Personal protective equipment training & lived experience for healthcare staff during COVID-19

Objectives

To describe the lived experience of healthcare staff during the Coronavirus Disease 2019 (COVID-19) pandemic relating to the use of personal protective equipment (PPE) and investigate risks associated with PPE use, error mitigation and acceptability of mindfulness incorporation into PPE practice.

Methods

A qualitative human factors' study at two Irish hospitals occurred in late 2020. Data was collected by semi-structured interview and included role description, pre-COVID-19 PPE experience, the impact of COVID-19 on lived experience, risks associated with PPE use, contributory factors to errors, error mitigation strategies and acceptability of incorporating mindfulness into PPE practice.

Results

Of 45 participants, 23 of whom were nursing staff (51%), 34 (76%) had previously worn PPE and 25 (56%) used a buddy system. COVID-19 lived experience impacted most on social life/home-work interface (n=36, 80%). Nineteen staff (42%) described mental health impacts. The most cited risk concerned 'knowledge of procedures' (n=18, 40%). Contributory factors to PPE errors included time (n=15, 43%) and staffing pressures (n=10, 29%). Mitigation interventions included training/education (n=12, 40%). The majority (n=35, 78%) supported mindfulness integration into PPE practice.

Conclusions

PPE training should address healthcare staff lived experiences and consider incorporation of mindfulness and key organisational factors contributing to safety.

Localized axillary milia en plaque: a rare cutaneous case presentation of systemic amyloidosis

Systemic AL amyloidosis is known to be associated with plasma cell dyscrasias, including multiple myeloma. The cutaneous manifestations of systemic AL amyloidosis are varied, but typically include waxy plaques or subcutaneous nodules. We report a woman who presented with bilateral eruptions of hyperpigmented plaques in her axillae, which were diagnosed as milia en plaque. She had a history of multiple myeloma, for which she was under the care of a haematologist. This is the first documented case, to our knowledge, of an eruption in the axillae being milia en plaque.

Effect of intracerebroventricular injection of TiO2 nanoparticles on complex behaviour in the rat

There are no data available on the behavioural effects of centrally administered nanoparticles in freely moving intact mammals. Consequently, in the current study male Sprague-Dawley rats were trained to respond under an alternating-lever cyclic-ratio (ALCR) schedule of food reinforcement. Under this schedule, ascending and descending sequences of fixed-ratio (FR) lever press requirements for food reinforcement were presented over six cycles, with each discrete FR component completed on the alternate lever to the previous component. The final version of the schedule was comprised of an ascending followed by a descending sequence of the ratio values 2, 6, 12, 20, 30, 42 and 56, repeated over six cycles. When the rats were able to complete this version of the ALCR schedule in 40 min, each was implanted with a permanently indwelling ICV cannula aimed at the lateral ventricle of the brain, and allowed to recover for 7 days. On the first day of the experiment, all rats were injected with either titanium dioxide (TiO2, 9 nm, stabilised with gallic acid, 10 microl volume, 2 mg/ml) nanoparticles, or 10 microl saline (control). Two-hours after the ICV injections, the behaviour of all rats was measured using the ALCR schedule, and their behaviour was also measured (no ICV injection) for the next 7 days. Under the ALCR schedule, the number of lever-switching errors and incorrect lever perseverations significantly increased in the TiO2 group (p < 0.05). Other parameters of the ALCR schedule (RRRs and PRPs), which indicate the induction of malaise or general motor retardation, were not altered following ICV TiO2 injection. The findings of the current study indicate that central administration of TiO2 nanoparticles induced behavioural deterioration in freely moving intact animals, that the induced behavioural deterioration was a result of central rather than peripheral outcomes, and that this effect was chronic rather than acute.

Frequent mutations in SH2D1A (XLP) in males presenting with high-grade mature B-cell neoplasms

X-linked lymphoproliferative syndrome (XLP) is caused by mutations in SH2D1A, and is associated with overwhelming infectious mononucleosis, aplastic anemia, hypogammaglobulinemia, and B-cell lymphomas. However, the frequency of SH2D1A mutations in males who present with B NHL is unknown. Five cases of XLP were diagnosed among 158 males presenting with B NHL (approximately 3.2%). Four of the patients had two episodes of B NHL and one had a single episode of B NHL followed by aggressive infectious mononucleosis. Prospective screening for XLP in males with B-cell lymphoma at the time of initial diagnosis should be considered.

