Pica, iron deficiency, and the medical history

We describe two new forms of pica associated with iron deficiency and a new variant of a third. Previous reports on pica are tabulated. The value of a sympathetic, nonjudgmental approach to eliciting the medical history is emphasized.

Phase II trial of edatrexate in patients with advanced hepatocellular carcinoma

BACKGROUND

The methotrexate analogue edatrexate (10-ethyl-10-deaza-aminopterin, or 10-EDAM) has demonstrated greater activity than methotrexate has against murine tumors and human tumor xenografts. Phase II trials of edatrexate have already demonstrated its activity against breast, lung, and head and neck carcinomas. A phase II trial of edatrexate was conducted in patients with advanced hepatocellular carcinoma.

PATIENTS AND METHODS

Seventeen patients with previously untreated unresectable hepatocellular carcinoma were enrolled on the study. Edatrexate, 80 mg/m2 weekly for 5 weeks, was administered intravenously. The treatment course was repeated every 6 weeks. Tumor response was evaluated by computerized tomographic scan after 2 courses.

RESULTS

No complete or partial responses were observed in this trial. Two minor responses, each lasting less than 12 weeks, were observed. Twelve patients had elevated serum alpha-fetoprotein (AFP) levels at entry into the study; 4 of the 12 patients experienced a > or = 25% decrease in the level of this tumor marker; 3 of the 4 had a > 50% reduction in AFP level. Grade 3 and 4 toxic effects were granulocytopenia, thrombocytopenia, anemia, oral mucositis, skin reactions, fatigue, anorexia, and diarrhea.

CONCLUSIONS

Edatrexate administered at this dose and schedule appears to have little therapeutic efficacy against advanced hepatocellular carcinoma.

Acute arsenic poisoning: absence of polyneuropathy after treatment with 2,3-dimercaptopropanesulphonate (DMPS)

Two men aged 19 and 21 years ingested 1 g and 4 g respectively from 3 kg of a white crystalline powder that they thought was a substance of abuse. It was later identified as almost pure arsenic trioxide. Both had nausea and vomiting and one developed acute renal failure. Each was treated with 2,3-dimercaptopropanesulphonate (DMPS), and made a full recovery with no evidence of prolonged renal or neurological impairment. The DMPS-arsenic complex is probably associated with lower penetration into the CNS and as a consequence treatment with DMPS may result in lower acute and chronic neurotoxicity than treatment with the currently standard recommended chelating agent dimercaprol (British Anti-Lewisite; BAL).

A phase II trial of oral etoposide with mitoxantrone and ifosfamide/mesna consolidated with intravenous etoposide, methylprednisolone, high-dose arabinoside, and cisplatin as salvage therapy for relapsing and/or refractory lymphomas

PURPOSE

To evaluate the response to oral Etoposide when combined with mesna, ifosfamide, and mitoxantrone in patients with relapsed and/or refractory lymphoma. To evaluate response and its duration after administration of intravenous Etoposide, methylprednisolone, high-dose cytosine arabinoside, and cisplatin (ESHAP) as consolidation therapy after complete or partial responses (CR or PR, respectively) or after crossover therapy for progressive disease.

METHODS

Patients received MINE(o) consisting of mesna, 1.33 g/m2 infused over 1 hour daily x 3 followed 4 hours later by oral mesna at 500 mg; ifosfamide, 1.33 g/m2 infused over 1 hour daily x 3; mitoxantrone, 8 mg/m2 intravenously on day 1, and oral VP-16, 30 mg/m2 daily x 13. The ESHAP regimen consisted of intravenous VP-16, 40 mg/m2 infused over 2 hours daily x 4; methylprednisolone, 500 mg intravenously daily x 4; cytosine arabinoside, 1.5 g/m2 infused over 3 hours on day 4; and cisplatin, 25 mg/m2 given as a continuous 24-hour infusion daily x 4. Statistical analysis was performed using the 2-stage design described by Simon. For the oral VP-16 regimen to be of interest, at least 36% patients had to achieve a complete remission.

