Use of polymerase chain reaction and quantitative antibody tests in children born to human immunodeficiency virus-1-infected mothers

The diagnosis of human immunodeficiency virus (HIV) infection in children born to HIV-infected mothers is complicated by the presence of passively acquired maternal antibodies, and exclusion of infection in these infants remains problematic. The use of genome detection by polymerase chain reaction (PCR) amplification and the quantification of anti-HIV-1 antibodies were examined as methods for early diagnosis. Blood samples were taken from 84 non-breast-fed infants of HIV-infected mothers in five Italian and Spanish centres, a subgroup of children enrolled in the European Collaborative Study (ECS) for whom clinical and immunological information has been documented from birth. Whole blood was added to glycigel cryopreservative, stored, and tested in the United Kingdom by a nested PCR method. Antibody to HIV-1 was detected and quantified by titration using a gelatin particle agglutination test. PCR sensitivity and specificity were assessed. Twenty-one of the 84 children tested were infected. The estimated PCR sensitivity ranged from 0% (95% CI 0-26%) on day 1, 57% (19-85) on day 7, to 63% (33-92) on day 30. The negative predictive value of PCR ranged from 85% (83-88) on day 0 to 98% (94-100) at 3 months of age. On average, the level of maternal antibody halved every 33 days (31-36.5) in uninfected children. Between 6 and 9 months of age, increases in antibody titres in infected children were not more informative than absolute levels. These findings suggest that antibody measurement may supplement genomic diagnosis and that this collection method provides an alternative to the use of dried blood spots.

The appearance of drug resistance-associated point mutations in HIV type 1 plasma RNA precedes their appearance in proviral DNA

Point mutations in the reverse transcriptase (RT) gene of human immunodeficiency virus type-1 (HIV-1) have been associated with reduced sensitivity of the virus to inhibition by the antiretroviral drug zidovudine (ZDV). During therapy we have previously observed the accumulation of these mutations, at codons 41, 67, 70, 215, and 219 of the RT gene, in proviral DNA sequences from infected peripheral blood mononuclear cells (PBMCs) and in cell-free virus RNA. Using a quantitative point mutation assay (PMA) we have been able to quantify the proportions of mutant and wild-type sequences at these points in mixed populations of viral RNA and DNA derived from clinical samples. Thus we have confirmed that the mutations can be detected earlier in cell-free virus RNA than in PBMC proviral DNA and their accumulation in RNA precedes that in DNA. We have analyzed serial samples from 10 subjects undergoing zidovudine therapy and shown significantly higher levels of mutations in cell-free viral RNA than in PBMC proviral DNA at codons 41, 70, and 215 during the in vivo acquisition of the mutations. In the group of subjects studied the mean time delay between RNA and DNA reaching a given level of mutation was 25 days.

Malabsorption caused by coeliac disease in patients who have scleroderma

Coeliac disease may account for malabsorption in scleroderma patients even when test suggest bacterial overgrowth. A small bowel biopsy is essential.

Entry and evaluation of elderly patients in European Organization for Research and Treatment of Cancer (EORTC) new-drug-development studies

BACKGROUND

This study aimed to determine the extent to which elderly patients (> or = 65 years) currently are being entered in Phase II single-agent studies, and if advanced age is associated with increased toxicity.

METHODS

This analysis was based on the age distribution of 2344 patients with various solid tumors entering 16 Phase II EORTC single-agent trials from January 1983 to February 1992.

RESULTS

Of the study group, 22% were 65 years or older and 8% were 70 years or older. Delay in dose administration and dose reduction were significantly higher for elderly patients compared with younger patients (P < 0.05). When adjusting for previous chemotherapy pretreatment, no difference between elderly and nonelderly patients was noted in the frequency of grade 3 and 4 hematological toxicity, nausea, vomiting, and diarrhea. A significant higher frequency of episodes of severe oral toxicity (P < 0.05) and alopecia were observed for elderly patients, but a higher proportion (P < 0.05) of elderly patients received drugs for which stomatitis was an established side effect. No significant difference in the frequency of complete plus partial responses was observed between older and younger patients (9% versus 7%). Treatment discontinuation significantly increased with age, ranging from 24% for those younger than 50 years to 33% among elderly patients (x for trend = 12.83, P < 0.001). There was not evidence that excess toxicity was an obstacle to treatment continuation for elderly patients, whereas treatment discontinuation did occur for the older age group more frequently because of loss to follow-up and treatment refusal.

CONCLUSION

Selected elderly patients can and should enter new-drug-development protocols without an increased risk of more severe or frequent side effects. A priori exclusion based on an arbitrary chronologic age limit no longer should occur.

