Relapse of acute lymphoblastic leukemia in pregnancy: survival following chemoirradiation and autologous transfer of interleukin-2-activated stem cells

Four cases of relapse of acute lymphoblastic leukemia (ALL) in pregnancy have been reported previously. During the past 2 decades, ALL has become curable in a majority of children, many of whom have entered their reproductive years. Thus, additional occurrences of relapsing ALL during pregnancy can be anticipated. We present the fifth case in the English-language medical literature of recurrent ALL in pregnancy. A 20-year-old woman with ALL experienced a relapse during the third trimester of her first pregnancy. Reinduction therapy was started with vincristine and prednisone and the baby was delivered 3 weeks later. Umbilical cord blood was collected and stored. The patient then received intensive chemotherapy with whole body radiotherapy and autologous peripheral blood stem cell rescue. The ALL has been in second remission for 22 months. Our patient is the only current survivor of a relapse of ALL during pregnancy. In addition, the collection of umbilical cord blood from a pregnant woman with leukemia has not been reported previously.

Assessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy

INTRODUCTION

A provider-based vaccination strategy that has strong supportive evidence of efficacy at raising immunization coverage level is known as Assessment, Feedback, Incentives, and Exchange. The Maine Immunization Program, and the Maine Chapter of the American Academy of Pediatrics collaborated on the implementation and evaluation of this strategy among private providers.

METHODS

Between November 1994 and June 1996, the Maine Immunization Program conducted baseline immunization assessments of all private practices administering childhood vaccines to children 24 to 35 months of age. Coverage level assessments were conducted using the Clinic Assessment Software Application. Follow-up assessments were among the largest practices, delivering 80% of all vaccines.

RESULTS

Of the 231 practices, 58 were pediatric and 149 were family practices. The median up-to-date vaccination coverages among all providers for 3 doses of diphtheria-tetanus-pertussis vaccine and 2 doses of oral polio vaccine, and 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at age 12 and 24 months were 90% and 78%, respectively, and did not vary by number of providers in a practice or by specialty. Urban practices had higher coverage than rural practices at 12 months (92% vs 88%). The median up-to-date coverage for 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at 24 months of age improved significantly among those practices assessed 1 year later (from 78% at baseline to 87% at the second assessment). On average, the assessments required 21/2 person-days of effort.

CONCLUSIONS

We document the feasibility and impact of a public/private partnership to improve immunization delivery on a statewide basis.

IMPLICATIONS

Other states should consider using public/private partnerships to conduct private practice assessments. More cost-effective methods of assessing immunization coverage levels in private practices are needed.

Analysis of chromosome 6 markers in eight Utah schizophrenia pedigrees

Eight multiplex Utah schizophrenia pedigrees were screened for linkage by applying a non-parametric linkage program, GENEHUNTER, using 30 chromosome 6 DNA markers. The overall maximum NPL score of the combined pedigrees was 1.50 (P = 0.079) at marker D6s281, located near the q terminus. The highest overall maximum NPL score for an individual pedigree was 2.81 (P = 0.043). In the chromosome 6p region, where numerous positive findings have been reported, we obtained no positive results.

Evidence for a chromosome 2p13-14 schizophrenia susceptibility locus in families from Palau, Micronesia

A large multiplex schizophrenia pedigree ascertained from the Micronesian nation of Palau was genotyped with 406 microsatellite DNA markers evenly distributed throughout the genome. Assuming autosomal dominant inheritance, the highest genome-wide lod scores were found for DNA loci mapping to 2p13-14; the maximum lod score was 2.17 (theta = 0.05) at D2S441. A nonparametric APM analysis was also suggestive at D2S441 (APM score = 2.96, P = 0.011). Of the 14 affected cases in this extended family, eight share a large haplotype in this region spanning approximately 11 cM. When 16 other families containing 65 schizophrenic cases were typed in a follow-up study of this region, the maximum lod score remained positive (maximum at D2S441 1.69, theta = 0.20). APM results also remained positive at D2S441 for all 17 families (APM score = 4.87, P = 0.0006). The linkage and haplotype sharing results provide suggestive evidence for a 2p locus predisposing to schizophrenia in a subset of families in the Palauan population.

