Antimicrobial resistance in Staphylococcus aureus

Recognized since 1883 as a common cause of infection, Staphylococcus aureus' preantimicrobial-era bacteremia mortality rate was 82%. The mortality of that era threatens to return as evidence of growing vancomycin resistance undermines the utility of vancomycin therapy. Successful treatment of S. aureus infections requires knowledge of its antimicrobial resistance capacity.

Increased calcium/calmodulin protein kinase activity in astrocytes chronically exposed to ethanol: influences on glutamate transport

The effects of ethanol exposures on calcium/calmodulin-dependent protein kinase activity as well as its influence on glutamate uptake were determined in astrocytes prepared from neonatal rat cerebral cortex. Acute 15-min exposure to 100 mM ethanol had no effect on Ca2+/CaM-dependent protein kinase activity. However, chronic exposure to 100 mM ethanol for 4 days elicited a significant increase in the activity of this enzyme with no parallel increase in its expression. Ca2+/CaM-independent kinase activity was less than 1% of the Ca2+/CaM-dependent kinase activity and was unaffected by any of the ethanol exposures. Exposure to 100 mM ethanol for four days also resulted in a significant increase in Na+-dependent [3H]glutamate uptake which was reversed when ethanol-exposed astrocytes were co-incubated with KN-93, a specific inhibitor of Ca2+/CaM kinase. These results suggest that the effects of ethanol on glutamate transport may be mediated in part, by the level of Ca2+/CaM kinase activity.

Relationship of auditory middle latency response and stem-word completion test as indicators of implicit memory formation during general anesthesia

Anesthesia providers are unable to objectively evaluate the amnesic status of an anesthetized patient. One purpose of the study was to evaluate the anesthetized patient's ability to process auditory information while receiving an inhalational or intravenous anesthetic regimen. The other purpose was to examine the relationship of the Pa latency of the auditory middle latency response (AMLR) with the stem-word completion test as an intraoperative indicator of implicit memory formation during general anesthesia. One hundred one adults were randomly assigned in a single-blinded design to either a midazolam or sevoflurane anesthetic regimen. Midazolam was administered at 0.540 microgram/kg per minute with fentanyl and 50% nitrous oxide. The other anesthetic regimen was 1.4% end-tidal concentration of sevoflurane with fentanyl and 50% nitrous oxide. A list of 10 words was repeated 16 times. AMLRs were recorded intraoperatively. The difference between the midazolam groups borderlined statistical significance (P = .07) in illustrating that one may potentially process auditory information while anesthetized. Dissimilar findings were found between the sevoflurane groups (P = .77). An inverse correlation was demonstrated between the midazolam group and Pa latency of the AMLR (r = -0.40, P = .047). Multiple regression of the midazolam group demonstrated that the employment status (r2 = .297, P = .005) and the Pa latency (r2 = .238, P = .003) were the best predictors of the postoperative stem-word completion test (F = 12.61, P = .001). In contrast, no correlation was noted in the sevoflurane group (r = 0.43, P = .07). Thus, the continued evaluation of the AMLR as an intraoperative indicator of implicit memory formation is warranted. With the establishment of the AMLR as an indicator of implicit memory formation during general anesthesia, anesthesia providers could then address the occurrences of traumatic neurosis in the postoperative surgical patient and strive to avoid the medicolegal concerns that may face the healthcare team.

Relapse after complete response to anthracycline-based combination chemotherapy in metastatic breast cancer

In this study we examined the clinical characteristics of relapse before and after complete clinical response (CR) to anthracycline-based combination chemotherapy in metastatic breast cancer (MBC). Our goal was to determine whether similar clinical trends could be observed during first relapse and relapse after CR. Two hundred and sixty-three patients with MBC were identified who had achieved CR after anthracycline-based combination chemotherapy for first recurrence. From this group, 226 patients had relapse after CR after a minimum follow-up of 13 years. Clinical features of their disease at first relapse and after progression from CR (second relapse) were examined, including disease-free interval (DFI) from diagnosis until first relapse, sites of recurrence, response to subsequent therapy, and survival after progression from CR. There was a significant correlation between duration of CR and survival after progression from CR. Patients who relapsed < 12 months after achieving CR had a median survival of 8.8 months after second relapse, whereas those who relapsed beyond 3 years had a median survival of 21.5 months (p = 0.0034). Neither the duration of CR nor length of survival after second relapse was related to the length of initial DFI. Patients with a short duration of CR (< 12 months) more often experienced second recurrences at multiple sites and in visceral organs (62% and 75%, respectively) than did patients with prolonged CR (> 36 months) (27% and 45%, respectively, p < 0.001). The anatomic location of metastatic disease at the time of first and second relapses was similar within a CR duration group but different among the groups. Short CR duration was associated with more frequent recurrence at visceral sites and also with chemotherapy-resistant second relapse. In conclusion, prolonged CR is associated with long survival after second relapse; however, neither CR duration nor survival after second relapse is related to the length of initial DFI. This suggests that chemotherapy, when it induces CR, may change the pace of disease progression. The tissue pattern of recurrence appears to be similar between first and second relapse, suggesting that the cellular predilection for metastatic sites has been preserved.

