Hemifacial microsomia: a case report

Hemifacial microsomia is a congenital malformation in which there is a deficiency in the amount of hard and soft tissue on one side of the face. It is primarily a syndrome of the first branchial arch, involving underdevelopment of the temporomandibular joint, mandibular ramus, masticatory muscles and the ear. The affected ear may have an external soft-tissue malformation in addition to being lower set than on the contra lateral side. Hearing loss may result from underdevelopment of the osseous components of the auditory system and a diminished or absent external auditory meatus. Occasionally, second branchial arch defects involving the facial nerve and facial muscles coexist with Hemifacial microsomia. Radiographic examination in case of Hemifacial microsomia is of limited value because of superimposition of normal and abnormal bony structures. The skeletal and soft-tissue findings of a patient with Hemifacial microsomia who underwent three-dimensional computerized tomography is presented here to improve our knowledge and diagnostic skill of this uncommon entity.

An open, randomized, controlled, phase II, single centre, two-period cross-over study to compare the quality of life and toxicity experienced on PEG interferon with interferon-α2b in patients with multiple myeloma maintained on a steady dose of interferon-α2b

PURPOSE

To compare the effects of pegylated interferon-alpha2b (P-IFN) and interferon-alpha2b (IFN) on quality of life (QoL) and toxicity in patients with multiple myeloma maintained on a steady dose of IFN.

PATIENTS AND METHODS

Consenting, eligible myeloma patients on IFN maintenance therapy for at least 6 weeks were randomly (1:1) allocated to receive P-IFN for 3 months followed by IFN for 3 months, or to continue with IFN for 3 months followed by P-IFN for 3 months (cross-over design). Patients were assessed for toxicity and QoL. Dose of P-IFN was equivalent to IFN.

RESULTS

The study enrolled 60 patients. At enrollment, 35 patients were in complete remission, 20 in partial remission and 5 were minimal responders. P-IFN was associated with significantly better global QoL score (mean difference 8.4; P = 0.0002). There was a significant improvement in functional scales--physical (P = 0.03), emotional (P = 0.04), social (P = 0.0008) with P-IFN. Fatigue (P = 0.0003), pain (P = 0.02) and appetite loss (P = 0.003) symptom scales were less in patients while on P-IFN. There were no statistically significant differences between treatment arms in QoL as measured by QLQ-MY24.

CONCLUSION

These data suggest that patients on P-IFN have a better QoL. Dose escalation studies are warranted to investigate potential impact on survival.

A phase 1 study of the selective cyclin dependent kinase inhibitor P276–00 in patients with advanced refractory neoplasms

14117

Background: In human cancers, genetic and epigenetic events result in over-expression of cyclins or absence or diminished levels of Cdk inhibitors, providing tumor cells with selective growth advantage. This has prompted the development of pharmacological Cdk inhibitors that could potentially produce anti-tumor effect. P276–00 is a selective Cdk4-D1 and Cdk1-B inhibitor. This study was designed to determine the maximum tolerated dose (MTD), toxicity profile, pharmacokinetics, and antitumour activity of P276–00 given intravenously to patients with advanced refractory solid tumours. Methods: P276–00 was administered in escalating doses to cohorts of eligible patients (pts), starting with a dose of 9 mg/m2 as a 30 minute iv infusion day 1 to 5, and day 8 to 12, q 3 weekly. To date 22 pts have been entered on the study (cohort 1 - 4 pts at 9 mg/m2, cohort 2 - 4 pts at 12.6 mg/m2, cohort 3 - 6 pts at 17.6 mg/m2, cohort 4 - 8 pts at 24.6 mg/m2) with PS 0–2, and mean age of 56 years. Pharmacokinetic profiles were obtained on cycle 1 days 1 and 5. Skin biopsies were obtained immediately prior to starting study treatment and on day 21 of cycle 2 and will be analyzed for Ki67, cleaved caspase 3, phospho-Rb, cyclin D1 and cdk4, and microarray. Results: To date dose limiting toxicity has occurred in one pt. Grade 3 fatigue occurred in 1 pt at 17.6 mg/m2. The most common drug-related adverse events, which were all grade 1 or 2, were fatigue, nausea, hypotension, sweating, and dry mouth. No Grade 3 biochemical toxicities have been reported so far. There have been no responses noted to date. 4 pts have stable disease after 2 cycles. Pharmacokinetic results: The Cmax, t1/2, and AUC0–8 on day 1 were as follows: 9 mg/m2- 315 ng/mL, 6.6 hr, 883 ng.h/mL; 12.6 mg/m2- 402 ng/mL, 5.5 hr, 848 ng.h/mL; 17.6 mg/m2- 589 ng/mL, 5.3 hr, 1289 ng.h/mL; 24.6 mg/m2- 621 ng/mL, 5.6 hr, 1286 ng.h/mL. Conclusions: P276–00 is well tolerated, but grade 3 fatigue has been noted in 1 pt at 17.6 mg/m2 dose level. We have observed confirmed stable disease in one patient. PK results indicate that at 9 mg/m2,12.6 mg/m2, 17.6 mg/m2 and 24.6 mg/m2 we are able to cross the cdk4 enzyme IC50 approximately 10, 13, 19 and 20 times and cross the anti-proliferative IC50 1.1, 1.4, 2.1 and 2.2 times respectively. Accrual continues at the 34.4 mg/m2 dose level.

No significant financial relationships to disclose.

