Challenging symptoms in children with rare life-limiting conditions: findings from a prospective diary and interview study with families

AIM

The aim was to describe the nature, frequency, severity and management challenges of symptoms in children with two rare life-limiting conditions [Mucopolysaccharide (MPS) and Batten disease].

METHODS

This was an embedded mixed-method study set in the UK between 2009 and 2011. Twenty-six children from 23 families took part. Seventeen children had an MPS condition [MPS III (Sanfilippo) n = 15; MPS I (Hurler) n = 1; MPS IVA (Morquio); n = 1]. Nine children had Batten disease. Prospective data relating to symptoms were collected over 8 weeks using a symptom diary, and qualitative retrospective interviews with families were conducted. Main outcome measures included frequency, severity rating and identification of most challenging symptoms to manage.

RESULTS

The most common and severe symptoms in MPS III were agitation, repetitive behaviours, hyperactivity and disturbed sleep, and in Batten disease were agitation, joint stiffness, secretions, and disturbed sleep. The data highlighted the high prevalence of behavioural symptoms. Distress caused to families by symptoms was not related simply to their occurrence, but to difficulty in management, likelihood of control and extent to which they signalled disease progression and decline.

CONCLUSION

In challenging contrast to the dominant biomedical framing of these rare conditions it was behavioural symptoms, rather than the physical ones, that families documented as most frequent, severe and challenging to manage. The diary developed for this study has potential use in aiding parents and clinicians to document and communicate concerns about symptoms.

Low Temperature Crystallization of Amorphous Silicon Films Using an Excimer Laser

In an effort to enhance the electrical properties of silicon thin films, we have performed recrystallization experiments on a variety of amorphous silicon films using an excimer laser. The intense, pulsed UV produced by the laser (308nm, using XeCl gas) is highly absorbed by the amorphous material and thus provides intense localized heating in the near surface region. Two types of starting films were studied: plasma CVD a-Si:H and LPCVD a-Si. The subsequent modification produces crystallites whose structure and electrical characteristics vary due to starting material and laser scan parameters. The treated films have been characterized using Raman, x-ray diffraction, TEM, SIMS and transport measurements. The results indicate that crystallites nucleate in the surface region. The degree of crystallization near the surface increases dramatically as a function of deposited laser energy density and less so as a function of laser shot density. The hall mobility of the highly crystallized samples exhibit an increase of 2 orders of magnitude over the amorphous starting material. In the PECVD material, the rapid diffusion of hydrogen causes voids to be formed at intermediate laser energy densities and removal of film at higher energy densities. The LPCVD material withstands the high laser energies to produce well crystallized films with crystallite sizes greater then 1000Å.

Electrical Properties and Structural Defects in Epitaxial CaF2 on Si

In this paper, a study is made of the electrical properties and of the types of structual defects which can occur in epitaxial CaF2 grown on Si(111) substrates by molecular beam epitaxy (MBE). High-resolution transmission electron microscopy (HRTEM) and high-energy (≥2 MeV) He+ ion channeling techniques are used to characterize defects in the epitaxial layer and at the CaF2 /Si interface while current-voltage (I–V) and capacitance-voltage (C–V)3 measurements are used to characterize the electrical properties. The HRTEM images show an atomically abrupt interface between the CaF2 and Si. The most common defect we have been able to identify is associated with an atomic step at the interface and is similar to a Shockley partial dislocation at a (111) twin interface in an fcc crystal structure. The ion channeling measurements also indicate the presence of defects at the CaF2 /Si interface. The apparent defect density measured by ion channeling decreases in the CaF layer as one moves away from the interface at a rate which depends on ihe final thickness of the epitaxial film. Ion channeling has also been used to measure strain and it is found that, while thin layers of epitaxial CaF2 on Si(111) have large strain, the strain becomes vanishingly small as the layers exceed 200 nm in thickness. This result can be adequately explained using an equilibrium model for the introduction of strain relieving misfit dislocations and indicates that epitaxial fluoride layers may be useful as thermal mismatch buffers in heteroepitaxial structures. In C–V measurements of epitaxial CaF2 layers on Si(111) which have been fabricated into metal-insulator-semiconductor structures, the capacitance is observed to remain constant over a large variation in applied voltage. This constant capacitance region can be explained as due to a high density of interface states in the band gap. In addition, I–V measurements indicate that, at low fields, the CaF2 resistivity exceeds 1014 Ω-cm. At high fields, the CaF2 starts to conduct in a manner which we speculate is due to defects at the CaF2/Si interface. The field at which this conduction takes place has been ovserved to exceed 1 MV/cm for a 42-nm-thick CaF2 film with the device geometry used for this work.

