ICU and 6-month outcome of oncology patients in the intensive care unit

BACKGROUND

Advances in oncological care have led to improved short- and long-term prognosis of cancer patients but admission to the intensive care unit (ICU) remains controversial.

AIM

The objective was to assess the outcome of patients with haematological malignancies and solid tumours admitted to the ICU as emergencies, and to identify risk factors for mortality.

DESIGN AND METHODS

Retrospective and prospective analysis of 185 cancer patients admitted to the ICU at Guy's Hospital (259 admissions), a large tertiary referral oncology centre between February 2004 and July 2008.

RESULTS

One hundred and fifteen patients had haematological malignancies of whom 30.4% died in ICU. Seventy patients had solid tumours. ICU mortality was 27.1%. Fifty-four patients had >1 admission to ICU. ICU survivors had significantly lower acute physiology and chronic health evaluation II scores and less failed organ systems on admission to ICU and less organ failure during stay in the ICU. Neutropenia, sepsis and re-admission were not associated with an increased mortality. Six-month mortality rates for patients with haematological malignancies and solid tumours were 73 and 78.6%, respectively.

CONCLUSION

Short-term outcome of critically ill cancer patients in ICU is better than previously reported. The decision to admit cancer patients to ICU should depend on the severity of the acute illness rather than factors related to the malignancy. In appropriate patients, invasive organ support and re-admission should not be withheld.

The management and outcome of women with post-hydatidiform mole 'low-risk' gestational trophoblastic neoplasia, but hCG levels in excess of 100 000 IU l(-1)

Background:

Gestational trophoblastic neoplasia (GTN) after a hydatidiform mole is either treated with single- or multi-agent chemotherapy determined by a multifactorial scoring system. Women with human chorionic gonadotrophin (hCG) levels >100 000 IU l⁻¹ can remain within the low-risk/single-agent category and usually choose one drug therapy. Here we compare the success and duration of single- vs multi-agent chemotherapy in this patient group.

Methods:

Between 1980 and 2008, 65 women had a pre-treatment hCG >100 000 IU l⁻¹ and were low risk. The initial hCG level, treatment regimens, changes and duration and overall survival were recorded.

Results:

Of 37 patients starting low-risk/single-agent treatment, 11 (29.7%) were treated successfully, whereas 26 (70.3%) required additional multi-agent chemotherapy to achieve complete remission (CR). Combination chemotherapy was initially commenced in 28 women, and 2 (7%) required additional drugs for CR. The overall duration of therapy for those commencing and completing single- or multi-agent chemotherapy was 130 and 123 days (P=0.78), respectively. The median-treatment duration for patients commencing single-agent but changing to multi-agent chemotherapy was 13 days more than those receiving high-risk treatment alone (136 vs 123 days; P=0.07). All 3 patients with an initial hCG >400 000 IU l⁻¹ and treated with single-agent therapy developed drug resistance. Overall survival for all patients was 100%.

Conclusion:

Low-risk post-molar GTN patients with a pre-treatment hCG >100 000 and <400 000 IU l⁻¹ can be offered low-risk single-agent therapy, as this will cure 30%, is relatively non-toxic and only prolongs treatment by 2 weeks if a change to combination agents is required. Patients whose hCG is >400 000 IU l⁻¹ should receive multi-agent chemotherapy from the outset.

Clinical and biochemical improvement in acromegaly during pregnancy

Numerous case reports of pregnancy in acromegaly exist, however detailed descriptions of changes in placental and pituitary GH and IGF-I throughout gestation are rare. A 19-yr-old female presented to this institution with signs and symptoms of a GH-secreting pituitary adenoma. Following transphenoidal hypophysectomy, she had 3 unplanned pregnancies, despite ongoing active disease. No pregnancy was complicated by glucose intolerance or hypertension and 3 healthy newborns were delivered near or at term. Clinical improvement was observed during each pregnancy, accompanied by IGF-I levels lower than in the non-pregnant state, the majority lying within the normal range. This was despite increasing placental GH levels, and was not consistent with previous reports in the literature. Further surgical and medical therapies for acromegaly failed to normalize nonpregnant GH or IGF-I levels in this woman. Estrogen is known to alter GH signaling via its interaction with Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathways. We hypothesize that increasing concentrations of estrogen or other pregnancy-related hormones resulted in her clinical and biochemical improvement during pregnancy. This may be used for future therapeutic benefit.