Vascular risk factors and cognitive impairment in a stroke-free cohort

OBJECTIVE

To examine vascular risk factors, as measured by the Framingham Stroke Risk Profile (FSRP), to predict incident cognitive impairment in a large, national sample of black and white adults age 45 years and older.

METHODS

Participants included subjects without stroke at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study with at least 2 cognitive function assessments during the follow-up (n = 23,752). Incident cognitive impairment was defined as decline from a baseline score of 5 or 6 (of possible 6 points) to the most recent follow-up score of 4 or less on the Six-item Screener (SIS). Subjects with suspected stroke during follow-up were censored.

RESULTS

During a mean follow-up of 4.1 years, 1,907 participants met criteria for incident cognitive impairment. Baseline FSRP score was associated with incident cognitive impairment. An adjusted model revealed that male sex (odds ratio [OR] = 1.59, 95% confidence interval [CI] 1.43-1.77), black race (OR = 2.09, 95% CI 1.88-2.35), less education (less than high school graduate vs college graduate, OR = 2.21, 95% CI 1.88-2.60), older age (10-year increments, OR = 2.11, per 10-year increase in age, 95% CI 2.05-2.18), and presence of left ventricular hypertrophy (LVH, OR = 1.29, 95% CI 1.06-1.58) were related to development of cognitive impairment. When LVH was excluded from the model, elevated systolic blood pressure was related to incident cognitive impairment.

CONCLUSIONS

Total FSRP score, elevated blood pressure, and LVH predict development of clinically significant cognitive dysfunction. Prevention and treatment of high blood pressure may be effective in preserving cognitive health.

Inpatient staff perceptions in providing care to individuals with co-occurring mental health problems and illicit substance use

ACCESSIBLE SUMMARY

This paper reports on a piece of research which is summarized below. • This research explored how mental health inpatient staff, (including nurses, doctors and other professional disciplines) experience caring for patients who both have mental health problems and who use illicit drugs. (Illicit drugs are illegal drugs which incur a criminal prosecution for possession and/or use). The results of the study were gathered from questionnaires and interviews which asked staff about their viewpoints and experiences. • The questionnaire results included a section which measured staff attitude towards patients who use illicit drugs and who have mental health problems. Staff who had received training in how to work with people with these problems were found to have a less negative attitude towards these patients. The length of time staff members had worked in their posts or had worked in a particular setting did not have any effect on their attitude. For example, their attitude was not more or less negative towards patients with these problems. • Ten members of staff were interviewed to find out more in-depth information about their viewpoints and experiences. Overall, these staff members reported a lack of training, difficulty in accessing support and problematic issues within the teams they worked. • This paper highlights the importance of training to support staff in working with mental health patients who use illicit drugs; and how this affects staff attitude positively towards patients with these problems.

ABSTRACT

The extent of illicit substance use within inpatient mental health settings is becoming a major cause of concern. This poses growing challenges not only for the management of inpatient units, but also for providing continuity of care. Service users with co-occurring substance use are more likely to disengage from services. The process of engagement can be hindered by negative attitudes of staff. This study aimed to identify and explore multidisciplinary staff attitudes and experiences in caring for inpatients with co-occurring ill-mental health problems and illicit substance use. A questionnaire incorporating the Drug and Drugs Problems Perceptions Questionnaire (DDPPQ) was used with a non-probability sample of 84 multidisciplinary staff working on nine mental health units. Semi-structured interviews were then carried out with 10 members of staff. Overall, respondents reported: lack of training; difficulty in accessing support structures; and problematic issues with multidisciplinary decision making and processes. The DDPPQ results showed that staff who had received training held less negative attitudes towards illicit substance users regardless of their length of clinical work experience or type of work setting. Recommendations are made about the importance of training and staff support for the development of less negative attitudes towards this client group.

