Clinical features and treatment outcome of childhood T-lineage acute lymphoblastic leukemia according to the apparent maturational stage of T-lineage leukemic blasts: a Children's Cancer Group study

PURPOSE

Leukemic cells from T-lineage acute lymphoblastic leukemia (ALL) patients are thought to originate from T-lymphocyte precursors corresponding to discrete stages of T-cell ontogeny. Here we sought to determine the influence of leukemic cell apparent maturational stage on treatment outcomes in pediatric T-lineage ALL.

PATIENTS AND METHODS

From 1983 through 1993, 407 pediatric T-lineage ALL patients were enrolled onto two sequential series of risk-adjusted treatment protocols of the Children's Cancer Group. In the current analysis, T-lineage ALL patients were immunophenotypically classified as follows: CD7+ CD2- CD5- pro-thymocyte leukemia (pro-TL), CD7+ (CD2 or CD5)+ CD3- immature TL, and CD7+ CD2+ CD5+ CD3+ mature TL.

RESULTS

Similar induction outcomes of 91.4%, 97.1%, and 98.3% were obtained by the pro-, immature, and mature TL groups, respectively. Four-year event-free survival (EFS) was lower for pro-TL patients (57.1%; SD = 8.4%,) compared with immature and mature TL patients (68.5%; SD = 3.5%; and 77.1%; SD = 4.0%, respectively) with an overall significance of .05 (log-rank test) or .04 (log-rank trend test). Relative hazards rates (RHR) were 2.11 and 1.22 for pro-TL and immature TL versus mature TL, respectively. Highly significant differences were found for overall survival (P = .005, log-rank test; P = .009, log-rank trend test). Multivariate analysis confirmed that the prognostic influence of ontogeny grouping was independent of that of other prognostic factors.

CONCLUSION

Leukemic cells of the pro-TL maturation stage identify a small subgroup of T-lineage ALL patients who have a significantly worse EFS outcome than patients whose cells are of a more mature stage of development.

A logistic regression model for the decision to perform access surgery

Access surgery may be recommended to about 80% of patients who present with advanced forms of periodontal disease. In this report, a multivariate logistic regression analysis which incorporated several clinical parameters for each tooth examined, i.e., tooth type, furcation involvement, bleeding on probing, attachment level, probing depth, mobility and BANA test score, was conducted using generalized estimating equations (GEE). This approach identified parameters that were significantly associated at p < 0.05 level with the need for access surgery or extraction for periodontal purposes. The estimated probabilities derived from the GEE model were plotted over the complete spectrum of operating conditions to obtain a receiver-operator characteristic (ROC) curve. At a probability cutpoint of 0.8, the decision threshold for surgery/extraction at the pretreatment examination would have a sensitivity of 76.1% and a specificity of 75.3%. We have taken this 0.8 cut point to look at specific clinical decisions made by our examiners after the patients had received scaling and root planing plus 2 weeks unsupervised usage of systemic antimicrobials. The clinicians' decision was taken as the primary reference standard. The model's estimated decision agreed with the clinicians' decision in 226 of the 284 teeth, for an accuracy of 80%. The specificity was 90% and the sensitivity was 43%.

Hypertension and subclinical carotid artery atherosclerosis in blacks and whites. The Atherosclerosis Risk in Communities Study. ARIC Investigators

OBJECTIVE

To describe the distribution of hypertension and its association with subclinical atherosclerosis in blacks and whites.

DESIGN

Population-based survey of 15,587 middle-aged adults from the Atherosclerosis Risk in Communities Study. Ultrasound-measured carotid artery intima media thickness (IMT) was used to estimate atherosclerosis. Hypertension was defined by the revised fifth Joint National Committee categories. Continuous systolic and diastolic blood pressure measurements also were evaluated.

