Does work have to be so painful? A review of the literature examining the effects of fibromyalgia on the working experience from the patient perspective

Background

Chronic pain conditions, such as fibromyalgia, adversely affect individuals’ abilities to work.

Aim

The aim of this study was to examine, from the perspective of patients, the effects that fibromyalgia symptoms had on their ability to work, the challenges that they encountered in the workplace that did not foster their continued employment, and the types of modifications to their work or workplace that they thought would facilitate their productivity and ability to work.

Methods

A scoping review method, applying techniques of systematic review, was used to conduct a research synthesis of the literature regarding fibromyalgia and work that looked at this issue from the patient perspective.

Results

A variety of themes emerged from the analysis and could be broadly categorized into (1) the work experience was a challenging one with which to cope; (2) relationships were strained at work; (3) clinical symptoms had repercussions on subjects’ attitudes toward work and the relation to life outside of work; and (4) a variety of possible solutions were considered to help subjects better cope with fibromyalgia and work.

Conclusions

Strategies that potentially could foster continued employment of patients with fibromyalgia include those at the micro, meso, and macro levels. Health care providers can support patients’ employment goals by collaborating with patients and their employers, dispelling stigma regarding the illness, and providing practical and specific advice regarding workplace accommodations.

Risk factors and timing of relapse after allogeneic transplantation in pediatric ALL: for whom and when should interventions be tested?

We previously showed that minimal residual disease (MRD) detection pre-hematopoietic cell transplant (HCT) and acute GvHD (aGvHD) independently predicted risk of relapse in pediatric ALL. In this study we further define risk by assessing timing of relapse and the effects of leukemia risk category and post-HCT MRD. By multivariate analysis, pre-HCT MRD <0.1% and aGvHD by day +55 were associated with decreased relapse and improved event-free survival (EFS). Intermediate leukemia risk status predicted decreased relapse, and improved EFS and overall survival (OS). Patients with pre-HCT MRD ⩾0.1% who did not develop aGvHD compared with those with MRD <0.1% who did develop aGvHD had much worse survival (2 years EFS 18% vs 71%; P=0.001, 2 years OS 46 vs 74%; P=0.04). Patients with pre-HCT MRD <0.1% who did not experience aGvHD had higher rates of relapse than those who did develop aGvHD (40% vs 13%; P= 0.008). Post-HCT MRD led to a substantial increase in relapse risk (HR=4.5, P<0.01). Patients at high risk of relapse can be defined after transplant using leukemia risk category, presence of MRD pre or post HCT, and occurrence of aGvHD. An optimal window to initiate intervention to prevent relapse occurs between day +55 and +200 after HCT.

Combining HLA-DR risk alleles and anti-Epstein-Barr virus antibody profiles to stratify multiple sclerosis risk

Background:

Risk factors for multiple sclerosis (MS) include human leukocyte antigen (HLA)-DR and Epstein-Barr virus (EBV)-specific antibody responses, including an epitope within EBV nuclear antigen 1 (EBNA-1) that is of recent interest.

Objective:

The objective of this paper is to assess case-control associations between MS risk and anti-EBV antibody levels as well as HLA-DR profiles, gender and age in a population-based cohort.

Methods:

Serological responses to EBV were measured in 426 MS patients and 186 healthy controls. HLA-DR typing was performed using sequence-based methods.

Results:

MS patients had significantly higher levels of antibodies against epitope-specific and polyspecific EBNA-1 and viral capsid antigen (VCA), compared with controls (all p < 10−15). In regression analyses, anti-EBNA-1 and anti-VCA antibody levels, protective HLA-DR*04/07/09 alleles and gender (all p < 0.003) contributed independently to a model that classified cases and controls with an odds ratio > 20 (sensitivity 92%, specificity 64%). Notably, the strong influence of high-risk HLA-DR alleles was abrogated after inclusion of EBV serology results.

Conclusions:

The ability to discriminate MS cases and controls can be substantially enhanced by including anti-EBV serology as well as HLA-DR risk profiles. These findings support the relevance of EBV-specific immunity in MS pathogenesis, and implicate both HLA-dependent and HLA-independent immune responses against EBNA-1 as prominent disease risk factors.

