Physical and occupational therapists' perceptions of sustainability of a knowledge translation intervention to improve the use of outcome measures in inpatient rehabilitation: a qualitative study

PURPOSE

To assess the perceptions, barriers, and facilitators of sustaining the use of outcome measures of physical and occupational therapists following a three-year knowledge translation intervention.

METHODS

A phenomenological qualitative study was conducted at an inpatient rehabilitation hospital on 13 clinicians (6 physical therapists and 7 occupational therapists) participating in the knowledge translation intervention. Data collection used semi-structured interviewing during three focus groups to understand the lived experience of clinicians participating in the knowledge translation project. Data were analyzed using the Consolidated Framework for Implementation Research (CFIR) codebook.

RESULTS

Two investigators coded twelve CFIR constructs into barriers and facilitators for outcome measure use. Four key themes emerged as determinants for outcome measures use: (1) Organizational support and clinician engagement; (2) the knowledge translation intervention; (3) the outcome measures themselves; and (4) the patients. Clinicians reported using outcome measures for patient education, treatment planning, and goal setting, while they found other outcome measures lacked functional significance. Facilitators included organizational support, access to knowledge, ongoing training, and clinician engagement. Ongoing barriers included the need for more training and the need to select different tests.

CONCLUSIONS

This study found proper selection of outcomes measures is important and attributed the sustainability of the knowledge translation intervention to organizational support, clinician engagement and ongoing training. The clinicians wanted continued training to overcome new barriers. Barriers identified in this study were unique to the typical barriers identified for outcome measure use. Ongoing barrier assessments are needed for continued refinement of knowledge translation interventions to enhance sustainability.

Doctoral physical therapy students’ increased confidence following exploration of active video gaming systems in a problem-based learning curriculum in the United States: a pre- and post-intervention study

PURPOSE

Active video gaming (AVG) is used in physical therapy (PT) to treat individuals with a variety of diagnoses across the lifespan. The literature supports improvements in balance, cardiovascular endurance, and motor control; however, evidence is lacking regarding the implementation of AVG in PT education. This study investigated doctoral physical therapy (DPT) students’ confidence following active exploration of AVG systems as a PT intervention in the United States.

METHODS

This pretest-posttest study included 60 DPT students in 2017 (cohort 1) and 55 students in 2018 (cohort 2) enrolled in a problem-based learning curriculum. AVG systems were embedded into patient cases and 2 interactive laboratory classes across 2 consecutive semesters (April–December 2017 and April–December 2018). Participants completed a 31-question survey before the intervention and 8 months later. Students’ confidence was rated for general use, game selection, plan of care, set-up, documentation, setting, and demographics. Descriptive statistics and the Wilcoxon signed-rank test were used to compare differences in confidence pre- and post-intervention.

RESULTS

Both cohorts showed increased confidence at the post-test, with median (interquartile range) scores as follows: cohort 1: pretest, 57.1 (44.3–63.5); post-test, 79.1 (73.1–85.4); and cohort 2: pre-test, 61.4 (48.0–70.7); post-test, 89.3 (80.0–93.2). Cohort 2 was significantly more confident at baseline than cohort 1 (P<0.05). In cohort 1, students’ data were paired and confidence levels significantly increased in all domains: use, Z=-6.2 (P<0.01); selection, Z=-5.9 (P<0.01); plan of care, Z=-6.0 (P<0.01); set-up, Z=-5.5 (P<0.01); documentation, Z=-6.0 (P<0.01); setting, Z=-6.3 (P<0.01); and total score, Z=-6.4 (P<0.01).

CONCLUSION

Structured, active experiences with AVG resulted in a significant increase in students’ confidence. As technology advances in healthcare delivery, it is essential to expose students to these technologies in the classroom.

Knowledge translation intervention increased the use of outcome measures by physical therapists in inpatient rehabilitation

Background and Purpose: Outcome measures (OMs) have been emphasized by healthcare professions to optimize patient examination; however, a lack of regular use of OMs exists. The purpose of this study was to describe the outcome of a knowledge translation (KT) intervention to increase the use of OMs by physical therapists in an inpatient rehabilitation setting.Methods: A quasi-experimental pre-post study design was used. A multi-component KT intervention including education, organizational support, documentation, and environmental changes to increase the use of five OMs was implemented. Audit and feedback (A&F) was added to the KT intervention at month 6. Documented use of OMs was determined through manual chart audit (n = 864) and electronically (n = 2599). Regression analyses were used to identify factors associated with OMs use across time and diagnoses.Results: Following the addition of A&F to the KT intervention at month 6, there was a significant increase in the odds of OMs use across all time intervals (months 6-12, 12-18, 18-24)(Odds Ratio (OR) 5.9, 95% Confidence Interval (CI) 4.1-8.5; OR 8.5, 95% CI 6.0-12.1; OR 10.8, 95% CI 7.6-15). There was also a significant increase in the odds of documenting OMs on individuals with neurological diagnoses (OR 0.3, 95% CI 0.5-0.8).Conclusions: This KT intervention increased and sustained OMs use over 24-months. This intervention can be replicated to improve the evidence-based practices of physical therapists.