A minimally hypomorphic mutation in Btk resulting in reduced B cell numbers but no clinical disease

Reduced B cell numbers and a mutation in Btk are considered sufficient to make the diagnosis of X-linked agammaglobulinaemia. In the process of conducting family studies, we identified a 58-year-old healthy man with an amino acid substitution, Y418H, in the adenosine-5'-triphosphate binding site of Btk. Immunofluorescence studies showed that this man had 0.85% CD19+ B cells (normal 4-18%) in the peripheral circulation and his monocytes were positive for Btk. He had borderline low serum immunoglobulins but normal titres to tetanus toxoid and multiple pneumococcal serotypes. To determine the functional consequences of the amino acid substitution, a Btk- chicken B cell line, DT40, was transfected with expression vectors producing wild-type Btk or Y418H Btk. The transfected cells were stimulated with anti-IgM and calcium flux and inositol triphosphate (IP3) production were measured. Cells bearing the mutant protein demonstrated consistently a 15-20% decrease in both calcium flux and IP3 production. These findings indicate that even a modest decrease in Btk function can impair B cell proliferation or survival. However, a mutation in Btk and reduced numbers of B cells are not always associated with clinical disease.

The growing incidence of cancer: role of lifestyle and screening detection (Review)

The increasing incidence of a variety of cancers after the Second World War confronts scientists with the question of their origin. In Western countries, expansion and ageing of the population, as well as progress in cancer detection using new diagnostic and screening tests cannot fully account for the observed growing incidence of cancer. Our hypothesis is that environmental factors play a more important role in cancer genesis than it is usually agreed: i) over the last 2-3 decades, alcohol consumption and tobacco smoking in men have significantly decreased; ii) obesity is increasing in many countries, but the growing incidence of cancer also concerns cancers not related to obesity nor to other lifestyle-related factors; iii) there is evidence that the environment has changed over the same time scale as the recent rise in cancer incidence, and that this change included the accumulation of many new carcinogenic factors in the environment; iv) genetic susceptibility to cancer due to genetic polymorphism cannot have changed over one generation and actually favours the role of exogenous factors through gene-environment interactions; v) age is not the unique factor to be considered since the rising incidence of cancers is seen across all age categories, including children; vi) the fetus is specifically vulnerable to exogenous factors. A fetal exposure during a critical window period may explain why current epidemiological studies may be negative in adults. We therefore propose that the involuntary exposure to many carcinogens in the environment contributes to the rising trend in cancer incidence.

A possible bichromatid mutation in a male gamete giving rise to a female mosaic for two different mutations in the X-linked gene WAS

In genetic disorders caused by point mutations or small frameshift mutations, affected members of the same family are expected to have the same mutation in the causative gene. We have recently evaluated a family in which this was not the case. Maternal cousins with Wiskott-Aldrich syndrome (WAS; MIM 301000) had two different but contiguous single base pair deletions in WAS. The proband had an A deletion in codon 242 in exon 7 of WAS; his two cousins had a C deletion in codon 241. The mother of the proband was heterozygous for the A deletion allele, but her three sisters, including the mother of the affected cousins, were heterozygous for the C deletion. Both deletions occurred on the haplotype from the unaffected maternal great-grandfather. The maternal grandmother, who was a carrier of WAS, based on a non-random pattern of X chromosome inactivation in T cells, was mosaic for both deletions. These findings are most consistent with the mutations originating in a male gamete with different mutations on the two strands of DNA, a bichromatid mutation.

Identification and analysis of dihydrofolate reductase alleles from Plasmodium falciparum present at low frequency in polyclonal patient samples

