An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation

OBJECTIVE

To determine the preliminary feasibility, acceptability, and effects of Meaning-Centered Grief Therapy (MCGT) for parents who lost a child to cancer.

METHOD

Parents who lost a child to cancer and who were between six months and six years after loss and reporting elevated levels of prolonged grief were enrolled in open trials of MCGT, a manualized, one-on-one cognitive-behavioral-existential intervention that used psychoeducation, experiential exercises, and structured discussion to explore themes related to meaning, identity, purpose, and legacy. Parents completed 16 weekly sessions, 60-90 minutes in length, either in person or through videoconferencing. Parents were administered measures of prolonged grief disorder symptoms, meaning in life, and other assessments of psychological adjustment preintervention, mid-intervention, postintervention, and at three months postintervention. Descriptive data from both the in-person and videoconferencing open trial were pooled.ResultEight of 11 (72%) enrolled parents started the MCGT intervention, and six of eight (75%) participants completed all 16 sessions. Participants provided positive feedback about MCGT. Results showed postintervention longitudinal improvements in prolonged grief (d = 1.70), sense of meaning (d = 2.11), depression (d = 0.84), hopelessness (d = 1.01), continuing bonds with their child (d = 1.26), posttraumatic growth (ds = 0.29-1.33), positive affect (d = 0.99), and various health-related quality of life domains (d = 0.46-0.71). Most treatment gains were either maintained or increased at the three-month follow-up assessment.Significance of resultsOverall, preliminary data suggest that this 16-session, manualized cognitive-behavioral-existential intervention is feasible, acceptable, and associated with transdiagnostic improvements in psychological functioning among parents who have lost a child to cancer. Future research should examine MCGT with a larger sample in a randomized controlled trial.

Decrease in Intercourse Satisfaction in Men Who Recover Erections After Radical Prostatectomy

INTRODUCTION

Recovery of erections after radical prostatectomy (RP) is assumed to lead to recovery in sexual satisfaction. Although data suggest a relationship between sexual function and sexual satisfaction, it is unclear whether presurgical levels of sexual satisfaction are attained for men who "recover" erections post-RP.

AIM

The goal of this analysis is to determine whether the recovery of erectile function restores presurgical levels of sexual satisfaction.

METHODS

We assessed 229 men pre-RP and 24-months post-RP. At both time points, participants completed the Erectile Function Domain (EFD) and the Intercourse Satisfaction Domain (ISD) of the International Index of Erectile Function (IIEF). Erectile function recovery at 24 months was defined as (1) (EFD≥24) or (2) EFD back to baseline (BTB). One hundred sixty-six men with penetration hardness erections (PHEs) at baseline (EFD >24) were included in the analyses. Repeated measure t-tests were used to compare changes in ISD scores and effect size (Cohen's d) was calculated to determine the clinical significance of these changes. Multivariable analyses (MVA) were used to test the relationship between EFD and ISD.

RESULTS

The mean age of men was 58 (SD = 7) years. The mean EFD score at baseline was 29 (SD = 2), which declined significantly to 20 (SD = 10) at 24 months. ISD also decreased significantly between baseline and 24 months (12 to 8.3, P < .001, d = 0.87), even among men with PHEs at 24 months (12.3 to 11.3, P < .001, d = 0.50) and men who achieved BTB erections at 24 months (12.4 to 11.7, P = .02, d = 0.35). For men with PHEs at 24 months, MVAs identified baseline ISD (beta = 0.46) and 24-month EFD (beta = 0.23) as the only significant predictors of 24-month ISD. However, among men who achieved BTB erections at 24 months, baseline ISD (beta = 0.49) was the only significant predictor of 24-month ISD.

CLINICAL IMPLICATIONS

These findings underscore the importance of the integration of psychological support and medical care to best meet the needs of patients. Furthermore, these results can be used to facilitate pre-RP communication and counseling with patients to improve understanding and manage post-RP expectations.

STRENGTHS & LIMITATIONS

The study methodology, specifically the use of BTB as a means of defining erectile function and the longitudinal, prospective study design are relative strengths. Despite the longitudinal design, the study did not include a control group of healthy, age-matched men.

CONCLUSION

Results highlight the enduring impact of sexual dysfunction, namely erectile dysfunction, on intercourse satisfaction following RP and suggest that restoration of function in and of itself does not ensure the restoration of satisfaction. Terrier JE, Masterson M, Mulhall JP, et al. Decrease in intercourse satisfaction in men who recover erections after radical prostatectomy. J Sex Med 2018;15:1133-1139.

Individual meaning-centered psychotherapy for the treatment of psychological and existential distress: A randomized controlled trial in patients with advanced cancer

BACKGROUND

Patients with advanced cancer have high rates of psychological distress, including depression, anxiety, and spiritual despair. This study examined the effectiveness of individual meaning-centered psychotherapy (IMCP) in comparison with supportive psychotherapy (SP) and enhanced usual care (EUC) in improving spiritual well-being and quality of life and reducing psychological distress in patients with advanced cancer.

METHODS

Patients (n = 321) were randomly assigned to IMCP (n = 109), SP (n = 108), or EUC (n = 104). Assessments were conducted at 4 time points: before intervention, midtreatment (4 weeks), 8 weeks after treatment, and 16 weeks after treatment.

RESULTS

Significant treatment effects (small to medium in magnitude) were observed for IMCP, in comparison with EUC, for 5 of 7 outcome variables (quality of life, sense of meaning, spiritual well-being, anxiety, and desire for hastened death), with Cohen's d ranging from 0.1 to 0.34; no significant improvement was observed for patients receiving SP (d < 0.15 and P > .05 for all variables). The effect of IMCP was significantly greater than the effect of SP for quality of life and sense of meaning (d = 0.19) but not for the remaining study variables.

CONCLUSIONS

This study provides further support for the efficacy of IMCP as a treatment for psychological and existential/spiritual distress in patients with advanced cancer. Significant treatment effects (small to moderate effect sizes) were observed in comparison with usual care, and somewhat more modest differences in improvement (small effect sizes) were observed in comparison with SP. Thus, the benefits of meaning-centered psychotherapy appear to be unique to the intervention and highlight the importance of addressing existential issues with patients approaching the end of life. Cancer 2018. © 2018 American Cancer Society.

