Stem cell stories: from bedside to bench

The stem cell story is not a simple story but a complex narrative: one that requires careful analysis in order to identify major themes and plots. This paper offers an analysis of the ethics of the clinical application of stem cells and argues that even quite risky therapies can be ethical. These arguments cannot be used to justify all aspects of contemporary stem cell science, including human embryonic stem cell science, which remains theoretical and speculative. It is argued that the homogenisation of stem cell science obscures the distinction between clinical application and experimental laboratory science in a morally problematic way.

Uncertainty of sweat chloride testing: does the right hand know what the left hand is doing?

Although analytical variation in sweat electrolyte testing can be easily estimated, there is limited data on total variation. This study aims to evaluate the total variation of the sweat test by measuring the difference between sweat electrolyte values in specimens obtained simultaneously from two sites. Chloride is recommended in published guidelines as the only discriminant for the diagnosis of cystic fibrosis, and sodium may be measured as a guide to the adequacy of collection and analysis. Both are reported here. Sweat was collected in patients by the Gibson Cooke method from two sites simultaneously. Coefficient of variation in this laboratory is 4.1 and 5% for chloride and sodium, respectively. 295 patients had sufficient sweat collected from both sites for analysis. The values for chloride and sodium were compared between the two sites. The total coefficient of variation (CVt) calculated for the whole group between the two sites was 20.2% for chloride and 16.9% for sodium, and the standard deviations 4.3 mmol/L and 4.8 mmol/L, respectively. In patients with intermediate chloride concentrations; in different age groups; and when those tests with a difference between sodium and chloride concentration of more than 15 were excluded, minimal differences in these figures were observed. Use of strictly defined cut-off points to discriminate between normal and intermediate electrolyte values, and between intermediate and raised electrolyte values, does not reflect the variation in sweat electrolyte content found within an individual patient. This has important implications for reporting.

Ethical and governance challenges in human fetal tissue research

Genetics holds the key to understanding normal human biology and possibly many of the major causes of human disease and impairment. Research into human developmental genetics seems, therefore, to be both necessary and justified. However, such research requires the use of embryonic and fetal tissue obtained from spontaneous abortions and elective termination of pregnancy. This paper examines the arguments in favour of using tissue from elective terminations and the evolution of regulatory frameworks for this research. The paper argues that the recent statutory and regulatory reforms in the UK have not properly addressed the issue of ethically obtaining postimplantation human embryos for research. It is argued that the recent reforms have left the Polkinghorne guidelines untouched but that these are now unequal to the task. A practical suggestion for reform of the approach to the informing and consent of potential donors is offered.

Quantitative trait loci for lodging resistance, plant height and partial resistance to mycosphaerella blight in field pea (Pisum sativum L.)

With the development of genetic maps and the identification of the most-likely positions of quantitative trait loci (QTLs) on these maps, molecular markers for lodging resistance can be identified. Consequently, marker-assisted selection (MAS) has the potential to improve the efficiency of selection for lodging resistance in a breeding program. This study was conducted to identify genetic loci associated with lodging resistance, plant height and reaction to mycosphaerella blight in pea. A population consisting of 88 recombinant inbred lines (RILs) was developed from a cross between Carneval and MP1401. The RILs were evaluated in 11 environments across the provinces of Manitoba, Saskatchewan and Alberta, Canada in 1998, 1999 and 2000. One hundred and ninety two amplified fragment length polymorphism (AFLP) markers, 13 random amplified polymorphic DNA (RAPD) markers and one sequence tagged site (STS) marker were assigned to ten linkage groups (LGs) that covered 1,274 centi Morgans (cM) of the pea genome. Six of these LGs were aligned with the previous pea map. Two QTLs were identified for lodging resistance that collectively explained 58% of the total phenotypic variation in the mean environment. Three QTLs were identified each for plant height and resistance to mycosphaerella blight, which accounted for 65% and 36% of the total phenotypic variation, respectively, in the mean environment. These QTLs were relatively consistent across environments. The AFLP marker that was associated with the major locus for lodging resistance was converted into the sequence-characterized amplified-region (SCAR) marker. The presence or absence of the SCAR marker corresponded well with the lodging reaction of 50 commercial pea varieties.

