Experience with prophylactic oral ciprofloxacin in gynecological cancer patients developing severe chemotherapy-induced neutropenia

The development of significant neutropenia is a relatively frequent complication of cytotoxic chemotherapy of malignant disease. In an effort to develop a cost-effective management strategy to prevent serious infectious events associated with severe chemotherapy-induced neutropenia, patients treated in the Gynecological Oncology Program of the Cleveland Clinic Taussig Cancer Center have been administered ciprofloxacin, a potent broad-spectrum antibiotic, 500 mg orally twice a day, beginning at the time of documentation of grade 4 neutropenia. The antibiotic is continued until granulocyte recovery. A total of 44 patients (57 treatment courses) have been treated in this manner. There have been no complications of therapy and no episodes of subsequent infections due to ciprofloxacin-resistant organisms. Two patients required hospital admission following the development of significant fever, despite the use of ciprofloxacin. While these results are encouraging and suggest that the use of prophylactic ciprofloxacin is a highly cost-effective management approach in this setting, randomized controlled trials are necessary to define the ultimate benefit of this clinical strategy.

Comparison of higher-dose intradermal hepatitis B vaccination to standard intramuscular vaccination of healthcare workers

OBJECTIVE

To compare the immunogenicity of hepatitis B vaccine administered via intradermal (ID) versus intramuscular (IM) route.

METHODS

Subjects chose either to specify the route of immunization or to undergo random allocation to vaccination by the ID (0.15 mL) or the IM (1.0 mL) route. Yeast-derived recombinant hepatitis B vaccine was given at 0, 30, and 180 days. Hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) were measured by microparticle enzyme immunoassay.

RESULTS

763 subjects were enrolled. Baseline screening identified 65 subjects (8%) who were positive for HBsAb or HBcAb. Vaccination was completed by 590 (85%) of 698 enrollees (370 ID, 220 IM). Seroconversion rates (geometric mean titers [GMT]>0 IU/mL HBsAb) for those vaccinated ID were 99% and 96% for screening at 9 months and 1 year post-vaccination, respectively; subjects vaccinated intramuscularly had similar rates of 95% and 96%. Seropositivity rates (GMT > or = 10 IU/mL HBsAb) showed a similar pattern, with 95%, 92%, and 73% at 9 months and 1 and 2 years, respectively, for those vaccinated ID, and 94%, 93%, and 81% for those having IM vaccination. GMT for HBsAb was significantly higher for individuals vaccinated IM than for those vaccinated ID (P<.0001). The GMT ratio for the IM and ID routes decreased over time, being 9.3 at 9 months, 7.8 at 1 year, and 5.9 at 2 years. An unanticipated side effect of intradermal vaccination was skin discoloration at injection sites, which persisted for at least 2 years postvaccination. Two thirds (112/166) of respondents reported that they would have selected the ID route despite the discoloration.

CONCLUSIONS

Higher-dose ID vaccination (3 vs 1 microg per injection) uses one sixth of the dose required for standard IM vaccination. It is a cost-effective way to vaccinate populations against hepatitis B virus, but the long-term efficacy of the ID route must still be investigated.

Routine HLA-B genotyping with PCR-sequence-specific oligonucleotides (PCR-SSO) detects eight new alleles: B*0807, B*0809, B*1551, B*3529, B*3532, B*4025, B*5304 and B*5508

This paper describes eight new alleles (B*0807, B*0809, B*1551, B*3529, B*3532, B*4025, B*5304 and B*5508) that have been found by routine HLA-B genotyping with sequence-specific oligonucleotides (SSOs). All of the new alleles have variations which cause changes in residues that occur within antigen binding pockets and T-cell recognition sites of the antigen. The new polymorphisms within these new alleles may affect the nature and specificity of peptide binding and cause differential T-cell activation, which may have an affect in transplantation.

A fluorescence-based assay for 3' --> 5' exoribonucleases: potential applications to the study of mRNA decay

A cell-free mRNA decay assay has been adapted to permit the kinetics of 3' --> 5' exoribonuclease activities to be monitored in real time. RNA probes containing 5' caps and 3' poly(A) tails generated by transcription in vitro are 3' labeled using fluorescein-N6-ATP and poly(A) polymerase. Release of fluorescein-conjugated adenosine residues from the 3' end of the RNA substrate is monitored by a time-dependent decrease in fluorescence anisotropy in the presence of cytosolic proteins. To demonstrate the utility of the assay, an RNA probe was constructed containing a fragment of the c-myc 3' untranslated region and an 85-base poly(A) tail. Following 3' fluorescein labeling, the rate of 3'-terminal adenosine excision was monitored in the presence of an S100 cytosolic extract prepared from K562 erythroleukemia cells. Removal of the fluorescein-tagged A residues resolved to a first-order decay function, allowing the rate constant and enzyme-specific activity to be determined in this extract. Further applications and advantages of this technology are discussed.

