Correlates of Severity of Smoking Among Persons with Severe Mental Illness

Individuals with schizophrenia and severe mental illness smoke cigarettes at rates that well exceed the general population. Little is known about the correlates and sequelae of increased smoking severity on persons with severe mental illness. A total of 304 smokers from six community mental health centers were assessed for smoking history, psychiatric symptoms, co-occurring disorders, subjective quality of life, and expired carbon monoxide (CO). Statistical analyses identified correlates of smoking severity, as assessed by number of cigarettes smoked per week. The average number of cigarettes smoked per week was 136+/-83. Increased smoking was associated with higher levels of expired CO and being Caucasian, and with a greater likelihood of a current diagnosis of hypertension and oral/gum disease. Greater smoking severity was also associated with greater perceived stress, poorer overall subjective quality of life, and lower satisfaction with finances, health, leisure activities, and social relationships. This study confirms high rates of heavy smoking among persons with severe mental illness. The association of increased quantity of cigarettes smoked with being Caucasian is consistent with previous reports in mentally ill and non-mentally ill populations. The linkage of heavy smoking with poorer quality of life and co-occurring medical disorders suggests the importance of smoking reduction and cessation strategies to reduce smoking and decrease patients' total pack years of smoking.

A model of the relationship between the epidemiology of Johne’s disease and the environment in suckler-beef herds

A non-predictive, dynamic and stochastic herd-level simulation model of an outbreak of Johne's in a suckler-beef herd is reported. Importantly, the model incorporates, with a simple method, the environment as the primary source of infection, reflecting the consensual understanding of the disease. The model also takes into account the density of the infectious agent in the environment. A sensitivity analysis suggests that the model is highly and equally sensitive to certain parameters (probability of infection in the presence of one unit of bacterial density, infectious area and bacterial shedding rate). Mathematical reasons for this similarity in sensitivity are presented. Compared to many other diseases, data for Johne's are scarce. Therefore models of Johne's outbreaks including this one cannot be predictive or easily validated. The qualitative results: (a) demonstrate the modelled effect of inclusion of infection via the environment; (b) suggest management factors that could be tested by experimentation or observation. Estimates for the rate of transmission, arising from the model output, are similar to published empirical estimates. The results of future empirical research should aid scientific understanding of the disease, help validate this model and might bring economic benefits through improved management.

Oxidation of sulfonamides, macrolides, and carbadox with free chlorine and monochloramine

The oxidation of 10 antibiotics-carbadox, erythromycin-H(2)O, roxithromycin, sulfadimethoxine, sulfamerazine, sulfamethazine, sulfamethizole, sulfamethoxazole, sulfathiozole, and tylosin during chlorination and monochloramination in laboratory and surface waters was investigated to identify kinetics and treatment effectiveness. A kinetic model that incorporates pH-based speciation of both oxidant species and sulfonamide antibiotics was developed and validated. Specific rate constants for the individual ionic species were developed for the dominant reactant pairs. Liquid chromatography/mass spectrometry, preceded by solid phase extraction, was used to analyze antibiotics in kinetic experiments. With experimental conditions of 25 degrees C and reaction times of up to 2 h, an initial concentration of 1 mg/L of free chlorine removed an average of 88 percent of the antibiotics over a pH range of 6.1-9.1. Monochloramine was less effective at typical drinking water dosage concentrations of 3 mg/L, with average removals of 35, 10, and 0 percent at a pH of 6.1, 7.6, and 9.1, respectively.

Preclinical and clinical investigation of histone deacetylase inhibitor valproic acid given orally in androgen independent prostate cancer

