National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

1447 Trends in Lower Extremity Amputation Incidence in European Union 15+ Countries 1990-2017

Aim

To assess trends in lower extremity amputation (LEA) incidence in European Union (EU15+) countries for the years 1990-2017.

Method

This was an observational study using data obtained from the 2017 Global Burden of Disease (GBD) Study. Age standardised incidence rates (ASIRs) for LEA (stratified into toe amputation, and LEA proximal to toes) were extracted from the GBD Results Tool (http://ghdx.healthdata.org/gbd-results-tool) for EU15+ countries for each of the years 1990-2017. Trends were analysed using Joinpoint regression analysis.

Results

Between 1990 and 2017, variable trends in the incidence of LEA were observed in EU15+ countries. For LEAs proximal to toes, increasing trends were observed in six of 19 countries and decreasing trends in nine of 19 countries, with four countries showing varying trends between sexes. For toe amputation, increasing trends were observed in eight of 19 countries and decreasing trends in eight of 19 countries for both sexes, with three countries showing varying trends between sexes. Australia had the highest ASIRs for both sexes in all LEAs at all time points, with steadily increasing trends. The USA observed the greatest reduction in all LEAs in both sexes over the time period analysed (LEAs proximal to toes: female patients 22.93%, male patients 29.76%; toe amputation: female patients 29.93%, male patients 32.67%). The greatest overall increase in incidence was observed in Australia.

Conclusions

Variable trends in LEA incidence were observed across EU15+ countries. These trends do not reflect previously observed reductions in incidence of PAOD over the same time period.

Eurobloodpack: a common European design for blood bag systems with integral leucodepletion filters

Three EBA specified blood bag configurations ('Eurobloodpack') are described which are capable of meeting >80% of its member's requirements. These include a 'top-and-top' and two 'bottom-and-top' packs enabling aseptic, pre-donation collection of up to 40 ml of samples, 427.5-522.5 ml of whole blood and the preparation of an extensive range of blood components. Features currently beyond the scope of ISO standardisation have been controlled including: anticoagulant and additive volumes; collection needle and sampling system; transfer tubing; cross-match line; base label; leucodepletion filter performance; compatibility of access ports and transfusion sets. Eurobloodpack has significant advantages for blood services and blood bag manufacturers.

Cryoprecipitate prepared from plasma treated with methylene blue plus light: increasing the fibrinogen concentration

When cryoprecipitate is prepared from plasma which has been treated with methylene blue plus light (MB) for the purpose of virus inactivation, clottable fibrinogen content is 40% lower compared with units prepared from untreated plasma. Initial studies showed that when frozen MB plasma units were removed to +2 to +6 degrees C for 4 h and then returned to -40 degrees C prior to cryoprecipitation, fibrinogen recoveries increased from 24 to 42%. Although fibrinogen yield improved when plasma units were stored at +2 to +6 degrees C for varying lengths of time, FVIII levels decreased with increasing time. Conditioning for 8 h was studied in more detail. Groups of two plasma units were mixed together, divided into two equal units, frozen/thawed and treated with MB. One of each pair was stored continually at -40 degrees C, whereas the other was removed to +2 to +6 degrees C for 8 h. Samples were assayed for fibrinogen, FVIII, VWF:Ristocetin cofactor activity (RCo), VWF:Ag and VWF:Collagen binding (CB). The cryoprecipitate fibrinogen content increased to a mean of 207 mg unit(-1). VWF:Ag, VWF:RCo and VWF:CB recoveries also increased. FVIII recovery decreased from 50 to 45% (mean 124 iu unit(-1)). Conditioning has been validated for routine production of cryoprecipitate from imported plasma.

Haplotype tagging for the identification of common disease genes

Genome-wide linkage disequilibrium (LD) mapping of common disease genes could be more powerful than linkage analysis if the appropriate density of polymorphic markers were known and if the genotyping effort and cost of producing such an LD map could be reduced. Although different metrics that measure the extent of LD have been evaluated, even the most recent studies have not placed significant emphasis on the most informative and cost-effective method of LD mapping-that based on haplotypes. We have scanned 135 kb of DNA from nine genes, genotyped 122 single-nucleotide polymorphisms (SNPs; approximately 184,000 genotypes) and determined the common haplotypes in a minimum of 384 European individuals for each gene. Here we show how knowledge of the common haplotypes and the SNPs that tag them can be used to (i) explain the often complex patterns of LD between adjacent markers, (ii) reduce genotyping significantly (in this case from 122 to 34 SNPs), (iii) scan the common variation of a gene sensitively and comprehensively and (iv) provide key fine-mapping data within regions of strong LD. Our results also indicate that, at least for the genes studied here, the current version of dbSNP would have been of limited utility for LD mapping because many common haplotypes could not be defined. A directed re-sequencing effort of the approximately 10% of the genome in or near genes in the major ethnic groups would aid the systematic evaluation of the common variant model of common disease.

