Prognostic Role of Biologically Active Volume of Disease in Patients With Metastatic Lung Adenocarcinoma

BACKGROUND

Number of metastatic sites can identify patient populations with non-small cell lung cancer (NSCLC) that benefit from aggressive therapy. Total volume of disease is also relevant. We evaluated the prognostic impact of biologically active volume of disease (BaVD) on patients with metastatic lung adenocarcinoma.

MATERIALS AND METHODS

Positron emission tomography/computerized tomography (PET/CT) scans from patients with newly diagnosed lung adenocarcinoma prior to starting any therapy were identified. SUV thresholds of 3 and 4 were used to auto-contour all FDG avid areas. Kaplan-Meier analysis and Cox regression were performed to examine influence on OS.

RESULTS

One hundred forty-eight patients were included in the analysis. The median BaVD when using an SUV threshold of 3 was 122.8 mL. The median BaVD when using an SUV threshold of 4 was 46.2 mL When stratified by median BaVD using an SUV of 3, median OS was higher for patients with <=122.8 mL (2.12 years) compared to patients with >122.8 mL (1.46 years) (log-rank P = .001). Similarly, when stratified by median BaVD using an SUV of 4, median OS was higher for patients with <=46.2 mL (1.91 years; 95% CI: 1.65-3.22 years) compared to patients with >46.2 mL (1.48 years; 95% CI: 1.07-1.80 years) (log-rank P = .007). On multivariable analysis, BaVD was significantly associated with OS when using an SUV threshold of 3 (HR: 20.169, P < .001) and 4 (HR: 4.117, P < .001).

CONCLUSION

BaVD is an important prognostic factor in metastatic lung adenocarcinoma and may aid identification of patients with limited disease who may be candidates for more aggressive therapies.

Coordination difficulties and self-esteem: The views of children, adolescents, and their parents

INTRODUCTION

This study aimed to examine the views of children and adolescents with significant coordination difficulties, and their parents, regarding factors they considered had most supported and hindered the development of their self-esteem (SE).

METHODS

A survey was sent to members of the Dyspraxia Support Group of New Zealand asking participants to prioritise the three factors that had most positively and negatively influenced the development of the young person's SE. Quantitative content analysis was utilised to summarise responses in order to describe main influences.

RESULTS

Both groups rated love and support from family as an important factor that had promoted SE. Young people placed more emphasis than parents on friendship and rewarding activities. Parents emphasised the importance of a supportive school environment and the benefits of "diagnosis." Both groups frequently rated aspects directly related to coordination difficulties and bullying as negative influences on SE.

CONCLUSION

The results provide information for young people with coordination difficulties, their parents, and occupational therapists regarding useful strategies for developing healthy SE. Occupational therapists have a critical role in the assessment of children and adolescents with coordination difficulties which leads to better understanding of the young person by others. Additionally, task-oriented treatment approaches are indicated and are likely to lead to increased rates of participation of young people in rewarding activities, including with friends. Further research is required to determine whether these occupational therapy interventions promote increases in SE.

Persistence of anxiety symptoms after elective caesarean delivery

BACKGROUND

In the UK, 11.8% of expectant mothers undergo an elective caesarean section (ELCS) representing 92 000 births per annum. It is not known to what extent this procedure has an impact on mental well-being in the longer term.

AIMS

To determine the prevalence and postpartum progression of anxiety and depression symptoms in women undergoing ELCS in Wales.

METHOD

Prevalence of depression and anxiety were determined in women at University Hospital Wales (2015-16; n = 308) through completion of the Edinburgh Postnatal Depression Scale (EPDS; ≥13) and State-Trait Anxiety Inventory (STAI; ≥40) questionnaires 1 day prior to ELCS, and three postpartum time points for 1 year. Maternal characteristics were determined from questionnaires and, where possible, confirmed from National Health Service maternity records.

RESULTS

Using these criteria the prevalence of reported depression symptoms was 14.3% (95% CI 10.9-18.3) 1 day prior to ELCS, 8.0% (95% CI 4.2-12.5) within 1 week, 8.7% (95% CI 4.2-13.8) at 10 weeks and 12.4% (95% CI 6.4-18.4) 1 year postpartum. Prevalence of reported anxiety symptoms was 27.3% (95% CI 22.5-32.4), 21.7% (95% CI 15.8-28.0), 25.3% (95% CI 18.5-32.7) and 35.1% (95% CI 26.3-44.2) at these same stages. Prenatal anxiety was not resolved after ELCS more than 1 year after delivery.

CONCLUSIONS

Women undergoing ELCS experience prolonged anxiety postpartum that merits focused clinical attention.

DECLARATION OF INTEREST

None.

