Gemcitabine, cisplatin and methylprednisolone (GEM-P) is an effective salvage regimen in patients with relapsed and refractory lymphoma

There is currently no standard salvage chemotherapy regimen in relapsed and refractory lymphoma. Gemcitabine is a novel nucleoside analogue, which acts synergistically with cisplatin both in vitro and in clinical studies. We evaluated the combination of gemcitabine, cisplatin and methylprednisolone (GEM-P) in 41 heavily pretreated patients with relapsed and refractory Hodgkin's and non-Hodgkin's lymphoma. The best-achieved response rate (RR) was 79% (95% CI 64-91), with a complete RR of 21%. In patients with chemo-resistant disease, the RR was 63%. Myelosuppression was the main toxicity, the incidence of Grade 3 or 4 anaemia, neutropenia and thrombocytopenia was 17.1, 61.0 and 53.7% respectively. Only one patient had neutropenic sepsis and none of the patients suffered from haemorrhage. Grade 3 or 4 nonhaematological toxicity was minimal and stem cell mobilisation was not inhibited. GEM-P is an effective salvage regimen and its use prior to autologous stem cell transplant warrants further investigation.

Nonlinear anisotropic diffusion filtering of three-dimensional image data from two-photon microscopy

Two-photon microscopy in combination with novel fluorescent labeling techniques enables imaging of three-dimensional neuronal morphologies in intact brain tissue. In principle it is now possible to automatically reconstruct the dendritic branching patterns of neurons from 3-D fluorescence image stacks. In practice however, the signal-to-noise ratio can be low, in particular in the case of thin dendrites or axons imaged relatively deep in the tissue. Here we present a nonlinear anisotropic diffusion filter that enhances the signal-to-noise ratio while preserving the original dimensions of the structural elements. The key idea is to use structural information in the raw data-the local moments of inertia-to locally control the strength and direction of diffusion filtering. A cylindrical dendrite, for example, is effectively smoothed only parallel to its longitudinal axis, not perpendicular to it. This is demonstrated for artificial data as well as for in vivo two-photon microscopic data from pyramidal neurons of rat neocortex. In both cases noise is averaged out along the dendrites, leading to bridging of apparent gaps, while dendritic diameters are not affected. The filter is a valuable general tool for smoothing cellular processes and is well suited for preparing data for subsequent image segmentation and neuron reconstruction.

Factors influencing concordance with compression stockings after venous leg ulcer healing

OBJECTIVE

To investigate the factors influencing patient concordance with compression stockings after venous leg ulcer healing.

METHOD

In 2001 patients discharged from a specialist leg ulcer service in New Zealand were approached to participate in a structured interview about their use of compression stockings in the first six months following venous leg ulcer healing. Univariate analyses were performed to identify significant associations between factors and stocking use. Multiple logistic regression was employed to model the factors associated with frequency of stocking use.

RESULTS

A total of 163 patients were identified, of whom 129 (79%) agreed to participate. Sixty-seven (52%) reported wearing stockings every day for the first six months after their ulcers had healed, 21 (16%) stated that they had worn the most days, seven (5%) had worn them occasionally and 29 (22%) had not worn them at all after their ulcer had healed. Five (4%) did not provide data. Two factors distinguished those who wore stockings from those who did not 75% of the time: the belief that wearing stockings was worthwhile and the belief that stockings were uncomfortable to wear. Commonly cited factors, such as age, sex, difficulty in applying stockings and cosmetic appearance were not significantly related to stocking use. Cost did not seem to influence the decision to purchase compression stockings.

CONCLUSION

Many factors previously thought to influence concordance appear to have little impact on compression-stocking use in people whose venous leg ulcers had healed.

Diversifying microbial natural products for drug discovery

Historically, nature has provided the source for the majority of the drugs in use today. More than 20,000 microbial secondary metabolites have been described, but only a small percentage of these have been carried forward as natural product drugs. Natural products are in tough competition with large chemical libraries and with combinatorial chemistries. Hence, each step of a natural product program has to be more efficient than ever, starting from the collection of environmental samples and the selection of strains, to metabolic expression, genetic exploitation, sample preparation and chemical dereplication. This review will focus on approaches for diversifying microbial natural product strains and extract libraries, while decreasing genetic and chemical redundancy.

