Phase I study of carboplatin, doxorubicin and weekly paclitaxel in patients with advanced ovarian carcinoma

BACKGROUND

Doxorubicin is an active compound in epithelial ovarian cancer (EOC), but adding it to carboplatin-paclitaxel causes toxicity. Toxicity can be reduced by weekly administration. We examined the tolerability of weekly paclitaxel in combination with carboplatin and doxorubicin.

PATIENTS AND METHODS

Chemotherapy naïve patients with EOC were treated with doxorubicin (50 mg/m(2) day 1), carboplatin (AUC 6 day 1) and paclitaxel (days 1, 8, 15, 21), 28-day cycle. Three patients were treated at each paclitaxel dose level, starting at 60, 75 and 90 mg/m(2)/week. If more than two patients in a cohort experienced dose-limiting toxicity (DLT) three more patients were treated at the dose level below.

RESULTS

Twelve patients with advanced EOC received a median of six cycles (range 2-6) of the three-drug combination. DLT occurred at dose level 3: prolonged grade 4 febrile neutropenia, 1 patient; grade 3 peripheral neuropathy, 1 patient. All six patients treated at dose level 2 experienced short-lived grade 4 neutropenia, which led to dose modifications resulting in an actual delivered dose of paclitaxel of 64 mg/m(2)/week. Eight out of 12 patients had measurable disease on CT scan: four obtained a partial remission; three had stable disease.

CONCLUSIONS

The combination of carboplatin, doxorubicin and paclitaxel in patients with EOC is active and its main toxicity is myelosuppression. Dose intensity of paclitaxel can be maintained in a three-drug combination through weekly administration (65 mg/m(2)).

Rapid access multidisciplinary lymph node diagnostic clinic: analysis of 550 patients

Lymphadenopathy is common, affecting patients of all ages. The current referral pattern for investigating patients with lymphadenopathy varies widely with no universally practised pathway. Our institution set up a lymph node diagnostic clinic (LNDC) accepting direct referrals from primary care physicians. Details of clinical presentation and investigations were recorded prospectively. Between December 1996 and July 2001, 550 patients were referred (M: 203; F:347). The median age was 40 years (range 14-90). The median time between initial referral and the first clinic visit was 6 days. Of 95 patients diagnosed to have malignant diseases, the median time from the first clinic visit to reaching malignant diagnosis was 15 days. Multivariate logistic regression analysis identified five significant predictors for malignant nodes: male gender (risk ratio (RR)=2.72; 95% confidence interval (CI): 1.63-4.56), increasing age (RR=1.05; 95% CI: 1.04-1.07), white ethnicity (RR=3.01; 95% CI: 1.19-7.6) and sites of lymph nodes: supraclavicular region (RR=3.72; 95% CI: 1.52-9.12) and > or = 2 regions of lymph nodes (RR=6.41; 95% CI: 2.82-14.58). Ultrasound and fine-needle aspiration cytology of palpable lymph nodes were performed in 154 and 289 patients, respectively. An accuracy of 97 and 84% was found, respectively. In conclusion, a multidisciplinary lymph node diagnostic clinic enables a rapid, concerted approach to a common medical problem and patients with malignant diseases were diagnosed in a timely fashion.

Assessing the burden of respiratory disease in the UK

This review explores the health and social burden of some of the main respiratory diseases (asthma, chronic obstructive pulmonary disease, cryptogenic fibrosing alveolitis, cystic fibrosis, lung cancer, mesothelioma, obstructive sleep apnoea and tuberculosis) in order to increase awareness of these diseases and highlight areas where improvements in care are required. The overall impact of respiratory diseases in the U.K. in terms of prevalence, mortality, morbidity and economic costs, with particular reference to secondary care has been considered and comparisons made with the rest of Europe where data are available. Respiratory diseases are responsible for a significant proportion of serious morbidity and premature death among the population of the U.K. and they will continue to present a growing challenge; special support is needed to tackle this burden.

Selective exposure and dissonance after decisions

Well-known literature reviews from the 1960s question whether cognitive dissonance underlies experimental participants' selective exposure of themselves to consonant messages and avoidance of dissonant ones. A meta-analytic review of 16 studies published from 1956 to 1996 and involving 1,922 total participants shows that experimental tests consistently support the supposition that dissonance is associated with selective exposure (r = .22, p < .001). Statistical power exceeded .99. Advances in statistical methodology and increased attention to selecting appropriate tests of dissonance theory were essential to finally resolving this question.

