCD allogeneic bone marrow transplant. We studied the correlation between the morphology of the lesions; their clonality based on immunoglobulin (Ig) heavy chain gene rearrangement analysis and immunohistochemistry; their proliferative activity as measured by immunoperoxidase staining for the proliferating cell nuclear antigen (PCNA) and the presence of p53 gene product overexpression. Histologically, our cases corresponded to the two morphologic categories of polymorphic B-cell lymphoma (PBCL, seven cases) and malignant lymphoma immunoblastic (ML-IB, three cases). Ig light-chain staining showed monoclonality in a minority of the cases, whereas Ig gene rearrangement analysis by polymerase chain reaction revealed B-cell clonality in three of seven cases of PBCL and in all three cases of ML-IB. The Epstein-Barr virus (EBV) genome, the expression of EBV latent membrane protein or both were found in all 10 specimens. High proliferative activity (PCNA > or = 66%) was found in all cases, with a mean PCNA value of 56% in PBCL and 84% in ML-IB. Five specimens were p53+ (two of seven PBCL and three of three ML-IB). Two of four PBCL cases resolved with the administration of donor leukocytes. All of the remaining patients died of the PT-LPD within a short time from admission. Our results show that the PT-LPDs after TCD bone marrow transplantation are characterized by a high frequency of high-grade histologic subtypes, frequent monoclonality, high proliferative activity, frequent overexpression of p53 gene product, and poor prognosis. These characteristics observed in only a minority of cases of PT-LPDs occurring after solid organ transplantation may account for the less aggressive clinical behavior observed in those diseases.

[3H]benzylpempidine, a new radioligand for probing a putative channel site on nicotinic cholinergic receptors

A study was undertaken to assess the receptor binding characteristics of [3H]4-benzylpempidine to an allosteric site on calf brain membranes associated with nicotinic cholinergic receptors and to compare the binding affinity of novel arylpempidine analogs with their ability to antagonize the behavioral effects of nicotine in mice. Scatchard analysis of the binding yielded a K(d) of 20 nM and a B(max) of 330 fmols/mg membrane protein. [3H]4-benzylpempidine appears to be a more satisfactory ligand than [3H]mecamylamine, since it possessed a 50-fold greater affinity and its binding was far less sensitive to inorganic ions and Tris. Among the arylpempidine analogs 4-m-chlorobenzylidenepempidine and 4-benzylidenepempidine had the lowest K(i) values (1.4 nM and 5.0 nM, respectively) and were the most potent in antagonizing nicotine-induced seizures in mice. Although the K(i) values for pempidine and mecamylamine were 1-2 orders of magnitude greater than any of the arylpempidines, the dose required to antagonize nicotine-induced seizures in mice was comparable to the arylpempidines. One explanation for this apparent discrepancy in the correlation of binding affinity and nicotine antagonism is the lower brain penetration of arylpempidines compared to mecamylamine, following their systemic administration to mice.

Minimizing graft rejection in allogeneic T cell-depleted bone marrow transplantation

Between October 1991 and May 1994, 42 patients were treated with cyclophosphamide, thiotepa, and total body irradiation followed by an allogeneic transplantation of marrow depleted of T cells with soybean agglutinin and E-rosetting. Patients included in this study had acute myelogenous leukemia (13), chronic myelogenous leukemia (12), acute lymphocytic leukemia (nine), Hodgkin's disease or non-Hodgkin's lymphoma (four), multiple myeloma (three), or myelodysplastic syndrome (one). The mean age was 34 (range 8 to 51 years). Nineteen patients had a matched sibling donor and 18 received marrow from 6/6 matched unrelated donors while five received transplants from unrelated donors disparate at one DR locus (5/6 match). Time to granulocyte engraftment (AGC > or = 500/mm3) occurred at a mean of 16.5 days for related and 11.4 days for unrelated transplant recipients, and was related to the increased use of G-CSF in the unrelated population. There was no correlation with number of mononuclear cells, T cells, or CD34-positive cells infused, the rate of engraftment or the incidence of transplant complications. Multivariate analysis determined that G-CSF administration and a diagnosis other than ALL were the only factors associated with a faster rate of engraftment. Patients receiving unrelated donor transplants, those with ALL, or those who had a low T cell number infused (< or = 8.0 x 10(3) cells/kg) experienced delayed hospital discharge. The regimen resulted in excellent rates of engraftment (95.2%) with only one failure to engraft and one graft rejection. The incidence of grade III-IV acute graft-versus-host disease was 0% with sibling and 26.1% with unrelated donors. There were no cases of veno-occlusive disease. Fifty percent of patients are alive with a mean follow-up of 26.4 months. We conclude that this regimen is well tolerated and results in excellent engraftment with a low incidence of severe graft-versus-host disease and few therapy-related toxicities.

