Surveillance CT scans are a source of anxiety and fear of recurrence in long-term lymphoma survivors.

BACKGROUND: We aimed to assess anxiety and the psychological impact of routine surveillance scans in long-term survivors of adult aggressive lymphoma. PATIENTS AND METHODS: In this cross-sectional observational study of 70 survivors of curable adult aggressive lymphoma, we measured anxiety and the doctor-patient relationship and performed a qualitative interview (n = 30) focused on patient perception of routine follow-up imaging studies. RESULTS: Participants were diagnosed with aggressive lymphoma a median of 4.9 years (2.4-38.0 years) before enrollment. Thirty-seven percent of patients were found to meet criteria for clinically significant anxiety, which was not associated with years since diagnosis. In multivariate analysis, history of relapse and a worse doctor-patient relationship were independently associated with higher anxiety levels. Despite representing a largely cured population, in qualitative interviews patients reported fear of recurrence as a major concern and considerable anxiety around the time of a follow-up imaging scan. CONCLUSIONS: Routine surveillance scans exacerbate underlying anxiety symptoms and fear of recurrence in survivors of aggressive lymphoma. Strategies to minimize follow-up imaging and to improve doctor-patient communication should be prospectively evaluated to address these clinically significant issues.

Development of a novel equine whole transcript oligonucleotide GeneChip microarray and its use in gene expression profiling of normal articular-epiphyseal cartilage.

REASONS FOR PERFORMING STUDY: No large scale equine microarray is available commercially to allow genomic and transcriptional profiling of the majority of genes that would define the genetic basis of equine disease. OBJECTIVES: To generate a whole transcript target labelled GeneChip to interrogate the equine transcriptome and validate chip performance using RNA samples derived from organs, articular cells and normal cartilage. METHODS: Equine mRNA and selected equine gene sequences derived from perfect cross-hybridisation of equine RNA on human microarray GeneChips, were used to design a custom equine gene microarray. Sequence data were used as a template for generation of a glass-slide based 5'-3' multi-exon-encompassing gene chip. The microarray was characterised using RNA derived from organs including spleen, liver, brain and kidney, and RNA from cultured chondrocytes, cartilage, synovial tissue and stem cells, employing a whole transcript target labelling assay to sample mRNA across the 5'-3' spectrum. RESULTS: The custom microarray simultaneously interrogated over 12,300 equine specific genes. Probing the chip with mixtures of total RNA derived from parenchymatous organs and articular tissues resulted in 61.7 and 62.8% present calls, respectively. This gene chip provided expression information on up to 90% of the key molecules in important signalling, metabolic and development pathways. Cartilage specific matrix genes were abundantly expressed in normal articular cartilage, but surprisingly high levels of collagen types I, III, V and XI, reflected expression from the epiphyseal layers of maturing articular epiphyseal cartilage. CONCLUSION: An oligonucleotide microarray with over 12,300 probe sets was generated by uniquely combining a labelling strategy incorporating expressed sequence tags from the entire transcriptome and supplementing selected human sequences that cross-hybridised with the horse. Validation showed robust performance of the microarray. POTENTIAL RELEVANCE: This array may be a useful tool to elucidate the pathogenesis of equine diseases.

Modeling of spatially referenced environmental and meteorological factors influencing the probability of Listeria species isolation from natural environments.

Many pathogens have the ability to survive and multiply in abiotic environments, representing a possible reservoir and source of human and animal exposure. Our objective was to develop a methodological framework to study spatially explicit environmental and meteorological factors affecting the probability of pathogen isolation from a location. Isolation of Listeria spp. from the natural environment was used as a model system. Logistic regression and classification tree methods were applied, and their predictive performances were compared. Analyses revealed that precipitation and occurrence of alternating freezing and thawing temperatures prior to sample collection, loam soil, water storage to a soil depth of 50 cm, slope gradient, and cardinal direction to the north are key predictors for isolation of Listeria spp. from a spatial location. Different combinations of factors affected the probability of isolation of Listeria spp. from the soil, vegetation, and water layers of a location, indicating that the three layers represent different ecological niches for Listeria spp. The predictive power of classification trees was comparable to that of logistic regression. However, the former were easier to interpret, making them more appealing for field applications. Our study demonstrates how the analysis of a pathogen's spatial distribution improves understanding of the predictors of the pathogen's presence in a particular location and could be used to propose novel control strategies to reduce human and animal environmental exposure.

