Allogeneic bone marrow transplantation vs chemotherapy for the treatment of childhood acute lymphoblastic leukaemia in second complete remission (revisited 10 years on)

In 1989 we carried out a trial comparing allogeneic BMT to chemotherapy (CT) in 76 children with relapsed acute lymphoblastic leukaemia (ALL). Ten years on we have clinically revised outcome to firmly establish the role of each treatment, to analyse the importance of length of first remission and to provide long-term actuarial results for disease-free survival (DFS) and relapse rate in each group. For 21 patients within the transplantation group, probability of DFS and relapse are 42.8 +/- 10.8% and 40.2 +/- 11.7% (s.e.), respectively. In the chemotherapy group, probability of DFS is 10.0 +/- 4.74% (P = 0.001) and probability of relapse 87.5 +/- 5.2% (P = 0.0004). These results strongly reflect those at initial analysis, confirming a key role of BMT in the management of ALL in second remission. Moreover, on univariate analysis only two factors influenced DFS: treatment group and length of first complete remission (less or more than 30 months from first CR). Thus, it seems clear that the best therapeutic option in early relapse is BMT, whereas DFS in late relapse is at the limit of significance (P = 0.07), with a higher relapse rate in the CT group. Although encouraging results using intensified rotational combination chemotherapy have been published, prospective randomised studies are needed to assess with certainty the best therapeutic option in these patients.

Do the components of heat and moisture exchanger filters affect their humidifying efficacy and the incidence of nosocomial pneumonia?

OBJECTIVES

To compare the efficiency of two heat and moisture exchange filters (HMEFs) of different compositions of the humidifying capacity and the rate of bronchial colonization and ventilator-associated pneumonia in patients in the intensive care unit (ICU).

DESIGN

Prospective, randomized study.

SETTING

ICU of a university hospital.

PATIENTS

All patients who required mechanical ventilation for 24 hrs or more during the study period.

INTERVENTIONS

At admission to the ICU, patients were randomly assigned to one of two groups. In one group, the patients were ventilated with Humid-Vent Filter Light HMEF. The condensation surface was made of paper impregnated with CaCl2. The filter membrane was made of polypropylene. In the other group, the patients were ventilated with the Clear ThermAl HMEF (Intersurgical, France). The condensation surface was made of plastic foam impregnated with AlCl2. The filter membrane was made of two polymer fibers (modacrylic and polypropylene). In both groups, HMEFs were changed daily.

MEASUREMENTS AND MAIN RESULTS

Seventy-seven patients were ventilated for 19+/-7 days with the Humid-Vent Filter Light HMEF and 63 patients for 17+/-6 days with the Clear ThermAl HMEF. Patients ventilated with the Humid-Vent Filter Light underwent 8.7+/-3.7 tracheal aspirations and 1.2+/-2.0 instillations per day and those with the Clear ThermAl, 8.2+/-3.9 and 1.5+/-2.4 per day, respectively (NS). The abundance of tracheal secretions and the presence of blood and viscosity, as evaluated by semiquantitative scales, were similar in both groups. One episode of tracheal tube occlusion was observed with the Humid-Vent Filter Light HMEF and none with the other HMEF (NS). Tracheal colonization was observed at a rate of 91% with the Humid-Vent Filter Light and 97% with the Clear ThermAl (NS). The rate of ventilator-associated pneumonia was similar in both groups (35%). Bacteria responsible for tracheal colonization and pneumonia were similar in both groups.

CONCLUSIONS

Despite differences in their components, the two HMEFs that were tested achieved similar performances in terms of humidification and heating of inspired gases. Only one episode of endotracheal tube occlusion was detected, and very few patients (three in each group) had to be switched to an active heated humidifier. No difference was observed either in the rate of tracheal colonization or of ventilator-associated pneumonia. These data show that the Humid-Vent Filter Light and the Clear ThermAl HMEFs are suited for use with ICU patients.

