Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: a feasibility study and initial results

Parents of children hospitalized with major congenital heart disease often state that the weeks following discharge from hospital are particularly difficult. There is a sudden change from 24-h medical supervision and care to outpatient reviews. Videoconferencing not only gives the family an opportunity to have visual and audio contact with staff but also allows clinicians to visually assess the patient. We have investigated the feasibility of using videoconferencing to provide support for families at home. We also report the early results of a randomized control trial comparing videoconference support with regular telephone support and the current clinic review follow-up.

Polymorphic MLH1 and risk of cancer after methylating chemotherapy for Hodgkin lymphoma

BACKGROUND AND OBJECTIVE

Methylating agents are effective chemotherapy agents for Hodgkin lymphoma, but are associated with the development of second primary cancers. Cytotoxicity of methylating agents is mediated primarily by the DNA mismatch repair (MMR) system. Loss of MLH1, a major component of DNA MMR, results in tolerance to the cytotoxic effects of methylating agents and persistence of mutagenised cells at high risk of malignant transformation. We hypothesised that a common substitution in the basal promoter of MLH1 (position -93, rs1800734) modifies the risk of cancer after methylating chemotherapy.

METHODS

133 patients who developed cancer following chemotherapy and/or radiotherapy (n = 133), 420 patients diagnosed with de novo myeloid leukaemia, 242 patients diagnosed with primary Hodgkin lymphoma, and 1177 healthy controls were genotyped for the MLH1 -93 polymorphism by allelic discrimination polymerase chain reaction (PCR) and restriction fragment length polymorphism assay. Odds ratios and 95% confidence intervals for cancer risk by MLH1 -93 polymorphism status, and stratified by previous exposure to methylating chemotherapy, were calculated using unconditional logistic regression.

RESULTS

Carrier frequency of the MLH1 -93 variant was higher in patients who developed therapy related acute myeloid leukaemia (t-AML) (75.0%, n = 12) or breast cancer (53.3%. n = 15) after methylating chemotherapy for Hodgkin lymphoma compared to patients without previous methylating exposure (t-AML, 30.4%, n = 69; breast cancer patients, 27.2%, n = 22). The MLH1 -93 variant allele was also over-represented in t-AML cases when compared to de novo AML cases (36.9%, n = 420) and healthy controls (36.3%, n = 952), and was associated with a significantly increased risk of developing t-AML (odds ratio 5.31, 95% confidence interval 1.40 to 20.15), but only in patients previously treated with a methylating agent.

CONCLUSIONS

These data support the hypothesis that the common polymorphism at position -93 in the core promoter of MLH1 defines a risk allele for the development of cancer after methylating chemotherapy for Hodgkin lymphoma. However, replication of this finding in larger studies is suggested.

An introduction to Toll-like receptors and their possible role in the initiation of labour

Toll-like receptors (TLR) have emerged as key upstream mediators of inflammation at many tissue sites in humans. Inflammatory processes are involved in the process of parturition suggesting that TLR activity within gestation-associated tissues might have an important role in the initiation and/or maintenance of normal term labour and in various pathological states of pregnancy such as infection-associated preterm labour. Either TLRs or their signalling molecules might be excellent therapeutic targets for prevention of preterm labour.

Determining a strategy for managing radioactive particles in the environment: establishing the BPEO

The United Kingdom Atomic Energy Authority (UKAEA) is in the process of identifying the long-term management strategy for radioactive particles in the environment. Application of the standard best practicable environmental option (BPEO) methodology to this issue is, however, complicated because particles reside in both the on-shore and off-shore environments. Methods for implementation of potential management options may vary due to the differing characteristics of the on- and off-shore environments. A different management option may therefore be required, and furthermore the dynamic interaction between these two environments influences how these options could be combined to provide an overall management strategy. UKAEA has developed the standard BPEO appraisal process so that distinct management options for both environments are initially assessed separately. This allows identification of the key issues that influence how they are combined into an overall management strategy. Over the last two years the public consultation on this issue has progressed substantially and therefore the paper presented at the Nairn conference in 2005 has been revised to take into account the work carried out to date.

Assessing the environmental risk from hot particles in the vicinity of Dounreay--a case for inaction?