RESULTS

Among participants not reporting use of antihypertensive medication, 43% to 52% of black and 68% to 78% of white participants had optimal to high-normal blood pressure across the 4 study centers; 11% to 22% of black and 6% to 9% of white participants had stage I or higher hypertension. Use of antihypertensive medications was reported by 34% to 45% of blacks and 20% of whites; 11% to 17% of blacks had stage I or higher hypertension compared with 4% to 7% of whites when treated. Higher hypertension categories were associated with thicker intima medias in all ethnic and gender groups, in participants who did and did not use medications. In participants who did not use medications, multiple linear regression models adjusted for diastolic blood pressure and other risk factors found that systolic blood pressure was positively associated with IMT except in black men; diastolic blood pressure was not related to IMT in blacks and had a negative relation with IMT in white men and a J-shaped relation with IMT in white women. Results of similar direction and magnitude were found in participants who used medications.

CONCLUSIONS

Hypertension was higher in blacks than whites and was associated with subclinical atherosclerosis. The association of atherosclerosis with hypertension is accounted for predominantly by systolic blood pressure. The intriguing negative association of diastolic blood pressure and atherosclerosis implies that pulse pressure may be an important correlate of atherosclerosis.

Nonsurgical treatment of patients with periodontal disease

OBJECTIVE

To determine whether the short-term use of systemic antimicrobials (metronidazole or doxycycline) and locally delivered antimicrobials (metronidazole, chlorhexidine) in patients with advanced forms of periodontal disease could prevent the normally necessary access surgery.

STUDY DESIGN

Ninety-four patients were randomly assigned with the use of a double-blind protocol.

RESULTS

There was a 93% reduction in the need for periodontal surgery about individual teeth and an 81% reduction in the need for tooth extractions. Only 93 teeth of an initial total of 783 teeth actually needed surgery or extractions. Eighty-one percent of the patients entered into the maintenance phase of treatment without needing surgical treatments.

CONCLUSION

These findings indicate that a treatment paradigm based on the diagnosis and treatment of anaerobic infections is likely to be successful in those patients for whom access surgery is recommended.

Bilateral gracilis neosphincter construction for treatment of faecal incontinence

Neosphincter formation with gracilis muscle is used for faecal incontinence refractory to conservative measures and after failed sphincter repair. In this study both gracilis muscles were used to create a neosphincter to determine whether this provides superior physiological and clinical results. Ten patients of median age 39 (range 18-73) years were treated. The mean resting and squeeze pressures before operation were 16 (range 0-40) and 44 (range 0-68) cmH2O respectively. The operation was covered by a defunctioning loop left iliac fossa colostomy. Nine of the ten patients have had the stoma closed and are fully continent after a mean follow-up of 24 (range 6-40) months. One patient who had an ileoanal pouch and bilateral graciloplasty has urgency of defaecation. None of the patients has to wear a pad or is taking constipating agents. All nine patients have satisfactory evacuation on isotope defaecography and are continent to artificial stool. After operation the mean resting and squeeze pressures were 78 (range 70-112) and 121 (range 90-188) cmH2O respectively. Bilateral graciloplasty provides satisfactory results for grade 4 faecal incontinence refractory to other operative and non-operative measures, and may be an alternative to stimulated dynamic graciloplasty.

Scintigraphic measurement of ileocaecal transit in irritable bowel syndrome and chronic idiopathic constipation

This study investigated the hypothesis that some features of functional gastrointestinal disorders may be associated with abnormalities of ileocaecal transit by measuring ileocaecal transit using a scintigraphic technique in 43 patients with chronic constipation, 20 patients with irritable bowel syndrome (IBS), and 18 control subjects. Subjects ingested enteric coated capsules, which delivered 111-indium radionuclide to the distal ileum. Gammacamera images were acquired at hourly intervals until caecal filling was complete. Ileocaecal transit was defined as the time between peak scintigraphic activity in the terminal ileum and peak activity in the caecum. The mean (SD) ileocaecal transit of 103 (50) minutes in patients with IBS was significantly faster than that in control subjects (mean (SD) ileocaecal transit 174 (78) minutes, p < 0.002). There were no significant differences in ileocaecal transit between patients with chronic idiopathic constipation and the control subjects, or between patients with constipation predominant and diarrhoea predominant IBS. This study developed a practical scintigraphic method of measuring ileocaecal transit. The rapid ileocaecal transit in both the constipation and diarrhoea predominant forms of IBS suggests that bloating may not after all result from delayed ileal emptying.

