Multiple myeloma in the elderly

While multiple myeloma is an incurable disease for nearly all patients, current chemotherapy and supportive care can result in significant disease control and improved duration of survival and quality of life. With the average age of patients about 70, most of the high-dose curative strategies exclude the bulk of patients affected by the disease. Recent advances in understanding the biology and pathophysiology of myeloma have led to novel therapies aimed at altering drug resistance, improving duration of the plateau phase, interrupting the cytokine growth stimulation, and improving management of common complications including infections, anemia, and bone lesions. These latter approaches are not restricted to younger patients, and early evidence indicates that elderly patients are also likely to benefit.

Increased adhesion of neutrophils to retinal vascular endothelial cells exposed to hyperosmolarity

Recent studies suggest that leukocytes may contribute to capillary occlusion and endothelial cell injury in diabetic retinopathy. The present study is an attempt to determine whether high glucose concentration/hyperosmolar conditions would increase neutrophil adhesion to retinal endothelial cell monolayers. Confluent monolayers of bovine retinal endothelial cells were incubated for 24 hr in 96-well microtiter plates in 5.5, 20, 50 or 100 mM glucose using 20, 50 or 100 mM mannitol as osmotic controls. After 24 hr the cells were observed by phase microscopy, washed, and then incubated with isolated human neutrophils for 20 min. Non-adherent neutrophils were washed from the monolayers, and the number of adherent neutrophils was determined using an Elisa assay for neutrophil elastase. Adhesion of neutrophils to confluent monolayers of human umbilical vein and bovine aortic endothelial cells at all levels of glucose were assayed in a similar fashion for comparison. Neutrophil adherence to bovine retinal endothelial cells was significantly increased (P < 0.05, n = 8; paired t-test) at all elevated glucose concentrations compared with adherence at control (5.5 mM) glucose concentration. The effect was also concentration dependent with 20, 50 and 100 mM glucose resulting in 35, 57 and 70% increases respectively over controls. However, mannitol at equal concentrations produced similar increases in neutrophil adherence, indicating that the increases in adhesion caused by elevated glucose concentration were due to hyperosmolarity and not some special effect of glucose.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of childhood acute lymphoblastic leukemia: results of Dana-Farber Cancer Institute/Children's Hospital Acute Lymphoblastic Leukemia Consortium Protocol 85-01

PURPOSE

The goals of this treatment program were as follows: to improve event-free survival (EFS) rates for high-risk (HR) patients by increasing the intensity of induction treatment; to improve EFS rates for infants by adding a special postinduction intensification; to treat the CNS using cranial irradiation doses that were lower than in our historic control group; and to confirm our previously obtained good results for children with T-cell disease.

PATIENTS AND METHODS

Two hundred twenty children with acute lymphoblastic leukemia (ALL) from all risk groups, including infants and patients with T-cell disease, were treated between 1985 and 1987 with multiagent chemotherapy and cranial irradiation.

RESULTS

The 7-year EFS rate (+/- SE) for all 220 patients was 78% +/- 3% at a median follow-up duration of 6.2 years, 89% +/- 4% for the 82 patients classified as standard risk (SR), and 72% +/- 4% for the remaining 138 patients classified as HR and very high risk (VHR). Eleven infants had an EFS rate of 55% +/- 15% that might be attributable to treatment with high doses of methotrexate and cytarabine (ara-c). Twenty children with T-cell disease had an EFS rate of 70% +/- 10%. CNS leukemia relapse (isolated or combined with bone marrow) occurred in four of 82 SR patients who received 18 Gy of cranial irradiation and four of 138 HR and VHR patients who received 24 Gy.

CONCLUSION

This protocol, which featured early intensive treatment including asparaginase, doxorubicin, and cranial irradiation, provided good long-term disease control for children with ALL.