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Background: Considerable preclinical data suggests that histone deacetylase inhibitors (HDAIs) can cause differentiation and apoptosis of prostate cancer cell lines and inhibit prostate cancer xenografts in vivo. There is evidence that valproic acid (VPA) is a HDAI and can be administered safely to cancer patients intravenously (Atmaca et al J Clin Oncol 2004). Methods: In the current investigation, 6 cell lines of a variety of solid tumors including prostate cancers were treated with escalating concentrations of VPA (0.5, 1, 2 and 4 mM) over 24–144 hours. Cell growth inhibition was studied by a modified MTS assay. Simultaneously, patients with androgen independent prostate cancers were treated with dose escalations of oral VPA every week or as tolerated (10, 15, 20, 25 mg/kg). Weekly total and free serum VPA, PSA and serum testosterone levels were obtained. In addition, lymphocytes were collected for histone H3 acetylation. Results: VPA inhibited all solid tumor cell lines in a dose-dependent and time-dependent fashion. Optimal (>50% over control) inhibition of most cell lines required 2–4 mM exposure over at least 72–96 hours. Prostate and lung cancer lines were more sensitive to inhibition after VPA administration. A total of 5 patients (Median age 71, Range 48–78) were treated with VPA. Major adverse events included Gr 1 confusion (1 pt), Gr 1 fatigue (3 pts), Gr 1 Dizziness (2 patients) and Gr 1 nausea and vomiting (1 pt). When PSA levels were normalized for simultaneously drawn serum testosterone (Median 20, Range 16–281 ng/dl), all patients had transient drops in PSA. In 3 of 4 evaluable patients, normalized PSA increased after patients were discontinued from VPA because of side effects or co-morbid conditions. In 1 patient, normalized PSA declined after re-challenge with VPA. Conclusions: In this study, VPA has demonstrable activity in cell lines and in patients as measured by lowered PSA levels. Normalization of PSA to serum testosterone might be important to detect clinical effects of HDAIs. Updated clinical data and a correlation between PSA, serum levels of VPA and histone acetylation will be presented.

No significant financial relationships to disclose.

Occurrence and removal of chloro-s-triazines in water treatment plants

Atrazine, simazine, and propazine and their major chlorinated degradates (deethylatrazine, deisopropylatrazine, and didealkylatrazine) are considered as a group to be endocrine-disrupting chemicals by the U.S. Environmental Protection Agency. On this basis, regulatory action levels are currently under consideration for the total chloro-s-triazine (TCT) levels in drinking waters. To assess the concentrations of each of these species in drinking water and their treatability in conventional water treatment, a comprehensive, full-scale studywas conducted that included frequent monitoring at 33 and 47 water utilities during 2003 and 2004, respectively. Approximately 900 paired raw and treated water samples were analyzed using a gas chromatography/mass spectrometry method with preconcentration using a mixed-mode, solid-phase extraction that allowed quantitation of each species including didealkylatrazine. The results showed that atrazine concentrations were generally well within the 3 microg/L maximum contaminant level (MCL) and that simazine and propazine concentrations were generally negligible. Ninety-fifth-percentile values for the ratio of TCT/atrazine were 4.8 and 4.7, respectively. Effectiveness of conventional treatment technologies, including carbon, was observed to vary significantly. Concerns that didealkyatrazine concentrations may be high and significantly elevate the TCT appear to be unfounded. In general, the results suggest that potential treatment requirements for TCT are not likely to be any more difficult for utilities to meet than the current requirements for atrazine.

Treatability of chloro-s-triazines by conventional drinking water treatment technologies

Recent research shows that herbicide atrazine (ATZ), simazine (SIM), and propazine (PROP), as well as their three chlorinated degrades-desethylatrazine (DEA), deisopropylatrazine (DIA), and didealkylatrazine (DDA)-may cause a common toxic effect in terms of endocrine disruption. The US Environmental Protection Agency (EPA) is currently considering a regulatory trigger based on the sum of these concentrations of these six chloro-s-triazines. While limited removal data exists for the parent compounds, little information is available for the degrades formed biologically and/or chemically in the environment and in the treatment plants. It is therefore critical to assess the removal efficiency in a typical water plant of the parent herbicides, as well as the daughter products. In this work, conventional drinking water treatment technologies were evaluated under typical water treatment plant conditions to determine their effectiveness in removing six chloro-s-triazines: ATZ, SIM, PROP, DEA, DIA, and DDA. Experiments were conducted using synthetic solutions prepared by spiking both distilled water and Missouri River water with the study compounds. Two powder activated carbons (PAC)--Calgon WPH and Norit HDB-were shown to be partially effective in removing the studied chloro-s-triazines. Ozonation efficiency varied, depending on different water sources, with respect to the removal of atrazine and didealkylatrazine. Coagulation/flocculation/sedimentation with alum and iron salts, excess lime/soda ash softening, and disinfection by free chlorine were all ineffective methods for removing chloro-s-triazines. It appears that chloro-s-triazine compounds are not readily removed by most conventional drinking water treatment processes, with the exception of use of activated carbon.

Construction and characterization of a series of vectors for Schizosaccharomyces pombe

A set of vectors was created to allow cloning and expression studies in Schizosaccharomyces pombe. These vectors had a uniform backbone with an efficient Sz. pombe ARS, ARS3002, but different selectable markers--his3+, leu1+, ade6+ and ura4+. The vectors functioned efficiently as autonomously replicating plasmids that could also be converted into integrating vectors. The ura4+-containing vector was used to construct a Sz. pombe genomic library.