The Inverse Care Law programme: evaluating a population based intervention in primary care within deprived communities in Wales

BackgroundThe Inverse Care Law (ICL) programme was set up in South Wales valleys and aiming to achieve a measurable closing of the gap in health outcomes between the most and least deprived areas. ObjectivesPeople in deprived communities in Wales were invited for health checks to identify risks of cardiovascular disease followed by targeted interventions towards lifestyle risk factors, e.g. poor diet, physical inactivity, smoking and high alcohol intake, under the ICL programme piloted in Aneurin Bevan (AB) and Cwm Taf (CT) University Health Boards. MethodsWelsh Longitudinal General Practice (WLGP) data held in Secure Anonymised Information Linkage (SAIL) databank was utilised to evaluate outcomes through project-specified clinical codes and uptake of the programme, linked with the Welsh Demographic Service Dataset (WDSD) providing demographic characteristics. FindingsThere were 7,094 people completing health checks in AB and CT University Health Boards between February 2015 and November 2016. 96% of these were in the three most deprived Welsh Index of Multiple Deprivation (WIMD) quintiles. 51% were referred within primary care for follow-up based on their health check results, 71% were overweight/obese, and 20% were identified as current smokers of within which 28% were referred to smoking sensation services, with further analyses to follow. ConclusionsImplementations and effectiveness of the interventions and impact of health checks will be evaluated longitudinally on a scheduled basis with repeated analyses. Challenges and results will help refining the programme to be delivered across Wales.

Lower-body negative pressure decreases noninvasively measured intracranial pressure and internal jugular vein cross-sectional area during head-down tilt

Long-term spaceflight induces a near visual acuity change in ~50% of astronauts. In some crew members, postflight cerebrospinal fluid (CSF) opening pressures by lumbar puncture are as high as 20.9 mmHg; these members demonstrated optic disc edema. CSF communicates through the cochlear aqueduct to affect perilymphatic pressure and tympanic membrane motion. We hypothesized that 50 mmHg of lower-body negative pressure (LBNP) during 15° head-down tilt (HDT) would mitigate elevations in internal jugular vein cross-sectional area (IJV CSA) and intracranial pressure (ICP). Fifteen healthy adult volunteers were positioned in sitting (5 min), supine (5 min), 15° HDT (5 min), and 15° HDT with LBNP (10 min) postures for data collection. Evoked tympanic membrane displacements (TMD) quantified ICP noninvasively. IJV CSA was measured using standard ultrasound techniques. ICP and IJV CSA increased significantly from the seated upright to the 15° HDT posture (P < 0.05), and LBNP mitigated these increases. LBNP at 25 mmHg reduced ICP during HDT (TMD of 322.13 ± 419.17 nl) to 232.38 ± 445.85 nl, and at 50 mmHg ICP was reduced further to TMD of 199.76 ± 429.69 nl. In addition, 50 mmHg LBNP significantly reduced IJV CSA (1.50 ± 0.33 cm²) during 15° HDT to 0.83 ± 0.42 cm² LBNP counteracts the headward fluid shift elevation of ICP and IJV CSA experienced during microgravity as simulated by15° HDT. These data provide quantitative evidence that LBNP shifts cephalic fluid to the lower body, reducing IJV CSA and ICP.NEW & NOTEWORTHY The current study provides new evidence that 25 or 50 mmHg of lower body negative pressure reduces jugular venous pooling and intracranial pressure during simulated microgravity. Therefore, spaceflight countermeasures that sequester fluid to the lower body may mitigate cephalic venous congestion and vision impairment.

FOXL2 copy number changes in the molecular pathogenesis of BPES: unique cohort of 17 deletions

Blepharophimosis Syndrome (BPES) is an autosomal dominant developmental disorder of the eyelids with or without ovarian dysfunction caused by FOXL2 mutations. Overall, FOXL2deletions represent 12% of all genetic defects in BPES. Here, we have identified and characterized 16 new and one known FOXL2 deletion combining multiplex ligation-dependent probe amplification (MLPA), custom-made quantitative PCR (qPCR) and/or microarray-based copy number screening. The deletion breakpoints could be localized for 13 out of 17 deletions. The deletion size is highly variable (29.8 kb - 11.5 Mb), indicating absence of a recombination hotspot. Although the heterogeneity of their size and breakpoints is not reflected in the uniform BPES phenotype, there is considerable phenotypic variability regarding associated clinical findings including psychomotor retardation (8/17), microcephaly (6/17), and subtle skeletal features (2/17). In addition, in all females in whom ovarian function could be assessed, FOXL2 deletions proved to be associated with variable degrees of ovarian dysfunction. In conclusion, we present the largest series of BPES patients with FOXL2 deletions and standardized phenotyping reported so far. Our genotype-phenotype data can be useful for providing a prognosis (i.e. occurrence of associated features) in newborns with BPES carrying a FOXL2 deletion.

Impact of psychosocial interventions on children with disruptive and emotional disorders treated in a health camp

OBJECTIVE

The aim of the present study was to evaluate the impact of a health camp psychosocial intervention on children with behavioural and emotional problems and the impact of a parenting programme for their parents. The practical utility of introducing two outcome measures was also evaluated.

METHOD

A total of 157 consecutively referred children, with a range of emotional and behavioural problems, were rated by parents and teachers, before and after their residential stay, using the Strengths and Difficulties Questionnaire (SDQ). Concurrent change in parenting attitudes was assessed using the Adult Adolescent Parenting Inventory-2. One hundred parents participated in a parenting programme. Both child and parent outcomes for these parents were contrasted with those of the 57 non-participating parents.

RESULTS

The whole group showed significant improvements in SDQ rated Emotional, Conduct, Hyperactive and Total problems. These were of moderate effect size. The parenting programme had minimal impact on parenting attitudes and no adjunctive value was demonstrated.

CONCLUSIONS

The Health Camp intervention appeared moderately beneficial for a range of common childhood emotional and behavioural problems. In contrast, there was no demonstrable effect from the parenting programme on either parenting attitudes or child outcomes. The SDQ appeared to have clinical utility as an outcome measure.