Immunization coalitions that work: training for public health professionals

Coalition development is a major strategy to increase immunization rates. However, if local and state coalitions are to succeed, their staffs need training and technical assistance in coalition development, community planning, and program implementation. The National Coalition Training Institute trains key health agency staff in 87 state, territorial, and urban sites to perform needs assessments, use data to guide planning, plan comprehensive strategies, and evaluate their coalitions. The curriculum is based on training needs that are identified by a national survey of immunization coalitions, effective approaches, and participant evaluation. According to evaluations conducted during its first year, the National Coalition Training Institute is meeting the needs of participants.

Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis

PURPOSE

There is a lack of consensus regarding indications and long-term efficacy of the many surgical techniques for treating stress incontinence. Historically pubovaginal sling has been reserved for cases of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and retropubic suspensions have been used mainly for sphincteric incontinence unassociated with intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for all types of stress incontinence.

MATERIALS AND METHODS

A total of 251 consecutive women with all types of stress incontinence who underwent pubovaginal fascial sling by a single surgeon were retrospectively and prospectively reviewed. Patients were evaluated preoperatively with history, physical examination, standardized symptom questionnaire, voiding diary, pad test, uroflow, post-void residual urine, video urodynamics and cystoscopy. Postoperatively women with at least 1-year followup were assessed by an independent third party (J. R.) who had no prior knowledge of them, and who recorded the parameters of the questionnaire, examination with a full bladder, voiding diary, pad test, uroflow and post-void residual urine.

RESULTS

Overall stress incontinence was cured or improved in 92% of the patients with at least 1-year followup (median 3.1 years, range 1 to 15). The majority of patients with postoperative incontinence had de novo (3%) or persistent (23%) urge incontinence. Permanent urinary retention developed in 4 patients (2%).

CONCLUSIONS

Fascial pubovaginal sling is an effective treatment for all types of stress incontinence with acceptable long-term efficacy.

Intussusception in an infant with acute lymphoblastic leukemia: a case report and review of the literature

PURPOSE

An ileocecal intussusception developed in a 7-month-old infant with acute lymphoblastic leukemia (ALL) during induction therapy. Gastrointestinal complications, especially intussusception, are rare in children with ALL.

PATIENT AND METHODS

The history of a 7-month-old white boy with ALL in whom an ileocecal intussusception developed 1 week into induction chemotherapy was reviewed. In addition, a literature search was performed to determine the prevalence of this complication in children with acute leukemia.

RESULTS

On day 4 of induction chemotherapy for B-lineage ALL, the infant developed abdominal distension with hypoactive bowel sounds. After a barium enema and abdominal computed tomography scan, the symptoms were determined to be caused by an ileocecal intussusception. Chemotherapy was resumed 1 week after immediate surgical intervention (reduction of intussusception and resection of the "leading edge") with an uneventful post-operative recovery. Histopathologic examination of the resected edge revealed an intact mucosa with areas of necrosis in the submucosa. This was associated with a dense lymphoid infiltrate composed of mature lymphocytes and leukemic cells, edema, and focal necrosis. Despite a 1-week delay in chemotherapy, a complete remission was documented at day 32.

DISCUSSION

The prevalence of intussusception in children with ALL and its possible etiology are discussed. The pathologic changes, clinical manifestations, and treatment outcome are briefly mentioned.

Posttransplant lymphoproliferative disorder in pediatric bone marrow transplant recipients: disseminated disease of donor origin demonstrated by fluorescence in situ hybridization

BACKGROUND

Posttransplant lymphoproliferative disorders in bone marrow transplantation are typically rapidly progressive and fatal B-cell lymphoid proliferations associated with Epstein-Barr virus, and are mostly of donor origin. We report three pediatric bone marrow transplant cases in which posttransplant lymphoproliferative disorder was diagnosed at postmortem examination. Epstein-Barr virus in these cases was identified by a combined in situ hybridization-immunoperoxidase technique and donor origin was identified by fluorescence in situ hybridization.

METHODS

Tissues obtained from postmortem examination were evaluated by light microscopy, immunohistochemistry, combined in situ hybridization-immunoperoxidase technique with Epstein-Barr virus-encoded RNA probe, and fluorescence in situ hybridization with X and Y centromeric probes.