Morphology of the lymphoid organs of the bottlenose dolphin, Tursiops truncatus

The anatomy of the lymphoid organs was studied during the course of detailed dissections of 50 beach-stranded bottlenose dolphins, Tursiops truncatus. Constant lymph nodes occur in 4 groups, based on their location and structure. These groups are somatic, including nodes of the cervical region and pelvic recess; lung-associated, included marginal, diaphragmatic and hilar nodes; visceral, including the mesenteric, pancreatic, pericolic and porta hepatis nodes; and aortic arch nodes. Lymphatic drainage of the lung is primarily to the marginal and diaphragmatic nodes. The mesenteric node mass is well-endowed with capsular and trabecular smooth muscle, and a network of muscle fascicles within the organ implies an important contractile function in the circulation of lymph. In addition to constant nodes, occasionally nodes are found in relation to the thoracic aorta, the kidney, and under the scapula. Gut-associated structures include dorsal and ventral oropharyngeal tonsils, mucosal aggregates in the straight segment of the intestine (colon) and anal tonsils; this gut-associated lymphoid tissue tends to involute with age, being greatly reduced by puberty. Formed lymphoid organs include the thymus and the spleen, the latter being relatively small in relation to body size. None of these structures is unique among cetaceans, but the anal tonsils are particularly well developed in T. truncatus. The lymphoid aggregates in the colon resemble the arrangement in the vermiform appendix, which is lacking in most cetaceans, and may have functions analogous to that organ.

Direct medical charges associated with myocardial infarction in patients with and without diabetes

OBJECTIVES

This study was designed to measure the direct medical charges for patients with and without diabetes who experience myocardial infarction.

METHODS

We completed a retrospective cohort analysis (from the third-party payer perspective) to determine the total direct medical charges (eg, hospitalizations, outpatient visits, pharmacy, and emergency room visits) incurred by an inner city sample of 293 patients during the 12 months following myocardial infarction during the period from January 1993 through February 1997.

RESULTS

The 87 patients with diabetes had a higher per patient total direct medical charge (inclusive of initial hospitalization) compared to the 206 patients without diabetes ($18,577 versus $26,414) and approximately $3000 more per person year of observation. Hospitalizations (initial and during the follow-up period) accounted for 88% of the total direct medical charges. The mean charge for the initial hospitalization was higher for patients with diabetes ($12,730 versus $15,394). In a subset, the mean charge per cardiovascular-related hospitalization that occurred during the follow-up period was also higher for patients with diabetes ($6344 versus $9648).

CONCLUSIONS

Consistent with what we expected, patients with diabetes incurred higher total direct medical charges as a result of and following myocardial infarction. These data can be used in future cost-effectiveness evaluations for therapies developed to treat patients with diabetes who experience myocardial infarction or for therapies designed to reduce the risk of macrovascular complications associated with diabetes.

Selective genotyping for the role of 5-HT2A, 5-HT2C, and GABA alpha 6 receptors and the serotonin transporter in the level of response to alcohol: a pilot study

BACKGROUND

The vulnerability to alcohol dependence appears to be genetically influenced through a variety of mechanisms. One potentially genetically mediated channel may be a low level of response (LR) to alcohol, which has been seen in children of alcoholics and noted to predict future alcohol abuse and dependence. This pilot study uses a case and control genetic association approach to evaluate the possible role of five genotypes in both LR and alcoholism in informative subgroups of men with high and low LR scores documented 15 years earlier.

METHODS

As part of a larger study, 41 men, about 39 years old, were selected from among the first 113, completed 15-year follow-ups in a prospective study. The 17 subjects whose LRs at age 20 were in the lower third were compared on five polymorphisms of four genes with 24 men whose reactions to alcohol had been above the median.