Short communication: Investigation of antibiotic alternatives to improve health and growth of veal calves

The inherent disease susceptibility of veal calves results in frequent antimicrobial use. Improvements in antimicrobial stewardship necessitate alternative therapies to improve calf health and growth, while reducing the need for antimicrobials important to human health. This study investigated the effect of 2 alternative therapies, lactoferrin (an iron-binding protein found in colostrum) and cinnamaldehyde (an essential oil of the cinnamon plant) on growth, disease incidence, and mortality risk in special-fed veal calves. On the day of arrival to the growing facility (3 to 7 d of age), calves (n = 80 per treatment) were randomized to 1 of 3 treatments: (1) control (no supplement), (2) lactoferrin (1 g/d in milk replacer for 7 d), or (3) cinnamaldehyde (1 g/d in milk replacer for 21 d). Body weight was measured on the day of arrival (d 0), 21, and 42 d postarrival. Health assessments were performed twice weekly through 21 d, and mortality records were obtained through 6 wk postarrival. A repeated-measures ANOVA was used to compare growth between treatment groups, and a Poisson regression model (PROC GENMOD, SAS v. 9.4, SAS Institute Inc., Cary, NC) was used to test differences between groups in the incidence of diarrhea (fecal score ≥2 with and without depression and temperature) and disease through 3 wk postarrival. Body weight and average daily gain were similar between treatments. Neither lactoferrin nor cinnamaldehyde had an effect on diarrhea incidence. However, the risk of navel inflammation was significantly lower for calves that received cinnamaldehyde compared with calves in the control group. Mortality through 6 wk postarrival was low, with 4, 1, and 0 deaths from the control, lactoferrin, and cinnamaldehyde treatment groups, respectively. Additional research is needed to investigate various doses of these alternative therapies on calf health and growth, in addition to different routes of administration.

Veal calf health on the day of arrival at growers in Ohio

Veal calves are at high risk for disease and mortality in early life. Calves face a number of stressors before arriving at the grower, including long transport times, which may contribute to poor health. Our objectives were to 1) estimate the prevalence of poor health outcomes in veal calves on arrival at growers in Ohio; 2) determine risk factors for health outcomes on arrival, including BW and auction site (spread across 5 states in the Northeastern United States); and 3) determine if health outcomes on arrival predict early mortality. A physical examination was conducted on approximately 30 calves (mean of 45.9 kg [SD 3.0]) from 12 cohorts ( = 383 calves). Exams included a blood sample to determine packed cell volume (an estimate of dehydration using a cutoff > 46%) and total protein (an estimate failure of passive transfer using a cutoff < 5.5 g/dL and 6.0 g/dL to account for dehydration). Diarrhea, respiratory disease, depression, navel inflammation, and a skin tent test (a second indicator of dehydration) were also recorded. Mortality within 4 wk of age was collected from farm records. Descriptive statistics were used to describe the prevalence of calves with poor health outcomes on arrival. Generalized linear mixed models were used to identify risk factors for poor health on arrival and assess if poor health increased the incidence risk of mortality. Upon arrival, 6% (95% confidence interval 4.4 to 7.6%) of calves had failure of passive transfer using a cut-off of 5.5 g/dL, and 22.5% (18.1 to 26.8%) had failure of passive transfer using a cut-off of 5.5 g/dL, and 22.5% (18.1 to 26.8%) had failure of passive transfer using a cut-off of 6.0%; 14% (9.1 to 18.8%) had diarrhea, 0.5% (0 to 1.3%) had respiratory disease, 14% (8.5 to 19.3%) were depressed, and 27% (22.7 to 30.7%) had inflamed navels. In addition, 35.1% (23.5 to 46.6%) of calves were dehydrated using a skin tent test, but only 1.3% (0.0 to 2.9%) were dehydrated based on the packed cell volume threshold. Auction site was associated with depression on arrival ( = 0.008) and tended to be associated with skin tent on arrival ( = 0.08). None of the health variables were predictors of early mortality; however, mortality was generally low for all cohorts (4.3%; range 1.7 to 6.8%). These results estimate the prevalence of dehydration, diarrhea, navel inflammation, and depression in veal calves on arrival at growers and demonstrate that some health outcomes are dependent on auction site. We conclude that there are many opportunities to intervene to improve their health and welfare before the calves arrive at the grower.

Perceived Family Functioning Predicts Baseline Psychosocial Characteristics in U.S. Participants of a Family Focused Grief Therapy Trial

CONTEXT AND OBJECTIVES

Screening and baseline data on 170 American families (620 individuals), selected by screening from a palliative care population for inclusion in a randomized controlled trial of family-focused grief therapy, were examined to determine whether family dysfunction conferred higher levels of psychosocial morbidity. We hypothesized that greater family dysfunction would, indeed, be associated with poorer psychosocial outcomes among palliative care patients and their family members.

METHODS

Screened families were classified according to their functioning on the Family Relationships Index (FRI) and consented families completed baseline assessments. Mixed-effects modeling with post hoc tests compared individuals' baseline psychosocial outcomes (psychological distress, social functioning, and family functioning on a different measure) according to the classification of their family on the FRI. Covariates were included in all models as appropriate.

RESULTS

For those who completed baseline measures, 191 (30.0%) individuals were in low-communicating families, 313 (50.5%) in uninvolved families, and 116 (18.7%) in conflictual families. Family class was significantly associated (at ps ≤ 0.05) with increased psychological distress (Beck Depression Inventory and Brief Symptom Inventory) and poorer social adjustment (Social Adjustment Scale) for individual family members. The family assessment device supported the concurrent accuracy of the FRI.

CONCLUSION

As predicted, significantly greater levels of individual psychosocial morbidity were present in American families whose functioning as a group was poorer. Support was generated for a clinical approach that screens families to identify those at high risk. Overall, these baseline data point to the importance of a family-centered model of care.

