Artesunate and mefloquine in the treatment of uncomplicated multidrug-resistant hyperparasitaemic falciparum malaria

Oral artesunate is the most effective treatment for uncomplicated hyperparasitaemia in falciparum malaria. To assess the contribution of mefloquine to therapeutic efficacy in an area endemic for mefloquine-resistant Plasmodium falciparum, an open randomized comparison of a 5 d course of oral artesunate (total dose 12 mg/kg) with and without a single dose of mefloquine (25 base mg/kg) was conducted in 100 adults and children with uncomplicated hyperparasitaemia (> 4% parasitized red blood cells). Both regimens were well tolerated and gave equally rapid clinical responses (84% of patients were aparasitaemic and 96% were afebrile within 48 h), but the recrudescence rate assessed at day 42 was 6% in those receiving artesunate with mefloquine compared to 36% in those receiving artesunate alone (adjusted hazard ratio 7, 95% confidence interval [95% CI] 2-32; P < 0.01). In addition, the efficacy of a 7 d course of artesunate, with and without the addition of mefloquine, was monitored in 178 patients who were not part of the randomized comparison. The failure rate was again lower in those receiving artesunate and mefloquine--7% (95% CI 2-13) compared with 26% (95% CI 8-44) in patients treated with artesunate alone. An oral regimen of 5 d or more of artesunate, together with mefloquine (25 mg/kg) given on day 2, is an effective treatment for uncomplicated hyperparasitaemic falciparum malaria in this area of high level multidrug resistance.

Cell wall preparations from environmental yeasts: effect on alveolar macrophage function in vitro

Organic dust toxic syndrome (ODTS) is associated with inhalation of high concentrations of organic materials and is a noninfectious illness characterized by fever, malaise, myalgia, and neutrophilic inflammation of the lower respiratory tract. Studies in our laboratory of fungi in fresh lumber have demonstrated that yeasts may predominate and have raised the issue of potential exposure of sawmill workers to yeasts. Zymosan, a cell wall preparation from Saccharomyces cerevisiae, is a potent stimulator of alveolar macrophages (AM). In the present study, preparations from the cell walls of Pichia fabianii, Candida sake, Trichosporon capitatum, Rhodotorula glutinis, and Cryptococcus laurentii were compared with zymosan and beta-1,3-glucan for their ability to stimulate AM and activate complement. All species activated complement. P. fabianii, C. sake, T. capitatum, R. glutinis, C. laurentii, as well as zymosan and glucan, stimulated superoxide anion and leukotriene B4 production in a dose-dependent fashion, but R. glutinis and C. laurentii were much less active. Zymosan, glucan, P. fabianii, and R. glutinis treatment of AM resulted in increased phagocytosis of labeled sheep RBCs, whereas there was no effect with C. sake or C. laurentii and T. capitatum significantly inhibiting phagocytosis. These results suggest that exposure to high concentrations of yeast could provoke pulmonary inflammation resulting in an episode of ODTS.

Postoperative radiation therapy in non-small cell lung cancer

One hundred seventy-three patients with the diagnosis of non-small cell lung cancer (NSCLC) were treated with surgery and postoperative radiation therapy (RT) at the Radiation Oncology Center, Washington University, St. Louis. All patients had been retrospectively reviewed and restaged according to the new American Joint Committee (AJC) staging classification. Seventeen patients were stage I, 69 were stage II, 74 were stage IIIA, and 2 patients were stage IIIB. In 11 patients, accurate staging could not be determined. Indications for postoperative RT were positive surgical margins (32 patients), metastatic hilar nodes (78 patients), and metastatic mediastinal nodes (62 patients). Locoregional control for stages I, II, and IIIA was 85, 75, and 85%, respectively. Five-year actuarial survival was 35% for stage I and 20% for stages II and IIIA. Patients with N0 disease (positive margins) had 5-year survival of 25%, whereas patients with N1 and N2 disease had a 5-year survival of 20%.

Agrobacterium-mediated transformation of Amaranthus hypochondriacus: light- and tissue-specific expression of a pea chlorophyll a/b-binding protein promoter

Mature embryos of Amaranthus hypochondriacus (amaranth) were used to develop an in vitro culture system for plant regeneration and genetic transformation. Plants were regenerated from embryo-derived callus cultivated on Murashige and Skoog medium supplemented with 10 µM 2,4-dichlorophenoxyacetic acid or 3,6-dichloro-2-methoxybenzoic acid and 10% coconut liquid endosperm. Transgenic plants were obtained by inoculation of mature embryo explants with a disarmed Agrobacterium strain containing the plasmid pGV2260(pEsc4), which carried the genes encoding neomycin phosphotransferase type II and β-glucuronidase. The presence of transgenes in the genome of transformed amaranth plants and their progeny was demonstrated by Southern blot hybridization. Tissue specific and light-inducible expression directed by a pea chlorophyll a/b-binding protein promoter was observed in transgenic amaranth plants and their progeny.