Reporting simplified colonic transit studies using radionuclides: clinician friendly reports

This study describes a graphic presentation of the results of a simplified segmental colonic transit model. This study requires three sets of images on three consecutive days after intake of indium-111 resin capsule at each time point. The per cent of ingested activity is calculated in each region of the colon and in the faeces. The program uses standard PC compatible graphic package, CorelDRAW (Corel Corporation). The report for the patients' notes consists of three schematic diagrams of colon with regions identified and a pot representing the faecal activity. The per cent of administered activity in each region and pot is both printed and represented by shades of grey (white representing 0% and black 100% activity), for each region and the pot. The distribution of activity is clearly seen at each time point and the report is presented on single A4 size sheet of paper. Using a simplified colonic study protocol it is possible to produce clinician friendly reports on a single sheet of paper.

Temporary discontinuation of warfarin therapy: changes in the international normalized ratio

OBJECTIVE

To measure the rate of decrease of the international normalized ratio (INR) after temporary discontinuation of warfarin therapy.

DESIGN

Prospective evaluation of an outpatient cohort.

SETTING

University medical center anticoagulation clinic.

PATIENTS

22 patients receiving a fixed evening dose of warfarin for whom temporary discontinuation of therapy was deemed safe.

MEASUREMENTS

Serial plasma samples were drawn for INR measurements approximately 20, 65, 115, and 185 hours after patients received the last dose of warfarin. In five patients, INR was measured twice daily for 5 days.

RESULTS

For patients with a mean steady-state INR of 2.6, the mean INR 65 hours (2.7 days) after discontinuation of warfarin therapy was 1.6 (range, 1.11 to 2.16); 20 of 22 patients (91%) had an INR greater than 1.2. The mean INR 115 hours (4.7 days) after discontinuation of warfarin therapy was 1.1; 5 of 22 patients (23%) had an INR of 1.2 or greater. In 5 patients studied in detail, the INR decreased exponentially and had a half-life that ranged from 0.52 to 1.2 days; the onset of maximal decrease began 24 to 36 hours after discontinuation of warfarin therapy. In the total cohort, age was a significant (P < 0.005) independent predictor of smaller decreases in the INR between day 1 and day 3 (regression coefficient = -6.8% +/- 2%/2 days per decade of age; R2 = 0.34).

CONCLUSIONS

By simulating preoperative discontinuation of warfarin therapy, we found that the INR decreases exponentially, with wide interpatient variation in the rate of decrease. Age is associated with a slower rate of decrease. To be certain that the INR at the time of the surgery is less than 1.2, warfarin should be withheld for 96 to 115 hours (4 doses) in patients with a steady-state INR between 2.0 and 3.0. For patients with a higher steady-state INR, a longer wait is necessary.

Use of geometric center and parametric images in scintigraphic colonic transit studies

BACKGROUND/AIMS

Scintigraphic studies give detailed information on colonic transit. In this study, several methods of presenting such data were compared and discussed. The aim of the study was to evaluate the role of geometric center (GC) and parametric images in interpretation of colonic transit studies.

METHODS

Segmental colonic transit was measured in 117 patients: 50 with constipation, 24 with irritable bowel syndrome, 22 with fecal incontinence, 14 who were postsurgery, and 7 normal volunteers. 111In-labeled resin was administered in a pH-sensitive capsule, and images were acquired for 3 days. The percentage of activity in four regions of colon and in the feces was measured.

RESULTS

Five patterns of colonic transit were identified (16 rapid transit, 48 intermediate, 14 generalized delay, 5 left-sided delay, and 34 right-sided delay). The geometric center (sum of fraction of activity x region number) was calculated at each time point. Using the geometric center, the groups could be differentiated (P < 0.01) except for those with left-sided delay. In individual patients, patterns of colonic transit could not be determined using the geometric center alone. Gray-scale presentation of percent activity in each region (parametric images) allowed patterns of colonic transit to be identified in individuals.

CONCLUSIONS

Use of the geometric center is suitable for comparison of groups of patients, whereas parametric images identify patterns in individual patients.