This study assesses the impact on species other than humans associated with radioactive particles present in the marine environment close to the UKAEA Dounreay site, through a review of marine survey data, to establish the distribution of species and the likelihood of encountering a particle, and considering retention, dissolution or absorption of the particle. Assumptions are made regarding particle density, distribution, size and bio-availability of the radioactive materials. From this, impacts are assessed against the likelihood of mortality or other significant harm to individuals and interpreted in terms of local populations. Results obtained indicate that no significant impact, at the population level, is likely to be observed. This does not preclude that some individuals will be affected. It does, however, suggest that any decision to remediate, if based predominantly on environmental considerations, should be cognisant of the damage caused by remediation itself and subsequent exploitation of the environment by humans.

An open, randomized, controlled, phase II, single centre, two-period cross-over study to compare the quality of life and toxicity experienced on PEG interferon with interferon-α2b in patients with multiple myeloma maintained on a steady dose of interferon-α2b

PURPOSE

To compare the effects of pegylated interferon-alpha2b (P-IFN) and interferon-alpha2b (IFN) on quality of life (QoL) and toxicity in patients with multiple myeloma maintained on a steady dose of IFN.

PATIENTS AND METHODS

Consenting, eligible myeloma patients on IFN maintenance therapy for at least 6 weeks were randomly (1:1) allocated to receive P-IFN for 3 months followed by IFN for 3 months, or to continue with IFN for 3 months followed by P-IFN for 3 months (cross-over design). Patients were assessed for toxicity and QoL. Dose of P-IFN was equivalent to IFN.

RESULTS

The study enrolled 60 patients. At enrollment, 35 patients were in complete remission, 20 in partial remission and 5 were minimal responders. P-IFN was associated with significantly better global QoL score (mean difference 8.4; P = 0.0002). There was a significant improvement in functional scales--physical (P = 0.03), emotional (P = 0.04), social (P = 0.0008) with P-IFN. Fatigue (P = 0.0003), pain (P = 0.02) and appetite loss (P = 0.003) symptom scales were less in patients while on P-IFN. There were no statistically significant differences between treatment arms in QoL as measured by QLQ-MY24.

CONCLUSION

These data suggest that patients on P-IFN have a better QoL. Dose escalation studies are warranted to investigate potential impact on survival.

Prophylactic defibrotide in allogeneic stem cell transplantation: minimal morbidity and zero mortality from veno-occlusive disease

Veno-occlusive disease (VOD) is a common and high-risk complication of allogeneic stem cell transplantation (SCT). Defibrotide has recently been used successfully to treat the disorder. We report on 58 patients who received defibrotide prophylaxis without concurrent heparin. No patients fulfilled the Baltimore criteria for VOD or died of the condition within 100 days of SCT. None of this group developed haemorrhagic complications secondary to defibrotide. These observations suggest that prophylaxis with defibrotide alone may reduce the incidence of VOD post-SCT although a randomised controlled trial is warranted to further evaluate its role.

Use of physiological doses of human growth hormone in haematological patients receiving intensive chemotherapy promotes haematopoietic recovery: a double-blind randomized, placebo-controlled study

In vivo and in vitro studies suggest human growth hormone (hGH) receptors on bone marrow stem cells may be biologically active and could be exploited to promote haemopoetic recovery after intensive chemotherapy. Patients with haematological malignancies receiving intensive chemotherapy and requiring hospitalization were randomized in a double-blind, placebo-controlled single-centre trial. Patients were randomly assigned to receive either hGH 500 microg/day or placebo, for 6 weeks. There was no significant difference in patient characteristics at baseline between the placebo and treatment arms. Patients treated with hGH showed significantly faster recovery of platelets to 25 x 10(9)/l (median of 16 versus 19 days; P = 0.03) compared to the placebo-controlled arm (hazard ratio 1.47 favouring hGH, 95% confidence interval (CI), 1.03-2.08). Time to relapse did not differ significantly between arms. There was no change in the anthropometric parameters at the start and end of hGH/placebo therapy. The study drug was well tolerated. Treatment with hGH in physiological doses improves platelet recovery, but is not associated with a lower relapse rate or improved anthropometric parameters in patients receiving intensive chemotherapy.

Childhood asthma and return to school in Sydney, Australia

OBJECTIVES

To describe the seasonal pattern of hospital admissions for childhood asthma in Sydney, Australia and investigate the relationship between these admissions and time of return to school.

