Resurfacing of the patella in total knee arthroplasty. A prospective, randomized, double-blind study

During a two-year period, eighty-nine patients who were scheduled to have a total knee arthroplasty for the treatment of degenerative osteoarthrosis were randomly assigned to one of two groups: resurfacing of the patella or retention of the patella. All patients received the same posterior cruciate-sparing prosthesis, and all operations were performed by, or under the direct supervision of, one of us. Three patients died in the early postoperative period. The remaining eighty-six patients (118 knees; fifty-eight that had had resurfacing of the patella and sixty that had not) formed the study group. They were followed for a mean of thirty months (range, twenty-four to forty-four months). Evaluation was performed with use of the clinical scoring system of The Knee Society, a patient-satisfaction questionnaire, specific questions regarding patellofemoral symptoms and function, and radiographs. All clinical evaluations were performed by the same research nurse, without the involvement of a physician, in a blinded manner (neither the nurse nor the patient had knowledge of whether the patella had been resurfaced). Preoperatively, the mean Knee Society score, on a scale ranging from 0 to 200 points, was 89.7 points (range, 33 to 132 points); postoperatively, this score improved to a mean of 172.7 points (range, 98 to 200 points). With the numbers available for study, we could detect no significant difference between the knees that had had patellar resurfacing and those that had not with regard to the over-all score (p = 0.63), the subscore for pain (p = 0.56), or the subscore for function (p = 0.77). We also could detect no difference between the treatment groups, with the numbers available, with regard to patient satisfaction or the responses to questions involving the function of the patellofemoral joint, including the ability to exit from an automobile, to rise from a chair, and to climb stairs. Thirty-two patients had bilateral total knee replacement with resurfacing of the patella in one knee and retention of the patella in the other. These patients expressed no clear preference for either knee. Eight (13 per cent) of the sixty knees that had not had resurfacing were painful anteriorly compared with four (7 per cent) of the fifty-eight that had; this was not a significant difference (p = 0.38), with the numbers available. The anterior pain that was noted postoperatively was predominantly of new onset; it had not been observed preoperatively in three of the four knees that had had resurfacing or in four of the eight that had not. No additional treatment options were offered to the patients who had anterior pain in the knee after resurfacing. However, six (10 per cent) of the sixty knees that had not had resurfacing had it subsequently, because of anterior pain in the knee, after the twelfth postoperative month (range, fifteen to thirty-nine months). The pain decreased in four of these knees. Thus, total knee arthroplasty with retention of the patella yielded clinical results that were comparable with those after total knee arthroplasty with patellar resurfacing, but it was associated with a 10 per cent prevalence of the need for subsequent resurfacing. The prevalence of anterior pain after total knee arthroplasty was not influenced by whether or not the patella had been resurfaced. The postoperative clinical scores, the postoperative development of anterior pain, and the need for subsequent resurfacing were not predicted by the presence of preoperative anterior pain, obesity, or the grade of chondromalacia observed intraoperatively. Because of the short duration of follow-up, these results should be considered preliminary. Additional follow-up is planned.

Cascaded optical parametric oscillations

We have observed the spectral and temporal characteristics of a 1.064-mm pumped, continuously tunable optical parametric oscillator (OPO) using a periodically poled lithium niobate nonlinear crystal. An efficient secondary OPO pumped by the resonant signal of the primary OPO was observed. Predictions obtained from theory agree with observed results and provide insight into the dynamics of pulsed parametric oscillation. 1997 Optical Society of America.

Detection of HLA class I-specific antibodies by the QuikScreen enzyme-linked immunosorbent assay

The GTI QuikScreen test is an enzyme-linked immunosorbent assay (ELISA) that uses soluble HLA class I antigens as targets. In tests of 5,893 human serum specimens, we evaluated the reliability, sensitivity, and utility of the GTI QuikScreen test for detecting HLA class I-specific antibody. We found that the test could reliably detect HLA-specific antibodies of the immunoglobulin G (IgG) but not the IgM class. The degree of correlation with lymphocytotoxicity testing varied among the different serum sources, with the best correlation achieved with sera from renal transplant candidates (r > 0.7) and the poorest with sera from patients with end-stage liver disease (r = 0.26), possibly because of elevated alkaline phosphatase levels in the liver patients. Test reproducibility was high (96%), and test failure rate was low (1.7%). The test sensitivity is comparable to that of the antiglobulin cytotoxicity and, possibly, even flow cytometric tests. There was a highly significant (P < 0.001) correlation between the optical densities obtained in the ELISA and the percent panel reactive antibody determined by cytotoxicity testing. Therefore, although designed only to determine the presence or absence of HLA-specific antibody, GTI QuikScreen test results also provided an indication of the extent of sensitization. The test is one of the most effective and efficient ways to determine if antibodies producing a positive result in crossmatch tests are specific for HLA class I antigens. As an adjunct to serum screening by cytotoxicity testing, the GTI QuikScreen test can produce a substantial savings of time and effort that reduces the cost to the laboratory and to the patient.