LST1 and NCR3 expression in autoimmune inflammation and in response to IFN-gamma, LPS and microbial infection

Many genes in the central region of the major histocompatibility complex (MHC) encode proteins involved in immune and inflammatory responses. In this study, we have further characterized two genes in the MHC class IV region, leucocyte-specific transcript (LST) 1 and natural cytotoxicity-triggering receptor 3 (NCR3) (also known as 1C7 and natural killer (NK)p30). The specific function of LST1 is not known, although expression analysis and functional data suggest an immunomodulatory role. The LST1 gene undergoes extensive alternative splicing, giving rise to both membrane-bound (encoded by exon 3) and soluble isoforms. The NCR3 protein is involved in NK-mediated cytotoxicity and plays a role in NK/dendritic cell crosstalk. Expression of these genes was examined, by real-time reverse transcriptase-polymerase chain reaction, in autoimmune-induced inflammation, specifically rheumatoid-arthritis-affected blood and synovium, and in response to stimulation with inflammatory mediators and bacterial agents. The expression of LST1, specifically splice variants encoding soluble isoforms and NCR3, was increased in rheumatoid-arthritis-affected blood and synovium and was associated with more severe inflammation in the synovium. Furthermore, both genes were significantly up-regulated in response to lipopolysaccharide, interferon (IFN)-gamma and bacterial infection. These findings suggest that NCR3 and soluble isoforms of LST1 may play a role in inflammatory and infectious diseases.

Cholesterol tracking from childhood to adult mid-life in children from the Busselton study

AIM

To determine if subjects' cholesterol levels tracked relative to their peers from early childhood to adult mid-life.

METHODS

Longitudinal study using subjects from the Busselton Population Study. Data were available from 1967 on a triennial basis until 1983, and a re-survey held in 1994. The study included 1764 subjects aged 5-18 y at first measurement. Pearson's correlation coefficient, adjusted for age and survey year, was used to examine cholesterol tracking. The proportion of children who persisted with cholesterol measurements in the extreme high quartile was assessed over time before and after adjusting data for regression to the mean. The variability of the children's cholesterol level was examined by track width using the method of Porkka.

RESULTS

The correlation coefficients for tracking were from 0.35 to 0.55. Stronger correlations coincided with shorter time periods between measurements. Before adjustment for regression to the mean, 55-60% of children from the highest quartile at first measurement remained in the same quartile 27 y later. After adjustment for regression to the mean, the number of children with levels in the extreme high quartile decreased, but 80% of these persisted in that quartile.

CONCLUSION

Intra-individual variations in cholesterol levels have an important influence on population tracking levels and need to be considered when interpreting tracking results from early childhood to adult mid-life. However, removing the effect of regression to the mean by taking multiple measurements of cholesterol will probably improve prediction for individuals.

Pre-weaning performance and health of pigs born to cloned (fetal cell derived) swine versus non-cloned swine

The objective of this study was to compare the pre-weaning performance of pigs derived from cloned versus non-cloned parents. Five cloned gilts and one cloned boar were used to produce five litters of pigs. One of five cloned females and the cloned boar were derived from two genetically unmanipulated fetal fibroblast cell lines. The remaining female clones were derived from a fetal fibroblast cell line in which random insertion of a alpha-1,3-galactosyltransferase gene targeting construct had occurred. Fetal cell lines had similar genetic backgrounds and were derived from three different fetuses in three different litters. Five litters of pigs were also generated from matings between two non-cloned boars and five non-cloned gilts. The mean gestation length, mean litter size, mean birth and weaning weights for male and female pigs were similar for litters derived from cloned parents versus non-cloned parents. The proportions of pigs born live and pigs that survived to weaning were also similar for pigs born to cloned as compared to non-cloned parents. In summary, matings between cloned swine derived from fetal fibroblast cell lines yielded litters of pigs that were similar in the number born, piglet birth weight and perinatal and pre-weaning mortality to litters produced by non-cloned swine.