The effect of atovaquone on etoposide pharmacokinetics in children with acute lymphoblastic leukemia

PURPOSE

The use of trimethoprim/sulfamethoxazole in the prevention of Pneumocystis carinii pneumonia in patients with acute lymphoblastic leukemia (ALL) may cause undesirable adverse effects: fungal overgrowth, neutropenia, and drug resistance. A possible alternative is atovaquone, a hydroxynaphthoquinone with anti-Pneumocystis carinii activity. However, it is not known if atovaquone alters the disposition or adverse effects of antileukemic drugs.

METHODS

Using a crossover study design, we compared the pharmacokinetics of etoposide and its CYP3A4-formed catechol metabolite when given as a 300 mg/m2 i.v. infusion following daily atovaquone versus trimethoprim/sulfamethoxazole in nine patients.

RESULTS

The area under the concentration time curve (AUC) of etoposide, etoposide catechol and the catechol to etoposide AUC ratio were slightly higher (a median of 8.6%, 28.4%, and 25.9%) following atovaquone as compared to trimethoprim/sulfamethoxazole (P=0.055, P= 0.031 and P=0.023), respectively. In vitro analysis in human liver microsomes showed modest inhibition of etoposide catechol formation in the presence of atovaquone. Using uptake of 3H-vinblastine in L-MDR1 cells, atovaquone was shown to inhibit P-glycoprotein with an apparent Ki of 95.6 microM.

CONCLUSIONS

Although the effect of atovaquone on etoposide disposition was modest, in light of the fact that the risk of etoposide-related secondary acute myeloid leukemia has been linked to minor changes in schedule and concurrent therapy, we suggest caution with the simultaneous administration of atovaquone and etoposide, particularly if used with other CYP3A4/P-glycoprotein substrates.

Clinical features of hereditary progressive arthro-ophthalmopathy (Stickler syndrome): a survey

PURPOSE

To define variations in the clinical manifestations of Stickler syndrome.

METHODS

A questionnaire was sent to 612 persons.

RESULTS

Of the 316 usable replies, 95% of persons had eye problems (retinal detachment occurred in 60% of patients, myopia in 90%, and blindness in 4%); 84% had problems with facial structures such as a flat face, small mandible, or cleft palate; 70%, hearing loss; and 90%, joint problems, primarily early joint pain from degenerative joint disease. Treatment included cryotherapy and laser therapy for retinal detachment, repair of cleft palate, use of hearing and mobility aids, and joint replacements.

CONCLUSIONS

There are wide variations of symptoms and signs among affected persons, even within the same family. There are delays in diagnosis, lack of understanding among family members, denial about the risk of serious eye problems, and joint disease.

Safety and single-dose pharmacokinetics of abacavir (1592U89) in human immunodeficiency virus type 1-infected children

Abacavir (formerly 1592U89) is a potent 2'-deoxyguanosine analog reverse transcriptase inhibitor that has been demonstrated to have a favorable safety profile in initial clinical trials with adults with human immunodeficiency virus (HIV) type 1 infection. A phase I study was conducted to evaluate the pharmacokinetics and safety of abacavir following the administration of two single oral doses (4 and 8 mg/kg of body weight) to 22 HIV-infected children ages 3 months to 13 years. Plasma was collected for analysis at predose and at 0.5, 1, 1.5, 2, 2.5, 3, 5, and 8 h after the administration of each dose. Plasma abacavir concentrations were determined by high-performance liquid chromatography, and data were analyzed by noncompartmental methods. Abacavir was well tolerated by all subjects. The single abacavir-related adverse event was rash, which occurred in 2 of 22 subjects. After administration of the oral solution, abacavir was rapidly absorbed, with the time to the peak concentration in plasma occurring within 1.5 h postdosing. Pharmacokinetic parameter estimates were comparable among the different age groups for each dose level. The mean maximum concentration in plasma (Cmax) and the mean area under the curve from time zero to infinity (AUC0-infinity) increased by 16 and 45% more than predicted, respectively, as the abacavir dose was doubled from 4 to 8 mg/kg (Cmax increased from 1.69 to 3.94 micrograms/ml, and AUC0-infinity increased from 2.82 to 8.09 micrograms.h/ml). Abacavir was rapidly eliminated, with a mean elimination half-life of 0.98 to 1.13 h. The mean apparent clearance from plasma decreased from 27.35 to 18.88 ml/min/kg as the dose increased. Neither body surface area nor creatinine clearance were correlated with pharmacokinetic estimates at either dose. The extent of exposure to abacavir appears to be slightly lower in children than in adults, with the comparable unit doses being based on body weight. In conclusion, this study showed that abacavir is safe and well tolerated in children when it is administered as a single oral dose of 4 or 8 mg/kg.

