AlphaIIb's cytoplasmic domain is not required for ligand-induced clustering of integrin alphaIIbbeta3

The platelet integrin alphaIIbbeta3 exhibits bidirectional signaling, in that intracellular messengers enable adhesive macromolecules to bind to its ectodomain, while ligation promotes the association of cytoskeletal proteins with its cytoplasmic domains. In order to understand the linkage between these distant regions, we investigated the effects of receptor occupancy on the solution structure of both full-length recombinant alphaIIbbeta3 and alphaIIbDelta991beta3, an integrin truncation mutant which lacks one cytoplasmic domain. Lysates of (35)S-labeled human A549 cells expressing either full-length alphaIIbbeta3 or alphaIIbDelta991beta3 were examined by sucrose density gradient sedimentation followed by immunoprecipitation to determine the distributions of integrin protomers and oligomers. Recombinant alphaIIbbeta3 exhibited a weight-average sedimentation coefficient, S(w)=11.3+/-1.4 S with 73% sedimenting as protomers/dimers (9.1+/-1.0 S) and 27% as oligomers (15.4+/-0.4 S). Truncation mutant alphaIIbDelta991beta3 exhibited a similar pattern with 65% sedimenting as protomers/dimers. Upon ligation with eptifibatide, both full-length alphaIIbbeta3 and alphaIIbDelta991beta3 sedimented mainly at >14 S, indicating 2-3-fold increased oligomerization. Thus we have demonstrated that alphaIIb's cytoplasmic region is not required for integrin clustering, a key event in outside-in signaling.

Enhancing adherence to HAART: a pilot program of modified directly observed therapy

Based on the model of directly observed therapy (DOT) for tuberculosis, we implemented an uncontrolled pilot program of modified DOT to increase adherence to HAART. Participants met every weekday with an outreach worker who observed them taking the morning dose of HAART. Thirty-seven patients with a history of poor adherence were enrolled and followed for a mean duration of 10 months. The program was feasible and well accepted by the participants. Self-reported adherence to nonobserved doses improved, and those who remained in the program for a year (n = 18) demonstrated a mean 1.53-log decrease from baseline in plasma HIV RNA level.

Syringe prescription to prevent HIV infection in Rhode Island: a case study

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system.

Prescribing syringes to prevent HIV: a survey of infectious disease and addiction medicine physicians in Rhode Island

This article describes the assessment of physicians' attitudes and practices regarding prescribing syringes to injection drug users (IDUs). A brief, anonymous, self-administered questionnaire was sent to all Infectious Disease and Addiction Medicine specialists in Rhode Island. Of 49 eligible physicians, 39 responded (response rate 80%). Most (95%) indicated that there is a legitimate medical reason for IDUs to obtain sterile syringes. Many (71%) agreed that they would prescribe syringes to prevent disease in IDUs if it were clearly legal to do so. We can conclude that physician syringe prescription to IDUs may be an acceptable supplement to existing HIV prevention strategies.

Differences in length of stay for Hospital in the Home patients: comparing simple clinical coding with medical record review

AIM

To determine whether the apparently longer length of stay (LOS) reported for patients with cellulitis managed in Hospital in the Home (HITH) compared with those managed as inpatients was correct.

METHODS

Data, including LOS, from the Victorian In-patient Minimum Database (VIMD) of all patients with cellulitis managed between July 1998 and June 1999 at a large metropolitan teaching hospital were analysed and compared with a retrospective medical record review of the same patients.

RESULTS

In the VIMD data, there were 266 episodes of cellulitis during the study period. However, the medical record review found that six episodes were not separate, but rather a continuation of treatment for the same episode of cellulitis, and that 18 were not episodes of cellulitis, but were pilonidal sinus infections. In the VIMD data set, the mean LOS for patients treated in HITH was generally longer than that for inpatients (7.2 days vs 5.1 days, respectively, P = 0.002). However, in the retrospective medical record review, the LOS for patients treated in HITH was similar to inpatients (7.3 days versus 7.0 days, respectively, P = 0.68).

CONCLUSIONS

In contrast to the VIMD data, the medical record review demonstrated that, overall, patients with cellulitis had a similar LOS irrespective of whether they were managed at home or in hospital. This study confirms that caution is required in interpreting the VIMD data, highlights the importance of carefully monitoring the introduction of new treatment modalities and indicates areas for further research.

Treating cancer patients. Practical monitoring and management of therapy-related complications

OBJECTIVE

To review investigation and management of some common long-term complications associated with cancer chemotherapy and radiation therapy.

QUALITY OF EVIDENCE

Databases searched using MeSH key words "cancer chemotherapy," "cancer chemotherapy complications," "radiation therapy," and "radiation therapy complications" included Ovid and CANCERLIT. Overall the literature in this area is not strong; treatment guidelines and consensus conferences generally are lacking. Recommendations in this paper are mainly based on the results of individual studies and case reports, as few randomized controlled trials have been performed. Where appropriate, recommendations incorporate results of published treatment guidelines and consensus conferences.

MAIN MESSAGE

For most solid tumours, patients should be most frequently monitored during the first 3 years after completing initial treatment for cure. Follow-up monitoring usually incorporates physical examination as well as radiologic and laboratory investigations. Patients should not be lost to follow up once treatment is completed, but monitored regularly, especially while they are at highest risk for disease recurrence. Long-term complications associated with cancer therapy include postsplenectomy sepsis syndrome; central and peripheral nervous system toxicities; ocular complications; thyroid, pituitary, testicular, or ovarian dysfunction; pulmonary toxicity; vascular or lymphatic, gastrointestinal, or osseous complications; genitourinary problems; and possible secondary malignancy.

CONCLUSION

Primary care physicians are key to facilitating appropriate follow up of treated cancer patients. To do this, they must be aware of practical aspects of monitoring and management of therapy-related complications.

