Outcomes of adolescents with acute lymphoblastic leukaemia.

INTRODUCTION: Compared with young children who have acute lymphoblastic leukaemia (ALL), adolescents with ALL have unfavourable disease profiles and worse survival. However, limited data are available regarding the characteristics and outcomes of adolescents with ALL who underwent treatment in clinical trials. The aim of this study was to investigate the causes of treatment failure in adolescents with ALL. METHODS: We retrospectively analysed the outcomes of 711 children with ALL, aged 1-18 years, who were enrolled in five clinical trials of paediatric ALL treatment between 1993 and 2015. RESULTS: Among the 711 children with ALL, 530 were young children (1-9 years at diagnosis) and 181 were adolescents (including 136 younger adolescents [10-14 years] and 45 older adolescents [15-18 years]). Compared with young children who had ALL, adolescents with ALL were less likely to have favourable genetic features and more likely to demonstrate poor early response to treatment. The 10-year overall survival and event-free survival rates were significantly lower among adolescents than among young children (77.9% vs 87.6%, P=0.0003; 69.7% vs 76.5%, P=0.0117). There were no significant differences in the 10-year cumulative incidence of relapse, but the 10-year cumulative incidence of treatment-related death (TRD) was significantly greater among adolescents (7.2%) than among young children (2.3%; P=0.002). Multivariable analysis showed that both younger and older adolescents (vs young children) had worse survival and greater incidence of TRD. CONCLUSION: Adolescents with ALL had worse survival because they experienced a greater incidence of TRD. There is a need to investigate optimal treatment adjustments and novel targeted agents to achieve better survival rates (without excessive toxicity) among adolescents with ALL.

Air dispersal of multidrug-resistant Acinetobacter baumannii: implications for nosocomial transmission during the COVID-19 pandemic.

AIM: To describe the nosocomial transmission of Air, multidrug-resistant, Acinetobacter baumannii, nosocomial, COVID-19 Acinetobacter baumannii (MRAB) in an open-cubicle neurology ward with low ceiling height, where MRAB isolates collected from air, commonly shared items, non-reachable high-level surfaces and patients were analysed epidemiologically and genetically by whole-genome sequencing. This is the first study to understand the genetic relatedness of air, environmental and clinical isolates of MRAB in the outbreak setting. FINDINGS: Of 11 highly care-dependent patients with 363 MRAB colonization days during COVID-19 pandemic, 10 (90.9%) and nine (81.8%) had cutaneous and gastrointestinal colonization, respectively. Of 160 environmental and air samples, 31 (19.4%) were MRAB-positive. The proportion of MRAB-contaminated commonly shared items was significantly lower in cohort than in non-cohort patient care (0/10, 0% vs 12/18, 66.7%; P<0.001). Air dispersal of MRAB was consistently detected during but not before diaper change in the cohort cubicle by 25-min air sampling (4/4,100% vs 0/4, 0%; P=0.029). The settle plate method revealed MRAB in two samples during diaper change. The proportion of MRAB-contaminated exhaust air grills was significantly higher when the cohort cubicle was occupied by six MRAB patients than when fewer than six patients were cared for in the cubicle (5/9, 55.6% vs 0/18, 0%; P=0.002). The proportion of MRAB-contaminated non-reachable high-level surfaces was also significantly higher when there were three or more MRAB patients in the cohort cubicle (8/31, 25.8% vs 0/24, 0%; P=0.016). Whole-genome sequencing revealed clonality of air, environment, and patients' isolates, suggestive of air dispersal of MRAB. CONCLUSIONS: Our findings support the view that patient cohorting in enclosed cubicles with partitions and a closed door is preferred if single rooms are not available.