Docetaxel: an active new drug for treatment of advanced epithelial ovarian cancer

BACKGROUND

Because of the relative scarcity of natural paclitaxel (Taxol), which has been recently recognized as a highly cytotoxic agent for use in platinum-refractory ovarian cancer, synthetic and semisynthetic substitutes have been actively pursued. Docetaxel (Taxotere), a new semisynthetic taxoid, has been selected for clinical development because it is twice as potent as paclitaxel in promoting assembly of tubulin and in inhibiting microtubule depolymerization. Docetaxel also shows equal or greater cytotoxicity in relevant preclinical models.

PURPOSE

Because docetaxel has produced consistent antitumor responses in ovarian cancer patients in phase I trials, we planned and conducted a phase II clinical trial to evaluate the drug's effectiveness and its toxic effects.

METHODS

The present trial, which started in May 1992 and ended in December 1992, involved 97 patients with advanced epithelial ovarian cancer. The target study population had disease relapse or disease progression within 12 months of the last administration of a first-line or second-line platinum-based regimen with at least one bidimensionally measurable target lesion. The patients received docetaxel at a dose of 100 mg/m2 given as a 1-hour infusion every 3 weeks without premedication for minimizing potential hypersensitivity. Docetaxel-induced side effects were graded according to the National Cancer Institute's Common Toxicity Criteria.

RESULTS

The overall response rate was 23.6% in 76 assessable patients versus 20% if all 90 eligible patients were included in the comparison (95% confidence interval [CI] = 11%-29%). Among 34 eligible patients whose tumor progressed on the most recent platinum treatment, the response rate was 23.5% (95% CI = 8%-39%). The median progression-free survival for all eligible patients was 3.9 months, and the median overall survival was 8.4 months. Docetaxel-associated toxicity in 90 assessable patients consisted of short-lived neutropenia in 81 (90%) patients, which was complicated by fever and hospitalization in seven (8%); hypersensitivity reactions were seen in 29 (31%) patients, with significant reactions seen in seven (8%); and neurotoxicity in 43 (48%) patients, with grade 3 or above toxicity seen in only three (3%). The treatment also produced skin reactions in 58 (64%) patients, of whom only four (4%) showed the intensity of grade 3. Eleven (12%) patients experienced pleural effusions, which were the effects of the drug considered to be of greatest concern. Peripheral edema and weight gain due to fluid retention were reported in 40 (44%) and 17 (19%) patients, respectively.

CONCLUSION

Docetaxel appears to be effective in the treatment of platinum-refractory ovarian cancer patients.

HIV-1 RNA serum-load and resistant viral genotypes during early zidovudine therapy

The response of HIV-1 to initial zidovudine (ZDV) treatment was assessed in 11 patients with severe HIV disease. We quantified serum HIV-1 concentrations and mutations associated with ZDV resistance by culture-independent methods. There was a prompt fall in serum HIV-1 RNA within 1-2 days of treatment with maximum suppression by seven days, which was paralleled by changes in serum p24 antigen (p24 Ag). Serum RNA started to return to pretreatment levels within weeks. The HIV reverse transcriptase (RT) gene in most patients developed mutations associated with drug resistance within months and as early as 25 days on therapy in one patient. The codon changes were not sufficient to explain the early return of serum HIV-1 RNA levels and their patterns continued to evolve after patients stopped taking ZDV. The significance of these findings is discussed in relation to the limited long-term efficacy of ZDV. The dynamic time course of viral load and RT responses to ZDV is of particular importance in short-term interventions such as pregnancy.

Epirubicin chemotherapy and advanced breast cancer after adjuvant CMF chemotherapy

There have been conflicting reports on the effect of prior adjuvant chemotherapy on the response of advanced breast cancer to primary chemotherapy. We report a retrospective review of the outcome of chemotherapy with epirubicin 100 mg/m2 for advanced breast cancer in 39 patients who had previously received adjuvant cyclophosphamide, methotrexate and 5-fluorouracil (CMF). The response rate (complete responses plus partial responses) was 38.5%, with a median duration of response of 33 weeks. There was no significant difference in the response rate or duration of survival when these patients were compared with matched controls who had not received adjuvant chemotherapy. However, the limitations of this study were such that an adverse effect of adjuvant CMF on the response to epirubicin cannot be excluded.

