Asymptomatic cardiac ischemia pilot (ACIP)

This pilot study demonstrated that (1) patients with CAD and asymptomatic cardiac ischemia can be randomized to medical or revascularization strategies using a complex and demanding protocol, (2) asymptomatic cardiac ischemia can be suppressed in 40-50% of patients with clinically advanced coronary disease with relatively low to moderate doses of medication titrated over a period of 12 weeks (3). Revascularization was the most effective of the treatment strategies studied in reducing ischemia. Any type of therapy, whether it be drugs or revascularization requiring repetitive monitoring with ambulatory ECG or other methods to detect ischemia over a long period of time, will escalate the cost of quality medical care for our patients. Thus, the health care costs implications and treatment of asymptomatic ischemia are enormous. But the apparent cost advantage of treating only symptoms, that is ignoring all ischemia, could disappear if treatment of ischemia reduces the risk of adverse events. The clinical question to be addressed in the future is what is necessary to reduce the cardiac-event rates of death and myocardial infarction in this group of patients? Will more aggressive drug therapy eliminate more ischemia and will therapy directed at the elimination of all detectable ischemia improved clinical outcome better than therapy directed to control angina only? These questions can only be answered by a large clinical trial. The results of such a trial will provide the basis and rationale for safe and effective therapy for patients with coronary disease and evidence of cardiac ischemia. Whatever the answer to this important medical and scientific question is, it will have tremendous economic implications.(ABSTRACT TRUNCATED AT 250 WORDS)

Phase I trial of continuous infusion carboplatin and etoposide in children with refractory acute leukemia: a Pediatric Oncology Group study

PURPOSE

The purpose of this phase I study was to determine the toxicities and response to continuous infusion carboplatin in combination with a fixed dose of etoposide (VP-16) in children with refractory acute leukemia.

PATIENTS AND METHODS

From January 1989 to February 1992, 20 patients received 28 courses of treatment. Each course of treatment consisted of a 1-hour intravenous (IV) infusion of VP-16 100 mg/m2/d for 5 days, followed by a 23-hour IV infusion of carboplatin each day. The initial, total 5-day dose of carboplatin (1,000 mg/m2) was escalated by 250- to 375-mg increments to a final, total dose of 1,875 mg/m2 over 5 days.

RESULTS

Significant marrow suppression was observed in all patients, with prolonged marrow aplasia at the 1,875-mg/m2 dose level. Grade III diarrhea occurred in three patients; 10 patients experienced life-threatening infection and three had severe thrombocytopenic bleeding. Major marrow responses (two complete remissions and two partial remissions) occurred in four patients (20%).

CONCLUSION

In view of the apparent antileukemic efficacy and minimal extramedullary toxicity, carboplatin deserves further study in a phase II trial.

Effects of treatment strategies to suppress ischemia in patients with coronary artery disease: 12-week results of the Asymptomatic Cardiac Ischemia Pilot (ACIP) study

OBJECTIVES

The Asymptomatic Cardiac Ischemia Pilot (ACIP) study was initiated to determine the feasibility of a large trial in evaluating the effects of treatment of ischemia on outcome (mortality and myocardial infarction). The study was designed to examine the effects of medical treatment to control angina compared with treatment strategies guided by ambulatory electrocardiographic (ECG) ischemia or coronary anatomy.

BACKGROUND

Treatments to suppress ischemia (asymptomatic and symptomatic) have not been evaluated in a large prospective, randomized trial. Before undertaking such a trial, issues about recruitment and treatment strategies must be addressed.

METHODS

The 618 enrolled patients had coronary artery disease suitable for revascularization, ischemia on stress test and asymptomatic ischemia on ambulatory ECG. Patients were assigned randomly to one of three treatment strategies: 1) angina-guided medical strategy with titration of anti-ischemic medication to relieve angina (angina-guided strategy); 2) angina-guided plus ambulatory ECG ischemia-guided medical strategy with titration of anti-ischemic medication to eliminate both angina and ambulatory ECG ischemia (ischemia-guided strategy); and 3) revascularization by angioplasty or bypass surgery (revascularization strategy).

RESULTS

Ambulatory ECG ischemia was no longer present at the week 12 visit in 39% of patients assigned to the angina-guided strategy, 41% of patients assigned to the ischemia-guided strategy and 55% of patients assigned to the revascularization strategy. All strategies reduced the median number of episodes and total duration of ST segment depression during follow-up ambulatory ECG monitoring. Revascularization was the most effective strategy. Treadmill test results were concordant with those of ambulatory ECG monitoring. For most patients in the two medical strategies, angina was controlled with low to moderate doses of anti-ischemic medication, and the majority of patients (65%) in the revascularization strategy did not require medication for angina.

