Familial hemophagocytic lymphohistiocytosis: how late can the onset be?

BACKGROUND AND OBJECTIVES

Most patients with familial hemophagocytic lymphohistiocytosis (HLH) develop the disease within the first two years of age. In a minority of cases a later occurrence has been reported, with an upper age limit of eight years. A significant concordance of the age at onset within each family has also been observed.

RESULTS

We report four cases of families with HLH diagnosed at an unusually late age, comprised between between 9 and 17 years; in each of these families another child developed the disease in infancy. The natural killer activity of the patients was depleted; nevertheless, we had indirect evidence that, in at least two families, mutations of the perforin gene were not causing the disease.

INTERPRETATION AND CONCLUSIONS

Such a late onset is very unusual and suggests that there is a subgroup of families with HLH in which the disease may present early or late in different members. Thus in some families with HLH the siblings might remain at risk of developing the disease for several years. Their actual risk cannot be defined until the genetic mutation is identified in each family and assessed in each member.

The nature of advanced practice nursing

In attempting to define "advanced practice," we argue that nursing as such is teleological or goal-directed with those goals being defined by the patient or client in interaction with the nurse. In helping the patient meet identified goals, the nurse requires 2 kinds of knowledge-general and particular. General includes theory (know what/why), pattern recognition (know what), and practical knowledge (know how). Particular (know who) is personal knowledge about the patient. The advanced practice nurse, by virtue of graduate education, is able to move beyond the familiar and experientially learned. He or she makes a deliberate attempt to situate self in a dialectic between general and particular knowledge in such a way that the interplay opens possibilities. Knowing when a particular action would be most helpful is defined as practical wisdom. We argue that a highly developed sense of practical wisdom is the hallmark of advanced practice.

Endoscopic documentation of unintentional perforation of the dividing membrane during amnioreduction for twin-twin transfusion syndrome

OBJECTIVE

The purpose of this report is to document endoscopically the occurrence of unintentional piercing of the dividing membrane in a monochorionic twin pregnancy with twin-twin transfusion syndrome (TTTS).

MATERIALS AND METHODS

The dividing membrane was visualized endoscopically during laser therapy in a patient with TTTS who had previously undergone therapeutic amniocentesis. The donor twin had no visible bladder, but the amniotic fluid volume had normalized after amniocentesis.

RESULTS

The suspected membrane perforation was identified endoscopically during laser surgery. Five areas of vascular communications were identified and photocoagulated.

CONCLUSIONS

Sonographic evidence of normalization of the amniotic fluid volumes after therapeutic amniocentesis with persistent nonvisualization of the bladder of the donor twin should not be interpreted as a sign of improvement of TTTS, but rather as indirect evidence of unintentional perforation of the dividing membrane. This complication can be confirmed endoscopically.

Opening pandora's box: the practical and legal dangers of involuntary outpatient commitment

Policy makers have recently begun to reconsider involuntary outpatient commitment as a means of enhancing public safety and providing mental health services to people deemed to be noncompliant with treatment. The authors review the therapeutic claims for outpatient commitment and take the position that there is insufficient evidence that it is effective. They offer arguments that outpatient commitment may not improve public safety and may not be more effective than voluntary services. The authors further point out that outpatient commitment may undermine the delivery of voluntary services and may drive consumers away from the mental health system. The authors conclude that outpatient commitment programs are vulnerable to legal challenge because they may depart from established constitutional standards for involuntary treatment.

Constraints on equifinality: goals are good explanations only for controllable outcomes

What makes a goal or a precondition a better explanation of an action or outcome? Recent research shows that whereas goals are preferred for common actions, preconditions are preferred for actions that require substantial resources, particularly when those actions are obstructed. Two studies examined whether judgments of goals and preconditions reflect the controllability of the events, and whether previous findings apply to events generated by participants. Participants judged goals and preconditions as explanations for desirable extreme and moderate events and assessed the controllability and probability of the events. For common events, goals were better explanations than preconditions, whereas for the extreme scenarios, preconditions were judged equal or better explanations. The extreme events were seen as less controllable than the moderate events, and the controllability of the events predicted judgments of goals as explanations. The results suggest that participants see goals as better explanations only for events that the person can control, and they judge preconditions to be good explanations for events where the person has little control. These findings suggest that equifinality may apply only to those actions and outcomes where the preconditions are readily obtainable.

Lifelong learning in ethical practice: a challenge for continuing medical education

BACKGROUND

Formal education in the identification, analysis, and resolution of ethical issues in clinical practice is now an essential component of undergraduate and postgraduate medical education. Physicians educated before the 1980s have had little or no formal education in ethics. This article describes a project for assessing the content and format appropriate for the continuing education needs of practicing physicians.

METHODS

A questionnaire and follow-up facilitated small-group discussions with a physician ethicist around case-based problems were used to identify the ethical issues in practice where participants felt the need for continuing education.

RESULTS

The project confirmed that practitioners had very little formal ethics in medical school and less since starting practice despite encountering ethical issues. The most frequently used method of learning about ethics was informal discussion among those who have the same lack of formal education. Physicians did not feel that they needed a "very high" level of confidence and competence in handling ethical issues, even those commonly encountered. Participants indicated strongly that they lacked a systematic approach to the identification and analysis of ethical issues and suggest incorporation of the ethical component into regular CME.