Docetaxel (Taxotere) in advanced gastric cancer: results of a phase II clinical trial. EORTC Early Clinical Trials Group

Thirty-seven eligible patients, median age 59 years (range 37-72) and median performance status 1 (0-2), with advanced, untreated, measurable gastric carcinoma were given docetaxel, 100 mg m-2 i.v. over 60 min without premedication, once every 3 weeks. Metastatic sites included the liver in 12 patients and retroperitoneal lymph nodes in 16. Eight of the 33 evaluable patients (24%) achieved a partial remission for a median of 7.5 months (3-11+). An additional 11 patients had stabilisation of disease. The patients received a median of four cycles of docetaxel (range 1-8) for a total of 156 courses. Dose reduction was necessary in 30 cycles; 14 cycles were delayed a mean of 3 days. Haematological toxicity consisted mainly of non-cumulative neutropenia, with a median nadir count of 0.35 x 10(9) l-1 (0.04-1.64) and eight episodes (5%) of leucopenic fever; non-haematological toxicities included alopecia, mild nausea and vomiting and allergic manifestations such as skin rash and pruritus. There were no drug-related deaths. Our data indicate that docetaxel is an active agent in advanced gastric cancer; further clinical investigations seem warranted.

Docetaxel (Taxotere) is active in non-small-cell lung cancer: a phase II trial of the EORTC Early Clinical Trials Group (ECTG)

In a multicentre trial of the EORTC ECTG we have treated 43 non-pretreated patients with advanced non-small-cell lung cancer (NSCLC) with the new semisynthetic taxoid docetaxel (Taxotere). Six patients were ineligible; of the 37 eligible patients, ten had prior radiotherapy and 18 prior surgery. They received 100 mg m-2 in 1 h i.v. every 3 weeks, usually in an outpatient setting. Prophylactic steroids, antihistaminics or antiemetics were not routinely given. Two patients were not evaluable because they withdrew from the study because of a hypersensitivity reaction after the second cycle. The main toxicity was neutropenia (80% of cycles), although infections were rare (4%). One patient died from sepsis during neutropenia. Hypersensitivity reactions necessitating interruption of docetaxel (Taxotere) infusions were found in only 10% of cycles. The overall response rate was 23% with one complete response, and seven partial responses. Stable disease was found in 16 patients. The median duration of response was 36 weeks, and the median survival of all patients was 11 months. Docetaxel (Taxotere) is among the most active drugs for treatment of NSCLC.

Muscle cramping in phase I clinical trials of tirapazamine (SR 4233) with and without radiation

PURPOSE

Tirapazamine (SR 4233) is a benzotriazine di-N-oxide which acts as a hypoxic cytotoxic agent and as a radiation enhancer when given shortly before or after radiation. Three Phase I clinical trials were designed to determine the maximum tolerated dose, toxicities, pharmacokinetics, and effects on irradiated tumors and normal tissues.

METHODS AND MATERIALS

Tirapazamine 9 mg/m2 to 21 mg/m2 was given i.v. 1/2 to 1 h prior to irradiation on a multiple dose schedule of 10 consecutive doses. This was later revised to a three times-per-week schedule for 12 doses. In a second clinical trial, tirapazamine was given in a single dose of 18 mg/m2 to 293 mg/m2 i.v. after irradiation. In a third trial, tirapazamine was administered without irradiation in single doses of 36 mg/m2 to 250 mg/m2, with an option for retreatment.

RESULTS

Subjects reported muscle cramping of varying degrees of severity on all three dose schedules. One patient experienced Grade 3 cramping and treatment was discontinued. The most frequent site of cramping were the lower extremities. Creatine phosphokinase (CPK) values were elevated in three patients with associated muscle soreness in one patient. MB (cardiac) isoenzymes were elevated in one patient with no evidence of cardiac muscle damage, and returned to baseline at drug completion. No consistent abnormalities in clinical laboratory values were found. Stretching of the muscle was most effective in relieving the cramping.

CONCLUSION

Muscle cramping has been the most frequently reported toxicity in Phase I studies of tirapazamine, though it does not appear to be dose limiting. Dose escalation on the three clinical trials continues. In vitro studies to investigate the cramping are ongoing.

Coping with toxicities of docetaxel (Taxotere)

BACKGROUND

In phase II studies of the EORTC-ECTG, acute hypersensitivity reaction, edema and skin toxicity were important side effects of docetaxel (TaxotereTM).

PATIENTS AND METHODS

Fifty patients with solid tumors were treated with docetaxel at the University Hospital of Antwerp. Of these, 28% developed an acute hypersensitivity reaction and 20% edema. Twelve and three hours before the next docetaxel administrations those with the acute hypersensitivity reaction were subsequently pretreated orally with 32 mg of methylprednisolone, 10 mg of cetirizine and 1 mg of ketotifen.

CONCLUSIONS

The acute hypersensitivity reaction could be completely blocked in all but in 1 of 14 patients, and this pretreatment schedule had an important prophylactic effect on edema formation. Skin toxicity was successfully treated with an ointment of glycerin and chlorhexidine.

