The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients

PURPOSE

Febrile neutropenia remains a potentially life-threatening complication of anticancer chemotherapy, but some patients are at low risk for serious medical complications. The purpose of this study was to develop an internationally validated scoring system to identify these patients.

MATERIALS AND METHODS

Febrile neutropenic cancer patients were observed in a prospective multinational study. Independent factors assessable at fever onset, predicting low risk of complications, on a randomly selected derivation set, were assigned integer weights to develop a risk-index score, which was subsequently tested on a validation set.

RESULTS

On the derivation set (756 patients), predictive factors were a burden of illness indicating absence of symptoms or mild symptoms (weight, 5; odds ratio [OR], 8.21; 95% confidence interval [CI], 4.15 to 16.38) or moderate symptoms (weight, 3; OR, 3.70; 95% CI, 2.18 to 6.29); absence of hypotension (weight, 5; OR, 7.62; 95% CI, 2.91 to 19.89); absence of chronic obstructive pulmonary disease (weight, 4; OR, 5. 35; 95% CI, 1.86 to 15.46); presence of solid tumor or absence of previous fungal infection in patients with hematologic malignancies (weight, 4; OR, 5.07; 95% CI, 1.97 to 12.95); outpatient status (weight, 3; OR, 3.51; 95% CI, 2.02 to 6.04); absence of dehydration (weight, 3; OR, 3.81; 95% CI, 1.89 to 7.73); and age less than 60 years (weight, 2; OR, 2.45; 95% CI, 1.51 to 4.01). On the validation set, a Multinational Association for Supportive Care in Cancer risk-index score >/= 21 identified low-risk patients with a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%.

CONCLUSION

The risk index accurately identifies patients at low risk for complications and may be used to select patients for testing therapeutic strategies that may be more convenient or cost-effective.

Evidence for high-energy extraterrestrial neutrinos at the IceCube detector

We report on results of an all-sky search for high-energy neutrino events interacting within the IceCube neutrino detector conducted between May 2010 and May 2012. The search follows up on the previous detection of two PeV neutrino events, with improved sensitivity and extended energy coverage down to about 30 TeV. Twenty-six additional events were observed, substantially more than expected from atmospheric backgrounds. Combined, both searches reject a purely atmospheric origin for the 28 events at the 4σ level. These 28 events, which include the highest energy neutrinos ever observed, have flavors, directions, and energies inconsistent with those expected from the atmospheric muon and neutrino backgrounds. These properties are, however, consistent with generic predictions for an additional component of extraterrestrial origin.

Court-ordered obstetrical interventions

In a national survey, we investigated the scope and circumstances of court-ordered obstetrical procedures in cases in which the women had refused therapy deemed necessary for the fetus. We also solicited the opinions of leading obstetricians regarding such cases. Court orders have been obtained for cesarean sections in 11 states, for hospital detentions in 2 states, and for intrauterine transfusions in 1 state. Among 21 cases in which court orders were sought, the orders were obtained in 86 percent; in 88 percent of those cases, the orders were received within six hours. Eighty-one percent of the women involved were black, Asian, or Hispanic, 44 percent were unmarried, and 24 percent did not speak English as their primary language. All the women were treated in a teaching-hospital clinic or were receiving public assistance. No important maternal morbidity or mortality was reported. Forty-six percent of the heads of fellowship programs in maternal-fetal medicine thought that women who refused medical advice and thereby endangered the life of the fetus should be detained. Forty-seven percent supported court orders for procedures such as intrauterine transfusions. We conclude from these data that court-ordered obstetrical procedures represent an important and growing problem that evokes sharply divided responses from faculty members in obstetrics. Such procedures are based on dubious legal grounds, and they may have far-reaching implications for obstetrical practice and maternal and infant health.

