Use of hematopoietic progenitors in whole blood to support dose-dense chemotherapy: a randomized phase II trial in small-cell lung cancer patients

PURPOSE

Small-cell lung cancer (SCLC) is exquisitely chemosensitive, but few patients are cured by conventional chemoradiotherapy. Recent studies suggest that increased cytotoxic dose-intensity might improve survival. In this randomized phase II study, we tested the feasibility of dose intensification using sequential reinfusion of hematopoietic progenitors in whole blood.

PATIENTS AND METHODS

SCLC patients with a favorable prognosis were treated with six cycles of ifosfamide, carboplatin, and etoposide (ICE), at 4-week (standard treatment) or 2-week (intensified treatment) intervals. Intensified treatment was supported by daily subcutaneous filgrastim injections and reinfusion of 750 mL of autologous blood collected immediately before each cycle.

RESULTS

Fifty consecutive patients were randomized to standard (n = 25) or intensified (n = 25) ICE. A total of 94% completed at least three treatment cycles, and 70% completed six cycles; 96% of treatments were given at full dose. The planned dose-intensity was 1.0 for standard and 2.0 for intensified ICE. The median received dose-intensity for cycles 1 through 3 was 0.99 (range, 0.33 to 1.02) for the standard treatment arm and 1.80 (range, 0.99 to 1.97) for the intensified treatment arm (P <.001). Over all six cycles, the median received dose-intensity was 0.95 (range, 0.17 to 1.03) for the standard treatment arm and 1.60 (range, 0.60 to 2.01) for the intensified treatment arm (P <.001). Febrile neutropenia was more common on the standard treatment arm (84% v 56%), resulting in more days of intravenous antibiotics (median, 10 v 3 days; P =.035). Transfusion requirements were similar in the two groups.

CONCLUSION

Sequential reinfusion of hematopoietic progenitors in whole blood can safely support substantial increases in dose-intensity of ICE chemotherapy for SCLC.

Tamoxifen mutagenesis and carcinogenesis in livers of lambda/lacI transgenic rats: selective influence of phenobarbital promotion

Administration of tamoxifen (TAM) (20 mg/kg per day p.o.) for 6 weeks to female lambda/lacI transgenic rats caused a 4-fold increase in mutation frequency (MF) at the lacI gene locus in the livers of dosed animals compared with controls. After cessation of dosing, the MF showed a further increase with time at 2, 12 and 24 weeks, respectively. Phenobarbital promotion of similarly treated animals resulted in no increase in mutation frequency compared with TAM alone. Treatment with phenobarbital or TAM+phenobarbital resulted in time-dependent increases in liver weight compared with the corresponding controls. There was an increase in cell proliferation in the phenobarbital and TAM+phenobarbital groups, and at 24 weeks in the TAM dosed animals compared with controls. There was also a progressive increase in the number of GST-P expressing foci in the livers of TAM and TAM + phenobarbital rats compared with controls. The induction of cell proliferation and GSTP foci in the rat liver by phenobarbital is consistent with its ability to promote tamoxifen-initiated liver tumours in the rat. If the lacI gene is regarded as being representative of the rat genome in general (albeit that the gene is bacterial) the above observations suggest that promotion by tamoxifen confers selective advantage on mutated genes at loci that contribute to the tumour phenotype and that promotion of rat liver tumours by tamoxifen is not dependent simply upon the enhancement of cellular proliferation.

Reversal of primary root caries using dentifrices containing 5,000 and 1,100 ppm fluoride

