Reduced intensity conditioning using intravenous busulfan, fludarabine and rabbit ATG for children with nonmalignant disorders and CML

The major problems with busulfan/cyclophosphamide (Bu/Cy)-containing conditioning regimens are acute toxicities and graft failure. To decrease acute toxicities, we have prospectively evaluated a reduced intensity conditioning (RIC) regimen using targeted dosing of i.v. busulfan, fludarabine, and rabbit ATG (Bu/Flu/rATG) in children with diagnoses that historically would have been conditioned with Bu/Cy regimens. Nineteen pediatric patients were enrolled in the study. The donors included HLA-matched and one antigen-mismatched unrelated volunteers (n = 11), unrelated cord blood (n = 1), and related donors (n = 7). Four patients developed graft failure, which occurred between 1 and 8.5 months post transplant. All four of them underwent a second transplantation and 3/4 are alive without evidence of disease. The mean follow-up of living patients is 29.5 +/- s.d. 11 months. Despite excellent 2-year post-transplant overall survival (89 +/- s.d.7%) and event-free survival (74 +/- s.d.10%), the study was closed prematurely due to high graft failure rate (21%). Receiving a transplant from a mismatched unrelated donor was identified as a risk factor for graft failure. The Bu/Flu/rATG RIC regimen was very well tolerated, resulted in excellent overall survival, and provided sustained engraftment in patients undergoing transplant from matched sibling and unrelated donors. However, it did not provide sustained engraftment in the majority of children with nonmalignancies undergoing mismatched unrelated donor transplants.

Expression of the coxsackievirus- and adenovirus receptor in gastrointestinal cancer correlates with tumor differentiation

Modified adenoviruses represent a new approach to treatment of gastrointestinal cancer. However, their uptake by cells in many cases requires the major receptor for adenoviruses, the coxsackievirus and adenovirus receptor (CAR). Thus, lack of CAR expression is a potential cause of intrinsic resistance of tumor cells to this type of treatment. To evaluate this, we studied the localization of CAR protein in normal and malignant gastrointestinal tissues. In normal tissues, CAR was concentrated at sites of cell-cell interaction, in particular at the apico-lateral cellular surface. Expression was particularly strong around bile and pancreatic ducts, which is in agreement with CAR's physiological function as a tight-junction protein. In GI malignancies (esophageal, pancreatic, colorectal and liver cancer), expression of the receptor varied substantially. Loss of CAR expression at cell-cell junction was evident in many samples. A significant correlation between CAR expression and histological grade was found, with moderately to poorly differentiated tumors most frequently demonstrating loss or reduction of CAR expression. These data indicate that CAR expression is frequently altered in gastrointestinal malignancy, potentially reducing the efficacy of adenovirus-based therapies.

A rapid method for identifying high-risk patients consenting for HIV testing: introducing The Edinburgh Risk Assessment Table for HIV testing

Lack of time for conducting standard HIV pre-test counselling has been reported as a barrier to HIV testing. Use of a risk assessment table will identify high-risk patients to whom pre-test counselling may be limited. The aim of this study is to investigate the performance of a Risk Assessment Table for HIV testing designed in the Department of Genitourinary (GU) Medicine, Edinburgh. A prospective study was carried out on patients attending the Department of GU Medicine, Edinburgh between June 30th 2002 and July 1st 2003, who consented to HIV testing. Patients with any risk factor had standard pre-and post-test counselling. Those without any risk factor were tested and provided with leaflets on HIV testing.A total of 3337 patients were tested in the study period and 727 (22%) had risk factor for HIV infection. Twenty-nine patients (0.9%) were HIV-infected. The Risk Assessment Table failed to identify two infected patients. Routine use of the Risk Assessment Table saves time of the medical staff by only providing pre-test counselling to high-risk patients.