Assessment of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is the archetypal autoimmune disease given its complex clinical and molecular manifestations. Like the other rheumatic diseases, appropriate management is critically dependent upon the proper assessment of disease activity, organ damage, and quality of life. Here, we describe the components of the comprehensive assessment of SLE, including accurate physical and laboratory diagnosis, monitoring of disease activity, recording of accumulated organ morbidity, and integration of these with the patient's own perceptions of health status and quality of life. In doing so, we will review the most appropriate laboratory tests and indices currently used in standard clinical care and in clinical research.

Inhaled nitric oxide for primary pulmonary hypertension in pregnancy.

BACKGROUND: Primary pulmonary hypertension is a rare and dangerous entity in pregnancy. Previous studies have found a 35-50% maternal mortality rate in the peripartum period. To date, most reports have described treatment of these patients with diuretics, digoxin, and calcium-channel blockers. CASE: We describe the successful treatment of a primigravida with severe primary pulmonary hypertension. We used elective intubation before labor, inhaled nitric oxide therapy, and assisted vaginal delivery with epidural anesthesia that resulted in a viable infant and survival of the mother. CONCLUSION: Nitric oxide can be used to successfully treat primary pulmonary hypertension in pregnancy.

Range modulation in proton therapy--an optimization technique for clinical and experimental applications.

A fast optimization algorithm for range modulation in clinical and experimental applications of proton therapy is described. The method is versatile towards the number of parameters provided for range modulation, i.e. the trade-off between accuracy and simplicity of the latter can be chosen freely. The approach is, therefore, adaptable to most operating proton therapy facilities. It requires only a few basic measurements as input data and results in a depth dose uniformity of better than 2%. A typical calculation takes less than 90 s on a DEC VAXstation 3100, FORTRAN. The method has been extensively tested at the TRIUMF Proton Therapy Facility in Vancouver, BC.

The effects of nicotinamide plus carbogen or pions for microscopic SCCVII tumors.

We evaluated the sensitizing effect of nicotinamide plus carbogen (N&C) and the relative biological effectiveness (RBE) of pions on microscopic tumors where necrotic tumor centers have not yet been established. Female C3H/He mice and SCCVII tumors were used. The irradiation started two days after tumor implantation. In experiment 1, the tumor beds were irradiated at various doses with 250 KVp photons in 5 fractions over 5 days. Nicotinamide (500 mg/kg/mouse/day in 0.2 ml) was injected intraperitoneally (i.p.) 60 min before irradiation, and carbogen (95% O2 + 5% CO2) was flushed at the rate of 10 l/min for 10 min before irradiation and throughout the entire irradiation procedure. In experiment 2, the tumor beds were irradiated at various doses with pions or 250 KVp photons in 10 fractions over 5 days. In both experiments, the mice were observed for 100 days. The rate of tumor appearance was evaluated and the 50% tumor control dose (TCD50) calculated. The sensitizing ratio (SR) of N&C obtained from the TCD50 assay was 1.46 and the RBE of pions was 1.24. The SR of N&C and the RBE of pions were lower for microscopic tumors than those previously reported for macroscopic tumors. These results were probably due to the absence or reduced presence of radiobiological hypoxic component in the microscopic lesion. However, N&C can be considered to provide an advantage for treatment of even clinical microscopic tumors.

The effects of seasons and light therapy on G protein levels in mononuclear leukocytes of patients with seasonal affective disorder.

BACKGROUND: Information-transducing heterotrimeric G proteins have been implicated previously in the mechanism of action of mood stabilizers and in the pathophysiology of mood disorders. Mononuclear leukocytes of patients with unipolar and bipolar depression have been characterized by reduced measures of the stimulatory and inhibitory G proteins. In this study, patients with seasonal affective disorder (SAD) were measured for mononuclear leukocyte G protein levels while depressed during the winter, following light therapy, and in remission during the summer. METHODS: Twenty-six patients with SAD and 28 healthy subjects were assessed in the study. The immunoreactivities of Gs alpha, Gi alpha, and Gbeta subunit proteins were determined by Western blot analysis of mononuclear leukocyte membranes with selective polyclonal antibodies for the various G subunit proteins, followed by densitometric quantitation using an image analysis system. RESULTS: Untreated patients with SAD and winter, atypical-type depression showed significantly reduced mononuclear leukocyte immunoreactive levels of Gs alpha and Gi alpha proteins, similar to previous observations in patients with nonseasonal major depression. The reduced G protein levels were normalized with 2 weeks of light therapy. The same patients while in remission during the summer had G protein levels that were similar to those of healthy subjects. CONCLUSIONS: G protein-immunoreactive measures in patients with SAD are suggested as a state marker for winter depression, which is normalized by light treatment and during the summer. We speculate that light may exert its effects via normalization of transducin (Gt protein) levels, which are thought to be reduced in winter depression.