UAB 0210: A phase I/II trial of induction chemotherapy followed by concomitant docetaxel/radiotherapy with subcutaneous amifostine for advanced squamous cell carcinoma of the head and neck (SCCHN)

6061

Background: Attempts to improve the outcome of locally advanced SCCHN have generally added chemotherapy to radiation, though the optimal manner of integration has been controversial. To impact distant and local control, we utilized neoadjuvant chemotherapy followed by concomitant boost radiation (CBR) with docetaxel as a radiosensitizer. To improve cytoprotection, subcutaneous amifostine was added during radiotherapy. Methods: From April 2003-March 2007 46 patients with stage III or IV newly diagnosed SCCHN were enrolled (30 Caucasian, 16 African-American). Treatment consisted of 3 cycles of neoadjuvant chemotherapy with cisplatin 75 mg/m2 and docetaxel 75 mg/m2 intravenously at 21 day intervals followed by CBR and concurrent dose-escalated weekly docetaxel starting at 20 mg/m2. Standard 2D radiotherapy was used in the majority of patients. Subcutaneous amifostine was administered at 500 mg during each day of radiation. Results: 39 patients were evaluable. The neoadjuvant chemotherapy was well tolerated by the majority of patients and appeared effective; no patient had progressive disease while on therapy. Three patients required a change to carboplatin due to toxicity. Weekly docetaxel during all weeks of CBR was not tolerable due to severe mucositis and the phase I component defined the MTD of concurrent docetaxel as 20 mg/m2 for 4 cycles during CBR. 4 patients (10%) had persistent disease at completion of treatment. Amifostine administration was well tolerated though 4 patients required discontinuation of the drug. The majority of recurrences have been localized at the primary site (6 patients). 3 patients developed isolated pulmonary metastasis. Only 2 patients remain PEG dependent with median follow-up of 24 months. Conclusions: Induction chemotherapy using cisplatin and docetaxel is feasible and easy to administer in the outpatient setting; those patients who had a major radiographic and clinical response did particularly well in follow-up. Weekly docetaxel can be safely and effectively administered during CBR with good local control. Amifostine can be safely administered via the subcutaneous route; the benefit in locally advanced patients is difficult to assess.

No significant financial relationships to disclose.

Hydrogen cyanide as a biomarker for Pseudomonas aeruginosa in the breath of children with cystic fibrosis

HYPOTHESIS

Hydrogen cyanide (HCN) is emitted by Pseudomonas aeruginosa (PA) in vitro. We hypothesized that exhaled HCN could be measured using Selected Ion Flow Tube Mass Spectrometry (SIFT-MS) and that concentrations would be higher in children with cystic fibrosis (CF) and PA infection than in children with asthma.

METHODS

Children aged 7-17 years with CF (n = 16) or asthma (n = 21) attending outpatient clinics provided breath samples between July and December 2007. HCN was measured using the SIFT-MS Profile 3 instrument. FeNO was measured with a Sievers NOA 280i analyzer. Baseline inter-group differences between HCN and FeNO concentrations were compared using the Mann-Whitney U test. Children were invited to re-attend fortnightly. Breath samples, spirometry, growth and clinical status were measured at each visit.

RESULTS

There were significant baseline differences in exhaled HCN and FeNO concentrations between the two groups. Children with CF had higher median HCN concentrations than those with asthma: 13.5 parts per billion (ppb) (IQR 8.1-16.5) versus 2.0 ppb (IQR 0.0-4.8) (P < 0.001). Children with CF had lower median FeNO levels compared to children with asthma: 13.4 ppb (IQR 8.9-17.6) versus 57.9 ppb (IQR 34.0-85.7) (P < 0.001). Intra-subject variability was high and significant changes in HCN concentrations were not observed related to changes in lung function or clinical status.

CONCLUSION

This study provides proof of principle that HCN is detectable in the breath of children with CF and is elevated compared to children with asthma. Further studies are required to capture data from acutely unwell children and more accurately delineate responses to treatment.

Endogenous knock-down of survival genes improves chemotherapeutic response in a T-ALL cell line

9522

Background: New targets for more effective, less toxic therapeutic approaches to childhood acute lymphoblastic leukemia (ALL) can be developed by discovering pathways unique to the blast. Using microarray technology, we identified potential target genes that are up-regulated at relapse compared to diagnosis (Blood 2006;108:711–7). Two genes, survivin and securin, were selected for analysis because they are involved in cell cycle regulation, apoptosis and cellular transformation. We hypothesized that decreasing endogenous expression of these genes would increase apoptosis and sensitize cells to chemotherapy. Methods: Short hairpin RNA constructs (shRNA) targeting both transcripts and a control shRNA were engineered. LSN2181295 (sodium salt of LY2181308), an antisense molecule targeting survivin developed by Eli Lilly and its mismatch control (LSN2293329) were also tested. The T- ALL cell line Molt4 was transiently transfected with shRNA constructs or antisense oligos. Western blot and qRT-PCR were performed to determine the time course of target knock-down while apoptosis was assessed by annexin-V labeling. Following transfection, cells were also treated with varying doses of etoposide and doxorubicin for 24 hrs prior to FACS analysis. Results: The survivin and securin shRNAs blocked endogenous gene expression by 80–90%, with maximal effect achieved at 48 hrs. Transfection of Molt4 cells with survivin and securin shRNAs induced ∼13% and 35% apoptosis, respectively, as compared to a control shRNA. When used in combination with chemotherapeutic agents, the shRNA constructs potentiated the effect of both doxorubicin and etoposide at low dosages (≤100 nM and ≤0.4 uM respectively, p values <0.01). The antisense survivin drug had a similar effect as the survivin shRNA and also potentiated the effect of vincristine. Conclusion: Targeting levels of survivin and securin in conjunction with standard chemotherapy maximizes leukemia cell kill and effectively lowers the amount of chemotherapy needed to achieve cell death. Such an approach may improve overall survival for patients at relapse and could also lead to the delivery of effective chemotherapy at less toxic doses.