LasR of Pseudomonas aeruginosa is a transcriptional activator of the alkaline protease gene (apr) and an enhancer of exotoxin A expression

The lasR gene of Pseudomonas aeruginosa is required for transcription of the genes for elastase (lasB) and LasA protease (lasA), two proteases associated with virulence. We report here that the alkaline protease gene (apr) also requires the lasR gene for transcription. Alkaline protease mRNA was absent in the lasR mutant PAO-R1 and present when an intact lasR gene was supplied in trans as determined by Northern (RNA) analysis. The lasR gene also enhances exotoxin A production. Exotoxin A activity in supernatants of PAO-R1 were 30% less than in supernatants of the parental strain, PAO-SR. Multiple copies of lasR in trans in PAO-R1 in increased toxin A activity to twice the parental levels. Analysis of PAO-R1 containing the toxA promoter fused to beta-galactosidase suggests that LasR acts at the toxA promoter or at upstream toxA mRNA sequences. beta-Galactosidase activity was approximately 40% lower in PAO-R1 than in the parental strain, PAO-SR. Furthermore, the effect of LasR on the toxA promoter is not due to the stimulation of transcription of regA, a transcriptional activator of toxA. No difference in chloramphenicol acetyltransferase (CAT) activity was noted between PAO-SR and PAO-R1 containing transcriptional regA promoter-CAT gene fusions. These results broaden the regulatory dominion of lasR and suggest that the lasR gene plays a global role in P. aeruginosa pathogenesis.

HIV-1 plasma viraemia quantification: a non-culture measurement needed for therapeutic trials

Accurate measures of inhibition of virus replication are needed to evaluate the efficacy of antiretroviral agents in large clinical trials. We describe an accurate, economical and rapid method for the direct detection and quantification of cell-free human immunodeficiency virus type -1 (HIV-1) in serum or plasma. The method includes affinity capture of the virus by latex microparticles coated with HIV-1 envelope-specific antibodies, reverse transcription primed by an HIV-1 specific oligonucleotide and amplification by nested PCR of the synthesised cDNA. We show that the method can be applied to large numbers of serum samples, is reproducible and is highly applicable to the monitoring of viral load in HIV-1 infected patients, especially during the investigation of drug efficacy.

The rebirth and blooming of forensic medicine, Milton Helpern Lecture

This features a presentation by Dr. Sidney Kaye on the occasion of the Milton Helpern Lecture at the annual meeting of the National Association of Medical Examiners near Fort Myers in Florida in 1989. The author experienced the "golden age" of forensic medicine as a student and associate of Dr. Alexander Gettler in the New York Medical Examiner's Office. He also worked with Dr. Rutherford Gradwohl in the St. Louis Police Department and was one of the founders of the American Academy of Forensic Sciences. He was the toxicologist in the Virginia medical examiners' system before moving to Puerto Rico. His discussion is a historical review of his experiences in developing forensic sciences.

A new motion responsive pacemaker: first clinical experience with an acceleration sensor pacemaker

A new accelerometer-based adaptive rate pacemaker (EXCEL VR) was evaluated to investigate its behavior at nominal settings during treadmill exercise testing and postural changes. Eight patients with sinus rhythm were selected to compare intrinsic heart rate to sensor mediated rate. Throughout exercise treadmill testing, changes in the sensor mediated rate closely paralleled actual physiological changes. The Pearson product moment correlation of pacing rate with sinus frequency, calculated for all patients, was r = 0.82 (P = 0.001). Change in the patient's physical position resulted in immediate change in sensor rate, which corresponded appropriately to the type of position change and activity level. Average (+/- SD) pacing rate was 62.4 +/- 2.7 beats/min supine; 67 +/- 3.8 beats/min sitting; 69.8 +/- 6.4 beats/min standing; 81.6 +/- 8.7 beats/min slow walking; and 96.8 +/- 1.3 beats/min fast walking. After 4 minutes of recovery, the average pacing rate dropped to 65 +/- 3 beats/min. The interaction between the accelerometer and the pulse generator at nominal settings was accurate and infrequently required the use of its many programming options. The accelerometer sensor and pulse generator algorithm in this device during postural change and exercise resulted in physiological-like changes in sensor mediated heart rate.

A microtitre format point mutation assay: application to the detection of drug resistance in human immunodeficiency virus type-1 infected patients treated with zidovudine

An assay for the analysis of point mutations in DNA fragments amplified by the polymerase chain reaction is described. The method was applied to the analysis of mutations leading to single amino acid changes in the reverse transcriptase gene of human immunodeficiency virus type-1 that are associated with decreased sensitivity of the virus to the effects of the nucleoside analogue zidovudine. The assay uses a microtitre format allowing large numbers of clinical samples to be analysed, and is a quantitative assay giving information on the relative proportions of wild-type and mutant sequence at the point being analysed. The analysis of mutations in codons 67, 70, 215, and 219 of the RT gene in samples taken at various time points after the commencement of zidovudine therapy shows a high variability in the rate at which these mutations arise and in the proportions of wild-type and mutant sequences observed. The method we describe has wide application to the analysis of other point mutations in clinical or research studies.

