Ethnic differences in complement system biomarkers and their association with metabolic health in men of Black African and White European ethnicity

Inflammation plays a fundamental role in the development of several metabolic diseases, including obesity and type 2 diabetes (T2D); the complement system has been implicated in their development. People of Black African (BA) ethnicity are disproportionately affected by T2D and other metabolic diseases but the impact of ethnicity on the complement system has not been explored. We investigated ethnic differences in complement biomarkers and activation status between men of BA and White European (WE) ethnicity and explored their association with parameters of metabolic health. We measured a panel of 15 complement components, regulators, and activation products in fasting plasma from 89 BA and 96 WE men. Ethnic differences were statistically validated. Association of complement biomarkers with metabolic health indices (BMI, waist circumference, insulin resistance, and HbA1c) were assessed in the groups. Plasma levels of the key complement components C3 and C4, the regulators clusterin and properdin and the activation marker iC3b were significantly higher in BA compared to WE men after age adjustment, while FD levels were significantly lower. C3 and C4 levels positively correlated with some or all markers of metabolic dysfunction in both ethnic groups while FD was inversely associated with HbA1c in both groups, and clusterin and properdin were inversely associated with some markers of metabolic dysfunction only in the WE group. Our findings of increased levels of complement components and activation products in BA compared to WE men suggest differences in complement regulation that may impact susceptibility to poor metabolic health.

Comparative genomic analysis of clinical Candida glabrata isolates identifies multiple polymorphic loci that can improve existing multilocus sequence typing strategy

Candida glabrata is the second leading cause of candidemia in many countries and is one of the most concerning yeast species of nosocomial importance due to its increasing rate of antifungal drug resistance and emerging multidrug-resistant isolates. Application of multilocus sequence typing (MLST) to clinical C. glabrata isolates revealed an association of certain sequence types (STs) with drug resistance and mortality. The current C. glabrata MLST scheme is based on single nucleotide polymorphisms (SNPs) at six loci and is therefore relatively laborious and costly. Furthermore, only a few high-quality C. glabrata reference genomes are available, limiting rapid analysis of clinical isolates by whole genome sequencing. In this study we provide long-read based assemblies for seven additional clinical strains belonging to three different STs and use this information to simplify the C. glabrata MLST scheme. Specifically, a comparison of these genomes identified highly polymorphic loci (HPL) defined by frequent insertions and deletions (indels), two of which proved to be highly resolutive for ST. When challenged with 53 additional isolates, a combination of TRP1 (a component of the current MLST scheme) with either of the two HPL fully recapitulated ST identification. Therefore, our comparative genomic analysis identified a new typing approach combining SNPs and indels and based on only two loci, thus significantly simplifying ST identification in C. glabrata. Because typing tools are instrumental in addressing numerous clinical and biological questions, our new MLST scheme can be used for high throughput typing of C. glabrata in clinical and research settings.

Understanding the perspectives of older adults and elderly regarding vaccination; a snapshot in four European countries

Prevention of infectious diseases in elderly by immunization is a prerequisite to ensuring healthy ageing. However, in order for the vaccine programs to be effective, these need to be provided by health care professionals who have up-to-date knowledge and high motivation. Furthermore, the knowledge and attitudes towards vaccination in the targeted age groups needs to be fully understood. When focusing on the information provision, it is important to know from whom or which institution older adults and elderly would like to receive and in which form.

In January 2019, an international project called the VITAL (The Vaccines and InfecTious diseases in the Ageing population) project was started, within the framework of IMI (Innovative Medicines Initiatives). One of the goals of the VITAL project is to develop strategies to educate and train health care professionals (HCPs) and to promote awareness among stakeholders involved in elderly care management.

We briefly focus on the results of studies undertaken in four European countries (Italy, France, The Netherlands and Hungary), which reveal the perspective of older adults and elderly regarding influenza, pneumococcal, herpes zoster vaccination and respiratory syncytial virus (RSV) as well as generic characteristics of the vaccines and diseases.

We will show how attitudes towards vaccination are represented in our study population and which determinants influence the decision-making process of accepting vaccination. Furthermore, we shall elaborate on how the decision-making process towards vaccination takes place and which additional information is needed.