Ion channels and membrane rafts in apoptosis

Ion channels have been demonstrated to be a central element in the induction and the execution of apoptosis. In particular, mitochondrial ion channels, including not only the permeability transition pore but also a mitochondrial, ATP-sensitive (mKATP) channel as well as a mitochondrial calcium-activated potassium channel are involved critically in apoptotic changes in mitochondria. Ion channels in the cell membrane that are altered by induction of apoptosis include potassium, chloride and calcium channels. The Kv1.3 potassium channel belongs to the best-characterized ion channels involved in apoptosis and a genetic model of cells deficient for Kv1.3 has indicated a critical role for Kv1.3, at least in some forms of apoptosis. The mechanisms regulating ion channels during apoptosis are, however, still poorly defined. Recent studies have suggested a function for distinct membrane domains, termed rafts, in the cell membrane for the regulation of ion channels during apoptosis. Small sphingolipid- and cholesterol-enriched membrane domains are modified by many apoptotic stimuli to form large ceramide-enriched membrane platforms. These platforms serve to cluster receptor molecules, to re-organize intracellular signalling molecules including ion channels, to bring ion channels into close contact with their regulators and/or to separate proteins from a specific ion channel. Finally, the lipid composition of the cell membrane might be involved directly in ion channel regulation.

Sex determination by PCR analysis of DNA extracted from incinerated, deciduous teeth

Establishing the biological sex of human remains is a very important part of identifying victims of fire when severe soft tissue destruction has occurred. Deciduous (children's) teeth were exposed to a range of incineration temperatures 100-500 degrees C for 15 minutes. Polymerase Chain Reaction (PCR) amplification was used to identify specific human amelogenin regions. There was successful identification of human biological sex, from deciduous teeth exposed to incineration temperatures of 200 degrees C and below, using standard ethidium bromide gel staining. There was greater sensitivity using fragment analysis by laser induced fluorescence which achieved sex identification from some teeth heated to 400 degrees C.

Treatment of MTBE by air stripping, carbon adsorption, and advanced oxidation: technical and economic comparison for five groundwaters

An investigation was made of the treatability of methyl tert-butyl ether (MTBE) in five groundwaters with highly varied water quality characteristics. Air stripping, granular activated carbon (GAC) adsorption, and the O(3)/H(2)O(2) and UV/H(2)O(2) advanced oxidation processes were compared in a mobile water treatment pilot plant under a variety of process conditions. Air stripping was shown to have the lower unit treatment costs for higher flowrates (i.e., 3800L/min), although relatively tall towers were required for greater treatment requirements. At low flowrates (i.e., 38L/min), advanced oxidation provided the lowest treatment costs for four of five waters (but was ineffective for a high chemical oxygen demand water). Both the O(3)/H(2)O(2) and UV/H(2)O(2) processes were more efficient at pH 7 versus 9 due in part to increased scavenging at higher pH. GAC was examined using rapid small-scale column tests (RSSCT). GAC was effective at most conditions, although it was also the most costly alternative for most waters. The results of this study can help to provide specific guidance into process selection for treating MTBE in contaminated groundwaters.

Edentulism and associated factors in people 60 years and over from urban, rural and remote Western Australia

BACKGROUND

Edentulism is declining in the aged, in turn increasing demand on dental services. The aim of this study was to describe the pattern of edentulism and associated factors for people 60 years or over in urban, rural and remote Western Australia.

METHODS

A cross-sectional telephone interview survey was conducted of 2100 people aged 60 years or over (urban n=800, rural n=800, remote n=500), identified through the State Electoral Roll, who were living in non-institutionalized accommodation in Western Australia and who were able to speak English sufficiently well to be interviewed in English.

RESULTS

The main outcome measure was edentulism. The prevalence of edentulism was 25 per cent for people in urban areas, 34 per cent for people in rural areas and 32 per cent for people in remote areas. Respondents aged 60-69 years had less than half the edentulism than respondents aged 80 years or over. Multivariable logistic regression models showed geographic location, age, gender, education and occupation were significantly associated with edentulism.

CONCLUSIONS

The percentage of edentulism was highest in rural areas with some clear demographic trends. These future aged cohorts are likely to follow the same patterns of social and geographic disadvantage as found for the current edentate cohort. The results were consistent with other studies while providing state level multivariate results to assist service planning.

Efficacy, tolerability, safety and pharmacokinetics of a nanofiltered intravenous immunoglobulin: studies in patients with immune thrombocytopenic purpura and primary immunodeficiencies

BACKGROUND AND OBJECTIVES

A nanofiltration step with the capacity to reduce blood-borne pathogens was introduced into the manufacturing process of intravenous immunoglobulin (IVIG). In order to demonstrate the efficacy, safety and pharmacokinetics of the modified product, we conducted Phase II/III studies comparing the nanofiltered IVIG (IVIG-N) with its parent product, Sandoglobulin, in patients with chronic immune thrombocytopenic purpura (ITP) and primary immunodeficiencies (PID).