Skin blood flow changes in response to intradermal injection of bupivacaine and levobupivacaine, assessed by laser Doppler imaging

BACKGROUND AND OBJECTIVES

The vascular effects of local anesthetics are important determinants of their therapeutic activity. Drugs that vasoconstrict have the potential clinical advantages of limited systemic uptake and prolonged duration of effect. The aim of this study was to assess quantitatively the cutaneous vasoactivity of racemic bupivacaine and one of its enantiomers, levobupivacaine.

METHODS

Four concentrations of each drug (0.1 mL each of 0.125%, 0.25%, 0.5%, and 0.75%), as well as normal saline, were injected intradermally into randomly assigned sites on the forearms of 10 volunteers. We measured skin blood perfusion using laser Doppler imaging before injection and at 2.5, 10, 20, 40, 60, and 90 minutes thereafter.

RESULTS

Both drugs produced a rapid, dose-dependent increase in skin perfusion (P <.001). Saline also caused an increase in perfusion, although less sustained. By 40 minutes, most responses had returned to baseline levels. However, after this time, perfusion continued to decrease, below baseline, for both bupivacaine and levobupivacaine. The exception to this was 0.75% bupivacaine, the response to which was significantly higher than the same concentration of levobupivacaine over this later period (P <.05).

CONCLUSIONS

Bupivacaine and levobupivacaine both have a biphasic effect on skin microvessels. The vasoconstriction observed after 40 minutes may occur when the quantity of drug remaining at the administration site has decreased to a lower level. The continued vasodilatation caused by bupivacaine is more difficult to interpret. The results suggest that these local anesthetics cause vasodilatation at high doses and vasoconstriction at lower, subclinical doses. This hypothesis and the clinical relevance of these effects warrant further investigation.

Expression of Rattus norvegicus mtDNA in Mus musculus cells results in multiple respiratory chain defects

The production of in vitro and in vivo models of mitochondrial DNA (mtDNA) defects is currently limited by a lack of characterized mouse cell mtDNA mutants that may be expected to model human mitochondrial diseases. Here we describe the creation of transmitochondrial mouse (Mus musculus) cells repopulated with mtDNA from different murid species (xenomitochondrial cybrids). The closely related Mus spretus mtDNA is readily maintained when introduced into M. musculus mtDNA-less (rho(0)) cells, and the resulting cybrids have normal oxidative phosphorylation (OXPHOS). When the more distantly related Rattus norvegicus mtDNA is transferred to the mouse nuclear background the mtDNA is replicated, transcribed, and translated efficiently. However, function of several OXPHOS complexes that depend on the coordinated assembly of nuclear and mtDNA-encoded proteins is impaired. Complex I activity in the Rattus xenocybrid was 46% of the control mean; complex III was 37%, and complex IV was 78%. These defects combined to restrict maximal respiration to 12-31% of the control and M. spretus xenocybrids, as measured polarographically using isolated cybrid mitochondria. These defects are distinct to those previously reported for human/primate xenocybrids. It should be possible to produce other mouse xenocybrid constructs with less severe OXPHOS phenotypes, to model human mtDNA diseases.

High street prices of syringes correlate with strict syringe possession laws

The current epidemic of injection drug use in the United States and abroad has precipitated an increase in transmission of infectious diseases, including human immunodeficiency virus (HIV), hepatitis B, hepatitis C, and human T-lymphotrophic virus II (HTLV-II) in injection drug users (IDUs) who share syringes and other injection equipment. Sharing is often due to a lack of available sterile syringes, which is, in part, a result of laws and regulations controlling the purchase and possession of syringes. These laws, in turn, raise the price of questionably sterile black market syringes, inadvertently encouraging the reuse and sharing of syringes. To date, very little information has been gathered on the street price of syringes in different communities. We surveyed 42 needle exchange programs (NEPs) in the United States in July and August 1998 to determine the street prices of syringes. The relationship among local laws regulating syringe possession, the enforcement of those laws, and street syringe prices was examined. There was a strong correlation between the presence of syringe possession laws and higher street syringe price ($2.87 vs. $1.14, p< .01). In areas with syringe possession laws, cost was significantly higher when laws were perceived to be enforced strictly ($3.66 vs. $2.08, p<.01). Street prices for syringes are an easily quantifiable indirect measure of availability of sterile syringes and may reflect syringe sharing and reuse.

The carers of hospital in the home patients focus on clinical processes, procedures and the prediction of deterioration

The aim of this study was to explore the psychological processes and information needs in a group of 78 Hospital-in-the-Home (HITH) carers, randomly selected from two university teaching hospital HITH programs in Melbourne. Semi-structured interviews were conducted and explored with a computerised lexical thematic content analysis program. The results revealed that psychological themes of carers were mainly related to HITH clinical processes, procedures and the prediction of complications or deterioration of the patient. Carers indicated that they needed further information on the patients' clinical conditions, emergency procedures and how to detect deterioration. The implication for HITH nurses is that information provided to HITH carers should at least include these topics. The information needs of HITH carers appear to be different to those of the carers of individuals with chronic illness, consequently, nurses need to develop very specific patient and carer information materials for the HITH setting.

Chemotherapy standards for hospital in the home: how useful?

The process of developing practice standards is complex and resource intensive. The aim is to produce standards that meet the practicalities of clinical practice, are meaningful and achievable and that enhance the quality of patient care. This article details the process of developing chemotherapy standards for Hospital in the Home (HITH) and describes the results of a pilot project and the implications for nursing practice in this relatively new area of care delivery. Five Melbourne metropolitan Hospital in the Home (HITH) programs participated in the pilot process and evaluated the standards against their own programs. There was a wide variation in the skill sets nurses required depending on the structure of the HITH program. There were differences between programs in the nature of the interventions provided at home, documentation of treatments and points of contact for patients out of hours. Areas of concern identified by staff in the participating programs included the level of detail the standards required for assessment of the patients' home as an appropriate site to administer chemotherapy and the qualifications required by staff managing HITH chemotherapy patients.

