Ecological outcomes of adolescents in a psychoeducational residential treatment facility

Cross-sectional follow-up data on 111 adolescents in a re-education residential facility were obtained in three domains--school, legal, and level of care--at 6, 12, 18, and 24 months postdischarge. Reports by community-based professionals on individual functioning were assessed on several criteria, the most stringent of which indicated successful outcomes for nearly 60% of the adolescents. Characteristics of the more successful students are noted, applications of the psychoeducational residential approach for program structure are considered, and implications for positive ecological outcomes are discussed.

A phase I/II trial of paclitaxel, carboplatin, and gemcitabine in untreated patients with advanced non-small cell lung cancer

Paclitaxel and carboplatin is widely used in the treatment of patients with advanced non-small cell lung cancer (NSCLC); however, median survival remains < 1 year. One strategy to improve survival is to add a third active drug with a differing mechanism of action. Gemcitabine is a novel antimetabolite with considerable activity in NSCLC. The primary objective of this Phase I/II study was to determine the maximally tolerated dose of gemcitabine administered with fixed doses of paclitaxel and carboplatin in untreated patients with advanced NSCLC.

Prospective long-term study of vagus nerve stimulation for the treatment of refractory seizures

PURPOSE

To determine the long-term efficacy of vagus nerve stimulation (VNS) for refractory seizures. VNS is a new treatment for refractory epilepsy. Two short-term double-blind trials have demonstrated its safety and efficacy, and one long-term study in 114 patients has demonstrated a cumulative improvement in efficacy at 1 year. We report the largest prospective long-term study of VNS to date.

METHODS

Patients with six or more complex partial or generalized tonic-clonic seizures enrolled in the pivotal EO5 study were prospectively evaluated for 12 months. The primary outcome variable was the percentage reduction in total seizure frequency at 3 and 12 months after completion of the acute EO5 trial, compared with the preimplantation baseline. Subjects originally randomized to low stimulation (active-control group) were crossed over to therapeutic stimulation settings for the first time. Subjects initially randomized to high settings were maintained on high settings throughout the 12-month study.

RESULTS

The median reduction at 12 months after completion of the initial double-blind study was 45%. At 12 months, 35% of 195 subjects had a >50% reduction in seizures, and 20% of 195 had a >75% reduction in seizures.

CONCLUSIONS

The efficacy of VNS improves during 12 months, and many subjects sustain >75% reductions in seizures.

Milk fat conjugated linoleic acid (CLA) inhibits growth of human mammary MCF-7 cancer cells

The relationship between growth and the antioxidant enzyme defence system in human MCF-7 (breast) cancer cells treated with bovine milk fat enriched with conjugated linoleic acid (CLA) was studied. Milk enriched in CLA was obtained from cows on pasture supplemented with full fat rapeseeds and full fat soyabeans (1). Cell number decreased up to 90% (p < 0.05) and lipid peroxidation increased 15-fold (p < 0.05) following incubation of MCF-7 cells for 8 days with increasing levels of milk fat yielding CLA concentrations between 16.9 and 22.6 ppm. Growth suppression and prooxidant effects of milk fat CLA were independent of the variable composition of the milk fat samples, suggesting that CLA was the active ingredient in milk fat responsible for the cytotoxic effect. Mixtures containing isomers of CLA (c9, t11-, t10, c12-, c11, t13- and minor amounts of other isomers) and linoleic acid (LA) at similar concentrations to the milk fat samples were as effective at inhibiting growth and stimulating peroxidation of MCF-7 cells as the milk fatty acids. Incubation of the cells with the c9, t11 CLA isomer (20 ppm) or the mixture of CLA isomers (20 ppm) for 8 days resulted in a 60% decrease (p < 0.05) in viability compared with untreated controls and was significantly (p < 0.05) more effective than incubation with the t10, c12 CLA isomer (20 ppm), which caused only a 15% decrease in cell numbers under similar conditions. A 25% increase (p < 0.05) in cell proliferation occurred when LA (20 ppm) alone was incubated with MCF-7 cells for 8 days. 14C-CLA was preferentially incorporated into the phospholipid fraction of the MCF-7 cell lipids in a dose-dependent manner and CLA accumulated in cell membranes more efficiently when the cells were incubated in the presence of milk fat than the c9, t11 synthetic CLA isomer. Superoxide dismutase (SOD), catalase and glutathione peroxidase (GPx) activities were induced in MCF-7 cells exposed to milk fat (containing 16.9-22.6 ppm CLA) over 8 days. The data indicate that milk fat triglyceride-bound CLA, consisting primarily of the c9, t11 isomer, was cytotoxic towards MCF-7 cells.