No significant financial relationships to disclose.

A phase I study of clofarabine in combination with cyclophosphamide and etoposide: A new regimen in pediatric patients with refractory or relapsed acute leukemia

9529

Background: Clofarabine is a promising new agent in the treatment of childhood leukemia as evidenced by single agent activity in previous phase I and II studies. We conducted a pilot phase I study of clofarabine used in combination with cyclophosphamide and etoposide to determine the maximum tolerated dose (MTD) and dose limiting toxicities (DLT). Methods: Patients between 1 and 21 years old with relapsed or refractory acute lymphoblastic leukemia (ALL) and acute myelogenous leukemia (AML) were enrolled. A standard 3+3 design was followed to determine the safe dose when used in combination. All drugs were administered by IV infusion daily for 5 consecutive days in induction and 4 days in consolidation. Patients received up to 2 induction cycles depending on the response, followed by consolidation cycles (maximum of 8 total cycles). The initial doses (cohort 1) were as follows: clofarabine: 20 mg/m2/day, etoposide 75 mg/m2/day and cyclophosphamide 340 mg/m2/day. Once etoposide and cyclophosphamide were escalated to their target dose (100 mg/m2/day and 440 mg/m2/day respectively in cohort 3), clofarabine was then increased to 30 mg/m2/day in cohorts 4 and would be increased to 40 mg/m2/day in cohort 5. Results: Thirteen patients (10 ALL; 3 AML) were enrolled in the first 4 dose cohorts to this date. The median number of prior regimens was 2. Response data (based on investigator assessment) are available for the first 8 patients: 6 patients (including 1 patient with AML) achieved either complete remission (CR) or complete remission without platelet recovery (CRp), for an overall response rate of 75%. Four patients proceeded to HSCT. One patient in cohort 4 experienced a DLT which resolved (grade 3 elevation of lipase) and possible veno-occlusive disease leading to cohort expansion. Common toxicities noted include febrile neutropenia and fever. Conclusions: The phase I study is ongoing until determination of MTD for this combination but these early results indicate that this combination shows significant activity in children with refractory or relapsed acute leukemias and is well-tolerated.

No significant financial relationships to disclose.

Hematopoietic stem cell transplant (HSCT) versus intensive chemotherapy in infant acute lymphoblastic leukemia (ALL)

9514

Background: Infants (<366 days) with ALL and an MLL rearrangement (MLL-R), have a dismal prognosis. Early relapse is common and event free survival (EFS) is poor. The Children's Oncology Group (COG) parallel pilot trials, 1953 and 9407, were designed to prospectively compare early HSCT to intensified chemotherapy in infants with MLL-R ALL. This is the largest prospective trial investigating the role of HSCT in such patients (pts) in first remission (CR-1). Methods: From 1997–2000, 186 pts were registered (132 MLL-R). Both trials were identical through Induction, Induction Intensification and Re-Induction (Re-I), then diverged. Pts with MLL-R ALL with matched/one antigen mismatched - related/unrelated donors were to undergo HSCT (mandated on 1953/optional on 9407) at completion of Re-I. The HSCT regimen was ara-c, cyclophosphamide, steroid and total body irradiation; graft vs. host prophylaxis was cyclosporine. Results: Compliance with protocol mandated conditioning for HSCT was poor and 28/53 HSCT pts received non-protocol preparative regimens. By life table comparisons, the 5 year HSCT EFS was 50.9% (SE=9.9%, RHR 1.13) vs. 48.7% (SE=10.1%) p=0.68 in 47 control pts (chemotherapy-treated, MLL-R), who survived 143 days (median time to HSCT = 143 days). By statistical regression analysis the RHR for HSCT was 1.454 (90% CI 0.911, 2.318), p-value = 0.19, showing a trend in favor of chemotherapy alone. Neither donor source nor preparative regimen affected HSCT outcome. Chemotherapy outcomes were similar on 1953 and 9407. Events for HSCT pts were most common in the first 6 months: 20 events (11 HSCT related deaths/9 relapses). In the control group, 7/9 events in this time period were due to relapse. Conclusion: These results show no advantage for HSCT in CR1 in infants with MLL-R ALL. These data do not support the routine use of HSCT in CR1 in MLL-R infants.