Lack of germline CDK6 mutations in familial melanoma

Germline mutations in genes encoding several components of the retinoblastoma pathway have been linked with inherited predisposition to melanoma. Most commonly, such mutations involve CDKN2A, a cyclin-dependent kinase inhibitor of two kinases, CDK4 and CDK6, which phosphorylate the retinoblastoma protein (pRB) and thereby promote passage through the G1/S cell-cycle restriction point. Less frequently, germline mutations in the CDK4 gene have also been linked with an increased risk of melanoma. Despite the sequence and functional homology between CDK4 and CDK6, the role of germline mutations in CDK6 in melanoma predisposition is unknown. We detected no CDK6 mutations within the p16 (CDKN2A) binding domain in index cases from 60 melanoma-prone kindreds that lacked germline mutations in the coding regions of either CDKN2A or within the entire CDK4 coding region. We conclude that germline mutations in CDK6 do not make a significant contribution to melanoma predisposition.

Tracking and follow-up of marginalized populations: a review

Maintaining study cohorts is a key element of longitudinal research. Participant attrition introduces the possibility of bias and limits the generalizability of a study's findings, but with appropriate planning it is possible to sustain contact with even the most transient participants. This paper reviews the essential elements of tracking and follow-up of marginalized populations, which are (1) collection of contact information, (2) thorough organization of tracking efforts, (3) attention to staff training and support, (4) use of phone and mail follow-up, (5) use of incentives, (6) establishing rapport with participants, (7) assurance of confidentiality, (8) use of agency tracking, (9) use of field tracking, and (10) attention to safety concerns. Diligent application of these tracking strategies allows researchers to achieve follow-up rates of 75 percent to 97 percent with vulnerable populations such as homeless, mentally ill adults, injection drug users, and runaway youth.

Cross-Canada spread of methicillin-resistant Staphylococcus aureus via transplant organs

We report our investigation of the transmission of methicillin-resistant Staphylococcus aureus (MRSA) through transplantation. The kidneys, liver, and corneas were harvested from a child who died in Nova Scotia. Several days postmortem it was learned that culture of a premortem endotracheal tube aspirate from the donor yielded MRSA. Both kidneys were transplanted into a child in Nova Scotia and the liver into a child in Alberta. Both recipients subsequently became blood culture-positive for MRSA. One corneal ring from the donor was MRSA-positive. All four MRSA isolates were mecA-positive by polymerase chain reaction (PCR). The relatedness of the MRSA isolates was examined by restriction fragment length polymorphism (RFLP) analysis, a 16S-23S ribosomal PCR typing method, and comparison of antibiograms. Results were identical for all four MRSA isolates. These findings indicate that MRSA from the donor was transferred to recipients during implantation of harvested organs in Alberta and Nova Scotia, a cross-Canada spread.

Needle exchange program participation by anabolic steroid injectors, United States 1998

A significant number of people are currently misusing and abusing anabolic steroids. Hepatitis B, C, and HIV have all been documented to occur among anabolic steroid injectors (ASIs), most likely from the sharing of injection equipment. A survey was administered to 42 needle exchange programs (NEPs) from 17 states in the US to determine ASI participation. Sixty percent of the NEPs surveyed reported having at least some ASIs as participants, however, only 512 ASIs were identified among the 36,000 total monthly participants (1.4%). With the expanding number of NEPs in the US, it is possible to reach a higher proportion of ASIs with clean syringes and education, thus offering the means to prevent the spread of infection in this population.

Obstacles to needle exchange participation in Rhode Island

OBJECTIVE

This study explores obstacles to participation in needle exchange programs (NEPs) among injection drug users (IDUs) in the state of Rhode Island, U.S.A.

METHODS

A written questionnaire was administered at two Rhode Island drug detoxification sites in 1998.

RESULTS

488 self-administered surveys were completed, 226 (46.3%) respondents had injected drugs in the past 6 months. 62.1% reported sharing syringes in the past 6 months, and each syringe was used a mean of 10.7 times. Major obstacles to NEP participation were a lack of awareness of the program (25.6%), inconvenient location or hours (15.9%), and fear of identification and/or police harassment (12.2%). Non-white race was a significant predictor of being unaware of the NEP (p = .01) and not participating in the NEP (p = .03). 13.1% of IDUs who used the NEP were referred to the detoxification program by the NEP. Among all IDUs surveyed, 51.0% had participated in a NEP.

CONCLUSIONS

NEPs are important in reducing the spread of bloodborne pathogens among IDUs and are effective referral sources for drug treatment. Surveys of IDUs at sites other than NEPs, such as detoxification facilities, can identify obstacles to the use of NEPs.

Mutation detection using fluorescent enzyme mismatch cleavage with T4 endonuclease VII

Mutation detection techniques are often limited by sensitivity, ease of use and short fragment lengths. Enzyme mismatch cleavage (EMC) is a technique capable of rapidly scanning 1 kbp fragments of DNA for mutations. It relies on the ability of a bacteriophage resolvase enzyme, T4 endonuclease VII, to cleave DNA at single base pair mismatches and small heteroduplex loops. Originally the process was performed using radioactively labeled DNA and the results analysed after denaturing polyacrylamide gel electrophoresis and autoradiography. However, access to systems capable of detecting fluorescent species migrating through a gel and the widespread availability of fluorescently tagged primers have greatly improved upon the original technique. A number of mutations were detected using fluorescent EMC and the results compared to performing the technique using radiolabeled DNA. Fluorescent EMC detected the presence, position and number of mutations in DNA fragments as large as 1 kbp. The fluorescent method was found to have advantages over the original method in its ease of use, increase in signal-to-noise ratio and the ability to multiplex samples by labeling DNA fragments with different fluorophores. This improvement on an already established method provides a sensitive, robust technique for mutation detection.