Extracellular glutathione peroxidase mRNA and protein in human cell lines

Extracellular glutathione peroxidase (E-GPx) and cellular glutathione peroxidase (C-GPx) are selenoenzymes encoded by two distinct genes. Using specific immunoprecipitations of [75Se]selenium metabolically labeled human cell lines in culture, it was found that Caco-2, Hep3B, Hep G2, and Caki-2 synthesize C-GPx and E-GPx and secrete E-GPx. HBL-100, BT-20, and MCF-7 synthesize only C-GPx. The relationship between Se status (as determined by C-GPx activity) and E-GPx and C-GPx mRNA steady-state levels was investigated in Hep G2, Caco-2, and Caki-2. The most Se-deficient Hep G2, Caco-2, and Caki-2 cells had 8.7 +/- 2.6, 11.2 +/- 4.9, and 9.4 +/- 5.0%, respectively, of C-GPx activity of the replete cells. The steady-state levels of mRNA were measured by Northern and slot blot hybridization analysis. By Northern analysis, a single band was present at 1.0 and 1.80 kb for C-GPx and E-GPx mRNA, respectively, in all three cell lines. Scanning densitometry of the blots revealed that the most Se-deficient cells had 30-50% C-GPx mRNA and 60-80% E-GPx mRNA of the replete cells. It is concluded that, in addition to previously examined human cell lines, Hep3B and Caco-2 make and secrete E-GPx while HBL-100 and BT-20 do not. The slightly reduced levels of G-GPx and E-GPx mRNA in Se-deficient human cell lines can only partially account for the decreased C-GPx activity in Se-deficient human cell lines.

Substance P and adrenocorticotropic hormone do not affect T-lymphocyte adhesion to vascular endothelium or surface expression of adhesion receptors

Substance P (SP) and adrenocorticotropic hormone (ACTH) are peptides that have been shown to have both neurological and immunological effects. Because of the demonstrated effects upon immune function, we examined the effects of these peptides on T-lymphocyte adhesion to vascular endothelium and surface adhesion receptor expression. Neither the adhesion assays nor the expression assays showed any statistically significant effect of SP (10 microM) or ACTH (1 microM) for any incubation period used. We conclude that, while SP and ACTH have a variety of immunomodulatory effects, direct modulation of T-lymphocyte adhesion to vascular endothelium is probably not one of them.

Human kidney proximal tubules are the main source of plasma glutathione peroxidase

The sites of synthesis of extracellular (E) glutathione peroxidase (GPX), a unique selenoglycoprotein present in plasma, are not known. To investigate the possibility that the kidney is the main source for the plasma GPX, we examined GPX activities and selenium concentrations in the plasma of patients with renal failure on dialysis and nephrectomized patients before and after kidney transplantation. Plasma GPX activities in these patients were 42, 22, and 180% of normal EGPX activity, respectively, whereas plasma Se levels were within the normal range. Twenty-four hours after nephrectomy of anesthetized rats, plasma GPX activity was 30.0 +/- 6.4% of the activity at zero time. Northern hybridization analysis of eight human tissues probed with EGPX and cellular glutathione peroxidase (CGPX) cDNA revealed that the ratio of EGPX to CGPX was highest in the kidney. cRNA in situ hybridization studies on kidney slices showed that only proximal tubular epithelial cells and parietal epithelial cells of Bowman's capsule contained EGPX transcripts. Caki-2, a proximal tubular renal carcinoma cell line, makes and actively secretes EGPX. Taken together, these results strongly suggest that kidney proximal tubular cells are the main source for GPX activity in the plasma.

Profile of depressive symptoms in younger and older medical inpatients with major depression

OBJECTIVE

To examine and compare the profile of cognitive symptoms, somatic symptoms, and somatic complaints in younger and older medical inpatients diagnosed with major depressive disorder (MDD).

DESIGN

Cross-sectional cohort.

PATIENTS AND SETTING

Male patients aged 20-39 years (n = 116) and aged 70-102 years (n = 332), consecutively admitted to the medical and neurological services of a VA medical center, underwent psychiatric evaluations for depression.

MEASUREMENTS

Depressive symptoms were measured using the observer-rated Hamilton Depression Scale and the self-rated Geriatric Depression Scale using an "inclusive" approach (symptoms rated regardless of etiology). Data on 12 common somatic complaints were also collected. Clinical diagnoses of MDD were made by a psychiatrist based on the Diagnostic Interview Schedule and other psychiatric and physical health data.

RESULTS

After controlling for severity of medical illness, functional status, and alcohol use, symptoms that discriminated MDD best among younger men were loss of interest, feelings of guilt or of being a burden, suicidal thoughts, and depressed mood (primarily cognitive and affective symptoms). Among older men, loss of interest, insomnia, suicidal thoughts, and hypochondriasis most strongly differentiated depressed from non-depressed patients (mixture of cognitive and somatic symptoms); fatigue, weight loss, genital symptoms, and somatic anxiety were weakly related or unrelated to MDD. Number of somatic complaints (headache, dizziness, palpitations, etc.) helped differentiate patients with MDD; although equally common among depressed young and older patients, a distinct pattern of complaints emerged in each age group.

