Allogeneic haemopoietic stem cell transplantation for multiple myeloma or plasma cell leukaemia using fractionated total body radiation and high-dose melphalan conditioning

We have evaluated the outcome of allogeneic haemopoietic stem cell transplantation for multiple myeloma using a conditioning regimen comprising fractionated total body irradiation and high-dose melphalan (110 mg/m2). The study comprised 25 patients (median age 49 years) who had been transplanted by either bone marrow (n = 13) or G-CSF mobilized peripheral blood stem cells (n = 12). Overall transplant-related mortality was 30% but was lower for patients < 50 years of age at transplant (21%). The main cause of treatment-related mortality was viral infection. Of the 19 patients evaluable post-transplant, 17 have so far achieved complete remissions. Currently, with a median follow-up of 3.4 years, 18 out of 25 patients are alive, of whom 15 are in continuing complete remission (CR) and 2 in second remission after suffering localized relapses, which were treated with radiotherapy and donor leucocyte infusions. Patients transplanted after 1 line of previous therapy, < 50 years of age and receiving peripheral blood stem cells (PBSC) rather than bone marrow (BM) had a superior outcome, although there was no statistically significant factor. We conclude that allogeneic transplantation should be considered as a potentially curative option for younger patients with myeloma and that the regimen using fractionated total body irradiation and melphalan has a high CR rate and a relatively low risk of treatment-related mortality, particularly in younger patients.

Overexpression of 3-ketoacyl-acyl-carrier protein synthase IIIs in plants reduces the rate of lipid synthesis

A cDNA coding for 3-ketoacyl-acyl-carrier protein (ACP) synthase III (KAS III) from spinach (Spinacia oleracea; So KAS III) was used to isolate two closely related KAS III clones (Ch KAS III-1 and Ch KAS III-2) from Cuphea hookeriana. Both Ch KAS IIIs are expressed constitutively in all tissues examined. An increase in the levels of 16:0 was observed in tobacco (Nicotiana tabacum, WT-SR) leaves overexpressing So KAS III when under the control of the cauliflower mosaic virus-35S promoter and in Arabidopsis and rapeseed (Brassica napus) seeds overexpressing either of the Ch KAS IIIs driven by napin. These data indicate that this enzyme has a universal role in fatty acid biosynthesis, irrespective of the plant species from which it is derived or the tissue in which it is expressed. The transgenic rapeseed seeds also contained lower levels of oil as compared with the wild-type levels. In addition, the rate of lipid synthesis in transgenic rapeseed seeds was notably slower than that of the wild-type seeds. The results of the measurements of the levels of the acyl-ACP intermediates as well as any changes in levels of other fatty acid synthase enzymes suggest that malonyl-ACP, the carbon donor utilized by all the 3- ketoacyl-ACP synthases, is limiting in the transgenic plants. This further suggests that malonyl-coenzyme A is a potential limiting factor impacting the final oil content as well as further extension of 16:0.

ESTIMATING THE COMPLEXITY OF ANIMAL BEHAVIOUR: HOW MOUNTAIN GORILLAS EAT THISTLES

Abstract

Mountain gorillas use elaborate, multi-stage procedures for dealing with plant defences. This paper investigates the use of mathematically-inspired, informational measures to gauge the complexity of one of these tasks, eating thistle Carduus nyassanus, from field observations of 38 adults and juveniles. Behaviour was analysed at two levels, a detailed, movementbased description of the form of actions, and an organizational description of techniques that were composed of a series of many actions. Complexity, as measured by counting the sizes of behavioural repertoires, correlated at the two levels. Repertoires were shown to be incomplete, but the rates of cumulative increase in actions differed between tasks. Thistle eating was the most complex, and apparently involved many more actions than even chimpanzee tool-use. Techniques were highly selective arrangements of actions, so that their organization (sequence, bimanual coordination, hierarchical structure) reflected cognitive capacity. Although ideally it would preferable to estimate complexity of task organization, this may seldom be feasible, and was not in this case. Instead, the length of a regularly occurring sequence of actions may be the best practical estimate of an underlying complexity of mental process. Confidence in this measure will be increased if it broadly agrees with other, independent estimates of task complexity; in the case of gorilla plant processing, both the size of repertoire of functionally distinct actions and the degree of lateral specialization were, like sequence length, greater for thistle processing than for other tasks studied to date.

The distribution of caprylate, caprate and laurate in lipids from developing and mature seeds of transgenic Brassica napus L

The composition and positional distribution of lipids in developing and mature transgenic Brassica napus seeds accumulating up to 7 mol% of caprylate (8:0), 29 mol% caprate (10:0) or 63 mol% of laurate (12:0) were examined. The accumulation of 8:0 and 10:0 resulted from over-expression of the medium-chain-specific thioesterase (Ch FatB2) alone or together with the respective chain-length-specific condensing enzyme (Ch KASIV). Seeds containing high levels of 12:0 were obtained from plants expressing bay thioesterase (BTE) alone or crossed with a line over-expressing the coconut lysophosphatidic acid acyltransferase (LPAAT), an enzyme responsible for the increase in acylation of 12:0 at the sn-2 position. In all instances, 10:0 and 12:0 fatty acids were present in substantial amounts in phosphatidylcholine during seed development with a drastic decrease of 80-90% in mature seeds. At all stages of seed development however, 8:0 was barely detectable in this membrane lipid. Altogether, these results indicate that these transgenic seeds exclude and/or remove the medium-chain fatty acids from their membrane and that this mechanism(s) is more effective with the shorter-chain fatty acids. Furthermore, seeds of 8:0- and 10:0-producing lines had only negligible levels of these fatty acids present in the sn-2 position of the triacylglycerols. In contrast, all 12:0-producing seeds had a substantial amount of this fatty acid in the sn-2 position of the triacylglycerols, suggesting that the endogenous LPAAT is able to acylate 12:0 if no other acyl-CoA species are available.