The effect of rolling walker use on interpretation of Timed Up and Go test scores: a preliminary study

Studies have shown that the type of assistive device used during the Timed Up and Go test impacts the time it takes to complete the test. This study examines the impact of the use of a rolling walker within individuals on Timed Up and Go scores and assessment of fall risk. The Berg Balance Scale, Timed Up and Go, and linear gait speed were used to measure balance and fall risk on 13 older adults as part of their usual reassessment in preparation for discharge. Timed Up and Go and gait speed scores were compared assistive device conditions. The Berg Balance Scale was used as a benchmark fall risk assessment. Linear gait speed was similar in both conditions. Timed Up and Go times were slower for all patients using a rolling walker versus a cane or no assistive device. Consideration for the effect of assistive device use on Timed Up and Go scores has important implications as it may influence interpretation of fall risk.

Selenium Dependent Glutathione Peroxidase: A Physiological Regulatory System for Platelet Function

In human platelets the selenoenzyme glutathione peroxidase (GSH-Px) acts as a scavenger of the peroxides generated during the burst of arachidonic acid (AA) metabolism. Such a mechanism inhibits the biosynthesis of both thromboxane A2 (TXA2) and lipoxygenase products. The same mechanism is not effective on the prostacyclin (PGI2) biosynthesis from cultured endothelial cells. In order to evaluate this effect in vivo, besides in vitro, we activated the enzyme in eight normal volunteers by increasing their daily Se intake for 8 weeks, monitoring: platelet GSH-Px activity, platelet aggregation induced by A A and U 44069, and concurrent malondialdehyde (MDA) and thromboxane B2 (TXB2) production, urinary excretion of renal and systemic TXA2 and PGI2 metabolites, platelet enzyme activities of the hexose monophosphate pathway and glutathione content, platelet adenine nucleotides, bleeding time, plasma Se concentration. We found: a) progressive platelet GSH-Px activation by Se paralleling an enhancement of platelet aggregation threshold values for AA, but not for U 44069; b) concurrent inhibition of platelet biosynthesis of TXA2 both in vitro and in vivo while the biosynthesis of systemic prostacyclin was unaffected; c) a progressive increase in the bleeding time, unmodified by aspirin. In conclusion, we believe that Se-dependent GSH-Px represents a physiological mechanism regulating the biosynthesis of prostanoids with implications in platelet function and that a Se dietary supplement might be considered in the prevention of arterial thrombosis.

Immune response to Hepatitis B vaccine in patients with celiac disease: A systematic review and meta-analysis

It is debated whether patients with celiac disease (CD) have non-protective antibody responses to HBV vaccination more frequently than non-affected subjects. To perform a literature review and meta-analysis on protective response to HBV vaccination in CD patients. RCTs and observational controlled studies were eligible. Outcome of interest was an anti-HBs (HBsAb) titer ≥ 10 IU/L after last vaccine dose. Comparative index was rate ratio (RR). Heterogeneity between studies was addressed and funnel plots were analyzed. Meta-regression models were applied to investigate effect size due to study-specific variables. Twelve retrospective studies on a total of 1,447 participants and 4 prospective studies on 184 subjects were selected. The RR was 0.732 (95% C.I.: 0.664-0.808) and 0.777 (95% C.I.: 0.629-0.960) in the prospective and retrospective studies, respectively. The I(2), indicating heterogeneity, was 51.1% in retrospective, 39.8% in prospective studies. Non-protective antibody responses occurred more frequently in patients than controls. Due to limitations in the available studies, additional trials to evaluate post-vaccination HBsAb titer in CD patients are needed.

Weight status and gross motor skill in kindergarten children

PURPOSE

Childhood obesity rates are increasing globally. Physical activity is one behavioral variable that influences weight status. Participation in physical activity requires basic gross motor proficiency in early childhood. The purpose of this study was to examine the relationship between gross motor skill level and weight status in a large national representative sample of kindergarten-aged children.

METHODS

Body mass index percentile ranking was calculated for 4650 children from the Early Childhood Longitudinal Study-Birth Cohort. Children were classified into underweight, healthy, overweight, or obese categories according to the Centers for Disease Control and Prevention criteria. The Early Screening Inventory Revised was used to evaluate gross motor skill level.

RESULTS

Children with obesity displayed lower gross motor skill levels compared with peers of healthy weight. Largest differences were seen in locomotor and balance skills.

CONCLUSIONS

Clinicians should consider adjusting gross motor expectations for locomotor or stability tasks in young children with obesity.