Improved platelet counting using two-dimensional laser light scatter

Clinical management of platelet disorders depends on accurate platelet counts. We evaluated a new analytic approach for platelet counting based on improved platelet discrimination. Current automated counting methods provide accurate platelet counts for most samples but often are unable to discriminate platelets accurately from nonplatelet particles such as microcytic RBCs, RBC fragments, and cellular debris that may falsely elevate platelet counts. The new approach measures 2 light-scatter angles of platelets and nonplatelet particles as they pass through a laser beam. The volume and refractive index of each platelet and particle are derived from the light-scatter measurements using the Mie scattering theory. Together, these 2 measurements provide improved platelet discrimination compared with 1-dimensional methods. With its improved discrimination, 2-dimensional platelet analysis provides more accurate platelet counts in samples containing interfering particles and may contribute to more effective clinical management of patients with platelet disorders.

Hydroxyurea-induced leg ulcers

Hydroxyurea is an analogue of urea that inhibits DNA synthesis. It inhibits ribonucleotide reductase, the enzyme which converts ribonucleotide diphosphates to their deoxyribonucleotide forms. This causes selective killing of cells in the S phase of the cell cycle. Hydroxyurea is well absorbed orally, has a plasma half-life of 4 hours and is mostly excreted in the urine. It is used to treat chronic myeloid leukaemia, polycythemia vera, thrombocythaemia, sickle cell anaemia and at lower doses psoriasis. It is generally well-tolerated. The most frequently encountered sideeffects are nausea, vomiting and diarrhoea. The most serious side-effect, myelosuppression, is usually rapidly reversed on cessation of the drug.

The BMP1 gene is essential for pathogenicity in the gray mold fungus Botrytis cinerea

In Magnaporthe grisea, a well-conserved mitogen-activated protein (MAP) kinase gene, PMK1, is essential for fungal pathogenesis. In this study, we tested whether the same MAP kinase is essential for plant infection in the gray mold fungus Botrytis cinerea, a necrotrophic pathogen that employs infection mechanisms different from those of M. grisea. We used a polymerase chain reaction-based approach to isolate MAP kinase homologues from B. cinerea. The Botrytis MAP kinase required for pathogenesis (BMP) MAP kinase gene is highly homologous to the M. grisea PMK1. BMP1 is a single-copy gene. bmp1 gene replacement mutants produced normal conidia and mycelia but were reduced in growth rate on nutrient-rich medium. bmp1 mutants were nonpathogenic on carnation flowers and tomato leaves. Re-introduction of the wild-type BMP1 allele into the bmp1 mutant restored both normal growth rate and pathogenicity. Further studies indicated that conidia from bmp1 mutants germinated on plant surfaces but failed to penetrate and macerate plant tissues. bmp1 mutants also appeared to be defective in infecting through wounds. These results indicated that BMP1 is essential for plant infection in B. cinerea, and this MAP kinase pathway may be widely conserved in pathogenic fungi for regulating infection processes.

Optimal loading rates and economic analyses for anaerobic digestion of poultry waste

Four combinations of litter and carcasses from broiler chickens were examined utilizing a thermophilic, stirred-tank digester of demonstration size of approximately 10,000 gal. Under computed optimal loading rates, litter with paper bedding had the highest daily production of methane over an 8-day retention period. The greatest methane production per lb of volatile solids was achieved over 10 days with litter and paper bedding combined with carcasses. This research found that sufficient poultry litter is generated within 20 mi (32 km) of Moorefield, WV, to support a commercial-sized digester operation. However, anaerobic digestion of poultry waste cannot be financially supported by methane production alone. To be financially viable, anaerobic digestion requires a disposal fee for poultry waste and/or the sale of the digested solid effluent as an organic fertilizer to retail markets.

