Irinotecan therapy in adults with recurrent or progressive malignant glioma

PURPOSE

To determine the activity, toxicity, and pharmacokinetics of irinotecan (CPT-11, Camptosar; Pharmacia & Upjohn, Kalamazoo, MI) in the treatment of adults with progressive, persistent, or recurrent malignant glioma.

PATIENTS AND METHODS

Patients with progressive or recurrent malignant gliomas were enrolled onto this study between October 1996 and August 1997. CPT-11 was given as a 90-minute intravenous (i.v.) infusion at a dose of 125 mg/m2 once weekly for 4 weeks followed by a 2-week rest, which comprised one course. Plasma concentrations of CPT-11 and its metabolites, SN-38 and SN-38 glucuronide (SN-38G), were determined in a subset of patients.

RESULTS

All 60 patients who enrolled (36 males and 24 females) were treated with CPT-11 and all were assessable for toxicity, response, and survival. Pharmacokinetic data were available in 32 patients. Nine patients (15%; 95% confidence interval, 6% to 24%) had a confirmed partial response, and 33 patients (55%) achieved stable disease lasting more than two courses (12 weeks). Toxicity observed during the study was limited to infrequent neutropenia, nausea, vomiting, and diarrhea. CPT-11, SN-38, and SN-38G area under the plasma concentration-time curves through infinite time values in these patients were approximately 40%, 25%, and 25%, respectively, of those determined previously in patients with metastatic colorectal cancer not receiving antiepileptics or chronic dexamethasone treatment.

CONCLUSION

Response results document that CPT-11, given with a standard starting dose and treatment schedule, has activity in patients with recurrent malignant glioma. However, the low incidence of severe toxicity and low plasma concentrations of CPT-11 and SN-38 achieved in this patient population suggest that concurrent treatment with anticonvulsants and dexamethasone enhances drug clearance.

Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation

BACKGROUND

Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals.

METHODS

Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients.

FINDINGS

Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001).

INTERPRETATION

The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.

Epidemiology, etiology, and impact of traveler's diarrhea in Jamaica

CONTEXT

Traveler's diarrhea (TD) can incapacitate travelers. Characteristics of TD could be helpful in identifying individuals who might benefit from a vaccine against TD.

OBJECTIVE

To determine epidemiology, etiology, and impact of TD in Jamaica. Design Two-armed, cross-sectional survey conducted between March 1996 and May 1997.

SETTING

Sangster International Airport and 10 hotels in Montego Bay area, Jamaica.

SUBJECTS

To investigate epidemiology and impact, 30369 short-term visitors completed a questionnaire just before boarding their homebound aircrafts. To investigate etiology, 322 patients (hotel guests) with TD provided stool samples.

MAIN OUTCOME MEASURES

Attack and incidence rates of reported diarrhea and of classically defined TD (> or =3 unformed stool samples in 24 hours and > or =1 accompanying symptom), incapacity, risk factors, and etiology.

RESULTS

The attack rate for diarrhea was 23.6% overall, with 11.7% having classically defined TD. For a mean duration of stay of 4 to 7 days, the incidence rate was 20.9% (all TD) and 10.0% (classic TD). Among airport respondents, the incapacity lasted a mean of 11.6 hours. Less than 3% of all travelers avoided potentially high-risk food and beverages. The most frequently detected pathogens were enterotoxigenic Escherichia coli, Rotavirus, and Salmonella species.

CONCLUSIONS

A realistic plan for reducing TD is needed. Preventive measures such as the improvement of hygienic conditions at the destination, and/or the development of vaccines against the most frequent pathogens associated with TD may contribute toward achieving this goal.

Rifaximin versus ciprofloxacin for the treatment of traveler's diarrhea: a randomized, double-blind clinical trial

Rifaximin is a poorly absorbed rifamycin derivative under investigation for treatment of infectious diarrhea. Adult students from the United States in Mexico and international tourists in Jamaica were randomized to receive either rifaximin (400 mg twice per day) or ciprofloxacin (500 mg twice per day) for 3 days, following a double-blinded model, from June 1997 to September 1998. A total of 187 subjects with diarrhea were studied. Time from initiation of therapy to passage of last unformed stool was comparable for those receiving rifaximin or ciprofloxacin (median, 25.7 hours versus 25.0 hours, respectively). There was no significant difference in the proportion of subjects in the 2 groups with respect to clinical improvement during the first 24 hours (P=.199), failure to respond to treatment (P=.411), or microbiological cure (P=.222). The incidence of adverse events was low and similar in each group. Rifaximin is a safe and effective alternative to ciprofloxacin in the treatment of traveler's diarrhea.