Assessment of acute abdominal pain in the pregnant patient

The request to image a pregnant patient with abdominal pain often leads to concern and frustration for the referring clinician as well as the radiologist. In this report we will review the basic principles of radiation safety when imaging the pregnant woman, consider the diagnostic possibilities for the causes of abdominopelvic pain, and discuss the available imaging modalities to provide a basis for tailoring an imaging plan to the individual patient.

Sleeping with the enemy? A randomized controlled trial of a collaborative health authority/industry intervention to influence prescribing practice

AIMS

To evaluate the effectiveness of a health authority/pharmaceutical company collaborative intervention to influence the choice of proton pump inhibitors

METHODS

Randomized controlled trial, with general practices forming the unit of allocation and analysis.

RESULTS

Constructive working relationships were achieved with five of six pharmaceutical companies involved. One hundred and two out of 140 practitioners in intervention group practices received at least one visit from an industry representative. There were no reports of representatives operating outside their agreed remit. Prescribing in both the intervention and control group moved towards that recommended by the guidelines but there was no difference between the groups in either the proportion of prescriptions in line with the guidelines or the overall cost.

CONCLUSIONS

Health authorities can achieve professional working relationships with the pharmaceutical industry although no changes in practice attributable to the intervention are achieved. Further work is required to develop effective means to influence prescribing in line with independent guidelines especially in the context of the development of Primary Care Groups.

A new HLA-A*02 allele, A*0234, detected by polymerase chain reaction using sequence-specific primers (PCR-SSP)

A novel HLA-A*02 allele, A*0234, was identified in a potential unrelated bone marrow donor typed by polymerase chain reaction using sequence-specific primers (PCR-SSP). Positive reactions obtained upon testing with PCR-SSP did not fit any known combination of alleles indicating the possible presence of a novel allele. Sequencing of clones from this individual revealed the presence of a novel allele, HLA-A*0234. The sequence of exons 2, 3 and part of exon 4 showed that A*0234 differed from A*02011 by a single nucleotide in exon 2 at position 282 (C to G). The nucleotide substitution results in an amino acid change at residue 70 (Histidine to Glutamine) in the alpha1 domain.

New DRB1* alleles (HLA-DRB1*1135, DRB1*1430 and DRB1*1433) and a confirmatory sequence (DRB1*1133)

Three new DRB1 alleles (DRB1*1135, DRB1*1430 and DRB1*1433) and a confirmatory sequence (DRB1*1133) have been identified after following up unusual or novel polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) patterns during routine typing of the DRB1*03,*08,*11,*12,*13 and *14 allele groups. Of the new alleles found and described in this paper, two alleles were initially detected by the PCR-RFLP method which produced unexpected restriction polymorphism (DRB1*1133 and DRB1*1135) while the remaining two were found after following up rare allele typings from this technique (DRB1*1430 and DRB1*1433).

Tibiotalocalcaneal arthrodesis with intramedullary interlocking nail fixation

The use of intramedullary rod fixation for tibiotalocalcaneal fusion is gaining popularity. Many methods of fixation have been employed in the past, but intramedullary fixation has been shown to achieve higher fusion rates, provide fixation along the weight-bearing axis, and control rotational deformities. The authors describe the history, indications, technical considerations, and postoperative care of patients treated with fixation using an intramedullary rod with interlocking screws.

Paclitaxel-associated hypersensitivity reactions: experience of the gynecologic oncology program of the Cleveland Clinic Cancer Center

PURPOSE

: This study expands the existing limited data as to whether patients developing clinically significant paclitaxel-induced hypersensitivity reactions can continue to be treated with this important antineoplastic agent and how such retreatment might be undertaken.

PATIENTS AND METHODS

More than 450 patients received paclitaxel, either as a single agent or in a combination regimen, for a female pelvic malignancy in the Gynecologic Oncology Program of the Cleveland Clinic Cancer Center from January 1995 through December 1998.