RESULTS

The overall response rate achieved with MINE(o) was 40% (15% CR, 25% PR). Seven patients with prior exposure to cytosine arabinoside and cisplatin (AP) received MINE(o) alone of whom only one achieved a response (CR). Thirteen patients without prior exposure to AP received consolidation (2 patients) or crossover (11 patients) therapy with ESHAP. Crossover therapy with ESHAP further improved the response in only two of five patients with partial response to MINE(o) and none of six patients who failed MINE(o). Median response duration for the patients who received MINE(o)/ESHAP was 12 weeks (range, 4-55 weeks).

CONCLUSIONS

Oral VP-16 combined with ifosfamide/mesna and mitoxantrone at the doses and schedules indicated has little activity against relapsed and/or refractory lymphomas. Crossover therapy with ESHAP did not further improve the response rate. The duration of response after MINE(o)/ESHAP was short.

Targeted HIV seroprevalence among Vietnamese in southern California

OBJECTIVE

The prevalence of HIV among southern California Vietnamese is unknown. We collected seroprevalence data on targeted Vietnamese in Orange County, California who may be at risk for HIV infection.

METHODS

The assumption of elevated risk was based on rates of infection reported among other U.S. groups. Vietnamese (N = 874) from six county sites were tested during 1992: (1) attendees at county HIV/STD clinics and (2) IDU program; (3) male inmates of the county jail and (4) of a juvenile detention centre; (5) males in a driving under the influence of alcohol (DUI) remedial program; and (6) patients for nonpregnancy-related syphilis screening.

RESULTS

The number of cases detected and risk factors were: (1) county HIV/STD clinics--5/223 (2.3%), all men who had sex with men; (2) men's jail--1/122 (0.8%), risk factors unknown; (3) juvenile hall--1/145 (0.7%), risk factors unknown; (4) IDU program--0/33; (5) syphilis screening--0/284; and (6) DUI program--0/67.

CONCLUSIONS

HIV infection exists among southern California Vietnamese, and men who have sex with men appear to be at a risk for HIV infection similar to others practicing high risk behaviors in the U.S. population. Preventive education needs to be targeted explicitly at these individuals.

Phase II trial of intravenous melphalan in advanced colorectal carcinoma

BACKGROUND

Relatively few studies have examined the activity of alkylating agents in the treatment of advanced colorectal adenocarcinoma. Recent reports have suggested possible therapeutic activity for high-dose intravenous melphalan administered with autologous bone marrow transplantation (BMT) support. We conducted a phase II study to determine the efficacy of administering intravenous melphalan at doses that do not require BMT support in patients with advanced colorectal adenocarcinoma.

PATIENTS AND METHODS

Fifteen patients with histologically proven, bidimensionally measurable disease were treated. The starting dose of melphalan was 30 mg/m2, with dose escalation permitted.

RESULTS

No objective responses were observed. Toxic effects were primarily reversible granulocytopenia and thrombocytopenia. There were no treatment-associated deaths.

CONCLUSION

Melphalan's lack of efficacy at the doses administered does not disprove the steep chemotherapy dose-response relationship postulated for many solid tumors. However, we feel that it is unlikely that repetitive courses of high dose melphalan with autologous BMT support will be a practical approach to the management of advanced colorectal adenocarcinoma.

Phase II trial of edatrexate in patients with advanced pancreatic adenocarcinoma

BACKGROUND

The methotrexate analogue 10-ethyl-10-deazaaminopterin (10-EdAM, or edatrexate) has shown antitumor activity in preclinical testing and clinical studies of patients with breast, lung and head and neck carcinomas. A phase II study was conducted in patients with advanced pancreatic adenocarcinoma.

PATIENTS AND METHODS

Forty patients were enrolled on the clinical trial. Edatrexate was administered intravenously at a dose of 80 mg/m2 weekly for 5 weeks. The treatment course was repeated every 6 weeks.

RESULTS

Two partial responses were observed. Both of these patients had partial responses which lasted 2 and 3.5 months. The median survival for all patients was 3.5 months. Serious (grade 3 or 4) toxic effects were primarily mucosal, hematologic, and dermatologic. Two patients experienced severe pulmonary toxic reactions.

CONCLUSION

At the dose and schedule used, edatrexate was poorly tolerated and did not demonstrate significant antitumor activity.