Ondansetron compared with metoclopramide in the control of emesis and quality of life during repeated chemotherapy for breast cancer

This was a multicentre, randomised, double-blind, parallel-group study which included female breast cancer patients, receiving their first of 6 scheduled courses of chemotherapy (cyclophosphamide greater than or equal to 500 mg/m2). Patients received an intravenous dose of 16 mg dexamethasone with either 8 mg ondansetron or 60 mg metoclopramide before chemotherapy, followed by oral dosing with 8 mg ondansetron or 20 mg metoclopramide 3 times daily for 5 days. A total of 93 patients were treated with ondansetron and 94 patients with metoclopramide. On day 1 of their first course of treatment 91 and 60% of patients in the ondansetron and metoclopramide groups respectively were free of emesis (p less than 0.001). Over the 5-day treatment period, the corresponding figures were 81 and 48% (p less than 0.001). The results for nausea also revealed highly statistically significant treatment differences (p less than 0.001) in favour of ondansetron for both day 1 and day 1-5 analyses of the first treatment course. Over the series of courses, 67% of patients receiving ondansetron completed all 6 courses with a maximum of 2 emetic episodes on their worst day, compared with 28% of patients receiving metoclopramide (p less than 0.001). A similar analysis for nausea revealed that 49% of patients receiving ondansetron completed all 6 courses with 'none' or 'mild' nausea compared with 27% of patients receiving metoclopramide (p less than 0.001). These differences were reflected in quality of life data (Rotterdam Symptom Checklist). After the first course of treatment, a statistically significant improvement (p = 0.002) in the psychological subscale scores was observed after ondansetron compared with metoclopramide. No differences were observed in the physical or functional activity subscales after the first course. However, the quality of life results over the series of courses revealed a more pronounced difference in favour of ondansetron in the psychological subscale scores (p less than 0.001) as well as trends in favour of ondansetron in the physical (p = 0.096) and functional activity (p = 0.056) subscales. Extrapyramidal symptoms were reported in 19% of patients in the metoclopramide group and resulted in 15% of patients withdrawing from their randomised anti-emetic schedule, either during or between treatment courses. Other adverse events were generally minor in nature and did not necessitate withdrawal from treatment. In conclusion, this study shows that ondansetron is significantly superior to metoclopramide (each with a single pre-treatment dose of dexamethasone) in the control of emesis over 6 courses of chemotherapy for breast cancer.(ABSTRACT TRUNCATED AT 400 WORDS)

Storage and preservation of whole blood samples for use in detection of human immunodeficiency virus type-1 by the polymerase chain reaction

Methods used in the diagnosis of human immunodeficiency virus type-1 (HIV-1) infection by the polymerase chain reaction (PCR) usually require the separation of lymphocytes from a whole-blood sample within 24 hours of patient sampling. A method is described in which blood samples are mixed with a cryopreservative ('Glycigel'), stored frozen, and DNA suitable for use in an HIV PCR recovered. Samples can be stored at -20 degrees C for up to 3 months and still give positive results with all samples from infected patients; storage at -80 degrees C for at least 3 months shows no loss of titre. The method shows no loss of sensitivity compared to previously described sample preparation methods. Deglycerolised Glycigel supernatants were found to be suitable for conventional anti-HIV-1 serological studies and loss of sensitivity only represented the dilution effect due to sample preparation. Application of the method as a means of storing samples frozen at the point of sampling and transporting them to a central laboratory for processing is demonstrated using samples taken from HIV-1-infected mothers and their babies.

Effect of regB on expression from the P1 and P2 promoters of the Pseudomonas aeruginosa regAB operon

Exotoxin A production in Pseudomonas aeruginosa is dependent on two regulatory genes, regA and regB, which are located in tandem on the chromosome. Expression of regA and regB is controlled by two promoters (P1 and P2) situated upstream of the regAB locus. We have studied the effect of the regA and regB gene products on transcription from the regAB promoters. Transcriptional and translational fusions, under the control of the P. aeruginosa regA promoters, were used to analyze the regulation of these promoters in a variety of genetic backgrounds. When the regA P1 promoter was supplied in trans to strains lacking expression of regB (PAO1) or lacking transcription of the regAB operon (PA103-29), little activity from the P1 promoter was detected. In contrast, activity from the P2 promoter was not affected in either PAO1 or PA103-29. Sequence analysis of the regAB operon of PA103-29 detected two mutations. One of the mutations is predicted to result in a premature stop codon in the regA open reading frame. We complemented PA103-29 with a construction containing regA and an inactive regB or a construction containing both regA and regB to directly analyze the effect of regB on transcription of the regAB operon. When PA103-29 was complemented with regA but not regB, we could not detect any transcription from the P1 promoter. Complementation of PA103-29 with both regA and regB resulted in a high level of transcription from the P1 promoter and a corresponding early transcriptional activation of toxA. Our results indicated that induction of transcription from the P1 promoter requires the regB open reading frame and thus the regAB operon is autogenously regulated in P. aeruginosa.