RESULTS

The 14 men with the LL genotype of the serotonin transporter (5-HTT) polymorphism and the seven with the Pro/Ser genotype of the GABAA alpha 6 polymorphism had demonstrated lower LR scores at about age 20, and had significantly higher proportions of alcoholics than the other genotypes for those loci. All four subjects with combined LL and Pro/Ser genotypes had developed alcoholism and demonstrated the lowest LR scores overall. There was no evidence that two polymorphisms of the 5-HT2A receptor gene and one of the 5-HT2C receptor gene were related to LR or alcoholism in this sample.

CONCLUSIONS

These results are consistent with animal and human studies suggesting a possible role for genetic variation in the GABAA alpha 6 and the serotonin transporter in the reaction to alcohol and the alcoholism risk.

HIV type 1 V3 domain serotyping and genotyping in Gauteng, Mpumalanga, KwaZulu-Natal, and Western Cape Provinces of South Africa

More than 20.8 million people are living with HIV/AIDS in sub-Saharan Africa, with southern Africa the worst affected area and accounting for one of the fastest growing AIDS epidemics worldwide. Samples from 81 patients, including 25 from KwaZulu-Natal, 26 from Gauteng, 5 from Mpumalanga, and 25 from Western Cape Province, were serotyped using a competitive V3 peptide enzyme immunoassay (cPEIA). Viral RNA was also isolated from serum and the V3 region amplified by reverse transcriptase polymerase chain reaction (RT-PCR) to obtain a 240-bp product for direct sequencing of 29 samples. CLUSTAL W was used to make multiple sequence alignments. Distance calculation, tree construction methods, and bootstrap analysis were done using TREECON. Subtype C-like V3 loop sequences predominate in all provinces tested in South Africa. Discordant sero- and genotype results were observed in one patient only. The correlation between sero- and genotyping was 96% (24 of 25) in KwaZulu-Natal and 100% in Gauteng and Mpumalanga. In Western Cape Province 18% of patients were identified as sero/genotype B and 82% as sero/genotype C. Our data show that results of the second-generation V3 cPEIA correlated well with V3 sequencing and would be a rapid and affordable screening test to monitor the explosive southern African HIV-1 epidemic.

The sleep of abstinent pure primary alcoholic patients: natural course and relationship to relapse

Sleep in male pure primary alcoholic inpatients was examined at a mean of 16 days (n = 29), 19 weeks (n = 29), 14 months (n = 9), and 27 months (n = 4) of abstinence. Results were as follows: (1) the sleep of abstinent alcoholic patients is short, fragmented, and shallow early in abstinence; (2) a patient's sleep improves slowly over at least the first year of abstinence; however, (3) some facets of a patient's sleep remain abnormal even after 27 months of abstinence; (4) insomnia and sleep fragmentation after approximately 5 months of abstinence may be related to relapse by 14 months. The mechanism underlying the relationship between sleep and withdrawal in alcoholic patients is not well understood, and the issue of treating sleep problems as an adjunct to prevention of relapse warrants further investigation.

Emergence of vancomycin resistance in Staphylococcus aureus. Glycopeptide-Intermediate Staphylococcus aureus Working Group

BACKGROUND

Since the emergence of methicillin-resistant Staphylococcus aureus, the glycopeptide vancomycin has been the only uniformly effective treatment for staphylococcal infections. In 1997, two infections due to S. aureus with reduced susceptibility to vancomycin were identified in the United States.

METHODS

We investigated the two patients with infections due to S. aureus with intermediate resistance to glycopeptides, as defined by a minimal inhibitory concentration of vancomycin of 8 to 16 microg per milliliter. To assess the carriage and transmission of these strains of S. aureus, we cultured samples from the patients and their contacts and evaluated the isolates.

RESULTS

The first patient was a 59-year-old man in Michigan with diabetes mellitus and chronic renal failure. Peritonitis due to S. aureus with intermediate resistance to glycopeptides developed after 18 weeks of vancomycin treatment for recurrent methicillin-resistant S. aureus peritonitis associated with dialysis. The removal of the peritoneal catheter plus treatment with rifampin and trimethoprim-sulfamethoxazole eradicated the infection. The second patient was a 66-year-old man with diabetes in New Jersey. A bloodstream infection due to S. aureus with intermediate resistance to glycopeptides developed after 18 weeks of vancomycin treatment for recurrent methicillin-resistant S. aureus bacteremia. This infection was eradicated with vancomycin, gentamicin, and rifampin. Both patients died. The glycopeptide-intermediate S. aureus isolates differed by two bands on pulsed-field gel electrophoresis. On electron microscopy, the isolates from the infected patients had thicker extracellular matrixes than control methicillin-resistant S. aureus isolates. No carriage was documented among 177 contacts of the two patients.