Prevalence of Müllerian duct anomalies detected at ultrasound

The true prevalence of müllerian duct abnormalities is not well established. We used standard ultrasound examinations to establish the prevalence of müllerian duct abnormalities in girls and women who were evaluated for reasons unrelated to the presence of uterine anomalies. Prospective ultrasound examinations for nonobstetric indications in 2,065 consecutive girls and women (aged 8-93) showed that 8 had anomalies, including bicornuate uterus, septate uterus, and double uterus. In this first attempt to determine the prevalence of uterine anomalies in the general population, using noninvasive methodology, the rate of anomalies was 3.87 per 1,000 women (exact 95% confidence interval: 1.67-7.62), or approximately 1 in 250 women. This prevalence estimate may be greater than the true rate if selection biases are strong, or less than the true prevalence if ultrasound detection rates are low. As a first attempt to establish the prevalence by pelvic ultrasound in a consecutive series, these data may serve as a baseline estimate.

Focal amyotrophy in neurofibromatosis 2

Neurofibromatosis type 2 (NF2) is an autosomal dominant disorder characterised by bilateral vestibular schwannomas and other CNS tumours including meningiomas and spinal schwannomas. Occasionally, peripheral neuropathy occurs in these patients but this is the first report of focal amyotrophy. Clinical, electrophysiological, and imaging data from four NF2 patients seen at a specialist neurofibromatosis clinic over a 4 year period are described in whom symptomatic focal amyotrophy preceded the diagnosis of NF2. Two presented with wasting and weakness of a single muscle group, several years before NF2 was diagnosed. In one patient a mononeuritis multiplex was the presenting feature of NF2, and in one patient focal wasting and weakness developed after the diagnosis of NF2 was made. In none of the four cases could a focal peripheral nerve or root neurofibroma be identified despite extensive imaging with MRI, and the limitations of neuroimaging for identifying a structural cause in patients with NF2 with a focal peripheral nerve lesion is discussed. It is likely that NF2 may affect peripheral nerve structures in a manner distinct from a compressive schwannoma.

Physician expressions of uncertainty during patient encounters

Uncertainty is inherent in clinical medicine and may contribute to variability in physician practice patterns, patient satisfaction, and exchange of information. However, research on physician disclosure of uncertainty to patients is sparse. We measured the frequency of physician expressions of uncertainty to patients using audiotapes of visits to 43 physicians by 216 continuity patients in a university-affiliated general medicine clinic. We also analyzed the audiotapes using Roter Interaction Analysis. Physicians completed Gerrity's Physician's Reaction to Uncertainty scale and patients completed the Kranz Health Opinion Survey and a standardized satisfaction questionnaire. Physicians made verbal expressions of uncertainty in 71% of clinic visits. Physicians with greater self-rated reluctance to disclose uncertainty to patients made fewer expressions. Physicians who made more uncertainty expressions also used more positive talk and partnership building, and gave more information to patients. Physicians also expressed more uncertainty to patients with more education, greater desire for information, and more questions. Physician uncertainty expression were associated with greater patient satisfaction, but not independently of other physician verbal behaviors that were also associated with satisfaction.

Physiologic responses to laparoscopic aortofemoral bypass grafting in an animal model

OBJECTIVE

To measure and compare the physiologic, metabolic, and hemodynamic responses to aortofemoral bypass grafting by three techniques: open or conventional laparotomy, laparoscopic-assisted (minilaparotomy), and totally laparoscopic grafting.

METHODS

Twenty-four laboratory-bred hounds were randomized to one of three groups (open, laparoscopic-assisted, or totally laparoscopic). Four sets of parameters were measured: hemodynamic (intraoperative continuous cardiac output monitoring), inflammatory or hematologic (serial leukocyte and platelet levels), metabolic responses (serial blood glucose, serum cortisol and insulin, plasma epinephrine, plasma norepinephrine, and dopamine levels), and catabolic (24-hour urinary nitrogen excretion).

RESULTS

Cardiac output increased transiently with aortic cross-clamping, more in the laparoscopic-assisted and total laparoscopic groups than in the open group, but the differences were not significant. White blood counts nearly doubled within 12 hours of surgery but were similar in all three groups. Platelet counts decreased significantly in all three groups, but no significant intergroup effects were observed. Metabolic parameters (e.g., blood glucose, cortisol, and catecholamine) rose significantly during surgery but fell to normal within 24 hours, with no important difference between groups. For the first 24 hours, urinary urea excretion fell by 50% but returned to normal by 7 days in all three groups.

CONCLUSIONS

In the experimental animal model, the hemodynamic, hematologic, and metabolic responses to laparoscopic and laparoscopic-assisted aortofemoral bypass grafting are similar to those produced by conventional laparotomy graft placement. These data call into question whether laparoscopic techniques for aortic surgery have a significant physiologic advantage in humans.

Screening of abdominal aortic aneurysm: a pragmatic approach

In order to evaluate the feasibility of a selective screening programme for abdominal aortic aneurysm (AAA) within an urban setting and assess its impact on the expected increase in workload for the local hospital(s), a population based, prospective study was performed. A total of 4823 men aged 65 years were invited for ultrasound examination of the abdominal aorta between January 1993 and April 1997 as part of a general practice-based aneurysm screening programme covering two districts with a general hospital each. All examinations were carried out by senior radiographers using a portable B mode grey scale machine and a 3.5 MHz curvi-linear array probe. Patients with a maximum aortic diameter of over 3 cm were annually recalled, those with over 4 cm were referred to hospital for an out-patient's appointment. Those with AAA greater than 5 cm were considered for surgery. Of those approached, 3497 (72.5%) took part in the study, 1206 (25%) did not attend and 120 (2.5%) were excluded by their general practitioners (GPs) on medical grounds. Of the men taking part, 3130 (89.5%) had an aortic diameter equal to or less than 2.5 cm, 196 (5.6%) between 2.6 and 3.0 cm, and 171 (4.9%) had aortic diameters greater than 3 cm--29 of whom had AAA greater than 5 cm with a mean diameter of 6.0 cm (range 5.1-9.0 cm). Of 127 men with an initial diameter of 3.1-4.0 cm (mean progression in size of 2.3 mm/year), 22 enlarged to > 4 cm and 3 to > 5 cm. Of 24 men with an initial diameter of 4.1-5.0 cm, 6 enlarged to > 5 cm. Some 69 (2%) patients were referred to hospital requiring a total of 125 consultations (1.8 consultations per patient); 21 underwent surgery and one died from rupture whilst awaiting surgery. Five patients refused their operation and two failed to attend the clinic (all > 5 cm) but remain well to date. No patient died following surgery. We conclude that, screening for AAA in men at age 65 years within an urban setting is feasible and well received by patients and GPs. Screening does not lead to a huge increase in terms of outpatient appointments and operations for AAA.