Use of inter-simple sequence repeats and amplified fragment length polymorphisms to analyze genetic relationships among small grain-infecting species of ustilago

ABSTRACT In the smut fungi, few features are available for use as taxonomic criteria (spore size, shape, morphology, germination type, and host range). DNA-based molecular techniques are useful in expanding the traits considered in determining relationships among these fungi. We examined the phylogenetic relationships among seven species of Ustilago (U. avenae, U. bullata, U. hordei, U. kolleri, U. nigra, U. nuda, and U. tritici) using inter-simple sequence repeats (ISSRs) and amplified fragment length polymorphisms (AFLPs) to compare their DNA profiles. Fifty-four isolates of different Ustilago spp. were analyzed using ISSR primers, and 16 isolates of Ustilago were studied using AFLP primers. The variability among isolates within species was low for all species except U. bullata. The isolates of U. bullata, U. nuda, and U. tritici were well separated and our data supports their speciation. U. avenae and U. kolleri isolates did not separate from each other and there was little variability between these species. U. hordei and U. nigra isolates also showed little variability between species, but the isolates from each species grouped together. Our data suggest that U. avenae and U. kolleri are monophyletic and should be considered one species, as should U. hordei and U. nigra.

Merging the cognitive behavioral and psychopharmacological paradigms in comparative studies: controversies, issues, and some solutions

In the past, many studies attempting to compare pharmacological and psychosocial treatments for mood and anxiety disorders have been conducted by partisans of either approach. More recently, rigorously conducted, unbiased comparative studies have begun to appear. Here we reviewed our own experience in designing and conducting a multicenter study comparing medication and cognitive behavioral therapy and their combination for the treatment of panic disorder.

Bullying and victimization of primary school children in England and Germany: prevalence and school factors

Differences in definitions and methodologies for assessing bullying in primary school children between countries have precluded direct comparisons of prevalence rates and school factors related to bullying. A total of 2377 children in England (6-year-olds/Year 2: 1072; 8-year-olds/Year 4: 1305) and 1538 in Germany (8-year-olds/Year 2) were questioned individually using an identical standard interview. In both countries the types of bullying to victimize others were similar: boys were most often perpetrators, most bullies were also victims (bully/victims), most bullying occurred in playgrounds and the classroom, and SES and ethnicity only showed weak associations with bullying behaviour. Major differences were found in victimization rates with 24% of English pupils becoming victims every week compared with only 8% in Germany. In contrast, fewer boys in England engaged every week in bullying (2.5-4.5%) than German boys (7.5%), while no differences were found between girls. In England, children in smaller classes were more often victimized. Further study of the group of bully/victims, schooling differences in England vs. Germany and implications for prevention of bullying are discussed.

Bullying involvement in primary school and common health problems

AIMS

To examine the association of direct (e.g. hitting) and relational (e.g. hurtful manipulation of peer relationships) bullying experience with common health problems.

METHODS

A total of 1639 children (aged 6-9 years) in 31 primary schools were studied in a cross sectional study that assessed bullying with a structured child interview and common health problems using parent reports. Main outcome measures were common physical (e.g. colds/coughs) and psychosomatic (e.g. night waking) health problems and school absenteeism.

RESULTS

Of the children studied, 4.3% were found to be direct bullies, 10.2% bully/victims (i.e. both bully and become victims), and 39.8% victims. Direct bully/victims, victims, and girls were most likely to have physical health symptoms (e.g. repeated sore throats, colds, and coughs). Direct bully/victims, direct victims, and year 2 children were most likely to have high psychosomatic health problems (e.g. poor appetite, worries about going to school). Pure bullies (who never got victimised) had the least physical or psychosomatic health problems. No association between relational bullying and health problems was found.