Prevalence of naturally occurring surface gene variants of hepatitis B virus in nonimmunized surface antigen-negative Chinese carriers

Previous studies have suggested that hepatitis B virus (HBV) variants may account for the presence of HBV DNA in hepatitis B surface antigen (HBsAg)-negative patients (occult HBV infection). However, it is not known how widespread these variants are and how they influence the course of liver disease. To determine the prevalence of variants within the major hydrophilic region (MHR) of HBsAg, we investigated 2,565 subjects, including subjects with chronic hepatitis, cryptogenic cirrhosis, hemodialysis patients, and blood donors. Fifty-one of them had occult HBV infection. The entire S gene from 46 of these patients was sequenced from amplified serum HBV DNA. Forty-three percent (20 of 46) had mutations in the MHR of HBsAg. Thirty-two amino acid substitutions between positions 100-160 of the MHR of HBsAg were detected in 18 patients, and these ranged from 1 to 4 per patient. These changes involved 11 positions inside and 5 outside of the historical first and second loops of the "a" determinant, and included the following: Q101K, T115A, K122N, T123A, T126N, Q129N, G130R, T131I, M133T, F134L, C138Y, K141E, P142S, G145R, N146S, and C147F/R. Combinations of mutations were detected in 9 patients, and 7 of these have not been described before. Two further patients had insertion mutations immediately before the "a" determinant. Monoclonal antibody binding tests with the Royal Free hepatitis B surface (RFHBs) panel of antibodies revealed decreased immunoreactivity in 6 novel variants of HBsAg. The existence of patients with occult HBV infection caused by HBsAg variants, therefore, has implications for their possible transmission through sexual contact and by blood transfusion.

Successful closure of coronary artery perforation using makeshift stent sandwich

An elderly woman underwent stenting of mid left anterior descending coronary artery (LAD) 2 days after myocardial infarction. During high-pressure stent dilatation, vessel perforation was noted. We assembled a "stent sandwich" in the cardiac catheterization laboratory and used it successfully to seal the perforation with good angiographic result. Although the long-term patency remains an issue, this case demonstrates the feasibility of using makeshift covered-stent as a bailout for arterial perforation in selected cases where emergency thoracotomy is undesirable.

Treatment of the neuromuscular junction with 4-aminopyridine results in improved reinnervation following nerve injury in neonatal rats

During early postnatal development, nerve injury results in the death of a large proportion of motoneurones and poor recovery of muscle function. Our previous results have shown that premature enhancement of transmitter release from nerve terminals prevents the death of motoneurones following neonatal nerve injury. Whether this increase in motoneurone survival is reflected in an improvement in the reinnervation of muscle was studied here. The muscles in one hindlimb of newborn rats were treated with 4-aminopyridine. Three days later, the sciatic nerve was crushed in the treated leg. When the animals were seven, 14 and 21days of age, the soleus and extensor digitorum longus muscles were removed and processed for GAP-43 (a 43-kDa growth-associated protein) and synaptophysin immunocytochemistry. Both GAP-43 and synaptophysin were expressed in normal soleus and extensor digitorum longus muscles at seven days. Synaptophysin was still expressed at 14 days, but GAP-43 expression had declined. Following nerve injury at three days of age, there was no GAP-43 or synaptophysin immunoreactivity in nerve terminals at seven days. By 21 days, there were 17.3+/-2.1 GAP-43-positive terminals per section in the soleus and 17.7+/-1.4 in the extensor digitorum longus, with mean terminal areas of 47.5+/-3.3 and 49.8+/-2.6 microm(2), respectively. In animals in which nerve crush was preceded by 4-aminopyridine treatment, at 21 days there were 32.9+/-2.6 GAP-43-immunoreactive terminals in the soleus and 44.9+/-2.3 in the extensor digitorum longus, with a mean area of 122.7+/-6.6 microm(2) in the soleus and 136.2+/-9.7 microm(2) in the extensor digitorum longus. These results indicate that in muscles pretreated with 4-aminopyridine, prior to nerve crush at three days, there are significantly more terminals, which occupy a larger area than in untreated muscles. Thus, increasing transmitter release prior to nerve injury significantly improved the ability of axons to reinnervate muscle.

Hepatitis B surface antigen variants in vaccinees, blood donors and an interferon-treated patient

Variants of hepatitis B virus (HBV), with amino acid substitutions in the major antigenic "a" determinant of hepatitis B surface antigen (HBsAg), have been described mainly in vaccinated children. In the present study in addition to vaccinated children, we have investigated Chinese blood donors positive for anti-HBc alone, and a patient with continuing liver disease after interferon-induced seroconversion to anti-HBs. Variants were detected in two of four children with break-through infections. One child had a double mutation (P142S and G145R) and the other a G145A substitution. Three of seven anti-HBc positive Chinese blood donors had a T131I substitution, whilst the interferon-treated patient had a treble amino acid substitution (P142S, G145R and N146D). The present results indicate that HBsAg variants may exist in individuals other than vaccinated children.

