The presence of radiological features on chest radiographs: how well do clinicians agree?

AIM

To compare levels of agreement amongst paediatric clinicians with those amongst consultant paediatric radiologists when interpreting chest radiographs (CXRs).

MATERIALS AND METHODS

Four paediatric radiologists used picture archiving and communication system (PACS) workstations to evaluate the presence of five radiological features of infection, independently in each of 30 CXRs. The radiographs were obtained over 1 year (2008) from children with fever and signs of respiratory distress, aged 6 months to <16 years. The same CXRs were interpreted a second time by the paediatric radiologists and by 21 clinicians with varying experience levels, using the Web 1000 viewing system and a projector. Intra- and interobserver agreement within groups, split by grade and specialty, were analysed using free-marginal multi-rater kappa.

RESULTS

Normal CXRs were identified consistently amongst all 25 participants. The four paediatric radiologists showed high levels of intraobserver agreement between methods (kappa scores between 0.53 and 1.00) and interobserver agreement for each method (kappa scores between 0.67 and 0.96 for PACS assessment). The 21 clinicians showed varying levels of agreement from 0.21 to 0.89.

CONCLUSION

Paediatric radiologists showed high levels of agreement for all features. In general, the clinicians had lower levels of agreement than the radiologists. This study highlights the need for improved training in interpreting CXRs for clinicians and the timely reporting of CXRs by radiologists to allow appropriate patient management.

Fluoroscopy as a surrogate for lung tumour motion

OBJECTIVES

The aim of this article was to test a simple approach of using pixel density values from fluoroscopy images to enable gated radiotherapy.

METHODS

Anterior and lateral (LAT) from images were acquired from 18 patients referred for radical radiotherapy for non-small cell lung cancer for a period of 30-45 s. The amplitude of movement and the number of breathing cycles were determined in the right-left (RL) and superoinferior (SI) directions on the anterior images and the anteroposterior (AP) and SI directions on the lateral images. The breathing pattern was created by analysing the variation in a summation of pixel values within a defined area. The greatest and lowest 30% of pixel values were set as the duty cycle to represent inhale and exhale amplitude-based gating.

RESULTS

A median of eight breathing cycles was captured for each patient with a duration of 2.2-11.8 s per cycle. The mean (range) motion was 4.7 mm (2.4-5.8 mm), 7.2 mm (2.3-17.6 mm), 6.2 mm (1.9-13.8 mm) and 4.8 mm (2.4-11.3 mm) in the RL, SI (AP), SI (LAT) and AP directions, respectively. A total of 10/14 anterior videos and 7/11 LAT videos had correlations between motion and breathing of >0.6. Margins of 5.5 mm, 6.8 mm and 6.6 mm in the RL, SI and AP directions, respectively, were determined to gate in exhale. The benefit of gating was greater when motion was >5 mm.

CONCLUSION

The simple approach of using pixel density values from fluoroscopy images to distinguish inhale from exhale and enable gating was successfully applied in all patients. This technique may potentially provide an accurate surrogate for tumour position.

The ties that bind: perceived social support, stress, and IBS in severely affected patients

BACKGROUND

This study assessed the association between social support and the severity of irritable bowel syndrome (IBS) symptoms in a sample of severely affected IBS patients recruited to an NIH-funded clinical trial. In addition, we examined if the effects of social support on IBS pain are mediated through the effects on stress.

METHODS

Subjects were 105 Rome II diagnosed IBS patients (F = 85%) who completed seven questionnaires which were collected as part of a pretreatment baseline assessment.

KEY RESULTS

Partial correlations were conducted to clarify the relationships between social support and clinically relevant variables with baseline levels of psychopathology, holding constant number of comorbid medical diseases, age, gender, marital status, ethnicity, and education. Analyses indicated that social support was inversely related to IBS symptom severity. Social support was positively related with less severe pain. A similar pattern of data was found for perceived stress but not quality of life impairment. Regression analyses examined if the effects of social support on pain are mediated by stress. The effects of social support on bodily pain were mediated by stress such that the greater the social support the less stress and the less pain. This effect did not hold for symptom severity, quality of life, or psychological distress.

CONCLUSIONS & INFERENCES

This study links the perceived adequacy of social support to the global severity of symptoms of IBS and its cardinal symptom (pain). It also suggests that the mechanism by which social support alleviates pain is through a reduction in stress levels.

