Phase I and pharmacologic study of paclitaxel administered weekly in patients with relapsed ovarian cancer

PURPOSE

Paclitaxel has shown significant activity in advanced ovarian cancer. In vitro studies with paclitaxel have suggested that fractionated brief infusion schedules may be more effective than the standard 24-hour infusion. We commenced a phase I evaluation of escalating-dose paclitaxel (40, 50, 60, 80, 100 mg/m2) administered weekly as a 1-hour infusion in patients with recurrent ovarian cancer. All patients had received prior paclitaxel and cisplatin therapy. All patients received standard premedication.

PATIENTS AND METHODS

Eighteen patients are assessable on this phase I study. The mean age was 54 years (range, 48 to 74). The median number of prior chemotherapy regimens was three (range, two to five). The mean paclitaxel-free interval was 10.1 months (range, 1 to 24).

RESULTS

A total of 194 cycles of therapy were administered, with a mean of 10 (range, one to 12) per patient. No mucositis or grade III neuropathy was seen. Alopecia occurred in one out of 18 assessable patients. The mean neutrophil nadir was 4.0 x 10(9)/L. At the top dose level (100 mg/m2) delivered, dose-intensity was 90.75% of that planned and greater than two fold the standard dose-intensity. Partial responses were seen in four of 13 assessable patients (30%). Two patients with progression of disease on standard three-week paclitaxel schedules switched to a weekly schedule with demonstrated response. Increasing paclitaxel dose correlated with measured area under the curve (AUC) (R2 = .614). Dose-limiting toxicity was reached at 100 mg/m2 with two of three patients experiencing a treatment delay, thus defining a maximum-tolerated dose of 80 mg/m2 in this group of heavily pretreated patients on this weekly schedule.

CONCLUSION

(1) Paclitaxel administered as a 1-hour infusion is well tolerated; (2) this schedule of administration does not result in cumulative myelosuppression; and (3) this schedule of administration results in dose-intensive paclitaxel delivery with a favorable toxicity profile.

Human CIA30 is involved in the early assembly of mitochondrial complex I and mutations in its gene cause disease

In humans, complex I of the respiratory chain is composed of seven mitochondrial DNA (mtDNA)-encoded and 38 nuclear-encoded subunits that assemble together in a process that is poorly defined. To date, only two complex I assembly factors have been identified and how each functions is not clear. Here, we show that the human complex I assembly factor CIA30 (complex I intermediate associated protein) associates with newly translated mtDNA-encoded complex I subunits at early stages in their assembly before dissociating at a later stage. Using antibodies we identified a CIA30-deficient patient who presented with cardioencephalomyopathy and reduced levels and activity of complex I. Genetic analysis revealed the patient had mutations in both alleles of the NDUFAF1 gene that encodes CIA30. Complex I assembly in patient cells was defective at early stages with subunits being degraded. Complementing the deficiency in patient fibroblasts with normal CIA30 using a novel lentiviral system restored steady-state complex I levels. Our results indicate that CIA30 is a crucial component in the early assembly of complex I and mutations in its gene can cause mitochondrial disease.

Epoetin alfa therapy increases hemoglobin levels and improves quality of life in patients with cancer-related anemia who are not receiving chemotherapy and patients with anemia who are receiving chemotherapy

PURPOSE

To evaluate efficacy, safety, and quality of life (QOL) changes with epoetin alfa therapy for anemia in patients with nonmyeloid malignancies.

PATIENTS AND METHODS

Anemic cancer patients were enrolled onto this prospective, open-label study from 34 centers across Canada. The trial had two cohorts: patients who were and were not receiving chemotherapy during the 16-week study. All patients initially received epoetin alfa 150 IU/kg subcutaneously three times per week. The dose was doubled after 4 weeks for patients who did not experience sufficient response.

RESULTS

Of the 183 patients enrolled in the nonchemotherapy cohort, statistically significant and clinically relevant improvements in QOL were observed with epoetin alfa therapy using both the FACT-An questionnaire and linear analog scale assessment. Hemoglobin levels increased significantly (P <.001; mean increase 2.5 g/dL from baseline to end of study) and these increases were positively correlated with improved QOL and change in Eastern Cooperative Oncology Group (ECOG) scores. There was a significant reduction in the percentage of patients who required blood transfusions. The 218 patients in the chemotherapy cohort also experienced significant improvements in QOL, decreased transfusion use, and increased hemoglobin levels that correlated with QOL improvements and change in ECOG scores. Epoetin alfa was well-tolerated in both cohorts.