As resistance to chloroquine spreads in sub-Saharan Africa, pyrimethamine plus sulfadoxine (PSD) is increasingly used as a first-line treatment for falciparum malaria. Populations of Plasmodium falciparum (Pf) resistant to PSD have been selected quickly in other regions. The resistance is strongly correlated with point mutations in dihydrofolate reductase (DHFR) and dihydropteroate synthase (DHPS), the two targets of the drug. It is critical to identify drug-resistant Pf-DHFR alleles that are present at a low frequency in these populations since alleles that confer drug resistance will be quickly selected by PSD use. It is difficult to identify these rare alleles by standard molecular techniques. We have designed a yeast expression system that facilitates the identification and rapid analysis of Pf-DHFR alleles that confer PSD resistance, even when they are present at very low frequency in polyclonal patient samples. We analyzed samples from patients in Kilifi, Kenya collected between 1992 and 1995. We determined the prevalence of the drug-sensitive and drug-resistant alleles in patient samples analyzed in parallel by an allele-specific enzyme digestion (ASED) assay. We identified a pyrimethamine-resistant allele (S108N) present at a frequency of < 1% in a sample that was scored as only S108 by ASED. In addition, a novel pyrimethamine-resistant allele (1164M) was isolated twice, once each from two different patient samples. This approach will allow determination of the prevalence of Pf-DHFR alleles that confer pyrimethamine resistance in particular regions, and the rapid identification of novel alleles that confer drug resistance.

Fatigue in children and adolescents with cancer

Fatigue is a common symptom found in the adult oncology literature. However, little is known about its occurrence, causes, conceptual and operational definitions, and effective interventions in children and adolescents with cancer. The purpose of this study was to define and describe fatigue experienced by children and adolescents receiving treatment for cancer. A focus group approach was used to reveal the contextual understanding of fatigue through discussions. Eleven focus groups were convened during a 2-month period at two major children's cancer centers. Twenty-nine children participated in the focus groups: 14 were 7 to 12 years of age and 15 were 13 to 16 years of age. Focus groups were held separately for each age group, lasted from 30 to 45 minutes, and were audiotaped. The audiotapes were transcribed verbatim, and Ethnograph software was used to number the data to sort and code the information. Researchers at both study sites coded the data independently within the context of the unit of analyses, which, in this study, were the study questions. Codes and descriptions were developed for the definitions of fatigue, causes of fatigue, and what helps. Eight codes emerged from the children groups and 12 from the adolescent groups to define fatigue. Six codes were developed from the children groups and 12 from the adolescent groups to describe causes of fatigue. Three codes from the children groups and eight from the adolescent groups described what helps. This study is the first to evaluate fatigue as a symptom in children and adolescents with cancer. Findings from this study will provide the foundation for developing a conceptual model for cancer-related fatigue in children and adolescents.

Effect of propylthiouracil treatment during prenatal and early postnatal development on the neocortex of rat pups

The effects of a pre- and postnatal hypothyroid environment on the development of the neocortex have been determined. Rats were treated with propylthiouracil (PTU) with or without thyroid hormone supplementation during pregnancy and throughout the early development of the pups. The Cavalieri method was used to provide an estimate of the volume of the neocortex, and a combination of the Cavalieri method and the 'disector' particle-counting method provided an unbiased estimate of the numbers of glia and neurons in the neocortex. In pups from non-treated rats the mean volume of the neocortex increased from 31.3 mm3 at 5 days postnatally to 191.5 mm3 at 20 days and then remained constant to day 48. Similarly, the mean number of glial cells increased from 5.2 x 10(6) at day 5 to 12.0 x 10(6) on day 20 and then remained constant to day 48. The mean number of neurons in the neocortex in the control condition was constant at about 14.6 x 10(6) from day 5 to day 48. PTU treatment during pregnancy and postnatal development significantly decreased the mean volume of the neocortex at all of the stages studied, for example from 31.3 to 23.3 mm3 (p less than 0.001) on day 5 and from 191.5 to 155.0 mm3 (p less than 0.001) on day 20. Supplementation with thyroxine (T4) or tri-iodothyronine partially reversed this at certain stages. For example, the mean volume of the neocortex at 48 days was 197.5 mm3 in control rats, 118.1 mm3 in PTU-treated rats and 169.3 mm3 in PTU-treated rats supplemented with T4. Within the neocortex, the volume of the neuropile was more severely affected than was the volume of the neuron cell bodies.(ABSTRACT TRUNCATED AT 250 WORDS)

Unbiased estimation of particle density in the tandem scanning reflected light microscope

The tandem scanning reflected light microscope has the property of being able to obtain information from 'inside' solid objects by taking a thin optical section at the focal plane of the objective lens. This plane can be focused up and down through the specimen. We describe an unbiased 3-D counting rule for the TSRLM, which is applied to the estimation of osteocyte lacunar density in whole bone. This is shown to be an extremely efficient way of making such an estimate. Further possibilities for the application of the microscope in the field of stereology are discussed.

