Early childhood trauma and disorders of extreme stress as predictors of treatment outcome with chronic posttraumatic stress disorder

History of early childhood trauma was prevalent and highly correlated with Disorders of Extreme Stress Not Otherwise Specified (DESNOS) in a sample of veterans in inpatient treatment for chronic posttraumatic stress disorder (PTSD). DESNOS predicted reliable change on a variety of measures of psychiatric symptomatology (including PTSD) and psychosocial functioning independently of the effects of PTSD diagnosis and early childhood trauma history. DESNOS also predicted treatment outcome on PTSD and quality of life measures after controlling for the effects of ethnicity, war zone trauma exposure severity, initial level of symptomatic severity or quality of life, Axis I (PTSD and major depression) and Axis II (personality disorder) diagnostic status, and early childhood trauma history. Early childhood trauma was not predictive of outcome. DESNOS appears to play an important role in assessment and treatment planning for psychotherapeutic rehabilitation of chronic PTSD.

Intussusception in an infant with acute lymphoblastic leukemia: a case report and review of the literature

PURPOSE

An ileocecal intussusception developed in a 7-month-old infant with acute lymphoblastic leukemia (ALL) during induction therapy. Gastrointestinal complications, especially intussusception, are rare in children with ALL.

PATIENT AND METHODS

The history of a 7-month-old white boy with ALL in whom an ileocecal intussusception developed 1 week into induction chemotherapy was reviewed. In addition, a literature search was performed to determine the prevalence of this complication in children with acute leukemia.

RESULTS

On day 4 of induction chemotherapy for B-lineage ALL, the infant developed abdominal distension with hypoactive bowel sounds. After a barium enema and abdominal computed tomography scan, the symptoms were determined to be caused by an ileocecal intussusception. Chemotherapy was resumed 1 week after immediate surgical intervention (reduction of intussusception and resection of the "leading edge") with an uneventful post-operative recovery. Histopathologic examination of the resected edge revealed an intact mucosa with areas of necrosis in the submucosa. This was associated with a dense lymphoid infiltrate composed of mature lymphocytes and leukemic cells, edema, and focal necrosis. Despite a 1-week delay in chemotherapy, a complete remission was documented at day 32.

DISCUSSION

The prevalence of intussusception in children with ALL and its possible etiology are discussed. The pathologic changes, clinical manifestations, and treatment outcome are briefly mentioned.

Data elements for emergency department systems, release 1.0 (DEEDS): a summary report. DEEDS Writing Committee

Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations.

Data elements for emergency department systems, release 1.0 (DEEDS): a summary report. DEEDS Writing Committee

Variations in the way that data are entered in ED record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations.

The CD4/CD8 ratio in BAL fluid is highly variable in sarcoidosis

Patients with pulmonary sarcoidosis frequently have increased numbers of lymphocytes and a high ratio of CD4+ to CD8+ T-lymphocytes (CD4/CD8 ratio) in bronchoalveolar lavage (BAL) fluid. Some investigators have suggested that these parameters can be used to distinguish sarcoidosis from other types of interstitial lung disease with a high degree of reliability. However, we hypothesized that the BAL CD4/CD8 ratio measured during the initial diagnostic evaluation of patients with biopsy-proven sarcoidosis is highly variable. BAL lymphocytes were analysed via flow cytometry to determine the CD4/CD8 ratio in a population of 86 patients with histological and clinical evidence of sarcoidosis, who underwent BAL as part of their initial diagnostic evaluation. In these patients, the CD4/CD8 ratio ranged 0.5-37.3, with a median value of 3.35 (mean 6.49). The CD4/CD8 ratio was greater than 4 in only 36 (42%) subjects. Ten patients (12%) had a CD4/CD8 ratio less than 1. The distribution of CD4/CD8 ratios was similar in the presence or absence of BAL lymphocytosis. In conclusion, the CD4/CD8 ratio in bronchoalveolar lavage fluid is highly variable in biopsy-proven sarcoidosis. Bronchoalveolar lavage lymphocyte subset determination is a diagnostic test with low sensitivity for this disease.

