Neonatal Respiratory Support Utilization in Low- and Middle-Income Countries: A Registry-Based Observational Study

BACKGROUND

Newborns with hypoxemia often require life-saving respiratory support. In low-resource settings, it is unknown if respiratory support is delivered more frequently to term infants or preterm infants. We hypothesized that in a registry-based birth cohort in 105 geographic areas in seven low- and middle-income countries, more term newborns received respiratory support than preterm newborns.

METHODS

This is a hypothesis-driven observational study based on prospectively collected data from the Maternal and Newborn Health Registry of the NICHD Global Network for Women's and Children's Health Research. Eligible infants enrolled in the registry were live-born between 22 and 44 weeks gestation with a birth weight ≥400 g and born from January 1, 2015, to December 31, 2018. Frequency data were obtained to report the number of term and preterm infants who received treatment with oxygen only, CPAP, or mechanical ventilation. Test for trends over time were conducted using robust Poisson regression.

RESULTS

177,728 (86.3%) infants included in this study were term, and 28,249 (13.7%) were preterm. A larger number of term infants (n = 5,108) received respiratory support compared to preterm infants (n = 3,287). Receipt of each mode of respiratory support was more frequent in term infants. The proportion of preterm infants who received respiratory support (11.6%) was higher than the proportion of term infants receiving respiratory support (2.9%, p < 0.001). The rate of provision of respiratory support varied between sites.

CONCLUSIONS

Respiratory support was more frequently used in term infants expected to be at low risk for respiratory disorders compared to preterm infants.

Examining maternal morbidity across a spectrum of delivery locations: An analysis of the Global Network's Maternal and Neonatal Health Registry

OBJECTIVE

To better understand maternal morbidity, using quality data from low- and middle-income countries (LMICs), including out-of-hospital deliveries. Additionally, to compare to the WHO estimate that maternal morbidity occurs in 15% of pregnancies, which is based largely on hospital-level data.

METHODS

The Global Network for Women's and Children's Health Research Maternal Newborn Health Registry collected data on all pregnancies from seven sites in six LMICs between 2015 and 2020. Rates of maternal mortality and morbidity and the differences in morbidity across delivery location and birth attendant type were evaluated.

RESULTS

Among the 280 584 deliveries included in the present analysis, the overall maternal mortality ratio was 138 per 100 000, while 11.7% of women experienced at least one morbidity. Rates of morbidity were generally higher for deliveries occurring within hospitals (19.8%) and by physicians (23.6%). The lowest rates of morbidity were noted among women delivering in non-hospital healthcare facilities (5.6%) or with non-physician clinicians (e.g. nurses, midwives [5.4%]).

CONCLUSION

The present study shows important differences in reported maternal morbidity across delivery sites, with a trend towards lower morbidity in non-hospital healthcare facilities and among non-physician clinicians.

Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries

BACKGROUND

Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency.

METHODS

We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses.

RESULTS

Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD).

CONCLUSIONS

Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers).

TRIAL REGISTRATION

Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).

Association of haemoglobin levels in the first trimester and at 26-30 weeks with fetal and neonatal outcomes: a secondary analysis of the Global Network for Women's and Children's Health's ASPIRIN Trial

OBJECTIVE

Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes.

DESIGN

ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6⁺⁰ -13⁺⁶  weeks and 26⁺⁰ -30⁺⁰  weeks of gestation with fetal and neonatal outcomes.

SETTING

Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala.

POPULATION

A total of 11 976 pregnant women.

METHODS

Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes.

MAIN OUTCOME MEASURES

Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g.

RESULTS

The mean haemoglobin levels at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6⁺⁰ -13⁺⁶  weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation.

CONCLUSIONS

Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger.

TWEETABLE ABSTRACT

Both lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6-13 weeks and 26-30 weeks of gestation.

Endotypes of chronic rhinosinusitis with nasal polyps with and without NSAID â€" intolerance

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2-dominated inflammatory disease of the upper air- ways. A subgroup of patients with CRSwNP suffer from intolerance to nonsteroidal anti-inflammatory drugs (NSAID) and develop NSAID-exacerbated respiratory disease (NERD). The aim of the study was to compare the cytokine based inflammatory endotype of nasal secretions of CRSwNP patients with and without NSAID intolerance.

METHODS

Nasal secretions were collected from twenty-six patients suffering from CRSwNP, thirteen with NERD and thirteen without NSAID intolerance. As control, nasal secretions were collected from fifteen healthy donors. Tryptase and ten human cyto- kines were analyzed: interleukin (IL)-4, IL-5, IL-6, IL-8, IL-12p70, IL-13, IL-17A, IL-23, IFN-g, and TNF-a by a cytokine multiple array on a Luminex 200 platform.

RESULTS

Grade of polyposis and frequency of polyp surgery was more severe in NERD- compared to non-NERD patients. IL-6 and IL-5 in CRSwNP was significantly increased compared to healthy participants. IL-5 and IL-13 were significantly increased in subjects suffering from NERD compared to CRSwNP patients without NERD.

CONCLUSION

We identified IL-13 as a possible specific biomarker in nasal secretions of patients with NERD, which allows us to differentiate between CRSwNP with vs. without NERD. The characterization of inflammatory endotypes in CRSwNP enables the introduction of the best available therapy in the context of precision medicine.