Accurate confidence limits for quantiles under random censoring.

In survival analysis, estimates of median survival times in homogeneous samples are often based on the Kaplan-Meier estimator of the survivor function. Confidence intervals for quantiles, such as median survival, are typically constructed via large sample theory or the bootstrap. The former has suspect accuracy for small sample sizes under moderate censoring and the latter is computationally intensive. In this paper, improvements on so-called test-based intervals and reflected intervals (cf., Slud, Byar, and Green, 1984, Biometrics 40, 587-600) are sought. Using the Edgeworth expansion for the distribution of the studentized Nelson-Aalen estimator derived in Strawderman and Wells (1997, Journal of the American Statistical Association 92), we propose a method for producing more accurate confidence intervals for quantiles with randomly censored data. The intervals are very simple to compute, and numerical results using simulated data show that our new test-based interval outperforms commonly used methods for computing confidence intervals for small sample sizes and/or heavy censoring, especially with regard to maintaining specified coverage.

A computer program for the statistical analysis of repeated event data using a mixed effects regression model.

This paper presents a computer program for fitting mixed effects regression models to repeated events data. The method has been described by Abu-Libdeh, Turnbull and Clark (Biometrics 46 (1990) 1017-1034). Such data can occur in longitudinal studies where subjects experience repeated events over time. The program allows the stepwise construction of a series of regression models which can be used to examine and test the influence of the various measured covariates upon the event rates. Two examples are provided. The first is a simple example involving the incidence of mammary tumors in rats. The second involves a very large complex data set from a clinical trial for the prevention of recurrent skin tumors.

Visual field loss secondary to radiation-induced cerebral necrosis.

Radiation-induced cerebral necrosis has been well documented in the literature. Because radiation induced cerebral necrosis can occur to any part of the central nervous system that falls within the irradiated area, the visual pathway is highly susceptible to damage as it passes from the eye to the visual cortex. With proper visual field testing and interpretation, optometrists may serve as primary diagnosticians in radiation-induced cerebral necrosis and actively participate in the long-term management of these patients. This case presents a patient with visual field loss secondary to a temporal lobe lesion whose etiology was thought to be radiation-induced. The incidence, pathophysiology, and clinical features of radiation-induced cerebral necrosis as well as other differential diagnoses are discussed.

Anti-LPS antibodies reduce endotoxemia in whole body 60Co irradiated primates: a preliminary report.

Long periods in space may expose astronauts to the potentially harmful effects of ionizing radiation. We have used a primate model to evaluate any role of lipopolysaccharide (LPS, endotoxin) in radiation sickness. Vervet monkeys, which had been whole-body 60Co irradiated with an LD100 exposure, had periodic blood samples taken for the determination of LPS, anti-LPS IgG antibodies and bacteriological studies. On day 2 post-irradiation, primates were treated i.m. with either sterile 0.9% saline, or equine anti-LPS hyperimmune plasma (Anti-LPS), or orally with tripotassium-dicitrato-bismuthate ("Denol"). Gram positive bacteria were evident in blood samples of all animals as early as 2 d post-irradiation. Gram negative bacteria were found in the blood of saline- and Denol-treated primates by days 5 and 8, respectively, but first appeared on day 13 in the anti-LPS-treated animals. The saline controls and Denol-treated animals showed insignificant rises in plasma LPS on day 3, which increased further thereafter achieving significance on day 8 (p less than 0.01). These elevated levels persisted until death. However, in anti-LPS-treated monkeys, LPS concentrations remained below baseline until day 9, after which they rose significantly until death, but, were significantly less than the concentrations in both other groups (p less than 0.001). The anti-LPS-treated animals survived significantly longer than both the other groups (p less than 0.005). Since LPS may cause nausea, vomiting, diarrhea, anorexia and headaches, Anti-LPS administration may be of value in reducing plasma LPS concentration in humans and improving their performance and survivability.