Tuberculosis in badgers; a review of the disease and its significance for other animals

This review examines the current state of knowledge of aspects of tuberculosis in the badger. The gross pathology and pathogenesis are elaborated as well as the immune mechanism, diagnosis of infection and excretion and viability of infected products. The epidemiology in badgers is considered, as is the significance of infection in this species for other wildlife species as well as domestic animals sharing the same habitat. Trials of the effects of the removal of badgers on the occurrence of tuberculosis in cattle are summarised. It is concluded that badgers are well adapted as the primary host of bovine tuberculosis in parts of Britain and much of Ireland.

Observation of high-energy astrophysical neutrinos in three years of IceCube data

A search for high-energy neutrinos interacting within the IceCube detector between 2010 and 2012 provided the first evidence for a high-energy neutrino flux of extraterrestrial origin. Results from an analysis using the same methods with a third year (2012-2013) of data from the complete IceCube detector are consistent with the previously reported astrophysical flux in the 100 TeV-PeV range at the level of 10(-8)  GeV cm-2 s-1 sr-1 per flavor and reject a purely atmospheric explanation for the combined three-year data at 5.7σ. The data are consistent with expectations for equal fluxes of all three neutrino flavors and with isotropic arrival directions, suggesting either numerous or spatially extended sources. The three-year data set, with a live time of 988 days, contains a total of 37 neutrino candidate events with deposited energies ranging from 30 to 2000 TeV. The 2000-TeV event is the highest-energy neutrino interaction ever observed.

Familial defective apolipoprotein B-100: detection in the United Kingdom and Scandinavia, and clinical characteristics of ten cases

Familial defective apolipoprotein B-100 (FDB) is a recently identified, dominantly inherited genetic disorder, which leads to increased serum concentration of low density lipoprotein (LDL) cholesterol with reduced affinity for the LDL receptor. This disorder is associated with a G to A mutation in exon 26 of the apolipoprotein B (apo B) gene which creates a substitution of glutamine for arginine in the codon for amino acid 3500. We have searched for this mutation in 374 unrelated individuals with hyperlipidaemia from the United Kingdom, and in 371 unrelated individuals with a primary clinical diagnosis of atherosclerosis from the United Kingdom and Scandinavia. Ten individuals, 9 from the U.K. and 1 from Denmark, were identified. The frequency of the mutation was 3% in individuals classified clinically as having familial hypercholesterolaemia (FH) and 3% in individuals with type IIa hyperlipidaemia without FH, and was not found in patients with types IIb and III hyperlipidaemia. The mutation was rare in individuals with a primary clinical diagnosis of atherosclerosis. Plasma lipid levels and clinical characteristics of the ten patients identified in the present study are similar to those reported for heterozygous FH. Thus, in our study, FDB is associated with moderate to severe hypercholesterolaemia, and appears to be a serious disorder causing premature cardiovascular disease. Individuals with this mutation can be identified unambiguously using routine molecular screening techniques.

A selective oleic acid albumin agar medium for the cultivation of Mycobacterium bovis

The modification of Middlebrook's 7H11 oleic acid albumin agar medium by the addition of fresh bovine serum and lysed sheep red cells to encourage growth of Mycobacterium bovis is described. The improved medium was made selective by the addition of antibiotics and a comparative trial of this medium and the guineapig test in the isolation of M. bovis from badger tissues is reported. A close agreement between the two tests was found; the guinea-pig test detected 95% of all isolations and culture detected 91%.

Breakfast cereal and caffeinated coffee: effects on working memory, attention, mood, and cardiovascular function