The role and effectiveness of computer-assisted learning in physical therapy education: a systematic review

Physical therapy educators seek teaching methodologies to efficiently educate students. The purpose of this article was to perform a systematic review of the literature pertaining to the use and effectiveness of computer-assisted learning (CAL) in physical therapy education. Criteria were established for article selection. Articles related to use included those reporting at least a 30% survey response return and a sample of at least 50. Articles regarding effectiveness included only randomized control studies related to use in physical therapy and physical therapy assistant education. Six articles related to the use and 17 articles related to the effectiveness were identified. Early published investigations were focused in the area of anatomy. The survey studies related to use indicated that educators highly valued CAL, but they reported initial use to be low due to cost. Expanding software development has resulted in higher contemporary use. CAL can effectively convey content material compared to traditional methods of instruction. CAL is largely underresearched in the field of physical therapy compared to other health professions. Recommendations for future research include larger studies, broader representation of the practice field, and development of interactive programming.

The potential role of recombinant activated FVII in the management of critical hemato-oncological bleeding: a systematic review

Recombinant activated factor VII (rFVIIa) is an hemostatic agent that was originally developed for the treatment of hemorrhage in patients with hemophilia and inhibitors. However, in the last few years rFVIIa has been employed with success in a broad spectrum of congenital and acquired bleeding conditions. In this systematic review we present the current knowledge on the use of this drug in patients suffering from hemato-oncological disorders, which are quite commonly complicated by severe hemorrhage. On the whole, data in the literature suggest a potential role for rFVIIa in the management of bleeding unresponsive to standard therapy in patients with hematological malignancies, including those undergoing bone marrow transplant. However, the vast majority of the currently available data are derived from uncontrolled studies including single cases or small series of patients. Thus, further trials with larger numbers of patients are needed to establish the most appropriate doses and timing of rFVIIa and to assess its efficacy and safety in this setting.

Hyperferritinaemia Without Iron Overload: Pathogenic and Therapeutic Implications

It is not unusual to meet increased levels of ferritinaemia in patients apparently healthy. Among other causes of hyperferritinaemia, recently was described the Hereditary Hyperferritinemia Cataract Syndrome, a genetic condition characterized by increased serum ferritin values without iron overload and bilateral nuclear cataract, both of early onset. It has been demonstrated that single or double point mutations or deletions in the stem-loop structure of the iron regulatory element (I.R.E.) located in the 5 untranslated regions of the ferritin L-subunit gene (19q13.1) are responsible for the upregulation of ferritin. This overexpression only for the L-chain gives rise to typical piles in several tissues. When this altered ferritin accumulates in lens it causes bilateral nuclear cataracts, that is the peculiar sign of this syndrome. It is essential to differentiate true iron overload from Hereditary Hyperferritinaemia Cataract Syndrome (H.H.C.S.), because these patients rapidly develop iron deficient anaemia when venosectioned. Here we describe a case report about a 40 years old healthy female blood donor who presented isolated hyperferritinaemia without iron overload, in the absence of concomitant pathologies. Anamnestic, biochemical, instrumental and clinical investigations led us to diagnose H.H.C.S., a pathology first described in 1995. From 1995 to date about 40 cases concerning patients showing the characteristics of this syndrome from Europe, USA, and Australia were described. Biochemical, genetical and clinical investigations led finally to understand every matter of this pathology, providing conclusive and exhaustive explanations.

Interferon and ribavirin in HIV-negative haemophiliacs with chronic hepatitis C who were nonresponders to a previous interferon treatment

Between January 1999 and December 2001, 33 HIV-negative haemophiliacs with interferon-nonresponsive chronic hepatitis C were treated with interferon (IFN) alpha2b (5 MU three times weekly) and ribavirin (1-1.2 g daily) for 12 months. Four patients (12.1%) dropped out of the study due to adverse effects. At the end of therapy, normalization of ALT occurred in 14/33 treated patients (42.4%) and HCV-RNA was cleared in 12 (36.4%). Eleven patients (33.3%) became sustained responders. Genotype 1 was the only factor associated with a poor response to therapy (P < 0.001). Our study shows that IFN and ribavirin combination therapy is effective in HIV-negative chronically HCV-infected haemophiliacs who do not respond to a previous IFN treatment.

Improved prognosis of Pseudomonas aeruginosa bacteremia in 127 consecutive neutropenic patients with hematologic malignancies

OBJECTIVES

Although decreasing in frequency, Pseudomonas aeruginosa bacteremia is still a major challenge for neutropenic cancer patients. In patients with hematologic malignancies, the prognosis of P. aeruginosa bacteremia is particularly poor due to the prolonged and severe neutropenia, mucosal damage, and other defects in immunity related both to the underlying disease and to the cytotoxic therapy.

METHODS

To verify the outcome of P. aeruginosa bacteremia and to try to define possible prognostic factors, the authors reviewed the medical records of 127 consecutive episodes of P. aeruginosa bacteremia observed in the hematologic unit of the Verona University School of Medicine.