Open rhinoplasty using a columellar strut: effects of the graft on nasal tip projection and rotation

BACKGROUND

Despite the discordance in the literature concerning the effect of columellar strut grafts on nasal tip rotation, this method is often used when an increase in nasolabial angle or nasal tip projection is desired.

OBJECTIVES

We aimed to elucidate the change in nasolabial angles and nasal tip projections after exclusive columellar strut graft implantations and in addition to other surgical steps. Furthermore, differences in these parameters between patients with conchal and septal columellar strut grafts were investigated.

METHODS

A monocentric retrospective cohort study of 173 open septorhinoplasties with columellar strut graft technique, between 2006 and 2016, was conducted. The pre- and postoperative nasal tip projection, nasolabial and nasofrontal angle and interalar distance were determined and the Goode-ratio was calculated.

RESULTS

In cases where uprotation was not specifically desired, neither nasolabial angles nor tip projections changed significantly, irrespective of whether a columellar strut graft was used alone or with additional surgical steps. If an uprotation through surgery was desired, a significant mean increase in nasolabial angle of 4.4° was achieved. Furthermore, conchal instead of septal columellar strut grafts showed significantly better results.

CONCLUSION

In our study, a columellar strut graft-without any additional surgical step-does only have an improving impact on nasal tip rotations and projections, if specifically intended to by the surgeon. In other words, if the strut graft was not chosen for an uprotational intention, it did not relevantly impact on the nasolabial angle or nasal tip projection. However, in patients where an uprotation is desired, the columellar strut graft still represents a meaningful tool. Since conchal instead of septal columellar strut grafts showed better results, we suggest using them for these patients.

LEVEL OF EVIDENCE

2b.

Occurrence of occult CSF leaks during standard FESS procedures

OBJECTIVE

To determine the incidence of occult cerebrospinal fluid leaks (CSF) after functional endoscopic sinus surgery (FESS) and to evaluate the diagnostic performance of beta2-transferrin in blood-contaminated conditions.

STUDY DESIGN

Prospective cohort study.

METHODS

An analysis of 57 intraoperative samples using hydrogel 6 beta2-transferrin assay after FESS was undertaken. In case of CSF positive samples and continuing rhinorrhea, reanalysis after more than 1 year was conducted. In-vivo analysis of a primary spontaneous CSF leak sample took place to verify difficulties in detecting beta2-transferrin in blood-contaminated settings. Own titrations were performed to evaluate detection limits of CSF by beta2-transferrin and beta-trace protein assays in these settings.

RESULTS

An incidence of 13% for occult CSF leaks after FESS was found. In blood-contaminated conditions, routine beta2-transferrin assays showed low sensitivity. In over 1 year follow-up, all samples were negative for CSF and none of them developed clinical relevant CSF leaks or meningitis.

CONCLUSION

Occult and clinically irrelevant CSF leaks do occur in a significant proportion of patients during and shortly after FESS. Intra- and postoperatively, routine beta2-transferrin assays show low sensitivity. They should not be used in these settings. The clinical course of patients with occult CSF leaks indicated possibility of an uneventful follow-up.

Relationship between achieved personalized glycaemic targets and monitoring of clinical events in elderly diabetic patients

AIM

Recent guidelines for the management of type 2 diabetes (T2DM) in the elderly recommend adjusting the therapeutic target (HbA_1c) according to the patient's health. Our study aimed to explore the association between achieving the recommended personalized HbA_1c target and the occurrence of major clinical events under real-life conditions.

METHODS

The T2DM S.AGES cohort was a prospective multicentre study into which 213 general practitioners recruited 983 non-institutionalized T2DM patients aged>65 years. The recommended personalized HbA_1c targets were<7%, <8% and <9% for healthy, ill and very ill patients, respectively. Major clinical events (death from any cause, major vascular events and/or hospitalization) were recorded during the 3-year follow-up. Mixed-effects logistic regression models were used for the analyses.

RESULTS

Of the 747 patients analyzed at baseline, 551 (76.8%) were at their recommended personalized HbA_1c target. During follow-up, 391 patients (52.3%) experienced a major clinical event. Of the patients who did not achieve their personalized HbA_1c target (compared with those who did), the risk (OR) of a major clinical event was 0.95 (95% CI: 0.69-1.31; P=0.76). The risk of death, major vascular event and hospitalization were 0.88 (95% CI: 0.40-1.94; P=0.75), 1.14 (95% CI: 0.7-1.83; P=0.59) and 0.84 (95% CI: 0.60-1.18; P=0.32), respectively.

CONCLUSION

Over a 3-year follow-up period, our results showed no difference in risk of a major clinical event among patients, regardless of whether or not they achieved their personalized recommended HbA_1c target. These results need to be confirmed before implementing a more permissive strategy for treating T2DM in elderly patients.