Adapting Meaning-Centered Psychotherapy for the palliative care setting: Results of a pilot study

AIMS

To establish preliminary evidence for the feasibility, acceptability, and utility of an abbreviated version of Meaning-Centered Psychotherapy tailored to the needs of palliative care patients in the final weeks or months of life.

BACKGROUND

Surprisingly, few mental health interventions have specifically targeted the psychological needs of palliative care patients, when physical comfort seems to take precedence over mental health and emotional needs. Yet the need for mental health services targeting these patients is clear, as one in three palliative care patients experience clinically significant depression and an equal proportion experience clinically significant anxiety.

DESIGN

This pilot study used an open-label design to assess the feasibility, acceptability, and perceived utility of Meaning-Centered Psychotherapy-palliative care, a brief intervention that focuses on enhancing meaning at the end of life.

SETTING/PARTICIPANTS

A total of 12 patients admitted to a palliative care hospital for supportive care consented to participate in the study.

RESULTS

Of the 11 patients that began treatment (one patient died before the first session), 8 completed the three-session intervention. Patients expressed positive feedback about the structure, focus, and length of the intervention, but varied in precisely which elements they found most helpful.

CONCLUSION

An abbreviated version of Meaning-Centered Psychotherapy tailored to the needs of palliative care patients (Meaning-Centered Psychotherapy-palliative care) appears to be feasible, acceptable, and has the potential to help patients better cope with the challenges inherent in confronting death and dying. Further research, with larger and more representative samples, is needed in order to clarify the strengths and weaknesses of this approach.

Bilateral glossopharyngeal neuropathy following chemo and radiation therapy for a primitive neuroectodermal tumour

This case describes a young adult male patient diagnosed and treated for a primitive neuroectodermal tumour (PNET) at 3 years of age. Chemotherapy and radiation therapy used following surgical treatment of this tumour have known neurotoxic complications, some of which have delayed onset. In this case, the patient exhibited sudden onset, persistent bilateral and deep ear pain that was consistent with a neuropathy of the glossopharyngeal nerve occurring 17 years after the completion of therapy for PNET. Treatment with pregabalin was successful with near-complete resolution of the complaint. The diagnostic certainty in this case is discussed in relation to the current diagnostic criteria for neuropathic pain.

Typology of perceived family functioning in an American sample of patients with advanced cancer

CONTEXT

Poor family functioning affects psychosocial adjustment and the occurrence of morbidity following bereavement in the context of a family's coping with advanced cancer. Family functioning typologies assist with targeted family-centered assessment and intervention to offset these complications in the palliative care setting.

OBJECTIVES

Our objective was to identify the number and nature of potential types in an American palliative care patient sample.

METHODS

Data from patients with advanced cancer (N = 1809) screened for eligibility for a larger randomized clinical trial were used. Cluster analyses determined whether patients could be classified into clinically meaningful and coherent groups, based on similarities in their perceptions of family functioning across the cohesiveness, expressiveness, and conflict resolution subscales of the Family Relations Index.

RESULTS

Patients' reports of perceived family functioning yielded a model containing five meaningful family types.

CONCLUSION

Cohesiveness, expressiveness, and conflict resolution appear to be useful dimensions by which to classify patient perceptions of family functioning. "At risk" American families may include those we have called hostile, low-communicating, and less-involved. Such families may benefit from adjuvant family-centered psychosocial services, such as family therapy.

Renal tubular epithelial cell apoptosis by Fas-FasL–dependent self-injury can augment renal allograft injury

The role of Fas-FasL interactions in kidney allograft injury may be complex as renal tubular epithelial cells (TEC) express both Fas and FasL. The role and regulation of TEC self-injury has not been investigated. In co-cultures of TEC, FasL-bearing, Fas-null TEC was demonstrated to induce apoptosis of TEC-bearing Fas. Co-culturing effector lpr-TEC (M3.1-lpr) with target WT-TEC (CS3.7) at a ratio of 10:1 (E/T) induced 15.2 +/- 2.4% of target apoptosis as compared to its basal level of 2.6 +/- 0.3%. Similarly lpr-TEC induced apoptosis in gld-TEC (MRM-gld) from a basal level of 3.7 +/- 0.2% to 6.4 +/- 0.3%. Expression of kidney Fas-FasL on injury was tested in a renal transplant model. C57BL/6 (B6) mice were transplanted with Fas-deficient C3H-lpr/lpr or FasL mutation C3H-gld/gld kidneys as compared to normal (wild-type [WT]) C3H/Hej donors. Survival of both lpr and gld recipient was improved compared to WT donors (P <.05) as was function of lpr and gld kidneys indicated by a lower serum creatinine (LPR: 41 +/- 8 micromol/L; GLD: 52 +/- 7 micromol/L) as compared to the WT donors (84 +/- 8 micromol/L, P <.001). These results demonstrate that activated TEC may commit a novel and previously unreported form of self-injury (fractricide) through Fas-FasL. These results suggest that inhibition of renal Fas or FasL might be a useful strategy to prevent TEC loss during rejection.

Influence of oocyte collection technique on initial chromatin configuration, meiotic competence, and male pronucleus formation after intracytoplasmic sperm injection (ICSI) of equine oocytes

There is a great variability in the success of horse oocyte maturation and fertilization among laboratories. This study was conducted to determine if the meiotic and developmental competence of horse oocytes could be dependent on the method of oocyte collection, i.e., aspiration of follicular fluid with a vacuum apparatus, or opening follicles and scraping the granulosa layer. Horse oocytes were recovered from abattoir ovaries by aspiration or scraping and classified as having compact (Cp), expanded (Ex), or partial (P) cumuli. In Experiment 1 (Part A in May and Part B in October), oocytes were fixed immediately after collection to assess whether the collection method influenced the initial chromatin configuration of oocytes. In Experiment 2, in vitro maturation rates of oocytes recovered by aspiration or scraping were compared. In Experiment 3, oocytes were matured in vitro and submitted to intracytoplasmic sperm injection (ICSI). Initial chromatin configuration differed according to collection method in that there was a significantly higher prevalence of diffuse chromatin within the germinal vesicle in oocytes recovered by scraping than in oocytes recovered by aspiration (29/87, 33% and 28/166, 17%, respectively; P < 0.01). Maturation of oocytes to metaphase II did not significantly differ between scraped and aspirated oocytes (56/101, 55.4 % vs. 65/106, 61.4%, respectively). The overall pronucleus formation rate after ICSI of oocytes recovered by scraping was not significantly different than that of oocytes recovered by aspiration (50/99, 52.6% vs. 50/85, 68.5 %, respectively); however, the rate of abnormal fertilization was significantly higher for oocytes collected by aspiration (14/73, 19% vs. 6/94, 6%, respectively; P <0.05). These results demonstrate that the collection method affects the population of recovered oocytes and may contribute to differences in results observed among laboratories working with horse oocytes.