Phase I safety and pharmacokinetics study of micronized atovaquone in human immunodeficiency virus-infected infants and children. Pediatric AIDS Clinical Trials Group

A phase I dose-escalating safety and pharmacokinetic study evaluated an oral suspension of micronized atovaquone (m-atovaquone) in infants and children stratified into age groups from 1 month to 12 years of age. Dosages of 10, 30, and 45 mg/kg of body weight/day were evaluated as single daily doses over a period of 12 days. Steady-state concentrations in plasma were determined on day 12, and single postdose concentrations were measured on days 1, 3, 5, 7, 9, 13, 15, 18, 21, and 24. Prior studies with adults suggest that the average plasma atovaquone concentration of 15 micrograms/ml is associated with therapeutic success in more than 95% of patients with Pneumocystis carinii pneumonitis. The results showed m-atovaquone to be safe and well tolerated. Dosages of 30 mg/kg/day were adequate to achieve an average steady-state concentration of greater than 15 micrograms/ml in children ages 1 to 3 months and 2 to 12 years, but a dosage of 45 mg/kg/day was needed to reach this concentration in infants 3 to 24 months of age. The oral suspension of atovaquone is safe and well tolerated in children. A single daily dose of 30 mg/kg provides bioavailability considered adequate for therapy of P. carinii pneumonia, but infants between 3 and 24 months of age may require a dosage of 45 mg/kg/day.

Secondary structure and shape of plasma sex steroid-binding protein--comparison with domain G of laminin results in a structural model of plasma sex steroid-binding protein

We have analyzed the secondary structure, shape and dimensions of plasma sex steroid-binding protein (SBP) by CD, size-exclusion chromatography and electron microscopy. CD spectra show extrema at 186 nm and 216 nm characteristic for beta-sheet structures. Analysis with different algorithms indicates 15% alpha-helix, 43% beta-sheet and 10-16% beta-turn structures. An irreversible structural change is observed upon heating above 60 degrees C, which correlates with the loss of steroid-binding activity. As the SBP sequence shows similarity with domains of several multidomain proteins, including laminins, we evaluated the structure of domain G of laminin-1. The CD spectrum shows extrema at 200 nm and 216 nm. Deconvolution results in 13% alpha-helix, 32% beta-sheet and 15% beta-turn structures. Steroid-binding assays indicate that laminin and fragments thereof have no activity. Size-exclusion chromatography reveals that SBP has an extended shape and can be modeled as a cylinder with a length and diameter of 23 nm and 3 nm, respectively. This shape and the dimensions are in agreement with the appearance on electron micrographs. We propose a model for the structure of SBP in which two monomers assemble head to head with the steroid-binding site located in the center of the rod-like particle.

Direct evidence for the localization of the steroid-binding site of the plasma sex steroid-binding protein (SBP or SHBG) at the interface between the subunits

Complete dissociation of dimeric plasma sex steroid-binding protein (SBP or SHBG) was obtained in 6 M urea at 10 degrees C. Removal of urea resulted in the refolding of monomers, followed by reformation of dimeric SBP, which migrates with the same mobility as the native protein. Dimerization does not require Ca+2 or steroid. Renatured monomers yield dimers with dissociation constants for 5 alpha-dihydrotesterone (DHT) and 17 beta-estradiol (E2) indistinguishable from those of native human SBP. This phenomenon was also demonstrated by mixing human and rabbit SBPs that, upon renaturation, form a hybrid dimer composed of one human subunit and one rabbit subunit. The hybrid binds both DHT and E2 in contrast to rSBP, which only binds the androgen. Therefore, we conclude that (1) docking of the two subunits creates an asymmetric steroid-binding site located at the interface between the subunits, and (2) only one face of the dimer defines the specificity for binding E2 by encompassing portion of a structural motif that recognizes the flat ring A of E2. The remaining portion, which recognizes the saturated ring A of DHT, is shared by both faces of the dimer. Because native monomers do not exist alone, the often-asked question of whether the SBP monomer binds steroid can be considered meaningless; steroid-binding activity is expressed only in the dimeric state. Finally, formation of the hybrid indicates that SBP dimerization represents a conserved event during the molecular evolution of SBP, suggesting that the structural elements responsible for dimerization will be homologous in SBPs from other species.

