Prostate-specific antigen velocity and the odds of detecting gleason 8 to 10 prostate cancer at biopsy

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Background: Increased detection of high-grade prostate cancer was observed in the Prostate Cancer Prevention Trial (PCPT) in men receiving finasteride that halves prostate-specific antigen (PSA) and eliminates subsequent PSA rise from benign prostatic hyperplasia. Therefore despite doubling PSA, men receiving finasteride needed a larger PSA rise to exceed 4 ng/ml and have prostate biopsy recommended compared to placebo. We evaluated whether the PSA rise during the year before biopsy (PSA velocity) was associated with prostate cancer detection. Methods: Between 1/90 and 12/03, of 2125 prostate biopsies performed for a PSA exceeding 4 ng/ml or a nodule on digital rectal examination (DRE), prostate cancer was identified in 1418. Multivariable logistic regression analyses were performed evaluating the detection of Gleason 6 or less, 7, or 8 to 10 cancer. Covariates included the continuous variables of PSA velocity and level, number of prior negative biopsies and age and the categorical variables of ethnicity, DRE findings and family history. Results: As shown in the table , PSA velocity was only associated with Gleason 8 to 10 cancers (Adjusted Odds Ratio: 1.05 [95% Confidence Interval: 1.02 to 1.08]; p = 0.001). Age, PSA level and DRE status were associated across Gleason scores (p-values 0.005 or less), whereas family history (p-values 0.02 or less) and number of prior negative biopsies (p-values 0.01 or less) were associated with Gleason 7 or less cancers. Conclusion: PSA velocity is associated with Gleason 8 to 10 cancers at biopsy providing rationale for the PCPT results and a tool to enhance detection of clinically significant prostate cancer.

[Table: see text]

No significant financial relationships to disclose.

Severe influenza B myocarditis and myositis

OBJECTIVE

To report an influenza B infection with associated myocarditis and severe skeletal myositis.

DESIGN

Case report.

SETTING

Cardiac intensive care unit in a university-affiliated children's hospital.

PATIENT

A 4-yr-old girl.

RESULTS

The patient was successfully supported with extracorporeal membrane oxygenation for profound myocardial dysfunction and a combination of plasmapheresis and continuous venovenous hemodialysis for rhabdomyolysis and acute renal failure.

CONCLUSIONS

This case provides a reminder that patients presenting with viral illness or myoglobinuria accompanied by renal failure, with or without associated myocarditis, may be demonstrating symptoms of influenza B.

Iron supplementation increases disease activity and vitamin E ameliorates the effect in rats with dextran sulfate sodium-induced colitis

Inflammatory bowel disease is often associated with iron deficiency anemia and oral iron supplementation may be required. However, iron may increase oxidative stress through the Fenton reaction and thus exacerbate the disease. This study was designed to determine in rats with dextran sulfate sodium (DSS)-induced colitis whether oral iron supplementation increases intestinal inflammation and oxidative stress and whether the addition of an antioxidant, vitamin E, would reduce this detrimental effect. Four groups of rats that consumed 50 g/L DSS in drinking water were studied for 7 d and were fed: a control, nonpurified diet (iron, 270 mg, and dl-alpha-tocopherol acetate, 49 mg/kg); diet + iron (iron, 3000 mg/kg); diet + vitamin E (dl-alpha-tocopherol acetate, 2000 mg/kg) and the diet + both iron and vitamin E, each at the same concentrations as above. Body weight change, rectal bleeding, histological scores, plasma and colonic lipid peroxides (LPO), plasma 8-isoprostane, colonic glutathione peroxidase (GPx) and plasma vitamin E were measured. Iron supplementation increased disease activity as demonstrated by higher histological scores and heavier rectal bleeding. This was associated with an increase in colonic and plasma LPO and plasma 8-isoprostane as well as a decrease in colonic GPx. Vitamin E supplementation decreased colonic inflammation and rectal bleeding but did not affect oxidative stress, suggesting another mechanism for reducing inflammation. In conclusion, oral iron supplementation resulted in an increase in disease activity in this model of colitis. This detrimental effect on disease activity was reduced by vitamin E. Therefore, the addition of vitamin E to oral iron supplementation may be beneficial.