What explains black-white differences in survival in idiopathic dilated cardiomyopathy? The Washington, DC, Dilated Cardiomyopathy Study

We have found race to be an independent predictor of mortality in a preliminary analysis of data from an ongoing study of patients with idiopathic dilated cardiomyopathy. Our previous, analyses, however, were based on only 12 to 24 months of follow-up. In the present analysis, which is based on up to 5 years of follow-up, we extended our earlier observations and examined whether other socioeconomic factors account for the association with race. A total of 128 patients from five Washington, DC, area hospitals were included in the analysis. One hundred three (80.5%) of the patients were black and 25 (19.5%) were white. The black patients were less likely to have private health insurance, less educated on average, and more likely to have a household income < or = $15,000. No racial differences were found in cardiac medication usage, with the exception of beta blockers and antiarrhythmics. The cumulated survival among black patients at 12 and 60 months was 71.5% and 39.1%, respectively, compared with 92% and 31.4% among whites. Age, ventricular arrhythmias, and ejection fraction were significant predictors of survival in univariate analysis. The univariate association with black race was of borderline significance. In multivariable analysis using the proportional hazards model, age and ejection fraction were significant independent predictors of survival. The association with ventricular arrhythmias was of borderline significance. The association with black race, which was statistically nonsignificant, was diminished even further by adjustment for income and type of health insurance. Thus, the previously reported association with black race may be accounted for by socioeconomic factors related to access to health care.

Regional metabolic alterations in Alzheimer's disease: an in vitro 1H NMR study of the hippocampus and cerebellum

The concentrations of selected metabolites in the hippocampus and cerebellum of 13 Alzheimer's diseased (AD) and four nondemented postmortem brains were measured using high resolution 1H NMR spectroscopy. For both the hippocampal region and the cerebellum, the putative neuronal marker N-acetyl aspartate (NAA) was significantly lower in AD brains relative to the nondemented brains. For the hippocampal region, the NAA concentration correlated inversely with semiquantitative assessments of neuronal loss and neurofibrillary tangles. The gamma-aminobutyric acid levels in both hippocampus and cerebellum of an age- and a postmortem interval-matched subset of AD brains were lower than those of the controls. Because the cerebellum is generally thought to be unaffected by AD, the NAA decrease in the Alzheimer cerebellum may be due to lesions of either the Alzheimer or non-Alzheimer type in contralateral cerebrum.

Increased frequency of autoaggression syndrome associated with autologous stem cell transplantation in breast cancer patients

In our BMT Unit, we have observed a high frequency of skin rash associated with fever and other clinical findings during engraftment of autologous BM and/or PBSC. Thirty patients with breast cancer and 12 patients with Hodgkin's or non-Hodgkin's lymphoma, treated with the same regimen, were analyzed retrospectively or prospectively to characterize the clinical syndrome, its frequency, and its clinical course, as well as to define the factors affecting its incidence. In patients developing skin rash, the median and range for time to onset of skin rash and for time to increase in WBC after reinfusion of stem cells were identical (8 days, range 5-13) and did not differ significantly (P = 0.533). Twenty-three patients (55%) had skin rash, 18 patients had fever. Other, less frequent manifestations include platelet transfusion refractoriness (PTR), diarrhea, diffuse alveolar hemorrhage, and autoimmune thrombocytopenia or hemolytic anemia. A higher proportion of breast cancer patients developed the syndrome in comparison to lymphoma patients (67% vs 25%, P = 0.051). Acute GVHD grade I-II was established histologically in six patients with the syndrome. Comparison of the incidence of the syndrome by different variables using Fisher's exact test revealed significance for disease category (P = 0.02) and number of previous treatment regimens (P = 0.002) as predictive factors for developing the autoaggression syndrome. In other words, patients with breast cancer and those with only one previous treatment regimen were more likely to develop the syndrome. This study suggests that an autoaggression GVHD-like syndrome accompanies the early phase of autologous engraftment and that a higher frequency of the syndrome might be seen in breast cancer patients undergoing high-dose chemotherapy and autologous stem cell transplantation.

Marginal vitamin and mineral intakes of young adults: the Bogalusa Heart Study

PURPOSE

To determine reported vitamin and mineral intakes, vitamin supplement use, and food consumption patterns of young adults.

METHODS

Twenty-four-hour dietary recalls were collected from 1988-1991 on a cross-sectional sample of 504 young adults in Bogalusa, Louisiana, between the ages of 19 and 28 years (58% female; 70% white). Reported vitamin and mineral intake data were analyzed for race and gender differences. Descriptive and inferential statistics were calculated where appropriate. Food sources of selected vitamins and minerals were also examined.

RESULTS

Reported intakes of vitamins A, B6, E, D, and C, folacin, magnesium, iron, zinc, and calcium were most likely to be inadequate compared with the Recommended dietary Allowances (RDA); with more females than males reported nutrient intakes less than two thirds of the RDA. Approximately 10% of the population reported taking a vitamin/mineral supplement over the 24-h survey period. Food source data indicated that breads and grains, milk, vegetables and soups, fruits, and beef were the primary contributors of the selected vitamins and minerals.

CONCLUSIONS

Public health organizations and dietitians need to educate young adults on practical strategies for making wise food choices rich in nutrient content relative to energy value to ensure intakes that approach the RDAs.

Physical and sedentary activity in school children grades 5-8: the Bogalusa Heart Study

Physical and sedentary activity in children and adolescents has immediate health benefits and can also set a pattern that carries over into adulthood, resulting in long-term health benefits. Activity levels in a free-living biracial sample of children and adolescents, ages 9-15 yr (N = 995), were examined using a 24-h recall instrument, the Self-Administered Physical Activity Checklist. Selected sedentary activities (television watching and video-/computergame playing) were also assessed. Overall, boys were more physically active than girls and engaged in more heavy physical activity, while girls reported a larger percentage of time spent in light and moderate physical activities. Gender and, to a lesser extent, ethnic differences were seen in the types of activities reported. Although most physical activity occurred after school, children who reported no physical education class during school had less physical activity overall. There was a decrease in moderate physical activity with increasing grade levels in school and an increase in sedentary behavior. Black children reported more sedentary activity than white children, and girls reported more than boys. Although this 24-h recall method has limitations, it allows characterization of the activity of groups of children and provides useful data for policy recommendations.