MeV ion jets from short-pulse-laser interaction with thin foils

Collimated jets of carbon and fluorine ions up to 5 MeV/nucleon ( approximately 100 MeV) are observed from the rear surface of thin foils irradiated with laser intensities of up to 5 x 10 (19)W/cm(2). The normally dominant proton acceleration could be surpressed by removing the hydrocarbon contaminants by resistive heating. This inhibits screening effects and permits effective energy transfer and acceleration of other ion species. The acceleration dynamics and the spatiotemporal distributions of the accelerating E fields at the rear surface of the target are inferred from the detailed spectra.

A phase I dose-finding study of a combination of pegylated liposomal doxorubicin (Doxil), carboplatin and paclitaxel in ovarian cancer

Standard chemotherapy for advanced epithelial ovarian cancer is a combination of platinum-paclitaxel. One strategy to improve the outcome for patients is to add other agents to standard therapy. Doxil is active in relapsed disease and has a response rate of 25% in platinum-resistant relapsed disease. A dose finding study of doxil-carboplatin-paclitaxel was therefore undertaken in women receiving first-line therapy. Thirty-one women with epithelial ovarian cancer or mixed Mullerian tumours of the ovary were enrolled. The doses of carboplatin, paclitaxel and doxil were as follows: carboplatin AUC 5 and 6; paclitaxel, 135 and 175 mg m(-2); doxil 20, 30, 40 and 50 mg m(-2). Schedules examined included treatment cycles of 21 and 28 days, and an alternating schedule of carboplatin-paclitaxel (q 21) with doxil being administered every other course (q 42). The dose-limiting toxicities were found to be neutropenia, stomatitis and palmar plantar syndrome and the maximum tolerated dose was defined as; carboplatin AUC 5, paclitaxel 175 mg m(-2) and doxil 30 mg m(-2) q 21. Reducing the paclitaxel dose to 135 mg m(-2) did not allow the doxil dose to be increased. Delivering doxil on alternate cycles at doses of 40 and 50 mg m(-2) also resulted in dose-limiting toxicities. The recommended doses for phase II/III trials are carboplatin AUC 6, paclitaxel 175 mg m(-2), doxil 30 mg m(-2) q 28 or carboplatin AUC 5, paclitaxel 175 mg m(-2), doxil 20 mg m(-2) q 21. Grade 3/4 haematologic toxicity was common at the recommended phase II doses but was short lived and not clinically important and non-haematologic toxicities were generally mild and consisted of nausea, paraesthesiae, stomatitis and palmar plantar syndrome.

Induction of donor-specific tolerance to islet allografts in nonhuman primates

Pancreatic tissue grafting is by far the most physiological therapeutic solution to the insulin deficiency of diabetes. Recent clinical trials have indicated somewhat successful use of nonsteroidal immunosuppressive regimens and a successful nonhuman primate trial using CD154 for costimulation blockade was reported. However, these protocols need to be replaced with safe and efficacious ones in which long-term allotolerance would make these treatments routine in a clinical setting. With the specific objective of testing whether peripheral infusions of stem cells or stem cell fractions in conjunction with islet allografting would induce allograft tolerance, we have established a macaque diabetic model. The macaques were rendered diabetic by streptozotocin and required daily doses of insulin to maintain lower blood glucose levels. The diabetic macaques then received islets and stem cells from unrelated and MHC-mismatched donors without any immunosuppression. In our initial analysis, 5 of 7 macaques that received stem cell infusions at the time of islet allografting have shown allograft survival longer than the group of macaques that received islets without the stem cell infusion. One of these five macaques has been normoglycemic for 10 months, with no exogenous insulin. This macaque received stem cell population enriched for CD34+ cells with depletion of CD18 cells, which have shown low or no allostimulatory potential in mixed lymphocyte cultures. Increased levels in insulin and C-peptide levels were shown in the macaques after islet transplantation.