In the second part of the session, we shall invite the audience to reflect on the findings and identify the factors they consider most important for setting up a training and education programme on vaccination.

Prognostic Value and Development of a Scoring System in Horses With Systemic Inflammatory Response Syndrome

Background

Despite its widespread use in equine medicine, the clinical value of the systemic inflammatory response syndrome (SIRS) concept in horses remains unknown.

Objectives

To study the prognostic value of measures of SIRS in horses and identify the best model of severe SIRS to predict outcome.

Animals

A total of 479 consecutive adult horse emergency admissions to a private primary referral practice.

Methods

Prospective observational study. All adult horses admitted for emergency treatment over the study period were included. Multivariate logistic regression and stepwise model selection were used.

Results

Each of the 4 SIRS criteria was associated with outcome in this population. Thirty‐one percent of emergency cases had 2 or more abnormal SIRS criteria on admission and were defined as SIRS cases. SIRS was associated with increased odds of death (odds ratio [OR] = 8.22; 95% CI, 4.61–15.18; P < .001), an effect mainly found for acute gastrointestinal cases. SIRS cases were assigned a SIRS score of 2, 3, or 4, according to the number of abnormal SIRS criteria fulfilled on admission, and SIRS3 and SIRS4 cases had increased odds of death compared to SIRS2 cases (OR = 4.45; 95% CI, 1.78–11.15; P = .002). A model of severe SIRS including the SIRS score, blood lactate concentration, and color of the mucous membranes best predicted outcome in this population of horses.

Conclusions and Clinical Importance

Systemic inflammatory response syndrome is associated with an increased risk of death in adult horses presenting with acute gastrointestinal illnesses. The model of severe SIRS proposed in this study could be used to assess the status and prognosis of adult equine emergency admissions.

Phylogeography and bindin evolution in Arbacia, a sea urchin genus with an unusual distribution

Among shallow water sea urchin genera, Arbacia is the only genus that contains species found in both high and low latitudes. In order to determine the geographical origin of the genus and its history of speciation events, we constructed phylogenies based on cytochrome oxidase I and sperm bindin from all its species. Both the mitochondrial and the nuclear gene genealogies show that Arbacia originated in the temperate zone of the Southern Hemisphere and gave rise to three species in the eastern Pacific, which were then isolated from the Atlantic by the Isthmus of Panama. The mid-Atlantic barrier separated two additional species. The bindin data suggest that selection against hybridization is not important in the evolution of this molecule in this genus. Metz et al. in a previous publication found no evidence of selection on bindin of Arbacia and suggested that this might be due to allopatry between species, which obviated the need for species recognition. This suggestion formed the basis of the conclusion, widely spread in the literature, that the source of selection on sea urchin bindin (where it does occur) was reinforcement. However, the range of Arbacia spatuligera overlaps with that of two other species of Arbacia, and our data show that it is hybridizing with one of them. We found that even in the species that overlap geographically, there are no deviations from selective neutrality in the evolution of bindin.

5-hydroxytryptamine signalling in irritable bowel syndrome with diarrhoea: effects of gender and menstrual status

BACKGROUND

Symptomatology and physiology differ between men and women and across the menstrual cycle in irritable bowel syndrome (IBS). Ovarian hormones influence 5-hydroxytryptamine (5-HT), an amine known to play a role in gut motor-sensory function.

AIM

To assess the effects of gender and menstrual status on platelet-depleted plasma (PDP) 5-HT concentration in IBS patients with diarrhoea (IBS-D) patients compared with healthy volunteers (HV).

METHODS

Platelet-depleted plasma 5-HT concentrations were assessed under fasting and fed conditions in 73 IBS-D patients (aged 18-58 years; 18 men) and 64 HV (aged 18-50 years; 24 men). Women were divided into those with low or high progesterone/oestrogen (P/O) levels.

RESULTS

Irritable bowel syndrome patients with diarrhoea had higher PDP 5-HT concentrations than HV under fasting (P = 0.002) and fed (P = 0.049) conditions. This was particularly related to IBS-D men having higher PDP 5-HT concentrations than healthy controls (P = 0.002). Moreover, PDP 5-HT concentrations in IBS-D women with low P/O levels were similar to healthy controls.