The relative biological effectiveness of the modulated proton beam at TRIUMF.

PURPOSE: The purpose of this study was to determine the relative biological effectiveness (RBE) of proton beam and to study its dependency on fraction number. METHODS: The relative biological effectiveness (RBE) of fractionated protons compared with 60Co gamma-rays was investigated for the acute mouse skin reaction. The 80 MeV protons generated at the TRIUMF cyclotron were spread out from 7 to 25 mm to irradiate entire legs. One, two, four, and eight fractions were tested. RESULTS: RBE values ranged from 1.15 to 1.24 for the acute skin reaction. Fraction dose dependence of RBEs was not observed.

Role of serotonin transporter promoter repeat length polymorphism (5-HTTLPR) in seasonality and seasonal affective disorder.

Seasonal variations in mood and behavior (seasonality) and seasonal affective disorder (SAD) have been attributed to seasonal fluctuations in brain serotonin (5-HT). the short (s), as opposed to the long (l), allele of the 5-HT transporter linked polymorphism (5-HTTLPR) has been associated with neuroticism and depression. We hypothesized that this short allele would also be associated with SAD and with higher levels of seasonality. Ninety-seven SAD patients and 71 non-seasonal healthy controls with low seasonality levels were genotyped for 5-HTTLPR and compared statistically. Patients with SAD were less likely to have the l/l genotype (27.8% vs 47.9%; P < 0.01) and more likely to have the s allele (44.8% vs 32.4%; P < 0.02) as compared to controls. The three 5-HTTLPR genotypes were also differentially distributed in patients and controls (P < 0.03). The SAD patients with the l/l genotype had a lower mean seasonality score than did patients with the other two genotypes (mean +/- s.d. = 15.3 +/- 2.8 vs 17.1 +/- 3.4 respectively; P < 0.02). The 5-HTTLPR short allele contributes to the trait of seasonality and is a risk factor for SAD, providing further evidence for a relationship between genetic variation in the 5-HT transporter (5-HTT) and behavior.

Heterozygosity for a defective gene for CC chemokine receptor 5 is not the sole determinant for the immunologic and virologic phenotype of HIV-infected long-term nonprogressors.

HIV-1-infected long-term nonprogressors are a heterogeneous group of individuals with regard to immunologic and virologic markers of HIV-1 disease. CC chemokine receptor 5 (CCR5) has recently been identified as an important coreceptor for HIV-1 entry into CD4+ T cells. A mutant allele of CCR5 confers a high degree of resistance to HIV-1 infection in homozygous individuals and partial protection against HIV disease progression in heterozygotes. The frequency of CCR5 heterozygotes is increased among HIV-1- infected long-term nonprogressors compared with progressors; however, the host defense mechanisms responsible for nonprogression in CCR5 heterozygotes are unknown. We hypothesized that nonprogressors who were heterozygous for the mutant CCR5 gene might define a subgroup of nonprogressors with higher CD4+ T cell counts and lower viral load compared with CCR5 wild-type nonprogressors. However, in a cohort of 33 HIV-1-infected long-term nonprogressors, those who were heterozygous for the mutant CCR5 gene were indistinguishable from CCR5 wild-type nonprogressors with regard to all measured immunologic and virologic parameters. Although epidemiologic data support a role for the mutant CCR5 allele in the determination of the state of long-term nonprogression in some HIV-1- infected individuals, it is not the only determinant. Furthermore, long-term nonprogressors with the wild-type CCR5 genotype are indistinguishable from heterozygotes from an immunologic and virologic standpoint.

