A phase I study of acivicin in refractory pediatric solid tumors. A Pediatric Oncology Group study

Forty-two patients with progressive solid tumors and brain tumors were entered in this Phase I study of the glutamine antagonist acivicin given intravenously over thirty minutes daily for five days. The major toxicities encountered were myelosuppression and central nervous system toxicity (nightmares and somnolence). The maximum tolerated dosage on this schedule was 26 mg/M2 daily for five days. Six patients including three patients with brain tumor had stable disease.

Phase I clinical trial of recombinant human tumor necrosis factor in children with refractory solid tumors: a Pediatric Oncology Group study

PURPOSE

A phase I study was undertaken to determine the toxicity and maximum-tolerated dose (MTD) of recombinant human tumor necrosis factor (rTNF) in children.

PATIENTS AND METHODS

Twenty-seven patients with recurrent or refractory solid tumors were enrolled on the study. rTNF was administered daily for 5 days by 30-minute intravenous (IV) infusion, and doses were escalated in cohorts of three to six patients. Courses were repeated after a 9-day rest period, if toxicity was tolerable. Daily doses ranged from 100 to 350 micrograms/m2.

RESULTS

Most courses were associated with grade I/II fever, rigors, nausea, or vomiting. Three patients experienced moderate dyspnea that responded to supplemental oxygen. All abnormalities resolved on discontinuation of the infusion. One patient had a cardiac arrest 90 minutes after receiving the first dose of rTNF and died 10 days later of related complications. In two other patients, rTNF was discontinued due to persistent grade IV hypotension. Toxicities were not consistently related to dose and no cumulative effects were noted. The dose-limiting toxicity was transient hepatic dysfunction, which occurred in three of six patients receiving 350 micrograms/m2; this toxicity was rapidly reversed on discontinuation of the rTNF. One patient, whose non-Hodgkin's lymphoma had recurred after bone marrow transplantation, had a partial response. Disease was stabilized in two patients.

CONCLUSION

We recommend that phase II testing proceed at a dose of 300 micrograms/m2/d on the schedule described.

Ifosfamide with mesna uroprotection and etoposide in recurrent, refractory acute leukemia in childhood. A Pediatric Oncology Group Study

BACKGROUND

Ifosfamide has previously been shown to be active as a single agent and in combination with doxorubicin, etoposide, and teniposide in pediatric solid tumors and adult acute leukemia. The authors performed a dose-escalation trial of ifosfamide with a fixed dosage of etoposide, with mesna uroprotection, in children with multiply recurrent acute leukemia.

METHODS

Chemotherapy was administered daily for 5 days. Etoposide 100 mg/m2 was followed by ifosfamide at an initial dosage of 1.6 g/m2. The ifosfamide was escalated in 20% increments to the maximum tolerated dosage in cohorts of three patients. Mesna 400 mg/m2 was given immediately before the ifosfamide and then at 3 and 6 hours after ifosfamide in the initial patients. Subsequent patients were treated with mesna 400 mg/m2 just before ifosfamide, and then every 2 hours to a total dosage equal to the ifosfamide dosage.

RESULTS

Forty-four heavily pretreated patients were entered on study. Forty were evaluable for toxicity and 36 for response as well. The maximum tolerated dosage of ifosfamide was 4.0 g/m2/d for 5 days (20 g/m2/course). Overall, 10 patients achieved complete remission, and 3 achieved partial remission. Remissions were brief, although four patients went on to bone marrow transplant while in remission. One patient is still alive.

CONCLUSIONS

The combination of etoposide and ifosfamide with mesna uroprotection showed promising activity in children with multiply recurrent acute leukemia.

Racial differentials in the identification of hypercholesterolemia

BACKGROUND

African Americans have higher rates of cardiovascular disease than white Americans. To address this differential, barriers to cardiovascular risk reduction need to be identified. This study examines the association of race with the likelihood of screening for and diagnosis of hypercholesterolemia.

