Microcosm assessment of potential molluscicides for control of the rice snail Isidorella newcombi sens. lat. (Gastropoda: Basommatophora: Planorbidae)

Twenty-seven pesticides were evaluated for their toxicity to mature Isidorella newcombi (Adams & Angas), a serious pest of irrigated rice in NSW, Australia. Evaluations were conducted using microcosms in which typical field conditions were simulated. Only 3 compounds, niclosamide, n-tritylmorpholine, and nicotinanilide, provided >95% mortality at an initial screening rate of 3 mg/L. These compounds were assessed at a range of rates using both immediate and delayed-exposure bioassays to determine LC values and comparative persistence. Niclosamide (as Bayer Bayluscide� 250 g/L EC) and n-tritylmorpholine (as Shell FresconB 165 g/L EC) were the most toxic (LC90, immediate exposure, 0.19 mg/L for both compounds), whilst the corresponding LC90 value for nicotinanilide (laboratory grade in DMSO) was 0.53 mg/L. Persistence (reflected by a slower increase in LC90 values over time in delayed exposure bioassays) was strongest in nicotinanilide and weakest in n-tritylmorpholine. Although niclosamide is the most promising compound for the control of I. newcombi, further development of nicotinanilide is also recommended, as it represents a potentially valuable tool for use in situations where low fish toxicity is required.

Three-year results of prevention programs on marijuana use: the New Hampshire study

The effects on marijuana use of 1) a drug prevention curriculum, or 2) this curriculum with added parent and other adult community activities in comparison with 3) a control community were investigated. Baseline information on drug-related behaviors from a sample of fourth, fifth, and sixth graders aged nine to fourteen years in rural New Hampshire (N = 1200) were obtained. The children completed these initial questionnaires in classrooms in 1987. In the comprehensive community intervention regular marijuana use was reduced by over 50 percent. No program had a significant effect on the initiation of marijuana use. The predictors of initiation were being in a higher grade, low school satisfaction, poor academic achievement, feeling unloved by one's family, feeling unpopular, and being part of a drug-using peer group. The baseline predictors of subsequent regular marijuana use were poor academic achievement, feeling unpopular, and being part of a drug-using peer group. In interviews the cultural and social contexts of marijuana use were explored. Strategies to prevent marijuana use need to take into account the profile of the marijuana-using child, the adult community's attitudes and beliefs about drugs, and the access of drug sellers and users to children.

Use of granulocyte colony stimulating factor to reduce the toxicity of super-VAC chemotherapy in advanced solid tumours in childhood

Children with advanced solid tumours at the Royal Alexandra Hospital for Children (RAHC) receive an intensive four drug chemotherapy combination, Super-VAC (cyclophosphamide, 500 mg/m2, adriamycin, 30 mg/m2, actinomycin-D, 0.5 mg/m2, all daily for 3 days, and vincristine, 1.5 mg/m2 weekly). The majority of patients respond well to three courses of such therapy, but with considerable morbidity, including fever, neutropenia, and mucositis. In an attempt to reduce the morbidity of Super-VAC, G-CSF was added. We documented various parameters in 12 patients who received 28 cycles with G-CSF and compared them to an historical control group of 37 cycles in the preceding 14 patients who received Super-VAC. The median duration of each cycle was 23 days with G-CSF and 28 days without G-CSF (P = 0.004). However, differences in requirements for inpatient care (median 16 v. 20 days), intravenous antibiotics (median 9 v. 10 days), amphotericin (median 5 v. 3 days), morphine (median 8.5 v. 7 days), or TPN (median 6.5 v. 8 days) did not reach statistical significance. As expected, a significant difference in neutrophil recovery was demonstrated between the two groups (median 11 v. 16 days, P < 0.0001) but not in platelet recovery (median 13 v. 13 days). The use of G-CSF with Super-VAC resulted in a shorter cycle length, so increasing the dose intensity. A reduction in morbidity could not be demonstrated. No toxic side effects from G-CSF were noted.

