The unmet need for anti-tumour necrosis factor (anti-TNF) therapy in ankylosing spondylitis

OBJECTIVES

Anti-tumour necrosis factor (anti-TNF) therapy is effective in the treatment of ankylosing spondylitis (AS), but guidelines are needed because of the cost. The primary aim of this study was to evaluate the proportion of patients with AS who meet the criteria for anti-TNF therapy as well as to explore the relationship between disease activity, health status and quality of life in patients with AS who would potentially meet the criteria compared with those who would not.

METHODS

All patients with a confirmed diagnosis of AS were identified via a search through the clinic correspondence database and sent postal questionnaires. Data captured included demographics, disease activity, aspects of functional impairment, activity limitation and quality of life using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pain scores (using a visual analogue scale), the Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), short-form 36 (SF-36) and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. The unpaired Student's t-test, chi(2) test and Mann-Whitney U-test were performed for comparisons of groups where appropriate.

RESULTS

Out of 325 mailed questionnaires, 246 (76%) were returned. The mean age of the patients who replied to the questionnaire was 52 yr (+/-12 yr) and 25% (62) were females. Mean BASDAI was 49 (+/-24) and 64% had a BASDAI > or = 40. There were significant differences between the groups with a BASDAI above and below 40 in pain by VAS, functional ability (BASFI, HAQ), health status (SF-36) and quality of life (ASQoL). Almost two-thirds (64%) of patients would meet the criteria for anti-TNF therapy under recommended guidelines.

CONCLUSION

Patients with AS demonstrated poor functional status and poor quality of life. There is a large unmet need for effective therapy in AS, with almost two-thirds of patients meeting the proposed criteria for biological therapy. Patients with a BASDAI > or = 40 had a worse functional status and quality of life than those who have a BASDAI of <40. These results indicate that the need for effective intervention for AS is a priority area.

Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis

Clinicians often use foot orthoses to manage the symptoms of plantar fasciitis. Although there has been considerable research evaluating the effectiveness of orthoses for this condition, there is still a lack of scientific evidence that is of suitable quality to fully inform clinical practice. Randomized controlled trials are recognized as the "gold standard" when evaluating the effectiveness of treatments. We discuss why randomized controlled trials are so important, the features of a well-conducted randomized controlled trial, and some of the problems that arise when trial design is not sound. We then evaluate the available evidence for the use of foot orthoses, with particular focus on published randomized controlled trials. From the evidence to date, it seems that foot orthoses do have a role in the management of plantar fasciitis and that prefabricated orthoses are a worthwhile initial management strategy. At this time, however, it is not possible to recommend either prefabricated or customized orthoses as being better, and it cannot be inferred that customized orthoses are more effective over time and therefore have a cost advantage. Additional good-quality randomized controlled trials are needed to answer these questions.

Effects of experimentally induced plantar insensitivity on forces and pressures under the foot during normal walking

Pressures under the foot during level walking were measured in 15 healthy young adults (8 females, 7 males, mean age 25.7, S.D. 5.3) before and after immersing the feet in ice-cold water (2 degrees C) for 30 min to evaluate the role of plantar insensitivity on gait patterns. Following ice water immersion, there was a significant decrease in walking speed. Maximum forces and peak pressures under the foot decreased, with the exception of an increase in loading under the third to fifth metatarsal heads. Contact times increased under all regions of the foot, and force-time and pressure-time integrals increased under the second and third to fifth metatarsal head regions. It is concluded that plantar insensitivity significantly alters the distribution, duration, and to a lesser extent, the magnitude of forces and pressures under the foot when walking. These results suggest that in the neuropathic foot, gait changes caused by plantar insensitivity may be partly responsible for the redistribution and altered duration of loading, whereas the increase in the magnitude of forces and pressures are primarily due to other disease-related factors.

Factors associated with triathlon-related overuse injuries

STUDY DESIGN

Descriptive correlational investigation.

OBJECTIVES

To assess the incidence of, and potential risk factors associated with, overuse injury in triathlon.

BACKGROUND

The sport of triathlon is rapidly increasing in popularity with a concomitant rise in the prevalence of injuries sustained by triathletes.

METHODS AND MEASURES

The training and injury patterns of 131 triathletes were surveyed over a 10-week prospective period during the triathlon competition season. A complementary retrospective 6-month analysis of training history and prior overuse injuries was conducted.