RESULTS

Presence of pneumonia and septic shock, persistence and severity of neutropenia, delayed and inappropriate antibiotic therapy, and unresponsive underlying disease had negative impact on clinical outcome of P. aeruginosa bacteremia.

CONCLUSIONS

With recognition of the risk factors and more careful management, the prognosis of P. aeruginosa bacteremia in neutropenic patients with hematologic malignancies has improved in recent years.

Acute promyelocytic leukaemia: epidemiology and risk factors. A report of the GIMEMA Italian archive of adult acute leukaemia. GIMEMA Cooperative Group

Acute promyelocytic leukaemia (APL) exhibits peculiar epidemiological, clinical, cytogenetic and molecular features, compared to the other acute myeloid leukaemias (AML). Data on epidemiology and occupational risk factors for APL desumed from the GIMEMA archive are reported and compared with those of the other AML. An exploratory case-case study was designed on AML patients from 56 haematology centres in Italy. Overall, 4296 patients older than 15 yr with a new diagnosis of acute leukaemia were recorded between July 1992 and July 1997. Of these, 335 were classified as APL, and 2894 as other AML. The median age of APL patients was 43 compared to 59 yr for the other AML (p < 0.00001). In order to identify peculiar risk factors for APL development, different parameters were compared in the 2 groups. After adjusting by age no significant differences were observed with regard to education, lifetime prevalence of cancer among siblings and previous diseases in the patient's history. Occupational exposure as a possible risk factor for APL showed no increased risk compared to other AML among farmers, builders and leather workers. A significant association was found in electricians (OR=4.4, 95% CI=2.0-9.7) and a weak association was found in wood workers (OR=3.2, 95% CI=0.8-10.8). The proportion of APL with respect to other AML was significantly higher in the north east of Italy compared to the rest of the country (OR=1.7, 95% CI=1.3-2.2). These data confirm the younger age of APL patients compared to the other AML. A possible role of electromagnetic fields is suggested by the higher risk of APL in electrical workers and in the more industrialized areas of the country.

AIDS-related non-Hodgkin's lymphomas from an Italian area

In a retrospective study, 42 (7.7%) of 545 patients with AIDS from a single area of Italy had non-Hodgkin's lymphoma (28 systemic and 14 primary central nervous system lymphomas). The improved outcome and survival of treated patients outlines the clinical benefit of antineoplastic treatment in selected cases.

Estimated 6-year event-free survival of 55% in 60 consecutive adult acute lymphoblastic leukemia patients treated with an intensive phase II protocol based on high induction dose of daunorubicin

On the basis of a previous experience suggesting that daunorubicin dose in induction was an independent prognostic factor in adult ALL, we designed a chemotherapeutic regimen (ALLVR589) characterized by high doses of daunorubicin (270 mg/m2) in induction and by high-dose Ara-C in post-remission. The protocol was otherwise conventional: induction and post-remission therapy were followed by chemo-radio prophylaxis of the central nervous system (CNS) and periodical reinductions over a 3-year maintenance period. Sixty consecutive patients (male 42, female 18, median age 34 years, range 14-71; B-lineage, 35; T-lineage, 25; Ph' and bcr/abl positive, 7) recruited between 1989 and 1996, were evaluated for treatment outcome. Complete remissions were 56 (93%), one patient had refractory disease, early deaths were five (8%); 19/56 (34%) patients relapsed, five of whom were Ph'+. Median time to relapse was 11 months (range 3-47); 68% of relapses occurred within 12 months from CR. No CNS relapses were observed. After a median follow-up of 44 months (1-100), 33/60 (55%) patients remain event-free; 23/60 (38%) are off-therapy in continuous CR (median follow-up from diagnosis: 63 months; range 38-100). These results suggest that increasing DNM dosage in induction is one of the possible approaches to improve the outcome of adult ALL by decreasing the relapse occurrence.

[Non-Hodgkin's lymphomas of the oromaxillofacial area. A clinical contribution]

The authors present a clinico-statistical review (January 1987-December 1994) of 19 patients with non-Hodgkin's lymphoma of the oro-maxillo-facial region, diagnosed in the Dentistry Department of the University of Verona in collaboration with the Haematology Department. Particular attention has been devoted to the localisation, symptomatology, diagnosis and histological typing of non-Hodgkin's lymphoma of the maxillofacial region, stressing the importance of diagnosis and staging, based on a multidisciplinary approach, in order to be able to plan the most appropriate therapeutic management of patients with the disease.

