Asthma severity and inflammation markers in children

The relationship of airway inflammation with asthma severity remains unclear. Our aim was to correlate the results of recommended methods of assessment of inflammation with measures of asthma control, in children with a wide range of asthma severity. The study was a cross-sectional investigation of 58 children receiving a wide range of treatment, including 10 treated without regular maintenance therapy and 29 treated with high-dose inhaled corticosteroids (CS). Exhaled nitric oxide (NO), serum eosinophil cationic protein (ECP), and induced sputum (processed for eosinophil count and ECP level) were related to recent symptoms, lung function, and bronchial responsiveness. There was no significant correlation between the results of any

METHOD

Neither did any marker of airway inflammation relate to recent symptoms, unlike PC20, which did. There was a significant, inverse correlation between the forced expiratory volume in 1 s (FEV1) and both NO and sputum ECP (r=-0.46, p=<0.001; r=-0.48, p=0.004, respectively). Sputum eosinophils were inversely related to the dose of methacholine that corresponded to a 20% fall in FEV1 (PC20) (r=-0.57, p=0.02). Serum ECP did not relate to any measure of asthma control. There was no association of any recommended inflammation markers with current symptoms and only a weak relationship between them and physiological measures. The place of these markers remains unclear and their use in clinical practice needs further investigation by long-term longitudinal studies.

Tightening the net: children, community, and control

The recent move to revitalize social democracy in the UK under the New Labour government, explored by Giddens as 'the Third Way', embraces many of Etzioni's ideas on communitarianism. The principles that emerge from these political philosophies, such as the involvement of local communities in policy consultations and implementation, have largely been welcomed as a reflection of the aim of revitalizing civic society in the context of a range of social policies. It is argued, however, that for children, contrary to this general trend, many of these policies represent attempts to increase the social control of children. Their effect has been to restrict children's agency and their rights, rather than to increase their participation as citizens, and thus,in spite of the requirements of the UN Convention on the Rights of the Child, children continue to be marginalized.

Evidence for different subgroups of difficult asthma in children

BACKGROUND

Children with difficult asthma experience frequent symptoms despite treatment with high dose inhaled steroids. Persistent symptoms may result from persistent airway inflammation which can be monitored by measuring exhaled nitric oxide (NO). This study aimed to assess the role of airway inflammation, using NO as a surrogate, in children with difficult asthma and to investigate the response to oral prednisolone.

METHODS

NO was measured in 23 children (mean age 11.7 years) with difficult asthma, before and after 2 weeks of treatment with oral prednisolone. The clinical response was assessed by spirometric tests, peak flow, bronchodilator use, and symptoms. Adherence to treatment was assessed by measuring serum prednisolone and cortisol concentrations. NO was measured in 55 healthy children to establish a normal range.

RESULTS

NO concentrations were higher in asthmatic patients than in controls (geometric mean 11.2 v 5.3 ppb, p<0.01). Using grouped data, the concentration of NO fell following prednisolone (11.2 v 7.5 ppb, p<0.01) accompanied by an improvement in morning peak flow (p<0.05). The baseline NO concentration was raised (>12.5 ppb) in nine asthmatic patients and remained high after prednisolone in five. Thirteen had normal levels of NO (<12.5 ppb) before and after prednisolone. Thirteen asthmatic patients remained symptomatic following prednisolone; NO levels were raised on both occasions in five of these and were normal in seven.

CONCLUSIONS

As a group, the asthmatic subjects demonstrated evidence of airway inflammation which responded to prednisolone. At least two subgroups of patients were identified: one with persistently raised NO levels despite treatment with oral prednisolone indicating ongoing steroid insensitive inflammation, and another with normal levels of NO. Both subgroups included patients with persistent symptoms, which suggests that different patterns of difficult asthma in children exist.