A channelized Hotelling observer study of lesion detection in SPECT MAP reconstruction using anatomical priors

In emission tomography, anatomical side information, in the form of organ and lesion boundaries, derived from intra-patient coregistered CT or MR scans can be incorporated into the reconstruction. Our interest is in exploring the efficacy of such side information for lesion detectability. To assess detectability we used the SNR of a channelized Hotelling observer and a signal-known exactly/background-known exactly detection task. In simulation studies, we incorporated anatomical side information into a SPECT MAP (maximum a posteriori) reconstruction by smoothing within but not across organ or lesion boundaries. A non-anatomical prior was applied by uniform smoothing across the entire image. We investigated whether the use of anatomical priors with organ boundaries alone or with perfect lesion boundaries alone would change lesion detectability relative to the case of a prior with no anatomical information. Furthermore, we investigated whether any such detectability changes for the organ-boundary case would be a function of the distance of the lesion to the organ boundary. We also investigated whether any detectability changes for the lesion-boundary case would be a function of the degree of proximity, i.e. a difference in the radius of the true functional lesion and the radius of the anatomical lesion boundary. Our results showed almost no detectability difference with versus without organ boundaries at any lesion-to-organ boundary distance. Our results also showed no difference in lesion detectability with and without lesion boundaries, and no variation of lesion detectability with degree of proximity.

Social and sexual behaviours aid transmission of bacteria in birds

Understanding the behavioural mechanisms that mediate pathogen transmission in social hosts like birds could provide the empirical bases for explaining the epidemiological dynamics of zoonotic infections in vertebrates. By experimentally infecting the feathers and cloaca of captive zebra finches (Taeniopygia guttata), with the bacterium Bacillus licheniformis PWD1 (BL), we examined the self-contamination and horizontal transmission of birds sharing the same environment. We also examined whether sexual transmission of bacteria is gender biased. Our results show that bacteria placed on the plumage of the birds lead to self and allo-infections of the bird guts, possibly through preening behaviours and bacterial ingestion. Furthermore, we found that sexual transmission of the bacteria was asymmetrical, being higher when males are the transmitting sex. Our results suggest the existence of an oral-faecal-genital route of bacterial transmission for avian hosts, wherein bacteria present on feathers infect their host guts through self and allo-preening and bacterial ingestion. Gut bacteria can then be transmitted sexually with transmission rate being higher when males are the infected sex.

Use of physiological doses of human growth hormone in haematological patients receiving intensive chemotherapy promotes haematopoietic recovery: a double-blind randomized, placebo-controlled study

In vivo and in vitro studies suggest human growth hormone (hGH) receptors on bone marrow stem cells may be biologically active and could be exploited to promote haemopoetic recovery after intensive chemotherapy. Patients with haematological malignancies receiving intensive chemotherapy and requiring hospitalization were randomized in a double-blind, placebo-controlled single-centre trial. Patients were randomly assigned to receive either hGH 500 microg/day or placebo, for 6 weeks. There was no significant difference in patient characteristics at baseline between the placebo and treatment arms. Patients treated with hGH showed significantly faster recovery of platelets to 25 x 10(9)/l (median of 16 versus 19 days; P = 0.03) compared to the placebo-controlled arm (hazard ratio 1.47 favouring hGH, 95% confidence interval (CI), 1.03-2.08). Time to relapse did not differ significantly between arms. There was no change in the anthropometric parameters at the start and end of hGH/placebo therapy. The study drug was well tolerated. Treatment with hGH in physiological doses improves platelet recovery, but is not associated with a lower relapse rate or improved anthropometric parameters in patients receiving intensive chemotherapy.

Flow cytometric quantification of antigen D sites on red blood cells of partial D and weak D variants in India

The D antigenic sites are diminished in weak D and partial D variants. The aim of this study was to estimate D antigen on RBC in weak D and partial D variants in Indian population by using flow cytometric method. Blood samples of 42 cases of partial D, eight cases of weak D and 123 normal Rh phenotypes identified by serological methods were used in the study. An indirect immunofluorescence method was employed using 29 monoclonal anti-D as primary antibody. The D antigenic sites were calculated using control RBC as internal standard. The D antigenic sites in weak D and partial D variants are less than that found in normal Rh phenotypes. In weak D, the D antigenic sites were between 1500 and 7000 D antigens per cell. Among partial D variants, DVI had minimum and DVa had maximum number of D sites. Flow cytometry is a very good tool for demonstrating minor variation in D antigen when serological methods are inconclusive. The D antigenic sites per RBC in partial D variants identified in Indian population are reported for the first time.

Lymphatic filariasis: possible pathophysiological nexus with oxidative stress

Wuchereria bancrofti-mediated lymphatic filariasis is widely prevalent. Diversity in immune response presumably may lead to myriad clinical presentations, such as overt chronic filariasis, occult filariasis with atypical systemic manifestation and asymptomatic microfilariae carrier state. Anticipated oxidative stress during inflammatory response to infective conditions might complicate the immune response and thus might alter the disease outcome. The present study was carried out to assess the status of oxidative stress in different clinical presentations of bancroftian filariasis. Twenty-five microfilariae carriers and 30 cases each of chronic filariasis and occult filariasis were compared to 30 endemic normal individuals. Serum malondialdehyde level and superoxide dismutase enzyme activity were measured by spectrophotometric methods and levels of filarial antigen were measured by ELISA. In the filarial cases, the levels of these parameters were assayed again after treatment with diethylcarbamazine citrate (DEC). Results showed significant (P<0.05) association of oxidative stress with chronic and occult filariasis but not with microfilarial carriers. DEC therapy in both clinical cases and carriers resulted in a significant reduction of oxidative stress associated with decreased antigen level (P<0.01). These findings suggest the possible involvement of oxidative stress in filarial disease pathology.