CONCLUSION

Epoetin alfa administered to patients with cancer-related anemia for up to 16 weeks resulted in significantly improved QOL, increased hemoglobin levels, and decreased transfusion use. These benefits were observed in cancer patients who were not receiving chemotherapy as well as those who were.

The regulation of mitochondrial DNA copy number in glioblastoma cells

As stem cells undergo differentiation, mitochondrial DNA (mtDNA) copy number is strictly regulated in order that specialized cells can generate appropriate levels of adenosine triphosphate (ATP) through oxidative phosphorylation (OXPHOS) to undertake their specific functions. It is not understood whether tumor-initiating cells regulate their mtDNA in a similar manner or whether mtDNA is essential for tumorigenesis. We show that human neural stem cells (hNSCs) increased their mtDNA content during differentiation in a process that was mediated by a synergistic relationship between the nuclear and mitochondrial genomes and results in increased respiratory capacity. Differentiating multipotent glioblastoma cells failed to match the expansion in mtDNA copy number, patterns of gene expression and increased respiratory capacity observed in hNSCs. Partial depletion of glioblastoma cell mtDNA rescued mtDNA replication events and enhanced cell differentiation. However, prolonged depletion resulted in impaired mtDNA replication, reduced proliferation and induced the expression of early developmental and pro-survival markers including POU class 5 homeobox 1 (OCT4) and sonic hedgehog (SHH). The transfer of glioblastoma cells depleted to varying degrees of their mtDNA content into immunocompromised mice resulted in tumors requiring significantly longer to form compared with non-depleted cells. The number of tumors formed and the time to tumor formation was relative to the degree of mtDNA depletion. The tumors derived from mtDNA depleted glioblastoma cells recovered their mtDNA copy number as part of the tumor formation process. These outcomes demonstrate the importance of mtDNA to the initiation and maintenance of tumorigenesis in glioblastoma multiforme.

Postradiation osteonecrosis of the mandible: a long-term follow-up study

OBJECTIVES

The objective of this study was to assess the long-term progress of 26 patients who experienced postradiation osteonecrosis of the jaw between 1975 and 1989.

STUDY DESIGN

Of 26 patients who had been previously managed with hyperbaric oxygen therapy as a part of their treatment for postradiation osteonecrosis of the jaw, 20 were evaluated to determine their current status of the condition: resolved, chronic persisting (unresolved), or active progressive (symptomatic).

RESULTS

Two of 20 patients experienced recurrences of the condition. In one of these patients, surgical treatment was identified as the stimulus of postradiation osteonecrosis. In the other patient, the recurrence appeared to be related to periodontal disease activity. In 60% (12 of 20) of the patients, the condition remained resolved, improvement in clinical staging occurred in 10% (2 of 20) (from symptomatic to unresolved or resolved), and 20% (5 of 20) of the patients continued to demonstrate chronic persisting postradiation osteonecrosis at the end of the long-term follow-up period.

CONCLUSION

This study supports the contention that postradiation osteonecrosis can occur at any time after radiation therapy, and that patients remain at risk up to 231 months after treatment of the cancer and probably indefinitely after radiation therapy. Our findings also suggest that risk of second episodes of the condition after management of an initial episode is low. In addition, our follow-up study revealed that chronic nonprogressive postradiation osteonecrosis can remain stable without extensive intervention including combined hyperbaric oxygen therapy and surgery.

