Flexible diets for diabetes care

The nutritional aspect of diabetes treatment is often the most difficult component of care for the patient and the health professional. The demands imposed by major alter ations in lifestyle, the artificiality of therapeutic eating pro grams, and the lack of available and proven counseling are possible causes of poor patient compliance. "Diets" may also be socially stigmatic to patients with diabetes. While advances have been made in many areas of nutrition and diabetes, there has been relatively little change in the traditional nutritional counseling methods, intended to lead to an understanding and adherence to a sound nutritional program.

The evolving definition of the general goals of nutri tional therapy and the lack of success with traditional ap proaches to nutritional care of diabetes have recently stimu lated the search for alternate nutritional regimens. These programs have been called "flexible diets. " They all base food selection upon the quality of food content rather than food group as in the exchange diet. Indiuidual counseling is important and is directed primarily to modify present eat ing habits rather than radical changes. The continued de velopment of flexible diets may be an exciting area of nutri tional development in the future.

Diagnosis of human parvovirus infection by dot-blot hybridization using cloned viral DNA

The human parvovirus can be detected in serum by the immunological techniques of immune electron microscopy (IEM), counterimmunoelectrophoresis (CIE), and radioimmunoassay (RIA). A portion of the genome of this virus has been cloned in pAT153 and used as a 32P-labelled probe in dot-blot hybridization assays to detect parvovirus DNA in serum specimens. This test proved a highly sensitive means of detecting virus in microlitre volumes of serum, giving positive results for samples containing 0.5 pg viral DNA, equivalent to 10(4) virus particles. Unlike CIE and RIA the test is not affected by the presence of parvovirus-specific antibody in serum specimens, and has permitted virus to be detected in specimens obtained up to 11 days after the onset of clinical symptoms of aplastic crisis.

Two housing systems for calves

Thirty-six male Holstein calves were in an experiment with 2 X 2 factorial design with the objective of comparing management systems and milk feeding. Housing systems were similar except calves on A system were housed in pens .66 m wide with grated floors whereas calves on B system were in pens that were 1.36 m wide with solid floors bedded with straw. Within each management system nine calves were fed milk at 8% of body weight and nine calves at 12% of body weight. There was no interaction between management system and feeding percent. Preweaning calves fed more milk gained faster (.64 versus .50 kg/day) compared with calves fed less. Management system did not influence body weight gain or feed conversion prior to weaning, but postweaning A system resulted in slower gains (.74 versus .90 kg/day) and less favorable feed conversion (2.00 versus 1.77 kg dry matter intake/kg body weight gain) than calves housed under the B system. Eosinophil count was higher during 5th and 7th wk of the experiment for calves housed in A compared with B system. Measurements of body weight gain and feed conversion were effective in differentiating between two housing systems for calves.

The human tumor clonogenic assay in human breast cancer

The human tumor clonogenic assay (HTCA) was evaluated in 407 fresh samples of breast cancer from 288 patients. Seventy samples were inadequate for testing. Adequate in vitro growth for drug testing (greater than 30 colonies/plate) was obtained in 91 (27%) of the 337 viable samples, inadequate growth for drug evaluation (5 to 30 colonies/plate) in 17%, and no colony formation (less than 5 colonies/plate) in 56%. Operationally defining a greater than or equal to 50% inhibition of colony formation as in vitro drug sensitivity, the in vitro response rates to 12 anticancer drugs tested against ten to 36 different cancers (arranged in decreasing order according to the number of tests performed) were as follows: doxorubicin (14%), bisantrene (54%), vinblastine (33%), mitomycin (36%), interferon clone A (23%), 5-fluorouracil (20%), methotrexate (17%), leukocyte interferon (33%), mitoxantrone (42%), cyclophosphamide (25%), m-AMSA (16%), and melphalan (10%). Among 25 patients receiving single-agent therapy, there were ten (59%) of 17 with in vitro sensitivity who responded; resistance was correctly predicted in nine patients (100%), P = .01. Among 34 patients treated with combination chemotherapy, seven (50%) of 14 with in vitro sensitivity responded, and resistance was predicted in 13 (65%) of 20 patients. Difficulties in using the HTCA in breast cancer (including small specimen size, difficulties in disaggregation, and inadequacy of growth) will require additional research. Nonetheless, the assay appears to detect in vitro activity as well as resistance of a variety of anticancer agents and appears to predict clinical responsiveness to standard as well as some investigational single agents.

Phase II trial of vinzolidine, an oral vinca alkaloid, in Hodgkin's disease and non-Hodgkin's lymphoma

Vinzolidine, a semisynthetic vinblastine derivative, was tested in an oral formulation in 21 heavily pretreated patients with lymphoma. Partial remissions were seen in four patients with Hodgkin's disease (50%) and in one patient with non-Hodgkin's lymphoma (8%). Significant side effects included neurotoxicity and dose-related myelosuppression. Vinzolidine is an active vinca alkaloid which merits further evaluation in patients with lymphoma, particularly Hodgkin's disease.