STUDY DESIGN

Time-series analysis of daily hospital admissions for childhood asthma in Sydney from 1994 to 2000.

METHODS

We defined the time series of all asthma-related hospital admissions in Sydney between 1994 and 2000 for age groups 1-4 and 5-14 years. We analysed the time series for each age group using a generalized additive model with a log-link function, an offset term and quasi-likelihood estimation. Daily admissions were modelled using penalised regression splines adjusting for long term trends, school terms and holidays, weekday and influenza epidemics.

RESULTS

After adjusting for potential confounding, the risk of asthma admission increased to a peak between 2 and 4 weeks after the first day of school in each term and varied between 1.5 and 3 times the risk prior to return to school for both age groups. The largest increase in asthma risk occurring in term one after the long summer holiday. The increase in admission risk began soon after the first day of school of each term for school age children 5-14 years, but not in pre-school age children 1-4 years.

CONCLUSIONS

Returning to school after term holidays is strongly associated with increased risk of hospital admissions for asthma in children, especially following the long summer holiday. Preventive measures focused on return to school have the potential to substantially decrease admissions for asthma in children.

International uniform response criteria for multiple myeloma

New uniform response criteria are required to adequately assess clinical outcomes in myeloma. The European Group for Blood and Bone Marrow Transplant/International Bone Marrow Transplant Registry criteria have been expanded, clarified and updated to provide a new comprehensive evaluation system. Categories for stringent complete response and very good partial response are added. The serum free light-chain assay is included to allow evaluation of patients with oligo-secretory disease. Inconsistencies in prior criteria are clarified making confirmation of response and disease progression easier to perform. Emphasis is placed upon time to event and duration of response as critical end points. The requirements necessary to use overall survival duration as the ultimate end point are discussed. It is anticipated that the International Response Criteria for multiple myeloma will be widely used in future clinical trials of myeloma.

Parainfluenza type 3 infection post stem cell transplant: high prevalence but low mortality

Parainfluenza type 3 (PIV 3) is a well-recognized cause of respiratory illness after stem cell transplantation (SCT), with an estimated incidence of 2-7% and a high mortality rate associated with lower respiratory tract infection (LRTI). A 12-month retrospective study was undertaken in which 23 positive cases of PIV 3 occurred in SCT recipients. The frequency of infection was 36.1% in matched unrelated donor SCT recipients, 23.8% in sibling allogeneic SCT recipients and 2.3% in autologous transplant recipients. Seventeen cases were outpatient or community acquired despite standard infection control measures. Eleven patients only developed upper respiratory tract symptoms. LRTI symptoms developed in 12 patients, of whom eight had a new infiltrate on chest X-ray. Overall mortality at 30 days from PIV 3 diagnosis was 4% (one patient). Four patients died within 100 days of PIV 3 diagnosis, but PIV 3 was not believed to be the primary cause of death in any of these patients. Early ribavirin was used in eight patients and only one patient who received ribavirin died. These results suggest a higher prevalence of PIV 3 but a lower mortality than documented previously, particularly in allogeneic transplant recipients. The authors propose that the high prevalence reflects the unit's policy of active surveillance for respiratory viruses and the difficulty in preventing transmission of PIV 3, especially in the outpatient setting during an outbreak period. Ribavirin treatment may improve outcome in patients with LRTI but is not required in all patients with PIV 3.

Computer Controlled Pneumatic Servo Drives

This paper describes how microprocessor-based controls can be used to produce low cost pneumatic servo drives which could find wide application in manufacturing industries. The approach incorporates digital compensation for system non-linearities so that, when positioning loads in a ‘point to point’ mode, it is possible to achieve a significant improvement in both the static and dynamic performance of the drive.

For the compensation algorithms implemented a theoretical foundation is presented based on a linearized model of pneumatic drives. The paper also describes how microprocessor-based hardware and software have been constructed to evaluate performance criteria. This test facility has allowed the software implementation of the compensation algorithms to be refined so that satisfactory performance can be achieved with both translational and rotational drives utilizing various forms of transmission. The test facility has also allowed various control system elements to be evaluated so that pneumatic drives suitable for industrial application, can be specified.

