Acute urinary toxicity following transperineal prostate brachytherapy using a modified Quimby loading method.

PURPOSE: To examine the acute urinary toxicity following transperineal prostate implant using a modified Quimby loading method with regard to time course, severity, and factors that may be associated with a higher incidence of morbidity. METHODS AND MATERIALS: One hundred thirty-nine patients with prostate adenocarcinoma treated with brachytherapy from 1997 through 1999 had follow-up records available for review. Patients considered for definitive brachytherapy alone included those with prostate specific antigen (PSA) < or = 6, Gleason score (GS) < or = 6, clinical stage < T2b, and prostate volumes generally less than 40 cc. Patients with larger prostate volumes were given neoadjuvant antiandrogen therapy. Those with GS > 6, PSA > 6, or Stage > T2a were treated with external beam radiation therapy followed by brachytherapy boost. Sources were loaded according to a modified Quimby method. At each follow-up, toxicity was graded based on a modified RTOG urinary toxicity scale. RESULTS: Acute urinary toxicity occurred in 88%. Grade I toxicity was reported in 23%, grade II in 45%, and grade III in 20%, with 14% requiring prolonged (greater than 1 week) intermittent or indwelling catheterization. Overall median duration of symptoms was 12 months. There was no difference in duration of symptoms between patients treated with I-125 or Pd-103 sources (p = 0.71). After adjusting for GS and PSA, multivariate logistic regression analysis showed higher incidence of grade 3 toxicity in patients with larger prostate volumes (p = 0.002), and those with more seeds implanted (p < 0.001). Higher incidence of prolonged catheterization was found in patients receiving brachytherapy alone (p = 0.01), with larger prostate volumes (p = 0.01), and those with more seeds implanted (p < 0.001). CONCLUSION: Interstitial brachytherapy for prostate cancer leads to a high incidence of acute urinary toxicity, most of which is mild to moderate in severity. A prolonged need for catheterization can occur in some patients. Patients receiving brachytherapy alone, those with prostate volumes greater than 30 cc, and those implanted with a greater number of seeds have the highest incidence of significant toxicity.

Interval appendectomy for perforated appendicitis in children.

To determine the efficacy, safety, and cost of managing perforated appendicitis with intravenous antibiotics followed by an interval appendectomy, the charts of 87 children with ruptured appendicitis were retrospectively reviewed. These patients were treated with intravenous fluid resuscitation and antibiotics (consisting of clindamycin and ceftazidime) and underwent appendectomy, either on that admission (n = 46) or as a delayed interval procedure (n = 41). Antibiotics in all cases were discontinued either at home or in the hospital after the child was a febrile for 48 hours with normal white and differential blood cell counts, and the two groups were compared. Seven patients (17%) "failed" the interval appendectomy protocol. All but one "failure" was due to the development or persistence for >72 hours of a bowel obstruction. The data are described below as percent or mean +/- 1 standard deviation. [table: see text] We conclude that antibiotics and interval appendectomy is a safe effective alternative for the management of perforated appendicitis. When successful, hospitalization, charges, and morbidity are less with this approach. A persistent bowel obstruction for 72 hours is an indication to proceed with appendectomy on admission.

Nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae in children with sickle cell disease.

OBJECTIVE: We studied the prevalence of nasopharyngeal (NP) carriage, antimicrobial susceptibilities, and serotypes of Streptococcus pneumoniae (SP) in children with sickle cell disease (SCD) in the Mid-South. In addition, we examined risk factors for NP carriage of penicillin-resistant SP (PRSP). STUDY DESIGN: Between July 1994 and December 1995, we obtained NP cultures from 312 children with SCD followed at the Mid-South Sickle Cell Center, 208 (67%) of whom were receiving penicillin prophylaxis. RESULTS: Among the 312 patients, colonization with SP occurred in 42 (13%), 30 (71%) of whom were receiving penicillin prophylaxis. Twenty-three of the 42 SP isolates (55%) were resistant to penicillin; 5 of the 23 (22%) were highly resistant. PRSP organisms were also resistant to cefotaxime (43%), trimethoprim-sulfamethoxazole (57%), and erythromycin (22%). Serotypes 6A, 6B, 14, 19A, and 23F accounted for 19 (90%) of 21 resistant strains. Children who were treated with antibiotics during the preceding month were more likely to carry PRSP than children who were not treated. CONCLUSIONS: There is a high prevalence of NP carriage of PRSP in children with SCD in the Mid-South, which raises concerns regarding the continued effectiveness of penicillin prophylaxis in these children. Further studies on the antimicrobial susceptibilities of resistant organisms and the relationship between NP carriage of SP and invasive disease are needed before developing new recommendations for prophylaxis and treatment.

