Pre-Operative Embolisation of Musculoskeletal Tumours - A Single Centre Experience

Introduction

The management of musculoskeletal tumours is complex and requires a multi-disciplinary approach. Preoperative embolisation can be often employed to reduce intra-operative blood loss and complication rates from surgery. We report our experience with the safety, technical success and efficacy of pre-operative embolisation in musculoskeletal tumours.

Materials and Methods

Thirteen consecutive patients who underwent pre-operative embolisation of a musculoskeletal tumour followed by surgical intervention at our institution from May 2012 to January 2016 were enrolled into the study. Patient demographics, tumour characteristics, embolisation techniques and type of surgery were recorded. Technical success of embolisation, amount of blood loss during surgery and transfusion requirements were estimated.

Results

There were five female and eight male patients who underwent pre-operative embolisation during the study period. The age ranged between 16 to 68 years, and the median age was 54. Technical success was achieved in all patients. Mean intra-operative blood loss was 1403ml, with a range of 150ml to 6900ml. Eight patients (62%) required intra-operative blood products of packed red blood cells and fresh frozen plasma. No major complications occurred during embolisation.

Conclusion

Pre-operative trans-arterial embolisation is feasible and safe for a variety of large and hypervascular musculoskeletal tumours. Our small series suggests that preoperative embolisation could contribute to the reduction of the intra-operative and post-operative blood product transfusion. It should be considered as a pre-operative adjunct for major tumour resections with a high risk of bleeding. The use of the haemoglobin gap complemented the assessment of perioperative blood loss.

Phase II trial of dasatinib for recurrent or metastatic c-KIT expressing adenoid cystic carcinoma and for nonadenoid cystic malignant salivary tumors

BACKGROUND

Adenoid cystic carcinoma (ACC) is a subtype of malignant salivary gland tumors (MSGT), in which 90% of cases express cKIT. Dasatinib is a potent and selective inhibitor of five oncogenic protein tyrosine kinases (PTKs)/kinase families including cKIT. We conducted a phase II study to determine the antitumor activity of dasatinib in ACC and non-ACC MSGT.

PATIENTS AND METHODS

In a two-stage design, patients with progressive, recurrent/metastatic ACC (+cKIT) and non-ACC MSGT (separate cohort) were treated with dasatinib 70 mg p.o. b.i.d. Response was assessed every 8 weeks using RECIST.

RESULTS

Of 54 patients: 40 ACC, 14 non-ACC (1, ineligible excluded); M:F = 28 : 26, median age 56 years (range 20-82 years), ECOG performance status 0 : 1 : 2 = 24 : 28 : 2, prior radiation: 44, prior chemotherapy: 21. The most frequent adverse events (AEs) (as % of patients, worst grade 2 or higher) were: fatigue (28%), nausea (19%), headache (15%), lymphopenia (7%), dyspnea (11%), alanine aminotransferase increased (7%), anorexia (7%), vomiting (7%), alkaline phosphatase increased (6%), diarrhea (6%), neutropenia (6%), and noncardiac chest pain (6%). No grade 4 AE occurred, 15 patients experienced a grade 3 AE, primarily dyspnea (5) and fatigue (4), and cardiac toxicity (1 prolonged QTc). Among ACC patients, best response to dasatinib: 1 patient (2.5%) had partial response, 20 patients (50%) had stable disease (SD) (3-14 months), 12 patients (30%) had PD, 2 withdrew, 3 discontinued therapy due to AE, and 2 died before cycle 2. Median progression-free survival was 4.8 months. Median overall survival was 14.5 months. For 14 assessable non-ACC patients, none had objective response, triggering early stopping rule. Seven had SD (range 1-7 months), 4 PD, 2 discontinued therapy due to AE, and 1 died before cycle 2.

CONCLUSION

Although there was only one objective response, dasatinib is well tolerated, with tumor stabilization achieved by 50% of ACC patients. Dasatinib demonstrated no activity in non-ACC MSGT.

Depression, anxiety and stress among patients with diabetes in primary care: A cross-sectional study

BACKGROUND

The incidence of diabetes mellitus is ever increasing. Individuals with diabetes mellitus may have concurrent mental health disorders and are shown to have poorer disease outcomes. The objectives of this study were to determine the prevalence of depression, anxiety and stress (DAS) in diabetes patients aged 20 years or more in the primary care setting.

METHODS

This was a cross-sectional study involving the use of self-administered questionnaire conducted in eight primary care private and government clinics in Pulau Pinang and Melaka, Malaysia. The validated DASS-21 questionnaire was used as a screening tool for the symptoms of DAS. Prior permission was obtained from the patients and, clearance from ethical committee was obtained before the start of the study. Data analysis was done using SPSS statistical software.

RESULTS

A total of 320 patients with diabetes from eight centres were enrolled via convenience sampling. Sample size was calculated using the Kish's formula. The prevalence of DAS among patients with diabetes from our study was 26.6%, 40% and 19.4%, respectively. Depression was found to be significantly associated with marital status and family history of DAS; anxiety was significantly associated with monthly household income, presence of co-morbidities and family history of DAS; and stress was significantly associated with occupation and family history of DAS.

