Analysis of factors that correlate with mucositis in recipients of autologous and allogeneic stem-cell transplants

PURPOSE

To identify predictors of oral mucositis and gastrointestinal toxicity after high-dose therapy.

PATIENTS AND METHODS

Mucositis and gastrointestinal toxicity were prospectively evaluated in 202 recipients of high-dose therapy and autologous or allogeneic stem-cell rescue. Of 10 outcome variables, three were selected as end points: the peak value for the University of Nebraska Oral Assessment Score (MUCPEAK), the duration of parenteral nutritional support, and the peak daily output of diarrhea. Potential covariates included patient age, sex, diagnosis, treatment protocol, transplantation type, stem-cell source, and rate of neutrophil recovery. The three selected end points were also examined for correlation with blood infections and transplant-related mortality.

RESULTS

A diagnosis of leukemia, use of total body irradiation, allogeneic transplantation, and delayed neutrophil recovery were associated with increased oral mucositis and longer parenteral nutritional support. No factors were associated with diarrhea. Also, moderate to severe oral mucositis (MUCPEAK > or = 18 on a scale of 8 to 24) was correlated with blood infections and transplant-related mortality: 60% of patients with MUCPEAK > or = 18 had positive blood cultures versus 30% of patients with MUCPEAK less than 18 (P =.001); 24% of patients with MUCPEAK > or = 8 died during the transplantation procedure versus 4% of patients with MUCPEAK less than 18 (P =.001).

CONCLUSION

Gastrointestinal toxicity is a major cause of transplant-related morbidity and mortality, emphasizing the need for corrective strategies. The peak oral mucositis score and the duration of parenteral nutritional support are useful indices of gastrointestinal toxicity because these end points are correlated with clinically significant events, including blood infections and treatment-related mortality.

Cost-effectiveness of treatment of early stage endometrial cancer

OBJECTIVE

The purpose of this study was to determine the average life-years gained and cost per life-year gained in treatment of early endometrial cancer.

METHODS

We performed a decision analysis using statistical models for survival after treatment for Stage I endometrial cancer. Estimates for survival probabilities without treatment, with surgery alone, and with surgery and radiation were derived from the literature. Charges and costs of treatment were estimated based on data from our institution. We calculated the average number of life-years gained and the cost per life-year gained of various treatment options based on these estimates. Sensitivity analyses were performed to determine the effect of uncertainty about parameter estimates on the results derived from our model.

RESULTS

Based on the assumptions of our model, most of the life-years gained in treatment of early endometrial cancer are attributable to hysterectomy, with a very low associated cost. For the "average" woman with endometrial cancer, about 10 life-years are gained from hysterectomy at a cost of $1000 per life-year gained, whereas adjuvant radiation yields on average 1 year of life gained at $4000 per life-year gained. Both life-years gained and cost are dramatically affected by age at diagnosis and to a lesser extent by histologic grade and comorbid medical conditions.

CONCLUSIONS

This analysis suggests that the use of hysterectomy and adjuvant radiation in treatment of early endometrial cancer is a worthwhile use of health care resources. More sophisticated models may help determine the cost-effectiveness of various treatment strategies in specific subgroups of patients.

Production of influenza-stimulated tumor necrosis factor-alpha by monocytes following acute influenza infection in humans

Tumor necrosis factor-alpha (TNF-alpha) is often measured in the serum or plasma of patients with severe infections, and marked elevation correlates with poor outcome. The relationship of TNF-alpha to protection from disease is frequently not observed because prospective studies of infectious agents are difficult to perform. We took advantage of a human antiviral influenza challenge study to correlate TNF-alpha production with seroconversion and symptom development. TNF-alpha production was measured by ELISA in the plasma compartment or was measured by intracellular production at the single cell level in the monocyte gated population. Monocyte TNF-alpha was associated with asymptomatic seroconversion, whereas there was no change in the plasma at the times measured. Measurement of TNF-alpha at the single cell level by flow cytometry may allow for better differentiation of the protective role of this cytokine in future studies.