This study compared the ability of two sodium fluoride dentifrices, one containing 5,000 ppm fluoride (Prevident 5000 Plus) and the other 1,100 ppm fluoride (Winterfresh Gel), to reverse primary root caries lesions (PRCLs). A total of 201 subjects with at least one PRCL each entered the study and were randomly allocated to use one of the dentifrices. After 6 months, 186 subjects were included in statistical analyses. At baseline and after 3 and 6 months, the lesions were clinically assessed and their electrical resistance measured using an electrical caries monitor. After 3 months, 39 (38.2%) of the 102 subjects in the 5,000 ppm F- group and 9 (10.7%) of 84 subjects using the 1,100 ppm F- dentifrice, had one or more PRCLs which had hardened (p = 0.005). Between baseline and 3 months, the log10 mean +/- SD resistance values of lesions for subjects in the 1,100 ppm F- group had decreased by 0.06+/-0.55, whereas those in the 5,000 ppm F- group had increased by 0.40+/-0.64 (p<0.001). After 6 months, 58 (56.9%) of the subjects in the 5,000 ppm F- group and 24 (28.6%) in the 1,100 ppm F- group had one or more PRCLs that had become hard (p = 0.002). Between baseline and 6 months, the log10 mean +/- SD resistance values of lesions for subjects in the 1,100 ppm F- group decreased by 0.004+/-0.70, whereas in the 5,000 ppm F- group, they increased by 0.56+/-0.76 (p<0.001). After 3 and 6 months, the distance from the apical border of the root caries lesions to the gingival margin increased significantly in the 5,000 ppm F- group when compared with the 1,100 ppm F- group. The plaque index in the 5,000 ppm F- group was also significantly reduced when compared with the 1,100 ppm F- group. The colour of the lesions remained unchanged. It was concluded that the dentifrice containing 5,000 ppm F- was significantly better at remineralising PRCLs than the one containing 1,100 ppm F-.

A review of evaluative studies of computer-based learning in nursing education

Although there have been numerous attempts to evaluate the learning benefits of computer-based learning (CBL) packages in nursing education, the results obtained have been equivocal. A literature search conducted for this review found 25 reports of the evaluation of nursing CBL packages since 1966. Detailed analysis of the evaluation methods used in these reports revealed that most had significant design flaws, including the use of too small a sample group, the lack of a control group, etc. Because of this, the conclusions reached were not always valid. More effort is required in the design of future evaluation studies of nursing CBL packages.

Appropriate insulin regimes for type 2 diabetes: a multicenter randomized crossover study

OBJECTIVE

To directly compare the rate of hypoglycemia and metabolic control achieved on once-daily ultralente insulin administration with twice-daily NPH insulin administration in patients with type 2 diabetes. Patient treatment satisfaction and quality of life were also examined before and during each treatment.

RESEARCH DESIGN AND METHODS

A crossover study was performed involving five centers and 79 patients with type 2 diabetes (fasting blood glucose > 8 mmol/l) with a 2-month run-in followed by two 6-month periods of either NPH or ultralente insulin administration. Patients were managed by a specialist nurse using a dosage adjustment protocol.

RESULTS

HbA1c was lower with NPH insulin therapy during each of the 6-month periods (9.7 +/- 0.2 vs. 9.1 +/- 0.3 and 9.8 +/- 0.2 vs. 9.0 +/- 0.3 mmol/l; both P < 0.01). The difference was accounted for by higher evening glucose levels with ultralente insulin (fasting 8.2 +/- 0.3 vs. 8.2 +/- 0.3 mmol/l, 6:00 P.M. 11.5 +/- 0.4 vs. 10.6 +/- 0.4 mmol/l). Despite worse control, the total number of hypoglycemic episodes was greater with ultralente insulin (220 vs. 171), and hypoglycemic episodes requiring third-party assistance occurred almost entirely with ultralente (14 vs. 1). Treatment satisfaction scores increased more with NPH insulin compared with ultralente and rose further upon changing to NPH insulin, but fell upon changing to ultralente insulin. These changes were highly significant (P < 0.001). Diabetes quality of life improved on both regimens.

CONCLUSIONS

These data clearly demonstrate the lower hypoglycemia rate, better glucose control, and greater treatment satisfaction accompanying therapy for type 2 diabetes with twice daily NPH compared with once daily ultralente insulin.

Antideuteron yield at the AGS and coalescence implications

We present Experiment 864's measurement of invariant antideuteron yields in 11.5A GeV/c Au+Pt collisions. The analysis includes 250x10(6) triggers representing 14x10(9) 10% central interactions sampled for events with high mass candidates. We find (1/2pip(t))d(2)N/dydp(t) = 3.5+/-1.5(stat)+0.9-0.5(syst)x10(-8) GeV-2 c(2) for 1.8<y<2.2, < p(t)> = 0.35 GeV/c ( y(c.m.) = 1.6) and 3.7+/-2.7(stat)+1.4-1.5(syst)x10(-8) GeV-2 c(2) for 1.4<y<1.8, < p(t)> = 0.26 GeV/c, and a coalescence parameter B2; of 4.1+/-2. 9(stat)+2.3-2.4(syst)x10(-3) GeV2 c(-3). Implications for coalescence and antimatter annihilation are discussed.