Tolerability and safety of novel half milliliter formulation of glatiramer acetate for subcutaneous injection: an open-label, multicenter, randomized comparative study

Daily glatiramer acetate (GA) 20 mg/1.0 mL is a first-line treatment for relapsing-remitting multiple sclerosis (RRMS). To reduce the occurrence of injection pain and local injection site reactions (LISRs), a reduced volume formulation of GA was developed. This study compared pain and LISRs after injecting the marketed and the novel formulations. RRMS patients currently injecting GA participated in this multicenter, randomized, crossover comparative study. All patients administered once-daily subcutaneous injections of GA 20 mg/1.0 mL (marketed formulation) or GA 20 mg/0.5 mL (reduced volume formulation) for 14 days. Patients were crossed-over to the alternate treatment for an additional 14 days. Using a Visual Analog Scale (VAS), patients recorded in daily diaries the severity of injection pain immediately and 5 min post-injection, and the presence and severity of LISRs (swelling, redness, itching, lump) within 5 min and 24 h post-injection. VAS pain scores were ranked significantly lower immediately and 5 min after GA 20 mg/0.5 mL injections (p < 0.0001). Although LISRs were rare for both preparations, the severity of reactions ranked significantly lower and fewer symptoms occurred within 5 min and 24 h of using the reduced volume formulation (p < 0.0001). GA injected subcutaneously in a reduced volume formulation is a more tolerable option.

Alzheimer's and seizures: interleukin-18, indoleamine 2,3-dioxygenase and quinolinic Acid

Emergent seizures are common in Alzheimer's disease (AD), although the mechanisms mediating this are unknown. It is proposed that stress induced interleukin-18 (IL-18), via interferon-gamma (IFNy) and independently, increases indoleamine 2,3-dioxygenase (IDO) and subsequent quinolinic acid (QA) in microglia. QA increases seizures and concurrently contributes to neuronal loss via excitotoxicity. The ApoE4 allele interacts with IL-18 polymorphisms to increase the risk of AD, and seems likely to potentiate the emergence of seizures. Concurrent changes in IDO and the kynurenine pathways at the blood-brain-barrier (BBB) have implications for treatment, including in the efficacy of different anti-hypertensives. Melatonin is proposed to inhibit these overlapping excitotoxic and neurodegenerative processes, and would be a useful adjunctive treatment.

Electron Microscopy of Chorionic Villus Samples for Prenatal Diagnosis of Lysosomal Storage Disorders

Some lysosomal storage disorders cause progressive prenatal accumulation of undegradable metabolites that manifest as membrane-bound vacuoles in endothelial cells, fibroblasts, and trophoblast, identifiable by electron microscopic examination of chorionic villus samples (CVS). There were 111 CVS, which had ultrastructural examination for suspected storage disorders at Great Ormond Street Hospital (1988-2005). There were 31 positive diagnoses, including glycogen storage disease type II, gangliosidosis type 1, mucopolysaccharidosis type 1, MPS not specified, Niemann-Pick type A, sialidosis/mucolipidosis type 1, neuronal ceroid lipofuscinoses (including variant forms), Wolman disease, sialic acid storage disease, and storage disease not specified. In most of these cases the indication was a previously affected individual. Seventy-seven cases showed no evidence of storage disease; 3 samples were inadequate for ultrastructural diagnosis. In selected cases, one-third of CVS may demonstrate distinctive ultrastructural features allowing prenatal diagnosis of a range of storage diseases.

Feelings: what questions best discriminate women with and without eating disorders?

This study explored feelings that discriminate between eating disorder and community groups of women. Responses to 25 questions about body image (9), eating (8) self-esteem (3) general psychology (5) were collected in 2002-2003 (N=268) and 2005-2006 (N=472). Wilk's lambda was used to test discrimination. The most discriminating psychological questions were: 'feeling unhappy and unable to cope as well as usual', 'unease attending social functions', 'fearing loss of control over emotions'; and for eating questions were: 'feeling uneasy if other people saw you eating', 'feeling preoccupied with food/eating', 'fearing loss of control over eating'. For body image only 'feeling preoccupied with body weight/shape' and 'fearing loss of control over your body' discriminated. Questions relating to weight and shape for self-esteem ('feeling fat', 'fearing weight gain' and 'wanting to lose weight') discriminated poorly. Results for both cohorts were consistent. Preoccupation with thoughts of eating or body image and fear of loss of control of these would be useful additions to eating disorders criteria. Psychological impairment should also be present.