Maternal cigarette smoking and pregnancy outcome

Maternal smoking rates in pregnancy have declined, particularly in the non-manual social classes, and perinatal mortality rates have fallen over the last 20 years. We have therefore re-evaluated the relationship between maternal cigarette smoking and pregnancy outcome against this background. A total of 608 stillbirths and 634 infant deaths were identified using the All Wales Perinatal Survey. The cause of death was classified using the clinicopathological system. Maternal smoking rates and social class groupings were compared with those in a cohort of 16047 survivors born to women resident in South Glamorgan. The smoking rate was 37.8% in mothers of babies who died compared with 27.2% in mothers of survivors, an odds ratio (OR) of 1.63 [95% CI 1.44, 1.84]. The OR for unexplained stillbirth was 1.72 [95% CI 1.38, 2.13], placental abruption 2.07 [95% CI 1.29, 3.31], infection 3.70 [95% CI 2.23, 6.13] and sudden infant death syndrome 4.84 [95% CI 3.05, 7.69]. Maternal smoking was not associated with death due to prematurity or a congenital anomaly. Despite changes in smoking habits and the causes of perinatal death, smoking during pregnancy continues to be strongly associated with fetal and infant mortality. It is important that health promotion activities are effective in reducing smoking during pregnancy.

beta-arrestins regulate interleukin-8-induced CXCR1 internalization

The functional role of neutrophils during acute inflammatory responses is regulated by two high affinity interleukin-8 receptors (CXCR1 and CXCR2) that are rapidly desensitized and internalized upon binding their cognate chemokine ligands. The efficient re-expression of CXCR1 on the surface of neutrophils following agonist-induced internalization suggests that CXCR1 surface receptor turnover may involve regulatory pathways and intracellular factors similar to those regulating beta2-adrenergic receptor internalization and re-expression. To examine the internalization pathway utilized by ligand-activated CXCR1, a CXCR1-GFP construct was transiently expressed in two different cell lines, HEK 293 and RBL-2H3 cells. While interleukin-8 stimulation promoted CXCR1 sequestration in RBL-2H3 cells, receptor internalization in HEK 293 cells required co-expression of G protein-coupled receptor kinase 2 and beta-arrestin proteins. The importance of beta-arrestins in CXCR1 internalization was confirmed by the ability of a dominant negative beta-arrestin 1-V53D mutant to block internalization of CXCR1 in RBL-2H3 cells. A role for dynamin was also demonstrated by the lack of CXCR1 internalization in dynamin I-K44A dominant negative mutant-transfected RBL-2H3 cells. Agonist-promoted co-localization of transferrin and CXCR1-GFP in endosomes of RBL-2H3 cells confirmed that receptor internalization occurs via clathrin-coated vesicles. Our data provides a direct link between agonist-induced internalization of CXCR1 and a requirement for G protein-coupled receptor kinase 2, beta-arrestins, and dynamin during this process.

Cytomegalovirus (CMV) resistance in patients with CMV retinitis and AIDS treated with oral or intravenous ganciclovir

Treatment of cytomegalovirus (CMV) retinitis with oral ganciclovir results in relatively low plasma concentrations of drug, which theoretically could cause more frequent viral resistance compared with intravenous (iv) ganciclovir. By use of a plaque-reduction assay to quantify phenotypic sensitivity to ganciclovir, virus isolates were studied from patients with CMV retinitis participating in four clinical trials of oral ganciclovir. Before treatment, 69% of patients were culture-positive but just 1.1% of patients yielded a resistant CMV, defined as a median inhibitory concentration (IC50) >6 microM. On treatment, the first resistant isolate was recovered at 50 days. Overall, 3.1% of patients receiving iv ganciclovir and 6. 5% of those taking oral ganciclovir shed resistant CMV (median ganciclovir exposures of 75 and 165 days, respectively). Since IC50s for clinical isolates increased proportionately with treatment duration, it is likely that viral resistance would be more frequent with longer treatment.

Strand displacement amplification and homogeneous real-time detection incorporated in a second-generation DNA probe system, BDProbeTecET

BACKGROUND

Amplified DNA probes provide powerful tools for the detection of infectious diseases, cancer, and genetic diseases. Commercially available amplification systems suffer from low throughput and require decontamination schemes, significant hands-on time, and specially trained laboratory staff. Our objective was to develop a DNA probe system to overcome these limitations.

METHODS

We developed a DNA probe system, the BDProbeTecTMET, based on simultaneous strand displacement amplification and real-time fluorescence detection. The system uses sealed microwells to minimize the release of amplicons to the environment. To avoid the need for specially trained labor, the system uses a simple workflow with predispensed reagent devices; a programmable, expandable-spacing pipettor; and the 96-microwell format. Amplification and detection time was 1 h, with potential throughput up to 564 patient results per shift. We tested 122 total patient specimens obtained from a family practice clinic with the BD ProbeTecET and the Abbott LCx(R) amplified system for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae.