Identification of two major B cell forms of nodular mixed lymphoma

To resolve the controversy over the immunologic nature of nodular mixed lymphoma (NM), we examined nine cases of NM for surface antigens using both tissue section and cell suspension methods. These were contrasted with 12 cases of nodular poorly differentiated lymphocytic lymphoma. We found two major B cell types of NM, those with monoclonal immunoglobulin (SIg+)-positive nodules with an SIg+B1+B2+Ia+T- phenotype (four cases) and those with nodules devoid of immunoglobulin with an SIg-B1+B2-Ia+T- phenotype (five cases). Our SIg+ NM cases appear similar to nodular poorly differentiated lymphocytic lymphoma (SIg+B1+B2+Ia+T-), except suspension assay indicates fewer SIg+ cells in NM. In our SIg- NM cases, the neoplastic nodules consistently expressed B1 and Ia-like antigens and lacked T cells, indicating a B cell neoplasm similar to many large cell lymphomas. By demonstrating a B cell antigen in SIg- nodules, we substantially resolve the controversial NM cases previously called "null" or T cell. The two distinct immunotypes indicate the complexity of B cell antigenic expression in NM and might also explain the variable response to therapy in NM described in previous studies. Finally, we describe NM cases with the simultaneous occurrence of several stages of B cell differentiation. This suggests that some NM cases are not frozen in a single stage of B cell development but may express a range of B cell antigens. NM, then, may be a paradigm of variable, simultaneous B cell maturation.

Phase I trial of esorubicin (4'deoxydoxorubicin)

A phase I study of 4'deoxydoxorubicin (esorubicin) was performed on an every-21-day bolus intravenous (IV) schedule in 36 patients with advanced cancer. Thirty-four patients were evaluable for toxicity analysis. Toxicity included mild nausea, occasional local skin reactions, and mild to moderate alopecia. Myelo-suppression was dose limiting. Clinically evident congestive heart failure was not observed. However, two patients developed premature ventricular contractions. Overall, esorubicin was better tolerated than doxorubicin at equally potent doses. Although response analysis was not the primary objective of this phase I study, minor responses were observed in melanoma, breast cancer, lymphoma, and gastric cancer. On the basis of this study, a starting dose of 30 mg/m2 IV every 21 days is recommended for good-risk patients with escalation to 32.5 mg/m2 depending on bone marrow tolerance. For patients with poor bone marrow reserve, a starting dose of 25 mg/m2 every 21 days is recommended. Phase II trials with esorubicin in this dosage schedule are clearly warranted in a wide variety of metastatic neoplasms including a substantial population of patients who have not received prior chemotherapy.

Vindesine, carmustine, doxorubicin, and prednisone (EBAP) in recurrent lymphomas: a Southwest Oncology Group study

Seventy-eight patients with Hodgkin's disease and non-Hodgkin's lymphoma who had failed prior chemotherapy or radiation therapy were treated with a combination of vindesine, carmustine, doxorubicin, and prednisone (EBAP). Outpatient therapy was administered at 21-day intervals. Complete and partial responses were seen in 32 patients (41%). The response rate was higher for Hodgkin's disease (59%) than for non-Hodgkin's lymphoma (31%). The median duration of response was 31 weeks in both groups, with a median survival of all patients of 35 weeks (responders, 122 weeks; nonresponders, 16 weeks). Myelotoxicity was greater using EBAP than in the earlier reported program with vincristine, carmustine, doxorubicin, and prednisone, and in the absence of higher response rates does not support the use of vindesine over vincristine in combination programs using nitrosoureas, anthracyclines, and prednisone.

Double-blind crossover study of the antiemetic efficacy of high-dose dexamethasone versus high-dose metoclopramide

Nausea and vomiting remain common and debilitating side effects of therapy with many anticancer drugs. Recent reports have shown that both metoclopramide and dexamethasone are effective drugs for the treatment of severe nausea and vomiting caused by cis-platinum. A double-blind crossover study comparing the antiemetic properties of high-dose oral and intravenous regimens of metoclopramide and dexamethasone in outpatients was carried out. Standardized patient questionnaires and interviews were used to evaluate response. Dexamethasone and metoclopramide protected against more than five episodes of emesis in 48% and 40% of patients, respectively. Nausea persisted for less than six hours in 45% of patients on dexamethasone and in 37% on metoclopramide. The antiemetic efficacy of both regimens was retained through repeated courses of chemotherapy. Side effects were minimal with dexamethasone; however, 33% of patients experienced unacceptable extrapyramidal side effects to metoclopramide. Patient preference was significantly in favor of dexamethasone: 70% of patients chose to continue dexamethasone compared to 22% who preferred metoclopramide and 8% who chose other antiemetics. Dexamethasone was the preferred antiemetic in this patient population due to minimal side effects.