This study examined the effects of breakfast cereal and caffeinated coffee on working memory, attention, mood, and cardiovascular function. One hundred and forty-four volunteers (72 male, 72 female, mean age 21 years) were assigned to one of the groups formed by combining breakfast (cereal versus no breakfast) and caffeine (caffeinated versus decaffeinated coffee) conditions. The volunteers completed a baseline session between 0800 and 0845 h. The breakfast/caffeine administration took place between 0845 and 0915 h. They then completed another test session (starting at 0945) and had a coffee break at 1045, followed by a final session starting at 1145. The results showed that those who consumed breakfast cereal had a more positive mood at the start of the test sessions, performed better on a spatial memory task, and felt calmer at the end of the test session than those in the no breakfast condition. Ingestion of caffeine had no effect on initial mood or working memory, but it did improve encoding of new information and counteracted the fatigue that developed over the test session. Caffeine increased blood pressure and pulse rate, whereas breakfast cereal consumption only had an effect on pulse. Overall, these results confirm previous findings on the effects of breakfast and caffeine, and demonstrate distinct profiles for two common examples of early-morning food and drink, breakfast cereal and caffeinated coffee.

The infrapatellar fat pad: anatomy and clinical correlations

This study examined the anatomy of the infrapatellar fat pad (IFP) in relation to knee pathology and surgical approaches. Eight embalmed knees were dissected via semicircular parapatellar incisions and each IFP was examined. Their volume, shape and constituent features were recorded. They were found in all knees and were constant in shape, consisting of a central body with medial and lateral extensions. The ligamentum mucosum was found inferior to the central body in all eight knees, while a fat tag was located superior to the central body in seven cases. Two clefts were consistently found on the posterior aspect of the IFP, a horizontal cleft below the ligamentum mucosum in six knees and a vertical cleft above, in seven cases. Our study found that the IFP is a constant structure in the knee joint, which may play a number of roles in knee joint function and pathology. Its significance in knee surgery is discussed.

Intensive care unit syndrome: a dangerous misnomer

The terms intensive care unit (ICU) syndrome and ICU psychosis have been used interchangeably to describe a cluster of psychiatric symptoms that are unique to the ICU environment. It is often postulated that aspects of the ICU, such as sleep deprivation and sensory overload or monotony, are causes of the syndrome. This article reviews the empirical support for these propositions. We conclude that ICU syndrome does not differ from delirium and that ICU syndrome is caused exclusively by organic stressors on the central nervous system. We argue further that the term ICU syndrome is dangerous because it impedes standardized communication and research and may reduce the vigilance necessary to promptly investigate and reverse the medical cause of the delirium. Directions for future research are suggested.

Digital subtraction angiography of the abdominal aorta and renal arteries. Comparison with conventional aortography

Digital subtraction angiography (DSA) was used to study the cardiovascular system in more than 400 patients and was specifically compared with conventional angiography of the aorta and renal arteries in 30 patients. For the renal arteries, the overall accuracy of DSA was 71% (50/70). Excluding 11 cases of inadequate visualization of the renal arteries on DSA, the sensitivity of the new technique was 93% (55/59) and the specificity 91.5% (54/59). Aortic disease, including intravascular clots and occlusions, was faithfully delineated by DSA.

A critical analysis of on-scene helicopter transport on survival in a statewide trauma system

BACKGROUND

Recently, questions have been raised regarding the effectiveness of helicopters in trauma care. We conducted a retrospective study to evaluate the effect of on-scene helicopter transport on survival after trauma in a statewide trauma system.

METHODS

Data were obtained from a statewide trauma registry of 162,730 patients treated at 28 accredited trauma centers. Patients transported from the scene by helicopter (15,938) were compared with those transported by ground with advanced life support (ALS) (6,473). Interhospital transfers and transports without ALS were excluded. Statistical analysis was performed using one-way analysis of variance and logistic regression.

RESULTS

Patients transported by helicopter were significantly (p < 0.01) younger, were more seriously injured, and had lower blood pressure. They were also more likely to be male and to have systolic blood pressure < 90 mm Hg. Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival.

CONCLUSION

A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.