The role of vesicular stomatitis virus matrix protein in inhibition of host-directed gene expression is genetically separable from its function in virus assembly

Recently, the vesicular stomatitis virus matrix (M) protein has been shown to be capable of inhibition of host cell-directed transcription in the absence of other viral components (B. L. Black and D. S. Lyles, J. Virol. 66:4058-4064, 1992). M protein is a major structural protein that is known to play a critical role in virus assembly by binding the helical ribonucleoprotein core of the virus to the cytoplasmic surface of the cell plasma membrane during budding. In this study, two M protein mutants were tested to determine whether the inhibition of host transcription by M protein is an indirect effect of its function in virus assembly or whether it represents an independent function of M protein. The mutant M protein of the conditionally temperature-sensitive (ts) vesicular stomatitis virus mutant, tsO82, was found to be defective in its ability to inhibit host-directed gene expression, as shown by its inability to inhibit expression of a cotransfected target gene encoding chloramphenicol acetyltransferase. The ability of the tsO82 M protein to function in virus assembly was similar to that of wild-type M protein, as shown by its ability to complement the group III ts M protein mutant, tsO23. Another mutant, MN1, which lacks amino acids 4 to 21 of M protein demonstrated that the abilities of M protein to inhibit chloramphenicol acetyltransferase gene expression and to localize to the nucleus were unaffected by deletion of this lysine-rich amino-terminal region but that the ability to function in virus assembly was ablated. Thus, the two M protein mutants examined in this study exhibited complementary phenotypes: tsO82 M protein functioned in virus assembly but was defective in inhibition of host-directed gene expression, while MN1 M protein functioned in inhibiting gene expression but was unable to function in virus assembly. These data demonstrate that the role of M protein in inhibition of host transcription can be separated genetically from its role in virus assembly.

Watchful waiting or watchful progression?: Prostate specific antigen doubling times and clinical behavior in patients with early untreated prostate carcinoma

BACKGROUND

Prostate specific antigen doubling time (PSAdt) is a dynamic model of prostate tumor biology. It predicts aggressive disease and subsequent clinical recurrence after radical treatment. However, as yet there is only limited evidence for its validity in the watchful waiting population.

METHODS

One hundred and thirteen previously untreated patients with adenocarcinoma of the prostate who were referred to the British Columbia Cancer Agency for a management opinion subsequently were placed into a prospective watchful waiting program. The reasons for watchful waiting, previous medical history, serial PSA, and histopathologic data were recorded.

RESULTS

The median age of patients was 75 years (range, 49-85 years). The median follow-up from the time of the first appointment was 14 months (range, 0-58 months). The reasons for watchful waiting were correlated highly with T classification (P = 0.003) and past medical history (P = 0.002). Approximately 40% of T1 patients and 51% of T2 patients had clinical progression by 2 years, increasing to 60% at 3 years. On multivariate analysis PSAdt strongly correlated with clinical progression (P < 0.0001), stage progression (P = 0.01), and time to treatment (P = 0.0001); tumor grade and initial stage were not found to be predictive for any of the endpoints studied. Initial PSA only was significant in predicting for time to treatment (P = 0.03). Approximately 50% of patients with a PSAdt of <18 months progressed within 6 months. At last follow-up, no deaths from prostate carcinoma had been recorded. Overall survival at 2 and 5 years was 92% and 68%, respectively.

CONCLUSIONS

Using digital rectal examination, the findings of this study demonstrated high rates of clinical tumor progression within the watchful waiting population. PSAdt rather than standard histopathologic criteria was found to be the most powerful indicator of disease activity.

Expression of Rattus norvegicus mtDNA in Mus musculus cells results in multiple respiratory chain defects

The production of in vitro and in vivo models of mitochondrial DNA (mtDNA) defects is currently limited by a lack of characterized mouse cell mtDNA mutants that may be expected to model human mitochondrial diseases. Here we describe the creation of transmitochondrial mouse (Mus musculus) cells repopulated with mtDNA from different murid species (xenomitochondrial cybrids). The closely related Mus spretus mtDNA is readily maintained when introduced into M. musculus mtDNA-less (rho(0)) cells, and the resulting cybrids have normal oxidative phosphorylation (OXPHOS). When the more distantly related Rattus norvegicus mtDNA is transferred to the mouse nuclear background the mtDNA is replicated, transcribed, and translated efficiently. However, function of several OXPHOS complexes that depend on the coordinated assembly of nuclear and mtDNA-encoded proteins is impaired. Complex I activity in the Rattus xenocybrid was 46% of the control mean; complex III was 37%, and complex IV was 78%. These defects combined to restrict maximal respiration to 12-31% of the control and M. spretus xenocybrids, as measured polarographically using isolated cybrid mitochondria. These defects are distinct to those previously reported for human/primate xenocybrids. It should be possible to produce other mouse xenocybrid constructs with less severe OXPHOS phenotypes, to model human mtDNA diseases.