Immunocytochemical localization of oestrogen receptors in perichondrium of antlers in red deer (Cervus elaphus)

Remodelling of cancellous bone of antlers to compact bone can be stimulated by administration of oestrogens and previous work has demonstrated the presence of specific oestrogen binding in this tissue. In this study the presence of oestrogen receptors (ER) in antler tissue from red deer males was examined by immunocytochemistry using a monoclonal mouse anti-human ER serum. Strong positive staining was detected in the tip regions of immature antlers and was confined primarily to the cells forming a fibrous layer of the perichondrium. This finding indicates that the effects of oestrogens on remodelling of cancellous bone of the antler may be mediated indirectly by the surrounding connective tissue layers.

Mutation frequency in the lacI gene of liver DNA from lambda/lacI transgenic mice following the interaction of PCBs with iron causing hepatic cancer and porphyria

The synergistic interaction of iron overload, AHR: genotype and exposure to a mixture of polychlorinated biphenyls (PCBs) (Aroclor 1254) in mice leads to hepatic porphyria, oxidative DNA damage and cancer. In humans, hepatocellular cancer is associated with iron overload and hepatic porphyria. Neither the mechanism of hepatic carcinogenesis induced by PCBs in rodents nor hepatocellular cancer induced by iron and porphyria in humans are understood. To test the hypothesis that chronic interaction of iron and PCBs may induce mutagenesis in liver DNA, lambda /lacI transgenic C57BL/6 mice were given iron dextran (600 mg iron/kg) and then administered Aroclor 1254 in the diet (0.01%) for 7 weeks. Hepatic iron, CYP1A activity and CYP1A1/1A2 protein were elevated >20-fold as a result of iron or Aroclor treatments, respectively, but porphyria with associated histological changes only developed in the combined iron/Aroclor treatment group. lambda/lacI shuttle vectors were isolated from liver genomic DNA and the mutational frequency (MF) in the lacI gene determined. Both iron and Aroclor treatments alone caused significant small increases in MF (1.5- and 1.4-fold, respectively), however, the MF following the combined iron and Aroclor treatment (1. 6-fold) was not greater than the additive effects. In contrast, the MF was significantly elevated (4.7-fold) in liver DNA of mice 2 weeks following five daily doses of N-nitrosodimethylamine (4 mg/kg). These studies demonstrate that neither PCBs nor iron overload caused marked point mutations even in a combination regime that leads to oxidative damage and cancer. There was also no strong evidence either that porphyrins or chronic CYP1A1 expression induced by the PCBs after this period caused marked point mutagens or simple deletions. Hence, to understand the PCBs-iron synergism more complex scenarios than point mutations or simple deletions must be invoked.

Partners' expressed emotion and the control and management of type 1 diabetes in adults

OBJECTIVE

"Expressed emotion" (EE) refers to a set of valid and reliable measures of family emotional attitudes, which are robust predictors of illness course in several psychiatric conditions and which have recently been studied in some medical conditions. We hypothesised that high EE in partners of diabetes patients would be associated with poorer glucose control, management of and adaptation to diabetes.

METHODS

Sixty adult Type 1 diabetes patients, who were attending routine clinics at a specialist diabetes centre, and their partners were interviewed separately and completed various questionnaire measures. Partners' EE was rated from a modified Camberwell Family Interview; patients were interviewed to assess self-management practices. Glycated hemoglobin (HbA(1c)) was the measure of glucose control.

RESULTS

Only 10/60 (17%) partners were classified as high EE. Patients with high-EE partners had significantly worse self-management scores, more negative appraisal of diabetes, and higher depression scores than those with low-EE partners, but there was no association between EE measures and HbA(1c).

CONCLUSIONS

In contrast to findings from previous research on the families of patients with psychiatric illnesses, only a minority of partners of adult patients with Type 1 diabetes are classified as high-EE. We found no evidence that partners' EE was related to patients' blood glucose control.