CONCLUSIONS

The emergence of S. aureus with intermediate resistance to glycopeptides emphasizes the importance of the prudent use of antibiotics, the laboratory capacity to identify resistant strains, and the use of infection-control precautions to prevent transmission.

Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy

PURPOSE

To assess patient and tumor characteristics associated with a complete pathologic response (pCR) in both the breast and axillary lymph node specimens and the outcome of patients found to have a pCR after neoadjuvant chemotherapy for locally advanced breast cancer (LABC).

PATIENTS AND METHODS

Three hundred seventy-two LABC patients received treatment in two prospective neoadjuvant trials using four cycles of doxorubicin-containing chemotherapy. Patients had a total mastectomy with axillary dissection or segmental mastectomy and axillary dissection followed by four or more cycles of additional chemotherapy. Patients then received irradiation treatment of the chest-wall or breast and regional lymphatics. Median follow-up was 58 months (range, 8 to 99 months).

RESULTS

The initial nodal status, age, and stage distribution of patients with a pCR were not significantly different from those of patients with less than a pCR (P>.05). Patients with a pCR had initial tumors that were more likely to be estrogen receptor (ER)-negative (P<.01), and anaplastic (P = .01) but of smaller size (P<.01) than those of patients with less than a pCR. Upon multivariate analysis, the effects of ER status and nuclear grade were independent of initial tumor size. Sixteen percent of the patients in this study (n = 60) had a pathologic complete primary tumor response. Twelve percent of patients (n = 43) had no microscopic evidence of invasive cancer in their breast and axillary specimens. A pathologic complete primary tumor response was predictive of a complete axillary lymph node response (P<.01 ). The 5-year overall and disease-free survival rates were significantly higher in the group who had a pCR (89% and 87%, respectively) than in the group who had less than a pCR (64% and 58%, respectively; P<.01).

CONCLUSION

Neoadjuvant chemotherapy has the capacity to completely clear the breast and axillary lymph nodes of invasive tumor before surgery. Patients with LABC who have a pCR in the breast and axillary nodes have a significantly improved disease-free survival rate. However, a pCR does not entirely eliminate recurrence. Further efforts should focus on elucidating the molecular mechanisms associated with this response.

Hodgkin's disease with lymphocyte predominance: long-term results based on current histopathologic criteria

PURPOSE

To define the disease course, therapeutic strategies, patterns and rates of relapse and causes of death for patients with Hodgkin's disease with lymphocyte predominance (LPHD) and to assess prognostic factors including nodular and diffuse histologic patterns.

PATIENTS AND METHODS

The records of all previously untreated patients with LPHD who received initial treatment at the University of Texas M. D. Anderson Cancer Center (UTMDACC) from 1960 through 1992 were reviewed. Clinical and histopathologic characteristics, specifically nodular and diffuse LPHD, and treatment groups were assessed by overall and relapse-free survival, patterns of relapse, and causes of death.

RESULTS

Of 70 patients, 58 (83%) had nodular LPHD and 12 (17%) had a diffuse pattern: clinical characteristics were similar between the two subtypes. The median age of all patients was 25 years, 79% were male, 96% presented with stage I or II disease and 93% were free of B symptoms. Laparotomy (23 patients) failed to upstage any patient with a negative lymphogram. With a median follow-up of 12.3 years for alive patients, 19 (27%) patients have relapsed. All 3 relapses among the patients with diffuse subtype occurred within 3 years while 9 of 16 relapses occurred after 5 years with nodular subtype. However, we did not detect any statistically significant difference in relapse free survival or survival between the subtypes in our patient population. There was some suggestion that patients aged 40 and older experienced shorter survival; no other pretreatment characteristics were noted to be associated with relapse free survival or survival. Though there were no relapses within the radiation fields, no effect of extent of radiation therapy on relapse rate was observed. Thirteen (19%) patients have died, 6 (8.6%) of whom succumbed to LPHD. Two patients developed diffuse large cell lymphoma.