No significant financial relationships to disclose.

Effect of nitinol wire surface properties on albumin adsorption

The superelastic, shape memory alloy nitinol ( approximately 50% nickel and approximately 50% titanium) is an important medical device material used for stent applications. However, the role specific surfaces properties have in protein adsorption remain controversial. In this study the effects of nitinol wire surface roughness, hydrophobicity and elemental composition upon albumin adsorption are investigated. In particular, we demonstrate that the technique of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in the so-called surface mode can be used for the direct detection of albumin on the wire surfaces. In addition, albumin adsorbing to the wires was determined by using (125)I-labelled albumin. Albumin was detected on all wire samples. Surface roughness and hydrophobicity appeared to have no effect on albumin adsorption. There was however a clear correlation between the surface nickel and oxygen concentration and the amount of albumin adsorbed. Samples with higher levels of nickel and less oxygen in the surface oxide layer of the wires showed increased albumin adsorption, which could lead to improved biocompatibility. However, nickel is a toxic substance and can cause many adverse effects on humans, and thus nitinol with a slightly enriched surface nickel concentration that does not exhibit nickel release may have potential as a medical device material.

Radiosensitization with a COX2 inhibitor with chemoradiation for head and neck cancer

5582

Background: Cyclo-oxygenase 2 (COX2) inhibitors have shown promise as radio- and chemosensitizers. We conducted a phase IB/II study to evaluate the toxicity and efficacy of celecoxib, a selective COX2 inhibitor, administered concurrently with carboplatin, paclitaxel, and radiation for locally advanced or recurrent head and neck cancer. Methods: Patients with stage III/IV or recurrent squamous cell carcinoma of the oropharynx, oral cavity, hypopharynx, or larynx were eligible. Primary endpoints were toxicity, local control and survival. Patients were treated with weekly carboplatin (AUC = 2.0), paclitaxel (30 mg/m2) and concurrent radiation (70 Gy). Celecoxib (400 mg bid) was started 1 week prior to the initiation of radiotherapy and was given for a total of 2 years. In 12/04, the study closed due to concerns of cardiotoxicity with COX-2 inhibitors. Celecoxib was discontinued in all patients. The study restarted in 5/06 with the modification that celecoxib would be given only during radiation. Results: Between 12/02 and 1/06, a total of 28 patients were enrolled: 89% were male, median age was 56.5, 3 with recurrent cancer and 25 treated definitively. Five patients have been treated on the modified study. Grade 3/4 toxicities include: mucositis (35% G3), dermatitis (18% G3; 7% G4), febrile neutropenia (21% G3; 3% G4), dysphagia (57% G3), nausea/vomiting (29% G3). Thirty percent did not complete prescribed chemotherapy due to myelosuppression. Acturarial 2 year outcomes in the 20 evaluable, definitively treated patients: 65% survival, 76% local control. Conclusions: Compared to published data using carbo/taxol and RT, an unexpectantly high incident of febrile neutropenia was observed but no increase in radiation dermatitis or mucositis. Two year survival data is comparable to published data.

No significant financial relationships to disclose.

A phase I/II trial of induction chemotherapy followed by concomitant docetaxel with concomitant boost radiotherapy (CBR) and amifostine for advanced head and neck cancer (HNC)

15525

Background: Concomitant chemo-radiation for head and neck cancer has emerged as the optimal method of treating advanced head and neck cancers, although the acute and late toxicities can be formidable. The addition of induction chemotherapy to concomitant chemo-radiation for head and neck cancer is designed to impact the incidence of distant metastasis while delivering aggressive local treatment. This trial evaluates the tolerability and effectiveness of induction chemotherapy followed by CBR with concurrent docetaxel and subcutaneous (SC) amifostine in locally advanced squamous cell carcinoma of the head and neck (SCCHN). Methods: Patients with stage III/IV nonmetastatic SCCHN received 3 cycles of primary chemotherapy with docetaxel and cisplatin, each at 75 mg/m2. Patients then received 4 weekly doses of docetaxel at 20 mg/m2 with concurrent CBR. SC amifostine was given at a dose of 500 mg in divided doses during each day of XRT. Results: The phase I component defined the MTD of concurrent docetaxel as 20 mg/m2 for 4 cycles during CBR. 18 patients are evaluated for response. No patient developed progressive disease during primary chemotherapy. Grade 3–4 mucositis was common, but all patients completed the planned concomitant docetaxel. At 6 months after treatment, 7/18 patients still used a feeding tube, though most have had them subsequently removed. Amifostine given by SC was well tolerated; 7 patients developed transient hypotension not requiring any intervention, with grade1 dermatitis and nausea reported. 2 patients discontinued amifostine due to rash or persistent hypotension. Conclusions: Response to induction chemotherapy was greater then 75% by radiological assessment, with no patient developing distant metastasis thus far. Local control has been excellent but side effects from docetaxel and CBR have necessitated prolonged use of feeding tubes for up to 6 months. SC amifostine has been well tolerated without significant side effects. This aggressive therapy is effective treatment for locally advanced SCCHN.