Control of chironomid larvae (Diptera: Chironomidae) in establishing rice crops using starch-based chlorpyrifos pellets

Starch-based pellets containing 10% (w/w) chlorpyrifos were evaluated for control of chironomid larvae in rice crops immediately after flooding. Chlorpyrifos pellets at rates of 2.0, 3.5, and 6.0 kg/ha (0.2, 0.35, and 0.6 kg AI/ha), and, as a reference treatment, 150 ml/ha of 500 g/liter chlorpyrifos emulsifiable concentrate (EC) (0.075 kg AI/ha) were evaluated in New South Wales, Australia. The pellets reduced total midge larvae by 93-94% over the initial 36 days posttreatment, with some indication of residual control 50 days posttreatment at all rates. Chironominae were reduced by 80-85%, and other chironomids (predominantly Tanypodinae) by 98% during the first 36 days posttreatment. Increasing the pellet application rate above 2.0 kg/ha did not improve control. Although the EC formulation provided 100% control of all larvae for 12 days, control declined thereafter. The EC formulation reduced total larval numbers by 55% over the first 36 days posttreatment, with Chironominae increasing by 28% and other chironomids being reduced by 84%. Significantly (P < 0.05) higher water column toxicity levels were recorded for the EC formulation in the first 3 days after application.

Childhood acute myeloid leukemia: outcome in a single center using chemotherapy and consolidation with busulfan/cyclophosphamide for bone marrow transplantation

PURPOSE

To report the impact of bone marrow transplantation (BMT) with busulfan/cyclophosphamide (BuCy) as end consolidation in a cohort of consecutively diagnosed children with acute myeloid leukemia (AML).

PATIENTS AND METHODS

Between May 1987 and November 1992, 43 patients were diagnosed with AML. Tissue typing at diagnosis determined whether patients would proceed to autologous or allogeneic BMT as end consolidation after six cycles of chemotherapy. Conditioning for BMT was with BuCy, followed by allogeneic or unpurged autologous marrow infusion.

RESULTS

Of 37 patients who received chemotherapy, 35 achieved remission (95%) after one to six courses of treatment and 34 (92%) were transplanted. Five relapsed before BMT, four were subsequently transplanted in second complete remission (CR2) (n = 3) or untreated first relapse (n = 1), and one failed to respond to further therapy. All other patients proceeded to BMT in first complete remission (CR1). Eleven patients received allografts: one relapsed and one died of graft-versus-host disease (GvHD), for a leukemia-free survival rate of 90% at a median of 41 months after BMT (range, 3 to 60). For 23 autografts, there were two toxic deaths and eight relapses, with a leukemia-free survival rate of 61% at a median of 11 months after BMT (range, 0 to 66). The high relapse rate following autologous BMT led us to escalate the dose of Bu from 16 mg/kg to 600 mg/m2 using a single daily dose of Bu.

CONCLUSION

With modern supportive therapy, most newly diagnosed children with AML will enter remission and are eligible for intensification therapy. BuCy is well tolerated in children, which allowed us to escalate the dose of Bu in recent patients. Further follow-up is needed to determine whether this has an impact on the relapse rate following autologous BMT.

Acute myeloid leukaemia in patients with trisomy 21 (Down syndrome) treated by bone marrow transplantation

Patients with trisomy 21 have an increased incidence of haematological disorders, including neonatal 'leukaemoid reaction' (transient myeloproliferative disorder [TMD]), and acute leukaemias. In the past it has been felt that patients with trisomy 21 and acute leukaemia do not tolerate, and hence may not warrant, therapy as intensive as those without the syndrome. The present authors' experience and the current literature do not support this view. Two cases are reported of acute myeloid leukaemia in children with trisomy 21, successfully treated with intensive chemotherapy and bone marrow transplantation.