CONCLUSIONS

Patients with LPHD usually present with localized and asymptomatic disease. Laparotomy is unnecessary if the lymphogram is negative. Nodular histology occurred in the majority of patients. Though all relapses from diffuse subtype occurred within 3 years in contrast to some late relapses observed for nodular subtype, there was no statistically significant difference in relapse free survival or survival between the subtypes. The extent of irradiation had no effect on relapse free survival or survival. We could not find any evidence that LPHD should be treated any different from the classical Hodgkin's disease at this point despite suggestions that it be classified as a non-Hodgkin's B-cell lymphoma.

A death education curriculum for emergency physicians, paramedics, and other emergency personnel

Although death education is a standard component in most medical schools and nursing programs, few include instruction on dealing with sudden death. Typically, death education courses overlook instruction in areas germane to emergency medicine, e.g., making death notifications, interacting with survivors during the immediate grief period, and reducing professional stress innate to working with newly bereaved persons. This curriculum was developed to address the paucity of existing death education materials for emergency professionals. Topics include death perspectives and awareness, death typology, cultural and religious considerations, communicating with bereaved persons, making death notifications, and dealing with initial grief reactions. Units of instruction are outlined, including educational goals, descriptions of units, teaching strategies, and supplemental readings.

Extracorporeal recording of mouse hemodynamic parameters by ultrasound velocity dilution

The use of mice as models for cardiovascular studies has traditionally been difficult because of their small size and the lack of appropriate instrumentation to perform fundamental measurements of cardiac output (CO) and total blood volume (TBV). The advent of transgenic techniques to develop mouse strains that mimic human disease makes the development of this instrumentation crucial. The current study outlines a novel technique for the determination of CO and TBV in the mouse using an extracorporeal arteriovenous (A-V) shunt, combined with the measurement of ultrasound dilution after the intravenous administration of small volumes of isotonic saline. The potential sources of error associated with Stewart-Hamilton dilution techniques were addressed by the research. The new techniques were applied in three anesthetized mice (27-36 gm). Isotonic saline (10-80 microl) was injected intravenously while measuring ultrasound dilution in the A-V shunt. The CO ranged from an average of 6.8+/-0.71 to 12.7+/-1.7 ml/min. Heart rates were not significantly altered by the intravenous administration of isotonic saline. The TBV ranged from 4.36+/-0.22 to 5.15+/-1.04 ml/100 gm. These results agree with the literature and suggest that these techniques will prove useful in cardiovascular studies of mice.

Non-insulin-dependent diabetic microangiopathy in the inner ear

Hearing loss has long been associated with diabetes mellitus. Microangiopathy, associated with thickening of the basement membranes of small vessels, has been implicated as a major source of multiple system organ disease.

OBJECTIVE

This study was designed to evaluate changes in basement membrane thickness in the inner ear of laboratory animals suffering from non-insulin-dependent diabetes mellitus (NIDDM) with, and without, exposure to moderate intensity noise exposure in an attempt to extrapolate the same disease process in humans.

DESIGN

Spontaneously hypertensive-corpulent non-insulin-dependent rats (SHR/N-cp) were selected as a genetic model for the above study. Both lean and obese rats were used in this study. A genetically similar control group of animals (LA/N-cp) were used as controls. These animals express both the lean and obese phenotypes, but they lack the NIDDM gene. Forty-eight animals in each group were sacrificed at the end of the study. The cochleas were dissected and fixed. The basement membrane of the stria vascularis was examined using transmission electron microscopy.

SETTING

This study was a laboratory-based, standard animal study.

MAIN OUTCOME

This study was designed to show microangiography of the inner ear as related to NIDDM with, and without, obesity and noise exposure.

RESULTS/CONCLUSIONS

NIDDM alone does not cause statistically significant basement membrane thickening; however, NIDDM in combination with obesity and/or noise exposure did show significant thickening and the combination of all three showed the greatest thickening. NIDDM appeared to be the greatest contributing factor.

Evaluation of a novel, anti-herpes simplex virus compound, acyclovir elaidate (P-4010), in the female guinea pig model of genital herpes

The antiviral effect of acyclovir elaidate in the female guinea pig model of genital herpes was investigated in a series of experiments. The antiherpesvirus effects of this novel compound, 9-(2'-[trans-9"-octadecenoyloxyl]ethoxymethyl)guanine (code no. P-4010), were studied in both primary and recurrent genital herpes in the female guinea pig, following oral gavage or intraperitoneal injection, with different formulations of the compound, and in comparison with acyclovir (ACV) or penciclovir (PCV). The results indicate that compound P-4010 has a greater capability than either ACV or PCV in reducing the clinical symptoms of primary genital herpes induced following the inoculation of herpes simplex virus type 2 (HSV-2) intravaginally into guinea pigs. In addition, the administration of P-4010 twice daily over a 10-day period by the intraperitoneal route (15 to 40 mg/kg of body weight/day) or by oral gavage (50 to 200 mg/kg/day), commencing 4 h subsequent to intravaginal HSV-2 infection, resulted in a degree of reduction in the incidence and severity of spontaneous, recurrent genital herpes in these animals. The findings are discussed in the light of the value and relevance of the female guinea pig model of genital herpes for the assessment of anti-herpes simplex virus compounds.