Molecular analysis of INK4 genes in breast carcinomas

Cell cycle regulators have recently been implicated in oncogenic transformation of cells, including the cyclins active in the G1 phase of the cell cycle and their respective cyclin-dependent kinases (CDK) whose activities are regulated by a set of inhibitors of CDK (CDKI). Since CDKIs can inhibit cell proliferation, they may have a role as tumor suppressor genes. To determine if alterations of CDKI genes may be involved in tumorigenesis of breast cancer, we examined the mutational status of p16(INK4A), p15(INK4B), p18(INK4C), p19(INK4D) CDKI genes in 36 primary breast carcinomas and 9 breast cancer cell lines using polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP), direct DNA sequencing, and Southern blot analysis. Furthermore, amplification of cyclin D1, D2, D3 genes were also examined in these samples. One mutation of p15(INK4B) gene occurred, resulting in change of aspartic acid to asparagine at codon 85. Since aspartic acid at this position is conserved between all four human and murine INK4 proteins, this missense mutation may have functional significance. The sample with a p15(INK4B) point mutation was accompanied by amplification of the cyclin D1 gene. A deletion of the p18(INK4C) gene was found in a primary tumor. Three deletions of the p16(INK4A) gene and two deletions of the p15(INK4B) gene were found in the cell lines. Also, we found amplification of the p15(INK4B) and p16(INK4A) loci in a clinical sample as well as amplification of the p19(INK4D) in another sample, and amplification of the myeloperoxidase (MPO) gene in one cell line and two primary tumors. We suspect that a critical gene for breast cancer is amplified near the MPO gene. These data indicate that CDKI mutations are moderately rare in breast cancer and are often associated with the simultaneous alteration of more than one cell-cycle regulatory gene.

HIV RNA quantitation: marker of HIV infection

Assessment of the status and prognosis of an HIV-infected individual traditionally has been difficult for the clinician. The use of markers of disease progression such as CD4+ has been found to not be a complete indicator of the status of an HIV-infected individual. As a result, determining appropriate therapy for the treatment of this viral infection has been both unpredictable and challenging. Recent development of a laboratory assay has brought a new tool in the management of HIV. The assay is a quantitation of the amount of detectable HIV RNA and estimates the amount of HIV viral load or HIV viral burden present in the blood. Since the development of this assay, HIV RNA quantitation has rapidly become an important surrogate marker of HIV infection. In addition, this quantitation is used to determine the effectiveness of anti-HIV therapies. Understanding the differences and results of quantitative assays is imperative in the management of HIV-infected patients. This article summarizes the events leading to the creation of quantitative assays, explanations and comparisons of the current quantitative assays, and nursing considerations for the implications and uses of viral load markers.

A specific method for the measurement of tacrolimus in human whole blood by liquid chromatography/tandem mass spectrometry

Tacrolimus (FK 506) measurement by immunoassays in clinical samples of organ transplant patients often lacks a specific reference method. A method combining liquid chromatography (LC) with tandem mass spectrometry (MS/MS) was developed to quantify tacrolimus in whole blood. Liquid-liquid extraction was performed on 1 ml of sample before narrow-bore LC/MS/MS analysis. Ascomycin was used as an internal standard. The standard curve was composed of seven points ranging from 1 to 50 micrograms/l (average r2 = 0.9999). Limits of detection and quantitation were 0.25 and 0.75 microgram/l, respectively. Imprecision was < 5% across the therapeutic range. Tacrolimus recovery averaged 62%. The most abundant metabolites detected in clinical samples were 13-O- and 15-O-demethyl tacrolimus. This method was used in a comparison study with a microparticle enzyme immunoassay (MEIA): MEIA = 1.03 LC/MS/MS -0.084 (microgram/l), (Sy/x = 1.43), r2 = 0.933. With its high sensitivity and specificity, this LC/MS/MS method presents a good reference method for immunoassay evaluation as well as a valuable tool for metabolism studies.

High-dose chemotherapy and stem-cell rescue in the treatment of high-risk breast cancer: prognostic indicators of progression-free and overall survival

PURPOSE

To examine the predictive value of tumor- and treatment-specific prognostic indicators of relapse-free survival (RFS) and overall survival (OS) in patients with high-risk breast cancer (HRBC) treated with high-dose chemotherapy (HDCT) and stem-cell rescue.

