Mineral homeostasis and bone mass in children treated for acute lymphoblastic leukemia

Clinical observations of bone pain, abnormal gait, and unusual fractures during remission of leukemia led us to assess mineral status in a cohort of 16 children with acute lymphoblastic leukemia treated with intensive chemotherapy. During maintenance and 6 months after the completion of therapy, blood and urine were analyzed for calcium and magnesium and blood for osteocalcin, vitamin D, and parathyroid hormone. Bone mineral content and bone width of the distal one third of the radius of the nondominant arm was measured by single-photon absorptiometry. During therapy, mild ionic hypocalcemia (less than 1.19 mmol/L) and hypomagnesemia (less than 0.77 mmol/L) were demonstrated in 9 and 8 of 16 children, respectively; hypercalciuria (8/16) and hypomagnesiuria (12/16) were also observed. Plasma osteocalcin values correlated with plasma magnesium levels (r = 0.54; p less than 0.05). Oral magnesium supplements normalized plasma magnesium, calcium, and osteocalcin levels, all of which were normal at the postchemotherapy study. Plasma 1,25-dihydroxyvitamin D levels were nondetectable (less than 8 ng/ml) in 12 of 13 patients receiving therapy and in 7 of 14 patients not receiving therapy; alkaline phosphatase activity increased significantly after therapy (179 +/- 86 to 340 +/- 101 units/L), and parathyroid hormone levels were normal in both studies. Bone mineral content/bone width ratio was less than 1 SD below the mean for age- and sex-related population standards in 70% of patients. These data indicate that alterations in magnesium, calcium, and vitamin D metabolism in children treated for acute lymphoblastic leukemia may be instrumental in inducing or sustaining altered bone turnover during chemotherapy.     

HIV infection in haemophilia--a European cohort

Ten haemophilia centres in northern Europe have pooled data on 202 haemophilic children who were infected with HIV between 1979 and 1986. All cases were under 16 years of age on 1 July 1985. The age at infection ranged from 1-15 years. Thirty seven cases (18%) had progressed to AIDS by 1 July 1991 and 15 of these have died. Persistent generalised lymphadenopathy has been noted in 102 patients of whom 18 (17%) have developed AIDS. Twenty three of the remaining patients (23%) have not. CD4+ T cell counts have fallen steadily. Of 36 patients who have had shingles since seroconversion, 19 (53%) had counts below 0.2 x 10(9)/l. Thirty five out of 145 patients without shingles (24%) had similar values. The mean IgA concentration in patients with CD4+ T cell counts above 0.5 x 10(9)/l was 2.38 g/l, between 0.2 and 0.5 was 3.07 g/l, and in those with CD4+ T cell counts below 0.2 x 10(9)/l the mean IgA concentration was 4.58 g/l. Treatment patterns have altered between 1989 and 1991, with increased use of zidovudine in patients without AIDS and a marked increase in primary prophylaxis against pneumocystis pneumonia. This has been associated with a decline in the incidence of pneumocystis as an indicator disease in new AIDS cases from 56% in 1989 to 20% in 1991. These observations indicate that persistent generalised lymphadenopathy does not worsen the outlook, but shingles does. Rising IgA concentrations are markers for disease progression. Modern prophylactic regimens are delaying the onset of indicator disease, but CD4 values continue to fall steadily.     

Direct demonstration of transsynaptic degeneration in the human visual system: a comparison of retrograde and anterograde changes

Transneuronal degeneration of retinal ganglion cells was directly demonstrated in a patient who had unilateral removal of the striate cortex forty years prior to necropsy. For comparison, another case is presented showing anterograde transneuronal atrophy forty years after enucleation of one eye.     

Simple analogs of the toxin callicarpone.

Callicarpone, a component 10 times as toxic to fish as rotenone, has been isolated from the leaves of Callicarpa candicans. It is reasonable to assume that callicarpone will act as an insecticidal agent as does rotenone. Therefore, the structure-activity relationship of callicarpone was examined by synthesizing a series of compounds having certain of its structural features. Those compounds were tested for insecticidal and antimicrobial activities. A study of synthetic analogs elucidated the functional group chemistry of callicarpone so that a synthesis might be undertaken. Piperitone oxide showed approximately 1/100th the activity of rotenone against Daphnia magna. 1-(alpha-Hydroxyisopropyl)-3-oxocyclohexene oxide showed activity against myobacterium while 2,3,4,6,7,8-hexahydronaphthalene-1,4-dione showed inhibitory activity against the mycobacterium and two yeasts.     

Area Health Education Centers: strengths, challenges, and implications for Academic Health Science Center leaders

Drawing from the results of an empirical study, we discuss the strengths and challenges of Area Health Education Centers in three domains-mission, programs, and organization--and highlight their implications for Academic Health Science Center leaders.     

A shortage of health information management professionals: how would we know?