METHODS

Possible associations between demographic variables and screening for and diagnosis of hypercholesterolemia were examined on data gathered in a prospective fashion in an office-based family medicine residency training program in Rochester, New York. A consecutive sample of all patients seen between December 15, 1988, and April 15, 1990, about whom there was complete data collection (age, sex, insurance, race, and other cardiovascular risk factors) were included in the multivariate analyses (N = 4256).

RESULTS

After controlling for age, sex, insurance status, socioeconomic status, number of visits, and other cardiovascular risk factors, it was found that minorities were less likely to have been screened for cholesterol levels than whites (adjusted odds ratio [AOR] = 0.84, 95% confidence interval [CI] = 0.98 to 0.72). The mean cholesterol level did not differ by race (mean cholesterol for whites, 204 mg/dL [5.28 mmol/L], and for minorities, 203 mg/dL [5.25 mmol/L], t = 0.7, P = .47). Among those screened, minorities were less likely than whites to have been diagnosed with hypercholesterolemia (AOR = 0.62, 95% CI = 0.86 to 0.44; and 0.47 (95% CI = 0.28 to 0.78] in those with a cholesterol level greater than 240 mg/dL [6.2 mmol/L]).

CONCLUSIONS

Our data suggest that provider behavior in diagnosing hypercholesterolemia varies by the race of the patient.

Familial adenomatous polyposis (Gardner's syndrome) and thyroid carcinoma. A case report and review of the literature

The case history of a 24-year-old woman with Gardner's syndrome [familial adenomatous polyposis (FAP)] and papillary thyroid carcinoma is presented, representing the 37th report of this association. Although FAP is transmitted as an autosomal dominant trait with similar penetrance in both sexes, thyroid carcinoma has been found almost exclusively in women (94.3%). The majority have been papillary carcinomas (88.5%), which have become apparent during the third decade (average 23.6, range 16-40 years). Most (55.5%) thyroid carcinomas have been discovered 1-17 years after FAP was identified, although some have been found before (29.6%), or at the same time (14.8%) FAP was diagnosed. Multicentric papillary carcinomas have been reported in 64% (14 of 22) of FAP patients, a frequency at least twofold greater than usual. Although papillary carcinoma found before age 30 (as it was in most patients with FAP) typically has an excellent prognosis, one patient with FAP developed distant metastases from thyroid carcinoma and a 28-year-old woman's death was attributed to papillary carcinoma. The high frequency of multicentric papillary thyroid carcinoma in young patients with FAP and the potential for metastases and death due to thyroid carcinoma warrant aggressive diagnostic screening at regular intervals with neck palpation, ultrasonography, and if necessary, fine-needle aspiration biopsy. When thyroid carcinoma is found, total or near-total thyroidectomy should be considered because of the tumor's high likelihood of being multifocal.(ABSTRACT TRUNCATED AT 250 WORDS)

GAL4 fusion vectors for expression in yeast or mammalian cells

We describe two sets of vectors, one for yeast (pY1, pY2 and pY3) and one for mammalian cells (pM1, pM2, and pM3), that simplify the production of fusion proteins containing the DNA-binding domain of GAL4. This protein fragment, consisting of GAL4 amino acid (aa) residues 1-147, binds to a specific 17-bp nucleotide sequence, but is incapable of activating transcription unless fused to a protein that can contribute an activating function. Genetic strategies exploiting this property of GAL4 (aa 1-147) have been developed to characterize transcription factor functional domains, protein-protein interactions, and site-specific proteolysis. The vectors we describe allow fusion to the C terminus of GAL4 (aa 1-147) in any reading frame, and thus facilitate these experimental strategies.