Induction of islet allotolerance in nonhuman primates

Recent clinical trials have pioneered the successful use of a nonsteroidal immunosuppressive regimen and established a basis for application in a routine clinical setting. In this study, a single islet transplant was not sufficient to regulate blood glucose levels, and a second transplant became necessary. A similar observation was made in our macaque islet transplant study, where animals after the second transplantation have shown trends towards normoglycemia in the presence of mycophenolate mofetil. All five animals that received the second transplant have shown an initial rise in C peptide levels, which rapidly decreased as we tapered the MMF dose from 20 mg/kg BID to 5 mg/kg SID. Two animals of the five that were preconditioned with MMF one week prior to transplantation have shown significantly higher C peptide levels. We believe that it is very important to understand the relationship between the first graft failure and subsequent islet allograft success. Since graft success did not correlate with number of transplanted islets, the correction of blood glucose levels toward normoglycemia after the second transplantation suggests a mechanism by which the allotolerance to second transplant is facilitated by the first islet transplantation. These initial observations suggest approaches to "tolerize" the recipient to accept the second-transplant islets (a) through preconditioning the animal to improve the rate of success for the first transplant or (b) through tolerization to islets in the first transplant to facilitate better engraftment of the second-transplant islets.

Detection of biogenic CO production above vascular cell cultures using a near-room-temperature QC-DFB laser

We report the first application of pulsed, near-room-temperature quantum cascade laser technology to the continuous detection of biogenic CO production rates above viable cultures of vascular smooth muscle cells. A computer-controlled sequence of measurements over a 9-h period was obtained, resulting in a minimum detectable CO production of 20 ppb in a 1-m optical path above a standard cell-culture flask. Data-processing procedures for real-time monitoring of both biogenic and ambient atmospheric CO concentrations are described.

Mitochondrial sequence analysis for forensic identification using pyrosequencing technology

Over recent years, requests for mtDNA analysis in the field of forensic medicine have notably increased, and the results of such analyses have proved to be very useful in forensic cases where nuclear DNA analysis cannot be performed. Traditionally, mtDNA has been analyzed by DNA sequencing of the two hypervariable regions, HVI and HVII, in the D-loop. DNA sequence analysis using the conventional Sanger sequencing is very robust but time consuming and labor intensive. By contrast, mtDNA analysis based on the pyrosequencing technology provides fast and accurate results from the human mtDNA present in many types of evidence materials in forensic casework. The assay has been developed to determine polymorphic sites in the mitochondrial D-loop as well as the coding region to further increase the discrimination power of mtDNA analysis. The pyrosequencing technology for analysis of mtDNA polymorphisms has been tested with regard to sensitivity, reproducibility, and success rate when applied to control samples and actual casework materials. The results show that the method is very accurate and sensitive; the results are easily interpreted and provide a high success rate on casework samples. The panel of pyrosequencing reactions for the mtDNA polymorphisms were chosen to result in an optimal discrimination power in relation to the number of bases determined.

Breast cancer stage at diagnosis in relation to duration of medicaid enrollment

BACKGROUND

Stage at diagnosis has been used to compare the quality of cancer screening services by health insurance type, using membership at diagnosis or treatment. This study evaluates breast cancer stage among women on Medi-Cal, California's Medicaid program, in relation to duration of coverage to assess the impact of including women with recently acquired benefits in the Medi-Cal group.

METHODS

Breast cancers diagnosed in 1993 among women ages 30 to 64 were obtained from the statewide, population-based cancer registry and linked to Medi-Cal enrollment files. Women on Medi-Cal when diagnosed were categorized based on months covered during the 12 months preceding diagnosis (12, 1-11, or none), and compared with all other women with breast cancer. Logistic regression models measured the effect of duration of Medi-Cal coverage on the odds of late-stage disease, controlling for demographic, socioeconomic, health access, and tumor characteristics.

RESULTS

Among women with Medi-Cal benefits when diagnosed, 18% were not covered during the year preceding diagnosis, and late-stage disease was common among these women. The odds ratio for late-stage disease among all women on Medi-Cal was 1.67 (95% CI 1.41, 1.97), but was reduced by 42% to 1.39 (95% CI 1.15, 1.67) when women without benefits before diagnosis were excluded from the Medi-Cal group.

CONCLUSIONS

Women with Medi-Cal benefits before diagnosis were more likely to be diagnosed with late-stage disease than other women with breast cancer. However, the practice of assigning health insurance status based on enrollment at diagnosis underestimates the effect of access to breast cancer screening through Medicaid.

Pseudotumor deltoideus: a previously undescribed anatomic variant at the deltoid insertion site

A spectrum of eccentric bone irregularities were observed in the humeral deltoid tuberosity region of five patients. Patients were referred for associated pain or for the incidental radiographic findings. The lesions are characterized radiographically by a relative lucency at or adjacent to the deltoid tuberosity, variably increased uptake on the bone scan, and mild cortical irregularity or adjacent eccentric marrow abnormality on MRI and CT. The term pseudotumor deltoideus is coined for these previously undescribed anatomic variants. Imaging studies and extended clinical follow-up in these patients support an inactive or indolent process that may be managed conservatively. The potential etiology and role of these cortical irregularities as tumor simulators is emphasized.