PATIENTS AND METHODS

Between June 1989 and September 1994, 114 patients with HRBC (stage II with > or = 10 axillary lymph nodes involved, stage IIIA, and stage IIIB inflammatory carcinoma) received adjuvant chemotherapy followed by HDCT with etoposide, cyclophosphamide, and either doxorubicin (CAVP) or cisplatin (CCVP). Variables analyzed included stage, tumor size, number of axillary nodes involved, grade and receptor status, and types of adjuvant chemotherapy and radiation therapy and HDCT.

RESULTS

With a median follow-up time of 46 months (range, 23 to 93), Kaplan-Meier estimates of 3.5-year OS for stage II, IIIA, and IIIB HRBC are 82% (95% confidence interval [CI], 67% to 97%), 79% (95% CI, 67% to 91%), and 72% (95% CI, 53% to 91%); RFS estimates are 71% (95% CI, 56% to 85%), 57% (95% CI, 43% to 72%), and 50% (95% CI, 29% to 71%) irrespective of the HDCT regimen. In univariate analysis, the risk of relapse was lower for patients with progesterone receptor (PR)-positive tumors (risk ratio [RR], 0.43; 95% CI, 0.22 to 0.81; P = .01) and higher for patients with inflammatory carcinoma (RR, 2.20; 95% CI, 1.02 to 4.76; P = .05). OS was better for patients with PR (RR, 0.16; 95% CI, 0.05 to 0.55; P = .003) and estrogen receptor (ER)-positive tumors (RR, 0.42; 95% CI, 0.17 to 1.02; P = .05); OS was worse for patients with high-grade primary tumors (RR, 4.08; 95% CI, 1.21-13.7; P = .02). In multivariate analysis, PR positivity was associated with improved RFS (P = .01) and OS (P = .001).

CONCLUSION

HDCT in selected patients with HRBC is safe and warrants further evaluation. Patients with receptor-negative, high-grade, or inflammatory tumors require improvement in their therapeutic options. Better assessment of the role of HDCT awaits completion of ongoing randomized trials.

Use of a live chlamydial vaccine to prevent ovine enzootic abortion

A lyophilised chlamydial vaccine was prepared from the 1B temperature-sensitive strain of ovine Chlamydia psittaci. Ewes inoculated with a low titre of the live vaccine four weeks before artificial insemination were challenged on day 70 of gestation with five UK field isolates of C psittaci, including strains A22 and S26/3 previously incorporated into a commercial inactivated vaccine. There was a significantly lower chlamydial abortion rate after challenge in the vaccinated group (7.1 per cent) than in the unvaccinated group (80 per cent). All the lambs born to the vaccinated ewes were viable and of good quality. The vaccine also reduced the number of infected ewes in the group and the severity of the infection. The compatibility of the chlamydial vaccine and a toxoplasma vaccine was also tested. The abortion rate of ewes vaccinated with the two vaccines at separate injection sites (16 per cent) was less than that of ewes vaccinated with both vaccines at one site (32 per cent).

Induction of graft-versus-leukemia effect in a patient with chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is incurable with conventional therapy. Recent data report favorable results with allogeneic transplant. We report a patient with CLL with persistent leukemia post-transplant who obtained remission after discontinuing immune suppression.

Androgen effects on bioactive and immunoreactive gonadotrophin levels during puberty in male baboons

The effect of androgens on changes in circulating LH and FSH during pubertal development was examined longitudinally in a 3 year study in male hamadryas baboons. Baboon LH and FSH were measured by a species-specific radioimmunoassay and bioactive LH (B-LH) was measured by the mouse in vitro Leydig cell bioassay. Control baboons (n = 5) progressed normally through puberty. Eight baboons were castrated prepubertally; of these four received testosterone implants at the chronological age (CA) of clinical puberty (4.0 +/- 0.1 yr, mean +/- SEM). The timing of the postcastration rise in B-LH levels ranged between 1 and 15 months later (median 3.5 months) (CA 3.5 +/- 0.2 yr) thus supporting the hypothesis that central activation of gonadotrophins occurs at the time of puberty, independent of gonadal influences. Similar results were seen for immunoreactive-LH (IR-LH) and IR-FSH levels. IR- and B-LH levels continued to rise with age (P < 0.0003) in the untreated castrated baboons, associated with an increased LH B/I ratio. Administration of testosterone resulted in temporary suppression of B-LH, IR-LH and IR-FSH levels; however gonadotrophin levels subsequently rose with age despite increased testosterone levels. Thus the mechanisms initiating puberty involve both gonad-independent events as well as alterations in negative androgenic feedback sensitivity on gonadotrophin secretion.