Regional water quality patterns in an alluvial aquifer: direct and indirect influences of rivers

The influence of rivers on the groundwater quality in alluvial aquifers can be twofold: direct and indirect. Rivers can have a direct influence via recharge and an indirect one by controlling the distribution of fine-grained, organic-carbon rich flood deposits that induce reducing conditions. These direct and indirect influences were quantified for a large alluvial aquifer on the Swiss Plateau (50km(2)) in interaction with an Alpine river using nitrate as an example. The hydrochemistry and stable isotope composition of water were characterized using a network of 115 piezometers and pumping stations covering the entire aquifer. Aquifer properties, land use and recharge zones were evaluated as well. This information provided detailed insight into the factors that control the spatial variability of groundwater quality. Three main factors were identified: (1) diffuse agricultural pollution sources; (2) dilution processes resulting from river water infiltrations, revealed by the δ(18)OH2O and δ(2)HH2O contents of groundwater; and (3) denitrification processes, controlled by the spatial variability of flood deposits governed by fluvial depositional processes. It was possible to quantify the dependence of the nitrate concentration on these three factors at any sampling point of the aquifer using an end-member mixing model, where the average nitrate concentration in recharge from the agricultural area was evaluated at 52mg/L, and the nitrate concentration of infiltrating river at approximately 6mg/L. The study shows the importance of considering the indirect and direct impacts of rivers on alluvial aquifers and provides a methodological framework to evaluate aquifer scale water quality patterns.

Commonly cited incentives in the community implementation of the emergency maternal and newborn care study in western Kenya

BACKGROUND

Mortality of mothers and newborns is an important public health problem in low-income countries. In the rural setting, implementation of community based education and mobilization are strategies that have sought to reduce these mortalities. Frequently such approaches rely on volunteers within each community.

OBJECTIVE

To assess the perceptions of the community volunteers in rural Kenya as they implemented the EmONC program and to identify the incentives that could result in their sustained engagement in the project.

METHOD

A community-based cross sectional survey was administered to all volunteers involved in the study. Data were collected using a self-administered supervision tool from all the 881 volunteers.

RESULTS

881 surveys were completed. 769 respondents requested some form of incentive; 200 (26%) were for monetary allowance, 149 (19.4%) were for a bicycle to be used for transportation, 119 (15.5%) were for uniforms for identification, 88 (11.4%) were for provision of training materials, 81(10.5%) were for training in Home based Life Saving Skills (HBLSS), 57(7.4%) were for provision of first AID kits, and 39(5%) were for provision of training more facilitators, 36(4.7%) were for provision of free medication.

CONCLUSION

Monetary allowances, improved transportation and some sort of identification are the main incentives cited by the respondents in this context.

Preoperative advantages of HF sonography of pilonidal sinus

Pilonidal sinus is a not infrequent disease, probably due to a disontogenetic origin. Histologically, there is a pseudocystic formation in the subcutaneous adipose tissue, containing some hair bulbs. It usually presents a recurring inflammatory course. The pathologic formation does not normally have thick wall, being made up of thin epidermal epithelium, without internal vascularisation and with frequent subcutaneous fistulae. Even though the clinical diagnosis is rather easy, surgery may prove, on the contrary, a demanding task, with a high incidence of recurrence and complications. An adequate knowledge of the condition and its development, with a precise definition of the margins of the lesions, may simplify the surgery, reducing the chance of recurrence or complications. The use of echography in the diagnosis of this disease, in our cohort of 72 patients, has always provided valuable information. In particular, 13 and 18 MHz linear probes and 20 MHz mechanical array have been used, and the latter in particular for the evaluation of fistolous cavities/passageways under the skin. Results. In all our cases, echography has demonstrated pseudocystic formations, without real walls, with fairly high levels of internal echoes, compared to the hair follicles, or, more rarely, true macrocalcifications with one or more cavities/passageways near the skin, without internal vascularisation, according to the histological findings. Echographic data are rapidly obtained, and can prove useful for surgeons for a a better management of patients. Conclusion. We consider diagnostic echography, using high frequency probes, useful for the anatomical definition of this disease, as well as to enable better surgical management.

Selective lymphadenectomy for penile cancer

INTRODUCTION

Lymph node treatment in patients with penile cancer has been longly debated in the last 15 years, with surgeons advocating therapeutic lymphadenectomy and others advocating selective lymphadenectomy (SLND).

MATERIALS AND METHODS

We evaluated the outcome of clinically node negative penile cancer patients treated with SLND. Since March 2000, 35 node negative penile cancer patients were operated on mainly at the Division of Plastic Surgery, San Gallicano Institute, Rome (Italy), with SLND.

RESULTS

A sentinel node was detected in 34 out of 35 patients (42 groins). With a minimum of five years follow up, metastases were noted in 5 out of 35 patients. Out of the remaining 30 patients, 2 developed node metastases in the operated inguinal region (6.6%).

DISCUSSION

SLND for penile cancer compared to surveillance only greatly improves survival rate and disease-free rate (91% vs 79% after 3 years follow-up). Identification of more specific markers for SCC lymph node metastases will make the false negative-rate drop further.

Cagliari University Hospital (CUH) protocol for immediate alloplastic breast reconstruction and unplanned radiotherapy. A preliminary report

INTRODUCTION

Alloplastic breast reconstruction necessitating postmastectomy radiotherapy (PMRT) is at increased risk for complications such as capsular contracture, infection, extrusion, and poor cosmetic results. However, often the indication for PMRT is not decided until a permanent histological examination with review of the permanent sections is carried out, and the expander has already been inserted. Techniques described to face this issue (delayed-immediate reconstruction and Memorial Sloan Kettering Cancer Center protocol) both have disadvantages.