Effect of oral iron supplementation on oxidative stress and colonic inflammation in rats with induced colitis

BACKGROUND

Iron supplementation may increase disease activity in ulcerative colitis, possibly through the production of reactive oxygen species from the Fenton reaction.

AIM

To assess the effects of two doses of oral iron on intestinal inflammation and oxidative stress in experimental colitis.

METHODS

Colitis was induced in rats by giving 5% dextran sulphate sodium in drinking water for 7 days. First, using a 2 x 2 factorial design, rats with or without dextran sulphate sodium received the regular diet or a diet containing iron 3%/kg diet. Second, rats with dextran sulphate sodium-induced colitis were supplemented with iron 0.3%/kg diet and compared with rats on dextran sulphate sodium and regular diet. The body weight change, histological scores, colon length, rectal bleeding, plasma and colonic lipid peroxides, colonic glutathione peroxidase and plasma vitamin E and C were measured. Faecal analysis for haem and total, free and ethylenediaminetetra-acetic acid-chelatable iron was also performed.

RESULTS

Iron 3% and iron 0.3% increased the activity of dextran sulphate sodium-induced colitis, as demonstrated by higher histological scores, heavier rectal bleeding and further shortening of the colon. This was associated with increased lipid peroxidation and decreased antioxidant vitamins. Faecal iron available to the Fenton reaction was increased in a dose-dependent manner.

CONCLUSIONS

Iron supplementation taken orally enhanced the activity of dextran sulphate sodium-induced colitis and is associated with an increase in oxidative stress.

Hearing loss in rheumatoid arthritis

OBJECTIVE

Hearing loss, both sensorineural and conductive, has been reported in patients with rheumatoid arthritis (RA). The aim of this study was to try and ascertain the type of hearing loss and to determine the cause for any conductive element noted in these cases.

DESIGN AND SETTING

A prospective case-control study in the otolaryngology department of a university teaching hospital in the United Kingdom.

METHODS AND OUTCOME MEASURES

This study compared 35 patients with RA with 35 age- and sex-matched controls. All patients had pure-tone audiometry, speech discrimination, tympanometry, acoustic reflex, and acoustic reflex decay carried out. Statistical analysis of the two groups was carried out using the F test for differences in variation and the t-test for independent samples.

RESULTS

Sensorineural hearing loss that was statistically significant (p < .05) at 500 Hz, 1 kHz, and 2 kHz in both ears was found in 60% of the RA group and in 34.29% of the control group. A conductive hearing loss that was statistically significant (p < .05) at 250 Hz, 500 Hz, 1 kHz, and 2 kHz in the right and left ears was found in 17.14% of the RA patients and in 5.71% of the control group. Speech discrimination did not show a statistically significant difference between the two groups. Tympanometry showed that the conductive element was probably owing to laxity of the middle ear transducer mechanism. Acoustic reflex and reflex decay did not show statistically significant differences between the two groups.

CONCLUSION

Sensorineural hearing loss of the cochlear variety is a common finding in patients with RA, whereas conductive loss, although seen, is much less common. Increased laxity of the middle ear transducer mechanism is the likely cause of the conductive element.

Effect of iron supplementation on oxidative stress and intestinal inflammation in rats with acute colitis

In this study, we investigated the effect of intraperitoneal iron dextran (100 mg/100 g body weight) on oxidative stress and intestinal inflammation in rats with acute colitis induced by 5% dextran sulfate sodium. In both colitis and healthy animals, disease activity index, crypt and inflammatory scores, colon length, plasma and colonic lipid peroxides, and plasma vitamins E, C, and retinol were assessed. The results showed that iron-supplemented groups had moderate iron deposition in the colonic submucosa and lamina propria. In the colitis group supplemented with iron, colon length was significantly shorter; disease activity index, crypt, and inflammatory scores and colonic lipid peroxides were significantly higher; and plasma alpha-tocopherol was significantly lower compared to the colitis group without iron supplementation. There was no intestinal inflammation and no significant increase in colonic lipid peroxides in healthy rats supplemented with iron. In conclusion, iron injection resulted in an increased oxidative stress and intestinal inflammation in rats with colitis but not in healthy rats.