CONCLUSIONS

This pilot study demonstrated that cardiac ischemia can be suppressed in 40% to 55% of patients with either low or moderate doses of medication or revascularization and that a large trial is feasible.

Phase I study of oral etoposide in children with refractory solid tumors

PURPOSE

To determine the maximum-tolerated dose (MTD), dose-limiting toxicity, and plasma concentrations of orally administered etoposide (VP-16) in pediatric oncology patients.

PATIENTS AND METHODS

In a phase I study, 20 children with refractory solid tumors received oral VP-16 (the intravenous preparation diluted with sodium chloride) three times daily for 21 days. Daily dose levels studied were 50 mg/m2 (n = 5), 60 mg/m2 (n = 7), and 75 mg/m2 (n = 8). VP-16 concentrations were measured in blood samples collected on days 1, 7, 14, and 21.

RESULTS

Grade 3 to 4 thrombocytopenia and/or neutropenia causing interruption of the 21-day course or persisting for more than 7 days after the last day of chemotherapy was seen at all dose levels, but was not dose-limiting. One patient treated at the 50-mg/m2 daily dose died of sepsis. At the 75-mg/m2 dose level, diarrhea was dose-limiting. Estimated plasma VP-16 concentrations were greater than 1 micrograms/mL for median periods of 9.4, 15.4, and 13.5 hours per day at daily doses of 50, 60, and 75 mg/m2, respectively. Responses were observed in seven of 14 patients who received at least one additional course of etoposide after a rest period of 7 days. There was one complete and two objective responses. Four patients were considered to have stable disease.

CONCLUSION

The intravenous preparation of VP-16 administered orally appears to be well tolerated by heavily pretreated pediatric patients. On the three-times daily, 21-day schedule, a daily dose of 75 mg/m2 exceeds the MTD, with diarrhea as the dose-limiting toxicity. The recommended dose for oral etoposide is 60 mg/m2/d administered every 8 hours.

Photoaffinity labeling for evaluation of uridinyl analogs as specific inhibitors of rat liver microsomal UDP-glucuronosyltransferases

The UDP-glucuronosyltransferases (UGT) involved in glucuronidation of endogenous and exogenous toxic compounds transfer the glucuronic acid residue from UDP-glucuronic acid (UDP-GlcUA), to various acceptor groups. A series of compounds that contain N-acyl phenylaminoalcohol derivatives linked to uridine or isopropylideneuridine were tested as UGT inhibitors. The potency of these inhibitors was determined by studying their effect on the photoaffinity labeling of rat liver microsomal UGTs by two photoaffinity probes, [beta-32P]5-azido-UDP-glucuronic acid (5N3UDP-GlcUA) and [beta-32P]5-azido-UDP-glucose (5N3UDP-Glc) and on the enzymatic formation of the two glucuronide conjugates (3-O- and carboxyl-specific) of lithocholic acid. All but one of the compounds tested proved to have an inhibitory effect on UGTs, both in the photoaffinity labeling system and in the enzymatic glucuronidation assay. In the photoaffinity labeling system, the inhibitors containing the isopropylidene moiety were less effective than their unprotected derivatives; however, the protected forms were, with one exception, more potent inhibitors of enzymatic activity. The photoaffinity labeling of UGTs with [beta-32P]5N3UDP-Glc was more susceptible to inhibition by all derivatives than that with [beta-32P]5N3UDP-GlcUA. The effect of one inhibitor, PP50B, on the two enzymatic activities involved in LA glucuronidation was extensively tested. A double-reciprocal plot suggested a competitive inhibition for UDP-GlcUA with an apparent Ki of 35 microM for LA 3-O-glucuronide formation and 94 microM for the carboxyl-linked glucuronide of the same substrate.

Neurofibromatosis type I and malignancy: review of 32 pediatric cases treated at a single institution

Thirty-two cases of neurofibromatosis Type I (NF1) were identified among 6,678 pediatric cancer patients treated at St. Jude Children's Research Hospital over a 29-year period. A total of 35 malignant neoplasms have been diagnosed in these patients. Two of three patients with second malignant neoplasms had colon cancer at the primary or second tumor. Of particular interest are two cases in which both NF1 and malignant peripheral nerve sheath tumors were present in multiple successive generations: a patient with colon cancer and non-Hodgkin lymphoma who has a constitutional abnormality of the p53 gene, and a patient with acute lymphoblastic leukemia with the Philadelphia chromosome and other cytogenetic abnormalities, including the t(8;14). Outcome of patients in the largest subgroup, that of malignant peripheral nerve sheath tumors, was favorable only for those patients having resectable extremity lesions. In contrast, all patients with central nervous system tumors are surviving. These cases reflect the molecular and cytogenetic abnormalities that can be present in NF1 and the variety of tumors that may result in these patients.