Adenosine inhibits cytosolic calcium signals and chemotaxis in hepatic stellate cells

Adenosine is produced during cellular hypoxia and apoptosis, resulting in elevated tissue levels at sites of injury. Adenosine is also known to regulate a number of cellular responses to injury, but its role in hepatic stellate cell (HSC) biology and liver fibrosis is poorly understood. We tested the effect of adenosine on the cytosolic Ca2+ concentration, chemotaxis, and upregulation of activation markers in HSCs. We showed that adenosine did not induce an increase in the cytosolic Ca2+ concentration in LX-2 cells and, in addition, inhibited increases in the cytosolic Ca2+ concentration in response to ATP and PDGF. Using a Transwell system, we showed that adenosine strongly inhibited PDGF-induced HSC chemotaxis in a dose-dependent manner. This inhibition was mediated via the A(2a) receptor, was reversible, was reproduced by forskolin, and was blocked by the adenylate cyclase inhibitor 2,5-dideoxyadenosine. Adenosine also upregulated the production of TGF-beta and collagen I mRNA. In conclusion, adenosine reversibly inhibits Ca2+ fluxes and chemotaxis of HSCs and upregulates TGF-beta and collagen I mRNA. We propose that adenosine provides 1) a "stop" signal to HSCs when they reach sites of tissue injury with high adenosine concentrations and 2) stimulates transdifferentiation of HSCs by upregulating collagen and TGF-beta production.

Population-based validation of dihydrofolate reductase gene mutations for the prediction of sulfadoxine-pyrimethamine resistance in Uganda

Mutations in the dihydrofolate reductase gene (dhfr) of Plasmodium falciparum have been proposed as molecular markers for the surveillance of sulfadoxine-pyrimethamine (SP)-resistant malaria, but such proposals have not been validated. At 7 Ugandan sites in 1999, we determined the population-based prevalence of infections with mutations and the mutant allele frequency of dhfr codons 108, 51, and 59 using a random sample of infected individuals aged 1-45 years. Sulfadoxine-pyrimethamine treatment failure was independently estimated by in vivo tests in 327 children aged 6-59 months with clinical malaria. The prevalence of infections with the single point mutations and the dhfr codons 108 and 51 mutant allele frequency were not correlated to SP treatment failure. However, the dhfr codon 59 mutant allele frequency was positively correlated to SP treatment failure (r = 0.72, P = 0.06). The ratio of the infections with the mutant to wild genotype (M/W) and that of the mutant to wild allele (MA/WA) had the same values. Both dhfr codon 59 M/W and MA/WA ratio were significantly and positively correlated to SP treatment failure (r = 0.73, P = 0.05). Moreover, the prevalence of infections with only 2 mutations (Asn-108 plus Ile-51) was significantly and inversely correlated to the prevalence of infections with 3 mutations (Asn-108 plus Ile-51 plus Arg-59) (r = 0.92, P = 0.004), suggesting the stepwise accumulation of the dhfr mutations is Asn-108 Ile-51 Arg-59 and further supporting the idea of using the dhfr codon 59 M/W ratio as a molecular index for the prediction of SP treatment failure. Atthe population level, the dhfr codon 59 M/W ratio is a simple and stable index for the estimation of SP treatment failure.

Population pharmacokinetics of artemether and dihydroartemisinin following single intramuscular dosing of artemether in African children with severe falciparum malaria

AIMS

To determine the population pharmacokinetics of artemether and dihydroartemisinin in African children with severe malaria and acidosis associated with respiratory distress following an intramuscular injection of artemether.

METHODS

Following a single intramuscular (i.m.) injection of 3.2 mg kg-1 artemether, blood samples were withdrawn at various times over 24 h after the dose. Plasma was assayed for artemether and dihydroartemisinin by gas chromatography-mass spectrometry. The software program NONMEM was used to fit the concentration-time data and investigate the influence of a range of clinical characteristics (respiratory distress and metabolic acidosis, demographic features and disease) on the pharmacokinetics of artemether and dihydroartemisinin.

RESULTS

A total of 100 children with a median age of 36.4 (range 5-108) months were recruited into the study and data from 90 of these children (30 with respiratory distress and 60 with no respiratory distress) were used in the population pharmacokinetic analysis. The best model to describe the disposition of artemether was a one-compartment model with first-order absorption and elimination. The population estimate of clearance (clearance/bioavailability, CL/F) was 14.3 l h-1 with 53% intersubject variability and that of the terminal half-life was 18.5 h. If it was assumed that artemisin displays "flip-flop" kinetics, the elimination half-life was estimated to be 21 min and the corresponding volume of distribution was 8.44 l, with an intersubject variability of 104%. None of the covariates could be identified as having any influence on the disposition of artemether. The disposition of dihydroartemisinin was fitted separately using a one-compartment linear model in which the volume of distribution was fixed to the same value as that of artemether. Assuming that artemether is completely converted to dihydroartemisinin, the estimated value of CL/F for dihydroartemisinin was 93.5 l h-1, with an intersubject variability of 90.2%. The clearance of dihydroartemisinin was formation rate limited.

CONCLUSIONS

Administration of a single 3.2 mg kg-1 i.m. dose of artemether to African children with severe malaria and acidosis is characterized by variable absorption kinetics, probably related to drug formulation characteristics rather than to pathophysiological factors. Use of i.m. artemether in such children needs to be reconsidered.