MATERIALS AND METHODS

The protocol we suggest is based on (1) reconstruction with tissue expander placement at the time of mastectomy; (2) complete tissue expansion during postoperative chemotherapy; (3) radiotherapy, as suggested by oncologists; (4) two or three fat grafting session, according to Coleman's technique, 4-6 months after RT; (5) exchange of the tissue expander for a permanent implant approximately 3 months after the completion of fat grafting. Ten patients were treated according to these guidelines.

RESULTS

Results at 15 months have been encouraging, with no grade 3-4 Baker's capsular contracture.

DISCUSSION

Although the group of patients treated according to our CUH Protocol for immediate implant-based breast reconstruction and radiotherapy is small, and follow-up is short; nevertheless, results are encouraging.

[Radiofrequency ablation as a palliative therapy option in ENT tumors: in vivo and in vitro testing]

BACKGROUND

High frequency thermotherapy (HFTT) is an established palliative therapy for hepatic malignancies. An in vivo and in vitro trial examined the preconditions for the application of HFTT with liquid-cooled wet electrodes for minimally invasive palliation of head and neck tumors.

MATERIAL AND METHOD

HFTT was applied with needle electrodes, cooled with isotonic saline solution, and a high-frequency generator (Elektrotom HiTT 106, Berchtold, Tuttlingen) to porcine tongue and narcotized, juvenile domestic pigs to the tongue and neck, and monitored in realtime by B-mode ultrasound.

RESULTS

The direction of spread of the hyperthermic zone is well observed using ultrasound. Determining the direction of spread is not possible with cooled-tip electrode needles. Severe complications were not observed during the application.

CONCLUSION

RFA with liquid-cooled needle applicators is not safely applicable for the therapy of head and neck tumors.

Host- rather than virus-related factors reduce health-related quality of life in hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infection is associated with decreased health-related quality of life (HRQOL). Although HCV has been suggested to directly impair neuropsychiatric functions, other factors may also play a role.

PATIENTS AND METHODS

In this cross-sectional study, we assessed the impact of various host-, disease- and virus-related factors on HRQOL in a large, unselected population of anti-HCV-positive subjects. All individuals (n = 1736) enrolled in the Swiss Hepatitis C Cohort Study (SCCS) were asked to complete the Short Form 36 (SF-36) and the Hospital Anxiety Depression Scale (HADS).

RESULTS

833 patients (48%) returned the questionnaires. Survey participants had significantly worse scores in both assessment instruments when compared to a general population. By multivariable analysis, reduced HRQOL (mental and physical summary scores of SF-36) was independently associated with income. In addition, a low physical summary score was associated with age and diabetes, whereas a low mental summary score was associated with intravenous drug use. HADS anxiety and depression scores were independently associated with income and intravenous drug use. In addition, HADS depression score was associated with diabetes. None of the SF-36 or HADS scores correlated with either the presence or the level of serum HCV RNA. In particular, SF-36 and HADS scores were comparable in 555 HCV RNA-positive and 262 HCV RNA-negative individuals.

CONCLUSIONS

Anti-HCV-positive subjects have decreased HRQOL compared to controls. The magnitude of this decrease was clinically important for the SF-36 vitality score. Host and environmental, rather than viral factors, seem to impact on HRQOL level.

[A case of vulvar melanoma: surgical strategy and five years follow-up]

We report a case of a woman with vulvar melanoma, arisen from a plane melanocytic lesion, extended from clitoris to the left minor labium. After diagnostic biopsy, a preoperative lymphoscintigraphy with 99m-Tc nanocolloid was performed. Surgery consisted in a radical vulvectomy, radio-controlled lymphadenectomy and vulvar reconstruction by two bilateral subgluteus soft-tissue flaps, anastomosing the urethral and vaginal stumps. Five years follow-up was negative for neoplastic recurrence.

[Merkel cell carcinoma and sentinel lymph node dissection: nine cases report]

Merkel cell carcinoma (MCC) is an aggressive cutaneous-neuroendocrine neoplasia with poor prognosis and high propensity for locoregional and distant metastasis. Lack of knowledge about its biological behavior, pathogenesis, and prognostic factors, complicates the prospective evaluation. Sentinel node dissection, concomitant with radical excision of the lesion, has increased in the last few years. The suitability of this technique is linked to the MCC high tendency to spread "in primis" at locoregional nodes such as other malignancies such as cutaneous melanoma. Aim of the study is the prospective evaluation of the sentinel node dissection and of the adjuvant therapies in 9 patients MCC affected. All patients, underwent evaluation and staging of the neoplasia. Diagnosis was made by excisional biopsy and histological examination. Sentinel node dissection was performed in patients without clinical locoregional metastases (8 cases). Patients with sentinel node positive for metastasis underwent radical lymphadenectomy (3 cases). One patient affected by clinically locoregional metastases had, at once, radical lymphadenectomy. Radiotherapy and/or chemotherapy as adjuvant therapy were implemented (4 cases).

