Hemoglobin Hakkari: an autosomal dominant form of beta thalassemia with inclusion bodies arising from de novo mutation in exon 2 of beta globin gene

Certain beta globin gene mutations produce a thalassemia major phenotype in the heterozygous state. While most such patients have thalassemia intermedia, we describe a young Guatemalan child with a de novo mutation in the beta globin gene, codon 31 T --> G (Hemoglobin Hakkari), who developed severe anemia at the age of 10 months and remains transfusion-dependent. The substitution of B13 leucine with arginine in the beta globin results in alteration of a critical heme contact point resulting in an extremely unstable variant hemoglobin and a clinical picture that is characterized by ineffective erythropoiesis and numerous intracytoplasmic inclusions within the erythrocyte precursors of the bone marrow. .

What Happens to People after Malignant Cord Compression? Survival, Function, Quality of Life, Emotional Well-being and Place of Care 1 Month after Diagnosis

AIMS

To present further findings from the Scottish Cord Compression Study, in which the diagnosis, management and outcome of 319 patients with a definitive diagnosis of malignant cord compression (MCC) were examined.

MATERIALS AND METHODS

In total, 256 (80%) patients in the study consented to be interviewed shortly after diagnosis and at follow-up interviews. One hundred and twenty-eight patients were interviewed 1 month after diagnosis (40% of the total; 57% [128/224] of patients alive 1 month after diagnosis; 68% [128/188] of patients who also consented to follow-up). Survival data of the whole MCC population and data from interviewing 128 patients 1 month after diagnosis are presented.

RESULTS

The median survival of all patients was 59 days (95% confidence interval [CI] 43-75 days). The median Karnofsky performance status was 50 (interquartile range 40-60), indicating a need for considerable nursing and medical care, and was poorest for patients with lung cancer (median 40; interquartile range 30-60). The place of care was dependent on mobility at diagnosis; patients walking at diagnosis were more likely to be at home, whereas patient requiring assistance or who were unable to walk were more likely to be in institutional care (P = 0.019). Mobility and bladder function were determined by mobility and bladder function at diagnosis (P < 0.001). Of those unable to walk at diagnosis, 7% regained full mobility. Of those catheterised at presentation, 28% regained full bladder function. Forty-seven per cent (56/120, 95% CI 40-54) of patients interviewed were in pain despite oncological treatment and 18% (22/ 120; 95% CI 8-19) reported the pain as severe (visual analogue scale > 7). The median quality-of-life (Schedule for Evaluation of Individualised Quality of Life) score was 72/100, and was higher in patients with a better performance status (P = 0.026). A minority of patients (8%) screened positive for anxiety and depression using the Hospital Anxiety and Depression scale.

CONCLUSIONS

Notwithstanding the difficulties in following up this group of patients, this paper reports valuable findings detailing the experience of patients with MCC 1 month after diagnosis and treatment.

Navigating uncharted water: research ethics and emotional engagement in human inquiry

Sensitive research necessitates routine ethical practices of confidentiality, anonymity and worthiness. However, when co-constructing narratives with participants, the nurse researcher also faces unexplored ethical issues that arise out of the emotional intensity and professional responsibility inherent in the relationship. Such issues may be recognized and managed using clinical supervision in addition to academic supervision. Researcher vulnerability adds depth and complexity to human inquiry.

Blurring the boundaries: scenario-based simulation in a clinical setting

CONTEXT

The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi-clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the 'patient' and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the 'Virtual Chaperone') is evaluated for use in clinical settings.

METHODS

A qualitative design (observation and interview studies) investigated volunteer medical students undertaking 2 procedure scenarios (insertion of urinary catheter and wound closure with sutures) within the accident unit of a large London hospital. All procedures were observed in real time and recorded digitally (using the Virtual Chaperone). A protocol was used for structured feedback. Observational and interview data was analysed using standard qualitative techniques.

RESULTS

Seven sessions with 22 undergraduate medical students took place over 9 months within 1 centre. Data confirmed the feasibility of using a moveable, self-contained training scenario within an authentic clinical setting. Overall, the response from participants was positive.

CONCLUSION

Scenario-based teaching within an authentic clinical environment is feasible and perceived by participants to be educationally useful. This approach blurs traditional boundaries between skills laboratory teaching and clinical practice and may offer considerable advantages in training for clinical procedures.

Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability

Quality of life (QOL) was determined using the shortened version of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL-Dw), in 180 patients, shortly after a diagnosis of malignant cord compression. The median SEIQoL score was 66 (maximum 100). Twenty-five per cent of patients had a score >83. SEIQoL correlated with KPS (P<0.004) but the range of scores for each level of performance was very wide. Although there was an association between SEIQoL and ability to walk, the difference was small and not significant. SEIQoL was adversely affected by emotional distress as measured using HAD (P<0.01), although few patients were identified as being severely depressed. The findings are a reminder that QOL as determined by the patient may not coincide with health professionals' opinions.

The use of handheld computers in scenario-based procedural assessments

This paper describes the authors' experiences of using handheld computers within scenario-based formative assessments aimed at developing clinical procedural skills. Previous experiences of using paper forms in these assessments were problematic. Multiple paper forms were generated and data sets were sometimes incomplete. Forms adapted for use on handheld computers offer significant potential advantages over paper-based versions. These include streamlining the process of data collection, entry and retrieval, thereby reducing data loss and providing learners with immediate and cumulative feedback on their performance. All participants in this study found the Personal Digital Assistant (PDA) forms easy to use. Further adaptation, together with increased familiarity with PDA technology, will address users' feedback by providing more space for free text and a larger visual field. Technical expertise is required for the development and delivery of PDA-based forms, but their potential for use in formative and summative assessments is considerable.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

Don't wait for a sensory level--listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression

AIM

To report details concerning symptoms (especially pain) preceding the development of malignant cord compression (MCC); delays between onset/reporting of symptoms and confirmed diagnosis of MCC; accuracy of investigations carried out.

METHODS

A prospective observational study examined the diagnosis, management and outcome of 319 patients diagnosed with MCC at three Scottish cancer centres between January 1998-April 1999. The process was considered from the perspectives of the patient, the GP and the hospital doctor.

RESULTS

At diagnosis, most patients (82%) were either unable to walk or only able to do so with help. Pain was reported by nearly all patients interviewed (94%) and had been present for approximately 3 months (median=90 days). It was severe in 84% of cases, with the distribution and characteristics of nerve root pain in 79%. The site of pain did not correspond to the site of compression. Where reported, weakness and/or sensory problems had been noticed by the patient for some time before diagnosis (median intervals 20 and 12 days, respectively). Most patients reported early symptoms to their General Practitioner (GP) and diagnosis was established, following referral and investigation, approximately 2 months (median=66 days) later.

CONCLUSION

Patients who develop spinal metastases are at risk of irreversible spinal cord damage. Weakness and sensory abnormalities are reported late and identified even later, despite patients having reported pain for a considerable time. Patients with cancer who describe severe back or spinal nerve root pain need urgent assessment on the basis of their symptoms, as signs may occur too late. Plain films and bone scans requested for patients in this audit predicted accurately the level of compression in only 21% and 19% of cases, respectively. The only accurate investigation to establish the presence and site of a compressive lesion is magnetic resonance imaging (MRI). A referral guideline based on suspicious symptoms in addition to suspicious signs is suggested.

Teaching and learning about sexual histories during undergraduate medical education: a comparison of two approaches

Experiential small group workshops on taking a sexual history were introduced at Imperial College School of Medicine (ICSM). With the introduction of a new curriculum and an increase in the number of students, together with a growing awareness of economic constraints in medical education, a large group session on the same topic was developed. In both sessions students identify barriers to taking a sexual history, contexts in which a sexual history is appropriate and skills necessary for an effective sexual history interview. This paper describes and contrasts the content, methodology and student evaluations of both types of sessions. The results showed that in the short term students perceived benefits from both methods of teaching. Further work is required to determine the long-term effects of such training.

Intussusception following the Ladd procedure

HYPOTHESIS

The Ladd procedure for malrotation predisposes children to postoperative intussusception (POI).

DESIGN

Retrospective case-control review.

SETTING

University-affiliated tertiary care pediatric hospital.

PATIENTS

Five of 159 patients undergoing the Ladd procedure between 1995 and 1998 developed POI. Predisposing factors were sought by comparison with age-matched controls who underwent the Ladd procedure during the same period. The entire Ladd group was compared with all 1717 patients undergoing any other laparotomy during the same period for incidence of POI.