Myelodysplastic and myeloproliferative disorders of childhood: a study of 167 patients

Myelodysplastic syndromes (MDS) and myeloproliferative syndromes (MPS) of childhood are a heterogeneous group of clonal disorders of hematopoiesis with overlapping clinical features and inconsistent nomenclature. Although a number of genetic conditions have been associated with MDS and MPS, the overall contribution of inherited predispositions is uncertain. We report a retrospective study examining clinical features, genetic associations, and outcomes in 167 children with MDS and MPS. Of these patients, 48 had an associated constitutional disorder. One hundred one patients had adult-type myelodysplastic syndrome (A-MDS), 60 had juvenile myelomonocytic leukemia (JMML), and 6 infants with Down syndrome had a transient myeloproliferative syndrome (TMS). JMML was characterized by young age at onset and prominent hepatosplenomegaly, whereas patients with A-MDS were older and had little or no organomegaly. The most common cytogenetic abnormalities were monosomy 7 or del(7q) (53 cases); this was common both in patients with JMML and those with A-MDS. Leukemic transformation was observed in 32% of patients, usually within 2 years of diagnosis. Survival was 25% at 16 years. Favorable prognostic features at diagnosis included age less than 2 years and a hemoglobin F level of less than 10%. Older patients tended to present with an adult-type MDS that is accommodated within the French-American-British system. In contrast, infants and young children typically developed unique disorders with overlapping features of MDS and MPS. Although the type and intensity of therapy varied markedly in this study, the overall outcome was poor except in patients with TMS.

Maintaining a catalog of manually-indexed, clinically-oriented World Wide Web content

With no quality controls and a highly distributed means of posting information, finding high-quality, clinically-oriented content on the World Wide Web can be difficult. Maintaining a catalog of such information can be equally challenging. CliniWeb is a catalog of quality-filtered and clinically-oriented content on the Web designed to enhance access to such information. This paper describes a group of semi-automated tools have been developed to maintain the CliniWeb database. One allows easier identification of content by utilizing Web crawling techniques from high-level pages. Another allows easier selection of content for inclusion and its indexing. A final one checks links to help keep the database current. These are augmented by general plans to adopt more detailed metadata and linkages into the medical literature.

MLL genomic breakpoint distribution within the breakpoint cluster region in de novo leukemia in children

PURPOSE

To assess translocation breakpoint distribution within the MLL genomic breakpoint cluster region (bcr), 40 cases of de novo leukemia in children were examined by karyotype and Southern blot analysis.

PATIENTS AND METHODS

Criteria for inclusion were karyotypic or molecular rearrangement of chromosome band 11q23. Of the 40 cases, 31 occurred in infants. Twenty cases were acute lymphoblastic leukemia (ALL), 17 were acute myeloid leukemia (AML), and 3 were biphenotypic.

RESULTS

Karyotype identified 27 cases with translocation of chromosome band 11q23 and 2 with abnormalities of band 11q13 but not 11q23. Southern blot analysis showed rearrangement within the MLL genomic bcr in 38 of the 40 cases. In these 38, additional probe-restriction digest combinations localized MLL genomic breakpoints to the 5' portion of the bcr in 14 cases and to the 3' portion in 18; material was insufficient for further localization to 5' or 3' within the bcr in 6 cases. In the two remaining cases, both with t(4;11)(q21;q23), one breakpoint mapped 5' of the bcr between intron 3 and exon 5, whereas the other breakpoint was neither within nor 5' of the MLL genomic bcr.

CONCLUSIONS

Suggested trends warranting investigation in more patients were breakpoint sites in the 3' bcr in AML and in patients older than 12 months. The distribution of MLL genomic breakpoints within the bcr in de novo leukemia in children is distinct from that in adults, where the breakpoints cluster in the 5' portion of the bcr.

RAS mutations in pediatric leukemias with MLL gene rearrangements

Translocations of the MLL gene at chromosome band 11q23 are the most common cytogenetic alterations in de novo leukemia in infants and in leukemia related to chemotherapy with DNA topoisomerase II inhibitors. Experiments on knock-in mice suggest that additional mutational events may by required for full leukemogenesis. Therefore, we used single-strand conformation polymorphism analysis and an allele-specific restriction enzyme assay to investigate the frequency of KRAS and NRAS mutations in 32 pediatric leukemias with translocation of the MLL gene. Of 25 de novo cases, 13 were acute lymphoblastic leukemia (ALL), 10 were acute myeloid leukemia (AML), and 2 were biphenotypic. Three secondary leukemias were AML, 1 was biphenotypic, 1 was ALL, and 2 were diagnosed as myelodysplasia. The frequency of RAS mutations was 2 of 10 in de novo AML. Both mutations occurred in infant monoblastic variants. RAS mutations were otherwise absent in this series. This is the first report of congenital leukemias where translocation of the MLL gene and RAS mutation coexist. The frequency of RAS mutations in de novo AMLs with MLL gene translocations is similar to that in other forms of AML, but RAS mutations play a limited role in lymphoid and treatment-related leukemias with similar translocations.