RESULTS

Of the more than 450 patients, 44 (approximately 9%) developed at least one episode of a clinically relevant hypersensitivity reaction to the cytotoxic drug. All 43 individuals (plus an additional four patients referred to our center after having previously experienced a severe paclitaxel-associated hypersensitivity reaction at another institution) who were retreated with paclitaxel were ultimately able to receive the agent. Five patients required treatment with a standardized desensitization regimen, developed by our group, to successfully receive paclitaxel.

DISCUSSION

On the basis of this large single-institution study of paclitaxel-associated hypersensitivity reactions, we conclude that with appropriate precautions essentially all individuals experiencing these reactions can be safely treated with this agent.

Serum CA-125 as a marker of disease activity in uterine papillary serous carcinoma

Papillary serous carcinoma of the endometrium exhibits many clinical features of ovarian cancer, including a high metastatic potential and response to platinum-based chemotherapy. We investigated the clinical utility of the serum CA-125 antigen level, an established marker of response or progression in ovarian cancer, to serve as a indicator of these events in patients with this highly malignant subtype of endometrial cancer. Of 21 individuals with this cancer treated in our program from 11/91 to 6/97, 16 had baseline CA-125 determinations prior to the administration of chemotherapy, of whom 13 were elevated above the normal range. Of these 13 patients, 8 (57%) experienced either a major reduction or normalization of CA-125 levels following therapy, consistent with their clinical course at that point in time. Similarly, of 11 patients who ultimately relapsed, 8 (73%) were found to have a rise in the CA-125 antigen level which closely corresponded to, or proceeded, clinical relapse. A single patient was demonstrated to have disease progression with a declining level of CA-125. We conclude the serum CA-125 antigen level is a useful indicator of disease response or progression in individuals with papillary serous carcinoma of the endometrium.

New HLA class II alleles in the Indonesian population

This paper describes two new class II alleles of the major histocompatibility complex (MHC), DRB1*1431 and DRB3*0303, that have been found in the Indonesian population. In addition, the identification of DRB1*0819 is presented as a confirmatory report.

Impairment of neocortical metabolism predicts progression in Alzheimer's disease

Progression rates of Alzheimer's disease (AD) vary considerably, and they are particularly difficult to predict in patients with mild cognitive impairment. We performed a prospective multicenter cohort study in 186 patients with possible or probable AD, mostly with presenile onset. In a cross-sectional analysis at entry, impairment of glucose metabolism in temporoparietal or frontal association areas measured with positron emission tomography was significantly associated with dementia severity, clinical classification as possible versus probable AD, presence of multiple cognitive deficits and history of progression. A prospective longitudinal analysis showed a significant association between initial metabolic impairment and subsequent clinical deterioration. In patients with mild cognitive deficits at entry, the risk of deterioration was up to 4.7 times higher if the metabolism was severely impaired than with mild or absent metabolic impairment. Copyrightz1999S.KargerAG, Basel

Structural organization of the N-terminal domain of apolipoprotein A-I: studies of tryptophan mutants

Site-directed mutagenesis and detailed fluorescence studies were used to study the structure and dynamics of recombinant human proapolipoprotein (proapo) A-I in the lipid free state and in reconstituted high-density lipoprotein (rHDL) particles. Five different mutants of proapoA-I, each containing a single tryptophan residue, were produced in bacteria corresponding to each of the naturally occurring Trp residues (position -3 in the pro-segment, 8, 50, 72, and 108) in the N-terminal half of the protein. Structural analyses indicated that the conservative Phe-Trp substitutions did not perturb the conformation of the mutants with respect to the wild-type protein. Steady-state fluorescence studies indicated that all of the Trp residues exist in nonpolar environments that are highly protected from solvent in both the lipid-free and lipid-bound forms. Time-resolved lifetime and anisotropy studies indicated that the shape of the monomeric form of proapoA-I is a prolate ellipsoid with an axial ratio of about 6:1. In addition, the region surrounding Trp 108 appears to be more mobile than the rest of the protein in the lipid-free state. However, in rHDL particles, no significant domain motion was detected for any of the Trp residues. The results presented in this work are consistent with a model for monomeric lipid-free proapoA-I in which the N-terminal half of the molecule is organized into a bundle of helices.

Is it better to leave or restore carious deciduous molar teeth? A preliminary study

INTRODUCTION

The objective of this study was to compare the extraction and exfoliation experience of filled and unfilled carious deciduous molar teeth.