Morphology of the complex laryngeal gland in the Atlantic bottlenose dolphin, Tursiops truncatus

A complex lymphoepithelial gland is a constant feature in the larynx of Atlantic bottlenose dolphins, Tursiops truncatus, based on study of 56 animals. Larynges were removed from fresh, non-decomposed beach-stranded animals for gross examination and histological sampling. A large lymphoepithelial gland occurs in the rostro-ventral mucosa of the larynx, overlying the cricoid cartilage. It presents as a well-defined, elevated, and heavily trabeculated area. Histological examination reveals a pseudostratified columnar epithelium which branches into the underlying submucosa. The epithelial-lined folds and crypts thus formed are surrounded by aggregations of lymphocytes, which infiltrate this epithelium. Mucous glands are often associated with these lymphoid aggregations. The histological appearance of the laryngeal gland is remarkably similar to the palatine, or dorsal oropharyngeal tonsils, of T. truncatus. It may be analogous to the nasopharyngeal adenoid of terrestrial animals. Age-related involution of the laryngeal gland is not as obvious with increasing animal age (or length) as it is in other mucosa-associated lymphoid tissue. The distribution of this gland among cetaceans is not yet known. We have observed it in individuals of every species we have studied, including Lagenodelphis hosei, Stenella coeruleoalba, Stenella attenuata, Globicephala macrorhynchus, Steno bredanensis, Physeter catodon, Pseudorca crassidens, Mesoplodon europaeus, and Kogia breviceps.

Results and long term follow-up for 1581 patients with metastatic breast carcinoma treated with standard dose doxorubicin-containing chemotherapy: a reference

BACKGROUND

The authors report results and long term follow-up for 1581 patients with metastatic breast carcinoma treated with doxorubicin-containing combination chemotherapy at a single institution; this report is meant to serve as a reliable reference for single-arm studies of newer therapies in this patient population.

METHODS

Prospectively collected data from 18 successive doxorubicin-containing protocols for the treatment of metastatic breast carcinoma were evaluated.

RESULTS

The response rate was 65.0% (95% confidence interval [CI]: 62.5-67.3%), complete response (CR) rate was 16.6% (95% CI: 14.8-18.6%), and partial response (PR) rate was 48.5% (95% CI: 46.0-50.9%). Median progression free survival (PFS) was 11.5 months (95% CI: 10.9-12.3 months) and median overall survival (OS) was 21.3 months (95% CI: 20.3-22.7 months). Survival correlated with response to therapy; median PFS and OS were 22.4 and 41.8 months, respectively, for the patients who achieved CR (n=263) and 14 and 24.6 months, respectively, for PR patients (n=766). The median OS of patients who had progressive disease during chemotherapy was 3.8 months. The response rate, PFS and OS correlated with number of organs involved and especially with tumor burden. Patients with hormone receptor-positive tumors had a similar response rate to that of patients with hormone receptor negative tumors but had significantly longer PFS (medians of 14.3 and 8.7 months, respectively) and OS (medians of 28.6 and 18.1 months, respectively).

CONCLUSIONS

In patients with metastatic breast carcinoma, doxorubicin-containing chemotherapy had a response rate of 65% and a CR rate of 16.6%. PFS and OS were 11.5 months and 21.3 months, respectively, for all responders and 22.4 months and 41.8 months, respectively, for those who had CR.

Treatment of Philadelphia chromosome-positive early chronic phase chronic myelogenous leukemia with daily doses of interferon alpha and low-dose cytarabine

PURPOSE

To evaluate the efficacy of the combination of interferon alpha (IFN-alpha) and daily low-dose cytarabine (ara-C) in the treatment of patients with early chronic-phase chronic myelogenous leukemia (CML) (within 1 year of diagnosis). Improving the degree of hematologic and cytogenetic response in patients with Philadelphia chromosome (Ph)-positive CML may improve prognosis. Both IFN-alpha and ara-C induce cytogenetic responses as single-agent therapy in CML.

