The importance of diagnostic cytogenetics on outcome in AML: analysis of 1,612 patients entered into the MRC AML 10 trial. The Medical Research Council Adult and Children's Leukaemia Working Parties

Cytogenetics is considered one of the most valuable prognostic determinants in acute myeloid leukemia (AML). However, many studies on which this assertion is based were limited by relatively small sample sizes or varying treatment approach, leading to conflicting data regarding the prognostic implications of specific cytogenetic abnormalities. The Medical Research Council (MRC) AML 10 trial, which included children and adults up to 55 years of age, not only affords the opportunity to determine the independent prognostic significance of pretreatment cytogenetics in the context of large patient groups receiving comparable therapy, but also to address their impact on the outcome of subsequent transplantation procedures performed in first complete remission (CR). On the basis of response to induction treatment, relapse risk, and overall survival, three prognostic groups could be defined by cytogenetic abnormalities detected at presentation in comparison with the outcome of patients with normal karyotype. AML associated with t(8;21), t(15;17) or inv(16) predicted a relatively favorable outcome. Whereas in patients lacking these favorable changes, the presence of a complex karyotype, -5, del(5q), -7, or abnormalities of 3q defined a group with relatively poor prognosis. The remaining group of patients including those with 11q23 abnormalities, +8, +21, +22, del(9q), del(7q) or other miscellaneous structural or numerical defects not encompassed by the favorable or adverse risk groups were found to have an intermediate prognosis. The presence of additional cytogenetic abnormalities did not modify the outcome of patients with favorable cytogenetics. Subgroup analysis demonstrated that the three cytogenetically defined prognostic groups retained their predictive value in the context of secondary as well as de novo AML, within the pediatric age group and furthermore were found to be a key determinant of outcome from autologous or allogeneic bone marrow transplantation (BMT) in first CR. This study highlights the importance of diagnostic cytogenetics as an independent prognostic factor in AML, providing the framework for a stratified treatment approach of this disease, which has been adopted in the current MRC AML 12 trial.

Capacity to choose place of residence: autonomy vs beneficence?

Health care workers often perceive a conflict between autonomy and beneficence when dealing with clients living at risk in the community. Respect for personal freedom and the desire to help and protect vulnerable people frequently appear to demand opposite interventions. The assessment of decision-making capacity is a vital part of any process that deals with these complicated situations and can resolve some of the apparent conflict. Standardized assessment tools which are flexible enough to deal with the complexities of capacity assessment are needed. Health care workers aim to maximize the safety of people incapable of making decisions while protecting the freedom and autonomy of the capable. Some limits to autonomy must be accepted, especially where others' interests are threatened.

The effect of nonoxynol-9 and chlorhexidine on HIV and sperm in vitro

The effect of chlorhexidine and nonoxynol-9, either singly or in combination, on the replication and infectivity of HIV and the survival of both lymphocytes (MT2 cells) and human spermatozoa, was studied in vitro. Exposure of MT2 cells to 200 microg/ml nonoxynol-9 or 1 mg/ml chlorhexidine for one minute destroyed their viability. A combination of 60 microg/ml of nonoxynol-9 and chlorhexidine, however, killed MT2 cells under the same conditions. Nonoxynol-9 and chlorhexidine were both spermicidal, 268 microg/ml nonoxynol-9, or 2.063 mg/ml chlorhexidine caused complete immobilization of sperm after one minute. The same effect was achieved by a combination of 200 microg/ml nonoxynol-9 and 1.0 mg/ml chlorhexidine. The effect of chlorhexidine and nonoxynol-9 on the replication of HIV was estimated by the output of p24 (the HIV core protein) and the concentration of virus was determined by titration with MT2 cells. Separately, 300 microg/ml nonoxynol-9 alone completely inactivated HIV, while 1 mg/ml chlorhexidine was 80%-100% effective. Certain combinations of nonoxynol-9 and chlorhexidine were antagonistic in their inactivation of HIV, up to 400 microg/ml chlorhexidine partly neutralized the action of 200-500 microg/ml nonoxynol-9.