Molecular monitoring of the Leu-164 mutation of dihydrofolate reductase in a highly sulfadoxine/pyrimethamine-resistant area in Africa

The selection of point mutation at codon 164 (from isoleucine to leucine) of the dihydrofolate reductase (DHFR) enzyme in Plasmodium falciparum is associated with high sulfadoxine /pyrimethamine (SP) resistance. Using the yeast expression system that allows the detection of dhfr allele present at low level, the presence of this mutation had previously been reported between 1998–1999 in Muheza, Tanzania, an area of high SP resistance. Eighty five P. falciparum isolates, obtained from the same area between 2002 and 2003, were analysed for the presence of Leu-164 mutation, using standard protocol based on PCR-RFLP. None of the isolates had the Leu-164 mutation.

Role of the pfcrt codon 76 mutation as a molecular marker for population-based surveillance of chloroquine (CQ)-resistant Plasmodium falciparum malaria in Ugandan sentinel sites with high CQ resistance

The mutant genotype at codon 76 of the pfcrt gene (T76) has been proposed as a molecular marker for surveillance of chloroquine (CQ)-resistant Plasmodium falciparum malaria but this proposal has not been validated by population-based surveys. In 1998-99, in 6 Ugandan sentinel sites, the prevalence of P. falciparum infections with the T76 genotype and the level of CQ use were measured by community surveys, and CQ resistance was determined by in-vivo tests on 6-59-month-old children with clinical malaria. The prevalence of T76 was not related to the overall clinical (early and late treatment failure: ETF + LTF; r = 0.14, P = 0.78) or parasitological (RI + RII + RIII; r = 0.17, P = 0.73) CQ resistance. However, the percentage of individuals carrying only infections with the T76 genotype (T76 alone) increased with increasing ETF (r = 0.76, P = 0.07) and type RIII parasitological failure (r = 0.69, P = 0.12). Similarly, the ratio between T76 and K76 (the wild type) prevalences (T76/K76) was strongly and positively correlated with ETF (r = 0.85, P = 0.03) and RIII (r = 0.82, P = 0.04). Moreover, T76 alone (r = 0.90, P = 0.01) as well as T76/K76 (r = 0.90, P = 0.01) significantly increased with increasing community CQ use. T76 alone and T76/K76 can be useful markers to estimate the ETF and RIII prevalence as well as the amount of CQ use in the community.

Intensity of malaria transmission, antimalarial-drug use and resistance in Uganda: what is the relationship between these three factors?

We studied (in 1998 and 1999) some factors that may be linked to the spread of chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) resistance in 7 discrete communities in Uganda. Exposure to malaria infection was measured by parasitological surveys in children aged 1-9 years, drug use by community surveys and drug resistance by in-vivo tests on children aged 6-59 months with clinical malaria. CQ use was inversely related to parasite prevalence (r = -0.85, P = 0.01). CQ and SP treatment failure rates varied significantly according to parasite prevalence (P = 0.001 and 0.04 respectively). The highest CQ (42.4%, 43.8%) and SP (12.5%, 14.8%) treatment failure rates were observed in sites characterized by high parasite prevalence. Using areas with medium parasite prevalence as reference, the relative risk (RR) for CQ treatment failure was 3.2 (95% CI 1.6-6.4) in high parasite prevalence sites and 3.1 (95% CI 1.2-7.7) in low parasite prevalence sites. The RR for SP treatment failure was also higher in sites with high parasite prevalence but low in those with low parasite prevalence. According to our findings, drug resistance seems to spread faster in higher transmission areas, regardless of drug pressure. In low transmission areas, drug pressure seems to be the critical factor. A decrease in transmission coupled with rational use of drugs may delay the spread of resistance.

Chlorproguanil-dapsone for treatment of drug-resistant falciparum malaria in Tanzania

BACKGROUND

Resistance to the affordable malaria treatments chloroquine and pyrimethamine-sulfadoxine is seriously impeding malaria control through treatment in east Africa. We did an open, alternate drug allocation study to assess the efficacy of chlorproguanil-dapsone in the treatment of falciparum malaria clinically resistant to pyrimethamine-sulfadoxine.

METHODS

Children younger than 5 years with non-severe falciparum malaria, attending Muheza district hospital in Tanzania, were treated with the standard regimen of pyrimethamine-sulfadoxine. Patients whose clinical symptoms resolved but who remained parasitaemic 7 days after pyrimethamine-sulfadoxine were followed up for 1 month. Clinical malaria episodes were retreated with either single dose pyrimethamine-sulfadoxine or a 3-day regimen of chlorproguanil-dapsone. Those with parasitaemia after 7 days were treated with chlorproguanil-dapsone. Parasite DNA was collected on day 7 after first treatment with pyrimethamine-sulfadoxine and we looked for point mutations in the genes encoding dihydrofolate reductase (dhfr) and dyhydropteroate synthetase (dhps).