Giant lymph node hyperplasia a diagnostic dilemma in the neck

Giant lymph node hyperplasia (GLNH) or Castleman's disease is a rare pathological entity commonly presenting as a solitary mediastinal tumour (unifocal variant), although other anatomical sites have been reported including the head and neck, abdomen and axilla. Though the head and neck is the second commonest site for this lesion, only 60 cases [1,2] have been reported in the literature. Pre-operative diagnosis of the unifocal variant can be difficult as routine investigations carried out in the clinic setting are often inconclusive. A multicentric form of this disease with a poorer prognosis in comparison to the unifocal lesion has been described by Gaba et al. in 1978 [3]. We present a case of an unusually large, slow growing, asymptomatic, unifocal variant of this tumour restricted to the neck which underwent successful surgical excision. A review of the literature, histopathological characteristics and differential diagnosis is also presented.

Kinetics of hepadnavirus loss from the liver during inhibition of viral DNA synthesis

Hepadnaviruses replicate by reverse transcription, which takes place in the cytoplasm of the infected hepatocyte. Viral RNAs, including the pregenome, are transcribed from a covalently closed circular (ccc) viral DNA that is found in the nucleus. Inhibitors of the viral reverse transcriptase can block new DNA synthesis but have no direct effect on the up to 50 or more copies of cccDNA that maintain the infected state. Thus, during antiviral therapy, the rates of loss of cccDNA, infected hepatocytes (1 or more molecules of cccDNA), and replicating DNAs may be quite different. In the present study, we asked how these losses compared when woodchucks chronically infected with woodchuck hepatitis virus were treated with L-FMAU [1-(2-fluoro-5-methyl-beta-L-arabinofuranosyl) uracil], an inhibitor of viral DNA synthesis. Viremia was suppressed for at least 8 months, after which drug-resistant virus began replicating to high titers. In addition, replicating viral DNAs were virtually absent from the liver after 6 weeks of treatment. In contrast, cccDNA declined more slowly, consistent with a half-life of approximately 33 to 50 days. The loss of cccDNA was comparable to that expected from the estimated death rate of hepatocytes in these woodchucks, suggesting that death of infected cells was one of the major routes for elimination of cccDNA. However, the decline in the actual number of infected hepatocytes lagged behind the decline in cccDNA, so that the average cccDNA copy number in infected cells dropped during the early phase of therapy. This observation was consistent with the possibility that some fraction of cccDNA was distributed to daughter cells in those infected hepatocytes that passed through mitosis.

The effect of cisplatin dose and surgical resection in children with malignant germ cell tumors at the sacrococcygeal region: a pediatric intergroup trial (POG 9049/CCG 8882)

PURPOSE

This study was designed to evaluate (1) the efficacy of standard or high-dose cisplatin with etoposide and bleomycin and (2) the role of surgical resection in infants and children with malignant germ cell tumors of the sacrococcygeal region (SCT).

METHODS

Seventy-four of 317 children presenting to Pediatric Oncology Group (POG)/Children's Cancer Group (CCG) institutions from 1990 through 1996 with malignant germ cell tumors had malignant SCT. There were 62 girls and 12 boys with a median age of 21 months (range, 3 days to 37 months) and median serum alpha-fetoprotein of 35,500 ng/mL. Twelve had undergone resection of a benign SCT as a newborn. Forty-four (59%) had evidence of metastatic disease at time of diagnosis. Presentation by type (Altman classification) was I, 0; II, 2; III, 30; and IV, 42. The initial procedure was biopsy in 45 and resection in 29. Patients were assigned randomly to receive 4 cycles of chemotherapy with etoposide (E) and bleomycin (B) and either high-dose cisplatin (200 mg/m(2) per cycle; HDP) or standard dose cisplatin (100 mg/m(2) per cycle; P). After completion of chemotherapy, 42 of 45 initially treated with biopsy underwent resection.