CONCLUSIONS

Cognitive symptoms of depression can help to distinguish medical inpatients with and without MDD. In older adults, however, somatic symptoms cannot be ignored and may be more important for diagnosing MDD than previously realized. These findings will help clinicians identify patients with MDD and differentiate them from non-depressed patients with medical illness.

Age-related increase in phorbol myristate acetate-induced lymphocyte adhesion to vascular endothelium

Lymphocyte adhesion to vascular endothelium is an important part of immune function. This investigation sought to detect differences between the adhesion of lymphocytes from young and aged human donors to vascular endothelium with and without treatment of the lymphocytes with phorbol myristate acetate (PMA), an activator of protein kinase C (PKC) that stimulates this adhesive process. T-lymphocytes were isolated from young and aged donors and adhesion assays were conducted with human umbilical vein endothelial cells (HUVEC). In some cases the HUVEC were activated by pre-incubation with tumor necrosis factor, a cytokine that increases their adhesiveness, before the addition of lymphocytes in the presence or absence of PMA. The results show that, in the basal state, lymphocytes from young and aged donors had similar levels of adherence, while with PMA activation, lymphocytes from aged donors had a significantly higher level of adherence to both activated and non-activated HUVEC. No cytotoxic effect on the HUVEC was detected. These results suggest a role for lymphocytes in diseases that predominantly affect the elderly and that are thought to involve interaction between lymphocytes and endothelium. In addition, these results indicate that there may be a change in PKC function in lymphocytes with aging.

Comparative pharmacokinetic studies of three asparaginase preparations

PURPOSE

As part of pharmacologic studies of asparaginase (ASNase), we determined the half-life of ASNase activity and protein, and the effect of dose, repeated doses, different drug preparations, and hypersensitivity reactions on the half-life (t1/2) of serum ASNase activity.

PATIENTS AND METHODS

We measured ASNase activity (spectrophotometric assay) in serum samples obtained from patients with acute lymphoblastic leukemia (ALL) at various times during their therapy with intramuscular ASNase. ASNase protein was measured by enzyme-linked immunoadsorbent assay (ELISA).

RESULTS

Studies following the initial dose of Escherichia coli-derived ASNase demonstrated no difference in apparent t1/2 following 25,000 IU/m2 versus 2,500 IU/m2 (1.24 v 1.35 days, P = .2). The apparent t1/2s following maintenance doses of E coli ASNase (middle dose t1/2, 1.28 days, or last dose t1/2, 1.14 days) showed no difference when compared with the initial dose of ASNase (P = .3 to .9). There was no significant difference between the apparent t1/2s of ASNase activity and ASNase protein (n = 8, P = .2 to .6). The serum t1/2 was 0.65 and 5.73 days for patients receiving Erwinia or polyethylene glycol (PEG)-modified E coli ASNase, respectively, as the induction dose. ASNase activity was undetectable in sera of four patients studied in the week following an anaphylactic reaction to E coli ASNase and the t1/2 was significantly shorter in five patients with a history of allergic reaction to E coli ASNase who were studied following a dose of PEG ASNase, (t1/2, 1.80 days).

CONCLUSION

We conclude that (1) the apparent t1/2 of ASNase is dependent on enzyme preparation used, but is not affected by dose or by repeated use; (2) the apparent t1/2 of E coli ASNase as a protein is the same as the apparent t1/2 of enzymatic activity; and (3) patients who have had a hypersensitivity reaction to E coli ASNase have a decreased apparent t1/2 with both E coli and PEG ASNase.