FINDINGS

360 children were enrolled and treated with pyrimethamine-sulfadoxine. On day 7, 192 (55%) of 348 had cleared parasitaemia. Of the remaining 156 parasitaemic children, 140 (90%) were followed up to day 28, and 92 (66%) of 140 developed clinical malaria. These 92 patients were alternately retreated with either pyrimethamine-sulfadoxine (46) or chlorproguanil-dapsone (46). 28 (61%) of 46 children retreated with pyrimethamine-sulfadoxine were still parasitaemic at day 7, compared with three (7%) of 44 [corrected] children retreated with chlorproguanil-dapsone. Resistance to pyrimethamine-sulfadoxine increased from 45% (156/348) at the first treatment to 61% (28/46) after retreatment. 83 of 85 parasite isolates collected after the first pyrimethamine-sulfadoxine treatment, and before and after the second treatments with pyrimethamine-sulfadoxine and chlorproguanil-dapsone showed triple-mutant dhfr alleles, associated with a variety of dhps mutations.

INTERPRETATION

Most patients treated with pyrimethamine-sulfadoxine, who remain parasitaemic at day 7, develop new malaria symptoms within 1 month. Chlorproguanil-dapsone was a practicable therapy under these circumstances. Analysis of parasite dhfr and dhps before and after treatment supports the view that pyrimethamine-sulfadoxine resistance in this part of Africa is primarily due to parasites with three mutations in the dhfr domain.

Inhibition of efflux pumps as a novel approach to combat drug resistance in bacteria

Efflux mechanisms have become broadly recognized as major components of resistance to many classes of antibiotics. Some efflux pumps selectively extrude specific antibiotics, while others, referred to as multidrug resistance (MDR) pumps, expel a variety of structurally diverse compounds with differing antibacterial modes of action. There are numerous potentially beneficial consequences of the inhibition of efflux pumps in improving the clinical performance of various antibiotics, and several companies and research laboratories have initiated programs to discover and develop efflux pump inhibitors. This review will summarize recent achievements in this new, very exciting and equally challenging field.

Identification and characterization of inhibitors of multidrug resistance efflux pumps in Pseudomonas aeruginosa: novel agents for combination therapy

Whole-cell assays were implemented to search for efflux pump inhibitors (EPIs) of the three multidrug resistance efflux pumps (MexAB-OprM, MexCD-OprJ, MexEF-OprN) that contribute to fluoroquinolone resistance in clinical isolates of Pseudomonas aeruginosa. Secondary assays were developed to identify lead compounds with exquisite activities as inhibitors. A broad-spectrum EPI which is active against all three known Mex efflux pumps from P. aeruginosa and their close Escherichia coli efflux pump homolog (AcrAB-TolC) was discovered. When this compound, MC-207,110, was used, the intrinsic resistance of P. aeruginosa to fluoroquinolones was decreased significantly (eightfold for levofloxacin). Acquired resistance due to the overexpression of efflux pumps was also decreased (32- to 64-fold reduction in the MIC of levofloxacin). Similarly, 32- to 64-fold reductions in MICs in the presence of MC-207,110 were observed for strains with overexpressed efflux pumps and various target mutations that confer resistance to levofloxacin (e.g., gyrA and parC). We also compared the frequencies of emergence of levofloxacin-resistant variants in the wild-type strain at four times the MIC of levofloxacin (1 microg/ml) when it was used either alone or in combination with EPI. In the case of levofloxacin alone, the frequency was approximately 10(-7) CFU/ml. In contrast, with an EPI, the frequency was below the level of detection (<10(-11)). In summary, we have demonstrated that inhibition of efflux pumps (i) decreased the level of intrinsic resistance significantly, (ii) reversed acquired resistance, and (iii) resulted in a decreased frequency of emergence of P. aeruginosa strains that are highly resistant to fluoroquinolones.

Chloroquine is not a risk factor for seizures in childhood cerebral malaria

OBJECTIVES

There are a number of case reports in the medical literature suggesting an association between the ingestion of chloroquine and subsequent seizure activity. Our study was designed to investigate the relationship between blood levels of chloroquine (CQ), its metabolite desethylchloroquine (DCQ), and seizures in children admitted to hospital with cerebral malaria.

METHODS

Serial blood levels of CQ and DCQ were measured over the first 24 h of hospital admission in children with cerebral malaria. The number and duration of all seizures was recorded, and statistical analysis subsequently performed to determine the relationship between seizure activity and blood concentrations of CQ and DCQ.

RESULTS

Chloroquine was detected in 92% (100/109) of admission blood samples. 54% (59/109) of the patients had one or more seizures after admission, while 8% (9/109) had an episode of status epilepticus. Median (interquartile range) baseline concentrations of CQ and DCQ were, respectively, 169.4 microg/ml (75.1-374.9) and 352.3 microg/ml (81.9-580.1) for those children who had seizures after admission, compared to CQ 227.5 microg/ml (79.4-430.2) and DCQ 364.0 microg/ml (131.3-709.4) for those who did not have seizures (P > 0.5 for all comparisons). Baseline concentrations of CQ and DCQ were not significantly associated with the occurrence of seizures lasting for 5 min or more. The nine children who had an episode of status epilepticus had significantly lower median admission levels of CQ than those without status epilepticus: 75.1 microg/l (7.4-116.5) vs. 227.5 microg/l (85.6-441.2), P = 0.02. Multivariate logistic regression analysis, taking into account factors likely to affect the risk of seizures in hospital, failed to change the significance of these results.

CONCLUSIONS

These findings suggest that chloroquine does not play an important role in the aetiology of seizures in childhood cerebral malaria.