Anticoagulation therapy and primary care internal medicine: a nurse practitioner model for combined clinical science

The anticoagulation clinics at the University of Virginia Health Sciences Center and the University of California at Davis Medical Center are nurse-practitioner-operated, are affiliated with the general medicine clinic, and rely on portable prothrombin time (PT) monitors that use whole blood and provide timely as well as accurate results reported in PT seconds or as the international normalized ratio (INR). On-site PT/INR testing at these clinics simplifies anticoagulation, mandates direct patient contact, and facilitates primary as well as comprehensive care for patients requiring multispecialty services in large tertiary care centers. Encounters are relatively brief, averaging 19 minutes; 72% of the encounter time involves anticoagulation care and 28% involves primary care. Anticoagulation results using portable PT/INR monitors are safe and accurate based on comparisons with results from clinics relying on standard instruments.

Black-white differences in electrocardiographic left ventricular mass and its association with blood pressure (the ARIC study). Atherosclerosis Risk in Communities

Black-white differences in the association between antihypertensive therapy, continuous measures of mean arterial and pulse pressures and left ventricular (LV) mass estimated from a multivariable electrocardiographic algorithm were examined in 6,020 men (23% black) and 7,970 women (29% black) participating in the Atherosclerosis Risk in Communities (ARIC) study. Mean arterial and pulse pressures, weight, the percentage of subjects taking antihypertensive medication, and LV mass were higher in black than in white men (98 vs 89 mm Hg, 47 vs 46 mm Hg, 188 vs 187 pounds, 30% vs 17%, and 243 vs 217 g, respectively). Results of similar direction but greater magnitude were observed in black versus white women (mean arterial pressure, 94 vs 85 mm Hg; pulse pressure, 50 vs 47 mm Hg; weight, 180 vs 153 pounds; percent treated, 42% vs 18%; and LV mass, 203 vs 169 g, respectively). In multivariable regression analyses, blacks had higher levels of LV mass, and LV mass increased more sharply with increasing mean arterial pressure in blacks than in whites after adjusting for age, pulse pressure, and weight. At equal mean arterial and pulse pressures, age, and weight, treated blacks had higher LV mass than treated whites. These data indicate that blacks have higher LV mass than whites, and a more pronounced blood pressure-LV mass relation after controlling for other risk factors and treatment status. Given the prognostic importance of LV hypertrophy,

Simplified method for the measurement of segmental colonic transit time

Segmental colonic transit has been measured in 101 patients. Two MBq of 111Indium absorbed on resin pellets and encapsulated in an enteric coated capsule was given at 7 00 am. Hourly images during the first day, and three images during each subsequent day were acquired for up to three days. Using all scan and patient data the scans were categorised in one of the five patterns of colonic transit: normal, rapid, right delay, left delay, or generalised delay. The geometric centres and per cent activity at each time point was compared between the five groups of colonic transit patients to find the best time for imaging and so to distinguish the five groups. During the first day, early images did not help in diagnosis of patterns of transit, however, in the later images (six hours onwards after the ingestion of the activity) the rapid transit groups could be identified. Images at 27 and 51 hours were both required to distinguish all five groups of patients from each other. Only in the 'normal' transit patients was there some excretion of the activity during the course of the second day, otherwise there was no difference in the images taken in the course of a day (second or third day). A simplified protocol requires a minimum of three images to distinguish all five patterns of colonic transit. The activity should be ingested in the morning (7 00 am) and the first image taken at the end of the working day (8-10 hours after ingestion), the second image on the morning of the second day, and the third image during the course of the third day. This simple protocol would provide all the clinically relevant information necessary for correct classification of the colonic transit.