Further experience with regional radiofrequency hyperthermia and cytotoxic chemotherapy for unresectable hepatic neoplasia

The authors report on 178 patients with unresectable hepatic tumors who have been treated with 1 to 25 (median, 6) courses of radiofrequency hyperthermia (RFHT) and chemotherapy. In 137 patients, the hepatic tumors consisted of metastases from colorectal adenocarcinomas. For patients who had no previous therapy and who had colorectal metastases with no extraheptic disease, cumulative survival at 52 weeks' follow-up was 80.5% and partial tumor regression was seen in 78.4%. Among the 69 patients who previously had conventional treatment for their hepatic disease, partial regression was seen in 43.5%. We are no longer monitoring tumor core temperature routinely, as the invasive methods currently in use yield irreproducible results; the risks to the patient cannot be justified in view of the questionable relevance of the data obtained. A prospective randomized study of systemic chemotherapy with or without RFHT in patients with colorectal hepatic metastases is in progress.

Palliation of advanced head and neck cancer with radiofrequency hyperthermia and cytotoxic chemotherapy

Fourteen patients with recurrent malignant tumours of the head and neck were treated with radiofrequency hyperthermia and chemotherapy after conventional therapy had failed. After 2 to 11 treatment courses and a follow-up of 30 weeks, the neoplasms in three patients had completely regressed and one had a partial response. Of eight patients who died, two had partial responses initially; a third patient died of complications relating to surgical resection of the tumour after a partial response. Three of five patients whose tumours were unresponsive to methotrexate responded when this drug was given with radiofrequency hyperthermia. There were seven minor skin burns in six patients. Further studies of radiofrequency hyperthermia and chemotherapy for palliation of head and neck cancer are planned.

The effect of radiofrequency hyperthermia and chemotherapy upon human neoplasms when used with adjuvant metronidazole

It appears that metronidazole causes an increase in tumor core temperature above that achieved with RFHT alone, by an as yet undetermined mechanism. Furthermore, radiofrequency hyperthermia, in combination with chemotherapy, can produce objective evidence of tumor repression in 30 to 50 per cent of the patients with metastatic cancer. These results justify proceeding to a randomized prospective trial of RFHT and chemotherapy in specific human neoplasms. Such a study is currently being undertaken at this center.

Effect of radiofrequency hyperthermia and chemotherapy on primary and secondary hepatic malignancies when used with metronidazole

Hyperthermia is selectively toxic to neoplastic tissue. Since August 1981, 357 patients with incurable tumors in various body areas have been treated with chemotherapy and radiofrequency hyperthermia (RFHT) with adjuvant metronidazole at this center. Of this group, the cases of 102 patients with hepatic tumors are reported here. Patients received one to ten treatment courses, each course consisting of two to five daily RFHT sessions. Systemic temperature rose 0.6 +/- 0.3 degrees C during treatment, and tumor core temperature (measured by percutaneous transhepatic thermistor) reached 39.5 +/- 1.2 degrees C in 38 monitored patients. Results have been encouraging; in particular, among 15 patients with newly diagnosed colorectal metastases limited to the liver (and as yet untreated for their secondary disease), there has been objective partial tumor regression in 66.7%. Side effects have been few. Skin burns and subcutaneous fat necrosis were seen in 3.9% and 13.7% of patients, respectively. Tumor temperature is difficult to measure reliably and does not correlate with machine power or tumor response. A phase III trial is currently underway to determine the efficacy of RFHT and chemotherapy for patients with hepatic metastases from colorectal adenocarcinoma.