Risky sex behavior and substance use among young adults

Many young adults, despite widespread prevention and education efforts that target this age group, engage in behaviors that place them at risk of HIV infection. These behaviors include frequent experimentation with alcohol and other drugs before sex, sexual activity with different partners, and inconsistent safe-sex practices. The combination of these risky behaviors causes increased concern about the spread of HIV among this age group. The study discussed in this article examined the relationship between substance use during adolescence and HIV risk behavior among young adults ages 19 to 21 with and without a college education. Results indicated that increased use of alcohol and marijuana at younger ages is related to riskier sexual activity and increased use of alcohol and marijuana as young adults. Recommendations for interventions are made.

Mechanisms of insecticide resistance in the aphid Nasonovia ribisnigri (Mosley) (Homoptera: Aphididae) from France

Nasonovia ribisnigri, a main pest of salad crops, has developed resistance to various insecticides in southern France, including the carbamate pirimicarb and the cyclodiene endosulfan, two insecticides widely used to control this aphid. Here we have investigated the mechanisms of resistance to these two insecticides by studying cross-resistance, synergism, activity of detoxifying enzymes, and possible modifications of the target proteins. Resistance to pirimicarb was shown to be mainly due to a decreased sensitivity of the target acetylcholinesterase; this modification conferred also, resistance to propoxur but not to methomyl and the two tested organophosphates (acephate and paraoxon). Endosulfan resistance was associated with a moderate level of resistance to dieldrin, and resistance to both insecticides was due, in part, to increased detoxification by glutathione S-transferases (GST). The endosulfan resistant strain displayed the same amino acid at position 302 of the Rdl gene (GABA receptor) as susceptible aphids (e.g. Ala), indicating that the Ala to Ser (or to Gly) mutation observed among dieldrin resistant strains of other insect species was not present.

[On what depends the dependence? Thoughts on the law establishing a specific subsidy of dependence in old age]

The dependency of elderly persons became recently an autonomous issue beside the problem of the pensions or the disability. We can explain this late apparition in the field of social policy by a strong attention paid to problems of the pensions and the lack of interest to the new concept of disability. But the main reason is the disagreement on two main questions. There is no common vision on the resources that the community must devote to help dependent people and their family. Moreover there is no agreement on the quality assurance of the services provided. The public debate for the first law was focused on the measure of the dependency and its budget. The second, in a context of growth of the number of dependent people, must integrate the need of support for an increasing number of families, and the condition for production of care of quality.

Influence of sampling site on concentrations and carbohydrate-degrading enzyme activities of protozoa and bacteria in the rumen

Four ruminally cannulated cows were used to assess the distribution of the concentrations and carbohydrate-degrading enzyme activities of the liquid-associated protozoa (LAP) and solid-associated bacteria (SAB) in the rumen. The cows were fed diets (7 kg of DM/d) of 100% hay (Diet F) or 60% barley plus 40% hay (Diet C) in a 2 x 2 crossover experimental design. Samples of ruminal digesta were collected successively from the dorsal (DS), ventral (VS), and anterior (AS) sacs 1h before and 3 h after the morning feeding on two sampling days with a 2-d interval. Irrespective of diet and sampling time, the greatest proportion of entodiniomorphs, representing the main population of protozoa, was found in the DS (40% mean; P < .05). Low pH values observed in the DS (P < .05) indicated higher fermentative activity in this site than in the other parts of the rumen. Protozoa may contribute more than previously thought to the high digestive potential present at the top of the rumen that has classically been attributed to bacteria. The specific activity of plant cell wall polysaccharide-degrading enzymes in the LAP was correspondingly greater (P < .05) for DS than for VS or AS. For the two diets and sampling times, specific activity of fibrolytic enzymes in the SAB tended to be less in the upper than in the lower parts of the rumen, and less in the VS than in the AS. This tendency became significant (P < .05) for total fibrolytic enzyme activity. Differences in bacterial colonization of particles among the three sampling sites may explain such differences in fibrolytic activity of the SAB. Data suggest a spatio-temporal complementary action of the bacteria and protozoa in ruminal plant cell wall degradation, at least with the barley diet, for which the number of protozoa was highest.

Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery

BACKGROUND

There is a lack of information and knowledge about the practical importance of even low concentrations of the excretion of local anesthetics into breast milk, particularly concerning bupivacaine. The present work aims to confirm, under practical clinical conditions of admission of parturients, the passage of local anesthetics (lidocaine and bupivacaine) into breast milk after an epidural anesthesia.

METHODS

Twenty-seven pregnant women admitted for cesarean delivery received epidural anesthesia with 0.5% bupivacaine and 2% lidocaine. Blood and milk samples were simultaneously collected at 2, 6 and 12 h after the beginning of the epidural infusion. Lidocaine, bupivacaine and its main metabolite, pipecolylxylidide (PPX), were determined in serum and milk by a gas-liquid chromatographic technique. APGAR scores were systematically performed at delivery and a clinical examination was done 24 h after delivery.

RESULTS

Our data indicate that lidocaine and bupivacaine as well as PPX are excreted into breast milk. The milk/serum ratio based upon area under the curve values were 1.07 +/- 0.82, 0.34 +/- 0.24 and 1.37 +/- 0.61 mean +/- SD for lidocaine, bupivacaine and PPX, respectively. Most of the newborns had a maximal APGAR score. Our study does not reveal any adverse reactions related to the excretion of local anesthetics into breast milk.

CONCLUSION

This study documents the magnitude of excreted lidocaine, bupivacaine and PPX in breast milk, and indicates that the use of both lidocaine and bupivacaine for epidural anaesthesia is safe with regard to breast-feeding.

Effect of neutron-gamma radiation on dopamine and serotonin metabolism in the rat brain: a regional analysis

The concentrations of dopamine (DA) and its metabolites and the levels of 5-hydroxyindoleacetic acid (5-HIAA), the metabolite of serotonin, were determined in discrete cerebral areas of rats 3 hr after (neutron-gamma) irradiation at 4 and 7 Gy. After the 7 Gy irradiation, no significant effect was observed. After the 4 Gy exposure, the most marked difference between irradiated and control rats was in the levels of DA and its metabolites in the striatum. We observed a decrease of DA, HVA, and DOPAC levels in the striatum and an opposite pattern in the substantia nigra. Whatever the brain area observed, an increase of 5-HIAA levels was noted.

Rapid thinning of parts of the southern greenland ice sheet

Aircraft laser-altimeter surveys over southern Greenland in 1993 and 1998 show three areas of thickening by more than 10 centimeters per year in the southern part of the region and large areas of thinning, particularly in the east. Above 2000 meters elevation the ice sheet is in balance but thinning predominates at lower elevations, with rates exceeding 1 meter per year on east coast outlet glaciers. These high thinning rates occur at different latitudes and at elevations up to 1500 meters, which suggests that they are caused by increased rates of creep thinning rather than by excessive melting. Taken as a whole, the surveyed region is in negative balance.

Type 2 diabetes: evidence for linkage on chromosome 20 in 716 Finnish affected sib pairs

We are conducting a genome scan at an average resolution of 10 centimorgans (cM) for type 2 diabetes susceptibility genes in 716 affected sib pairs from 477 Finnish families. To date, our best evidence for linkage is on chromosome 20 with potentially separable peaks located on both the long and short arms. The unweighted multipoint maximum logarithm of odds score (MLS) was 3.08 on 20p (location, chi = 19.5 cM) under an additive model, whereas the weighted MLS was 2.06 on 20q (chi = 57 cM, recurrence risk,lambda(s) = 1. 25, P = 0.009). Weighted logarithm of odds scores of 2.00 (chi = 69.5 cM, P = 0.010) and 1.92 (chi = 18.5 cM, P = 0.013) were also observed. Ordered subset analyses based on sibships with extreme mean values of diabetes-related quantitative traits yielded sets of families who contributed disproportionately to the peaks. Two-hour glucose levels in offspring of diabetic individuals gave a MLS of 2. 12 (P = 0.0018) at 9.5 cM. Evidence from this and other studies suggests at least two diabetes-susceptibility genes on chromosome 20. We have also screened the gene for maturity-onset diabetes of the young 1, hepatic nuclear factor 4-a (HNF-4alpha) in 64 affected sibships with evidence for high chromosomal sharing at its location on chromosome 20q. We found no evidence that sequence changes in this gene accounted for the linkage results we observed.