Study of association between p53 mutation and tamoxifen therapy in women with hormone receptor positive invasive ductal cancer

10630

Background: ERα promotes cell proliferation in breast tumors whereas p53 impedes cell cycle progression. We have reported direct link between these two opposing pathways. Our preclinical studies have demonstrated that ERα binds directly to p53 and negatively regulates its function and that anti estrogens disrupted the ERα- p53 interaction. Previous retrospective studies by us and others in advanced breast cancer patients had shown presence of wild type p53 in ER+ve breast tumors is associated with better response to endocrine therapy. Objective: To demonstrate women with hormonal receptor(ER) +ve non-metastatic invasive ductal cancer (IDC) with wild type p53 in the tumor tissue will have better DFS and/or OS with tamoxifen compared to those with abnormal p53. Methods: Tissue micro array (TMA) from archival tumor tissue of patients with IDC seen at Roswell Park Cancer Institute (RPCI) between 1992 and 2001 was made. The p53 status was assessed by IHC staining of the TMA, was considered positive (abnormal) if ≥10% nuclear staining was noted. Only those patients in TMA with the following criteria were included for this report; non-metastatic IDC treated at RPCI, patients who received adjuvant tamoxifen (for ER+ve tumors), p53 IHC data available. Results: 83 patients in the TMA with ER+ve tumors who were treated with tamoxifen met the study criteria to test our hypothesis. 35 patients with ER-ve tumors were analyzed to evaluate p53 effect unrelated to p53-ER interaction. Median follow up was 5 years. 16/83 (19%) ER+ve tumors and 11/35 (31%) ER-ve tumors had abnormal p53. 14 (17%) ER+ve and 11(31%) ER-ve patients experienced recurrence. 16(19%) ER+ve and 6(17%) ER-ve patients died (all causes) during the follow up period. Univariate analysis with respect to p53 for OS and DFS were undertaken. No significant OS or DFS difference were noted between patients with tumor tissue wild type and abnormal p53, for both ER+ve or ER-ve tumors. Conclusions: This study does not show any difference in outcome with tamoxifen therapy between tumors with wild type and abnormal p53. A Study with larger sample size involving sequence analysis and IHC is required to conclusively demonstrate the effect of the two common occurrences (ER+ve and abnormal p53) and tamoxifen.

No significant financial relationships to disclose.

Prognostic significance of leptin (L) and leptin receptor (OB-R) expression in human breast cancer (BC)

20054

Background: L is a cytokine-like hormone that controls adipocyte mass and energy balance by binding to OB-R. Both L and OB-R have been implicated in carcinogenesis and were recently identified in human BC. The clinical significance of increased expression of L and OB-R in human BC is unclear. Methods: The anti-L rabbit (A-20) and anti-OB-R goat (M-18) polyclonal antibodies (ABs) from Santa Cruz Biotechnology were applied in indirect immunohistochemical (IHC) assays. Following antigen retrieval, ABs were reacted with 5 μm paraffin sections of tissue microarrays (TMAs). TMAs included 1mm cores of 316 women with operable BC and contained invasive cancer (IC), ductal carcinoma insitu (DCIS), surrounding histologically normal tissue (N) and nodal metastases (M). For L, nuclear (LN) and cytoplasmic (LC) staining were evaluated separately. For OB-R, one qualitative score (0, +1, +2, +3) was applied to each case. For analysis, 0, +1 were considered low and +2, +3 were considered high expression. Expression of LN, LC, and OB-R were evaluated with respect to clinicopathologic variables; disease free survival (DFS) and survival (S) were evaluated using Cox regression. Results: Median S and DFS were 11.4 and 10.1 years. Tissue from 113 patients with IC, 93 patients with N, 49 patients with M, and 36 patients with DCIS were evaluable for LC, LN and OB-R. OB-R expression was significantly higher in lobular vs. ductal carcinomas (p < .001). Increased expression of LC, LN, or OB-R was not associated with aggressive pathologic features studied in IC and DCIS. On multivariate analysis, highest expression of LN (+3) in IC was significantly associated with poor survival, p = .038, HR 3.51 (1.07–11.51 95% CI). Strong expression of LN in N was also associated with decreased survival, p = .043, HR 8.43 (1.07, 66.30 95% CI). Strong expression of OB-R expression in N was significantly associated with increased DFS and S, p = .004, HR 0.21 (.07–0.61 95% CI) and p = .007, HR .29 (.11–.71 95% CI). Conclusions: In this limited study, LN appears to have a negative impact on survival in women with invasive BC when elevated in IC and N. Elevated levels of LR appear to have a protective effect when elevated in N. Larger studies are needed to confirm our findings and elucidate the mechanisms responsible for these observations.

No significant financial relationships to disclose.

Raised Plasma Soluble P-Selectin in Peripheral Arterial Occlusive Disease Enhances Leukocyte Adhesion

Raised levels of soluble P-selectin (sP-selectin) have been reported in the plasma of patients with vascular diseases; however, the functional importance of this ligand remains unclear. In this study we have examined a potential role for plasma sP-selectin in regulating neutrophil adhesion in patients with peripheral arterial occlusive disease (PAOD). Patients with PAOD had significantly higher levels of sP-selectin (mean±SD: 73.3±13.0 versus 16.7±6.4 ng/mL) and enhanced whole blood leukocyte adhesion to platelets under shear. To examine whether the raised sP-selectin levels can directly influence leukocyte adhesion, isolated neutrophils were incubated with plasma from PAOD patients before and after immunodepletion of sP-selectin. Neutrophil adhesion to fibrinogen increased 2-fold following incubation with PAOD plasma, which was abrogated on sP-selectin immunodepletion. We subsequently demonstrated that recombinant sP-selectin dose-dependently (75 to 250 ng/mL) increased leukocyte adhesion to fibrinogen and platelet monolayers. This increase was PSGL-1 and Src kinase-dependent and correlated with an increase in sP-selectin-mediated Mac-1 activation. sP-selectin–stimulated neutrophil adhesion to platelet monolayers was inversely correlated with shear, such that at low shear (50 s −1 ) a 92.7%±15.7 increase in adhesion was observed decreasing to 38.5%±11.9 at 150 s −1 and 10.1%±7.4 at 300 s −1 . These studies suggest a potentially important role for sP-selectin in modulating neutrophil adhesion in patients with PAOD, particularly at sites of low shear, where it raises the possibility that raised plasma sP-selectin levels may enhance leukocyte recruitment to vascular injury and promote disease progression.