Association between quantitative traits underlying asthma and the HLA-DRB1 locus in a family-based population sample

The region of human chromosome 6 containing the MHC has been identified as influencing asthma and atopy (allergy) by several genome-wide searches. The MHC contains many genes with potential effects on innate and specific immunity. As a first step in dissecting MHC influences on asthma and its underlying quantitative phenotypes, we have examined the HLA-DRB1 locus in a population sample consisting of 1004 individuals from 230 families from the rural Australian town of Busselton. The locus was strongly associated with the (log(e)) total serum IgE concentration, accounting for 4.0% of the sigma(2) (variance) in that trait (multi-allelic test, P=0.00001). The locus also influenced specific IgE titres to common allergens (multi-allelic tests, 2.8% sigma(2) for the house dust mite allergen Der p I, P=0.0013; 3.0% of sigma(2) for Der p II, P=0.0007; and 2.1% of sigma(2) for the cat allergen Fel d I, P=0.014). No associations were found to the categorical phenotype of asthma, or to the quantitative traits of peripheral blood eosinophil counts and bronchial hyper-responsiveness. Transmission disequilibrium tests excluded genetic admixture as a cause of false-positive findings. The results indicate that HLA-DRB1 alleles modulate the total serum IgE concentration and IgE responses to allergens, but do not account for the previous observations of linkage of asthma to the MHC.

Frequency and site-dependent variations in vibration detection thresholds on the face

An adaptive psychophysical procedure was used to estimate the vibration detection threshold at seven spatially matched sites on the two sides of the face and at one scalp site. Repeated measurements over six testing sessions were made for stimuli vibrating at 1, 10 and 100 Hz for each of 21 neurologically healthy, young adult females. Approximately 14 stimulus trials were required to obtain each estimate of the threshold amplitude. Thresholds varied as a function of frequency (p < 0.0001), side (p < 0.001) and site (p < 0.0001). Compared to stimulation at 100 Hz at which the estimates were lowest, thresholds were 3.1 times greater at 10 Hz and 5.4 times greater at 1 Hz. Thresholds were lowest on the vermilion and highest on the cheek and chin. The preauricular skin and scalp exhibited an intermediate level of sensitivity. Whereas thresholds were comparable on the two sides of the face for stimulation at 1 Hz, they averaged 1.33 times greater on the right side for stimulation at 10 and 100Hz. Moreover, thresholds obtained during the last two sessions were 16% higher than those obtained during the first two sessions (p < 0.02), suggesting that subjects on average became more conservative in reporting the presence of the stimulus. The sensitivity in discriminating differences in tactile function favors use of the rapidly administered testing procedure in a clinical setting.

Audit of percutaneous endoscopic gastrostomy (PEG): a questionnaire survey of hospital consultants

One of the commonest indications for PEG is nutritional support in dysphagia. We investigated the current practice of PEG insertion in South Wales (UK). A postal questionnaire was sent to hospital consultants with responsibility for acute medical/geriatric intake in the South Wales area. Eighty-eight of 114 (78.5%) responded. In 69 of 107 (65%) responses (Radiologists and Geriatricians also performed PEG in some hospitals) Gastroenterologists performed the insertion of PEG. Seventy-one (87%) always involved speech therapists before PEG insertion. Forty-five (55%) and 47 (57%) always involved dieticians and nurses, respectively. Eighty (92%) involved carers before PEG. Sixty-three (76%) used nasogastric feed for nutritional support before PEG. Thirty-six of 80 (45%) responses would wait more than 2 weeks before inserting PEG (range less than 7 days to more than 6 weeks). Five (6.5%) preferred long-term nasogastric feed to PEG. Twenty-five (30%) had definite knowledge of a PEG clinic in their hospital and 38 of 77 (49%) who responded to this question said there was no routine follow-up or were not aware about follow up of PEG patients. There is wide variation in the timing of PEG insertion and involvement of paramedical staff. More research needs to be undertaken to provide evidence so guidelines can be developed in this area. Follow up of patients with PEG is poor but current evidence suggests follow up of these patients may be worth while as some patients with dysphagic stroke can regain their swallow late.