Retroviral gene transfer in autologous bone marrow transplantation for adult acute leukemia

To evaluate whether marrow contributes to relapse after autologous bone marrow transplantation (AuBMT) for acute leukemia, transplanted marrow was marked with the G1N retroviral vector (Genetic Therapy Inc.) containing the neomycin phosphotransferase gene (neo). Between April 1992 and August 1993, 4 patients were transplanted for acute myeloid leukemia (AML) in second complete remission (CR) and 1 patient for acute lymphoid leukemia in first CR. An average of 12.4% (range 5-19%) of transplanted marrow mononuclear cells were exposed to G1N vector for 4 hr. In the vector-treated portion of the marrow, 4.9% of GM-CFU and 3.6% of erythroid burst-forming units (BFU-E) were resistant to G418 in vitro. In the 5 patients, the polymerase chain reaction (PCR) detected the neo sequence on only two occasions after AuBMT. Of 4 patients surviving 1 year after transplantation, only 1 had evidence of gene marked cells by PCR. Two AML patients have relapsed, one of whom had evidence of neo sequences in the bone marrow at day 100 but not at relapse 11 months after AuBMT. The second patient relapsed 18 months after AuBMT but never had PCR evidence of neo sequences before or after relapse. Our results indicate vector-transduced autologous bone marrow from heavily pretreated adults with acute leukemia mark with low efficiency, although vector sequences have been detected in bone marrow and peripheral blood up to 1 year after transplant. Of the 2 relapsed patients, no evidence of vector-marked leukemic blasts have been detected.

An epidemiological study of rheumatoid arthritis in a northern Ontario clinical practice: the role of ethnicity

This study was designed to investigate differences between cultural groupings in rheumatoid arthritis (RA). The sample was made up of 235 individuals suffering from RA from four groupings: Canadian aboriginals, Finnish Canadians, Italian Canadians and other caucasian Canadians. The study was a retrospective chart analysis (non-randomly selected) designed to compare ethnic groupings on the following dimensions: demographic factors, clinical manifestations of RA, laboratory results, and drug therapy response. Results of the study support to some extent findings from previous research. Specifically, the following was found. The study showed a female to male predominance in sufferers of RA in all but one ethnic group. Canadian aboriginals tended to contract the disease much earlier in life than other ethnic groups. More Canadian aboriginals reported a family history of RA than other groupings. Only Canadian aboriginals and caucasian Canadians showed involvement of the C1-C2 joint with subluxation. Italian Canadians tended to have a higher mean haemoglobin than other groupings, while Canadian aboriginals tended to have a higher mean platelet count than other groupings, and an elevated anti-nuclear antibody count. While most of the drugs used to treat RA produced no significantly distinct reactions, the Italian and Canadian caucasian groups had the highest percentage of subjects with reactive dermatitis.

Lymphocytosis of donor origin in cerebrospinal fluid, and marrow aplasia after donor leukocyte infusion for EBV-lymphoproliferative disease

A 29-year-old woman underwent a T cell-depleted unrelated donor transplant for CML in chronic phase. Sixty-three days after marrow infusion, the patient developed fevers and generalized lymphadenopathy. Lymph node biopsy was consistent with monoclonal EBV-associated immunoblastic lymphoma for which the patient received 10(5) CD3-positive donor leukocytes per kilogram. Six days after leukocyte infusion the patient developed mental status changes without focal neurological deficit. MRI revealed no mass lesions. Cerebral spinal fluid revealed a white blood cell count of 1650 cells/mm3 which were shown to be T lymphocytes of donor origin. The CSF was tested and found to be PCR positive for EBV virus interval repeat 1 sequence (IR1). The lymphocytosis and mental status changes resolved without specific intervention. Subsequently she developed marrow aplasia, which was believed to be secondary to the infusion of donor leukocytes. Possible mechanisms for these two previously unreported side-effects of donor leukocyte infusion are discussed.

Respiratory failure from corn starch aspiration: a hazard of diaper changing

Corn starch powder is widely used for routine infant skin care as a substitute for talcum powder, as it is believed to have fewer respiratory hazards. We describe a one-month-old infant who presented to an emergency department with respiratory failure and a severe pneumonitis from aspiration of corn starch powder. The patient recovered after five days of mechanical ventilatory support. We conclude that careless use of corn starch for infant skin care can lead to accidental aspiration of this substance and severe respiratory disease.

Gabapentin adjunctive therapy in neuropathic pain states

OBJECTIVE

This is a report of a trial of the new antiepileptic agent gabapentin in patients with intractable neuropathic pain.

DESIGN

A case series of patients with a diagnosis of neuropathic pain whose previous management was inadequate were given oral gabapentin in increasing doses and were followed for a minimum of 2 months, monitored for efficacy and side effects.

SETTING

An outpatient pain management center located within a major university medical center.

PATIENTS

Convenience sample of patients referred for management of intractable neuropathic pain.

INTERVENTIONS

Simplification of existing pharmacologic management, addition of gabapentin, and attempted reduction of opiate analgesic doses.

MAIN OUTCOME MEASURES

Patient self-reports and pain scores in successive office visits.

RESULTS

Gabapentin provides analgesic activity for patients with neuropathic pain and has the advantage of a low side effect profile and drug toxicity.