Optimized standby rate reduces the ventricular rate variability in pacemaker patients with atrial fibrillation

Patients with chronic atrial fibrillation (AF) and symptomatic bradycardia often receive ventricular-based pacemakers. However, many of these patients continue to have symptoms of palpitations, which may be due to ventricular rate variability. It has previously been shown that continuous ventricular pacing during AF has a stabilizing effect on the ventricular rate. Hence, a study was initiated to determine whether a patient-specific optimal ventricular standby rate that reduces the ventricular rate variability, without over-pacing, could be predicted. A ventricular rate stabilization (VRS) pacing algorithm that increases the pacing rate until instability is reduced below a threshold was developed. The VRS algorithm was utilized to determine a patient-specific standby rate in 15 patients with chronic AF, intact AV nodal conduction, and implanted pacemakers. The computer algorithm controlled a pacemaker programmer to automatically change the pacemaker's ventricular pacing rate via telemetry. Patients were studied for 15 minutes with VRS and for 15 minutes with 50 ppm fixed rate pacing (control). The results were as follows: (1) VRS versus control = P < 0.05; (2) mean ventricular pacing rate (ppm): 77 +/- 13 versus 50 +/- 0; (3) mean ventricular rate (beats/min): 82 +/- 13 versus 79 +/- 12; (4) ventricular rate coefficient of variation (%): 11 +/- 1 versus 22 +/- 5; (5) percent pacing: 75 +/- 8 versus 6 +/- 8; (6) percent of RR intervals less than minimum pacing interval eliminated: 58 +/- 12; (8) regression analysis: mean VRS pacing rate (beats/min) = 0.96 x mean control ventricular rate + 2.3, r2 = 0.85. We concluded that: (1) a moderate increase in the ventricular pacing rate was required to substantially stabilize the ventricular rate; (2) the resulting mean ventricular rate increased marginally; (3) a majority of RR cycles less than each patient's minimum pacing interval were eliminated; and (4) there was a linear relationship between the mean ventricular rate during control and the optimal ventricular pacing rate. Thus, a ventricular pacing rate close to the mean ventricular rate during control consistently reduced the ventricular variability. Although pacing at an increased ventricular standby rate reduces variability at rest, the optimal solution would likely be an adaptive rate algorithm that changes the ventricular standby rate as the mean intrinsic rate varies.

A multicentre assessment of the specificity of ten anti-HBc screening tests

Samples from 1828 donations were screened for anti-HBc at seven sites in the UK using kits supplied by 10 manufacturers. Only 10 (0.55%) donations were considered to have true anti-HBc reactivity and these were detected by all 10 kits. Additional markers of HBV infection were found in nine of these 10 donations. Additional reactives were found by all kits, the number ranging from 1 to 43. In the four more specific kits, the 10 true reactives were clearly distinguished from the 'false reactives' by the strength of the reaction. It is concluded that the reliance on a single ELISA test for anti-HBc diagnosis is unwise. The use of a second test known to be more specific than the screening ELISA is recommended.

Torsades de pointes ventricular tachycardia following right pneumonectomy: insights into the relation between right cardiac sympathetic nerve damage, QT intervals, and arrhythmias

Polymorphic ventricular tachycardia in association with prolongation of the QT interval on the surface electrocardiogram (ECG) has long been recognized as an important cause of life threatening arrhythmias that can occur with congenital or acquired abnormalities of cardiac repolarization. One hypothesis of the origin of these arrhythmias states that overactivity of the left-sided sympathetic or under activity of the right-sided sympathetic neural input to the heart leads to prolonged repolarization and ventricular arrhythmias. This hypothesis has led to the application of left cervicothoracic sympathetectomy for control of arrhythmias in congenital long QT syndromes. Although animal models have shown QT prolongation following right stellate ganglionic section or left stellate stimulation, spontaneous ventricular arrhythmias following stellate stimulation or block in man have not been demonstrated. We report the case of a patient with life threatening ventricular arrhythmias following surgical damage to the right cardiothoracic sympathetic nerves.

Abdominal aortic aneurysm and associated colorectal carcinoma: a management problem

The increasing age of the population has led to the more common occurrence of multi-organ disease. Colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) in the same patient is a difficult management problem. Over 10 years, 23 patients with CRC and AAA were treated at Concord Hospital. The management and outcome of these patients was reviewed to identify an optimum plan for patients with both conditions. The average age of patients was 71 years, ranging from 52 to 90 years. There was only one female patient in the series. In 19 of the patients, the AAA and CRC were synchronous, while in the other four patients the AAA and CRC were remote events. Within the group of patients with synchronous AAA and CRC. 12 had the diagnosis of both conditions made pre-operatively. However, in seven cases an unexpected AAA or CRC was found at operation for the other condition. Sixteen patients underwent resection of the CRC, while only eight underwent repair of the AAA. There were three deaths following CRC resection, two following AAA resection, and one following simultaneous CRC resection and AAA repair. Two of 10 patients with large (> 6 cm) AAA, who underwent CRC resection, ruptured the AAA in the postoperative period. A further patient ruptured 10 months following CRC resection. Colorectal cancer was given priority over AAA when these conditions were found simultaneously. The present study suggests that a large AAA (> 6 cm) should be either given preferential treatment, or resected simultaneously, in view of the high risk of rupture.