CONCLUSIONS

Direct bullying (e.g. hitting) has only low to moderate associations with common health problems in primary school children. Nevertheless, health professionals seeing children with repeated sore throat, colds, breathing problems, nausea, poor appetite, or school worries should consider bullying as contributory factor.

Effect of written and computerized decision support aids for the U.S. Agency for Health Care Policy and Research depression guidelines on the evaluation of hypothetical clinical scenarios

OBJECTIVE

The objective of this study was to compare the effects of written and computerized decision support aids (DSAs) based on U.S. Agency for Health Care Policy and Research depression guidelines.

METHODS

Fifty-six internal medicine residents were randomized to evaluate clinical scenarios using either a written or a computerized DSA after first assessing scenarios without a DSA. The paired difference between aided and unaided scores was determined for diagnostic accuracy, treatment selection, severity and subtype classification, antipsychotic use, and mental health consultations.

RESULTS

Diagnostic accuracy with the written DSA increased from 64% to 73%, and with the computerized DSA decreased from 67% to 64% (P=0.0065). Residents using the computerized DSA (vs. no DSA) requested fewer consultations (65% vs. 52%, P=0.028). In post hoc analysis, the written DSA increased sensitivity (66% to 89%, P<0.001) and the computerized DSA improved specificity (66% to 86%, P=0.0020) but reduced sensitivity (67% to 49%, P = 0.011).

CONCLUSIONS

A written DSA improved diagnostic accuracy, whereas a computerized DSA did not. However, the computerized DSA improved specificity and reduced mental health consultations.

Randomized, controlled trial comparing once daily and three times daily gentamicin in children with urinary tract infections

OBJECTIVE

To undertake population pharmacokinetic modeling and to determine the safety and efficacy of once daily (OD) gentamicin dosing in children with severe urinary tract infections (UTI).

METHODS

An open, randomized, controlled trial comparing OD with three times daily (TD) gentamicin dosing in hospitalized children ages 1 month to 12 years with UTI. Daily doses (milligrams per kg per day) of gentamicin in both groups were 7.5 (<5 years old), 6.0 (5 to 10 years old) and 4.5 (>10 years old).

RESULTS

There were 179 children enrolled (90 OD, 89 TD). Baseline clinical characteristics and pathogens were similar, except that circulatory compromise and renal cortical scintigraphic defects were more common in the OD group. Median gentamicin treatment durations were 3.0 (OD) and 2.7 (TD) days. Mean peak gentamicin concentrations were 17.3 (OD) vs. 6.4 (TD) mg/l; 99% of peak concentrations were >7 mg/l in the OD group whereas 16% of peak concentrations were <5 mg/l in the TD group. Mean trough concentrations were 0.35 (OD) vs. 0.55 (TD) mg/l. In the OD group 4% of trough concentrations were > or = 2 mg/l, whereas in the TD group only 0.7% were > or = 2 mg/l. Age or prior elevated peak concentrations did not predict high trough concentrations. Population pharmacokinetic modeling of the data fitted a one-compartment model with first order elimination. There were no clinical or bacteriologic failures. The two disease-related complications were confined to the OD group. No nephro- or ototoxicity was identified.

CONCLUSIONS

With age-appropriate dosing and measurement of serum trough concentrations before the second dose, OD gentamicin is safe and effective for the treatment of UTI requiring parenteral treatment in children aged 1 month to 12 years.

Home enteral tube feeding following cerebrovascular accident

BACKGROUND AND AIMS

In the UK, cerebrovascular accident (CVA) is the third commonest cause of death and the commonest diagnosis in patients receiving home enteral feeding (HETF). This study aimed to use data from the British Artificial Nutrition Survey (BANS) collected between 1996 and 1999 to assess the outcome of patients on HETF, including mortality, return to oral feeding, level of physical activity, and level of dependency, which has resource implications.