Nutritional quality of a high carbohydrate diet as consumed by children: The Bogalusa Heart Study

To study the nutritional adequacy of a high carbohydrate diet as consumed by children in a 24-h period, a sample of 568 10-y-old children was stratified into four levels of carbohydrate intake: < 45% of total energy (kJ), 45%-50% energy, 50%-55% energy, and >55% energy. Composition of the diet for those consuming >55% energy from carbohydrates was adequate in total energy, with 29% energy from fat, 11 % energy from saturated fatty acid, an average of 88 mg dietary cholesterol/4200 kJ and less than 10% energy from sucrose. Increased carbohydrate intake was attributed to an increased consumption of total sugars, starch and fiber. The percentage of children meeting two thirds or more of the Recommended Dietary Allowances for niacin and zinc was lower in the high carbohydrate intake group than in any of the low carbohydrate intake groups. Children with a high carbohydrate intake consumed more fruits, breads, grains, milk, desserts, candy and non-dairy beverages than those with a lower carbohydrate intake who consumed more meats. To meet current dietary recommendations for increased carbohydrate intake when meal patterns are designed, it is necessary to incorporate adequate amounts of foods from all of the food groups to maximize nutritional quality.

Improved survival of patients with chronic myelogenous leukemia undergoing allogeneic bone marrow transplantation

A total of 28 patients with chronic myelogenous leukemia (CML) in chronic phase (CP) received bone marrow allografts from HLA-matched siblings at the University of Florida between August 1984-July 1992. The present study compares the disease-free survival (DFS) for those patients who were transplanted before or after August 1988 using the same conditioning regimen. The analysis shows significant difference in 3-year DFS for those patients transplanted post- vs. pre-August 1988 (69.6% vs. 20%, respectively; P = 0.006). A decrease in pneumonitis due to different etiologies from pre-August 1988 (6/13, 46%) to post-August 1988 (1/15, 7%) was statistically significant (P = 0.029). A decrease, although statistically insignificant, in the overall incidence and severity of acute and chronic graft vs. host disease (GVHD) after August 1988 was also noticed. This study indicates significantly improved outcome for patients with CML in CP who have been treated in the University of Florida after August 1988. Better supportive care and prophylaxis for GVHD most likely contributed to such improvement.

Effects of the hematopoietic growth factors GM-CSF, IL-3, and IL-6 on human tumor colony-forming units taken directly from patients

BACKGROUND

One concern regarding the use of hematopoietic growth factors (e.g., GM-CSF, IL-3, and IL-6) to accelerate hematologic recovery after treatment of solid tumors with high doses of chemotherapy is that these factors may stimulate tumor growth.

MATERIALS AND METHODS

We tested the effects of GM-CSF, IL-3 or IL-6 (continuous exposure to 1, 10, and 100 ng/ml of each cytokine) on tumor cells taken directly from patients with solid tumors using the human tumor cloning assay. The range of concentrations of the cytokines used in our study included the concentrations that appear to be clinically relevant.

RESULTS

Of the evaluable samples, stimulation of tumor growth was noted in 0/16 exposed to GM-CSF, in 3/72 (4%) exposed to IL-3, and in 1/65 (2%) exposed to IL-6. Inhibition of tumor proliferation was noted in no sample exposed to GM-CSF, in 7 (10%) exposed to IL-3 and in 7 (10%) exposed to IL-6.

CONCLUSIONS

The use of GM-CSF, IL-3 or IL-6 to reduce myelosuppression after high dose chemotherapy appears unlikely to result in stimulation of the growth of the most common solid tumors. It is also unlikely that either IL-3 and IL-6 alone will be useful as antitumor agents against solid tumors.

Prediction of adult cardiovascular multifactorial risk status from childhood risk factor levels. The Bogalusa Heart Study

There is increasing interest in identifying children at risk for later development of cardiovascular disease. The authors studied 1,457 children who were first examined as part of the Bogalusa Heart Study in 1973 and again 15 years later as young adults. Age-, race-, and sex-specific quartiles were defined for each of three risk factor variables-ponderal index (weight/height3), systolic blood pressure, and cholesterol--for both the child and adult measures. Adults were classified as clustered if they were in the top quartile for each of the variables. Clustered adults had higher levels of several risk factor variables, in addition to the criteria variables, than did nonclustered individuals. Of children who placed in the top quartile on three factors, 21.8% were clustered as adults. Only 1.1% of those with no risk factor levels in the top quartile were clustered as adults (p < 0.0001). Logistic regression was used to predict adult cluster status from childhood variables levels. All three factors were significant predictors, with blood pressure being the most powerful. This well-fitting model is easily interpretable in terms of standard deviations and can be a useful model for identifying at-risk children.