FINDINGS

In spite of the small study population and the volunteer nature of the participants, the project demonstrated the identification of ethics content for CME similar to that used in medical education. Further work is needed to assess objective needs for ethics education in addition to the perceived needs of clinicians.

Prescribing exercise for cardiac patients: knowledge, practices, and needs of family physicians and specialists

PURPOSE

To determine the following about prescribing exercise for cardiac patients: physicians' present and needed knowledge; their present practices; barriers that hinder them; and perceived need for and content of a protocol for prescribing exercise.

METHODS

(1) Questionnaire mailed to 371 family physicians (FPs), 31 internists, and 25 cardiologists; and (2) four focus groups consisting of 25 FPs, 1 internist, and 3 cardiologists.

RESULTS

Questionnaire response rate was 45% (n = 192). Because responses were similar and the group was small, internists and cardiologists were combined as "specialists." Generally, questionnaire data agreed with focus group data, with the latter providing more detail. Family physicians perceived they know little about prescribing a specific exercise program while specialists perceived they know little about motivating patients to begin an exercise program. The method most frequently used by both physician groups to increase exercise is providing general advice. The main barriers to prescribing exercise were inadequate knowledge (FPs only), patient education materials, and community resources. Both groups rated highly the need for a protocol for prescribing exercise and indicated it should: (1) include identification of patient's stage of change; (2) include indications and contraindications for exercise; (3) provide guidelines for developing a specific exercise prescription; (4) contain patient education materials, and (5) be simple and short.

CONCLUSIONS

Family physicians perceive they know little about prescribing a specific exercise program for cardiac patients while specialists perceive they know little about motivating patients. Physicians rate highly the need for a protocol to help them prescribe exercise for cardiac patients.

Detection of sequence variation in the HVII region of the human mitochondrial genome in 689 individuals using immobilized sequence-specific oligonucleotide probes

We have developed a rapid, immobilized probe-based assay for the detection of sequence variation in the hypervariable segment II (HVII) of the mitochondrial DNA (mtDNA) control region. Using a panel of 17 sequence-specific oligonucleotide (SSO) probes immobilized on nylon membrane strips, we typed 689 individuals from four population groups. The genetic diversity value for each population was calculated from the frequency data, and the frequencies of distinct "mitotypes" in each group were determined. We performed DNA sequence analysis of 129 samples to characterize the sequences associated with "blanks" (absence of probe signals) and weak probe signals. Out of 689 samples, we observed five heteroplasmic samples (excluding the variable C-stretch beginning at position 303) using the immobilized SSO probe panel. The SSO probe strips were used for the analysis of shed hairs and bloodstains from several criminal cases in Sweden, one of which is described here. We conclude that this mtDNA typing system is useful for human identification and significantly decreases casework turnaround time.

A meta-analysis of fear appeals: implications for effective public health campaigns

The fear appeal literature is examined in a comprehensive synthesis using meta-analytical techniques. The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, and are more persuasive than low or weak fear appeals. The results also indicate that fear appeals motivate adaptive danger control actions such as message acceptance and maladaptive fear control actions such as defensive avoidance or reactance. It appears that strong fear appeals and high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses. Future directions and practical implications are provided.

Staphylococcal toxin-induced T cell proliferation in atopic eczema correlates with increased use of superantigen-reactive Vbeta-chains in cutaneous lymphocyte-associated antigen (CLA)-positive lymphocytes

Staphylococcal superantigens have been implicated in the pathogenesis of atopic dermatitis (AD). This may occur through superantigenic activation of T lymphocytes and their subsequent induction of the skin homing receptor CLA on activated cells. We investigated the proliferative responses of peripheral blood mononuclear cells (PBMC) from 10 patients with an infective exacerbation of AD and six normal controls to the staphylococcal superantigens, staphylococcal enterotoxin A and B (SEA, SEB) and toxic shock syndrome toxin-1 (TSST-1), and the mitogens phytohaemagglutinin (PHA) and concanavalin A (Con A). We also assessed CLA and T cell receptor (TCR) Vbeta-chain expression by immunofluorescence and flow cytometry before and after stimulation. PBMC from AD patients showed two-fold increased proliferation to SEA and SEB (P < 0.01) compared with normals, whereas the response to mitogenic stimulation was identical. Analysis of (TCR) Vbeta-chain expression demonstrated increased use of superantigen-reactive Vbeta families in freshly isolated PBMC in AD patients compared with controls. This pattern of Vbeta-chain expression was only observed in the CLA+ but not the total population of T cells. Furthermore, there was a positive correlation between the enhanced PBMC proliferative response and increased expression of superantigen-reactive Vbeta families in atopic patients. These data support the concept that superantigens are important in the pathogenesis of this common condition, and also provide evidence that the increased use of certain Vbeta families in circulating, CLA+, skin homing lymphocytes is of functional significance.