No significant financial relationships to disclose.

Influence of Nitinol wire surface treatment on oxide thickness and composition and its subsequent effect on corrosion resistance and nickel ion release

Medical implants and devices are now used successfully in surgical procedures on a daily basis. Alloys of nickel and titanium, and in particular Nitinol are of special interest in the medical device industry, because of their shape memory and superelastic properties. The corrosion behavior of nitinol in the body is also of critical importance because of the known toxicological effects of nickel. The stability of a NiTi alloy in the physiological environment is dependant primarily on the properties of the mostly TiO(2) oxide layer that is present on the surface. For the present study, a range of nitinol wires have been prepared using different drawing processes and a range of surface preparation procedures. It is clear from the results obtained that the wire samples with very thick oxides also contain a high nickel content in the oxide layer. The untreated samples with the thicker oxides show the lowest pitting potential values and greater nickel release in both long and short-term experiments. It was also found that after long-term immersion tests breakdown potentials increased for samples that exhibited lower values initially. From these results it would appear that surface treatment is essential for the optimum bioperformance of nitinol.

Darbepoetin alfa administered once monthly maintains hemoglobin concentrations in patients with chronic kidney disease

BACKGROUND

Darbepoetin alfa is an erythropoiesis-stimulating glycoprotein that functions by the same mechanism as recombinant human erythropoietin (rHuEPO), but has a three-fold longer serum half-life. Reduction in the frequency of darbepoetin alfa administration would be beneficial to patients with renal disease and their healthcare providers. This study evaluated the effect of extending the darbepoetin alfa dosing interval to once monthly in patients with chronic kidney disease (CKD) not receiving dialysis.

METHODS

This study was a multicenter, open-label study of 97 patients with CKD not on dialysis. Patients receiving stable subcutaneous doses of darbepoetin alfa once every two weeks were converted to darbepoetin alfa once monthly for 29 weeks. The proportion of patients who successfully maintained hemoglobin concentrations between 10.0 and 12.0 g/dl and the mean darbepoetin alfa dose were evaluated. Safety measurements (e.g. adverse events, laboratory parameters, blood pressure) and seroreactivity were assessed.

RESULTS

Hemoglobin concentration was maintained within the target range in 79% (95% confidence interval (CI) = 71% to 87%) of all patients receiving darbepoetin alfa and in 85% (95% Cl = 78% - 93%) of patients who completed the study period. The mean +/- standard deviation monthly darbepoetin alfa dose was similar between baseline (88.7 +/- 49.9 microg) and the evaluation period (86.6 +/- 78.8 microg). The safety profile for monthly darbepoetin alfa administration was comparable with that previously observed with more-frequent administration.

CONCLUSION

Patients with CKD who are clinically stable on darbepoetin alfa administered once every two weeks can be safely and effectively converted to darbepoetin alfa administered once monthly.

The influence of passivation and electropolishing on the performance of medical grade stainless steels in static and fatigue loading

The effects of surface passivation and electropolishing on the mechanical performance of a group of biomedical grade stainless steels have been investigated. Surface roughness measurements showed that the treatments had a significant effect on the final surface finish. However, static mechanical testing demonstrated no difference in static mechanical properties, regardless of surface treatment. High cycle fatigue testing was carried out at a frequency of 120 Hz with a load ratio of R=0.1, in both air and a simulated in vivo wet corrosive environment. 316LVM (cold worked) proved superior to 316L (annealed) in fatigue performance, in both dry and wet environments. The fatigue performance of both materials did depend on the surface treatment, with electropolishing resulting in better performance than passivation. The fatigue performance of both materials was significantly better in the dry environment in comparison to the wet environment. The dry-to-wet deterioration in fatigue performance was somewhat dependent on the surface treatment for the 316L material but almost independent of surface treatment for the 316LVM material. Significant surface pitting and damage was evident for 316L during fatigue in the wet environment, whereas almost no pitting and damage was observed for 316LVM.