CONCLUSION

The prevalence of DAS was higher in patients with diabetes compared with the general community. We recommend to routinely screen all patients with diabetes using the DASS-21 questionnaire because it is easy to perform and inexpensive.

Helical tomotherapy for anal cancer: Initial clinical outcomes and organ motion

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Background: Helical tomotherapy (HT) delivers rotational IMRT with megavoltage CT (MVCT) guidance for patient positioning, offering improved dose conformality and accuracy. We report preliminary clinical outcomes using HT in patients with anal cancer with estimated organ motion and delivered doses.

Methods: From 9/2005-8/2009, 15 patients with anal cancer were treated with HT and concurrent chemotherapy (MMC 10 mg/m2 IV bolus d1 and 29; 5FU 1,000 mg/m2/day CI d1-4 and 29-32). Median doses for primary tumor, involved lymph nodes and uninvolved lymph nodes were 50.5, 50.4 and 45 Gy. Dose specifications and target definitions were per RTOG 0529 for the majority. Treatment plans, daily MVCT, and initial clinical outcomes and toxicity were retrospectively analyzed. Center-of-mass (COM) locations and volumes of the targets and OAR with daily shifts were analyzed on selected patients. Doses actually delivered daily were reconstructed.

Results: At median follow-up of 15 months, all patients were alive without any evidence of recurrence. There were 40% male, 27% HIV+, 13% T3/4, and 47% lymph node positive. Four patients required treatment break of ≤ 1 week. There were no non-hematologic grade 4/5 toxicities. Overall non-hematologic grade 3 toxicity was 33.3% (GI and skin). All other patients had ≤ grade 2 GI or skin toxicity that completely resolved with aggressive supportive care. There was 40% overall hematologic grade 4 toxicity. Overall hematologic grade 3 toxicity was 60%. Daily shifts were 0.6 ± 3.3, 0.4 ± 3.0, and 0.5 ± 2.2 (SD) mm in lateral, longitudinal and vertical directions. Average daily displacements of the COM from their locations on the planning CT were 9 ± 3, 7 ± 4, 9 ± 2, and 7 ± 2 (SD) mm, for anus, rectum, bladder and vulva. Interfractional organ motion and deformation resulted in variations in the dose delivered in each fraction.For example, daily dose covering 95% of PTV varied by 4%, and vulva volume covered by 50 Gy changed by 23% daily.

Conclusions: HT with concurrent chemotherapy is well-tolerated compared to historical reports. Interfractional organ motion is significant and can result in deviations in dose delivery to the target and OAR. Such deviations should be considered in analyzing dose response outcome.

No significant financial relationships to disclose.

pKDR/KDR ratio predicts response in a phase I/II pharmacodynamic study of erlotinib and bevacizumab for recurrent or metastatic head and neck cancer (HNC)

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Background: EGFR activation up-regulates VEGF, which has been correlated with resistance to anti-EGFR agents. We previously reported early results (Vokes, JCO, 2005) of a phase I-II study of the EGFR inhibitor erlotinib (E) with the VEGF antibody bevacizumab (B) in recurrent or metastatic HNC. We now present results from the pharmacodynamic analysis as well as updated outcome data. Methods: Phase I/II trial of fixed dose erlotinib (E) 150 mg orally daily with escalation of bevacizumab (B) to a maximum of 15 mg/kg q 3 weeks and continued at 15 mg/kg in the phase II portion. Pts were randomized to receive the initial bevacizumab dose on either day 1 or 15. Paired biopsies were taken at baseline and after 2 weeks of treatment (after E alone or E+B) and analyzed by immunofluorescence and laser scanning analysis for target inhibition and apoptosis markers (VEGFR2/KDR, EGFR, CD31, and respective activated forms [pKDR, pEGFR]). Results: Paired biopsies were available from 20 patients. At baseline pKDR/KDR (ratio) correlated with clinical outcome and differed significantly between responses (CR>SD: p<0.01; CR>PD: p<0.0005). Interestingly, endothelial cell EGFR levels also appeared to correlate with response (CR+SD>PD: p<0.03). Paired tissue samples showed that E or E +B treatment increased apoptosis in tumor cells (pre: 0.96%, post: 7.02%: p<0.05) and endothelial cells (pre: 0%, post: 12%: p=0.15). Further, E+B treatment reduced expression of endothelial KDR, EGFR and VEGF levels compared to E alone. We previously reported an overall response rate of 14.6% (48 evaluable patients in the phase II cohort). Updated median follow-up was 7.3 months (2.1 years for patients still alive). The updated median overall/ progression free survival was 7.3 months/ 3.9 months with 30.6%/ 8.2% of patients alive at 1/2 years. Conclusions: Compared to E alone the combination of E + B showed increased inhibition of endothelial survival factors. pKDR/KDR appears to predict response to E+B. The promising clinical efficacy of E+B and potential predictive biomarkers warrant further validation in larger cohorts. (Supported by NIH N01 CM-57018–16)

No significant financial relationships to disclose.