Social desirability scores are associated with higher morning cortisol levels in firefighters

OBJECTIVE

To examine the association of social desirability (SD) responding ("defensiveness") and cortisol levels.

METHODS

Marlowe-Crowne SD scores and morning salivary cortisol were measured in firefighters.

RESULTS

SD scores were associated with higher cortisol levels (r=.28) in 60 firefighters under age 45, but not in 25 older firefighters (or the combined sample).

CONCLUSION

The results are consistent not only with SD scores being an indicator of coarctation of experience as a coping mechanism, but also (at least for younger persons) perhaps a risk factor for the psychobiological dysfunctions associated with chronic elevations of cortisol.

Induction of matrix metalloproteinases MMP-1 and MMP-2 by co-culture of breast cancer cells and bone marrow fibroblasts

Two invasive breast cancer cell lines (MDA-MB-231 and BT-549) were found to be more adherent and have greater migratory capacity on bone marrow fibroblasts than three non-invasive cell lines (MCF-7, T47D and BT-483). Antibodies to the adhesion molecules CD44, E-cadherin, ICAM- 1, and integrin chains alpha2, alpha3, alpha4, alpha5, alpha6, alpha v, beta1, beta3 and beta7 failed to inhibit breast cancer cell migration through bone marrow fibroblasts. Inhibitors of matrix metalloproteases, 1, 10-phenanthroline, Ro-9790, TIMP-1 and TIMP-2 were able to attenuate the migration of MDA-MB-231 cells through bone marrow fibroblast monolayers suggesting a role for these enzymes in the migration of breast cancer cells through bone marrow adherent layers. Co-culture of MDA-MB-231 cells and bone marrow fibroblasts resulted in augmentation of the levels of the matrix metalloproteases MMP-1 and MMP-2 in culture supernatants. Soluble factors produced by bone marrow fibroblasts were responsible for the increase in MMP-1 levels. However, maximal MMP-2 production was dependent on direct contract between the breast cancer cells and the bone marrow fibroblasts. Modulation of MMP production by cell-cell contact or soluble factors suggests a mechanism by which breast cancer cells can enhance their ability to invade the bone marrow microenvironment.

Segregation analysis of the specific response to allergens: a recessive major gene controls the specific IgE response to Timothy grass pollen

Segregation analysis of the specific response to allergens (SRA) was performed in a sample of 234 randomly selected Australian families using the regressive models. Various SRA phenotypes were considered using broad and narrow definitions of these phenotypes, according to the type of test used, skin test or RAST test, and the specificity of the response to allergen. Strong evidence for familial dependencies among blood relatives was shown for most SRA phenotypes, especially when using a broad definition. There was no evidence for a Mendelian factor accounting for the familial transmission of these broadest phenotypes, which may involve multiple factors preventing the clear detection of a major effect with Mendelian transmission. However, segregation of a Mendelian recessive major gene was detected for one SRA sub-phenotype, the IgE response to a single allergen, Timothy grass pollen, measured by the RAST test. Identification of a specific SRA phenotype controlled by a major gene may have important implications for further linkage studies.

(E)-1-alkyl-4-

(E)-1-Alkyl-4-[2-(alkylsulfonyl)-1-ethenyl]pyridinium salts were synthesized in two steps. These sulfones were stable at pH 7.3 and underwent a nucleophilic vinylic substitution (S(N)V) with mercaptans, including thiouracile, to give the corresponding 4-(thiovinyl)-pyridinium salts. The X-ray diffraction structure of (E)-1-methyl-4-[2-(ethylsulfanyl)-1-ethenyl]pyridinium iodide indicated conjugation of the sulfur with the pyridinium ring. (Z)-1-Methyl-4-[2-(methylsulfanyl)-1-ethenyl]pyridinium iodide, prepared from the corresponding thioether by reaction with methyl iodide in diethyl ether, underwent isomerization to the E isomer in a first-order reaction in deuterated [D6]DMSO with an activation energy of 14 kcalmol(-1). At pH 7, the (E)-1-methyl-4-[2-(methylsulfonyl)-1-ethenyl]pyridinium iodide (19) reacted specifically with thiols. The reaction of this sulfone with glutathione in a TES buffer at pH 7 was a second-order reaction (k = 4,100 M(-1)s(-1) at 30 degrees C) and gave the corresponding substitution product with an intense long wavelength absorption band (lambdamax=360 nm, epsilon = 27,500 M(-1)cm(-1)). The modification of different enzymes of known structure with 19 showed the high selectivity of this reagent towards thiol groups and its usefulness in the quantitative determination of free thiol groups in proteins.