Clinical experience with HLA-B7 plasmid DNA/lipid complex in advanced squamous cell carcinoma of the head and neck

OBJECTIVE

To investigate the safety and efficacy of alloantigen plasmid DNA therapy in patients with advanced head and neck squamous cell carcinoma using Allovectin-7 (Vical Inc, San Diego, Calif), a DNA/lipid complex designed to express the class I major histocompatibility complex antigen HLA-B7.

DESIGN

Multi-institutional prospective trial.

SETTING

Academic medical setting.

PATIENTS

A total of 69 patients were enrolled in 3 sequential clinical trials: a single-center phase 1 trial and 2 multicenter phase 2 trials. Eligibility criteria included unresectable squamous cell carcinoma that failed conventional therapy, Karnofsky performance status score of 70 or greater, and no concurrent anticancer or immunosuppressive therapies.

INTERVENTION

Patients received 2 biweekly intratumoral injections of 10 microg (phase 1 and first phase 2 trials) or 100 microg (second phase 2 trial) of Allovectin-7 followed by 4 weeks of observation. Patients with stable or responding disease after the observation period were given a second treatment cycle identical to the first.

MAIN OUTCOME MEASURES

Patients were assessed for toxic effects, and tumor size was measured after cycles 1 (at 6 weeks) and 2 (at 16 weeks).

RESULTS

Allovectin-7 treatment was well tolerated, with no grade 3 or 4 drug-related toxic effects. Of 69 patients treated, 23 (33%) had stable disease or a partial response after the first cycle of treatment and proceeded to the second cycle. After the second cycle, 6 patients had stable disease, 4 had a partial response, and 1 had a complete response. Responses persisted for 21 to 106 weeks.

CONCLUSIONS

Intratumoral plasmid DNA immunotherapy for head and neck cancer with Allovectin-7 is safe, and further investigations are planned in patients with less advanced disease, where it could potentially improve patient survival and reduce the need for radical high-morbidity treatments.

GSLII positivity is not confined to oligodendrocytes in adult mammalian CNS

The in vivo binding pattern of the lectin Griffonia simplicifolia II (GSLII) was evaluated in sections of adult cat optic nerve following reports that it is a marker for oligodendrocytes in adult rodent CNS and that it may also be an oligodendroglial lineage marker. Following as closely as possible the immunocytochemical methodology employed in these reports, staining for GSLII was incorporated into sets of consecutive one micron thick sections comprising known cell-type specific reference markers backed up by electron microscopy. With this correlative protocol both lectin positive and lectin negative cells could be reliably identified. The material examined included normal control tissue and tissue containing previously studied demyelinating lesions of various ages in which oligodendrocyte progenitors and precursors have been characterized. GSLII was found to stain not only mature oligodendrocytes in adult cat optic nerve but also activated microglia, macrophages, polymorphonuclear leucocytes and other haematogenous cells. Lectin positivity was not found in oligodendroglial precursors, endothelial cells, astrocytes or ramified microglia. This study emphasises that care needs to be taken before assigning lineage marker status to individual lectins or antibodies.

Functional results of primary closure vs flaps in oropharyngeal reconstruction: a prospective study of speech and swallowing

BACKGROUND

The preservation of speech and swallowing function is the primary goal when reconstructing soft tissue defects in the oral cavity or oropharynx. The type of reconstructive procedure used should be based on outcome data examining speech and swallowing function; yet, there is a paucity of such information.

OBJECTIVES

To present the results of a multi-institutional prospective study of speech and swallowing function before and after soft tissue reconstruction of the oral cavity and oropharynx, and to compare 3 methods of reconstruction with respect to speech and swallowing function: primary closure, distal myocutaneous flap, and microvascular free flap.

DESIGN

Prospective case-comparison study.

SETTING

Four leading head and neck cancer institutions.

PATIENTS

The patients were selected from a database of 284 patients treated at the different institutions. The patients were matched for the location of the oral cavity or oropharyngeal defect and the percentage of oral tongue and tongue base resection. Those patients who had previous speech and swallowing deficits and patients in whom postoperative fistulas or wound infections developed were excluded from the study.

METHODS

The patients underwent speech and swallowing evaluation preoperatively and 3 months after healing. This evaluation included videofluoroscopic studies of swallowing and tests of speech intelligibility and sentence articulation. Videofluoroscopy provided measures of swallowing efficiency and bolus movement. Liquid and paste consistencies were used in evaluating swallowing function.

MAIN OUTCOME MEASURE

The functional results of the reconstruction.

RESULTS

Patients who had primary closure were more efficient at swallowing liquids, had less pharyngeal residue, a longer oral transit time with paste, and higher conversational intelligibility than patients who underwent reconstruction with a distal flap. Compared with patients who underwent reconstruction with a free flap, those who had primary closure had more efficient swallowing of liquids, less pharyngeal residue, and shorter pharyngeal delay times with paste. No difference in the speech and swallowing function existed between patients treated with distal myocutaneous flaps and those treated with microvascular free flaps.