The risk of cytomegalovirus infection in seronegative transfusion recipients not receiving exogenous immunosuppression

We studied 637 transfusion recipients seronegative for cytomegalovirus (CMV) in the following categories: neonates; pregnant women; and patients experiencing trauma, burns, cardiovascular surgery (adult or pediatric), major surgery, or gastrointestinal hemorrhages. Cultures and serological tests were used to follow up subjects for evidence of CMV infection for a period of three months after their last transfusion. Six (0.9%) developed CMV infection. No significant differences in risk among patient categories were observed. Infected patients received a significantly larger mean number of units of cellular blood products (CBP; 50.0 +/- 38.9 vs. 6.2 +/- 8.5; P less than .001) and plasma (23.7 +/- 15.3 vs. 2.6 +/- 4.6, P less than .001) than did uninfected patients. This result represents a risk per unit of CBP transfused of 0.14%, or approximately 0.38% per unit of seropositive CBP transfused. We observed, however, that patients exposed to CBP from greater than 30 donors had a higher risk of acquiring CMV infection than would be predicted if infectious units were randomly distributed among all donors (P less than .01).

Family grief therapy: a preliminary account of a new model to promote healthy family functioning during palliative care and bereavement

The family is usually the primary provider of care for the terminally ill patient with cancer or other serious progressive illness. The way in which such a family functions is a major determinant of psychological well-being for its members. Through screening with the Family Relationships Index (FRI) (Moos and Moos, 1981), dysfunctional families and those at risk can be identified, and then helped to achieve better family functioning, thus improving psychosocial outcome of their grief. In this paper, we describe the techniques and themes involved in the application of our empirically developed model of family grief therapy, designed as a preventive intervention for use in the setting of palliative care and bereavement.

Tracking and follow-up of marginalized populations: a review

Maintaining study cohorts is a key element of longitudinal research. Participant attrition introduces the possibility of bias and limits the generalizability of a study's findings, but with appropriate planning it is possible to sustain contact with even the most transient participants. This paper reviews the essential elements of tracking and follow-up of marginalized populations, which are (1) collection of contact information, (2) thorough organization of tracking efforts, (3) attention to staff training and support, (4) use of phone and mail follow-up, (5) use of incentives, (6) establishing rapport with participants, (7) assurance of confidentiality, (8) use of agency tracking, (9) use of field tracking, and (10) attention to safety concerns. Diligent application of these tracking strategies allows researchers to achieve follow-up rates of 75 percent to 97 percent with vulnerable populations such as homeless, mentally ill adults, injection drug users, and runaway youth.

Subunit interactions of vesicular stomatitis virus envelope glycoprotein stabilized by binding to viral matrix protein

The mechanism by which viral glycoproteins are incorporated into virus envelopes during budding from host membranes is a major question of virus assembly. Evidence is presented here that the envelope glycoprotein (G protein) of vesicular stomatitis virus binds to the viral matrix protein (M protein) in vitro with the specificity, reversibility, and affinity necessary to account for virus assembly in vivo. The assay for the interaction is based on the ability of M protein to stabilize the interaction of G protein subunits, which exist as trimers of identical subunits in the virus envelope. The interaction with M protein was shown by using G proteins labeled with fluorescent probes capable of detecting subunit dissociation and reassociation in vitro. The results show that the M protein isolated from virions either as purified soluble protein or as nucleocapsid-M protein complexes interacts with the G protein in vitro and that the reaction is reversible. The interaction between the G and M proteins was not serotype specific, but no interaction between the vesicular stomatitis virus M protein and the influenza virus hemagglutinin could be detected. These results support the conclusion that the interactions described here are the ones that govern assembly of G protein into virus envelopes in vivo.