The degree of antenatal ventriculomegaly is related to pediatric neurological morbidity

OBJECTIVE

Our hypothesis was that the degree of antenatally diagnosed cerebral ventriculomegaly is related to aneuploidy, perinatal mortality and long-term neurological morbidity.

METHODS

Ninety-one cases of ventriculomegaly identified from 1 June 1994 to 1 July 1999 were examined for prenatal, intrapartum and neonatal complications. Pediatric follow-up was reviewed for infants with ventriculomegaly from birth up to as long as 4 years. Minor neurological morbidity was defined as a score of 70-80 on the clinical adaptive test/clinical linguistic and auditory milestone scale and included mild motor or language delay. Major morbidity included a score of < 70, evidence of cerebral palsy, or seizure disorder. The incidence of neurological complications was compared, on the basis of the degree of ventriculomegaly, with group 1 being > 10-15 mm and group 2 being > 15 mm.

RESULTS

Twenty-seven cases (18 with neural tube defects and nine with holoprosencephaly) were excluded. Among the remaining 64 patients, 39 had a ventricular diameter of > 10-15 mm and comprised group 1. Five of the 39 cases (12.8%), all with other ultrasound anomalies, elected to terminate. The incidence of aneuploidy in group 1 was 14.2%. Among the 19 cases with isolated ventriculomegaly, 17 (89%) were normal and two (11%) had minor neurological morbidity. In group 1 there were two cases associated with cytomegalovirus (CMV) infection. Of the 25 cases in group 2, eight (32%), all with other ultrasound anomalies, elected to terminate. The incidence of aneuploidy in group 2 was 17.4%. For the nine cases with isolated ventriculomegaly of > 15 mm, one (11%) was normal (p < 0.001), five (56%) had minor neurological morbidity requiring a ventriculoperitoneal shunt (p = 0.035), and three (33%) had major neurological morbidity (p = 0.045) when compared to cases of isolated ventriculomegaly in group 1. There was one case of CMV infection in group 2. All perinatal deaths in both groups were associated with other anomalies.

CONCLUSIONS

Amniocentesis to determine karyotype and the presence of CMV is warranted for all cases of ventriculomegaly of > 10 mm. The degree of antenatal ventriculomegaly is related to pediatric neurological morbidity and, when it is > 15 mm, it is associated with an increase in abnormal neurological development.

Results of follow-up of human contacts of bovine tuberculosis in cattle during 1993-7 in North Staffordshire

The purpose of the study was to describe the results of follow up of human contacts of bovine tuberculosis. The bovine tuberculosis cases occurred on farms in North Staffordshire between 1993 and 1997. A total of 162 people were identified as having close contact with cattle diagnosed as having bovine tuberculosis, or who had drunk unpasteurized milk from a herd with bovine tuberculosis. A retrospective review of chest clinic notes was performed. One hundred and thirty-eight people attended for follow up, and Heaf test results, necessity for chest X-ray and further clinical follow-up are described. No case of human Mycobacterium bovis infection was identified. It is suggested that follow-up of human contacts is limited to those with close contact with herds who have bovine tuberculosis and cattle with visible pulmonary lesions or evidence of udder infection. Children on the farms with affected cattle should also be offered BCG in advance of the routine school's programme.

Bronchial repair with pulmonary preservation for severe blunt trauma

After a motorcycle accident, a 22-year-old male was diagnosed with multiple rib fractures, left-sided tension pneumothorax, hemothorax and left upper lobe bronchus rupture at its origin. An emergency left thoracotomy revealed an almost complete avulsion of the upper lobe bronchus from the main stem bronchus, a severely damaged pulmonary artery, and a concurrent deep intraparenchymal lower lobe laceration. Since the patient was hemodynamically stable, a decision was made to preserve as much lung as possible. In the event of complex pulmonary trauma, pulmonary preservation is desirable since emergency pneumonectomy is usually associated with high mortality. Early bronchoscopic assessment, careful anesthetic management, and meticulous surgical technique with liberal use of fibrin glue were crucial to successful outcome.