Elective abdominal aortic aneurysm operations--the results of a single surgeon series of 243 consecutive operations from a district general hospital

BACKGROUND

There are few data on the morbidity and mortality of planned elective surgery for infrarenal abdominal aortic aneurysm (AAA) as a single surgeon series. This audit is of a consecutive series of AAA operations performed by one surgeon in one district general hospital over a 13-year period.

METHODS

243 patients were operated on for AAA between 1985 and 1998. Data were collected on the majority of patients prospectively. A reliable method was devised to identify all patients. Any missing complication and mortality data were then collected retrospectively.

RESULTS

13 patients died as a result of their operation (5.3%). In patients over the age of 80 years (36), five patients died (14%) and in the 207 patients under the age of 80 years, eight died (3.8%). Cardiac deaths were the most frequent cause (38%); 82 patients had recorded complications (34%). The operative mortality rate has increased in later years, (2.2% to 7.1%), largely due to an increase in the very elderly accepted for operation (12% to 16%), and a possible increase in co-morbidity.

CONCLUSIONS

An acceptable and comparable mortality rate can be achieved in a district general hospital. The complication rate is high indicating the need for very intense medical and nursing care for these patients postoperatively. There is a considerable variance in mortality rates with age and risk even in the practice of one surgeon, indicating a need to be very knowledgeable and cautious in interpreting postoperative mortality data. This is the largest single surgeon series to date in the UK.

Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: randomized comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy

BACKGROUND

Most patients with chronic heart failure (CHF) receive the same dose of angiotensin-converting enzyme (ACE) inhibitors because there is currently no measure of treatment efficacy. We sought to determine whether titration of vasodilator therapy according to plasma brain natriuretic peptide (BNP) concentration may be of value in the individual optimization of vasodilator therapy in CHF.

METHODS AND RESULTS

Twenty patients with mild to moderate CHF receiving stable conventional therapy including an ACE inhibitor were randomly assigned to titration of ACE inhibitor dosage according to serial measurement of plasma BNP concentration (BNP group) or optimal empirical ACE inhibitor therapy (clinical group) for 8 weeks. Only the BNP-driven approach was associated with significant reductions in plasma BNP concentration throughout the duration of the study and a significantly greater suppression when compared with empiric therapy after 4 weeks [-42.1% (-58.2, -19.7) vs -12.0% (-31.8, 13.8), P =.03]. Both treatment strategies were well tolerated and associated with favorable neurohormonal and hemodynamic effects; however, in comparison between groups, mean heart rate fell (P =.02) and plasma renin activity rose (P =.03) in the BNP group when compared with the clinical group.

CONCLUSIONS

Plasma BNP concentration may be chronically reduced by tailored vasodilator therapy in CHF. Furthermore, titration of vasodilator therapy according to plasma BNP was associated with more profound inhibition of the renin-angiotensin-aldosterone system and significant fall in heart rate when compared with empiric therapy.

Considering the alternatives

Health care providers frequently talk about values and community care, and their mission statements often espouse a commitment to cooperative relationships with their patients. Good intentions aside, the reality is that some health care providers may be unable to accommodate patients who are unable to pay for services. Distrust is guaranteed when an industry's words and deeds don't match, but several caregivers are thinking outside the lines to find solutions to their patients' payment problems.

Mobilisation of peripheral blood stem cells with IVE and G-CSF improves CD34+ cell yields and engraftment in patients with non-Hodgkin's lymphomas and Hodgkin's disease

The transplantation of mobilised peripheral blood stem cells is associated with more rapid engraftment than marrow transplantation. We have previously reported that G-IVE (G-CSF, ifosphamide, VP-16, epirubicin) improves the yield of CD34+ cells mobilised in patients with lymphoproliferative disorders compared with cyclophosphamide 3 g/m2 and G-CSF (G/CYCLO). In this study we have extended these observations to a larger series of patients including different lymphoma subtypes. Ninety-seven patients undergoing stem cell mobilisation were studied. Forty-two patients with lymphoproliferative disorders received G-IVE for mobilisation and 55 patients G/CYCLO. The median number of mobilised CD34+cells per leucapheresis was significantly higher for those patients receiving G-IVE: 5.82 x 106/kg (0.19-36) compared with 1.2 x 106/kg (0.04-17), P < 0.001 which resulted in a significantly reduced number of leucapheresis procedures performed in the G-IVE group. When patients were analysed dependent on underlying disease G-IVE mobilised significantly more CD34+cells per leucapheresis for all lymphoma types reaching 8.41 x 10(6)/kg (0.2-32) compared to 1.32 x 10(6)/kg (0. 06-17) for patients with high-grade NHL mobilised with G-IVE and C-GCSF respectively (P = 0.012). For patients with low-grade NHL 3. 12 x 10(6)/kg (0.10-24.39) compared to 1.08 x 10(6)/kg (0.04-9.74) were collected (P = 0.04) and for patients with Hodgkin's disease 3.02 x 10(6)/kg (1.48-36) and 1.04 x 10(6)/kg (0.1-12.3) (P = 0.001). Mobilisation with G-IVE resulted in the achievement of clinically significant CD34+ cell thresholds in a significantly higher proportion of patients compared to cyclophosphamide and G-CSF reaching >2.5 x 10(6)/kg CD34+ cells in 88% vs 62% (P = 0.004), >5 x 10(6)/kg in 67% vs18% (P = 0.001) and >10 x 10(6)/kg in 31% vs 14.5% (P = 0.05). Furthermore, an analysis of engraftment demonstrated that there was a significant reduction in the time to achieve platelet counts of >20 and >50 x 10(9)/l in patients receiving each incremental dose of CD34+ cells. We conclude that G-IVE mobilizes significantly more CD34+cells than G/CYCLO in patients with lymphoproliferative disorders. This effect is consistent in patients with high-grade NHL, low-grade NHL and HD and results in fewer failed stem collections and increased CD34+ cells available for transplantation which results in significantly accelerated platelet engraftment post transplant.