Astrocytic hypertrophy: an important pathological feature of chronic experimental autoimmune encephalitis in aged rats

Experimental autoimmune encephalomyelitis (EAE) was induced in young (2-3 month old), middle-aged (12-13 month old) and geriatric (24-26 month old) Lewis (JC) rats by active immunisation with myelin basic protein (MBP) in complete Freund's adjuvant (CFA). It was found that aged Lewis (JC) rats developed a more chronic form of EAE than younger rats of the same strain, a phenomenon observed in both male and female rats despite males developing more severe disease than females at all ages. Middle-aged recipients also developed more severe disease than young recipients when EAE was induced by the adoptive transfer of lymphocytes from actively immunised young donors, suggesting that disease chronicity in middle-aged animals is a property of the central nervous system (CNS) milieu. Histological studies demonstrated that disease chronicity did not correlate with the number of inflammatory lesions in the CNS, young animals containing substantial numbers of CNS lesions following recovery and lesions being largely absent from middle-aged animals which still exhibited signs of disease. No significant differences were found in the degree of fibrin deposition or demyelination between young and middle-aged or symptomatic and asymptomatic animals. However, astrocytic hypertrophy was found to correlate with manifestation of disease in both young and middle-aged animals and in particular with disease chronicity in middle-aged animals. In parallel studies, no significant differences were found in the levels of the inflammatory mediators tumor necrosis factor (TNF)-alpha, prostaglandin E (PGE)2, reactive nitrogen intermediates (RNI) and corticosterone in young and middle-aged animals. However, markedly elevated corticosterone levels were found in both young and middle-aged animals with the development of clinical signs which returned to baseline levels with the resolution of clinical signs. Elevated levels of RNI were evident in animals immediately prior to and during the early stages of symptomatic EAE. Although these results suggest that nitric oxide may play a role in the pathogenesis of disease, whereas corticosterone may play a role in the immunoregulation of the disease, these factors cannot explain differences in disease chronicity evident in middle-aged animals.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of atovaquone (566C80) with trimethoprim-sulfamethoxazole to treat Pneumocystis carinii pneumonia in patients with AIDS

BACKGROUND

Both trimethoprim-sulfamethoxazole and pentamidine are effective as treatments for Pneumocystis carinii pneumonia, but adverse effects frequently limit their use. Atovaquone (566C80) is a new hydroxynaphthoquinone with activity against P. carinii.

METHODS

We conducted a double-blind, multicenter study in patients with the acquired immunodeficiency syndrome and mild or moderately severe P. carinii pneumonia. They were randomly assigned to 21 days of orally administered treatment three times daily with either atovaquone (750 mg) or trimethoprim (320 mg) plus sulfamethoxazole (1600 mg).

RESULTS

Of the 322 patients with histologically confirmed P. carinii pneumonia, 160 received atovaquone and 162 received trimethoprim-sulfamethoxazole. Of those who could be evaluated for therapeutic efficacy, 28 of 138 patients given atovaquone (20 percent) and 10 of 146 patients given trimethoprim-sulfamethoxazole (7 percent) did not respond (P = 0.002). Treatment-limiting adverse effects required a change of therapy in 11 patients in the atovaquone group (7 percent) and 33 patients in the trimethoprim-sulfamethoxazole group (20 percent) (P = 0.001). Therapy involving only the initial drug was successful and free of adverse effects in 62 percent of those assigned to atovaquone and 64 percent of those assigned to trimethoprim-sulfamethoxazole. Within four weeks of the completion of treatment, there were 11 deaths in the atovaquone group (4 due to P. carinii pneumonia) and 1 death in the trimethoprim-sulfamethoxazole group (P = 0.003). Diarrhea at entry was associated with lower plasma drug concentrations (P = 0.009), therapeutic failure (P < 0.001), and death (P < 0.001) in the atovaquone group but not in the trimethoprim-sulfamethoxazole group.

CONCLUSIONS

For the treatment of P. carinii pneumonia, atovaquone is less effective than trimethoprim-sulfamethoxazole, but it has fewer treatment-limiting adverse effects.