A general cavity theory.

A cavity theory is used to relate the dose deposited in the cavity (sensitive volume of the detector) to that in the surrounding medium which may be of different atomic number or composition. Burlin proposed a general cavity theory to include all cavity sizes. The Burlin theory ignores all secondary-electron scattering effects which results in large discrepancies in dose to the cavity compared with the experimental results in high atomic number media. Kearsley proposed a new general cavity theory which includes secondary-electron scattering at the cavity boundary. The Kearsley theory showed excellent agreement with experimental results for 60Co y-rays but poor correlation for 10 MV x-rays. The Kearsley theory has numerous parameters and the magnitude of the input parameters is arbitrary; therefore the dose to the cavity depends on the choice of parameters. We have developed a new cavity theory which includes secondary-electron backscattering from the medium into the cavity. The strengths of this proposed theory are that it contains few parameters and a methodical way of determining the magnitude of the parameters experimentally. the proposed theory gives better agreement with experimental results in lithium fluoride thermoluminescence dosimeters for 60Co y-rays and 10 MV x-rays in aluminium, copper and lead than do the Burlin and Kearsley cavity theories.

Studies on lymphoid tissue from HIV-infected individuals: implications for the design of therapeutic strategies.

Lymphoid tissue is a major reservoir of human immunodeficiency virus (HIV) infection in vivo. In addition, the lymphoid microenvironment provides a replicative advantage to the virus in that it provides a milieu of activated target cells that allows for efficient virus spread. The process of mobilization and activation of immune competent cells directed against the virus paradoxically contributes to the propagation of virus replication. Disruption of the lymphoid microenvironment during the progression of HIV disease is a poorly understood process, which may be of considerable importance pathogenically. Studies of lymph node biopsy samples taken 8 weeks apart from individuals who did not undergo any change in their therapeutic regimen (i.e., patients who either remained untreated or remained on their ongoing nucleoside analogue reverse transcriptase inhibitor monotherapy regimen) revealed little change in histopathology or viral load over the 8-week period. These results with successive lymph node biopsy samples taken from different sites indicate that an isolated lymph node biopsy accurately reflects the pathologic process associated with HIV infection and that this process diffusely involves the lymphoid system. Treatment with reverse transcriptase inhibitor monotherapy of patients in relatively early stage HIV disease had no detectable impact on the viral load in lymphoid tissue, suggesting the need to investigate more potent antiretroviral regimens during this stage of disease. Among patients with moderately advanced HIV disease, switching to combination therapy from a monotherapy regimen resulted in decreased viral replication in lymph nodes; this effect was associated with decreases in plasma viremia. Despite the fact that measures of viral replication decreased significantly, the net frequency of HIV-infected cells in peripheral blood and lymph nodes remained unchanged. Potent antiretroviral drug combinations may be capable of profound and long-term downregulation of plasma viremia. It will be essential to monitor the status of viral trapping, viral burden, and viral replication within lymphoid tissue during treatment with such drugs to determine accurately their true potential for impact on these key features of HIV pathogenesis.

Measurements of relative biological effectiveness of the 70 MeV proton beam at TRIUMF using Chinese hamster V79 cells and the high-precision cell sorter assay.

