Surveillance of Aspergillus galactomannan antigenemia for invasive aspergillosis by enzyme-linked immunosorbent assay in neutropenic patients treated for hematological malignancies

INTRODUCTION

The incidence of invasive fungal infections is increasing in patients with hematological malignancies. Invasive aspergillosis is one of the most frequently encountered infections with a high mortality rate. New diagnostic tests for invasive aspergillosis such as the detection of Aspergillus galactomannan antigen by a sandwich enzyme-linked immunosorbent assay (ELISA) have recently been described. The objective of this study was to evaluate this assay as a potential surrogate for invasive procedures used to diagnose IA.

MATERIALS AND METHODS

We analyzed the performance of a commercially available ELISA test which we routinely use for the surveillance of galactomannan antigenemia in patients with hematological malignancies experiencing chemotherapy-induced prolonged neutropenia (ANC < 500/mm(3) for more than 7 days). Serum samples were collected on a weekly basis. Test positivity was defined in accordance with the manufacturer's recommendations.

RESULTS

Over the 2 year study period, we analyzed 507 samples obtained during 193 neutropenic episodes from 135 patients. Ten, six and two patients were considered to have proven, probable or possible invasive aspergillosis, respectively, based on clinical, radiological or microbiological data. Forty-four positive (Index>1.5) and 26 'undetermined' (1.5 > Index > 1.0) test results were observed in 17 and ten patients respectively. All invasive aspergillosis cases had at least a positive or an undetermined test result. Only one positive and one undetermined result were found in two patients before the onset of clinical or radiological signs suggesting invasive aspergillosis. Sensitivity was 69% and specificity 96% if only positive results are considered; when 'undetermined' test results were combined with positive results, sensitivity attained 100% and specificity 92% suggesting that the cutoff value for positivity can be lowered from 1.5 to 1.0.

CONCLUSIONS

Although the ELISA test did not appear to play a role in the early diagnosis of invasive aspergillosis and in the anticipation of antifungal therapy in our experience, it clarifies the diagnosis of infection in probable or possible invasive aspergillosis especially when the cutoff value is lowered and is useful for monitoring patients receiving specific therapy.

Patterns of regional and distant metastasis in patients with conjunctival melanoma: experience at a cancer center over four decades

OBJECTIVE

The regional lymph nodes generally are believed to be the most common first site of metastasis for conjunctival malignant melanoma, but the pattern of nodal metastasis in this disease has not been well established. The goal of this study was to determine the frequency, location, and timing of regional lymph node metastasis in patients with conjunctival melanoma treated at one cancer center over four decades.

DESIGN

Retrospective case series.

PARTICIPANTS

Twenty-seven patients.

METHODS

The clinical records of 27 patients with conjunctival malignant melanoma were reviewed retrospectively.

MAIN OUTCOME MEASURES

The rates of local conjunctival recurrence, regional nodal metastasis, and distant metastasis were analyzed along with overall survival. The follow-up time ranged from 2.5 to 17 years (median, 6 years).

RESULTS

Eleven patients (41%) experienced clinical regional lymph node metastasis 1.5 to 6.0 years (mean, 3.2 years) after the initial diagnosis. The involved lymphatics were the preauricular (parotid) nodes in 8 patients (73%), the submandibular nodes in 1 patient (9%), and the deeper cervical nodes in 2 patients (18%). In seven patients (26%), distant metastasis developed without evidence of prior or concurrent regional nodal disease. Patients in whom distant metastasis developed without clinical evidence of regional nodal involvement were more likely to have had local conjunctival recurrence (P = 0.03) and a higher number of local recurrences (P = 0.05) compared with patients with regional lymph nodes as the site of first metastasis. The 5- and 10-year overall survival rates were 74% and 41%, respectively.

CONCLUSIONS

Regional lymph node metastasis occurred in a higher percentage of patients with conjunctival malignant melanoma than has been reported previously. Preauricular lymph nodes were most commonly involved. Distant metastasis without prior or concurrent lymph node involvement was not a rare event.

[Paratesticular rhabdomyosarcoma]

The authors report a case of embryonal paratesticular rhabdomyosarcoma in a 9-year-old child and discuss the treatment modalities in the light of data from the literature.