Corneodesmosin expression in psoriasis vulgaris differs from normal skin and other inflammatory skin disorders

SUMMARY

Corneodesmosin (Cdsn) is a late differentiation epidermal glycoprotein putatively involved in keratinocyte adhesion. The Cdsn gene lies within the susceptibility region on chromosome 6p21.3 (PSORS1) for psoriasis, a common chronic disfiguring skin disease. A particular allelic variant of Cdsn has a strong association with psoriasis. Therefore, genetically and biologically, Cdsn is a possible candidate gene for psoriasis susceptibility. To investigate a potential role for Cdsn in psoriasis pathogenesis, protein expression studies were performed by quantitative immunohistochemistry on normal skin, psoriatic skin (lesional and nonlesional), and other skin disorders using monoclonal antibodies (G36-19 and F28-27). In normal and nonlesional skin, Cdsn was expressed in stratum corneum and one or two layers of superficial stratum granulosum. In lesional psoriasis, there was a significant increase in Cdsn expression, which was observed in multiple layers of stratum spinosum and in stratum corneum. The expression pattern varied from granular, cytoplasmic immunoreactivity to cell surface labeling with weakly immunoreactive cytoplasm. In chronic atopic dermatitis, lichen planus, mycosis fungoides, and pityriasis rubra pilaris, Cdsn immunoreactivity was confined to stratum corneum and upper stratum granulosum with no stratum spinosum immunoreactivity. Immunoelectron microscopy of normal and lesional psoriatic skin demonstrated Cdsn release concomitant with involucrin incorporation into cell envelopes and completed before mature envelope formation. Extracellular release of Cdsn occurred at a lower level of the epidermis in psoriasis than normal skin. These protein expression studies provide evidence of altered Cdsn expression in psoriasis consistent with a role of Cdsn in disease pathogenesis. Further functional and genetic studies of Cdsn are justified to determine its role as a potential psoriasis-susceptibility factor.

Ultrasound prenatal diagnosis of fetus in fetu

A case of fetus in fetu was diagnosed prenatally using ultrasound. The differential diagnosis between a fetus in fetu and a highly differentiated teratoma is discussed. The importance of prenatal diagnosis of fetus in fetu and the effect on subsequent management are described.

In-utero treatment of fetal bladder-outlet obstruction by a ureterocele

Fetal bladder-outlet obstruction by ureteroceles is usually treated at birth. However, such obstruction may be detrimental to the health of the fetus and so in-utero correction is preferable. We describe the successful cytoscopy guided laser incision, with no complications, of a uterocele that was causing bladder-outlet obstruction in a fetus of 19 weeks and 6 days gestation.

Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma

BACKGROUND

Preoperative identification of lymph node metastases associated with esophageal carcinoma may influence treatment. EUS is the most accurate method for locoregional staging of these tumors. The impact of EUS-guided fine-needle aspiration (EUS-FNA) on lymph node staging in esophageal carcinoma is unclear.

METHODS

From May 1996 to May 1999, 74 patients with esophageal carcinoma underwent preoperative EUS. After October 1998 EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. The results of EUS with and without FNA were retrospectively reviewed and compared. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Ten of the 74 patients had to be excluded for lack of lymph node stage confirmation. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group).

RESULTS

The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Complications comprised 1 patient who developed self-limited bleeding after dilation that did not preclude completion of the EUS (1%, 95% CI [0%, 7%]).

CONCLUSIONS

EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.

Trial-related discrimination in HIV vaccine clinical trials

Participants in preventive HIV vaccine trials may experience negative social consequences of trial participation, including problems related to a vaccine-induced positive HIV antibody test, yet few vaccine studies have reported on this issue. From October 1995 through November 1998, 1516 AIDS Vaccine Evaluation Group (AVEG) volunteers were assessed for reports of trial-related discrimination (TRD). Ninety TRD events were reported by 76 (5%) of 1516 volunteers. The most commonly reported incidents (n = 52, 57.8%) were negative reactions of friends, family, and co-workers to the volunteer. Few incidents (approximately 10%) were reported as linked to HIV testing. The majority of events (n = 47, 52%) were described by volunteers as "resolved" at the time of reporting, 36 (40%) as "not resolved," and for 7 (8%) events volunteers did not report resolution status. Reported incidents were analyzed by logistic regression to determine their association with the volunteer's age, sex, race, sexual orientation, and HIV risk category. There was no association between volunteer characteristics and TRD. Logistic regression and analysis of variance (ANOVA) were used to analyze association of trial sites with the number of TRD events reported. After controlling for site variation in data collection and reporting, no significant differences were found between the sites in terms of the number or type of TRD reported. Fears that TRD would be widespread and severe have not been borne out by this analysis. While the results of this study are reassuring, they should be interpreted with caution, as it is unclear whether these results may be extended to phase III trials enrolling large numbers of individuals at higher risk of HIV acquisition.