Emergence phenology of Chironomus tepperi Skuse and Procladius paludicola Skuse (Diptera: Chironomidae) during rice crop establishment in southern New South Wales

Midge emergence from untreated rice bays was monitored with conical traps during crop establishment. Chironomus tepperi Skuse was the numerically dominant species in all 3 seasons of the study, and generally had only 1 generation, although there was some evidence of a minor, non-overlapping second generation in the 1992 season. Emergence of first generation C. tepperi was highly synchronised, with peaks occurring 16-17 days after flooding. Procladius paludicola Skuse became the dominant species in trap collections after C. tepperi emergence declined, and had multiple overlapping generations. Members of the genus Procladius are predacious rather than phytophagous. Chironomus tepperi and P. paludicola together comprised 45.6-80.4% (mean 68.1%) of midges emerging during the first 48 days after flooding. More than 30 midge species were recorded from the trial site, but C. tepperi was the only phytophagous species recorded in sufficient numbers to warrant individually targeted control. Although C. tepperi has, in a practical sense, only 1 generation in establishing rice bays, growers have consistently reported that multiple chemical treatments are necessary to prevent crop damage. There are several possible explanations for this apparent anomaly. Chemical seed treatments may be failing to disperse sufficiently to control the first C. tepperi generation. Also, the elimination of chironomid larvae through the use of seed treatments may be making fields receptive to reinfestation by C. tepperi if oviposition is being regulated by the presence of larval populations. A third possibility is that phytophagous species other than C. tepperi, although poorly represented individually, may sometimes be abundant enough collectively to cause significant crop damage.

Pain and symptom control in paediatric palliative care

Important differences become evident in a comparison of cancer pain between children and adults. Management of pain in children is commonly multidisciplinary, is less dependent on invasive measures and relies more on systemic therapy. Children are not little adults: their immaturity, developing cognition and dependence all influence their experience and interpretation of pain. Much progress has been made in altering practices such as under-prescribing and underdosing that have adversely affected adequate control of pain in children. The challenge for paediatric health care providers in the mid 1990s is not only to be informed of current practices in pain and symptom control in paediatric palliative care, but also to remember to establish those practices in day to day management. Even though pain and its effects in children are now better understood, it is often still not managed optimally. Good management of pain in children depends on accurate assessment. In the past 10 years, assessment of pain in children has advanced considerably. However, assessment of pain in the preverbal child is still inadequate and in need of attention. Sedation, tolerance and involuntary movements may occur as side effects of opioids in children and may cause significant problems in management of the dying child. Psychostimulants can diminish sedation to some extent, but there is little information as yet on the value of these drugs in children. Tolerance to opioids may develop quickly, leading to poor control of pain and distress for the child. Strategies to improve management of tolerance include use of regional anaesthetic techniques such as the epidural/intrathecal route for opioid administration. Involuntary movements induced by opioids are uncommon but have the potential to cause significant distress. The mechanisms underlying these side effects of opioids need to be established. Strategies are needed for the effective treatment and prevention of these side effects. Neuropathic pain can be severe, distressing and difficult to treat. Experience of its treatment in terminally ill children is limited. Effective use of tricyclic antidepressants and systemically administered local anaesthetics is still to be determined. Regional anaesthetic techniques may be of great benefit when neuropathic pain cannot be controlled with systemic therapy. Procedural pain is more common than pain related to disease in the management of paediatric cancer. Further research is needed to identify the best approach to its management. We have found nitrous oxide to be of great benefit in management of procedural pain in children. Non-pharmacological methods of treatment of pain in children, such as transcutaneous electrical nerve stimulation or acupuncture, may also be useful and should receive continuing evaluation. There are significant and current issues in paediatric palliative care besides management of pain. There are difficulties in the provision of home nursing care for children with cancer in the terminal phase of their illness, including lack of community nursing services at night and on weekends and lack of adequate home help for parents. Attitudes of staff involved in the care of the child and family and their commitment to working as a multidisciplinary team strongly influence the quality and success of care given. Pain control and palliative medicine are evaluable by measures of quality assurance or outcome, and adoption of such evaluations should improve standards of care. Euthanasia in children is even more difficult as an ethical dilemma than in adults. Optimum symptom control with current techniques should almost always obviate its consideration. We are opposed to euthanasia. Psychosocial and cultural issues all influence the family's experience of palliative care. Further research is necessary in all of these areas.(ABSTRACT TRUNCATED)