AIDS-associated B-cell non-Hodgkin's lymphoma masquerading as a cutaneous T-cell neoplasm: an aberrant immunophenotype requiring comprehensive analysis for lineage resolution

An increased prevalence of intermediate- and high-grade B-cell non-Hodgkin's lymphoma (NHL) is a major manifestation of the disease spectrum associated with human immunodeficiency virus (HIV) infection. Rarely, lymphoproliferations are of T-cell, null cell, or mixed-lineage phenotypes. We describe an unusual B-cell NHL that presented as a left alar ulcer in a man with acquired immunodeficiency syndrome (AIDS) and rectal carcinoma. Biopsy of the lesion and a draining cervical lymph node showed atypical dermal lymphoid infiltration with effacement of nodal architecture and involvement of adjacent skeletal muscle by a diffuse infiltrate of large and small lymphocytes. On paraffin section immunochemistry, the large lymphoid cells expressed CD45 and CD45RO, but not CD43 or CD20. The small background cells were positive for CD3, CD43, and CD45RO. These overall results were consistent with a diagnosis of a T-cell process. Gene rearrangement studies, however, demonstrated a clonal B-cell population indicative of B-cell NHL. The clinical course was marked by rapid shrinkage of tumor with chemotherapy followed by profound wasting and death. Anomalous coexpression or lack of expression of T- and B-cell markers may be seen in AIDS-related NHL. Reliance on paraffin section immunohistology may provide misleading information, and caution is recommended in assigning a specific lineage to such lymphoproliferations without additional immunologic or genotypic analyses. Whether our case represents a distinct clinicopathologic entity or is simply a peculiar manifestation of HIV-related B-cell NHL remains uncertain.

Primary extramedullary leukemia of the prostate: case report and review of the literature

We present the case of a 67-year-old male with primary extramedullary leukemia of the prostate gland, the first reported case in the literature to the best of our knowledge. His initial symptoms consisted of episodes of urinary retention. He underwent transurethral resection of the prostate, and a diagnosis of high-grade lymphoma was rendered. He then received a course of doxorubicin-based lymphoma chemotherapy regimen. However, based on a panel of immunocytochemical stains, a diagnosis of extramedullary leukemia or chloroma was confirmed. His bone-marrow examination at this point was normal. He underwent radiation therapy to the prostate with a total dose of 3960 cGy. Seven months after his initial presentation, he progressed to acute nonlymphocytic leukemia (ANLL), M2 by FAB classification. He was successfully treated with induction and consolidation chemotherapy with Ara-C and idarubicin, and was maintained in complete remission up to 19 months of follow-up. Eight other cases of prostatic leukemia reported in the literature are presented. Five cases occurred in association with ANLL, 2 cases as sites of ANLL relapse, and 1 case in association with myelodysplasia. The use of immunohistochemical stains has aided us in diagnosis of extramedullary leukemia. Surgery, radiation therapy, and chemotherapy play complementary roles in the treatment of prostatic extramedullary leukemia.

Linking stress and injury in the farming environment: a secondary analysis of qualitative data

The first step in injury prevention is to understand the injury problem. This includes examining the nature of the problem from the perspective of the target community. This article uses qualitative methods to explain the nature of the injury problem and identifies prevention strategies through a three-step process: identify a causal model, validate the model, and identify strategies using the causal model. A causal model linking safety performance and safety demand, health decision making, and occupational stress was derived by secondary analysis of farm family focus group data (step 1) and validated by other farm family focus groups (step 2). Prevention strategies identified from the causal model (step 3) include decreasing the number of roles performed exclusively by one individual, developing an easy-to-use planning tool that assists farmers in anticipating and reducing future work demands, and developing an education module that incorporates injury costs into safety decision making.

Cues to parent involvement in drug prevention and school activities

This exploratory study used focus group methods to identify strategies that promote parent involvement with young children in an alcohol, tobacco, and other drug (ATOD) prevention program. The Health Belief Model (HBM) guided the interview process and data analysis. Five focus groups were conducted with low-income parents and school personnel from two urban elementary schools in Lexington, Kentucky. Cues to Action was the most frequent HBM construct expressed by both parents and school personnel in regard to ATOD prevention programs and general school activities. Enthusiasm for school activities expressed by children to their parents was identified as the core cue to parent involvement. Transportation, child care, and incentives were the basic requirements for parent involvement. Positive attitudes of school personnel, a combination of communication strategies, and multiple channels for involvement were major cues to parent involvement. Recommendations for involving parents in ATOD prevention and general school activities are suggested.

