Robot-assisted nephroureterectomy for upper tract urothelial carcinoma-feasibility and complications: a single center experience

BACKGROUND

Robot-assisted nephroureterectomy (RANU) is the primary treatment for upper tract urothelial carcinoma (UTUC) at our hospital for patients with clinical stage less than T2, and for patients with invasive tumours, but unfit for major surgery.

OBJECTIVE

To assess peri-operative conditions and outcomes of RANU at our unit, and to evaluate the safety of the procedure.

METHODS

The medical records of all 166 patients undergoing RANU for suspected UTUC and followed for more than three months in a large university hospital in Sweden were reviewed retrospectively. After the exclusion of twenty patients because of previous cystectomy, simultaneous surgical procedure, or other tumour types than UTUC in the pathological report, 146 patients remained for the analyses. The primary endpoint was complication rate according to Clavien-Dindo at 90 days. Secondary endpoints were perioperative bleeding, violation of oncological surgical principles, hospital stay, and re-admission within 90 days.

RESULTS

The median age was 75 [(Inter Quartile Range) IQR 70-80] years and 57% of the patients had an ASA score above 2. According to Clavien-Dindo, one patient had a grade 3 complication, and no patient had a grade 4-5 complication. The median blood loss was 50 (IQR 20-100) ml and the median hospital stay was 6 (IQR 5-7) days. Twelve patients were re-admitted to the hospital within 90 days (eight with urinary tract infection/haematuria, one with hematoma, and three with other diseases).

CONCLUSION

Robot-assisted nephroureterectomy is a safe procedure for patients with upper tract urothelial carcinoma, with a low risk of major surgical complications.

Hematopoietic cell transplant in pediatric acute myeloid leukemia after similar upfront therapy; a comparison of conditioning regimens

The impact of conditioning regimen prior to hematopoietic cell transplant (HCT) in pediatric AML-patients is not well studied. We retrospectively analyzed the impact of Busulfan-Cyclophosphamide (BuCy), Busulfan-Cyclophosphamide-Melphalan (BuCyMel) and Clofarabine-Fludarabine-Busulfan (CloFluBu) in pediatric AML-patients, with similar upfront leukemia treatment (NOPHO-DBHconsortium), receiving an HCT between 2010 and 2015. Outcomes of interest were LFS, relapse, TRM and GvHD. 103 patients were included; 30 received BuCy, 37 BuCyMel, and 36 CloFluBu. The 5-years LFS was 43.3% (SE ± 9.0) in the BuCy group, 59.2 % (SE ± 8.1) after BuCyMel, and 66.7 % (SE ± 7.9) after CloFluBu. Multivariable Cox regression analysis showed a trend to lower LFS after BuCy compared to CloFluBu (p = 0.07). BuCy was associated with a higher relapse incidence compared to the other regimens (p = 0.06). Younger age was a predictor for relapse (p = 0.02). A strong correlation between Busulfan Therapeutic Drug Monitoring (TDM) and lower incidence of aGvHD (p < 0.001) was found. In conclusion, LFS after BuCyMel and CloFluBu was comparable, lower LFS was found after BuCy, due to higher relapse incidence. CloFluBu was associated with lower incidence of aGvHD, suggesting lower toxicity with this type of conditioning. This finding is also explained by the impact of Busulfan monitoring.

Minimal residual disease quantification by flow cytometry provides reliable risk stratification in T-cell acute lymphoblastic leukemia

Minimal residual disease (MRD) measured by PCR of clonal IgH/TCR rearrangements predicts relapse in T-cell acute lymphoblastic leukemia (T-ALL) and serves as risk stratification tool. Since 10% of patients have no suitable PCR-marker, we evaluated flowcytometry (FCM)-based MRD for risk stratification. We included 274 T-ALL patients treated in the NOPHO-ALL2008 protocol. MRD was measured by six-color FCM and real-time quantitative PCR. Day 29 PCR-MRD (cut-off 10-3) was used for risk stratification. At diagnosis, 93% had an FCM-marker for MRD monitoring, 84% a PCR-marker, and 99.3% (272/274) had a marker when combining the two. Adjusted for age and WBC, the hazard ratio for relapse was 3.55 (95% CI 1.4-9.0, p = 0.008) for day 29 FCM-MRD ≥ 10-3 and 5.6 (95% CI 2.0-16, p = 0.001) for PCR-MRD ≥ 10-3 compared with MRD < 10-3. Patients stratified to intermediate-risk therapy on day 29 with MRD 10-4-<10-3 had a 5-year event-free survival similar to intermediate-risk patients with MRD < 10-4 or undetectable, regardless of method for monitoring. Patients with day 15 FCM-MRD < 10-4 had a cumulative incidence of relapse of 2.3% (95% CI 0-6.8, n = 59). Thus, FCM-MRD allows early identification of patients eligible for reduced intensity therapy, but this needs further studies. In conclusion, FCM-MRD provides reliable risk prediction for T-ALL and can be used for stratification when no PCR-marker is available.

Minimal residual disease monitoring in childhood B lymphoblastic leukemia with t(12;21)(p13;q22); ETV6-RUNX1: concordant results using quantitation of fusion transcript and flow cytometry

INTRODUCTION

The translocation t(12;21)(p13;q22) resulting in the fusion gene ETV6-RUNX1, is the most frequent gene fusion in childhood B lymphoblastic leukemia. In the Nordic Society of Paediatric Haematology and Oncology ALL-2008 treatment protocol, treatment stratification in B-lineage ALL is based on results of minimal residual disease (MRD) analysis with fluorescence-activated cell sorting (FACS). In this study, we determined whether RT-qPCR of the ETV6-RUNX1 fusion transcript can be a reliable alternative for MRD analysis.