The ties that bind: perceived social support, stress, and IBS in severely affected patients

BACKGROUND

This study assessed the association between social support and the severity of irritable bowel syndrome (IBS) symptoms in a sample of severely affected IBS patients recruited to an NIH-funded clinical trial. In addition, we examined if the effects of social support on IBS pain are mediated through the effects on stress.

METHODS

Subjects were 105 Rome II diagnosed IBS patients (F = 85%) who completed seven questionnaires which were collected as part of a pretreatment baseline assessment.

KEY RESULTS

Partial correlations were conducted to clarify the relationships between social support and clinically relevant variables with baseline levels of psychopathology, holding constant number of comorbid medical diseases, age, gender, marital status, ethnicity, and education. Analyses indicated that social support was inversely related to IBS symptom severity. Social support was positively related with less severe pain. A similar pattern of data was found for perceived stress but not quality of life impairment. Regression analyses examined if the effects of social support on pain are mediated by stress. The effects of social support on bodily pain were mediated by stress such that the greater the social support the less stress and the less pain. This effect did not hold for symptom severity, quality of life, or psychological distress.

CONCLUSIONS & INFERENCES

This study links the perceived adequacy of social support to the global severity of symptoms of IBS and its cardinal symptom (pain). It also suggests that the mechanism by which social support alleviates pain is through a reduction in stress levels.

THE CONDITIONS AND CHARACTERS OF THE IMMUNITY PRODUCED IN THE GUINEA PIG BY INSTILLATION OF HORSE SERUM INTO THE NOSE

1. Normal guinea pigs treated by four to six instillations of horse serum into the nose on alternate days become either hypersensitive or refractory to an intravenous injection of 0.38 cc. of serum given 16 days after the last instillation. If the amount of serum in each instillation is as much as 0.2 cc., anaphylactic death is caused by the toxic injection. If the amount of serum in each instillation is reduced to 0.04 cc. the first intravenous injection is without marked effect, and a second injection and subsequent injections of the same amount of antigen are well tolerated in about half the cases. 2. The effect produced by a given dose of serum, whether protective or anaphylactic, depends probably upon the extent of contact with the mucous membrane of the nose. 3. Guinea pigs which, after nasal treatment, have become tolerant to a definite maximum intravenous injection of the antigen appear to increase the degree of their tolerance, at least up to a resting period of more than 4 months. The same does not hold in animals immunized by the peritoneal route. 4. The first two or three instillations of a series probably determine the biologic character, whether of hypersensitiveness or hyposensitiveness, of reaction towards the serum. 5. It is probable that, contrary to the case in parenteral sensitization, hypersensitiveness and protection, respectively, set up by nasal instillations and not followed by parenteral injections, gradually disappear in about 50 to 100 days. 6. We have failed in attempts to eliminate hypersensitiveness, due to subcutaneous injection of serum, by nasal instillations which would protect the normal animal from the development of anaphylaxis. 7. It is suggested that the principles of prophylaxis evolved under these relatively simple conditions should be applied in the study of infectious disease.

Acute scrotal pain with a twist

Intratesticular lesions identified on ultrasound are usually malignant. It presents a particular dilemma to the surgeon when conservative approach is considered. A 55-year-old smoker with peripheral vascular disease had attended the accident and emergency with acute left hemiscrotal pain of 24-h duration. Clinical examination revealed a swollen, tender hemiscrotum. Ultrasound had demonstrated a hypo-echoic lesion in the testis measuring 2 x 1.8 cm. This was reported as possible infarct and managed conservatively. On review after 4 weeks, the patient was still symptomatic with persistent dull pain. A repeat scan in 4 weeks showed persistence of the lesion raising the possibility of tumour. Tumour marker profile was not elevated. The patient had a radical orchidectomy and the histology showed segmental infarction of the testis with thrombosis of the segmental testicular vessels. Peripheral vascular disease can cause segmental infarction of the testis due to the end arterial blood supply; in these cases, magnetic resonance scan can be diagnostic. Once confirmed, segmental infarcts can be safely managed conservatively.