In leukaemic CD5+ B cells the expression of BCL-2 gene family is shifted toward protection from apoptosis

This study further investigated the mechanisms that control apoptosis in leukaemic CD5+ B cells, and focused on the Bcl-2 gene family. The pattern of expression of Bcl-2, Bcl-xL, Bcl-xS and Bax genes, selected because of their interrelated role in the control of apoptosis, was analysed in a series of CD5+ B-cell chronic lymphoid leukaemias. Cells from 34 patients with chronic lymphoid leukaemia of B-cell type (23 B-chronic lymphocytic leukaemia (B-CLL) and 11 mantle cell lymphoma (MCL) in leukaemic phase) were investigated. High levels of Bcl-2 mRNA were observed by Northern blot and high levels of Bcl-2 protein were detected by cytofluorograph analysis with a specific monoclonal antibody (MAb) in all cases. Strong Bax expression was detected by RT-PCR in 20/23 B-CLL cases; Bax was also observed in 8/11 MCL in leukaemic phase with variable degree of intensity. In both B-CLL and MCL samples the presence of Bax protein was confirmed by cytofluorograph analysis. RT-PCR detected high levels of Bcl-xL in 16/23 B-CLL and in 8/11 MCL in leukaemic phase, whereas Bcl-xS was detectable in low to trace amounts respectively in 13/23 B-CLL and in 6/11 MCL in leukaemic phase. According to the functional role of Bcl-2, Bcl-xL, Bcl-xS and Bax, these data indicate that the pattern of Bcl-2 family genes expression in leukaemic CD5+ B cells is skewed toward prevention of apoptosis and may thus favour the relentless accumulation of CD5+ leukaemic B cells.

Soluble forms of p55-IL-2R alpha, CD8, and CD30 molecules as markers of lymphoid cell activation in infectious mononucleosis

BACKGROUND

Epstein-Barr virus (EBV) infection in infectious mononucleosis (IM) is associated with lymphocyte activation leading to the expansion of cells expressing activation-associated antigens. Most of these antigens are released as soluble molecules in vitro and in vivo.

METHODS

We investigated the serum levels of the soluble forms of the CD8 (sCD8), p55-IL-2R alpha (sIL-2R alpha), and CD30 (sCD30) molecules in 55 patients following primary EBV infection. These data were compared with the phenotypic pattern of circulating lymphoid subsets.

RESULTS

In all cases at presentation, lymphocytosis, mainly characterized by the expansion of a CD8+, HLA-DR+, p75-IL-2R beta+, p55-IL-2R alpha- population, was associated with high levels of the investigated soluble molecules. Their mean values (+/- SD) were: 17,172 +/- 12,885 U/mL for sCD8 (vs 334 +/- 95 in controls), 2,922 +/- 2,813 U/mL for sIL-2R alpha (vs 331 +/- 115 in controls), and 477 +/- 451 U/mL for sCD30 (vs 4.9 +/- 6.4 in controls). Follow-up study (15 cases, up to 60 days) showed a progressive decline of all soluble molecules, associated with a reduction of activated CD8+/HLA-DR+/p75-IL-2R beta+ T-cells. By the 30th day, values of sIL-2R alpha and sCD30 (729 +/- 333 U/mL and 20 +/- 21 U/mL, respectively) were only slightly higher than in normal controls, whereas sCD8 levels remained consistently higher (1,777 +/- 1,385 U/mL, p < .001).

CONCLUSIONS

sCD8, sIL-2Ra and sCD30 serum levels in IM reflect the total bulk and/or the activation-related events of infected and reactive cells. The variations in these soluble molecules during the follow-up provide useful information on the in vivo biological modifications occurring after EBV infection.

Serum levels of soluble CD30 are elevated in the majority of untreated patients with Hodgkin's disease and correlate with clinical features and prognosis

PURPOSE

To evaluate the serum levels of the soluble form of the CD30 molecule (sCD30) in patients with Hodgkin's disease (HD) to establish whether there is a correlation with clinical features at presentation and prognosis.

PATIENTS AND METHODS

The sCD30 serum levels of 117 patients were measured at diagnosis with a commercial sandwich enzyme-linked immunoadsorbent assay (ELISA) test kit, and in 78 of these patients the sCD30 levels were also recorded during the follow-up period.

RESULTS

sCD30 levels at diagnosis were increased (> 20 U/mL) in a high proportion of patients (87.2%; mean +/- SD, 108 +/- 134 v 5.3 +/- 5.7 U/mL in controls, P < .0001) and correlated with stage (stages I + II, 73 +/- 97 U/mL; III + IV, 162 +/- 165 U/mL; P < .0001), with presence of B symptoms (stage A, 69 +/- 82 U/mL; stage B, 162 +/- 171 U/mL; P < .0001), and, to some extent, with tumor burden (bulky presentation, 141 +/- 129 U/mL; nonbulky, 91 +/- 133 U/mL; P = .058). Patients with sCD30 levels greater than 100 U/mL at diagnosis had a significantly higher rate of poor outcome in terms of failure to achieve a complete remission (CR) or disease relapse after CR achievement. In fact, the event-free survival (EFS) duration of patients with sCD30 levels greater than 100 U/mL was significantly worse (P = .0016). Using multivariate analysis, an sCD30 level greater than 100 U/mL retained its significance after adjustment for other prognostic parameters.