Using gender analysis to build voluntary counselling and testing responses in Kenya

The rapid expansion of voluntary counselling and testing (VCT) for HIV in sub-Saharan Africa has led to concerns over the quality and equity of the services. Kenya has seen an unprecedented scale-up of VCT, and valuable lessons have been learnt at national as well as at district and community levels. We combined quantitative and qualitative research methodology and showed how the results of gender analysis can be used to develop equity in VCT scale-up. A gender-disaggregated analysis of VCT client data was conducted for the first 8 months of 2003. These quantitative data revealed that despite an increased vulnerability to HIV, women are underrepresented in VCT sites in all settings in Kenya. Our data also showed that women were also less likely to use condoms or to take home condoms after a VCT visit than their male counterparts. Further exploration through in-depth qualitative work with women and men allowed a better understanding of the reasons behind gender differences in Kenyan VCT sites and helped to develop strategies to address gender inequity. We conclude that there is an ongoing need to mainstream gender in monitoring and evaluation strategies to ensure services meet the needs and priorities of all groups.

Analysis of renal service provision in south and mid Wales

OBJECTIVES

This paper estimates point prevalence of renal replacement therapy (RRT) utilization within population strata defined by geography and deprivation in south and mid Wales. It investigates spatial accessibility of main and satellite renal units by comparing population and patient numbers within bands of travel time.

STUDY DESIGN

Prevalence study based on patient registers.

METHODS

From a list of patient and renal unit locations, geocoded at the level of unit postcodes, and electoral division-level denominator population data, we calculated RRT point prevalence for the 16 unitary authorities in the study area, fifths of small area deprivation, and three bands of travel time from the nearest main renal unit and any (main or satellite) unit.

RESULTS

Overall point prevalence was 633 per million population (pmp) and this varied from 256 to 780 pmp across unitary authorities. RRT prevalence was lower in more deprived areas. Sixty-nine percent of the population and 73% of patients lived within 30 min of a main renal unit. Eighty-four percent of the population and 88% of patients lived within 30 min of a main or satellite renal unit.

CONCLUSIONS

The provision of satellite renal units has significantly improved spatial accessibility of RRT services. However, a substantial proportion of the population remains geographically distant from renal units. This has important implications for planning of future provision of RRT, given the inverse relationship between RRT acceptance and travel time, and the impact on quality of life of patients who travel frequently to renal units.

Impact of ambient air pollution on birth weight in Sydney, Australia

BACKGROUND

Studies in Asia, Europe, and the Americas have provided evidence that ambient air pollution may have an adverse effect on birth weight, although results are not consistent.

METHODS

Average exposure during pregnancy to five common air pollutants was estimated for births in metropolitan Sydney between 1998 and 2000. The effects of pollutant exposure in the first, second, and third trimesters of pregnancy on risk of "small for gestational age" (SGA), and of pollutant exposure during pregnancy on birth weight were examined.

RESULTS

There were 138,056 singleton births in Sydney between 1998 and 2000; 9.7% of babies (13,402) were classified as SGA. Air pollution levels in Sydney were found to be quite low. In linear regression models carbon monoxide and nitrogen dioxide concentrations in the second and third trimesters had a statistically significant adverse effect on birth weight. For a 1 part per million increase in mean carbon monoxide levels a reduction of 7 (95% CI -5 to 19) to 29 (95% CI 7 to 51) grams in birth weight was estimated. For a 1 part per billion increase in mean nitrogen dioxide levels a reduction of 1 (95% CI 0 to 2) to 34 (95% CI 24 to 43) grams in birth weight was estimated. Particulate matter (diameter less than ten microns) in the second trimester had a small statistically significant adverse effect on birth weight. For a 1 microgram per cubic metre increase in mean particulate matter levels a reduction of 4 grams (95% CI 3 to 6) in birth weight was estimated.

CONCLUSION

These findings of an association between carbon monoxide, nitrogen dioxide, and particulate matter, and reduction in birth weight should be corroborated by further study.

A health impact assessment of increased aspirin use in Wales

AIM

To estimate the likely magnitude of health impact if all individuals at increased risk of cardiovascular events in Wales (total population 2.9 million) took low-dose aspirin.

METHODS

Data from a variety of different sources were collected and systematically combined using simple methods and conservative assumptions.

RESULTS

Aspirin may reduce cardiovascular mortality by 2-25% and avoid 330-3250 deaths per annum after allowing for a small number of fatal undesirable effects.

COMMENT

Wales might lead the way in developing an aspirin programme.