Hyperthermia as a treatment for neoplasia

The use of hyperthermia to treat malignant neoplasms is currently a "hot" issue. It has been demonstrated that heating tumour cells to 42 degrees C or above leads to their self-destruction by decreased cellular metabolism and aerobic respiration. The selective accumulation of heat in the malignant tissue at 42 degrees to 44 degrees C, compared with the temperature of normal tissue, is probably related to the different blood supply within the tumour. The historical background and the experimental and clinical results of hyperthermia are reviewed. The advantages and disadvantages of the different thermotherapy techniques currently in use are discussed. Hyperthermia is probably more efficient if combined with other antitumour treatment modalities.

Combination chemotherapy with and without the methanol-extracted residue of bacillus Calmette-Guerin (MER) in extensive non-small-cell lung cancer: a prospective randomized study for the Piedmont Oncology Association

One-hundred-three patients with extensive non-small-cell lung cancer were entered into a prospective, randomized trial to determine the value of MER as an adjuvant to chemotherapy. Patients were stratified according to histology and performance status. All patients received CCNU, methotrexate, and Adriamycin with 48 patients also receiving MER. All patients had a performance status of 2 or less (less than 50% bedridden), 49% had prior radiation therapy, only one patient had prior chemotherapy, and all had extensive disease. Of the patients, 42% had epidermoid cancer, 21% had large cell cancer, 32% had adenocarcinoma, and 4% had mixed adenosquamous or undifferentiated carcinoma. The response rates and response durations of the two treatment regimens were similar. Of the patients, 18% had an objective response; in 4% it was complete. An additional 29% had a stable response. Median duration of response ranged from 21 to 23 weeks. Median survival rates for non-MER and MER treatment groups were 21.5 and 18.6 weeks, respectively. The four complete responders have a survival of 24, 85, 86+, and 129 weeks. MER did not improve response for hematopoietic tolerance, was associated with significant morbidity, and was poorly tolerated. The value of immunotherapy in lung cancer remains to be established.

A randomized comparative trial of chemotherapy and irradiation therapy for stage II breast cancer

One hundred fifty-eight evaluable patients with Stage II carcinoma of the breast with positive lymph nodes were treated either with adjuvant chemotherapy or irradiation therapy followed by chemotherapy. Patients were randomized to test the effectiveness of L-phenylalanine mustard (L-PAM) with and without postoperative irradiation therapy (R.T.) against cyclophosphamide, 5-fluorouracil, and methotrexate (CMF) with and without postoperative irradiation therapy in decreasing the frequency of recurrence. No significant difference was observed between L-PAM as compared with R.T. plus L-PAM (P = 0.85). The difference between CMF and R.T. plus CMF was significant in support of CMF alone (P = 0.04). The frequency of recurrence between R.T. plus L-PAM and R.T. plus CMF showed no difference. A comparison of the chemotherapy only regimens showed an advantage of CMF over L-PAM (P = 0.05). Both the delay in starting chemotherapy and the significant decrease in percent optimal drug dosage during the first six cycles of therapy are factors that may influence the high frequency of relapse observed in the R.T. plus chemotherapy groups. Of the four treatments, CMF has the lowest frequency of recurrence.

Chemotherapy vs. chemoimmunotherapy with methanol extraction residue of Bacillus Calmette-Guerin (MER) in advanced breast cancer: a randomized trial by the Piedmont Oncology Association

Effects of the addition of MER, a nonspecific, nonviable immunostimulant, to two combination chemotherapy programs were explored in patients with metastatic breast cancer. Patients were randomized to either CDVFP [cyclophosphamide (C), doxorubicin (D), vincristine (V), fluorouracil (F) and prednisone (P)] or CD alternating with methotrexate (M) and F (CD/MF). Each group was also randomized to receive MER, 0.4 mg S.C. every four weeks or no immunotherapy. The response rates were CDVFP 56%, CDVFP + MER 54%, CD/MF 43%, and CD/MF + MER 43%. No significant differences were noted in response rate. Median durations of response and survival were similar for each group: CDVFP 16.2 and 25.2 months, respectively; CDVFP + MER 14.0 and 23.3 months, CD/MF 12.1 and 26.1 months, and CD/MF + MER 15.5 and 25.6 months. Patients who achieved CR frequently had soft-tissue disease (7/17) and patients with disease in 1 or 2 metastatic sites had a significantly higher response rate than those in greater than or equal to 3 sites. MER did not enhance response rate, duration of response, or survival. Also MER did not diminish myelosuppression.