Tracheal hamartoma: report of a child with a neck mass.

Tracheal hamartoma represents an oddity in children. Only one case was found in the English literature as a distal tracheal intraluminal lesion causing obstructive symptoms. All other reported cases were in older patients, who were presumed to have asthma or chronic obstructive pulmonary disease. The authors report on a 21-month-old girl who presented with an anterior neck mass fixed to the trachea. Imaging studies showed a lesion (2.5 x 2.3 x 1.7 cm) anterior to the right lobe of the thyroid, extending to the trachea posteriorly and down to the thoracic inlet inferiorly. The mass had a mixture of soft tissue densities with a focus of calcification. Results of thyroid studies were normal, and there was no adenopathy. Neck exploration showed a white, firm, lobulated mass fixed to the trachea, which was resected completely. The postoperative course was unremarkable. Histological studies showed a mixture of mature cartilage, fat, fibroconnective tissue, and spindle cells with myxoid degeneration, consistent with tracheal hamartoma. Based on a literature search, this is the first reported case of extraluminal tracheal hamartoma presenting as a neck mass in a pediatric patient.

Evaluation of the automated leucocyte count and differential from the Cell-Dyn 3500 in sickle cell disease.

Erythrocytes resistant to standard lysing reagents are known to occur in sickle cell disease. These lyse-resistant erythrocytes can cause aberrant automated leucocyte counts and differentials. The ability of the Cell-Dyn 3500 automated haematology analyser to eliminate resistant erythrocytes and accurately count and differentiate leucocytes was evaluated. Samples were obtained from paediatric patients with sickle cell disease or haemoglobin SC disease. The Cell-Dyn 3500, using impedance and optical counting with a hypotonic salt "extended lyse mode', was compared to the Cell-Dyn 3000, an optical analyser that also uses a hypotonic salt lyse, the Cell-Dyn 400, a "hard detergent lyse' impedance counter, and a reference 400-cell manual white cell differential (National committee for Clinical Laboratory Standards [NCCLS] Approved Guideline H20-A). Seventy-five samples from patients with sickle cell disease or haemoglobin SC disease were evaluated for total leucocyte count, percentage of lymphocytes, percentage of neutrophils, and nucleated red blood cells (NRBC) flags. The Cell-Dyn 3500 correlated well with Cell-Dyn 400 leucocyte counts, with a correlation coefficient of 0.95. When compared to the manual differential, the correlation coefficient for lymphocytes was 0.93 and for neutrophils 0.95. The Cell-Dyn 3500 NRBC flag had a sensitivity of 47.7% and a specificity of 80.6%. The predictive value of a positive flag was 77.7%. The Cell-Dyn 3500's extended lyse mode clearly enhances the accuracy of leucocyte counts and differentials in patients with sickle cell disease.

Leukocyte myeloperoxidase and salivary lactoperoxidase: identification and quantitation in human mixed saliva.