Neoplastic transformation of the endocervix associated with downregulation of lactoferrin expression

The incidence of cervical adenocarcinomas in young women over the last two decades has increased. Even with increasing knowledge of the role of human papillomavirus in the etiology of adenocarcinoma of the cervix, there is a paucity of data concerning the genetic and epigenetic factors that contribute to the histologic features and biologic behaviors of these tumors. Lactoferrin is a basic glycoprotein found in human milk, secondary granules of neutrophils, and many body secretions, and it has been associated with carcinogenesis of the endometrium, breast, and lymphoid systems. In this study, we examined the expression of lactoferrin in normal human endocervical epithelium and in cervical adenocarcinomas in relation to proliferative index, steroid receptor status, p53 protein expression, and apoptosis. Immunohistochemical and in situ studies demonstrated that lactoferrin protein and mRNA were strikingly downregulated upon neoplastic transformation of the endocervix as early as in adenocarcinoma in situ when compared with the prominent expression exhibited by the normal cervical epithelium. Furthermore, neoplastic transformation of endocervical epithelial cells was accompanied by a pronounced stimulation of proliferation and a substantial reduction in the expression of the estrogen and progesterone receptors and p53 but little or no change in the number of apoptotic cells. In conclusion, we identified lactoferrin as a novel cancer-specific marker of endocervical adenocarcinomas that may be useful in the early detection of the disease, prediction of prognosis, and the development of new therapeutic modalities.

Diagnostic utility of bone marrow sampling in HIV positive patients

OBJECTIVE

To evaluate the diagnostic utility of bone marrow (BM) sampling in HIV positive patients.

DESIGN

Retrospective cohort analysis.

SETTING

Specialist HIV/AIDS service in London.

SUBJECTS

215 consecutive HIV infected patients undergoing 246 BM samplings for investigation of pyrexia without localising signs, haematological abnormalities, or staging/investigation of lymphoma.

MAIN OUTCOME MEASURE

Diagnostic yield from (and impact on management of) BM sampling.

RESULTS

Of 122 BM samples taken to investigate pyrexia, 33 (27%) revealed the cause on microscopy: unexpected lymphoma in seven (6%), mycobacteriosis in 25 (20%), and toxoplasmosis in one (1%). Marrow infiltration was confirmed in 11 of 38 BM samples taken for staging/investigation of lymphoma/leukaemia. In afebrile patients, of 22 with pancytopenia, BM samples showed HIV associated changes in 17 and specific diagnoses in five (mycobacterial infection in three, haemophagocytic syndrome in one, and megaloblastic change due to vitamin B-12 deficiency in one); of 21 with isolated thrombocytopenia, 20 (95%) BM samples showed immune thrombocytopenic purpura to be the cause and the remaining patient had BM changes of aplasia; of 29 with isolated anaemia, 28 had BM changes of HIV associated dysplasia/erythroid dysplasia and one had unsuspected iron deficiency; all 10 with isolated leucopenia/neutropenia had BM changes ascribed to HIV infection exacerbated by concurrent sepsis or medication; of four BM samples taken for other reasons, one showed mycobacterial infection.

CONCLUSIONS

BM sampling has diagnostic utility in HIV infected patients with pyrexia without localising signs, pancytopenia, and staging/investigation of lymphoma; this test has little value in the investigation of afebrile patients with isolated thrombocytopenia, anaemia, or leucopenia as HIV is usually the underlying cause.

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child's family and with other health care practitioners to determine the child's role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child's developing capacity for decision-making.

Lens clarity after lens-sparing vitrectomy in a pediatric population

PURPOSE

The purpose of the study is to assess lens clarity after pediatric lens-sparing vitrectomy.

METHODS

The study offers a retrospective analysis of 85 eyes of 77 pediatric patients who underwent lens-sparing vitrectomy for tractional retinal detachment or opaque media, and who were observed for 10 to 55 months.

RESULTS

A total of 57 eyes maintained clear lenses at last follow-up examination. Cataract was found in 13 (15%) of the 85 eyes. Fifteen eyes (18%) had undergone lens removal as part of reoperation for progressive ocular disease.

CONCLUSION

Sixty-seven percent of pediatric lenses remained clear after lens-sparing vitrectomy.