RESULTS

it is estimated that about 1.7% of all patients suffering a CVA in the UK between 1996 and 1999 received HETF. At one year, 29.6% died while receiving HETF and another 13% returned to oral feeding. Mortality increased with age and was twice as high in those managed in nursing homes compared to those in their own homes. The patients receiving tube feeding spent only 0.6% of their time in hospital. A total of 43.9% of patients were bed-bound at home (1.9% unconscious) and an additional 30.3% were house-bound. Only 21.2% were independent, and the majority were totally dependent on their carers. In CVA patients on HETF the level of dependency was greater than for those with all types of diagnoses (n=12,997).

CONCLUSION

This study has described the outcome of a large number of patients receiving HETF in the UK. Since patients spent less than 1% of their time in hospital, HETF relieves pressure on the expensive hospital environment, but places more demands on the carers, who have to deal with severely disabled patients. Recovery of swallowing function should be assessed intermittently to prevent unnecessary HETF.

The association between direct and relational bullying and behaviour problems among primary school children

The prevalence of direct and relational bullying and their differential relationship to behaviour problems in young primary school children was investigated. Individual interviews were conducted with 1982 children aged 6 9 years (mean age 7.6 years) and 1639 parents completed the Strength and Difficulties Questionnaire regarding behaviour problems of their children. Of the 1639 children with both data sets, 4.3% were direct bullies, 39.8 % victims, and 10.2% both bullied and were victimised frequently (bully/victims). The rates for relational bullying were 1.1% bullies, 37.9% victims, and 5.9% bully/victims. All children involved in direct bullying had significantly increased total behaviour problems, hyperactivity, conduct problems, and peer problem scores, and lower prosocial behaviour scores compared to those not involved in bullying (neutrals). Findings were similar for relational bullying involvement and behaviour problems for bully/victims and victims but less pronounced. Relational bullies had the lowest behaviour problem scores while being rated the least prosocially inclined children, consistent with the concept of a cool manipulator. Overall, direct bully/victims and children who were involved in both direct and relational bullying behaviour had the highest rates of behaviour problems. No relationship between victimisation and increased emotional problems were found. Those involved in bullying behaviour who show externalising and hyperactivity problems in primary school may be at increased risk for persistent conduct problems. Different interventions may be needed for those involved in relational bullying only, both direct and relational bullying, and those with additional behaviour problems.

Users' views on palliative care services: ethical implications

This article is based on the findings of a study that elicited the views of terminally ill patients (n = 15), their carers (n = 10) and bereaved carers (n = 19) on the palliative care services they received. It explores the range of ethical issues revealed by the data. Although the focus of the original study was on community services, the participants frequently commented on all aspects of their experience. They described some of its positive and negative aspects. Of concern was the reported lack of sensitivity to the role of the family among health professionals. The family, as carers, service users and advocates, represent a challenge to professional boundaries and the ethical norms of confidentiality and best interest. The accounts reveal the complexity of the ethical issues that characterize terminal care, issuing specific ethical challenges to nurses and other health professionals involved in this field.

Primary care services received during terminal illness

The World Health Organization (1990) provides guidelines on what constitutes effective palliative care. However, it remains unclear whether people with a terminal illness living in their own homes have access to the services they need. This article reports on a study carried out in the United Kingdom on the views of people with a terminal illness (n = 15), their lay carers (n = 10) and bereaved carers (n = 19). Participants were asked about the primary care services they had received and their views on both helpful and unhelpful aspects of service provision. All terminally ill people in the study (except one) had cancer, which raises questions about access to palliative care services for non-cancer populations. Participants had contact primarily with district nurses, general practitioners and Macmillan nurses (specialist nurses). Few other services were received. A number of important issues arose from the data, indicating that lay carers in particular were not always receiving the information and support they needed in order to be effective caregivers.