Impact of Hematopoietic Cell Transplantation on Cardiovascular Risk Factors and Insulin Sensitivity

The use of hematopoietic cell transplantation (HCT) for treating malignant conditions in children has increased over the past five decades, leading to a growing population of long-term survivors.This population of childhood HCT survivors faces increased risks of adverse medical effects due to cancer treatments, including adverse cardiovascular disease (CVD) risk factors such as metabolic syndrome, insulin resistance. but the impact of exposure to HCT preparative conditioning regimen has not been clearly delineated. These risk factors, including obesity, dyslipidemia, hypertension, and insulin resistance (IR), are significant contributors to premature cardiovascular disease and represent a leading cause of non-relapse deaths in childhood cancer and HCT survivors. This study aimed to assess the early development of CVD risk factors and their relationship to insulin resistance in a large population of pediatric and young adult HCT survivors of childhood hematologic malignancies. The study compared their cardiovascular risk profiles, insulin resistance (measured by euglycemic hyperinsulinemic clamp studies), and body composition (determined by dual X-ray absorptiometry - DXA) with a cohort of sibling controls. We enrolled 151 HCT recipients (26.36 ±0.90 years at study enrollment; time since HCT of 2.6-31.5 years) and 92 sibling controls to complete at cardiovascular risk assessment including insulin sensitivity by hyperinsulinemic euglycemic clamp, anthropometry, body composition by dual X-ray absorptiometry, blood pressure, and serum biomarkers. We used linear models to test for mean differences in all continuous outcomes between survivors and siblings, accounting for intra-family correlations with generalized estimating equations. Recipients of HCT were found to have lower insulin sensitivity and more likely to have adverse CVD risk factors in comparison to their healthy siblings. Significantly higher percent fat mass and visceral adipose tissue, and significantly lower lean body mass were noted in HCT recipients than sibling controls despite having a similar body mass index between the two groups. Total body irradiation in the conditioning regimen was one of the strongest factors associated with lower insulin sensitivity, dyslipidemia and abnormal body composition leading to sarcopenic obesity. This study reveals that pediatric and young adult HCT survivors are more insulin resistant and have a higher prevalence of adverse cardiovascular risk factors compared to sibling controls. The presence of cardiovascular risk factors at a relatively young age raises concerns about an escalating trajectory of cardiovascular disease in this population. Therefore, regular monitoring of HCT survivors for cardiometabolic risk factors and early intervention will be crucial for preventing cardiovascular-related complications in the future. The findings underscore the importance of survivorship care for pediatric and young adult HCT survivors, with a focus on managing cardiovascular risk factors and promoting a healthy lifestyle to mitigate long-term adverse effects. Early identification and targeted interventions can significantly improve the long-term health outcomes of this vulnerable population, reducing the burden of cardiovascular disease and related complications.

Feasibility and acceptability of a home-based resistance training intervention in adolescent and young adult hematopoietic cell transplant survivors

BACKGROUND

Adolescent and young adult (AYA) hematopoietic cell transplantation (HCT) survivors are at increased risk of metabolic syndrome and lean body mass (LBM) deficits. Resistance training (RT) is a potential intervention to improve LBM, metabolic fitness, and reduce risk of cardiovascular disease.

PROCEDURE

Eligible participants ages 13-39 years, 80-120 days post-HCT, transfusion independent, and prednisone dose ≤1 mg/kg/day were approached. Baseline assessments of body composition (DXA), anthropometrics, and strength testing were completed and participants were taught a 12-week, home-based RT intervention with weekly remote coaching. Follow-up assessments were at day +200 (FU1) and +365 post-HCT (FU2). Feasibility targets were (a) 60% enrollment of approached patients, (b) 80% completion of weekly phone calls, and (c) 80% completion of the RT intervention and FU1 assessments. Acceptability was based on positive responses in qualitative interviews.

RESULTS

Twenty of 31 (65%) eligible AYAs enrolled. Three participants failed to complete baseline measurements (2 = scheduling barriers, 1 = passive refusal) and four participants who completed baseline assessments did not receive the intervention (1 = medical reasons, 2 = no longer interested). Of those who completed baseline assessments, 13 received the intervention, completed 88.5% of coaching calls, and 11 (65%) completed FU1. LBM (kg) increased or remained unchanged in nine of nine participants with complete body composition data at FU1 (mean 1.1 kg; 95%CI: 0.4, 1.9). All participants who completed FU1 reported they would recommend the intervention to an AYA HCT survivor.

CONCLUSIONS

A home-based RT intervention in AYA HCT survivors early post HCT is both feasible and acceptable and may maintain or increase LBM.