A 60 kDa polypeptide of skeletal-muscle sarcoplasmic reticulum is a calmodulin-dependent protein kinase that associates with and phosphorylates several membrane proteins

Activation of a calmodulin (CaM)-dependent protein kinase associated with rabbit skeletal-muscle sarcoplasmic reticulum (SR) results in the phosphorylation of polypeptides of 450, 360, 165, 105, 89, 60, 34 and 20 kDa. Radioligand-binding studies indicated that a membrane-bound 60 kDa polypeptide contained both CaM- and ATP-binding domains. Under renaturing conditions on nitrocellulose blots, the 60 kDa polypeptide of the membrane exhibited CaM-dependent autophosphorylation activity, suggesting that it was the CaM-dependent protein kinase of SR. Ca2+/CaM-independent autophosphorylation of polypeptides of 62 and 45 kDa was found to occur in the light SR, whereas the Ca2+/CaM-dependent autophosphorylation activity was enriched in the heavy SR. Both these kinase activities were absent from transverse tubules, although these membranes were enriched in CaM-binding polypeptides of 160, 100 and 80 kDa. In the absence of Ca2+, CaM bound to a 33 kDa polypeptide of the membrane. The purified ryanodine receptor was not phosphorylated by the purified CaM kinase, although it was a substrate for protein kinase C. Affinity-purified antibodies to brain CaM kinase II cross-reacted with the 60 kDa polypeptide in Western blots and immunoprecipitated the 60 kDa polypeptide, along with the 360, 105, 89, 34 and 20 kDa phosphoproteins, from Nonidet-P-40-solubilized SR membranes. Antibodies raised against the 60 kDa kinase polypeptide did not cross-react with the other phosphoproteins, suggesting that these polypeptides were distinct and unrelated. Subcellular distribution of the 60 kDa kinase indicated the specific association of the polypeptide with the junctional-face membrane of SR. The CaM-dependent incorporation of 32P into various membrane proteins was inhibited by the CaM kinase II fragment (290-309), with an IC50 value of 2 nM for the inhibition of incorporation into the 60 kDa kinase polypeptide. Recent studies [Wang and Best (1992) Nature (London) 359, 739-741] have shown that a CaM kinase activity intrinsic to the membrane can inactivate the Ca(2+)-release channel of skeletal muscle SR. Since our results demonstrate that the 60 kDa polypeptide of SR is a CaM-dependent protein kinase, we suggest that this kinase, through its associations, may be responsible for gating the Ca(2+)-release channel.

Evaluation of CHIP (iproplatin) in recurrent pediatric malignant solid tumors. A phase II study (Pediatric Oncology Group)

CHIP (325 mg/M2), a second generation cisplatin derivative, was administered intravenously every 3 weeks to 85 pediatric patients with recurrent sarcomas (19), osteosarcomas (20), neuroblastoma (23), germ cell tumors (10), and other malignant tumors (7). Thirty-eight of them had been previously exposed to cisplatin. Partial remissions were only observed in 3 of 23 (13% SE = 7%) patients having neuroblastoma. Severe thrombocytopenia (65%) and neutropenia (35%) were the dose limiting factors.

Radiological features during and following treatment of spinal tuberculosis

A retrospective study was performed in order to document the sequence and time scale of radiological changes occurring during the healing of spinal tuberculosis. 28 episodes occurred in 26 patients, of whom only two were Caucasian. All demonstrated good response to conventional chemotherapy. Soft-tissue masses increased in size for up to 1.5 months and took about 12 months to resolve. Bone destruction was seen in all cases and progressed in 70% of patients, whilst on treatment. There was loss of vertebral body height in 79%, which progressed for up to 14 months; any recovery of height was a very late feature. Sclerosis was seen at presentation in 52% and developed in most of the remaining patients within 5 months of instigating treatment. It progressed for up to 14 months and took, on average, 31 months to return to normal. Reduction in disc height was commonly seen and the vertebrae fused in three-quarters of those affected, the time of onset of fusion being very variable. To manage patients with spinal tuberculosis, an appreciation of the variability of radiological changes that can occur during treatment is necessary.