METHODS

Seventy-eight bone marrow samples from 29 children at diagnosis and day 15, 29, and 78 during treatment were analyzed for MRD with FACS and with quantitative reverse transcription polymerase chain reaction (RT-qPCR). Fusion transcript MRD was defined as the ETV6-RUNX1/GUSB ratio at the follow-up time point (day 15/29/78) divided with the ETV6-RUNX1/GUSB ratio at diagnosis (%).

RESULTS

MRD analysis with FACS and with RT-qPCR of ETV6-RUNX1 fusion transcript showed strong correlation. All cases showed concordant results at the treatment stratifying time points day 29 and day 78, when comparing the two methods with a cutoff set to 0.1%.

CONCLUSION

RT-qPCR is a valuable addition and could also be an alternative to FACS in cases where FACS is not achievable for MRD analysis.

Asparaginase-associated pancreatitis: a study on phenotype and genotype in the NOPHO ALL2008 protocol

Asparaginase (ASP)-associated pancreatitis (AAP) occurs during acute lymphoblastic leukemia treatment. Among 1285 children (1.0-17.9 years) diagnosed during July 2008-December 2014 and treated according to the Nordic/Baltic ALL2008 protocol, 86 (cumulative incidence=6.8%) developed AAP. Seventy-three cases were severe (diagnostic AAP criteria persisting >72 h) and 13 mild. Cases were older than controls (median: 6.5 vs 4.5 years; P=0.001). Pseudocysts developed in 28%. Of the 20 re-exposed to ASP, 9 (45%) developed a second AAP. After a median follow-up of 2.3 years, 8% needed permanent insulin therapy, and 7% had recurrent abdominal pain. Germline DNA on 62 cases and 638 controls was genotyped on Omni2.5exome-8-v1.2 BeadChip arrays. Overall, the ULK2 variant rs281366 showed the strongest association with AAP (P=5.8 × 10^-7; odds ratio (OR)=6.7). Cases with the rs281366 variant were younger (4.3 vs 8 years; P=0.015) and had lower risk of AAP-related complications (15% vs 43%; P=0.13) compared with cases without this variant. Among 45 cases and 517 controls <10 years, the strongest associations with AAP were found for RGS6 variant rs17179470 (P=9.8 × 10^-9; OR=7.3). Rs281366 is located in the ULK2 gene involved in autophagy, and RGS6 regulates G-protein signaling regulating cell dynamics. More than 50% of AAP cases <10 years carried one or both risk alleles.

Translational Mini-Review Series on B cell subsets in disease. Reconstitution after haematopoietic stem cell transplantation - revelation of B cell developmental pathways and lineage phenotypes

Haematopoietic stem cell transplantation (HSCT) is an immunological treatment that has been used for more than 40 years to cure a variety of diseases. The procedure is associated with serious side effects, due to the severe impairment of the immune system induced by the treatment. After a conditioning regimen with high-dose chemotherapy, sometimes in combination with total body irradiation, haematopoietic stem cells are transferred from a donor, allowing a donor-derived blood system to form. Here, we discuss the current knowledge of humoral problems and B cell development after HSCT, and relate these to the current understanding of human peripheral B cell development. We describe how these studies have aided the identification of subsets of transitional B cells and also a robust memory B cell phenotype.

Twenty-three deaths with gamma-hydroxybutyrate overdose in western Sweden between 2000 and 2007

BACKGROUND

gamma-Hydroxybutyrate (GHB) is a drug of abuse with a status as being safe. In spite of a reputation of low toxicity, a huge number of deaths associated with this drug have been recorded during recent years in Sweden. It is unclear whether coingestion with other drugs or ethanol causes death in GHB overdoses or whether GHB itself is the main cause of death.

OBJECTIVES

The aim of this study was to analyze the cause of death in GHB-related fatalities seen in our region.

METHODS

All cases of deaths with GHB during the year 2000-2007 in the region of western Sweden were studied retrospectively. The cases were classified as either GHB poisonings without any, with a minor or a major influence of other drugs on the cause of death.

RESULTS

Twenty-three cases were diagnosed as deaths due to GHB overdose. Ninety-one percent coingested other substances. Ninety-one percent of the decedents were male. Age varied between 16 and 46, with the median age at 25 years. Forty-three percent of the cases were classified as GHB poisonings without any or a minor influence of other drugs on the cause of death. Thirty percent also ingested ethanol. Two patients (9%) were only intoxicated with GHB.

CONCLUSIONS

Intoxication with GHB carries some mortality. Combining GHB with ethanol does not explain the many deaths in our region, nor do extremely high plasma concentrations of GHB. The intake of opioids increases the toxicity of GHB. The drug itself has such biological activities that an overdose is dangerous and may lead to death.