Genital infection in male partners of women with chlamydial infection

The aim of the present study was to examine the prevalence of infection among male contacts of women with endocervical chlamydiae. The study population consisted of men who attended the Department of Genitourinary Medicine at Edinburgh Royal Infirmary as named contacts of women with endocervical chlamydiae. The diagnosis of Chlamydia trachomatis was based on a polymerase chain reaction. Of 632 male contacts of 404 infected women, 155 (24%) attended the clinic, and 147 had satisfactory tests for chlamydiae; 64 (44%) men had chlamydial infection. A greater proportion of symptomatic men (14/22) were infected compared with asymptomatic men (50/125) (P<0.02). Symptomatic men attended the department earlier (median 0.0 days) than asymptomatic male contacts (median 11 days) (P<0.05). A greater proportion of male contacts of women with one partner (105/254) attended the clinic than those of women with two or more partners (42/112). Better counselling policies for chlamydial infection are needed to ensure improved rate of diagnosis and treatment of male contacts.

Hepatitis B vaccination of men who have sex with men: experience with an accelerated course of vaccination in a genitourinary medicine clinic

An accelerated course of hepatitis B vaccination was offered to men who had sex with men attending a genitourinary medicine clinic. The uptake and completion rates of the vaccine between 1 November 2002 and 28 February 2004 were compared with data for 1994. The uptake of vaccine was significantly higher during the former audit period than the latter (310 [98%] of 315 versus 146 [74%]). There was, however, no significant difference in completion rates between the two audit periods: 220 (73%) of the 302 men who initiated the accelerated schedule, compared with 118 (81%) of the 146 men who completed the standard course in 1994. Innovative means of ensuring completion of vaccination are needed.

The outcome of oropharyngeal gonorrhoea treatment with different regimens

Little is known of the efficacy of different antibiotics for the treatment of oropharyngeal gonorrhoea in routine clinical practice. The aim of the study was to investigate the treatment outcome of oropharyngeal gonorrhoea with different antibiotics. Case-notes of culturally proven oropharyngeal gonorrhoea diagnosed between January 1998 and January 2003 were reviewed for the antibiotic of choice and the result of test-of-cure (TOC) seven and 14 days after treatment. Of 117 episodes of pharyngeal gonorrhoea, 77 episodes (66%) were followed up with one TOC and 25 (21%) had two TOC. Treatment failure was recorded in 10% (8/77) of episodes: the failure rate was 28% (4/14) in patients treated with amoxicillin 3 g/probenecid 1 g stat and 11% (4/35) in those treated with ciprofloxacin 500 mg stat. The failure rate in treating pharyngeal gonorrhoea supports the need for a pharyngeal TOC culture as part of routine follow-up for patients infected at this site. As only 66% of patients had a TOC culture, efforts should be made to increase the number of patients having a TOC.

The diversity of the opa gene in gonococcal isolates from men who have sex with men

OBJECTIVES

To use a molecular typing method (opa-typing) to characterise gonococcal isolates obtained from men who have sex with men (MSM) attending a genitourinary medicine (GUM) clinic in Edinburgh during 2001. To compare the results of opa-typing with A/S (auxotype/serovar) phenotyping, and with epidemiological information obtained by contact tracing.

METHODS

Isolates were opa-typed by a PCR-RFLP method where the restriction fragments resulting from digestion with three separate restriction enzymes were resolved by polyacrylamide gel electrophoresis. Isolates were considered to have the same opa-type if the band patterns were identical or if they differed by one band between the three digestions.

RESULTS

40 opa-types were detected from a collection of 73 gonococcal isolates from 61 patients. 26 opa-types were unique, being found in one individual each, 14 different opa-types were found in more than one patient. Opa-typing was found to have a discrimination index (DI) of 0.96, compared to a DI of 0.87 for A/S phenotyping, indicating that opa-typing is better at discriminating between unrelated isolates. Opa-typing confirmed three epidemiological links established by contact tracing, and uncovered a further 13 clusters of isolates.