Effect of surgeon's diagnosis on surgical wound infection rates

To determine the impact of a surgeon's diagnosis of surgical wound infections on infection rates, during a 6-month period we prospectively examined patients undergoing surgical wound surveillance for any of four services (orthopedic surgery, general surgery, neurosurgery, or cardiovascular surgery). Criteria were judged as standardized if the infection control practitioner observed pus, redness, or drainage associated with positive culture or if a diagnosis of deep-seated infection was made. Surgeon's diagnosis was judged as a nonstandardized criterion. Using the Centers for Disease Control's criteria, we identified 113 surgical wound infections in 3024 patients undergoing surgical procedures in the four services. Of these, 95 (84%) met objective criteria (pus observed in 53%; drainage, redness, and positive culture in 20%; and deep-seated infection in 11%). In 18 patients (16%), the nonstandardized criterion alone was used for diagnosis. There was wide variation in use of the nonstandardized criterion, ranging from 5% of orthopedic infections to 21% of cardiovascular surgery infections and 40% of neurosurgical infections. For individual surgeons with at least one wound infection, the range of surgeon's diagnosis was up to 67%. We conclude that a surgeon's diagnosis can have a major impact on surgical wound infection rates; this impact is not borne equally among surgical services or individual surgeons.

New combination of the old drugs for elderly patients with small-cell lung cancer: a phase II study of the PAVE regimen

PURPOSE

A regimen of cisplatin, doxorubicin, vincristine, and etoposide (PAVE) was designed for patients with small-cell lung cancer (SCLC) who were older than 65 years, with the following objectives compared with standard chemotherapy regimens: maintain efficacy, diminish toxicity, enhance compliance, and improve chemotherapy administration convenience at an acceptable cost.

PATIENTS AND METHODS

The PAVE regimen consisted of cisplatin 30 mg/m2 intravenously (i.v.) day 1; doxorubicin 40 mg/m2 i.v. day 1; vincristine 1.0 mg/m2 i.v. day 1; and etoposide 100 mg/m2 i.v. day 1 and orally days 3 and 5. Cycles were repeated every 3 weeks for four cycles. Patients with limited-stage disease and selected patients with extensive-stage disease received thoracic irradiation delivered concurrently with etoposide-cisplatin (EP) at the time of the second chemotherapy cycle.

RESULTS

Sixty-six eligible patients were treated, which included 25 patients with limited-stage disease and 41 patients with extensive-stage disease. Median survival was 70 weeks and 5-year survival was 25% for limited-stage disease. Median survival was 46 weeks for extensive-stage disease. Only one treatment-related death occurred and severe toxicity was infrequent. The median delivered dose-intensity was according to protocol and the mean delivered total dose was 80% of intended.

CONCLUSION

The treatment outcome achieved with PAVE in a phase II study of elderly patients compared favorably with published results of standard regimens in patient populations with better prognostic factors. Because the PAVE regimen can be delivered with good compliance, has acceptable toxicity, and is associated with logistic advantages compared with standard regimens, this protocol is suitable for further investigative trials in elderly patients with SCLC.

Trends and sources of nosocomial fungaemia

Concurrent surveillance of blood culture isolates in a 1000-bed tertiary care hospital over a 7-year period from 1986 to 1993 identified 102 episodes of nosocomial fungaemia, representing 6.6% of all episodes of nosocomial bloodstream infections and 0.49/1000 admissions. No significant change in the frequency, rate, source or microbial aetiology of nosocomial fungaemia occurred over the 7-year period. Candida albicans accounted for 74%, followed by Candida (Torulopsis) glabrata (8%), C. parapsilosis (7%), C. tropicalis (3%), C. lusitaniae (2%), C. krusei, Malassezia furfur Saccharomyces cerevisiae, Hansenula anomala and Cryptococcus albidus (one each). 'Primary' fungaemia, usually attributed to intravascular catheters, was considered to be the source in 65% of cases, with 64% of these patients receiving total parenteral nutrition (TPN). Other important sources of infection included the urinary tract (11%), the gastrointestinal tract (8%) and the respiratory tract (7%). Sixty-four % of patients were in one of the hospital's seven intensive care units (ICUs) when their infection developed, the neonatal ICU and adult medical/surgical ICU each accounting for 21%. Only 7% of cases were associated with neutropenia and another 14% with malignancy or immunosuppression. Death occurred within 7 days of diagnosis of fungaemia in 23 cases. In eight instances, fungaemia was considered the main cause of death. We conclude that in our hospital nosocomial fungaemia is largely caused by C. albicans, occurring in association with intravascular catheter use and TPN in ICU patients. Most cases are not associated with recognized immune defence defects. Fungaemia is associated with a high short-term mortality rate.