Measurements of relative biological effectiveness (RBE) have been made on the range-modulated 70 MeV proton beam at TRIUMF using a precise cell sorting survival assay. In this study, Chinese hamster V79-WNRE cells were suspended in medium containing liquid gelatin at 37 degrees C in irradiation tubes and the gel was allowed to solidify by cooling to 4 degrees C. Complete cell survival responses were measured at 11 positions with 2 mm spacing within a proton stopping peak width of approximately 2 cm. Survival responses after proton irradiation were compared with responses to 60Co gamma rays measured at the same time, and RBE values were determined as a function of both dose and depth. Above doses of 4 Gy, the average RBE for these cells throughout the modulated proton stopping distribution was 1.21 +/- 0.05, measured at a survival of 1%. However, we also observed that, within the spread-out Bragg peak, the RBE increased with increasing depth, from approximately 1.2 at the proximal part to > 1.3 at the distal part of the peak. At the distal edge of the stopping distribution, the RBE value increased significantly, to an extent that may be of concern when this region of the treatment volume is close to sensitive tissues. Below 4 Gy, the RBE value was also dependent on radiation dose, increasing significantly to values of approximately 1.37 and 1.56 at 2 and 1 Gy, respectively. Our results illustrate that the use of a single RBE value in different irradiation protocols can be an oversimplification, and argues for the use of "proton gray doses" rather than "gamma-ray equivalent grays."

Immune reaction induced by X-rays and pions and its stimulation by schizophyllan (SPG).

Female C57BL/6 mice aged 6-8 weeks with transplanted Lewis lung cancer cells were used to investigate the anti-tumour effects and immune reactions in tumour tissue induced by X-ray and pion irradiation and their modification by schizophyllan (SPG). The effect of SPG on the rate of lung metastasis and the survival time of the mice was also studied using the same tumour system. These studies showed that in this tumour system the "practical' relative biological effectiveness (RBE) of pions was 1.33 in the dose ranges used (3 Gy x 4 = P3; 6 Gy x 4 = P6). SPG increased the suppression of tumour growth associated with moderate doses of radiation: X-rays (4 Gy x 4 = X4) or P3. SPG also decreased the number of lung metastases and prolonged the life span of the mice, these effects being independent of radiation. The addition of SPG to radiation increased both the macrophage infiltration and T-lymphocyte infiltration in the local tumour and the lung nodules. There did not appear to be any major differential effect of SPG on the pion-treated mice compared with those treated with X-rays.

Early skin response to fractionated doses of pions for determining therapeutic gain factors.

This study concerns the biological effectiveness of fractionated doses of pions on early skin reactions near the implanted tumor, to evaluate the therapeutic gain factors of pions. The C3H mouse limbs bearing microscopical SCCVII tumors were irradiated with pions (9.6-38.4 Gy) or x-rays (14.4-50.4 Gy) in 2-7 fractions. Nicotinamide (500 mg/kg) and carbogen (a mixture of 95% O2 + 5% CO2), as hypoxic radiosensitizers, were administered prior to the x-rays, to confirm the presence of hypoxic cells in the skin. The mean skin scores and number of damaged nails assessed. The ratios of x-ray/pion doses needed for giving comparable skin reactions were 1.3-1.5. Nicotinamide and carbogen enhanced the skin reactions. When the ratios were compared with those of tumor cure, the pions showed no therapeutic gains. One of the possible causes was that the presence of hypoxic cells in the skin may have reduced the therapeutic gain.

Proton dose monitoring with PET: quantitative studies in Lucite.

The feasibility of using PET for proton dose monitoring is examined here in detail. First experimental studies in a Lucite phantom have been performed at the medical TRIUMF proton beamline for proton energies of 62 MeV and 110 MeV. The proton dose delivered to the phantom ranged from 16 Gy up to 317 Gy. The induced activity was analysed 20-40 min after the irradiation with a PET scanner. The obtained depth activity profiles were compared to our calculation based on a model using available isotope production cross-section data. Both the observed absolute count rates and the activity profiles were found to agree very well with this model. Effects such as proton range straggling, inelastic nuclear interactions and the energy spectrum of the emitted positrons were studied in detail and found to change the activities by 5-10%. The lateral deposition of dose in the phantom could be very well localized by the induced activity. However, the spatial correlation between dose depth profiles and depth activity profiles was found to be poor, hence the extraction of isodose profiles from activity profiles seems to be very difficult.