Relationship between carotid intima-media thickness and arterial stiffness in children after Kawasaki disease

BACKGROUND

Evidence of premature atherosclerosis and systemic arterial stiffening in patients after Kawasaki disease is accumulating.

AIM

To test the hypothesis that carotid intima-media thickness (IMT), a surrogate marker of atherosclerosis, is associated with systemic arterial stiffness in children after Kawasaki disease.

METHODS

A cohort of 72 patients was studied, comprising 26 patients with Kawasaki disease and coronary aneurysms (group I), 24 patients with Kawasaki disease and normal coronary arteries (group II) and 22 healthy age-matched children (group III). The carotid IMT, carotid artery stiffness index, brachioradial pulse wave velocity (PWV), fasting total cholesterol, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol were determined and compared among the three groups.

RESULTS

The carotid IMT was related to indices of arterial stiffness, and significant determinants of carotid IMT were identified by multivariate analysis. The mean (standard deviation (SD)) carotid IMT of both group I (0.41 (0.04) mm) and group II (0.39 (0.04) mm) was significantly greater than that of group III (0.36 (0.04) mm; p<0.001 and p = 0.008, respectively). For the entire cohort, carotid IMT correlated positively with LDL cholesterol (r = 0.31, p = 0.009), carotid artery stiffness index (r = 0.40, p = 0.001) and brachioradial PWV (r = 0.28, p = 0.016), but not with age, body mass index, systemic blood pressure, and HDL and total cholesterol. Multiple linear regression analysis identified carotid artery stiffness index (beta = 0.25, p = 0.028) and subject grouping (beta = -0.39, p = 0.001; model R(2) = 0.29) as significant correlates of carotid IMT.

CONCLUSION

The increased carotid IMT in children after Kawasaki disease is associated with systemic arterial stiffening.

Concurrent chemotherapy practice patterns for head and neck cancer: What is standard of care?

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Background: The superiority of concurrent high dose cisplatin and radiation (RT) compared to RT alone for pts with locally advanced squamous cell cancer of the head and neck (SCCHN) has been demonstrated in large prospective phase III clinical trials. However, little is known regarding general prescribing patterns for chemotherapy (CT) utilization in combined modality treatment (CMT) for SCCHN. We conducted the present study to gain insight as to whether results from pivotal phase III trials affect utilization of concurrent CT in academic and community centers. Methods: We analyzed individual data from 326 SCCHN pts treated with concurrent CT and RT between 03/2003 and 12/2004 from 53 centers (43 community-based, 7 academic, and 3 VA or military) using electronically captured data from IntelliDose, a chemotherapy order software program. Results: Of 326 total pts, 123 pts (38%) received single agent cisplatin. From this group, 71 (58%) received low dose cisplatin (<74 mg/m2, mean initial dose 67 mg), while 52 patients (42%) received high dose cisplatin (≥ 74 mg/m2, mean initial dose 189 mg). 72 pts (22%) received carboplatin/paclitaxel, 60 pts (18%) received cisplatin /5FU, 18 pts (5.5%) received single agent carboplatin, while 6 pts (1.8%) received cetuximab either alone or in combination with cisplatin. Other infrequently used regimens (each < 5%) cumulatively accounted for 14% of pts treated. Comparison of chemotherapy utilization between academic and community-based practice centers showed no statistical difference with respect to use of high dose cisplatin versus low dose cisplatin, or single agent cisplatin versus non-cisplatin regimens. Conclusions: Despite evidence from phase III studies that concurrent high dose cisplatin is the standard of care for CMT of locally advanced SCCHN, utilization of other regimens, such as weekly low dose cisplatin, are commonly utilized.

[Table: see text]

A phase II study of lapatinib (GW572016) in recurrent/metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN)

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Background: Epidermal growth factor receptor (EGFR) inhibitors have demonstrated reproducible activity in patients with R/M SCCHN. HER2 is the preferred dimerization partner for EGFR. Lapatinib is a dual EGFR and HER2 kinase inhibitor that has demonstrated promising preclinical activity in SCCHN models. Methods: This phase II multi-institutional study enrolls patients with R/M SCCHN into 2 cohorts: those without prior exposure to an EGFR inhibitor (arm A) and those with prior exposure to an EGFR inhibitor (arm B). All subjects were treated with lapatinib 1500mg OD. Primary endpoints were response rate (arm A) and progression-free survival (arm B). Results: 42 subjects have been enrolled (27 arm A, 15 arm B; 35 male, 7 female, median age 60 years). Toxicity was generally mild without any dose reductions or patient withdrawal due to adverse effects. Diarrhea was the most frequent toxicity occurring in 40% of patients. Other toxicities observed included fatigue (21%), rash (21%) and nausea (14%). 2 patients experienced grade 3 toxicity (1 diarrhea, 1 emesis). 1 patient had a reduction in left ventricular ejection fraction (60% to 40%) which was asymptomatic and recovered to baseline upon discontinuation of lapatinib. No objective responses were observed in either arm. In an intent-to-treat analysis stable disease was the best response observed in 37% of arm A and 20% of arm B subjects. Median PFS was 1.6 months in arm A and 1.7 months in arm B. Conclusions: Lapatinib as a single agent in R/M SCCHN, although well tolerated, appears to have little activity in either EGFR inhibitor naïve or refractory subjects.