CONCLUSIONS

Opa-typing is a more discriminative method than A/S phenotyping when determining relatedness in gonococcal isolates. The ability of opa-typing to identify sexual networks not disclosed by contact tracing and conventional phenotyping make it a useful method for studying the spread of gonorrhoea with the potential to contribute to the control of this infection.

Fludarabine, adriamycin and dexamethasone (FAD) in newly diagnosed advanced follicular lymphoma: a phase II study by the British National Lymphoma Investigation (BNLI)

The optimal first-line treatment for symptomatic patients with advanced stage follicular lymphoma remains unclear. Fludarabine-based combination regimens have been extensively used in relapsed disease and merit consideration as first-line therapy. We here report the results of a phase II study of FAD (fludarabine, adriamycin, dexamethasone) regimen in 30 patients with advanced stage follicular lymphoma requiring treatment. The response rate was in excess of 90% with 39% achieving a complete remission. The major toxicity was myelosuppression, but only 3% of cycles were associated with grade IV leucopenia. The high response rate has not translated into major improvements in failure-free survival and consideration must be given to alternative treatment modalities to consolidate the high rate of initial responses.

A significant proportion of HIV-infected patients admitted to hospital have immunosuppression as a result of failure of highly active antiretroviral therapy

OBJECTIVES

To investigate the immunological and virological features of patients on highly active antiretroviral therapy (HAART) admitted to a tertiary centre.

METHODS

A retrospective study was carried out on HIV-infected patients on HAART admitted to the Regional Infectious Disease Unit in Edinburgh between June 2002 and July 2003.

RESULTS

A total of 125 patients who had been on HAART for at least 6 months were admitted during the study period. The frequencies of hepatitis C virus (HCV) and hepatitis B virus (HBV) coinfection were 52% (78 of 150 patients) and 48% (72 of 150 patients), respectively (P>0.05 for comparison of frequencies of hepatitis B and C). Of patients who had been on HAART for at least 6 months, 50% (63 of 125 patients) were immuno-suppressed and had significantly higher bed-days 6 (3-12) compared with those with CD4>200 cells/microL (P<0.002). Amongst immuno-suppressed patients, 38% (24 of 63) had undetectable viral load after at least 6 months of therapy. Those patients were mostly (67%) intravenous drug users and had a significantly higher median age (43 years; range 38-47 years) than other patients (P<0.001).

CONCLUSIONS

Earlier start of HAART and addition of interleukin (IL)-2 to the treatment regimens of patients at risk of slow CD4 T-cell count recovery may reduce the duration of their subsequent hospital admissions.

The prevalence of rectal chlamydial infection amongst men who have sex with men attending the genitourinary medicine clinic in Edinburgh

Little is known about the prevalence of rectal chlamydial infection amongst men who have sex with men (MSM). Previous studies using culture methods reported this to be between 4-6%. The emergence of nucleic acid amplification tests has significantly increased the sensitivity and specificity for chlamydial detection, making it possible to estimate the prevalence of rectal infection more accurately. A prospective cross sectional study involving 443 MSM who were screened for sexually transmitted infections (STIs) between May 1999 and January 2002. Rectal swabs for chlamydiae were obtained in addition to specimens for routine STI screening. Rectal chlamydiae were detected by ligase chain reaction (LCR) utilizing the Abbott LCX Amplicor with confirmation by COBASE amplicor for the majority of cases. Those with rectal chlamydial infection were treated with azithromycin. The characteristics of men with rectal chlamydial infection were compared with those who were not infected at this site. Rectal chlamydia was detected in 32 (7.2%) of 443 patients. Those with rectal chlamydial infection were more likely to have rectal symptoms (12/32) or having a partner with confirmed chlamydial (2/32) or gonococcal (3/32) urethritis than those MSM without rectal chlamydial infection. They were also more likely to have a history of receptive anal sex (25/32) in the previous three months compared to those MSM without rectal chlamydial infection (263/411). The most common symptoms of patients with rectal chlamydial infection were pruritus ani and peri-anal pain. Eight (25%) of those with rectal chlamydial infection were known to be HIV seropositive. Rectal chlamydial infection is common amongst MSM and is effectively diagnosed by LCR. The test should be included in the routine STI screening offered to MSM.