Effect of phenobarbital on seizure frequency and mortality in childhood cerebral malaria: a randomised, controlled intervention study

BACKGROUND

Seizures commonly complicate cerebral malaria and are associated with an increased risk of death and neurological sequelae. We undertook a randomised study to assess the efficacy of intramuscular phenobarbital in preventing seizures in childhood cerebral malaria.

METHODS

Children with cerebral malaria admitted to one hospital in Kilifi, Kenya, were randomly assigned a single intramuscular dose of phenobarbital (20 mg/kg) or identical placebo. Clinical tolerance was assessed at the start of the trial, with particular reference to respiratory depression and hypotension. Seizures were timed and recorded, and treated in a standard way. Plasma phenobarbital concentrations were measured. Analyses were by intention to treat.

FINDINGS

440 children with cerebral malaria were admitted to the hospital; 100 were not recruited to the study. Of the remaining 340, 170 received phenobarbital and 170 placebo. The drug was adequately absorbed and well tolerated. Seizure frequency was significantly lower in the phenobarbital group than in the placebo group (18 [11%] vs 46 [27%] children had three or more seizures of any duration; odds ratio 0.32 [95% CI 0.18-0.58]) but mortality was doubled (30 [18%] vs 14 [8%] deaths; 2.39 [1.28-4.64]). The frequency of respiratory arrest was higher in the phenobarbital group than in the placebo group, and mortality was greatly increased in children who received phenobarbital plus three or more doses of diazepam (odds ratio 31.7 [1.2-814]).

INTERPRETATION

In children with cerebral malaria, phenobarbital 20 mg/kg provides highly effective seizure prophylaxis but is associated with an unacceptable increase in mortality. Use of this dose cannot, therefore, be recommended.

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.

Infection with Plasmodium berghei alters benzodiazepine receptor in rat brain

The purpose of this study was to assess the effect of malaria infection on benzodiazepine binding in rat brain. Young male Wistar rats were infected with the rodent parasite Plasmodium berghei, while age-matched control rats (n = 5) received normal saline intraperitoneally. Parasitemia was determined in blood of infected animals. Animals were killed after two weeks, and synaptosomal brain membrane homogenate was prepared from cerebral cortex. Membrane homogenate was incubated in duplicate with 3H-flunitrazepam (0.2-10 nM in buffer, pH 7.4) and binding parameters determined. The number of receptors (Bmax) was decreased marginally but significantly (P = 0.047) in malaria-infected (MI) rats (MI rats: 1.12 +/- 0.1 pmol.mg-1 protein; control rats: 1.42 +/- 0.08 pmol.mg-1 protein) while binding affinity (Kd) was not altered (MI rats: 1.18 +/- 0.3 nM; control rats: 1.02 +/- 0.15 nM). These results suggest that malaria may be associated with decreased benzodiazepine activity.

Pharmacokinetics of antimycobacterial drugs in patients with tuberculosis, AIDS, and diarrhea

To test the hypothesis that antituberculous drug disposition is altered in patients with AIDS, we studied the steady-state pharmacokinetics of isoniazid (300 mg/d), rifampin (600 mg/d), and pyrazinamide (1,500 mg/d) in 29 adults (14 patients infected with human immunodeficiency virus [HIV] and 15 non-HIV-infected patients) with tuberculosis in Nairobi, Kenya. Intestinal integrity was assessed with xylose. Neither HIV infection nor diarrhea accounted for the interpatient variability in the area-under-the-plasma concentration vs. time curve (AUC), the maximum concentration, or the terminal half-life (t1/2) of isoniazid, rifampin, and pyrazinamide. No significant association between HIV infection or diarrhea and pharmacokinetics was seen for any of the compounds. In addition, neither the AUC nor the t1/2 of any of these drugs reflected interpatient differences in CD4 lymphocyte counts. Xylose absorption was uniformly low. We did not demonstrate that HIV infection, diarrhea, or CD4 lymphocyte counts contributed significantly to the variability in pharmacokinetics of isoniazid, rifampin, and pyrazinamide in TB patients in Nairobi.

Chlorproguanil/dapsone for uncomplicated Plasmodium falciparum malaria in young children: pharmacokinetics and therapeutic range

The disposition of chlorproguanil/dapsone (one daily dose for 3 d of 1.2 and 2.4 mg/kg respectively) has been studied in young children with Plasmodium falciparum malaria, to provide data complementary to a clinical trial of this drug combination. Unbound concentrations of chlorcycloguanil (the active metabolite of chlorproguanil) and dapsone in clinical samples have been related to the unbound drug concentrations which produced defined outcomes in tests in vitro of drug efficacy and toxicity. Twelve children with uncomplicated malaria were treated: all cleared parasitaemia within 72 h and made uneventful recoveries. After the first dose of chlorproguanil/dapsone the maximum unbound chlorcycloguanil concentration in clinical samples (19 ng/mL [about 60 nM]) was 2 orders of magnitude above the 50% inhibitory concentration (IC50) value for this drug against the K39 stain of P. falciparum, while falling 2 orders of magnitude below its IC50 against human bone marrow cells; the maximum unbound dapsone concentration in clinical samples (160 ng/mL [about 645 nM]) was 10-fold higher than its IC50 against the K39 strain. However, because of the rapid elimination of chlorproguanil from the body (half-life 12.6 +/- 6.3 h), the minimum fractional inhibitory concentrations of unbound chlorcycloguanil/dapsone against the K39 strain were probably exceeded for no more than 6 d. These data, together with the clinical trial, will be helpful in deciding whether current chlorproguanil/dapsone doses are optimal for the treatment of falciparum malaria.