In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler's diarrhea in four geographic regions

The emergence of resistant enteropathogens has been reported worldwide. Few data are available on the contemporary in vitro activities of commonly used antimicrobial agents against enteropathogens causing traveler's diarrhea (TD). The susceptibility patterns of antimicrobial agents currently available or under evaluation against pathogens causing TD in four different areas of the world were evaluated. Pathogens were identified in stool samples from U.S., Canadian, or European adults (18 years of age or older) with TD during 1997, visiting India, Mexico, Jamaica, or Kenya. MICs of 11different antimicrobials were determined against 284 bacterial enteropathogens by the agar dilution method. Ciprofloxacin, levofloxacin, ceftriaxone, and azithromycin were highly active in vitro against the enteropathogens, while traditional antimicrobials such as ampicillin, trimethoprim, and trimethoprim/sulfamethoxazole showed high levels and high frequencies of resistance. Rifaximin, a promising and poorly absorbable drug, had an MIC at which 90% of the strains tested were inhibited of 32 microg/ml, 250 times lower than the concentration of this drug in the stools. Amdinocillin, nalidixic acid, and doxycycline showed moderate activity. Fluoroquinolones are still the drugs of choice for TD in most regions of the world, although our study has a limitation due to the lack of Escherichia coli samples from Kenya and possible bias in selection of the patients for evaluation. Azithromycin and rifaximin should be considered as promising new agents. The widespread in vitro resistance of the traditional antimicrobial agents reported since the 1980s and the new finding of resistance to fluoroquinolones in Southeast Asia are the main reasons for monitoring carefully the antimicrobial susceptibility patterns worldwide and for developing and evaluating new antimicrobial agents for the treatment of TD.

Feasibility of four consecutive high-dose chemotherapy cycles with stem-cell rescue for patients with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor after craniospinal radiotherapy: results of a collaborative study

PURPOSE

This study was designed to determine the feasibility and safety of delivering four consecutive cycles of high-dose cyclophosphamide, cisplatin, and vincristine, each followed by stem-cell rescue, every 4 weeks, after completion of risk-adapted craniospinal irradiation to children with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor (PNET).

PATIENTS AND METHODS

Fifty-three patients, 19 with high-risk disease and 34 with average-risk disease, were enrolled onto this study. After surgical resection, high-risk patients were treated with topotecan in a 6-week phase II window followed by craniospinal radiation therapy and four cycles of high-dose cyclophosphamide (4,000 mg/m2 per cycle), with cisplatin (75 mg/m2 per cycle), and vincristine (two 1.5-mg/m2 doses per cycle). Support with peripheral blood stem cells or bone marrow and with granulocyte colony-stimulating factor was administered after each cycle of high-dose chemotherapy. Treatment of average-risk patients consisted of surgical resection and craniospinal irradiation, followed by the same chemotherapy given to patients with high-risk disease. The expected duration of the chemotherapy was 16 weeks, with a cumulative cyclophosphamide dose of 16,000 mg/m2 and a planned dose-intensity of 1,000 mg/m2/wk.

RESULTS

Fifty of the 53 patients commenced high-dose chemotherapy, and 49 patients completed all four cycles. The median length of chemotherapy cycles one through four was 28, 27, 29, and 28 days, respectively. Engraftment occurred at a median of 14 to 15 days after infusion of stem cells or autologous bone marrow. The intended dose-intensity of cyclophosphamide was 1,000 mg/m2/wk; the median delivered dose-intensity was 1,014, 1,023, 974, and 991 mg/m2/wk for cycles 1 through 4, respectively; associated median relative dose-intensity was 101%, 102%, 97%, and 99%. No deaths were attributable to the toxic effects of high-dose chemotherapy. Early outcome analysis indicates a 2-year progression-free survival of 93.6% +/- 4.7% for the average-risk patients. For the high-risk patients, the 2-year progression-free survival is 73.7% +/- 10.5% from the start of therapy and 84.2% +/- 8.6% from the start of radiation therapy.