Synthetic-aperture imaging through an aberrating medium: experimental demonstration

A simple technique for high-resolution imaging of distant objects is described and experimentally demonstrated. The technique, referred to as Fourier telescopy, is a variant of Fourier microscopy, which additionally uses phase closure for correction of intervening aberrations. It is an active-illumination technique that is scalable to angular resolutions of 1 nrad and to illuminators of extremely low power. A laboratory experiment demonstrates reconstruction of images of two simple objects with an angular resolution of 83 µrad.

Evaluation of reproductive capacity in germ cell tumor patients following treatment with cisplatin, etoposide, and bleomycin

PURPOSE

To evaluate the infertility rate in patients with germ cell tumors receiving chemotherapy with cisplatin, etoposide (VP-16), and bleomycin (PVP16B).

PATIENTS AND METHODS

Thirty patients were evaluated. All patients had undergone chemotherapy with two to four cycles of PVP16B. A single semen analysis was performed 24 to 78 months following initiation of chemotherapy. All 30 patients were continuously disease-free. Eight of these patients had also undergone nerve-sparing retroperitoneal lymph node dissection (RPLND).

RESULTS

The median sperm concentration was 33.9 x 10(6), with a median volume of 3.2 mL. The median total sperm count was 86.4 x 10(6). Oligospermia (< 40 x 10(6) total sperm count) was found in 13 patients (43%), including six (20%) who were azoospermic. There was a high incidence of morphologically abnormal sperm, with only one patient having more than 50% normal spermatozoa. Only 13 patients (43%) had sperm motility greater than 50%. Five patients had positive semen antisperm immunoglobulin G (IgG). Eight patients fathered children, including three with document oligospermia.

CONCLUSION

Patients with germ cell tumors successfully treated with PVP16B chemotherapy are at substantial risk for persistent semen abnormalities. However, some patients with oligospermia will slowly recover and others are still capable of reproductive capacity despite continued oligospermia.

Cataractogenesis in rats induced by in utero exposure to RG 12915, a 5-HT3 antagonist

RG 12915, a selective 5-HT3 antagonist developed for the treatment of emesis and nausea associated with cancer chemotherapy, was administered by gavage to four groups of pregnant rats from Gestation Day 6 to 17 at doses of 0, 1, 10, and 100 mg/kg/day, as part of a Segment II (developmental toxicity) study. The 100 mg/kg/day dose was maternally toxic as indicated by decreased body weight gain and food consumption during the treatment period. A portion of the rats were allowed to deliver and rear their litters and three pups from two litters in the 100 mg/kg/day group were observed to have lens opacities (visible to the naked eye) at weaning. At a later examination, when the offspring were approximately 4 months old, four additional animals from the same two litters had cataracts. A slight growth retardation was also observed postweaning in the offspring of the 100 mg/kg/day group. To confirm the lens findings and more precisely define the no-effect dose, another study was conducted in which pregnant rats were administered daily RG 12915 doses of 0, 10, 30, 60, or 100 mg/kg/day from Gestation Day 6 to 17. There was a dose-related decrement in maternal body weight gain during the treatment period in the 30, 60, and 100 mg/kg/day groups (12, 28, and 47%, respectively) compared to the control group. A treatment-related incidence of nuclear cataract was observed in the offspring of the 60 and 100 mg/kg/day groups (litter incidence 6 and 45%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical and basic pharmacology of mivacurium: a short-acting nondepolarizing benzylisoquinolinium diester neuromuscular blocking drug

Mivacurium is a benzylisoquinolinium diester. The drug is a nondepolarizing relaxant which is hydrolysed by plasma cholinesterase at 70-88% of the rate of suxamethonium. Enzymatic hydrolysis gives the drug its short duration of action. The length of paralysis is about 2-2.5 times that of suxamethonium and one-half to one-third that of the intermediate-acting nondepolarizers. The development of mivacurium represents a collaboration between industrial pharmacologists and chemists at Burroughs Wellcome Co. (USA) and investigators at the Massachusetts General Hospital, Boston, MA, USA.

Intrauterine therapy for homozygous alpha-thalassemia

BACKGROUND

Alpha-thalassemia is one of the most common genetic disorders in the world and is becoming more common in the United States with the increase in immigration of susceptible populations. This disease has been stated previously to be incompatible with extrauterine life.

CASE

A Filipino woman with a prior loss due to hemoglobin Bart's underwent prenatal diagnosis that confirmed recurrence in the index pregnancy. Intravascular intrauterine exchange transfusions maintained appropriate fetal growth. A cesarean delivery yielded a 2190-g male infant with minor malformations. The postnatal course was characterized by mild respiratory insufficiency. Postnatal chronic transfusion therapy is underway pending consideration for bone marrow transplantation.

CONCLUSION

Antenatal diagnosis and therapy of homozygous alpha-thalassemia can prevent the prenatal consequences of hydrops and fetal death. New technologies such as stem cell transplantation may help to avert both prenatal and postnatal consequences.