No significant financial relationships to disclose.

Central and peripheral arterial stiffness in patients after surgical repair of tetralogy of Fallot: implications for aortic root dilatation

OBJECTIVES

To test the hypotheses that (1) the central conduit arteries stiffen preferentially over the peripheral conduit arteries in patients with repaired tetralogy of Fallot (ToF); and (2) central arterial stiffening is related to aortic root dilatation.

DESIGN AND PATIENTS

Heart-femoral pulse wave velocity (PWV), femoral-ankle PWV, carotid augmentation index and body surface area-adjusted aortic sinotubular dimension were determined in 31 children after ToF repair and compared with those in 31 age-matched controls after left-to-right shunt repair. In addition, the PWVs and augmentation index were related to the sinotubular junction dimension.

SETTINGS

Tertiary paediatric cardiac centre.

RESULTS

Compared with controls, patients had significantly greater heart-femoral PWV (mean 666 (SD 151) v 587 (81) cm/s, p = 0.021) and carotid augmentation index (-14.1 (17.0)% v -25.2 (14.6)%, p = 0.016), whereas the right (888 (202) v 845 (207) cm/s, p = 0.42) and left (918 (227) v 851 (215) cm/s, p = 0.25) femoral-ankle PWVs were similar between the two groups. The sinotubular junction z score of patients was significantly greater than that of controls (4.7 (1.5) v 1.1 (1.4), p < 0.001). Univariate analysis showed that the sinotubular junction z score correlated positively with heart-femoral PWV (r = 0.43, p = 0.001) and carotid augmentation index (r = 0.46, p = 0.001). Multiple linear regression similarly identified heart-femoral PWV (beta = 0.30, p = 0.04) and carotid augmentation index (beta = 0.31, p = 0.04) (model R(2) = 0.26) as significant determinants of sinotubular junction z score.

CONCLUSIONS

The aorta stiffens in patients with repaired ToF, which may contribute to progressive dilatation of the aortic root in the long term.

Expression of multiple outer membrane protein sequence variants from a single genomic locus of Anaplasma phagocytophilum

Anaplasma phagocytophilum is the causative agent of an emerging tick-borne zoonosis in the United States and Europe. The organism causes a febrile illness accompanied by other nonspecific symptoms and can be fatal, especially if treatment is delayed. Persistence of A. phagocytophilum within mammalian reservoir hosts is important for ensuring continued disease transmission. In the related organism Anaplasma marginale, persistence is associated with antigenic variation of the immunoprotective outer membrane protein MSP2. Extensive diversity of MSP2 is achieved by combinatorial gene conversion of a genomic expression site by truncated pseudogenes. The major outer membrane protein of A. phagocytophilum, MSP2(P44), is homologous to MSP2 of A. marginale, has a similar organization of conserved and variable regions, and is also encoded by a multigene family containing some truncated gene copies. This suggests that the two organisms could use similar mechanisms to generate diversity in outer membrane proteins from their small genomes. We define here a genomic expression site for MSP2(P44) in A. phagocytophilum. As in A. marginale, the msp2(p44) gene in this expression site is polymorphic in all populations of organisms we have examined, whether organisms are obtained from in vitro culture in human HL-60 cells, from culture in the tick cell line ISE6, or from infected human blood. Changes in culture conditions were found to favor the growth and predominance of certain msp2(p44) variants. Insertions, deletions, and substitutions in the region of the genomic expression site encoding the central hypervariable region matched sequence polymorphisms in msp2(p44) mRNA. These data suggest that, similarly to A. marginale, A. phagocytophilum uses combinatorial mechanisms to generate a large array of outer membrane protein variants. Such gene polymorphism has profound implications for the design of vaccines, diagnostic tests, and therapy.

Initial seizure threshold of bilateral electroconvulsive therapy in Chinese

INTRODUCTION

This preliminary study examined the initial seizure threshold for bilateral electroconvulsive therapy (ECT) in Chinese and the correlates of this seizure threshold.

METHOD

Fifty-four patients underwent stimulus dose titration in a standardized protocol.

RESULTS

The mean initial seizure threshold was 117 mC (range 48-403 mC). Stepwise regression analysis showed that age, body mass index, and gender were independently related to seizure threshold and accounted for 36, 7, and 6% of its variance, respectively. Determination of a relationship between gender and seizure threshold was limited by the higher starting electrical dosage in men.

DISCUSSION

This preliminary study suggests that the seizure threshold for bilateral ECT in Chinese is comparable with that in the Western population. Our finding that body mass index is related to seizure threshold has not been reported previously. We also propose several differences between bilateral and unilateral ECT in the determinants of seizure threshold.

Immunization of mice against West Nile virus with recombinant envelope protein

West Nile (WN) virus is a mosquito-borne flavivirus that emerged in the United States in 1999 and can cause fatal encephalitis. Envelope (E) protein cDNA from a WN virus isolate recovered from Culex pipiens in Connecticut was expressed in Escherichia coli. The recombinant E protein was purified and used as Ag in immunoblot assays and immunization experiments. Patients with WN virus infection had Abs that recognized the recombinant E protein. C3H/HeN mice immunized with E protein developed E protein Abs and were protected from infection with WN virus. Passive administration of E protein antisera was also sufficient to afford immunity. E protein is a candidate vaccine to prevent WN virus infection.