Alcohol affects rat testicular interstitial fluid volume and testicular secretion of testosterone and beta-endorphin

The effects of alcohol on testicular interstitial fluid (TIF) volume and the secretion of testosterone and beta-endorphin (beta E) into this important testicular compartment were assessed in the rat. Alcohol time- and dose-response curves were constructed for changes in TIF volume and the bioactive concentrations of testosterone and immunoreactive beta E (i-beta E). Alcohol (3 g/kg) decreased TIF volumes and increased TIF i-beta E secretion 0.5 to 6 hr after injection and decreased TIF testosterone 1 to 6 hr after injection. These effects were dose-related at 2 hr postinjection. The possible role of alcohol-induced reductions in serum luteinizing hormone and testosterone levels in mediating the effects of alcohol on TIF volume was also examined. We found that pretreating rats with human chorionic gonadotropin, which reversed alcohol-induced suppression in levels of serum gonadotropins and testosterone, failed to reverse the effects of alcohol on TIF volume and the secretion of testosterone and i-beta E. These results indicate that alcohol decreases TIF volume, inhibits TIF testosterone secretion and stimulates TIF i-beta E secretion and, furthermore, suggest that these effects are not indirectly mediated by decreased levels of gonadotropins or testosterone, but by direct effects of alcohol on gonadal function. The strong inverse correlation between TIF i-beta E and testosterone secretion after alcohol administration and previous evidence that testicular opioids inhibit the biosynthesis of testosterone suggest that alcohol may act through testicular beta E to suppress the synthesis and release of testosterone in the testes.

Response to nondepolarizing muscle relaxants in children with tumours

The rate of onset of action of d-tubocurarine (64 patients) or alcuronium (36 patients) was studied electromyographically in 100 children who had abdominal, bone or cerebral tumours. It was found that there was a significantly delayed onset (over three times longer than controls) or additional doses were required in patients with malignant liver, renal and bone tumours who received d-tubocurarine. The onset of alcuronium blockade was also prolonged but to a lesser extent. When tumours with an abnormal prolongation of onset of relaxation were successfully treated by chemotherapy and/or surgery, the response reverted to normal. Children with benign tumours or masses had normal responses. In contrast, neuroblastomas were associated with little prolongation of onset. Cerebral tumours showed a variable response, with the observed changes being unreliable indicators of degree of malignancy.

Responses to small doses of suxamethonium in four children with abnormal cholinesterase--a case report

Four patients with genetic cholinesterase abnormalities were studied with electromyography after being given suxamethonium 0.1 mg/kg. An abnormal homozygous patient was paralysed for 17 minutes. The duration of response in heterozygous patients was 2-4 minutes, being shorter when cholinesterase activity levels were near normal.

Suxamethonium--electromyographic studies in children

Suxamethonium was administered to 225 children aged from one to sixteen years, in doses varying from 0.1 to 0.5 mg/kg. Dose responses were determined. ED95 was 445 micrograms/kg in one to four year olds, 454 micrograms/kg in the five to ten years group and 270 micrograms/kg in eleven to fifteen year olds (P less than 0.05). There is a wider variability in patient responses to 0.1 and 0.2 mg/kg than to the higher doses. Sixty-two children in the three age groups were given suxamethonium 1 mg/kg. The time from injection to maximum block and to 50% recovery increased with increasing age (P less than 0.05).

Does suxamethonium influence the subsequent dose requirements of alcuronium and its reversibility in children?

Suxamethonium is often used for intubation prior to the use of a nondepolarizing muscle relaxant. This study was performed to determine whether suxamethonium altered the dose of alcuronium required to produce neuromuscular block. The findings were that suxamethonium 1.0 mg/kg did not alter the depth, duration or reversibility of block if given before alcuronium 0.3 mg/kg. Reversal with neostigmine was more rapid following 50 micrograms/kg than after 25 micrograms/kg. If recovery from neuromuscular block was greater than 25 per cent, the lower dose produced satisfactory reversal, whether or not suxamethonium had been given previously.