Determining the service lives of organic-vapor respirator cartridges for nitroglycerin under workplace conditions

Results of a field study that estimated the service lives of several different brands of organic-vapor respirator cartridges for nitroglycerin are presented. Respirator carbon tubes (RCTs) were used to sample in a workplace where gun powder was manufactured and where nitroglycerin levels varied from approximately 0.1-0.7 mg/m3. Tenax adsorbent tubes were used to monitor for nitroglycerin upstream and downstream of RCTs and were subsequently analyzed by a gas-chromatography method. A series of 10 trials failed to find evidence of nitroglycerin breakthrough. Estimates of the minimum service lives of respirator cartridges varied from 7-81 hours for nitroglycerin levels of 1.0 mg/m3, 10 times the current Occupational Safety and Health Administration Permissible Exposure Level. One trial specifically examined the potential of nitroglycerin to prematurely break through a cartridge due to bed migration, and results failed to indicate this as a potential problem. A field validation of the Tenax adsorbent tube method for nitroglycerin monitoring resulted in an accuracy of +/- 77-88% at the 95% confidence level. An unexpected finding was that up to 10% of the ambient nitroglycerin collected was adsorbed to an aerosol. This finding led to the recommendation that the addition of a prefilter to an organic vapor cartridge may be required when using air-purifying respirators to protect workers from some nitroglycerin exposures.

Central nervous system treatment in childhood acute lymphoblastic leukemia. Long-term follow-up of patients diagnosed between 1973 and 1985

BACKGROUND

Despite advances in the treatment of childhood acute lymphoblastic leukemia (ALL), optimal therapy of the central nervous system (CNS) remains controversial.

METHODS

Between 1973 and 1985, 540 children with ALL (199 standard risk and 341 high risk) were treated on four protocols.

RESULTS

The 7-year event-free survival rate (+/- standard error) was 62.1% (+/- 2.1) for the entire group: 71.8% (+/- 3.2) for standard-risk and 56.4% (+/- 2.7) for high-risk patients. Five hundred eighteen of the children entered complete remission and received cranial irradiation with intrathecal methotrexate for CNS treatment; 197 had standard-risk ALL and 321 had high-risk ALL. Thirty-one patients (5 standard risk and 26 high risk) had a CNS relapse with or without concurrent bone marrow relapse as an initial event, the latest of which was observed 49 months after complete remission. The cumulative incidence of CNS relapse was 6.0% (+/- 1.1) for the entire group: 2.5% (+/- 1.1) for standard-risk and 8.2% (+/- 1.5) for high-risk patients (P = 0.01). CNS recurrence of leukemia, whether as an "isolated" site or a "combined" site of relapse, was a major adverse event. Only 4 of 31 patients were alive for 25+, 28+, 54+, and 71+ months after a CNS relapse. The median survival time after CNS relapse was 22 months: 21 months for the 20 patients who had an isolated CNS relapse, and 23 months for the 11 patients who had a CNS relapse concurrent with a recurrence in other sites.

CONCLUSIONS

Although attempts to diminish CNS treatment-related morbidity are warranted for standard-risk patients, the authors recommend that intensive CNS treatment be enhanced for the high-risk patients because CNS relapses continue to occur in this population. Furthermore, CNS relapse after cranial irradiation was associated with a very poor prognosis and needs to be treated as intensively as a bone marrow relapse.

Epithelioid osteosarcoma of bone. Immunocytochemical evidence suggesting divergent epithelial and mesenchymal differentiation in a primary osseous neoplasm

BACKGROUND

The combination of a primary osteosarcoma of bone with a second carcinomatous cell type has been recognized, although immunohistochemical studies currently have not been performed in an attempt to understand the histogenesis of such a tumor.

METHODS

In this report, the authors performed immunohistochemical studies on a primary osseous carcinosarcoma. Using a biotin-streptavidin peroxidase conjugate technique, the expression of keratin, epithelial membrane antigen, and vimentin was analyzed.

RESULTS

The epithelial cells expressed cytokeratin and epithelial membrane antigen but did not express vimentin. The mesenchymal cells strongly expressed vimentin, and only rare cells expressed cytokeratin.

CONCLUSIONS

The clinical, morphologic, and immunophenotypic data in this instance strongly suggest divergent differentiation of a primitive multipotential uncommitted stem cell in a primary osseous tumor.

Role of antioxidant enzymes in the induction of increased experimental metastasis by hydroxyurea

BACKGROUND

Treatment of tumor cells with hydroxyurea and other DNA-damaging agents has been shown to increase the experimental metastatic potential of these cells.

PURPOSE

We sought to elucidate some of the biochemical and genetic changes that promote tumor cell metastasis in hydroxyurea-treated cells. We hypothesized that drug treatment induces resistance to oxidative damage and that elimination of this resistance reverses the drug-induced experimental metastatic capabilities of tumor cells.