Leisure activities of adolescent school students: predictors of participation and interest

Frequency of participation and levels of interest in more than 60 leisure pursuits were measured via a questionnaire administered to 1248 adolescent high school students. The relationship between participation and levels of interest was measured by correlation as well as by asking the students to nominate up to three activities they would like to participate in but cannot and to indicate the reason for their non-participation. Factor analyses reduced the Participation and Interest items to six factors each. Multiple regressions were then conducted on the derived factor-score variables. Sex was the major predictor of participation in sports and vocational activities and of interest in sporting and gregarious activities. Age, school location, ethnicity and SES were lesser predictors for groups of activities such as the social and outdoor pursuits. The results are discussed in terms of the theoretical and practical implications of the relationship between participation and interest as well as the prediction of participation and interest levels by developmental and social factors.

Local-regional non-rhabdomyosarcomatous soft tissue sarcomas of the head and neck

Between 1962 and 1987, 112 consecutive patients were treated at St. Jude Children's Research Hospital for soft tissue sarcomas of the head and neck region; 18 of these children (16%) had histologic subtypes other than rhabdomyosarcoma. We evaluated the impact of surgery, postoperative chemotherapy, and irradiation on local control and survival in these cases. Three patients who had complete resection of tumors and received no further treatment are alive without disease at 36, 42, and 162 months. Local control was achieved in 1 of 2 patients with microscopic residual tumor and 4 of 9 patients with gross residual tumor who were treated with irradiation (2500-5040 cGy). Chemotherapy was the only postoperative treatment in three patients; only one achieved lasting local control. One patient was treated with irradiation only; his primary site showed no tumor cells at autopsy following an automobile accident. Overall, local control was achieved in 50% of patients; the disease-free survival rate at 3 years was 44%. The prognosis for patients with nonresectable tumors remains unsatisfactory because of the difficulty in securing local control. A revised therapeutic approach to these patients is presented.

Young children understanding that looking leads to knowing (so long as they are looking into a single barrel)

3 experiments were conducted to investigate the claim made by Wimmer, Hogrefe, and Perner that 3-4-year-old children do not understand that people gain knowledge about something by looking at it. The first experiment involved a simple forced-choice procedure in which children had to judge which of 2 assistants knew what was inside a box when one of the assistants had looked inside and the other had lifted it up. In this experiment, the children did realize that the assistant who had looked in the box knew its contents. The second experiment followed the Wimmer et al. procedure, but with a simpler question form. The children were just asked to state whether someone knew what was in the box. Again, the children were able to work out that a person who had looked in a box knew what was inside it. In the third experiment, a direct comparison was made between the simpler question and the more complex, double-barreled question asked by Wimmer et al. The children found the more complex question considerably harder. The results of these experiments suggest that, in contrast to the claims made by Wimmer et al., 3- and 4-year-old children do understand that looking leads to knowing, and that their difficulty in the Wimmer et al. study was mainly with the form of the question that they were asked.

Comparison of parent and teacher ratings of adaptive behavior of children with mental retardation

The Adaptive Behavior Scale-School Edition was administered to 22 parents and 22 teachers, using the third party assessment method to obtain ratings of the adaptive behavior of children with mental retardation. No significant differences in parents' and teachers' ratings for Personal Self-Sufficiency, Community Self-Sufficiency, and Personal-Social Responsibility were found. Teachers and parents also did not differ significantly in ratings of the importance of the behaviors subsumed by these factors. Difficulty in rating some items reflected differences in the accessibility of these behaviors for teachers and parents. Results suggest that group differences may not exist between parents' and teachers' ratings once the method of administration and familiarity with the instrument are controlled. Occasionally, however, a parent's rating may differ from a teacher's sufficiently to lead to a different classification.

A model legal-financial education workshop for families caring for neurologically impaired elders

A program is described through which families become acquainted with the issues, legal terminology, and resources for planning to provide and finance care to neurologically impaired elders. A survey of 68 participating families indicated over 90% had taken one or more planning actions following the workshop, including developing a specific plan for providing and financing services and developing a power-of-attorney for decision-making. Implications for other programs are discussed.