Granulocyte colony-stimulating factor (G-CSF) production and G-CSF receptor structure in patients with congenital neutropenia

Congenital neutropenia (Kostmann's syndrome [KS]) is an autosomal recessive syndrome that is characterized by profound neutropenia, resulting in major clinical infections and death. Since the neutropenia and symptoms in KS improve in response to exogenous administration of granulocyte colony-stimulating factor (G-CSF), we studied bone marrow cytokine (G-CSF, granulocyte-macrophage CSF [GM-CSF], and interleukin-6) production under both basal and stimulated conditions. No differences in G-CSF, GM-CSF, or IL-6 gene expression were found in bone marrow stromal cells between normal controls and KS patients, and all three cytokines were detected by enzyme-linked immunosorbent assay (ELISA) in medium conditioned by bone marrow stromal cells from normal donors and patients with KS. Each KS patient tested had detectable, functional G-CSF in their own serum before exogenous G-CSF administration. Since G-CSF production appeared normal in KS patients, we then asked whether we could detect structural defects in the signaling portion of G-CSF receptor genes. Polymerase chain reaction (PCR) amplification of the G-CSF receptor transmembrane region alone, and of the transmembrane plus cytosolic portions of the receptor, yielded the size products predicted from the sequences of the normal G-CSF receptor. Single-strand conformational polymorphism (SSCP) analysis of G-CSF receptor PCR products demonstrated no variance in structural conformation between KS patients and normal subjects. These results demonstrate that bone marrow stromal cells in patients with KS secrete normal concentrations of functional G-CSF and suggest that the neutropenia in KS patients is caused by an inability of neutrophilic progenitor and precursor cells to respond to normal, physiologic levels of G-CSF. Such a defect, clinically responsive to pharmacologic doses of G-CSF, might be caused by defects in the post-G-CSF receptor signal transduction pathway.

Fistulas in ano: endoanal ultrasonographic assessment assists decision making for surgery

Eighteen patients with a clinical impression of a complex fistula in ano, had anal endosonography to delineate the anatomy of the fistula track and identify associated areas of sepsis. The clinical impression of a complex fistula was refuted by endosonography and subsequent surgical exploration in two cases. Horseshoe tracks were identified in nine (50%) patients and fluid collections, not evident on clinical examination were identified in eight (45%) patients. Accurate identification of the internal opening with a 7 MHz transducer was possible in two (11%) cases. External sphincter damage was evident in four (22%) patients. Surgical findings matched endosonographic appearances in all but one case (94%). Anal endosonography is an accurate and minimally invasive method of delineating the relation of fistula tracks to the anal sphincters and identifying deep areas of sepsis in relation to such fistulas.

Pathogenesis of gall stones in Crohn's disease: an alternative explanation

The increased prevalence of gall stones in Crohn's disease is thought to be related to depletion of the bile salt pool due either to terminal ileal disease or after ileal resection. This study was designed to examine whether this hypothesis is correct and explore alternative explanations. Two hundred and fifty one randomly selected patients (156 females, 95 males, mean age 45 years) were interviewed and screened by ultrasonography to determine the prevalence of gall stones in a large population of patients with Crohn's disease. Sixty nine (28%) patients had gall stones proved by ultrasonography (n = 42), or had had cholecystectomy for gall stone disease (n = 27). The risk factors for the development of gall stones including sex, age, site, and duration of disease, and previous intestinal resection were examined by multivariate analysis. Age and duration of disease were positive risk factors for gall stones and were covariables. The site of disease and of previous intestinal resection did not predispose to gall stones. Previous surgery was an independent risk factor for the development of gall stones, the risk increasing with number of laparotomies. It is suggested that mechanisms other than ileal dysfunction may predispose to gall stones. Postoperative gall bladder hypomotility with biliary sludge formation may be precursors of gall stone formation in patients with Crohn's disease.

Scintigraphic defecography: quantitative and dynamic assessment of anorectal function

PURPOSE

Conventional assessment of anorectal function with defecating videoproctography is semiquantitative and the high radiation exposure precludes prolonged or repeated testing. The aim of this study was to develop a dynamic scintigraphic method of assessing anorectal function.

METHODS

Fourteen patients with fecal incontinence, 18 patients with chronic constipation, and 8 control subjects were assessed by scintigraphic defecography. This involves introduction of a technetium-99m-radiolabeled artificial stool into the rectum of the subject and acquisition of gamma camera images during evacuation.