Weight loss associated with HIV seroconversion among injection-drug users

To describe symptoms associated with human immunodeficiency virus (HIV) seroconversion, we studied a cohort of 366 injection-drug users (IDUs) with a study design that included recall every 3 months to collect symptom histories using a structured questionnaire. Eleven HIV seroconversions were observed in 621.5 person years at risk (PYAR), equivalent to 1.8 seroconversions/100 PYAR. Cox regression analysis showed age < or = 35 years to be a significant risk factor for HIV seroconversion after controlling for gender, race, and the frequency of drug injection. An embedded case-control analysis then compared symptom histories of HIV seroconverters with those of age-(+/- 5 years) and visit number-matched controls who remained HIV seronegative for > or = 3 months longer than the HIV-seroconverters. Multivariate case-control analysis adjusted for injection frequency yielded significant associations of HIV seroconversion with histories of weight loss > or = 4.5 kg (seven of 11 cases; odds ratio [OR] = 11.6, 95% confidence interval [CI] 3.1, 43.1) and oral ulcers (three of 11 cases; OR = 7.6, 95% CI = 1.2, 48.2) in the 3 months before the subjects' first HIV-seropositive study visit. We conclude that histories of recent symptoms reported by HIV-seroconverting IDUs differ from those reported by non-HIV-seroconverting IDUs, and weight loss may be particularly common among IDUs experiencing primary HIV infection.

Induction of the chemotactic S100 protein, CP-10, in monocyte/macrophages by lipopolysaccharide

The murine S100 protein CP-10 is a potent chemotactic factor for murine and human myeloid cells in vivo and in vitro. This is the first report describing regulations of the CP-10 gene by a proinflammatory stimulus, lipopolysaccharide (LPS), in cells of the monocyte/macrophage lineage. Murine monocyte/macrophage-like WEHI 265 and RAW 264.7 cells preexposed to 5 to 50 ng/mL LPS expressed significant levels of CP-10 mRNA 4 hours, and maximal at 20 hours, after a secondary LPS challenge. This was accompanied by increasing levels of cell-associated and released CP-10 protein. In contrast, a single dose of LPS upregulated CP-10 mRNA in elicited peritoneal macrophages, whereas mRNA and protein levels decreased following LPS challenge. The state of macrophage differentiation may control responsiveness as LPS had no effect on CP-10 basal levels in bone marrow derived macrophages. LPS-induced CP-10 expression was controlled at the transcriptional level and nuclear run-on and protein synthesis inhibition assays indicated that LPS priming and challenge of RAW cells occurred via distinct pathways. MRP14, another S100 protein generally coordinately expressed with human MRP8, was not induced by LPS under the same conditions. We propose that CP-10 may play a key role in recruitment of leukocytes into tissues in response to gram-negative bacterial infection.

Preliminary results from a psychoeducational program to rehabilitate chronic patients

Twenty-two chronic psychiatric patients enrolled in a psychoeducational rehabilitation program were assessed before and after the program to determine whether participation decreased severity of psychopathology and improved community functioning and quality of life. The program consisted of five 14-week modules that provided training in five skill areas: medication and symptom self-management, coping with anxiety and depression, social skills, living skills, and leisure skills. Most patients experienced significantly reduced psychopathology and negative symptoms and improved quality of life and community functioning. The program appears helpful to clients, and a controlled trial to further evaluate its effects is underway.

Retinoblastoma in association with the chromosome breakage syndromes Fanconi's anaemia and Bloom's syndrome: clinical and cytogenetic findings