Dietary fiber intake of children: the Bogalusa Heart Study

Age and secular trends in dietary fiber intake of children were examined using the 24-hour dietary recall method. Dietary fiber intake of five cohorts of 10-year-olds (n = 1254); two cohorts of 13-year-olds (n = 360); and children ages 10 (n = 767), 13 (n = 249), 15 (n = 108), and 17 (n = 89) years was examined from 1976 to 1988. Total dietary fiber intake remained unchanged from 1976 to 1988, even after adjusting for energy intake; averaging 12 or 5 g/100 calories (kcal). Black children had higher fiber intakes per 1000 kcal than white children from ages 10 to 17 years. Consumption of vegetables and/or soups and breads and/or cereals accounted for 53% (10 years) to 70% (13 years) of the total fiber consumed. When children were stratified into quartiles based on fiber intake per 1000 kcal, the percent of energy from total fat and saturated fat was lower, and the percent of energy from carbohydrates was higher in children with higher fiber intakes per 1000 kcal. Additional studies are needed to document dietary fiber intakes of children and their impact on overall diet composition and cardiovascular risk factors.

Impact of meat consumption on nutritional quality and cardiovascular risk factors in young adults: the Bogalusa Heart Study

OBJECTIVE

To document the contribution of meat consumption to the overall nutritional quality of the diet and assess its impact on cardiovascular risk factors in young adults.

DESIGN AND SETTING

A cross-sectional survey of young adults in Bogalusa, La.

SUBJECTS

We collected 24-hour dietary recalls from 504 19- to 28-year-olds from 1988 through 1991.

STATISTICAL ANALYSES

We examined dietary composition by meat consumption quartiles. Analysis of variance and Newman-Keuls range tests were performed.

RESULTS

Young adults consume an average of 6.5 oz meat daily; whites most often consumed beef and blacks most often consumed pork and poultry. Persons in the < 25th percentile for meat consumption consumed a diet closest to recommended levels--with 11% of energy from protein, 55% from carbohydrate, 32% from fat, 11% from saturated fatty acids, and 264 mg dietary cholesterol. In contrast, persons in the > 75th percentile for meat consumption consumed a diet with 18% of energy from protein, 40% from carbohydrate, 41% from fat, 13% from saturated fatty acids, and 372 mg dietary cholesterol. Intakes of heme iron and phosphorus were lower and calcium intake higher in persons in the < 25th percentile compared with those in the > 75th percentile for meat consumption. The percent of persons meeting two thirds of the Recommended Dietary Allowances for vitamin B-12, niacin, and zinc was greater in the > 75th percentile for meat consumption compared with the < 25th percentile for meat consumption. We noted no differences across meat consumption quartiles in blood lipids and lipoproteins, anthropometric measurements, and hemoglobin levels.

APPLICATIONS/CONCLUSIONS

Consumption of moderate amounts of lean meat, along with healthier choices in other food groups, may be necessary to meet the current dietary recommendations.

Alcohol consumption among adolescents and young adults: the Bogalusa Heart Study, 1981 to 1991

This report describes the alcohol consumption of adolescents and young adults who participated in the Bogalusa Heart Study, 1981 to 1991. Data were collected in three cross-sectional surveys of school-age children (11 to 19 years) and three surveys of young adults (18 to 32 years). White males had the highest proportion of drinkers and Black females had the lowest. By the end of the decade, adult White and Black male drinkers were about equal. Most individuals drank once or twice a week, but daily drinkers had the highest weekly alcohol intake. An association between alcohol and high-density lipoprotein cholesterol was found only in the latest survey and probably reflects the aging of the cohort.

Multiorgan failure associated with lomustine overdose

OBJECTIVE

To report a lomustine overdose in a patient with anaplastic astrocytoma.

CASE SUMMARY

A 28-year-old woman with anaplastic astrocytoma was treated with partial resection and radiation therapy followed by a lomustine-containing regimen. The patient took lomustine 1400 mg po over a week, her regular dose being 200 mg on day 1 of the regimen. Pancytopenia developed within a week after the last dose of lomustine and the patient was admitted to the bone marrow transplant unit for supportive care. About 3 weeks later, the patient gradually developed a multiorgan dysfunction, including liver, brain, and lungs without evidence of infection or tumor progression, and died on day 45 of hospitalization.

DISCUSSION

This is the third reported case of lomustine overdose that resulted from supplying the patient with more tablets than needed for 1 dose. Although late hematopoietic recovery may be possible after such a high dose of lomustine, other organ toxicities might be detrimental.

CONCLUSIONS

Physicians and pharmacists should avoid supplying more tablets than needed for 1 lomustine dose. High doses of lomustine may cause irreversible multiorgan toxicities.

Efficacy of sulofenur and a second generation diarylsulfonylurea, N-[5-(2,3-dihydrobenzofuryl)sulfonyl]-N'-(3,4-dichlorophenyl)urea (LY295501), against colon adenocarcinoma xenografts

Sulofenur and a second generation diarylsulfonylurea (DSU), N-[5-(2,3-dihydrobenzofuryl)sulfonyl]-N'-(3,4-dichlorophenyl)urea (LY295501), were evaluated against a panel of eight colon adenocarcinoma xenografts. Of these tumors, four were derived from adult patients and four from young patients (age range 11-26 years). Both drugs were administered twice daily by oral gavage, 5 days each week for two or three consecutive weeks. The maximum tolerated dose for sulofenur was 300 mg/kg/dose for three courses and 200 mg/kg/dose for LY295501. Against 'adult' derived tumors, sulofenur caused a high proportion of objective regressions of advanced xenografts in two of four lines, with significant inhibition of growth in three tumor lines. Colon adenocarcinomas from young patients were similarly sensitive to sulofenur with a high proportion of complete and partial responses in two of three lines. LY295501 demonstrated a very similar spectrum of activity against this panel of xenografts. Tumors intrinsically resistant to sulofenur were resistant to LY295501, although this agent was slightly more active than sulofenur against tumors from younger patients. In addition, xenografts were established from a cloned colon adenocarcinoma line (GC3/c1) and its derivative GC3/LYC5) selected in vitro for resistance to sulofenur. GC3/c1 xenografts were highly responsive to both sulofenur and LY295501, whereas GC3/LYC5 xenografts were completely resistant to both agents administered at the maximum tolerated dose and schedule. These results indicate that the second generation DSU, LY295501, demonstrates a similar spectrum of activity against colon tumors as does sulofenur, and that the mechanism of action and/or resistance to the two drugs is probably similar.