Effects of gonadal steroids in women with a history of postpartum depression

OBJECTIVE

Endocrine factors are purported to play a role in the etiology of postpartum depression, but direct evidence for this role is lacking. The authors investigated the possible role of changes in gonadal steroid levels in postpartum depression by simulating two hormonal conditions related to pregnancy and parturition in euthymic women with and without a history of postpartum depression.

METHOD

The supraphysiologic gonadal steroid levels of pregnancy and withdrawal from these high levels to a hypogonadal state were simulated by inducing hypogonadism in euthymic women-eight with and eight without a history of postpartum depression-with the gonadotropin-releasing hormone agonist leuprolide acetate, adding back supraphysiologic doses of estradiol and progesterone for 8 weeks, and then withdrawing both steroids under double-blind conditions. Outcome measures were daily symptom self-ratings and standardized subjective and objective cross-sectional mood rating scales.

RESULTS

Five of the eight women with a history of postpartum depression (62.5%) and none of the eight women in the comparison group developed significant mood symptoms during the withdrawal period. Analysis of variance with repeated measures of daily and cross-sectional ratings of mood showed significant phase-by-group effects. These effects reflected significant increases in depressive symptoms in women with a history of postpartum depression but not in the comparison group after hormone withdrawal (and during the end of the hormone replacement phase), compared with baseline.

CONCLUSIONS

The data provide direct evidence in support of the involvement of the reproductive hormones estrogen and progesterone in the development of postpartum depression in a subgroup of women. Further, they suggest that women with a history of postpartum depression are differentially sensitive to mood-destabilizing effects of gonadal steroids.

Information needs and decisional preferences among women with ovarian cancer

OBJECTIVES

Studies show that women with cancer want more information about and participation in all aspects of their healthcare including decision-making. However, most studies have been done on women with breast cancer, which often runs a lengthy course and has strong patient-advocacy groups. Little is known about the preferences of women with ovarian cancer, the fifth leading cause of cancer death in women, which often has a more rapidly fatal course.

METHODS

This study of women with ovarian cancer investigates what information is most vital for women with ovarian cancer, their preferred role in decision-making, and the influence of sociodemographic, disease-related, and psychological factors.

RESULTS

Questionnaires were completed by 105 women with ovarian cancer in two Canadian university hospital oncology clinics. Their mean age was 55.8 +/- 14. 9 years. Most were married, well-educated, and considered their health status to be excellent or good, even though over 60% had metastatic disease. Over 80% of these women wanted detailed information about ovarian cancer during the diagnosis, treatment, and posttreatment stages of their disease. In particular, they wanted information pertaining to the disease, treatment, and self-care issues. Approximately 60% of women preferred to share decision-making with their doctors at every stage of the illness. Psychological variables and disease severity were found to influence information needs and decisional preferences. In general, the more psychologically distressed the women, the more information they wanted about coping strategies and the more serious the illness, the more shared decision-making was desired.

CONCLUSION

These results present a challenge to health care providers in more adequately meeting the individual information needs of women with ovarian cancer and involving them to the extent that they wish in the decision-making process.

Acceptance of voluntary HIV testing and the prevalence of HIV infection in women with cervical neoplasia in Toronto

Over a 13-month period (1998-99), 661 adult women under the age of 50 years with a diagnosis of high grade squamous intraepithelial lesions (HSIL) or invasive cervical cancer in the previous 5 years and who were unaware of their HIV status were approached to participate in this study. After pretest counseling, patients completed a short questionnaire about risk factors for HIV infection, had blood samples drawn for HIV testing,and arranged a follow-up appointment for test results and post-test counseling. The acceptance rate for HIV testing was 73% (N = 432 with HSIL and N = 51 with invasive cervical cancer). Most women reported heterosexual intercourse as their only risk factor for HIV infection, with the majority (95.1%) reporting more than one lifetime sexual partner. Women who declined participation were significantly older (P < 0.01) than participants and nonwhites were more likely to decline (P < 0.001). None of the study participants had positive HIV test results (0/483; 95% CI, 0.00-0.009). Although HIV testing was accepted by most women following pretest counseling, there were no women who tested HIV-positive who were previously unaware of their status. Consequently we do not recommend routine HIV testing in this population.