Extremely high cytoplasmic diversity in natural and breeding populations of Lolium (Poaceae)

Ten chloroplast microsatellite markers were used to characterise chloroplast genetic diversity at allelic and haplotypic level in 104 accessions of Lolium perenne, other Lolium species, Festuca species and x Festulolium cultivars. Furthermore, genetic relationships between the accessions and biogeographic distribution of haplotypes were investigated using a range of Nei's population genetic diversity measures and analysis of molecular variance (AMOVA). An extremely high number (511) of haplotypes was detected in 1575 individuals. Nei's gene diversity values among L. perenne accessions ranged between 0 and 0.333. Much of the L. perenne European ecotype diversity (61%), as calculated using AMOVA, could be attributed to within-population variance and this is likely caused by, and maintained by, high levels of natural and anthropogenic seed dispersal. Plastid gene pools and maternal lineages for L. perenne could be clearly identified. Evidence was found, using AMOVA, to show a likely migration route of L. perenne from Southern regions of Europe northwards.

Crucial importance of PKC-β(I) in LFA-1–mediated locomotion of activated T cells

Crawling T cell locomotion in which activated lymphocyte function-associated antigen 1 (LFA-1) integrins participate is associated with translocation of the protein kinase C-beta (PKC-beta) isoenzyme to the microtubule cytoskeleton. In normal T cells and T lymphoma cell lines, this type of motility is accompanied by PKC-beta-sensitive cytoskeletal rearrangements and the formation of trailing cell extensions, which are supported by microtubules. Expression of PKC-beta(I) and enhanced green fluorescent protein (EGFP) in nonmotile PKC-beta-deficient T cells restored their locomotory behavior in response to a triggering stimulus delivered via LFA-1 and correlated directly with the degree of cell polarization. We have also shown that PKC-beta(I) is a component of the tubulin-enriched LFA-1-cytoskeletal complex assembled upon LFA-1 cross-linking. These observations may have physiological equivalents at advanced (post-integrin activation) stages of lymphocyte extravasation.

Improvement and optimization of two engineered phage resistance mechanisms in Lactococcus lactis

Homologous replication module genes were identified for four P335 type phages. DNA sequence analysis revealed that all four phages exhibited more than 90% DNA homology for at least two genes, designated rep2009 and orf17. One of these genes, rep2009, codes for a putative replisome organizer protein and contains an assumed origin of phage DNA replication (ori2009), which was identical for all four phages. DNA fragments representing the ori2009 sequence confer a phage-encoded resistance (Per) phenotype on lactococcal hosts when they are supplied on a high-copy-number vector. Furthermore, cloning multiple copies of the ori2009 sequence was found to increase the effectiveness of the Per phenotype conferred. A number of antisense plasmids targeting specific genes of the replication module were constructed. Two separate plasmids targeting rep2009 and orf17 were found to efficiently inhibit proliferation of all four phages by interfering with intracellular phage DNA replication. These results represent two highly effective strategies for inhibiting bacteriophage proliferation, and they also identify a novel gene, orf17, which appears to be important for phage DNA replication. Furthermore, these results indicate that although the actual mechanisms of DNA replication are very similar, if not identical, for all four phages, expression of the replication genes is significantly different in each case.

Midterm results of arthroscopic co-planing of the acromioclavicular joint

BACKGROUND

There has been recent concern about long-term morbidity associated with arthroscopic co-planing of the acromioclavicular joint in the treatment of impingement syndrome.

OBJECTIVE

The purpose of this study was to assess the results of the co-planing procedure, special attention being paid to acromioclavicular joint morbidity.

METHODS

The study included 56 patients who were operated on by the senior author. Outcomes were evaluated both objectively and subjectively through physical examinations and telephone surveying. Each patient had subacromial decompression at the time of the index surgery. Other concomitant arthroscopic procedures included rotator cuff repair and labral debridement or repair.

RESULTS

Average follow-up was 4 years (range, 2-7 years). Thirty-five (95%) of 37 patients had no subjective pain and no objective tenderness to direct palpation or compression of the acromioclavicular joint. The joint was not clinically hypermobile in comparison with that on the opposite side in any patient. In all, 95% of patients had good or excellent results in terms of the University of California at Los Angeles Shoulder Score. Of the 2 patients who did have pain and tenderness at the acromioclavicular joint, both had had multiple operations on their shoulders before the index procedure. Nineteen patients were not examined clinically but did complete a telephone survey; these 19 patients were not symptomatic at the acromioclavicular joint.

CONCLUSIONS

To fully treat impingement syndrome, the surgeon should remove osteophytes under the lateral clavicle and medial acromion. With good technique, the surgeon can leave the anterior, posterior, and superior acromioclavicular joint capsule intact. We conclude that for appropriate clinical indications, beveling the inferior 20% to 25% of the clavicle to make it co-planar with the decompressed acromion is safe and is not an etiologic factor in acromioclavicular joint pain or instability.