Controlled clinical laboratory comparison of BACTEC plus aerobic/F resin medium with BacT/Alert aerobic FAN medium for detection of bacteremia and fungemia

Blood specimens collected from adult patients with suspected sepsis in four medical centers were inoculated into BACTEC Plus/F and BacT/Alert FAN aerobic culture bottles. Both bottles of 7,401 bottle pairs contained the prescribed blood volume of 8 to 12 ml. Bottles were incubated in their respective instruments for a standard 7-day protocol or until the instruments signaled that they were positive. A total of 720 isolates that were judged to represent true infections were recovered from 338 patients; 451 isolates were recovered from both bottles, 143 were recovered from only the Plus/F bottle, and 126 were recovered from only the FAN bottle (P was not significant). Although more Histoplasma capsulatum isolates were recovered from Plus/F bottles (P < 0.005), there were no other statistically significant differences in recovery rates of individual species or groups of organisms between the two systems. Of 329 monomicrobic patient septic episodes, 244 episodes were detected by both blood culture systems, 40 were detected only by the BACTEC system, and 45 were detected only by the BacT/Alert system (P was not significant). There was no significant difference between the two systems in the detection of septic episodes among patients receiving antibiotic therapy at the time of blood cultures. Of the cultures found to be positive within the first 72 h of incubation, detection was on average earlier by the BACTEC system (16.9 h) than by the BacT/Alert system (18.7 h). Larger differences in average time to detection were seen with streptococci (10.7 h by the BACTEC system and 17.9 h by the BacT/Alert system) and yeasts (an average of 29.4 h by the BacT/Alert system versus 37.2 h by the BACTEC system). With the exception of the differences noted above, BACTEC Plus/F aerobic resin and BacT/Alert aerobic FAN blood culture bottles were comparable in their abilities to recover aerobic and facultative organisms.

Clonal expansion of germline B-lineage acute lymphoblastic leukemia in severe combined immunodeficient mice

CD19+ B lineage acute lymphoblastic leukemias (ALLs) with unrearranged Ig and TCR genes are designated germline B lineage ALLs. We used CDR3 PCR to determine whether pediatric germline B lineage ALLs contain minor subclones with rearranged Ig H V genes. In six of seven cases there were no PCR detectable CDR3 rearrangements. One case with a smear pattern on CDR3 PCR contained multiple unique CDR3 sequences at frequencies of 1-2 per 2,600, suggesting that polyclonal B cells were present at low frequency. To verify that the germline patterns were from leukemic cells and evaluate in vivo subclone differentiation, a germline B lineage ALL with the t(4;11) translocation was propagated in severe combined immunodeficient SCID) mice. The Ig and TCR genes in the leukemic cells recovered from mouse tissues were germline by Southern blot analysis except for single rearrangements that suggested subclone evolution at the Ig H and lambda loci in addition to the germline population. No CDR3 sequences were detected, indicating that the observed Ig H gene rearrangement most likely was a DJ joining. This study suggests that the transformed cell in germline B lineage ALL represents an early pro-B cell with limited tendency to further differentiate.

Replacement therapy with a monoclonal antibody purified protein C concentrate in newborns with severe congenital protein C deficiency

Protein C replacement therapy with a monoclonal antibody purified, virus inactivated protein C concentrate was carried out in nine infants (three male, six female) with severe congenital protein C deficiency and life-threatening purpura fulminans and/or thrombosis associated with disseminated intravascular coagulation (DIC). Eight infants were homozygous for protein C deficiency; one was a compound heterozygote. The treatment period varied from 22 days to three years. The half-life of protein C was found to be as short as two to three hours during activation of the coagulation system, increasing to approximately ten hours after stabilization. During the acute phase, protein C levels of 0.10 to 0.25 IU/mL were associated with elevated markers of coagulation activation indicating DIC, while protein C levels greater than 0.25 were associated with normalization of coagulation markers. No product-related side effects were reported. Episodes of bleeding or purpura recurred in all patients who were switched to oral anticoagulant therapy, necessitating reinstatement of protein C replacement therapy, either as needed to control symptoms, or on a long-term prophylactic schedule, alone or in addition to oral anticoagulation. Home treatment with protein C concentrate allowed a near-normal life-style for patients who otherwise would be hospitalized for long periods of time.

ALL-1 gene rearrangements in DNA topoisomerase II inhibitor-related leukemia in children

We examined clinical, morphologic, and cytogenetic features and ALL-1 (MLL, Htrxl, HRX) gene rearrangements in 17 cases of secondary leukemia that occurred 11 months to 9 years from diagnoses of primary cancers in children who received topoisomerase II inhibitors or developed secondary leukemias typical of those associated with this therapy. Primary diagnoses included nine solid tumors and eight leukemias. Ten secondary leukemias were acute myeloid leukemia (AML), one was of mixed lineage, two were acute lymphoblastic leukemia (ALL), and four presented as myelodysplasia. Of 15 cases with 11q23 involvement, 11 (73%) were cytogenetically identifiable; four cases had molecular rearrangement only. By Southern blot, rearrangements within the ALL-1 gene were similar to sporadic cases. The results of this analysis suggest the following: (1) In most pediatric cases of topoisomerase II inhibitor-associated leukemia, there is disruption of the breakpoint cluster region of the ALL-1 gene at chromosomal band 11q23. (2) Exposure histories vary in secondary 11q23 leukemia, as the only topoisomerase II inhibitor was dactinomycin in one case, and, in another case, no topoisomerase II inhibitor was administered. (3) There is clinical, morphologic, cytogenetic, and molecular heterogeneity in pediatric secondary 11q23 leukemia. (4) There are some survivors of pediatric secondary 11q23 leukemia, but the outcome is most often fatal.

Bone marrow transplantation in Fanconi anemia using matched sibling donors

Eighteen patients with Fanconi anemia (FA) with evidence of bone marrow (BM) aplasia underwent allogenic BM transplants (BMT) from matched sibling donors (MSD). Median age at BMT was 7.6 years. Conditioning consisted of low-dose cyclophosphamide (CY; 5 mg/kg x 4 days) and thoracoabdominal irradiation (TAI; 400 cGy). Graft-versus-host disease (GVHD) prophylaxis included cyclosporin A and prednisone. In addition antithymocyte globulin (ATG) was administered in the pretransplant period to promote engraftment and in the posttransplant period for additional GVHD prophylaxis. Engraftment occurred rapidly (median, 12 days for an absolute neutrophil count > or = 0.5 x 10(9)/L; median, 22 days for platelet count > or = 50 x 10(9)/L). Seventeen patients have sustained engraftment and are transfusion-independent, with Lansky scores of 100% at median follow-up of 27 months. One patient developed graft failure 4 months after initial engraftment and required a second BM infusion. None of the patients developed acute GVHD; 3 patients (16%) developed chronic GVHD. BMT is a feasible option for FA patients having an MSD and should be performed at a young age and early in the course of the disease, before the development of complications. We believe the addition of ATG to the transplant regimen of low-dose CY, TAI, and cyclosporin was responsible for improvement in the survival of FA patients undergoing BMT. The regimen was well tolerated and was associated with a low incidence of complications including GVHD.