An elective single autograft with high-dose melphalan: single-center study of 451 patients

In all, 451 myeloma patients, 51% previously untreated, underwent elective single autotransplantation after 200 mg/m(2) melphalan between 1985 and 2001 at the Royal Marsden Hospital. The therapy sequence was: Induction (vincristine, doxorubicin, methylprednisolone+/-cyclophosphamide), marrow or filgrastim-mobilized blood stem cell harvest, autograft, and interferon-alpha2b maintenance. A total of 27 (6%) died of transplant-related toxicity, all within 3 months. Complete or near-complete remission was seen in 59% with an overall response rate of 91%. Subsequent disease progression was seen in 285, and 17 died of unrelated causes. In all, 206 patients were alive at the last follow-up, 6 months to 17.7 years post-transplant (median 65 months); 122 without disease progression at 6 months to 17.7 years (median 58 months). The median overall (OS) and event-free (EFS) survivals were 5.9 and 2.4 years, with 10-year OS and EFS probabilities of 31.4 and 16.5%, respectively. In Cox analysis, it was seen that significantly longer OS occurred for patients who had beta-2-microglobulin <3.5 mg/l (P<0.0001), age <60 years (P=0.001) and albumin > or =35 g/l (P=0.009). EFS was also longer if beta-2-microglobulin was <3.5 mg/l (P=0.0056) and patients were <60 years of age (P=0.033). We conclude that with a single planned autograft, patients with myeloma have an excellent outcome.

Non-dilated obstructed pelvicalyceal system

Renal insufficiency because of obstruction may not always be represented by dilated pelvicalyceal system. This may make diagnosis and thence the management very difficult with the present available investigative armamentarium. Experience and clinical acumen may help with a decision of empirical treatment in the form of stenting or nephrostomy in these cases. This may be diagnostic as well as curative of the renal failure. We present herewith three such challenging cases managed by us. We also have reviewed the literature as to the diagnosis and management of such cases.

Fungal contamination of air conditioning units in operating theatres in India

Postoperative fungal infections may be caused by discharge of spores from contaminated air conditioning (AC) units. The filters of such units may act as a nidus for the growth of fungi. In this survey, filters of AC units in 25 operating theatres in India were evaluated quarterly over two years. The overall rate of fungal colonization of the AC filters was 26%. In addition, window-mounted AC units had higher fungal counts than wall-mounted AC units. We conclude that although the exact load of fungal spores necessary to initiate infections is unknown, AC units in operating theatres should be meticulously maintained and frequently monitored to minimize the chances of growth and proliferation of potentially pathogenic fungi. Data from this study also suggest that the design of the AC unit may play an important role in reducing fungal spore counts in the air of operating theatres in developing countries.

Misplaced Macroplastique injection presenting as a vaginal nodule and a bladder mass

We describe a very unusual presentation of misplaced Macroplastique injection. This incidentally showed up as bladder lesion and vaginal nodule during a tension-free vaginal tape surgery.

"Minimal intervention management" for gastroschisis: a preliminary report

The replacement of eviscerated bowel, without anaesthesia, has been performed safely in stable neonates with gastroschisis. This technique, termed "minimal intervention management", was used in three infants treated at the Newborn Special Care Nursery of the University Hospital of the West Indies. Two infants had excellent results but one had bowel perforation during the procedure, necessitating conversion to formal laparotomy under general anaesthesia. In selected patients, advantages of this technique include the ability to be guided by patient response during the procedure in order to avoid excessive intra-abdominal tension, the avoidance of anaesthesia and minimal cost. This technique is proposed for wider use in developing countries.

Thrombolysis with percutaneous transluminal balloon angioplasty of a blocked modified Blalock-Taussig shunt

Transcatheter balloon recanalization of occluded Blalock-Taussig shunts in the early post-operative period has been reported in the past but there are issues regarding the role of thrombolysis in this situation. We present our experience with such a procedure in an infant with blocked modified Blalock-Taussig shunt.

Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in Afro-Caribbean Jamaican women with postmenopausal bleeding

Postmenopausal bleeding is traditionally investigated with invasive procedures. Recent studies in white populations have suggested that these procedures can be avoided, as ultrasonographic endometrial thickness of < 5 mm is not associated with malignancy. We performed a prospective study in 75 Jamaican Afro-Caribbean women with postmenopausal bleeding to determine whether an endometrial thickness of < 5 mm excluded endometrial cancer. We also examined the aetiology of postmenopausal bleeding and looked for possible risk factors. Double-layer transvaginal ultrasonographic measurement of the endometrial thickness was followed by hysteroscopy, suction curettage and histopathological confirmation. Correlation between imaging and pathology was not reliable. Half the patients with endometrial cancer had an endometrial thickness of between 3 mm and 4 mm. Seventy per cent of the women with endometrial thickness of greater than 5 mm had benign pathology. Additionally, the following characteristics were found to be more strongly associated with women with endometrial cancer: age over 65 years and 5 or more years since menopause. However parity < 2 appeared not to have a significant effect.