MAIN OUTCOME MEASURES

Differences in weight, percentile weight, age, length of nasogastric suction, time to oral intake, and length of stay between Ladd patients developing POI and age-matched controls from the Ladd group were compared using the Mann-Whitney U test. Incidence of POI after the Ladd procedure and "other laparotomy" was compared using chi2 analysis.

RESULTS

In the Ladd group, there were 5 cases of POI (3.1%). There was 1 case of POI (0.05%) after all other laparotomies (P<.001). Symptoms developed at a mean +/- SD of 7.2 +/- 2.1 days. Upper gastrointestinal tract with small bowel follow-through showed partial bowel obstruction in 4 cases and was normal in 1 case. Reexploration took place at a mean +/- SD of 9.2 +/- 2.8 days. Children developing POI after undergoing the Ladd procedure were less likely to be small for their age (P= .03) than age-matched controls undergoing the Ladd procedure.

CONCLUSIONS

The Ladd procedure predisposes children to POI. Aggressive investigation, including reexploration, should not be delayed if a child has symptoms of prolonged ileus within 2 weeks after undergoing a Ladd procedure.

Variation in measurement of ankle-brachial pressure index in routine clinical practice

PURPOSE

The purpose of this study was to determine the variation in ankle-brachial pressure index (ABPI) measurements in routine clinical practice.

METHODS

Analysis was done of preoperative and postoperative ABPIs in 130 limbs contralateral to those undergoing femoral bypass grafting in 123 patients over a 15-month period.

RESULTS

The mean initial ABPI was 0.72 (range 0.22 to 1.10). The range of observed differences between the preoperative and postoperative ABPIs was from -0.33 to +0.25. The mean (+/-SD) difference between the first and second ABPIs was 0.00 (+/-0.11). The 95% confidence limits of the difference were -0.21 to 0.21. There was no trend for the size or direction of the difference in ABPI to vary according to the mean ABPI, brachial blood pressure, or time between tests.

CONCLUSIONS

ABPI is routinely used as an objective measure of peripheral vascular disease. The variation observed in this study is comparable with values obtained in reproducibility studies and is greater than that accepted in clinical practice. The difference between an ABPI measurement and the actual ABPI and the difference between repeat single measurements are not the same and should be distinguished. Vascular laboratories should determine the accuracy of ABPI measurement on a local basis to guarantee and maintain quality assurance.

Apparent monomorphism of ALDH2 in seven American Indian populations

Deficiency of mitochondrial aldehyde dehydrogenase (ALDH2) has been previously reported in South American Indians. We therefore assayed five individuals from each of five South American Indian populations (Quechua, Karitiana, Ticuna, Surui, Guahiba), and two North American populations (Maya and Moskoke) for the presence of the Oriental ALDH2(2) variant. These samples were also surveyed for other alleles altering ALDH2 function. Allele-specific amplification assay (ASA) did not detect the ALDH2(2) allele in any of the New World populations studied. The entire coding sequence of the ALDH2 cDNA was enzymatically amplified in partially overlapping fragments. Each fragment was digested using restriction endonucleases and subfragments 148-285 b.p. in length were analyzed by the single-stranded conformation polymorphism (SSCP) technique. No variants were detected within the coding region of the ALDH2 gene in any of the seven American Indian populations. Three potentially correct explanations for these results are suggested. First, an ALDH2 polymorphism is present but undetectable by SSCP; second, none of the studied individuals were ALDH2 negative; third, the polymorphism occurs beyond the coding region of ALDH2 gene.

Early outcome and intermediate follow-up of vascular stents in the femoral and popliteal arteries without long-term anticoagulation

PURPOSE

The role of arterial stenting in the treatment of femoral and popliteal arterial disease is controversial and has been hampered by recommendations for patients to be given anticoagulants (oral warfarin) for several months or more. This study was undertaken to evaluate the immediate and midterm outcomes of vascular stents implanted percutaneously in the femoral and popliteal arteries, without long-term anticoagulation.

METHODS

Over a 3-year period, 32 patients admitted to a vascular surgery service had arterial stents implanted in the femoral (n = 22) or popliteal (n = 10) artery for the following indications: recurrent stenosis after angioplasty (n = 13), suboptimal result after angioplasty of occluded (n = 12) or calcified stenotic arteries (n = 2), percutaneous transluminal angioplasty-induced thrombosis or dissection (n = 5). Access to the artery was gained by percutaneous insertion of a hemostatic sheath into the ipsilateral common femoral artery. Systemic heparin was given at the time of stent insertion, and patients were prescribed daily low-dose aspirin.