RESULTS

Three pediatric patients underwent sex-mismatched, T-cell-depleted bone marrow transplants complicated by graft versus host disease, rapidly progressive multiple organ failure, and postmortem diagnosis of posttransplant lymphoproliferative disorder. Histologic examination and immunohistochemistry studies demonstrated immunoblastic lymphoma (one case) or polymorphic B-cell lymphoma (two cases). In all cases, Epstein-Barr virus-encoded RNA was detected by a combined in situ hybridization-immunoperoxidase technique. Fluorescence in situ hybridization for X and Y chromosomes in paraffin sections demonstrated donor origin in two cases (one case was indeterminate).

CONCLUSION

Fluorescence in situ hybridization was used to prove donor derivation of Epstein-Barr virus-associated posttransplant lymphoproliferative disorders in pediatric bone marrow transplant recipients. Many features of posttransplant lymphoproliferative disorders in pediatric bone marrow transplant recipients are very similar to adult cases, although a higher proportion of children appear to be diagnosed postmortem and have a fatal outcome.

Quality assurance in managed vision benefits

Quality assurance is an important responsibility of those who purchase managed vision care benefits. In conducting a quality assurance program, it is important to respect patient confidentiality and the practitioner's right to exercise professional discretion. An effective program will not only accomplish its main objective of attaining high-quality care, but it can also enhance member satisfaction and improve provider relations.

The London Academic Training Scheme: learning research methods through teaching

BACKGROUND

The London Academic Training Scheme (LATS) provides a 1-year training programme in research methods and teaching for GPs who have recently finished vocational training. This paper describes an adult educational approach to learning about research methods through teaching as part of the LATS trainees' weekly academic programme.

OBJECTIVE

We aimed to provide and evaluate a course exploring research methodologies used in primary care by a three-step approach to learning, with trainees taking the main role as teachers.

METHOD

Trainees on the LATS programme met for one afternoon each week for one term. During alternate sessions a pair of trainees would deliver a whole afternoon's seminar on one aspect of primary care research methodology. The teaching of each session was evaluated by the whole group, by academic supervisors and by experts.

RESULTS

Sessions were scored by participants for content, style of presentation, educational value and enjoyment on a seven-point rating scale where 1 = no value, 4 = neutral and 7 = very valuable. All sessions scored above 4 and usually above 5 for each aspect. Open comments collected showed that trainees greatly appreciated this self-directed approach to learning and teaching.

CONCLUSION

The active involvement of learners as teachers is a practical and rewarding means of using adult educational principles in providing an academic programme.

CINCH: an urban coalition for empowerment and action. Consortium for the Immunization of Norfolk's Children

CINCH (Consortium for the Immunization of Norfolk's Children) is an urban coalition that was developed in 1993 to improve childhood immunization rates in Norfolk, Virginia. CINCH involves diverse citizens and institutions in effective community-based assessment, planning, and action. A needs assessment from 1993 found that only 49% of Norfolk 2-year-olds were adequately immunized. Using this data, CINCH developed a plan focused on education and communication, support for at-risk families, increased access to immunizations, and improved immunization delivery. After federal funding ended in 1995, members voted to expand the scope of the coalition to address additional child health needs and to broaden the membership. CINCH is a model for a sustainable city-citizen learning environment that intervenes to "help families help themselves to better health." The coalition is presented as an organization that focuses on community empowerment and development. The stages of coalition development and implications for coalition implementation in other sites are discussed.

Effectiveness of pediatric practice consultation on missed opportunities for immunization

OBJECTIVE

To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines.

DESIGN

The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed.

RESULTS

The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions.

CONCLUSIONS

There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities.

A population-based study of access to immunization among urban Virginia children served by public, private, and military health care systems

BACKGROUND

Pediatric immunization rates have increased in the United States since 1990. Nevertheless, national survey data indicate that up to one third of 2-year-old children in some states and urban areas lack at least one recommended dose of diphtheria-tetanus-pertussis (DTP)-, polio-, or measles-containing vaccines. Immunization has become a key measure of preventive pediatric health care in the United States. To achieve and maintain the national immunization goal that 90% of children receive all recommended immunizations by 2 years of age, the role of the health care system in immunization delivery must be examined. Urban eastern Virginia has a diverse population that obtains immunization services from public, private, and military providers and insurers. At the time of this survey, immunization services in Virginia were available free to all children through public health clinics and to military families when using a military facility.

OBJECTIVE

To examine access to pediatric immunization services and health system factors associated with underimmunization in a representative sample of children at 12 and 24 months of age.