Experience with eosin-5'-maleimide as a diagnostic tool for red cell membrane cytoskeleton disorders

The diagnosis of hereditary spherocytosis (HS) is based on red cell morphology and other conventional tests such as osmotic fragility, autohemolysis and acidified glycerol lysis. However, milder cases are at times difficult to diagnose. Confirmation by red blood cell (RBC) membrane protein analysis is not possible in most laboratories. Recently, a flow cytometric method has been described for quantitating the fluorescence intensity of intact red cells after incubation with the dye eosin-5'-maleimide (EMA), which binds specifically to the anion transport protein (band-3) at lysine-430. This has been shown to be an effective screening test for red cell membrane disorders. We evaluated the usefulness of this approach for screening membrane protein disorders such as HS and hereditary elliptocytosis (HE) and its value in discriminating this group from other hemolytic anemias, such as glucose-6-phosphate dehydrogenase (G6PD) deficiency, beta-thalassemia trait, sickle cell anemia and autoimmune hemolytic anemia. Fluorescence intensity, expressed in mean channel fluorescence (MCF) units, was determined using a Becton Dickinson FACS Caliber flow cytometer. Membrane protein analysis was carried out by sodium dodecyl sulfate-polyacrylamide gel eletrophoresis (SDS-PAGE). RBCs from patients with HS and HE gave significantly lower MCF values (P < 0.001) than the normal control group and other patient groups. The diagnosis of HS in four cases was confirmed by RBC membrane protein electrophoresis and all showed a deficiency of spectrin. The advantage of the EMA dye method are its specificity for membrane disorders, as well as being a simple, user-friendly and rapid method which is inexpensive, provided a flow cytometer is available.

Rubella virus and birth defects: Molecular insights into the viral teratogenesis at the cellular level

BACKGROUND

In utero rubella virus (RV) infection of a fetus can result in birth defects that are often collectively referred to as congenital rubella syndrome (CRS). In extreme cases, fetal death can occur. In spite of the availability of a safe and effective vaccine against rubella, recent worldwide estimates are that more than 100,000 infants are born with CRS annually.

RECENT PROGRESS

Recently, several significant findings in the field of cell biology, as well as in the RV replication and virus-cell interactions, have originated from the authors' laboratory, and other researchers have provided insights into RV teratogenesis. It has been shown that 1) an RV protein induces cell-cycle arrest by generating a subpopulation of tetraploid nuclei (i.e., 4N DNA) cells, perhaps representative of the tetraploid state following S phase in the cell cycle, due to its interaction with citron-K kinase (CK); 2) RV infection induces apoptosis in cell culture, and 3) CK functional perturbations lead to tetraploidy, followed by apoptosis, in specific cell types.

CONCLUSIONS

Based on several similarities between known RV-associated fetal and cellular manifestations and CK deficiency-associated phenotypes, it is reasonable to postulate that P90-CK interaction in RV-infected cells interferes with CK function and induces cell-cycle arrest following S phase in a subpopulation, perhaps representative of tetraploid stage, which could lead to subsequent apoptosis in RV infection. Taking all these observations to the fetal organogenesis level, it is plausible that P90-CK interaction could perhaps be one of the initial steps in RV infection-induced apoptosis-associated fetal birth defects in utero.

Reassessing autotransplantation for acute myeloid leukaemia in first remission – a matched pair analysis of autologous marrow vs peripheral blood stem cells

The role of autologous stem cell transplantation in adult patients with acute myeloid leukaemia (AML) in first remission is unclear, yet it has become standard treatment for myeloma and this paper explores whether the source of transplanted stem cells may explain this paradox. In total, 57 patients from the Royal Marsden Hospital who received an unpurged bone marrow transplant (ABMT) were matched with 114 patients from the EBMT registry who had undergone peripheral blood stem cell transplantation (PBSCT). Patients were matched for karyotype, FAB type, remission-autograft interval and age. In the PBSCT group, haematopoietic recovery was significantly faster and nonrelapse mortality at 4 years was significantly lower (13 vs 1%, P=0.04). The relapse rate and overall survival at 4 years (20 vs 31% and 77 vs 63%) were also better with PBSCT, although the differences were not statistically significant. Autografting should be reassessed in a randomised trial for first remission AML patients using peripheral blood as a source of stem cells rather than bone marrow.

High-dose melphalan and autotransplantation followed by post transplant maintenance chemotherapy for acute lymphoblastic leukemia in first remission

A total of 65 adults with acute lymphoblastic leukemia (ALL) received 200 mg/m2 melphalan and an autograft in first remission, with a plan to receive 6-mercaptopurine (6MP), methotrexate (MTX), and vincristine-prednisone (VP) for 2 years afterwards. There was no transplant-related mortality. In all, 69% of patients received 6MP, 54% received MTX, and 49% received VP. The cumulative incidence of relapse at 5 years was 52%. The 5-year probabilities of disease-free (DFS) and overall (OS) survival were 48 and 55%. Age >30 years, >4 weeks to attain remission, and t(9;22) or t(4;11) karyotypes were adverse prognostic features. Patients with 0 (standard risk), 1 (intermediate risk), and 2-3 (high risk) adverse features had 5-year cumulative incidences of relapse of 19, 59, and 100% (P<0.0001), and 5-year probabilities of DFS of 80, 41, and 0% (P<0.0001). The 5-year probabilities of DFS for patients receiving 0, 1, 2, and 3 maintenance therapy agents were 19, 40, 51, and 70% (P=0.0097). Maintenance therapy intensity was an independent determinant of outcome in Cox analysis. These data show that a high-dose melphalan-based autograft is safe and could be widely applicable in ALL in first remission, and that maintenance chemotherapy very likely contributes to improved outcome of autografted ALL patients.

Rubella virus P90 associates with the cytokinesis regulatory protein Citron-K kinase and the viral infection and constitutive expression of P90 protein both induce cell cycle arrest following S phase in cell culture

In utero infection of developing fetus by Rubella virus (RV) causes cell division inhibition of critical precursor cells in organogenesis, CNS-associated birth defects and induction of apoptosis in cell culture. The underlying mechanisms of RV-induced congenital abnormalities are not known. Here, we identified a novel interaction between RV replicase P90 protein and a cytokinesis-regulatory protein, the Citron-K kinase (CK), in a yeast two-hybrid cDNA library screen. Aberrations in cytokinesis and subsequent apoptosis do occur in specific cell types when the CK gene is knocked out or, its regulatory function is perturbed. Our analysis found that full-length P90 binds CK and in RV-infected cells P90 colocalizes with CK in the cytoplasm. Furthermore, during RV infection as well as cellular expression of P90 alone, we identified a discrete subpopulation of cells containing 4N DNA content, indicating that these cells are arrested in the cell cycle following S phase, suggesting that cellular expression of viral P90 during RV infection perturbs cytokinesis. Previous reports by others established that RV infection leads to apoptosis in cell culture. These observations together taken to the fetal organogenesis level, favor the idea that RV P90, by binding to cellular CK, invokes cell cycle aberrations resulting in the cell- and organ-specific growth inhibition and programmed cell death during RV infection in utero, which commonly is referred to as RV-induced teratogenesis.