CONCLUSIONS

Similar to IBS-D women with high P/O levels, IBS-D men also have raised PDP 5-HT concentrations. 5-HT concentration normalizes at menses in IBS-D women, suggesting a shift in the mechanisms responsible for abnormal 5-HT signalling in these patients.

Interferon-α after autologous stem cell transplantation in pediatric patients with advanced Hodgkin's lymphoma

Thirteen children with refractory or recurrent Hodgkin's lymphoma (HL) received high-dose chemotherapy and autologous hematopoietic stem cell transplant (ASCT). After hematologic recovery, 10 patients were given interferon-alpha (IFN-alpha) as adjuvant therapy, starting at a dose of 0.5 x 10(6) U/m2 subcutaneously, three times a week. The dose was escalated as tolerated. Patients were treated for a median of 12 (4-24) months. Transient myelosuppression was the most common toxicity and led to temporary treatment interruption in five patients. The IFN-alpha dose was increased in nine patients, to a median final dose of 3.5 x 10(6) U/m2/week. With a median follow-up of 67 (range 25-114) months, nine of the 10 patients are alive and in continuous remission. One patient relapsed. Three patients were not treated with IFN-alpha initially, two because of rapidly progressive disease. One patient received IFN-alpha for treatment of relapse after transplant, and is alive in remission 10 years later. IFN-alpha has activity in children with advanced HL, and prolonged, low-dose treatment given after ASCT can be tolerated. Its therapeutic effect as a post-transplant adjuvant warrants further investigation.

Venous haemodynamic effects of anti-thromboembolism stockings

Objective: The aim of this study was to assess the haemodynamic changes in the deep veins of 13 volunteers, following application of 13 made-to-measure graduated compression stockings all designed to exert different compression gradients along the limb.

Methods: The compression gradients were designed to apply pressures from 12–22 mmHg at the ankle to 9–20 mmHg at the calf and 5–10 mmHg at the thigh. These had been laboratory tested by the Hosiery Pressure Tester Mark II (HATRA). A medical stocking tester (MST) was subsequently used to measure the actual pressure measurements on the volunteers. A duplex scanner was used to measure the venous velocity in the deep veins at predetermined sites.

Results: The application of all the stockings increased the mean velocity in the popliteal vein by 38.7% (confidence interval [CI] 8–64%, P<0.01) but produced only a slight statistically insignificant increase in velocity in the femoral vein. No particular stocking profile gave significantly better results. A good correlation was found between the MST and HATRA tester measurements of the stocking pressures at the ankle and calf, but the MST method usually recorded higher pressures for the thigh measurements.

Conclusions: All profiles of graduated stockings appear to increase the velocity of blood in the deep veins above the knee, but only four pressure profiles (average 16.5, 14 and 6 mmHg) produced significant increases in velocity. There was no evidence to suggest that any one specific compression profile was superior to others at increasing the venous velocity in the popliteal vein.

Evaluation of duplex ultrasonography versus other investigations in the diagnosis of ‘venous aetiology’ in patients with leg ulcers

Background

The aim was to compare duplex imaging, venography, foot volumetry and air plethysmography in patients with healed leg ulcers considered to be caused by venous disease to discover whether duplex scanning alone could confirm a venous aetiology. The importance of isolated reflux in a segment of the deep system below a competent valve was assessed.

Methods

A total of 125 patients with 153 healed leg ulcers was examined. An Acuson (Mountain View, California, USA) scanner was used to detect reflux lasting for more than 0·5 s in the deep, superficial and calf perforating veins; the findings were compared with those obtained with ascending venography, foot volumetry and air plethysmography.

Results

Thirteen legs showed no reflux on duplex imaging, but ten of these had abnormal foot volumetry and 12 had abnormal plethysmography. Venography showed post-thrombotic change in 26 legs, but there was evidence of deep venous scarring in only six on duplex ultrasonography. Eight of 75 legs with a normal venogram had ‘complete’ (thigh-to-calf) deep reflux on duplex imaging. Forty-five legs showed segmental deep reflux on duplex imaging, of which 29 had associated perforating vein incompetence. Mean half-refilling times on foot volumetry were 8·46 s for femoral and 5·84 s for popliteal reflux, compared with 3·84 s in the 33 patients who had thigh-to-calf reflux (P &lt; 0·05).