Phase I evaluation of diaziquone in childhood cancer. A Pediatric Oncology Group study

We conducted a phase I clinical study of aziridinylbenzoquinone (Diaziquone, AZQ) given as a 4 hour infusion weekly X 4. Forty-five children with recurrent acute leukemia and 33 children with various advanced solid tumors participated. Severe myelosuppression was the dose limiting toxic effect, occurring in all patients at the upper dose levels. Gastrointestinal and hepatic toxicities were infrequent and not severe. No allergic reactions occurred. Objective tumor regression was noted in 3 of 25 patients with a CNS tumor and in 6 of 45 patients with acute leukemia. For phase II trials the recommended dosage of Diaziquone given by this schedule is 18 mg/M2/week X 4 for patients with a solid tumor, and is 30 mg/M2/week X 4 for children with acute leukemia.

Phase I study of a 120-hour continuous intravenous infusion of 5-fluorouracil in pediatric patients with recurrent solid tumors: a Pediatric Oncology Group study

To determine the maximum tolerated dose of 5-fluorouracil administered as a 120-hour continuous intravenous infusion to pediatric patients, we performed a phase I study using a starting dosage of 900 mg/m2/day. The maximum tolerated dosage (MTD) was 1,100 mg/m2/day. At this dosage level 40% of courses were complicated by grade 3 mucositis. Three additional patients were treated at the dosage level of 1,000 mg/m2/day after the MTD was determined. We recommend the dosage level of 1,000 mg/m2/day for phase II studies of 5-fluorouracil administered as a 120-hour continuous intravenous infusion to pediatric patients.

Randomized, controlled trial of clonidine for smoking cessation in a primary care setting

Clonidine hydrochloride has been reported to reduce tobacco withdrawal symptoms and facilitate smoking cessation. We enrolled 185 subjects, 92 receiving clonidine and 93 receiving placebo, in a randomized, double-blind study of clonidine for smoking cessation in a primary care setting. Clonidine had no demonstrable effect on withdrawal (8 of 11 measures favoring placebo). At 4 weeks, 17 (18%) subjects receiving clonidine had quit compared with 13 (14%) receiving placebo (chi 2 = 0.7; 90% confidence interval of benefit from clonidine, -4% to 13%). At 4 weeks, the mean number of cigarettes smoked was 17.7 for those receiving clonidine and 17.5 for those receiving placebo (t = 0.1; 90% confidence interval of benefit from clonidine, -4.1 to 3.7 cigarettes per day). These results provide little support for a beneficial effect of clonidine on tobacco withdrawal symptoms, quitting, or smoking reduction in a primary care setting.

Small cell carcinoma of the pleura

Extrapulmonary small cell carcinoma is uncommon. Small cell carcinoma of pleural primary origin has not, based on a literature review of the past three decades, been reported. We have reported a case of small cell carcinoma of the pleura, discussed its management and significance, and briefly reviewed the pertinent literature.

Sensitivity of Campylobacter pylori to colloidal bismuth subcitrate

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Effects of vasodilators on rates of change of nasopharyngeal temperature and systemic vascular resistance during cardiopulmonary bypass in anaesthetized dogs

The effects of various vasodilating agents on the rates of change of nasopharyngeal temperature and total systemic vascular resistance of anaesthetized dogs during cardiopulmonary bypass were studied. Intravenous administration of nitroglycerine (14 micrograms/kg per min, infused at 35 degrees C and 36 degrees C), sodium nitroprusside (5 micrograms/kg per min, infused at 36 degrees C) and phenoxybenzamine (1 mg/kg bolus, given at 32 degrees C and 36 degrees C) did not have any effect on the total cooling time or the rate of cooling from 36 degrees C to 18 degrees C. However, in dogs treated with phenoxybenzamine the time taken to rewarm to 36 degrees C was significantly shorter than those observed in the control, nitroglycerine or sodium nitroprusside treated animals. This difference in rewarming time was mainly due to the more even rate of rewarming induced by phenoxybenzamine. Moreover, a significantly greater reduction in systemic vascular resistance was observed in phenoxybenzamine treated animals than in the other treatment groups.