Human salivary lactoperoxidase (HS-LP) is synthesized and secreted by the salivary glands, whereas myeloperoxidase (MPO) is found in PMN leukocytes, which migrate into the oral cavity at gingival crevices. HS-LP levels vary with changes in salivary gland function, but increased numbers of MPO-containing leukocytes indicate infection or inflammation of oral tissues. To determine the contribution of each enzyme to the peroxidase activity of mixed-saliva samples, activity was assayed at pH 5.4 with tetramethylbenzidine as the substrate, with and without the inhibitor dapsone (4,4'-diaminodiphenylsulfone). Dapsone blocked the activity of HS-LP but not MPO. The enzymes were also separated and partially purified from the soluble portion of saliva samples and from detergent extracts of the saliva sediment. Chromatographic properties of the proteins were similar to those of LP from bovine milk (BM-LP) and MPO from human leukocytes. The identity and amounts of the enzymes were confirmed by the absorption spectra and by immunoblotting with antibodies to BM-LP and human MPO. Eosinophil peroxidase (EPO), a distinct enzyme found in eosinophilic leukocytes, was not detected by chromatography or with antibodies to human EPO. On average, 75% of the activity in samples from normal donors was due to MPO and 25% to HS-LP. When corrected for the lower specific activity of HS-LP in this assay, the average amount of MPO (3.6 micrograms/mL) was twice the amount of HS-LP (1.9 micrograms/mL). The amount of MPO corresponded to 1 x 10(6) PMN leukocytes/mL of saliva. The enzymes were distributed differently: Eighty-nine percent of the HS-LP was in the soluble portion of saliva, and 78% of the MPO was in the sediment, which contained 51% of the total activity. In contrast to results obtained with PMN leukocytes from blood, detergent was not required for MPO activity to be measured in saliva, indicating that the enzyme was accessible to peroxidase substrates. The results indicate that MPO is responsible for a large portion of peroxidase-catalyzed reactions in mixed saliva. The unique function of HS-LP may be carried out within the salivary glands, prior to secretion into the oral cavity.

Antibacterial activity of hydrogen peroxide and the lactoperoxidase-hydrogen peroxide-thiocyanate system against oral streptococci.

In secreted fluids, the enzyme lactoperoxidase (LP) catalyzes the oxidation of thiocyanate ion (SCN-) by hydrogen peroxide (H2O2), producing the weak oxidizing agent hypothiocyanite (OSCN-), which has bacteriostatic activity. However, H2O2 has antibacterial activity in the absence of LP and thiocyanate (SCN-). Therefore, LP may increase antibacterial activity by using H2O2 to produce a more effective inhibitor of bacterial metabolism and growth, or LP may protect bacteria against the toxicity of H2O2 by converting H2O2 to a less-potent oxidizing agent. To clarify the role of LP, the antibacterial activities of H2O2 and the LP-H2O2-SCN- system were compared by measuring loss of viability and inhibition of bacterial metabolism and growth. The relative toxicity of H2O2 and the LP system to oral streptococci was found to depend on the length of time that the bacteria were exposed to the agents. During incubations of up to 4 h, the LP system was from 10 to 500 times more effective than H2O2 as an inhibitor of glucose metabolism, lactic acid production, and growth. However, if no more H2O2 was added, the concentration of the inhibitor OSCN- fell because of slow decomposition of OSCN-, and when OSCN- fell below 0.01 mM, the bacteria resumed metabolism and growth. In contrast, the activity of H2O2 increased with time. H2O2 persisted in the medium for long periods of time because H2O2 reacted slowly with the bacteria and streptococci lack the enzyme catalase, which converts H2O2 to oxygen and water. After 24 h of exposure, H2O2 was as effective as the LP system as an inhibitor of metabolism. H2O2 also caused a time-dependent loss of viability, whereas the LP system had little bactericidal activity. The concentration of H2O2 required to kill half the bacteria within 15 s was 1.8 M (6%) but fell to 0.3 M (1%) at 2 min, to 10 mM (0.03%) at 1 h, and to 0.2 mM (0.0007%) with a 24-h exposure. The results indicate that if high levels of H2O2 can be sustained for long periods of time, H2O2 is an effective bactericidal agent, and the presence of LP and SCN- protects streptococci against killing by H2O2. Nevertheless, the combination of LP, H2O2, and SCN- is much more effective than H2O2 alone as an inhibitor of bacterial metabolism and growth.

Granular cell tumor of the larynx: report of two pediatric cases.

Granular cell tumors are uncommon neoplasms of the head and neck that usually involve the tongue. The larynx is an atypical site of involvement in adults and a rare site in children. We report two cases of subglottic granular cell tumors, one in a 10-year-old boy and the other in a 6-year-old girl. Although both were initially misdiagnosed as having asthma, radiologic, laryngoscopic, and histologic evaluation of the obstructions eventually furnished the correct diagnosis. The patients were successfully treated by surgical excision of their subglottic masses. The history, presentation, pathologic findings, management, and prognosis of this rare pediatric laryngeal tumor are explored.

