Primary mediastinal nonseminomatous germ cell tumors. Results of a multimodality approach

Before cisplatin-based chemotherapy, long-term survival after resection of primary mediastinal nonseminomatous germ cell tumors was unusual. We reviewed the case histories of 48 patients who underwent multimodality treatment for mediastinal nonseminomatous germ cell tumor between 1976 and 1988. Twenty-eight patients received initial therapy at Indiana University and 20 were referred after having had unsuccessful initial therapy elsewhere. In 44 patients (92%) the levels of either one or both serum tumor markers were elevated at the time of diagnosis. Five patients had choriocarcinoma, three embryonal carcinoma, 12 yolk sac carcinoma, four teratocarcinoma, 22 mixed cell type, and two had an unclassified type. Twenty-two of the 28 patients in our initial therapy group had a complete response to treatment, as defined by normal serum tumor markers and absence of residual tumor. In this group, 16 patients had resection of residual disease after chemotherapy, four had total or near total resection before chemotherapy, and only two had chemotherapy alone. Seventeen patients are surviving after this treatment with a median survival of 64 months and a 57% 5-year Kaplan-Meier survival rate. Only two of the 20 patients who were referred for salvage chemotherapy had a complete response. Both required resection of residual disease after salvage chemotherapy. Only one patient survived after this treatment. There was no significant treatment morbidity or mortality. A multimodality approach to primary mediastinal nonseminomatous germ cell tumor with intensive cisplatin-based chemotherapy, emphasis on normalizing serum tumor markers, and aggressive resection of residual disease now offers survival to a significant number of patients.

Adherence assay of 51chromium-labeled human polymorphonuclear leukocyte using glass beads

There is a need for a reliable and relatively simple assay of in vitro adherence capacity. We have modified a previously described method of adherence of 51Cr-labeled PMN to glass beads and developed an assay which should be of value in both the clinical and research areas. The assay measures PMN adherence in the non-stimulated state and also following stimulation with phorbol myristate acetate (PMA) or endotoxin-activated plasma (EAP) using as few as 0.25 X 10(6) PMN. The differences observed between the adherence of stimulated and non-stimulated PMN were highly significant.

Closed Ender nailing of femur fractures in older children

Twenty-eight patients ranging from 8 to 13 years old were treated at Childrens Hospital of Alabama for diaphyseal femur fractures. We studied two groups: 14 patients (Group I) were treated by conventional 90-90 balanced skeletal traction with late spica cast application; 14 patients (Group II) with multiple associated injuries or hyperkinetic problems were treated with closed retrograde Ender nailing. Groups I and II compared closely with regard to age, sex, fracture type and location, and mechanism of injury. The alignment, leg length, length of hospitalization, and length of therapy were analyzed. Our experience indicates that closed retrograde Ender nailing of diaphyseal femur fractures is an ideal technique where operative reduction and stabilization are indicated in older children. The technique yields results superior to conventional methods of treatment, with the advantage of early discharge from the hospital and return to school.

Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails

Treatment of infected nonunion of tibial fractures has focused on irradicating infection before attempting to secure union. To secure union in the presence of infection in cases not amenable to conventional treatment, intramedullary nailing combined with open wound management was the treatment in 19 fractures of infected tibial nonunions in 18 patients. Eighteen fractures united. Drainage lessened or ceased after union of fractures and/or removal of nails. Only three cases had bone grafts. All were initially Type III open fractures. The majority occurred in motorcycle accidents. Time to union averaged 6.6 months (range, three to 14 months). Fourteen cases (15 tibias) healed without further drainage; four had minimal but persistent drainage. In properly selected cases, the treatment was safe and effective.

Bromide space determination using anion-exchange chromatography for measurement of bromide

A high-pressure liquid chromatographic method for bromide measurement is used to determine extracellular water volume in humans. The method uses 5 microL serum ultrafiltrate and has a sensitivity of 7.5 pmol. Because of the extreme sensitivity of this method, relatively small quantities of Br can be administered and small amounts of blood are needed for the analysis. By this method, the mean corrected Br space in 82 healthy adults representing a wide range of body weights was 0.218 +/- .034 L/kg (mean +/- 1 SD) with a range of 0.153-0.295 L/kg, which is consistent with reported values. There was a significant, inverse relationship between corrected Br space per kilogram and obesity as measured by body mass index. The corrected Br space in six children aged 3-36 mo was 0.335-0.394 L/kg, which is also consistent with reported values in children of this age. This method for Br measurement can easily and readily be applied for the determination of extracellular water volume.