Gastrointestinal and Cardiovascular Safety Profiles of Neratinib Monotherapy in Patients with Advanced ErbB2-Positive Breast Cancer

Background: In a phase 2 study, oral neratinib was administered to patients (pts) with advanced breast cancer in 2 cohorts, those with prior trastuzumab treatment (prior T, n=66) and those with no prior trastuzumab treatment (no prior T, n=70). Neratinib demonstrated robust antitumor activity with objective response rates of 26% and 51%, respectively, and was generally tolerable (Burstein et al. Cancer Res 2009;69:72S). Diarrhea, all grades, occurred in 89% of total pts. Characteristics of the diarrhea and left ventricular ejection fraction (LVEF) measurements are described. Methods: Pts were required to have ErbB2 gene amplification in tumor tissue as measured by fluorescence in situ hybridization by independent assessment. Serial LVEF measurements were made with a multigated acquisition scan or echocardiogram. Pts were ineligible if baseline LVEF was &lt;50%. Adverse events were graded based on the NCI Common Terminology Criteria, v 3.0. Pts received oral neratinib 240 mg daily. Results: Data collected by 18 Mar 2009 are reported; the median (range) duration of neratinib treatment was 4.5 (0.2-23.5) months for pts with prior T and 7.8 (0.5-24.2) months for pts with no prior T. Diarrhea, all grades occurred in 93% of the total population (prior T: 97%, no prior T: 89%); grade 3-4 diarrhea occurred in 21% of the total population (prior T: 30%, no prior T: 13%). Median times of onset were 2 and 3 days after first dose of neratinib, respectively, and median durations of diarrhea were 7 and 5 days. In study week 1, 86% and 73% of pts with prior T and no prior T, respectively, had diarrhea; this decreased to 12-14% in months 3 and 4 (Table). Diarrhea was the cause of dose interruptions in 36% of pts with prior T and 11% of pts with no prior T and of dose reductions in 30% of pts with prior T and 5% of pts with no prior T; only 1 pt (prior T) discontinued treatment due to diarrhea. Pts used anti-diarrheal medications for supportive therapy (prior T: 91%, no prior T: 67%). For LVEF measurements, there was little variation from baseline in most pts during the study. Four pts had at least 1 LVEF measurement &lt;50% (2 of these pts had measurements within the institutional range of normal). None had congestive heart failure. One of these pts had grade 3 atrioventricular block and grade 3 bradycardia, which were considered unrelated to neratinib. Discussion: Neratinib treatment was not associated with clinically significant cardiotoxicity. Pts who developed diarrhea with neratinib monotherapy had early onset, but frequency and severity decreased with time on study. Despite the high frequency of diarrhea with neratinib treatment, it was readily managed with supportive therapy and dose interruptions and/or reductions.Time Course of Diarrhea in ErbB2-Positive Breast Cancer Patients Treated With NeratinibStudy PeriodPrior T: No. on StudyPrior T: % With Diarrhea, All Grades*Prior T: % With Diarrhea, Gr 3-4*No Prior T: No. on StudyNo Prior T: % With Diarrhea, All Grades*No Prior T: % With Diarrhea, Gr 3-4*Week 166861770737Week 2-466611170436Month 260331066152Month 34713060120Month 44312058140*For pts with multiple toxicity grades in a period, the maximum grade was reported.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5096.

Preventing behaviour problems through a universal intervention in Jamaican basic schools: a pilot study

OBJECTIVE

To evaluate the effect of a preventative intervention in Jamaican basic schools on child behaviour and parent-teacher contacts.

DESIGN AND METHODS

Five basic schools in Kingston, Jamaica, were randomly assigned to an intervention (n = 3) or control (n = 2) condition. Intervention involved seven whole-day teacher workshops using the Incredible Years Teacher Training Programme supplemented by fourteen lessons on social and emotional skills in each class. Within each classroom (n = 27), children were screened for behaviour difficulties through teacher report and children with the greatest difficulties were selected for evaluation of outcomes (135 children). Teachers'reports of child behaviour using the Strengths and Difficulties Questionnaire and of the quality of teacher-parent contacts were collected at the beginning and end of the school year Multilevel regression analyses controlling for school and classroom were used to evaluate the effects of intervention on child behaviour.

RESULTS

Significant benefits of intervention were found for children's conduct problems (regression coefficient (b) = -0.62, 95% confidence interval (CI): -0.01, -1.23), hyperactivity (b = -0.84, 95% CI: -1.57, -0.11) and peer problems (b = -1.24, 95% CI: -1.89, -0.59). The effect sizes were 0.26 for conduct problems, 0.36 for hyperactivity and 0.71 for peer problems. No significant benefits were found for the prosocial and emotional problems subscales. The intervention also resulted in increases in the number of positive teacher-parent contacts (p < 0.0001). No benefits were found for the number of negative teacher-parent contacts.

CONCLUSION

This is a promising approach for reducing children's externalizing behaviour and peer problems and for improving the quality of teachers' contacts with parents of children with behaviour problems.