Classical pituitary apoplexy: clinical features, management and outcome

OBJECTIVE

The term classical pituitary apoplexy describes a clinical syndrome characterized by sudden headache, vomiting, visual impairment and meningismus caused by the rapid enlargement of a pituitary adenoma usually due to haemorrhagic infarction of the tumour. Most published reports looking at the clinical features and management of pituitary apoplexy have not differentiated between patients with clinical and subclinical apoplexy, the latter diagnosed at surgery. Furthermore, little is reported on the clinical outcome, in particular visual and endocrinological, and the role of radiotherapy. The purpose of this study was to observe not only the clinical presentation but also the possible predisposing events, investigations, management, clinical outcome as well as the role of radiotherapy in patients presenting with classical pituitary apoplexy.

PATIENTS AND DESIGN

In a retrospective analysis 1985-96, the medical records of 21 male and 14 female patients (mean age 49.8 years, range 30-74) with classical pituitary apoplexy were reviewed. This represents all patients seen with this condition over the stated period.

MEASUREMENTS

In all patients, pre- and post- operative measurements were made of FT4, FT3, TSH, PRL, LH, FSH, cortisol (0900 h), GH, oestradiol (females) and testosterone (males). Pituitary imaging was by computerized tomography (CT) scan, magnetic resonance imaging (MRI) or both.

RESULTS

Patients were followed for up to 11 years (mean 6.3 years: range 0.5-11). Headache (97%) was the commonest presenting symptom, followed by nausea (80%) and a reduction of visual fields (71%). Hypertension, defined as a systolic > 160 mmHg and/or a diastolic > 90 mmHg, was seen in 26% of patients. MRI correctly identified pituitary haemorrhage in 88% (n = 7), but CT scanning identified haemorrhage in only 21% (n = 6). By immunostaining criteria, null-cell adenomas were the most common tumour type (61%). Transsphenoidal surgery resulted in improvement in visual acuity in 86%. Complete restoration of visual acuity occurred in all patients operated on within 8 days but only in 46% of patients operated on after this time (9-34 days). Long-term steroid or thyroid hormone replacement was necessary in 58% and 45% of patients, respectively. Of the male patients, 43% required testosterone replacement, and long-term desmopressin therapy was required in 6%. Only two patients (6%) with tumour recurrence after transsphenoidal surgery for the initial apoplectic event, subsequently required radiotherapy.

CONCLUSIONS

In classical pituitary apoplexy, headache is the commonest presenting symptom and hypertension may be an important predisposing factor. MRI is the imaging method of choice. Transsphenoidal surgery is safe and effective. It is indicated if there are associated abnormalities of visual acuity or visual fields because, when performed within 8 days, it resulted in significantly greater improvement in visual acuity and fields than if surgery was performed after this time. Radiotherapy is not indicated immediately as the risk of tumour recurrence is small, but careful follow-up initially with annual imaging is indicated in this group.

Vascular surgical society of great britain and ireland: review of 94 tibial bypasses for intermittent claudication

BACKGROUND: The management of intermittent claudication is usually non-operative. Most surgeons accept, however, that intervention may be warranted for those with debilitating symptoms. Such interventions are limited to above-knee bypass or balloon angioplasty. However, the authors have performed almost 4500 bypasses for limb salvage, with careful audit of results, and suggest that, in very carefully selected cases, tibial bypass can also be performed for intermittent claudication. The present study aimed to review the results of infrainguinal bypass in this unit; to compare the results for above-knee, below-knee popliteal and tibial bypass in claudicants using either in situ or excised vein as the conduit; and to examine the indications and long-term follow-up for those undergoing tibial bypass for claudication. METHODS: A database has been maintained prospectively in this unit since 1986. Details of all patients undergoing infrainguinal bypass for claudication were retrieved. In-hospital charts were also reviewed and cross-referenced with the computer database. In addition to demographic details, data were extracted on operative indication and procedure, postoperative complications, return to desired level of activity and long-term graft patency. RESULTS: From 1987 to 1997, 409 infrainguinal reconstructions were performed for intermittent claudication (9 per cent of all infrainguinal reconstructions). Of these 73 per cent were in men and 27 per cent in women with a mean age of 64 (range 24-91) years. The operative procedures comprised 165 above-knee popliteal grafts, 150 bypasses to the below-knee popliteal artery and 94 to tibial arteries. There were no operative deaths. However, one of 165 patients who had an above-knee popliteal graft underwent an amputation. Primary and secondary patency rates at 4 years were 62 and 64 per cent for above-knee popliteal bypass, 77 and 81 per cent for below-knee popliteal bypass, and 86 and 90 per cent for tibial bypass. Cumulative survival was 93 per cent at 4 years. CONCLUSION: Tibial bypass for severely disabling claudication can be performed with minimal morbidity and mortality rates, and is at least as durable as more commonly performed bypasses. These data indicate that concern over limb loss, death and limited life span may be exaggerated.

Human cyclophilin has a significantly higher affinity for HIV-1 recombinant p55 than p24

The ability of cyclophilin to bind a panel of recombinant HIV-gag proteins was assessed using sensitive, quantitative, sandwich enzyme-linked immunosorbant assays (ELISAs). Significantly higher binding to cyclophilin was observed when recombinants contained at least 12 carboxy-terminal amino acids of p17 in addition to p24 sequences. These results indicate that the carboxy-terminus of p17 is important for optimal binding of cyclophilin to p24 and support the theory that cyclophilin acts on the uncleaved HIV-1 gag (p17-p24) precursor.