The use of resolvases T4 endonuclease VII and T7 endonuclease I in mutation detection

Mutation and polymorphism detection is of increasing importance in the field of molecular genetics. This is reflected by the plethora of chemical, enzymatic, and physically based methods of mutation detection. The ideal method would detect mutations in large fragments of DNA and position them to single base-pair (bp) accuracy. Few methods are able to quickly screen kilobase lengths of DNA and position the mutation at the same time. The Enzyme Mismatch Cleavage (EMC) method of mutation detection is able to reliably detect nearly 100% of mutations in DNA fragments as large as 2 kb and position them to within 6 bp. This method exploits the activity of a resolvase enzyme from T4, T4 endonuclease VII, and, more recently, a second bacteriophage resolvase, T7 endonuclease I. The technique uses these enzymes to digest heteroduplex DNA formed by annealing wild-type and mutant DNA. Digestion fragments indicate the presence, and the position, of any mutations. The method is robust and reliable and much faster and cheaper than sequencing. These attributes have resulted in its increasing use in the field of mutation detection.

Validating Crohn's disease activity indices for use in assessing postoperative recurrence

BACKGROUND

The Crohn's Disease Activity Index (CDAI) has been used in medical trials with scores <150 indicative of remission. Its value in assessing postoperative recurrence is unknown. The objective of this study was to explore the utility of the CDAI in determining the presence or absence of symptomatic disease recurrence in patients having previously undergone ileocolic resection for Crohn's disease.

METHODS

Ninety-three patients underwent clinical and colonoscopic evaluation within 12 months of ileocolic resection. Endoscopic appearance was assessed using the Rutgeerts score (i0-i4). Symptomatic disease recurrence was defined by the composite of symptom severity warranting therapy and an endoscopic score ≥ i2. CDAI scores were calculated. Comparisons were made using the receiver operator curve (ROC).

RESULTS

Thirty-nine (42%) patients had recurrent disease (22% symptomatic, 20% endoscopic only) at 12 months. Median CDAI for symptomatic recurrence was 198 (interquartile range [IQR]: 106-293), 80 for asymptomatic subjects (IQR 35-115). The area under the ROC curve for symptomatic disease and CDAI was 0.78 (95% confidence interval [CI] 0.64-0.91). Recurrence was best predicted by a CDAI of ≥ 148 (sensitivity 70%, specificity 81%). A strong linear relationship existed between the CDAI and Inflammatory Bowel Disease Questionnaire (r = 0.82).

CONCLUSIONS

The CDAI performs reasonably well in the postoperative setting and 150 appears the best cutpoint for indicating symptomatic disease. However, it is likely not suitable for use as the primary outcome measure. These data suggest that a combination of symptom assessment plus endoscopic evidence of recurrence should remain the gold standard definition for assessing outcomes in postoperative CD trials.

Bacteremic nosocomial pneumonia. A 7-year experience in one institution

STUDY OBJECT

To describe the epidemiology, microbiology, and outcome of nosocomial pneumonia with secondary bloodstream infection.

DESIGN

Prospective cohort study.

SETTING

Tertiary care Canadian teaching hospital.

PATIENTS

Inpatients.

MEASUREMENT

All inpatient blood cultures were concurrently monitored over an 89 month period. Following chart review, patients experiencing nosocomial bloodstream infection due to pneumonia were identified. A standardized definition of pneumonia was used.

RESULTS

One hundred forty-nine episodes occurred in 145 patients, 0.66/1,000 hospital admissions, 8.4% of all nosocomial bloodstream infections. No change in rate occurred in the study period. Fifty-four percent of episodes developed in one of seven ICUs. Staphylococcus aureus was the most frequently identified etiologic organism (27%). The ICU and non-ICU cases did not differ in etiology. No organism became more prevalent during the study period. Twenty percent of patients died within 1 week of first positive culture; episodes associated with Pseudomonas species had a much higher mortality rate (45%) than other infections (14%) (p = 0.002). The ICU and non-ICU infections had a similar mortality rate.

CONCLUSION

Pneumonia is an important cause of nosocomial bloodstream infection, but it is not increasing in frequency or changing in etiology in our institution. The ICUs are a major contributor to this problem but have the same case short-term mortality rate and microbial etiology as non-ICU cases. Cases associated with Pseudomonas have a much higher mortality rate.