Formation of DNA adducts in rat lung following chronic inhalation of diesel emissions, carbon black and titanium dioxide particles

Exposure of rats to diesel emissions results in the development of lung tumors. The objective of this study was to determine whether the polycyclic aromatic hydrocarbons (PAHs), nitro-PAHs or other polycyclic organic matter adsorbed to diesel particles induces the formation of DNA adducts in the lung when compared to particles with little or no adsorbed organic matter. Rats were exposed to diesel emissions containing particles with over 30% solvent-extractable adsorbed organic matter and to particles with < 0.1% adsorbed organic matter (carbon black particles and TiO2). Wistar rats were exposed to diesel emissions (7.5 mg/m3) for 2 months, 6 months and 2 years and for 2 years to carbon black (11.3 mg/m3) and TiO2 particles (10.4 mg/m3) to compare tumorigenic response and DNA adduct formation in the lung. Two versions of the 32P-postlabeling assay for the detection of DNA adducts were used to tentatively identify nitrated-amine or arylamine adducts formed relative to other nitro PAH based on the demonstrated sensitivity of these adducts to nuclease P1 treatment. Total adduct levels were determined for peripheral lung tissue DNA as detected in a diagonal radioactive zone. One major adduct which migrated outside this region (adduct 1) and a nuclease P1-sensitive adduct (adduct 2) were quantitated separately. Adduct 1 increased significantly over time in the filtered air exposed animals but decreased markedly at the 2 year time points regardless of particle type, presumably as a result of adduct dilution through de novo cell synthesis or cell proliferation invoked in response to particle loading and/or effect on the endogenous synthesis or degradation of DNA reactive moieties. The nuclease sensitive adduct (adduct 2), possibly resulting from exposure to nitro-PAHs, was detected in diesel-exposed rats but was not detected in the rats exposed to TiO2 and carbon black. No significant elevation in PAH-derived adducts, relative to the filtered air controls, was observed in the rodents exposed to diesel emission. Our data suggest that long-term contact with these particles may result in a cell proliferative response, enhanced degradation of I-compounds not related to cell proliferation, and/or synthesis of I-compounds, irrespective of the differences in organic content associated with the three particle types. This response may be an important factor in explaining the reported similarity in tumorigenic response in rodents exposed to diesel emissions, carbon black and TiO2 particles.

Sulphated proteoglycan is required for collecting duct growth and branching but not nephron formation during kidney development

Kidney epithelia have separate origins; collecting ducts develop by ureteric bud growth and arborisation, nephrons by induced mesenchyme-epithelium transition. Both express sulphated glycosaminoglycans (GAGs) which are strikingly upregulated during nephron differentiation. However, sodium chlorate, an inhibitor of GAG sulphation, and the GAG-degrading enzymes heparitinase plus chondroitinase, did not prevent nephron development. In contrast, ureteric bud growth and branching were reversibly inhibited by the above reagents, the inhibition correlating quantitatively with sulphated GAG deprivation caused by a range of chlorate concentrations. Growth and branching could be independently restored during GAG deprivation by hepatocyte growth factor and phorbol-12-myristate acetate (PMA) respectively. Together these signalling effectors stimulated both branch initiation and growth. Thus growth and morphogenesis of ureteric bud involve distinct signalling pathways both regulated by GAGs.

Host defenses in the aged: evaluation of components of the inflammatory and immune responses

Host defenses were evaluated in 70 healthy aged volunteers. Individuals who had diseases or who were taking medication known to affect the inflammatory and immune responses were excluded from the study. Volunteers were followed for 24 months to correlate their state of health with the evaluation of host defenses. Polymorphonuclear leukocyte function and the serum opsonic capacity for Escherichia coli and Staphylococcus aureus were normal. Assays of complement components and activity revealed unexplained elevations in native C3 and properdin, normal concentrations of factor B, normal conversion of C3 by inulin, and normal levels of hemolytic complement. The levels of IgG and IgA did not differ from levels noted in younger controls, but the concentration of IgM was decreased and that of IgE increased. The prevalence of autoantibodies was low. None of the volunteers were anergic, but lymphocyte responses to mitogens were depressed in three-day cultures. The number and percentages of E-rosette-forming cells and cells bearing surface IgD or IgM were normal. No lymphopenia was noted.

