[Implementing in-patient smoking cessation interventions. Basic characteristics of smoking patients in a lung health department]. / Implementierung von Maßnahmen zur Tabakentwöhnung im Krankenhaus. Basisdaten eines pneumologischen Patientenkollektivs.

BACKGROUND: Hospitals have a unique key role in promoting smoking cessation. However, cessation interventions are uncommon in clinical routine despite their proven effectiveness. For planning a tailored intervention for hospitalised patients we examined the characteristics of smokers in our department for lung diseases. METHODS AND PATIENTS: From July to September 2009 we evaluated the smoking status of all admitted patients. The smoking status was validated by measuring the CO-Hb. Smokers admitted for the first time on one of our regular wards received a comprehensive questionnaire. Patients with a duration of stay of 2 days or less and patients with substantial cognitive or linguistic limitations were excluded. Clinical data was collected from the participating smokers. RESULTS: 25% of all admitted patients were smokers. The participation rate was almost 90% of the eligible smokers. Our questionnaire was very well accepted und provided multitude helpful information for a following cessation counselling. Up to 3 or 4 smokers per day should be anticipated for a cessation intervention at an 80-bed-hospital. At least one counselling contact could be enabled. Although 75% of participants had experienced at least one unsuccessful quit attempt, only a minority used any support or help for cessation so far. CONCLUSIONS: Specific questionnaires to evaluate the smoking history of patients in hospitals are very suitable and facilitate a subsequent bedside-counseling. To come up with their key role in promoting smoking cessation more hospitals as yet should implement cessation interventions.

Altering glomerular epithelial function in vitro using transient and stable transfection.

Damage of the glomerular filtration barrier leads to proteinuria and progressive renal failure. Several independent lines of research have implicated the glomerular epithelial cell (GEC) as a key player in initiation and propagation of pathways leading to glomerulosclerosis. A growing number of molecules activated in this process have been identified. To further define their cellular function, manipulation of these molecules using pharmacological or genetic approaches in tissue culture systems are required. In this study, strategies for altering GEC gene expression by transient and stable transfection of fluorescence labeled proteins will be presented and discussed. The insight gained through these and comparable systems should allow a detailed dissection of the molecular pathways active in GEC function and failure.

The ultrasonic localization of abdominal wall adhesions.

Laparoscopic candidates with abdominal scars may have adhesions that result in visceral injury during trocar insertion. The purpose of this study was to evaluate the use of preoperative ultrasound mapping of abdominal wall adhesions, to provide safe initial laparoscopic access, and to guide the placement of subsequent trocars, facilitating adhesolysis when necessary. Thirty consecutive patients with previous abdominal surgery who were scheduled for laparoscopy underwent a preoperative ultrasonic examination of the abdominal wall using a 7-MHz linear ultrasound probe. Spontaneous viscera slide was measured during longitudinal scanning (normal = 2-5 cm) and induced viscera slide was evaluated during longitudinal and transverse scanning (normal = 1 cm or more) over the existing abdominal scar, the peri-umbilical region, and the remaining abdominal quadrants. Sixteen (53%) of 30 patients had adhesions under their scar and only four patients (25%) had umbilical adhesions. The 12 patients without umbilical adhesions all had successful closed cannulation while open cannulation at alternate sites was successful in the four individuals with umbilical adhesions. Blind umbilical needle cannulation was successfully done in all of the remaining 14 patients (47%) without visceral injury, including three patients (21%) with upper abdominal scars who were adhesion-free elsewhere. No adhesions were encountered that had not been preoperatively predicted by ultrasound. We conclude that examination of the abdominal wall with spontaneous and induced viscera slide, using ultrasound scanning, can reliably detect intraabdominal adhesions. The examination is best done on a highly selective basis by the operating surgeon to guide the location for initial trocar insertion and determine the type of abdominal wall cannulation in those individuals with previous abdominal scars.

Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy.