Thalidomide after allogeneic haematopoietic stem cell transplantation: activity in chronic but not in acute graft-versus-host disease

Thalidomide was used to treat acute (n=21) or chronic (n=59) graft-vs-host disease (GVHD) in 80 haematopoietic stem cell allograft recipients after failure to respond to the combination of cyclosporine and corticosteroids with or without other agents. The median time to onset of acute GVHD was 11 days, and thalidomide was started at a median of 48 days post transplant. In addition to corticosteroids and cyclosporine, 13 patients had also received other agents before thalidomide. None of the patients responded and all died of acute GVHD. For chronic GVHD (limited in 13, extensive in 46), thalidomide was started at a median of 385 days post transplant. In addition to corticosteroids and cyclosporine, 34 patients received azathioprine concomitantly. In all patients, thalidomide was added to the ongoing immunosuppressive regimen. The median duration of therapy with thalidomide was 60 days (range, 11-1210; <2 weeks in 11). In total, 13 patients (22%) had complete response, eight (14%) partial response and 38 (64%) no response. Response rates were comparable for limited (39%) and extensive (33%) chronic GVHD. At a median of 53 months, 19 patients are alive, 13 without evidence of chronic GVHD. Survival was significantly better in patients who responded to thalidomide. The principal causes of death were progressive chronic GVHD (n=29) and relapsed leukaemia (n=7). In conclusion, thalidomide has no activity in acute GVHD, but has some activity in chronic GVHD in combination with other agents.

Posterior cruciate ligament at total knee replacement. Essential, beneficial or a hindrance?

We report the results of a prospective randomised trial which assessed the role of the posterior cruciate ligament (PCL) following total knee replacement (Genesis I; Smith and Nephew, Memphis, Tennessee). Over a four-year period, 211 patients underwent total knee replacement by the senior author (TJW). They were randomised at surgery to have the PCL either retained, excised or substituted with a posterior stabilised insert. If it was not possible to retain the ligament due to soft-tissue imbalance, it was released from its tibial insertion until suitable tension was obtained. This created a fourth group, those who were intended preoperatively to have the ligament retained, but in whom it was partially released as a result of findings at the time of surgery. All patients were evaluated using the Knee Society rating system (adapted from Insall). A total of 188 patients (212 knees) was available for follow-up at a mean of 3.5 years after surgery. Preoperatively, there was a varus deformity in 191 knees (90%) and a valgus deformity in 21 (10%). There were no statistical differences in the knee or function scores or the range of movement between the excised, retained and substituted groups. There were, however, significantly worse knee and function scores in the group in whom the PCL was released (p = 0.002).

Posterior cruciate ligament at total knee replacement

We report the results of a prospective randomised trial which assessed the role of the posterior cruciate ligament (PCL) following total knee replacement (Genesis I; Smith and Nephew, Memphis, Tennessee). Over a four-year period, 211 patients underwent total knee replacement by the senior author (TJW). They were randomised at surgery to have the PCL either retained, excised or substituted with a posterior stabilised insert. If it was not possible to retain the ligament due to soft-tissue imbalance, it was released from its tibial insertion until suitable tension was obtained. This created a fourth group, those who were intended preoperatively to have the ligament retained, but in whom it was partially released as a result of findings at the time of surgery.

All patients were evaluated using the Knee Society rating system (adapted from Insall). A total of 188 patients (212 knees) was available for follow-up at a mean of 3.5 years after surgery. Preoperatively, there was a varus deformity in 191 knees (90%) and a valgus deformity in 21 (10%).

There were no statistical differences in the knee or function scores or the range of movement between the excised, retained and substituted groups. There were, however, significantly worse knee and function scores in the group in whom the PCL was released (p = 0.002).

Signaling events underlying thrombus formation

Recent in vivo studies have highlighted the dynamic and complex nature of platelet thrombus growth and the requirement for multiple adhesive receptor-ligand interactions in this process. In particular, the importance of von Willebrand factor (VWF) in promoting both primary adhesion and aggregation under high shear conditions is now well established. In general, the efficiency with which platelets adhere and aggregate at sites of vessel wall injury is dependent on the synergistic action of various adhesive and soluble agonist receptors, with the contribution of each of the individual receptors dependent on the prevailing blood flow conditions. In this review, we will discuss the major platelet adhesive interactions regulating platelet thrombus formation under high shear, with specific focus on the VWF (GPIb and integrin alphaIIbbeta3) and collagen receptors (GPVI and integrin alpha2beta1). We will also discuss the signaling mechanisms utilized by these receptors to induce platelet activation with specific emphasis on the role of cytosolic calcium flux in regulating platelet adhesion dynamics. The role of soluble agonists in promoting thrombus growth will be highlighted and a model to explain the synergistic requirement for adhesive and soluble stimuli for efficient platelet aggregation will be discussed.

Impact of cytogenetics on the outcome of autotransplantation for acute myeloid leukemia in first remission: is the benefit of intensive pretransplant therapy limited to patients with good karyotypes?

