Developmental delay of infants and young children with and without fetal alcohol spectrum disorder in the Northern Cape Province, South Africa

OBJECTIVE

To describe the extent and nature of developmental delay at different stages in childhood in a community in South Africa, with a known high rate of Fetal Alcohol Spectrum Disorder (FASD).

METHOD

cohort of infants, clinically examined for FASD at two time periods, 7-12 months (N= 392; 45 FASD) and 17-21 months of age (N = 83, 35 FASD) were assessed using the Griffiths Mental Developmental Scales (GMDS).

RESULTS

Infants and children with FASD perform worse than their Non-FASD counterparts over all scales and total developmental quotients. Mean quotients for both groups decline between assessments across subscales with a particularly marked decline in the hearing and language scale at Time 2 (scores dropping from 110.6 to 83.1 in the Non-FASD group and 106.3 to 72.7 in the FASD group; P = 0.004). By early childhood the developmental gap between the groups widens with low maternal education, maternal depression, high parity and previous loss of sibling/s influencing development during early childhood.

CONCLUSION

The FASD group show more evidence of developmental delay over both time points compared to their Non-FASD counterparts. Demographic and socio-economic factors further impact early childhood. These findings are important in setting up primary level psycho-educational and national prevention programmes especially in periurban communities with a focus on early childhood development and FASD.

Adverse incidents resulting in exposure to body fluids at a UK dental teaching hospital over a 6-year period

Background:

The safety and protection of patients and health care workers is of paramount importance in dentistry, and this includes students in training who provide clinical care. Given the nature of dental care, adverse incidents can and do occur, exposing health care workers to body fluids and putting them at risk of infection, including contracting a blood-borne virus. The aim of this research was to analyze trends in the volume, rate, nature, management, and outcome of adverse incidents reported at one dental teaching hospital from 2005 to 2010.

Methods:

Descriptive analysis of trends in the volume, rate, nature, management, and outcome of adverse incidents reported at one dental teaching hospital over a six-year period was undertaken in relation to the level of outpatient and day surgery activity.

Results:

In total, 287 incidents were reported over a six-year period, which amounted to 0.039% of outpatient or day surgery appointments. Nearly three quarters of all the incidents (n = 208, 72%) took place during treatment or whilst clearing away after the appointment. The most frequent incidents were associated with administration of local anesthetic (n = 63, 22%), followed by burs used in dental hand pieces (n = 51, 18%).

Conclusion:

This research confirms that adverse incidents are a feature of dental hospitals and reports the common sources. The importance of accurate and consistent reporting of data to ensure that these issues are monitored to inform action and reduce risks to staff, students, and patients are highlighted.

Prognostic significance of total disease length in esophageal cancer

BACKGROUND

This study tested the hypothesis that endoluminal ultrasound (EUS) defined total length of disease (including both the primary tumor and the position and number of proximal and distal lymph nodes-ELoD) and the associated EUS lymph node metastasis count (ELNMC) are better predictors of outcome than endoscopic esophageal cancer (OC) length and radiological tumor node metastasis stage in patients who undergo potentially curative treatment with surgery or definitive chemoradiotherapy (dCRT).

METHODS

A total of 645 consecutive patients diagnosed with OC and managed by a multidisciplinary team were staged by CT and EUS. The primary outcome measure was survival from date of diagnosis.

RESULTS

A total of 323 patients received surgery (208 neoadjuvant chemotherapy), and 322 who were deemed unsuitable for surgery received dCRT. Univariable analysis revealed that survival was related to EUS T (p < 0.0001), N (p < 0.0001), EUS primary tumor length (p = 0.037), ELoD (p = 0.011), ELNMC (p < 0.0001), and treatment type (p = 0.001). Multivariable analysis revealed two factors: ELoD (hazard ratio (HR), 0.961; 95 % confidence interval (CI), 0.925-0.998; p = 0.041) and ELNMC (HR, 1.08; 95 % CI, 1.015-1.15; p = 0.016) were independently associated with survival.

CONCLUSIONS

ELoD and ELNMC should become part of routine OC radiological staging to optimize stage-directed therapeutic outcomes.

Open Air Laboratories (OPAL): a community-driven research programme

OPAL is an English national programme that takes scientists into the community to investigate environmental issues. Biological monitoring plays a pivotal role covering topics of: i) soil and earthworms; ii) air, lichens and tar spot on sycamore; iii) water and aquatic invertebrates; iv) biodiversity and hedgerows; v) climate, clouds and thermal comfort. Each survey has been developed by an inter-disciplinary team and tested by voluntary, statutory and community sectors. Data are submitted via the web and instantly mapped. Preliminary results are presented, together with a discussion on data quality and uncertainty. Communities also investigate local pollution issues, ranging from nitrogen deposition on heathlands to traffic emissions on roadside vegetation. Over 200,000 people have participated so far, including over 1000 schools and 1000 voluntary groups. Benefits include a substantial, growing database on biodiversity and habitat condition, much from previously unsampled sites particularly in urban areas, and a more engaged public.