CONCLUSION

sCD30 in HD at presentation strictly correlates with clinical features. Serum levels greater than 100 U/mL at diagnosis entail a significantly higher risk of treatment failure, a factor that is independent of other prognostic parameters.

Detection of membrane and intracellular antigens by flow cytometry following ORTHO PermeaFix fixation

In the present study, we explored the suitability of a new cell fixative (ORTHO PermeaFix, OPF) for the detection by flow cytometry of intracellular molecules while preserving the cell surface immunoreactivity, scatter features and morphology. The effect of OPF was investigated on whole blood of ten normal donors, and on separated blasts of 17 leukemic patients. OPF fixation for 45 min to 24 h maintained the morphology of lymphoid cells with minimal cellular distortion and scatter changes, and only slightly modified cell surface immunoreactivity. For at least 1 week following fixation, the cells were still suitable for immunostaining with monoclonal antibodies that recognize the main lymphoid populations. These included CD3, CD4 and CD8 for T-cell subsets, CD19 and CD16 for B lymphocytes and NK cells, and CD45 for leukocyte common antigen (LCA). The OPF fixation of leukemic cells allowed the simultaneous detection of nuclear TdT in conjunction with membrane CD19, and with membrane and/or cytoplasmic CD22 in common-ALL, as well as with cytoplasmic CD3 in T-ALL cases. Our findings suggest that with the introduction of this new fixative into the routine laboratory service, a number of convenient and practical arrangements can be made which increase the efficiency of immunodiagnosis. Small laboratories with no inhouse flow-cytometric facilities can now accumulate OPF-treated whole blood samples for at least 3-4 days and send these to reference laboratories. In addition, the immunodiagnosis of acute leukemia is greatly facilitated by combination staining for membrane and intracellular antigens both at diagnosis and when the analysis of minority populations is warranted for detecting minimal disease.

Relationship between Daunorubicin dosage delivered during induction therapy and outcome in adult acute lymphoblastic leukemia

The long-term results of a therapeutic regimen for adult acute lymphoblastic leukemia (ALL) have been analysed with the main purpose to evaluate the impact of Daunorubicin (DNM) dosage given during the induction. The files of 86 consecutive adult ALL patients treated in our institution between 1974 and 1988 were reviewed. They received the same induction regimen based on Vincristine, DNM and Prednisone, consolidation with L-Asparaginase, central nervous system prophylaxis, and 3-year maintenance with 6-mercaptopurine and Methotrexate with periodic cycles of reinduction. We analysed the overall and disease-free survival (DFS) in relation to various prognostic factors, focusing on the dosage of DNM actually received during the induction period. Complete remission (CR) was achieved in 68 (79%) patients and the overall DFS was of 32 months (median follow-up 37 months); 22 patients (25.6%) are off-therapy and disease-free. The actual dosage of DNM received during induction turned out to be an independent DFS prognostic factor. In fact, patients who received more or less than 175 mg/sqm in induction had a median DFS of 44 and 12 months, respectively (p = 0.05). The plateau of DFS in the two groups was 44% and 21%, respectively. Similar data were found analyzing the dose-intensity (mg/sqm/week) of DNM given in induction. Our data suggest that the actual dosage of DNM given in induction plays a role in the long term DFS of adult ALL.

Early lymphoid blastic crisis following major karyotypic conversion in a chronic myeloid leukemia patient treated with interferon-alpha

A major karyotypic conversion following interferon-alpha treatment delays or prevents blastic crisis in patients with chronic myeloid leukemia. We report here a 12-year-old boy with Ph1+ chronic myeloid leukemia who, after achieving a major karyotypic conversion following 12 months interferon-alpha treatment, developed an early lymphoid blastic transformation 7 months later while still under interferon-alpha therapy. A number of possible explanations for this quite unexpected event are discussed.

Serum levels of soluble interleukin-2 receptor in Hodgkin disease. Relationship with clinical stage, tumor burden, and treatment outcome

BACKGROUND

Previous studies suggested a possible role for the detection of soluble interleukin-2 receptor (sIL-2R) in Hodgkin disease (HD). In this study, the authors investigated, in a large series of patients, sIL-2R serum levels in relation to disease features at presentation and prognosis. Their usefulness as markers in the management of individual cases was evaluated.

METHODS

The sIL-2R serum levels were measured in 195 patients at diagnosis. In 72 of these patients, sIL-2R serum levels were also monitored after diagnosis. An additional 87 cases were tested only in complete remission (CR), and 25 were tested only at relapse.