RESULTS

Based on reportable results, the BDProbeTecET results for both organisms were 100% sensitive and 100% specific relative to the LCx.

CONCLUSIONS

The BDProbeTecET is an easy-to-use, high-throughput, closed amplification system for the detection of nucleic acid from C. trachomatis and N. gonorrhoeae and other organisms.

Antimicrobial resistance in gram-positive pathogens isolated in the UK between October 1996 and January 1997

Antimicrobial resistance in gram-positive pathogens from 30 centres in the UK (ten Teaching, ten Associate Teaching and ten District General Hospitals) was studied over a 4 month period between October 1996 and January 1997. High-level resistance (HLR) and low-level resistance (LLR) to penicillin amongst pneumococci was 3.3% and 3.4%, respectively. However, considerable variation in resistance rates was observed depending on geographical location (LLR range 0-15.4% and HLR range 0-30.8%). Considerable variation in resistance rates was also observed for Staphylococcus aureus to methicillin, with rates ranging from 0% to 56.7% depending on locality. Using conventional MIC methodology, none of the isolates of S. aureus was considered as having reduced sensitivity to vancomycin. However, eight isolates grew on Brain Heart Infusion Agar containing vancomycin (4 mg/L) after prolonged incubation and are therefore worthy of further investigation by electron microscopy. With Enterococcus faecalis, resistance rates were similar between the three types of hospital and only four isolates were considered resistant to glycopeptide antibiotics (one vanA and three vanB phenotype).

Medical packaging: more for less?

The market for medical devices is governed by the need to have validated products and processes, clean manufacturing environments and proven shelf-life. All this, often for products that are disposable, low-unit-cost items and, as such, highly price sensitive. This, in turn, has an impact on the businesses supplying the market. This article considers one such supply market, packaging, and the steps taken by packaging manufacturers to respond to these pressures while maintaining long-term, viable products.

Human corneal ablation threshold using the 193-nm ArF excimer laser

PURPOSE

To determine the human corneal threshold ablation energy density for the 193-nm ArF excimer laser, approximating clinical conditions.

METHODS

The VISX Star (Santa Clara, CA) 193-nm argon fluoride excimer laser was used to ablate the cornea in human eye bank eyes under clinical conditions. Corneas were exposed to energy densities of 10, 20, 30, 35, 40, 45, and 140 to 160 mJ/cm2. Corneas were fixed for light and transmission electron microscopy immediately after laser exposure.

RESULTS

Different ablation thresholds for various corneal structural elements were observed. The ablation threshold for the collagen in the corneal stroma was determined to be 30 mJ/cm2. Keratocytes had ablation thresholds of 40 mJ/cm2. These different ablation thresholds accounted for the production of stromal peaks and valleys, with the keratocytes atop the peaks.

CONCLUSIONS

Different corneal structural elements have different ablation threshold energy densities.

An in vitro comparison of the computerized tomography/CAD-CAM and direct bone impression techniques for subperiosteal implant model generation

Subperiosteal implants are currently fabricated by using the classic two-stage direct bone impression technique or by the use of the one-stage computer tomography/computer-assisted design-computer-assisted manufacture (CT/CAD-CAM) method. This study compares the accuracy of the two techniques by using cadaver maxillae and mandibles as the models for fabrication of casts. Seven cadaver jaw specimens were collected and subjected to direct bone impressions and to CT scans. Those derived from the direct bone impressions were poured in die stone, while the CT scans were sent for fabrication of CAD-CAM-generated casts. On each of the 14 models so produced, a cast grid was fabricated that was designed as a measuring device. The preciseness of fit of each grid was subjected to analyses that presented levels of accuracy. Statistical evaluation of these levels, reduced to numerical indices, revealed that the direct bone techniques resulted in acceptable castings in seven of seven cases, whereas the CAD-CAM method yielded adequate castings in five of seven cases.

Cytomegalovirus-specific IFNgamma and IL-4 are produced by antigen expanded human blood lymphocytes from seropositive volunteers

The cytokine responses to cytomegalovirus (CMV) antigen in seropositive and seronegative individuals were measured using a combination of antigenic expansion and intracellular staining. Intracellular IFNgamma and IL-4 were produced in a dose-dependent manner by T cells in response to CMV only in the seropositive population. The potential for individual cells to produce both Th1 and Th2 cytokines simultaneously was clear, as IL-4 was most often produced in those cells with the highest IFNgamma production. The cytokine-specific nature of this response was demonstrated by fluorescence microscopy, which showed granular cytoplasmic staining, and at the mRNA level by ribonuclease protection assays. These methods expand our ability to evaluate the immune response to CMV, and can now be correlated to a number of clinical conditions.