In vitro and in vivo investigations into the biocompatibility of diamond-like carbon (DLC) coatings for orthopedic applications

Diamond-like carbon (DLC) shows great promise as a durable, wear- and corrosion-resistant coating for biomedical implants. The effects of DLC coatings on the musculoskeletal system have not been investigated in detail. In this study, DLC coatings were deposited on polystyrene 24-well tissue culture plates by fast-atom bombardment from a hexane precursor. Two osteoblast-like cell lines were cultured on uncoated and DLC-coated plates for periods of up to 72 h. The effects of DLC coatings on cellular metabolism were investigated by measuring the production of three osteoblast-specific marker proteins: alkaline phosphatase, osteocalcin, and type I collagen. There was no evidence that the presence of the DLC coating had any adverse effect on any of the parameters measured in this study. In a second series of experiments, DLC-coated cobalt-chromium cylinders were implanted in intramuscular locations in rats and in transcortical sites in sheep. Histologic analysis of specimens retrieved 90 days after surgery showed that the DLC-coated specimens were well tolerated in both sites. These data indicate that DLC coatings are biocompatible in vitro and in vivo, and further investigations into their long-term biological and tribological performance are now warranted.

Genetic counseling impacts decision for prophylactic surgery for patients perceived to be at high risk for breast cancer

BACKGROUND

This study addresses the impact a comprehensive genetic counseling program had on women considering prophylactic mastectomy or oophorectomy.

METHODS

Sixty patients underwent detailed family evaluation and risk was estimated. Recommendations were made regarding testing. Ramifications of testing were discussed in detail.

RESULTS

Thirty-one women (37%) were considering prophylactic surgery believing themselves to be at high risk. Of these, 23 had testing recommended. Seven patients proceeded with prophylactic surgery based solely on high-risk assessment. Ten women were tested; five were positive. Three patients proceeded with prophylactic surgery despite a negative test. One decided against surgery despite a positive test. After counseling, prophylactic surgery was performed in just over half the initial candidates.

CONCLUSIONS

Breast cancer risk estimation and genetic evaluation can be complex. Comprehensive genetic risk assessment programs can play a significant role in the management of patients considering prophylactic surgery for perceived high risk.

Familial hemophagocytic lymphohistiocytosis: how late can the onset be?

BACKGROUND AND OBJECTIVES

Most patients with familial hemophagocytic lymphohistiocytosis (HLH) develop the disease within the first two years of age. In a minority of cases a later occurrence has been reported, with an upper age limit of eight years. A significant concordance of the age at onset within each family has also been observed.

RESULTS

We report four cases of families with HLH diagnosed at an unusually late age, comprised between between 9 and 17 years; in each of these families another child developed the disease in infancy. The natural killer activity of the patients was depleted; nevertheless, we had indirect evidence that, in at least two families, mutations of the perforin gene were not causing the disease.

INTERPRETATION AND CONCLUSIONS

Such a late onset is very unusual and suggests that there is a subgroup of families with HLH in which the disease may present early or late in different members. Thus in some families with HLH the siblings might remain at risk of developing the disease for several years. Their actual risk cannot be defined until the genetic mutation is identified in each family and assessed in each member.

The nature of advanced practice nursing

In attempting to define "advanced practice," we argue that nursing as such is teleological or goal-directed with those goals being defined by the patient or client in interaction with the nurse. In helping the patient meet identified goals, the nurse requires 2 kinds of knowledge-general and particular. General includes theory (know what/why), pattern recognition (know what), and practical knowledge (know how). Particular (know who) is personal knowledge about the patient. The advanced practice nurse, by virtue of graduate education, is able to move beyond the familiar and experientially learned. He or she makes a deliberate attempt to situate self in a dialectic between general and particular knowledge in such a way that the interplay opens possibilities. Knowing when a particular action would be most helpful is defined as practical wisdom. We argue that a highly developed sense of practical wisdom is the hallmark of advanced practice.