MATERIALS AND METHODS

Patients with ITP (n = 27) with platelet counts of < 20 x 10(9)/l were treated with Sandoglobulin or IVIG-N infusions at a dose of 0.4 g/kg body weight on five consecutive days. The primary efficacy end-point was the number of patients with an increase in platelet counts to > 50 x 10(9)/l. Secondary end-points were time to and duration of response, and regression of bleeding. Patients with PID (n = 36) were treated for 6 months with Sandoglobulin or IVIG-N at doses of 0.2-0.8 g/kg, infused at 3- or 4-week intervals. The primary end-point was the number of days absent from school/work. Secondary end-points were hospitalization, use of antibiotics and feeling of well-being. In both studies, tolerability was assessed by recording of adverse events and laboratory determinations. Viral safety was ascertained by serology supplemented with nucleic acid detection methods. Pharmacokinetics were analysed in patients with PID using serum concentration-time data for immunoglobulin G (IgG), and IgG antibodies to hepatitis B surface antigen (anti-HBsAg).

RESULTS

In the ITP study, the primary end-point was met by 12/16 patients on IVIG-N and by 10/10 patients on Sandoglobulin (P = 0.123). A shift towards lesser bleeding intensity was seen in both groups. In the PID study, seven of 18 patients on IVIG-N and six of 16 patients on Sandoglobulin missed days at work/school, with monthly mean absences of 0.4 and 0.5 days (P = 0.805). The feeling of well-being was comparable in both groups. In the ITP study, adverse events with a causal relationship to medication were suspected in six patients on IVIG-N and in seven on Sandoglobulin. In the PID study, three patients on IVIG-N and two on Sandoglobulin experienced possible drug-related adverse events. In both studies, serological and polymerase chain reaction (PCR) tests gave evidence for virus safety. Pharmacokinetics showed constant peak and trough serum IgG levels in all patients, indicating almost steady-state conditions for both formulations. The overall half-life (t1/2) for total IgG was 33 +/- 17 days in the IVIG-N arm and 25 +/- 16 days in the Sandoglobulin arm; for anti-HBsAg t1/2, values were 17 +/- 7 and 17 +/- 9 days, respectively.

CONCLUSIONS

IVIG-N is efficacious, well tolerated and safe in patients with ITP and PID. Its pharmacokinetic properties were comparable to those of Sandoglobulin.

Randomized controlled trials in schizophrenia: a critical perspective on the literature

OBJECTIVE

The randomized trial provides an opportunity to minimize the inclusion of biases in the evaluation of interventions in psychiatry. Difficulties arise, however, when applying their results to 'real world' clinical practice and decision-making. We, therefore, examined the real world applicability of schizophrenia trials.

METHOD

A narrative overview of the content and quality of the randomized trials relevant to the care of those with schizophrenia is provided.

RESULTS

Complex, explanatory, under-powered randomized drug trials dominate evaluative research in schizophrenia.

CONCLUSION

Explanatory designs are a necessary but insufficient step in establishing the true worth of interventions in schizophrenia. Research from other spheres of mental health and wider health care suggest that pragmatic trials are feasible. This design allows large scale trials to be conducted which include patients which we would recognize from routine practice and which record outcomes which are of genuine interest to decision-makers.

Sequential extracts of human bone show differing collagen synthetic rates

Type I collagen is the major bone protein. Little is known quantitatively about human bone collagen synthesis in vivo, despite its importance for the understanding of bone formation and turnover. Our aim was to develop a method that could be used for the physiological and pathophysiological investigation of human bone collagen synthesis. We have carried out preliminary studies in patients undergoing hip replacement and in pigs to validate the use of the flooding dose method using (13)C- or (15)N-labelled proline and we have now refined our techniques to allow them to be used in a normal clinical or physiological setting. The results show that the application of a flooding dose causes bone free-proline labelling to equilibrate with that of blood in pigs and human beings, so that only 150 mg of bone will provide enough sample to prepare and measure the labelling of three fractions of bone collagen (dissolved in NaCl, acetic acid and pepsin/acetic acid) which have the same relative labelling (1.0:0.43:0.1) as measured by GC-combustion-isotope ratio MS. The rates of incorporation were substantially faster than in skeletal muscle samples taken at the same time. The results suggest that different fractions of human bone collagen turnover at markedly higher rates than had been previously considered. This approach should allow us to discover how growth and development, food, activity and drugs affect bone collagen turnover and to measure the effects on it of ageing and bone disease.