The effect of prophylactic nitroglycerin infusion on the incidence of regional wall-motion abnormalities and ST segment changes in patients undergoing coronary artery bypass surgery

The effects of nitroglycerin (NTG) on regional wall-motion abnormalities, ST segment changes, and the incidence of myocardial infarction (MI), cardiac failure, and mortality were studied in 30 patients undergoing coronary artery bypass. Patients received continuous infusions of either normal saline or NTG (1 microgram/kg per min [low dose] or 2 micrograms/kg per min [high dose]) beginning at anesthesia and continuing for 4 hours postoperatively. The occurrence of wall-motion abnormalities as detected by transesophageal echocardiography was 38 events in the normal saline group (N = 10). Significantly fewer events (p < 0.05) were recorded in the low dose and high dose NTG groups (20 events and 15 events, respectively) compared to controls. There were no significant differences between the control and NTG groups with regard to the incidence of Holter ST segment events or the incidence of MI, cardiac failure, or cardiac death. NTG reduced the incidence of echocardiographic wall-motion abnormalities in a dose dependent manner while having no significant effect on other parameters examined.

A preliminary evaluation of 566C80 for the treatment of Pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome

BACKGROUND

The drug 566C80 is an investigational hydroxynaphthoquinone that is active against Pneumocystis carinii in vitro and in animal models. Initial studies in humans indicate that 566C80 is safe and has adequate bioavailability after oral administration.

METHODS

We conducted an open-label trial of 566C80 in 34 adults with the acquired immunodeficiency syndrome (AIDS) and untreated pneumocystis pneumonia. All the patients had a partial pressure of arterial oxygen of at least 60 mm Hg while breathing room air. They were enrolled sequentially in three cohorts taking 566C80 at different dosages, all administered orally: 750 mg three times daily for 5 days, then twice daily for 16 days; 750 mg three times daily for 21 days; and 750 mg four times daily for 21 days.

RESULTS

All 34 patients survived, and 27 (79 percent) were successfully treated with 566C80 alone. The mean partial pressure of oxygen in 33 patients was 78 mm Hg at entry and 93 mm Hg after the course of 566C80 (P less than 0.001). In five patients (15 percent) the drug was discontinued because of lack of response. In four patients (12 percent), the drug was discontinued because of toxicity (fever and rash in two patients each). In two of these, treatment was considered to have succeeded because 566C80 was not discontinued because of toxicity until after day 14. Five of the successfully treated patients had rashes that resolved despite continued therapy. In nine patients, serum alanine aminotransferase levels rose above 100 U per liter. During the first three months after the completion of therapy, pneumocystis pneumonia recurred in 4 of the 27 successfully treated patients, and another 3 patients had recurrences between month 3 and month 6 of follow-up. The mean (+/- SEM) steady-state plasma levels of 566C80 were similar in the three cohorts: 16.3 +/- 2.10, 20.4 +/- 2.48, and 18.9 +/- 3.08 micrograms per milliliter in the patients taking the drug twice daily, three times daily, and four times daily, respectively.

CONCLUSIONS

From these preliminary data, the investigational compound 566C80 appears to be a safe, effective, and well-tolerated therapy for P. carinii pneumonia of mild-to-moderate severity in patients with AIDS.

An investigation of the safety of the blood reinfusion step used with tunneled venous access devices in children with cancer

Infection has been identified as the most serious potential complication of the indwelling catheter. As a result, the primary nursing goal using the catheters is to prevent infection. Nurses must frequently manipulate the catheters when securing blood specimens and are concerned that this manipulation may serve as a source of infection for the immunocompromised pediatric oncology patient. One particular step in catheter manipulation during blood sampling is blood reinfusion, ie, residual blood in the catheter is withdrawn and set aside while a second sample is collected for laboratory analysis but is subsequently returned to the patient through the catheter. The purpose of this study was to examine this nursing procedure for its potential of contaminating the blood sample that was to be reinfused, or for the potential of reinfusing a sample that contained preexisting pathogens independent of the procedure itself. An experimental design was used with 21 patients randomly assigned to an experimental group (unclean procedure to exaggerate the potential to incur pathogens during the process), and 21 randomly assigned to a control group (usual clean procedure followed with the reinfusion sample). The usual blood sampling procedure was altered for all participants as the typical amount of blood that normally constitutes the reinsertion sample was not reinserted, but was instead used to complete certain microbial analyses. Of the 42 participants, 17 were male and 25 were female; 35 were white and seven were black; 22 were diagnosed with leukemias and 20 with solid tumors. The age range for participants was 2 to 20 years (mean = 9.4 years, SD = 4.8).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary structure of a novel barley gene differentially expressed in immature aleurone layers