A pilot study of the Incredible Years Teacher Training programme and a curriculum unit on social and emotional skills in community pre-schools in Jamaica

BACKGROUND

School-based interventions involving teacher and/or child training have been shown to benefit teacher practices and to prevent conduct problems and improve children's social and emotional competence in developed countries; however, we are aware of no reports from a developing country. We conducted a pilot study of the Incredible Years Teacher Training programme and a curriculum unit on social and emotional skills based on concepts and activities drawn from the Incredible Years Dina Dinosaur Classroom Curriculum to determine if this approach is appropriate for use with Jamaican pre-school teachers and children.

METHODS

Five pre-schools in Kingston, Jamaica were randomly assigned to an intervention (3 pre-schools with 15 classrooms) or control (2 pre-schools with 12 classrooms) condition. Intervention involved seven whole-day teacher workshops using the Incredible Years Teacher Training programme supplemented by 14 child lessons in each class. The project was evaluated through structured observations of four categories of teacher behaviour and four observer ratings: two rating scales of child behaviour and two rating scales of classroom atmosphere.

RESULTS

Significant intervention benefits were found to teachers' behaviour with increased positive behaviour [b = 7.9; 95% confidence interval (CI): 3.5, 12.3], reduced negative behaviour (b =-3.5; 95% CI: -6.6, -0.2) and increases in the extent to which teachers promoted children's social and emotional skills (b = 46.4; 95% CI: 11.0, 81.7). The number of teacher commands was not significantly reduced (b =-2.71; 95% CI: -6.01, 0.59). Significant intervention benefits were found to ratings of child behaviour with an increase in children's appropriate behaviour (b = 5.7, 95% CI: 1.0, 10.8) and in children's interest and enthusiasm (b = 7.2, 95% CI: 0.9, 13.5). Intervention also benefited classroom atmosphere with increases in opportunities provided for children to share and help each other (b = 1.3, 95% CI: 0.5, 2.1) and in teacher warmth (b = 1.3, 95% CI: 0.9, 1.8).

CONCLUSION

This is a promising approach for improving the emotional climate of Jamaican pre-school classrooms and for improving child behaviour and participation.

Neratinib in combination with trastuzumab for the treatment of advanced breast cancer: A phase I/II study

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Background: Neratinib (HKI-272) is an orally administered irreversible pan-ErbB receptor tyrosine kinase inhibitor. In an ongoing phase II study, the preliminary objective response rate was 26% in patients with ErbB2+ advanced breast cancer with prior trastuzumab therapy. This study assessed the safety and preliminary efficacy of the combination of neratinib plus trastuzumab. Methods: Patients with advanced ErbB2+ breast cancer that progressed following trastuzumab therapy were enrolled. The primary endpoint was 16-week progression free survival rate (PFS). In part 1 (dose escalation), patients received neratinib 160 mg or 240 mg daily plus trastuzumab 4 mg/kg IV loading dose then 2 mg/kg weekly. In part 2, patients received weekly trastuzumab with neratinib 240 mg daily. Timed blood samples were collected for PK analyses. PK analysis is ongoing. Results: 45 patients (part 1 n = 8; part 2 n = 37) were enrolled (mean age 52 yr); 9 are active. In part 1, cohorts 1 and 2 were fully enrolled with 4 patients each. No dose limiting toxicities were observed. Most common AEs, any grade, were diarrhea (91%), nausea (51%), anorexia (40%), vomiting (38%), and asthenia (27%). Grade 3/4 AEs were diarrhea (13%), nausea (4%), vomiting (4%). Two patients receiving neratinib 240 mg reported AEs leading to withdrawal. No AEs of congestive heart failure and no significant drops of left ventricular ejection fraction were reported. Among 33 patients evaluable for efficacy, objective response rate was 27% (95% CI, 13% - 46%); 16-week PFS rate (for part 2) 47% (95% CI, 29% - 63%); median PFS was 19 weeks (95% CI 15 - 32 weeks). Conclusions: Neratinib plus trastuzumab was well tolerated with no significant or unexpected toxicities, and demonstrated clinical activity.