Interacting cytokines regulate in vitro human megakaryocytopoiesis

The effects of hematopoietic growth factors on in vitro human megakaryocytopoiesis were studied using a serum-depleted culture system. Both recombinant interleukin-3 (r-IL-3) and recombinant granulocyte-macrophage colony-stimulating factor (rGM-CSF) increased megakaryocyte (MK) colony formation (P less than .01) above that observed in baseline cultures. Recombinant interleukin-4 (rIL-4) and interleukin 1 alpha (rIL-1 alpha) failed either to promote MK colony formation alone or to increase rIL-3 or rGM-CSF promoted colony formation. Recombinant erythropoietin (rEpo) and purified thrombocytopoiesis-stimulating factor (TSF) did not increase (P greater than .05) MK colony formation when added alone but synergized with rIL-1 alpha, leading to a twofold increase in MK colony formation. Such a synergistic relationship was not observed between rIL-4 and rEpo. In addition, TSF enhanced the ability of rIL-3 but not rGM-CSF to promote MK colony formation. Addition of rEpo to optimal or suboptimal concentrations of rGM-CSF or suboptimal concentrations of rIL-3 resulted in a significant increase (P less than .05) in the total number of MK-containing colonies, due to the appearance of multilineage colonies containing MKs. The addition of rEpo to optimal concentrations of rIL-3 resulted in increased numbers of multilineage colonies containing MKs; however, the number of total MK-containing colonies was not significantly increased when compared to assays containing rIL-3 alone. By contrast, transforming growth factor-beta (TGF-beta) inhibited both rIL-3, and rGM-CSF promoted MK colony formation, with optimal inhibition resulting in a 35%-45% reduction of MK colony formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Odontomas

A total of 351 odontomas were retrieved and analyzed from 53,824 submitted specimens. The majority (53.6%) were diagnosed in the second decade of life; the most common location was the anterior portion of the maxilla (33.9%), but there was no overall predilection for the maxilla. An associated unerupted tooth was present in at least 47.6% of the cases. Dentigerous cysts were diagnosed in conjunction with 27.6% of the odontomas, and a calcifying and keratinizing odontogenic cyst was seen in 0.9% of the cases.

Secular trends in body mass in the United States, 1960-1980

Data from four National Health Examination Surveys conducted of the US population from 1960 to 1980 were analyzed to determine secular trends in obesity for white and for black adolescents and young adults of both sexes. Body mass index was categorized into four levels using cut points determined by the 50th, 75th, and 85th percentiles at the first survey in 1960-1962. The weighted proportions of persons in these body mass categories were determined, and statistical models were developed to describe secular trend and race effects. No consistent secular trends were found for white or black youths aged 12-17 years. No significant secular trends in obesity were found for white or black young males aged 18-34 years. Both for white and for black adult females, there were significant secular increases in the proportion of adult females in each of the successively heavier categories of body mass index. These increases were identical for white and for black adult females on the log-odds scale, but black adult females were already significantly heavier at the first survey. This race effect persisted throughout the entire time interval.

The ontogeny of pulmonary defenses: alveolar macrophage function in neonatal and juvenile rhesus monkeys

Using the technique of bronchoalveolar lavage, we isolated alveolar macrophages (AM) from the lower respiratory tract of newborn (1-4 days of age), infant (6-10 days of age), juvenile (3-6 months of age), and adult rhesus monkeys. The AM thus obtained were assayed in vitro to determine their chemotactic, phagocytic, and candidicidal capabilities. The predominant (greater than or equal to 89%) cell type in bronchoalveolar lavage effluent in all ages was the AM. Chemotaxis, phagocytosis, and killing of Candida albicans were markedly impaired in neonatal AM as compared with those from infants, juveniles, and adults. AM chemotactic activity achieved normal adult values by 6 days of age. Phagocytosis, and to a lesser extent candidicidal activity, were significantly improved in 6-day-old animals, but adult levels were still not achieved even by 6 months of age.