Conclusion

Absence of reflux in all venous segments on duplex imaging does not exclude a venous aetiology for ulceration. Segmental femoral and popliteal incompetence on duplex imaging is usually associated with other sites of valvular incompetence, but depresses calf function less than thigh-to-calf reflux.

Laser transmission through transparent membranes used in cutaneous laser treatment

BACKGROUND

Some clinicians perform cutaneous laser treatments through transparent membranes to protect themselves and the surroundings from contamination by ejected tissue particles. Transmissibility of these membranes influences the tissue irradiance.

OBJECTIVE

We compared the optical transmissibility of 8 membranes.

METHODS

In part 1, a Schwartz Electro-Optics Q-switched alexandrite laser (wavelength of 720-800 nm, beam diameter of 3 mm) was directed through 8 membranes. A Molectron JD 2000 Joulemeter Ratiometer obtained measurements of percent loss of laser energy (for calculation of percent transmission) through each. To evaluate other wavelengths used in skin treatment, an SLM Aminco UV-VIS model 2000 spectrophotometer measured variance of transmission over a spectral region from 350 to 900 nm in 4 of the membranes.

RESULTS

The samples listed in order of increasing amounts of light energy lost across the membrane as compared with control (direct irradiation) were as follows: (1) Handi Wrap plastic wrap: 7% loss, 93% transmission; (2) glass slide: 8% loss; (3) Bioclusive transparent dressing: 11% loss; (4) Tegaderm transparent dressing: 26% loss; (5) Vigilon dressing without plastic backing: 34% loss; (6) Vigilon dressing with one layer of plastic backing: 37% loss; (7) Acuderm dressing: 41% loss; and (8) OpSite IV: 48% loss.

CONCLUSIONS

Transmissibility of the interposed membranes must be considered when determining the dosimetry of light energy required by the target tissue.

Safety and immunogenicity of three lots of meningococcal serogroup C conjugate vaccine administered at 2, 3 and 4 months of age

The reactogenicity and immunogenicity of meningococcal serogroup C conjugate (MenC) vaccine was assessed in 322 infants vaccinated at 2, 3, and 4 months of age, with concomitant administration of mixed diphtheria-tetanus-whole-cell pertussis vaccine and Haemophilus influenzae type b conjugate vaccine (DTwP-Hib) and oral polio vaccine. All infants in whom post-vaccination meningococcal C anticapsular IgG levels were assayed (n = 265) attained > or = 2 microg ml(-1). Serum bactericidal titres were assayed for a proportion of subjects (n = 171), 98% of whom obtained a reciprocal titres > or = 8. Local reactions were less frequent at the MenC injection site than at the DTP-Hib site. Systemic events were frequent, but consistent with established DTwP-Hib experience. The study demonstrates that MenC vaccine is immunogenic and well tolerated in infants at manufacturing scale production levels.

Typical halo nevi in childhood: is a biopsy necessary?

We sent questionnaires to pediatric dermatologists inquiring whether anyone had seen a child with halo nevi that developed into melanoma. None of the respondents reported having seen such a development. We conclude that typical halo nevi in children are usually benign and a skin biopsy is probably not necessary.

A randomised, double-blind, controlled trial of the immunogenicity and tolerability of a meningococcal group C conjugate vaccine in young British infants

A double-blind, randomised, controlled trial was conducted in 248 British infants to assess the immunogenicity and tolerability of three doses of a meningococcal group C/CRM (197) conjugate vaccine (Lederle Laboratories, USA) given at 2, 3 and 4 months. Control children received three doses of Hepatitis B vaccine (Engerix B(R); SmithKline Beecham). At 5 months of age, 100% of children receiving the conjugate vaccine had specific immunoglobulin G concentrations >2.0 microg/ml (n=116) compared with only 4% of control children (n=121). Those receiving the conjugate also had 2.5- and 1.6-fold higher geometric mean concentrations of PRP and diphtheria antibodies, respectively. The vaccine was well tolerated.