Threonine uptake in Trypanosoma brucei

Threonine uptake by the parasitic protozoan Trypanosoma brucei has been assessed using an oil-phase separation technique for measuring rapid amino acid fluxes. It was shown that the storage conditions for the organism were critical for the production of reproducible data. Using this method it has been shown that threonine uptake occurs rapidly, being linear for less than 30 s at 37 degrees C in contrast with previous reported results. Kinetic analysis of threonine uptake at 25 degrees C and at physiological plasma threonine levels (20-700 microM) gave a Km of 250 microM and a Vmax of 8 nmol mg-1 cell protein min-1. At these concentrations threonine uptake takes place against a concentration gradient.

Dose-response and dose-survival advantage for high versus low-dose cisplatin combined with vinblastine and bleomycin in disseminated testicular cancer. A Southwest Oncology Group study

One-hundred fourteen patients with advanced testicular cancer were randomized to treatment consisting of either high-dose (120 mg/m2, monthly) or low-dose (15 mg/m2, daily X 5 monthly) cisplatin, both combined with vinblastine and bleomycin. There were 60 (53%) complete remissions and 42 partial remissions for an overall response rate of 90%. An additional 11 patients, 4 with carcinoma and 7 with mature teratoma, following surgical cytoreduction, were rendered free of disease. There was a significantly higher complete response rate for high dose induction chemotherapy, 63%, when compared with low dose, 43% (P = 0.03). A survival advantage was also observed for patients receiving high-dose therapy (P = 0.009). For the subgroup of patients with maximal disease and embryonal +/- teratoma +/- seminoma histology there was a clear advantage in favor of high-dose over low-dose therapy both in complete response rate and survival (P = 0.03). There have been only four relapses, all occurring within 1 year of study entry. While there has been a higher frequency of leukopenia, renal, neuromuscular, and mucosal toxicity with high-dose therapy, thus far no irreversible toxicity leading to functional impairment has been seen. The authors have demonstrated a clear-cut relationship for dose of therapy, not only with response and survival, but with the increased potential for cure as well.

The staging of Hodgkin’s disease revisited

The conventional staging of Hodgkin's disease (HD) including lymphangiography and staging laparotomy with splenectomy is well-known and commonly utilized. However, recent data on new imaging modalities (e.g. ultrasound, computed tomographic scanning) and prognostic factors (e.g. size of the mediastinal mass, extent of splenic involvement, etc.) suggest that a more rational approach to staging based on treatment considerations is now possible. In addition, careful restaging of patients in apparent remission, including surgical evaluation in selected patients, is also important. In this paper, these new concepts of the staging of HD are reviewed.

Intrathecal morphine for postoperative pain relief in children

Intrathecal morphine was given to 56 children undergoing open-heart surgery. The first 27 patients received 0.03 mg kg-1 and the other 29 received 0.02 mg kg-1. Satisfactory postoperative analgesia, lasting for 22 h or longer, was obtained in over 60% of the patients in each group. Respiratory depression occurred in six of the first group (0.03 mg kg-1), and three in the second (0.02 mg kg-1), most frequently between 3.5 and 4.5 h after the administration of the intrathecal morphine.

Phase II trial of bisantrene in patients with intermediate and high grade diffuse non-Hodgkin's lymphomas

Sixteen heavily pretreated patients with advanced intermediate and high-grade diffuse non-Hodgkin's lymphoma (NHL) were treated with 260 mg/M2 of bisantrene every three weeks. Thirty infusions of bisantrene were given without evidence of objective response. Pain in the infused arm, with or without signs of phlebitis, was the most common side effect occurring in 40% of treated patients. At the doses employed bisantrene had little activity as a single agent in this group of previously treated patients with unfavorable histology NHL.

Five-day schedule of vinzolidine, an oral vinca alkaloid, in a variety of tumors

This Phase I-II trial evaluated vinzolidine (VZL), a semisynthetic vinblastine derivative administered on a five-day oral schedule every 21 days, with 60% of the total dose on day 1 followed by 10% of the total on each of the following four days. Forty-four patients with advanced malignancies were entered in this study and 34 were evaluable for response. Three patients responded, with complete remissions in patients with adenocarcinoma of the lung (39+ weeks) and adenocarcinoma of the pancreas (20+ weeks) and a minor response in a patient with metastatic carcinoid (6 weeks). Myelosuppression was the dose-limiting toxicity, and was remarkable for its unpredictability among patients and even in the same patient receiving a constant dose of vinzolidine. There was one drug related death associated with myelosuppression. This study was closed because of the erratic myelotoxicity of oral vinzolidine. However, the activity observed with vinzolidine merits future trials, using a parenteral formulation which may have more predictable toxicity.