PERP expression stabilizes active p53 via modulation of p53-MDM2 interaction in uveal melanoma cells

The activation and regulation of target genes by the tumour-suppressor p53 dictates the fate of a cell, with cell cycle arrest or apoptosis being two distinct outcomes. PERP (p53 apoptosis effector related to PMP-22), a p53 transcriptional target, is induced specifically during apoptosis but not cell cycle arrest. Downregulation of PERP is associated with the aggressive, monosomy 3-type of uveal melanoma (UM), the most common primary intraocular tumour in adults, and increased PERP expression has a pro-apoptotic effect in UM cells. Here, we identify a novel effect of PERP expression, as elevated PERP protein positively influences active levels of its own transcriptional regulator, p53. Using fluorescent fusion proteins of PERP, p53 and MDM2, we demonstrate in single living UM cells that PERP expression significantly enhances p53 activity and its nuclear localization, increases p53-dependent transcription (including that of MDM2) while allowing oscillatory nucleo-cytoplasmic shuttling of p53/MDM2 complexes. Phosphorylation of p53 serine residues that interfere with the interaction between p53 and its negative regulator MDM2 and enhance pro-apoptotic gene transcription also occurs subsequent to PERP expression. These results implicate a role for PERP in amplifying functional p53 levels that promote p53-dependent apoptosis, and reveal a potential target for exploitation in enhancing p53 activity.

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective

To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non-adherence.

Method

Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence-related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self-reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress.

Setting

Six community pharmacies in the city of Leeds, UK, and patients' homes.

Key findings

A total of 143 patients were recruited and 441 medicine-related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P&lt;0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P&lt;0.001). The proportion of patients who reported non-adherence fell from 38 per cent to 14 per cent (P&lt;0.001).

Conclusion

This study shows that community pharmacists can target patients at risk of medication non-adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non-adherence and should be closely linked with the rest of the primary health care team.

‘Young’ Oral Fibroblasts Are Geno/Phenotypically Distinct

Wound healing within the oral mucosa results in minimal scar formation compared with wounds within the skin. We have recently demonstrated distinct differences in the aging profiles of cells (oral mucosal and patient-matched skin fibroblasts) isolated from these tissues. We hypothesized that the increased replicative potential of oral mucosal fibroblasts may confer upon them preferential wound-healing capacities. Passage-matched early cultures of oral mucosal fibroblasts and skin fibroblasts demonstrated distinct gene expression profiles, with several genes linked to wound healing/tissue repair. This was related to an increased ability of the ‘replicatively younger’ oral mucosal fibroblasts to repopulate a wound space and reorganize their surrounding extracellular matrix environment, key activities during the wound-healing process. We conclude that oral mucosal fibroblasts exhibit a preferential healing response in vivo, due to their ‘replicatively younger’ phenotype when compared with that of patient-matched skin fibroblasts.

Prognostic significance of the endoscopic ultrasound defined lymph node metastasis count in esophageal cancer

The key prognostic factor which predicts outcome after esophagectomy for cancer is the number of malignant lymph node metastases, but data regarding the accuracy of endoscopic ultrasound (EUS) in determining and predicting the metastatic lymph node count preoperatively are limited. The aim of this study was to assess the prognostic significance of EUS defined lymph node metastasis count (eLNMC) in patients diagnosed with esophageal cancer. Two hundred and sixty-seven consecutive patients (median age 63 years, 187 months) underwent specialist EUS followed by stage directed multidisciplinary treatment (183 esophagectomy [64 neoadjuvant chemotherapy, 19 neoadjuvant chemoradiotherapy], 79 definitive chemoradiotherapy, and 5 palliative therapy). The eLNMC was subdivided into four groups (0, 1, 2 to 4, >4) and the primary measure of outcome was survival. Survival was related to EUS tumor (T) stage (P < 0.0001), EUS node (N) stage (P < 0.0001), EUS tumor length (p < 0.0001), and eLNMC (P < 0.0001). Multivariable analysis revealed EUS tumor length (hazard ratio [HR] 1.071, 95% CI 1.008-1.138, P= 0.027) and eLNMC (HR 1.302, 95% CI 1.133-1.496, P= 0.0001) to be significantly and independently associated with survival. Median and 2-year survival for patients with 0, 1, 2-4, and >4 lymph node metastases were: 44 months and 71%, 36 months and 59%, 24 months and 50%, and 17 months and 32%, respectively. The total number of EUS defined lymph node metastases was an important and significant prognostic indicator.