Long term results of cyclophosphamide, adriamycin and platinum chemotherapy in advanced epithelial ovarian cancer

Between January 1980 and December 1983, 57 consecutive patients with advanced epithelial ovarian cancer (FIGO Stage IIc n = 5; III n = 45; IV n = 7) were treated with 6 cycles of cyclophosphamide 600 mg/m2, adriamycin 30-45 mg/m2 and platinum 50 mg/m2 (CAP) at 3 weekly intervals. Pathological complete remission (CR) was documented in 10 (18%) and 4 with no residual disease after primary cytoreductive surgery were free from progression (FFP). There were 19 partial remissions (PR) giving a 51% overall response rate. The median duration of CR was 33 months from second look surgery. Median survival (MS) for all patients was 22 months. Multivariate analysis indicated that response to chemotherapy was the most important prognostic factor, with MS for CR of 53 months, PR 23 months and stable or progressive disease 11 months (p = 0.001). Most CR (8 of 10) occurred in patients with minimal residual disease (no single lesion greater than 2.0 cm), but extent of disease, though significant in univariate analysis of prognostic factors was not an independent predictor of survival. Six patients (11%) are alive and tumour free with a minimum follow-up of 7 years. All had FIGO Stage III disease at presentation and four had no residual tumour after primary surgery.

Intrathecal IgG synthesis and specificity of oligoclonal IgG in patients infected with HIV-1 do not correlate with CNS disease

The CSF/serum immune response to HIV 1 was studied in 24 patients admitted for investigation. The level of antibody to HIV-1 and specificity of oligoclonal IgG were determined in blood and cerebrospinal fluid (CSF). The majority of patients demonstrated elevated levels of intrathecal IgG synthesis, with levels of HIV-1-specific antibody frequently being significantly higher in CSF than in serum. In 16 of 21 patients the CSF/serum antibody ratio indicated active intrathecal synthesis. Oligoclonal banding was present in CSF from all 24 patients. Immunoprinting of serum and CSF demonstrated antigenic specificity (p24, gp 160, RT) of the clonal antibodies in all of 12 patients though the patterns of reactivity in CSF did not necessarily correspond with that of serum. Although a specific association of particular patterns with HIV CNS disease was not found we feel that these markers should be included in longitudinal studies of HIV-related diseases of the CNS. The specificity of oligoclonal antibodies, both in CSF and in serum was demonstrated, and this specificity may be a useful marker for longitudinal studies in HIV-1 antibody-positive asymptomatic patients.

Carboplatin-based combination chemotherapy for advanced carcinoma of the cervix

A combination of carboplatin, vincristine, methotrexate and bleomycin (COMB) was given to 29 patients with locally advanced, metastatic or recurrent cervical carcinoma. A total of 85 cycles of chemotherapy were given, with half of the patients receiving greater than 3 cycles. Both the response rate (32.1%) and the median duration of response (30 weeks) were relatively disappointing. Renal toxicity was minimal, but one-third of our patients experienced severe (WHO grades 3 and 4) nausea and vomiting. This combination showed little advantage over carboplatin used as a single agent.

Treatment of flexor tenosynovitis of the hand ('trigger finger') with corticosteroids. A prospective study of the response to local injection

We developed a protocol to maximize medical therapy for "trigger finger." Fifty-eight patients with 77 episodes of flexor tenosynovitis of the hand that was resistant to rest, therapy with nonsteroidal anti-inflammatory drugs, and/or splinting were treated with single or multiple injections of depo-methylprednisolone acetate or triamcinolone acetonide. Patients were prospectively followed up for an average of 4.6 years. Results showed that symptoms and signs resolved in 61% after a single injection. Recurrent episodes, after prolonged pain-free intervals, occurred in 27% and were effectively re-treated with injection. In 12% of cases, either injection failed or early recurrence required surgical release. Local adverse reactions to injection, including pain at the injection site, stiffness, ecchymosis, or atrophy of subcutaneous fat, were self-limited. No episodes of postinjection infection or tendon rupture occurred. The medical management of flexor tenosynovitis with local corticosteroid injection(s) is effective in nearly 90% of cases and is free from serious adverse reactions.