Immunogenicity and reactogenicity of a pneumococcal conjugate vaccine administered combined with a haemophilus influenzae type B conjugate vaccine in United Kingdom infants

BACKGROUND

Streptococcus pneumoniae is a major disease burden in young children and the incidence of antibiotic-resistant pneumococcal strains is increasing. Multivalent pneumococcal saccharide-protein conjugate vaccines have recently been developed.

OBJECTIVES

To assess the immunogenicity and reactogenicity of a 7-valent pneumococcal conjugate vaccine (7VPnC) administered as a separate injection or as a combined injection with Haemophilus influenzae type b vaccine (HbOC) at 2, 3 and 4 months of age.

METHODS

Randomized controlled trial of 368 healthy UK infants receiving routine vaccines only (control group), routine vaccines and 7VPnC as a separate injection (separate group), or routine vaccines and 7VPnC combined with HbOC (combined group) at 2, 3 and 4 months. The control group received 7VPnC at 5, 6 and 7 months. All groups received pneumococcal polysaccharide vaccine at 13 to 16 months. Anticapsular IgG antibodies to 7VPnC serotypes were measured at 2, 5, 13 and 14 months and safety data collected.

RESULTS

IgG antibody concentrations at 5 months were higher in the two treatment groups compared with the controls for all 7VPnC serotypes (P < 0.001) and higher in the separate group than the combined group for five 7VPnC serotypes (P < 0.05). For both treatment groups antibody concentrations were higher at 14 months (range, 6.6 to 25.3 microg/ml) than at 5 months (range, 0.6 to 2.5 microg/ml) for all 7VPnC serotypes (P < 0.001).

CONCLUSION

7VPnC was well-tolerated, safe and immunogenic when administered as a separate or as a combined 7VPnC/HbOC injection. Although antibody responses were lower in the infants who received the combination compared with those who received 7VPnC as a separate injection, marked anamnestic responses to polysaccharide challenge were observed, suggesting that both groups were immunologically primed.

The effects of 10 years of recombinant human growth hormone (GH) in adult GH-deficient patients

The long term effects of GH replacement in adult GH-deficient (GHD) patients have not yet been clarified. We studied 21 GHD adults who originally took part in a randomized, double blind, placebo-controlled trial of GH treatment in 1987. After completion of that trial, 10 patients received continuous GH replacement for the subsequent 10 yr, whereas 11 did not. A group of 11 age- and sex-matched normal controls were also studied in 1987 and 1997. Lean body mass, as assessed by total body potassium measurement and computed tomography scanning of the dominant thigh, increased in the GH-treated group (P < 0.01 for both) only (P < 0.05 between groups for total body potassium). Low density lipoprotein cholesterol decreased in the GH-treated group (P < 0.05) only. Carotid intima media thickness was significantly greater (P < 0.05) in the untreated group than in the GH-treated group. Assessment of psychological well-being using the Nottingham Health Profile revealed improvement in overall score, energy levels, and emotional reaction in the GH-treated group compared with those in the untreated group (P < 0.02). In conclusion, GH treatment for 10 yr in GHD adults resulted in increased lean body and muscle mass, a less atherogenic lipid profile, reduced carotid intima media thickness, and improved psychological well-being.

A comparison of three procedures for the detection of Bence-Jones proteinuria

A traditional electrophoretic procedure for detection of Bence-Jones proteinuria, employing Amido black stain on 200-fold concentrated urine, has been compared to two procedures employing highly sensitive protein stains not requiring prior urine concentration. All three procedures were carried out on 80 random urine samples screened for Bence-Jones proteinuria and 10 samples were provided by patients attending a myeloma clinic. A new procedure employing modified Coomassie brilliant blue stain on unconcentrated urine showed comparable sensitivity to the established procedure (82% versus 88%, respectively) and specificity (77% versus 74%, respectively), when assessed against immunofixation as a reference method. However, the new method is considerably quicker and cheaper. A second method, employing Gold stain, showed enhanced sensitivity (94% versus 88% for Amido black) but lower specificity (62% versus 74% for Amido black). However, this method is labour intensive and relatively expensive. Our data suggest that the procedure employing modified Coomassie brilliant blue may be a suitable alternative to the traditional procedure commonly used in many clinical laboratories.