Evaluation of the predictive value of Her-2/neu overexpression and p53 mutations in high-risk primary breast cancer patients treated with high-dose chemotherapy and autologous stem-cell transplantation

PURPOSE

To ascertain the predictive value of Her-2/neu overexpression and p53 mutations, assessed by immunohistochemistry, in high-risk primary breast cancer (HRPBC) treated with high-dose chemotherapy (HDCT).

PATIENTS AND METHODS

We obtained paraffin-embedded tumor blocks from 146 HRPBC patients previously enrolled at our program onto clinical trials of HDCT for four to nine involved axillary lymph nodes, > or = 10 involved axillary nodes, or inflammatory carcinoma. All patients received the same HDCT regimen, with cyclophosphamide, cisplatin, and carmustine (STAMP-I), followed by autologous stem-cell transplantation. Median follow-up was 42 months (range, 5 to 90 months). The same pathologist, blinded to clinical outcome, reviewed all immunostained slides.

RESULTS

Positive results for Her-2/neu and p53 were found in 44.5% and 34% of the patients, respectively. Positivity for Her-2/neu was significantly associated with increased risk of relapse and death. No correlation was found between p53 mutations and relapse-free survival (RFS) or overall survival (OS). Multivariate analyses included Her-2/neu overexpression and the following variables previously identified as independent predictors of outcome in this population: tumor size, nodal ratio (number of involved nodes/number of dissected nodes), and hormone receptor status. All four variables had independent value.

CONCLUSION

Her-2/neu overexpression is an independent negative predictor of RFS and OS in HRPBC treated with HDCT. Its inclusion in our previously described predictive model increases the predictive capacity of this model for the low-risk subgroup. In contrast, p53 mutations lack predictive value in this setting.

A phase II study of biochemotherapy for the treatment of metastatic malignant melanoma

The use of interleukin-2 (IL-2) and interferon-alpha (IFNalpha) in combination with chemotherapy for the treatment of advanced malignant melanoma has generated considerable interest. In particular, the relatively high number of durable complete responses has suggested this may be a significant advance in the treatment of malignant melanoma. We report our experience at the University of Colorado in 43 patients, including many with poor prognostic factors. Patients received cisplatin 20 mg/m2 on days 1-4, vinblastine 1.6 mg/m2 on days 1-4, dacarbazine 800 mg/m2 on day 1, IL-2 9 x 10(6) IU/m2 per day intravenously over 24h on days 1-4 and IFNalpha 5 x 10(6) IU/m2 per day subcutaneously on days 1-5 every 3 weeks. The median follow-up for all patients was 34 months. Responses were seen in 20 patients (47%, 95% confidence interval 31-62%) and comprised five complete responses (CRs) (12%) and 15 partial responses (PRs) (35%). Two patients achieving a CR remain disease free at 45 and 47 months follow-up. In addition three patients who obtained a surgical CR and another with only minor residual changes on computed tomography scan have not progressed at 27, 30, 40 and 27 months, respectively. Toxicity was manageable, but all patients had at least one grade 3 or 4 toxicity, predominantly hypotension and neutropenia. There were no treatment-related deaths. In conclusion, the response rate and duration is within the range previously reported for biochemotherapy. The results of ongoing randomized studies are awaited to better define the value of biochemotherapy in the treatment of advanced melanoma.

Medical informatics educational tasks seen from practical perspective. Tempus-Phare Project CME-02555-96

This paper tries to synthesize the discussion of a seminar on medical informatics educational tasks held in May 1998 in Sinaia, Romania, within the frame of the Tempus-Phare Project CME-02555-96 entitled "Know How Transfer from University to Industry" and coordinated by the University of Medicine and Pharmacy Timisoara, Romania. Special emphasis was paid to particular features of medical education requirements in East European countries, with particular reference to Romania.