RESULTS

Successful stent implantation was achieved in 31 of the 32 patients. Acute thrombosis (< 30 days) occurred in two patients. There was no incidence of false aneurysm formation, acute leg ischemia, or vessel perforation. All patients were monitored by Doppler scanning index and duplex scanning within 24 hours, and thereafter at 3- to 6-month intervals. The mean ankle-brachial systolic pressure index improved from 0.60 (before treatment) to 0.88 (3 to 6 months after stenting). Stent occlusion has occurred in six patients; two stents were successfully salvaged with urokinase infusion. In follow-up to date (range 3 to 33 months) the primary patency rate by life-table analysis was 75% at 18 months, whereas the secondary patency rate was 89% at the same interval. Restenosis (> 50% lumen diameter) was detected by duplex ultrasonography in seven of 25 patent stents (28%) at a mean interval of 9.5 months (range 4 to 15 months); of these, four patients remained clinically symptom-free despite the ultrasound findings.

CONCLUSIONS

We conclude that vascular stents can be implanted into the femoropopliteal arteries with few complications and with acceptable early and intermediate patency rates, without the need for long-term anticoagulation. Restenosis is not prevented by stents, and the main value of stenting at this site appears to be in salvaging acute complications of percutaneous transluminal angioplasty, or to correct suboptimal results after recanalization of occluded arteries.

Air quality and respiratory functioning in children with pulmonary disorders

This study was conducted to examine the relation between daily ambient air conditions, contaminants (eg, aeroallergens such as mold spores and pollen), and respiratory health indices of children with respiratory disorders (eg, asthma) residing in metropolitan Baton Rouge, Louisiana. Daily measures of peak expiratory flow rate (PEFR), respiratory symptoms, and other indices of health were monitored as subjects went about their normal daily activities. The results of this study suggest that high summer temperatures had the greatest impact on children's health status and activity level, with humidity and mold counts also contributing significantly to a decline in respiratory health indices.

Is routine AFP screening in pregnancy reassuring?

The purpose of the study is to examine the impact of a negative result on a routine prenatal screening test, maternal serum alpha-fetoprotein screening for spina bifida and Down's syndrome. Three-hundred and nine women had the test and 30 did not. Twenty-one of the 309 did not think that they had been tested, and seven women who did not have the test thought that they had been tested. There were no significant differences between these four groups in anxiety, certainty about the baby's health or worry about the baby's health. These results suggest that the receipt of a negative result on this screening test does not provide reassurance. There are several possible explanations for this finding: the test is reassuring, but only for a small number of those undergoing the test; the test is reassuring but the study method was inappropriate and hence failed to detect it; the test is not reassuring because of a lack of knowledge about the meaning of a negative result or, the way in which results of testing are conveyed. The latter two explanations suggest that the potentially reassuring effects of such a result may be realised with more effective communication about test results.

Anxiety, knowledge and satisfaction in women receiving false positive results on routine prenatal screening: a randomized controlled trial

The majority of women receiving an abnormal result on routine prenatal screening subsequently give birth to unaffected children. Previous studies have documented high levels of anxiety in women receiving such false positive results. In an attempt to reduce this anxiety, two methods of preparing women for undergoing such testing were compared: provision of detailed written information about maternal-serum alpha-fetoprotein testing; and anxiety management training. Eligible women were randomly allocated to one of five groups. Eighty-five women subsequently received false positive results on routine alpha-fetoprotein testing. There was some evidence that completing the study questionnaires had an anxiety-reducing effect. In contrast with the results of previous studies, there was no evidence that receipt of an abnormal alpha-fetoprotein result resulted in raised anxiety. Neither of the interventions, alone or in combination, had an effect upon anxiety following an abnormal alpha-fetoprotein result. Receipt of detailed written information however, led to women having more knowledge and being more satisfied with the amount of information that they had. One in three of the class groups reported that the classes had influenced the way they had dealt with worries. Although the interventions did not reduce anxiety in this study, there are other reasons for considering their incorporation into routine clinical practice.