RESULTS

Fifty percent of triathletes sustained an injury in the 6-month preseason at an injury exposure rate of 2.5 per 1000 training hours. Thirty-seven percent were injured during the 10-week competition season at an injury exposure rate of 4.6 per 1000 training hours. Overuse accounted for 68% of preseason and 78% of competition season injuries reported. Increased years of triathlon experience, high running mileage, history of previous injury, and inadequate warming-up and cooling-down regimes appeared to have individual associations with injury incidence. When interactions were included in a multiple logistic regression model, increasing years of triathlon experience was the most significant predictor of preseason injury risk and a previous history of injury and high preseason running mileage increased the risk of injury during the competition season.

CONCLUSIONS

The results indicate that in assessing triathletes, a full training and competition history is required by the sports clinician for a comprehensive assessment of the factors that may contribute to overuse injury.

Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min

Guidelines for the performance of cardiopulmonary resuscitation (CPR) have been revised recently and now advocate that chest compressions are performed without interruption for 3 min in patients during asystole and pulseless electrical activity. The aim of the present study was to determine if rescuer fatigue occurs during 3 min of chest compressions and if so, the effects on the rate and quality of compressions. Forty subjects competent in basic life support (BLS) were studied. They performed continuous chest compressions on a Laerdal Skillmeter Resusci-Anne manikin for two consecutive periods of 3 min separated by 30 s. The total number of compressions attempted was well maintained at approximately 100 min(-1) throughout the period of study. However, the number of satisfactory chest compressions performed decreased progressively during resuscitation (P < 0.001) as follows: first min, 82 min(-1); second, 68 min(-1); third, 52 min(-1); fourth, 70 min(-1); fifth, 44 min(-1); sixth, 27 min(-1). We observed significant correlations between the number of satisfactory compressions performed and both height and weight of the rescuer. Female subjects achieved significantly fewer satisfactory compressions compared with males (P = 0.03). Seven subjects (five female, two male) were unable to complete the second 3-min period because of exhaustion. We conclude that rescuer fatigue adversely affects the quality of chest compressions when performed without interruption over a 3-min period and that this effect may be greater in females due to their smaller stature. Consideration should be given to rotating the rescuer performing chest compressions after 1 min intervals.

An evaluation of two foot-specific, health-related quality-of-life measuring instruments

In the past decade, health-related quality-of-life (HRQoL) assessment has become an important tool to measure change as a result of treatment in clinical trials. The aim of this project was to compare and contrast two foot-specific HRQoL questionnaires: the Foot Function Index (FFI) and the Foot Health Status Questionnaire (FHSQ). To assist in this process, a quasi-experimental trial was performed to evaluate the effectiveness of foot orthoses in improving HRQoL in people suffering from plantar fasciitis. The results from this study found that the FFI is generally less responsive to change, particularly in the domain of Activity Limitation. Nevertheless, significant improvements were found for two out of the three domains (Pain and Disability, but not Activity Limitation) for the FFI, as well as the overall score of FFI. In contrast, all four domains (Pain, Function, Footwear and General Foot Health) of the FHSQ showed significant improvement. Our experience with the questionnaires also revealed that certain questions in the Activity Limitation domain of the FFI can lead to inconsistent scoring, thus casting doubts over the suitability of this domain for use with patients with plantar fasciitis. Therefore, the FHSQ has several advantages when evaluating HRQoL in patients being treated with foot orthoses for plantar fasciitis, and should be viewed as the preferred questionnaire.

Understanding statistics. Putting p-values into perspective

Understanding statistics can be one of the more difficult and daunting tasks facing the clinician attempting to understand and use the research literature. While the fundamental aim of including statistics in literature is to justify the conclusions and to enhance the information presented, all too often, statistics serve only to intimidate and alienate clinicians. There are two sources for this barrier to understanding: poor comprehension of statistics by clinicians, and inappropriate presentation of statistics by researchers. In the third of our papers on evidence-based practice and the clinician, some basic principles of statistics are introduced. Aspects such as the concepts of clinical and statistical significance are discussed, and an outline of the appropriate use of specific statistics is provided. The hope is that this will enable the clinician to better judge the applicability of statistical techniques as applied in the published literature. Some of the newer, more 'clinician friendly' statistical approaches are also presented. Finally some of the cheats and shortcuts commonly encountered in the presentation of research are discussed, and the methods for dealing with them are outlined.