Postirradiation sarcoma after external beam radiation therapy for localized adenocarcinoma of the prostate: report of three cases

We report 3 cases of postirradiation sarcoma that arose in the pelvis 8, 15, and 16 years after completion of external beam radiation therapy (RT) for localized adenocarcinoma of the prostate. Although such cases must be regarded as extremely rare, postirradiation sarcoma should be considered as a potential cause of pelvic pain developing after RT.

Peritonitis due to Stenotrophomonas maltophilia in patients undergoing chronic peritoneal dialysis

The occurrence of cases of Stenotrophomonas maltophilia peritonitis in chronic peritoneal dialysis (PD) patients prompted a review of our experience with this condition. A search of microbiology records revealed seven episodes of S. maltophilia peritonitis in 7 patients in 1996 - 3.8% of all PD patients - compared to no cases in 1994 and 1995 (p = 0.01). Patients ranged in age from 16 to 64 years; there were 3 males and 4 females. Six of seven episodes of peritonitis were community acquired and one was hospital acquired. No temporal clustering of cases was seen. Patients were from different urban and rural communities. Patients used the same commercially supplied dialysate fluid, different dialysis techniques, and were taught a no-touch technique for connection. Treatment of peritonitis required removal of the Tenckhoff catheter in 4 of 7 cases. Fingerprinting of six available isolates by polymerase chain reaction using primers derived from the conserved region of the 16/23Sr RNA gene sequence and pulsed field gel electrophoresis revealed all to be unique strains. A case-control study comparing 7 S. maltophilia cases to 21 PD controls showed case patients to be younger and more likely to be on immunosuppressive therapy. We conclude that S. maltophilia has emerged as an important cause of peritonitis in our continuous ambulatory PD population. Evidence to date suggests community acquisition with no evidence of a common source.

Pion conformal radiation of prostate cancer: results of a randomized study

PURPOSE

To compare the efficacy of pion radiation therapy with conventional external beam photon therapy, for the treatment of locally advanced stage T3/4, N0, M0 adenocarcinoma of the prostate.

METHODS AND MATERIALS

Two hundred seventeen eligible patients were randomly allocated to either photon or pion therapy. No adjuvant hormone therapy was used.

RESULTS

Median follow-up was 42 months (range 2-90). Acute bladder toxicity was worse in the pion arm, p = 0.2, but other acute toxicity did not differ. Late grade 2 toxicity was significantly less in the pion arm (29% at 5 years versus 48%, p = 0.002), but late grade 3 or 4 toxicity did not differ. Clinical local control was not significantly different between treatment arms (64% after 5 years with photons, 56% with pions, p = 0.6). Cause-specific and overall survival also did not differ (p = 0.7). There was a significant delay in time to first failure in the photon arm, largely as a result of decreased biochemical relapse, p = 0.01. A multivariate analysis is presented.

CONCLUSION

Pion therapy was well tolerated, with increased acute toxicity and significantly decreased late tissue injury. This contrasts with the late toxicity observed with higher LET particle therapy such as neutron therapy. No improvement in local control with pion therapy was observed.

Central venous catheters as a source of hemodialysis-related bacteremia

OBJECTIVE

To describe investigations into an increase in hemodialysis-related bacteremia that occurred in our hospital in the first 6 months of 1996.

SETTING

Hemodialysis unit in a tertiary-care medical center.

METHODS

Prospective surveillance for hemodialysis bacteremia has been performed for several years. Cases that occurred in 1995 were compared to cases in the first 6 months of 1996. Unit data on dialysis runs and method of dialysis access were used to calculate rates. Nested polymerase chain reaction (PCR) was used to type 18 Staphylococcus aureus isolates from 1996. A case-control study comparing 80 randomly selected hemodialysis patients from 1995 and 1996 was performed to examine infection risk factors.

RESULTS

The hemodialysis bacteremia rate was 1.2 per 1,000 runs in 1995 and 2.8 per 1,000 in the first 6 months of 1996 (P=.0009). The 25 cases in 1995 and 32 in the first half of 1996 were similar in age, gender, means of vascular access, and microbial etiology. Central venous catheter (CVC) access accounted for >90% of cases in both time periods. S aureus was the most common microbial etiology (53% of the 1996 cases). PCR typing of S aureus isolates from 1996 demonstrated five different strains, the most common having six isolates. The use of CVCs as a means of vascular access abruptly increased in the unit in January 1996, from <30% of dialysis runs in 1995 to >40% in 1996 (P<.001), associated with structural changes in healthcare delivery in the region resulting in delays in performing surgical procedures, such as creation of vascular grafts and fistulae.

CONCLUSION

A marked increase in hemodialysis bacteremia occurred in 1996, associated with increased reliance on CVCs for vascular access in hemodialysis patients during a period of healthcare restructuring.

New combination of the old drugs for elderly patients with small-cell lung cancer: a phase II study of the PAVE regimen

PURPOSE

A regimen of cisplatin, doxorubicin, vincristine, and etoposide (PAVE) was designed for patients with small-cell lung cancer (SCLC) who were older than 65 years, with the following objectives compared with standard chemotherapy regimens: maintain efficacy, diminish toxicity, enhance compliance, and improve chemotherapy administration convenience at an acceptable cost.

PATIENTS AND METHODS

The PAVE regimen consisted of cisplatin 30 mg/m2 intravenously (i.v.) day 1; doxorubicin 40 mg/m2 i.v. day 1; vincristine 1.0 mg/m2 i.v. day 1; and etoposide 100 mg/m2 i.v. day 1 and orally days 3 and 5. Cycles were repeated every 3 weeks for four cycles. Patients with limited-stage disease and selected patients with extensive-stage disease received thoracic irradiation delivered concurrently with etoposide-cisplatin (EP) at the time of the second chemotherapy cycle.