Environmental and health impacts of February 14, 2014 radiation release from the nation's only deep geologic nuclear waste repository

The environmental impact of the February 14, 2014 radiation release from the nation's only deep geologic nuclear waste repository, the Waste Isolation Pilot Plant (WIPP) was assessed using monitoring data from an independent monitoring program conducted by the Carlsbad Environmental Monitoring & Research Center (CEMRC). After almost 15 years of safe and efficient operations, the WIPP had one of its waste drums rupture underground resulting in the release of moderate levels of radioactivity into the underground air. A small amount of radioactivity also escaped to the surface through the ventilation system and was detected above ground. It was the first unambiguous release from the WIPP repository. The dominant radionuclides released were americium and plutonium, in a ratio that matches the content of the breached drum. The accelerated air monitoring campaign, which began following the accident, indicates that releases were low and localized, and no radiation-related health effects among local workers or the public would be expected. The highest activity detected was 115.2 μBq/m(3) for (241)Am and 10.2 μBq/m(3) for (239+240)Pu at a sampling station located 91 m away from the underground air exhaust point and 81.4 μBq/m(3) of (241)Am and 5.8 μBq/m(3) of (239+240)Pu at a monitoring station located approximately one kilometer northwest of the WIPP facility. CEMRC's recent monitoring data show that the concentration levels of these radionuclides have returned to normal background levels and in many instances, are not even detectable, demonstrating no long-term environmental impacts of the recent radiation release event at the WIPP. This article presents an evaluation of almost one year of environmental monitoring data that informed the public that the levels of radiation that got out to the environment were very low and did not, and will not harm anyone or have any long-term environmental consequence. In terms of radiological risk at or in the vicinity of the WIPP site, the increased risk from the WIPP releases is exceedingly small, approaching zero.

Radiation release at the nation's only operating deep geological repository--an independent monitoring perspective

Recent incidents at the nation's only operating deep geologic nuclear waste repository, the Waste Isolation Pilot Plant (WIPP), resulted in the release of americium and plutonium from one or more defense-related transuranic (TRU) waste containers into the environment. WIPP is a U.S. Department of Energy mined geologic repository that has been in operation since March, 1999. Over 85,000 m3 of waste in various vented payload containers have been emplaced in the repository. The primary radionuclides within the disposed waste are 239+240Pu and 241Am, which account for more than 99% of the total TRU radioactivity disposed and scheduled for disposal in the repository. For the first time in its 15 years of operation, there was an airborne radiation release from the WIPP at approximately 11:30 PM Mountain Standard Time (MST) on Friday, February 14, 2014. The radiation release was likely caused by a chemical reaction inside a TRU waste drum that contained nitrate salts and organic sorbent materials. In a recent news release, DOE announced that photos taken of the waste underground showed evidence of heat and gas pressure resulting in a deformed lid, in material expelled through that deformation, and in melted plastic and rubber and polyethylene in the vicinity of that drum. Recent entries into underground Panel 7 have confirmed that at least one waste drum containing a nitrate salt bearing waste stream from Los Alamos National Laboratory was breached underground and was the most likely source of the release. Further investigation is underway to determine if other containers contributed to the release. Air monitoring across the WIPP site intensified following the first reports of radiation detection underground to ascertain whether or not there were releases to the ground surface. Independent analytical results of air filters from sampling stations on and near the WIPP facility have been released by us at the Carlsbad Environmental Monitoring & Research Center and confirmed trace amounts of 241Am and 239+240Pu, at ratios reflecting the suspect waste stream. The highest activity detected offsite was 115.2 μBq/m3 for 241Am and 10.2 μBq/m3 for 239+240 Pu. These concentrations in air were very small, localized, and below any level of public health or environmental concern.

An overview of Fukushima radionuclides measured in the northern hemisphere

The Great East Japan Earthquake and tsunami on March 11, 2011 resulted in the tragic accident at the Fukushima Nuclear Power Plant (NPP) and subsequently uncontrolled release of radioactive contaminants into the atmosphere. This review article attempts to compile and interpret data collected by various national and international monitoring networks in response to the Fukushima releases across the northern hemisphere. The majority of the releases occurred during the period March 12-22 with a maximum release phase from March 14-17, 2011. The radioactivity released was dominated by volatile fission products including isotopes of the noble gases (xenon and krypton), iodine, cesium, and tellurium. The radioactive gases and particles released in the accident were dispersed over the middle latitudes of the entire northern hemisphere and for the first time also measured in the southern Hemisphere. Isotopes of iodine and cesium were detected in air, water, milk and food samples collected across the entire northern hemisphere. Elevated levels of fission products were detected from March to May 2011 at many locations over the northern hemisphere. This article focuses on the most prevalent cesium and iodine isotopes, but other secondary isotopes are also discussed. Spatial and temporal patterns and differences are contrasted. The activity ratios of (131)I/(137)Cs and (134)Cs/(137)Cs measured at several locations are evaluated to gain an insight into the fuel burn-up, the inventory of radionuclides in the reactor and the isotopic signature of the accident. It is important to note that all of the radiation levels detected outside of Japan have been very low and are well below any level of public and environmental hazard.