Variation in organic matter and water color in Lake Mälaren during the past 70 years

Interest in long time series of organic matter data has recently increased due to concerns about the effects of global climate change on aquatic ecosystems. This study presents and evaluates unique time series of chemical oxygen demand (COD) and water color from Lake Malaren, Sweden, stretching almost seven decades (1935-2004). A negative linear trend was found in COD, but not in water color. The decrease was mainly due to installation of sewage works around 1970. Time series of COD and water color had cyclic pattern. It was strongest for COD, with 23 years periodicity. Similar periodicity observed in air temperature and precipitation in Sweden has been attributed to the North Atlantic Oscillation index and solar system orbit, suggesting that COD in Lake Mälaren is partly derived from algae. Discharge influenced water color more than COD, possibly because water color consists of colored substances brought into the lake from surrounding soils.

Long-term results in children with AML: NOPHO-AML Study Group--report of three consecutive trials

In all, 447 children with acute myeloid leukaemia (AML) have been treated on three consecutive NOPHO studies from July 1984 to December 2001. NOPHO-AML 84 was of moderate intensity with an induction of three courses of cytarabine, 6-thioguanine and doxorubicin followed by four consolidation courses with high-dose cytarabine. The 5-year event-free survival (EFS), disease free survival (DFS) and overall survival (OS) were 29, 37 and 38%. NOPHO-AML 88 was of high intensity with the addition of etoposide and mitoxantrone in selected courses during induction and consolidation. The interval between the induction courses should be as short as possible, that is, time intensity was introduced. The 5-year EFS, DFS and OS were 41, 48 and 46%. In NOPHO-AML 93, the treatment was stratified according to response to first induction course. The protocol utilised the same induction blocks as NOPHO-AML 88, but after the first block, children with a hypoplastic, nonleukaemic bone marrow were allowed to recover before the second block. Consolidation was identical with NOPHO-AML 88. The 5-year EFS, DFS and OS in NOPHO-AML 93 were 48, 52 and 65%. The new NOPHO-AML protocol has been based on experiences from previous protocols with stratification of patients with regard to in vivo response and specific cytogenetic aberrations.

Internal Standard in Surface-Enhanced Raman Spectroscopy

A method is presented for the use of SAM layers as internal standards for calibration in surface-enhanced Raman spectroscopy. Three cyano-containing compounds were attached to gold colloids via a metal-sulfur bond and evaluated for spectral stability and normalization capacity. The results show that the analyte, rhodamine 6G, and the internal standard signal enhancement covaried, and it was possible to quantify the analyte with PLS. The fact that the enhancing substrate was chaotic assemblies with large variation in signal enhancement shows the versatility of this method.

NESP55, a novel chromogranin-like peptide, is expressed in endocrine tumours of the pancreas and adrenal medulla but not in ileal carcinoids

Neuroendocrine secretory protein 55, NESP55, is an acidic protein belonging to the chromogranin family. The distribution of NESP55 in human tumours is not known. The aim of the present study was to study the expression of NESP55 in human gastrointestinal, pancreatic and adrenal tumours. A total of 118 human endocrine and nonendocrine tumours were examined by immunocytochemistry, and compared to the expression of chromogranin A (CgA) in the same tumours. Pancreatic endocrine tumours (14 out of 25), pheochromocytomas (19 out of 19), and neuroblastomas (seven out of 14) expressed NESP55, with the same strong labelling pattern in both benign and malignant tumours. Expression of NESP55 in pancreatic endocrine tumours and pheochromocytomas was confirmed by Western and Northern blot analysis. Immunocytochemical analysis demonstrated no labelling in ileal carcinoids (zero out of 15), and adrenocortical adenomas (zero out of 15). The majority of gastrointestinal and pancreatic carcinomas were negative for NESP55, with focal staining observed in two out of 30 tumours. In contrast, CgA was present in all neuroendocrine tumours examined (25 out of 25 pancreatic endocrine tumours, 19 out of 19 pheochromocytomas, 14 out of 14 neuroblastomas and 15 out of 15 ileal carcinoids). Thus, the expression of NESP55 in endocrine tumours of the gastrointestinal tract, pancreas and adrenals differs from that of CgA. Neuroendocrine secretory protein 55 is found in a subset of neuroendocrine tumours showing differentiation towards adrenal chromaffin cells and pancreatic islets cells.

Vincristine in childhood leukaemia: no pharmacokinetic rationale for dose reduction in adolescents

AIM

To investigate whether there is any pharmacokinetic rationale for the common practice of administering vincristine to adolescents at relatively lower doses than those to younger children.

METHODS

A total of 98 children, aged 1.3-17.3 y, with acute lymphoblastic leukaemia (ALL) were studied on day 1 of induction therapy. Plasma samples were drawn before and 10, 30, 360 and 1380 min after injection of vincristine 2.0 mg/m2 (maximum dose 2.0 mg) and analysed by high-performance liquid chromatography.

RESULTS

The median value (and range) for distribution half-life was 6.4 min (0.8-11.8), elimination half-life 1014 min (258-2570), volume of distribution 445 L/m2 (137-1241) and total body clearance 362 ml/min/m2 (134-2553). No correlation was found between age and any of these pharmacokinetic parameters. The area under the concentration time curve (AUC) was significantly correlated to age (p = 0.002; p - 0.31), as expected from the dosage of vincristine. The lower AUC in children with a body surface area > 1 m2, which is reached at 8-9 y of age, indicates that they received a less intense treatment because of the capping of the vincristine dose at 2.0 mg.

CONCLUSIONS

Vincristine pharmacokinetics were not age dependent in this paediatric population. Thus, we found no pharmacokinetic rationale for dose reduction in adolescents. The common practice of limiting the vincristine dose to 2.0 mg should be carefully reconsidered.