CONCLUSION

Administering four consecutive cycles of high-dose chemotherapy with stem-cell support after surgical resection and craniospinal irradiation is feasible in newly diagnosed patients with medulloblastoma/supratentorial PNET with aggressive supportive care. The early outcome results of this approach are very encouraging.

Multicentre comparison of the Glasgow Blatchford and Rockall Scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage

BACKGROUND

The Glasgow Blatchford Score (GBS) is increasingly being used to predict intervention and outcome following upper gastrointestinal haemorrhage (UGIH).

AIM

To compare the GBS with both the admission and full Rockall scores in predicting specific clinical end-points following UGIH.

PATIENTS AND METHODS

Data on consecutive patients presenting to four UK hospitals were collected. Admission history, clinical and laboratory data, endoscopic findings, treatment and clinical follow-up were recorded. Using ROC curves, we compared the three scores in the prediction of death, endoscopic or surgical intervention and transfusion. Results  A total of 1555 patients (mean age 56.7years) presented with UGIH during the study period. Seventy-four (4.8%) died, 223 (14.3%) had endoscopic or surgical intervention and 363 (23.3%) required transfusion. The GBS was similar at predicting death compared with both the admission Rockall (area under ROC curve 0.804 vs. 0.801) and full Rockall score (AUROC 0.741 vs. 0.790). In predicting endo-surgical intervention, the GBS was superior to the admission Rockall (AUROC 0.858 vs. 0.705; P<0.00005) and similar to the full Rockall score (AUROC 0.822 vs. 0.797). The GBS was superior to both admission Rockall (AUROC 0.944 vs. 0.756; P<0.00005) and full Rockall scores (AUROC 0.935 vs. 0.792; P<0.00005) in predicting need for transfusion.

CONCLUSIONS

Despite not incorporating age, the GBS is as effective as the admission and full Rockall scores in predicting death after UGIH. It is superior to both the admission and full Rockall scores in predicting need for transfusion, and superior to the admission Rockall score in predicting endoscopic or surgical intervention.

An outbreak of acute flaccid paralysis in Jamaica associated with echovirus type 22

An outbreak of acute flaccid paralysis in Jamaica in 1986 associated with echovirus type 22 is described. Six patients aged 1 to 27 years developed acute onset of severe flaccid paralysis, with inability to walk. Three cases had facial weakness, four required intensive care with assisted ventilation, and two died. Echovirus type 22 was isolated from the stool of two patients who showed a significant increase in antibody titre. Echovirus type 22 was also isolated from the stool of another patient who had aseptic meningitis without any neurological deficit. There was no evidence of poliovirus infection in any of these patients, most of whom were fully immunized. Of the four surviving cases with flaccid paralysis, three had residual weakness in their lower limbs and walked with an abnormal gait 3 years after the acute paralytic attack. This is the first report in the literature of acute flaccid paralysis associated with type 22 echovirus.

Enteroaggregative Escherichia coli as a cause of traveler's diarrhea: clinical response to ciprofloxacin

The purpose of this study was to determine the role of enteroaggregative Escherichia coli (EAEC) in the development of traveler's diarrhea and the clinical response of patients with EAEC diarrhea following treatment with ciprofloxacin. Sixty-four travelers with diarrhea and no other recognized enteropathogen were enrolled in treatment studies in Jamaica and Mexico from July 1997 to July 1998. EAEC was isolated from 29 travelers (45.3%). There was a significant reduction in the duration of posttreatment diarrhea in the 16 patients treated with ciprofloxacin, as compared with that in the 13 patients who received placebo (mean of 35.3 versus 55.5 hours; P = .049). There was a nonsignificant reduction in the mean number of unformed stools passed during the 72 hours after enrollment in the ciprofloxacin-treated group (5.6), as compared with that in the placebo group (7.5) (P = .128). This study provides additional evidence that EAEC should be considered as a cause of antibiotic-responsive traveler's diarrhea.