RESULTS

Sixty-six eligible patients were treated, which included 25 patients with limited-stage disease and 41 patients with extensive-stage disease. Median survival was 70 weeks and 5-year survival was 25% for limited-stage disease. Median survival was 46 weeks for extensive-stage disease. Only one treatment-related death occurred and severe toxicity was infrequent. The median delivered dose-intensity was according to protocol and the mean delivered total dose was 80% of intended.

CONCLUSION

The treatment outcome achieved with PAVE in a phase II study of elderly patients compared favorably with published results of standard regimens in patient populations with better prognostic factors. Because the PAVE regimen can be delivered with good compliance, has acceptable toxicity, and is associated with logistic advantages compared with standard regimens, this protocol is suitable for further investigative trials in elderly patients with SCLC.

Cooperative health care clinics: a group approach to individual care

In cooperative health care clinics (CHCC), health care is provided to older patients in a group setting. The CHCC concept, which was developed under a research grant by Kaiser Permanente in Colorado in 1991, showed improvement in patient and provider satisfaction, as well as improved quality of care and cost effectiveness. CHCC are being replicated in other sites under a research grant from the Robert Wood Johnson Foundation. In addition to formal findings from research studies, much has been learned about factors that have promoted the success of the program.

Watchful waiting or watchful progression?: Prostate specific antigen doubling times and clinical behavior in patients with early untreated prostate carcinoma

BACKGROUND

Prostate specific antigen doubling time (PSAdt) is a dynamic model of prostate tumor biology. It predicts aggressive disease and subsequent clinical recurrence after radical treatment. However, as yet there is only limited evidence for its validity in the watchful waiting population.

METHODS

One hundred and thirteen previously untreated patients with adenocarcinoma of the prostate who were referred to the British Columbia Cancer Agency for a management opinion subsequently were placed into a prospective watchful waiting program. The reasons for watchful waiting, previous medical history, serial PSA, and histopathologic data were recorded.

RESULTS

The median age of patients was 75 years (range, 49-85 years). The median follow-up from the time of the first appointment was 14 months (range, 0-58 months). The reasons for watchful waiting were correlated highly with T classification (P = 0.003) and past medical history (P = 0.002). Approximately 40% of T1 patients and 51% of T2 patients had clinical progression by 2 years, increasing to 60% at 3 years. On multivariate analysis PSAdt strongly correlated with clinical progression (P < 0.0001), stage progression (P = 0.01), and time to treatment (P = 0.0001); tumor grade and initial stage were not found to be predictive for any of the endpoints studied. Initial PSA only was significant in predicting for time to treatment (P = 0.03). Approximately 50% of patients with a PSAdt of <18 months progressed within 6 months. At last follow-up, no deaths from prostate carcinoma had been recorded. Overall survival at 2 and 5 years was 92% and 68%, respectively.

CONCLUSIONS

Using digital rectal examination, the findings of this study demonstrated high rates of clinical tumor progression within the watchful waiting population. PSAdt rather than standard histopathologic criteria was found to be the most powerful indicator of disease activity.

Family grief therapy: a preliminary account of a new model to promote healthy family functioning during palliative care and bereavement

The family is usually the primary provider of care for the terminally ill patient with cancer or other serious progressive illness. The way in which such a family functions is a major determinant of psychological well-being for its members. Through screening with the Family Relationships Index (FRI) (Moos and Moos, 1981), dysfunctional families and those at risk can be identified, and then helped to achieve better family functioning, thus improving psychosocial outcome of their grief. In this paper, we describe the techniques and themes involved in the application of our empirically developed model of family grief therapy, designed as a preventive intervention for use in the setting of palliative care and bereavement.

Increasing the availability of vasectomy in public-sector clinics

A program designed to improve the availability of vasectomy in public-sector clinics trained physicians at 43 facilities in no-scalpel vasectomy between 1993 and 1995. Among the 38 clinics that responded to a follow-up survey in 1996, the number of clinics providing vasectomies rose from 23 to 32, an increase of almost 40%, while the number of vasectomies performed rose by 18%. Seventeen of the 32 clinics performed more vasectomies after the training; 10 of the 17 had not previously provided the procedure. In-depth interviews with staff from seven sites that experienced large caseload increases and from seven that experienced decreases identified three elements for the successful establishment or expansion of vasectomy services-sufficient numbers of trained providers, funds to subsidize vasectomies for men who cannot afford them and activities to raise awareness about the availability of low-cost or free vasectomy.

Postradiation osteonecrosis of the mandible: a long-term follow-up study

OBJECTIVES

The objective of this study was to assess the long-term progress of 26 patients who experienced postradiation osteonecrosis of the jaw between 1975 and 1989.

STUDY DESIGN

Of 26 patients who had been previously managed with hyperbaric oxygen therapy as a part of their treatment for postradiation osteonecrosis of the jaw, 20 were evaluated to determine their current status of the condition: resolved, chronic persisting (unresolved), or active progressive (symptomatic).

RESULTS

Two of 20 patients experienced recurrences of the condition. In one of these patients, surgical treatment was identified as the stimulus of postradiation osteonecrosis. In the other patient, the recurrence appeared to be related to periodontal disease activity. In 60% (12 of 20) of the patients, the condition remained resolved, improvement in clinical staging occurred in 10% (2 of 20) (from symptomatic to unresolved or resolved), and 20% (5 of 20) of the patients continued to demonstrate chronic persisting postradiation osteonecrosis at the end of the long-term follow-up period.