'Horses for Courses': the differences between quantitative and qualitative approaches to research

Some clinicians may feel dissociated from, and intimidated by the ever-increasing emphasis on research. However, with an understanding of some of the basic principles and key terms, research can feel less daunting. It is the aim of this article, the second in a series of three focusing on understanding research, to introduce clinicians to the different approaches to research, to improve understanding of what the approaches mean, and to highlight when a particular approach may be appropriate. Furthermore, the article will provide an explanation of some of the common terms used within clinical research. This should aid the clinician in applying good, simple, scientific principles to evaluating clinical research evidence.

Integrating research into the clinic. What evidence based practice means to the practising podiatrist

This paper is the first in a series of three aimed at introducing clinicians to current concepts in research, and outlining how they may be able to apply these concepts to their own clinical practice. It has become evident in recent years that while many practitioners may not want to become actively involved in the research process, simply keeping abreast of the burgeoning publication base will create new demands on their time, and will often require the acquisition of new skills. This series introduces the philosophies of integrating what sometimes may appear to be abstract research into the realities of the clinical environment. It will provide practitioners with an accessible summary of the tools required in order to understand the research process. For some, it is hoped this series may provide some impetus for the contemplative practitioner to become a more active participant in the research process. This first paper addresses how the evidence based practice (EBP) revolution can be used to empower the individual practitioner and how good quality evidence can improve the overall clinical decision making process. It also suggests key strategies by which the clinician may try to enhance their clinical decision making process and make research evidence more applicable to their day to day clinical practice.

Inter-segment foot motion and ground reaction forces over the stance phase of walking

OBJECTIVE

To compare the magnitude and patterns of motion of the rearfoot segment relative to the leg, forefoot segment relative to the rearfoot, height change in the medial longitudinal arch and ground reaction forces of normal adult males during the stance phase of walking.

BACKGROUND

Knowledge of normal motion of the rearfoot and forefoot segments and of the arch during stance phase is important in clinical management.

METHODS

Motion data were obtained from surface markers, and force data from a force plate, from the right limb of participants while walking at a self-selected pace.

RESULTS

Stance phase range of motion across sagittal, frontal and transverse planes was 12 degrees, 4 degrees and 10 degrees for the forefoot, compared to 22 degrees, 8 degrees and 10 degrees for the rearfoot. Most motion occurred at the beginning and end of stance phase when support was via only the rearfoot or forefoot, and when forces were maximal. Arch height decreased from heel contact and increased after heel rise to its maximum at toe-off.

CONCLUSIONS

The extent of forefoot segment motion confirms the significance of midfoot joints to normal foot function. Between foot flat and heel rise, the forefoot pattern of motion is indicative of foot stability. Typical foot motion does not obey descriptions of triplanar motion such as 'pronation' and 'supination'.

RELEVANCE

Typical stance phase foot motion has been described according to a forefoot:rearfoot model and rearfoot:leg model of motion, together with profiles of medial longitudinal arch height and ground reaction forces. This information can be applied in the management of foot dysfunction and should stimulate research into midfoot motion and overall control of the foot.

Wound healing and infection in nail matrix phenolization wounds. Does topical medication make a difference?

After nail matrix ablation using phenolization, a medicated wound dressing (10% povidone iodine), an amorphous hydrogel dressing (Intrasite Gel), and a control dressing (paraffin gauze) were evaluated. Forty-two participants, randomly divided into three dressing groups, were evaluated. Healing time did not differ between the 10% povidone iodine (33 days), amorphous hydrogel (33 days), and the control dressing (34 days). For all groups, the clinical infection rate was lower than in previous studies, and there was no clinical difference between groups (one infection in the povidone iodine and control groups; none in the amorphous hydrogel group). However, in the amorphous hydrogel group, other complications, such as hypergranulation, were more likely. This investigation indicated that medicated or hydrogel dressings did not enhance the rate of healing or decrease infection rates.

The effect of high-Dye and low-Dye taping on rearfoot motion

High-Dye and low-Dye taping are commonly used by clinicians to treat a variety of foot and ankle pathologies, particularly those associated with excessive rearfoot pronation. While the effects of taping on end range of motion have been extensively studied, relatively little is understood about the effect of the two styles of taping on rearfoot motion. Eighteen participants were analyzed in three conditions: 1) barefoot, 2) with high-Dye taping, and 3) with low-Dye taping. Two-dimensional motion of the rearfoot was assessed for each condition. The results indicated maximum inversion was increased with both high-Dye and low-Dye taping as compared with no taping. Only high-Dye taping, however, significantly reduced the maximum eversion of the rearfoot. The results suggest that high-Dye taping is an appropriate taping choice when control of eversion of the rearfoot is desired.