Treatment of advanced breast cancer with mitomycin C combined with vinblastine or vindesine

Mitomycin C together with either vindesine or vinblastine was given to 48 patients with previously treated advanced breast cancer. Thirteen (35%) of the 37 evaluable patients had a complete (one patient) or partial (12 patients) response. Overall median duration of response was 189 days (range, 90-700 days). Fifteen patients received mitomycin C and vindesine with six responses (40%) and a median response duration of 247 days (range, 162-700 days). Twenty-two patients received mitomycin C and vinblastine with seven responses (32%) and median response duration of 164 days (range, 90-330 days). Response duration for patients treated with mitomycin C plus vindesine was longer than that associated with mitomycin C plus vinblastine (p = 0.09). Significant toxicity included myelosuppression and neurologic symptoms, but was uncommon (less than 10% of patients). Therefore, the combination of mitomycin C and a vinca alkaloid appears to be useful in far-advanced refractory breast cancer.

Posttreatment laparotomy for Hodgkin's disease

We examined and surgically restaged (using posttreatment laparotomy) 26 patients with stage III and IV Hodgkin's disease treated with combination chemotherapy and in apparent remission to determine the status of their clinical remission. Eleven patients had normal clinical restaging and surgical restaging. Fifteen patients had abnormal clinical restaging, mainly consisting of abnormal lymphangiograms or abdominal CT scans. Ten lymphangiograms were abnormal and could not exclude persistent lymphoma. Two of the 15 patients proved to have Hodgkin's disease involving the para-aortic nodes and the spleen. With a median follow-up of 24 months, two patients had relapses in supradiaphragmatic sites and no patient with a negative laparotomy had a recurrence abdominal sites. Restaging laparotomy in selected patients with Hodgkin's disease with abnormal lymphangiograms or CT scans may identify additional patients with residual lymphoma who require further therapy and, more importantly, may identify those patients who have no residual disease and, therefore, may be spared additional therapy. Mortality and morbidity were nil.

Characterization of the genome of the agent of erythrocyte aplasia permits its classification as a human parvovirus

It has recently been established that infection with a virus is the most common cause of transient arrest of erythrocyte production in the bone marrow, leading to aplastic crisis, in persons suffering chronic haemolytic anaemias. The physical characteristics of this human virus have suggested that it may be a member of the Parvoviridae. We report here that extraction of nucleic acid from this virus under annealing conditions yielded a single species of double-stranded DNA 5.5 kb in length. Treatment with heat or alkali converted this DNA into a rapidly migrating form sensitive to the single-strand-specific nuclease S1. Extraction of the virion DNA under conditions of low ionic strength where annealing would not be expected to occur yielded DNA which comigrated with the 5.5 kb single-stranded molecule. The results indicate that this virus packages equal numbers of complementary DNA strands into separate virions. It is suggested that this virus can be classified as a member of the genus parvovirus.

Weight and age at calving and weight change related to first lactation milk yield

Daily milk yields from 400 first lactations collected from one herd over 16 yr were utilized to ascertain relations of weight and age at calving and change of body weight during first lactation on milk yield and calving interval. These relationships were evaluated for the complete lactation and for each of five 60-day segments of the lactation. The influence of sire on the interrelationship between body weight, age at calving, and milk yield also were measured in data from sires with 10 or more daughters. Average milk yield (300 day) and gain of body weight during first lactation for all records were 5544 and 56.2 kg. Both year and season of calving influenced weight at calving, milk yield, and the relationship between the two. Milk yield was the greatest and body weight gain the least for heifers calving in the fall. Analysis of all records revealed that calving weight but not calving age accounted for a significant portion of variation of milk yield during the first four 60-day periods. Both calving weight and age accounted for a significant amount of the variation of total milk yield. There was a significant effect of sire on calving weight and milk yield but not on total weight gain, age at calving, number of services, or calving interval. There was an increase of number of services and a trend toward a longer calving interval with increasing milk yield. Although age and weight at calving were nearly equal for explaining variation of total yield of milk of first lactation, age at calving was of little value in explaining variation of milk yield of the 60-day intervals. The relationship of these observations to the use of age correction factors for extended first lactation records is discussed.

Methyl-glyoxal bis guanyl hydrazone (methyl-GAG, MGBG) in lymphoma and Hodgkin's disease. A Phase II trial of the Southwest Oncology Group

The Southwest Oncology Group has evaluated methyl-GAG on a weekly schedule among patients with lymphoma and Hodgkin's disease. Among 56 fully and partially evaluable patients responses were seen in 3 of 10 patients with Hodgkin's disease and 11 of 46 patients with lymphoma. Toxicity was acceptable. Methyl-GAG has significant antitumor activity among this group of heavily pretreated patients. Additional trials of methyl-GAG in combination with other agents are underway.