Interaction of insulin, glucagon-like peptide 1, gastric inhibitory polypeptide, and appetite in response to intraduodenal carbohydrate

The relation between gastrointestinal incretin hormones in the control of insulin release and short-term satiety by intestinal carbohydrate was investigated in 8 fasted, healthy male volunteers. Insulin, gastric inhibitory polypeptide (GIP), glucagon-like peptide 1 (GLP-1), and appetite ratings were measured during, and food intake was measured after, intraduodenal infusions of glucose or saline. Studies were conducted under hyperinsulinemic and euglycemic conditions. Raising plasma insulin with intravenous insulin infusion to concentrations slightly above usual postprandial concentrations (356.4 +/- 4.8 pmol/L) had no effect on GIP, GLP-1, or appetite ratings before the intraduodenal infusions began. Intraduodenal glucose infusion resulted in a further increase in plasma insulin to a peak of 779.4 +/- 114.0 pmol/L, caused an early increase in plasma GIP and a later increase in GLP-1 concentrations (P < 0.01), suppressed appetite (P < 0.05), and reduced energy intake (P < 0.01) compared with intraduodenal infusion of saline. There was a close association between the increase in GLP-1 and decrease in appetite. Infusion of octreotide to suppress the release of gastrointestinal hormones prevented the rise in insulin, GIP, and GLP-1 induced by intraduodenal glucose infusion and reversed the suppression of appetite and reduction in energy intake. These results suggest that 1) when infused to result in plasma concentrations slightly above usual postprandial concentrations, insulin does not inhibit its own release and 2) the effects of intraduodenal glucose on appetite may be mediated through the release of GLP-1 and not insulin.

Case notes, case histories, and the patient's experience of insanity at Gartnavel Royal Asylum, Glasgow, in the nineteenth century

This article is concerned primarily with questions as to how and why case notes were produced and utilized, and how they may (or may not) be used by historians. More specifically, it discusses how the Glasgow Royal Asylum's case notes may be deployed to access patients' experiences of madness and confinement. The deficiencies and biases of the case record are also explored. So too is the relationship of case notes with other asylum based records, including reception order questionnaires, with a separate section on patient writings as part of the case history corpus. This leads into an analysis of how the Asylum's case notes became case histories and for what purposes. These subjects are related to changes and continuities in medical ideologies about insanity, social attitudes to the insane and the nature of medical practice in asylums. Some fundamental shifts in emphasis in the use of the case note and case history occurred in this period. These shifts were associated with an increased emphasis on organic interpretations of mental disease and on clinical approaches to insanity; with the medicalization of asylum records and the wider discourse on insanity, and with declining deference to the public at large in the presentation of cases. The survey concludes by analysing the changing place of patient testimony within the case record.

Optimizing smoking cessation strategies

Smoking cigarettes remains the leading cause of preventable illnesses and premature deaths in the United States. Although approximately half of living Americans who have ever smoked have quit, recent studies show that more than 70% of current smokers would like to stop smoking. Health care providers can enhance smoking cessation in their clients by performing assessments of both the physical and psychologic addictive aspects of smoking as well as past and current cessation barriers. Based on the assessment, the clinician should formulate a treatment plan by individualizing appropriate education, counseling, motivation, and pharmacologic support. This article reviews the prevalence and hazards of smoking and supplies health care providers with interventions to assist clients in becoming and remaining nonsmokers.

Drosophila OVO zinc-finger protein regulates ovo and ovarian tumor target promoters

The ovo+ and ovarian tumor+ genes function in the germline sex determination pathway in Drosophila, but the hierarchical relationship between them is unknown. We found that increased ovo+ copy number resulted in increased ovarian tumor expression in the female germline and increased ovo expression in the male germline. The ovo locus encodes C2H2 zinc-finger proteins. Bacterially expressed OVO zinc-finger domain bound to multiple sites at or near the ovo and ovarian tumor promoters strongly suggesting that OVO is directly autoregulatory and that ovarian tumor is a direct downstream target of ovo in the germline sex determination hierarchy. Both positive and negative regulation by OVO proteins appears likely, depending on promoter context and on the sex of the fly. Our observation that two strong OVO-binding sites are at the initiator of the TATA-less ovo-B and ovarian tumor promoters raises the possibility that OVO proteins influence the nucleation of transcriptional pre-initiation complexes.