[Table: see text]

Safety and efficacy of neratinib (HKI-272) in combination with vinorelbine in patients with solid tumors

e14554

Background: Neratinib (HKI-272) is a potent irreversible pan-ErbB tyrosine kinase inhibitor. Preclinical studies have shown synergistic antitumor activity with the combination of trastuzumab plus vinorelbine in metastatic breast cancer.The recommended dose of neratinib in monotherapy is 240 mg. In this phase 1 study, a combination dose of neratinib plus vinorelbine that is tolerable was determined in patients (pts) with solid tumors. Methods: This is an open-label, 2-part study of ascending multiple daily oral doses of neratinib (160 mg, 240 mg) in combination with 25 mg/m2 IV vinorelbine (administered on days 1, 8 every 3 wks). Tumor measurements were made every 6 wks by modified RECIST criteria. Results: 6 pts have been treated at each dose level. Data for 12 pts (5 pts still ongoing) as of 30 Oct 2008 are presented (median age [range] of 53.5 [38–75] yrs; 83% female). The median duration of treatment [range] was 1.9 [1.5–2.7] m. There was only 1 dose limiting toxicity (DLT) of grade 3 neuropathy (pt had preexisting grade 1 neuropathy) at 160 mg neratinib-25 mg/m2 vinorelbine, so the dose was escalated to 240 mg neratinib- 25 mg/m2 vinorelbine. In this cohort, there were no DLTs, and since the neratinib and vinorelbine doses reached full standard doses there was no need for further dose escalation. AEs, any causality, all grades in ≥ 15% of pts included diarrhea (92%), nausea (67%), constipation (50%), fatigue (42%), vomiting and anthralgia (33% each), abdominal pain and anorexia, (25% each), anemia and neutropenia (17% each). Grade ≥3 AEs that occurred in ≥1 pt included neutropenia (2 pts), pneumonia (1 pt) and peripheral neuropathy (2 pts). Preliminary efficacy data show that 1 pt with stomach cancer had stable disease, lasting ≥21 weeks. Conclusions: The combination of 240 mg neratinib and 25 mg/m2 vinorelbine was found to be tolerable and to demonstrate early evidence of clinical benefit in pts with solid tumors, to be assessed further in pts with metastatic ErbB-2+ breast cancer in part 2.

[Table: see text]

Lack of TAR-DNA binding protein-43 (TDP-43) pathology in human prion diseases

AIMS

TAR-DNA binding protein-43 (TDP-43) is the major ubiquitinated protein in the aggregates in frontotemporal dementia with ubiquitin-positive, tau-negative inclusions and motor neurone disease. Abnormal TDP-43 immunoreactivity has also been described in Alzheimer's disease, Lewy body diseases and Guam parkinsonism-dementia complex. We therefore aimed to determine whether there is TDP-43 pathology in human prion diseases, which are characterised by variable deposition of prion protein (PrP) aggregates in the brain as amyloid plaques or more diffuse deposits.

MATERIAL AND METHODS

TDP-43, ubiquitin and PrP were analysed by immunohistochemistry and double-labelling immunofluorescence, in sporadic, acquired and inherited forms of human prion disease.

RESULTS

Most PrP plaques contained ubiquitin, while synaptic PrP deposits were not associated with ubiquitin. No abnormal TDP-43 inclusions were identified in any type of prion disease case, and TDP-43 did not co-localize with ubiquitin-positive PrP plaques or with diffuse PrP aggregates.

CONCLUSIONS

These data do not support a role for TDP-43 in prion disease pathogenesis and argue that TDP-43 inclusions define a distinct group of neurodegenerative disorders.

Phenotypic heterogeneity and genetic modification of P102L inherited prion disease in an international series

The largest kindred with inherited prion disease P102L, historically Gerstmann-Sträussler-Scheinker syndrome, originates from central England, with émigrés now resident in various parts of the English-speaking world. We have collected data from 84 patients in the large UK kindred and numerous small unrelated pedigrees to investigate phenotypic heterogeneity and modifying factors. This collection represents by far the largest series of P102L patients so far reported. Microsatellite and genealogical analyses of eight separate European kindreds support multiple distinct mutational events at a cytosine-phosphate diester-guanidine dinucleotide mutation hot spot. All of the smaller P102L kindreds were linked to polymorphic human prion protein gene codon 129M and were not connected by genealogy or microsatellite haplotype background to the large kindred or each other. While many present with classical Gerstmann-Sträussler-Scheinker syndrome, a slowly progressive cerebellar ataxia with later onset cognitive impairment, there is remarkable heterogeneity. A subset of patients present with prominent cognitive and psychiatric features and some have met diagnostic criteria for sporadic Creutzfeldt-Jakob disease. We show that polymorphic human prion protein gene codon 129 modifies age at onset: the earliest eight clinical onsets were all MM homozygotes and overall age at onset was 7 years earlier for MM compared with MV heterozygotes (P = 0.02). Unexpectedly, apolipoprotein E4 carriers have a delayed age of onset by 10 years (P = 0.02). We found a preponderance of female patients compared with males (54 females versus 30 males, P = 0.01), which probably relates to ascertainment bias. However, these modifiers had no impact on a semi-quantitative pathological phenotype in 10 autopsied patients. These data allow an appreciation of the range of clinical phenotype, modern imaging and molecular investigation and should inform genetic counselling of at-risk individuals, with the identification of two genetic modifiers.