Suppression of cell-mediated immunity in hypothyroidism

A 71-year-old man had severe hypothyroidism, chronic autoimmune thyroiditis, and bacteremia due to Edwardsiella tarda. Review of the literature identified the hypothesis that E tarda infections may occur more frequently in immunocompromised patients. Previous animal studies have shown decreases in lymphocyte function during hypothyroidism, with return of normal lymphocyte function during euthyroid states. Therefore, lymphocyte transformation studies were obtained, demonstrating severe decreases in our patient's lymphocyte function. Except for chronic autoimmune thyroiditis, other immune system abnormalities were excluded. Serial lymphocyte transformation studies showed gradual improvement in lymphocyte function during gradual return to euthyroid state. Possible pathophysiologic mechanisms for these findings will be reviewed.

Dietary fiber intake of children and young adults: the Bogalusa Heart Study

OBJECTIVE

To determine dietary fiber intake of children and young adults.

DESIGN AND SETTING

Cross-sectional surveys of children and young adults in Bogalusa, La.

SUBJECTS

Twenty-four-hour dietary recalls were collected from 1976 to 1988 on five cohorts of 10-year-olds (n = 1,254), two cohorts of 13-year-olds (n = 360), and young adults (n = 504) 19 to 28 years of age.

STATISTICS

Dietary fiber intake data were analyzed for age, race, and gender differences and for secular trends. Descriptive and inferential statistics were calculated where appropriate. Dietary composition and food sources were examined for race-specific and gender-specific quartiles for dietary fiber intake adjusted per 1,000 kcal.

RESULTS

Even after adjusting for energy intake, total dietary fiber intake remained unchanged from 1976 to 1988, averaging 12 g or 5 g/1,000 kcal. Blacks and males had higher total fiber intakes than whites and females at all ages. Consumption of vegetables and soups and breads and grains accounted for 53% (10-year-olds) to 70% (13-year-olds) of the total fiber consumed. When children were stratified into quartiles on the basis of fiber intake per 1,000 kcal, the percentage of energy from total fat and saturated fat was lower, and the percentage of energy from carbohydrate was higher, in children with higher fiber intakes per 1,000 kcal.

APPLICATIONS

Dietary fiber intake of children has remained the same in the past 12 years and is comparable with the intake of young adults, which is well below the recommended level. Children with high fiber intakes (upper quartile) consumed less fat, particularly saturated fat, and more carbohydrate than children with low fiber intakes. Increasing consumption of whole-grain products, fruits, vegetables, and legumes (prepared with minimal added fat) will be necessary to reach the goal of optimal fiber intake and could result in an eating pattern that approaches the current recommendations for dietary fat and saturated fat.

Evaluation of fatal dog bites: the view of the medical examiner and animal behaviorist

The multidisciplinary evaluation of fatal dog bites in the context of a case is discussed. This approach emphasizes detailed examination of the animals including matching of bite marks, autopsy, and canine behavioral analysis. It further provides details such as contributory medical conditions, past animal behavior and physical evidence linking the dogs to the attack. Such information is important in the legal proceedings that usually accompany these events.

Pathology induced by interleukin-6

Interleukin 6 (IL-6) is a multi-functional cytokine which plays an important role in the immune response, hemopoiesis and host defense. Recombinant human IL-6 (rhIL-6) was administered at high doses to mice, rats and non-human primates. In all species IL-6 had an immunostimulatory and hemopoietic (especially on megakaryocytes) effect. An acute phase response was most pronounced in non-human primates, which was not, however, associated with any major histopathological liver change. Finally, no evidence of glomerular pathology was found. Neutralising antibodies were detected within 10 days of rhIL-6 administration in all species.

Differential effects of sequential, simultaneous, and single agent interleukin-3 and granulocyte-macrophage colony-stimulating factor on megakaryocyte maturation and platelet response in primates

Recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) following interleukin-3 (IL-3) priming has been shown to increase thrombopoiesis. To elucidate the comparative abilities of IL-3 and GM-CSF in influencing megakaryocyte development in vivo, serial bone marrow analyses were performed on rhesus monkeys treated with 5 micrograms/kg/d of IL-3 and 5 micrograms/kg/d of GM-CSF sequentially for 4 days each, simultaneously for 8 days, and as single agents for 8 days. Platelet counts maximally increased to a mean of 7.5 x 10(5)/microL (n = 3) on days 11 through 12 in monkeys treated with sequential IL-3/GM-CSF. In contrast, neither IL-3 alone nor simultaneously administered IL-3/GM-CSF elicited increases in thrombopoiesis between days 3 and 15. GM-CSF elicited a variable platelet response. Megakaryocyte ploidy distributions were significantly (P < .001) shifted between days 7 and 10 in monkeys treated sequentially and between days 3 and 15 in monkeys treated with combined IL-3/GM-CSF and with GM-CSF alone but not in monkeys treated with IL-3 alone. The changes in mean DNA content and megakaryocyte size, as determined by digital image analysis, were larger in monkeys treated with sequential IL-3/GM-CSF and with GM-CSF alone than in simultaneously treated monkeys. In addition, sequentially but not simultaneously treated monkeys showed increased numbers of megakaryocytes on bone marrow biopsy. We conclude that administration of IL-3 followed by GM-CSF treatment increases thrombopoiesis by sequentially increasing megakaryocyte numbers and maturation and that these effects are diminished by simultaneous administration of the two cytokines.