XV454, a novel nonpeptide small-molecule platelet GIIb/IIIa antagonist with comparable platelet alpha(IIb)beta3-binding kinetics to c7E3

XV454 demonstrated high potency (IC50 = 14-25 nM) in inhibiting human platelet aggregation induced by adenosine diphosphate (ADP, 10 microM), thrombin receptor agonist peptide (TRAP) (10 microM), or collagen (20 microg/ml). XV454 exhibited a high degree of selectivity for platelet alpha(IIb)beta3 in comparison with c7E3, which is a nonspecific antagonist for both alpha(IIb)beta3 and alpha(v)beta3. Both XV454 and c7E3 bind with high affinity to either activated (A) or unactivated (U) human, baboon, or canine platelets. XV454 binds with a relatively higher affinity [Kd = 0.5 nM (A), 0.6 nM (U)] as compared with c7E3 [Kd = 9.1 nM (A), 9.2 (U) nM]. XV454 demonstrated a tight association with human, baboon, and, to a lesser extent, with canine platelets (t(1/2) of dissociation = 110 +/- 6, 80 +/- 10, and 23 +/- 2 min, respectively). Both c7E3 and XV454 associate tightly with a slower dissociation rate with unactivated human platelets: t(1/2) of 42 and 116 min, respectively. In non-human primates, oral (0.1 mg/kg, p.o.) and intravenous (0.05 mg/kg, i.v. bolus administration of XV454 methyl ester pro-drug resulted a long-lasting maximal antiplatelet efficacy for < or = 72 h with significant but reversible prolongation of bleeding time and without effects on platelet count, clinical chemistry, or hemodynamic profile. In conclusion, XV454 represents a potent antiplatelet agent in inhibiting platelet aggregation along with a high affinity and relatively slow dissociation rate from human platelet GPIIb/IIIa receptors that allow a long-lasting antiplatelet efficacy after single i.v. or oral administration.

Oral antiplatelet efficacy of the platelet GPIIb/IIIa antagonist, DMP754 in non-human primates

Binding kinetic studies with XV459, the active form of DMP754, demonstrated comparable binding kinetics (Kd and Koff) with platelets obtained from either human or baboons which were different from that with platelets obtained from dogs. Therefore, the present study was undertaken to evaluate the antiplatelet efficacy of DMP754 following oral administration in baboons. The dose levels evaluated were 0.1 and 1.0 mg/kg, IV and 0.1, 0.3, 1.0, and 3.0 mg/kg, oral of DMP754. Oral doses of DMP754 resulted in dose- and time-related inhibition of platelet aggregation along with a modest effect on bleeding time prolongation. DMP754 at similar oral doses had 24 hours of antiplatelet effects in baboon as compared to 8-12 hours duration of antiplatelet efficacy in dogs. At maximal antiplatelet doses DMP754 demonstrated no significant effects on platelet count, clinical chemistry or hemodynamic profiles in baboons. These data suggest that DMP754 is a potent orally active antiplatelet agent with extended duration after once a day oral administration in non-human primate.

Salpêtrière Hospital experience with biochemotherapy in metastatic melanoma

PURPOSE

This article investigates the safety and efficacy of a simple cisplatin-based biochemotherapy regimen, containing single-agent cisplatin plus recombinant interleukin-2 (rIL-2) and recombinant interferon-alpha (rIFN-alpha), in the treatment of metastatic melanoma.

PATIENTS AND METHODS

Between December 1990 and April 1997, 129 patients were treated with cisplatin (100 mg/m2, day 0) plus continuous intravenous infusion rIL-2 (18 MIU/m2/day, days 3-6 and days 17-21) and subcutaneous rIFN-alpha (9 MIU three times per week) plus or minus tamoxifen (160 mg/day) on three different protocols. Tumor response, disease-free survival, and overall survival were evaluated for all evaluable patients (N = 127).

RESULTS

The overall response rate was 49%, and 10% of patients achieved a complete response. Responses were observed at all sites of metastases. In one case, a patient with a large cutaneous inguinal mass experienced a dramatic regression of that lesion within 1 month. The median disease-free survival was 5 months, and median overall survival was 11 months. Patients who responded had a significant survival advantage over nonresponders, and patients who achieved a complete response had a significant survival advantage over patients with a partial response. Toxicities were manageable and reversible upon discontinuation of therapy.

CONCLUSION

The response rates achieved with this simple biochemotherapy regimen are comparable to those for other cisplatin-based biochemotherapy regimens, which use more complex multiagent chemotherapy regimens. We found no added clinical benefit from the addition of tamoxifen to cisplatin.