Orbital sinus histiocytosis: MR appearance.

This case report describes the appearance of orbital sinus histiocytosis by magnetic resonance (MR) imaging. Four years after the remission of unilateral cervical adenopathy due to sinus histiocytosis, a 6-year-old girl developed orbital sinus histiocytosis with extension into the middle cranial fossa. Computed tomography demonstrated a homogeneously enhancing lesion; on MR, this tumor was isointense to gray matter on T1-weighted, proton density, and T2-weighted images. Vascular embarrassment was clearly shown by MR.

Pneumocystis carinii antigenemia in acquired immunodeficiency syndrome.

The present study was conducted to determine the prevalence and significance of Pneumocystis carinii antigenemia in patients with acquired immunodeficiency syndrome (AIDS) and clinically or invasively diagnosed P. carinii pneumonitis. Single serum specimens from 20 AIDS patients invasively examined for P. carinii organisms and 106 AIDS patients with a clinical diagnosis only of P. carinii pneumonitis were blindly tested for P. carinii antigenemia by a counterimmunoelectrophoresis assay. In the 20 specimen-documented cases, the antigen test demonstrated a sensitivity of 75% and a specificity of 90%. The positive predictive value of the test was 90%, while the negative predictive value was 70%. In AIDS patients with specimen-documented P. carinii pneumonitis, the prevalence of P. carinii antigenemia coincided almost exactly with the prevalence of positive invasively obtained specimens (60 and 59%, respectively). In patients with a clinical diagnosis only of P. carinii pneumonitis, half as many (30%) were found to exhibit antigenemia. Sequential P. carinii antigen titers determined by a new latex agglutination technique on three AIDS patients with specimen-documented P. carinii pneumonitis demonstrated the influence of specific therapy upon P. carinii antigenemia and its potential prognostic application.

Pneumocystis carinii serologic study in pediatric acquired immunodeficiency syndrome.

Pneumocystis carinii antigen and IgG antibody profiles were prepared on 17 pediatric patients with acquired immunodeficiency syndrome (AIDS) with pneumonia who were examined by a variety of invasive methods for P carinii organisms. Overall, the accuracy of the antigen assay in invasively examined pediatric patients with AIDS with pneumonia was 94% (sensitivity, 100%; specificity, 90%), as antigen and invasive test results agreed in 16 of 17 patients. No statistically significant differences in IgG titer were observed between controls and patients invasively examined for P carinii, whether the organism was observed in the specimen or not. Since 38% of all serum samples referred were derived from "blood-borne" cases of AIDS, including patients who contracted AIDS as a result of both transfusion and hemophilia A, this suggests that P carinii pneumonia or P carinii pneumonia- like pneumonias may be more common in these individuals.

Borderline immunodeficiency in male homosexuals: is life-style contributory?

Results of our study suggest that white Southern male homosexuals without clinical evidence of AIDS who patronize "gay bars" may have significant zinc deficiency and moderately depressed T-helper/T-suppressor cell ratios. No single causative factor could be identified to explain the significantly low zinc and elevated copper levels measured in whole blood, as well as the depressed OKT4/OKT8 cell ratios. Seventy-four percent of the homosexual male subjects were "recreational" drug abusers, 81% used inhalant nitrites routinely, and 41% routinely treated themselves with antibiotics. Eighty-one percent practiced active and/or passive penile-oral insertion, and 55.5% practiced both active and passive anal intercourse. Of the latter, 19% reported anal bleeding. Clinically inapparent, though statistically significant, borderline immunodeficiency and aberrant zinc and copper levels may be a consequence of multiple factors comprising the gay bar life-style.

Preliminary studies on the development of a vaccine for Pneumocystis carinii. I. Immunological and biochemical characterization.