Taxonomy, cladistics and biogeography of the Australian genus Putoniessa Kirkaldy (Hemiptera : Cicadelloidea : Cicadellidae)

The morphology of Putoniessa Kirkaldy is reviewed and the genus revised. In total, 28 species are recognised: the type species, P. dignissima Kirkaldy, which is removed from synonymy; one new combination, P. dorsalis (Walker); eight previously described species, P. nigra (Walker), P. minima Evans, P. mackei Evans, P. draba Evans, P. taradalensis Evans, P. sordida Evans, P. nigrella Evans and P. turneri Evans; and 18 new species, P. rieki, P, brisbanensis, P. hickmani, P, neboissi, P. stanthorpensis, P. woodwardi, P. striata, P. evansi, P. variegata, P. tasmaniensis, P. grossi, P. serrata, P. northamensis, P. bifurcata, P. kiataensis, P. watsoni, P. fusca and P. aroka. P. nota Evans is excluded from the genus, and P. maculata Evans is synonymised under P. dorsalis (Walker). P. rivularis (Walker), originally described under Bythoscopus Germar, and P. galliensis Evans are considered as species of uncertain identity. The genus is shown to have a disjunct Bassian distribution with some eastern species extending northwards into the south-east of the Tomesian province. A consensus cladogram for Putoniessa, based on morphological characters, is presented. Large areas of the cladogram remain unresolved because of high levels of homoplasy among the limited number of reliable ingroup characters available. The cladogram does not support a purely vicariant biogeographic hypothesis. Theories that receive qualified support involve an eastern origin for the group followed by either an east-to-west dispersal or a vicariance event affecting a single taxon subsequent to initial speciation. A western origin for the group is strongly refuted.

Gallium-67 and technetium-99m-methylene diphosphonate skeletal scintigraphy in determining prognosis for children with stage IV neuroblastoma

Thirty-five children (aged 0-9 yr) who had presented with Stage IV neuroblastoma were studied to see if avidity for 67Ga or 99mTc-methylene diphosphonate (MDP) uptake in both primary and secondary sites at diagnosis conferred any prognostic significance. Twenty-three percent of the patients were disease free and off treatment at the time of study. Crude survival did not differ between groups. Duration of survival and the likelihood of completing treatment were related to the scintigraphic appearance at the time of diagnosis, after adjustment for potential confounding effects, using Cox's proportional hazards regression and multiple logistic regression. After adjustment for confounding influences, neither 67Ga avidity nor uptake of 99mTc-MDP was associated with a significantly worse prognosis, both in terms of adjusted survival and likelihood of completing treatment. Patients with 67Ga-avid scans at diagnosis did not demonstrate significantly worse survival (HR 1.47, 95% CI 0.43-5.11) than those without 67Ga avidity. They were somewhat less likely to complete treatment (OR 0.23, 95% CI 0.03-1.63), but this did not reach statistical significance. Similarly, although patients with 99mTc-MDP positive scans demonstrated somewhat worse survival (HR 2.47, 95% CI 0.45-13.54), this result did not reach statistical significance, nor were they less likely to complete treatment (OR 0.69, 95% CI 0.07-6.67) than those with 99mTc-MDP negative scans. Uptake of 99mTc-MDP into extraosseous sites was also not associated with worse survival (HR 1.45, 95% CI 0.58-3.62) nor with decreased likelihood of completing treatment (OR 0.78, 95% CI 0.12-5.09). Other than indicating disease stage, these results do not support the hypothesis that the scintigraphic appearance at diagnosis confers prognostic information in children with advanced neuroblastoma.