As a direct approach to elucidate the molecular biology of barley aleurone cell development, we differentially screened an aleurone cDNA library made from poly(A)+ RNA of immature grains for clones representing transcripts present in the aleurone but not in the starchy endosperm. For one of these clones, B22E, which hybridies to a 0.7 kb transcript, Northern and in situ hybridization revealed that expression is under complex spatial, temporal and hormonal control in barley grains. cDNAs corresponding to B22E transcripts were isolated from aleurone/pericarp and embryo of developing grains, and from germinating scutella. Among these were the nearly full-length aleurone/pericarp clone pB22E.a16 (541 bp). cDNAs matching the sequence of this clone (type 1 transcript) were found for all tissues investigated. In addition, cDNAs with an extra 12 bp insertion (type 2 transcript) were obtained from germinating scutella. The two different transcripts can encode novel barley proteins of 115 and 119 amino acids, respectively. A gene designated B22EL8 was isolated and sequenced; it encodes the type 1 B22E transcript and contains two introns of 145 and 125 bp. Particle bombardment of barley aleurone with a B22EL8 promoter-GUS (beta-glucuronidase) construct demonstrates that the promoter (3 kb) is active in developing barley grains. The promoter is not, however, active in the seeds of tobacco plants transgenic for the B22EL8 gene, indicating the existence of sequences specific for monocots. A comparison of 1.4 kb of upstream sequence of B22E with the maize c1 promoter reveals a number of short, identical sequences which may be responsible for aleurone cell-specific gene transcription.

Red cell folate assays: some answers to current problems with radioassay variability

Red cell folate specimens were added to the Quality Assurance Program (QAP) of the Royal College of Pathologists of Australasia in 1986. The interlaboratory variation in the results of these red cell folate surveys has been persistently unsatisfactory. This study reports an investigation into the factors contributing to the wide variation of results reported in QAP surveys. Survey results were studied, replies to a questionnaire regarding methods sent to all participants were assessed and some new experimental studies were performed. Factors contributing to the poor QAP results include variation in dilution and diluent, calculation errors, failure to freeze the hemolysate prior to assay and to follow the kit manufactorer's instructions, stability of dithiothreitol, and variations in kit methods, especially in the release of bound folate by "boil" and "no-boil" methods. Photodecomposition and the form and concentration of ascorbate may also be significant. Adequate preparation of the hemolysate sample should ensure release of all protein-bound red cell folate with the reduction of all folates to a single form. Kit manufactures, users and the QAP committee can all contribute in all attempt to rectify current sources of error.

Rectal bleeding. Do other symptoms aid in diagnosis?

It has been shown previously that it is difficult for a general practitioner to predict anal vs. colorectal sources of bleeding in patients presenting with rectal bleeding. The aim of the present study was to determine whether there are any aspects of such a patient's history or clinical features that strongly indicate bleeding from a colorectal cancer or polyp. One hundred forty-five consecutive patients, aged 40 years and older, who had complained of rectal bleeding to a general practitioner, were referred to a specialist for full colonic investigation. Among 15 symptoms and clinical features examined, few had any statistically significant association with the source of bleeding. There was an elevated probability of colorectal cancer (21 percent) in patients who had seen blood mixed with feces. Most bowel symptoms and clinical features are not helpful in deciding whether to proceed with full colorectal assessment in patients aged 40 and older who have rectal bleeding of recent onset.

A second Australian family with hemoglobin North Shore (beta 134 Val----Glu)

A second Australian family is reported with Hemoglobin North Shore (beta 134 Val----Glu), an unstable hemoglobin, causing no clinical symptoms. All affected family members showed only mild reticulocytosis and microcytosis on the blood film, despite the strongly positive isopropanol test for Hb (hemoglobin) stability and numerous red cell inclusions. Hb North Shore constituted 31-38% of the total hemoglobin and migrated on the anodal side of Hb A at pH 8.9. The association of a mildly raised Hb A2 level and thalassemic phenotype with Hb North Shore previously reported, is confirmed in this study.

Dapsone-trimethoprim for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

All patients with the acquired immunodeficiency syndrome and a first episode of Pneumocystis carinii pneumonia seen at the San Francisco General Hospital between November 1984 and April 1985 were evaluated for oral treatment with dapsone (100 mg/d) plus trimethoprim (20 mg/kg body weight X d). All 15 patients who met the entry criteria improved clinically and radiographically within 3 to 10 days after starting treatment. Repeat pulmonary function tests and gallium lung scans after 3 weeks of therapy also showed improvement. Although side effects occurred in 14 patients, in only 2 were they severe enough to require stopping therapy. Both of these patients had worsening skin rash, and dapsone-trimethoprim therapy was stopped after 10 days. When compared with trimethoprim-sulfamethoxazole or pentamidine used to treat P. carinii pneumonia in similar patients, oral dapsone-trimethoprim is at least as effective, seems to be better tolerated, and may have a lower frequency of serious side effects.