Pharmacokinetics of doxorubicin in children with acute lymphoblastic leukemia: multi-institutional collaborative study

BACKGROUND

In adults, it has been shown that the pharmacokinetics of doxorubicin are highly variable, despite standardization of the dose based on body surface area (BSA). The purpose of this study was to determine the plasma concentrations of doxorubicin and its active metabolite doxorubicinol in children treated for acute lymphoblastic leukemia (ALL).

PROCEDURE

Children, 107 in number, aged 1.3-17.3 years, were studied at Day 1 of induction therapy according to the current Nordic protocol. Five infants, 3-9 months old, were also included. Plasma samples were drawn 23 hr after the start of a 24-hr infusion of doxorubicin 40 mg/m(2), and analyzed by reversed-phase liquid chromatography.

RESULTS

There was a more than 10-fold difference between patients in dose normalized plasma concentration of doxorubicin, median 62.8 ng/ml, range 22.6-334 ng/ml. The doxorubicin concentrations differed significantly between age groups (P = 0.003). Children aged 4-6 years had the highest doxorubicin concentrations, median 77.9 ng/ml, followed by 2-4-year-old children, median 64.3 ng/ml. Both younger and older children had median values of about 50 ng/ml. Patients with white blood cell (WBC) count > 50 x 10(9)/L at diagnosis had significantly lower doxorubicin concentrations, median 55.3 ng/ml, than those with WBC count < 10 x 10(9)/L, median 64.4 ng/ml (P = 0.015). There was no difference in doxorubicin concentration between boys and girls. No correlation was found between doxorubicin levels and serum aminotransferases or serum creatinine. The concentration of doxorubicinol was 13% (median value) of that of doxorubicin. Four infants, 7-9 months old, had plasma clearance between 350-431 ml/min/m(2), which is in the same range as in older children. A 3-month-old infant had a clearance of 181 ml/min/m(2).

CONCLUSIONS

The age groups who had the highest doxorubicin concentrations, (2-) 4-6-year-old children, are known to make up a large proportion of standard risk ALL cases with good prognosis. The correlation between doxorubicin plasma levels and clinical effect needs further study. The influence of age, body composition, and tumor burden on the pharmacokinetics of antineoplastic drugs should also be further explored, aiming at improvements in the current dosing regimen based on BSA.

Proinflammatory cytokines mediate the systemic inflammatory response associated with high-dose cytarabine treatment in children

BACKGROUND

Treatment with high-dose cytarabine (1-beta-D-arabinofuranosylcytosine) is often associated with an acute febrile reaction sometimes including abdominal pain, myalgia, and rash. The similarity of these symptoms to those caused by hypersecretion of cytokines in the systemic inflammatory response syndrome (SIRS) prompted us to investigate the plasma levels of proinflammatory cytokines during treatment of children with high-dose cytarabine.

PROCEDURE

Sixteen children treated for hematological malignancies and in clinical remission were studied during treatment with six infusions of cytarabine given every 12 hr at a dose of 2 g/m(2). Blood samples for analysis of tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), interleukin-1gamma (IL-1gamma), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10) and interleukin-1 receptor antagonist (IL-1ra) were obtained prior to treatment and subsequently at 12, 36 and 60 hr. Additional samples were collected as soon as fever occurred.

RESULTS

Thirteen of 16 patients developed fever at a median time of 30 hr following start of treatment. At 12 hr levels of TNF-alpha were elevated followed by a rise in IL-6, IFN-alpha, and IL-1ra, peaking at the onset of fever. Thereafter these levels slowly declined whereas low IL-10 levels became detectable.

CONCLUSIONS

We conclude that high-dose cytarabine treatment often induces release of TNF-alpha followed by the sequential release of other proinflammatory cytokines. Most likely these cytokines mediate the development of symptoms comprising the cytarabine syndrome.

Multivariate evaluation of doxorubicin surface-enhanced Raman spectra

Multivariate evaluation of surface-enhanced Raman spectra of doxorubicin in plasma was performed. In a principal component analysis (PCA) all spectral features were modelled into three principal components. The major variation of the data was shown to be the variation of doxorubicin Raman signal together with the doxorubicin fluorescence, whereas the variation due to plasma was of minor importance. It was also shown that the surface-enhanced Raman scattering (SERS) measurements were independent on such factors as measurement occasion and silver colloids. The presented results show that with some improvements, quantification of doxorubicin directly in plasma could be possible.

No disadvantage in outcome of using matched unrelated donors as compared with matched sibling donors for bone marrow transplantation in children with acute lymphoblastic leukemia in second remission

PURPOSE

We evaluated the outcome of children with acute lymphoblastic leukemia (ALL) in second remission (2CR), comparing bone marrow transplantation (BMT) using either matched sibling donors or unrelated donors (URDs).

PATIENTS AND METHODS

A total of 65 patients, aged 2 months to 20 years at BMT, with ALL in 2CR underwent allogeneic BMT at seven Nordic centers during 1990 to 1997. Of the first relapses, 85% were in bone marrow; 46% occurred on therapy, and 54%, off therapy. The preparative regimens were cyclophosphamide plus total-body irradiation +/- antithymocyte/antilymphocyte globulin, busulfan plus cyclophosphamide +/- antithymocyte/antilymphocyte globulin, or cytarabine plus total-body irradiation. Of the allografts, 37 were from HLA-matched siblings and 28 were from URDs.