Gallium nitrate in malignant lymphoma: a Southwest Oncology Group study

Gallium nitrate was evaluated by the Southwest Oncology Group in 38 patients with malignant lymphoma, both Hodgkin's disease and non-Hodgkin's lymphoma. Treatment was administered every 2 weeks at a dose of 700 mg/m2, with acceptable toxicity. Seven partial responses (18%) with a duration of 3-11 months were seen: one of seven in Hodgkin's disease and six of 26 in diffuse non-Hodgkin's lymphoma. No responses were noted in nodular types. Gallium nitrate has activity in lymphomas and should be combined with more active drugs for patients who have undergone less intensive prior therapy.

Initial chemotherapy for clinically localized lymphomas of unfavorable histology

Forty-five patients with localized non-Hodgkin's lymphoma of unfavorable histologic type (41 patients had diffuse histiocytic, 2 had nodular mixed, and 2 had minimally nodular histiocytic lymphoma) were treated with initial chemotherapy (28 patients), including cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP), or with initial CHOP followed by involved field radiotherapy (17 patients). Patients were clinically staged and found to have stage I (7 patients), stage IE (8), stage II (12), and stage IIE (18). Despite the presence of potentially adverse prognostic factors, including age older than 65 yr (11 patients), bulky disease (17), gastrointestinal involvement (9), and "B" symptoms (4), 44 of 45 patients (98%) achieved a complete response. Forty-two patients (93%) are alive with a median follow-up time of 41 mo (range 3-128 mo). Thirty-eight patients (84%) remain continuously free of disease. Neither the pretreatment clinical features nor the type of treatment significantly influenced the outcome for patients treated with initial chemotherapy. Patients who failed treatment relapsed at distant sites or in initially involved sites whether or not they received radiotherapy. Initial treatment for localized lymphomas of unfavorable histology with chemotherapy regimens of proven curative potential in advanced disease is a successful treatment strategy and obviates the need for extensive staging. The role of involved field radiotherapy following initial chemotherapy needs to be defined.

Phase II evaluation of amsacrine (m-AMSA) in solid tumors, myeloma, and lymphoma: a University of Arizona and Southwest Oncology Group Study

A phase II trial was conducted to determine the clinical activity of amsacrine (m-AMSA) in patients with heavily pretreated solid tumors, myeloma, and lymphoma at the University of Arizona Cancer Center. Additionally, m-AMSA was evaluated at other Southwest Oncology Group institutions in breast cancer, myeloma, melanoma, and oat cell cancer of the lung. At a dose of 120 mg/m2 given iv every 28 days, 12 partial responses were observed in 221 patients evaluable for response. Some antitumor activity was observed in breast cancer (four responses of 65 patients), non-Hodgkin's lymphoma (three of nine), Hodgkin's disease (two of five), and sarcoma (two of 15). A partial response was also documented in one of two patients with cervical cancer. Among the 135 patients treated at the University of Arizona who were extensively evaluated for toxic effects, only myelosuppression and anemia were seen in a significant number of patients. At this dose and schedule, 29% of patients developed leukopenia of less than 3000 cells/mm3, 16% developed a thrombocytopenia of less than 100,000 cells/mm3, and 29% had an acute fall in hemoglobin of greater than or equal to 2 g/100 ml. In addition, two patients suffered grand mal seizures which were not clearly drug-related. These results suggest that further study of m-AMSA in lymphoma, sarcoma, and cervical cancer is warranted.

Treatment of cutaneous T-cell lymphoma (mycosis fungoides) with 13-cis-retinoic acid

Four patients with refractory cutaneous T-cell lymphoma (mycosis fungoides) were treated with 13-cis-retinoic acid. Near complete clearing of extensive tumours and plaques was seen in one patient, who remains in partial remission with continued improvement after fifteen months. Two patients showed improvement in pruritus and 50% reduction in plaques by four and six weeks, respectively. The fourth patient had improvement in pruritus and clearing of plaques, but dryness and scaling necessitated reduction and eventually withdrawal of the treatment.

Mitoxantrone in advanced breast cancer: a phase II trial of the Southwest Oncology Group

124 patients with metastatic breast cancer were entered into this phase II trial of mitoxantrone (DHAD). Patients were stratified prior to treatment as good or poor risk, and whether they had received previous therapy with an anthracycline derivative. Mitoxantrone was given every 21 days at a starting dose of 12 mg/m2 for good risk patients and 10 mg/m2 for poor risk patients. Among the group who had not received anthracyclines, 12 are fully or partially evaluable for response with five classified as good risk. One complete response, ongoing at 52 weeks was seen in this group. Of the seven poor risk patients, stable disease was seen in two. 103 patients with prior anthracycline exposure are fully or partially evaluable, 31 good risk and 72 poor risk. There were three partial responses in each group. Toxicity was primarily myelosuppression, and was more severe in the poor risk group. Mitoxantrone when used on this schedule has minimal activity among heavily pretreated patients with metastatic breast cancer.