Developing and evaluating an emergency nursing orientation pathway

OBJECTIVE

Orientee evaluation forms frequently focus on tasks and technical skills rather than decision-making skills. An orientation pathway was developed to evaluate orientee clinical decision-making skills. The pathway can assist in identifying orientees who require additional educational resources or interventions. Early interventions may decrease the length of orientation, increase an employee's length of stay in the institution, and contribute to cost savings.

METHODS

The pathway was developed with employee exit interview data, preceptor interviews, identification of critical indicators, and the orientation literature. The pathway consists of six categories. Indicators within each category were identified and ranked according to four levels of proficiency (level 1 for the least proficient and level 4 for the most proficient). A convenience sample of seven ED orientee and preceptor pairs agreed to participate in the pilot use of the pathway. An expected timeline of progress had been developed by a group of 20 preceptors during a preceptor workshop. An average proficiency level (score) was obtained for each category for 12 weeks with the weekly scores plotted on the pathway. This level was compared with the expected proficiency level in each category for each week. Demographic information was obtained from the orientee and preceptor pairs to determine whether certain characteristics facilitate pathway progression. Data were analyzed with frequency distributions, and measures of central tendency and variance. Spearman's rank correlations were used to examine the proficiency level in each category for each week in relation to demographic characteristics of the preceptor and orientee.

RESULTS

Orientees progressed faster than expected in all categories. It took 8 weeks for an orientee to attain the highest proficiency level in all categories. The fastest progress was made in the category " Accurately Evaluates Patient Responses." Slowest progress was made in the category "Safety in Blood and Drug Administration." Preceptors and orientees rated in the pathway as very useful.

DISCUSSION

Further studies with the orientation pathway may help to determine the ideal time frame for orientation, characteristics of orientees who progress as expected or faster, and educational strategies to facilitate orientee progression and clinical decision making.

Lymphocytosis of large granular lymphocytes in patients with Hodgkin's disease

Clonal disorders of large granular lymphocytes (LGL) of either CD3- (NK cell) or CD 3+ (T-cell) phenotype have been described. B-cell malignancies such as hairy cell leukemia and non-Hodgkin's lymphoma have been observed in association with the T-cell type of LGL leukemia. Here we report the occurrence of LGL lymphocytosis in four patients with Hodgkin's disease. Immunophenotyping studies showed that these LGL were CD 3- in three patients and CD3+ in the other. LGL were polyclonally expanded in both patients in whom clonality could be assessed.

Regulation and targeting of T-cell immune responses by IgE and IgG antibodies

A set of chimeric antibodies with identical F(ab')2 fragments specific for the hapten 5-iodo-4-hydroxyl-3-nitrophenacetyl (NIP), but with different human Fc parts (gamma 1, gamma 2, gamma 3, gamma 4, epsilon), was used to compare the role of IgG and IgE antibodies in antigen presentation by human Epstein-Barr virus (EBV) B cells. Two or three molecules of NIP were coupled to one molecule of Der pI (Der pI-(3)NIP), a major allergen of Dermatophagoides pteronyssinus. Both monomeric IgG and performed complexes of various Der pI/IgG ratios failed to bind significantly to the Fc receptor for IgG on B cells (Fc gamma RII; CD32). Binding of IgG3 (> IgG1)-containing complexes (optimal ratio of antigen to antibody = 1:1) could be enhanced by increasing the number of haptens per Der pI molecule to nine or more. However, antigen presentation mediated by IgG and CD32 was not seen with either pulsed B cells or B cells that were allowed to capture the IgG complexes during the whole stimulation period. IgE binding to CD23 and subsequent IgE-mediated antigen presentation was seen under all conditions tested. Even monomeric immune complexes (IC) (Der pI-(3)NIP/IgE), in the absence of CD23 cross-linking, induced an immune response. As the number of natural epitopes for human antibodies on Der pI was less than five, we conclude that, in vivo, complexes consisting of Der pI/IgG will be directed to antigen-presenting cells expressing the high-affinity receptor for IgG (CD64), whereas IgE will allow antigen presentation by CD23-expressing cells, including B cells.

Familial occurrence of LGL leukaemia

The aetiology of LGL leukaemia is now known; however, we recently detected HTLV-II from such a patient. We describe here the occurrence of LGL leukaemia in a mother and her son. Serum from the son reacted to HTLV-I/II gag proteins, but not a recombinant HTLV-I env protein p21e; serum from the mother was negative. PCR analyses in both patients were negative for pX and pol sequences shared by HTLV-I/II and also for specific gag sequences of HTLV-I and HTLV-II. These data show that familial cases of LGL leukaemia are not associated with prototypical HTLV-I or HTLV-II infection.