Risky business: stories from the field of rural community nurses' work in domestic violence

This paper reports on a descriptive study into family violence in rural Victoria. Focus groups were held in a number of areas across rural Victoria with a total of 24 community nurse participants. The focus groups were audio-taped and the tapes transcribed to enable the clustering of themes. The dominant themes were: picking up cues, helping and helplessness, holding secrets and quiet resistance. Underpinning all these themes however, was the notion of 'risky business'. All nurses in the study gave examples of situations that they encountered; their ways of helping; of working around a system that is unhelpful; and the ways in which their work while skilled, thoughtful and wise, is also costly in terms of the emotional wounds they carry. Rural nurses work with considerable risk and courage as they engage in the care and support of women experiencing family violence.

Women's beliefs about "natural" hormones and natural hormone replacement therapy

OBJECTIVE

To assess women's beliefs about natural hormones, including what they believe the term "natural" means, and their beliefs about the risks, side effects, and efficacy of natural hormone replacement compared to standard hormone replacement.

DESIGN

Eighty-two women completed a 20-item survey available at a local compounding pharmacy. Respondents were white (100%), middle-aged (mean age, 47.22 years), and college educated (95.1%); 32.9% were perimenopausal, and 50.0% were postmenopausal; 58.5% were currently using hormone replacement therapy and, of those, 77.1% were using human bio-identical hormones.

RESULTS

Ninety percent of the respondents ( n = 74) reported that they had heard about natural hormones. Of those, most believed natural meant plant-derived (44.6%) and/or not synthesized or made without chemicals (50.0%). Most reported hearing about natural hormones from a healthcare provider (66.2%) and/or magazines and books (55.4%). When compared with standard hormone replacement, most respondents endorsed the beliefs that natural hormones have fewer or no risks (71.4%), have fewer or no side effects (69.0%), and are equally or more effective for managing menopause symptoms (61.8%). In addition, many endorsed the beliefs that natural hormone replacement is equally or more effective than standard hormone replacement for protection against osteoporosis (47.1%) and heart disease (40.0%), although many endorsed "don't know" for bone (45.7%) and heart (54.3%) protection.

CONCLUSIONS

Among women responding to a survey in a compounding pharmacy, most believed that, compared with standard hormones, natural hormones are safer, cause fewer side effects, and are equally or more effective for symptom management. Many believed natural hormone replacement is equally or more effective for long-term bone and heart protection. Educating women on the nature, risks, and benefits of natural hormone therapy is recommended.

What is the optimal therapy of brain metastases?

The conclusions of a symposium held in London in October 1999 and devoted to the optimal management of brain metastatic disease were: 1. Prognostic factors are: size and number of metastases (and the presence of mass effect); the status of the systemic cancer outside the central nervous system; performance/neurological status; the age of the patient; and the type of cancer. 2. Surgical management of the single, superficially located brain metastasis with symptomatic mass effect is recommended in good performance status patients. Many would follow this routinely by whole brain radiotherapy. 3. Whole brain radiotherapy is often not followed by durable control of the disease and carries morbidity; better management plans are required. In poor prognosis patients the delivery of radiotherapy may not always be indicated. 4. The current literature demonstrates that stereotactic radiosurgery can enhance the likelihood of sterilizing individual brain metastases compared with whole brain radiotherapy alone. 5. The results of questionnaire showed that the histological diagnosis and latency to onset made little difference to the opinion of neuroscience clinicians, who generally favoured stereotactic radiation therapy over whole brain radiotherapy (with or without a conventionally delivered boost) for all patients with less than four metastases. The opinions of oncologists differed. For bronchial and breast cancer patients, whole brain radiotherapy, with or without a boost, was favoured by the majority, particularly in oat cell cancer. However, with a long latency to 'isolated' brain metastasis, oncologists favoured focal radiation therapy. There was a strong preference amongst oncology experts to reserve stereotactic radiation therapy for apparently isolated brain metastasis; this opinion applied to bronchus and breast cancer, and also to melanoma. 6. Whole brain radiotherapy followed by positron emission tomography scanning to determine what viable metastatic disease remained (and potentially treatable by stereotactic/focal technology) was favoured by most of delegates who answered this question.