Endoscopic documentation of unintentional perforation of the dividing membrane during amnioreduction for twin-twin transfusion syndrome

OBJECTIVE

The purpose of this report is to document endoscopically the occurrence of unintentional piercing of the dividing membrane in a monochorionic twin pregnancy with twin-twin transfusion syndrome (TTTS).

MATERIALS AND METHODS

The dividing membrane was visualized endoscopically during laser therapy in a patient with TTTS who had previously undergone therapeutic amniocentesis. The donor twin had no visible bladder, but the amniotic fluid volume had normalized after amniocentesis.

RESULTS

The suspected membrane perforation was identified endoscopically during laser surgery. Five areas of vascular communications were identified and photocoagulated.

CONCLUSIONS

Sonographic evidence of normalization of the amniotic fluid volumes after therapeutic amniocentesis with persistent nonvisualization of the bladder of the donor twin should not be interpreted as a sign of improvement of TTTS, but rather as indirect evidence of unintentional perforation of the dividing membrane. This complication can be confirmed endoscopically.

Opening pandora's box: the practical and legal dangers of involuntary outpatient commitment

Policy makers have recently begun to reconsider involuntary outpatient commitment as a means of enhancing public safety and providing mental health services to people deemed to be noncompliant with treatment. The authors review the therapeutic claims for outpatient commitment and take the position that there is insufficient evidence that it is effective. They offer arguments that outpatient commitment may not improve public safety and may not be more effective than voluntary services. The authors further point out that outpatient commitment may undermine the delivery of voluntary services and may drive consumers away from the mental health system. The authors conclude that outpatient commitment programs are vulnerable to legal challenge because they may depart from established constitutional standards for involuntary treatment.

Constraints on equifinality: goals are good explanations only for controllable outcomes

What makes a goal or a precondition a better explanation of an action or outcome? Recent research shows that whereas goals are preferred for common actions, preconditions are preferred for actions that require substantial resources, particularly when those actions are obstructed. Two studies examined whether judgments of goals and preconditions reflect the controllability of the events, and whether previous findings apply to events generated by participants. Participants judged goals and preconditions as explanations for desirable extreme and moderate events and assessed the controllability and probability of the events. For common events, goals were better explanations than preconditions, whereas for the extreme scenarios, preconditions were judged equal or better explanations. The extreme events were seen as less controllable than the moderate events, and the controllability of the events predicted judgments of goals as explanations. The results suggest that participants see goals as better explanations only for events that the person can control, and they judge preconditions to be good explanations for events where the person has little control. These findings suggest that equifinality may apply only to those actions and outcomes where the preconditions are readily obtainable.

Lifelong learning in ethical practice: a challenge for continuing medical education

BACKGROUND

Formal education in the identification, analysis, and resolution of ethical issues in clinical practice is now an essential component of undergraduate and postgraduate medical education. Physicians educated before the 1980s have had little or no formal education in ethics. This article describes a project for assessing the content and format appropriate for the continuing education needs of practicing physicians.

METHODS

A questionnaire and follow-up facilitated small-group discussions with a physician ethicist around case-based problems were used to identify the ethical issues in practice where participants felt the need for continuing education.

RESULTS

The project confirmed that practitioners had very little formal ethics in medical school and less since starting practice despite encountering ethical issues. The most frequently used method of learning about ethics was informal discussion among those who have the same lack of formal education. Physicians did not feel that they needed a "very high" level of confidence and competence in handling ethical issues, even those commonly encountered. Participants indicated strongly that they lacked a systematic approach to the identification and analysis of ethical issues and suggest incorporation of the ethical component into regular CME.

FINDINGS

In spite of the small study population and the volunteer nature of the participants, the project demonstrated the identification of ethics content for CME similar to that used in medical education. Further work is needed to assess objective needs for ethics education in addition to the perceived needs of clinicians.

Prescribing exercise for cardiac patients: knowledge, practices, and needs of family physicians and specialists

PURPOSE

To determine the following about prescribing exercise for cardiac patients: physicians' present and needed knowledge; their present practices; barriers that hinder them; and perceived need for and content of a protocol for prescribing exercise.

METHODS

(1) Questionnaire mailed to 371 family physicians (FPs), 31 internists, and 25 cardiologists; and (2) four focus groups consisting of 25 FPs, 1 internist, and 3 cardiologists.