Pharmacokinetics and pharmacodynamics of efavirenz and nelfinavir in HIV-infected children participating in an area-under-the-curve controlled trial

Fifty human immunodeficiency virus (HIV)-infected children participated in an area-under-the plasma concentration-time curve (AUC)-controlled trial of efavirenz and nelfinavir. Pharmacokinetic evaluations were performed at weeks 2, 6, and 56. Efavirenz and nelfinavir doses were adjusted to achieve AUC values of 60-120 and > or = 10 mg h/l, respectively. Thirty-seven (74%) children met the efavirenz target and 41 (82%) the nelfinavir by week 10. Children with AUC values for both drugs above the first quartile were more likely to reach < 400 copies/ml of HIV RNA at week 8. Efavirenz and nelfinavir oral clearance increased 37 and 62% from weeks 2 to 56, respectively, in 34 children who continued on therapy at week 56. AUC values at week 56 were not different between children who did or did not have HIV RNA < 400 copies/ml. Dose adjustment to achieve specific AUC values in these children reduced the risk of suboptimal exposure and achieved high rates of virologic suppression.

Gait and posture impairment, parkinsonism and cognitive decline in older people

Our objective was to examine the frequency of gait and posture impairment and parkinsonism in 3 waves of the Canadians Study of Health and Aging (CSHA) and to determine their relationship to the development of cognitive impairment-not dementia (CIND) and dementia. A secondary analysis of a Canadian population-based cohort study was performed. People 65 years of age and older without cognitive impairment or dementia underwent examination for the presence of gait or posture impairment (GPI) or parkinsonism (based on the presence of 2/3 signs among resting tremor, rigidity or bradykinesia), both defined by a clinical examination. Risk for development of cognitive impairment or dementia was examined at 5 and 10 year follow up in pre-specified logistic regression models adjusted for age, sex, education and in separate models, frailty. The frequency of GPI ranged from 25 to 30% in cognitively unimpaired to 46-53% in CIND and demented subjects. Parkinsonism was more common with increasing cognitive impairment at each wave of the CSHA. Both GPI and parkinsonism predicted cognitive decline. Frailty reduced, but did not eliminate the impact of these motor measures and was itself a significant predictor of cognitive decline. In conclusion, motor impairment and frailty are common in older people and are associated with an increased risk of cognitive decline and dementia. GPI is common in CIND, while GPI and parkinsonism are both common in dementia.

Wetland management: an analysis of past practice and recent policy changes in Ontario

The Ontario Government has recently released its latest Provincial Policy Statement (PPS), which includes a policy concerning wetland protection. This paper uses interviews with key respondents and the results of three separate case studies that examined the former PPS in order to assess the ability of the new policy to improve wetland conservation efforts in Ontario. The case studies include wetland conservation and urban stormwater management in the City of London for the periods 1978-1999 and 1978-2000, respectively. As well, agricultural drainage that occurred in the Township of Zorra for the period 1978-1997 is used to address this management dimension. While progress is evident, the current policy will be difficult to implement effectively because it inadequately deals with the fundamental aspects of management: fragmented jurisdiction, interagency communication, financial arrangements, enforcement, and promoting informed decision making.

Molecular profiling of malignant peritoneal mesothelioma identifies the ubiquitin-proteasome pathway as a therapeutic target in poor prognosis tumors

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Background: Malignant peritoneal mesothelioma (MPM) is an aggressive neoplasm derived from cells lining serosal membranes. The characteristics of the epithelial (E) type MPM are distinct from those of the biphasic and sarcomatous (BS) type tumors. The goal of our study was to examine the molecular basis for this distinction. Methods: We used global molecular profiling with DNA microarrays to identify pathways associated with histologic subtype of 16 MPM tumor specimens acquired from patients entered into pilot multimodality protocols at our Institution. We performed immunohistochemistry on a tissue microarray and quantitative-real time PCR to validate the microarray results. Results: We performed average linkage agglomerative hierarchical clustering using microdissected MPM specimens and normal peritoneal tissue. The tumors segregated into two clades associated with histological subtype, which were distinct from the controls. 476 genes were differentially expressed between E and BS histologic classes (P < .001, with permutation test P value of .001). To identify biologically important differentially expressed genes and pathways, we examined the functional annotation of mesothelioma histologic subtype classifiers using the Pathway Comparison tool of BRB-Array. Among the differentially expressed categories was the ubiquitin-proteasome (UP) pathway, which was upregulated in BS tumors. Cytoxicity experiments by MTS assay indicated that, by the computation of combination indexes of activity, cells derived from BS tumors were exquisitely sensitive to sequential combination regimens containing the proteasome inhibitor (PI) bortezomib and oxaliplatin. The mechanism of this synergistic response, which was not detected in cells of E tumor origin, was apoptosis. Conclusions: Together, our results identify the ubiquitin-proteasome pathway as a biomarker of poor prognosis biphasic and sarcomatous malignant peritoneal mesothelioma tumors and suggest that proteasome inhibitors could increase the effectiveness of cytotoxic chemotherapy in this subset of patients.