Severe thrombocytopenia and patterns of bleeding in neonates: results from a prospective observational study and implications for use of platelet transfusions

OBJECTIVE

To describe patterns of clinical bleeding in neonates with severe thrombocytopenia (ST and platelet count <60 × 10(9) L(-1)), and to investigate the factors related to bleeding.

STUDY DESIGN

Seven tertiary-level neonatal units enrolled neonates (n = 169) with ST. Data were collected prospectively on all clinically apparent haemorrhages. Relationships between bleeding, platelet count and baseline characteristics were explored through regression analysis.

RESULTS

Bleeding was recorded in most neonates with ST (138/169; 82%), including 123 neonates with minor bleeding and 15 neonates with major bleeding. The most common sites of minor bleeding were from the renal tract (haematuria 40%), endotracheal tube (21%), nasogastric tube (10%) and skin (15%). Gestational age <34 weeks, development of ST within 10 days of birth and necrotizing enterocolitis were the strongest predictors for an increased number of bleeding events. For neonates with ST, a lower platelet count was not a strong predictor of increased bleeding.

CONCLUSIONS

The majority of neonates with ST bleed, although most episodes are minor. These findings establish the importance of clinical factors for bleeding risk, rather than minimum platelet count. Further studies should assess the clinical significance of different types of minor bleed for neonatal outcomes, the predictive value of minor bleeding for major bleeding and the role of platelet transfusions in preventing bleeding.

Plutonium in the WIPP environment: its detection, distribution and behavior

The Waste Isolation Pilot Plant (WIPP) is the only operating deep underground geologic nuclear repository in the United States. It is located in southeastern New Mexico, approximately 655 m (2150 ft) below the surface of the Earth in a bedded Permian evaporite salt formation. This mined geologic repository is designed for the safe disposal of transuranic (TRU) wastes generated from the US defense program. Aerosol and soil samples have been collected near the WIPP site to investigate the sources of plutonium in the WIPP environment since the late 1990s, well before WIPP received its first shipment. Activities of (238)Pu, (239+240)Pu and (241)Am were determined by alpha spectrometry following a series of chemical separations. The concentrations of Al and U were determined in a separate set of samples by inductively coupled plasma mass spectrometry. The annual airborne concentrations of (239+240)Pu during the period from 1998 to 2010 show no systematic interannual variations. However, monthly (239+240)Pu particulate concentrations show a typical seasonal variation with a maximum in spring, the time when strong and gusty winds frequently give rise to blowing dust. Resuspension of soil particles containing weapons fallout is considered to be the predominant source of plutonium in the WIPP area. Further, this work characterizes the source, temporal variation and its distribution with depth in a soil profile to evaluate the importance of transport mechanisms affecting the fate of these radionuclides in the WIPP environment. The mean (137)Cs/(239+240)Pu, (241)Am/(239+240)Pu activity ratio and (240)Pu/(239)Pu atom ratio observed in the WIPP samples are consistent with the source being largely global fallout. There is no evidence of any release from the WIPP contributing to radionuclide concentrations in the environment.

Tracing blood units to their recipients: results of a two-centre study

An important principle of the use of blood components is the ability to trace them from the donor to the recipient. This study set out to establish whether there was sufficient documentation in patient case notes to confirm the transfusion of blood components in a sample of computer blood bank records at two large teaching hospitals in UK. The criteria for verification of transfusion were taken from guidelines from the British Committee for Standards in Haematology (Transfusion Medicine 1999, 9, 227-238). The blood bank computer records indicated that 486 units of blood components were issued and not returned to the blood bank for 80 patients during a 2-month period. Of the 486 units, transfusion of 409 units (84%) was verified against patient notes, but 77 units (16%) could not be verified as received by the patient. The study showed that documentation of transfusions was variable. For example, written prescriptions were only found for 204 units (42%). These results have implications for 'lookback studies' involving blood transfusion. Further efforts are required to educate those involved in transfusing blood about the need for accurate documentation.