Inhibition of malignant cell growth by 311, a novel iron chelator of the pyridoxal isonicotinoyl hydrazone class: effect on the R2 subunit of ribonucleotide reductase

The key roles of iron and iron proteins in cell proliferation make them potential targets for cancer therapy. However, clinical trials directed toward perturbation of tumor iron homeostasis by iron chelation have been limited to the use of deferoxamine (DFO). There is thus a need to develop agents with greater efficacy. In the present study, we investigated the mechanism of cytotoxicity of 311 (2-hydroxy-1-naphthylaldehyde benzoyl hydrazone), a novel iron chelator of the pyridoxal isonicotinoyl class. We found that 311 inhibited the growth of CCRF-CEM cells in a time- and concentration-dependent fashion with an IC(50) that was approximately 20-fold lower than that of DFO. 311 also inhibited the growth of breast, bladder, and head and neck cancer cell lines. Using electron spin resonance (ESR) spectroscopy analysis, we found that a 12-h exposure of CCRF-CEM cells to 311 inhibited the tyrosyl radical ESR signal of the R2 subunit of ribonucleotide reductase. However, overproduction of the R2 subunit in hydroxyurea-resistant CCRF-CEM cells was associated with a decrease in sensitivity of cells to 311 but not to DFO. Our studies show that 311 is a more potent cytotoxic agent than DFO, with activity against both hematopoietic and nonhematopoietic cell lines regardless of their p53 status. Furthermore, the ESR studies suggest that inhibition of the R2 subunit of ribonucleotide reductase is at least one mechanism by which 311 blocks cell proliferation.

Influenza A among patients with human immunodeficiency virus: an outbreak of infection at a residential facility in New York City

Although annual influenza vaccination is recommended for persons who are infected with human immunodeficiency virus (HIV), data are limited regarding the epidemiology of influenza or the effectiveness of influenza vaccination in this population. We investigated a 1996 outbreak of infection with influenza A at a residential facility for persons with AIDS. We interviewed 118 residents and employees, reviewed 65 resident medical records, and collected serum samples for measurement of influenza antibody titers. After controlling for history of smoking, influenza vaccination, and resident or employee status, in a multivariate model, HIV infection was not statistically associated with influenza-like illness (ILI). Symptoms and duration of ILI were similar for most HIV-infected and HIV-uninfected persons. However, 8 (21.1%) of 38 HIV-infected persons with ILI (vs. none of 15 HIV-uninfected persons) were either hospitalized, evaluated in an emergency room, or had ILI lasting > or = 14 days (P=.06). Vaccination effectiveness (VE) was similar for HIV-infected and HIV-uninfected persons. Vaccination was most effective among HIV-infected persons with CD4 cell counts of >100 cells/microL (VE, 65%; 95% CI, 36%--81%) or HIV type 1 virus load of <30,000 copies/mL (VE, 52%; 95% CI, 11%--75%). Providers should continue to offer influenza vaccination to HIV-infected persons.

Stimulus dose titration for electroconvulsive therapy

Stimulus dose titration for electroconvulsive therapy (ECT), the method to determine seizure threshold accurately, has not been commonly practiced. We describe our early experience of dose titration in 22 Chinese patients and compare seizure thresholds measured by dose titration with values predicted by the formula-based 'half-age'

METHOD

Seizure thresholds, as measured by dose titration, varied fourfold among our sample and the average value was 105.5 mC or 16.7 J. At the titration session, 27% of patients had seizures after a single stimulation and 37% had seizures after two stimulations. Only one patient required four stimulations to induce a seizure. No patient had significant adverse events associated with the dose titration procedure. The 'half-age' method in average overestimated seizure thresholds by 44% when compared with that measured by dose titration and in 23% of our sample, the overestimation was more than 100%. The pros and cons of dose titration and 'half-age' prediction method will be discussed. Our early experience suggests that dose titration could be performed in the majority of patients receiving ECT.

Expression of a gene encoding the major antigenic protein 2 homolog of ehrlichia chaffeensis and potential application for serodiagnosis

The major antigenic protein 2 (MAP2) homolog of Ehrlichia chaffeensis was cloned and expressed. The recombinant protein was characterized and tested in an enzyme-linked immunosorbent assay (ELISA) format for potential application in the serodiagnosis of human monocytic ehrlichiosis. The recombinant protein, which contained a C-terminal polyhistidine tag, had a molecular mass of approximately 26 kDa. The antigen was clearly identified by Western immunoblotting using antihistidine antibody. However, immune sera failed to react with the recombinant on immunoblots when the antigen was denatured by heat or reduced using beta-mercaptoethanol. The recombinant MAP2 (rMAP2) was used in an ELISA format with 60 blinded serum samples. Twenty of the serum samples were previously demonstrated to contain antibodies reactive with E. chaffeensis by indirect immunofluorescence assays (IFAs). The remaining 40 samples were seronegative. All samples negative by IFA were also found to be negative for antibodies against the rMAP2 of E. chaffeensis by using the ELISA. Only 1 of 20 IFA-positive samples tested negative in the rMAP2 ELISA. There was 100% agreement using IFA-negative samples and 95% agreement using IFA-positive samples, resulting in a 97.5% overall agreement between the two assays. These data suggest that the rMAP2 homolog of E. chaffeensis may have potential as a test antigen for the serodiagnosis of human monocytic ehrlichiosis. To our knowledge, this recombinant is unique because it is thus far the only E. chaffeensis recombinant antigen that has been shown to work in an ELISA format.