METHODS

We examined the effect of hydroxyurea treatment on B16 melanoma cells with respect to experimental metastatic potential, resistance to hydrogen peroxide (H2O2), glutathione peroxidase activity and messenger RNA (mRNA) level, glutathione reductase activity, glutathione levels, glutathione-S-transferase activity, and catalase activity and mRNA level.

RESULTS

Hydroxyurea-treated cells were transiently more metastatic following intravenous injection in syngeneic mice and transiently more resistant than untreated cells to exogenous H2O2. Hydroxyurea-induced experimental metastases and H2O2 resistance were eliminated by depletion of intracellular glutathione with buthionine sulfoximine. Glutathione peroxidase activity and mRNA level, glutathione reductase activity, and reduced glutathione levels were all transiently increased in hydroxyurea-treated cells, whereas the increase in glutathione-S-transferase activity was sustained. Catalase activity was modestly increased with no increase in its mRNA levels.

CONCLUSIONS

In B16 melanoma cells, experimental metastasis induced by hydroxyurea appears to depend on a process that requires glutathione. Hydroxyurea treatment also induces resistance to exogenous H2O2, which may be due to induction of glutathione and antioxidant enzyme activity.

IMPLICATIONS

The role of antioxidants in B16 melanoma cells offers new insights into the metastatic process and the cellular response to chemotherapy.

On the importance of helping families: policy implications from a national study

This study is a companion to our 4-year study (Birenbaum, Guyot, & Cohen, 1990) on financing health care for individuals with autism or severe mental retardation. We reported on nonmedical expenditures and opportunity costs pertaining to maintaining a child or young adult with serious developmental disabilities in the home or in residential care and discussed policy implications for assisting their families. We proposed that (a) personal care and family support should be included in health care requirements, (b) family-centered care should be promoted, (c) appropriate programs and care should be provided for young adults no longer in school, (d) financing and organizing of family supports and subsidies should be administratively simple, (e) Medicaid should be expanded to increase use of home- and community-based services, and (f) financial support should be provided to families.

A fatal case of constrictive pericarditis due to a marked, selective pericardial accumulation of amyloid

Distinguishing constrictive pericarditis from restrictive cardiomyopathy, usually due to amyloidosis, is a relatively frequent and difficult diagnostic problem. This report describes, for the first time, a patient with constrictive pericarditis caused by direct, extensive infiltration of the pericardium by amyloid, with only minimal amyloid in the myocardium, and a normal heart weight of 320 g. This patient demonstrates that amyloid may be predominantly deposited in the pericardium and actually cause constrictive pericarditis, as well as simulate its hemodynamic presentation by myocardial deposition. Given a clinical and hemodynamic presentation compatible with either constrictive or restrictive disease, an endomyocardial biopsy or other biopsy revealing amyloidosis does not necessarily rule out pericardial constriction that may be due to amyloid infiltration. The relationship between constrictive pericarditis, seen in this patient, and the other more common manifestations of amyloid heart disease, and the hemodynamic profiles of amyloid cardiomyopathy and constrictive pericarditis are reviewed.

Modulation of the respiratory burst in human neutrophils by isoproterenol and dibutyryl cyclic AMP

The effects of a beta-adrenergic agonist and a cyclic AMP analogue on activation, activity, and termination of FMLP-stimulated superoxide anion production were investigated. Incubation with isoproterenol resulted in a 50% reduction in the maximal rate of superoxide production and a 3-4-fold increase in the rate of termination of superoxide production. Exposure to 1 mM dibutyryl cyclic AMP resulted in a 40% decrease in the maximal rate and a 3-fold increase in the rate of termination of FMLP-induced superoxide production. Neither agent had a significant effect on the lag time prior to superoxide anion generation.

A comparative study of monoclonal gammopathies and immunoglobulin levels in Japanese and United States elderly

OBJECTIVE

To define the prevalence of monoclonal immunoglobulin (Ig) proteins and quantitative serum immunoglobulin levels in elderly Japanese in comparison with elderly Caucasians as possible factors related to the reported lower incidence of multiple myeloma in elderly Japanese than in elderly Caucasians.

DESIGN

Survey study

SETTING

Community Center in Yokohama, Japan and Retirement Community in the United States.

PARTICIPANTS

Convenience sample of community-dwelling elderly subjects (age 63-95) presenting for health screening examinations in each setting. Frozen serum samples were obtained from routine screening from 146 consecutive Japanese subjects and 111 US subjects.