RESULTS

In the sibling versus URD graft recipient groups, the posttransplantation 5-year event-free survival was 39% versus 54% (P =.4), the estimated posttransplantation relapse rate was 76% versus 40% (P = not significant [NS]), and the toxic death rate was 19% versus 11% (P = NS). The incidence of significant (grade 2 to 4) acute graft-versus-host disease (GVHD) was 38% versus 64% (P <.05) and was 14% versus 32% (P <.10) for severe (grade 3 to 4) acute GVHD; the incidence of chronic GVHD was 26% versus 57% (P <.05) and was 13% versus 22% (P = NS) for extensive chronic GVHD in the sibling and URD groups.

CONCLUSION

BMT with matched URD allografts offers at least equal survival for children with ALL in 2CR, as compared with allografts from matched sibling donors. URD allografts were not associated with a higher toxic mortality rate, although both acute and chronic GVHD were more frequent with URD. Indications for using matched URD allografts in ALL 2CR can be considered the same as for using matched sibling donors.

Serum antibody levels and avidities to Escherichia coli O antigens and poliovirus type 1 antigen are increased in children treated for malignant disease

BACKGROUND

Treatment of malignant disease in children is often associated with low serum immunoglobulin and reduced specific antibody levels. The aim of this study was to investigate if the functional affinity of specific antibodies in serum and saliva is reduced as well and to evaluate if antigenic exposure or treatment duration affects this antibody avidity.

PROCEDURE

Serum samples were obtained from 45 children and salivary specimens from 30 children with malignant disease. The children were tested either prior to, during, or after chemotherapy. Levels of antibody to E. coli O and to poliovirus type 1 antigens were determined using an ELISA and isotype-specific relative antibody avidity was measured using thiocyanate to elute antibodies from solid-phase immobilized antigens.

RESULTS

Children with malignant disease had higher levels and relative avidity indexes of serum antibodies to both antigens as compared to controls. The duration of treatment and type of malignant disease were unrelated to these parameters. In saliva, the level of antibodies to E. coli O antigens, but not to poliovirus type 1 antigen, increased during treatment.

CONCLUSIONS

Both the amount and avidity of serum antibodies to these antigens are increased in children with malignant disease. This may be due to a dysregulation of the immune system caused by the malignancy and seems not to be dependent on exposure. In contrast, the avidity and levels of these antibodies in saliva seem to correlate with the presence of antigenic exposure.

Bone marrow fibrosis and radiological changes of the long bones in children with acute megakaryocytic leukaemia

The diagnosis of acute megakaryocytic leukaemia (AMkL) may be difficult to establish owing to difficulties in obtaining adequate bone marrow aspirates secondary to bone marrow fibrosis. We describe three children without Down's syndrome under 2 y of age with AMkL. Although none of the patients had the non-random t(1;22) (p13;q13) translocation, bone marrow cells from all patients exhibited chromosome abnormalities with complex karyotypes, including trisomy 21 in two cases. All patients had profound bone marrow fibrosis and characteristic lamellar diaphyseal radiological changes of the long bones.

Loss of heterozygosity of 3p markers in neuroblastoma tumours implicate a tumour-suppressor locus distal to the FHIT gene

Neuroblastoma is a heterogeneous childhood tumour of the sympathetic nervous system, in which deletions of chromosomal region 1p and amplification of the MYCN oncogene correlate with aggressive tumour behaviour. However, the majority of neuroblastoma tumours show neither of these aberrations, indicating that other chromosomal regions may be involved in tumorigenesis. Here, we report findings of loss of heterozygosity (LOH) on chromosome 3. In our neuroblastoma material, nine of 59 (15.3%) tested tumours showed allelic loss of chromosome 3p markers. We found significant clinical and biological differences between tumours with the loss of one entire chromosome 3 vs tumours with partial loss in chromosome region 3p. All children with tumours with whole chromosome 3 loss are long-term survivors, whereas all children with tumours showing partial 3p LOH have died from tumour progression. A consensus region found to be deleted in all the tumours with 3p deletions was defined by markers D3S1286 and D3S1295, i.e. 3p25.3-p14.3, distal to the FHIT gene.

Interleukin 6, but not tumour necrosis factor-alpha, is a good predictor of severe infection in febrile neutropenic and non-neutropenic children with malignancy

OBJECTIVE

Interleukin-6 (IL6), tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) are important mediators of the inflammatory response in human infection. The aim of this study was to determine the relationship between serum levels of IL6, TNF-alpha, IFN-gamma and CRP in febrile children with malignant disease, and relate these levels to aetiology of fever, presence of neutropenia and the effect of untreated malignancy.

METHODS

110 febrile episodes in 70 children with malignant disease were included. Cytokine analyses were performed with sensitive immunoradiometric methods using double monoclonal antibodies.

RESULTS

IL6 had a sensitivity of 74% in detecting sepsis in children with fever and malignant disease. This sensitivity was not influenced by the presence of neutropenia or newly diagnosed malignancy. A positive correlation between IL6 and the CRP levels on the following day was observed (r = .53). TNF-alpha was elevated in 22% of the episodes and mean levels were significantly higher in untreated malignancy but lower in neutropenic patients. IFN-gamma was elevated in 18% of cases and correlated strongly with mean TNF-alpha levels.