Changes in lipopolysaccharide concentrations in hepatic portal and systemic arterial plasma during intestinal ischemia in monkeys.

The time course of changes in the level of plasma lipopolysaccharides (LPS) in both the hepatic portal and the systemic arterial circulations, together with changes in cardiovascular parameters, was ascertained during a 1 hr occlusion of the superior mesenteric artery (SMA) in six primates. The LPS concentrations before occlusion of the SMA in the hepatic portal and systemic arterial circulation were 0.051 +/- 0.009 and 0.065 +/- 0.011 ng/ml, respectively (NS). At the end of the occlusion period, there was no significant increase in either the hepatic portal or systemic arterial plasma LPS concentrations. Immediately on removal of the occlusion, however, the LPS concentration in the portal plasma increased and peaked at 0.431 +/- 0.124 ng/ml (P less than 0.01) within 17.5 +/- 1.71 min, whereas in the systemic arterial circulation the LPS concentration began to rise but only after a delay of approximately 10 min to peak at 0.287 +/- 0.126 ng/ml (P less than 0.05) within 32.5 +/- 4.23 min of reperfusion. The mean arterial pressure (MAP) declined during the reperfusion period from 98.6 +/- 6.89 to 65.0 +/- 9.5 mm Hg (P less than 0.05). The heart rate showed a small but not significant increase (P greater than 0.2) after about 80 min of reperfusion. These data indicate that the gut is the source of the increased plasma LPS concentration following occlusion of the SMA.

Oral administered nonabsorbable antibiotics prevent endotoxemia in primates following intestinal ischemia.

Plasma lipopolysaccharide (LPS) concentrations have been found to increase during a temporary occlusion of the superior mesenteric artery (SMA). We have attempted to show, by a prophylactic oral administration of a nonabsorbable antibiotic to monkeys subjected to an SMA occlusion shock, that the increased LPS is intestinal in origin. A total of eight monkeys were subjected to a temporary occlusion of the SMA. Four monkeys received prophylactic oral administration of a nonabsorbable antibiotic, while the rest acted as controls. The plasma LPS concentrations before occlusion in the control and the kanamycin group were 0.069 +/- 0.006 and 0.092 +/- 0.005 ng/ml, respectively. At the end of the 1-hr occlusion period the plasma LPS concentration in the controls increased to 0.09 +/- 0.009 ng/ml (P less than 0.1) and peaked to 0.378 +/- 0.103 ng/ml (P less than .001) within 20 min of reperfusion. Thereafter, the plasma LPS concentration returned slowly to baseline. In the kanamycin group the plasma LPS concentration remained at baseline throughout both the occlusion and reperfusion periods. These data suggest that the origin of the increased plasma LPS concentration seen following temporary occlusion of the SMA is from the gut, and is information of possible importance in patients about to undergo intestinal surgery.

Strenuous exercise causes systemic endotoxemia.

Eighteen triathletes were studied before and immediately after competing in an ultradistance triathlon. Their mean plasma lipopolysaccharide (LPS) concentrations increased from 0.081 to 0.294 ng/ml (P less than 0.001), and their mean plasma anti-LPS immunoglobulin G (IgG) concentrations decreased from 67.63 to 38.99 micrograms/ml (P less than 0.001). Both pretriathlon plasma LPS and anti-LPS IgG levels were directly related to the intensity of training (P less than 0.02 and P less than 0.01, respectively). It is possible that training-induced stress led to some leakage of LPS into the circulation, which, in turn, resulted in self-immunization against LPS. The effects on athletic performance in relation to exercise-induced changes in plasma LPS and anti-LPS IgG levels require further investigation.

Portal and systemic plasma lipopolysaccharide concentrations in heat-stressed primates.