Some general methods for the analysis of categorical data in longitudinal studies

This paper is concerned with the analysis of multivariate categorical data from epidemiologic and clinical studies with longitudinal designs. An expository discussion of pertinent hypotheses for such situations is provided within the context of two relevant data sets. Appropriate large-sample tests of these hypotheses are developed through the application of weighted least squares to generate Wald statistics. These procedures are illustrated with extensive analyses of one of these data sets. In some situations, the resulting cross-classification of the response variables leads to extremely sparse frequency data, especially when the number of subjects is not large. For such repeated measurement designs in which a single variable is measured repeatedly over time, this paper considers the use of a generalized Mantel-Haenszel strategy for tests of marginal homogeneity (symmetry). These randomization model methods are illustrated for data in which the repeated measurement variable is reported on an ordinal scale. This paper also focuses on the available computing software to implement these methods within the version 5 release of the SAS system. The randomization model approach can be implemented within the FREQ procedure and a broad range of models and hypotheses can be investigated within the CATMOD procedure.

Cord serum bromide concentration: variation and lack of association with pregnancy outcome

Excessive maternal bromide exposure during pregnancy from drugs and occupation have been reported to have adverse effects on the fetus and newborn, including central nervous system depression at birth and possible teratogenicity. To define further fetal bromide exposure during pregnancy, we determined the cord serum bromide concentration in 1267 newborn babies born in Rochester, New York, during the 6-month period from January 1, 1984 to June 30, 1984. There was a normal distribution of the cord serum bromide concentration values (mean +/- SD = 8.6 +/- 2.6 mg/L; range 3.1 to 28.5 mg/L). The highest concentration was still significantly below the minimal bromide concentration associated with toxic effects (720 mg/L). There was no association between the cord serum bromide concentration and indices of fetal health including Apgar scores, presence of congenital malformations, and neonatal disposition. No mothers were taking significant amounts of bromide-containing drugs during pregnancy. The second highest cord serum bromide concentration (21.4 mg/L) was in a woman who was an amateur photographer and developed her own film, which required her to use chemicals containing bromide. Our results indicate that excessive fetal bromide exposure is rare and probably occurs only in the setting of maternal use of bromide-containing drugs or occupational exposure during pregnancy.

Effect of fish oil concentrates on hemorheological and hemostatic aspects of diabetes mellitus: a preliminary study

Fish oil concentrates (Max EPA) were given without other diet modification for eight weeks to five insulin-dependent diabetics and five healthy volunteers, in order to determine their effect on possible in vitro indices of thrombosis. Cholesterol, HDL, LDL, fasting blood sugar, hemoglobin A1c, platelet count, and the osmotic fragility of red blood cells were not significantly changed from baseline values after eight weeks of fish oil consumption. Serum triglyceride levels were lowered by the fish oil (diabetics 130 +/- 23 to 89 +/- 26 mg/dl: normals 107 +/- 16 to 57 +/- 5 mg/dl). Nine out of ten subjects required more arachidonic acid to aggregate their platelets, and six out of ten required more collagen. Whole blood viscosity at low shear rates was increased in diabetics before the fish oil ingestion, and was reduced both in normals and in diabetics after eight weeks of treatment. Before fish oil administration, the diabetics had higher levels of von Willebrand Factor (vWF) (208 +/- 31%) than did controls (117 +/- 26%). There was a statistically significant decrease of serum von Willebrand Factor both in diabetics (p less than 0.01) and in normals (p less than 0.05) after six weeks of treatment. Analysis of the multimeric composition of the vWF indicated that the vWF molecule was not altered. Addition of eicosapentaenoic acid (EPA) or crude fish oil to human umbilical cord endothelial cell cultures did not change vWF levels in the supernatant. Whether these changes in platelet aggregation, whole blood viscosity and vWF can actually be translated into an in vivo amelioration of the vascular complications in diabetes remains to be determined in a carefully controlled clinical trial.

Improved treatment of femoral shaft fractures in children. The "pontoon" 90-90 spica cast

In the past 15 to 20 years, little improvement has been made in the standard treatment of femur fractures in children. Children younger than two years of age or weighing less than 30 pounds are normally treated with skin traction or immobilized in a plaster cast or both. Older or heavier children are often treated with skeletal traction, followed by early or late application of spica cast in the neutral position. A method of spica cast treatment that immobilizes the limb in the 90-90 position using a reinforced cast incorporating a distal femoral traction pin--the pontoon spica--allows for early cast application and discharge from the hospital and encourages early motion of the knee joint. A series of 23 femur fractures in 21 patients were treated with this method. This series is compared with a series of 38 fractures treated with conventional methods. The follow-up period ranged from three to 24 months. The pontoon method provided better results in control of alignment than the conventional method, with no greater discrepancy in leg lengths than generally observed after skin traction and hip spica casts. The average hospital cost reduction was 73%, or approximately $13,334. There were no major complications with the pontoon method, which is now a standard treatment for femoral fractures in children.