Foot orthosis prescription habits of Australian and New Zealand podiatric physicians

This research project investigated the orthotic prescription habits of podiatric physicians in Australia and New Zealand. A 23-item questionnaire was distributed to all members of the Australian Podiatry Association and the New Zealand Society of Podiatrists. When asked what type of foot orthoses they prescribe most often, 72% of respondents reported functional foot orthoses; the next most common response was prefabricated orthoses (12%). A typical prescription for functional foot orthoses consisted of a modified Root style orthosis, balanced to the neutral calcaneal stance position, with the shell made from polypropylene and an ethyl vinyl acetate (EVA) rearfoot post applied. The majority of podiatric physicians surveyed used a commercial orthotic laboratory to fabricate their orthoses. However, New Zealand respondents were three times more likely to prescribe prefabricated foot orthoses, and males were twice as likely as females to manufacture the orthoses themselves rather than use a commercial orthotic laboratory.

Efficacy of foot orthoses. What does the literature tell us?

This paper reviews the literature relating to foot orthoses, in particular foot orthoses that attempt to alter biomechanical function. Whilst few well-controlled studies have been performed, the findings from the available literature are generally positive. The authors provide an overview of this literature and then summarise the findings. The literature is categorised into six research outcome areas: (i) patient satisfaction, (ii) pain and deformity, (iii) plantar pressures, (iv) position and motion, (v) muscle activity, and (vi) oxygen consumption. In addition, the difficulties associated with researching foot orthoses are discussed.

Syndrome of inappropriate secretion of antidiuretic hormone in malignancy

OBJECTIVES

To provide a review of pathophysiology, epidemiology, signs and symptoms, diagnosis, treatment, and nursing management of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in malignancy.

DATA SOURCES

Research reports, review articles, and book chapters relevant to SIADH.

CONCLUSIONS

The principle cause of hyponatremia in malignancy is SIADH. Early recognition and prompt treatment can prevent serious neurologic sequelae. Antineoplastic therapy and methods to correct hyponatremia constitute effective treatment strategies.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a major role in nursing assessment, appropriate interventions and symptom control, and promoting resolution of problems and optimal quality of life in patients with malignancy complicated by SIADH.

Lithium as a potential adjuvant to 131I therapy of metastatic, well differentiated thyroid carcinoma

As lithium inhibits the release of iodine from the thyroid but does not change iodine uptake, it may potentiate 131I therapy of thyroid cancer. The effects of lithium on the accumulation and retention of 131I in metastatic lesions and thyroid remnants were evaluated in 15 patients with differentiated thyroid carcinoma. Two 131I turnover studies were performed while the patients were hypothyroid. One was performed while the patient received lithium; the second served as a control study. From a series of gamma-camera images, it was found that lithium increased 131I retention in 24 of 31 metastatic lesions and in 6 of 7 thyroid remnants. A comparison of 131I retention during lithium with that during the control period showed that the mean increase in the biological or retention half-life was 50% in tumors and 90% in remnants. This increase occurred in at least 1 lesion in each patient and was proportionally greater in lesions with poor 131I retention. When the control biological half life was less than 3 days, lithium prolonged the effective half-life, which combines both biological turnover and isotope decay, in responding metastases by more than 50%. More 131I also accumulated during lithium therapy, probably as a consequence of its effect on iodine release. The increase in the accumulated 131I and the lengthening of the effective half-life combined to increase the estimated 131I radiation dose in metastatic tumor by 2.29 +/- 0.58 (mean +/- SEM) times. These studies suggest that lithium may be a useful adjuvant for 131I therapy of thyroid cancer, augmenting both the accumulation and retention of 131I in lesions.

Video assessment of rearfoot movements during walking: a reliability study

OBJECTIVE

Rearfoot motion, particularly rearfoot pronation, has been associated with many foot and leg pathologies. The assessment of abnormal rearfoot pronation frequently involves the use of video assessment in both clinical and research settings, but the reliability of this assessment has not been addressed.

DESIGN

In this study, 14 participants were videotaped during walking. Five clinicians individually viewed the recordings on two separate occasions and assessed whether the participant's rearfoot motion was abnormal.

SETTING

University Gait Analysis Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Patients from the university's podiatry clinic were assessed for rearfoot motion by five experienced clinicians.

INTERVENTION

Because this was a reliability study, no intervention was undertaken.

MAIN OUTCOME MEASURES

Clinicians were asked to assess the videotape of the patients walking and indicate on a 3-point scale if they considered the person to be abnormally pronating. Retest and intertester results were compared.