Semi-quantitative measurement of Plasmodium falciparum antigen PfHRP2 in blood and plasma

Plasmodium falciparum histidine rich protein 2 (PfHRP2) antigen was measured semi-quantitatively in whole blood, plasma, and supernatants and red blood cells of cultures in vitro using the dipstick ParaSight-F test and also by a quantitative antigen-capture enzyme-linked immunosorbent assay (ELISA). In vitro, PfHRP2 was secreted mainly during the second half of the asexual cycle with a marked rise during schizont development and rupture. The total PfHRP2 secreted before schizogony corresponded to approximately 4% of that contained in the red blood cells. In samples from 55 patients with acute falciparum malaria, the level of detection by ELISA corresponded to parasitaemias of 100/microL for whole blood and 1600/microL for separated plasma. Whole blood PfHRP2 levels were correlated significantly with admission parasitaemia (r = 0.76, P < 0.0001) and the stage of parasite development (r = 0.43, P < 0.01). Although whole blood PfHRP2 concentrations were higher in severe malaria, plasma concentrations of PfHRP2 were considerably higher in severe malaria (median titre 1:320, range zero to 1:1280) than in uncomplicated malaria (median titre 1:5, range zero to 1:80; P < 0.0001). The ratio of whole blood to plasma PfHRP2 was lower in severe than in uncomplicated malaria (median 4, range 0.25 to 256, versus 64, range 4 to 1280; P < 0.0001). With plasma samples the intensity of colour change on the dipstick correlated well with more precise measurement of optical density in the ELISA (r = 0.88, P < 0.0001). These results suggest that measurement of PfHRP2 in plasma could provide an alternative approach to the assessment of the parasite biomass, and thus prognosis, in severe malaria, and that this could be done simply by using the currently available dipsticks.

Asthma in Greenwich, UK: impact of the disease and current management practices

A great deal of the care of patients with asthma takes place in general practices. The aim of the present study was to describe the impact of asthma in the community and to identify current asthma self-management practices. A two-part questionnaire survey was conducted in a random sample (23%; n=24,398) of persons aged 16-50 yrs, registered with one of the 41 general practices in Greenwich, London, UK. The two parts were: a screening questionnaire identifying persons with current asthma (defined as waking with shortness of breath in the last 12 months, attack of asthma in the last 12 months, or currently taking treatment for asthma); and an asthma questionnaire (completed by those with asthma) assessing quality of life, frequency of asthma symptoms, possession and use of self-management tools, and action in the event of an exacerbation of asthma. The crude response rate was 51%, but this may be an underestimate due to errors in the sampling frame. The prevalences of wheeze and asthma in the past 12 months were 26% and 14%, respectively. Among asthma patients: 43% reported symptoms occurring three or more times per week, and 20% were woken by asthma symptoms on three or more nights per week; most had asthma with a mild impact on quality of life; 26% used inhaled steroids on most days in the preceding month; 16% had a peak flow meter at home; and 7% had oral steroids available. Of the 44% of subjects with asthma, who could identify an exacerbation of asthma in the preceding 6 months: 19% had used a peak flow meter during the episode; 19% had changed their treatment without first being told to do so by a doctor; and 50% had sought urgent medical help. Smokers used less appropriate asthma management and subjects whose asthma had a severe impact on quality of life used more treatment and peak flow monitoring. In conclusion, the prevalence of asthma among adults in Greenwich, UK, has increased since a similar survey in 1986. Many people have fairly mild asthma and a smaller number have severe disease. Much remains to be done to promote appropriate strategies for self-management of asthma exacerbations.

Patients' perceptions of changes in their blood pressure

OBJECTIVES

(1) To investigate patients' experience of changes in their blood pressure (BP) in an every day setting and the accuracy of patients' predictions; and (2) to examine what influences patients' belief that they can tell when their BP is up.

SUBJECTS

A total of 102 hypertensive patients were recruited sequentially as they presented for routine BP checks. The setting was an inner city general practice.

DESIGN

Patients attended for BP checks on a weekly basis. Before each check they were asked whether they thought their BP was higher, lower or the same as usual. Subjects were classified as predictors if they thought they could tell when their BP was up. On completing their series of BP checks each subject completed symptom and Hospital Anxiety and Depression questionnaires.

MAIN OUTCOME MEASURES

Accuracy of BP predictions, BP levels and variability, number of symptoms reported and anxiety level.

RESULTS

One hundred and two hypertensive patients entered the study of whom 51 patients were predictors. The majority (86%) of predictors could not accurately predict their BP. There were no significant differences in either BP or variability between predictors and non-predictors. Predictors were significantly more anxious and reported more symptoms than non-predictors.

CONCLUSIONS

For the majority of predictors there is no significant relationship between predictions of BP and clinical measurements. Predictor status is associated with the reporting of more symptoms and higher levels of anxiety. Doctors should counsel patients against using subjective BP assessments to guide their use of antihypertensive medication.