Psychometric properties of the Driving Practices Questionnaire: assessment of risky driving

A national public health goal is to reduce injuries and deaths from motor vehicle crashes (MVC). The development and psychometric evaluation of the 10-item Driving Practices Questionnaire (DPQ) to measure risky driving is described. Based on responses from 297 drivers divided into safe, unsafe, and injured groups, the DPQ was evaluated using item and factor analysis, and reliability and validity measures. Principal axis factor analysis isolated one factor with 42.3% of the variance explained. The alpha coefficient for the scale was .87 and test-retest correlation was .94. High DPQ scorers were three times more likely to have prior traffic violations. The identification of driver subtypes will assist the testing of injury prevention interventions.

Assessment of the effects of instrumentation, monoclonal antibody, and fluorochrome on flow cytometric immunophenotyping: a report based on 2 years of the NIAID DAIDS flow cytometry quality assessment program

This study of the effect on CD4%, CD8%, CD3+8+%, and CD3% of flow cytometer, monoclonal antibody, and fluorochrome was based on 71 whole-blood samples, each evaluated by 42 to 59 laboratories during 2 years of a flow cytometry quality assessment program. For the 24 HIV-positive specimens, FACScans produced significantly lower CD4% values than EPICS-Cs or EPICS Profiles, and for the 47 HIV-negative specimens, FITC was associated with significantly lower CD4% values than PE or RD1, but differences were never larger than 2% and regressions accounted for only 3-12% of the variability. The labs using the most common CD4 technique had significantly higher between-laboratory variability than all other labs grouped together. For both CD8 and CD3+8+, measurements on FACScans were significantly higher than measurements on EPICS, and measurements using Leu2 were significantly higher than measurements using T8, with regressions accounting for 12-31% of the variability. The machine differences in medians were 3-7% for labs using Leu2-FITC. It might be worthwhile to discourage the use of Leu2-FITC for measuring CD8% but no change in instrument, monoclonal antibody, or fluorochrome would greatly improve interlaboratory agreement on CD4%.

Reversed helper/suppressor T-lymphocyte ratio in bronchoalveolar lavage fluid from patients with breast cancer and Pneumocystis carinii pneumonia

Pneumocystis pneumonia (PCP) usually occurs in patients with hematologic malignancies and acquired immunodeficiency syndrome (AIDS). Patients with solid tumors represent a very small fraction of the reported cases of PCP. Over an 18-month period, PCP was diagnosed in three patients who had received radiation and chemotherapy for breast cancer. In all three patients, there was no serologic or clinical evidence of AIDS. Direct staining of bronchoalveolar lavage fluid (BAL) revealed Pneumocystis carinii, and cellular analysis of BAL revealed an increased percentage of lymphocytes with reversed helper/inducer:suppressor/cytotoxic T-cell (CD4:CD8) ratio. Because decreased CD4:CD8 ratio in BAL is commonly accepted as findings consistent with hypersensitivity pneumonitis and AIDS, we conclude that similar findings in patients without AIDS are not specific for hypersensitivity pneumonitis, and P. carinii should be ruled out in the appropriate clinical setting.

Clinical applications of cytometry: 5th annual meeting

The 5th annual Clinical Applications of Cytometry meeting was held September 12-15, 1990 in charleston, SC. The theme which emerged repeatedly throughout the meeting was the need to take full advantage of the quantitative power of cytometry to provide the most useful clinically relevant diagnostic and prognostic information. Greater quantitative power is based on careful and reproducible standards and quality control. The same principles, albeit with somewhat different approaches, apply to cell surface immunofluorescence analysis, DNA measurements, and image cytometry assessments. Monoclonal antibody probes against oncogenes, others against lymphokines within the Golgi, and a novel fluorogenic substrate designed to quantitate the activity of a mitochondrial enzyme were exciting developments described at the meeting.