CONCLUSION

Contrary to the current theory of oral and oropharyngeal reconstruction, we found that the use of primary closure resulted in equal or better function than the use of flap reconstruction in patients with a comparable locus of resection and percentage of oral tongue and tongue base resection.

Planned early neck dissection before radiation for persistent neck nodes after induction chemotherapy

Optimal management of advanced neck metastases as part of an organ preservation treatment approach for head and neck squamous carcinoma (HNSC) is unclear. Since 1989, our management paradigm for patients on organ preservation was modified to incorporate planned early neck dissection before radiation therapy for patients who did not achieve a complete response (CR) of neck nodes after induction chemotherapy (IC). The purpose of this study was to determine if planned early neck dissection is a safe and effective approach in the management of advanced nodal disease as part of organ preservation. Fifty-eight consecutive patients with advanced HNSC who were entered in organ preservation trials using induction chemotherapy and radiation with surgical salvage were studied. Median follow-up was 26 months. Of the 58 patients, 71% were stage IV. Patients were grouped by nodal response to chemotherapy and N class, and were analyzed with respect to patterns of recurrence, complications, and survival. Overall, the rate of CR of neck nodes was 49%. Fifty-one percent had less than a complete response of neck nodes after IC and required planned early neck dissection. There were no significant differences in patterns of recurrence, complications, interval time to start of radiation, recurrence, or survival rates between the CR and less than CR groups. These data suggest that planned early neck dissection for patients with less than CR in the neck after IC is not detrimental with respect to neck relapse or overall survival. We believe that planned early neck dissection can be safely incorporated into future organ preservation treatment protocols for patients with advanced head and neck carcinoma.

CaN19 expression in benign and malignant hyperplasias of the skin and oral mucosa: evidence for a role in regenerative differentiation

CaN19, a member of the S100 family of calcium-binding proteins, is known to be "underexpressed" in cultured breast carcinoma-derived cell lines relative to their normal counterparts. By Northern blotting, we confirm these results and find that CaN19 is also markedly "underexpressed" in several carcinoma-derived cell lines of the skin, oral mucosa, and urogenital tract. However, exceptions to the inverse correlation between CaN19 expression and malignancy have been identified, bringing into question the hypothesis that CaN19 functions as a tumor suppressor gene. Unexpectedly, CaN19 mRNA was strongly expressed in bulk specimens of basal and squamous cell carcinomas of the skin and oral cavity. However, in situ hybridization revealed only limited CaN19 expression in tumor cells themselves; the bulk of expression is localized to hyperplastic perilesional epidermis. Tumor cell expression of CaN19 was similar in primary and locally metastatic tumors, indicating that this gene is not necessarily down-regulated during tumor progression. Coordinate overexpression of CaN19 and the "hyperproliferalive" keratin K6a was observed only in tissues undergoing squamous differentiation. Taken together with other recent results from our laboratory, these findings suggest the hypothesis that CaN19 participates in an epidermal growth factor receptor-dependent pathway of regenerative squamous differentiation.

Molecular genetics of Leber's hereditary optic neuropathy: study of a six-generation family from Western Australia

Molecular genetic studies were carried out on a 6-generation family from Western Australia with Leber's hereditary optic neuropathy. Pedigree analysis confirms the maternal inheritance of the genetic lesion underlying the disorder in this family. The presence of a recently reported disease-associated mutation at nucleotide 11778 of the mtDNA was established in one clinically affected family member by the sequencing of an appropriate 1.6 kb PCR-amplified fragment of the mtDNA; this mutation leads to an Arg340----His amino acid replacement in the ND4 subunit of respiratory complex I. The 11778 G to A base substitution is associated with the loss of an SfaNI restriction site. Examination of the representative members for this site revealed that while only mtDNA carrying this substitution could be detected in the leukocytes of 4 family members of the sixth generation, the mutated mtDNA was found to co-exist with the normal mtDNA population (heteroplasmy) in a clinically unaffected member from the fifth generation. This observation suggests that the nt 11778 mutation observed in this LHON family is relatively new; the observation of both heteroplasmy and apparent homoplasmy of the mtDNA in different family members might reflect the normal progression in the establishment of a mitochondrially inherited mutation.