Surgical wound infections occurring in day surgery patients

The occurrence of surgical wound infection in outpatient day surgery has not been extensively studied despite the increasing popularity of this mode of treatment. The present study was conducted to determine the frequency of surgical wound infections in a day surgery population. We randomly selected during a 6-month period 635 (25%) of 2540 patients undergoing a day surgery procedure in which a skin incision was made. The patients were telephoned 1 month after their procedure by an infection control practitioner. Infection was diagnosed if the patient reported that (1) their physician had made a diagnosis of a wound infection or (2) pus was or had been issuing from the wound. Of the 515 patients contacted, 72% had undergone a clean and 28% a clean-contaminated procedure. Patient risk factors for infection were almost completely absent in our day surgery patients. Twenty-six wound infections were diagnosed, 19 of which were identified by physicians' diagnosis and 7 by patient description, for a rate of 5.05%. Two patients required hospitalization for their infections, and 14 were treated with antibiotics. The clean wound infection rates were 4.62%, less than half the infection rate seen in our patients undergoing inpatient surgery at 1 month follow-up by the same surveillance technique. We conclude that day surgery infection rates are much lower than inpatient surgery infection rates at our facility, probably because of a relative absence of risk factors in the day surgery patients.

Transfusion-acquired cytomegalovirus infection in neonates. A prospective study

The incidence of cytomegalovirus (CMV) infection was determined in 114 transfused neonates of any birthweight born to CMV antibody-negative mothers. In a second phase of this study, an additional 28 transfused infants weighing less than 1250 g, born to both CMV antibody-negative and antibody-positive mothers, were followed. All infants underwent weekly virus culture and monthly serology during hospitalization and at 6 to 12 weeks after their last transfusion. Only one of 126 (0.8%) seronegative infants and one of 16 (6.3%) seropositive infants developed CMV infection. If the assumption is made that the CMV-infected infant received only 1 unit of infectious blood, the risk of transfusion-acquired CMV infection to seronegative infants is 0.16 percent per cellular unit transfused or 0.37 percent per seropositive cellular unit transfused. Despite similarities in the prevalence of CMV antibody in the donor population, the age of blood products used, and the mean number of donor exposures, a significantly lower incidence of CMV infection was found in the seronegative transfused infants than that in two previously published studies (p less than 0.01, p less than 0.001). Because no mortality and very little morbidity could be attributed to transfusion-acquired CMV infection in the nurseries, the authors can see no justification for the provision of specialized blood components for the prevention of CMV infection in this patient population.

Aftercare attendance and post-treatment functioning of severely substance dependent residential treatment clients

The present study evaluated the impact of a structured aftercare programme following residential treatment for severe alcohol and/or heroin dependent clients. Over 17 months, 77 participants were recruited to the study and allocated randomly to either a structured aftercare (SA) programme or to unstructured aftercare (UA) of crisis counselling on request. Independent clinicians interviewed participants and collaterals, at 4-month (median) intervals, for 12 months following residential treatment. SA compared to UA was associated with a fourfold increase in aftercare attendance and one-third the rate of uncontrolled principal substance use at follow-up. Participants who attended either type of aftercare relapsed a median of 134 days later than those who attended no aftercare. Overall, 23% of monitored participants remained abstinent throughout, 21% maintained controlled substance use and 56% relapsed, within a median of 36 days following residential treatment. The only significant predictor of days to relapse, controlling for age, was pretreatment use of additional substances. Participants with pretreatment additional substance use relapsed a median of 192 days earlier than those who had used no other substances. The degree of agreement between participant self-reports and collateral reports was fair-to-moderate and moderate among collaterals. Intention-to-treat analyses revealed significant and clinically meaningful reductions in substance use in this sample of severely dependent residential treatment clients. The generalizability of these results is limited because of significant differences in age and presenting substance between the study sample and other clients admitted to the service during the study. This latter group of younger, male, heroin-dependent clients with polydrug use who refuse opioid pharmacotherapy, are more likely to drop out of treatment or relapse early following treatment and continue to present a challenge to treatment services.

Syringe prescription to prevent HIV infection in Rhode Island: a case study

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system.