A total of 81 adults with acute myeloid leukemia (AML) (47% favorable karyotypes) were autografted in first remission after melphalan-total body irradiation, having received 0 (n=7), 1 (n=19), 2 (n=51), or 3 (n=4) consolidation chemotherapy cycles before harvest. The cumulative 5-year incidences of relapse and transplant-related mortality were 37 and 17%, respectively. The actuarial 5-year probability of disease-free survival (DFS) was 46%. In Cox analysis, favorable karyotypes, increasing numbers of consolidation cycles (0 vs > or =1 or 1 vs >1), and higher nucleated cell doses were associated with lower relapse rates and higher DFS. Patients with favorable karyotypes benefited from every additional cycle of consolidation therapy (0 vs > or =1 as well as 1 vs >1). Among patients with other karyotypes, while the benefit of one cycle of consolidation was clear (0 vs > or =1), there was no obvious beneficial impact of further consolidation therapy (1 vs >1). Administration of consolidation chemotherapy prior to harvest is essential in AML. While it is possible to enhance the benefit of consolidation with favorable karyotypes by delivering two cycles, its usefulness is limited in others. In them, it may be worthwhile exploring alternatives not normally used in AML (eg high-dose cyclophosphamide) that could have antileukemic effects while permitting mobilization of stem cells.

Haploidentical vs autologous hematopoietic stem cell transplantation in patients with acute leukemia beyond first remission

This is a retrospective comparison of partially mismatched related donor transplantation (PMRDT) and autotransplantation (ABMT) in advanced acute leukemia. Patients underwent T-cell-depleted PMRDT (n=164) or ABMT (n=131) for acute myeloid leukemia (n=130) or acute lymphoblastic leukemia (n=165). Fewer PMRDT patients were in remission (29 vs 85%; P<0.0001). The 5-year cumulative incidence of transplant-related mortality (TRM) was 52% after PMRDT and 16% after ABMT (P<0.0001). The 5-year cumulative incidence of relapse was 32% after PMRDT and 54% after ABMT (P=0.006). The actuarial unadjusted 5-year disease-free survival (DFS) was 16% after PMRDT and 30% after ABMT. In Cox's regression analysis, PMRDT (P<0.0001) and age >15 years (P=0.002) were associated with higher TRM, active disease (P=0.0021), ABMT (P=0.0074) and male sex (P=0.011) with higher relapse, and age >15 years (P=0.0007) and PMRDT (P=0.047) with lower DFS. Amongst second remission patients, TRM was higher after PMRDT (P=0.0003), relapse was higher after ABMT (P=0.034), and 5-year DFS was comparable (32% ABMT and 25% PMRDT). ABMT, if feasible, may be preferable to PMRDT in advanced acute leukemia patients since lower relapse after PMRDT is offset by higher TRM. If an autograft is not feasible because of nonavailability of autologous cells or very advanced disease, PMRDT is a potential alternative.

Supplemental premolars in a 13 year old child--a case report

A case of 13 old year is presented with supernumerary maxillary premolars one on either side. Radiograph revealed presence of five more supernumerary teeth unerupted in both maxilla and mandible. The implications of early diagnosis and management to prevent further complications are discussed.

Patients' recollection of day case knee arthroscopy procedure

A prospective study of 103 consecutive patients who underwent day case knee arthroscopy was performed. The purpose was to evaluate the information delivery system, patient comprehension, and issues of informed consent pertaining to day case arthroscopy procedures. There were 34 females and 69 males in the study group and their mean age was 38.6 years (range: 14.4 to 74.9 years). The diagnosis, procedure, and aftercare were explained to the patients in the outpatients clinic by a trained nurse and by the operating surgeon just prior to the operation. The nurse before the operation gave the patients an information booklet. Postoperatively the patients were informed about the findings and diagnosis prior to their discharge from the day care facility. Patients were requested to complete a questionnaire. Three weeks later they were given the same questionnaire, prior to consultation, in the outpatient clinic. These two forms were compared with the operative findings and diagnosis documented in the copy, of the questionnaire completed by the surgeon as well as the case notes. Most patients (38.8%; 40 patients) had no recollection; 3.9% (4 patients) had partial recollection at their consultation three weeks later; 19.4% (20 patients) found that the arthroscopic photograph was not helpful in making them understand the procedure; and 9.7% (10 patients) found the information booklet to be unhelpful. Further, 23.3% (24 patients) said that it would not help if the booklet were sent to them prior to the operation. The recollection rate was also correlated to their position on the operating list, to ascertain the effect of the anesthetic. There was a 65.9% (58 patients) recollection rate in those patients who were on the first half of the list and there was only a 33.33% recollection rate in those patients who were last or second to the last [p = 0.0225]. We recommend regular evaluation and improvement in the communication and information delivery system provided to patients.

Response to induction chemotherapy is not essential to obtain survival benefit from high-dose melphalan and autotransplantation in myeloma

Two hundred and twenty-two myeloma patients autografted after 200 mg/m(2)melphalan were studied to examine the relationship between response to induction chemotherapy and outcome. Induction comprised cyclophosphamide, vincristine, doxorubicin and methylprednisolone (C-VAMP) every 3 weeks for one cycle beyond maximum response. 81% responded to C-VAMP (chemosensitive) with 40 complete (CR) and 139 partial (PR) remissions, and 43 did not respond (NR; <50% reduction in paraprotein; primary refractory). Overall, 130 patients (59%) attained or remained in CR post-transplant; including 40% of NR, 53% of PR, and 97% of CR after C-VAMP (P < 0.0001). Amongst these 130 patients, the 5-year OS was independent of response to C-VAMP (NR 79%, PR 74%, CR 60%; P = 0.69). Similarly, among the 69 patients in PR post-transplant, the 5-year OS was independent of response to C-VAMP. In Cox analysis, lack of response to C-VAMP did not affect outcome significantly. These data show that lack of response to induction therapy does not automatically predict poor long-term outcome in myeloma, since a substantial proportion of these patients attain CR after autograft and enjoy extended survival. Myeloma patients should not be disqualified from an autograft based upon lack of response to induction chemotherapy.