Effectiveness of two fluoride dentifrices to arrest root carious lesions

PURPOSE

To compare the effectiveness of Prevident 5000 Plus (5,000 ppm F) and Colgate Winterfresh Gel (1100 ppm F) to arrest root carious lesions.

MATERIALS AND METHODS

201 subjects with at least one root carious lesion were recruited from dental school patients. They were randomly assigned to use either Prevident 5000 Plus (5000 ppm F) or Colgate Winterfresh Gel (1100 ppm F) as sodium fluoride in the same silica base. Measurements of lesion hardness, area, distance from the gingival margin, cavitation and plaque were recorded at baseline and after 3 months by a single examiner.

RESULTS

After 3 months 38% of subjects using Prevident 5000 Plus and 10% using Winterfresh Gel had one or more lesions that had become hard (P < 0.001). Non-cavitated lesions at baseline were more likely to become hard than cavitated lesions. Compared to the Winterfresh group there was significant increase in the distance from the base of the lesion to the gingival margin and plaque scores were reduced in those using Prevident 5000 Plus.

A six-week clinical efficacy study of a tooth whitening tartar control dentifrice for the removal of extrinsic tooth stain

The objective of this double-blind clinical study was to investigate the tooth whitening efficacy of a new commercially available calculus-inhibiting dentifrice (Colgate Tartar Control Plus Whitening Fluoride dentifrice) containing tetra-sodium pyrophosphate, sodium tripolyphosphate, and PVM/MA copolymer in a 0.243% sodium fluoride/silica base (test dentifrice), compared to a commercially available, non-tooth whitening dentifrice containing 0.243% sodium fluoride in a silica base (control dentifrice). Following a baseline examination for, extrinsic tooth stain, qualifying adult male and female subjects from the Manchester, United Kingdom area were randomized into two treatment groups which were balanced for gender, age and level of extrinsic tooth stain. Subjects were instructed to brush their teeth twice daily (morning and evening) for one minute with their assigned dentifrice using a soft-bristled toothbrush. Examinations for extrinsic tooth stain were repeated after six weeks' use of the study dentifrices. Seventy-nine(79) subjects complied with the protocol and completed the entire study. At the six-week examination, subjects assigned to the test dentifrice treatment group exhibited statistically significant reductions of over 40% with respect to both extrinsic tooth stain area and extrinsic tooth stain intensity relative to those subjects assigned to the control dentifrice treatment group.

Cortical cell death induced by IL-1 is mediated via actions in the hypothalamus of the rat

The cytokine IL-1 mediates diverse forms of neurodegeneration, but its mechanism of action is unknown. We have demonstrated previously that exogenous and endogenous IL-1 acts specifically in the rat striatum to dramatically enhance ischemic and excitotoxic brain damage and cause extensive cortical injury. Here we tested the hypothesis that this distant effect of IL-1 is mediated through polysynaptic striatal outputs to the cortex via the hypothalamus. We show that IL-1beta injected into the rat striatum with the excitotoxin alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (S-AMPA) caused increased expression of IL-1beta (mRNA and protein) mainly in the cortex where maximum injury occurs. Marked increases in IL-1beta mRNA and protein were also observed in the hypothalamus. S-AMPA, injected alone into the striatum, caused only localized damage, but administration of IL-1beta into either the striatum or the lateral hypothalamus immediately after striatal S-AMPA resulted in widespread cell loss throughout the ipsilateral cortex. Finally we showed that the cortical cell death produced by striatal coinjection of S-AMPA and IL-1beta was significantly reduced by administration of the IL-1 receptor antagonist into the lateral hypothalamus. These data suggest that IL-1beta can act in the hypothalamus to modify cell viability in the cortex. We conclude that IL-1-dependent pathways project from the striatum to the cortex via the hypothalamus and lead to cortical injury, and that these may contribute to a number of human neurological conditions including stroke and head trauma.

A celebration of 100 years' achievement in child health

This, the second of a two-part article, will reflect upon the gains made in the health and welfare of children within the UK over the last 50 years of the 20th century. It will show how government reforms covering health, welfare, and education have continued to improve all aspects of children's lives. It will also show how nursing, midwifery, and health visiting have tried to continue to meet the changing needs of children and their families. Lastly, it will highlight the increasing rate of change during this time and predict what may await children and young people in the first part of the new millennium.