RESULTS

Overall 4-year survival rate is 90% (SE = 4%) and 4-year event-free survival (EFS) is 84% (SE = 6%). Event-free survival data for subgroups of interest are as follows: 4-yr EFS% (SE) P Values Mets (44) 88 (6).48 No Mets (30) 80 (8) HDP EB (37) 89 (6).21 P EB (37) 78 (7) Initial Resection (29) 90 (7).50 Delayed Resection (42) 83 (7) Complete Resection (49) 90 (5).19 CR/PR Partial Resection (22) 77 (10) Biopsy Only (3) 33 (27).005 (3 way)

CONCLUSIONS

(1) The current survival rate of malignant sacrococcygeal tumors is excellent even with metastases. (2) Delayed surgical resection is not associated with an adverse outcome. (3) In this subset the treatment comparison was inconclusive however, followed the trend in the overall study of more than 300 children in which the high-dose cisplatin group had superior EFS (P<.05).

TeleBAT: Mobile telemedicine for the brain attack team

TeleBAT is our application of an integrated mobile telecommunications system (MTS) to the clinical problem of acute stroke. Although efforts are ongoing to educate patients to seek emergency treatment at the first signs of stroke, we sought to shorten time to treatment once the patient is known to the emergency medical system. Ambulance paramedics acquire valuable assessment data about a stroke patient en route to a medical center. We tested the feasibility of using wireless digital cellular communication to provide a stroke neurologist with real-time visual access to the neurological examination of patients conducted during transport to our stroke treatment center. Audio and visual information, and patients vital signs were transmitted from our interfacility ambulance. The MTS was designed to be user-friendly and includes turnkey operation inside the ambulance and flexible access through a internet browser by the clinicians in the hospital. With 4 simultaneous cellular phone connections, each with a bandwidth of 9.6 kilobytes per second, the throughput was a 320x240-pixel image every 2 seconds. The image quality requirement was determined through empirical testing by using a videotaped National Institutes of Health Stroke Scale examination. A framework to assess adequacy was developed and defined as the ability of the clinician to make an identical clinical judgment when visual access to the patient was provided by either audio-visual transmission or by face-to-face examination. We have shown mobile telemedicine linking prehospital providers with a stroke center neurologist and thus have come one step closer to transforming the prehospital phase of transport to prehospital phase of treatment.

Surgical resection alone is effective treatment for ovarian immature teratoma in children and adolescents: a report of the pediatric oncology group and the children's cancer group

OBJECTIVE

In both adult women and children the potential for malignant recurrence from ovarian immature teratoma has prompted the standard use of chemotherapy after complete resection of the primary tumor. The efficacy of postoperative chemotherapy in children and adolescents with ovarian immature teratoma, however, has not been established. A pediatric intergroup trial (INT 0106) was designed to determine the need for postoperative chemotherapy in patients with ovarian immature teratoma after management with surgical resection only.

STUDY DESIGN

Between 1990 and 1995, 44 patients with completely resected ovarian immature tumor and without postoperative chemotherapy, who were able to undergo assessment, were accrued. Tumor tissue was evaluated by central pathology review to confirm diagnosis and determine tumor grading of immature neural elements. Patients were followed carefully for recurrence of disease with appropriate diagnostic imaging and serum marker studies.

RESULTS

Thirty-one patients had pure ovarian immature teratoma with a tumor grade of 1 (n = 17), 2 (n = 12), or 3 (n = 2). Age at diagnosis ranged between 1.5 and 15 years (median, 10). Of the 29 patients studied, the serum alpha-fetoprotein level was elevated in 10 (34%); the median level was 25 ng/ml. Thirteen patients had ovarian immature teratoma plus microscopic foci of yolk sac tumor. Tumor grade was 1, 2, or 3 in 1, 6, and 6 patients, respectively. Age ranged between 6 and 20 years (median, 12). In the 12 patients evaluated for serum alpha-fetoprotein, 10 (83%) had elevated levels; the median level was 262 ng/ml. The 4-year event-free and overall survival for the ovarian immature teratoma group and for the ovarian immature teratoma plus yolk sac tumor group was 97.7% (95% confidence interval, 84.9%-99.7%) and 100%, respectively. The only yolk sac tumor relapse occurred in a child with ovarian immature teratoma and yolk sac tumor who was then treated with chemotherapy and is alive and free of disease 57 months after recurrence.