High-dose methylprednisolone therapy for acute graft-versus-host disease associated with matched unrelated donor bone marrow transplantation

Acute graft-versus-host disease (aGVHD) is a major barrier to successful bone marrow transplantation (BMT) with matched unrelated donors. Eight of eight recipients of matched unrelated donor BMT developed aGVHD. We used a regimen of high-dose methylprednisolone (5 mg/kg/day for 4 days with responders continuing on treatment, and dose escalation to 10 mg/kg/day for non-responders) as initial therapy of aGVHD. One patient died on the second day of steroid administration. Each of the seven remaining patients responded to methylprednisolone, five at the 5 mg/kg/day dose and two at the 10 mg/kg/day dose. Three of five patients developed flare of aGVHD during reduction of the corticosteroid dosage and died with aGVHD and infection. Two patients have undergone reduction of methylprednisolone at a modified rate without a flare. Infectious complications during methylprednisolone treatment were very common and contributed to the death of the three patients with flare of aGVHD. Four patients in whom aGVHD was in remission survived serious systemic infections. High-dose methylprednisolone is effective initial therapy for aGVHD associated with matched unrelated BMT, but is associated with a high risk of serious infections.

Evaluation of 9-dimethylaminomethyl-10-hydroxycamptothecin against xenografts derived from adult and childhood solid tumors

The topoisomerase I inhibitor 9-dimethylaminomethyl-10-hydroxycamptothecin (topotecan) was evaluated against a panel of xenografts comprising four lines of adult colon adenocarcinoma, three colon tumors derived from adolescents, six childhood rhabdomyosarcomas from previously untreated patients as well as sublines selected in vivo for resistance to vincristine and melphalan, and three lines of childhood osteogenic sarcoma. Efficacy was determined at maximal tolerated dose levels using intermittent i.p. administration [every 4 days for 4 doses (q4dx4)] or daily p.o. or i.p. administration 5 days per week for up to 20 courses. On a q4dx4 schedule, the maximum tolerated dose (MTD) was 12.5 mg/kg per administration, which caused marked weight loss and lethality in approximately 5% of the tumor-bearing mice. This schedule caused significant growth inhibition (but no tumor regression) in advanced adult colon adenocarcinomas. The minimal treated/control (T/C) ratios were 0.49, 0.54, and 0.3 for three of the tumor lines and were achieved at 18-21 days after the initiation of treatment. In contrast, rhabdomyosarcomas were considerably more sensitive, with T/C ratios being < 0.1 for three lines, whereas topotecan was less active against two other rhabdomyosarcoma xenografts (minimal T/C ratios, 0.17 and 0.14). As inhibitors of topoisomerase I have been demonstrated to have activity in the replication phase of the cell cycle (S-phase-specific), prolonged administration schedules were examined. Mice received topotecan 5 days per week for 3 weeks either by i.p. injection or by oral gavage (p.o.). In selected experiments, p.o. administration was continued for up to 20 weeks. Oral administration for 3 weeks (2 mg/kg per dose) resulted in complete regression of all six lines of rhabdomyosarcoma, with two lines demonstrating no regrowth during the period of observation (> or = 84 days). Similar results were obtained after i.p. administration, suggesting significant schedule dependency for these tumors. For colon tumors, the daily administration schedule (i.p. or p.o.) demonstrated some advantage over the intermittent schedule, resulting in partial regressions and significant inhibition of the growth of several colon adenocarcinoma lines. In rhabdomyosarcoma Rh12 and VRC5 colon adenocarcinoma, both of which demonstrated intermediate sensitivity to topotecan, and in osteosarcoma OS33, protracted p.o. administration for 13-20 weeks (1.0-1.5 mg/kg per dose given daily x 5 days) caused complete regression without regrowth in Rh12 and OS33 tumors and partial regression of all VRC5 tumors. No toxicity was observed using this schedule of administration. Topotecan demonstrated significant activity against all three osteosarcoma xenografts examined, with optimal schedules causing complete regression in two lines.(ABSTRACT TRUNCATED AT 400 WORDS)

Myxedema coma

Myxedema coma is a rare condition associated with high mortality. The pathophysiology is complex and often involves profound hypothyroidism as well as an inciting event. The diagnosis should be suspected based on the clinical presentation, and treatment should not be delayed while awaiting confirmatory laboratory data. In critically ill patients, laboratory differentiation between severe hypothyroidism and the euthyroid-sick syndromes is difficult and may require measurement of free hormone levels. Treatment consists of correction of electrolyte abnormalities, passive rewarming, treatment of infections, respiratory and hemodynamic support, administration of stress-dose glucocorticoids, and thyroid hormone replacement. Intravenous thyroxine, between 200 and 500 micrograms as the initial dose followed by 50 to 100 micrograms/day, is recommended. Concurrent therapy with triiodothyronine can also be considered.