Infection with parvovirus-like virus and aplastic crisis in chronic hemolytic anemia

From 1980 to 1982 seven adults with chronic hemolytic anemia were admitted to Cook County Hospital, Chicago, with aplastic crisis. Six of these patients had sickle cell anemia, the seventh patient had beta thalassemia intermedia. Virologic studies showed that six patients had acute infection with the human parvovirus-like virus; in the remaining patient the lack of appropriate specimens precluded viral diagnosis. We describe the features of the virus infection and accompanying erythroid aplasia, and discuss the role of parvovirus-like virus as the etiologic agent in the arrest of erythrocyte production.

Phase II study of amsacrine (m-AMSA) in advanced lymphomas: a Southwest Oncology Group study

Amsacrine was administered to 73 evaluable patients with previously treated malignant lymphoma in the Southwest Oncology Group. The drug was administered iv every 3 weeks at a dose of either 90 mg/m2 to poor-risk patients (38 patients) or 120 mg/m2 to good-risk patients (35 patients) in 500 ml of 5% dextrose in water over 1 hour. The overall complete plus partial response rate is 16% (12 responses among 73 evaluable patients), with a response duration of 1-33 months. The dose-limiting toxic effect was myelosuppression, with leukopenia in 29 patients and thrombocytopenia in 18 patients. Our experience in the Southwest Oncology Group demonstrates the activity of amsacrine in malignant lymphoma.

Improved complete remission rates and survival for patients with large cell lymphoma treated with chemoimmunotherapy. A Southwest Oncology Group Study

Between 1974 and 1977, 652 patients with non-Hodgkin's lymphoma without prior chemotherapy were randomized to 1 of 3 combination chemotherapy programs designed to induce complete remission (CR): COP-bleomycin (180 patients), CHOP-bleomycin (232 patients) or CHOP plus immunotherapy with Bacillus Calmette Guerin (BCG) (240 patients). With mature follow-up, the major effect of BCG immunotherapy was observed in patients with large cell lymphomas (diffuse or nodular "histiocytic") and not in other common lymphoma subtypes. CR rate for 65 patients with large cell lymphoma treated with CHOP-BCG was 68% compared to 48% in 61 patients treated with CHOP-bleomycin (P = 0.02) (two-tailed test) or 44% for 45 patients treated with COP-bleomycin (P = 0.02). CR duration for both CHOP-based regimens was similar and superior to that produced by COP-bleomycin (P = 0.03). Survival of patients with large cell lymphoma treated with CHOP-BCG was better than that observed with CHOP-bleomycin (P = 0.02) or COP-Bleomycin (P = 0.002). Although the explanation for the favorable effect of BCG remains unclear, further clinical trials to evaluate the combination of chemotherapy and other "biologic response modifiers" is warranted for patients with lymphoma.

Scalp hypothermia: a comparison of ice packs and the Kold Kap in the prevention of doxorubicin-induced alopecia

Two methods of scalp hypothermia were compared in preventing alopecia, a side effect of doxorubicin chemotherapy that has a significant psychologic impact on the patient. Thirty-three patients received scalp ice packs consisting of crushed ice in plastic bags. Twenty-nine patients received Kold Kap, a device that produces chilling via an endothermic reaction. Scalp hypothermia was applied for 5-10 min before the doxorubicin bolus and left in place for 30-40 min afterward. The percent of hair loss was rated at each visit and photographs were used to further quantitate any hair loss. Sixty-three percent of Kold Kap and 56% of ice pack patients had good or better protection and did not require wigs. Excellent protection (less than 25% loss) was provided for 51% of Kold Kap and 33% of ice pack patients. Similar protection was provided to Kold Kap patients regardless of dose, while ice pack patients received significantly better protection if their doxorubicin doses were less than 50 mg. Scalp hypothermia is an effective method of preventing doxorubicin-induced alopecia.

The clinical significance of the morphological subdivision of diffuse "histiocytic" lymphoma: a study of 162 patients treated by the Southwest Oncology Group

We grouped 162 patients wtih advanced, diffuse histiocytic lymphoma (DHL) into various morphological subtypes to ascertain whether there were any significant differences in survival among them. These patients were staged and treated from 1972 to 1977 according to the protocols of the Southwest Oncology Group. Of the 159 patients on whom a consensus on the diagnosis was reached, 115 were classified morphologically as having large non-cleaved, 26 as B-immunoblastic, 9 as large cleaved, and 6 as T-immunoblastic. The 3 remaining patients did not fit any of these subtypes, but each had a single prominent nucleolus in most tumor cells ("prominent nucleolus" type). Morphological subdivision of DHL did not identify any subgroup of patients with a significantly longer survival, but clinical parameters such as stage, symptoms, and type of treatment significantly influenced survival times.