Folinic acid and enhanced renal elimination in formic acid intoxication

Ingestion of over 60 g of formic acid by an adult is potentially fatal. We report a case of a 36-year-old woman with a history of depression who ingested 110 g of formic acid. She survived a complicated intensive care hospitalization following usage of intravenous folinic acid, urinary alkalinization, intravenous furosemide and supportive care. We suggest a management protocol aimed at minimizing formate toxicity by enhancing hepatic formate degradation via the folinic acid 'one carbon pool' and by enhanced renal elimination of formate.

Detection and identification of Mycobacterium tuberculosis directly from sputum sediments by amplification of rRNA

Seven hundred fifty-eight processed sputum sediments received for the diagnosis of tuberculosis or other mycobacterial infections were tested by utilizing a rRNA target amplification assay and traditional culture techniques. The results from the rRNA target amplification assay (Gen-Probe Amplified Mycobacterium Tuberculosis Direct Test), available in 5 h, were compared with the results from standard culture techniques held for 6 weeks. A total of 119 specimens (16%) were culture positive for Mycobacterium tuberculosis. Overall sensitivity, specificity, positive predictive value, and negative predictive value were 82, 99, 97, and 96%, respectively, for the Gen-Probe assay; 88, 100, 100, and 97%, respectively, for culture; and 53, 99.8, 99.6, and 91%, respectively, for fluorochrome stain. The Gen-Probe assay employs the isothermal enzymatic amplification of M. tuberculosis complex rRNA followed by detection of the amplicon with an acridinium ester-labeled DNA probe. This assay has the potential of reducing the time for diagnosis of tuberculosis to 1 day.

Features, prevention and management of acute overdose due to antidiabetic drugs

Hypoglycaemic medication forms a disparate group of therapeutic compounds including insulin, the sulphonylureas and biguanides. They are all designed to prevent hyperglycaemia and in general are well tolerated. Careful prescribing practice and patient education by the physician can do much to reduce the risk of adverse effects from diabetic therapy. However, the presentation of adverse effects, together with accidental and non-accidental overdose, is a frequent clinical problem. Furthermore, the possible impairment of hypoglycaemic awareness in patients prescribed human insulin has added complexity to diabetic management. The cardinal features of insulin overdose are hypoglycaemia and hypokalaemia. The sulphonylureas predominantly cause hypoglycaemia, while the biguanides may precipitate lactataemia and acidosis. Recognition of hypoglycaemia is therefore crucial in avoidance of toxicity. Intravenous dextrose is the mainstay of therapy following gut decontamination (for the oral agents). The efficacy of glucagon is dependent on hepatic glycogen stores and should therefore be used with caution. Diazoxide is not recommended. More recently, octreotide has been shown to be effective in sulphonylurea overdose. Patients should be admitted and monitored with serial blood sugar measurements for a minimum of 1 to 2 days as clinically warranted.

Subarachnoid haemorrhage associated with MDMA abuse

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A proportional hazards model for truncated AIDS data

An important source of information on the latency period for AIDS is the data from individuals infected by contaminated blood transfusion. However, a difficulty in the analysis and interpretation of these data is that information is available only on individuals who are infected and develop the disease prior to some specific time. In this paper, we propose an approach to the analysis of such data under a proportional hazards model. The proposed approach allows testing for group effects in the presence of multiple explanatory variables.

Phase I study of 5-fluorouracil with folinic acid combined with recombinant human granulocyte-macrophage colony-stimulating factor

A Phase I study was conducted to determine whether the addition of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) to a combined 5-fluorouracil (5-FU) and folinic acid (FA) regimen would allow an escalated starting dose of 5-FU. FA (500 mg/m2) was administered as a 2-hour infusion on days 1 through 5, with 5-FU administered as a bolus injection 1 hour after the initiation of FA. Fifteen patients were enrolled in the trial; six were entered at a dose level of 375 mg/m2 of 5-FU, six at 450 mg/m2, and three at 540 mg/m2. rhGM-CSF was administered subcutaneously on days 6 through 15. A course of therapy was repeated every 28 days. Serious toxicity was observed at 450 mg/m2, with two patients developing grade 3 mucositis and one, grade 4 mucositis. Dose-limiting toxicity occurred at 540 mg/m2, at which point three patients developed grade 4 mucositis. One patient with metastatic colon cancer who received 5-FU at 540 mg/m2 achieved a partial response. Because of this persistent mucositis, the addition of rhGM-CSF used in this schedule would not allow an increased starting dose of 5-FU.