Assessing exposure to disinfection by-products in women of reproductive age living in Corpus Christi, Texas, and Cobb county, Georgia: descriptive results and methods

We conducted a field study in Corpus Christi, Texas, and Cobb County, Georgia, to evaluate exposure measures for disinfection by-products, with special emphasis on trihalomethanes (THMs). Participants were mothers living in either geographic area who had given birth to healthy infants from June 1998 through May 1999. We assessed exposure by sampling blood and water and obtaining information about water use habits and tap water characteristics. Two 10-mL whole blood samples were collected from each participant before and immediately after her shower. Levels of individual THM species (chloroform, bromodichloromethane, dibromochloromethane, and bromoform) were measured in whole blood [parts per trillion (pptr)] and in water samples (parts per billion). In the Corpus Christi water samples, brominated compounds accounted for 71% of the total THM concentration by weight; in Cobb County, chloroform accounted for 88%. Significant differences in blood THM levels were observed between study locations. For example, the median baseline blood level of bromoform was 0.3 pptr and 3.5 pptr for participants in Cobb County and Corpus Christi, respectively (p = 0.0001). Differences were most striking in blood obtained after showering. For bromoform, the median blood levels were 0.5 pptr and 17 pptr for participants in Cobb County and Corpus Christi, respectively (p = 0.0001). These results suggest that blood levels of THM species vary substantially across populations, depending on both water quality characteristics and water use activities. Such variation has important implications for epidemiologic studies of the potential health effects of disinfection by-products.

Under-users of antenatal care: a comparison of non-attenders and late attenders for antenatal care, with early attenders

Demographic, behavioural, environmental, economic and obstetric history data from the Jamaican Perinatal Morbidity and Mortality Survey were examined to identify characteristics of women who do not attend for antenatal care, or present late instead of early for care, using multiple logistic regression. Non-attenders were more likely to be teenagers, unmarried, in unions of very short duration, smokers and women who felt that friends and relatives were not supportive. Multigravid non-attenders often had short inter-pregnancy intervals and included women who had experienced a post neonatal death. They were often drawn from deprived environments (lack of sanitation, water supplies). Late attenders shared features common to non-attenders (teenagers, unmarried, multigravid). Many however were self employed and did not fit the depressed profile of the non-attender. Most multigravidae who attended late had had previously uneventful pregnancies, including this one. Early attenders had little in common with non-attenders or late attenders. They were older, many had a secondary or tertiary education, were married and were generally middle class women. The group however included high risk multigravidae who had previous pregnancy complications or bad outcomes. Programmes aimed at reaching non-attenders must focus on the wider social and economic needs of these women and must give them a sense of their own power to effect change in their lives. Reaching the late attender will be more difficult and may be unnecessary with the possible exception of the teenager. She needs to be treated in a more sympathetic and non-judgmental way as this is often a high risk pregnancy. More fundamental changes require improved educational and employment opportunities for women as the best consumer is an educated consumer.

Past obstetric history and risk of perinatal death in Jamaica

Singleton survivors born to multigravidae in the whole island of Jamaica in 2 months (September-October 1986) were compared with singleton perinatal deaths occurring to multigravidae throughout the island in the 12-month period September 1986 to August 1987. Past obstetric history was obtained from the mothers using a structured questionnaire. Deaths were categorised using the Wigglesworth classification. Logistic regression was used to compare current outcomes in women who had had at least one previous pregnancy. Antepartum fetal deaths with (1) outcome of last pregnancy; (2) previous Caesarean section; (3) previous stillbirth; and (4) increasing gravidity. In the presence of these factors maternal age ceased to be statistically significant. Deaths from immaturity were strongly associated with the past obstetric history, with increased risks for pregnancies to mothers with a history of previous miscarriage, perinatal death and premature live births. In general, however, the higher the gravidity the lower the risk. In the presence of these factors, maternal age showed no significant association. Intrapartum asphyxia was also associated with the outcome of the last pregnancy, history of prior stillbirth or neonatal death. First pregnancies were at significantly higher risk than second pregnancies (P < 0.05). For perinatal deaths as a whole, and in the presence of maternal age, the following were statistically significant independent factors: (1) the outcome of the immediately preceding pregnancy (high risks associated with prior miscarriage, stillbirth and premature live births); (2) previous Caesarean section (increased risk); (3) previous perinatal deaths; and (4) more than one prior early fetal loss. The results indicated that prior poor obstetric history bears similar risks of subsequent adverse outcome in the developing as in the developed world. There was no variation in risk, however, with interpregnancy interval or previous termination. Much of the variation in risk of perinatal death with maternal age among multigravidae appears largely to be secondary to past obstetric history.