PATIENTS AND METHODS

One hundred forty patients with Ph-positive early chronic-phase CML received subcutaneous injections of IFN-alpha 5 megaunits/m2 daily and ara-C 10 mg daily. Their median age was 46 years; 53% had good-risk disease, 33% had intermediate-risk disease, and 14% had poor-risk disease. Their results were compared with those of patients receiving IFN-alpha with or without intermittent ara-C (7 days/mo).

RESULTS

A complete hematologic response (CHR) was achieved in 92% of patients. A cytogenetic response was seen in 74%: it was major in 50% (Ph-positive < 35%) and complete in 31% (Ph-positive 0%). With a median follow-up of 42 months, the 4-year estimated survival rote was 70% (95% confidence interval, 61% to 79%). Significant side effects included fatigue (43%; grade 3/4, 11%), weight loss (19%; grade 3/4, 11%), muscle and bone aches (20%; grade 3/4, 7%), oral ulcers (4%), diarrhea (6%), and neurologic changes (27%, grade 3/4, 6%). The median dose of IFN-alpha was 3.7 megaunits/m2 daily, mainly because of reductions for myelosuppression (70% of cases); the median ara-C dose was 7.5 mg daily. Prognostic risk groups were predictive for response to the IFN-alpha plus ara-C combination. The incidence of CHR was higher with IFN-alpha plus daily ara-C compared with IFN-alpha plus intermittent ara-C and IFN-alpha alone (no ara-C) (92% v 84% v 80%, P = .01), as were the incidences of cytogenetic response (74% v 73% v 58%; P = .003) and major cytogenetic response (50% v 38% v 38%; P = .06). The median time to achievement of major cytogenetic response was significantly shorter than that for previous IFN-alpha regimens (7 v 10 v 12 months; P < .01). However, with the present follow-up, the survival and time to blastic transformation were similar.

CONCLUSION

The combination of IFN-alpha plus daily low-dose ara-C seems to be promising for the treatment of CML. High rates of CHR and cytogenetic response were observed with acceptable toxicity and a lower daily dose of IFN-alpha compared with our previous studies.

Clinical implications for four drugs of the DSM-IV distinction between substance dependence with and without a physiological component

OBJECTIVE

The DSM-IV work group asked researchers and clinicians to subtype substance dependent individuals according to the presence or absence of physiological symptoms. A recent report from the Collaborative Study on the Genetics of Alcoholism demonstrated that among alcohol-dependent men and women, a history of tolerance or withdrawal was associated with a more severe clinical course, especially for individuals with histories of alcohol withdrawal. This article evaluates similar distinctions among subjects in the collaborative study who were dependent on marijuana, cocaine, amphetamines, or opiates.

METHOD

Structured interviews gathered information from 1,457 individuals with a lifetime diagnosis of marijuana dependence, 1,262 with histories of cocaine dependence, 647 with amphetamine dependence, and 368 subjects with opiate dependence. For each drug, the clinical course was compared for subjects whose dependence included a history of withdrawal (group 1), those dependent on each drug who denied withdrawal but reported tolerance (group 2), and those who denied both tolerance and withdrawal (group 3).

RESULTS

The proportion of dependent individuals who denied tolerance or withdrawal (group 3) ranged from 30% for marijuana to 4% for opiates. For each substance, individuals in groups 1 and 2 evidenced more severe substance-related problems and at least a trend for greater intensities of exposure to the drug; those reporting withdrawal (group 1) showed the greatest intensity of problems.

CONCLUSIONS

The designation of dependence in the context of tolerance or withdrawal identifies individuals with more severe clinical histories. These results support the importance of the designation of a physiological component to dependence, especially for people who have experienced a withdrawal syndrome.

Polysomnography and depressive symptoms in primary alcoholics with and without a lifetime diagnosis of secondary depression and in patients with primary major depression

BACKGROUND

There is evidence suggesting that there is: (1) additive polysomnographic effects of alcoholism and depression; and (2) elevated baseline REM density in primary alcoholics with (PASD) and without lifetime history of secondary depression (NPA).

METHODS

23 PASDs, 59 NPAs, and 23 primary major depression patients (PMD) underwent polysomnography. Any drinking within 3 months after a 1-month inpatient alcohol rehabilitation defined relapse.

RESULTS

PASDs' polysomnography was more like NPAs than PMDs. Polysomnography reflected 3-month sobriety status more than diagnosis.