[Public health professionals' perceptions regarding two dimensions of health promotion: the ecological approach and community participation]

The aim of this paper is to explore public health professionals' perceptions regarding two dimensions of the new health promotion movement: the ecological approach and the principle of community participation. Data were collected by focus-groups of public health professionals (n = 22) in one Public Health Directorate in Québec. Results indicate a fair degree of integration of these two dimensions into the respondents' professional practice. However, limitations related to the work environment and to the theoretical underpinnings of these two components might impede the respondents' ability to integrate them into their practice.

Virulence gene regulation in pathogenic Escherichia coli

The ability to regulate gene expression throughout the course of an infection is important for the survival of a pathogen in the host. Thus, virulence gene expression responds to environmental signals in many complex ways. Frequently, global regulatory factors associated with specific regulators co-ordinate expression of virulence genes. In this review, we present well-described regulatory mechanisms used to co-ordinate the expression of virulence factors by pathogenic Escherichia coli with a relative emphasis on diseases caused by E. coli in animals. Many of the virulence-associated genes of pathogenic E. coli respond to environmental conditions. The involvement of global regulators, including housekeeping regulons and virulence regulons, specific regulators and then sensor regulatory systems involved in virulence, is described. Specific regulation mechanisms are illustrated using the regulation of genes encoding for fimbriae, curli, haemolysin and capsules as examples.

T2 vertebral bone marrow changes after space flight

Bone biopsies indicate that during immobilization bone marrow adipose tissue increases while the functional cellular fraction decreases. One objective of our Spacelab flight experiment was to determine, using in vivo volume-localized magnetic resonance spectroscopy (VLMRS), whether bone marrow composition was altered by space flight. Four crew members of a 17 day Spacelab mission participated in the experiment. The apparent cellular fraction and transverse relaxation time (T2) were determined twice before launch and at several times after flight. Immediately after flight, no significant change in the cellular fraction was found. However, the T2 of the cellular, but not the fat component increased following flight, although to a variable extent, in all crew members with a time course for return to baseline lasting several months. The T2 of seven control subjects showed no significant change. Although these observations may have several explanations, it is speculated that the observed T2 changes might reflect increased marrow osteoblastic activity during recovery from space flight.

Prevention of graft-versus-host disease in high risk patients by depletion of CD4+ and reduction of CD8+ lymphocytes in the marrow graft

From March 1994 to September 1997, 30 patients with hematological malignancies (12 ANLL, 10 CML, four ALL and four multiple myeloma) received HLA-identical allogeneic bone marrow transplants with the marrow graft selectively depleted of CD4+ lymphocytes and the CD8+ cell content adjusted to 1x10(6)/kg. Total depletion of CD4+ and partial depletion of CD8+ lymphocytes was carried out by an immunomagnetical method. All patients were considered as having high risk for developing GVHD by at least one of the following criteria: patient age >35 years; donor age >35 years; donor multiparity or marrow from an unrelated donor. Twenty-four cases received marrow from an identical sibling and six from an unrelated donor. In order to assess the role of methotrexate (MTX) in addition to cyclosporin A (CsA) after transplant, patients were randomly assigned to received either CsA alone (n = 15) or CsA plus a short course of MTX (n = 15). No case of primary graft failure was observed, but two patients developed late graft failure. Six patients presented grade II acute GVHD and no case of severe III-IV GVHD was seen. The actuarial probability of developing grade II-IV acute GVHD was 25.9+/-9.6% for the entire population. Patients receiving post-transplant CsA + MTX had significantly less probability of acute GVHD than those receiving CsA exclusively (6.7+/-6.4% vs. 50.5+/-17.8%, P = 0.03) and the schedule of post-transplant immunosuppression was the only factor associated with the incidence of acute GVHD in a multivariate analysis. The actuarial incidence of chronic GVHD for the entire population was 31.8+/-12.5, and there was no significant difference between both groups with additional prophylaxis. Four patients with CML and three with ANLL relapsed: the actuarial probability of remaining in complete remission for all patients was 53.6+/-17.3%. For patients with acute leukemia, the probability of remaining in complete remission did not differ significantly between those transplanted in first complete remission and those receiving a transplant in more advanced phases of the disease (87.5+/-11.6% vs. 72.9+/-16.5%; P = 0.44). The incidence of mixed chimerism assessed by PCR was 34%. Nineteen patients are alive between 2 and 43 months post-transplant, the probability of overall survival being 57.8+/-10.4%. Our data indicate that this method of selective T cell depletion is very effective in preventing acute GVHD in high risk patients, particularly when used in combination with post-transplant CsA + MTX.