Oral antioxidant supplementation for fatigue associated with primary biliary cirrhosis: results of a multicentre, randomized, placebo-controlled, cross-over trial

BACKGROUND

We have previously reported, in an uncontrolled trial, an improvement in fatigue scores in patients with primary biliary cirrhosis given oral antioxidant supplementation. We now present data from a controlled trial.

PATIENTS AND METHODS

Sixty-one patients with primary biliary cirrhosis-associated fatigue were randomized into a double-blind, placebo-controlled, cross-over trial. Participants received 12 weeks each of placebo and antioxidant supplementation (vitamins A, C and E, selenium, methionine and ubiquinone) in random order, separated by a 4-week washout period. The primary trial outcome (fatigue) was assessed using the Fisk scale. Other symptoms of primary biliary cirrhosis were measured using Likert and visual analogue scales.

RESULTS

Forty-four patients completed both arms of the trial. No significant changes in fatigue were recorded in the active phase of treatment (median improvement in Fisk score, 1; P = 0.61). Small improvements in Fisk scores were recorded during placebo therapy (median improvement, 4; P = 0.03). Neither medication was associated with improvement in any other symptoms related to primary biliary cirrhosis. Adverse effects were more common during active therapy and were mild and self-limiting. One patient died from unrelated causes during active treatment.

CONCLUSIONS

Although oral antioxidant supplementation appears to be safe, we could not find any evidence for a beneficial effect on fatigue or other liver-related symptoms.

Gender differences in adult health: an international comparison

This article uses data from the United States, Jamaica, Malaysia, and Bangladesh to explore gender differences in adult health. The results show that women fare worse than men across a variety of self-reported health measures in all four countries studies. These health status disparities between men and women persist even after appropriate corrections are made for the impact of (a) differential mortality selection by gender and (b) sociodemographic factors. Data from Jamaica indicate that gender disparities in adult health arise early and persist throughout the life cycle, with different age profiles for different measures.

General anaesthesia or conscious sedation for painful procedures in childhood cancer: the family's perspective

BACKGROUND

Until recently, midazolam sedation was routinely used in our institution for bone marrow aspirates and lumbar punctures in children with cancer. It has been perceived by many doctors and nurses as being well tolerated by children and their families.

AIM

To compare the efficacy of inhalational general anaesthesia and midazolam sedation for these procedures.

METHODS

A total of 96 children with neoplastic disorders, who received either inhalational general anaesthesia with sevoflurane, nitrous oxide, and oxygen (GA) or sedation with oral or nasal midazolam (SED) as part of their routine preparation for procedures were studied. The experiences of these children were examined during their current procedure and during their first ever procedure. Main outcome measures were the degree of physical restraint used on the child, and the levels of distress and pain experienced by the child during the current procedure and during the first procedure. The family's preference for future procedures was also determined.

RESULTS

During 102 procedures under GA, restraint was needed on four occasions (4%) when the anaesthetic mask was first applied, minimal pain was reported, and children were reported as distressed about 25% of the time. During 80 SED procedures, restraint was required in 94%, firm restraint was required in 66%, the child could not be restrained in 14%, median pain score was 6 (scale 0 (no pain) to 6 (maximum pain)), and 90% of the parents reported distress in their child. Ninety per cent of families wanted GA for future procedures. Many families reported dissatisfaction with the sedation regime and raised concerns about the restraint used on their child.

CONCLUSIONS

This general anaesthetic regime minimised the need for restraint and was associated with low levels of pain and distress. The sedation regime, by contrast, was much less effective. There was a significant disparity between the perceptions of health professionals and those of families with respect to how children coped with painful procedures.

High-dose methotrexate for primary CNS lymphoma in the elderly

Primary central nervous system lymphoma (PCNSL) in the immunocompetent patient reaches a peak incidence in the sixth and seventh decades of life. This retrospective study reviewed the efficacy and tolerability of high-dose methotrexate (HDMTX) in an elderly patient population. Between May 1995 and September 1998, ten consecutive elderly patients with histologically proven PCNSL were treated with HDMTX. The median age was 72.5 years and eight patients (80%) were older than 70 years. HDMTX was well tolerated with no episodes of grade 4 toxicity nor febrile neutropenia. Toxicity included grade 3 nausea (1), grade 2 mucositis (2), and grade 2 asymptomatic elevation of liver transaminases (2). Grade 1 toxicity occurred in three patients with nausea, diarrhea, and mild reversible elevation in serum creatinine in one patient each. Six patients had a complete response and three patients achieved a partial response, giving an overall response rate of 90% (95% confidence interval, 56%-100%). The median overall survival for the cohort was 36 months (range 4-43 months). In summary, HDMTX is well tolerated in this elderly population with PCNSL and achieves response rates and median survival comparable with other chemotherapy or radiotherapy regimens.