Effect of educational program on compliance with glove use in a pediatric emergency department

OBJECTIVE

To investigate the effect of an educational program on compliance with glove use in a pediatric emergency department.

DESIGN

Without their knowledge, participants were observed for routine use of gloves during vascular access procedures before and after an educational program. Participants with up to 3 years' vascular access experience were defined as less experienced and those with 4 or more years' experience were defined as more experienced. Their success rates performing vascular access procedures with and without wearing gloves were also monitored.

SETTING

Inner-city pediatric hospital emergency department.

PARTICIPANTS

Twenty-three emergency department registered nurses.

INTERVENTIONS

A 30-minute lecture with slides, written materials, and posters addressing the reasons and need for universal precautions, and recommended methods of barrier precautions to prevent skin and mucous membrane exposure when handling sharp instruments.

MEASUREMENTS/MAIN RESULTS

For the less experienced registered nurses, the compliance rate before the educational program was 70% and remained at about 93% afterward. For the more experienced registered nurses, the compliance rate before the program was only 15%. After the program, this compliance rate rose to 93%, but declined to only 50% by the fifth month. The registered nurses' success rate on the first attempt at vascular access while wearing gloves was 75% compared with 70% without gloves.

CONCLUSION

Educational programs can result in a clinically significant increase in glove use by pediatric emergency department registered nurses. Long-term improvement was less pronounced for the group of more experienced registered nurses. We also observed that glove use does not appear to interfere with the proficient performance of vascular access procedures.

Phase II study of gemcitabine in advanced colorectal adenocarcinoma

A phase II trial of gemcitabine (difluorodeoxycytidine) was conducted in 14 patients with advanced colorectal adenocarcinoma. Gemcitabine was administered intravenously over 30 minutes at weekly intervals for 3 consecutive weeks each month. The starting dose was 800 mg/m2, with dose escalation as tolerated. No complete or partial response were observed. Ten patients experienced progressive disease while on therapy. Toxic effects were primarily hematologic in nature. Grade 3 toxicities included leukopenia (one patient at 1000 mg/m2), granulocytopenia (two patients at 800 mg/m2), anemia (two patients at 800 mg/m2), and myalgia (one patient at 800 mg/m2). No grade 4 toxic effects or treatment-associated deaths were observed. Gemcitabine, at the doses and schedule used in this study, did not demonstrate activity against advanced colorectal adenocarcinoma.

Modulation of fluorouracil with recombinant alfa interferon: M. D. Anderson Clinical trial

Clinical trials have been initiated examining the combination of fluorouracil (5-FU) and recombinant interferon alfa-2a (rIFN-2a) in the treatment of advanced colorectal carcinomas. An early trial reported a response rate of 76%, encouraging further investigation. Clinical trials have used 5-FU administered as a continuous intravenous infusion, 750 mg/m2 per day for 5 consecutive days, followed by weekly bolus administration of 5-FU 750 mg/m2. Recombinant interferon alfa-2a, 9 million units, was administered subcutaneously three times weekly. Of 45 evaluable patients treated at The University of Texas M. D. Anderson Cancer Center, a response rate of 35% (95% confidence interval, 22%, 50%) was observed. Twenty-five percent of patients developed grade 4 toxicity and 82% developed grade 3 toxicity. The median survival was 16 months. Investigation of this combination will require randomized trials to further assess activity in relation to alternative treatments.

Isolation of Mycobacterium thermoresistibile following augmentation mammaplasty

This is the first case report of a Mycobacterium thermoresistibile infection following augmentation mammaplasty and is the fourth human case report of M. thermoresistibile infection. Antimicrobial susceptibility results determined by a modified proportion method using a 3-day incubation were the same as those determined by the standard 3-week assay.