External quality assurance in hematology. The programme of the Royal College of Pathologists of Australasia

The Royal College of Pathologists of Australasia introduced a comprehensive national external quality assurance programme (QAP) in hematology in 1979. This now provides regular monthly trials of full blood counting, supplemented by 3-monthly sets of samples for a large variety of other tests for "state of the art" studies, together with case slides for diagnosis for 294 participants. In addition educational supplements are provided, based on one or other aspect of each major quarterly trial. The frequency and variety of tests and analysis of participants' results conform to suggested standards for similar national schemes elsewhere in the world. There is evidence that the programme has helped raise the standards of hematopathology in Australasia and has identified areas which require improvement. It is envisaged that the scheme will satisfy the requirements of state legislation designed to accredit pathology laboratories. Future development should include a refinement of objective methods of scoring performance, especially in areas such as morphology where participants' results cannot readily be expressed numerically.

Conditions for isolation and regeneration of viable protoplasts of oil palm (Elaeis guineensis)

Protoplasts were isolated from cell cultures of oil palm (Elaeis Guineensis). The protoplasts were cultured on a "nurse" medium containing oil palm cells in the presence of which protoplasts formed cell walls and divided to form cell cultures.

Antral gastrin concentration in gastric ulcer disease. The finding of high concentrations in a few patients

Antral gastrin concentratin (AGC) was measured in forceps biopsy specimens of prepyloric mucosa obtained at endoscopy in 65 patients with various kinds of gastric ulcer and in 31 nonulcer control patients. AGC in 32 patients with a lesser curvature gastric ulcer, 10.0 +/- 2.0 (mean +/- 1 SE) ng gastrin/mg tissue was significantly less (P < 0.01) than AGC in 31 nonulcer control patients, 14.4 +/- 1.4. AGC was similar to the control values in 23 patients with a pyloric channel ulcer, 15.2 +/- 1.7; 5 patients with a greater curvature ulcer, 15.0 +/- 4.8; and 3 patients with both duodenal and gastric ulcers, 15.8 +/- 0.7. AGC was significantly greater (P < 0.01) than the control values in 3 patients with a vagotomy and pyloroplasty and a gastric ulcer, 29.8 +/- 5.0. In contrast with most lesser curvature gastric ulcer patients who had low AGC, 3 gastric ulcer patients had antral gastrin values which were about three times the mean AGC of the controls. Two of these patients had fasting serum gastrin values which were more than twice the mean control fasting serum gastrin. Meal-stimulated integraed gastrin responses in these 3 patients ranged from three to nine times the mean control response. These findings suggest that a high AGC may account for a few instances of increased serum gastrin concentrations in gastric ulcer patients.

Clearance of lidocaine by hemodialysis

Because little has been known regarding the dialyzability of lidocaine, we studied the clearance of this drug by hemodialysis. The dialysance of lidocaine was found to range between 10.6 to 21.3 ml/min. Lidocaine-urea extraction ratio averaged 11%. Because of the low therapeutic and even toxic plasma levels, the amount of drug removed by dialysis is negligible. Therefore, dose adjustment is unnecessary during dialysis, and dialysis appears to be of little help in the treatment of lidocaine toxicity.

Basal and calcium-stimulated gastroesophageal sphincter pressure in patients with Zollinger-Ellison syndrome

Basal lower esophageal sphincter (LES) pressure was measured in 6 patients with the Zollinger-Ellison syndrome (ZES) and hypergastrinemia, and in 6 patients with duodenal ulcer and normogastrinemia. Basal LES pressure in ZES patients, 17.0 +/- 3.7 (mean +/- SE) mm Hg was similar to basal LES pressure in duodenal ulcer patients, 18.3 +/- 3.5 mm Hg (P greater than 0.10). LES pressure and serum gastrin concentration were not related in the ZES patients, r = 0.03, or in the duodenal ulcer patients, r = 0.20. Intravenous infusion of calcium gluconate in ZES patients produced a marked rise in serum gastrin concentration, delta = 1580 +/- 1110 pg per ml (P less than 0.001), and a moderate but significant rise in LES pressure, delta = 5.9 +/- 0.9 mm Hg (P less than 0.05). In duodenal ulcer patients calcium infusion produced only slight rises in gastrin concentration, delta = 10 +/- 12 pg per ml, and LES pressure, delta = 2.1 +/- 0.5 mm Hg, which were not significant (P greater than 0.10). This study suggests that basal LES pressure is not regulated by blood gastrin levels in the ZES. We interpret the calcium infusion study to show that the LES pressure in patients with ZES may respond to acute changes in endogenous gastrin levels.