The introduction of computers, the expansion of health insurance coverage through employers and government programs, and the increased use of personal health information have created a demand for a new breed of qualified medical record and health information personnel. The health information management workforce, which is entrusted with accurately coding, maintaining, storing, managing, analyzing, and disseminating all personal health information created from health care encounters, is reportedly in short supply. Given the complexity in defining and enumerating the profession, it is challenging to determine if such a shortage exists. There is a lack of uniformity across scope of practice, job titles, educational paths, and credentials. We report selected findings from a study of the health information management profession in North Carolina illustrating the methodologic problems encountered when measuring the supply and demand of this workforce. A case is made that greater standardization across these multiple facets of the profession would be beneficial to the workforce, and we offer recommendations on how this could be accomplished.     

Screening for handicapping hearing loss in the elderly

OBJECTIVE: To compare 2 screening methods for unrecognized handicapping hearing loss in the elderly. STUDY DESIGN: Cross-sectional study. POPULATION: Five hundred forty-six older individuals who underwent audiometry at biennial examination 22 of the Framingham Heart Study and who took the Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) questionnaire. OUTCOMES MEASURED: The 2 screening methods were the 10-item HHIE-S and 1 global question: "Do you have a hearing problem now?" The gold standard was an audiogram showing a pure tone threshold of 40 dB HL or higher at 1 and 2 kHz in one ear or at 1 or 2 kHz in both ears. Both screening methods were compared with the gold standard in terms of sensitivity, specificity, and predictive values. The 10-item screening version of the HHIE-S (cutoff score between 8 and 10) had a sensitivity of 35% and a specificity of 94% for detecting the criterion hearing loss. The global subjective measure had greater sensitivity (71%) but lower specificity (71%) than the HHIE-S. Combining the global question and the HHIE-S items failed to improve the specificity of the global question or the sensitivity of the HHIE-S. CONCLUSIONS: The global measure of hearing loss was more effective than the detailed questionnaire in identifying older individuals with unrecognized handicapping hearing loss. Primary care physicians are encouraged to ask their patients whether they have a hearing problem and refer patients who do for formal hearing testing.     

Results of randomized controlled trials of low-versus high-osmolality contrast media

The authors reviewed 100 randomized controlled trials (RCTs) conducted in humans to compare safety or efficacy of new low-osmolality contrast media (LOM) with that of high-osmolality contrast media (HOM). Findings of the 43 RCTs judged to be of the highest quality suggest that the efficacy of LOM in imaging is equal or superior to that of HOM for all routes of administration. Heat sensation occurred less often with LOM for all routes and pain occurred less often with LOM for intraarterial routes. No differences were seen in nephrotoxicity or in frequency of nausea, vomiting, urticaria, bronchospasm, laboratory test abnormalities, or neurologic events. Greater cardiovascular changes were seen with HOM, including increased or decreased heart rate, increased left ventricular end-diastolic pressure, decreased systolic pressure, and QT prolongation, depending on route of administration. To demonstrate whether a reduction in clinically significant adverse outcomes truly occurs with LOM, trials will need to enlist larger numbers of patients and employ appropriate outcome measures. Future trials should stratify patients according to their risk of adverse reactions to provide better information about benefits of LOM in low- versus high-risk patients.     

Lymphocyte chemokinetic factors derived from human tonsils: modulation by 1,25-dihydroxyvitamin D3 (calcitriol)

Although interleukin (IL)-2 may in part be responsible for lymphocyte accumulation to sites of active sarcoidosis, other cytokines that control such recruitment are not well characterized. Similarly, the pathogenic rationale for the ability of sarcoid macrophages to produce 1,25-dihydroxycholecalciferol (calcitriol) is not understood. We studied the release of chemokinetic lymphokines from human nylon wool-non-adherent tonsillar lymphocytes (HNTLs) employing a standard in vitro lymphocyte migration assay. If mitogen-stimulated HNTL supernatants were fractionated by high-performance liquid chromatography, five positive and one negative chemokinetic factors could be identified. The five lymphocyte chemoattractant factors (LCFs) ranged in mol wt from 5 to 35 kD and stimulated the in vitro migration of nonsensitized human lymphocytes by 200 to 500%. The LCFs appeared distinct from IL-2, IL-1, or gamma-interferon. Co-incubation of HNTLs with mitogen and 1 nM calcitriol prevented the production or release of two of the LCFs and significantly decreased the quantity of a third LCF. Calcitriol also resulted in the appearance of a second negative chemokinetic factor, lymphocyte migration inhibitory factor (LyMIF). Combined with our previous studies demonstrating that calcitriol interferes with IL-2-induced lymphocyte migration, these results provide a rationale for an anti-inflammatory role for calcitriol in sarcoidosis and other granulomatous disorders. These experiments also demonstrate that the control of lymphocyte recruitment to inflammatory foci is multifactorial.