An outbreak of Legionella micdadei pneumonia in transplant patients: evaluation, molecular epidemiology, and control

PURPOSE

To describe a nosocomial outbreak of Legionella micdadei pneumonia in transplant patients and to characterize the source of the outbreak and the control measures utilized.

SUBJECTS AND METHODS

We performed retrospective Legionella micdadei serologic testing to enhance case finding in transplant patients with pneumonia that lacked a documented microbial etiology, as well as prospective environmental surveillance of water sites and testing for Legionella in clinical specimens.

RESULTS

During a 3-month period, 12 cases of Legionella micdadei pneumonia were identified either by culture or serologic testing among 38 renal and cardiac transplant patients. Legionella micdadei isolates from hot water sources were found by pulsed-field gel electrophoresis to have a DNA banding pattern that was identical to the isolates from the first 3 culture-positive cases and from 2 cases that occurred 16 months later.

CONCLUSIONS

Hospitals caring for organ transplant recipients and other immunosuppressed patients must be aware of the possibility of environmental sources of outbreaks of Legionella infection. A first-line screen with the Legionella urine antigen test will identify Legionella pneumophila serogroup 1. However, specific cultures in outbreak situations should be considered to identify other Legionella pneumophila serotypes and the nonpneumophila Legionella species.

Transfusion-associated transmission of babesiosis in New York State

BACKGROUND

Babesiosis can be life-threatening in immunocompromised individuals. Although the disease is usually transmitted by tick bite, more than 20 cases have been reported of infection transmitted by transfusion of blood or blood components obtained from apparently healthy donors from endemic areas in the United States. This report describes several recent cases of transfusion-transmitted babesiosis in New York State.

STUDY DESIGN AND METHODS

Transfusion-associated incidents of babesiosis infection were identified and investigated. Seroprevalence of babesiosis in healthy blood donors in a highly endemic area was ascertained.

RESULTS

In three incidents, babesiosis was diagnosed in five of eight patients given infected blood: two premature infants, an elderly patient with gastrointestinal bleeding, and two patients with thalassemia. Seroprevalence in blood donors on Shelter Island (Suffolk County, eastern Long Island), a highly endemic area, was 4.3 percent in May 1998.

CONCLUSIONS

Infected donors lived in endemic areas and were asymptomatic with no history of tick bite. Blood collected in January 1997 from one donor was infectious. Those transfusion recipients who were infected were neonatal, elderly, or chronically transfused patients. Babesiosis should be included in the differential diagnosis of febrile illness in immunocompromised recipients of blood transfusion, particularly in the Northeastern United States.

Increased sensitivity of hydroxyurea-resistant leukemic cells to gemcitabine

Tumor cell resistance to certain chemotherapeutic agents may result in cross-resistance to related antineoplastic agents. To study cross-resistance among inhibitors of ribonucleotide reductase, we developed hydroxyurea-resistant (HU-R) CCRF-CEM cells. These cells were 6-fold more resistant to hydroxyurea than the parent hydroxyurea-sensitive (HU-S) cell line and displayed an increase in the mRNA and protein of the R2 subunit of ribonucleotide reductase. We examined whether HU-R cells were cross-resistant to gemcitabine, a drug that blocks cell proliferation by inhibiting ribonucleotide reductase and incorporating itself into DNA. Contrary to our expectation, HU-R cells had an increased sensitivity to gemcitabine. The IC50 of gemcitabine was 0.061 +/- 0.03 microM for HU-R cells versus 0.16 +/- 0.02 microM for HU-S cells (P = 0.005). The cellular uptake of [3H]gemcitabine and its incorporation into DNA were increased in HU-R cells. Over an 18-h incubation with radiolabeled gemcitabine (0.25 microM), gemcitabine uptake was 286 +/- 37.3 fmol/10(6) cells for HU-R cells and 128 +/- 8.8 fmol/10(6) cells for HU-S cells (P = 0.03). The incorporation of gemcitabine into DNA was 75 +/- 6.7 fmol/10(6) cells for HU-R cells versus 22 +/- 0.6 fmol/10(6) cells for HU-S cells (P < 0.02). Our studies suggest that the increased sensitivity of HU-R cells to gemcitabine results from increased drug uptake by these cells. This, in turn, favors the incorporation of gemcitabine into DNA, resulting in enhanced cytotoxicity. The increased sensitivity of malignant cells to gemcitabine after the development of hydroxyurea resistance may be relevant to the design of chemotherapeutic trials with these drugs.