Vulvar primitive melanoma and sentinel lymph node: case report

The case of a 54-year-old woman who developed vulvar melanoma arising from a melanocytic lesion, extending from the clitoris to the left labium minor, without clinical involvement of the groin node station bilaterally is presented. The patient first underwent an incisional diagnostic biopsy that revealed a melanoma 4 mm in thickness; subsequently preoperative lymphoscintigraphy with 99m Tc Nanocoll was executed. Surgery consisted of a radio-controlled lymphadenectomy and radical vulvectomy. Two bilateral subgluteus soft-tissue flaps were made to reconstruct the surgical defect, anastomosing the urethral and vaginal stump. At 36 months follow-up the patient was negative for neoplastic recurrence.

[Merkel cell carcinoma]

Merkel cell carcinoma is a rare form of skin cancer of likely neuroendocrine origin wich affects mainly white population in sun-exposed areas. It is an aggressive tumor and survival is dependent on stage at the time of diagnosis. The staging evaluation include CT imaging and recently PET scan. Surgical excision with or without lymph node dissection, followed by postoperative radiotherapy in stage II disease, is the standard treatment of non metastatic disease. The role of adjuvant chemotherapy is still controversial. In patients with metastatic disease, chemotherapy regimens active in small cell lung cancer are generally used. The combination of cyclophosphamide, doxorubicin and vincristine (CAV) has an overall response rate of 75%, whereas the response rate of etoposide in combination with cisplatin or carboplatin is 60%. Experience with other therapeutic agents, such as tumor necrosis factor, interferon and octreotide is scanty. Recently, encouraging preliminary results with targeted agents have been reported. Our experience in 14 patients, four of whom treated with chemotherapy for advanced disease, is in agreement with literature

Basal cell carcinoma of the nose requiring amputation arising after irradiation for childhood hemangioma

A 49-year-old female, who had undergone irradiation at six years of age as a treatment for a cutaneous nasal hemangioma, developed later a devastating basal cell carcinoma requiring sub-amputation of the nose and subsequent reconstruction with a pre-expanded forehead flap. Basal cell carcinomas are now frequently reported as late sequelae of previous low-dose irradiations after 10-20 years, and patients should be aware of this possible evolution.

Reduction of behavioural disturbances in elderly dogs supplemented with a standardised Ginkgo leaf extract

In this open clinical trial conducted in 10 veterinary practices, Ginkgo leaf extract was administered as a dietary supplement to 42 elderly dogs (mean age 11.4 years) at a daily dose of 40 mg/ 10 kg body weight for 8 weeks. The "severity of the geriatric condition" in dogs with a history of geriatric behavioural disturbances (mean duration 12 months), was significantly reduced after 8 weeks of treatment (P = 0.0002). The positive effect was already apparent after 4 weeks. Thirty-six % of the dogs were completely free of clinical signs at study end. Overall efficacy of treatment as judged by the investigator was good or very good in 79% of the dogs. Five of six clinical sign scores (disorientation, sleep/activity changes, behavioural changes, general behaviour and general physical condition/vitality) also showed a significant decrease over the treatment period. In conclusion, these findings provide promising results that could increase the quality of life in the elderly dog and, as a consequence, that of the pet owner. The Ginkgo leaf extract appears to be an efficacious agent that provides a safe dietary supplement for the elderly dog with age-related behavioural disturbances.

Topical tea tree oil effective in canine localised pruritic dermatitis--a multi-centre randomised double-blind controlled clinical trial in the veterinary practice

Tea tree oil, a volatile oil, is well known for its broad antibacterial and antifungal activity. A standardised and stabilised 10% tea tree oil cream was tested against a commercial skin care cream (control cream) in the management of canine localised acute and chronic dermatitis. Fifty-seven dogs with clinical manifestations of mostly pruritic skin lesions or alterations, skin fold pyodermas and other forms of dermatitis, corroborated by predominantly positive fungal and bacterial skin isolates, were enrolled by seven practising veterinarians and randomly allocated to two study groups (28:29) and were treated twice daily with a blinded topical preparation. After 10 days of treatment, success rates of 71% for the tea tree oil cream and 41% for the control cream (over-all efficacy documented by the veterinary investigator) differed significantly (p = 0.04), favouring tea tree oil cream treatment. Accordingly on day 10, the tea tree oil cream caused significantly faster relief than the control cream (p = 0.04) for two common clinical dermatitis signs, pruritus (occurring in 84 % of dogs) and alopecia. Only one adverse event was reported in the tea tree oil group (suspected not to be causally related to the study drug) and none in the control cream group. The tested herbal cream appears to be a fast-acting safe alternative to conventional therapy for symptomatic treatment of canine localised dermatitis with pruritus.