CONCLUSIONS

IL6 is a sensitive and early predictor of bacterial infection in both neutropenic and non-neutropenic febrile children with malignancy. It is more sensitive than CRP in detecting sepsis, but the predictive value is too low to allow IL6 levels to influence initial treatment decisions in patients with granulocytopenia. TNF-alpha production seems to be impaired in neutropenic children and serum TNF-alpha cannot be employed as an indicator of bacterial infection.

Epinephrine and sodium bicarbonate independently and additively increase survival in experimental amitriptyline poisoning

OBJECTIVES

Cardiac depression is the main adverse effect of severe tricyclic antidepressant poisoning. The aim of this study was to investigate whether treatment with epinephrine or norepinephrine increases survival as compared with standard treatment with sodium bicarbonate in experimental amitriptyline poisoning.

DESIGN

Nonrandomized, controlled intervention trial.

SETTING

University laboratory.

SUBJECTS

Male, anesthetized, paralyzed, and mechanically ventilated Sprague-Dawley rats (n = 91).

INTERVENTIONS

Rats subjected to a 60-min infusion of amitriptyline (2 mg/kg/min) were treated with a continuous infusion of either epinephrine, norepinephrine, sodium bicarbonate, epinephrine plus sodium bicarbonate, norepinephrine plus sodium bicarbonate, or placebo.

MEASUREMENTS AND MAIN RESULTS

Inotropic drug treatment was associated with an increased survival rate as compared with treatment with sodium bicarbonate and treatment with placebo. Epinephrine treatment was superior to norepinephrine. Additional treatment with sodium bicarbonate increased survival rate for each inotropic drug. Sodium bicarbonate and inotropic drug treatment independently increased the survival rate (p < .001 for both effects). No interaction between these two treatment effects was observed.

CONCLUSIONS

Both epinephrine and norepinephrine increased the survival rate in tricyclic antidepressant poisoning in rats. Sodium bicarbonate increased the survival rate independent of inotropic drug treatment. Furthermore, epinephrine was superior to norepinephrine when used both with and without sodium bicarbonate, and the most effective treatment was epinephrine plus sodium bicarbonate.

Bone marrow immunoglobulin-secreting cells are not reduced in children with leukaemia as compared to children with solid tumours

Children with leukaemia exhibit multiple immunological disturbances, including low circulating levels of immunoglobulins, caused by both the disease and chemotherapy. We investigated the number of isotype-specific immunoglobulin-secreting cells (ISCs) in the bone marrow at the time of diagnosis in 32 children and during therapy in 12 children with leukaemia. We compared these to the number of ISCs in 17 untreated children with solid tumours and related the ISCs to serum immunoglobulin levels, lymphocyte subsets, response to mitogenic stimulation and serum cytokine levels. Bone marrow specimens were analysed for isotype-specific (immunoglobulins G, A and M) ISCs using the ELISPOT method. At the time of diagnosis, for all isotypes, the total number of ISCs per millilitre of bone marrow in children with leukaemia was no different from that in children with solid tumours. Chemotherapy significantly decreased the number of ISCs. The quantitative relationship between the different isotypes was unaffected by both tumour type and therapy. It can be concluded that in childhood leukaemia, tumour replacement of bone marrow cells does not cause a decreased number of ISCs and can therefore not account for the low serum immunoglobulin levels observed at time of diagnosis. Chemotherapy reduces the number of ISCs without changing the isotype distribution.

Antiarrhythmic effects of magnesium sulphate. Report of three cases

A wide variety of antiarrhythmic agents is used in treatment of both supraventricular and ventricular arrhythmias. Magnesium sulphate has previously been used mainly in the treatment of torsade de pointe arrhythmias but several reports show that this agent may be used in the treatment of arrhythmias of different aetiology. We describe 3 patients who exhibited arrhythmias affecting haemodynamic performance. Case #1 had a subarachnoid haemorrhage and developed a supraventricular tachycardia. In case #2, ventricular tachycardia appeared during the postoperative course after abdominal surgery. Case #3 experienced critical heart failure due to dilated cardiomyopathy and had an irregular heart rhythm with multiple ectopic beats. In all three cases the administration of intravenous magnesium sulphate was successful in treating the arrhythmias. Magnesium sulphate is an antiarrhythmic agent that is effective mainly in treatment of ventricular arrhythmias. The drug can also be employed as second-line treatment of supraventricular arrhythmias.

Immunoglobulin levels and lymphocyte response to mitogenic stimulation in children with malignant disease during treatment and follow-up

Intensification of chemotherapeutic regimens has improved survival in childhood malignant disease. To characterize the impact of this intensified therapy on some aspects of the immune system, we have, in an unselected material of 220 children with malignant disease, investigated serum immunoglobulin levels and lymphocyte response at diagnosis and then subsequently during and up to 4 years after cessation of therapy. In leukemia and Hodgkin's disease, all immunoglobulin isotypes decreased during therapy. A profound depression of immunoglobulin M levels, lasting well after completion of therapy, was seen in all tumor types. The mitogenic response was attenuated in patients with leukemia at diagnosis but was rapidly restored after institution of therapy. Patients with solid tumors, particularly Hodgkin's disease, had a reduced mitogenic response during therapy. Thus these patients exhibit multiple immunological disturbances. The basis of the pronounced immunoglobulin M deficiency remains unclear.