RESULTS

The results indicated that there was poor intertester agreement (kappa = .19). Retest agreement, while slightly higher, varied from poor to fair (kappa = -.12 to kappa = 59).

CONCLUSIONS

Although video recordings have been thought to enhance reliability of assessment of rearfoot motion, the results indicated that the exclusive use of video recordings in the assessment of motion of the rearfoot was not reliable.

Blanket use of intranasal mupirocin for outbreak control and long-term prophylaxis of endemic methicillin-resistant Staphylococcus aureus in an open ward

In December 1992, a thoracic ward in a Melbourne teaching hospital experienced an increase in patients infected with methicillin-resistant Staphylococcus aureus (MRSA). It was decided to attempt to control the outbreak by cohorting positive patients (infected and colonized), as well as nurse cohorting, emphasis on handwashing, and use of intranasal mupirocin initially three times a day for three days, then thrice weekly, for all patients in the ward (with or without MRSA). The campaign comprised for phases of 53, 45, 92 and 365 days, respectively. Patient and nurse cohorting stopped at the end of phase I. In phases I and II, surveillance nose swabs were taken on admission, then twice weekly; in phase III, on admission and weekly and in phase IV, on admission until the end of 1993. In phases I and II (98 days), only one patient acquired MRSA. When the frequency of mupirocin prophylaxis was decreased to once weekly (phase III), two patients acquired MRSA in 92 days (no significant difference): thrice weekly administration resumed (phase IV), during which there were three acquisitions in 365 days. The rates of nose colonization of admissions were 6.4%, 6.3%, 9.7% and 3.1% in phase I-IV, respectively. Only three patients were treated with vancomycin between July 1993 and June 1994 (significantly lower than historical rates, P = 0.0086). No mupirocin resistance was seen in MRSA isolates from this ward during phases I, II and III. In areas of low-level endemic MRSA, the blanket use of thrice-weekly intranasal mupirocin may be effective in decreasing serious infections with MRSA, and does not necessarily elicit mupirocin resistance.

Aspirin and warfarin for thromboembolic disease after total joint arthroplasty

This study compares the benefits of aspirin and warfarin prophylactic agents for patients with thromboembolic disease after total joint arthroplasty. It is a prospective randomized study of 388 patients having total hip or total knee surgery. All consecutive patients having total hip or total knee surgery were entered into this study and evaluated with preoperative and postoperative ventilation perfusion scans and a postoperative venogram. The aspirin and warfarin treatment groups were compared by size and location of venographically revealed clots and changes in ventilation perfusion scans. The results showed that there was no difference in the size or location of deep venous thrombosis in the aspirin or warfarin treatment groups. The venogram was negative in 44.5% of patients; 28.8% had small ++calf clots, 16% had large calf clots, 3.9% had popliteal clots, and 6.7% had femoral clots. Patients with total knee replacement had a 2.6 times greater incidence of calf deep venous thrombosis than patients with total hip replacement. There was no difference between the aspirin and warfarin groups in the incidence of changes in ventilation perfusion scans (18.9%). There was no difference between the 2 groups in bleeding complications. The results suggest that aspirin and warfarin are equivalent in prophylaxis against thromboembolic disease, as determined by prevention of venographic changes or changes in ventilation perfusion scans.

Nuclear medicine in the diagnosis of deep venous thrombosis and pulmonary embolism

Nuclear medicine techniques offer a variety of approaches to the diagnosis of deep venous thrombosis and pulmonary embolism. Several radionuclide methods are available to visualize venous structures, and many radiolabeled agents have been developed for direct visualization of blood clots, including platelets and monoclonal antibodies. Although still available on a limited basis, radiolabeled fibrinogen uptake studies have been replaced largely by newer methods. Ventilation-perfusion lung scanning remains the mainstay of nuclear medicine detection of pulmonary embolism as it has for the past two decades.