Quantitative microscopy: I. A computer-assisted approach to the study of polymorphonuclear leukocyte (PMN) chemotaxis

A computer-assisted approach has been designed to analyze and quantitate polymorphonuclear leukocyte (PMN) chemotaxis. This approach involves a rapid, objective, and semiautomated (user-directed) image-analysis system that is video- and microscope-based. The entire system consists of a microvideo set-up that is put on line with a Digital DEC-LSI-11/73 microcomputer, interfaced with a Datacube analog-digital/digital-analog converter. Video signals of PMN movement are digitized by the system at a resolution of 240 pixels vertically by 320 pixels horizontally (at 256 gray levels) and stored in a 76,800-byte frame buffer. The digitized data are stored for later use or utilized immediately for image segmentation, image display, movement, and morphometric computations for each PMN in a maximum phase field (at 645 X high dry) of 50 PMNs at 10-second intervals. The digitized data are used for computation of cell perimeter, surface area, optical density, contour-ratio, position, speed, and direction of locomotion with the utilization of micro-image-analysis programs written in FORTRAN and MACRO assembly language, with the computer operating under RT-11/TSX+. The reliability, objectivity, and reproducibility of measurements made with this quantitative approach have been tested by comparing with manual-tracing measurements of PMN movement. A correlation factor of 0.99 has been obtained. However, the quantitative-microscopic approach is much faster, more objective, less tedious, and much easier to operate than the conventional manual-tracing method.

A computer-assisted image-analysis system for analyzing polymorphonuclear leukocyte chemotaxis in patients with diabetes mellitus

A computer-assisted image-analysis system that precisely tracks the cell movements of up to 50 polymorphonuclear leukocytes (PMNLs) was developed and used to quantitatively measure cellular chemokinesis and chemotaxis in normal individuals and in diabetic patients with hyperglycemia. The PMNLs were tested in Zigmond chambers with or without a gradient of 10(-7) M n-formylmethionylleucylphenylalanine (f-Met-Leu-Phe). Cellular movement was recorded on videotape by using a videocamera mounted on the microscope. The videotapes were analyzed by computer programs to calculate the speed and direction of each PMNL at 10-sec intervals. Average rates of chemokinesis were 19.6 microns/min without and 25.3 microns/min with f-Met-Leu-Phe. McCutcheon indices, which measure chemotaxis, were 0.01 without and 0.48 with f-Met-Leu-Phe. Similar values were observed in diabetic patients after fasting (average glucose, 217 mg/100 ml) and 2 hr after glucose challenge (average glucose, 309 mg/100 ml). These values demonstrate that PMNLs from diabetic patients with hyperglycemia move at normal rates and respond appropriately to f-Met-Leu-Phe.

Familial CHARGE syndrome: clinical report with autopsy findings

We report on a patient with CHARGE syndrome, as manifested by a coloboma of the optic nerve head, congenital heart defect (ASD, VSD, and parachute mitral valve), choanal atresia, severe growth retardation, genital hypoplasia, abnormal ears, cleft lip and palate, and pectus carinatum. His chromosomes were normal. He died at 19 months. His mother was short and had hearing impairment, choanal atresia, and a coloboma. We suggest that this represents evidence for dominant transmission of this disorder in this family. Other familial cases from the literature are reviewed.

Polymicrobial bacterial sepsis and defective neutrophil chemotaxis in an infant with cystic fibrosis

A 4 1/2-month-old, white girl was admitted to the hospital with respiratory distress and persistent polymicrobial bacteremia. Cystic fibrosis associated with malnutrition and a transient defect in peripheral neutrophil chemotaxis was diagnosed. This remarkable combination of presenting features in a patient with cystic fibrosis is the focus of this case report.

Hay-Wells syndrome

Hay-Wells syndrome is an autosomal dominant constellation of facial clefting, ankyloblepharon filiforme adnatum (fused eyelids), and ectodermal defects. Our patient, a child who had these unusual features at birth, led us to consider possible differential diagnoses based on clinical features and review of the literature.