RESULTS

The sIL-2R levels at diagnosis were increased (mean +/- 1222 +/- 1012 versus 331 +/- 145 U/ml in controls, P < 0.0001) and correlated with the stage and tumor burden (Stages I and II = 1058 +/- 1007, Stages III and IV = 1502 +/- 942 U/ml, P = 0.003; Stage A = 954 +/- 705, Stage B = 1880 +/- 1238 U/ml, P < 0.0001; bulky presentation = 1958 +/- 1430, nonbulky presentation = 1043 +/- 791 U/ml, P < 0.0001). Response to treatment was associated with progressive reduction of sIL-2R levels, which were normal in virtually all cases 1 year after CR. Significantly greater levels at diagnosis were found in 11 patients who experienced a poor response or progression after treatment (P = 0.004). Overall, abnormal data in CR were found in 59 of 159 patients and 9 of them subsequently experienced a relapse.

CONCLUSIONS

The sIL-2R serum levels in HD correlate with features at presentation and subsequent clinical courses. Higher levels at diagnosis entail a significantly higher risk of treatment failure.

Highly concentrated urine-purified Tac peptide fails to inhibit IL-2-dependent cell proliferation in vitro

Tac peptide, i.e., the p55 chain of the human interleukin-2 receptor (IL-2R) complex, is detectable as a soluble from (sIL-2R) in normal sera and, at increased levels, in patients with different diseases. Since several immunological abnormalities are observed in most conditions associated with an increase in sIL-2R levels, a down-regulatory effect on IL-2-dependent functions has been postulated as a consequence of binding and functional block of IL-2 by the excess of sIL-2R. To test this hypothesis, we purified sIL-2R from the urine of a patient with hairy cell leukemia and investigated the possible inhibitory effect of this peptide on the in vitro IL-2-induced cell proliferation. The urine-purified molecule was detectable by the specific immunoassay utilized to measure the serum Tac peptide and was constructed by a single polypeptide of about 50 kDa which was able to bind IL-2. Experiments performed with the IL-2-dependent murine CTLL-2 cell line and with PHA-stimulated human peripheral blood mononuclear cells showed that the purified sIL-2R at concentrations up to about 300 nM was unable to block IL-2-dependent cell proliferation. According to these data, which can be explained by the low affinity for IL-2 of the p55 IL-2R chain, it seems unlikely that in vivo the soluble Tac peptide can exert a down regulatory effect on IL-2-induced phenomena through a functional block of IL-2.

Ceftazidime and amikacin as empiric antibiotic therapy of febrile granulocytopenic patients with hematological malignancies. Report of 171 consecutive episodes

One hundred and seventy-one consecutive febrile episodes occurring in 130 neutropenic adult patients with hematological malignancies (mainly acute leukemia) were empirically treated with a combination antibiotic therapy consisting of ceftazidime (100 mg/kg/day) + amikacin (15 mg/kg/day). Of these, 161 were evaluable. In the majority of episodes (75 per cent) documented infections were identified as a cause of fever. There were 73 bacteremias (34 Gram-negative, 29 Gram-positive, 10 polymicrobial). One third of patients had pneumonia. Cure without change of the initial regimen was achieved in 45/73 (62 per cent) bacteremic episodes and in 12/13 episodes of microbiologically documented infections without bacteremia. There were 35 clinically documented infections and 26 (74 per cent) of these were cured. Of the 40 patients presenting with possible infections 26 (65 per cent) were cured. Overall, cure without modification of the initial antibiotic combination was achieved in 109/161 episodes (68 per cent). In spite of the frequent occurrence of persistent neutropenia (82 per cent), the infectious mortality was low (8.6 per cent), and often due to superinfection. The deaths due to primary infections were 6/161 (3.7 per cent). Side effects were mild and rare. In our experience ceftazidime + amikacin was an effective and safe empirical regimen for this population of hematologic patients with persistent neutropenia and severe documented infections.

A comparative analysis of three different techniques for the detection of breast cancer cells in bone marrow

Three different methods, morphologic, immunocytochemic, and fluorescence activated cell sorter (FC) analysis, were compared with respect to their efficiency in detecting breast cancer cells in bone marrow. In the first series of experiments, the three techniques were compared using bone marrow cells artificially mixed with a known amount of breast cancer cells, whereas in a second series bone marrow from breast cancer patients with bone metastases were used. The following results were obtained: When mixtures of the first series were analyzed, FC analysis detected from 1% to 10% of breast cancer cells in bone marrow (0.2% was a border line value), the morphologic method detected from 0.05% to 10%, and the immunocytochemic method, which was clearly superior, detected breast cancer cells in all mixtures (from 0.00025% to 10%). It was noted that, with both the morphologic and immunocytochemic methods, the percentage of breast cancer cells detected was 2 to 360 times higher than the percentage of added cells, and enrichment was inversely proportional to the percentage of added cells. This result could be a result of different separation of cells during centrifugation due to the different density of breast cancer cells. The superiority of the immunocytochemic method was confirmed in the second series of experiments.