Smokeless tobacco use among children: the New Hampshire Study

Rural public school children initially in grades 4, 5, and 6 participated in a 36-month follow-up study of substance abuse prevention. Children completed self-report questionnaires at baseline and annually for three years after the introduction of prevention programs. We compared outcomes of (1) a comprehensive school curriculum ("Here's Looking at You, 2000"), (2) the curriculum plus a parenting course ("Parent Communication Course") and a community task force (Johnson Institute Model), and (3) control condition. Neither the curriculum nor the curriculum plus parent and community intervention had any effect on smokeless tobacco use by this preadolescent and young adolescent population. We used stepwise logistic regression to determine prediction models for smokeless tobacco use. Initiation of smokeless tobacco use is associated with sex, grade, and having friends who use drugs. Although regular use increases with grade, poor family relations, and low school satisfaction, the greatest risk factor was ever trying smokeless tobacco. We describe the culture of smokeless tobacco use in this population, and we discuss the implications of our research for smokeless tobacco use prevention.

"Shuttle sheet": a patient-held medical record for pediatric oncology families

A patient-held medical record used by a pediatric oncology unit is described. Each patient's family is provided with a folder containing detailed information about the patient's current treatment. The record helps orient all health care workers involved in the patient's management to the treatment schedule, including exact doses of drugs. Details of blood counts and treatment given are entered by health care workers at each consultation, but the record is always retained by the family. The benefits of this record are that it saves time, reduces the likelihood of errors in scheduling and doses of cytotoxic drugs, and facilitates continuation of therapy at locations away from the supervising oncology unit. It reduces the amount of correspondence required for patient care, is a useful diary and treatment planner for the patient's family and hospital staff, and is an educational resource for the patient's family. It is a useful adjunct to the hospital's medical record for clinical trial data, is easily replaced if lost, and is inexpensive. It also assists surveillance of long-term survivors. The record is particularly valuable when used with patients who are being treated or assessed at more than one institution or by multiple health care workers. The record is in its 12th year of service and is used by more than 95% of patients on therapy attending the unit.

Cognitive effects of childhood leukemia therapy: a case for four specific deficits

Prophylactic treatment of the central nervous system (CNS) with cranial irradiation and antineoplastic drugs has made childhood acute lymphoblastic leukemia (ALL) a survivable disease, but at the same time there have been many reports of iatrogenic effects, including deficits in cognitive functioning. Previous research suggests a particular effect on the Freedom from Distractibility factor of the WISC-R, memory, and attention. These particular abilities are tested in a group of 43 ALL survivors, with comparisons against solid tumor as well as sibling controls. The results indicate that four cognitive processes are affected by CNS prophylaxis for ALL: short-term memory, speed of processing, visuomotor coordination, and sequencing ability. Younger children have a more severe speed of processing deficit and children treated with a less rigorous protocol appear to be slightly less affected generally. The specific cognitive deficits found are related to neurological evidence on both theoretical and empirical grounds. Results suggest that children who have received CNS prophylaxis are able to learn, but may be slower to acquire new material and may benefit from bimodal presentation.

Revision of the genus Alseis Kirkaldy (Homoptera : Cicadelloidea : Cicadellidae), with descriptions of six new species

The genus Alseis Kirkaldy is revised. Seven species are recognised: the type species, A. osborni Kirkaldy, and six new species, A. noccundraensis, A. brittoni, A. gattonensis, A. awoongaensis, A. hackeri and A. monstrosa. The genus is known only from eastern Australia. The known distributions of all species are mapped, and a key to males of the genus is presented.

Bulbar and pseudobulbar palsy complicating therapy with high-dose cytosine arabinoside in children with leukemia

Three of 38 children given high-dose cytosine arabinoside therapy developed a previously undescribed complication. Neurological problems are a frequent occurrence in patients given this therapy, particularly cerebellar ataxia, but the development of bulbar and pseudobulbar palsy has not been reported. In two of these cases, it was sufficiently marked for the course of treatment to be curtailed and occurred at a relatively low cumulative dose of the drug. Neurotoxicity can occur at any time using high-dose cytosine therapy.