Epidural analgesia. Effect on the likelihood of a successful trial of labor after cesarean section

From October 1984 to April 1986, 237 women who had had an earlier cesarean section underwent a trial of labor (TOL). The delivery outcomes for 87 who received epidural analgesia were compared retrospectively with those for the 150 who did not. There were no overt uterine ruptures. The rates were similar for successful TOL, uterine scar dehiscence, blood transfusions, endometritis and one- and five-minute Apgar scores. The rate of operative vaginal delivery was higher in the epidural group. When epidural subjects were divided into vaginal and cesarean delivery groups, the failed-TOL group differed from the successful-TOL group in greater maternal weight gain, heavier and longer infants, higher rate of oxytocin administration, less cervical dilation and higher station at epidural activation. When the oxytocin-treated subjects were excluded, however, the epidural and no-epidural patients had the same successful TOL rates (94% and 92%, respectively) and spontaneous vaginal delivery rates (70% and 76%, respectively). Epidural analgesia, when controlled for oxytocin use, appears to have no effect on the failed-TOL or operative vaginal delivery rate.

Oxytocin use after previous cesarean: why a higher rate of failed labor trial?

When used for patients undergoing trial of labor after previous cesarean, oxytocin is associated with an increased failure rate. Previous reports have not studied why this occurs. From October 1984 to April 1986, 237 patients with previous cesareans underwent a trial of labor. The delivery outcomes of 73 women who received oxytocin were compared with those of the 164 who did not. Rates were similar for uterine scar dehiscence, uterine rupture, operative vaginal delivery, blood transfusions, endometritis, and low Apgar scores. Successful trial of labor occurred in 68% in the oxytocin group, compared with 89% in the no-oxytocin group. Failed trial of labor was significantly more frequent in patients who received oxytocin for induction of labor than in those who did not. When subjects who received oxytocin were divided into induction (N = 47) and augmentation (N = 26) groups, successful trial of labor occurred in 58% of the former group versus 88% of the latter group. Other characteristics of the augmentation group were spontaneous labor, greater cervical dilation and effacement at initiation of oxytocin, shorter duration of infusion, and lower oxytocin infusion rates. For patients who have had previous cesareans and who desire trial of labor, oxytocin by controlled infusion is safe. Successful trial of labor may be enhanced by awaiting spontaneous labor or inducing with a favorable cervix.

Analysis of carboxyhemoglobin and cyanide in blood from victims of the Dupont Plaza Hotel fire in Puerto Rico

Ninety-seven people died from a fire that occurred in the Dupont Plaza Hotel in Puerto Rico on 31 Dec. 1986. All, except four who died later in the hospital, were found dead at the scene. All of the fatalities at the hotel (except for eight) were burned beyond recognition. Blood from seventy-eight of the victims was screened for carboxyhemoglobin at the Institute for Forensic Sciences in Puerto Rico and was then sent to the National Institute of Standards and Technology, Gaithersburg, Maryland, for analysis of carboxyhemoglobin and cyanide concentrations. The blood data indicated that carbon monoxide and hydrogen cyanide, singly or combined, were probably not responsible for the majority of the deaths that occurred in the badly burned victims. On the other hand, the significantly higher carboxyhemoglobin in the nonburned victims indicated that carbon monoxide alone or combined with hydrogen cyanide probably played a major role in the cause of their deaths.

Phase II studies of mitozolomide in melanoma, lung and ovarian cancer

Seventy-seven patients were treated with oral mitozolomide to assess the activity of this drug in melanoma, lung and ovarian cancer. Partial responses were seen in five of 18 evaluable patients with small cell lung cancer (SCLC) and three of 20 with melanoma. No activity was apparent in non small cell lung or epithelial ovarian cancer. The major toxicity was myelosuppression which necessitated reduction in the initial dosage from 115 to 90 mg/m2. However, even at this dose level, unpredictable WHO grade 4 toxicity occurred in non-pretreated patients. Thrombocytopenia was more common than leucopenia and eight patients required platelet transfusion for spontaneous or tumour-related haemorrhage. Myelotoxicity was considered responsible for two deaths and was a significant contributory factor in a further three. Non-haematological toxicity was minor. Thus, despite demonstrable activity in SCLC and melanoma, unpredictable myelosuppression is likely to preclude further assessment in combination chemotherapy regimes in these tumours.

Quantification of brainstem auditory evoked responses for patient monitoring

A method of quantifying the integrity of the brain stem auditory evoked responses (BAERs) is applied to specific cases in both the ICU and OR to demonstrate its usefulness as an adjunct to peak latency evaluation. This measure is particularly valuable when peak identification is difficult as a result of poor waveform coherence. Examples are included to demonstrate that this method can also give independent information from peak latency.