Thrombolysis in Myocardial Infarction (TIMI) Trial--phase I: hemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase

Two hundred ninety patients with acute myocardial infarction were treated according to random assignment with an intravenous infusion of either 80 mg of recombinant tissue plasminogen activator (rt-PA) over 3 h or 1.5 million units of streptokinase over 1 h. Patients received an intravenous bolus of heparin (5,000 U [USP]) before pretreatment coronary angiography and a continuous infusion (1,000 U/h) starting 3 h later. The frequency of major and minor hemorrhagic events (33% rt-PA, 31% streptokinase) and associated transfusions (22% rt-PA, 20% streptokinase) were comparable in both groups. More than 70% of bleeding episodes in each group occurred at catheterization or vascular puncture sites. Precipitable fibrinogen levels, measured in plasma samples collected in the presence of a protease inhibitor (aprotinin), declined in rt-PA and streptokinase groups by averages of 26 and 57% at 3 h and by 33 and 58% at 5 h, respectively (rt-PA versus streptokinase, p less than 0.001). At 5 h the plasma plasminogen declined by 57% (rt-PA) and 82% (streptokinase) (p less than 0.001); plasma fibrin(ogen) degradation products were higher in streptokinase-treated patients (244 +/- 12 micrograms/ml, mean +/- SE) than in rt-PA-treated patients (97 +/- 9 micrograms/ml, p less than 0.001). At 27 h, plasma fibrinogen and plasminogen levels were lower and fibrin(ogen) degradation products higher than pretreatment levels in both groups. The frequency of hemorrhagic events was higher in patients with greater changes in plasma factors at 5 h; within treatment groups the levels of fibrin(ogen) degradation products correlated with bleeding complications (p less than 0.005). Thus, in the doses administered, rt-PA induces systemic fibrinogenolysis that is substantially less intense than that induced by streptokinase. The high frequency of bleeding encountered is related to the protocol used, including vigorous anticoagulation, arterial punctures and thrombolytic therapy. These findings emphasize the need for avoidance of invasive procedures and for meticulous care in the selection and management of patients subjected to thrombolytic therapy.

Factors Affecting the Perceived Confidence of Extension Home Economists to be Community Health Promoters

Change agent activity is critical to how rapidly innovations in health such as exercise, diet modification, and cancer screening get diffused in populations. Because many rural areas lack health educators, and needs in rural areas tend to be more acute because of poverty, lower levels of education, and lack of access to health care services, diffusion is often slower and more uneven. A mail survey of 110 extension home economists (EHEs) in Virginia (response rate = 89%) found considerable interest among this group in undertaking expanded professional roles as community health promoters. In a multiple regression analysis, EHE exercise and weight control practices were predictive of their confidence in initiating a variety of professional activities related to exercise (p < .01) and weight control (p < .05), but the same relationships were not observed with other health practices. Perceived importance in helping clients following the health practices above was the variable in the regression model most highly predictive of expressed confidence in undertaking a range of health promotion activities. Several extension home economists expressed reluctance to become involved with smoking cessation activities because tobacco is a major cash crop in their counties and their organization provides technical assistance to tobacco growers there.

Participation and interest in leisure activities by adolescent schoolchildren

Knowledge of the leisure activities and pursuits of adolescents is important as it can provide a greater understanding of the social world of the adolescent. Further, it is necessary not only to know what adolescents actually do in their leisure time, but what they are interested in doing. In this study, the relationship between levels of participation and levels of interest in leisure activities was investigated via analysis of a comprehensive 77 item questionnaire administered to 247 adolescents. Factor analytic techniques were used to summarize the data, enabling comparisons to be made between boys and girls. Adolescents were found to engage in and be interested in activities characterised by their sex stereotyped nature, although in general none of the popular pursuits was either physically or mentally demanding. There was a high correlation between participation and interest, with adolescents participating in activities that interested them. The implications of these findings are discussed.

Nocturnal cough in asthma

The timing of nocturnal cough and its association with change in ambient temperature was documented in 11 asthmatic children, median age 5.1 years, while they were receiving continuous prophylaxis. Studies were performed in their homes on three nights. A voice activated system with electronic time signal recorded coughing. Ambient temperature was recorded every five minutes throughout the night on a Grant Squirrel data logger. Ten children coughed on 27 nights with a median of six bouts of coughing a night (range 0-272). The cough rate in the two hours after going to bed was significantly higher than the cough rate in the middle of the night (2-4 am or 4-6 am). Peak coughing times were 7-9 pm and 6-8 am. The room temperature was lowest between 5 and 7 am. There were no significant differences between cough rates during periods of rapid temperature change (more than 1 degree C an hour). The timing of nocturnal cough observed in this study differed from the known basophase of circadian cycles described for adults and children.

The impact of diabetes education and peer support upon weight and glycemic control of elderly persons with noninsulin dependent diabetes mellitus (NIDDM)

We assessed diabetes education and peer support interventions as facilitators of weight loss and glycemic control in a community sample of 79 elderly persons with noninsulin-dependent diabetes mellitus (NIDDM). Different groups received: education only, education and peer support, and no treatment. Peer support was higher in groups where it was actively facilitated. Weight loss and reduction in level of glycemic control occurred within groups receiving both diabetes education and peer support.