Long term renal prognosis of Henoch-Schönlein purpura in an unselected childhood population

All 270 patients presenting with Henoch-Schönlein Purpura over a 13-year period from a total childhood population of 155,000 were studied. This is an incidence of 13.5/100,000 children per year. Fifty-five (20%) were found to have initial evidence of renal involvement, and were re-examined at a mean of 8.3 years later. The 37 with isolated haematuria or haematuria with mild proteinuria (67%) recovered completely. Eighteen (33%) had nephritic or combined nephritic/nephrotic features, of these one died in the acute phase of the illness, only three others have persistent urinary abnormalities but have no biochemical evidence of renal impairment and only minor histological changes. The overall prognosis in this unselected population is therefore good with a mortality less than 1% overall and low long term morbidity of 1.1%. This study indicates a more optimistic outcome in this condition than the majority of published estimates based on more selected groups of patients.

Liver tumours and muscle relaxants. Electromyographic studies in children

Electromyographic studies of the onset of action of tubocurarine or alcuronium were performed on eight occasions in five patients who had liver masses. There was a slow onset of action and an increased dose requirement in those with malignant disease. Normal responses were found in a patient with benign nodular hyperplasia and in another where the malignant tumour was successfully treated with chemotherapy.

The influence of age on the cardiovascular toxicity of intravenous bupivacaine in young dogs

A study in anaesthetised dogs aged 2, 6, 13, 26 and 52 weeks or older was done to determine the dose of IV bupivacaine given by infusion required to produce severe cardiovascular depression as measured by a drop in mean blood pressure to about 25 mmHg or the development of life-threatening dysrrhythmias. Plasma local anaesthetic concentration was analysed at the time of ceasing the infusion. The toxic dose was significantly less in the six-week-old group than younger or older animals. The plasma concentrations associated with toxicity in the groups 13 weeks and younger were significantly lower than in the older dogs. Treatment of the induced toxicity included hyperventilation, adrenaline infusion, bretylium and/or cardioversion. The response to treatment was better in young dogs than adult dogs.

Electromyographic responses to small doses of suxamethonium in children after burns

Integrated electromyographic studies in burned patients, and in normal controls, during the administration of small doses of suxamethonium (0.1 or 0.2 mg kg-1) have shown that the level of paralysis and the duration of paralysis are significantly increased in burn patients and that the effect is greater with larger burns. Repeated studies on patients using these small doses have shown that patients with burns pass through a phase of extreme sensitivity to the effects of suxamethonium, usually sometime between 4 and 12 days after the burn.

Effect of 9.6-GHz pulsed microwaves on the orb web spinning ability of the cross spider (Araneus diadematus)

Eight cross spiders (Araneus diadematus) were exposed overnight (16 h) during web-building activity to pulsed 9.6-GHz microwaves at average power densities of 10, 1, and 0.1 mW/cm2 (estimated SARs 40, 4, and 0.4 mW/g). Under these conditions, 9.6-GHz pulsed microwaves did not affect the web-spinning ability of the cross spider.

Giant lymph node hyperplasia (Castleman's disease) of hyaline vascular type. Clinical heterogeneity with immunohistologic uniformity

Of three patients with giant lymph node hyperplasia (GLNH) of hyaline vascular type, one had multicentric involvement and systemic symptoms, and had the nephrotic syndrome develop. The two others had localized adenopathy and were asymptomatic. Immunohistochemistry carried out on frozen and paraffin-embedded tissue was uniform in all cases. For the most part this revealed a polyclonal B-cell population and a reactive T-cell population in keeping with reactive follicular hyperplasia. In contrast to the latter, however, was a total absence of Leu-7 (natural killer cell) activity. The significance of this is unclear but may represent an abnormal immunologic response in the face of overwhelming antigenic stimulation. GLNH is a clinically and pathologically heterogeneous disorder, the management of which is dependent on both the clinical presentation of the patient and the histologic appearances of the involved lymph nodes.