CONCLUSION

This study supports the contention that postradiation osteonecrosis can occur at any time after radiation therapy, and that patients remain at risk up to 231 months after treatment of the cancer and probably indefinitely after radiation therapy. Our findings also suggest that risk of second episodes of the condition after management of an initial episode is low. In addition, our follow-up study revealed that chronic nonprogressive postradiation osteonecrosis can remain stable without extensive intervention including combined hyperbaric oxygen therapy and surgery.

Phase I and pharmacologic study of paclitaxel administered weekly in patients with relapsed ovarian cancer

PURPOSE

Paclitaxel has shown significant activity in advanced ovarian cancer. In vitro studies with paclitaxel have suggested that fractionated brief infusion schedules may be more effective than the standard 24-hour infusion. We commenced a phase I evaluation of escalating-dose paclitaxel (40, 50, 60, 80, 100 mg/m2) administered weekly as a 1-hour infusion in patients with recurrent ovarian cancer. All patients had received prior paclitaxel and cisplatin therapy. All patients received standard premedication.

PATIENTS AND METHODS

Eighteen patients are assessable on this phase I study. The mean age was 54 years (range, 48 to 74). The median number of prior chemotherapy regimens was three (range, two to five). The mean paclitaxel-free interval was 10.1 months (range, 1 to 24).

RESULTS

A total of 194 cycles of therapy were administered, with a mean of 10 (range, one to 12) per patient. No mucositis or grade III neuropathy was seen. Alopecia occurred in one out of 18 assessable patients. The mean neutrophil nadir was 4.0 x 10(9)/L. At the top dose level (100 mg/m2) delivered, dose-intensity was 90.75% of that planned and greater than two fold the standard dose-intensity. Partial responses were seen in four of 13 assessable patients (30%). Two patients with progression of disease on standard three-week paclitaxel schedules switched to a weekly schedule with demonstrated response. Increasing paclitaxel dose correlated with measured area under the curve (AUC) (R2 = .614). Dose-limiting toxicity was reached at 100 mg/m2 with two of three patients experiencing a treatment delay, thus defining a maximum-tolerated dose of 80 mg/m2 in this group of heavily pretreated patients on this weekly schedule.

CONCLUSION

(1) Paclitaxel administered as a 1-hour infusion is well tolerated; (2) this schedule of administration does not result in cumulative myelosuppression; and (3) this schedule of administration results in dose-intensive paclitaxel delivery with a favorable toxicity profile.

Bacteremic nosocomial pneumonia. A 7-year experience in one institution

STUDY OBJECT

To describe the epidemiology, microbiology, and outcome of nosocomial pneumonia with secondary bloodstream infection.

DESIGN

Prospective cohort study.

SETTING

Tertiary care Canadian teaching hospital.

PATIENTS

Inpatients.

MEASUREMENT

All inpatient blood cultures were concurrently monitored over an 89 month period. Following chart review, patients experiencing nosocomial bloodstream infection due to pneumonia were identified. A standardized definition of pneumonia was used.

RESULTS

One hundred forty-nine episodes occurred in 145 patients, 0.66/1,000 hospital admissions, 8.4% of all nosocomial bloodstream infections. No change in rate occurred in the study period. Fifty-four percent of episodes developed in one of seven ICUs. Staphylococcus aureus was the most frequently identified etiologic organism (27%). The ICU and non-ICU cases did not differ in etiology. No organism became more prevalent during the study period. Twenty percent of patients died within 1 week of first positive culture; episodes associated with Pseudomonas species had a much higher mortality rate (45%) than other infections (14%) (p = 0.002). The ICU and non-ICU infections had a similar mortality rate.

CONCLUSION

Pneumonia is an important cause of nosocomial bloodstream infection, but it is not increasing in frequency or changing in etiology in our institution. The ICUs are a major contributor to this problem but have the same case short-term mortality rate and microbial etiology as non-ICU cases. Cases associated with Pseudomonas have a much higher mortality rate.

Amniotic fluid polarization of fluorescence and lecithin/sphingomyelin ratio decision criteria assessed

A negative finding of amniotic fluid (AF) phosphatidyl glycerol (PG) does not eliminate the need for determining the lecithin/sphingomyelin ratio (LSR). We use a novel approach to classify fetal lung maturity (FLM) data, and to validate the fluorescence polarization (FP) surfactant assay (Abbott), which replaces the PG assay and reduces the frequency of repeat LSR. This method finds the values (decision points) of these tests that allow for classifying the data with least errors. These tests best identify the risk of respiratory distress syndrome (RDS) from fetal lung immaturity. We find the decision values for tests by exploring the data for information content and optimize their selection using group-based reference. We previously defined normal reference as the maximum entropy set with no information. The uncertainty resolved by information provided in the data allows formation of syndromic classes. This is greatest at the values for the variables (decision-points) associated with the greatest decrease in entropy. Decision-values found for PF, EGA, PG, LSR that classify amniotic fluids into the mature and not-mature classes are in agreement with the results of ROC analysis. We validate the replacement of PG by the PF method. We also find a level of FP below which LSR might be required to resolve uncertainty and above which the FP indicates maturity. We confirm the ability to evaluate fetal maturity methods using information analysis.

Schoolwork, homework, life's work: the experience of students with and without learning disabilities

Elementary school students were interviewed about schoolwork, homework, and personal learning projects (e.g., learning about astronomy). Four groups of students were distinguished. Those in the first group experienced school knowledge as an integral part of life and inseparable from their personal projects; students in the second group saw such knowledge as necessary for preparing for life, but as less engaging than their personal projects. For those in the third group, schoolwork was an imposition, contrasting sharply with satisfying personal learning projects. Those in the fourth group lacked absorbing personal learning projects and found schoolwork to be an imposition. Students with learning disabilities (more than students without) fell into the last category. Fostering more favorable motivation and voice (ability to articulate purposes and critique schooling) in such students might involve changing their views of school knowledge, helping them find personal identity-building learning projects, and reducing the dichotomy between schoolwork and personal projects.