Airway smooth muscle in health and disease; methods of measurement and relation to function

Smooth muscle is present and probably functional in the airways in utero and increases in absolute area during growth with little further change during adulthood. It encircles the entire airway below the level of the main bronchus, in a roughly circular orientation, except at high lung volumes. It occupies relatively more of the airway wall in the peripheral airways, reaching a maximum in the membranous bronchioles. Measurement of smooth muscle area in the airway wall is confounded by clinical classification of cases, methods of tissue retrieval and preparation, staining and orientation of sections, magnification, image analysis and statistical methods of comparison between groups. Airway smooth muscle area is pathologically increased in inflammatory conditions of the airways such as chronic obstructive pulmonary disease, in relation to airways obstruction, and asthma, in relation to severity and airway size (between 25 and 250% compared with control cases). It is increased in sudden infant death syndrome, but there are few studies in other conditions such as bronchiectasis. In asthma, smooth muscle must shorten (not necessarily to an abnormal degree) for the structural abnormalities of the airway to manifest as excessive airway narrowing. Not surprisingly there is renewed interest in the relationships between the mechanical and contractile properties of smooth muscle, parenchymal properties and lung volume and how these interact to determine smooth muscle length. The relative importance of smooth muscle area and mechanical properties, altered airway structure and airway inflammation in disease are yet to be determined.

A two-rate hypothesis for patterns of retention in psychosocial treatments of cocaine dependence: findings from a study of African-American men and a review of the published data

In this article, we examine patterns of retention in psychosocial treatment programs for cocaine dependence. We present new data from a comparison trial of Drug Counseling and Supportive-Expressive Psychotherapy and review published data from all studies utilizing psychosocial interventions alone. We compared Drug Counseling and Psychotherapy on rates of pretreatment and during-treatment attrition in a sample of 294 African-American men seeking treatment for cocaine dependence (mean age, 37.6). Survival analyses were utilized to identify significant differences in during-treatment attrition between the two treatments and to identify significant changes in the rate of attrition during the course of each treatment. We then compared the patterns of retention in this study with those from other available published reports of psychosocial treatments for cocaine abuse. The weekly during-treatment attrition rate was not constant in either treatment condition, and the change in rate of attrition occurred at week six for both Drug Counseling and Psychotherapy. Comparison with other studies suggested that the during-treatment pattern of attrition among most psychosocial treatments for cocaine abuse is typified by two rates, with the rate of subject attrition early in treatment being greater than the rate of later attrition and also exhibiting greater variance. Future studies of treatment retention should identify significant shifts in the rate of during-treatment attrition, examine if the pattern of attrition is typified by two rates, and, if so, determine where the shift occurs. Future studies should also assess if changes in the rate of during-treatment attrition signal the timeframes within which strategies that enhance retention can be implemented in the treatment program.

Exhaled carbon monoxide in childhood asthma

OBJECTIVES

Oxidative stress and inflammation induce the expression of heme oxygenase-1, which produces carbon monoxide (CO), and nitric oxide synthase, which produces nitric oxide (NO). Exhaled CO and NO levels are elevated in asthmatic patients and are decreased after corticosteroid treatment, suggesting that they may be useful as noninvasive markers of airway inflammation.