A clinical trial of beta carotene to prevent basal-cell and squamous-cell cancers of the skin. The Skin Cancer Prevention Study Group

BACKGROUND

Beta carotene has been associated with a decreased risk of human cancer in many studies employing dietary questionnaires or blood measurements, and it has had protective effects in some animal models of carcinogenesis.

METHODS

We tested the possible cancer-preventing effects of beta carotene by randomly assigning 1805 patients who had had a recent nonmelanoma skin cancer to receive either 50 mg of beta carotene or placebo per day and by conducting annual skin examinations to determine the occurrence of new nonmelanoma skin cancer.

RESULTS

Adherence to the prescribed treatment was good, and after one year the actively treated group's median plasma beta carotene level (3021 nmol per liter) was much higher than that of the control group (354 nmol per liter). After five years of follow-up, however, there was no difference between the groups in the rate of occurrence of the first new nonmelanoma skin cancer (relative rate, 1.05; 95 percent confidence interval, 0.91 to 1.22). In subgroup analyses, active treatment showed no efficacy either in the patients whose initial plasma beta carotene level was in the lowest quartile or in those who currently smoked. There was also no significant difference between treated and control groups in the mean number of new nonmelanoma skin cancers per patient-year.

CONCLUSIONS

In persons with a previous nonmelanoma skin cancer, treatment with beta carotene does not reduce the occurrence of new skin cancers over a five-year period of treatment and observation.

A revision of the genus Epipsychidion Kirkaldy (Homoptera : Cicadelloidea : Cicadellidae)

The Australian cicadellid genus Epipsychidion Kirkaldy is revised. Two species are recognised: E. epipyropis Kirkaldy (the type species) and E. whitteni Evans. E. fides Evans is synonymised with E. epipyropis, and a lectotype designated for the latter. A key is provided to the males of the genus, and the known distributions of both species are mapped.

Carbohydrate metabolism on high dose growth hormone therapy in children treated for leukaemia

The effect on carbohydrate metabolism of a high dose growth hormone (GH) regimen (1.2 U/kg per week) was assessed on 24 children who had previously been treated for leukaemia. Sixteen patients received high dose GH and eight patients received a conventional dose of GH (0.6 U/kg per week). Oral glucose tolerance tests (OGTT) were performed at baseline and after 3 months of treatment with GH. For the entire group between 0 and 3 months, there was a significant increase in mean (and standard deviation) fasting plasma glucose (0.3 +/- 0.6 mmol/L), fasting insulin level (11 +/- 26 mU/L), and 2 h insulin level (20 +/- 40 mU/L). One patient, who received a conventional dose of GH, developed substantial carbohydrate intolerance. For the entire group, there was no change in response to a carbohydrate load at 3 months as measured by the area under the plasma glucose or insulin curve. There was no significant difference between conventional and high dose groups at 3 months as assessed by these parameters. This study demonstrates that a higher dose of GH may be used in these children in an attempt to improve their final height, without increased risk of carbohydrate intolerance in the short term.

The Skin Cancer Prevention Study: design of a clinical trial of beta-carotene among persons at high risk for nonmelanoma skin cancer

We describe a randomized clinical trial of oral beta-carotene (50 mg/day) for preventing nonmelanoma skin cancer. It is a multicenter study conducted at sites in California, Minnesota, and New Hampshire. This report describes the design of the study, baseline characteristics of the 1805 randomized patients, changes in their plasma beta-carotene and retinol levels after 1 year of treatment, and plans for statistical analyses. Important features of this study are (1) a high proportion of potential subjects were found to be ineligible or chose not to enter the study, (2) the study agent is readily available over the counter and in common foods, and (3) nonmelanoma skin cancer is a relatively minor health concern for most patients. These considerations necessitated intensive efforts to encourage compliance with the study regimen. There are also some unusual statistical features of the study. One is that the study outcome is routinely assessed only at annual examinations, so the precise time of failure cannot be identified. Also, a secondary goal of the study is to determine whether beta-carotene decreases the average number of new skin cancers per patient per year, and there are no established statistical methods for analysis of data in this situation. Alternative approaches to the analysis are discussed.