Two children presenting with sporadic unilateral retinoblastoma and exhibiting a high degree of chromosome breakage were noted to have unusual facies, microcephaly and abnormal skin pigmentation. In the first child the pattern of both spontaneous and mitomycin-C-induced chromosome breakage was characteristic of Fanconi's anaemia although the degree of breakage was extreme. She also exhibited a striking increase in X-ray-induced chromosomal damage in G0 lymphocytes as measured by dicentric formation and increase in chromatid-type aberrations. She had a number of typical clinical features, including cafe-au-lait patches and abnormalities involving the kidney; however, she demonstrated neither the hypoplasia of radius and thumb nor the typical aplastic phase of this disorder. At age 22 months the child became anaemic with trilineage myelodysplasia, which was rapidly followed by the development of acute myeloblastic leukaemia. The early onset (at age 4 months) of retinoblastoma may have been associated with the underlying genomic instability. The second child exhibited a pattern of chromosome breakage characteristic of Bloom's syndrome, in addition to a moderate increase in damage induced by mytomycin-C. She had the typical stunted growth and malar hypoplasia of Bloom's syndrome although she did not demonstrate the frequently described erythematous 'butterfly rash' Although patients with Fanconi's anaemia and Bloom's syndrome are recognised to be at an increased risk of cancer, retinoblastoma has not previously been described in patients with either condition. We suggest that underlying recessive chromosome breakage syndromes may be underdiagnosed in paediatric cancer patients, with important implications for prognosis and genetic counselling.

Strecker stents in the femoropopliteal arteries: value of duplex ultrasonography in restenosis assessment

PURPOSE

Experience with Strecker stent implantation in the femoropopliteal arteries has been described; however, few of the reports were prospective studies, and none routinely used site-specific assessment methods for follow-up evaluation of stent patency. The purpose of this study was to evaluate 1-year Strecker stent patency using duplex ultrasound imaging to obtain a more precise delineation of stent restenosis than is possible with other noninvasive assessment modalities.

METHODS

A prospective study involved 52 patients with 57 sites treated by angioplasty and Strecker stent deployment in the femoropopliteal arteries. Assessment included clinical evaluation; ankle-brachial index (ABI) measurements at rest and after exercise; and duplex ultrasound imaging preprocedurally and at 3 and 12 months after the intervention.

RESULTS

All 74 stents were deployed successfully in the 35 occluded arteries and 22 stenotic lesions. Acute reocclusion occurred in 6 (10%). At 3 months, primary patency was 81% and secondary patency 84%. Mean ( +/- SD) ABIs increased from 0.64 +/- 0.15 at rest and 0.32 +/- 0.17 after exercise to 0.89 +/- 0.14 and 0.68 +/- 0.23, respectively (p < 0.0001). At 12 months, primary patency was 79%, and secondary patency was 82%. Mean ABIs were 0.82 +/- 0.15 at rest and 0.52 +/- 0.22 after exercise at 12 months (p < 0.0002 compared with preprocedural ABIs). Analysis of the length of lesion treated showed betted results with shorter diseased segments, but this was not statistically significant (p > 0.05). Better outcomes were also obtained when one stent was used rather than two stents at 12 months (p = 0.15), but there was no difference at 3 months (p = 0.3). Thirty-four percent of the stented segments progressed from < 20% stenosis at 3 months to > 50% stenosis at 12 months. Overall, 19 (43%) of 44 segments progressed from < 50% stenosis at 3 months to a > 50% stenosis at 12 months. Restenosis seen at 3 months generally was in the native artery just proximal or distal to the stent, but at 12 months, restenosis was mainly inside the stent.

CONCLUSIONS

Strecker stents at 1-year demonstrated satisfactory patency in the femoropopliteal arteries when deployed for angioplasty salvage or recurrent disease. The 3- and 12-month evaluations obtained with duplex ultrasound provided site-specific hemodynamic data for stent assessment. Resting ankle pressures were a poor index of restenosis.

Recognition and classification of clinically dysplastic nevi from photographs: a study of interobserver variation

The recognition of dysplastic nevi from photographs can aid in population surveys of nevi and in epidemiological studies of melanoma risk. The reproducibility of techniques for recognizing nevi as dysplastic or for scoring them according to the degree of dysplasia has not been measured. Using photographs of 300 nevi taken in the course of a case-control study of melanoma, we assessed the agreement among six clinicians in independently categorizing nevi as dysplastic and in grading the degree of dysplasia. On average, reviewers agreed with each other 77% of the time in classifying a nevus as dysplastic or normal. Pairwise agreement within one point on a six-point scale occurred 87% of the time on average. These results suggest that criteria for recognizing nevi as clinically dysplastic from photographs can be applied reproducibility.