Development of a brief screening instrument: the HANDS

BACKGROUND

The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience.

METHODS

We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30.

RESULTS

The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist.

CONCLUSION

The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

Marked declines in human immunodeficiency virus-related mortality in Chicago in women, African Americans, Hispanics, young adults, and injection drug users, from 1995 through 1997

BACKGROUND

Declines in human immunodeficiency virus (HIV)-related mortality between 1995 and 1996 were seen across the United States but were small to nonexistent among people in marginalized sectors who are most likely to contract HIV and die of its effects. No comprehensive analysis describing HIV-related mortality in 1997 was available.

OBJECTIVE

To describe Chicago's HIV-related mortality trends up to and including 1997, with specific attention focused on marginalized populations.

METHODS

An analysis of cross-sectional HIV-related mortality data with emphasis on the years 1995 through 1997 was conducted for Chicago, Ill. Numbers, proportions, and rates of declines in HIV-related deaths were examined for the city as a whole and also among those diagnosed at Cook County Hospital, as a proxy for people with very low socioeconomic status.

RESULTS

Between 1995 and 1996 there was an overall decline of 19% in HIV-related mortality in Chicago but small or no declines among women, African Americans, Hispanics, injection drug users, and people aged 20 to 29 years and more than 50 years. Between 1995 and 1997 there was an overall decline of 61%. At that time the declines were spread more evenly across diverse groups. There were almost no significant differences between the declines for these groups at Cook County Hospital and in the rest of Chicago.

CONCLUSIONS

The HIV-related mortality has fallen dramatically in Chicago since 1995, the year of its maximum. During 1997, declines were seen among all groups. Declines were also seen among the most disenfranchised of the city. Access to care and the new combination therapies are apparently sustaining life for many in Chicago.

Preparative chromatographic resolution of enantiomers using polar organic solvents with polysaccharide chiral stationary phases

The preparative chromatographic resolution of racemic mixtures is rapidly becoming a standard approach for the generation of enantiomers in pharmaceutical research and development. This paper will discuss the optical resolution of numerous pharmaceutical intermediates and final products using polar organic solvents with polysaccharide chiral stationary phases. The advantages of this approach compared to more traditional mobile phases for preparative separations will be presented. In addition the ability to reverse elution order using polar organic solvents will be presented.

Is radical trachelectomy a safe alternative to radical hysterectomy for patients with stage IA-B carcinoma of the cervix?

BACKGROUND

The prognosis associated with lymph node negative, early stage carcinoma of the cervix is excellent, with 5-year survival rates greater than 90%. Radical trachelectomy in combination with pelvic lymph node dissection (RVT + LPL) has emerged as an alternative to radical hysterectomy (RH) for these patients who desire preservation of fertility. However, there are limited data to support its efficacy and safety.

METHODS

All patient information was collected prospectively and was subsequently extracted from the cervical cancer surgery database of the Division of Gynecologic Oncology at the University of Toronto. Patients treated by RVT + LPL for fertility preservation were compared with two groups of patients treated by RH. One control group was matched for age, tumor size, histology, depth of invasion, presence of capillary lymphatic space involvement, lymph node metastases, and use of adjuvant radiation. The other control group consisted of patients with tumor sizes </=2 cm, negative pelvic lymph nodes who had not received adjuvant radiation therapy.

RESULTS

Thirty of 32 patients treated by RVT + LPL between March 1994 and November 1998 were matched. The only statistically significant difference in prognostic factors between the patients who underwent RVT + LPL and unmatched controls (556 patients) was the median depth of invasion in the adenocarcinomas (2. 0 mm vs. 4.0 mm, respectively; P < 0.02). The 2-year actuarial recurrence free survival was 95%, 100%, and 97% for the patients who underwent RVT + LPL, matched controls, and unmatched controls, respectively. The actuarial conception rate at 12 months was 37%.

CONCLUSIONS

Acknowledging the small numbers and short follow-up, RVT + LPL appears to be similar in efficacy to RH. If longer follow-up with more patients confirms the above, this procedure will represent an acceptable alternative to RH for patients with early Stage I carcinoma of the cervix who desire preservation of fertility.