High-dose mercaptopurine and intermediate-dose cytarabine during first remission of acute myeloid leukemia

High-dose, continuous infusion of intravenous mercaptopurine (HD 6MP) followed by intermediate-dose continuous cytarabine (ID Ara-C) has been shown to produce remissions in children with relapsed acute myeloid leukemia (AML). The purpose of this pilot study was to explore the feasibility of using this drug regimen as a component of treatment during the first remission of AML. Of 17 children with newly diagnosed AML registered in the study, 14 developed complete remission on conventional induction therapy and subsequently received the HD 6MP and ID Ara-C combination. The dosages of HD 6MP were escalated from 500 mg/m2 to 1250 mg/m2 in 24-hr infusions. The initial dosages of ID Ara-C were escalated from 250 mg/m2 to 650 mg/m2/24 hr and from 1 day to 4 days. Conventional treatment for AML was administered simultaneously. Seven of the 14 children remain in initial complete remission for 15 to 46 months and have completed treatment. Severe pancytopenia was observed in all patients, but there were no toxic deaths and no deaths during remission. The inclusion of HD 6MP and ID Ara-C in the treatment of AML in first remission appears to be feasible. Evaluation of its efficacy will require a comparative clinical trial.

Retrograde flow in the deep veins of subjects with normal venous function

BACKGROUND

Duplex ultrasonography has become the optimal non-invasive method of assessing the deep venous system of the leg. The stimuli used to promote reverse flow, subject positioning, and the veins scanned have varied between studies. Reverse flow of less than 0.5 s is accepted as 'normal', however, all published studies have demonstrated 'normal' subjects with deep vein reverse flow exceeding this time. The aim of this study was to establish the duration of reverse flow in all deep vein segments, and to determine the optimal method of eliciting reverse flow in individuals with proven normal deep vein function.

METHODS

Duplex scanning was used to detect the presence and duration of reverse flow in the superficial femoral, popliteal and posterior tibial veins of 61 legs with normal venous function. The veins were scanned with each subject inclined at 10 degrees, 45 degrees and standing erect. The abrupt release of distal tourniquet compression and the Valsalva manoeuvre were used as stimuli for reverse flow.

RESULTS

There was significantly less reverse flow in distal veins than in proximal veins when the subject was scanned at 10 degrees and 45 degrees. Median (range) reverse flow in the femoral vein at 10 degrees was 0.21 (0-1.18) s, posterior tibial vein 0.08 (0-0.67) s, (P < 0.0001); in the femoral vein at 45 degrees was 0.14 (0.04-2.14) s, posterior tibial vein 0.07 (0-0.56) s, (P < 0.0001). The duration of reverse flow was significantly less in the superficial femoral and popliteal veins when the subjects were erect than when inclined at 10 degrees and 45 degrees. Median (range) reverse flow in the femoral vein at 10 degrees was 0.21 (0-1.18), and when standing 0.1 (0-1.36) (P < 0.0001); below-knee popliteal vein at 10 degrees was 0.15 (0.04-1.95) s, and when standing 0.10 (0-1.03) (P = 0.0004). Reverse flow of more than 0.5 s was never elicited in the posterior tibial veins if the subject stood, nor did it occur in the popliteal vein during a Valsalva manoeuvre.

CONCLUSION

The optimal sites to assess deep vein reverse flow are the posterior tibial vein following removal of distal compression with the patient standing, and the popliteal vein during a Valsalva manoeuvre, as retrograde flow more than 0.5 s does not occur in subjects with normal venous function.

Isolated pericardial effusion: an indication for fetal karyotyping?

The outcome and associations of 35 consecutive cases of isolated pericardial effusion detected in the fetus are presented. In all cases included in the study, there was no evidence of a structural abnormality or a rhythm disturbance detectable antenatally. Karyotyping revealed that 26% of cases had trisomy 21 and 31% of the total had some form of chromosomal anomaly. Our study shows that the outlook for isolated pericardial effusion is good. However, there is a high incidence of associated karyotypic anomalies, in particular trisomy 21. Fetal karyotyping is therefore recommended in these cases.