Cyclophosphamide versus cyclophosphamide, methotrexate, and 5-fluorouracil in advanced prostatic cancer: a randomized trial

Thirty-two evaluable patients with metastatic carcinoma of the prostate were entered into a prospective randomized trial comparing cyclophosphamide (CYC) with a combination of cyclophosphamide, methotrexate, and fluorouracil (CMF). Progressive disease after endocrine manipulation was noted in 97% (31/32) of patients before entry. Stable disease (S) was observed in 9 of 17 patients treated with CYC. One partial response (PR) and seven stable responses occurred in the 15 CMF patients. Median duration of stable response was 4.5 months for CYC and 4.5 months on CMF. Median survival of patients with PR and S receiving CYC was 10.1 and for CMF 8.8 months. Patients with progressive disease survived a median 1.7 and 2.6 months with CYC and CMF, respectively. Toxicity was moderate, and no deaths were attributable to sepsis or bleeding. Almost all patients in this study had bone lesions as the dominant site of disease; this made objective assessment of response difficult. There was no significant improvement in response conferred by the combination regimen. Although patients with metastatic prostatic cancer may benefit from chemotherapy, impressive clinical responses are uncommon.

A prospective study of histocompatible leukocyte and platelet transfusions during induction chemotherapy of adult acute nonlymphocytic leukemia

A prospective clinical trial was conducted to test the effectiveness of granulocyte transfusions during induction chemotherapy of patients with adult acute non-lymphocyte leukemia. Thirty-eight patients who received prophylactic granulocyte transfusions from related donors when their phagocyte counts decreased to less than 1000 microliter were compared to twenty-five controls who did not have qualified donors from which to obtain granulocyte transfusions. The frequency of complete remissions (CR) (28/38 versus 7/25) was significantly greater for the granulocyte transfusion group than for controls. Patients older than 45 responded more often in the transfused group (P less than 0.025) when compared to the similar age group in controls. Both duration of complete remission and survival were greater in the granulocyte transfused group. However, these differences were not statistically significant. Survival for all responders (complete plus partial remission) was longer for the granulocyte transfusion group (P = 0.01). No significant difference in frequency or severity of either infection or hemorrhage was noted in the two groups. The advantage noted in this study largely occurred in patients older than 45 and this suggests that this age group is more likely to respond if they have histocompatible donors from which to obtain granulocyte and platelet transfusions. Immune mechanisms may be involved in the beneficial effects observed with HLA compatible granulocyte transfusions.

Serum alkaline phosphatase determination. Value in the staging of advanced breast cancer

A retrospective study of 146 patients with metastatic disease was undertaken to verify the clinical impression that radionuclide scanning rarely, if ever, discloses hepatic metastases in breast cancer patients with normal serum alkaline phosphatase (AP) levels. Only two of 39 patients with abnormal liver scans had normal AP levels, and we conclude that liver scans are not necessary as a routine screening method for liver metastases when the AP level is normal. In contrast AP levels were not predictive of bone scan results. All patients with a twofold or greater elevation of the AP level had abnormal bone, liver, or bone and liver scans. Routine AP determinations provide accurate staging information, and their proper use can decrease the cost of initial and follow-up examination of patients with breast cancer.

Chemotherapy versus chemoimmunotherapy in advanced adenocarcinoma of the colon and rectum: a prospective randomized study

The combination of vincristine, methyl-CCNU, and methotrexate with or without MER-BCG achieved a 2% complete response (CR) and a 11% partial response (PR) with a median duration of 25-29 weeks in 124 evaluable patients with advanced adenocarcinoma of the colon and rectum. Responses were seen in previously untreated patients and in patients refractory to 5-fluorouracil. The median survival of these objective responders (CR + PR) was 57 weeks. The addition of MER-BCG did not appear to influence response rate or duration of survival and was accompanied by significant toxicity. Response was significantly correlated with performance status, sex, and disease free interval and survival with alkaline phosphatase and performance status. Patients with advanced colorectal carcinoma should be stratified according to these variables.