The insulin-like growth factor type I receptor stimulates growth and suppresses apoptosis in prostatic stromal cells

Stromal cells derived from benign prostatic hyperplasia synthesize and secrete measurable levels of insulin-like growth factor (IGF). Seventy-two-hour conditioned medium obtained from these cells contains IGF-II at levels ranging from 125-177 ng/mL.10(6) cells. IGF-I is almost undetectable. RT-PCR analysis has demonstrated that the genes for both the type I IGF receptor (IGF-IR) and the type II IGF receptor (IGF-IIR) are expressed by benign stromal cells in vitro. Competition binding analysis for IGF-I and IGF-II confirmed the existence of binding sites for both ligands with respective Kd and binding capacities of 4.9 x 10(-9) mol/L and 6.6 x 10(5) sites/cell and 4.7 x 10(-9) mol/L and 3.8 x 10(6) sites/cell. Under serum-free conditions, IGF-I and IGF-II at 500 ng/mL induce 80% and 113% increases in stromal cell density, respectively, over a 96-h period. Incubation with the IGF-IR-neutralizing antibody alpha IR3 (50 micrograms/mL) reduces the rate of stromal cell proliferation by approximately 60-80% even in the presence of stimulatory concentrations of IGFs. Camptothecin-induced apoptosis is inhibited by the addition of IGF-I and -II (500 ng/mL). alpha IR3 suppresses these survival signals and itself induces cell death in the prostatic stroma. The data suggest that IGF-IR is a pivotal molecule in prostatic stromal cell maintenance, and that specific antagonism may offer a novel means of controlling the fibromuscular expansion characteristic of benign prostatic hyperplasia.

Cost benefit of emerging technology in localized carcinoma of the prostate

PURPOSE

In a health care environment strongly concerned with cost containment, cost-benefit studies of new technology must include analyses of loco-regional tumor control, morbidity, impact on quality of life, and financial considerations.

METHODS AND MATERIALS

This nonrandomized study analyzes 124 patients treated with three-dimensional conformal radiation therapy (3D CRT) and 153 with standard irradiation (SRT) between January 1992 and December 1995, for histologically proven adenocarcinoma of prostate, clinical Stage T1 or T2. Mean follow-up is 1.4 years. Three-dimensional CRT consisted of six or seven coplanar oblique and lateral and, in some patients, AP fields designed to treat the prostate with a 1 to 1.7 cm margin. SRT consisted of 120 degrees bilateral arc rotation. Total doses to prostate were 67 to 70 Gy when pelvic lymph nodes were irradiated or 68.4 to 73.8 Gy when prostatic volume only was treated; dose per fraction was 1.8 Gy. Patients were interviewed weekly for severity of 12 acute intestinal and urinary pelvic irradiation side effects (0 to 4+ grading). Time and effort for 3D RTP and daily treatment with 3D CRT and SRT were recorded. Dose-volume histograms (DVHs) were calculated for gross tumor volume, planning target volume, bladder, and rectum. Actual reimbursement to the hospital and university was determined for 41 3D CRT, 43 SRT, and 40 radical prostatectomy patients treated during the same period.

RESULTS

Average treatment planning times (in minutes) were: 101 for 3D conformal therapy simulation, 66 for contouring of target volume and sensitive structures, 55 for virtual simulation, 39 for plan preparation and documentation, 65 for physical simulation, and 20 for approval of treatment plan. Daily mean treatment times were 19 min for 3D CRT with Cerrobend blocking, 16 with multileaf collimation, and 10 with bilateral arc rotation. Dosimetric analysis (DVHs) showed a reduction of 50% in volume of bladder or rectum receiving doses higher than 65 Gy. Acute side effects included dysuria, moderate difficulty in urinating, and nocturia in 25-39% of both SRT and CRT patients; loose stools or diarrhea in 5-12% of 3D CRT and 16-22% of SRT patients; moderate proctitis in 3% of 3D CRT and 12% of SRT patients (p = 0.01). Chemical disease-free survival (prostate-specific antigen < or =2 ng/ml) at 3 years was 90% with 3D CRT and 80% with SRT (p = 0.01). Average initial treatment reimbursements were $13,823 (3D CRT), $10,864 (SRT), and $12,250 (radical prostatectomy). Average total treatment reimbursement and projected cost of management of initial therapy failures per patients were $15,173, $16,264, and $16,405, respectively.