Neuropsychological sequelae of central nervous system prophylaxis in survivors of childhood acute lymphoblastic leukemia

We assessed neuropsychologically 106 children with acute lymphoblastic leukemia (ALL) who had all received cranial irradiation for the prevention of central nervous system (CNS) leukemia 1-13 years previously. Children were assessed for adverse late effects of their therapy, using age-appropriate Wechsler measures of overall intellectual ability and supplementary tests. Forty-five siblings near in age to the patients were tested as controls. The patients who had had the most intensive central nervous system (CNS) prophylaxis were found to have a WISC-R Full Scale IQ 17 points lower than the sibling control group. Performance IQ was more affected than verbal IQ. The patients were more easily distracted and less able to concentrate. The severity of the aftereffects was related to younger age at the time of CNS prophylaxis and to a higher dose of cranial irradiation but not to time since CNS prophylaxis. CNS prophylaxis using a combination of cranial irradiation and intrathecal methotrexate has lowered the incidence of CNS relapse in childhood ALL but is associated with considerable long-term morbidity in survivors.

Neuropsychological sequelae of central nervous system prophylaxis in survivors of childhood acute lymphoblastic leukemia

We assessed neuropsychologically 106 children with acute lymphoblastic leukemia (ALL) who had all received cranial irradiation for the prevention of central nervous system (CNS) leukemia 1-13 years previously. Children were assessed for adverse late effects of their therapy, using age-appropriate Wechsler measures of overall intellectual ability and supplementary tests. Forty-five siblings near in age to the patients were tested as controls. The patients who had had the most intensive central nervous system (CNS) prophylaxis were found to have a WISC-R Full Scale IQ 17 points lower than the sibling control group. Performance IQ was more affected than verbal IQ. The patients were more easily distracted and less able to concentrate. The severity of the aftereffects was related to younger age at the time of CNS prophylaxis and to a higher dose of cranial irradiation but not to time since CNS prophylaxis. CNS prophylaxis using a combination of cranial irradiation and intrathecal methotrexate has lowered the incidence of CNS relapse in childhood ALL but is associated with considerable long-term morbidity in survivors.

Treatment of advanced and inaccessible sarcomas with continuous intra-arterial chemotherapy prior to definitive surgery or radiotherapy--a possible alternative to amputation or disabling radical surgery

Four patients with advanced and inaccessible soft tissue sarcomas were treated with a regimen of intra-arterial chemotherapy followed by radiotherapy and/or surgical excision. Two of the patients had advanced sarcomas in the buttock and thigh regions which would otherwise have required hindquarter amputation in one case or disarticulation of the hip in the other case. These sarcomas responded significantly to intra-arterial chemotherapy to the extent that subsequent local surgery was effective in eradicating the residual tumours. No viable tumour cells were found in the resected specimens. In both patients amputation was avoided and local tumour eradication was achieved. In the other two patients, advanced and non-resectable sarcomas in the head were first treated with a similar regimen of intra-arterial chemotherapy. In both cases the tumours regressed in size prior to administration of local radiotherapy. After completion of chemotherapy and radiotherapy no viable tumour cells were detected in either lesion. In one case (originally a very extensive sarcoma of the jaw in a 5 year old child) a residual lump was resected but no viable tumour was detected in the resected specimen. These four patients represent our total experience with this plan of management. All responded well and there has been no evidence of local disease recurrence in any of the four patients. One patient (Case 2) did develop pulmonary and bone metastases from which she died 2 years later but the other three patients remain well with no evidence of residual disease, 11 years, 4 years and 20 months after presentation.