First observation of PeV-energy neutrinos with IceCube

We report on the observation of two neutrino-induced events which have an estimated deposited energy in the IceCube detector of 1.04±0.16 and 1.14±0.17 PeV, respectively, the highest neutrino energies observed so far. These events are consistent with fully contained particle showers induced by neutral-current ν(e,μ,τ) (ν(e,μ,τ)) or charged-current ν(e) (ν(e)) interactions within the IceCube detector. The events were discovered in a search for ultrahigh energy neutrinos using data corresponding to 615.9 days effective live time. The expected number of atmospheric background is 0.082±0.004(stat)(-0.057)(+0.041)(syst). The probability of observing two or more candidate events under the atmospheric background-only hypothesis is 2.9×10(-3) (2.8σ) taking into account the uncertainty on the expected number of background events. These two events could be a first indication of an astrophysical neutrino flux; the moderate significance, however, does not permit a definitive conclusion at this time.

Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department

Adults presenting to an emergency department with acute respiratory illness were studied prospectively in an effort to identify sensitive clinical criteria for the diagnosis of pneumonia. Of 308 patients studied, 118 (38%) had definite or equivocal infiltrates and were considered to have pneumonia. No single symptom or sign was reliably predictive of pneumonia. Cough was the most common symptom in patients with pneumonia (86%), but was equally common in those with other respiratory illness. Fever was absent in 36 patients with pneumonia (31%). Abnormal findings on lung examination, that is, rales, rhonchi, decreased breath sounds, wheezes, altered fremitus, egophony, and percussion dullness, were each found in fewer than half of the patients with pneumonia. Twenty-six patients (22%) with a completely normal chest examination had pneumonia. Abnormal vital signs (temperature greater than 37.8 degrees C (100 degrees F), pulse greater than 100/min, or respirations greater than 20/min) were 97% sensitive for the detection of pneumonia. These criteria retained their sensitivity when films were subjected to a second, blinded interpretation by a senior radiologist. We conclude that restricting chest roentgenograms to patients with at least one abnormal vital sign will detect almost all radiographically demonstrable pneumonia in adult emergency department patients.

In vitro cross-allergenicity of major aeroallergenic pollens by the radioallergosorbent technique

Cross-reactivity between major classes of aeroallergenic pollens has been estimated by comparing the inhibitory effects of selected allergens upon the reaginic activity of other native and non-native varieties, as measured by the radioallergosorbent technique (RAST). Common allergenic determinants were demonstrated in indigenous and nonindigenous ragween species. Although patterns of inhibitory capacity were less uniform among grass pollens, endemic species tended to have more common allergenic properties than nonendemic species. Tree pollens exhibited the greatest degree of heterogeneity, confirming the previous view that these pollens tend to be less cross-reactive. Concomitant skin test threshold studies utilizing the same groups of pollens were in general agreement with in vitro results. Because, threshold skin testing was affected by a number of uncontrollable variables, however, the current modification of RAST in estimating cross-allergenicity was more accurate and reliable than data based upon cutaneous tests. It was concluded that reagin neutralization by the RAST method is the best currently available method of assessing cross-allergenic properties of pollens.

Tuberculosis in wild badgers (Meles meles) in Gloucestershire: pathology

The gross and histological appearances of the lesions of tuberculosis in 36 wild badgers found to be infected with Mycobacterium bovis are described. These badgers were examined over a period of two years during an investigation into the possible epidemiological association of tuberculosis in badgers and cattle. The possible significance of the lesions in transmission of M bovis to cattle and other badgers is discussed. The histological appearance of the lesions was considered to be indicative of a lesser hypersensitivity reaction than is seen in the bovine.