Effects of epinephrine, norepinephrine, magnesium sulfate, and milrinone on survival and the occurrence of arrhythmias in amitriptyline poisoning in the rat

OBJECTIVES

Cardiac depression is the main adverse effect of severe tricyclic antidepressant poisoning. The aim of this study was to compare the effects of several inotropic drugs on survival and the occurrence of arrhythmias in the treatment of amitriptyline poisoning.

DESIGN

Nonrandomized, controlled intervention trial.

SETTING

University laboratory.

SUBJECTS

Eighty-six male Wistar rats anesthetized with pentobarbital and mechanically ventilated.

INTERVENTIONS

Rats subjected to a 60-min continuous infusion of amitriptyline (1.25 mg/kg/min) were treated with a continuous infusion of either epinephrine, norepinephrine, milrinone, magnesium, epinephrine + magnesium, or norepinephrine + magnesium.

MEASUREMENTS AND MAIN RESULTS

Without treatment, all animals exhibited arrhythmias on the electrocardiogram within 20 mins. All treatment drugs delayed the onset of arrhythmias, but significant differences were only observed after administration of epinephrine, epinephrine + magnesium sulfate, and norepinephrine + magnesium sulfate. All the inotropic drugs markedly increased survival. Sodium concentrations were unaffected by all treatments. In control animals, potassium concentrations increased during amitriptyline infusion. Norepinephrine treatment had no effect on potassium concentrations, whereas all other treatments resulted in decreased potassium concentrations.

CONCLUSIONS

All inotropic drugs used in the study increased survival in tricyclic antidepressant poisoning in rats without increasing the risk of arrhythmias. Furthermore, epinephrine and norepinephrine + magnesium sulfate were effective in preventing arrhythmias, possibly due to improved hemodynamic performance or potassium homeostasis.

Effects of magnesium sulfate and lidocaine in the treatment of ventricular arrhythmias in experimental amitriptyline poisoning in the rat

OBJECTIVES

Amitriptyline poisoning is associated with ventricular arrhythmias. Standard treatment is sodium bicarbonate but further intervention may be necessary. The present study compared the actions of lidocaine and magnesium sulfate on ventricular tachycardia induced by amitriptyline.

DESIGN

Nonrandomized, controlled, intervention trial.

SETTING

University laboratory.

SUBJECTS

Thirty male Wistar rats anesthetized with pentobarbital and mechanically ventilated.

INTERVENTIONS

After pretreatment with norepinephrine, the animals were subjected to a continuous infusion of amitriptyline. After the appearance of ventricular tachycardia, they were treated with magnesium sulfate (45 mg/kg + 15 mg/kg/min) or lidocaine (1 mg/kg + 0.5 mg/kg/min) or glucose infusion as a control.

MEASUREMENTS AND MAIN RESULTS

In the group treated with magnesium sulfate, electrocardiogram tracings demonstrated that nine of ten animals converted from ventricular tachycardia to sinus rhythm compared with one of ten in both the lidocaine- and glucose-treated groups (p < .001). The animals treated with magnesium sulfate also had a significantly longer total time in sinus rhythm (10.0 +/- 1.6 mins) than those rats treated with lidocaine (1.7 +/- 1.5 mins) or glucose (1.5 +/- 1.5 mins). Magnesium sulfate significantly decreased blood pressure and heart rate, but no severe hemodynamic side effects were observed.

CONCLUSIONS

Magnesium sulfate is effective in converting ventricular tachycardia in hyperadrenergic amitriptyline poisoning. In contrast, lidocaine had no effect on arrhythmias.

A single i.v. dose of ondansetron 8 mg prior to induction of anaesthesia reduces postoperative nausea and vomiting in gynaecological patients

The effect of a single intravenous dose of ondansetron in preventing postoperative nausea and emesis (retching and vomiting) (PONV) was investigated in a randomized, double-blind, placebo-controlled, multicentre, international study. Women of ASA class I-III, requiring gynaecological laparotomy, vaginal hysterectomy, or major vaginal surgery were selected for study. Two hundred and thirty-five received placebo, 231 received 1 mg ondansetron, 228 received 8 mg ondansetron and 229 received 16 mg ondansetron, as an infusion over five minutes before the induction of anaesthesia. A standardized balanced anaesthetic technique was employed. This consisted of premedication with either diazepam or temazepam, thiopentone induction, maintenance with nitrous oxide in oxygen supplemented with enflurane or isoflurane, intraoperative analgesia with fentanyl, neuromuscular blockade with any choice of agent and reversal with neostigmine and atropine. Postoperative analgesia was achieved with morphine, and prochlorperazine or metoclopramide were given if a rescue antiemetic was required. A greater percentage of patients in the 8 mg and 16 mg ondansetron groups experienced no postoperative emesis (44% and 39% respectively) than in the placebo and 1 mg ondansetron groups (29% and 28% respectively) for the first 24 hr postoperative period (8 mg vs placebo and 1 mg: P < or = 0.001; 16 mg vs placebo: P < 0.05; 16 mg vs 1 mg: P < 0.05). Similarly, the percentage of patients who did not experience postoperative nausea were 20%, 26%, 31% and 28% for the placebo, 1 mg, 8 mg and 16 mg ondansetron treatment groups, respectively (8 mg and 16 mg vs placebo P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Tumor necrosis factor-alpha in malignant disease

PURPOSE

Due to its important role in immunoregulation, we have investigated serum levels of tumor necrosis factor-alpha (TNF alpha), in children with newly diagnosed, untreated, malignant disease.