Herpes Simplex Virus Type 1 Remains the Principal Cause of Initial Anogenital Herpes in Edinburgh, Scotland

GOAL

The goal of this study was to investigate the trends in the prevalence of anogenital herpes caused by herpes simplex virus (HSV) type-1 and HSV-2 among patients attending a sexually transmitted infections clinic.

METHODS

We conducted a retrospective study of virologically proven first-episode genital herpes diagnosed in the Department of Genitourinary Medicine in Edinburgh between 1989 and 2002.

RESULTS

First-episode anogenital herpes was associated with HSV-1 in 659 (62%) women and 294 (42%) men (P <0.0002). HSV-1 was recovered more often from women younger than 25 years than from older women (P <0.0005). For both HSV-1 and HSV-2 infections, the median ages of heterosexual men (26.0 and 28.0 years, respectively) were significantly higher than those of women (23.0 and 25.0 years, respectively)(P <0.05). The median age of men who have sex with men with HSV-1 (29.0 years) was significantly higher than that of heterosexual men (26.0 years)(P <0.01).

CONCLUSION

HSV-1 remains the most common cause of symptomatic first-episode anogenital herpes, especially among young women in our clinic population.

Evaluation of ligase chain reaction for the non-cultural detection of rectal and pharyngeal gonorrhoea in men who have sex with men

OBJECTIVES

To compare a nucleic acid amplification test (ligase chain reaction) with culture for detecting rectal and pharyngeal gonorrhoea in men who have sex with men (MSM).

METHODS

Duplicate rectal and throat swabs from MSM attending a genitourinary medicine clinic were collected for culture on modified New York City medium and detection of gonococcal nucleic acid by the Abbott ligase chain reaction (LCR) utilising probes based on opa 1 gene sequences. LCR positive culture negative specimens were tested by a second LCR utilising probes based on pilin gene sequences. Patients with rectal and/or pharyngeal cultures yielding Gram negative diplococci confirmed as Neisseria gonorrhoeae by biochemical and immunological methods were diagnosed with rectal and/or pharyngeal gonorrhoea. The criteria for diagnosing rectal and pharyngeal infection by LCR included a positive opa LCR with a positive culture from the same site or, in the case of a negative culture, a positive opa LCR and a positive pilin LCR.

RESULTS

Duplicate rectal samples were obtained from 227 MSM. The results of LCR and culture were concordant in 219 samples (96.5%). The prevalence of rectal gonorrhoea by LCR and culture was 7.0% (16/227) and 4.0% (9/227), respectively. Duplicate throat samples were obtained from 251 MSM. The results of LCR and culture were concordant in 230 (91.6%) cases. The prevalence of pharyngeal gonorrhoea by LCR and culture was 12.7% (32/251) and 6.0% (15/251), respectively. The specificity of LCR was 99.5% (210/211) for rectal and 98.2% (215/219) for pharyngeal specimens.

CONCLUSIONS

The high prevalence and asymptomatic nature of pharyngeal and rectal gonococcal infection suggests that routine screening for infection at these sites by a nucleic acid amplification test method such as LCR should be considered as part of the overall strategy to control gonorrhoea in MSM.

A cross sectional study of water quality from dental unit water lines in dental practices in the West of Scotland

OBJECTIVE

To determine the microbiological quality of water from dental units in a general practice setting and current practice for disinfection of units.

DESIGN

A cross-sectional study of the water quality from 40 dental units in 39 general practices and a questionnaire of the disinfection protocols used in those practices.

SETTING

NHS practices in primarydental care.

SUBJECTS

Thirty-nine general practices from the West of Scotland.