Detection of unexpected clones of monosomy 7 in childhood acute lymphoblastic leukemia using fluorescence in situ hybridization

The feasibility of a fluorescence in situ hybridization (FISH) technique for the detection of leukemic clones with masked chromosomal aberration in interphase nuclei was tested in childhood acute lymphoblastic leukemia (ALL). Twenty-one cases of ALL previously studied by classical metaphase cytogenetics were retrospectively analysed using a centromere-specific chromosome 7 probe. Five cases with karyotypic abnormalities of chromosome 7 (2 with trisomy 7, 2 with monosomy 7 and 1 with trisomy & tetrasomy 7) showed a correlation with FISH results, whereas in five other cases monosomy 7 was found in 12-43% of cells only by FISH. The unexpected detection of monosomy 7 in these latter ALL patients suggests that either these clones are quiescent or unable to enter mitosis in vitro. This suggests that FISH and metaphase cytogenetics must be combined whenever possible to obtain comprehensive karyotypic information.

Haemopoietic stem/progenitor cell transplant in Fanconi anaemia using HLA-matched sibling umbilical cord blood cells

There have only been a few reports documenting the use of umbilical cord blood as a source of stem cells for haemopoietic reconstitution. We report our experience with a child with Fanconi anaemia (FA) who underwent a stem cell transplant using umbilical cord blood cells from his HLA matched sibling. Although the engraftment was somewhat slow, it was complete and comparable to other transplants performed in FA patients using HLA matched sibling marrow. There was no graft-versus-host disease. The post-transplant period was uncomplicated and, at a follow-up of 36 months, this child is well with normal blood counts and immune function.

Combination of classical and interphase cytogenetics to investigate the biology of myeloid disorders: detection of masked monosomy 7 in AML

Numerical abnormalities of chromosome 7 were detected by using fluorescence labeled in situ hybridization (FISH) procedure with a centromere-specific probe in four cases of acute myeloid leukemia (AML) and three cases of myelodysplastic syndromes (MDS). Comparison of these results with classical cytogenetic (CC) data demonstrated a good correlation between the two methods. FISH confirmed the finding of monosomy 7 in all patients who demonstrated this abnormality by CC. Two AML patients who did not show monosomy 7 by CC were unexpectedly found to contain this abnormality in 39.8% and 17% cells when examined by FISH. Given that our modified FISH method consistently yielded > 96% hybridization efficiency, these findings constitute an unexpected but real presence of monosomy 7 in a substantial number of interphase cells that had remained undetected by classical karyotyping. Finally, a number of maturing myeloid cells including granulocytes also demonstrated monosomy 7 by FISH, thereby confirming the ability of malignant cells to undergo differentiation. We conclude that FISH constitutes a highly sophisticated molecular technique which can be extremely useful in select cases for detecting 'masked monosomy 7' as well as helping to determine the lineage of terminally mature cells in AML, thereby providing a handle on the effects of cytokines or chemotherapy on normal vs leukemic clones.

In vivo cell cycle characteristics of pediatric leukemia patients

Following i.v. bromodeoxyuridine infusion, a double-label technique using in vitro tritiated thymidine was used to determine the labeling index (LI), duration of S-phase (Ts), and cell cycle time (Tc) in pediatric leukemia patients. Eleven patients with acute lymphoblastic leukemia (ALL) and six patients with acute nonlymphoblastic leukemia (ANLL) were studied. Results of cell cycle kinetic studies are given for each group. Although median values for AML and ALL patients are similar to values reported in previous studies, there is a wide range of values among individual patients. The variation among the kinetic properties of blast cells in these patients reflects the heterogeneity of the acute leukemias of childhood. Further studies will be done to determine if these parameters correlate with outcome of therapy for pediatric leukemia patients.

Contribution of in vivo proliferation/differentiation studies toward the development of a combined functional and morphologic system of classification of neoplastic diseases

Proliferation kinetics of both leukemia and a variety of solid tumors have been assessed after in vivo infusions of the thymidine analogues, iododeoxyuridine (IUdR) and bromodeoxyuridine (BrdU). In acute myeloid leukemia (AML), these data indicate that the pretherapy cell cycle time (Tc) of myeloblasts is a prognostic indicator for remission duration since patients with slowly cycling myeloblasts had more durable remissions. The presence of in vivo differentiation detected from the day 7 biopsy after chemotherapy was also of favorable prognosis as these individuals had statistically significant improvement in their remission duration. The data in solid tumors are not mature enough for determining their clinical significance. Since cell kinetic information is readily available in a prompt fashion using these novel techniques, data can be used to plan therapeutic strategies for patients. This review discusses the state-of-the-art techniques available for cell cycle kinetic studies and the clinical and prognostic utility of data that have been generated thus far.

In situ cell cycle kinetics in bone marrow biopsies following sequential infusions of IUdR/BrdU in patients with hematopoietic malignancies

Examination of the proliferative characteristics of myeloblasts was undertaken in situ in bone marrow (BM) biopsies of patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) following sequential infusions of iodo- (IUdR) and bromodeoxyuridine (BrdU). The ability to identify S-phase cells which have incorporated both or either one of the labels in vivo by using two monoclonal antibodies in vitro permitted the measurement of labeling index (LI) and durations of S-phase (Ts) and the total cell cycle (Tc) both from the BM aspirates and biopsies. While the LI is 2-3 times higher in biopsies, Ts and Tc are fairly comparable in the two samples in 8/10 cases (p = 0.02 and 0.003 respectively). Advantages associated with the determination of cell cycle parameters in BM biopsies have been discussed at length.