Patients who undergo laparoscopic cholecystectomy (LC) are operated on under general anesthesia, in a reverse Trendelenburg position, with 12-15-mmHg pneumoperitoneum. All of these factors can induce venous stasis of the legs, which may lead to postoperative deep-vein thrombosis (DVT). The objectives of this study were to assess the degree of hypercoagulability and to determine the rate of postoperative DVT in a group of 100 patients in whom LC was completed. Whole-blood thrombelastography (TEG) and plasma-activated partial thromboplastin time (PTT) determination were carried out preoperatively and on the 1st postoperative day. All patients received pre-, intra-, and postoperative graduated compression stockings and sequential pneumatic compression devices until fully ambulatory. Twenty-six percent of the patients with a risk score > 4, or a post-operative TEG index > +5.0, received subcutaneous heparin (5,000 units b.i.d.), beginning in the postoperative period and continuing for 4 weeks as an outpatient. A complete venous duplex scan of both legs was performed on the 7th postoperative day, at the time of their office visit. Our results revealed significant postoperative hypercoagulability for the TEG index (P < 0.005) and for PTT (P < 0.05). One patient had an asymptomatic DVT (1%), and no side effects from the mechanical or pharmacological prophylaxis occurred in this series. These data suggest that the low incidence of thrombosis in the face of theoretical and laboratory evidence of postoperative hypercoagulability may reflect an effective prophylactic regime.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of childhood acute lymphoblastic leukemia: results of Dana-Farber Cancer Institute/Children's Hospital Acute Lymphoblastic Leukemia Consortium Protocol 85-01.

PURPOSE: The goals of this treatment program were as follows: to improve event-free survival (EFS) rates for high-risk (HR) patients by increasing the intensity of induction treatment; to improve EFS rates for infants by adding a special postinduction intensification; to treat the CNS using cranial irradiation doses that were lower than in our historic control group; and to confirm our previously obtained good results for children with T-cell disease. PATIENTS AND METHODS: Two hundred twenty children with acute lymphoblastic leukemia (ALL) from all risk groups, including infants and patients with T-cell disease, were treated between 1985 and 1987 with multiagent chemotherapy and cranial irradiation. RESULTS: The 7-year EFS rate (+/- SE) for all 220 patients was 78% +/- 3% at a median follow-up duration of 6.2 years, 89% +/- 4% for the 82 patients classified as standard risk (SR), and 72% +/- 4% for the remaining 138 patients classified as HR and very high risk (VHR). Eleven infants had an EFS rate of 55% +/- 15% that might be attributable to treatment with high doses of methotrexate and cytarabine (ara-c). Twenty children with T-cell disease had an EFS rate of 70% +/- 10%. CNS leukemia relapse (isolated or combined with bone marrow) occurred in four of 82 SR patients who received 18 Gy of cranial irradiation and four of 138 HR and VHR patients who received 24 Gy. CONCLUSION: This protocol, which featured early intensive treatment including asparaginase, doxorubicin, and cranial irradiation, provided good long-term disease control for children with ALL.

Low-dose versus high-dose methotrexate during remission induction in childhood acute lymphoblastic leukemia (Protocol 81-01 update).

We evaluated event-free survival (EFS) and leukemia-free interval (LFI) of children treated for acute lymphoblastic leukemia (ALL). Patients were randomized to receive either a low dose or high dose of methotrexate (MTX) as a single agent at the time of diagnosis. Five days later, multidrug therapy was begun. We assessed the early antileukemic efficacy of the two doses of MTX, as well as toxicity and long-term efficacy. An increase in cell kill, as indicated by a larger decrease in the percentage of viable cells in the bone marrow between days 0 and 5, was observed for the high-dose MTX group when compared with the low-dose MTX group (P = .04). At 7.1 years of median follow-up, the 38 children randomized to receive high-dose MTX had a better EFS and LFI compared with the 39 patients randomized to receive low-dose MTX. The 7-year percentages (+/- SE) for EFS were 82% +/- 6% for high-dose MTX and 69% +/- 7% for low-dose MTX (P = .13). The 7-year percentages for LFI were 91% +/- 5% and 69% +/- 7%, respectively (P = .01). We recommend that high-dose MTX be considered as an effective addition to induction therapy in childhood ALL.