Testicular and epididymal sperm in a microinjection program: methods of retrieval and results

OBJECTIVE

To describe the methods of collection and laboratory preparation of epididymal and testicular sperm; to compare the fertilization and pregnancy rates; and to establish prognostic factors.

DESIGN

Retrospective analysis.

SETTING

Academic reproductive medicine clinic.

PATIENT(S)

One hundred twelve consecutive microinjection cycles in 80 patients using either epididymal or testicular sperm.

INTERVENTION(S)

Sperm were collected by microepididymal sperm aspiration, open testicular biopsy, or fine needle tissue aspiration testicular biopsy.

MAIN OUTCOME MEASURE(S)

Fertilization rate, implantation, and clinical pregnancy rates.

RESULT(S)

The fertilization rate was higher with epididymal sperm (67%) than with testicular sperm (50%). Implantation rates (fetal hearts per embryo, testicular: 11%, epididymal: 8%) and pregnancy rates (clinical pregnancy per oocyte collection procedure, testicular: 25%, epididymal: 29%) were not significantly different with epididymal and testicular sperm. Multiple regression analysis showed that normal fertilization rates were significantly lower with testicular sperm, immotile sperm, and severe spermatogenic disorders.

CONCLUSION(S)

Although fertilization rates are significantly lower with testicular sperm, higher implantation rates resulted in equivalent pregnancy rates. Thus, testicular aspiration of sperm for intracytoplasmic sperm injection is a simple, inexpensive method of sperm retrieval in cases of azoospermia resulting from genital tract obstruction or severe spermatogenic disorder.

Testicular aspiration of sperm for intracytoplasmic sperm injection: an alternative treatment to electro-emission: case report

The quantity and quality of spermatozoa produced by electro- or vibro-ejaculation in spinal cord injury patients is often poor, thus advanced reproductive techniques are required if pregnancy is to be achieved. On other occasions no spermatozoa are obtained. We present a successful case of pregnancy achieved using spermatozoa aspirated directly from the testicle combined with intracytoplasmic sperm injection in an in vitro fertilization cycle. We propose this as an alternative to electroejaculation in selected patients.

Testicular aspiration of sperm for intracytoplasmic sperm injection: a novel treatment for ejaculatory failure on the day of oocyte retrieval

OBJECTIVE

To present a successful outcome of an IVF cycle complicated by failure to produce a sperm sample on the morning of oocyte retrieval.

DESIGN

Case report.

SETTING

Hospital-based IVF clinic.

PATIENT

A couple suffering secondary infertility undergoing their first IVF and intracytoplasmic sperm injection (ICSI) cycle.

INTERVENTION

Fine-needle testicular biopsy for sperm retrieval.

MAIN OUTCOME MEASURES

Sperm retrieval, fertilization, pregnancy.

RESULTS

Sufficient spermatozoa were obtained for ICSI. Ten metaphase II oocytes were injected with two embryos being transferred fresh and four cryopreserved. A single fetal heart was confirmed at 6-week sonar.

CONCLUSION

Testicular aspiration of sperm for ICSI is a simple, inexpensive, and effective means of rescuing an IVF cycle in which the male partner unexpectedly has been unable to produce a sperm sample on the morning of oocyte collection.

Alpha1,3-L-fucosyltransferase expression in developing human myeloid cells. Antigenic, enzymatic, and mRNA analyses

In an attempt to correlate the cell surface expression of Lex and sialyl-Lex structures in immature and mature myeloid cells with the genes expressing alpha1,3-fucosyltransferase(s) we have examined: 1) the properties of the cellular alpha1,3-fucosyltransferases and the mRNA transcripts corresponding to the five cloned genes, Fuc-TIII, Fuc-TIV, Fuc-TV, Fuc-TVI, and Fuc-TVII, in mature granulocytes and in the myeloid cell line HL-60, before and after dimethyl sulfoxide-induced differentiation and 2) the properties of the alpha1,3-fucosyltransferases expressed in COS-7 cells transfected with plasmids containing Fuc-TIV and Fuc-TVII cDNAs. The previously shown increase in cell surface expression of sialyl-Lex on differentiation of HL-60 cells (Skacel P. O., Edwards A. J., Harrison C. T., and Watkins W. M. (1991) Blood 78, 1452-1460) is accompanied by a sharp fall in expression of Fuc-TIV mRNA and a persistence of expression of Fuc-TVII mRNA. The properties of the alpha1,3-fucosyltransferase expressed in COS-7 cells transfected with Fuc-TIV are consistent with this being the major gene responsible for the expression of Lex in the immature myeloid cells. In Northern blot analyses, no transcripts of Fuc-TIII, Fuc-TV, or Fuc-TVI were detected in total RNA from mature granulocytes or mRNA from HL-60 cells before or after differentiation. In total RNA from mature granulocytes, Fuc-TIV transcripts were only faintly visible, whereas Fuc-TVII transcripts were quite definitely expressed. The specificity properties of Fuc-TVII expressed in COS-7 cells are consistent with this gene being the major candidate alpha1, 3-fucosyltransferase controlling the expression of sialyl-Lex on mature cells. However, Lex continues to be expressed on the surface of mature granulocytes and cell extracts retain the capacity to transfer fucose to non-sialylated acceptor substrates. The question therefore remains as to whether these properties result from the weakly expressed Fuc-TIV gene or whether another alpha1, 3-fucosyltransferase gene remains to be identified.