Growth failure and growth-hormone deficiency after treatment for acute lymphoblastic leukaemia

In a study of 77 children who had been treated for acute lymphoblastic leukaemia (ALL) with an LSA2L2 (Memorial Sloan-Kettering) chemotherapy protocol plus radiotherapy (24 Gy) as cranial prophylaxis, growth was examined 3.0-9.5 years after diagnosis. The children's growth slowed and they crossed height percentiles towards the end of or after treatment. The Z-score, which reflects the deviation of height measurements from the population mean, was used to assess height change. The mean Z-score was 0.16 at diagnosis, -0.30 2 years later, -0.71 4 years later, and -1.37 6 years later. Height for age had fallen by more than 1 standard deviation of the population mean in 32% of survivors 4 years after diagnosis and in 71% 6 years after diagnosis. Younger children and those tall for age at diagnosis were more severely affected. Growth-hormone (GH) response to standard provocation tests was measured in 46 patients; 30 had partial or complete GH deficiency. Mean pulsatile GH secretion was low in the 34 patients tested. Cranial irradiation is probably the most important causative factor in the development of GH deficiency in survivors of ALL.

Unusual skin rash following withdrawal of oral 6-mercaptopurine in children with leukemia

Sixteen episodes of a distinctive, papular rash occurred in eight patients following withdrawal of 6-mercaptopurine (6MP) and methotrexate (MTX) used as maintenance therapy for acute lymphoblastic leukemia (ALL). The rash also developed in one of the eight patients when only 6MP was discontinued. The eruption occurred mainly on the face, and in this site resembled the perioral dermatitis seen following withdrawal of topical fluorinated steroids. The rash generally began within 3 weeks of stopping 6MP and lasted 3 to 4 weeks. It failed to improve with the use of topical corticosteroid. We conclude that this rash is caused by the withdrawal of oral 6MP.

Diagnosis and behavior of juvenile rhabdomyosarcoma

The main problems in the diagnosis of rhabdomyosarcoma are 1) distinction of undifferentiated examples from other small cell malignancies, especially soft-tissue Ewing's tumor and lymphoma; 2) distinction of spindling examples from fibrosarcoma, leiomyosarcoma, malignant fibrous histiocytoma, polyhistioma, and other sarcomas; 3) recognition of minimal criteria on small samples such as needle biopsy specimens or frozen sections; and 4) recognition of rhabdomyosarcoma in uncommon sites such as bone (mandible), perineum, retroperitoneum, and chest. In 95 pediatric cases diagnosed and treated at Royal Alexandria Hospital for Children--45 after the introduction of combined therapy--minimal diagnostic criteria were assessed. Cross-striations were found in only one third of cases; longitudinal myofibrils were more common and more helpful. There was much overlap between histologic types, and the microscopic patterns had little bearing on prognoses in preadolescent children. Fourteen cases could not be further differentiated ("embryonal sarcoma, probably rhabdomyosarcoma")--nine small-cell tumors; four tumors from genitourinary tract or head for which very small biopsy specimens were available, and one spindling retroperitoneal neoplasm. In all, slight evidence suggested embryonal rhabdomyosarcoma; this evidence included oat-shaped nuclei and, in a few cells, deeply eosinophilic cytoplasm, small elongated processes, or myxoid or alveolar foci--features that exclude lymphoma and Ewing's tumor. In six cases that were originally classified as poorly differentiated or undifferentiated, later material confirmed the presence of rhabdomyosarcoma by showing a predominantly well-differentiated (pleomorphic) or alveolar pattern after therapy. In 14 remaining undifferentiated cases, immunoperoxidase staining with antihuman-myoglobin serum was positive in five. With combined therapy there was 100 per cent survival among patients with paratesticular, limb, and stage I and stage II tumors; considerably improved survival among patients with head and neck, pelvic, and stage III tumors; and 100 per cent mortality among patients with intra-abdominal and stage IV tumors.