METHODS

Water samples were collected on two separate occasions from dental units and analysed for microbiological quality by the total viable count (TVC) method. Water specimens were collected from the triple syringe, high speed outlet, cup filler and surgery tap. Each participating practitioner was asked to complete a questionnaire. Results Microbial contamination was highest from the high speed outlet followed by the triple syringe and cup filler. On average, the TVC counts from the high speed water lines at 37 degrees C and for the high speed lines, triple syringe and cup filler at 22 degrees C were significantly higher than that from the control tap water specimens. The study included units from 11 different manufacturers with ages ranging from under one year to over eight years. The age of the dental unit analysed did not appear to influence the level of microbial contamination. Five of the practices surveyed used disinfectants to clean the dental units but these had no significant effect on the microbiological quality of the water. The majority of dental units (25 out of 40) were never flushed with water between patients. A number of different non-sterile irrigants were used for surgical procedures.

CONCLUSION

The microbiological quality of water from dental units in general dental practice is poor compared with that from drinking water sources. Suitable sterile irrigants should be used for surgical procedures in dental practice. Further work is required for pragmatic decontamination regimens of dental unit water lines in a general dental practice setting

Veno-occlusive disease of the liver in children with solid tumors undergoing autologous hematopoietic progenitor cell transplantation: a high incidence in patients with neuroblastoma

We retrospectively analyzed the incidence and risk factors for veno-occlusive disease (VOD) in 83 consecutive children with solid tumors, who underwent autologous blood or bone marrow (BM) transplantation at UCSF between 1992 and 2000. Forty-one patients were diagnosed with neuroblastoma and 42 had another solid tumor (Ewing's sarcoma, soft tissue sarcomas, germ cell tumors, etc). Patients with neuroblastoma were more likely than patients with other solid tumors (ST) to be < or =7 years of age, to have a decreased serum albumin level, and to have received abdominal radiation and surgery prior to transplant. Patients with neuroblastoma received a different conditioning regimen and a purged stem cell product. Twenty patients (24%) developed VOD. VOD was self-limited in 15 (75%) patients and severe in five (25%) patients. Univariate analysis identified the following risk factors for VOD: diagnosis of neuroblastoma (odds ratio 6.1, P < 0.01), abdominal radiation (odds ratio 4.1, P < 0.01), abdominal surgery (odds ratio 4.1, P < 0.01), and age < or =7 years of age (odds ratio 3.3, P = 0.02). Disease status at transplant, intensity of previous chemotherapy, conditioning regimen, progenitor cell source, ALT, AST, albumin level, renal function prior to transplant, or use of amphotericin, growth-factor or heparin during transplant, did not affect the incidence of VOD. On multivariate analysis, only the diagnosis of neuroblastoma remained significant (odds ratio 7.8, P = 0.03). Larger studies of patients with neuroblastoma are necessary in order to confirm our findings and better define the risk factors for VOD development in neuroblastoma patients.

A modified staging classification for cutaneous T-cell lymphoma

BACKGROUND

Despite refinements in the diagnosis of cutaneous T-cell lymphoma (CTCL), since 1979 there have been no changes to the staging of CTCL used to classify mycosis fungoides and Sézary syndrome.

OBJECTIVE

We reviewed the current staging of CTCL and examined the usefulness of a new staging scheme for mycosis fungoides and Sézary syndrome.

METHODS

We determined overall survival of 450 patients with mycosis fungoides and Sézary syndrome using the current and modified staging classifications.

RESULTS

There were no significant differences between survival of patients with stage IB (patches/plaques involving greater than 10% body surface area) and IIA (peripheral adenopathy) disease and of patients with stage IIB (tumor) and III (erythroderma) disease. There was a significant difference in survival between patients with extensive patch versus extensive plaque stage disease. Modification of the current classification by splitting T2 into patch versus plaque stage disease and incorporating tumors and erythroderma into stage III proved superior to the current scheme in predicting overall survival.

CONCLUSION

Modification of the current staging classification for CTCL yields subgroups useful in the prognostic assessment of CTCL.