Lipopolysaccharide (LPS) concentrations in hepatic portal and systemic arterial plasma were determined in five anesthetised monkeys heat-stressed by an environmental temperature of 41.0 +/- 0.3 degrees C and 100% relative humidity. As the rectal temperature (Tr) rose, the LPS concentrations in both the portal and systemic arterial plasma remained at the pre-heat-stress levels of 0.088 +/- 0.017 and 0.078 +/- 0.021 ng/ml (N.S.), respectively, until a Tr of 42.5-43.0 degrees C, when the LPS concentration increased slowly, first in the portal plasma and then in the systemic plasma. On the other hand, the concentration of plasma anti-LPS IgG antibodies began to decline at temperatures as low as 40 degrees C from 20.66 +/- 7.35 micrograms/ml (portal) and 22.14 +/- 7.43 micrograms/ml (arterial) to 5.51 +/- 1.28 micrograms/ml (portal) (P less than .05) and 4.6 +/- 1.69 micrograms/ml (arterial) (P less than .05) just prior to death. Above a Tr of 43 degrees C, the LPS concentration increased rapidly to a maximum of 0.244 +/- 0.05 ng/ml (portal) (P less than .01) and 0.224 +/- 0.06 ng/ml (arterial) (P less than .01). The mean arterial pressure remained more or less constant at 112 +/- 17.03 mm Hg until a Tr of 41.5 degrees C and then rapidly declined as Tr rose (P less than .01). The heart rate rose gradually from 154 +/- 14 min-1 as Tr increased and then rapidly after a Tr of 41.5 degrees C to a maximum of 307 +/- 13 min-1 at 43.0 degrees C. Thereafter it declined rapidly until death.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma endotoxin concentration in healthy primates and during E. coli-induced shock.

The normal range for circulating plasma endotoxin concentration was determined in 62 healthy primates (vervet monkeys, Cerecopithecus aethiops) by the chromogenic substrate modification of the Limulus amoebocyte lysate test, and found to have a mean of 0.076 +/- 0.004 ng/ml (range 0.000 to 0.0127). Four anesthetized primates received an LD100 iv infusion of Escherichia coli over one hour. Plasma concentrations of endotoxin (lipopolysaccharide, LPS) and anti-LPS IgG, and viable E. coli colonies in circulating whole blood samples were determined at specified intervals. Plasma antiendotoxin IgG concentration was determined by an enzyme-linked immuno-absorbent assay, and viable bacterial counts were assayed by standard plate count techniques. LPS concentration increased during E. coli infusion to a mean of 1.13 +/- 0.068 ng/ml (p less than .001) with a concomitant decrease in the concentration of anti-LPS IgG to 59 +/- 5% of control values (p less than .005). Viable circulating E. coli colonies increased during the infusion to a maximum of 425 X 10(6) cfu/ml 10 min after the completion of the infusion, but fell precipitously 20 min later to 10.1 X 10(6) cfu/ml. When each animal succumbed, their respective plasma LPS concentrations were still raised, whereas no viable circulating E. coli colonies were present at a dilution of 10(2). Elevated plasma LPS could prove to be a significant circulating pathogen during Gram-negative bacterial shock and supports the possible association between plasma LPS and morbidity, and mortality in septic shock.

Endotoxaemia in exhausted runners after a long-distance race.

The extent to which plasma endotoxin concentrations increased was measured in 89 randomly selected exhausted runners who required admission to the medical tent for treatment in the 1986 Comrades Marathon (89,4 km). Eighty-one per cent had concentrations above the upper limit of 0,1 ng/ml ('endotoxaemic'), including 2% above 1 ng/ml (the reported lethal level in humans), and only 19% had normal levels. There was a negative correlation between plasma endotoxin and plasma anti-endotoxin IgG concentration (P less than 0,025). Those runners completing the race in less than 8 hours had a significantly lower average endotoxin value than those taking longer than 8 hours (P less than 0,025). Also 80,6% of runners (58/72) with high plasma endotoxin values reported nausea, vomiting and/or diarrhoea, compared with 17,7% (3/17; P less than 0,001) with low endotoxin values. Elevated plasma endotoxin concentrations of 32 randomly selected endotoxaemic runners had returned to normal 1-3 weeks later, and most of them (25/32) had increased anti-endotoxin IgG concentrations (P less than 0,02). Fifty-nine runners randomly selected in a short run (21,1 km) 3 weeks after the 89,4 km run completed the race without problems and none showed any increase in endotoxin levels. Further studies in this field are warranted, especially the measurement of endotoxin and anti-endotoxin values from commencement of training to full fitness. It is possible that these measurements may prove useful as predictors of an athlete's or combat soldier's performance.