Restriction fragment length polymorphisms in the apo B gene in relation to coronary artery disease

We have determined the frequencies of the alleles at the EcoRI (E), XbaI (X) and PvuII (P) polymorphic restriction sites in the apo B gene in 124 white men with coronary artery disease (CAD) and in 146 white men free from CAD. The frequencies of the E- (restriction site absent) and X- alleles were both significantly higher in normocholesterolaemic men with CAD than in those without CAD, but the frequency of the P+ allele (restriction site present) was similar in the 2 groups. The frequency of the E- allele was significantly higher in CAD men with hypertriglyceridaemia than in normal men without hypertriglyceridaemia. In the normocholesterolaemic men without CAD, the mean serum cholesterol concentration was higher in those with genotype X++ than in those with genotype X--. Mean serum LDL-apo B and LDL-cholesterol concentrations did not differ significantly between men with different XbaI or EcoRI genotypes. Serum apo A-I levels differed significantly between normal men with different XbaI genotypes. Serum HDL-cholesterol levels differed significantly between CAD men with different XbaI genotypes. These results suggest that in white men the E- and X- alleles are in linkage disequilibrium with a nearby allele that is causally related to CAD. It is also possible that the amino acid substitution at position 4154 in apo B, brought about by the nucleotide change responsible for the EcoRI polymorphism, has a direct effect on the atherogenicity of LDL.

Characterization of osteoprotegerin binding to glycosaminoglycans by surface plasmon resonance: Role in the interactions with receptor activator of nuclear factor κB ligand (RANKL) and RANK

Osteoprotegerin (OPG) is a decoy receptor for receptor activator of nuclear factor kappaB ligand (RANKL), a key inducer of osteoclastogenesis via its receptor RANK. We previously showed that RANK, RANKL, and OPG are able to form a tertiary complex and that OPG must be also considered as a direct effector of osteoclast functions. As OPG contains a heparin-binding domain, the present study investigated the interactions between OPG and glycosaminoglycans (GAGs) by surface plasmon resonance and their involvement in the OPG functions. Kinetic data demonstrated that OPG binds to heparin with a high-affinity (KD: 0.28 nM) and that the pre-incubation of OPG with heparin inhibits in a dose-dependent manner the OPG binding to the complex RANK-RANKL. GAGs from different structure/origin (heparan sulfate, dermatan sulfate, and chondroitin sulfate) exert similar activity on OPG binding. The contribution of the sulfation pattern and the size of the oligosaccharide were determined in this inhibitory mechanism. The results demonstrated that sulfation is essential in the OPG-blocking function of GAGs since a totally desulfated heparin loses its capacity to bind and to block OPG binding to RANKL. Moreover, a decasaccharide is the minimal structure that totally inhibits the OPG binding to the complex RANK-RANKL. Western blot analysis performed in 293 cells surexpressing RANKL revealed that the pre-incubation of OPG with these GAGs strongly inhibits the OPG-induced decrease of membrane RANKL half-life. These data support an essential function of the related glycosaminoglycans heparin and heparan sulfate in the activity of the triad RANK-RANKL-OPG.

Human interferon alpha in malignant lymphoma and Hodgkin's disease. Results of the American Cancer Society trial

Forty-nine patients with non-Hodgkin's lymphoma or Hodgkin's disease were entered into a multi-institutional phase II trial to evaluate the antitumor activity of human interferon alpha, prepared from buffy coats. Interferon alpha was administered intramuscularly in doses of 1 X 10(6) u, 3 X 10(6) u or 9 X 10(6) u daily for 30 days. Objective partial responses were seen in 3 of 18 patients with nodular lymphoma, all at the 9 X 10(6) u dose. Interferon alpha was not observed to be of therapeutic benefit in the other subtypes of non-Hodgkin's lymphoma or Hodgkin's disease. The major toxicities consisted of fatigue, fever, myalgias and weight loss. Serum interferon levels obtained 3 to 4 hours after injection varied widely, even among patients treated at the same dose level. Despite the relatively low doses of interferon used and the brief period of administration, this study extends the earlier observations of the antitumor effect of interferon in nodular lymphoma. These results are discussed in relation to the cumulative experience in human lymphoma using alpha interferons induced in human leukocytes and those produced in bacteria by recombinant DNA techniques.