Long-term genetic and reproductive effects of ionizing radiation and chemotherapeutic agents on cancer patients and their offspring

The continuing search for a cure for cancer has lead to more aggressive therapies as new agents are developed with largely unknown late complications. Standard therapy for the majority of cancers today, following surgery, often consists of combinations of high doses of radiation and multi-drug therapy. Compared with exposures experienced by atomic bomb survivors, cancer survivors have been exposed to higher doses of partial body irradiation and combination chemotherapy over longer periods. Thus, cancer survivors provide a model system with which to evaluate the long-term effects on the human organism of high doses of agents known to damage DNA. Five-year survival after cancer diagnosis is now greater than 56%; more than 5 million Americans are considered cured of cancer. However, the late complications of cancer in long-term survivors has been poorly evaluated, especially in adults, and little is known of the most troubling possibility, that is, that the effects of cancer treatments could be passed on to the next generation. What little we know comes from studies of at most 5,000 survivors of childhood cancer, treated decades ago. So far, results are reassuring that with the means now available, we cannot detect clinical evidence of heritable damage. However, reproductive effects, including infertility, are common consequences of cancer therapy and may represent germ cell damage. We are just in the infancy of studies of germ cell mutagenesis in cancer survivors. The relatively small numbers of survivors, and the few types of exposures studied so far, provide only limited grounds for reassurance. More comprehensive, properly designed, studies of modern new agents are urgently need.

Sonographic detection of uterine and ovarian abnormalities in female survivors of Wilms' tumor treated with radiotherapy

OBJECTIVE

The purpose of this study was to use sonography to evaluate the size of the ovaries and uterus in survivors of Wilms' tumor who underwent radiotherapy.

SUBJECTS AND METHODS

Eighteen survivors of Wilms' tumor had their ovaries and uterus measured on sonography. Their ages at diagnosis and treatment ranged from 14 months to 6 years. Four girls were prepubertal (age, 5-9 years), 11 were postpubertal (age, 11-30 years), and three had primary ovarian failure (age, 15-23 years) at the time of imaging. Findings were compared with those of a control group of 25 prepubertal and 25 postpubertal girls and women. Gonadotropin levels were measured.

RESULTS

Three patients who underwent whole abdomen radiotherapy had elevated levels of gonadotropin and primary ovarian failure. Neither ovary was seen in two of the three patients and both ovaries were abnormally small (< or = 1 cm3) in the third patient. The uterus was abnormally small (length, < or = 4 cm) in all three of these patients even though two were being treated with hormone replacement therapy. Ten postpubertal patients who underwent hemiabdomen radiotherapy had normal gonadotropin levels and a normal-sized uterus on sonography; the ovary on the side that received radiotherapy was not seen in three of the 10 patients or was abnormally small (< or = 1.4 cm3) in two of the 10 patients compared with all normal ovaries in the postpubertal control group (p < .0001). One postpubertal patient with bilateral renal bed radiotherapy had normal ovaries and a normal-sized uterus. Significantly more patients in the postpubertal and ovarian failure radiotherapy group (5 [36%] of 14 patients) had one or both ovaries not seen than the control group (none [0%] of 25 patients; p = .0014). The uterus was significantly smaller than normal in three (23%) of the 13 patients in the postpubertal hemiabdomen and ovarian failure radiotherapy group versus none of the 25 patients in the postpubertal control group (p = .0339).

CONCLUSION

Postpubertal female survivors of Wilm's tumor who underwent radiotherapy as children may have one or two small or absent ovaries and a small uterus that can be detected by sonography. The response of the uterus to hormone replacement therapy can also be assessed on sonography.

Rheumatology. Part 2: The role of medication

Rheumatoid arthritis is a chronic, long-term inflammatory disease. Symptom relief can be achieved with analgesia and NSAIDs. The only way to influence its progress is by administering disease-modifying anti-rheumatic drugs.

Social work in psychiatric home care: regulations, roles, and realities

Home care services for people with psychiatric diagnoses are increasing in popularity with consumers, providers, and insurance companies. Traditionally, home care social workers have not provided in-home clinical services because of restrictive regulations and industry culture. This article presents strategies for establishing a clinical role for social workers in a psychiatric home care program that meets Medicare, Joint Commission on Accreditation of Healthcare Organizations, and NASW standards. A discussion of skills requirements, appropriate case assignment, professional role clarifications and differentiations, and marketing strategies is presented.

Infrainguinal arterial reconstruction for claudication: is it worth the risk? An analysis of 409 procedures

PURPOSE

Infrainguinal reconstruction traditionally has been reserved for patients with limb-threatening ischemia. Surgery for debilitating claudication, however, has been discouraged as a result of the perceived fear of bypass graft failure, limb loss, and significant perioperative complications that may be worse than the natural history of the disease. In this study, the results of infrainguinal reconstructions for claudication performed during the past 10 years were evaluated for bypass graft patency, limb loss, and long-term survival rates.

METHODS

Data were collected and reviewed from the vascular registry, the office charts, and the hospital records for patients who underwent infrainguinal bypass grafting for claudication.

RESULTS

From 1987 to 1997, 409 infrainguinal reconstructions were performed for claudication (9% of all infrainguinal reconstructions in our unit). The patient population had the following demographics: 73% men, 28% with diabetes, 54% smokers, and an average age of 64 years (range, 24 to 91 years). Inflow was from the following arteries: iliac artery/graft, 10%; common femoral artery, 52%; superficial femoral artery, 19%; profunda femoris artery, 16%; and popliteal artery, 2%. The outflow vessels were the following arteries: 165 above-knee popliteal arteries (40%), 150 below-knee popliteal arteries (37%), and 94 tibial vessels (23%). The operative mortality rate was 0%, and one limb was lost in the series from distal embolization. The primary patency rates were 62%, 77%, and 86% for above-knee popliteal artery, below-knee popliteal artery, and tibial vessel reconstructions at 4 years, and the secondary patency rates were 64%, 81%, and 90%, respectively. Cumulative patient survival rates were 93% and 80% at 4 and 6 years as compared with 65% and 52%, respectively, for infrainguinal reconstructions performed for limb salvage.

CONCLUSION

Infrainguinal arterial reconstruction for disabling claudication is a safe and durable procedure in selected patients. These data indicate that concern for limb loss, death, and limited life span of the patients with this disease may not be warranted.

Myotonic dystrophy is a significant cause of idiopathic polyhydramnios

OBJECTIVE

Myotonic dystrophy, the most common form of muscular dystrophy seen in pregnant women, may be a significant cause of middle trimester polyhydramnios. Our purpose was to determine the prevalence of myotonic dystrophy in women with idiopathic polyhydramnios and to characterize the ultrasonographic findings associated with cases.