LIMITATIONS

Not all PASD's met full major depression criteria upon admission.

CONCLUSIONS

Alcoholism affected polysomnography more than depression. Elevated admission REM density predicted 3-month relapse in PASDs and NPAs.

Neutralization of HIV-1 subtypes: implications for vaccine formulations

More than 20.8 million people are infected with HIV in sub-Saharan Africa, with South Africa having one of the fastest growing HIV-1 epidemics, where an estimated 2.4 million people were infected. Thirty-two sera from 25 patients were tested for their ability to neutralize HTLV-IIIB (IIIB) and four primary isolates representing subtypes B, C, D, and a recombinant gag C/env B type. A CEM-SS cell line-based assay was used and the neutralizing titer was defined as the reciprocal of the highest dilution giving a 50% reduction in p24 antigen production. All isolates were neutralized better by subtype-specific sera, except for the C4714 strain, which was neutralized by both subtype B and C sera. C4714 was neutralized by 18/25 (72%) sera, IIIB by 19/32 (59%) sera, D482 by 7/31(23%) sera, B3245 by 6/29 (21%) sera, and the recombinant B/C1491 isolate by 4/25 (16%) sera. Five sera were unable to neutralize any of the isolates. The V3 region of the isolates used in the neutralization assay was amplified by PCR, directly sequenced, and analyzed to reveal variability between the consensus HIV-1 sequences and the isolates. HIV-1 strain C4714 was neutralized more effectively with the sera tested than the IIIIB laboratory strain. Variability in the amino acid sequence of the V3 region, which can alter the conformation of the V3 loop secondary structure, can influence the neutralization of a particular viral isolate. Vaccine formulations should be broadened to include multiple subtypes, especially C subtypes, which is rapidly spreading worldwide.

The sleep of abstinent pure primary alcoholic patients: natural course and relationship to relapse

Sleep in male pure primary alcoholic inpatients was examined at a mean of 16 days (n = 29), 19 weeks (n = 29), 14 months (n = 9), and 27 months (n = 4) of abstinence. Results were as follows: (1) the sleep of abstinent alcoholic patients is short, fragmented, and shallow early in abstinence; (2) a patient's sleep improves slowly over at least the first year of abstinence; however, (3) some facets of a patient's sleep remain abnormal even after 27 months of abstinence; (4) insomnia and sleep fragmentation after approximately 5 months of abstinence may be related to relapse by 14 months. The mechanism underlying the relationship between sleep and withdrawal in alcoholic patients is not well understood, and the issue of treating sleep problems as an adjunct to prevention of relapse warrants further investigation.

Influence of age and body mass index on gamma-glutamyltransferase activity: a 15-year follow-up evaluation in a community sample

Most clinicians and researchers view serum gamma-glutamyltransferase (GGT) activity as a measure that can be interpreted equally in patients regardless of their demography. The present study evaluates the concurrent influence of age and body mass index (BMI) on GGT in a sample of 133 high functioning young men, with detailed assessment of the pattern of alcohol use at ages 20 [time 1 (T1)], 30 [time 2 (T2)], and 35 [time 3 (T3)]. GGT increased between T1 and T2 (15.4 +/- 9.65 units/liter vs. 20.1 +/- 12.07 units/liter, t = 4.17, p < 0.001), and between T2 and T3 (20.1 +/- 12.07 units/liter vs. 27.3 +/- 24.69 units/liter, t = 4.11, p < 0.001). Controlling for drinking quantity and frequency did not change the finding. The relationship between GGT and BMI was estimated after splitting the sample into normal (BMI < or = 25 kg/m2) and overweight (BMI > 25 kg/m2) subjects. The correlation between GGT and BMI in normal weight men at T1 was r = 0.15, p = 0.09, at T2 r = 0.00, p = 0.96, and at T3 r = 0.09, p = 0.09. In overweight subjects, correlation at T1 was r = 0.40, p = 0.20, at T2 r = 0.36, p < 0.05, and at T3 r = 0.44, p < 0.001. Controlling for the effect of alcohol consumption and/or age did not alter these conclusions. Testing for the interaction of age, BMI, and alcohol consumption did not yield relevant results. We concluded that GGT is positively related to age in the 20s to late 30s and to BMI in overweight subjects; both relationships of age and BMI were independent of alcohol consumption. The interpretation of GGT should take age and BMI into account when suspecting subclinical alcohol problems in young men.