Highly purified CD34+ cells isolated using magnetically activated cell selection provide rapid engraftment following high-dose chemotherapy in breast cancer patients

The primary objective of this study was to evaluate the safety of infusion of CD34+ cells, selected using a clinical scale magnetically activated cell sorting device, assessed by time to hematological engraftment and incidence of adverse events. Secondary objectives included evaluation of device performance in terms of purity and recovery of the CD34+ cell product. Breast cancer patients suitable for transplantation received cyclophosphamide and filgrastim for mobilisation, followed by three leukaphereses. The products of the first two leukaphereses underwent CD34+ cell selection. The product of the third leukapheresis was cryopreserved unmanipulated. Following high-dose cyclophosphamide, thiotepa and carboplatin, selected CD34+ cells were infused. In 54 patients who received selected cells only, the median time to platelet recovery and neutrophil recovery was 11 days (range 5-51) and 9 days (range 5-51), respectively. There were no adverse events associated with infusion of selected cells. A total of 126 leukapheresis samples was available before and after selection for central CD34+ analysis. The median purity was 96.1% (27.4-99.4) and the median recovery was 52. 3% (15.2-146.3). These data show that cells selected using magnetically activated cell selection provide safe and rapid engraftment after high-dose therapy. Bone Marrow Transplantation (2000) 25, 243-249.

Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients

BACKGROUND

Angiotensin-converting-enzyme inhibitors improve the outcome among patients with left ventricular dysfunction, whether or not they have heart failure. We assessed the role of an angiotensin-converting-enzyme inhibitor, ramipril, in patients who were at high risk for cardiovascular events but who did not have left ventricular dysfunction or heart failure.

METHODS

A total of 9297 high-risk patients (55 years of age or older) who had evidence of vascular disease or diabetes plus one other cardiovascular risk factor and who were not known to have a low ejection fraction or heart failure were randomly assigned to receive ramipril (10 mg once per day orally) or matching placebo for a mean of five years. The primary outcome was a composite of myocardial infarction, stroke, or death from cardiovascular causes. The trial was a two-by-two factorial study evaluating both ramipril and vitamin E. The effects of vitamin E are reported in a companion paper.

RESULTS

A total of 651 patients who were assigned to receive ramipril (14.0 percent) reached the primary end point, as compared with 826 patients who were assigned to receive placebo (17.8 percent) (relative risk, 0.78; 95 percent confidence interval, 0.70 to 0.86; P<0.001). Treatment with ramipril reduced the rates of death from cardiovascular causes (6.1 percent, as compared with 8.1 percent in the placebo group; relative risk, 0.74; P<0.001), myocardial infarction (9.9 percent vs. 12.3 percent; relative risk, 0.80; P<0.001), stroke (3.4 percent vs. 4.9 percent; relative risk, 0.68; P<0.001), death from any cause (10.4 percent vs. 12.2 percent; relative risk, 0.84; P=0.005), revascularization procedures (16.3 percent vs. 18.8 percent; relative risk, 0.85; P<0.001), cardiac arrest (0.8 percent vs. 1.3 percent; relative risk, 0.62; P=0.02), [corrected] heart failure (9.1 percent vs. 11.6 percent; relative risk, 0.77; P<0.001), and complications related to diabetes (6.4 percent vs. 7.6 percent; relative risk, 0.84; P=0.03).

CONCLUSIONS

Ramipril significantly reduces the rates of death, myocardial infarction, and stroke in a broad range of high-risk patients who are not known to have a low ejection fraction or heart failure.

Achievements in child health over the first half of the 20th century

This article will reflect upon the gains made in the health and welfare of children in the UK over the first half of this century. It will discuss how government reforms covering health, welfare and education have improved all aspects of children's lives and the contribution made by the relatively new professions of nursing, midwifery and health visiting. Finally, it will show how changing attitudes towards children and the two World Wars culminated in international recognition of children's rights. A future article will highlight the increasing rate of change seen in the second half of this century.