Surgical anatomy of the pudendal nerve and its clinical implications

A study of the surgical anatomy of the pudendal nerve (PN) was performed in 13 female and 7 male cadavers. The knowledge of the precise anatomy and anomalies of this important nerve would help in better localization of the nerve and its roots and branches for neurostimulation or for pudendal canal decompression in pudendal canal syndrome. Two routes were used in the dissection: gluteal and perineal. The PN was identified and its course was followed from its roots to its termination. The PN was composed of three roots derived from the 2nd, 3rd, and 4th anterior sacral rami (S 2,3,4). The roots received a contribution from S 1 in five cadavers and from S 5 in one. The three roots formed two cords. The first root continued as the upper cord while the second and third root fused together producing the lower cord. The PN was formed by union of the two cords a short distance proximal to the sacrospinous ligament, and then crossed the back of the ligament. In no specimen did the nerve cross the ischial spine. The inferior rectal nerve arose from the PN in the pudendal canal in 18 cadavers. In two cases it came out proximal to the canal; this would spare the two subjects the anorectal manifestations of the pudendal canal syndrome. As the PN crossed the back of the sacrospinous ligament, it gave origin to a branch that supplied the levator ani muscle. This branch was only found in male cadavers and we call it "accessory rectal nerve"; the levator ani muscle in such cadavers was doubly innervated on its perineal aspect.

Estimating the risks and prevalence of hypertension in a suburban area of Beijing

Community-oriented primary care (COPC) provides a framework for identifying and addressing a defined community's health and health care needs. The research reported upon here is based on a community health survey in a new suburban neighborhood (Tayuan region) in the Haidian district of Beijing, conducted by the Beijing Medical University Department of Preventive Medicine and Health Care, to serve as a basis for planning health care services for the residents in that community. The analyses focus on the prevalence and predictors of hypertension among older adult residents (those 45 years of age and older). Based on logistic regression analyses, the odds ratios (in parentheses) confirm that individuals with a family history of cardiovascular disease were more likely to have been diagnosed as hypertensive (1.57). Hypertensives were also more likely to have uncontrolled systolic (3.85) or diastolic (4.75) blood pressure and associated behavioral and biologic risks, such as obesity (1.87) and renal damage (2.60). These risks were even greater among current or former smokers. These analyses will inform the design of community-oriented primary care interventions in that particular community in the People's Republic of China. They also signal important implications and highlight practical methods for assessing and targeting interventions in U.S. communities facing comparable, but unexamined, risks.

Fournier's gangrene of the scrotum following anorectal disorders

Five cases of Fournier's gangrene of the scrotum following anorectal disorders were encountered in a period of 2 years. Perirectal abscess was the most common associated underlying condition occurring in three patients. E. coli was the predominant organism cultured in all cases. A chronic debilitating condition was encountered in 3 patients. The mortality rate was 20%, but serious life threatening complications occurred in 4 of our patients. Error in diagnosis and delay in initiating medical treatment were the main causes of the high mortality rate associated with the disease. We advocate thorough rectal examination including proctoscopy in all cases of Fournier's gangrene, especially when no obvious source is apparent.

Health insurance and utilization of medical care for children with special health care needs

Based on analyses of the 1988 National Center for Health Statistics, National Health Interview Survey, Child Health Supplement, this study examines the insurance coverage and utilization of physicians, hospitals, and prescribed medicine among the 9.6 million U.S. children with special health care needs, defined as children who had one or more selected chronic conditions that caused them to experience pain, discomfort, or being upset often or all of the time in the last year, or who were limited in their major childhood activities (playing or going to school) as a result of these or other impairments or health problems. The findings confirmed that substantial variation in access to routine medical care exists among these children. Though health status is an important predictor of which children use services in general, poor, minority children who lived with their mother or someone other than their parents, or those without insurance or an identifiable regular medical provider were most likely to experience financial barriers to access or were less apt to seek care than other children with comparable needs. Access to routine medical care remains particularly problematic for these subsets of children with special health care needs.

A comparison of visual and automated methods of analyzing fetal heart rate tests

OBJECTIVES

Our objective in this study was to compare evaluation and clinical implications of visual versus computerized analysis of nonstress tests.

METHODS

Nonstress tests of 575 high-risk patients were analyzed visually and by a computer using the Oxford Sonicaid System 8000. Standard reactivity criteria were used for visual assessment; the System 8000 used an algorithm with the Dawes-Redman criteria.

RESULTS

Ninety-six percent of nonstress tests that met Dawes-Redman criteria were reactive by visual analysis; 93% of reactive nonstress tests met Dawes-Redman criteria. Only 30% of tests that failed Dawes-Redman criteria were nonreactive, whereas 44% of nonreactive tests failed to meet Dawes-Redman criteria. Sensitivities, specificities, and positive and negative predictive values were similar for both approaches. Additional tests or interventions would have occurred in 9% of the cases analyzed by System 8000 and in 49% of the cases analyzed visually.

CONCLUSIONS

Although these approaches rate nonstress tests differently, their diagnostic performances are similar. Automated fetal heart rate testing may become an acceptable alternative to conventional visual analysis.