STUDY DESIGN

We measured forced expiratory volume in the first second, PC(20), and exhaled CO and NO levels in 29 children (18 boys, mean age 11.5 +/- 0.53 years) with asthma of different severity and 40 nonsmoking children without asthma (21 boys, mean age 8.1 +/- 0.35 years). We also studied whether upper respiratory tract infections were associated with elevated exhaled CO.

RESULTS

Exhaled CO levels (ppm) were significantly higher (2.17 +/- 0.21) in children with persistent asthma compared with those in children with infrequent episodic asthma (1.39 +/- 0.18, P <.05) and healthy children (1.01 +/- 0.12, P <.001). The CO levels in children with infrequent episodic asthma and the normal control group, however, were not different. In contrast, exhaled NO levels (ppb) were higher in children with persistent asthma (24.2 +/- 5.9, P <.001) and infrequent episodic asthma (14.5 +/- 3.73, P <.05) than in normal subjects (5.1 +/- 0.24), but no significant difference was seen between the 2 asthmatic groups. In healthy children with upper respiratory tract infections (n = 12), exhaled CO concentrations were significantly elevated (2.16 +/- 0.33) during the acute symptomatic phase. No correlation was found between exhaled CO and forced expiratory volume in the first second or PC(20).

CONCLUSIONS

Noninvasive measurement of exhaled CO may provide complementary data for assessment of asthma control in children. However, elevated CO levels are nonspecific and may be found in association with an acute viral illness.

Nitrotyrosine formation in the airways and lung parenchyma of patients with asthma

BACKGROUND

Recent evidence has shown that nitric oxide (NO) levels are increased in asthmatic airways. Although the role of NO in asthma is unknown, reactive metabolites of NO may lead to nitrotyrosine formation and promote airway dysfunction.

OBJECTIVE

The aim of this study was to determine whether nitrotyrosine, as a marker of nitrating species, could be found in the airways and lung parenchyma of subjects with asthma who died of status asthmaticus or other nonrespiratory causes.

METHODS

Lung tissue specimens were obtained from 5 patients who died of status asthmaticus, 2 asthmatic patients who died of nonrespiratory causes, and 6 nonasthmatic control subjects who died of nonrespiratory causes. Lung sections were stained for immunofluorescence with use of an antinitrotyrosine antibody, followed by a indiocarbocyanine (Cy5, Jackson Immunochemicals, Westgrove, Pa)-conjugated secondary antibody.

RESULTS

Nonasthmatic lungs showed little or no nitrotyrosine staining, whereas asthmatic lungs demonstrated significantly more staining of nitrotyrosine residues distributed in both the airways and lung parenchyma.

CONCLUSION

This study demonstrates the presence of nitrotyrosine, and hence evidence of formation of nitrating species, in the airways and lung parenchyma of patients with asthma who died of status asthmaticus or other nonrespiratory causes. This finding supports the concept that widespread airway and parenchymal inflammation occurs in asthma, and, more specifically, that NO and its reactive metabolites may play a pathophysiologic role in asthma.

Do adolescents who take overdoses have specific psychological characteristics? A comparative study with psychiatric and community controls

OBJECTIVE

To determine whether specific psychological factors characterize adolescents who take overdoses.

METHOD

Measures of problem-solving, depression, anger, impulsivity, and self-esteem were investigated in 33 adolescents after an overdose, 30 psychiatric controls, and 30 community controls, the groups being matched for age and sex. All subjects were interviewed twice, 6 weeks apart. The first interview in the overdose group followed an overdose.

RESULTS

Significant differences were found between the 3 groups on all of the variables at both interviews. However, when depressive affect (Beck Depression Inventory) was controlled for, all of these differences disappeared, except for impulsivity at the second interview. Here the overdose group remained more impulsive than the other groups even when depression was considered.

CONCLUSIONS

Depression is the most important factor in the presentation of a range of psychological characteristics of adolescents who take overdoses, and this remains true at 6-week follow-up. Impulsivity is apparently an important factor, independent of depression, in adolescent self-poisoning. Further research is required to determine the mediating role of impulsivity in this behavior and to identify treatment strategies for it.