STUDY DESIGN

We examined the cases of 67 patients who were delivered of infants at the University of Utah between 1992 and 1996 with a diagnosis of idiopathic polyhydramnios (amniotic fluid index >25). Women with diabetes mellitus, hydrops, or fetal anomalies known to cause polyhydramnios were excluded from the study. Amniotic fluid samples or cord blood samples were obtained from 41 patients, and polymerase chain reaction amplification and Southern blot analysis were performed to detect the presence of the myotonic dystrophy mutation. Ultrasonographic findings, prenatal course, and neonatal outcomes were reviewed in all cases.

RESULTS

Four of the 41 patients tested had the myotonic dystrophy mutation, yielding a prevalence in our population of 9.7%. Three of the 4 patients reported a family history of myotonic dystrophy. Ultrasonographic findings associated with a positive result included abnormal posturing of extremities (3/4) and unilateral clubbed foot (3/4). No other structural or growth abnormalities were seen. Two of the patients were delivered before term, 1 at 26 weeks and 1 at 32 weeks. Three of the 4 infants were severely affected, necessitating admission to the intensive care unit, and 1 died on day 11 after birth. One infant, whose myotonic dystrophy mutation consisted of between 800 and 900 triplet repeats, did not require admission to the intensive care unit.

CONCLUSION

Myotonic dystrophy may be seen as idiopathic polyhydramnios and should be considered as part of the differential diagnosis in these cases. Women with a familial history of myotonic dystrophy or ultrasonographic evidence of hypotonia, including positional abnormalities of the extremities, should be offered deoxyribonucleic acid testing for the myotonic dystrophy mutation.

KAS IV: a 3-ketoacyl-ACP synthase from Cuphea sp. is a medium chain specific condensing enzyme

cDNA clones encoding a novel 3-ketoacyl-ACP synthase (KAS) have been isolated from Cuphea. The amino acid sequence of this enzyme is different from the previously characterized classes of KASs, designated KAS I and III, and similar to those designated as KAS II. To define the acyl chain specificity of this enzyme, we generated transgenic Brassica plants over-expressing the cDNA encoded protein in a seed specific manner. Expression of this enzyme in transgenic Brassica seeds which normally do not produce medium chain fatty acids does not result in any detectable modification of the fatty acid profile. However, co-expression of the Cuphea KAS with medium chain specific thioesterases, capable of production of either 12:0 or 8:0/10:0 fatty acids in seed oil, strongly enhances the levels of these medium chain fatty acids as compared with seed oil of plants expressing the thioesterases alone. By contrast, co-expression of the Cuphea KAS along with an 18:0/18.1-ACP thioesterase does not result in any detectable modification of the fatty acids. These data indicate that the Cuphea KAS reported here has a different acyl-chain specificity to the previously characterized KAS I, II and III. Therefore, we designate this enzyme KAS IV, a medium chain specific condensing enzyme.

Utility of fetal measurements in the management of gestational diabetes mellitus

The metabolic management of gestational diabetes mellitus (GDM) during pregnancy traditionally has focused on maintenance of circulating maternal glucose concentrations in all patients within a range that is associated with a low rate of perinatal morbidity, especially morbidity related to excessive fetal growth and macrosomia. Clinical data reviewed elsewhere in this supplement provide guidelines for glycemic targets that appear to eliminate the excess risk to the fetus. However, because only a minority of infants are at risk for perinatal morbidity over the range of glycemia generally encountered in patients with GDM, attainment of those strict glycemic targets in all women with GDM requires implementation of self-monitoring of glucose and exogenous insulin therapy in many pregnancies that are not at risk. In this article, we review management approaches that take into account not only maternal glycemia, but also fetal growth and metabolic parameters in selecting GDM pregnancies for intensive metabolic therapy. The approaches can reduce the number of women with mild GDM who require self-monitoring of glucose and/or exogenous insulin therapy, thereby providing the potential to improve cost-effectiveness of antepartum management of GDM.

Laparoscopic versus open posterior adrenalectomy: comparison of acute-phase response and wound healing in the cushingoid porcine model

This prospective randomized study examined the acute-phase response and wound healing, comparing laparoscopic (LA) and open posterior (PA) adrenalectomy in a cushingoid porcine model. Repository corticotropin gel was given to 40 pigs for 21 days. Biochemical and tissue parameters of Cushing syndrome were confirmed. The pigs were randomized to undergo LA or PA. In addition to operating time and morbidity, the acute-phase response was compared by measuring the postoperative white blood cell count, fasting glucose, C-reactive protein, and nitrogen balance. Wound healing was assessed by (1) scored (1-4) gross appearance at 48 hours and 1 and 2 weeks; (2) histologic examination; and (3) tensile strength. There was no difference in operating time (mean +/- SD) (36 +/- 9 minutes open vs. 37 +/- 7 minutes laparoscopic), perioperative mortality, degree of leukocytosis, fasting glucose, or C-reactive protein (p > 0.05). Nitrogen balance, wound scores, and tensile strength at 24 hours and 1 week were more favorable in the LA group than in the PA group (p < 0.05). In the cushingoid porcine model, laparoscopic adrenalectomy was less catabolic and was associated with fewer wound complications than the open posterior adrenalectomy. These findings provide support for continued pursuit of laparoscopic methods for adrenalectomy in the clinical setting.

Development of an adjustable prosthesis for the treatment of gastroesophageal reflux: preliminary results in a porcine model

Dysphagia and recurrent gastroesophageal reflux complicate use of the Angelchik prosthesis. The authors developed an inflatable silicone device, similar to the Angelchik prosthesis, that may allow for the adjustment of the total pressure exerted around the gastroesophageal junction after implantation. To estimate its potential to prevent gastroesophageal reflux in humans, we used a short-term porcine model in which we measured the effective lower esophageal sphincter pressure in 10 anesthetized pigs using a computerized, three dimensional pressure vector volume analysis. Anesthesia and mobilization of the gastroesophageal junction did not modify the three dimensional pressure vector volume at the lower esophageal sphincter. Implantation of the deflated device significantly increased effective lower esophageal sphincter three dimensional pressure vector volume compared with baseline. Inflation of the device with 30 ml of saline further increased lower esophageal sphincter pressure significantly. Deflation of the device returned the pressure to the pre-inflation values. Using an animal model and short-term implantation, this new antireflux device appeared to offer the potential ability to adjust the pressure selectively at the gastroesophageal junction postoperatively. An added future feature of this device may be the ease of insertion using laparoscopic techniques. Long-term animal implantation studies and clinical trials are required to help establish the safety and efficacy of this device in humans.