Substance use and unsafe sex amongst homosexual men in Edinburgh

A self-reported behaviour survey using an anonymous critical incident based questionnaire was administered by trained interviewers in 1998. Five hundred and thirty-one homosexual and bisexual men were recruited from gay bars, clubs, cafes, a sauna and 'cruising ground' in central Edinburgh. The use of alcohol and recreational drugs and details of sexual activity over the preceding three months and at the last sexual encounter were recorded. Unsafe sex was defined as anal sex without the use of a condom with a partner of unknown or different HIV status. Safer sex was defined as all other types of sex, including anal sex with a condom and anal sex without a condom with a partner whose HIV status was known to be the same. Of the questionnaires completed, 506 were suitable for analysis; 29 men (6.1%) reported anal sex with a partner of unknown or different HIV status without a condom ('unsafe sex') during their last sexual encounter. A total of 53 men (10.5%) could recall an episode of unsafe sex within the last three months. Men who had used marijuana or inhaled nitrites ('poppers') less than two hours before sex, or whose sexual partners had done so, were more likely to have unsafe sex than those who had not. Although alcohol use was more likely before sex with casual partners, the use of alcohol less than 2 hours before sex was not associated with sex being unsafe.

Does timely assessment affect the anxiety associated with an abnormal mammogram result?

Anxiety following an abnormal mammogram result can be substantial. We examined whether the time to the first diagnostic test was associated with anxiety. We surveyed 449 women at 2 and 8 months after an abnormal mammogram result, and we reviewed their medical records. Twenty-six percent of women reported being very anxious about their abnormal mammogram result at the time of the two-month interview, and 22% reported persistent anxiety after 8 months. After adjustment, the number of days until the first diagnostic test was not associated with anxiety at the 2-month interview. By the second interview, women who received their first diagnostic test within the first week were significantly more anxious, as were women who did not receive their first test for at least 60 days after their results. Further work is needed to ascertain how to minimize the anxiety associated with the evaluation of an abnormal mammogram.

Serum prostate-specific antigen decline as a marker of clinical outcome in hormone-refractory prostate cancer patients: association with progression-free survival, pain end points, and survival

PURPOSE

Validated end points are lacking for clinical trials in hormone-refractory prostate cancer (HRPC). Controversy remains regarding the utility of a posttreatment decline of prostate-specific antigen (PSA). The purpose of this study was to determine whether posttreatment declines in PSA were associated with clinical measures of improvement in a randomized phase III trial of suramin plus hydrocortisone versus placebo plus hydrocortisone.

PATIENTS AND METHODS

A total of 460 HRPC patients were randomized to receive suramin plus hydrocortisone (n = 229) or placebo plus hydrocortisone (n = 231). All patients had symptomatic, metastatic HRPC requiring opioid analgesics. Clinical end points evaluated included overall survival, objective progression-free survival (OPFS), and time to pain progression (TTPP). An evaluation of overall survival, OPFS, and TTPP as a function of a PSA decline of > or = 50%, lasting at least 28 days, was undertaken by using a landmark analysis at 6, 9, and 12 weeks. A multivariate analysis of the impact of PSA decline was performed on these clinical end points.

RESULTS

A decline in PSA of > or = 50% lasting > or = 28 days was significantly associated with a prolonged median overall survival, OPFS, and TTPP, both in the entire group and the suramin plus hydrocortisone group at all three landmarks in both univariate and multivariate analysis.

CONCLUSION

In this prospective, randomized trial of suramin plus hydrocortisone versus placebo plus hydrocortisone, a posttherapy decline in PSA of > or = 50%, lasting 28 days, was associated with prolonged median overall survival, improved median progression-free survival, and median TTPP. This analysis suggests that a posttreatment decline in PSA may be a reasonable intermediate end point in HRPC trials and calls into question the clinical utility of preclinical assays evaluating the in vitro effect of given agents on PSA secretion.