Direct intralymphatic injection of radiolabeled 111In-T101 in patients with cutaneous T-cell lymphoma

Direct intralymphatic administration of radiolabeled monoclonal antibody in targeting antigen-bearing lymphoma cells in regional lymph nodes of patients with cutaneous T-cell lymphoma was evaluated. Seven consecutive patients undergoing staging lymphangiography received intralymphatic infusions of 111In-T101 to evaluate lymph node involvement. This procedure was accomplished without significant complication. The 111In-T101 rapidly distributed throughout the regional lymphatic compartment and passed into the systemic circulation. Tumor-bearing sites in the inguinal-femoral lymph nodes retained from 0.42 to 4.8% of the injected dose of radiolabeled antibody. Three patients were upstaged to Stage IVA based on tumor involvement found after radiolymphoscintigraphy-directed biopsy of groin lymph nodes, selected because of intense radioactivity by gamma camera imaging. Compared with previously reported s.c. antibody administration, there was a marked reduction in the radioactive exposure of normal tissues at the injection sites in the lower extremities. Direct intralymphatic delivery of 111In-T101 appears to be a feasible, efficient method for delivering therapeutic doses of radiolabeled antibody.

In vivo traffic of indium-111-oxine labeled human lymphocytes collected by automated apheresis

The in vivo traffic patterns of autologous lymphocytes were studied in five normal human volunteers using lymphocytes obtained by automated apheresis, separated on Ficoll-Hypaque gradients, and labeled ex vivo with 111In-oxine. Final lymphocyte infusions contained 1.8-3.1 X 10(9) cells and 270-390 microCi (9.99-14.43 MBq) 111In, or 11-17 microCi (0.41-0.63 MBq) per 10(8) lymphocytes. Gamma imaging showed transient lung uptake and significant retention of radioactivity in the liver and spleen. Progressive uptake of activity in normal, nonpalpable axillary and inguinal lymph nodes was seen from 24 to 96 hr. Accumulation of radioactivity also was demonstrated at the forearm skin test site, as well as in its associated epitrochlear and axillary lymph nodes, in a subject who had been tested for delayed hypersensitivity with tetanus toxoid. Indium-111-oxine labeled human lymphocytes may provide a useful tool for future studies of normal and abnormal lymphocyte traffic.

Interleukin-2 induces profound reversible cholestasis: a detailed analysis in treated cancer patients

Interleukin-2 (IL-2)-based immunotherapy is associated with profound reversible cholestasis and hyperbilirubinemia. We performed a nonrandomized retrospective and prospective analysis to determine the incidence, characteristics, clinical course, and nature of the IL-2-induced liver dysfunction in patients with cancer. Patients received IL-2 at a dose of 20,000 to 100,000 units (U)/kg thrice daily for up to 5 days. Fifty-one patients on adjuvant treatment protocols received a mean of 10.18 +/- 2.38 IL-2 doses and 11.67 +/- 4.16 doses were delivered to 210 patients with advanced disease during this period. Retrospective analysis of all patients receiving this therapy revealed increases in the following liver function tests expressed as median, 25th percentile, and 75th percentile (range): bilirubin (mg/dL) 4.5, 2.6, 6.5 (.4 to 38.5); alkaline phosphatase (U/L) 256, 179, 378 (56-1680); SGOT (U/L) 80, 52, 117 (18 to 483); SGPT (U/L) 91, 64, 132 (20-540); prothrombin time 13.4, 12.8, 14.5 (10.8 to 35.4); and albumin (g/dL) values decreased (trough) slightly 3.0, 2.8, 3.2 (2.3 to 3.8). Multiple regression analysis revealed several factors that were significantly associated with the increase in bilirubin when jointly considered (model P2 less than or equal to .001) including total IL-2 dosage, increase in creatinine, alkaline phosphatase, weight, and SGOT. Similar increases were noted in a prospectively evaluated group of 10 patients. A return to normal levels of bilirubin was noted within 5.6 days of stopping IL-2. Fasting serum cholylglycine increased from a mean of 32.3 +/- 1.6 to a peak of 1556.0 +/- 625.0 mg/mL. Although conventional ultrasound examinations were unrevealing, tissue ultrasound examinations revealed a mean scatterer spacing (MSS) increase compared to baseline of .10 +/- .04 (P less than .02) suggesting hepatic edema or an infiltrative process. Further, computerized hepatobiliary nuclear medicine scans revealed a delay in uptake (2.2 +/- 0.5 fold greater) and excretion (8.0 +/- 5.9 fold greater) of technetium-99m labeled disofenin. These findings support the development of profound reversible cholestasis as the primary basis for the elevated bilirubin in patients undergoing IL-2 treatment and may have implications for understanding the jaundice observed in some patients postoperatively as well as that associated with sepsis and other inflammatory disorders. Specifically, the release of IL-2 or the induction of other factors similarly induced by IL-2 may be responsible for these findings. Tissue ultrasound and computerized hepatobiliary scans provide additional noninvasive assessments of liver function and physiology.