Medical illness in psychiatric patients: barriers to diagnosis and treatment

We report a study of 102 consecutive admissions to the acute medical care unit of a large psychiatric hospital. The study was designed to investigate the epidemiology and the barriers to diagnosis and treatment of medical illness among female psychiatric inpatients. The majority of the patients were transferred to the unit because of nonspecific changes in physical condition or for behavioral differences. More than 70% of the patients were unable to communicate adequately with the physician. Ninety-two percent of the sample were found to have at least one with an average of three previously undiagnosed physical diseases not predicted by their symptoms on referral. We advocate a high index of suspicion of physical disease in the psychiatric population, and recommend an aggressive multidisciplinary diagnostic and therapeutic approach.

Occurrence of infection with a parvovirus-like agent in children with sickle cell anaemia during a two-year period

The occurrence of infection with a parvovirus-like agent during the period April 1979-May 1981 in children attending a single sickle cell clinic in London was investigated. Virus was detected in serum by counter-current immunoelectrophoresis (CIE) and immunoelectron microscopy (IEM). Viral antibody was detected by CIE and specific IgM antibody by an IgM-antibody capture assay. Of the 68 children studied nine presented in aplastic crisis and evidence of infection with the parvovirus-like agent at the time of the crisis was found in all nine. Eighteen of the other children were antibody-positive at some time during the study. In 11 children there was no evidence of recent infection; however, two of these had a history of aplastic crisis in previous years. The other seven seroconverted during the course of the study but did not show any haematological effects. Five of these had a primary infection, one appeared to have reinfection and in the seventh there were insufficient data to distinguish between the two. Possible explanations for the difference between those presenting with aplastic crisis and those with asymptomatic seroconversion are discussed.

Mistaken clinical and pathologic diagnoses of Hodgkin's disease: a Southwest oncology group study

Expert hematopathology review of initial diagnostic material was required for patients registered in a Southwest Oncology Group trial of advanced Hodgkin's disease (HD). Of 287 cases reviewed, 36 (13%) had been misdiagnosed as HD. The clinical and histologic features of the first 180 patients reviewed by the expert panel, including 21 (12%) patients for whom errors in diagnosis were discovered, were retrospectively analyzed to ascertain why mistakes in diagnosis had occurred. The most common error in pathologic interpretation was to confuse other malignant lymphomas with HD (14/21 patients), particularly large cell lymphomas with pleomorphic features and Reed-Sternberg-like cells. Rare conditions (Lennert's lymphoma or angioimmunoblastic lymphadenopathy) were also confused with HD. Mixed-cellularity and lymphocyte-depleted HD were the most frequently mistaken cell types (14/21 patients) and nodular-sclerosing HD was the least mistaken (two of 21). The clinical features of these 21 patients showed a high incidence of unusual extranodal sites of disease involvement including thyroid (one patient), ovary (one), skin (two), bone (three), and lung (seven). We next analyzed the clinical features of the remaining 107 cases in order to prospectively identify, based on atypical clinical preparations, patients who might not have HD. Subsequent histologic review revealed mistaken diagnosis in 15 patients (14%). Eight of the 15 patients (53%) were correctly identified as having disease other than HD on the basis of clinical presentation alone. Atypical clinical presentations, particularly unusual extranodal sites of disease along with a presumptive diagnosis of mixed cellularity or lymphocyte-depleted HD, should forewarn the clinical and the pathologist of a possible error in diagnosis.

The development and use of an antibody capture radioimmunoassay for specific IgM to a human parvovirus-like agent

An IgM-antibody capture radioimmunoassay (MACRIA) was developed for the detection of IgM antibody specific for the human parvovirus-like agent B19. Diagnosis of infection with this agent by either antigen detection or antibody seroconversion had been made by counter-current immunoelectrophoresis (CIE) in 18 cases of aplastic crisis occurring in children with homozygous sickle-cell disease. The MACRIA described here gave positive results in 17 of these 18 cases; in the remaining case only an acute specimen taken from the patient during viraemia and late convalescent specimens taken 184 and 247 days after onset of illness were available. The test was used to investigate 20 further cases of aplastic crisis in which neither viral antigen nor antibody seroconversion could be detected by CIE. Detection of virus-specific IgM permitted diagnosis of infection with this parvovirus-like agent in 17 of these cases. In the remaining three cases only single serum specimens taken late in convalescence, 82 days or more after the onset of symptoms, were available. In addition to these 34 cases of aplastic crisis in which primary infection with this agent was diagnosed by MACRIA, seven cases of apparent 'silent' infection detected by CIE were investigated. The test permitted the discrimination between primary infection and re-exposure to the virus in six of these patients. The use of this assay has added a considerable weight of evidence implicating primary infection with this parvovirus-like agent as an important cause of aplastic crisis in children with sickle-cell disease. Furthermore, MACRIA permits diagnosis of infection when only single serum specimens taken up to ten weeks after infection are available. Thus the use of this test will significantly facilitate the investigation of other clinical syndromes of presumptive infectious aetiology.