No significant financial relationships to disclose.

The effect of early stimulation on maternal depression: a cluster randomised controlled trial

AIM

To determine the effect of early childhood stimulation with undernourished children and their mothers on maternal depression.

METHODS

Mothers of 139 undernourished children (weight for age < or =-1.5 z-scores) aged 9-30 months were recruited from 18 government health centres in the parishes of Kingston, St Andrew, and St Catherine, Jamaica. They received weekly home visits by community health aides for one year. Mothers were shown play activities to do with their child using home made materials, and parenting issues were discussed. Frequency of maternal depressive symptoms was assessed by questionnaire. Child development was also measured.

RESULTS

Mothers in the intervention group reported a significant reduction in the frequency of depressive symptoms (b = -0.98; 95% CI -1.53 to -0.41). The change was equivalent to 0.43 SD. The number of home visits achieved ranged from 5 to 48. Mothers receiving > or =40 visits and mothers receiving 25-39 visits benefited significantly from the intervention (b = -1.84, 95% CI -2.97 to -0.72, and b = -1.06, 95% CI -2.02 to -0.11, respectively) while mothers receiving <25 visits did not benefit. At follow up, maternal depression was significantly negatively correlated with children's developmental quotient for boys only.

CONCLUSIONS

A home visiting intervention with mothers of undernourished children, with a primary aim of improving child development, had significant benefits for maternal depression. Higher levels of maternal depression were associated with poorer developmental levels for boys only.

Screening for amblyopia in childhood

BACKGROUND

Amblyopia is a reversible deficit of vision that has to be treated within the sensitive period for visual development. Screening programmes have been set up to detect this largely asymptomatic condition and refer children for treatment while an improvement in vision is still possible. The value of such programmes and the optimum protocol for administering them remain controversial.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of vision screening in reducing the prevalence of amblyopia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Group Trials Register, on The Cochrane Library Issue 2, 2005, MEDLINE (1966 to May 2005 week 1) and EMBASE (1980 to 2005 week 19). No language restrictions were placed on these searches. No handsearching was done.

SELECTION CRITERIA

We planned to analyse data from randomised controlled trials and cluster-randomised trials comparing the prevalence of amblyopia in screened versus unscreened populations.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study abstracts identified by the electronic searches. Full text copies of appropriate studies were obtained and, where necessary, authors were contacted. No data were available for analysis and no meta-analysis was performed.

MAIN RESULTS

Despite the large amount of literature available regarding vision screening no trials designed to compare the prevalence of amblyopia in screened versus unscreened populations were found. Data currently under preparation may be available for updates to the review.

AUTHORS' CONCLUSIONS

The lack of data from randomised controlled trials makes it difficult to analyse the impact of existing screening programmes on the prevalence of amblyopia. The absence of such evidence cannot be taken to mean that vision screening is not beneficial; simply that this intervention has not yet been tested in robust trials. To facilitate such trials normative data on age-appropriate vision tests need to be available and a consensus reached regarding the definition of amblyopia. In addition, the consequences of living with untreated amblyopia have yet to be quantified and a cost-benefit analysis carried out.

Antibiotics for trachoma

BACKGROUND

Trachoma is the world's leading cause of preventable blindness. In 1997 the World Health Organization launched an initiative on trachoma control based on the 'SAFE' strategy (surgery, antibiotics, facial cleanliness and environmental improvement).

OBJECTIVES

To assess the evidence supporting the antibiotic arm of the SAFE strategy by assessing the effects of antibiotics on both active trachoma (primary objective) and on Chlamydia trachomatis infection of the conjunctiva (secondary objective).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February 2005), and EMBASE (1980 to February 2005). We used the Science Citation Index to look for articles that cited the included studies. We searched the reference lists of identified articles and we contacted authors and experts for details of further relevant studies.