Dietary support with Boswellia resin in canine inflammatory joint and spinal disease

An open multi-centre veterinary clinical trial, comparing conditions before and after treatment with a herbal dietary supplement consisting of a natural resin extract of Boswellia serrata, was conducted by 10 practicing veterinarians in Switzerland. This traditional plant-based supplement is known for its anti-rheumatic and anti-inflammatory properties. 29 dogs with manifestations of chronic joint and spinal disease were enrolled. Osteoarthritis and degenerative conditions were confirmed radiologically in 25 of 29 cases. The resin extract (BSB108, product of Bogar AG) was administered with the regular food at a dose of 400 mg/10 kg body weight once daily for 6 weeks. Already after two weeks of treatment, an overall efficacy of the dietary supplement was evident in 71% of 24 eligible dogs. A statistically significant reduction of severity and resolution of typical clinical signs in individual animals, such as intermittent lameness, local pain and stiff gait, were reported after 6 weeks. Effects of external factors that aggravate lameness, such as "lameness when moving" and "lameness after a long rest" diminished gradually. In 5 dogs, reversible brief episodes of diarrhea and flatulence occurred, but only once was a relationship to the study preparation suspected. Because quality and stability of the resin extract were ensured, these data suggest that a standardized preparation can be recommended as a herbal dietary supplement providing symptomatic support in canine osteoarthritic disease.

Echinacea powder: treatment for canine chronic and seasonal upper respiratory tract infections

An open multi-centered veterinary clinical trial, comparing conditions before and after treatment with a herbal preparation, containing the powdered root of Echinacea purpurea, was conducted by 6 practicing veterinarians in Switzerland. The plant-based immune stimulant was administered to 41 dogs with manifestations of chronic and seasonal upper respiratory tract infections, including pharyngitis/tonsillitis, bronchitis and kennel cough. Each animal was at an individual stage of the disease, with various symptoms and different severity scores, at start of treatment. There was no control group. Echinacea powder (1:3) was administered with the food at a dose of 1.0 g/10 kg body weight once daily for 8 weeks. Overall efficacy showed significant improvement for 92% of 39 dogs after 4 weeks of treatment and this was confirmed after 8 weeks. Significant reductions of severity and resolution of typical clinical symptoms, of clear nasal secretions, enlargement of lymph nodes, dry cough, dyspnea and dry lung sounds, were evident after 4 weeks. Only two adverse effects, not suspected to be attributable to the study drug, were recorded. Because quality and stability of the Echinacea powder were defined, using an analytical standard and purity tests, these data suggest, that the Echinacea preparation can be recommended as a well tolerated alternative treatment of canine upper respiratory tract infections.

Comparison of two fluorescence immunoassay methods for the detection of endocrine disrupting chemicals in water

We describe two fluorescence immunoassays capable of detecting endocrine disrupting compounds in waste water. The first fluorescence method is a heterogeneous assay using total internal reflection fluorescence (TIRF) detection. The second method is a homogeneous assay that utilizes energy transfer (ETIA). Both fluorescence immunoassays are compared with respect to detection principle and ability to quantify the model analytes estrone, estradiol, and ethinylestradiol in a complex matrix regarding recovery rates and limits of detection. Calibrations were performed for the three analytes using both fluorescence methods. Limits of detection between 0.01 and 0.85 microg/l are achieved. In addition, measurements in synthetic waste water spiked with the analytes were performed. Both immunoassays allow the detection in waste water with recovery rates in the range of 70-112%.

[Plantar fibromatosis: ultrasonography results]

INTRODUCTION

Plantar fibromatosis, or Ledderhose's disease, is a fibrous proliferation arising within the plantar fascia end exhibiting typical clinical nodular features. The lesion appears as a firm single thickening or a nodule, occasionally painful, localized to the medial portion of the sole of the foot. This unusual condition has not been extensively studied with US and very little has been written about it.

MATERIAL AND METHODS

In 1998-99, six patients with plantar fibromatosis were submitted to US with 13 MHz linear array and 20 MHz mechanical annular array probes. All patients were examined in prone recumbency with the probe positioned on the sole of the foot. Only some of them were subsequently submitted to surgery.

RESULTS

Plantar fibromatosis exhibited an almost pathognomonic pattern and US proved to be a quick, noninvasive and cost-effective technique to confirm clinical diagnosis. The nodule is typically single and isoechoic, with maximum diameter of about 1 cm, inhomogeneous internal structure and few thin hyperechoic septa. The nodular fibrous proliferation adheres with the major axis along the plantar fascia; it exhibits clear-cut margins and US beam transmission is good. No calcifications or fluid collections are seen within the nodule. Color and power Doppler show no flow inside.

CONCLUSIONS

US is an adequate tool for the study of plantar fibromatosis.

[Chemotherapy of advanced stage melanoma using cisplatin, epirubicin and alpha-interferon]

PURPOSE

To evaluate the activity and toxicity of cisplatin (DDP), epirubicin (EPI) and interferon alfa-2a (a-IFN) in patients (pts) with metastatic melanoma.

PATIENTS AND METHODS

Thirty-seven pts with histologically-proven metastatic melanoma were treated with DDP 75 mg/m2 e.v. and EPI 90 mg/m2 e.v. on day 1 + alpha-IFN 9 MUI/die s.c. on days 4 to 8 and 18 to 22. Cycles were repeated every 4 weeks.

RESULTS

Characteristics of the patients were the following: median age 55 years (range, 24-75), median WHO performance status 1 (range, 0-2), prior chemotherapy 9, prior immunotherapy 16 (adjuvant/advanced 11/5), sites of disease: soft tissue only 10, lung 22, liver 11, bone 1, brain 3. In 35 evaluable patients we have obtained 3 complete and 10 partial responses, for an overall response rate of 37%. Dose-limiting toxicity was myelosuppression with grade (G) 4 neutropenia in 59.5% of patients and G4 thrombocytopenia in 11% of patients. Other toxicities were generally mild to moderate with nausea and vomiting in 67.5% of patients, flu-like syndrome in 78.5% and fatigue in 48.5% of the patients. Median time to response, median time to progression and survival were 3 (range, 2-6), 7 (range, 2-45+) and 10 months (range, 4-45+), respectively.