Phase II study of iproplatin (CHIP, JM-9) in advanced testicular cancers progressing after prior chemotherapy

Twenty-two patients with advanced testicular cancer received iproplatin at a dose of 180-240 mg/m2 every 4 weeks. All the patients progressed or recurred after chemotherapy including cisplatin. The most severe toxicity was thrombocytopenia with two toxic deaths after a first cycle of 240 and 180 mg/m2 respectively. Nausea and vomiting were almost universal but mild in intensity. One renal failure occurred 6 weeks after the first cycle while the tumor was progressing. No antitumor activity was observed in this heavily pretreated population of patients.

Phase II study of iproplatin in advanced ovarian carcinoma

Iproplatin (cis-dichloro-trans dihydroxy-bis-isopropyl-amine platinum [IV]; CHIP) was administered intravenously (IV) at monthly intervals at doses of 300 mg/m2 and 240 mg/m2 to ten previously untreated and 97 previously treated patients with advanced ovarian carcinoma. The overall response rate was 78% among patients with no prior chemotherapy, 42% among patients with prior chemotherapy not including cisplatin, and 22% among patients with prior chemotherapy including cisplatin. Overall response rates to iproplatin were 6.4% and 54% in patients with/without clinical evidence of tumor resistance to cisplatin. Thrombocytopenia was the dose-limiting toxicity, median time to nadir and to recovery being 2 and 4 weeks, respectively. Patients who had received prior chemotherapy regimens for greater than 1 year showed a 10% greater reduction in platelet count (mean platelet nadir +/- SD, 57.5 +/- 49.96 X 10(3)/microL) and a higher incidence of grade 3 to 4 thrombocytopenia after the first cycle than patients who had received prior chemotherapy regimens for less than 1 year (94.7 +/- 65.99 X 10(3)/microL) Moderate to severe vomiting and diarrhea occurred in 84% and 16% of patients pretreated with chemotherapy. Neuropathy (6%) was reported only in patients with prior cisplatin treatment. Mild and reversible renal toxicity was observed in 6% of cases. Iproplatin is an active drug in ovarian cancer; the results achieved in patients previously treated with cisplatin strongly suggest that the two drugs are cross-resistant.

Multicenter study of trilostane: a new hormonal agent in advanced postmenopausal breast cancer

Trilostane, an inhibitor of the production of adrenal estrogens, was administered, together with dexamethasone, to 97 eligible postmenopausal women with advanced breast cancer. Seventy-four patients who had either received trilostane for a minimum of 10 weeks or whose disease had progressed while on trilostane before this period were assessed for tumour response. Eighteen patients (25%) had objective responses (two complete, 16 partial); a further 21 patients had stable disease. The response rate among all 97 patients, including those not treated for a minimum 10-week period, was 19%. Thirty-two of 97 patients reported adverse reactions which were attributed to trilostane and/or dexamethasone. Therapy was stopped for 15 patients, and the dose of trilostane was reduced for ten. Diarrhea was the commonest side effect, being reported in 16 patients, of whom nine stopped treatment. Trilostane, given with a corticosteroid, is an effective alternative hormonal agent acting by adrenal blockade for postmenopausal women with advanced breast cancer.

Marked inter-patient variation in adriamycin biotransformation to 7-deoxyaglycones: evidence from metabolites identified in serum

Several factors are known to modulate the clinical pharmacokinetics of adriamycin (ADR). Biotransformation has not been studied in this context because of problems identifying serum metabolites. We have studied patterns of ADR biotransformation in 25 patients with normal liver and kidney function and in most cases receiving ADR for the first time. Three major serum metabolites were identified by HPLC, TLC and mass spectrometry and their pharmacokinetics were followed over a 24-hr period. The relative amount of each metabolite present in a patient was quantitated by calculating its AUC. Adriamycinol was the major metabolite detected in the majority of patients. Adriamycin 7-deoxyaglycone was detected in the serum of 15 patients where it accounted for a small percentage of the total ADR concentration (1-5%). Its apparent half-life was normally less than 30 min. Adriamycinol 7-deoxyaglycone was detected in the serum of only 13 patients where it accounted for a greater percentage of the total ADR concentration (10-20%). Its pharmacokinetics exhibited marked inter-patient variations, with apparent half-lives ranging from 0.1 to 24 hr. There was a correlation between the AUC of ADR and the relative amount of metabolites present in each patient (r = 0.73). Thus, biotransformation may explain, partly, inter-patient variations in ADR pharmacokinetics. In turn, variations in biotransformation are dictated by whether or not ADR is converted to 7-deoxyaglycones.