HiC-COM: a 2-month intensive chemotherapy regimen for children with stage III and IV Burkitt's lymphoma and B-cell acute lymphoblastic leukemia.

We designed a protocol that included 2 months of intensive Cytoxan (cyclophosphamide; Bristol-Myers Co, Evansville, IN), high-dose methotrexate (MTX), high-dose cytarabine (ara-C), and vincristine (HiC-COM) to improve event-free survival (EFS) for patients with advanced-stage Burkitt's lymphoma and B-cell acute lymphoblastic leukemia (ALL). We also wished to test the feasibility of rapidly cycling Cytoxan and high-dose ara-C based on signs of early marrow recovery. Twenty patients including 12 with stage III Burkitt's lymphoma and eight with stage IV Burkitt's lymphoma or B-cell ALL were entered onto this pilot study. The rate of complete remission was 95%. Four patients have relapsed. The 2-year actuarial EFS was 75% (median follow-up, 37 months). Two of the initial five patients developed transverse myelitis, which we believe may have been secondary to the concomitant administration of intrathecal (IT) and high-dose systemic ara-C. We conclude that this short but intensive regimen is highly effective for patients with advanced Burkitt's lymphoma and B-cell ALL. EFS has improved over previous less intensive regimens, and is comparable to regimens of longer duration.

Occult Candida thyroid abscess diagnosed by gallium-67 scanning.

A clinically silent fungal thyroid abscess was identified by Ga-67 citrate scanning and successfully drained surgically in a young leukemic patient. Whole-body radionuclide scanning remains a valuable method to help diagnose persistent fever in the immunocompromised host.

Four-agent induction and intensive asparaginase therapy for treatment of childhood acute lymphoblastic leukemia.

We prospectively assigned 289 consecutive children with acute lymphoblastic leukemia to receive one of two treatment programs on the basis of the presence or absence of certain risk factors at the time of diagnosis. Patients at high risk (62 percent of the total) had one or more of the following risk factors: age below two or above nine years, a white-cell count of 20,000 per cubic millimeter or more, the presence of T-cell immunologic markers, radiologic evidence of a mediastinal mass, and involvement of the central nervous system. Patients in both the standard-risk and high-risk groups were treated for two years, receiving intensive remission-induction therapy, central nervous system prophylaxis, weekly administration of high-dose asparaginase, and multiple-drug continuation therapy (which in the high-risk group included doxorubicin and a larger dose of prednisone). At a median follow-up of 35 months, the mean (+/- SE) event-free survival rates at four years among the patients in the standard-risk and high-risk groups were 86 +/- 4 percent and 71 +/- 4 percent, respectively (P = 0.003), for a total event-free survival of 77 +/- 3 percent. Within the high-risk group, the white-cell count at diagnosis and the sex of the patient were not significant prognostic indicators, but age below 12 months at diagnosis was associated with a very poor outcome. As compared with previous methods, this treatment program using four-drug induction and intensive asparaginase therapy has resulted in improved event-free survival in children with acute lymphoblastic leukemia.

Studies of a familial platelet disorder.

At least 22 members of a large kindred have a bleeding tendency resulting from an autosomal dominant disorder of platelet production and function. Phenotypic manifestations include mild to moderate thrombocytopenia, bleeding time prolongation, and abnormal platelet aggregation. Platelet survival time is normal. The platelet disorder in this family appears to differ from known hereditary thrombocytopenic or thrombocytopathic syndromes and may represent a new genetic disease. Six family members reportedly developed hematologic neoplasms: acute monocytic leukemia nine years after treatment for congenital neuroblastoma; lymphosarcoma at age 10 years; myeloid leukemia at age 23 years; acute myelocytic leukemia at age 62 years; leukemia of unknown type at age 48 years; and lymphocytic lymphoma at age 52 years.