Breast cancer after stopping estrogen plus progestin in postmenopausal women in the women's health initiative

Abstract #64

Background&#x2028; Following the Women's Health Initiative (WHI) estrogen plus progestin (E+P) trial report (JAMA 2002;288:321), menopausal hormone therapy use decreased dramatically in the United States. Subsequently, breast cancer incidence also dropped substantially, suggesting possible causality (NEJM 2007;16:1680); however, the etiology remains controversial.&#x2028; Methods&#x2028; To define effects of stopping E+P on breast cancer incidence more precisely, additional analyses were conducted in the WHI randomized trial of daily conjugated equine estrogens (CEE, 0.625 mg) plus medroxyprogesterone acetate (MPA, 2.5 mg) versus placebo. Furthermore, temporal trends for breast cancer diagnoses in the WHI observational study cohort were examined. Breast cancer risk factors, mammography utilization and calendar time-specific breast cancer incidence were assessed relative to E+P use.&#x2028; Results: The time-specific linear hazard ratio (HR) curves examining E+P influence on breast cancer in the E+P clinical trial (CT), and in the observational study (OS, the later adjusted for E+P use during follow-up) are attached.&#x2028; &#x2028; &#x2028; &#x2028; In the CT, breast cancer incidence, initially lower in the E+P group, increased with longer duration use but decreased postintervention despite closely comparable mammogram frequency between randomization groups. In the OS, breast cancer incidence was about two-fold higher in E+P users vs non-users (likely reflecting longer duration exposure) but decreased rapidly following year-to-year reductions in E+P use, while differences in mammogram frequency between E+P users and non-users were unchanged.&#x2028; Conclusion: These findings suggest that cessation of E+P use is associated with a rapid reduction in breast cancer incidence which is not explained by mammography utilization change and support the hypothesis that the recent reduction in breast cancer incidence seen in certain age groups is predominantly related to a decrease in combined menopausal therapy use.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 64.

Spinal injuries after falls from hunting tree stands

BACKGROUND CONTEXT

Spinal injuries are common sequelae of falls from hunting tree stands. Significant neurological injury is not uncommon and can result in significant morbidity as well as enormous expenditure of health care dollars. Recent literature on the subject is limited.

PURPOSE

The purpose of this study was to identify precipitating causes, characterize the spectrum of spinal injury, and determine potential interventional safety and prevention recommendations.

STUDY DESIGN

A retrospective study.

METHODS

Medical record review of 22 patients admitted either directly or via referral to a level I spinal cord injury referral center over a 10-year period (1995-2005) after a fall from a hunting tree stand.

RESULTS

All patients were men with a mean age of 46 years (range, 27-80 years). Initial acute care hospitalization averaged 10 days (range, 2-28 days). The average height of fall was 18 feet (range, 10-30 feet). Four of 19 falls (21%) occurred during the morning hours, 2 of 19 falls occurred during the afternoon, and 13 of 19 falls (68%) occurred during the evening hours. Time lapse from injury to presentation to an emergency department ranged from 30 minutes to 14 hours. Alcohol use was a factor in 2 of 20 falls (10%). Hypothermia complicated 3 of 21 cases (14%). Associated injuries were present in 12 of 21 patients (57%) and included fractures to the axial and appendicular skeleton, pneumothoraces, a retroperitoneal bleed, and a brachial plexopathy. Eight of 22 patients (37%) sustained injury to the cervical spine. Five of these 8 patients (63%) had neurological deficits (3 complete and 2 incomplete spinal cord injuries). Thirteen of 22 (59%) patients sustained injury to the thoracic or lumbar spine. Ten of these 13 (77%) had neurologic deficits (3 complete and 7 incomplete). Nine of 22 (41%) patients were treated nonoperatively; the remaining 13 (59%) underwent operative intervention.

CONCLUSIONS

Falls from hunting tree stands remain a significant cause of spinal injury and subsequent disability. The best intervention for these injuries is prevention. There is a continued need for hunter safety education to reduce the incidence of these injuries with emphasis on safety harness usage, proper installation and annual inspection of tree stands, hunting in groups with periodic contact, the use of communication devices, and abstinence from alcohol consumption while hunting.