The perinatal morbidity and mortality survey of Jamaica 1986-1987

The Jamaican Perinatal Morbidity and Mortality Survey was conducted between September 1986 and August 1987. A total of 10,310 consecutive births were identified and mothers interviewed in the first 2 months (main cohort study), 1405 neonatal admissions were evaluated over a 6-month period (morbidity study), and 1855 perinatal deaths and 73 late neonatal deaths identified over 12 months (mortality study)-55% of the deaths were given a postmortem examination. The perinatal mortality rate for the cohort study was 38.1 per 1000 births. This was 36.6 percent higher than the 1982 estimate of 27.9/1000 based on deliveries at the Victoria Jubilee Hospital, a specialist maternity institution which has at least 13,000 deliveries per annum.

Interreader reliability for a new classification of lumbar disk disease

RATIONALE AND OBJECTIVES

The nomenclature that divides disk herniations into protrusions and extrusions may increase the specificity of magnetic resonance (MR) imaging for clinically important lesions. Our goal was to determine this terminology's interreader reliability.

METHODS

Three readers who were unaware of patients' histories independently read MR images of 34 consecutive patients with back pain. Readers classified disks at the lowest three lumbar levels as normal, bulging, protruded, or extruded. Kappa and weighted kappa values were the primary measures of agreement.

RESULTS

Weighted kappa values showed fair-to-moderate agreement. Kappas for the dichotomous decision of extrusion present or absent were more variable, ranging from 0 to .78. Major disagreements (greater than a single category) occurred with 6.2% of all comparisons and in 10 of 34 volunteers; five involved extrusions.

CONCLUSION

Overall, readers achieved moderate agreement for this new nomenclature. However, agreement for the presence or absence of an extrusion was less reliable.

Perinatal mortality survey in Jamaica: aims and methodology

The Jamaican Perinatal Mortality Survey was designed to identify the true perinatal mortality rate, and assess the factors which could contribute towards a reduction in perinatal mortality on the island. All births in a 2-month period (n = 10527) were compared with all perinatal deaths occurring over a 12-month period (n = 2069). Over half the deaths (n = 1058) received a detailed post-mortem examination. Use of the Wigglesworth classification identifies the major component of perinatal death in this country to be associated with intrapartum asphyxia (44% of deaths). Deaths due to congenital malformations and miscellaneous causes contribute relatively little (< 10%) to the overall mortality rate. Over a quarter of deaths apparently occur before the onset of labour, and a fifth are prematurely liveborn but die of causes related to immaturity.

Outbreak of Bacillus Calmette-Guérin-associated lymphadenitis and abscesses in Jamaican children

An outbreak of axillary lymphadenitis and abscesses after Bacillus Calmette-Guérin (BCG) vaccination (Pasteur Paris, Batch N5122) occurred in 139 Jamaican children between January and July, 1988. The overall rate of this complication was 0.95%. The attack rate was 1.92% among the 0- to 6-week age group and 0.6% in the 7- to 52-week age group. Of 139 patients there were 77 males and 62 females and the mean age at presentation was 4 months. The mean size of the BCG scar, duration of healing and Mantoux reaction size differed significantly in patients compared with those of control infants (P less than 0.01). Mycobacterium bovis was isolated from 11 patients. Immunologically index patients and controls differed significantly only with respect to T lymphocyte subpopulation percentages and concanavalin A stimulation indices. Evaluation of the BCG vaccine did not reveal either increased potency or microbial contamination. We conclude that increased susceptibility to the Pasteur strain of BCG might have contributed to the increased incidence of complications in these Jamaican children and hence caution should be exercised in switching one vaccine for another as is often done in the developing countries.