Prophylactic corticosteroid increases survival in experimental heat stroke in primates.

It has been suggested that endotoxins or lipopolysaccharides (LPS), may contribute to heat stroke pathophysiology. In this study, 11 anesthetised monkeys were divided into 2 groups. The steroid group (n = 5) had received a dose of MPSS (30 mg.kg-1, i.v.) before being heat-stressed and the control animals (n = 6) received saline equivolumetrically. The animals were heat-stressed to a rectal temperature of 43.5 degrees C in an environmental temperature of 41 +/- 0.3 degrees C and 100% relative humidity and then allowed to recover at room temperature. Blood samples for LPS and anti-LPS IgG analyses were taken both before treatment and before and after heat-stress. The administration of prophylactic MPSS increased the survival rate significantly from 33% to 100% (p less than 0.05). The plasma LPS level in the steroid group showed very little change after heat-stress, whereas in the non-surviving controls there was a significant increase in plasma LPS level (from 0.089 +/- 0.007 to 0.257 +/- 0.031 ng.ml-1) (p less than 0.005). The control animals that survived showed very little increase in plasma LPS levels, but had about 300% greater plasma Anti-LPS IgG levels. We conclude that pretreatment with MPSS improves the survival rate during heat stroke, possibly by suppressing the rise in plasma LPS concentration.

Prophylactic corticosteroid suppresses endotoxemia in heat-stressed primates.

We previously found that lipopolysaccharides (LPS) leak from the gut lumen into the hepatic portal vein during heat stroke. Furthermore, we found that prophylactic corticosteroid administration could prevent a rise in plasma LPS concentration in superior mesenteric artery occlusion shock. In this study, we found that treatment prior to heat-stress with corticosteroids could prevent any rise in plasma LPS concentration in heat-stressed primates. Two groups of primates, one of which received a prophylactic dose of methylprednisolone sodium succinate (MPSS) (n = 4) were subjected to heat-stress (41 +/- 0.3 degrees C). Their arterial blood pressure, heart rate and rectal temperature (Tr) were continuously recorded. In the untreated control group (n = 8), the plasma LPS concentration tended to increase slowly at a Tr of 41.5 degrees C from an initial 0.06 +/- 0.013 ng.ml-1. Above a Tr of 43 degrees C, the plasma LPS level rose rapidly until at a Tr of 44.4 +/- 0.1 degrees C, the mean LPS level was 0.315 +/- 0.03 ng.ml-1 (p less than 0.001). Prophylactic treatment with MPSS suppressed the increase in plasma LPS levels to 0.066 +/- 0.01 ng.ml-1 before heat-stress and 0.03 +/- 0.01 ng.ml-1 at Tr 44.4 degrees C just before primate demise. The mean arterial pressure of the control group was lower than the treated group for any given Tr; between Tr 42-43 degrees this difference was significant (p less than 0.05). Moreover, the cardiovascular parameters began to deteriorate at a lower Tr in the control group.

Prevention of endotoxaemia by non-absorbable antibiotics in heat stress.