CONCLUSION

The results of this study suggest that surgery alone is curative for most children and adolescents with resected ovarian immature teratoma of any grade, even when elevated levels of serum alpha-fetoprotein or microscopic foci of yolk sac tumor are present. This experience strongly supports avoiding the long-term effects of chemotherapy in most children with ovarian immature teratoma by reserving postoperative therapy for cases with relapse.

Complete surgical excision is effective treatment for children with immature teratomas with or without malignant elements: A Pediatric Oncology Group/Children's Cancer Group Intergroup Study

PURPOSE

To determine whether the 3-year event-free survival (EFS) of children with completely resected immature teratomas is greater than 85%.

PATIENTS AND METHODS

Patients with immature teratomas treated at Pediatric Oncology Group or Children's Cancer Group institutions were eligible. Pathology was centrally reviewed to confirm diagnosis and tumor grading. Follow-up included physical examination, measurement of tumor markers (alpha fetoprotein and human chorionic gonadotropin), and imaging. All patients were monitored for events, defined as tumor recurrence, second malignancy, or death.

RESULTS

Seventy-three children (median age, 7.8 years) with extracranial immature teratomas were enrolled on study. Primary tumor sites included ovarian (n = 44), testicular (n = 7), and extragonadal (n = 22). However, on review, 23 patients had foci of yolk sac tumor (n = 21) or primitive neuroectodermal tumor (n = 2), whereas 50 had pure immature teratomas. Twenty-five patients had increased alpha fetoprotein (n = 18), human chorionic gonadotropin (n = 5), or both (n = 2); nine had foci of yolk sac tumor on review. Pathology review identified 23 patients with grade 1, 29 with grade 2, and 21 with grade 3 immature teratomas. With a median follow-up of 35 months, the overall 3-year EFS was 93% (95% confidence interval, 86% to 98%), with 3-year EFS of 97.8%, 100%, and 80% for patients with ovarian, testicular, and extragonadal tumors, respectively. Only four of 23 patients with immature teratoma and malignant foci developed recurrence, suggesting that surgical resection followed by close observation are effective treatment. Overall, five patients had disease recurrence 4 to 7 months from diagnosis, and four (80%) are disease free after platinum-based therapy. The fifth patient has residual tumor after cisplatin, etoposide, and bleomycin treatment requiring further therapy.

CONCLUSION

Surgical excision is safe and effective treatment for 80% to 100% of children with immature teratoma.

Can GP input into discharge planning result in better outcomes for the frail aged: results from a randomized controlled trial

OBJECTIVE

We aimed to assess whether GP input into discharge planning for high-risk aged in-patients admitted under the care of a geriatrician results in improved patient outcomes.

METHODS

We conducted a prospective randomized controlled trial in Sydney, Australia. The subjects were 364 patients aged 60 years and over. The main outcome measures included community service referral, accommodation changes, length of stay, readmission rate, length of time to first readmission and patient satisfaction with discharge arrangements.

RESULTS

No significant differences were found with regard to length of stay, readmission rates or time to first readmission. Test-group subjects were significantly more likely to be recommended for community services at discharge and to report that hospital personnel had discussed their discharge plan with them. Significantly more of the test group reported that their return home was well prepared.

CONCLUSIONS

Although GP pre-discharge visits did not alter the likelihood of 'hard outcomes such as risk of readmission', the results suggest that quality of care is enhanced amongst patients receiving a pre-discharge visit and that GPs can perform a key role in planning post-discharge care with other services.

Carer distress in the general population: results from the Sydney Older Persons Study

OBJECTIVE

To assess distress in a sample of carers who were selected from a community survey rather than recruited via community-service agencies.

METHODS

A community survey was carried out on 630 people aged 75 or over living in Sydney, Australia. Informants nominated by these elderly people were divided into full carer (n = 21), partial carer (n = 187) and non-carer groups (n = 344). Informants completed the General Health Questionnaire (a continuous measure of psychiatric symptoms), the life satisfaction index (a measure of well-being) and the interpersonal bonding measure (a measure of quality of the relationship with the elderly person). Elderly participants had a medical examination, were assessed for disability and were questioned about use of services.