Wound infection in total joint arthroplasty: effect of extended wound surveillance on wound infection rates

OBJECTIVE

To determine the effects of a wound monitoring program on infection rates after total joint arthroplasty.

DESIGN

Case series, comparing postoperative wound infection rates before and after hospital discharge.

SETTING

A university-affiliated tertiary-care hospital.

PATIENTS

A group of 865 patients who underwent primary or revision total hip or knee arthroplasty between September 1989 and September 1991 followed by in-hospital and post-discharge wound monitoring was compared with a baseline group of 204 patients who had undergone an arthroplasty procedure and in-hospital wound monitoring between March and September 1988; only 38 of these patients were selected for post-discharge monitoring.

INTERVENTIONS

In the study group, wounds were monitored every 48 to 72 hours to the time of patient discharge and at 30 days post-discharge. Monthly reports of surgeon-specific and overall infection rates were sent to each surgeon during both baseline and study periods.

MAIN OUTCOME MEASURES

Presence or absence of surgical wound infection.

RESULTS

The initial overall wound infection rate was 9.9%. This decreased to 3.8% in the study group, after the wound monitoring program had been in place for at least 18 months. Post-discharge monitoring accounted for the majority of wound infections diagnosed.

CONCLUSIONS

A wound monitoring program may be an important tool in lowering wound infection rates associated with total joint arthroplasty. Post-discharge monitoring is important in determining true wound infection rates.

Trends and sources of nosocomial fungaemia

Concurrent surveillance of blood culture isolates in a 1000-bed tertiary care hospital over a 7-year period from 1986 to 1993 identified 102 episodes of nosocomial fungaemia, representing 6.6% of all episodes of nosocomial bloodstream infections and 0.49/1000 admissions. No significant change in the frequency, rate, source or microbial aetiology of nosocomial fungaemia occurred over the 7-year period. Candida albicans accounted for 74%, followed by Candida (Torulopsis) glabrata (8%), C. parapsilosis (7%), C. tropicalis (3%), C. lusitaniae (2%), C. krusei, Malassezia furfur Saccharomyces cerevisiae, Hansenula anomala and Cryptococcus albidus (one each). 'Primary' fungaemia, usually attributed to intravascular catheters, was considered to be the source in 65% of cases, with 64% of these patients receiving total parenteral nutrition (TPN). Other important sources of infection included the urinary tract (11%), the gastrointestinal tract (8%) and the respiratory tract (7%). Sixty-four % of patients were in one of the hospital's seven intensive care units (ICUs) when their infection developed, the neonatal ICU and adult medical/surgical ICU each accounting for 21%. Only 7% of cases were associated with neutropenia and another 14% with malignancy or immunosuppression. Death occurred within 7 days of diagnosis of fungaemia in 23 cases. In eight instances, fungaemia was considered the main cause of death. We conclude that in our hospital nosocomial fungaemia is largely caused by C. albicans, occurring in association with intravascular catheter use and TPN in ICU patients. Most cases are not associated with recognized immune defence defects. Fungaemia is associated with a high short-term mortality rate.

The role of vesicular stomatitis virus matrix protein in inhibition of host-directed gene expression is genetically separable from its function in virus assembly

Recently, the vesicular stomatitis virus matrix (M) protein has been shown to be capable of inhibition of host cell-directed transcription in the absence of other viral components (B. L. Black and D. S. Lyles, J. Virol. 66:4058-4064, 1992). M protein is a major structural protein that is known to play a critical role in virus assembly by binding the helical ribonucleoprotein core of the virus to the cytoplasmic surface of the cell plasma membrane during budding. In this study, two M protein mutants were tested to determine whether the inhibition of host transcription by M protein is an indirect effect of its function in virus assembly or whether it represents an independent function of M protein. The mutant M protein of the conditionally temperature-sensitive (ts) vesicular stomatitis virus mutant, tsO82, was found to be defective in its ability to inhibit host-directed gene expression, as shown by its inability to inhibit expression of a cotransfected target gene encoding chloramphenicol acetyltransferase. The ability of the tsO82 M protein to function in virus assembly was similar to that of wild-type M protein, as shown by its ability to complement the group III ts M protein mutant, tsO23. Another mutant, MN1, which lacks amino acids 4 to 21 of M protein demonstrated that the abilities of M protein to inhibit chloramphenicol acetyltransferase gene expression and to localize to the nucleus were unaffected by deletion of this lysine-rich amino-terminal region but that the ability to function in virus assembly was ablated. Thus, the two M protein mutants examined in this study exhibited complementary phenotypes: tsO82 M protein functioned in virus assembly but was defective in inhibition of host-directed gene expression, while MN1 M protein functioned in inhibiting gene expression but was unable to function in virus assembly. These data demonstrate that the role of M protein in inhibition of host transcription can be separated genetically from its role in virus assembly.

The presence of an inhibitor of human skin collagenase in the roots of healthy and periodontally diseased teeth: changes that occur with age

The amount of anti-collagenase in the root has been reported in a group 18 to 35 years of age. Healthy roots had more than the diseased; and apical more than the cervical. The purpose of the present study is to determine the effect of age on these values. In a group 50 to 92 years of age, all values were markedly higher than in the younger group. In addition, all relationships between values were preserved. These include location and presence of disease. The higher levels might be due to an aging process or a protective defense against collagenase in the gingival crevice.