Experimental infection of the human granulocytic ehrlichiosis agent in horses

Human blood collected from two patients from Westchester County, New York with human granulocytic ehrlichia (HGE) infection was inoculated into two ponies. Inoculated ponies developed clinical signs similar to a previous report (Madigan et al., 1995). Histopathological changes involved follicular hyperplasia of lymphoid tissues. HGE DNA was detected by PCR in muscle, fascia, peritoneum, and adrenal gland after the ponies produced a high level of antibodies to HGE. We suggest that HGE may reside in poorly vascularized connective tissues, where the antibodies may have some difficulties to penetrate, resulting in persistent infection. Since HGE and E. equi cause very similar diseases in both humans and horses, they may be the same organism with minor genetic differences.

Cytoplasmic, nuclear, and platelet autoantibodies in human granulocytic ehrlichiosis patients

Serum samples from patients with confirmed human granulocytic ehrlichiosis (HGE) were tested for cytoplasmic, nuclear, and platelet autoantibodies and rheumatoid factor. The indirect fluorescence antinuclear antibody test on Hep-2 cells demonstrated antinuclear titers of > or = 40 and > or = 160 in 44 and 10%, respectively, of serum samples from HGE patients. Two patients (4%) had anticytoplasmic (mitochondrial and spindle apparatus) antibodies with a titer of 80 and two patients (4%) had anticytoplasmic (mitochondrial) antibodies with a titer of 160 or greater. Flow cytometry was used to demonstrate antiplatelet antibodies in 80% of first serum samples from HGE patients. Rheumatoid factor was not detected. Nuclear and cytoplasmic autoantibodies are a major cause of interference when the indirect fluorescence antibody test is used to detect fluorescence of morulae in Ehrlichia-infected equine neutrophils or HL-60 promyelocytes. Antiplatelet antibodies may contribute to the profound thrombocytopenia which is a characteristic laboratory feature during the acute phase of HGE infection. Whether autoantibodies precede infection or are caused by immune activation of HGE deserves further study.

Human granulocytic ehrlichiosis in New York

BACKGROUND

Human granulocytic ehrlichiosis (HGE), a potentially fatal tick-borne disease, was first described in the upper Midwest in 1994. Following reports of suspected cases of ehrlichiosis from New York physicians, descriptive and case-control studies were conducted to characterize the epidemiology and risk factors for HGE in New York residents.

METHODS

Descriptive data were gathered from surveillance and laboratory reports and hospital records. A confirmed case was defined as either (1) a 4-fold change in total antibody titer to Ehrlichia equi by indirect immunofluorescence or (2) a polymerase chain reaction assay positive for Ehrlichia phagocytophila/E equi group DNA. A probable case was defined as an acute febrile illness and either (1) a single E equi titer greater than or equal to 80 or (2) morulae on a peripheral blood smear. The case-control study included patients with confirmed HGE 18 years of age or older with the onset of disease in 1995 and 2 to 3 neighborhood-matched controls.

RESULTS

During 1994 and 1995, the New York State Department of Health, Albany, received reports of 241 residents who were tested for HGE; 30 met the confirmed case definition and 34 met the probable case definition. The median age of patients was 46 years (age range, 9-90 years), 35 (55%) were male, and 25 (45%) were hospitalized. Fever, headache, malaise, and myalgia were the most frequently reported symptoms. Fifty-six (88%) of the 64 patients resided in areas in which Lyme disease is hyperendemic. In the case-control analysis, cases were more likely than controls to have sustained a tick bite during 1995 (matched odds ratio, 5.0; 95% confidence interval, 0.9-49.8). Cases and controls did not differ by occupational exposure to ticks, underlying chronic diseases, or measures taken to prevent tick bites.

CONCLUSIONS

This study, which, to our knowledge, is the first population-based study of HGE, demonstrates the recent recognition of HGE in the state of New York. Control measures should be integrated with those for Lyme disease and should focus on minimizing contact with ticks and obtaining early treatment for infection.

Serological responses to Ehrlichia equi, Ehrlichia chaffeensis, and Borrelia burgdorferi in patients from New York State

Serological testing at the New York State Department of Health for human granulocytic ehrlichiosis in the residents of Westchester County, N.Y., was performed with specimens from 176 patients by the indirect fluorescent-antibody (IFA) technique with Ehrlichia equi MRK-infected neutrophils. To understand whether human monocytotropic ehrlichiosis also occurs in this northeastern geographic region, specimens were also tested for antibodies to Ehrlichia chaffeensis Arkansas. Screening tests and immunoblots for Lyme disease (Borrelia burgdorferi infection) were also performed. Thirty-two patients had antibodies only to E. equi and 21 patients had antibodies to both E. equi and E. chaffeensis, whereas 12 patients had only E. chaffeensis antibodies by the IFA technique. The remaining patients did not have antibodies to either ehrlichia. Eighteen serum samples from 13 of these patients were coded and sent to the Ehrlichia Research Laboratory (Baltimore, Md.) for repeat analysis by the IFA test and for E. equi and E. chaffeensis immunoblots. Immunoblot analysis for E. equi in samples with positive IFA test results confirmed the results for eight of the nine specimens. Immunoblot analyses for E. chaffeensis were negative for all 18 serum samples. Borrelia-reactive antibodies were found in sera both from patients with granulocytic ehrlichiosis and from patients with monocytotropic ehrlichiosis from New York State. Our results suggest that E. equi antigen is an appropriate substrate for identifying human granulocytic ehrlichiosis. E. chaffeensis antigen lacks appropriate sensitivity to serve as a surrogate substrate for the detection of human granulocytic ehrlichiosis and should be used solely for the diagnosis of human monocytotropic ehrlichiosis. Heat shock proteins may, in some cases, cause cross-reactivity between B. burgdorferi and ehrlichiae.