Drug and alcohol abuse in patients with acute burn injuries

We reviewed records of adult patients admitted to our burn unit who were reported to abuse drugs or alcohol from 1985 to 1988. The proportion of patients reported as abusing drugs increased significantly from 1987 to 1988, compared to previous years. However, there was no increase in the proportion of patients reported to abuse alcohol. Patients identified as abusing drugs had longer hospital stays, compared to patients who were not reported to abuse substances. Methamphetamine and cocaine were the drugs most often abused by patients who abused drugs or both drugs and alcohol. Mechanisms of burn injury in these patients included "accidental" burn injury related to acute intoxication, and self-injury due to psychosis or depression.

Cytotoxic T lymphocytes specific for self tumor immunoglobulin express T cell receptor delta chain

CTL are thought to play a role in the elimination of transformed cells in vivo. The effectiveness of such CTL is in part dependent on recognition of tumor specific antigens. Among the best characterized tumor-specific antigens are the unique or idiotypic determinants on the Ig of B cell lymphomas. Here we describe the generation and properties of human CTL specific for the idiotype on autologous B cell tumors. These cells are CD3+,CD4-,CD8- and express the delta chain of the TCR. Such cells may prove useful in tumor-specific adoptive therapy.

Preexisting psychiatric disorders in burn patients

The authors studied 51 of 56 consecutive eligible patients admitted to a burn unit. Sixty-nine percent of the patients had a preburn psychiatric diagnosis. Depression alone was present in more than half the sample. Few burns were strictly accidental; 68% involved some degree of complicity on the victim's part, but intentional burns were rare. Patients with depression were more likely to sustain their burns in a setting of risk-enhancing behavior.

Idiotype vaccination against murine B cell lymphoma. Humoral and cellular responses elicited by tumor-derived immunoglobulin M and its molecular subunits

C3H/HeN mice were immunized with idiotypic immunoglobulin M (IgM) and its molecular subunits from the syngeneic 38C13 lymphoma. Immunization with idiotypic IgM (38C-Id) resulted in idiotype-specific humoral and cellular immunity and protection against a lethal tumor cell challenge. Heavy (H38C) and light (L38C) chains were isolated by electroelution from preparative polyacrylamide gels. Both of these immunogens induced significant resistance to a subsequent tumor challenge. Variable region immunogens, in the form of trpE-fusion proteins, were obtained by cloning heavy and light chain variable region genes into the expression plasmid pATH-11. Of these, only the trpE-VH38C immunogen yielded immune resistance to tumor challenge. Finally, the nucleic acid sequence of 38C-Id light chain was determined and, based on the corresponding amino acid sequence and an analysis of predicted secondary structure, a region of potential antigenicity in complementarity-determining region 3 was chosen for the production of a synthetic peptide. Vaccination with this synthetic peptide resulted in significant suppression of tumor growth. Analysis of the humoral and cellular immunity generated by these vaccines revealed the presence of antibodies reactive with native idiotypic IgM only in 38C-Id, H38C, and trpE-VH38C immune sera, although the latter two were not idiotype-specific. Idiotype-specific lymphocytes, which proliferated in response to native 38C-Id, were observed in all immune animals. With the exception of the fusion protein immunogens, conjugation to an immunogenic carrier protein (keyhole limpet hemocyanin or thyroglobulin) was required for optimal humoral and cellular responses.

Idiotype vaccination against murine B cell lymphoma. Humoral and cellular responses elicited by tumor-derived immunoglobulin M and its molecular subunits

C3H/HeN mice were immunized with idiotypic immunoglobulin M (IgM) and its molecular subunits from the syngeneic 38C13 lymphoma. Immunization with idiotypic IgM (38C-Id) resulted in idiotype-specific humoral and cellular immunity and protection against a lethal tumor cell challenge. Heavy (H38C) and light (L38C) chains were isolated by electroelution from preparative polyacrylamide gels. Both of these immunogens induced significant resistance to a subsequent tumor challenge. Variable region immunogens, in the form of trpE-fusion proteins, were obtained by cloning heavy and light chain variable region genes into the expression plasmid pATH-11. Of these, only the trpE-VH38C immunogen yielded immune resistance to tumor challenge. Finally, the nucleic acid sequence of 38C-Id light chain was determined and, based on the corresponding amino acid sequence and an analysis of predicted secondary structure, a region of potential antigenicity in complementarity-determining region 3 was chosen for the production of a synthetic peptide. Vaccination with this synthetic peptide resulted in significant suppression of tumor growth. Analysis of the humoral and cellular immunity generated by these vaccines revealed the presence of antibodies reactive with native idiotypic IgM only in 38C-Id, H38C, and trpE-VH38C immune sera, although the latter two were not idiotype-specific. Idiotype-specific lymphocytes, which proliferated in response to native 38C-Id, were observed in all immune animals. With the exception of the fusion protein immunogens, conjugation to an immunogenic carrier protein (keyhole limpet hemocyanin or thyroglobulin) was required for optimal humoral and cellular responses.