Comparative lethality of methanol, ethanol and mixtures in female rats

The lethalities of pure methanol and pure ethanol were compared to two mixtures of ethanol/methanol with the following percentages (95/5% and 65/35% v/v). This study was conducted to simulate situations of human exposure to denaturated alcohol (by 5% methanol) or adulterated alcohol (by 35% methanol). Four groups of female adult virgin albino rats were treated with the four mixtures. A fifth group was used as a vehicle control. Graded oral doses were given to eight animals per dose. Lethality over 24 h was used as an end-point. The LD50 was calculated for each of the four treatments on a molar basis. A dose-response function for each mixture was plotted of percentage lethality vs. mmol kg-1 equivalent to the given ml kg-1 dose. Results showed a significantly different LD50 estimates (P less than 0.03) for the four mixtures. The order of lethal toxicity was as follows: 95/5% methanol/ethanol, pure methanol, pure ethanol then 65/35% methanol/ethanol. Slope comparisons indicated two pairs: 65/35% ethanol/methanol and pure ethanol yielding a steep slope, and 95/5% ethanol/methanol and pure methanol yielding a shallow slope. These data indicated that the acute lethality of ethanol/methanol mixtures is a complex unpredictable function. This toxicity presumably depends in a complicated way on the differences in the effective molecular weights of the two alcohols in each of the mixtures.

Ovine fetal urine contribution to amniotic and allantoic compartments

The ovine pregnancy has been extensively studied as a model for amniotic fluid metabolism potentially serving as a model for human oligohydramnios. However, it is recognized that the ovine pregnancy contains an allantoic fluid compartment not present in human pregnancies at term. Earlier studies in sheep suggested that the fetal urine contribution to allantoic fluid diminished at term, but without an explanation for maintenance of the significant volume of the allantoic cavity. In the present study we examined the relative fetal urine excretion of 3H-inulin into the allantoic and amniotic cavities in the near-term ovine pregnancy. Amniotic and allantoic volumes, as determined by technetium-labelled dextran and chromium-tagged erythrocyte dilution, were similar although there were significant differences in composition. The allantoic fluid compartment received an equal or greater proportion of fetal urine than did the amniotic fluid during the study period. These results indicate the importance of the allantoic fluid volume and composition in the study of ovine fluid dynamics.

Renal effects of ovine fetal arginine vasopressin secretion in response to maternal hyperosmolality

Acute increases in maternal plasma osmolality can increase amniotic fluid osmolality. Amniotic fluid is primarily derived from fetal urine production, and arginine vasopressin infusion can affect both fetal urine production and amniotic fluid osmolality. To assess the effect of short-term changes in maternal osmolality on fetal arginine vasopressin secretion and renal function, six ewes of 126 +/- 1 days' gestation received intravenous infusions of 20% mannitol (500 ml/10 min). In response to mannitol infusion, both maternal and fetal plasma osmolality increased significantly (302 +/- 3 to 326 +/- 2 and 300 +/- 1 to 309 +/- 2 mosm, respectively). Increased fetal plasma and urine arginine vasopressin concentrations were associated with significant increases in fetal urine osmolality (146 +/- 12 to 262 +/- 30 mosm) and sodium concentration (35.8 +/- 2.8 to 76.5 +/- 20 mu Eq/ml), but fetal urine production rates did not change (0.68 +/- 0.11 to 0.62 +/- 0.15 ml/min). These conclusions were reached: Acute increases in maternal osmolality can affect fetal arginine vasopressin secretion; arginine vasopressin-induced increases in fetal urine osmolality may contribute to increased amniotic fluid osmolality in response to maternal hyperosmolality.

Amniotic fluid proteins and lipids in normal and high-risk pregnancies and their relation to foetal outcome

Amniotic fluid total lipids (T.L.), lipid phosphorus (L.Ph.), phospholipids (Ph.L.), total cholesterol (T.Ch.), total proteins (T.P.) and inorganic phosphorus (I.Ph) were determined in a number of high risk pregnancies and compared to parallel data obtained for full term normal pregnancies. Amniotic fluid T.L., L.Ph., Ph.L. and T.Ch. were significantly decreased in diabetic and toxaemic cases. The decrement in L.Ph. and Ph.L. was more pronounced in diabetic and toxaemic mothers who delivered either still-births or neonates suffering from RDS or in cases of intrapartum death. The L.Ph. and Ph.L. were increased in case of toxaemic mothers who delivered living neonates with no RDS. In spite of the increase in T.Ch. in the same cases; the ratio of T.Ch to T.L. was constant except in cases with prolonged intrauterine foetal death where it was increased.