Four anaesthetised monkeys were given oral kanamycin (15 mg 1 kg 12 hourly) over five consecutive days before being heat stressed. Four other anaesthetised monkeys served as controls. The plasma lipopolysaccharide concentration in control primates increased initially from 0.044 (SEM 0.004) ng/ml to 0.062 (0.006) ng/ml as the rectal temperature increased from 37.5 to 39.5 degrees C. A second increase in lipopolysaccharides started at 42 degrees C and reached 0.308 (0.038) ng/ml (p less than 0.01) at 44.5 degrees C. Before heat stress the plasma lipopolysaccharide concentration in the primates who had been pretreated with kanamycin was 0.007 (0.006) ng/ml, and despite heating these animals to 44.5 degrees C no increase in plasma lipopolysaccharide concentrations were seen in this group. The cardiovascular variable during heat stress were more unstable in the control group and began to deteriorate at a lower temperature than in the group receiving antibiotic. These data suggest that the increased plasma lipopolysaccharide concentration during heat stress originates mainly from the gut.

Time course of endotoxemia and cardiovascular changes in heat-stressed primates.

Heat stress causes a marked reduction in splanchnic blood flow in order to compensate for the increased flow to the skin. Splanchnic ischemia causes a leakage of endotoxins from the gut lumen into the portal circulation and, especially in the presence of a compromised reticuloendothelial system, may cause severe systemic endotoxemia. Since many of the pathological features of heat stroke are similar to the shock state produced by LPS, we examined whether heat-stress causes endotoxemia. Five anesthetized monkeys were subjected to an environmental temperature of 41 degrees +/- 0.3 degrees C and relative humidity of 100%, until death. Rectal temperatures were recorded continuously, blood pressure and ECG were recorded at 5-min intervals, and arterial blood samples were taken at 15-30 min intervals. A decline in mean arterial pressure and rapid rise in heart rate occurred at about 42 degrees C. Plasma LPS remained at 0.071 +/- 0.006 ng.ml-1 until a rectal temperature of +/- 42 degrees C. Thereafter, it increased slowly until beyond 43 degrees C when it rose rapidly to 0.347 +/- 0.024 prior to death. Endotoxemia may have been a contributing factor in the pathogenesis of heat stroke. If so, then the use of anti-LPS antibodies may be expected to be beneficial.

Properties of equine anti-lipopolysaccharide hyperimmune plasma: binding to lipopolysaccharide and bactericidal activity against gram-negative bacteria.

Anti-lipopolysaccharide equine hyperimmune plasma (anti-LPS), which has been used successfully to treat LPS (endotoxin)-mediated disorders, has been further characterised. IgG present in anti-LPS had the highest affinity for LPS prepared from Salmonella typhimurium, S. typhi, S. abortus equi and Shigella flexneri and intermediate affinity for Escherichia coli O55:B5, E. coli O127:B8 and S. enteritidis. Anti-LPS destroyed by means of complement activation a wide range of gram-negative bacteria, including various species and strains of Klebsiella, Enterobacter, E. coli, Sh. flexneri, Providencia, Salmonella and Pseudomonas. Control plasmas or saline had little or no effect. Maximum killing occurred within seconds to minutes. Electronmicroscopy showed that anti-LPS treatment of K. pneumoniae caused extensive cell wall and cytoplastic membrane disruption, followed by the appearance of spheroplasts and cell ghosts. Antibodies were required in 100,000-fold excess to inhibit the limulus amoebocyte lysate reaction with LPS from E. coli. Anti-LPS thus contains IgG that binds to a wide range of LPS, and can destroy a wide range of gram-negative bacteria by means of complement activation.

A morphological study of the action of equine anti-lipopolysaccharide plasma on gram-negative bacteria.

Three strains of gram-negative bacteria--one each of Escherichia coli, Klebsiella pneumoniae and Enterobacter sp.--were treated with anti-lipopolysaccharide hyperimmune equine plasma (anti-LPS) or non-immune control plasma and examined by scanning electronmicroscopy. Within a few minutes of treatment with anti-LPS, bacteria were agglutinated. Evidence of cell membrane destruction was observed shortly thereafter and total cell disintegration and disruption occurred within 1-2 h. In contrast, non-immune plasma had no effect on cell morphology. This confirms the findings in previous microbiological studies that specific antibodies in anti-LPS bind to lipopolysaccharide (LPS endotoxin), and thereby initiate the destruction of gram-negative bacteria.