Cytochrome P450 polymorphisms are associated with reduced warfarin dose

BACKGROUND

Warfarin use is complicated by an erratic dose response. Interpatient variability associated with warfarin therapy may be partly attributable to polymorphisms of the cytochrome P450 (CYP) complex. The purpose of this study was to ascertain the frequency and influence of CYP polymorphisms on warfarin dosing in our patient population.

METHODS

Patients receiving warfarin therapy were recruited from the inpatient divisions of our hospital. Genotyping for known polymorphic alleles of the CYP subfamilies CYP2C9 (CYP2C9*1, CYP2C9*2, and CYP2C9*3) and CYP2A6 (CYP2A6*1, CYP2A6*2) with the use of standard methods of polymerase chain reaction amplification was performed. An unpaired t test was used to statistically compare genotypes.

RESULTS

Genotype frequency in 38 patients is as follows: CYP2C9*1/CYP2C9*1, 71%; CYP2C9*1/CYP2C9*2, 21%; CYP2C9*2/CYP2C9*2, 3%; CYP2C9*1/CYP2C9*3, 5%; CYP2A6*1/CYP2A6*1, 95%; CYP2A6*1/CYP2A6*2, 5%. Compared to a wild-type genotype, the presence of the CYP2C9*2, CYP2C9*3, or CYP2A6*2 allele was associated with a significant reduction in weekly warfarin dose (mean weekly warfarin dose [+/- SE] for wild-type genotype was 0.397 +/- 0.024 mg/kg/wk vs 0.307 +/- 0.03 mg/kg/wk for carriers of CYP2C9*2, CYP2C9*3, or CYP2A6*2 polymorphism; P =.03).

CONCLUSIONS

Polymorphisms that impair warfarin metabolism are common, occurring in 34% of patients, and are associated with increased warfarin sensitivity. The use of genotypic information to prescribe more accurate doses of warfarin may increase the safety and efficacy of this medication.

Quantification of Clostridium botulinum toxin gene expression by competitive reverse transcription-PCR

Clostridium botulinum produces a characteristic botulinum neurotoxin which can cause an often fatal neuroparalytic condition known as botulism. Although food-borne botulism is rare, critical screening by food companies is necessary to ensure that food products are safe. At present, the food industry assesses the risks of botulinum neurotoxin production by challenge testing to check any new food products and to check the efficacy of new storage regimes. Challenge testing involves artificial introduction of defined strains of microorganisms into food, and microbial growth and possible toxin production are then monitored. Botulinum toxin is normally analyzed by using the mouse bioassay. However, the mouse bioassay is expensive, slow, and politically sensitive because of animal rights issues. In this paper we describe adaptation of a new assay, competitive reverse transcription-PCR (RT-PCR), to monitor botulinum neurotoxin production. This method accurately measures the level of toxin-encoding mRNA in C. botulinum cells. Measurement of mRNA should provide a good indication of gene expression as mRNA is turned over rapidly in bacterial cells. In addition, the method is rapid, specific, and sensitive. The competitive RT-PCR method was developed to examine C. botulinum E VH toxin gene expression and was used to investigate the level of toxin production by C. botulinum E VH when the organism was grown in two different types of broth. The results which we obtained with the competitive RT-PCR method demonstrated that this method is more rapid and more sensitive than the mouse bioassay.

Late-onset central hypoventilation with hypothalamic dysfunction: a distinct clinical syndrome

Idiopathic central hypoventilation has occasionally been reported in previously well children after infancy. The relationship between this late-onset central hypoventilation syndrome (LO-CHS) and congenital central hypoventilation syndrome (CCHS) has not been established. Both CCHS and LO-CHS have been associated with neural crest tumors, such as ganglioneuroblastoma and ganglioneuroma, and they generally occur in the presence of a histologically normal central nervous system. At least 10 case reports of idiopathic LO-CHS featured evidence of hypothalamic dysfunction (HD), including hyperphagia, hypersomnolence, thermal dysregulation, emotional lability, and endocrinopathies. We report on a case of LO-CHS/HD successfully treated by nasal intermittent positive pressure ventilation (NIPPV). Despite the commonalties with CCHS, we propose that LO-CHS/HD is a distinct clinical syndrome. In addition to the markedly different age at presentation, features of hypothalamic dysfunction are not seen in CCHS. Review of the literature was undertaken to further clarify the full spectrum of the disease.