PATIENTS AND METHODS

These levels have been related to the presence of infection and to the serum content of three other cytokines, namely interleukin-1 beta, interleukin-2, and interferon-gamma. All cytokine analyses were performed using highly sensitive radioimmunoassays.

RESULTS

Children with leukemia had higher mean levels of TNF alpha (63.6 +/- 12.3 pg/ml) than did children with solid tumors (21.5 +/- 4.2 pg/ml) and control patients (10.5 +/- 2.6 pg/ml). TNF alpha levels in patients did not correlate with the levels of the other cytokines or with the presence of infection.

CONCLUSIONS

Children with malignant disease often have elevated TNF alpha levels. This elevation is dependent on the malignant disease process itself, and could either reflect the host immunological response or tumor cell production of TNF alpha.

Effects of epinephrine and norepinephrine on hemodynamic parameters and arrhythmias during a continuous infusion of amitriptyline in rats

Epinephrine and norepinephrine were evaluated in treatment of hemodynamic compromise in amitriptyline intoxication. One hundred and one male Wistar rats were monitored hemodynamically during amitriptyline intoxication and given one of three infusion rates (0.1, 0.5 or 5.0 mg/kg/min) of either epinephrine or norepinephrine. Sixteen rats served as controls and received only glucose after intoxication. Amitriptyline intoxication lowered mean arterial pressure, heart rate, left ventricular max dP/dt, and increased left ventricular end-diastolic pressure. All doses of norepinephrine and the two higher doses of epinephrine increased mean arterial blood pressure and left ventricular max dP/dt. Heart rate increased with both drugs, more with epinephrine, but not beyond pre-intoxicated levels at any dose. Left ventricular end-diastolic pressure was unaltered by both drugs. Malignant arrhythmias appeared in 7% of all animals, whereas a progressive decline of cardiac contractility caused cardiac arrest in 36% of all animals. This suggests that myocardial depression is the aspect most likely to cause death. At intermediate doses epinephrine resulted in significantly fewer arrhythmias and lower mortality compared to norepinephrine. We conclude that epinephrine and norepinephrine each appeared effective in reversing amitriptyline-induced hemodynamic alterations. Epinephrine had fewer arrhythmogenic properties than norepinephrine and may be preferable to norepinephrine.

Hemodynamic changes during laparoscopy with positive end-expiratory pressure ventilation

Hemodynamic measurements were performed in 10 healthy women undergoing elective laparoscopy for the investigation of infertility. A standardized anesthetic technique which included the application of positive end-expiratory pressure (PEEP), 0.49 kPa (3.7 mmHg) was utilized. The following variables were studied: cardiac output, stroke volume and left ventricular ejection time (determined non-invasively with impedance cardiography), heart rate, blood pressure, total peripheral vascular resistance and end-tidal carbon dioxide (ET-CO2). The combination of 25 degrees head-down tilt and PEEP ventilation during laparoscopy was associated with a pressure response that restored arterial pressures to essentially pre-anesthetic levels. Net cardiac effects were small. With this regime low pressure 0.7-1.1 kPa (5-8 mmHg) intra-abdominal insufflation with CO2 was associated with only minor cardiovascular changes. There were no indications that 0.49 kPa PEEP during laparoscopy produced adverse cardiovascular effects. The application of PEEP reduced (P less than 0.001) ET-CO2. There was no net increase in ET-CO2 after CO2-insufflation compared to the measurement after induction of anesthesia. This is in contrast to earlier studies without PEEP where a significant net increase in ET-CO2 was reported after CO2-insufflation.

[Buprenorphine (Temgesic) as a peroperative analgesic. A multicenter study]

Using buprenorphine as sole intravenous analgesic in balanced anaesthesia, we tried to find the most suitable dose of buprenorphine, and compared it to fentanyl, regarding analgetic, circulatory and side effects. Initial doses of 5, 10 and 15 micrograms/kg buprenorphine and 10 micrograms/kg fentanyl were compared. Peroperative analgesia was adequate with both drugs and neither gave circulatory effects of clinical significance. After buprenorphine three of 60 patients and after fentanyl five of 11 patients were given naloxone. Nausea was more common after buprenorphine. Postoperative analgesia after the last dose of buprenorphine averaged 13 h, highly significantly longer than the 2 h after fentanyl. The overall course was considered good in 93% of buprenorphine and 100% of fentanyl cases. Buprenorphine doses are discussed.

Cholesteryl sulphate and phosphate in the solid state and in aqueous systems

Cholesteryl sodium sulphate (CS) crystallizes as the dihydrate, the crystal structure of which is known. On heating the dihydrate, solid state phase transitions are observed at 65 degrees C and 95 degrees C and melting occurs at 165 degrees C. The structure of the high temperature phase has not been determined. Cholesteryl dihydrogen phosphate (CP) is not isostructural with any phases of CS. It undergoes a phase transition at 50 degrees C and melts at 190 degrees C. In systems with water CS is unstable whereas it was possible to determine the phase diagram of CP. In most of the composition range a crystalline hydrate is in equilibrium with a gel-phase. The latter has remarkable properties in that lamellar order exists with the 46 A lipid bilayer interleaved with water layers up to 1000 A. The monofilm behaviour of CS and CP at different pH levels is also reported.