Conclusions from clinical trials of the Southwest Oncology Group

Mature data from four clinical trials conducted by the Southwest Oncology Group from 1971 to 1978 for patients with all stages of Hodgkin's disease (HD) are reviewed in this paper. In the RAC #1 trial of stage I and II HD we demonstrated that involved-field radiotherapy plus six courses of MOPP chemotherapy improved relapse-free survival compared to standard radiotherapy alone (P = 0.12), especially in patients with B symptoms (P less than 0.03) or mediastinal disease (P = 0.08). However, at present, there is no significant difference in overall survival. In the CAR #1 study for patients with pathologic stage IIB, IIIA, and IIIB HD, we demonstrated that three or four courses of MOPP before radiotherapy produced a 90% complete remission (CR) rate, with 70% of the patients remaining free of disease at 5 years. In the CAR #2 study for patients with pathologic stage IIIA or IIIB disease, we demonstrated that chemotherapy alone (MOPP-bleomycin) was as effective as combined modality treatment (MOPP-bleomycin plus radiotherapy) in terms of CR rate (85% versus 89%, respectively), relapse-free survival, and survival. For advanced stages of HD we added doxorubicin to our MOPP-bleomycin schedule and demonstrated that MOP-BAP produced a 77% CR rate compared to 67% for MOPP-bleomycin (P = 0.10). Moreover, MOP-BAP produced consistently superior CR rates and survival in patients with more prognostically favorable presentations of HD. Our new ongoing study (MOPP #6) incorporates many of the concepts derived from these earlier clinical investigations.

Surgical restaging of Hodgkin's disease

Twenty-six patients with Hodgkin's disease were restaged both clinically and surgically within 2 months of completing their planned chemotherapy. Six patients (23%) had surgically proven persisting disease. Patients were divided into three groups: group I--eight patients had normal findings at clinical restaging and all were free of disease at surgery; group 2--13 patients had abnormal findings at clinical restaging, but only two (15%) were surgically documented to have persistent disease; and group 3--five patients had incomplete clinical restaging but, because of initial bulky disease, underwent surgical restaging, which showed that four patients had residual disease. The spleen was the site of persisting disease in all six patients with residual disease; four also had para-aortic nodal involvement. All 20 patients in pathologically documented complete remission remain relapse-free, with a mean followup of 26 months. This is significantly better (P less than 0.001) than the 21% relapse rate for 224 comparable patients in complete remission established by clinical but not surgical restaging. It appears that surgical restaging provides useful prognostic and therapeutic information in selected patients with Hodgkin's disease.

Altered respiratory control in newborn puppies after chronic prenatal exposure to alpha-1-acetylmethadol (LAAM)

Respiratory studies were conducted on newborn puppies chronically exposed to alpha-l-acetylmethadol . HCl (LAAM) during portions of gestation. Bitches received daily oral doses of LAAM from the second week through the sixth week of pregnancy (LAAM-6) or through the end of a 9-week pregnancy (LAAM-9), but not after parturition. LAAM-9 pups displayed narcotic abstinence signs during the first week after birth, while LAAM-6 pups did not. LAAM-9 pups had increased tidal volume, respiratory frequency, alveolar ventilation and O2-consumption and decreased alveolar CO2-tension during the first week of life compared to placebo-treated controls. The LAAM-9 CO2-response curve was significantly displaced to the left of control. These data are consistent with relative hyperventilation during neonatal withdrawal from LAAM. LAAM-6 pups had decreased tidal volume and alveolar ventilation during 4 of the 6 weeks studied. These changes in ventilation were associated with a decrease in O2 consumption. By 6 weeks after birth CO2-response curves of both LAAM-9 and LAAM-6 pups were shifted to the right of control. These changes in CO2-responsiveness suggest the possibility of prolonged disturbances of respiratory control which may continue beyond the sixth week of life.

A clinical trial of amygdalin (Laetrile) in the treatment of human cancer

One hundred seventy-eight patients with cancer were treated with amygdalin (Laetrile) plus a "metabolic therapy" program consisting of diet, enzymes, and vitamins. The great majority of these patients were in good general condition before treatment. None was totally disabled or in preterminal condition. One third had not received any previous chemotherapy. The pharmaceutical preparations of amygdalin, the dosage, and the schedule were representative of past and present Laetrile practice. No substantive benefit was observed in terms of cure, improvement or stabilization of cancer, improvement of symptoms related to cancer, or extension of life span. The hazards of amygdalin therapy were evidenced in several patients by symptoms of cyanide toxicity or by blood cyanide levels approaching the lethal range. Patients exposed to this agent should be instructed about the danger of cyanide poisoning, and their blood cyanide levels should be carefully monitored. Amygdalin (Laetrile) is a toxic drug that is not effective as a cancer treatment.