High-dose mercaptopurine followed by intermediate-dose cytarabine in relapsed acute leukemia

PURPOSE

This phase I/II study was designed to explore the feasibility, toxicity, and potential efficacy of administering high-dose continuous intravenous mercaptopurine (6MP) followed by intermediate-dose continuous intravenous cytarabine (Ara-C) to children with relapsed or unresponsive acute leukemia.

PATIENTS AND METHODS

Twenty-three children with relapsed or unresponsive acute leukemia (13 myeloid, 10 lymphoid) were entered onto the study. After initial hydration and alkalinization, 1,000 or 1,250 mg/m2 of 6MP was administered by continuous intravenous infusion over 24 hours. Following another period of hydration, 500 mg/m2 of Ara-C was administered by continuous intravenous infusion daily for 4 days. In 17 children, plasma concentrations of 6MP were measured at hours 4, 24, and 27 of the 6MP infusions. Plasma concentrations of Ara-C were measured at hours 8, 24, 48, 72, and 96 of the Ara-C infusions. Intracellular Ara-C triphosphate (Ara-CTP) concentrations were measured in peripheral-blood leukemia cells of the five patients with sufficient cells for measurement. Children who developed remission received repeated courses of this regimen every 3 to 4 weeks until relapse or completion of 12 courses.

RESULTS

Of 13 children with acute myeloid leukemia (AML), six developed complete remissions (CRs) lasting 7 months to nearly 4 years. Two children remain in CR with normal growth, development, and health 3 years after cessation of treatment. Of 10 children with acute lymphoid leukemia (ALL), one had a CR of 2 months' duration. Dose-limiting toxicity consisted of severe hematosuppression with fever, neutropenia, and serious infection. There were two toxic deaths. The mean steady-state plasma concentrations of 6MP were approximately 4 mumol/L and of Ara-C approximately 3 mumol/L. The median Ara-CTP concentration in peripheral-blood leukemia cells was 308 mumol/L at hour 8 of the Ara-C infusion.

CONCLUSION

High-dose continuous intravenous 6MP followed by intermediate-dose intravenous Ara-C produced CRs of longer than 6 months in approximately half of children with relapsed or unresponsive AML. Further study of this drug regimen is justified.

Humans anesthetized with sevoflurane or isoflurane have similar arrhythmic response to epinephrine

BACKGROUND

Anesthetics can alter the dose of exogenously administered epinephrine that causes cardiac arrhythmias. The purpose of this study was to test the hypothesis that in humans anesthetized with sevoflurane, the arrhythmic response to epinephrine is not different from the response in humans anesthetized with isoflurane.

METHODS

We determined the arrhythmogenicity of submucosally administered epinephrine in 40 ASA physical status 1 or 2 patients who were to undergo transsphenoidal surgery. Patients were assigned randomly to be given 1.0-1.3 minimum alveolar concentration sevoflurane or isoflurane. A surgeon, blinded to the anesthetic and the concentration of epinephrine, injected into the nasal submucosa epinephrine 10, 13.3, or 20 micrograms/ml in saline of volume sufficient for surgical need. We defined a "positive" response as three or more premature ventricular contractions within 5 min after initiation of injection. Responses between anesthetic groups within each dose range of epinephrine were compared by chi-squared analysis.

RESULTS

No patient given either anesthetic developed premature ventricular contractions with doses of epinephrine less than 5 micrograms/kg. At larger doses of epinephrine (5-9.9 and 10-14.9 micrograms/kg), the frequency of arrhythmias did not differ between patients given sevoflurane and patients given isoflurane. Patients anesthetized with 1.2 minimum alveolar concentration sevoflurane had blood pressure similar to and heart rate less than those of patients anesthetized with similar concentrations of isoflurane. Blood pressure and heart rate were increased similarly in both groups after laryngoscopy and tracheal intubation and after epinephrine injection.

CONCLUSIONS

Sevoflurane and isoflurane do not differ in their sensitization of the human myocardium to the arrhythmogenic effect of exogenously administered epinephrine.