CONCLUSIONS

Three-dimensional CRT irradiated less bladder and rectum volume than SRT; CRT initial reimbursement was 28% higher than SRT and 12% higher than radical prostatectomy. Because of projected better local tumor control, average total cost of treating a patient with 3D CRT or radical prostatectomy is equivalent to cost of SRT. Treatment morbidity was lower with 3D CRT. Our findings reflect an overall benefit with 3D CRT as a new promising technology in treatment of localized prostate cancer. Dose-escalation studies may enhance its efficacy and cost benefit.

The neurological basis of attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a serious disability with long-term consequences. At present the disorder is considered organic in pathology, particularly in regard to central nervous system functioning. This paper reviews research on ADHD. The role of neurochemical stimulation is discussed, and the signs of neurological deficits are explored. Nearly 600,000 young people in the United States receive medication daily for ADHD, and these drugs mimic brain neurotransmitters. The chemical action of these drugs and the cognitive, affective, and behavioral effects are discussed. Side effects and dosage levels are also examined. Basic behavior modification with ADHD children and how these techniques can be combined with effective drug treatment are elaborated.

Volume calculation by means of SPECT: analysis of imaging acquisition and processing factors

To assess the effect of image acquisition and processing factors on the volume calculated from single photon emission computed tomography (SPECT) images, the authors evaluated technical factors including image matrix size, size of the region of interest (ROI), activity concentration in the region, amount of background subtraction, type of reconstruction filter, section thickness, and number of projections. They found that the percentage of background subtraction was the single most important factor affecting volume calculation. The smaller the volume, the greater the amount of background subtraction needed before the ROI is drawn. As an acceptable means to circumvent the varying percentage of background subtraction for different volumes, a calibration curve was constructed relating the true volume with the calculated volume for a fixed percentage of background subtraction. The use of a 128 X 128 acquisition matrix and zooming of the reconstructed images were necessary for accurate calculation of volumes smaller than 300 mL.

Quantifying nursing needs in home health care

A study was conducted to determine what factors were most predictive of the quantity of nursing service and total agency service required by cardiac and cancer patients in home-care agencies. A retrospective record review on 397 patients in 9 randomly selected Connecticut home-care agencies collected demographic data on referral and payment source, support system, discharge status, primary care provider, and health status, as well as total number of professional and nonprofessional visits and length of stay. The Health Status Score, which measured deficits in daily activities and nursing problems, proved to be the best predictor. The ability of the Health Status Score to predict the need for total agency visits was particularly strong for cancer patients. The agency variable was a significant predictor of resource utilization, especially for cardiac patients. A significant limitation of the study was the inconsistency among the agencies regarding closure of records. Future research into resource use in home care depends on consistent and complete recording practices across agencies.

The pharmacokinetics, pharmacological responses and behavioral effects of acepromazine in the horse

After intravenous (i.v.) injection, acepromazine was distributed widely in the horse (Vd = 6.6 litres/kg) and bound extensively (greater than 99%) plasma proteins. Plasma levels of drug declined with an alpha half-life of 4.2 min, while the beta phase or elimination half-life was 184.8 min. At a dosage level of 0.3 mg/kg acepromazine was detectable in the plasma for 8 h post dosing. The whole blood partitioning of acepromazine was 46% in the plasma phase and 54% in the erythrocyte phase. Penile prolapse was clearly evident at doses from 0.01 mg/kg to 0.4 mg/kg i.v., and the duration and extent of protrusion were dose related. Hematocrit levels were significantly lowered by administration of 0.002 mg/kg i.v. (about 1 mg to a 500 kg horse) and increasing dosages resulted in greater than 20% lowering of the hematocrit from control levels. Pretreatment of horses with acepromazine also reduced the variable interval (VI 60) responding rate in all horses tested. These data show that hematocrit changes are the most sensitive pharmacological responses to acepromazine, followed by changes in penile extension, respiratory rate, VI responding and locomotor responses. Acepromazine is difficult to detect in plasma at normal clinical doses. However, because of its large volume of distribution, its urinary elimination is likely prolonged, and further work on its elimination in equine urine is required.

Atypical conditions for quantitative recovery of acepromazine and chlorpromazine from plasma

Recoveries of acepromazine and chlorpromazine from equine plasma were examined. Recoveries of both drugs from plasma were poor under theoretically optimal conditions for basic drugs. When a wide range of extraction pH was examined, it was found that more complete recoveries of these drugs from plasma were achieved at pH 5-6. Use of [3H] chlorpromazine showed that the rate of migration of the drug from an aqueous to a nonpolar environment was much faster at pH 6.0 than at pH 9.2 from both plasma and buffer solutions. Times required for equilibration with agitation were 15 min at pH 6.0, 1 h at pH 9.2, and 2 h at pH 11.0. With these agitation times and pH values, recoveries were more than 95% complete.