CONCLUSION

This combination is active and well tolerated in metastatic melanoma. Toxicity was manageable and has enabled us to conduct this trial on an outpatient basis.

[Role of high-definition and high frequency ultrasonography in determining tumor thickness in cutaneous malignant melanoma]

PURPOSE

We investigated the predictive capabilities of high frequency, high resolution ultrasound (US) in the preoperative assessment of tumor thickness in cutaneous malignant melanomas. This evaluation is a valuable help for correct surgical planning.

MATERIAL AND METHODS

December 1997 to August 1998, we studied with US over 120 pigmented skin lesions and collected the data, including the final histologic diagnosis, of 78 of them, which make our series. Sixty-six of 78 lesions were histologically defined as cutaneous malignant melanomas with superficial spread and the other 12 as melanocytic nevi. All examinations were carried out with an Esaotebiomedica AU 5 Harmonic scanner equipped with a 20-MHz annular array probe and a linear 13-MHz probe; B-mode, color and power Doppler images were always acquired.

RESULTS

The statistical analysis of the comparative US and histologic measurements of tumor thickness showed very good agreement, with a high Pearson's coefficient (R: .93). However, US frequently underestimated the actual thickness relative to histology, which is in contradiction with previous literature reports. We could study with US the melanoma in situ, which has never been described before. Last but not least, low-thickness melanomas had very few color and power Doppler signals.

CONCLUSIONS

US is the correct tool for the preoperative assessment of the thickness of cutaneous malignant melanomas because it provides high agreement with histologic data even in lesions thinner than 1 mm.

The developmental expression of neuronal nitric oxide synthase in cerebellar granule cells is sensitive to GABA and neurotrophins

In the adult cerebellar cortex, the differential expression of neuronal nitric oxide synthase (nNOS) can be used to discern discrete subsets of granule neurons. These subsets originate concurrently with the afferent innervation of granule neurons. Using primary cultures established from murine cerebella at different development stages, we analyzed the effects of the neurotransmitter GABA and the neurotrophins BDNF and NT-3 on nNOS expression in developing granule cells. We show a biophasic effect of GABA on nNOS expression, which correlates with the ability of this transmitter to increase intracellular calcium levels. BDNF and NT-3 are shown to increase nNOS levels in cultures derived from postnatal, but not in those from embryonic cerebella. Together with previous findings [Baader and Schilling; J Neurosci 1996; 16:1440-1449], these data suggest a scenario in which afferent innervation and growth factors cooperate to differentially affect nNOS expression at discrete developmental stages of cerebellar granule cells.

Involvement of the 4q21 region in human malignant melanomas: cytogenetic and immunocytochemical characterization of three primary cell cultures

The GRO1 oncogene (melanoma growth-stimulating activity alpha) has been localized in region 4q21. The involvement of this chromosomal region in clonal aberrations found in primary melanoma cell cultures could have an important role in the etiology and pathogenesis of this tumor. We characterized three primary cell cultures obtained from different patients, each of which showed clonal chromosomal aberrations involving the 4q21 region.

Anhedonia or anergia? Effects of haloperidol and nucleus accumbens dopamine depletion on instrumental response selection in a T-maze cost/benefit procedure

Two experiments were conducted to study the role of dopamine in the performance of a novel cost/benefit procedure. Rats were trained on a T-maze task in which one arm contained a high reinforcement density (4 x 45 mg Bioserve pellets) and the other arm contained a low reinforcement density (2 x 45 mg pellets). Different groups of rats were trained either with unobstructed access to both arms from the start area, or under a condition in which a large vertical barrier (44 cm) was placed in the arm that contained the high density of food reinforcement. In the first experiment, rats trained under each procedure received injections of 0.1 mg/kg haloperidol and tartaric acid vehicle as a control procedure. Analysis of variance indicated that there was a significant effect of the barrier on maze arm choice, a significant effect of haloperidol, and a significant drug x barrier interaction. Haloperidol did not affect arm choice in rats tested without the barrier present, but this drug significantly reduced the number of selections of the arm with high reinforcement density when the barrier was present. In the second experiment, groups of rats were trained as described above, and then received intraaccumbens injections of 6-hydroxydopamine or ascorbate vehicle. Nucleus accumbens dopamine depletions produced by 6-hydroxydopamine decreased the number of selections of the arm with high reinforcement density when the barrier was present, but had no effect on arm choice when the barrier was not present.(ABSTRACT TRUNCATED AT 250 WORDS)

Neural cell adhesion molecules in rat endocrine tissues and tumor cells: distribution and molecular analysis