High-dose methotrexate for primary CNS lymphoma in the elderly

Primary central nervous system lymphoma (PCNSL) in the immunocompetent patient reaches a peak incidence in the sixth and seventh decades of life. This retrospective study reviewed the efficacy and tolerability of high-dose methotrexate (HDMTX) in an elderly patient population. Between May 1995 and September 1998, ten consecutive elderly patients with histologically proven PCNSL were treated with HDMTX. The median age was 72.5 years and eight patients (80%) were older than 70 years. HDMTX was well tolerated with no episodes of grade 4 toxicity nor febrile neutropenia. Toxicity included grade 3 nausea (1), grade 2 mucositis (2), and grade 2 asymptomatic elevation of liver transaminases (2). Grade 1 toxicity occurred in three patients with nausea, diarrhea, and mild reversible elevation in serum creatinine in one patient each. Six patients had a complete response and three patients achieved a partial response, giving an overall response rate of 90% (95% confidence interval, 56%-100%). The median overall survival for the cohort was 36 months (range 4-43 months). In summary, HDMTX is well tolerated in this elderly population with PCNSL and achieves response rates and median survival comparable with other chemotherapy or radiotherapy regimens.

Approach to assessing the economic impact of insulin-related hypoglycaemia using the novel Local Impact of Hypoglycaemia Tool

AIM

To provide estimates of the costs of severe and non-severe insulin-related hypoglycaemia in the UK using the Local Impact of Hypoglycaemia Tool.

METHODS

Rates of hypoglycaemia were extracted from the UK Hypoglycaemia Study Group observational study. The costs of severe and non-severe hypoglycaemic episodes in insulin-treated adults with Type 1 and Type 2 diabetes were estimated from UK data sources. The rates and costs were then applied to specific populations to give an estimate of the cost of insulin-related hypoglycaemia for the UK, a specific locality, or a user-defined population. User-specific rates and costs could also be applied.

RESULTS

The estimated cost of a hypoglycaemic episode can range from as much as £2,152 for severe episodes (for which the patient is admitted to hospital) to as little as £1.67 for non-severe episodes. With a UK population of 64.1 million, the total estimated cost of managing insulin-related hypoglycaemia is £468.0 m per year (£295.9 m for severe episodes, £172.1 m for non-severe episodes). On a local health economy level, using a hypothetical general population of 100 000, the total cost of managing insulin-related hypoglycaemia is estimated to be £730,052 per year (£461,658 for severe and £268,394 for non-severe episodes).

CONCLUSIONS

The Local Impact of Hypoglycaemia Tool highlights the economic burden of insulin-related hypoglycaemia. Non-severe episodes are often overlooked because of their low individual cost, but their high frequency makes the cumulative cost substantial. The Local Impact of Hypoglycaemia Tool also shows clinicians and budget-holders the economic impact of lower rates of hypoglycaemia.

Environmental exposure to volatile organic compounds among workers in Mexico City as assessed by personal monitors and blood concentrations

Benzene, an important component in gasoline, is a widely distributed environmental contaminant that has been linked to known health effects in animals and humans, including leukemia. In Mexico City, environmental benzene levels, which may be elevated because of the heavy traffic and the poor emission control devices of older vehicles, may pose a health risk to the population. To assess the potential risk, portable passive monitors and blood concentrations were used to survey three different occupational groups in Mexico City. Passive monitors measured the personal exposure of 45 workers to benzene, ethylbenzene, toluene, o-xylene and m-/p-xylene during a work shift. Blood concentrations of the above volatile organic compounds (VOCs), methyl tert-butyl ether, and styrene were measured at the beginning and the end of a work shift. Passive monitors showed significantly higher (p > 0.0001) benzene exposure levels among service station attendants (median = 330 microg/m3; range 130-770) as compared to street vendors (median = 62 microg/m3; range 49-180) and office workers (median = 44 microg/m3, range 32-67). Baseline blood benzene levels (BBLs) for these groups were higher than those reported for similar populations from Western countries (median = 0.63 microg/L, n = 24 for service station attendants; median = 0.30 microg/L, n = 6 for street vendors; and median = 0.17 microgr;g/L, n = 7 for office workers). Nonsmoking office workers who were nonoccupationally exposed to VOCs had BBLs that were more than five times higher than those observed in a nonsmoking U.S. population. BBLs of participants did not increase during the work shift, suggesting that because the participants were chronically exposed to benzene, complex pharmacokinetic mechanisms were involved. Our results highlight the need for more complete studies to assess the potential benefits of setting environmental standards for benzene and other VOCs in Mexico.