RESULTS

Mean evacuation rate was 2.8 percent/second in incontinent patients and 0.9 percent/second in constipated patients (P < 0.001). The mean anorectal angles were 136 degrees and 133 degrees, respectively. There were 18 cases of pelvic floor descent and 6 rectoceles. Scintigraphic defecography provides quantitative information on rectal evacuation. Anorectal angle and pelvic floor movement can be examined. The radiation dose to pelvic organs is significantly less than with videoproctography.

CONCLUSION

We believe that scintigraphic defecography is the investigation of choice for objective and dynamic assessment of anorectal function.

The relation of lipoprotein[a] concentrations and apolipoprotein[a] phenotypes with asymptomatic atherosclerosis in subjects of the Atherosclerosis Risk in Communities (ARIC) Study

Plasma levels of lipoprotein[a] (Lp[a]) are associated with increased risk of coronary artery disease and show an inverse correlation with apolipoprotein[a] (apo[a]) molecular weight. We determined Lp[a] levels and apo[a] phenotypes in 171 cases with preclinical extracranial carotid atherosclerosis as ascertained by B-mode ultrasound and in 274 control subjects free of carotid atherosclerosis. Lp[a] protein levels measured by enzyme-linked immunosorbent assay ranged from 4 to 361 micrograms/mL in cases and from 2 to 392 micrograms/mL in controls, but median levels of Lp[a] were higher in cases than in controls (51 micrograms/mL versus 33 micrograms/mL, P < .003). In both groups, all 11 apo[a] polymorphs that are resolved by the procedure used were present, resulting in 43 and 39 different apo[a] phenotypes in cases and controls, respectively. An inverse relation between apo[a] polymorph size and Lp[a] level was observed in both cases (r = -0.49, P < .001) and controls (r = -0.34, P < .001). Apo[a] phenotype distributions were similar in cases and controls. However, in 17 phenotypes with three or more subjects per group, the difference of mean Lp[a] concentrations between cases and controls was 32 +/- 36 micrograms/mL (mean +/- SD). Thus, the higher Lp[a] levels in cases were not associated with a greater prevalence of small apo[a] polymorphs. Stepwise logistic regression analyses of known risk factors for coronary heart disease showed that plasma Lp[a] concentration was an independent predictor of case-control status, while Lp[a] phenotype was not, irrespective of the presence or absence of Lp[a] concentration in the model.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma lipid, lipoprotein cholesterol, and apoprotein distributions in selected US communities. The Atherosclerosis Risk in Communities (ARIC) Study

The distributions of plasma lipids, lipoproteins, and apoproteins of 14,524 female and male black and white participants 45 to 64 years old in the Atherosclerosis Risk in Communities (ARIC) Study are presented. All specimens were analyzed at a central laboratory. Mean total cholesterol levels increased with increasing age across all ages from 204 to 229 mg/dL (12%) in women and from 208 to 213 mg/dL (2%) in men. Triglyceride levels increased with age in women, remained stable in men, and were higher in whites than blacks. High-density lipoprotein (HDL) cholesterol levels were higher in black and white women (range, 57 to 59 mg/dL) compared with black men (49 to 52 mg/dL) or white men (42 to 43 mg/dL). Cholesterol associated with HDL was distributed in a relatively constant proportion between HDL3 (70% to 76%) and HDL2 (24% to 30%) for all race/sex groups. Low-density lipoprotein (LDL) cholesterol levels increased with age in black (14.7%) and white (17.1%) women and in black (4.4%) and white (3.7%) men; more than 50% of all participants had LDL cholesterol levels > 130 mg/dL. Apoprotein A-I and B levels followed the same trends as HDL cholesterol and LDL cholesterol levels, respectively. Lipoprotein(a) [Lp(a)] levels were twice as high in blacks as in whites, and women's Lp(a) levels were higher than men's Lp(a) levels for each race. Menopause was associated with elevated total cholesterol, LDL cholesterol, apoprotein B, and Lp(a) levels, and hormone replacement medication use in postmenopausal subjects was associated with higher HDL cholesterol, triglyceride, and apoprotein A-I levels and lower LDL cholesterol, apoprotein B, and Lp(a) levels.