Clinical follow-up of high mid-trimester maternal serum intact human chorionic gonadotrophin concentrations in singleton pregnancies

Mid-trimester biochemical screening of 38 143 pregnancies in south-east Scotland revealed 127 cases (0.34 per cent) in which the maternal serum (MS) intact human chorionic gonadotrophin (hCG) concentration was > or = 4 multiples of the median in singleton pregnancies (MOM). Three were lost to follow-up but in 72 (58 per cent) complications developed or there were associated fetal abnormalities. This percentage was greatest at very high hCG concentrations, 92 per cent with hCG > or = 10 MOM (n = 12) compared with 48 per cent with hCG concentrations of 4-4.99 MOM (n=69). 22 cases had an MS alpha-fetoprotein > or = 2 MOM in addition to an MS hCG > or = 4 MOM, and in only 3 of these was the pregnancy uneventful; 86 per cent were associated with abnormalities or pregnancy complications.

[Adenocarcinoma of unknown primary site with thoracic localization and HIV: four case reports]

INTRODUCTION

Non AIDS-defining cancer would have increased in HIV-patients as suggested by numerous studies. Four cases of adenocarcinoma of unknown primary site with thoracic localization that occurred in HIV-infected patients are described.

EXEGESIS

To date, there have been no published data about carcinomas of unknown primary site relating to HIV-infected patients; however, immunodepression could promote them. Carcinomas of unknown primary site account for 0.5 to 10% of all cancer in general population. Primary carcinoma is identified in approximately one third of the cases and often corresponds to lung cancer in case of sus-diaphragmatic metastasis, particularly in case of pleural metastasis. Lung cancer in HIV-infected patients affects mostly young men who smoke and are often intravenous drug addicts. Adenocarcinoma is the most common histological type of cancer.

CONCLUSION

Further studies of lung cancer in HIV-infected patients will help evaluate their frequency. In case of increasing frequency, lung cancer should then be included in AIDS-defining cancers.

Dyscalculia in the early stages of Alzheimer's disease

OBJECTIVE

To study mathematical deficits in the early stages of Alzheimer's disease (AD).

METHODS

Sixty-eight patients with mild AD and 242 normal controls (NC) received a standardized battery (EC 301-R) assessing number processing and calculation abilities. AD patients also received testing for language, memory, visuo-spatial and executive-attentional domains.

RESULTS

Sixty-four AD patients (94.1%) showed impaired performances on the EC 301-R. Mathematical deficits were evident both on calculation and number processing skills. Performance on the single tasks was related to attentional-executive resources and to impaired number representations. Heterogeneous patterns of preserved/impaired mathematical abilities were also observed in single cases.

CONCLUSION

Dyscalculia is an early sign of AD. It should be included among the reliable clinical hallmarks for the diagnosis of AD. Identification of dyscalculic symptoms in these patients requires composite assessment procedure.

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group

BACKGROUND

To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction.

METHODS

We enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter.

RESULTS

Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) -- and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05).

CONCLUSIONS

A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.