METHOD

The study was carried out in 1997 in four general dental practices in south Cheshire, UK and involved a longitudinal retrospective review of case notes. A quota sample of 20 case notes of children from each practice was selected according to strict criteria. Subjects had to: Have had experience of approximal caries in one or more of the deciduous molar teeth. Have a date of birth between 1st January 1984 and 31st December 1985. Be a regular attender and in continuous contact with the practice. Data were collected on a common data abstraction form. Variables measured included: Base-line dmft. Site and number of filled teeth. Site and number of unfilled carious teeth. Number of courses of antibiotics. Site and number of pulp therapies. Site, number, method (local or general anaesthetic) of extractions. Reasons for extraction. All teeth not recorded as being extracted were assumed to have exfoliated. In addition, information was collected on the dentists' treatment philosophies. A series of group discussions revealed that the four dentists fitted into two groups according to treatment philosophies; two dentists shared a philosophy of minimal intervention, the other two shared the same views of treating more radically.

RESULTS

There was no significant difference between the proportion of filled teeth and the proportion of carious unfilled teeth that were extracted (chi-square 0.05 P = 0.83). A logistic regression showed that for each course of antibiotics administered the odds of having an extraction was multiplied by 5.5 and children who were patients of the interventionist dentists were five times more likely to have an extraction than patients of non-interventionist dentists.

CONCLUSION

Although the study was preliminary in nature no clear benefit could be found in filling deciduous molar teeth against leaving carious teeth unfilled, if avoidance of extraction was the desired outcome. The treatment philosophy of dentists was a major factor in determining extraction or exfoliation outcomes. This issue is complex with many interacting factors to be accounted for and will require multiple well-designed studies to provide an answer.

Use of subatmospheric pressure to prevent doxorubicin extravasation ulcers in a swine model

Application of subatmospheric pressure to sites injected with doxorubicin prevented ulcer formation in treated sites (0 ulcers/16 sites) compared to control wounds (10 ulcers/16 sites) in a pig model.

BACKGROUND AND OBJECTIVES

Extravasation of doxorubicin hydrochloride (Adriamycin) frequently causes chronic ulcers, which usually progress and expose underlying structures such as tendons and bone. The exact mechanism of action that causes cell death and the chronic ulcers is unknown.

METHODS

Eight sites were injected intradermally with doxorubicin on each of 4 pigs. Four sites on each animal served as untreated controls. The remaining four sites were exposed to 125 mm Hg subatmospheric pressure applied 1 h after injection. The sites were observed on a three times per week schedule. Sites that did not develop ulcers were re-injected up to a total of four injections. The animals were observed for 5 weeks.

RESULTS

Ten of sixteen control sites developed ulcers. No subatmospheric pressure treated sites developed ulcers. The incidence of ulcer formation was significantly less for treated wounds compared to control wounds at P < 0.001 by Fisher's exact test.

CONCLUSIONS

This physical modality appears to successfully prevent ulcer formation after doxorubicin injection.

An effective and more convenient drug regimen for prophylaxis against paclitaxel-associated hypersensitivity reactions

"Standard" prophylaxis for paclitaxel-associated hypersensitivity reactions has included the systemic administration of H1 and H2 histamine antagonists, along with oral dexamethasone taken both the night prior to, and the morning of, each paclitaxel treatment. To improve patient convenience and compliance with steroid delivery, the Gynecologic Cancer Program of the Cleveland Clinic Foundation has treated patients with an all-intravenous prophylaxis regimen (diphenhydramine 50 mg, famotidine 20 mg, dexamethasone 20 mg) given 30 min prior to paclitaxel (without any earlier oral steroid dosing). To date, we have treated more than 200 patients who received all courses of paclitaxel with this simplified prophylactic regimen, of whom approximately 9% developed hypersensitivity reactions (major or minor). This incidence is comparable to our previously reported experience with hypersensitivity reactions in a similar number of patients receiving the standard prophylaxis (including oral dexamethasone) with their initial course of paclitaxel, and subsequent cycles employing this all-intravenous program. We conclude that this "modified" regimen for paclitaxel-associated hypersensitivity reactions (with all drugs administered approximately 30 min prior to the delivery of paclitaxel) is as effective as, and more convenient than, the standard regimen, and avoids delaying chemotherapy as a result of a patient failing to remember to take one or both oral steroid doses.