Phorbol esters potentiate evoked and spontaneous release by different presynaptic mechanisms

Phorbol esters enhance release from a variety of cell types. The mechanism by which phorbol esters potentiate presynaptic release from central neurons is unclear, although effects of phorbol esters both on the readily releasable pool of vesicles and on presynaptic calcium channels have been shown. Using confocal microscopy and the fluorescent styryl dye FM 1-43, we have examined the effects of phorbol-12,13-dibutyrate (PDBu) on presynaptic vesicle turnover at individually identified synapses in dissociated cultures obtained from neonatal rat hippocampus. Using different dye staining and destaining protocols we were able to resolve two effects of PDBu. Potentiation of evoked release by PDBu was insensitive to calcium channel antagonists, suggesting that this effect results from an increased number of vesicles in the readily releasable pool. Since we observed no effect of PDBu on the size of the total recycling vesicle pool, we conclude that phorbol esters alter the equilibrium between reserve and readily releasable pools. An additional effect of PDBu on spontaneous release was observed. This effect was antagonized by nifedipine but not omega-conotoxin GVIA or omega-agatoxin IVA. We conclude that PDBu influences spontaneous and evoked release by two different mechanisms: through L-type calcium channels and through an increase in the proportion of recycling vesicles in the readily releasable pool. In addition to further clarifying the mechanism of action of phorbol esters, these results suggest that phorbol esters may be a useful tool with which to probe the function of the readily releasable pool of presynaptic vesicles at CNS synapses.

Detailed mapping of a congenital heart disease gene in chromosome 3p25

Distal deletion of chromosome 3p25-pter (3p- syndrome) produces a distinct clinical syndrome characterised by low birth weight, mental retardation, telecanthus, ptosis, and micrognathia. Congenital heart disease (CHD), typically atrioventricular septal defect (AVSD), occurs in about a third of patients. In total, approximately 25 cases of 3p- syndrome have been reported world wide. We previously analysed five cases and showed that (1) the 3p25-pter deletions were variable and (2) the presence of CHD correlated with the proximal extent of the deletion, mapping a CHD gene centromeric to D3S18. To define the molecular pathology of the 3p- syndrome further, we have now proceeded to analyse the deletion region in a total of 10 patients (five with CHD), using a combination of FISH analysis and polymorphic markers, for up to 21 loci from 3p25-p26. These additional investigations further supported the location of an AVSD locus within 3p25 and refined its localisation. Thus, the critical region was reduced to an interval between D3S1263 and D3S3594. Candidate 3p25 CHD genes, such as PMCA2 (ATP2B2), fibulin 2, TIMP4, and Sec13R, were shown to map outside the target interval. Additionally, the critical region for the phenotypic features of the 3p- phenotype was mapped to D3S1317 to D3S17 (19-21 cM). These findings will accelerate the identification of the 3p25 CHD susceptibility locus and facilitate investigations of the role of this locus in non-syndromic AVSDs, which are a common form of familial and isolated CHD.

Population-based surveillance of Hib invasive infections in children in British Columbia Alberta and Ontario - 1995 to 1997

OBJECTIVE

To assess vaccine effectiveness through enhanced disease surveillance following the change in childhood immunization programs in 1995, when all provinces and territories chose to use polyribosyl ribitol phosphate-tetanus protein (PRP-T) Haemophilus influenzae type b (Hib) conjugate vaccine, generally in combination with diphtheria-pertussis-tetanus inactivated polio vaccine (DPT-IPV) (as PENTA vaccine) because the protective efficacy of this regimen had not been directly measured.

DESIGN

Prospective, active, laboratory-based Hib case surveillance was implemented in British Columbia and Alberta, and enhanced, stimulated laboratory surveillance in Ontario during 1995 to 1997, centred on invasive infections in children. Case details and immunization histories were uniformly collected and centrally collated.

MAIN RESULTS

Thirty-eight Hib cases were detected, but only 12 cases arose among PENTA-eligible children, an attack rate of 0.85 cases/100,000 child-years of observation. Annual case totals declined from 20 in 1995 to seven in 1997, when only one to three cases were encountered in each province and the incidence rate in children under age five years was 0.6/100,000. Only four cases occurred after primary immunization with PENTA, a failure rate of 0.28 cases/100,000 child-years of observation. Three cases among PENTA-eligible children reflected parental refusal of infant vaccinations, accounting for 25% of cases in eligible children.