Initial progress has been made toward the development of an experimental vaccine or immunostimulant for Pneumocystis carinii. Antigen derived from cell culture propagated P. carinii proved to be a potent immunogen in the rabbit and antibody thus produced demonstrated identity with intact murine and human lung-derived P. carinii organisms. Reactivity of the antibody with P. carinii soluble antigen in the blood of rats and human subjects with P. carinii pneumonitis (PCP) was demonstrated by the Ouchterlony technique, by counterimmunoelectrophoresis (CIE) and by latex particle agglutination (LPA). Murine-derived P. carinii antigen was utilized in an enzyme-linked immunosorbent assay (ELISA) for anti-P. carinii IgG and IgM produced in immunized rabbits and for human IgG antibody against P. carinii. Preliminary biochemical analysis of whole and solubilized cysts has been carried out, as well as slab gel electrophoresis and immunoblot profiling of solubilized organisms and naturally-occurring P. carinii antigen(s) in the blood of humans and rats with PCP. These studies represent an initial step toward the development of a vaccine or immunostimulant against PCP.

Excess leukemia in a refinery population.

A retrospective follow-up mortality study of white male employees of an oil refinery located in southern illinois revealed a statistically significant excess number of deaths due to leukemia compared with the experience of U.S. white males (standardized mortality ratio [SMR] = 213; 95% confidence interval [Cl], 117 to 358). The excess was due mainly to acute myeloid leukemia (AML) (SMR = 394; 95% Cl, 172 to 788). From 1973 to 1982, fourteen leukemia deaths were identified; eight of the cancers were of the AML cell type. The work histories of the decedents were examined for the potential for benzene exposure. Although specificity of the work histories was limited, the investigation has shown that the subjects did not work in jobs identified as having the highest benzene exposures. At this time, the excess leukemia remains unexplained.

Testicular function among epichlorohydrin workers.

Epichlorohydrin (1,2-epoxy-3-chloropropane) (ECH) is a colourless liquid used in the production of insecticides, agricultural chemicals, epoxy resins, and many other productions. It is highly reactive and an alkylating agent suspected of possessing carcinogenic properties in man. The results of a clinical-epidemiological investigation to ascertain whether exposure to ECH may be associated with sperm count suppression among ECH production workers at two chemical plants are presented. Medical histories and physical examinations with special emphasis on the genitourinary tract were completed on each participant. Blood samples and three semen specimens were also obtained. Since no internal control group were available, the data arising from this effort were analysed for each plant (plant A, 44 men; plant B, 84 men) using a control group of 90 chemical plants workers unexposed to any agents known to be toxic to the tests who were included in previous studies. This study provides no evidence that exposure to ECH at the concentrations existing at the two plants studied is responsible for sperm count suppression.

Pseudolymphoma of the breast.

A case of pseudolymphoma of the breast presenting as an isolated tumor mass in the breast of a 56-year-old female is described. Recognition of this rare lesion is important in order to differentiate it from other malignant neoplasms.

Dibromochloropropane and its effect on testicular function in man.

This study represents the largest series to date documenting the gonadotoxic effect in humans of dibromochloropropane, a widely used pesticide. Three semen analyses, serum hormonal determinations (luteinizing hormone, follicle-stimulating hormone and testosterone) as well as genital examinations were completed for 228 workers at 2 chemical production sites and consisting of a dibromochloropropane-exposed and non-exposed cohort. Parameteric and non-parametric statistical analyses of the data sets of the sperm densities from the 2 subpopulations demonstrated statistical significance (p less than 0.10) at the short-term (1.5 years) manufacturing plant. Log transformation of the sperm count and hourly exposure data were necessary to develop meaningful statistical conclusions. The serum concentration of follicle-stimulating hormone as a group mean was significantly greater at both production sites for the exposed cohort when compared to the non-exposed participants but decreased by 10 levels of magnitude when the group demonstraing shorter but more recent exposure was compared to those from the plant with longer chemical production. Finally, a dose-response model suggested significant changes in sperm density at the short-term but more recently operated production site when more than 100 adjusted hours of exposure were exceeded, while the longer operated but longer closed facility demonstrated a significant impairment only when more than 1,000 adjusted hours of dibromochloropropane exposure were surpassed. This difference in exposure data may reflect regenerative changes in the tests once the gonadotoxic substance had been removed but exact nature of the dibromochloropropane effect and the possibility of a "no effect" concentration remain to be defined clearly.