Clinical trials of fluorouracil with alpha-interferon in advanced colorectal carcinomas

Three clinical trials have been conducted with fluorouracil (5-FU) and recombinant interferon alfa-2a (rIFN-alpha 2a) in the treatment of advanced colorectal carcinoma. The regimen consisted of 5-FU (750 mg/m2/d) as an intravenous continuous infusion for 5 consecutive days followed by a week's rest. Weekly bolus 5-FU (750 mg/m2) was subsequently administered. Nine million units of rIFN-alpha 2a was administered subcutaneously three times weekly. The initial clinical trial conducted by investigators from the Albert Einstein Cancer Center (New York, NY) reported a 76% response rate with 13 of 17 patients responding. When this clinical trial was extended to 32 patients, 20 patients (63%) achieved partial responses. Investigators from the University of Texas M.D. Anderson Cancer Center (Houston, TX) enrolled 45 evaluable patients and reported 15 partial responses and one clinical complete response (response rate, 36%). A similar trial was conducted at Memorial Sloan-Kettering Cancer Center (New York, NY) with nine of 35 patients (26%) experiencing partial responses. Grades 3 to 4 toxicities in these three trials included mucositis, diarrhea, leukopenia, and neurotoxicity. Four treatment-related deaths were reported, with three of these deaths ascribed to profuse watery diarrhea associated with leukopenia. Current randomized trials are comparing this regimen with 5-FU plus folinic acid. Future strategies will examine alternative schedules of 5-FU with interferon, and will attempt to better define the mechanism of interaction.

Robust estimation of the variance in moment methods for extra-binomial and extra-Poisson variation

When faced with data in the form of overdispersed counts or proportions, moment methods allow consistent parameter estimation when only the form of the mean and variance is specified. If the variance form is misspecified, these methods still yield consistent parameter estimates, though with lower efficiency, and the variances of the estimates will be inconsistent. A variance correction is available that yields consistent variance estimates in these circumstances. The asymptotic and small-sample efficiencies of this correction are calculated, and its performance under variance misspecification is studied. A group-randomized breast self-examination prevention study that is now underway serves as a focal point for the study of these properties. The use of the variance correction in modelling is illustrated on a teratology data set.

Stiripentol in acute/chronic efficacy tests in monkey model

Acute and chronic efficacy tests of stiripentol (4,4-dimethyl-1-[3,4-(methylenedioxy)-phenyl]-1-penten-3-ol) were conducted in alumina-gel rhesus monkeys. In the acute study (n = 6), discrete serial seizures precipitated by 150 mg/kg of 4-deoxypyridoxine hydrochloride were challenged by intravenous administration of stiripentol and the data compared with those obtained with valproate similarly tested in other monkeys (reported here) and with those from four other standard anticonvulsants (phenytoin, carbamazepine, phenobarbital, and diazepam--data published previously). In the acute challenge (Study 1), stiripentol performed comparably to valproate by delaying the onset of seizures but not eliminating them as did the other four drugs. In two separate chronic studies (at different doses, n = 6 each), stiripentol was given every 4 h by gastric catheter for 4 weeks, preceded and followed by 4 weeks of baseline. In these studies, stiripentol significantly reduced EEG interictal spike rates at mean plasma concentrations from 20 to 27 micrograms/ml in Study 2 and 11 to 14 micrograms/ml in Study 3. From these results, and those evinced in other studies, it appears that stiripentol should be evaluated for absence epilepsy and possible synergistic effects in polytherapy.

Comparison of human fibroblast cells and primary rabbit kidney cells for isolation of herpes simplex virus

Human foreskin fibroblast cells and primary rabbit kidney cells were compared for efficiency in isolation of herpes simplex virus from 1,100 clinical specimens. Of the fibroblast cultures, 265 were positive, whereas 268 primary rabbit kidney cultures were positive. The results indicate that either cell type is acceptable for diagnostic use.

Virus inhibition assay for measurement of acyclovir levels in human plasma and urine

A simple microplate virus inhibition assay which measures the levels of acyclovir in plasma and urine samples from patients was developed. The assay is based upon the inhibition of the cytopathic effect of herpes simplex virus type 1 on human fibroblast cells. The extent of inhibition of virus cytopathic effect, caused by dilutions of samples from patients, allowed determination of acyclovir concentrations to be made. The assay, which measured biological activity, could detect acyclovir levels of greater than or equal to 1.0 microM. Peak and valley levels measured in plasma samples from two patients were comparable to values obtained by radioimmunoassay. The assay is simple, rapid, and quantitative, and it can be adapted to routine use for a large number of specimens.