Increased incidence of cancer in infants in the U.S.: 1980-1990

BACKGROUND

During the decade between 1980-1990, the rate of cancer in children in the U.S. increased. It is unknown whether cancer in infancy, which is biologically and clinically different from cancer in older children, also increased.

METHODS

To evaluate changes in cancer incidence in infants in the U.S. age < 1 year, data from the Surveillance, Epidemiology, and End Results (SEER) program and the U.S. Bureau of the Census were used to construct age specific, population-based cancer incidence rates.

RESULTS

Overall, the annual cancer rate in infants increased from 189 cases per million infants between 1979-1981 to 220 between 1989-1991. At both timepoints, female infants had higher cancer rates than male infants. Although the rates for female infants remained stable at 223 between 1979-1981 versus 236 between 1989-1991, rates for male infants increased from 158 to 205 during the same timepoints. Male infants had increased rates of central nervous system (CNS) tumors (P < 0.05), neuroblastoma, and retinoblastoma; female infants had increased rates of teratomas (P < 0.01) and hepatoblastomas. Between 1979-1981, the three most common types of cancer in infants were neuroblastoma, leukemia, and renal tumors (27%, 15%, and 14%, respectively), and were neuroblastoma, CNS tumors, and leukemia between 1989-1991 (27%, 15%, and 13%, respectively).

CONCLUSIONS

This study shows that the rate of certain types of cancer in infants in the U.S. is increasing. Studies of both genetic and environmental factors are needed to explain these increased rates and the changing distribution of cancer in the first year of life.

Expression of cyclooxygenase-1 and cyclooxygenase-2 in human breast cancer

BACKGROUND

Numerous studies have demonstrated that the levels of prostaglandins are greater in various cancers, including breast cancer and colon cancer, than in normal tissues. In particular, the inducible form of cyclooxygenase (COX), the rate-limiting enzyme in prostaglandin biosynthesis, is overexpressed in colon tumors. Epidemiologic studies have demonstrated that the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce the risk of colon cancer and, to a lesser extent, the risk of breast cancer. NSAIDs are known to inhibit COX, suggesting that the beneficial effect of NSAIDs in colon cancer may be related to COX overexpression in this disease. This possibility led us to ask whether COX is also overexpressed in breast cancers.

METHODS

Surgical specimens from 44 patients with breast cancer who had undergone lumpectomy or mastectomy were analyzed by immunoblot analysis and immunohistochemical analysis to determine the expression profile of the constitutively expressed form of cyclooxygenase (COX-1) and the inducible form (COX-2); the specimens from 14 patients included normal breast tissue.

RESULTS

Expression of COX-1 protein was substantially higher in 30 of 44 tumor samples than in any of the 14 normal tissue specimens. Immunoblot analysis revealed extremely high levels of COX-2 protein in two tumor samples. Immunohistochemical staining of specimens that expressed COX-1 and/or COX-2 revealed that COX-1 was localized in stromal cells adjacent to the tumor but not in tumor cells. In contrast, COX-2 was localized primarily in tumor cells but also appeared in stromal cells.

CONCLUSION

Our results suggest that overexpression of COX may not be unique to colon cancer and may be a feature common to other epithelial tumors.

Extraspinal causes of sciatica. A case report

STUDY DESIGN

A case of intrapelvic aneurysm is reported. It is as an example of one of the many extraspinal causes of sciatica.

OBJECTIVE

To demonstrate the importance of clinical examination in the assessment of patients with sciatic, despite continuing improvements in methods for imaging the spine.

SUMMARY OF BACKGROUND DATA

Extraspinal conditions cause sciatic in a rare but recognized group of patients. Their clinical symptoms can be very similar to those of patients with sciatic from lumbar disc protrusion.

METHODS

The clinical appearance, investigation, and treatment of a patient with an internal iliac artery aneurysm causing sciatic are discussed.

RESULTS

Surgical treatment of the patient's aneurysm resulted in relief of the symptoms of sciatica.

CONCLUSIONS

Although these cases are unusual in isolation, together they represent an important group. When a patient has sciatica, the clinician looks first to the spine for the origin of symptoms. Extraspinal causes are often not considered in the differential diagnosis. This oversight may be compounded by observation of asymptomatic disc protrusions on computed tomographic and magnetic resonance studies. The importance of clinical history and examination in the diagnosis of these lesions cannot be overemphasized.

Smoking in adult survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Health-related behaviors are of particular concern in survivors of childhood cancer as they are at increased risk for second cancers and long-term organ dysfunction. The purpose of this study was to compare the smoking behavior and associated factors in young-adult survivors of childhood acute lymphoblastic leukemia (ALL) with those in sibling controls.

METHODS

A telephone interview that surveyed smoking behavior was conducted with 592 young-adult survivors, treated before age 20 years on Children's Cancer Group ALL protocols, and 409 sibling controls. Using stratified chi-squared analyses and Cox proportional hazards models, we compared the rates of smoking initiation and smoking cessation between survivors and control subjects. Demographic characteristics (age, sex, race, and education) and psychological factors (mood and self-concept) were examined as predictors interacting with survivorship in logistic regression analyses to try to distinguish a subgroup of survivors who may be at greater risk for smoking.

RESULTS

Survivors were significantly less likely to have ever smoked (23.0% versus 35.7%; P<.0001) and thus were less likely to ever be regular, daily smokers than sibling controls (19.1% versus 31.3%; P<.0001). Survivors were less likely to quit smoking than sibling controls (26.6% versus 35.2%), although this result was not statistically significant. There were no interactions between survivor status and either demographic or psychological features on smoking behavior.

CONCLUSIONS

Young-adult survivors of childhood ALL are less likely to experiment with smoking but, once having started, are at similar risk for becoming habitual, persistent smokers as sibling controls.