Rapid flow cytometric susceptibility testing of Candida albicans

A rapid flow cytometric assay for in vitro antifungal drug susceptibility testing was developed by adapting the proposed reference method for broth macrodilution testing of yeasts. Membrane permeability changes caused by the antifungal agent were measured by flow cytometry using propidium iodide, a nucleic acid-binding fluorochrome largely excluded by the intact cell membrane. We determined the in vitro susceptibility of 31 Candida albicans isolates and two quality control strains (Candida parapsilosis ATCC 22019 and Candida krusei ATCC 6258) to amphotericin B and fluconazole. Amphotericin B MICs ranged from 0.03 to 2.0 microg/ml, while fluconazole MICs ranged from 0.125 to 128 microg/ml. This method results in clear-cut endpoints that were reproducible. Four-hour incubation was required for fluconazole, whereas a 2-h incubation was sufficient for amphotericin B to provide MICs comparable to the reference macrodilution method developed by the National Committee for Clinical Laboratory Standards Subcommittee on Antifungal Susceptibility Tests. Results of these studies show that flow cytometry provides a rapid and sensitive in vitro method for antifungal susceptibility testing of C. albicans.

Lymphocyte membrane modifications induced by HIV infection

Novel carbohydrate antigen expressions were observed on T lymphocytes from HIV infected patients using flowcytometric analysis with four mAbs; BM-1, ACFH-18, FH-2 and C-6. These carbohydrate antigens were also expressed on oncogenic transformed cells but were either not expressed or were weakly expressed in lymphocyte populations from healthy subjects. A dramatic change in glycosylation was induced on CD8+T cells from HIV infected patients. The glycosylation change correlated with the progression of the disease. The incidence of Ley antigen expression on CD8+T cells increased as the disease progressed with the ongoing impairment of immune function. The phenotype change that occurred with Ley antigen expression might reflect the abnormal activation of T lymphocytes of some specific, but unknown, population of CD8+T cells. Thus, carbohydrate changes on the cell surface may induce immunological abnormality and accelerate the damage within the CD4+T cell subset, resulting in an impairment of the antigen specific immune system.

Postoperative analgesia for oesophageal surgery: a comparison of three analgesic regimens

Sixty-four patients undergoing oesophageal surgery were randomly allocated to receive either a continuous lumbar epidural infusion of morphine or fentanyl, or, intramuscular morphine for postoperative analgesia. There was no statistical difference in analgesic requirements between the patients who underwent a thoracotomy for their procedure (n = 50) and those who did not (n = 14), as assessed by the total dose of opioid administered, visual analogue scale (VAS) and pain score (PS) comparison. However, by these criteria, epidural morphine infusion provided the most satisfactory analgesia (P less than 0.05). Despite the variable quality of analgesia achieved with the three regimens, the postoperative lung function tests were similar for all groups, and we conclude that routine lung function tests are not an appropriate method of comparing analgesic efficacy. Prophylactic administration of loratadine to 15% of our patients was not shown to be effective in diminishing the incidence of pruritus.

A comparison of two-lung high frequency positive pressure ventilation and one-lung ventilation plus 5 cm H2O non-ventilated lung CPAP, in patients undergoing anaesthesia for oesophagectomy

A randomised prospective controlled study was conducted during a one-year period on patients scheduled for oesophagectomy via a right thoracotomy approach. Twenty-two patients received one-lung ventilation (OLV group) and twenty patients received high frequency positive pressure ventilation (HFPPV group). Episodic hypoxaemia (SaO2 less than 90% for greater than 30 seconds, FiO2 1.0) occurred in eleven patients in the OLV group and six patients in the HFPPV group. No patient in the HFPPV group had a severe desaturation episode (SaO2 less than 80%, FiO2 1.0) compared with nine patients in the OLV group (P less than 0.05). The mean peak inspiratory pressure and average mean airway pressure were significantly lower in the HFPPV group 28.8 (SD 7.7) and 7.2 (SD 2.4) cm H2O respectively, compared with the OLV group, 40.0 (SD 9.9) and 11.9 (SD 4.9) cm H2O (P less than 0.05). Two-lung high frequency positive pressure ventilation has some advantages over one-lung ventilation during the thoracotomy phase of oesophagectomy because it is easy to administer, does not significantly compromise the surgical exposure and is associated with fewer severe undesirable physiological disturbances.