Loss-of-function mutations in the cathepsin C gene result in periodontal disease and palmoplantar keratosis

Papillon-Lefèvre syndrome, or keratosis palmoplantaris with periodontopathia (PLS, MIM 245000), is an autosomal recessive disorder that is mainly ascertained by dentists because of the severe periodontitis that afflicts patients. Both the deciduous and permanent dentitions are affected, resulting in premature tooth loss. Palmoplantar keratosis, varying from mild psoriasiform scaly skin to overt hyperkeratosis, typically develops within the first three years of life. Keratosis also affects other sites such as elbows and knees. Most PLS patients display both periodontitis and hyperkeratosis. Some patients have only palmoplantar keratosis or periodontitis, and in rare individuals the periodontitis is mild and of late onset. The PLS locus has been mapped to chromosome 11q14-q21 (refs 7, 8, 9). Using homozygosity mapping in eight small consanguineous families, we have narrowed the candidate region to a 1.2-cM interval between D11S4082 and D11S931. The gene (CTSC) encoding the lysosomal protease cathepsin C (or dipeptidyl aminopeptidase I) lies within this interval. We defined the genomic structure of CTSC and found mutations in all eight families. In two of these families we used a functional assay to demonstrate an almost total loss of cathepsin C activity in PLS patients and reduced activity in obligate carriers.

The Canadian Study of Cardiac Transplantation. Atherosclerosis. Investigators of the CASCADE Study

OBJECTIVES

To describe risk factors associated with the development of transplantation coronary artery disease (TCAD).

DESIGN

A retrospective study of the Canadian experience.

PATIENTS

Seven hundred and nineteen patients with follow-up of at least 12 months following transplantation and a minimum of one coronary angiogram were analyzed.

RESULTS

Two hundred and fourteen patients (30%) developed angiographic evidence of TCAD during an average follow-up of 50+/-25 months. Actuarial freedom rate from TCAD averaged 60%, and survival averaged 85% five years following transplantation. Abnormal coronary angiograms increased from 11% to 40% between the first and the fifth year following transplantation. The Cox multivariate final model showed that recipients of donor hearts of 50 years and older (RR 4.35, 95% CI 2.32 to 8.15), patients with two or more episodes of acute rejection (RR 1.56, 95% CI 1.11 to 2.21) and patients with a diagnosis of ischemic cardiomyopathy before transplantation (RR 1.38, 95% CI 1.03 to 1.84) were at higher risk of TCAD. The same risk factors also had a significant effect on survival, although patients who were administered a hepatic hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor during follow-up had a higher survival rate (95% versus 85%, P=0.01) five years following heart transplantation.

CONCLUSIONS

Recipients of hearts from older donors, patients with an ischemic heart disease before transplantation and those with several episodes of acute rejection are at increased risk for TCAD. Patients who are administered an HMG-CoA reductase inhibitor during follow-up have a higher survival rate five years following transplantation.

Antimicrobial susceptibility of enterococci recovered from commercial swine carcasses: effect of feed additives

Enterococcus faecium is an important nosocomial pathogen often displaying multiple antibiotic resistance. The increase in clinical isolates can be attributed in part to hospital practices in antibiotic usage, but there is concern that antibiotic-resistant strains might also originate in animals fed rations containing antibiotic growth promoters. Ingestion of meat from carcasses contaminated with faecal enterococci might then result in human colonization or resistance gene transfer to human enterococci. Because there are few comparisons of bacteria isolated from matched animals that have, or have not, been fed a diet containing antibiotic, two such groups of pig carcasses were sampled at a commercial abattoir. Forty isolates from each group of pigs were tested for their resistance to avilamycin and tylosin. Although a modest number of pigs was examined, and the number of strains of E. faecium tested was small, there was no evidence that the feeding of a growth promoter caused selection of enterococci resistant to tylosin or avilamycin.

Aortic dissection, patent ductus arteriosus, iris hypoplasia and brachytelephalangy in a male adolescent

We describe a 14-year-old male with dissection of the descending aorta, bilateral iris hypoplasia, striae distensae and brachytelephalangy, the latter being most marked in the thumbs. Inguinal herniae and a patent ductus arteriosus were surgically repaired in infancy. The pattern of abnormalities may constitute a previously undescribed syndrome. The proband died suddenly at the age of 17 years.