The evidence for the use of oral mucolytic agents in chronic obstructive pulmonary disease (COPD)

INTRODUCTION

Oral mucolytics are now recommended in some treatment guidelines for the management of chronic obstructive pulmonary disease (COPD). This article reviews the evidence for their use and their possible benefits.

SOURCES OF DATA

The review is based upon peer reviewed publications relating to the use of mucolytics in COPD cited in PubMed.

AREAS OF AGREEMENT

Much of the published evidence is of somewhat poor quality and many studies include patients with both chronic bronchitis and COPD. Mucolytics reduce exacerbations by up to 0.8 exacerbations per year, but have little additional benefit in those on standard maximum therapy.

AREAS OF CONTROVERSY

Data that mucolytics improve symptoms, alter mucus or impact health-related quality of life in COPD patients receiving other standard therapy are unconvincing. In those on little or no other treatment, they may reduce exacerbation rate.

GROWING POINTS

The use of mucolytics to treat acute exacerbations is promising.

AREAS TIMELY FOR DEVELOPING RESEARCH

Head-to-head trials of mucolytics versus long-acting bronchodilators and/or inhaled corticosteroids are lacking. Even in patients with severe COPD who remain symptomatic despite maximal inhaled therapy the role of mucolytics remains unproven.

Increased Oral Fibroblast Lifespan Is Telomerase-independent

Oral mucosal wound-healing is characterized by rapid re-epithelialization and remodeling, with minimal scar formation. This may be attributed to the distinct phenotypic characteristics of the resident fibroblasts. To test this hypothesis, we investigated patient-matched oral mucosal and skin fibroblasts. Compared with skin fibroblasts, oral mucosal fibroblasts had longer proliferative lifespans, underwent more population doublings, and experienced senescence later, which was directly related to longer telomere lengths within oral mucosal fibroblasts. The presence of these longer telomeres was independent of telomerase expression, since both oral oral mucosal fibroblasts and skin fibroblasts were negative for active telomerase, as assessed according to the Telomeric Repeat Amplification Protocol. This study has demonstrated that, compared with skin fibroblasts, oral mucosal fibroblasts are ‘younger’, with a more embryonic/fetal-like phenotype that may provide a notable advantage for their ability to repair wounds in a scarless fashion.

Influence of age on outcome after radical treatment of esophageal cancer with surgery or chemoradiotherapy (dCRT)

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Background: To compare the outcomes of stage directed surgical therapy and dCRT, related to age, to determine if there is an age threshold or Age x Treatment Interaction, above which the risks of serious treatment related complications outweigh any potential survival benefit. Methods: Prospective study of 504 consecutive patients managed by a single regional upper GI cancer network with curative intent based on CT, EUS and performance status; 270 underwent surgical based therapy [104 neoadjuvant chemotherapy, 49 neoadjuvant chemoradiotherapy, median age 61 (31–79) yr], and 234 dCRT [68 (41–83) yr]. One hundred and forty- one patients (28%) were aged over 70 years, of whom 40 (28%) underwent surgery, and 101 (72%) dCRT. Analysis was based on intention to treat and the primary measure of outcome was survival. Results: Deaths within 30 days of surgery, median and 5 yr survival were 1%, 30 months and 37% in patients <70 years, compared with 8.1%, 20 months and 18% in patients >70 years. Deaths within 30 days of dCRT, median and 5 yr survival were 0%, 21 months and 20% in patients <70 years, compared with 0%, 21 months and 33% in patients >70 years. On multivariable analysis, EUS T stage (HR 1.33, 95% CI 1.021 to 1.747, p=0.035), EUS defined lymph node metastasis count (HR 1.169, 95% CI 1.044 to 1.308, p=0.007), and age (HR 1.556, 95% 1.095 to 2.211, p=0.014) were independently and significantly associated with survival. There was an age related stepwise incremental increase in the ratio of hazard of death following surgery and dCRT, with a hazard cross-over observed at 69 years of age (Age x Treatment Interaction, 95% CI 62 to 86 yr, p=0.047). Conclusions: Age was an important and significant prognostic indicator and the estimated tipping point at which dCRT conveyed better outcomes than surgery was in the region of 70 years. Elderly patients diagnosed with esophageal cancer are arguably better treated with dCRT than multimodal surgical therapy.

No significant financial relationships to disclose.