INTERVENTION

None

MEASUREMENTS

Presence of monoclonal immunoglobulin protein determined by serum protein electrophoresis and immunofixation and quantitative Ig by laser nephelometry.

RESULTS

Four (2.7%) of the Japanese cohort had monoclonal gammopathies compared with 11 (10%) of the American cohort. Two of the monoclonal gammopathies were IgG Kappa and two were IgG Lambda. No cases of multiple monoclonal gammopathy were identified in the Japanese group, compared with 25% of the monoclonal gammopathies in the American group. The mean quantitative serum IgG level for the Japanese group was 1,685 +/- 520 mg/dL versus 1,118 +/- 402 mg/dL for the American group; mean quantitative IgA levels were 283 +/- 116 mg/dL versus 226 +/- 116 mg/dL (P < 0.001). Albumin levels were normal in both populations, suggesting that there was not an increase in occult inflammatory disorders in the Japanese population.

CONCLUSION

The low prevalence of monoclonal gammopathy in elderly Japanese is consistent with the reported lower frequency of multiple myeloma. The reason for the higher quantitative immunoglobulin levels in this population is unclear. Further cross-cultural investigation is warranted to explore the genetic influences on altered immune regulation with aging.

Predictors of two-year post-hospitalization mortality among elderly veterans in a study evaluating a geriatric consultation team

OBJECTIVE

To determine predictors of 2-year post-hospitalization mortality in a cohort of elderly hospitalized patients originally assembled to assess the impact of a Geriatric Consultation Team (GCT).

DESIGN

Two-year follow-up of an inception cohort.

SETTING

University-affiliated tertiary care VA Medical Center.

PATIENTS

One hundred sixty-seven veterans age 75 or older discharged following hospitalization on medical, surgical, or psychiatry services but not intensive care units.

INTERVENTION

None specifically studied here though cohort was previously part of randomized control trial of a Geriatric Consultation Team.

MEASUREMENT

Mortality during 2 years of post-hospitalization follow-up.

RESULTS

Two-year post-hospitalization mortality was 28 percent with no difference between the original GCT and control groups. For the entire sample, age, mental status, admission or discharge ADLs (but not change in ADL status), number of admission problems, number of discharge diagnoses, and discharge site were significant predictors of mortality in univariate analysis. Only discharge ADLs and discharge site remained significant in multivariate analysis.

CONCLUSION

Measures of ADLs during hospitalization are stronger predictors of mortality following hospitalization than disease diagnoses. Impaired ADLs and placement other than at home are significant predictors of mortality, suggesting that the decision for nursing home placement contains other independently predictive information within it and/or that the subsequent nursing home period produces excess mortality. As had been indicated in short-term follow-up, there was no survival advantage for the Geriatric Consultation Group.

Religious coping and depression among elderly, hospitalized medically ill men

OBJECTIVE

The investigators examined the frequency of religious coping among older medical inpatients, the characteristics of those who use it, and the relation between this behavior and depression.

METHOD

The subjects were 850 men aged 65 years and over, without psychiatric diagnoses, who were consecutively admitted to the medical or neurological services of a southern Veterans Administration medical center. Religious coping was assessed with a three-item index. Depressive symptoms were assessed by self-rating (the Geriatric Depression Scale) and observer rating (the Hamilton Rating Scale for Depression).

RESULTS

One out of every five patients reported that religious thought and/or activity was the most important strategy used to cope with illness. Variables that were associated with religious coping included black race, older age, being retired, religious affiliation, high level of social support, infrequent alcohol use, a prior history of psychiatric problems, and higher cognitive functioning. Depressive symptoms were inversely related to religious coping, an association which persisted after other sociodemographic and health correlates were controlled. When 202 men were reevaluated during their subsequent hospital admissions an average of 6 months later, religious coping was the only baseline variable that predicted lower depression scores at follow-up.

CONCLUSIONS

These findings suggest that religious coping is a common behavior that is inversely related to depression in hospitalized elderly men.