The adhesive properties of neural cell adhesion molecules (NCAMs) can be modified by alternative splicing of the primary transcript or posttranslational modifications. In the present study, we describe distinct forms of alternative splicing and posttranslational modification of the extracellular domain of NCAM of various endocrine tissues and derived tumor cells of the rat. Using an antiserum detecting the immunoglobulin-like domains of NCAM as well as a monoclonal antibody recognizing the NCAM-specific polysialic acid (PSA), we observed a similar staining pattern in adrenals, pituitary, and neoplastic endocrine cells. In endocrine tumor cells [pheochromocytoma (PC12), insulinoma (RINA2), and pituitary tumor cells (GH3)], NCAM immunoreactivity was most intense at contact sites between the cells. The immunocytochemical data were substantiated by results of in situ hybridization histochemistry. Specifically, higher levels of NCAM mRNA were detected in the adrenal cortex than in the medulla. In the pituitary, NCAM mRNA was more abundant in the anterior and intermediate lobes than in the neural lobe. The sequence of NCAM mRNAs in endocrine cells was analyzed by polymerase chain reaction and S1 nuclease protection assays. We found that major exons 4-13 of the NCAM mRNA in endocrine tissues and related tumor cell lines were homologous to those in the brain. However, PC12, RINA2, and GH3 tumor cells; normal rat pituitaries; and adrenals contained different amounts of NCAM mRNA with an alternative extra exon, termed VASE (also called pi in mouse) between constitutive exons 7 and 8. In addition, in pituitaries, we detected an alternative exon in splice site a between the constitutive exons 12 and 13, termed a15, with or without an AAG triplett. These sites are thought to be important for the adhesive properties of NCAM. Therefore, these results suggest that modifications of NCAM may be important for adhesive interactions in normal and neoplastic endocrine cells.

Basic fibroblast growth factor (bFGF) in rodent testis. Presence of bFGF mRNA and of a 30 kDa bFGF protein in pachytene spermatocytes

We have previously described a 30 kDa basic fibroblast growth factor (bFGF)-like protein in rodent testicular homogenates and have shown that pachytene spermatocytes are the sites of predominant immunoreactivity for this bFGF-like protein (Mayerhofer, A., Russell, L.D., Grothe, C., Rudolf, M. and Gratzl, M. (1991) Endocrinology 129, 921-924). We have now addressed the question whether this 30 kDa bFGF-like protein is a large bFGF form and whether it is produced by pachytene spermatocytes. We detected bFGF mRNA in homogenates of isolated mouse spermatocytes (which consisted mainly of pachytene spermatocytes) using S1 nuclease protection assays. As shown by Western blot analyses, the bFGF mRNA in mouse spermatocytes is translated into bFGF of an approximate molecular weight of 30 kDa. Neither bFGF mRNA, nor bFGF itself, was observed in isolated mouse Leydig cells. These results indicate that the immunoreactive bFGF-like protein observed previously in germ cells of the murine testis is identical to bFGF. Thus, germ cells of the testis produce bFGF, which may exert regulatory function in the process of spermatogenesis.

Relationship between maternal and fetal lung growth

This study analyzes the relationship between the maternal and fetal lungs, in rats in relation to litter size, to determine whether the enlargement of maternal lung during pregnancy is concurrent with that of the fetal lung. Pregnant albino rats were sacrificed on gestation day 21 (term 22 days). Maternal lung growth was assessed by measuring the lung weight, lung air volume and lung DNA content, and the fetal lung growth by lung DNA content. The findings were as follows: (1) no differences were noted between the lungs of non-pregnant rats and pregnant rats with small litter size (1-4); (2) pregnant rats with large litter size (10-18) had larger lungs than rats with small litter size; (3) there was a direct relationship between cellularity (DNA content) of the fetal lung and maternal lung when the latter underwent a growth change during pregnancy; (4) no relationship in cellularity was found between the maternal lung and placenta nor between the fetal lung and placenta. The results suggest that factors or processes which regulate the growth and dictate the size of the maternal lung during pregnancy similarly influence the fetal lung.

Maternal lung growth in surgically reduced litter size pregnancy

In our previous study (Faridy et al., this issue) we observed that pregnant rats with large litter size have larger lungs than rats with small litter size. The present study was conducted to test the hypothesis that in large litter size pregnancy, the maternal lung may not enlarge if, during pregnancy, the large litter size of 11-18 is surgically reduced to a small litter size of 3. A laparotomy was performed in pregnant albino rats at gestation day 7 (R7) or 14 (R14), all fetuses except 3 were removed and the rats were sacrificed at gestation day 21 (term 22 days). Maternal lung growth was assessed by measuring lung weight, lung DNA content and lung air volume, and the fetal lung growth by lung DNA content. The results were then compared with control pregnant rats of large (11-18) and small (1-3) litter size. The findings were: (1) reduction of litter size hindered maternal lung enlargement; (2) the earlier in pregnancy the surgical reduction was performed the smaller was the maternal lung, such that control (11-18) greater than R14 greater than R7 = control (1-3); (3) fetuses of R14 rats had larger lungs per body weight than R7 rats; (4) oxygen consumption of sham-operated rats with large litter size was higher (by 8-12%) than R7 rats. The results suggest that enlargement of maternal lung during pregnancy is related to litter size and perhaps to VO2. The fact that R14 fetal lung is larger than that of R7, supports our previous notion (Faridy et al., this tissue) that factors regulating the maternal lung growth similarly influence the fetal lung.