RESULTS

Elderly people who had a full carer were more disabled and had more medical diagnoses. Full, but not partial, carers reported more psychiatric symptoms and lower life satisfaction. In multivariate analysis, the main determinant of carer distress was a relationship in which the carer felt controlled by the elderly person.

CONCLUSION

When carers are selected from a population-based sample, only those who are full carers are more distressed. However, relationship factors are the most important determinant of distress.

Informant-based staging of dementia using the clinical dementia rating

The staging of dementia is ideally based on both an examination of the patient and a history taken from an informant. However, in some circumstances, only an informant history is possible. The aim of this study was to assess the validity of the Clinical Dementia Rating (CDR) when the rating is based solely on informant data. The CDR was used in a study of 360 persons aged 78 or older who were participants in a community survey, the Sydney Older Persons Study. The CDR was completed in two ways: (1) a social scientist made the ratings based on an informant interview; and (2) a physician made the ratings after an examination of the subject. All CDRs were scored in the conventional way, as well as by the revised method proposed by Gelb and St. Laurent (Alzheimer Dis Assoc Disord 1993;4:202-11). The informant CDR showed moderate agreement with the clinician CDR, showing that it would be a valid substitute in situations in which the subject could not be examined. The revised scoring method was slightly easier to implement than the conventional method.

Manual asymmetries in goal-directed movement: examination of the motor output hypothesis

Two experiments are reported which examined the viability of motor output hypothesis as an explanation for manual asymmetries in goal-directed movement. Experiment 1 isolated the variability due to force generation by directly assessing precision of force production during an isometric wrist flexion task. Experiment 2 examined the additional role of externally based and internally created timing patterns on the performance of a repetitive force production task. Virtually no effects involving hand were apparent in either experiment. These findings provide no support for a hypothesis based solely on motor output to adequately account for hand differences in the performance of rapid, goal-directed movement.

Health habits and risk of cognitive impairment and dementia in old age: a prospective study on the effects of exercise, smoking and alcohol consumption

Previous research has yielded inconsistent results on the effects of exercise, smoking and alcohol use on cognitive impairment and dementia in old age. We analysed data from the Sydney Older Persons Study to see if these health habits were associated with cognitive functioning, dementia or Alzheimer's disease. Health habits were assessed in Wave 1 of the study, when the subjects were aged 75 years or over. Three years later, the subjects were tested for cognitive functioning and clinically examined for dementia and Alzheimer's disease. The analysis was restricted to the 327 subjects examined in Wave 2 who were non-demented in Wave 1. There were few significant associations between health habits and cognitive performance and these were not found consistently across cognitive measures. No associations were found with dementia or Alzheimer's disease. While these health habits do not affect risk for dementia and cognitive impairment in the very elderly, who are at highest risk for these disorders, we cannot discount a role at younger ages.

Lamivudine therapy of WHV-infected woodchucks

Hepatitis B viruses establish a chronic, productive, and noncytopathic infection of hepatocytes. Viral products are produced by transcription from multiple copies (5-50) of covalently closed circular (ccc) viral DNA. This cccDNA does not replicate, but can be replaced by DNA precursors that are synthesized in the cytoplasm. The present study was carried out to determine if long-term treatment with an inhibitor of viral DNA synthesis would lead to loss of virus products, including cccDNA, from the liver of woodchucks chronically infected with woodchuck hepatitis virus. Viral DNA synthesis was inhibited with the nucleoside analog, lamivudine (2'-deoxy-3'-thiacytidine). Lamivudine treatment produced a slow but progressive decline in viral titers in serum, to about 0.3% or less of the initial level. However, even after maintenance of drug therapy for 3-12 months, > 95% of the hepatocytes in most animals were still infected. Significant declines in the percentage of infected hepatocytes and of intrahepatic cccDNA levels were observed in only three woodchucks, two in the group receiving lamivudine and one in the placebo control group. Moreover, virus titers eventually rose in woodchucks receiving lamivudine, suggesting that drug-resistant viruses began to spread through the liver starting at least as early as 9-12 months of treatment. Three types of mutation that may be associated with drug resistance were found at this time, in a region upstream of the YMDD motif in the active site of the viral reverse transcriptase. The YMDD motif itself remained unchanged. Not unexpectedly, the lamivudine therapy did not have a impact on development of liver cancer.