Mutations in the gene encoding immunoglobulin mu-binding protein 2 cause spinal muscular atrophy with respiratory distress type 1

Classic spinal muscular atrophy (SMA) is caused by mutations in the telomeric copy of SMN1. Its product is involved in various cellular processes, including cytoplasmic assembly of spliceosomal small nuclear ribonucleoproteins, pre-mRNA processing and activation of transcription. Spinal muscular atrophy with respiratory distress (SMARD) is clinically and genetically distinct from SMA. Here we demonstrate that SMARD type 1 (SMARD1) results from mutations in the gene encoding immunoglobulin micro-binding protein 2 (IGHMBP2; on chromosome 11q13.2-q13.4). In six SMARD1 families, we detected three recessive missense mutations (exons 5, 11 and 12), two nonsense mutations (exons 2 and 5), one frameshift deletion (exon 5) and one splice donor-site mutation (intron 13). Mutations in mouse Ighmbp2 (ref. 14) have been shown to be responsible for spinal muscular atrophy in the neuromuscular degeneration (nmd) mouse, whose phenotype resembles the SMARD1 phenotype. Like the SMN1 product, IGHMBP2 colocalizes with the RNA-processing machinery in both the cytoplasm and the nucleus. Our results show that IGHMBP2 is the second gene found to be defective in spinal muscular atrophy, and indicate that IGHMBP2 and SMN share common functions important for motor neuron maintenance and integrity in mammals.

Cerebral sinovenous thrombosis in children

BACKGROUND

Cerebral sinovenous thrombosis in children is a serious disorder, and information is needed about its prevention and treatment.

METHODS

The Canadian Pediatric Ischemic Stroke Registry was initiated in 1992 at the 16 pediatric tertiary care centers in Canada. Children (newborn to 18 years of age) with symptoms and radiographic confirmation of sinovenous thrombosis were included.

RESULTS

During the first six years of the registry, 160 consecutive children with sinovenous thrombosis were enrolled, and the incidence of the disorder was 0.67 cases per 100,000 children per year. Neonates were most commonly affected. Fifty-eight percent of the children had seizures, 76 percent had diffuse neurologic signs, and 42 percent had focal neurologic signs. Risk factors included head and neck disorders (in 29 percent), acute systemic illnesses (in 54 percent), chronic systemic diseases (in 36 percent), and prothrombotic states (in 41 percent). Venous infarcts occurred in 41 percent of the children. Fifty-three percent of the children received antithrombotic agents. Neurologic deficits were present in 38 percent of the children, and 8 percent died; half the deaths were due to sinovenous thrombosis. Predictors of adverse neurologic outcomes were seizures at presentation and venous infarcts.

CONCLUSIONS

Sinovenous thrombosis in children affects primarily neonates and results in neurologic impairment or death in approximately half the cases. The occurrence of venous infarcts or seizures portends a poor outcome.

Clinical diagnostic and intervention studies of children with semantic-pragmatic language disorder

The diagnosis of semantic-pragmatic language disorder (SPLD) has been the subject of a number of research studies over the last two decades. Classification and diagnostic debates, while illuminating, have done little to develop tools to improve services to these children. In this paper, two children whose communication difficulties are suggestive of an SPLD diagnosis but who have differing profiles are studied. Using existing models of psycholinguistics and pragmatics to guide assessment and intervention, the diversity of language and social communicative behaviours that are covered by the label SPLD are exemplified. Consideration is given to whether the term SPLD is appropriate for both children or whether Bishop's revision of the diagnosis to 'pragmatic language impairment' might be more useful. Methods of intervention and evaluation for semantic and pragmatic deficits in these two cases are described. It is argued that existing tools can enable accurate explanation and modelling of the communication of children with SPLD and that there is a role for intervention studies in helping to refine those tools, to improve therapies and to understand the nature of the condition more fully.

Breastfeeding trends at a Community Breastfeeding Center: an evaluative survey

OBJECTIVE

To evaluate the Community Breastfeeding Center's (CBC) impact on clients' breastfeeding experiences.

DESIGN

Retrospective survey; participants were mailed a questionnaire.

SETTING

A hospital-based drop-in center operated jointly by the Wellington-Dufferin-Guelph Health Unit and Headwaters Health Care Center and offering professional breastfeeding support and peer interaction.

PARTICIPANTS

The 164 mothers of singleton births, both inpatients and community clients, who attended the CBC during a 10-month period in 1996-1997 and completed a survey.

MAIN OUTCOME MEASURES

A mailed survey with forced-choice and open-ended questions.

RESULTS

Of the respondents, 90.9% rated their overall CBC experience as excellent or good. Seventy-three percent of respondents breastfed for 4 months or longer. Primiparae and mothers of preterm infants tended to visit the CBC more frequently, while achieving duration rates similar to other subgroups. Returning to work was the reason most frequently cited for stopping breastfeeding (35%).

CONCLUSION

The CBC is an effective community support strategy to lengthen breastfeeding duration and enhance clients' satisfaction with their breastfeeding experience.