Selenium dependent glutathione peroxidase: a physiological regulatory system for platelet function

In human platelets the selenoenzyme glutathione peroxidase (GSH-Px) acts as a scavenger of the peroxides generated during the burst of arachidonic acid (AA) metabolism. Such a mechanism inhibits the biosynthesis of both thromboxane A2 (TXA2) and lipoxygenase products. The same mechanism is not effective on the prostacyclin (PGI2) biosynthesis from cultured endothelial cells. In order to evaluate this effect in vivo, besides in vitro, we activated the enzyme in eight normal volunteers by increasing their daily Se intake for 8 weeks, monitoring: platelet GSH-Px activity, platelet aggregation induced by AA and U 44069, and concurrent malondialdehyde (MDA) and thromboxane B2 (TXB2) production, urinary excretion of renal and systemic TXA2 and PGI2 metabolites, platelet enzyme activities of the hexose monophosphate pathway and glutathione content, platelet adenine nucleotides, bleeding time, plasma Se concentration. We found: a) progressive platelet GSH-Px activation by Se paralleling an enhancement of platelet aggregation threshold values for AA, but not for U 44069; b) concurrent inhibition of platelet biosynthesis of TXA2 both in vitro and in vivo while the biosynthesis of systemic prostacyclin was unaffected; c) a progressive increase in the bleeding time, unmodified by aspirin. In conclusion, we believe that Se-dependent GSH-Px represents a physiological mechanism regulating the biosynthesis of prostanoids with implications in platelet function and that a Se dietary supplement might be considered in the prevention of arterial thrombosis.

Mediastinal large-B-cell lymphoma with sclerosis: a clinical study of 21 patients

We report the clinical findings of 21 consecutive patients affected by mediastinal large B-cell lymphoma with sclerosis. This type of lymphoma is a recently described histopathologic entity characterized on clinical grounds by distinctive features, which, according to our series, can be summarized as follows: young age (median, 30 years; range, 15 to 42 years), prevalence of females over males (15 v six), rare occurrence of superficial lymph node enlargement (three of 21 patients), and involvement of unusual extranodal sites (kidney six, adrenal cortex two patients). The clinical course appears to be closely related to treatment. In fact, complete remission (CR) was not obtained in the six patients submitted to conventional cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP plus bleomycin (CHOP-Bleo) regimens until 1985, as opposed to 13 CRs reached in the 15 patients subsequently treated with more aggressive regimens after 1985 (methotrexate with leucovorin, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin [MACOP-B], 12 patients; methotrexate, bleomycin, doxorubicin, cyclophosphamide, vincristine, and dexamethasone [M-BACOD], two patients; and vincristine, cyclophosphamide, fluorouracil, cytarabine, doxorubicin, methotrexate, and prednisone [F-MACHOP], one patient; plus involved-field radiotherapy, 10 patients). Among the 13 patients who achieved a CR, only one relapse was observed at 10 months. The median overall survival of complete responders after an observation period of 11 to 69 months has not yet been reached, and the event-free survival curve indicates that 90% of patients who achieve CR may be potentially cured.

Increased levels of soluble CD8 molecule in the serum of patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related disorders

In this study we investigated the serological levels of the soluble form of the CD8 molecule (s-CD8) in 97 human immunodeficiency virus (HIV) seropositive patients. The control groups included 20 normal heterosexual subjects and 19 healthy seronegative subjects belonging to risk groups for AIDS. Our results show that patients with HIV infection have significantly higher levels of s-CD8 U/ml than the control groups. When the patients were further subdivided according to the Centers for Disease Control (CDC) classification, s-CD8 U/ml values were consistently increased in all HIV patients, irrespective of the CDC stages. No statistically significant correlation was found between the serological levels of s-CD8/ml and the absolute numbers of CD8 lymphocytes/mm3, in both HIV seropositive patients and control groups. Since in the more advanced stages of HIV infection (IV-A, IV-C1) the decrease in the absolute number of CD8+ cells was not followed by a decrease in s-CD8 levels, it is conceivable that an increased release and/or shedding of s-CD8 per cell might occur in these patients. In fact, when the results were expressed as s-CD8 units per CD8 positive cell (s-CD8/absolute number of CD8), the levels of s-CD8/cell were higher in patients belonging to the IV-A and IV-C1 CDC groups (1.94 U/cell +/- 0.33 and 3.39 U/cell +/- 0.5, respectively) compared to normal controls (P less than 0.001), HIV seronegative subjects at risk for AIDS (P less than 0.001), and the other patients' groups (II and III CDC groups, respectively, P less than 0.001 and P less than 0.001). The evidence herein provided that in patients with HIV infection s-CD8 levels are increased suggests a possible pathogenetic role of the cells involved in the release of this molecule.