Vaccination of Lewis rats against Mycoplasma arthritidis-induced arthritis

The nature of Mycoplasma arthritidis antigens responsible for eliciting protective immunity in rats was studied by inoculation of rats with mycoplasmal components that had been subjected to a variety of physical and chemical treatments. All inocula tested induced good protection against development of clinical illness, as assessed by changes in body weight and appearance of joint swelling and/or temporary hind limb paralysis. Although all preparations stimulated development in inoculated rats of high titer of antimycoplasmal antibodies measured by ELISA, the complement-fixation antibody response was poor and, in some cases, lacking altogether. This indicated that completion-fixation antibodies may not be involved in protecting rats against M arthritidis-induced illness. Protective antigens were stable to heat (100 C for 10 minutes), formalin, and denaturation by sodium dodecyl sulfate (SDS). Inoculation with membrane and soluble cytoplasmic fractions was protective, as was inoculation with 5 M arthritidis fractions separated according to molecular weight by SDS-polyacrylamide gel electrophoresis (SDS-PAGE). For this latter experiment, rat antisera obtained after vaccination, but prior to challenge exposure, were tested by immunoblot analysis against electrophoretically separated M arthritidis membrane proteins. Interestingly, all antisera from these rats recognized antigens migrating far outside the molecular weight range of the cell fractions with which rats were inoculated. This indicated either that the protective antigens may be composed of numerous antigenically related subunits that separated by SDS-PAGE into a variety of molecular weight ranges or that a few major antigens may exist in several forms or phases within a given population of M arthritidis.

Subunit interactions of vesicular stomatitis virus envelope glycoprotein stabilized by binding to viral matrix protein

The mechanism by which viral glycoproteins are incorporated into virus envelopes during budding from host membranes is a major question of virus assembly. Evidence is presented here that the envelope glycoprotein (G protein) of vesicular stomatitis virus binds to the viral matrix protein (M protein) in vitro with the specificity, reversibility, and affinity necessary to account for virus assembly in vivo. The assay for the interaction is based on the ability of M protein to stabilize the interaction of G protein subunits, which exist as trimers of identical subunits in the virus envelope. The interaction with M protein was shown by using G proteins labeled with fluorescent probes capable of detecting subunit dissociation and reassociation in vitro. The results show that the M protein isolated from virions either as purified soluble protein or as nucleocapsid-M protein complexes interacts with the G protein in vitro and that the reaction is reversible. The interaction between the G and M proteins was not serotype specific, but no interaction between the vesicular stomatitis virus M protein and the influenza virus hemagglutinin could be detected. These results support the conclusion that the interactions described here are the ones that govern assembly of G protein into virus envelopes in vivo.

Wound infections in orthopedic surgery: effect of extended surveillance on infection rate

Substantial evidence now exists that ongoing surveillance of surgical wound infections can contribute to reduced infection rates. What is not yet determined is whether surveillance should be limited to the postoperative hospital stay or should be continued after patient discharge. To determine the number of infections occurring after discharge, the authors contacted a random sample of their patients who did not have wound infections during their hospitalization after orthopedic surgery. This was done 30 days after the procedure. The authors selected 273 patients of 1375 who underwent orthopedic surgery over a 7-month period and were able to contact 199 (73%). At the 30-day follow-up 23 patients (11.6%) had wound infections, as judged by wound discharge and physician prescription of antibiotics in 20 and the patient's description of pus issuing from the wound in 3. During the same period postoperative wound infections were found in only 19 (1.5%) of 1278 patients who were subjected to in-hospital surveillance. The authors conclude that, in patients who undergo orthopedic procedures, the majority of wound infections occur after discharge from the hospital and that infection rates based only on in-hospital surveillance greatly under represent true surgical wound infection rates for orthopedic procedures.

Effect of surgeon's diagnosis on surgical wound infection rates

To determine the impact of a surgeon's diagnosis of surgical wound infections on infection rates, during a 6-month period we prospectively examined patients undergoing surgical wound surveillance for any of four services (orthopedic surgery, general surgery, neurosurgery, or cardiovascular surgery). Criteria were judged as standardized if the infection control practitioner observed pus, redness, or drainage associated with positive culture or if a diagnosis of deep-seated infection was made. Surgeon's diagnosis was judged as a nonstandardized criterion. Using the Centers for Disease Control's criteria, we identified 113 surgical wound infections in 3024 patients undergoing surgical procedures in the four services. Of these, 95 (84%) met objective criteria (pus observed in 53%; drainage, redness, and positive culture in 20%; and deep-seated infection in 11%). In 18 patients (16%), the nonstandardized criterion alone was used for diagnosis. There was wide variation in use of the nonstandardized criterion, ranging from 5% of orthopedic infections to 21% of cardiovascular surgery infections and 40% of neurosurgical infections. For individual surgeons with at least one wound infection, the range of surgeon's diagnosis was up to 67%. We conclude that a surgeon's diagnosis can have a major impact on surgical wound infection rates; this impact is not borne equally among surgical services or individual surgeons.

Surgical wound infections occurring in day surgery patients

The occurrence of surgical wound infection in outpatient day surgery has not been extensively studied despite the increasing popularity of this mode of treatment. The present study was conducted to determine the frequency of surgical wound infections in a day surgery population. We randomly selected during a 6-month period 635 (25%) of 2540 patients undergoing a day surgery procedure in which a skin incision was made. The patients were telephoned 1 month after their procedure by an infection control practitioner. Infection was diagnosed if the patient reported that (1) their physician had made a diagnosis of a wound infection or (2) pus was or had been issuing from the wound. Of the 515 patients contacted, 72% had undergone a clean and 28% a clean-contaminated procedure. Patient risk factors for infection were almost completely absent in our day surgery patients. Twenty-six wound infections were diagnosed, 19 of which were identified by physicians' diagnosis and 7 by patient description, for a rate of 5.05%. Two patients required hospitalization for their infections, and 14 were treated with antibiotics. The clean wound infection rates were 4.62%, less than half the infection rate seen in our patients undergoing inpatient surgery at 1 month follow-up by the same surveillance technique. We conclude that day surgery infection rates are much lower than inpatient surgery infection rates at our facility, probably because of a relative absence of risk factors in the day surgery patients.