High expression of transforming growth factor-beta long cell cycle times and a unique clustering of S-phase cells in patients with acute promyelocytic leukemia

Expression of transforming growth factor-beta (TGF-beta), which inhibits the proliferation of hematopoietic progenitors, was investigated simultaneously with cell cycle characteristics in 63 bone marrow biopsies from 23 cases with acute promyelocytic leukemia (APL). Bromodeoxyuridine (BrdU) was administered to every patient (17 newly diagnosed) for determination of the labeling index (LI) and the durations of S-phase (Ts) and the cell cycle (Tc) of leukemic promyelocytes. APL cases had lower LI both in the bone marrow aspirate (6.1% v 11.4%, P = .008) and biopsy (21.1% v 28.0%, P = .001) and longer Tc (93.6 hours v 56.0 hours, P = .002) when compared with other French-American-British subtypes. TGF-beta expression (detected by a monoclonal anti-TGF-beta 2/beta 3 antibody) was dramatically high, especially in interstitial areas of the biopsies. S-phase cells were found as geographically restricted islands of proliferation (GRIPs) in 20 of 22 cases. Weekly biopsies showed an increment in TGF-beta on day 7 of therapy in 13 of 17 cases, while in vivo differentiation was noted in 9 of 15. We conclude that the presence of high TGF-beta expression may explain the biologic basis for the slowly cycling nature of leukemic promyelocytes in APL as well as the unique clustering of S-phase cells observed in GRIPs.

Comparison of two double labeling techniques to measure cell cycle kinetics in myeloid leukemias

Five patients with acute myeloid leukemia (AML) received a one hour infusion of iododeoxyuridine (IUdR) 100 mg/M2 to label S-phase cells in vivo. The aspirate was labeled in vitro either with tritiated thymidine (3HTdr) or bromodeoxyuridine (BrdU) to measure the duration of S-phase (Ts). The mean Ts using 3HTdr (Ts1) was 15.9h (13.1-19.8h) and using BrdU (Ts2) was 17.1h (14.5-20.6h). Total cell cycle time (Tc) ranged between 44.7h to 158.8h using Ts1 and 54.0h to 170.5h using Ts2. Based on this close approximation between the results, we confirm the reliability of the newly developed method that relies purely on immunohistochemical reaction.

Clinical performance of the implantable cardioverter defibrillator: electrocardiographic documentation of 101 spontaneous discharges

Records of 105 patients, who received an automatic implantable cardioverter defibrillator (AICD), were studied to investigate the causes of spontaneous AICD discharges and to correlate the symptoms with the arrhythmias triggering AICD discharges. During a follow-up period of 13 +/- 8 months, 46/105 (44%) patients had 566 spontaneous AICD discharges. A total of 101 discharges were documented with Holter monitoring in 23 patients. In this study group, there were 8 (8%) AICD discharges for 5 episodes of ventricular fibrillation, and 68 (67%) discharges for 63 episodes of sustained ventricular tachycardia. Patients lost consciousness in all episodes of ventricular fibrillation, but were symptomatic prior to only 36 (53%) discharges in ventricular tachycardia. Nonsustained ventricular tachycardia persisting for a period of 7.5 +/- 2 seconds resulted in 20 AICD discharges; patients were symptomatic prior to 13 (65%) discharges. Supraventricular tachycardias triggered three discharges. One patient had two spurious discharges during sinus rhythm. In conclusion, most of the spontaneous AICD discharges were appropriate for the detected rhythms, but only clinically appropriate for the management of arrhythmias in 75% of the cases. A significant portion of the patients with sustained or nonsustained ventricular tachycardias triggering AICD discharges were asymptomatic prior to discharge, which requires further assessment of the physiology of the arrhythmia as a component of the detection algorithm.

Cell cycle and clinical characteristics of patients with acute myeloid leukemia and myelodysplasia whose biopsies are reactive with anti-factor VIII antibody. A Leukemia Intergroup Study

Presence of megakaryocytic cells in patients with myeloid disorders were investigated by staining plastic embedded biopsy sections with an anti-Factor VIII antibody (AFA). Two hundred and fifty cases were studied, 207 of whom had acute myeloid leukemia (AML) while 43 had myelodysplastic syndromes (MDS). Abnormal clusters of AFA positive cells indicating multilineage disease were identified in 17% with primary AML (30/175), 38% with secondary AML (12/32) and 42% cases of MDS (18/43). Biological characteristics of these 60 AFA positive cases were investigated. No unique differences in cell cycle characteristics following bromodeoxyuridine (BrdU) were identified. We confirm several recent reports that the incidence of multilineage involvement in AML is substantial.

Detection of single-stranded DNA damage using monoclonal anti-thymidine antibody

A method to detect single-stranded DNA damage from individual cells has been developed using a monoclonal anti-thymidine antibody (MoAb20B7). Initially, HL-60 cells were incubated with daunomycin at different concentrations, and processed by MoAb20B7. While 73.5% of the cells incubated with 5 micrograms/ml of daunomycin for 24 h reacted positively with MoAb20B7, 83.5% cells at 10 micrograms/ml daunomycin dose were positive. Next, this method was combined with unscheduled DNA synthesis to simultaneously measure repair and damage from individual cells. Finally, patients with acute myeloid leukemias were studied before and 24 h after therapy with a daunomycin containing regimen. In vivo damage could be determined in a prompt fashion.

Pacemaker and defibrillator combination therapy for recurrent ventricular tachycardia

The judicious use of antitachycardia pacemakers can enhance the benefits of automatic implantable cardioverter defibrillators in certain patients. Both devices were implanted in 10 highly selected patients with drug-refractory pace-terminable sustained ventricular tachycardia. During the observation period of 8 +/- 4.8 months, the automatic pacemakers detected 1,542 episodes of ventricular tachycardia and appropriately managed 1,373. The automatic implantable defibrillator was activated at least once in every patient; on two documented occasions, the defibrillator discharged because the automatic pacemaker accelerated the tachycardia. Concomitant antiarrhythmic drugs could be reduced but not withdrawn. With meticulous device programming and testing, the two systems in combination can work synergistically to manage malignant ventricular arrhythmias in carefully selected patients.