A role for the Ca2(+)-dependent adhesion molecule, N-cadherin, in myoblast interaction during myogenesis

The formation of multinucleate skeletal muscle cells (myotubes) is a Ca2(+)-dependent process involving the interaction and fusion of mononucleate muscle cells (myoblasts). Specific cell-cell adhesion precedes lipid bilayer union during myoblast fusion and has been shown to involve both Ca2(+)-independent (CI)2 and Ca2(+)-dependent (CD) mechanisms. In this paper we present evidence that CD myoblast adhesion involves a molecule similar or identical to two known CD adhesion glycoproteins, N-cadherin and A-CAM. These molecules were previously identified by other laboratories in brain and cardiac muscle, respectively, and are postulated to be the same molecule. Antibodies to N-cadherin and A-CAM immunoblotted a similar band with a molecular weight of approximately 125,000 in extracts of brain, heart, and pectoral muscle isolated from chick embryos and in extracts of muscle cells grown in vitro at Ca2+ concentrations that either promoted or inhibited myotube formation. In assays designed to measure the interaction of fusion-competent myoblasts in suspension, both polyclonal and monoclonal anti-N-cadherin antibodies inhibited CD myoblast aggregation, suggesting that N-cadherin mediates the CD aspect of myoblast adhesion. Anti-N-cadherin also had a partial inhibitory effect on myotube formation likely due to the effect on myoblast-myoblast adhesion. The results indicate that N-cadherin/A-CAM plays a role in myoblast recognition and adhesion during skeletal myogenesis.

Evaluation of N-(5-indanylsulfonyl)-N'-(4-chlorophenyl)-urea against xenografts of pediatric rhabdomyosarcoma

N-(5-indanylsulfonyl)-N'-(4-chlorophenyl)-urea (LY186641), a novel anticancer compound, was evaluated against six lines of rhabdomyosarcoma xenografts, each of which was established from tissue biopsies from untreated patients, and additional sublines selected as xenografts for primary resistance to vincristine, melphalan, and ifosfamide. LY186641 was given by oral gavage twice daily for 10 consecutive days or as 5-day courses repeated at 7-day intervals. At the optimal schedule, complete regressions of advanced tumors were obtained in each of the six rhabdomyosarcoma lines. There was no apparent cross-resistance in RMS lines selected for vincristine resistance or against multiple-drug-resistance KB cells in vitro. There was slight cross-resistance in xenografts selected for melphalan resistance, but not in an ifosfamide-resistant line. These results indicate that LY186641 may have significant clinical activity in the treatment of childhood rhabdomyosarcoma.

The long march of the cerebrospinal fluid profile indicative of clinical definite multiple sclerosis; and still marching

Much progress has been made, especially in the last two decades, in laboratory aids to diagnosis and to follow the course of patients with multiple sclerosis (MS). The cerebrospinal fluid (CSF) profile indicative of MS, though not pathognomonic of MS, is present in almost every case of clinical definite MS in a chronic progressive phase (probably also true for early MS). The cardinal aspect of the profile is intra-blood-brain barrier (BBB) IgG synthesis which can be qualitatively detected by determining unique CSF oligoclonal IgG bands and quantitated by rate formula, mg/day. We believe that intra-BBB IgG synthesis is caused by a persistent antigen, most likely a virus, possibly measles. A number of issues about the profile are proposed and opportunities are presented to resolve them.

The primary care physician and psychiatric services

This article describes the relationship of self-assessed psychiatric skill among primary care physicians to their role in treating mental disorders. Physicians rated diagnostic skills more favorably than therapeutic skills. Factor analysis was used to identify three dimensions of physician skill: confidence in treatment of major disorders; confidence in treatment of anxiety; and diagnostic confidence. These variables were found to be associated with the reported number of patients with specific mental disorders managed by the physician.

Human alpha-lymphoblastoid interferon. A phase I study including pharmacokinetics and effects on hematologic stem cells (CFU-GMs)

Human alpha lymphoblastoid interferon (Wellferon) was administered to 33 patients in a phase I study. Patients received Wellferon intramuscularly every 12 hours for 14 doses in nine dosage levels ranging from 0.75 X 10(6) units to 50.0 X 10(6) units. Toxicity tended to be dose dependent and included fever/chills, malaise, hematologic toxicity, and digestive tract toxicity. Thirty X 10(6) u q 12 h was felt to be the maximum tolerated dose. Three partial responses (renal cell carcinoma, diffuse histiocytic lymphoma, Hodgkin's disease) were achieved. Interferon rapidly (2 to 3 hours after the initial injection) reached peak serum levels which varied generally with dose and exceeded 500 u/ml at the 30 and 50 X 10(6) u dosages. Multiple doses of interferon resulted in cumulative peak levels substantially higher than first dose levels (greater than 500 u/ml at dosages greater than 3 X 10(6) u/ml and greater than 1,500 u/ml at dosages greater than or equal to 18 X 10(6) u). Interferon given at high dosages persisted up to 10 days beyond the final injection. Despite hematologic toxicity, inhibition of CFU-GM was not seen.