Persistent chemosensitivity to platinum and/or paclitaxel in metastatic endometrial cancer

It has long been recognized that individuals with ovarian cancer who initially respond to a platinum-containing chemotherapeutic regimen may exhibt a second response to platinum (cisplatin or carboplatin) at the time of recurrence. In this report, we describe three individuals with metastatic endometrial cancer who demonstrated secondary responses to platinum/paclitaxel-based regimens. Endometrial cancer should be added to the list of malignancies for which platinum and/or paclitaxel are considered as second-line treatment options in patients previously responding to the agents.

The expression of inhibin/activin subunits in the human adrenal cortex and its tumours

Inhibins and activins are dimeric proteins of the transforming growth factor-beta superfamily which have been shown to be expressed in the adrenal cortex. Recent studies have suggested a role for these peptides in the pathogenesis and/or function of adrenal tumours. To investigate further their physiological and pathological roles, we have documented immunoreactivity for inhibin alpha, betaA and betaB subunits in normal adult and fetal human adrenals, in hyperplastic adrenals and in adrenal tumours. In the normal and hyperplastic adult gland, diffuse immunopositivity was demonstrated for beta subunits, suggesting that activins (beta beta dimers) can be expressed in all zones. Inhibin alpha was limited to the zona reticularis and the innermost zona fasciculata in the normal gland, extending centripetally into the zona fasciculata in hyperplasia, supporting a role for ACTH in the regulation of expression, and suggesting that expression of inhibins (alpha beta dimers) is restricted. Immunopositivity for all three subunits was seen in both fetal and definitive zones of the fetal cortex, indicating that both inhibins and activins could be expressed in both. Immunopositivity for all three subunits was seen in most adrenocortical tumours. Loss of immunopositivity for inhibin alpha in a subgroup of carcinomas might indicate a role in tumour progression. The greater intensity of staining for inhibin alpha in tumours associated with Cushing's syndrome again suggests a link with cortisol production.

Clinical features of hypersensitivity reactions to carboplatin

PURPOSE

To characterize the clinical features of carboplatin-associated hypersensitivity reactions.

PATIENTS

Patients with gynecologic malignancies treated at the Cleveland Clinic Foundation from June 1995 through July 1998 who experienced a carboplatin-associated hypersensitivity reaction were the subjects of this evaluation.

RESULTS

Of the 205 patients treated with carboplatin during this time period, 24 (12%) developed a carboplatin hypersensitivity reaction. The median number of platinum (carboplatin plus cisplatin) courses for the first episode was eight (range, six to 21). Only three patients (13%) developed this toxicity during their initial chemotherapy regimen, with the remainder experiencing a reaction during their second (n = 15) or third (n = 6) carboplatin treatment program for recurrent disease. Thirteen patients (54%) developed at least moderately severe symptoms (diffuse erythroderma, tachycardia, chest tightness, wheezing, facial swelling, dyspnea, hypertension, or hypotension). In approximately one half of patients, the reaction developed after more than 50% of the carboplatin had been infused. Only one of three patients was successfully treated with the agent upon rechallenge.

CONCLUSION

Carboplatin hypersensitivity reactions develop in patients who have been extensively pretreated with the agent. The clinical features are highly variable, but they are sufficiently different from those noted after the administration of paclitaxel that it should not be difficult to distinguish between reactions to the two agents. As carboplatin is increasingly used as initial and second-line chemotherapy of ovarian cancer and other malignancies, it can be anticipated that hypersensitivity reactions to the drug will become a more common and difficult clinical management issue.

Use of low-dose oral prednisone to prevent paclitaxel-induced arthralgias and myalgias

OBJECTIVES

The aim of this study was to examine the clinical utility of low-dose oral prednisone in preventing severe paclitaxel-associated arthralgias and myalgias.

METHODS

Patients treated with paclitaxel in the gynecologic oncology program of the Cleveland Clinic Foundation who developed arthralgias/myalgias which were uncontrolled through the use of nonsteroidal anti-inflammatory medications received low-dose oral prednisone (10 mg B.I.D. starting 24 h after the completion of chemotherapy and continuing for a total of 5 days) with their next paclitaxel course.

RESULTS

Of 46 patients meeting the criteria for treatment with the oral prednisone regimen (i.e., subjective feeling of unacceptable discomfort despite the use of nonsteroidal anti-inflammatory agents), 39 (85%) experienced substantial relief of symptoms. All but one of the responding patients requested continuation of the oral prednisone regimen with subsequent paclitaxel treatment cycles. There were no significant toxicities noted in any patient receiving prednisone.

CONCLUSION

This low-dose oral prednisone regimen results in substantial improvement in the majority of patients experiencing significant paclitaxel-associated arthralgias/myalgias.