Effect of IL-1 on experimental bone/bone-marrow metastases

Bone metastasis is a common event and a major cause of morbidity in cancer patients. The hematopoietic marrow of the bones, rather than the bone tissue per se, is the target organ in bone metastasis. In the bone marrow, IL-1 induces the release of hematopoietic growth factors that may affect tumor-cell growth. We treated groups of mice with rhuIL-1 alpha to examine its role in the establishment of experimental bone/bone-marrow metastasis. We found that injection of 2 micrograms of rhuIL-1 alpha 24 hr prior to, simultaneously with or 24 hr after the injection of 10(4) B16 melanoma cells into the left cardiac ventricle of mice resulted in a 2-fold increase in the average number of colonized bones per mouse. GM-CSF is produced by bone-marrow stromal cells in response to IL-1, and its receptor has been found on tumor cells, including melanoma cells. However, the administration of rmuGM-CSF to mice by either multiple injections or continuous infusion did not affect the number of colonized bones. Many of the biologic effects of IL-1 are mediated by prostaglandins. Treatment of mice with 100 micrograms of indomethacin, a potent inhibitor of prostaglandin synthesis, prior to the injection of rhuIL-1 alpha, prevented the increase in number of bone metastases. To determine whether constitutive productions of IL-1 and/or prostaglandins are involved in the pathogenesis of bone/bone marrow metastasis, we treated mice with antimouse IL-1 alpha neutralizing antibodies, rhuIRAP (an inhibitor of IL-1 activity) or indomethacin. We found no difference in the average number of colonized bones per mouse between treated and control mice. We conclude that exogenous administration of IL-1 enhances experimental bone/bone-marrow metastases, and that this phenomenon is mediated through prostaglandins. However, neither the constitutive production of IL-1 nor that of prostaglandins appear to play a role in the pathogenesis of bone/bone-marrow metastasis in our murine model system.

Breast cancer screening in older women: the geriatrician/internist perspective

There are many issues of concern to internists and geriatricians as they face the prospect of implementing breast cancer screening programs for elderly women. Population heterogeneity and variations in comorbidity require individualization in order to maximize benefit. Decision making is complicated by family interactions, especially for patients with altered cognition. The time it takes to perform exams and discuss possibilities in a busy office practice may be inhibitory. Internists will want to see more definitive data on efficacy, specifically in women > age 70, but patients in this age cohort may actually rely on physicians' recommendations to a greater extent than younger cohorts.

Incidence of secondary acute myelogenous leukemia after treatment of childhood acute lymphoblastic leukemia

BACKGROUND

Recent reports of secondary acute myelogenous leukemia (AML) occurring in children previously treated for acute lymphoblastic leukemia (ALL) prompted a review of patients with ALL treated at the Dana Farber Cancer Institute consortium (DFCI) between 1973 and 1987. Seven hundred fifty-two of 779 children treated for ALL entered complete remission. The mean follow-up time for the 752 patients was 4.4 years. Two children had AML develop 12 and 13 months after the diagnosis of ALL, respectively.

METHODS

The estimated overall risk of secondary AML was calculated for the patient population as instances per 1000 patient-years of follow-up. This was compared with recent reported cases from another institution.

RESULTS

The estimated overall risk of secondary AML was 0.61 instances per 1000 patient-years of follow-up (95% confidence interval: 0.15, 4.4). The difference between the risk of 0.61 among DFCI patients versus previously reported risk of 5.8 among a differently treated group of patients with ALL was statistically significant (P = 0.0008). No epipodophyllotoxin was used in the patients in the DFCI consortium. In contrast, an epipodophyllotoxin was used in 12 of 13 previously reported patients who had secondary AML develop.

CONCLUSIONS

The authors concluded that the use of epipodophyllotoxins may be associated with an increased risk of having secondary AML develop in patients with ALL.

A method for assessing drug therapy appropriateness

This study evaluated the reliability of a new medication appropriateness index. Using the index, independent assessments were made of chronic medications taken by 10 ambulatory, elderly male patients by a clinical pharmacist and an internist-geriatrician. Their overall inter-rater agreement for medication appropriateness (ppos) was 0.88, and for medication inappropriateness (pneg) was 0.95; the overall kappa was 0.83. Their intra-rater agreement for ppos was 0.94 overall, for pneg was 0.98 overall while the overall kappa was 0.92. The chronic medications taken by 10 different ambulatory elderly male patients were independently evaluated by two different clinical pharmacists. Their overall inter-rater agreement for ppos was 0.76, and for pneg was 0.93, while the overall kappa was 0.59. This new index provides a reliable method to assess drug therapy appropriateness. Its use may be applicable as a quality of care outcome measure in health services research and in institutional quality assurance programs.