CONCLUSIONS

PRP-T conjugate vaccine was highly effective when given in combination with DPT-IPV vaccine. Provincial programs that used this regimen resulted in the near elimination of invasive Hib disease in children, but unimmunized children remain at risk.

Oral pentoxifylline for treatment of venous leg ulcers

BACKGROUND

Healing of venous leg ulcers is improved by the use of compression bandaging but some venous ulcers do not respond to compression therapy. Pentoxifylline, a drug which helps blood flow, has been used to treat venous leg ulcers but to date there has been no systematic review.

OBJECTIVES

To assess the effects of pentoxifylline ('Trental 400') for treating venous leg ulcers, when compared with placebo, or in comparison with other therapies, in the presence or absence of compression therapy.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases and Wounds Groups specialised registers (date of search August 1999), and reference lists of relevant articles. We hand searched relevant journals and conference proceedings, and contacted Hoechst (the manufacturer of the drug) and experts in the field.

SELECTION CRITERIA

Randomised trials comparing pentoxifylline with placebo or other therapy in the presence or absence of compression, in patients with venous leg ulcers.

DATA COLLECTION AND ANALYSIS

Details from eligible trials were extracted and summarised by one reviewer using a coding sheet. Data extraction was independently verified by one other reviewer.

MAIN RESULTS

Nine trials involving 572 adults were included. The quality of trials was variable. Eight trials compared pentoxifylline with placebo; in five of these trials patients received compression therapy. In one trial pentoxifylline was compared with defibrotide in patients who also received compression. By pooling eight trials that compared pentoxifylline with placebo (with or without compression) it was found pentoxifylline was more effective than placebo in terms of complete healing or significant improvement (relative risk for healing with pentoxifylline compared with placebo 1.41, 95% confidence interval 1.19 -1.66). Pentoxifylline and compression was more effective than placebo and compression (relative risk for healing with pentoxifylline 1.30, 95% confidence interval 1.10-1.54). Combination of similar trials using compression obtained a number needed to treat (NNT) of 7 (95%confidence interval 4-17). A comparison between pentoxifylline and defibrotide found no difference in healing rates. More adverse effects were reported in the pentoxifylline group, although this was not statistically significant (relative risk for adverse effects with pentoxifylline 1. 25, 95% confidence interval 0.87-1.80). Nearly half of the adverse effects were reported to be gastro-intestinal.

REVIEWER'S CONCLUSIONS

Pentoxifylline appears to be an effective adjunct to compression bandaging for treating venous ulcers. There was no cost effectiveness data available and healthcare commissioners may therefore conclude that it not be considered a routine adjunct. Pentoxifylline in the absence of compression may be effective for treating venous ulcers in the absence of compression, although the evidence should be cautiously interpreted. The majority of adverse effects are likely to be tolerated by patients, and gastrointestinal disturbances (indigestion, diarrhoea and nausea) are the most frequent adverse effect.

H4 acetylation, XIST RNA and replication timing are coincident and define x;autosome boundaries in two abnormal X chromosomes

The inactive X (Xi) differs from its active homologue (Xa) in a number of ways, including increased methylation of CpG islands, replication late in S phase, underacetylation of histone H4 and association with XIST RNA. Global changes in DNA methylation occur relatively late in development, but the other properties all change during or shortly after the establishment of Xi and may play a role in the mechanism by which an inactive chromatin conformation spreads across most of the chromosome. In the present report, we use two human X;autosome translocation chromosomes to study the spreading of inactive X chromatin across X;autosome boundaries. In one of these chromosomes, t(X;6), Xp distal to p11.2 is replaced by 6p21.1-6pter and, in the other, ins(X;16), a small fragment derived from 16p13 is inserted into the distal third of Xq. In lymphoid cells from patients carrying these translocations in an unbalanced form, Xi was shown by HUMARA assay to be derived exclusively [t(X:6)] or predominantly [ins (X;16)] from the derived X chromosome. We used a combination of immunolabelling and RNA/DNA fluorescence in situ hybridization to define the distribution of XIST RNA, deacetylated H4 and late-replicating DNA across the two derived X chromosomes in inactive form. Within the limits of the cytogenetic techniques employed, the results show complete coincidence of these three parameters, with all three being excluded from the autosomal component of the derived X chromosome.