METHODS

We conducted a household survey in urban eastern Virginia from April through September 1993. A total of 12 770 households in Norfolk and Newport News, VA, were selected for inclusion in the study using probability-proportionate-to-size cluster sampling. Use of probability-proportionate-to-size sampling ensured that children within each city had equal probability of being included in the survey. Selected households were visited by trained interviewers to determine their eligibility, defined as having at least one child 12 to 30 months of age residing in the household. In eligible households, parents were asked to participate in a standardized, 15-minute interview. Survey respondents were asked about household demographics, and for each eligible child, the immunization history, health insurance, the name and location of all immunization providers, the usual immunization provider, and any problems the parent had experienced accessing immunization services with that child. Up-to-date (UTD) immunization status was defined as having all recommended doses of DTP, polio, and measles-mumps-rubella at 12 months (three DTP and two polio immunizations) and 24 months (four DTP, three polio, and one measles-mumps-rubella immunizations). The child's immunization history was assessed from parent and provider records only. Data analysis accounted for the survey's cluster sampling design (ie, within-cluster correlation). Because the immunization rates of the two cities did not differ significantly, unweighted analyses were used for ease of computation. Significance was determined for contingency tables by Wald's chi2 test.

RESULTS

A total of 749 children (91% of eligible households) participated in the survey. Study children were born between October, 1990, and July, 1992. Immunization records were obtained for 705 children (94%). Eighty-seven percent of respondents were mothers, 44% were African-American, 40% of children were military dependents, and 40% were enrolled in the Women, Infants and Children (WIC) program. Sixty-five percent of children were UTD at 12 months and 53% at 24 months. Parents reported that their children's usual immunization providers were private doctors (34%); public health, hospital clinics, or community health centers (32%); and military clinics or a military contract provider (34%). At least one problem accessing immunization services was reported by 35% of respondents, ranging from 29% among those who used a private doctor as their child's usual immunization provider to 46% among those using a military contract provider. Overall, the most commonly reported problem was clinic waiting time (12%), with reports of waiting time as a problem occurring most often among those using the military contract provider (22%) and public health clinics (17%). (ABSTRACT TRUNCATED)

Detection of immunoreactive parathyroid hormone-related protein in human cerebrospinal fluid

Immunoreactive parathyroid hormone-related protein (PTH-rP) was measured in simultaneously obtained cerebrospinal fluid (CSF) and plasma from 51 patients suspected of suffering from a prolapsed intervertebral disc. Endocrine or psychiatric diseases were excluded. In addition, immunoreactive parathyroid hormone (PTH) in the CSF samples was measured. Both, PTH-rP and PTH were assayed by immunoradiometric assay. The results indicate the presence of both, PTH-rP and PTH in CSF. The following concentrations (mean values +/- SD) were found: PTH-rP (pmol/l) in CSF without pleocytosis (n = 17) 0.432 +/- 0.157, with pleocytosis (n = 34) 0.654 +/- 0.675; in plasma (pmol/l) 54.1 +/- 14.632; PTH (nmol/l) in CSF without pleocytosis (n = 17) 0.454 +/- 0.099, with pleocytosis (n = 34) 0.437 +/- 0.140, and in plasma 4.272 +/- 0.794. The concentrations of both, PTH-rP and PTH, in CSF with and without pleocytosis were not significantly different. No correlation was found between PTH-rP and PTH values. The present study demonstrated PTH-rP as a normal constituent in human CSF.

Promoting clinically effective practice: general practitioners' awareness of sources of research evidence

BACKGROUND

Practitioners are being encouraged to base their clinical practice on research evidence. In order to do this, they must be aware of and use the sources of evidence.

METHODS

A questionnaire survey was undertaken to establish GPs' awareness of research evidence in their clinical practice and, in fundholding practices, its influence on purchasing plans. Questionnaires were sent to 360 lead fundholders in North Thames Region and 440 of a random sample of the remaining general practitioners in the region for comparison.

RESULTS

Questionnaires were returned by 62% of lead fundholders and 63% of GPs in the random sample. There was limited use of the electronic sources of clinical effectiveness. There was greater reported awareness of published sources of research evidence and fundholding GPs were significantly more likely to have referred to publications summarizing research evidence.

CONCLUSIONS

GPs seem to make more use of published clinical effectiveness sources than the electronic databases. Consequently, they need educational and technical support if they are to make full use of the available sources of research evidence available in other media.