Factor analysis and reliability studies of the Crown-Crisp Experiential Index (CCEI)

Factor analysis of the Crown-Crisp Experiential Index (CCEI) is described. Two groups took part in the study; one from a working population (n = 8292) and one from clients attending three Employment Rehabilitation Centres (n = 281). Comparison of the factors obtained from these two groups, and between these and the original CCEI subscales, are reported, together with estimates of reliability. Overall, the results point to the retention of the CCEI as a reliable instrument for measuring psychoneurotic illness.

Pre-eclampsia in pregnancies from donor inseminations

The outcome of 584 AID pregnancies was analysed in order to examine the possible role of immune mechanisms in the development of pre-eclampsia (PE). The overall incidence of PE was high (9.3%) compared with the expected incidence of 0.5-5.0%. The incidence was similar in both multigravid and primigravid women. The expected protective effect of a previous pregnancy was not seen, with a 47-fold increase in PE (observed versus expected) in AID pregnancies after a previous full-term pregnancy and a 15-fold increase after a previous pregnancy of short duration. In the context of AID pregnancies these findings tend to support the proposed 'fresh mating' concept of PE although the incidence is lower in multigravidas after a full-term (4.7%) than after a partial pregnancy (15.7%). This suggests that it may only be full-term pregnancy which protects against the development of PE. THe category and duration of infertility and the duration of marriage did not affect the incidence of PE except where the male partner was oligozoospermic. In this case the incidence of PE was higher where infertility was 3 years or longer. Further analysis of the findings failed to provide clear evidence to discriminate the role of HLA and tissue-specific non-HLA antigens in the feto-maternal relationship as determinants of the development of PE. Neither did the results support the operation of immunological enhancement induced by prior coital antigen exposure in the genesis of PE, but raised instead the possibility of the operation of a mechanism of sensitisation of the female partner to seminal components over a long period of time when the husband was oligozoospermic compared with one whose husband was azoospermic.

Correlates of intelligence and adaptive behaviour in Down's syndrome

Intelligence and adaptive behaviour scores of Down's syndrome children were compared with parental educational level, socio-economic indicators, and parental age at birth of the child. IQ and adaptive behaviour scores were positively correlated with parental education and socio-economic indicators. Adaptive behaviour scores of children born to older parents were significantly lower than scores of children born to younger parents.

Self-care skills: behavioral measurement with Klein-Bell ADL scale

A scale for measuring activities of daily living (ADL) functioning is described and reviewed. Teh Klein-Bell ADL Scale has been empirically constructed to yield a score of independent functioning for research and clinical purposes. Interrater reliability is 92%, even without extensive training in the use of the scale. Validity was measured by correlating ADL scores at discharge with hours/weeks of assistance (physical, verbal cueing, and type) received 5 to 10 months postdischarge; correlation was -0.86 (p less than 0.01), indicating that persons with low ADL scores receive much assistance, and that the amount of assistance received decreases steadily as the ADL score increases. Further research applications are suggested.

The Bristol Social Adjustment Guide: comparison between the offspring of alcoholic and non-alcoholic mothers

A German translation of the BSAG was completed by class-teachers of children whose mothers had a history of alcoholism. These children were judged as showing significantly more over-reactive behaviour in school than a control group of children whose mothers had no previous alcohol abuse. Furthermore, the alcoholic mothers also reported more over-active behaviour in their own childhood. The results are supportive of retrospective studies with adult alcoholics which indicate that childhood hyperactivity may be one precursor of subsequent alcohol abuse.

Light scattering from fibers: a closer look with a new twist

Scattering from an apparently perfect fiber, placed perpendicular to a laser beam, produces an out of plane scattering pattern containing an internal structure not predicted by simple fiber scattering theory. A photographic study of light scattered from twisted fibers shows that the effect is due to periodic disturbances along the fiber axis that act as coherent scattering centers.