Collection of peripheral blood stem cells in newly diagnosed myeloma patients without any prior cytoreductive therapy: the first step towards an 'operational cure'?

We have shown that primary therapy with non-myeloablative (140 mg/m(2)) high-dose melphalan (HDM) without hematopoietic support results in high response rates in untreated myeloma and very long-term survival of some patients. This study was designed to see if sufficient CD34 (+) cells can be harvested at presentation in newly diagnosed patients to administer myeloablative HDM (200 mg/m(2); HDM200) with autograft as primary therapy. This may improve outcome by rapid achievement of complete remission (CR) and possible avoidance of late myelodysplasia as a consequence of non-transplant induction chemotherapy. Thirty untreated patients received 1 g/m(2) methylprednisolone daily (days 1-6) and 12-16 micro g/kg G-CSF daily (days 3-6), and underwent leukapheresis on days 6 and 7. The median CD34(+) cell yield was 1.31 x10(6)/kg (range, 0.23-5.63), and was > or =1 x10(6)/kg in 73%. Cell yields were significantly lower than in 82 historical controls apheresed after completion of induction chemotherapy (median 2.16 x 10(6)/kg), and improved in patients who were apheresed again after induction chemotherapy. Three patients received primary therapy with HDM200 and autograft using these cells and attained CR. We conclude that it is possible to harvest stem cells in three-quarters of untreated myeloma patients. Increasing the number of apheresis procedures is needed to improve the number of CD34(+) cells collected.

A randomised controlled trial of outpatient versus inpatient cervical cerclage

Fifty patients with cervical incompetence were randomised to have cervical cerclage either as inpatients, spending 3 days in hospital post-procedure on supervised bed rest or as outpatients spending the time at home on bed rest. Both groups had a clinical diagnosis of cervical incompetence and both had either McDonald or Shirodkar cerclage with mersilene tape. Both groups were given salbutamol tablets for tocolysis, postoperatively. There were no significant difference in the demographic variables between the groups such as previous cerclage, gestational age at insertion, parity and gestational age at delivery. There were also no significant differences in early complications such as bleeding. Most late complications were also not different, including the spontaneous abortion rate, premature rupture of membranes, cervical dystocia and preterm delivery. However, more patients in the outpatient group had premature contractions (26.1% vs. 4.3% P=0.0479). More patients in the inpatient group had a delivery of a live neonate, 86.9% vs. 78.3%, but the difference was not statistically significant. In conclusion, out patient cerclage appears to be a valid option, the higher rate of premature contraction in this group is not a cause for concern in view of the similar mean gestational age at delivery.

Prevalence and incidence of hepatitis B virus infection in STD clinic attendees in Pune, India

OBJECTIVES

To estimate the prevalence and incidence of hepatitis B virus (HBV) infection among patients attending three STD clinics in Pune, India, and to identify associated risk factors.

METHODS

Of the 2098 patients screened at STD clinics in Pune during 1996, 497, who returned for at least one follow up visit, were screened for various markers of HBV infection (HBsAg, anti-HBs, anti-HBc), HIV antibody, and VDRL.

RESULTS

Of the 497 participants 3.6%, 26.5%, and 43.2% were positive for HBsAg, anti-HBs, and anti-HBc respectively. Tattooing (AOR 1.64, 95% CI 1.03 to 2.64) was found to be independently associated with presence of core antibody. Additionally, history of being in commercial sex work and history of a genital ulcer were independently associated with a positive anti-HBc antibody test (AOR 12.45, 95% CI 5.58 to 27.82 and AOR 1.70, 95% CI 1.09 to 2.66, respectively). 72 out of 497 (14.5%) participants were HIV positive at baseline. HIV-1 antibody positive patients were more likely to have a positive anti-HBc test (69.4% v 39.0%, p<0.001). 30 out of 282 participants, negative for anti-HBc antibody at enrolment, seroconverted subsequently, resulting in an incidence of 10.86 per 100 person years (95% CI 7.2%, 14.5%) (mean and accumulated follow up of 11.7 months and 276.17 person years, respectively).

CONCLUSIONS

A high prevalence and incidence of HBV infection, seen in STD clinic attendees underscore the need to provide HBV vaccine to commercial sex workers and their clients in India.

Does donor-recipient ABO incompatibility protect against relapse after allogeneic bone marrow transplantation in first remission acute myeloid leukemia?

It is not known if donor-recipient ABO blood group incompatibility contributes to graft-versus-leukemia after allogeneic BMT. One hundred and nineteen patients with acute myeloid leukemia in first remission underwent non-T cell-depleted marrow allografts from HLA-identical siblings after TBI and cyclophosphamide (n = 72) or melphalan (n = 47). GVHD prophylaxis comprised cyclosporine alone or cyclosporine-methotrexate. Twenty-two patients relapsed at 3-46 months (median 7): 18 of 76 patients with ABO-matched donors and four of 43 patients with ABO-mismatched donors (actuarial 5-year probabilities 33 +/- 6% vs 12 +/- 6%; P = 0.028). The incidence of acute and chronic GVHD was not affected by ABO mismatch. The following factors were studied in Cox analysis for effect on outcome: gender, age, FAB subtype, ABO mismatch, CR-transplant interval, conditioning, TBI dose, nucleated cell dose, lymphocyte recovery, acute GVHD, and chronic GVHD. Donor-recipient ABO match was the only factor independently associated with a higher risk of relapse (RR = 3.7; 95% Cl, 1.1-12.6; P = 0.04). ABO mismatch was also associated with superior overall and disease-free survivals. We conclude that ABO incompatibility may influence relapse rates and survival favorably after allogeneic BMT. It is not known if this holds true for allogeneic blood stem cell transplants.