Chronotropic response to exercise in patients with atrial fibrillation

The exercise chronotropic response of patients with chronic atrial fibrillation requiring pacemaker therapy for bradycardia was assessed to characterize the chronotropic response and identify patients who would potentially benefit from a rate adaptive pacemaker. The population consisted of all patients who received a VVI pacemaker between January 1980 and November 1987 who underwent exercise tolerance testing (n = 130) and were in atrial fibrillation (n = 19). There were 11 males and 8 females with a mean age of 62 +/- 14 years. Left ventricular function was normal in eight patients, mildly impaired in three, and severely impaired in two. Long-term medications were continued until the morning of the test; digoxin 73%, beta blockers 21%, calcium channel blockers 26%, and nitrates 21%. Maximal exercise tolerance tests were performed. Parameters assessed were: (a) heart rate at rest, the end of each stage, and at peak exercise; (b) percent heart rate reserve per stage; and (c) percent metabolic reserve per stage. Results were compared to 100 normal subjects on no medications and without evidence of medical illness or cardiac disease. Heart rates were depressed in 58% of the study patients (21% early, 53% late) and elevated in 74% (74% early, 32% late). All 19 (100%) patients had abnormal heart rate responses at some point during the exercise test. Only four patients (21%) had a response within one standard deviation from the mean of the normal population during either the early or late segment of the exercise test. Patients in chronic atrial fibrillation requiring pacemakers for bradycardiac support at rest have an abnormal chronotropic response to exercise.(ABSTRACT TRUNCATED AT 400 WORDS)

Preexcitation syndromes: surgical ablation therapy. The Cleveland Clinic experience

Thirty-four patients with preexcitation syndrome had surgical ablation of the accessory atrioventricular connection. All presented with sustained symptomatic arrhythmias, which had resulted in syncope in seven patients and aborted sudden cardiac death in four. Arrhythmias induced at electrophysiologic evaluation included orthodromic reciprocating tachycardia in 32 patients, antidromic reciprocating tachycardia in five patients, and atrial fibrillation in 29 patients. A single accessory atrioventricular connection was located in 32 patients and two patients had multiple accessory connections. The accessory connection was located with intraoperative mapping in all patients and the pathway was successfully ablated in 32. Eleven patients underwent a transmural approach and 23 patients underwent an epicardial dissection. Cryotherapy was used in 22 patients. After a mean follow-up of 32 months, 28 patients were free from all arrhythmias without drug therapy. Six patients continued to have symptomatic arrhythmias but only one case was suspected to be secondary to unsuccessful ablation of the accessory connection. One patient with heart block induced at the surgical procedure is dependent upon a pacemaker.

The usefulness of amiodarone in management of refractory supraventricular tachyarrhythmias

The efficacy of amiodarone was evaluated in 85 patients with supraventricular tachycardia (SVT) refractory to several antiarrhythmic agents (mean 3.8 +/- 1.0). All but six patients had organic heart disease. Patients were followed for 19 months (range 2-60 months). Response to amiodarone treatment was considered excellent (no recurrence of SVT) in 22 of 52 patients with paroxysmal atrial fibrillation (PAF), in four of 13 patients with chronic atrial fibrillation (CAF), and in three of 15 patients with Wolff-Parkinson-White syndrome-related circus movement tachycardia (WPW-CMT). Response was improved (marked improvement in symptoms with partial suppression of SVT) in 22 patients with PAF, in seven patients with CAF, in 10 patients with WPW-CMT, and in four patients with atrioventricular nodal reentry tachycardia. Response was considered poor (insignificant or no suppression of SVT) in three patients with PAF, in one patient with CAF, and in one patient with WPW-CMT. Seven patients required discontinuation of amiodarone due to adverse effects. We conclude that amiodarone is efficacious and relatively safe for control of SVT refractory to conventional antiarrhythmic agents irrespective of the underlying electrophysiologic mechanism.

Effects of extracorporeal shock wave lithotripsy on cardiac pacemakers and its safety in patients with implanted cardiac pacemakers

Effects of extracorporeal shock wave lithotripsy (ESWL) were studied on 15 pacemakers (standard single chamber n = 5, dual chamber n = 6, rate responsive single chamber [Activitrax] n = 4). In-vitro testing involved suspending the pacemakers in a bath of degassified, deionized water firmly taped to a platform at the point of maximal pressure, i.e., second focal point (F2), where they received pressure shocks (means = 1300) from the HM3 Dornier lithotriptor. The pacemakers, programmed to their most sensitive setting, were continuously pacing at nominal outputs (atrial and ventricular pacing in the DDD mode). All units were assessed by a pacing system analyzer before and after the study, then underwent destructive analysis. During standard single chamber pacing (VVI) the pacing stimulus triggered ESWL. For dual chamber devices, ESWL was triggered by the atrial paced event which induced inhibition of the ventricular output in two pacemaker. This was eliminated by reprogramming to a less sensitive setting. The pacemaker can, hermetic seal and internal circuitry were undamaged in all units. Two rate responsive single chamber pacemakers had their activity sensing piezoelectric elements shattered when placed at F2. Two other units placed 5 cm from F2 were stimulated to their maximum upper programmed pacing rate with ESWL therapy, but were otherwise unaffected. Subsequent to this study, six patients with pacemakers programmed to the VVI (five), DDD (one) modes implanted in the thorax underwent successful ESWL without pacemaker or arrhythmic event.

CONCLUSIONS

(A) It is generally safe for patients implanted with standard single chamber devices in a ventricular application to undergo ESWL without modifying the pacing/sensing parameters. (B) Patients implanted with dual chamber devices who pace in the atrium should be reprogrammed to the VVI mode during ESWL. (C) Patients with piezoelectric activity sensing rate responsive single chamber pacemakers should have this feature programmed off during ESWL and, if implanted in the abdomen, probably should not undergo ESWL.