The design and synthesis of thrombin inhibitors: the introduction of in vivo efficacy and oral bioavailability into benzthiazolylalanine inhibitors

The further optimisation of the novel lead compound CGH752 (Fig. 1) is described. By introducing various substituents into the 6-position of the 3,3-dimethyltetrahydroquinoline (DMTHQS) ring we have been able to favourably affect the in vitro and in vivo activity, and the pharmacokinetics of such compounds. One of the inhibitors synthesised (CGH1484) is bioavailable and shows efficacy in animal models of thrombosis.

Respiratory viral infections in adults with and without chronic obstructive pulmonary disease

A longitudinal cohort study of older adults with chronic obstructive pulmonary disease (COPD) who were stratified by FEV(1) at enrollment was done to define the etiology, frequency, severity, and medical-care impact of respiratory tract viral infections (RTVIs). Controls consisted of a group of subjects of comparable age with the patients. RTVIs were documented in 44% of observed acute respiratory illnesses in control subjects and in 27% of COPD subjects, who were followed for mean periods of 35 and 26 mo, respectively. In this heavily influenza-vaccinated cohort ( approximately 90% vaccinated each year), picornaviruses, parainfluenza viruses, and coronaviruses were most commonly identified. Mean time to return to clinical baseline was approximately 2 wk in each group. Control and COPD subjects with mild airways obstruction (baseline FEV(1) >/= 50% predicted) had few emergency-center visits or hospitalizations. Approximately half of COPD subjects with moderate/severe COPD (baseline FEV(1) < 50% predicted) had at least one emergency-center visit and/or hospitalization for acute respiratory illness. RTVIs were documented in 23% of hospitalizations and in 45% of patients admitted between December and March. RTVIs have a major impact on utilization of health care resources for COPD patients with moderate/severe airways obstruction.

In vitro laser welding of amniotic membranes

OBJECTIVE

To test in vitro the feasibility of welding amniotic membranes using Nd:YAG laser energy.

STUDY DESIGN

Fresh fetal membranes from term pregnancies were washed and cut into 1 cm2 pieces. Pooled cryoprecipitate (CPT), 50% albumin (Alb), or polytetrafluoroethilene (e-PTFE) were used as solder medium. The optimal settings of the laser were determined. Results were assessed quantitatively and semi-quantitatively using Pearson Chi-square analysis.

RESULTS

Laser welding of amniotic membranes was successful in 82.6% of experiments with e-PTFE and in 10.7% of experiments with CPT (P < 0.001). The strength of the welding was also significantly better with e-PTFE (P < 0.001). Optimal results were obtained using 1-7 Watts and 0.1-1 seconds. Laser welding was unsuccessful in 100% of experiments with Alb.

CONCLUSIONS

Laser welding of fetal membranes can be accomplished with e-PTFE and to a lesser degree with the CPT using Nd:YAG energy under low wattage-high exposure settings. Further studies are underway to test other grafting or soldering materials.

Arteriovenous malformation of the base of tongue: case report and literature review

Arteriovenous malformations of the head and neck pose a challenging therapeutic and reconstructive problem. In this report we describe a rare case of an arteriovenous malformation of the base of tongue. The patient, a young adult female, was treated with embolization followed by surgical resection using a lateral pharyngotomy approach. Reconstruction of the extensive base of tongue defect was accomplished using a radial forearm free flap. Currently, the patient is decannulated, articulates clearly, tolerates a normal diet, and is without recurrence. Our treatment approach is discussed in detail and compared with alternative techniques.

High throughput fluorescence polarization: a homogeneous alternative to radioligand binding for cell surface receptors

High throughput fluorescence polarization (FP) assays are described that offer a nonradioactive, homogeneous, and low-cost alternative to radioligand binding assays for cell surface receptors (G protein-coupled receptors and ligand-gated ion channels). FP assays were shown to work across a range of both peptide (vasopressin V1a and delta-opioid) and nonpeptide (beta1-adrenoceptor, 5-hydroxytryptamine3) receptors. Structure-activity relationships were investigated at beta1-receptors and were found to be consistent with radioligand binding assays. FP was shown to tolerate up to 5% DMSO with no loss in sensitivity or signal window. From a random set of 1,280 compounds, 1.9% were found to significantly interfere with FP measurement. If fluorescent or quenching compounds were eliminated (3% of all compounds), less than 0.4% of compounds were found to interfere with FP measurement. Assays could be run in 384-well plates with little loss of signal window or sensitivity compared to 96-well plate assays. New advances in FP measurement have therefore enabled FP to offer a high throughput alternative to radioligand binding for cell surface receptors.

Analyzing the quality of ophthalmic nursing research

The purpose of this project was to describe, classify, and analyze ophthalmic nursing research published between 1975 and 1996. Sixty-six quantitative research articles were reviewed. This mainly descriptive body of research covered such topics as assessment/screening, self-care, and risk factors. The research articles were generally rated as superior or average, with many of the average being at the low end of the scale. Twenty-eight percent of the research was not applicable to nursing practice, and 42% had low or no theoretical relevance to nursing. This review will help to establish a research agenda in the area of ophthalmic nursing.