RESULTS

Questionnaire response rate was 45% (n = 192). Because responses were similar and the group was small, internists and cardiologists were combined as "specialists." Generally, questionnaire data agreed with focus group data, with the latter providing more detail. Family physicians perceived they know little about prescribing a specific exercise program while specialists perceived they know little about motivating patients to begin an exercise program. The method most frequently used by both physician groups to increase exercise is providing general advice. The main barriers to prescribing exercise were inadequate knowledge (FPs only), patient education materials, and community resources. Both groups rated highly the need for a protocol for prescribing exercise and indicated it should: (1) include identification of patient's stage of change; (2) include indications and contraindications for exercise; (3) provide guidelines for developing a specific exercise prescription; (4) contain patient education materials, and (5) be simple and short.

CONCLUSIONS

Family physicians perceive they know little about prescribing a specific exercise program for cardiac patients while specialists perceive they know little about motivating patients. Physicians rate highly the need for a protocol to help them prescribe exercise for cardiac patients.

Detection of sequence variation in the HVII region of the human mitochondrial genome in 689 individuals using immobilized sequence-specific oligonucleotide probes

We have developed a rapid, immobilized probe-based assay for the detection of sequence variation in the hypervariable segment II (HVII) of the mitochondrial DNA (mtDNA) control region. Using a panel of 17 sequence-specific oligonucleotide (SSO) probes immobilized on nylon membrane strips, we typed 689 individuals from four population groups. The genetic diversity value for each population was calculated from the frequency data, and the frequencies of distinct "mitotypes" in each group were determined. We performed DNA sequence analysis of 129 samples to characterize the sequences associated with "blanks" (absence of probe signals) and weak probe signals. Out of 689 samples, we observed five heteroplasmic samples (excluding the variable C-stretch beginning at position 303) using the immobilized SSO probe panel. The SSO probe strips were used for the analysis of shed hairs and bloodstains from several criminal cases in Sweden, one of which is described here. We conclude that this mtDNA typing system is useful for human identification and significantly decreases casework turnaround time.

A meta-analysis of fear appeals: implications for effective public health campaigns

The fear appeal literature is examined in a comprehensive synthesis using meta-analytical techniques. The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, and are more persuasive than low or weak fear appeals. The results also indicate that fear appeals motivate adaptive danger control actions such as message acceptance and maladaptive fear control actions such as defensive avoidance or reactance. It appears that strong fear appeals and high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses. Future directions and practical implications are provided.

Staphylococcal toxin-induced T cell proliferation in atopic eczema correlates with increased use of superantigen-reactive Vbeta-chains in cutaneous lymphocyte-associated antigen (CLA)-positive lymphocytes

Staphylococcal superantigens have been implicated in the pathogenesis of atopic dermatitis (AD). This may occur through superantigenic activation of T lymphocytes and their subsequent induction of the skin homing receptor CLA on activated cells. We investigated the proliferative responses of peripheral blood mononuclear cells (PBMC) from 10 patients with an infective exacerbation of AD and six normal controls to the staphylococcal superantigens, staphylococcal enterotoxin A and B (SEA, SEB) and toxic shock syndrome toxin-1 (TSST-1), and the mitogens phytohaemagglutinin (PHA) and concanavalin A (Con A). We also assessed CLA and T cell receptor (TCR) Vbeta-chain expression by immunofluorescence and flow cytometry before and after stimulation. PBMC from AD patients showed two-fold increased proliferation to SEA and SEB (P < 0.01) compared with normals, whereas the response to mitogenic stimulation was identical. Analysis of (TCR) Vbeta-chain expression demonstrated increased use of superantigen-reactive Vbeta families in freshly isolated PBMC in AD patients compared with controls. This pattern of Vbeta-chain expression was only observed in the CLA+ but not the total population of T cells. Furthermore, there was a positive correlation between the enhanced PBMC proliferative response and increased expression of superantigen-reactive Vbeta families in atopic patients. These data support the concept that superantigens are important in the pathogenesis of this common condition, and also provide evidence that the increased use of certain Vbeta families in circulating, CLA+, skin homing lymphocytes is of functional significance.

The design and synthesis of thrombin inhibitors: the introduction of in vivo efficacy and oral bioavailability into benzthiazolylalanine inhibitors

The further optimisation of the novel lead compound CGH752 (Fig. 1) is described. By introducing various substituents into the 6-position of the 3,3-dimethyltetrahydroquinoline (DMTHQS) ring we have been able to favourably affect the in vitro and in vivo activity, and the pharmacokinetics of such compounds. One of the inhibitors synthesised (CGH1484) is bioavailable and shows efficacy in animal models of thrombosis.