SELECTION CRITERIA

We included only randomised trials that satisfied either of two criteria: (a) trials in which topical or oral administration of an antibiotic was compared to placebo or no treatment in people with trachoma, (b) trials in which a topical antibiotic was compared with an oral antibiotic in people with trachoma. A subdivision of particular interest was of trials in which topical tetracycline/chlortetracycline was compared with oral azithromycin, as these are the two World Health Organization recommended treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted investigators for missing data.

MAIN RESULTS

We found 15 studies that randomised a total of 8678 participants. For both outcomes (active trachoma and laboratory evidence of infection) the results of the chi squared tests suggested that there was significant statistical heterogeneity among the trials. There was also marked clinical heterogeneity. No summary statistics were calculated and we therefore present a narrative summary of the results. For the comparisons of oral or topical antibiotic against placebo/no treatment, the data are consistent with there being no effect of antibiotics but are suggestive of a lowering of the point prevalence of relative risk of both active disease and laboratory evidence of infection at three and 12 months after treatment. For the comparison of oral against topical antibiotics the results suggest that oral treatment is neither more nor less effective than topical treatment.

AUTHORS' CONCLUSIONS

There is some evidence that antibiotics reduce active trachoma but results are not consistent and cannot be pooled.

Whole genomewide linkage screen for neural tube defects reveals regions of interest on chromosomes 7 and 10

Neural tube defects (NTDs) are the second most common birth defects (1 in 1000 live births) in the world. Periconceptional maternal folate supplementation reduces NTD risk by 50-70%; however, studies of folate related and other developmental genes in humans have failed to definitively identify a major causal gene for NTD. The aetiology of NTDs remains unknown and both genetic and environmental factors are implicated. We present findings from a microsatellite based screen of 44 multiplex pedigrees ascertained through the NTD Collaborative Group. For the linkage analysis, we defined our phenotype narrowly by considering individuals with a lumbosacral level myelomeningocele as affected, then we expanded the phenotype to include all types of NTDs. Two point parametric analyses were performed using VITESSE and HOMOG. Multipoint parametric and nonparametric analyses were performed using ALLEGRO. Initial results identified chromosomes 7 and 10, both with maximum parametric multipoint lod scores (Mlod) >2.0. Chromosome 7 produced the highest score in the 24 cM interval between D7S3056 and D7S3051 (parametric Mlod 2.45; nonparametric Mlod 1.89). Further investigation demonstrated that results on chromosome 7 were being primarily driven by a single large pedigree (parametric Mlod 2.40). When this family was removed from analysis, chromosome 10 was the most interesting region, with a peak Mlod of 2.25 at D10S1731. Based on mouse human synteny, two candidate genes (Meox2, Twist1) were identified on chromosome 7. A review of public databases revealed three biologically plausible candidates (FGFR2, GFRA1, Pax2) on chromosome 10. The results from this screen provide valuable positional data for prioritisation of candidate gene assessment in future studies of NTDs.

Screening for correctable visual acuity deficits in school-age children and adolescents

BACKGROUND

Although the benefits of vision screening seem intuitive, the value of such programmes in junior and senior schools has been questioned. In addition to this there exists a lack of clarity regarding the optimum age, and frequency at which to carry out screening.

OBJECTIVES

The objective of this review is to evaluate the effectiveness of vision screening programmes carried out in schools in reducing the prevalence of undetected, correctable visual acuity deficits due to refractive error in school-age children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) on The Cochrane Library (Issue 3 2004), MEDLINE (1966 to August 2004) and EMBASE (1980 to August 2004). No language or date restrictions were placed on these searches. To date it has not been possible to carry out any manual searches but it is hoped to include these in a future update.

SELECTION CRITERIA

We planned to include randomised controlled trials including randomised cluster controlled trials.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study abstracts identified by the electronic searches. No trials were identified that met the inclusion criteria.

MAIN RESULTS

As no trials were identified, no formal analysis was performed. A narrative synthesis of other retrieved studies was undertaken in order to explain current practice.

AUTHORS' CONCLUSIONS

At present there are no robust trials available that allow the benefits of school vision screening to be measured. The disadvantage of attending school with a visual acuity deficit also needs to be quantified. The impact of a screening programme will depend on the geographical, and socio-economic setting in which it is conducted. There is therefore clearly a need for well planned randomised controlled trials, in various settings, to be undertaken so that the potential benefits and harms of vision screening can be measured.