The benefits of integrated nursing teams in primary care

This article reports a study in which a literature search, questionnaire study and interviews were used to measure the costs and benefits to patients and professionals when nurses work in integrated nursing teams in primary care. Our study showed that there are significant benefits for the nurses' employers, the primary health-care team, the nurses and the patients. Compared with traditional models, delivery by integrated nursing teams can offer a much higher quality service. Patients can expect to be cared for by a team in which morale is high, communication is good and care is efficient and effective. The team can also offer many specialist services that were not previously available. Integrated nursing teams are most effective when the management savings are used by the teams to meet their professional and client needs. Financial savings, therefore, cannot be expected. The difficulties that arise when such teams are set up should be short-term and surmountable, but will be influenced by the motivation of the team members and the efficiency of the human resource management.

Severe intermittent intraprosthetic regurgitation after mitral valve replacement with subvalvular preservation

Preservation of the subvalvular apparatus during mitral valve replacement preserves left ventricular function and improves long-term survival. Complications of subvalvular preservation include left ventricular outflow tract obstruction and prosthesis impingement. We report a case of severe intermittent intraprosthetic mitral regurgitation detected by transesophageal echocardiography after mitral valve replacement by a bileaflet mechanical prosthesis with subvalvular preservation. Intravalvular prosthetic valve regurgitation was caused by remnants of the subvalvular apparatus, which were shown at reoperation to interfere with prosthetic leaflet motion and which were excised. Postoperative transesophageal echocardiography showed neither abnormal mitral regurgitation nor residual mass. The use of intraoperative transesophageal echocardiography could enable the detection of this rare complication.

Tumour necrosis factor 5' promoter single nucleotide polymorphisms influence susceptibility to rheumatoid arthritis (RA) in immunogenetically defined multiplex RA families

Tumour necrosis factor (TNF) plays a pivotal role in the pathogenesis of rheumatoid arthritis (RA) and it has been shown that the TNF-lymphotoxin (TNF-LT) region influences susceptibility to RA. To investigate the role of the TNF-LT locus further, inheritance of TNF 5' promoter alleles was determined in multiplex RA families. Six previously defined TNF promoter single nucleotide polymorphisms (SNPs) (-238, -308, -376, -857, -863, -1031) were observed in these families and in addition, a heretofore undocumented adenine (A) to cytosine (C) substitution at position -572 relative to the transcription start site was defined. TNF 5' promoter SNPs were found to co-segregate with specific TNF microsatellite haplotypes. In particular, the SNP -308A allele was found to be inherited with the TNF a2, b3, c1, d1, e3 (H2) microsatellite haplotype (P < 0.001) which had previously been found to be associated with RA in individuals heterozygous for the HLA-DR 'shared epitope' (SE). When the data were stratified by the presence of the SE with further stratification according to SE DR subtypes and analysed by transmission disequilibrium test (TDT) for which offspring were assumed independent, the -308A and -857T alleles were found to be associated with RA in patients carrying the SE (P = 0.0076 and 0.0063 respectively). The data were further stratified to analyse for association in individuals homozygous or heterozygous for SE alleles. Results showed that the -308A allele was significantly associated with RA susceptibility in individuals heterozygous for the SE (P < 0.001) with the significance only occurring in patients carrying HLA-DR4 (P < 0.001), while the -857T allele was significant in individuals homozygous for the SE (P = 0.0039). Further analysis using the pedigree disequilibrium test (PDT) which conservatively adjusts for all sources of familial correlation except that conferred by linkage disequilibrium still indicated a significant role for the -308A and -857T alleles. These data provide evidence that TNF promoter SNPs may play an independent role in RA susceptibility in specific immunogenetically-defined groups of RA patients.

Update on family psychoeducation for schizophrenia

The Schizophrenia Patient Outcomes Research Team and others have previously included family psychoeducation and family support in best practices guidelines and treatment recommendations for persons with schizophrenia. In this article we review in detail 15 new studies on family interventions to consider issues around the implementation of family interventions in current practice. The data supporting the efficacy of family psychoeducation remain compelling. Such programs should remain as part of best practices guidelines and treatment recommendations. However, assessment of the appropriateness of family psychoeducation for a particular patient and family should consider (1) the interest of the family and patient; (2) the extent and quality of family and patient involvement; (3) the presence of patient outcomes that clinicians, family members, and patients can identify as goals; and (4) whether the patient and family would choose family psychoeducation instead of alternatives available in the agency to achieve outcomes identified.