Therapeutic vaccination of woodchucks against chronic woodchuck hepatitis virus infection

BACKGROUND/AIMS

Therapeutic vaccination is a new approach to treat patients with chronic hepatitis B virus infection. We have used the woodchuck model to examine the efficacy and safety of this approach.

METHODS

Seven woodchucks chronically infected with woodchuck hepatitis virus were immunized with surface antigen from this virus, purified from plasma, in conjunction with a peptide named FIS (encompassing amino acids 106-118: FISEAIIHVLHSR from sperm whale myoglobin), which is recognized by T helper lymphocytes. As controls, two woodchucks chronically infected with woodchuck hepatitis virus were immunized: one with FIS only and the other with surface antigen only.

RESULTS

Co-immunization with surface antigen and FIS, but not with FIS or surface antigen alone, induced anti-surface antibodies in 7/7 immunized woodchucks. In the two woodchucks in which the highest titer of anti-surface antibody was elicited, severe liver damage was observed: one died of fulminant hepatitis and the other became seriously ill with hepatic injury and had to be sacrificed.

CONCLUSIONS

Co-immunization of chronically infected woodchucks with surface antigen and a peptide recognized by T helper cells produces a good anti-surface antibody response. However, this strategy needs to be optimized before its implementation in humans. Although our experiments are not strictly comparable to vaccination of chronically hepatitis B virus-infected patients with recombinant or plasma-derived vaccines, we believe that precautions should be taken to avoid the risk of severe liver injury when immunizing hepatitis B virus carriers.

Sensitivity and specificity of the neonatal brain-stem auditory evoked potential for hearing and language deficits in survivors of extracorporeal membrane oxygenation

OBJECTIVE

We determined the sensitivity and specificity of neonatal brain-stem auditory evoked potentials (BAEP) as markers for subsequent hearing impairment and for developmental problems found later in infancy and childhood.

METHODS

BAEP studies were performed before discharge in infants treated with extracorporeal membrane oxygenation (ECMO), and two specific abnormalities were analyzed: elevated threshold and delayed central auditory conduction. Behavioral audiometry was repeated during periodic follow-up until reliable responses were obtained for all frequencies, and standardized developmental testing was also conducted. The sensitivity and specificity of an elevated threshold on the neonatal BAEP for detecting subsequent hearing loss, and the relationship of any neonatal BAEP abnormality to language or developmental disorders in infancy, were calculated.

RESULTS

Test results for 46 ECMO-treated infants (57.5%) were normal, and those for 34 infants (42.5%) were abnormal, with either elevated wave V threshold, prolonged wave I-V interval, or both on neonatal BAEP recordings. Most significantly, 7 (58%) of the 12 children with subsequent sensorineural hearing loss had left the hospital after showing normal results on threshold tests. There was no significant difference in the frequency of hearing loss between subjects with abnormal (5/21, or 24%) and those with normal BAEP thresholds (7/59, or 12%; Fisher Exact Test, p = 0.28). Therefore the sensitivity of neonatal BAEP testing for predicting subsequent hearing loss was only 42%. Neonatal BAEP specificity for excluding subsequent hearing loss was 76%. In contrast, on language development testing, 19 children demonstrated receptive language delay. Of these children, 12 (63%) had abnormal neonatal BAEP recordings and 7 (37%) had a normal BAEP threshold, normal central auditory conduction test results, or both (p = 0.04).

CONCLUSIONS

Neonatal BAEP threshold recordings were of limited value for predicting subsequent hearing loss common in ECMO-treated survivors. However, an abnormal neonatal BAEP significantly increased the probability of finding a receptive language delay during early childhood, even in those with subsequently normal audiometry findings. Because neonatal ECMO is associated with a high risk of hearing and receptive language disorders, parents should be counseled that audiologic and developmental follow-up evaluations in surviving children are essential regardless of the results of neonatal BAEP testing.