Focus groups among public, military, and private sector mothers: insights to improve the immunization process

The underimmunization of children younger than 2 years old is a major health problem in U.S. cities. Innovative methods to increase immunization rates are being researched and implemented. In 1993, six focus groups were conducted with 41 mothers (25 African Americans and 16 Caucasians) to discuss their views regarding immunizations and the services they received from health care providers in the public health (n = 27), military (n = 4), and private (n = 10) sectors. Participants viewed immunizations positively, but perceived many barriers to immunization. They suggested the following ways to improve the immunization process: enhancing knowledge acquisition, improving reminder and appointment systems, providing transportation and child care, decreasing waiting times, improving the clinic environment, and making the immunizations less traumatic. According to mothers in this study, obtaining an immunization on time is a complex task that requires planning and resources. The fewer resources that are available to mothers, the more difficult it is to succeeded. Health care providers must help mothers identify and remove barriers if immunization rates are to be increased.

[Laparoscopic resections of malignant diseases of the gastrointestinal tract]

As the importance of laparoscopic surgery for benign diseases of the gastrointestinal tract continues to grow, the application of this approach in cases of malignancy remains controversial. Although the concept of cancer recurrence in the area of surgical wounds is not new, the incidence of port site recurrence is the most obvious concern. Indications and contraindications for surgery as well as a standardized nomenclature describing the type of laparoscopic procedures being performed are some other issues that need to be clarified. Complete laparoscopic procedures or the combination of laparoscopy with open techniques can offer advantages and disadvantages that surgeons will have to take into consideration when making decisions. The skill of the operating team and the extent of disease define the boundaries of laparoscopic surgery possible. The continued research as well as development of intelligent instruments and standardized techniques might give laparoscopy a clear role in the treatment of abdominal malignancies.

Linkage of a neurophysiological deficit in schizophrenia to a chromosome 15 locus

Inheritance of a defect in a neuronal mechanism that regulates response to auditory stimuli was studied in nine families with multiple cases of schizophrenia. The defect, a decrease in the normal inhibition of the P50 auditory-evoked response to the second of paired stimuli, is associated with attentional disturbances in schizophrenia. Decreased P50 inhibition occurs not only in most schizophrenics, but also in many of their nonschizophrenic relatives, in a distribution consistent with inherited vulnerability for the illness. Neurobiological investigations in both humans and animal models indicated that decreased function of the alpha 7-nicotinic cholinergic receptor could underlie the physiological defect. In the present study, a genome-wide linkage analysis, assuming autosomal dominant transmission, showed that the defect is linked [maximum logarithm of the odds (lod) score = 5.3 with zero recombination] to a dinucleotide polymorphism at chromosome 15q13-14, the site of the alpha 7-nicotinic receptor. Despite many schizophrenics' extremely heavy nicotine use, nicotinic receptors were not previously thought to be involved in schizophrenia. The linkage data thus provide unique new evidence that the alpha 7-nicotinic receptor gene may be responsible for the inheritance of a pathophysiological aspect of the illness.

Promoting clinical effective practice. Attitudes of fundholding general practitioners to the role of commissioning

Aims to evaluate the acceptability of commissioning to improve clinical effectiveness in secondary care and explore the conditions under which fundholders would be willing to use commissioning in this way. Describes how fundholders in two contrasting districts in North Thames Region were interviewed in 1995-1996. Respondents were selected from a list of all fundholders in the district with few fundholding practices and from lists of fundholders holding contracts with specified hospitals in the district with many fundholders. Interviews were analysed using the constant comparison method of content analysis. All fundholders in the districts were eligible. The sample represented a broad range of fundholders, containing all fundholding waves and large and small practices. Managers and general practitioners from multifunds outside the districts were also interviewed to assess whether they faced different issues from single practice fundholders. Many respondents felt unable to use commissioning to improve clinically effectiveness despite their awareness of the policy. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use fundholding to challenge hospital practice. Respondents from early wave fundholding practices and those with training in critically appraising research literature expressed more readiness to review research evidence, but only a few early wave fundholders said they would consider evidence-based commissioning. Concludes that steps should be taken to educate fundholders in clinical effectiveness and provide appropriate information to them. Also, they must be persuaded that clinical effectiveness is not a politically-driven policy or they will resist it.