Intrathoracic cardiac position in the fetus

In a 4-year period, 83 fetuses have been noted to have an abnormal fetal heart position within the thorax on fetal echocardiography. In 55 cases where the heart lay in the right chest, this was due to the presence of a left-sided diaphragmatic hernia; in one case, the heart was abnormally far into the left chest because of a left-sided diaphragmatic hernia. Of the remaining 27 cases, the heart lay in the right chest in 16 cases. In seven of those 16, there was a congenital heart malformation; in six, there were lung anomalies; a hiatus hernia was present in one; both congenital heart disease and lung abnormality were present in one and one fetus had isolated dextrocardia. In nine cases, the heart lay in the center of the chest and in three, the heart lay further to the left than normal. Congenital heart disease was found in nine of these 12. Chromosomal anomalies were found in four of the 27 cases with an abnormal heart position but an intact diaphragm. In summary, it is important to be familiar with the normal cardiac orientation within the thorax and to investigate abnormalities of position. A diaphragmatic hernia will be the most common underlying cause but, where the diaphragm is intact, other explanations must be sought in order to counsel correctly or plan appropriate perinatal management. Lung disorders, congenital heart disease and chromosomal anomalies will be the principal differential diagnoses.

Chromosomal anomalies in fetal congenital heart disease

A series of 467 cases of congenital heart disease detected in prenatal life were analyzed to identify the forms of cardiac malformation associated with karyotypic defects and to calculate the incidence of chromosomal abnormalities associated with such malformations. Of these, 77 were proved to have chromosomal anomalies although not all were karyotyped. The results were analyzed in two ways. First, the whole series of 77 cases was examined in order to describe the form of congenital heart disease found in association as, although many cases were forms of heart disease known to be associated with chromosomal defects, several were unexpected. In many cases which proved positive, there were other abnormal findings on ultrasound, further suggesting a high likelihood of a chromosomal defect. Some cardiac defects, however, such as atrial isomerism or transposition of the great arteries, were not associated with trisomies. The second part of the study examined in detail the records of 124 cases of congenital heart disease seen in 1989, as these were more completely documented than the previous cases. No chromosomal anomaly was therefore thought to be missed. Of this group, 20 (16%) proved positive. This is a higher rate than would be expected in an unselected population of live births. The difference between prenatal and postnatal life can be accounted for by the increased rate of spontaneous fetal loss in those with chromosomal defects. We conclude that, because of the high rate of chromosomal anomaly, all continuing pregnancies where congenital heart disease has been found in the fetus should be karyotyped unless specific types of heart defect which are rarely associated are confidently defined.

Anti-cardiolipin antibodies in neurological disorders: cross-reaction with anti-single stranded DNA activity

Antiphospholipid (PL) antibodies have been detected in sera from patients with chronic neurological diseases associated with disorders of immunity. In an isotype specific radioimmunoassay for anti-cardiolipin (CL) antibodies, we found IgM anti-CL (greater than 2 s.d. above mean of controls) in 17/25 (68%) patients with myasthenia gravis (MG), 8/25 (32%) with the Lambert-Eaton myasthenic syndrome (LEMS), 5/17 (29%) with multiple sclerosis and 3/11 (27%) cases of migraine. IgG anti-CL was only found in low titres in sera from 10 patients with MG and three with LEMS. Significant anti-CL activity could not be detected in sera from nine patients with acute Guillain-Barré Syndrome (GBS), 12 chronic cases of epilepsy, 8/9 with oat cell carcinoma and 9/10 with acute stroke. Further tests on 39 sera with the highest anti-CL activity, from all of the above disease groups, showed a significant correlation between IgM anti-CL and IgM anti-ss DNA activities. In a series of competitive inhibition assays six sera from patients with MG were shown to have a proportion of both specific and cross-reactive IgM anti-CL and IgM anti-ss DNA antibodies. Anti-phospholipid antibodies occur in certain neurological diseases, at lower titres than seen in SLE, yet their cross-reactive binding to ss DNA suggests similar antibacterial origins as have been proposed for lupus auto-antibodies. In the absence of overt infection they might reflect a breakdown of tolerance for non-organ specific membrane antigens in diseases with predominantly organ specific membrane bound putative autoimmunogens.

Alloxan therapy for nesidioblastosis

Two patients with nesidioblastosis presented to the Royal Hospital for Sick Children in Glasgow and developed recurrent hypoglycemia after subtotal pancreatectomy. They were treated successfully with alloxan (mesoxalyl urea). Alloxan is recommended as an alternative to further radical surgery.