Cytotoxic activity of peripheral blood and cerebrospinal fluid lymphocytes from patients with multiple sclerosis and other neurological diseases. Analysis at the single cell level using morphological and surface marker phenotype criteria

The large granular lymphocyte (LGL) has been identified in normal individuals' MNC population as the NK-K cell (Ault and Weiner 1978; Timonen et al. 1981); it bears the OKM1 surface antigen (Breard et al. 1981; Fast et al. 1981) and while negative for T cell antigens OKT4 and OKT8, is a low avidity E-rosette forming cell. However, in a unfractionated nylon wool passed peripheral blood lymphocyte (NWP PBL) population, we show that not more than 50% of KN activity in normal or OND control NWP PBL and 30% NK activity in MS NWP PBL can be attributed to this cell. Nevertheless, 100% of control K cell activity and 50% of MS K cell activity can be mediated by an LGL. MS patients have normal proportions of LGLs in their NWP PBL. The proportion of LGLs in CSF of MS and OND patients is too low to account for the number of CSF K cells. While in control NWP PBLs, the LGLs are OKM1+ and mediate NK and ADCC, in MS the LGL NK effectors are probably different from LGL-K cell effectors. In MS both populations include effector cells with cell surface antigens. Thus, the OKM1+ LGL characteristics may not be used in analysis of NK and K cells in multiple sclerosis.

A prostaglandin endoperoxide analog increases gastric emptying and suppresses gastric secretion in rhesus monkeys

The effects of a stable endoperoxide analog, U-46619, were studied in five conscious chair-adapted rhesus monkeys. A dye dilution technique was used to determine simultaneously gastric fractional emptying, fluid output and ion output. A continuous infusion of either saline or U-46619 (0.2 micrograms/kg/min i.v.; 1 or 2 micrograms/kg/min s.c.) was given during a basal period and after distension of the stomach with an 80-ml water load. These studies demonstrate that U-46619 increases basal, but not postload fractinal emptying, and inhibits parietal secretion. These actions are similar to some of the effects of prostacyclin, prostaglandin E2 and prostaglandin F2 alpha on gastric emptying and secretion.

Effect of prostacyclin on gastric emptying and secretion in rhesus monkeys

The effects of prostacyclin (PGI2) on gastric emptying and secretion were studied in five unanesthetized chair-adapted rhesus monkeys. A dye dilution technique was used to determine simultaneously gastric fractional emptying, hydrogen ion (H+) output, fluid output, and H+ concentration of the gastric juice. A continuous intravenous infusion of either sodium carbonate buffer (control) or PGI2 (125, 175, or 250 ng/kg/min) was given during a 40-min basal period and following the intragastric administration of an 80-ml water load. During the basal period, 175 and 250 ng/kg/min significantly decreased H+ output compared to control. Only 250 ng/kg/min, however, significantly reduced basal fluid output compared to control. As a result, the H+ concentration of the gastric juice was lowered by both 175 and 250 ng/kg/min. The effects of PGI2 on H+ output, fluid output, and H+ concentration of the secreted juice after the water load were similar to those observed during the basal period. In addition to its anti-secretory action, PGI2 inhibited significantly postload, but not basal, gastric fractional emptying. Because a fall in intragastric H+ concentration is known to enhance fractional emptying, it appears that the retarding effect of PGI2 on fractional emptying is not mediated by its ability to suppress H+ output.

Management assessment center technique: an evaluation of the literature

In this article Lee Myers, manager, Medical Records, Geisinger Medical Center, Danville, PA, reviews the literature, mainly in the manpower development area, to provide an evaluative insight into the use of management assessment centers as a part of an organization's overall manpower planning and organizational development.

Mammographic patterns and risk of breast cancer

A study of 171 breast cancer cases matched by age and race to asymptomatic controls was undertaken to check Wolfe's assertion [1, 2] that breast cancer risk depends strongly on the mammographic classifications N1, P1, P2, and DY. The classifications were made blindly relative to all variables, including the case-control factor. Distribution of the four categories among the breast cancer patients in this study was consistent with the distribution found by Wolfe. (P = .46). Our age-standardized risk ratio estimates of the categories, relative to N1, are 1.5 for P1, 2.7 for P2, and 7.2 for DY. While not as striking as Wolfe's estimates, the same monotone trend is evident, and the cases and controls differ significantly with respect to the distributions of the four categories (P less than .01).

Subclinical eye movement disorders in patients with multiple sclerosis

Eye movements were quantitatively evaluated in 16 patients with well-documented multiple sclerosis who had minimal or no clinically apparent eye movement disorder. Induced saccade and pursuit eye movements were recorded with electro-oculography and analyzed with newly developed programs on a laboratory digital computer. Thirteen of the 16 patients had significant (p less than 0.05) impairment of saccades and/or smooth pursuit when compared with 25 normal subjects tested in our laboratory. The type and frequency of abnormalities were as follows: saccade dysmetria, eight; delayed saccade reaction time, five; bilateral saccade slowing, four; slowing of adducting saccades only (medial longitudinal fasciculus syndrome), one; and impaired smooth pursuit, both directions, three, and one direction only, three. In addition, four patients had vestibular nystagmus with eyes closed, and one patient had typical rebound nystagmus. These data suggest that quantitative assessment of eye movements in patients with suspected multiple sclerosis can help in identifying the important "second lesion."

The association of HLA antigens A3, B7, and DW2 with 330 multiple sclerosis patients in the United States

Reported associations of HLA antigens with MS have varied considerably. In this study we have examined 330 clinically definite MS patients from the United States. The frequency of DW2 (52%) was highly statistically significant in MS patients as compared to controls (p less than 0.00001). Neither A3 nor B7 was significantly increased in MS; however, the joint occurrences of A3-DW2 (20% vs 7%, p less than 0.001) and B7-DW2 (30% vs 13%, p less than 0.0002) are highly associated with MS.