Discrepancies between cerebral perfusion and metabolism after subarachnoid haemorrhage: a magnetic resonance approach

INTRODUCTION

There is a variable relation between angiographic vasospasm and delayed ischaemic neurological deficit (DIND). Magnetic resonance (MR) techniques have the potential to investigate the haemodynamic, metabolic, and structural changes occurring with these complications. These techniques have been applied to study DIND in patients recovering from subarachnoid haemorrhage.

METHODS

Fifteen studies were performed on 11 patients, 10 with DIND. Vasospasm was diagnosed angiographically or with transcranial Doppler. The MR protocol consisted of T2 weighted imaging, contrast enhanced dynamic perfusion scanning, TI weighted imaging, and two dimensional localised proton spectroscopy. Relative cerebral blood volume maps were generated from perfusion scans. Metabolite ratios were calculated from proton spectra.

RESULTS

All patients had cortical oedema on T2 weighted images, significantly more pronounced in patients of poor clinical grade (p<0.01). Spectra were normal in good grade patients. Lactate was increased and N-acetyl aspartate decreased in the poor grades, significantly worse in grade 4 compared with grade 3 patients (p<0.05). Spectral changes also correlated with the severity of oedema (p<0.05). Relative blood volumes were significantly higher in oedematous regions of poor compared with good grade patients (p<0.05). Lactate was seen in regions of the brain with increased relative blood volume.

CONCLUSIONS

Despite the paramagnetic effects of haemorrhage, or of the coils and clips used to treat aneurysms, this study demonstrates that patients recovering from subarachnoid haemorrhage can undergo complex MR studies. Oedema, lactate, and increased relative blood volume correlate well with each other and with DIND and poor clinical grade.

Genetic disease in offspring of long-term survivors of childhood and adolescent cancer

Numerous case series have addressed the concern that cancer therapy may damage germ cells, leading to clinical disease in offspring of survivors. None has documented an increased risk. However, the methodological problems of small series make it difficult to draw firm conclusions regarding the potential of cancer treatments to damage the health of future offspring. We conducted a large interview study of adult survivors of childhood cancer treated before 1976. Genetic disease occurred in 3.4% of 2,198 offspring of survivors, compared with 3.1% of 4,544 offspring of controls (P=.33; not significant); there were no statistically significant differences in the proportion of offspring with cytogenetic syndromes, single-gene defects, or simple malformations. A comparison of survivors treated with potentially mutagenic therapy with survivors not so treated showed no association with sporadic genetic disease (P=.49). The present study provides reassurance that cancer treatment using older protocols does not carry a large risk for genetic disease in offspring conceived many years after treatment. With 80% power to detect an increase as small as 40% in the rate of genetic disease in offspring, this study did not do so. However, we cannot rule out the possibility that new therapeutic agents or specific combinations of agents at high doses may damage germ cells.

Brain natriuretic peptide is stable in whole blood and can be measured using a simple rapid assay: implications for clinical practice

OBJECTIVES

To compare the stability of brain natriuretic peptide (BNP) to that of N-terminal atrial natriuretic peptide (NT-ANP) in whole blood and plasma stored under different conditions. To compare a rapid, simple, direct (unextracted) BNP assay to a conventional assay using plasma extraction.

DESIGN

Blinded, prospective, comparative study.

SETTING

Tertiary referral cardiology department.

SUBJECTS

Forty two subjects (24 men, 18 women) comprising 28 patients with left ventricular systolic dysfunction (LVSD) ranging from mild to severe and 14 healthy volunteers.

MAIN OUTCOME MEASURES

Stability of NT-ANP and BNP when stored as whole blood or plasma at room temperature over three days. Reproducibility of measurements.

RESULTS

BNP was stable in whole blood stored at room temperature for three days; mean change in concentration -7.4% (95% CI 0.6 to -14.8), (direct), -6.3% (5.0 to -16.4), (extracted); whereas a significant decline in BNP concentration was noted in plasma stored at room temperature; -23.2% (-13.7 to -31.6), (direct); -14.4% (-3.2 to -24.3), (extracted). By contrast a small nonsignificant rise in NT-ANP concentration was noted both in whole blood and plasma stored at room temperature for three days; whole blood +8.6% (+22.3 to -3.5), plasma +6.3%, (23.2 to -8.4). The reproducibility of the BNP measurements, and particularly the rapid, direct, measurement, was superior to that for NT-ANP.

CONCLUSIONS

BNP is shown to be stable in whole blood for three days and can be measured using a rapid, simple assay. Routine assay of BNP is feasible in ordinary clinical practice and may be of value to general practitioners and hospital based physicians in the diagnosis and management of patients with LVSD. Samples can be sent to a central laboratory without special handling requirements.

Evaluation of mental retardation: recommendations of a Consensus Conference: American College of Medical Genetics

A Consensus Conference utilizing available literature and expert opinion sponsored by the American College of Medical Genetics in October 1995 evaluated the rational approach to the individual with mental retardation. Although no uniform protocol replaces individual clinician judgement, the consensus recommendations were as follows: 1. The individual with mental retardation, the family, and medical care providers benefit from a focused clinical and laboratory evaluation aimed at establishing causation and in providing counseling, prognosis, recurrence risks, and guidelines for management. 2. Essential elements of the evaluation include a three-generation pedigree: pre-, peri-, and post-natal history, complete physical examination focused on the presence of minor anomalies, neurologic examination, and assessment of the behavioral phenotype. 3. Selective laboratory testing should, in most patients, include a banded karyotype. Fragile X testing should be strongly considered in both males and females with unexplained mental retardation, especially in the presence of a positive family history, a consistent physical and behavioral phenotype and absence of major structural abnormalities. Metabolic testing should be initialed in the presence of suggestive clinical and physical findings. Neuroimaging should be considered in patients without a known diagnosis especially in the presence of neurologic symptoms, cranial contour abnormalities, microcephaly, or macrocephaly. In most situations MRI is the testing modality of choice. 4. Sequential evaluation of the patient, occasionally over several years, is often necessary for diagnosis, allowing for delineation of the physical and behavioral phenotype, a logical approach to ancillary testing and appropriate prognostic and reproductive counseling.