Pregnancies after intracytoplasmic injection of sperm collected by fine needle biopsy of the testis

OBJECTIVE

To investigate the use of intracytoplasmic sperm injection with sperm collected by fine needle biopsy of the testis as a treatment for male genital tract obstruction.

DESIGN

Sperm isolated from a fine needle biopsy of the testis were used to inseminate oocytes by intracytoplasmic sperm injection.

SETTING

A hospital-based tertiary referral infertility service.

PATIENTS

Case studies of two couples in whom the male partner had a genital tract obstruction.

MAIN OUTCOME MEASURES

Fertilization and pregnancy.

RESULTS

In the first case, 9 oocytes fertilized normally out of 13 injected. After the transfer of fresh (one cycle) and frozen (four cycles) embryos, a single intrauterine fetal heart pregnancy was achieved. In the second case, five oocytes fertilized normally from nine oocytes injected; two embryos were transferred fresh and three were frozen. A single fetal heart intrauterine gestation was obtained after the initial transfer of two fresh embryos.

CONCLUSIONS

A high normal fertilization rate and pregnancies are possible with intracytoplasmic sperm injection using sperm collected directly from the testis. Sperm retrieval by fine needle biopsy offers a viable alternative to microsurgical aspiration and is also suitable for treating patients with intratesticular blockage.

The use of intracytoplasmic sperm injection for the treatment of severe and extreme male infertility

The outcome of treatment by intracytoplasmic sperm injection (ICSI) is described for patients with severe male infertility. In 296 consecutive cycles, a normal fertilization rate of 69% was achieved with 288 cycles (97%) resulting in embryos suitable for transfer. A total of 32 clinical pregnancies were achieved from the transfer of fresh embryos (clinical pregnancy rate of 12% per transfer) and an additional 44 clinical pregnancies were obtained after the transfer of frozen-thawed embryos (clinical pregnancy rate of 16% per transfer). Overall, 57 of the 76 pregnancies were ongoing or delivered. An analysis of outcome in 5 male factor subgroups revealed no significant differences in pregnancy and implantation rates between the categories. However, the fertilization rate was significantly lower in patients with oligoasthenoteratozoospermia and significantly higher in those patients for whom epididymal sperm were used for insemination. The treatment of patients with extreme male infertility is also described; normal fertilization and embryo development were obtained using ICSI in patients with mosaic Klinefelter's syndrome, severe sperm autoimmunity, round-headed acrosomeless sperm (globozoospermia), completely immotile sperm selected by hypo-osmotic swelling and sperm isolated from testicular biopsies. Three ongoing pregnancies were obtained from 6 patients for whom testicular sperm were used. These results demonstrate the value of ICSI in the management of severe male infertility, however, the treatment of some types of extreme male infertility using ICSI may be limited.

An update on the epidemiology of AIDS in Missouri

It has been 13 years since the initial report from the Centers for Disease Control and Prevention (CDC) describing the condition that came to be known as the acquired immunodeficiency syndrome (AIDS). Because of the public health significance of the AIDS epidemic, an elaborate national surveillance system, involving CDC along with state and local health departments, came to be established. The surveillance system now provides detailed information about the epidemiology of AIDS in this country. At the national level, through September 1993, 339,250 cases of AIDS have been reported to CDC; 204,390 of these individuals have died, for a case-fatality rate of 60.2%. Human immunodeficiency virus (HIV) infection/AIDS is now the leading cause of death in American men aged 25-44, and the fourth leading cause of death for women in this age group. The AIDS epidemic continues to disproportionately affect minorities. For blacks, the cumulative incidence rate is approximately 3.7 times that of whites; for Hispanics it is approximately 2.7 times that of whites. The majority of AIDS cases nationally are attributable to transmission of HIV among men who have sex with other men. However, the annual incidence of AIDS is currently rising faster among women than among men, and AIDS incidence is increasing more rapidly among persons who are reported to have acquired their infection through heterosexual contact than among persons in other exposure categories. Along with the increase in the number of cases in women, there has been a corresponding increase in the number of pre- or perinatally-acquired cases in children.(ABSTRACT TRUNCATED AT 250 WORDS)

Towards optimal regimens of parenteral quinine for young African children with cerebral malaria: the importance of unbound quinine concentration

Young African children with severe malaria are given quinine using a regimen designed for Thai adults. We measured quinine in the blood, plasma and plasma water of young children in Kenya after rapid intravenous and intramuscular dosing, and calculated the therapeutic range of unbound quinine. The peak plasma quinine concentration after rapid intravenous dosing was 12.3 +/- 3.7 mg/L (mean +/- SD), 43% higher than in adults given the same regimen previously; this was due to a smaller apparent volume of distribution in the children. The therapeutic range of unbound quinine was calculated as 0.2-2.0 mg/L. Simulations of unbound quinine were made for the standard quinine regimen: unbound drug concentrations rose above the therapeutic range after each dose. The possible risks of quinine-induced visual impairment are discussed. Alternative, lower dose regimens for young African children with severe malaria are described.