Oligoclonal immunoglobulin heavy chain gene rearrangement in a childhood immunoblastic lymphoma. Presentation as a polyphenotypic atypical lymphoproliferative reaction

The authors describe a diagnostically difficult case of childhood lymphoma that presented as an atypical polyphenotypic lymphoproliferative reaction. Initial immunophenotyping revealed the presence of IgG, IgA, kappa, and lambda within the neoplastic lymphocytes. The patient had circulating plasmacytoid lymphocytes and a polyclonal hypergammaglobulinemia. The patient died of widespread immunoblastic lymphoma in two months. Postmortem tumor DNA showed a oligoclonal pattern of immunoglobulin heavy chain gene rearrangement. Blots for T-cell receptor beta-chain rearrangement showed germline bands. Epstein-Barr virus DNA was present within tumor cells, but there was no history of prior immunosuppression or serologic evidence of Epstein-Barr virus infection. The apparent polyclonal nature of the immunoproliferation delayed the institution of chemotherapy.

Interactive computer-video modules for health sciences education

Advances in electronic image recording and computer technology have resulted in a remarkable increase in the power and flexibility of interactive computer-video teaching systems. The University of Washington Health Science Videodisc Development Group first demonstrated a laser videodisc controlled by a remote central computer in 1980. Even this rudimentary unit highlighted basic medical informatics principles including: rapid accessibility; a "generic" or multi-purposed format; ease of computer control; and large collections of valid, rigorously reviewed images. Advances in medical informatics have led to the development of the following previously undescribed series of teaching units: 1. The hypertext programs Hypercard, Linkway, and Guide have been used with videodiscs to develop easy-to-use instructional and reference materials. These materials demonstrate the ease with which a computer-naive instructor may develop new programs and the advantages that the intuitive nature of these programs brings to student users. 2. Patient simulations using single and double screens plus pre-defined knowledge structures; 3. Interactive single topic tutorials using preset knowledge structures; 4. A key-word-based disc searching system; 5. Electronic video microscopy; 6. A series of programs developed independently by health science faculty who have purchased multi-purpose videodiscs that demonstrate the flexibility of the multi-purpose or "generic": collection concept.

Results of the flow cytometry ACTG quality control program: analysis and findings

The AIDS Clinical Trial Group's (ACTG) Immunology Committee was charged with initiating a quality control program for all laboratories participating in the ACTG program reporting flow cytometry data. Forty-one laboratories were evaluated. This report defines the goals of this program and the subsequent findings after 19 send-outs were made. Both HIV positive volunteer donors and normal age-matched donors were used. Sample sets included both heparin and EDTA anticoagulated bloods. Laboratories were asked to report hematologic parameters as well as flow cytometry data both in percentages and absolute numbers. Results were evaluated using nonparametric statistical analysis. Robust CVs and interquartile ranges were used to define the performance of individual laboratories for each CD subset analyzed. Intralaboratory reproducibility was analyzed by paired sample sets. All laboratories were found to be able to define normal samples as normal. Seventy-five percent of the laboratories were able to define abnormal samples as abnormal. Twenty-five percent could not identify two abnormal samples as abnormal. Forty percent of the labs were found unable to reproduce paired samples within an absolute of +/- 5%. EDTA was found slightly superior to heparin in bloods evaluated by flow cytometry within 30 hr of collection. The analysis of specific histograms, questionnaires, and data analysis led to a specific set of recommendations for performance of flow cytometry studies.

Very low dose alpha-2b interferon for the treatment of hairy cell leukemia

Alpha-2b interferon (alpha-2b IFN), administered at 2 x 10(6) U/m2 three times per week is highly effective in the treatment of progressive hairy cell leukemia (HCL) and in the retreatment of patients who have relapsed after previous IFN therapy. To determine if a lower interferon dose would induce a comparable antileukemic effect with less toxicity, a-2b IFN was administered at 2 x 10(5) U/m2 subcutaneously three times per week to 17 patients with progressive HCL. Thirteen patients had HCL in relapse after a previous response to alpha-2b IFN; four patients were previously untreated. The median duration of treatment was 9 months. Toxicity consisted only of transient, mild flu-like symptoms in two patients. Of the 13 previously IFN-treated patients, four had a minimal response, one had no response, and eight had progressive disease. Of four previously untreated patients, one had a partial response, two had a minimal response, and one had no response. In seven of eight patients whose disease progressed on low-dose IFN, the dose was escalated to 2 x 10(6) U/m2 three times per week, and all seven patients demonstrated hematologic response within 3 months to the dose escalation. We conclude that alpha-2b IFN at 2 x 10(5) U/m2 three times per week is relatively ineffective for the treatment of relapse after previous IFN therapy.