Rapid identification and antimicrobial susceptibility testing of gram-negative bacilli from blood cultures by the AutoMicrobic system

A procedure was developed which allows direct identification and antimicrobial susceptibility testing of fermentative and nonfermentative gram-negative bacilli from positive blood cultures. A 10-ml sample was removed from turbid blood culture bottles, and the bacteria were washed and concentrated by centrifugation. The bacterial pellet was used to inoculate an Enterobacteriaceae Plus Identification Card and a Gram-Negative General Susceptibility Card of the AutoMicrobic system. Results with these cards were compared with results obtained with standard technique for 196 blood cultures seeded with recent clinical isolates. Identification of most cultures was available in 8 h, whereas the antimicrobial susceptibility results were available in an average of 4.7 h for all organisms. Direct identification was correct for 95% of the cultures, whereas the antimicrobial susceptibility data had an average agreement of 87% with 3.8% very major and 1.4% major errors. In using this procedure it was possible to provide accurate preliminary identification and results of antimicrobial susceptibility tests for gram-negative bacilli on the same day that a blood culture was determined to be positive.

Integration and transcription of virus DNA in herpes simplex virus transformed cell lines

The physical state of the HSV I DNA present in two biochemically transformed cell lines, a revertant line and a supertransformed cell line, was determined. These cells all contained fragments of the HSV genome and the transformed and supertransformed cell lines expressed virus thymidine kinase. It was found that the virus DNA in these cells was maintained in a complex state with approximately half of the HSV DNA present in a covalently integrated state and the other half in a non-integrated state. There was no major cell line difference in the distribution of integrated and non-integrated virus DNA. RNA transcripts representing 5% of the HSV I genome are present in each of these lines. This is more than is required to code for the virus thymidine kinase present in the transformed and supertransformed cell lines and suggests the presence of other virus proteins in these cells.

Herpes simplex virus necleic acid synthesis following infection of non-permissive XC cells

DNA hybridization kinetic analysis of cellular DNA following high multiplicity infection of non-permissive XC cells by herpes simplex virus type I showed that HSV DNA penetrates to the nucleus of the cell but that the number of virus DNA copies present in each cell quickly begins to decline. There did not appear to be any net virus DNA synthesis and the loss of virus DNA copies continued until there was approximately one per haploid genome equivalent. HSV-2 likewise did not show any detectable virus DNA replication. The residual virus information was stable for more than 48 h. CsCl density gradient analysis of the infected cell DNA suggested an association between the HSV DNA and that of the cells. Network analysis also supported the suggestion that a stable association between the virus DNA and host DNA begins shortly after infection. Cell division resulted in the segregation of the virus DNA but not its loss from the cell population. Virus-specific RNA synthesis was easily detectable and 40 to 50% of a labelled DNA probe was converted to an RNA:DNA hybrid.

Follow-up of stereotaxic amygdalotomy for seizure and behavior disorders

Stereotaxic amygdalotomy for the control of unmanageable behavior and/or intractable seizures is a controversial treatment approach with unknown risk-to-benefit ratios. Information about this subject was obtained from a retrospective follow-up study of 58 patients who received this form of treatment 1 to 11 years earlier (average 6 years). Assessments of the patients were made by invesgators external to the surgical treatment system, using structured psychiatric interviews, neuropsychological tests, and EEGs. In addition, global assessments were made, comparing pre- versus postoperative status. The objective data revealed no indication of worsening or damage with similar pre- and postoperative test scores and EEG features. Computer-scored interviews revealed considerable psychopathology in the ambulatory patients. Overall judgments of behavior, seizures, and functional levels indicated that more than a third of the group was probably improved, although the relationship of outcome to the surgery was indeterminate.

Familial associations with EEG variants in manic-depressive disease

Electroencephalographic (EEG) studies of 60 patients with bipolar manic-depressive disease disclosed an incidence of small sharp spikes plus a few other variations in 47% of the sample. In women these EEG features were significantly associated with a history of mental illness in the patient's mother or the maternal side of the family and an absence of mental disorder in the fathers. The reverse was true of women probands without these EEG characteristics. In the men small sharp spikes did not relate to parental psychopathology but half of the sisters of men with these EEG characteristics were found to be mentally ill. On the basis of these observations and previous work, we hypothesize that the small sharp spike EEG pattern might be an inherited characteristic related in some way to the familal transmission of manic-depressive disease.

Amebiasis in northern Saskatchewan: pathological aspects

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Dr. Allan A. Bailey

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The effect of thalidomide on the developing rat foetus

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