The role of platelet-activating factor in conscious, normotensive endotoxemia

The effects of endotoxin have been postulated to be mediated in large part by release of endogenous platelet-activating factor (PAF) due to the similarity of their hemodynamic and gastric effects in anesthetized animals, and to the ability of PAF inhibitors to ameliorate endotoxin's effects. We chose to examine the relationship with doses that would not produce circulatory shock, in unrestrained conscious animals, in order to mimic clinical situations. Adult male rats were prepared with vascular access, hemodynamic and temperature monitors, and gastric strain gauge transducers. After an overnight fast, rats received a 4-hr infusion of saline (0.5 ml/hr), endotoxin (12.5 mg/kg/hr), PAF (36 micrograms/kg/hr, or 600 ng/kg/min), or endotoxin plus the PAF inhibitor CV 3988 (1 mg/kg/hr, after an initial pretreatment of 1 mg/kg). Rats were killed, stomachs were harvested, and contents were analyzed at the end of the infusions. Blood pressure was not affected by any treatment, but all treated groups developed diarrhea and vasodilatation. Endotoxin and PAF infusions decreased heart rate and body temperature to a similar extent, although the PAF effect on temperature was delayed. The PAF inhibitor did not prevent the body temperature effect, but did reverse it. Gastric secretions were affected by PAF to a lesser extent than by endotoxin, and the PAF inhibitor did not decrease endotoxin's gastric secretory effects. PAF has similar systemic and gastric effects to endotoxin in conscious, unrestrained, normotensive animals. The systemic effects of endotoxin at 12.5 mg/kg/hr were prevented or reversed by the PAF inhibitor CV-3988 at 1 mg/kg/hr, but not the gastric secretory effects.

High-frequency jet ventilation in the early management of respiratory distress syndrome is associated with a greater risk for adverse outcomes

OBJECTIVE

The objective of this investigation was to determine if high-frequency jet ventilation (HFJV) used early in the treatment of premature infants with respiratory distress syndrome was effective in reducing pulmonary morbidity without increasing the occurrence of adverse neurologic outcomes.

STUDY DESIGN

A total of 73 premature infants who met the inclusion criteria (gestational age of less than 33 weeks, birth weight of more than 500 g, age of less than 24 hours, need for assisted ventilation with peak inspiratory pressure of more than 16 and FIO2 more than 0.30, and roentgenographic evidence of respiratory distress syndrome) were randomized to either conventional (n = 36) or to high-frequency jet (n = 37) ventilation. Our goals were to maintain the infants on the assigned ventilator for at least 7 days unless they could either be extubated or meet crossover criteria. Univariate analyses were initially used to compare the two groups. Stepwise logistic regression was subsequently used to assess whether various factors independently influenced adverse outcomes.

RESULTS

The two groups of infants were similar in all obstetrical, perinatal, and neonatal demographic characteristics. The mean birth weight and gestational age in the conventional group were 930 g and 26.6 weeks and in the HFJV group, 961 g and 26.9 weeks. The infants were randomized at similar ages (7.1 and 7.3 hours of life, respectively). Their prerandomization ventilator settings and arterial blood gases were nearly identical. There were no differences in pulmonary outcomes (occurrence of air leaks, need for oxygen or ventilation at 36 weeks postconception), and there were no differences in the mean number of days oxygen was required, number of days ventilated, or length of hospital stay. Infants ventilated with HFJV were significantly more likely to develop cystic periventricular leukomalacia (10 vs 2, P = .022) or to have a poor outcome (grade IV hemorrhage, cystic periventricular leukomalacia, or death) (17 vs 7, P = .016). Logistic regression analysis revealed HFJV to be a significant independent predictor of both cystic periventricular leukomalacia and a poor outcome. The presence of hypocarbia was not an independently significant predictor of adverse outcomes.

CONCLUSIONS

With the HFJV treatment strategy that we used, use of the high-frequency jet ventilator in the early management of premature infants with respiratory distress syndrome resulted in significantly more adverse outcomes than in those treated with conventional mechanical ventilation.