Extended tumour necrosis factor/HLA-DR haplotypes and asthma in an Australian population sample

BACKGROUND

Tumour necrosis factor (TNF) is a potent pro-inflammatory cytokine which is prominent in asthmatic airways. TNF shows genetic variations in secretion which are linked to polymorphisms in the TNF gene complex and the surrounding major histocompatibility (MHC) locus. These polymorphisms do not seem to be themselves functionally important. In these circumstances, the identification of disease associated haplotypes (combination of alleles on individual chromosomes) may narrow the search for polymorphisms which alter gene function.

METHODS

TNF-308, LTalpha NcoI, and HLA-DRB1 polymorphisms were investigated for association with asthma, bronchial responsiveness, and medication use in 1004 subjects in 230 families from a general population sample.

RESULTS

The common LTalpha NcoI*1/TNF-308*2/HLA-DRB1*03 haplotype, which was present in 11% of unrelated individuals, was weakly associated with asthma (OR = 1.38, p = 0.016, corrected for familial correlation). The rarer LTalpha NcoI*1/TNF-308*2/HLA-DRB1*02 haplotype, which was found in 0.6% of unrelated subjects, was more strongly associated with asthma (OR = 6.68, p = 0.002). This haplotype also showed association with bronchial hyperresponsiveness (OR = 21.9, p = 0. 0000) and the use of inhaled or oral steroids (OR 8.0, p = 0.04).

CONCLUSIONS

The results of this study show only two extended TNF/HLA-DR haplotypes to be associated with asthma. The search for functional alleles responsible for an increased risk of asthma should concentrate on the LTalpha NcoI*1/TNF-308*2/HLA-DRB1*02 haplotype.

Psychophysical assessment of the affective components of non-painful touch

A novel psychophysical procedure for the evaluation of the affective components of touch was developed. A fabric material was stroked across the test site at a controlled direction and velocity, after which the subject provided a numerical estimate of pleasantness. Significant differences were detected for the sites tested (FACE vs ARM), the fabric materials used (VELVET, COTTON and PLASTIC MESH), and the velocity of motion (0.5, 5 and 50 cm/s). Attesting to their validity, estimates of pleasantness correlated negatively with estimates of unpleasantness obtained for the same stimuli. Moreover, subjects were reasonably consistent in their ratings upon stimulus replication. These findings demonstrate that the hedonic qualities of touch can be psychophysically evaluated, and that valid and reliable estimates are obtained.

Increased airway smooth muscle in sudden infant death syndrome

The underlying pathophysiological mechanism behind death in the sudden infant death syndrome (SIDS) is uncertain. Although infants dying of SIDS frequently have a postmortem examination performed, no specific diagnostic pathology in any organ system has been identified. Previous theories relating to the cause of death in SIDS have included increased lower airway closure. We examined the airway morphometry of 57 infants who died of SIDS and compared these findings with those obtained from 21 age-matched infants who had died of non-SIDS causes. Airway wall dimensions, epithelial thickness, and the area of smooth muscle within the airway wall were measured. Airways from infants who died of SIDS showed a significantly higher proportion of airway smooth muscle than control airways when corrected for age and sex (p < 0.01). There was no significant difference between the groups for wall thickness or epithelial thickness. Increased airway smooth muscle in infants who have died of SIDS may contribute to excessive airway narrowing, raising the possibility that the cause of death in this condition is related to abnormalities in lower airway function.

Repetition of deliberate self-harm by adolescents: the role of psychological factors

The aim of this study was to examine the relationship between psychological variables and repetition of deliberate self-harm by adolescents (n=45) aged 13-18 years who had been admitted to a general hospital having taken overdoses. Standardized measures of depression, hopelessness, suicidal intent, impulsivity, trait and state anger, self-esteem and problem-solving (both self-report and observer-rated) were administered to the adolescents while still in the general hospital. Repetition was assessed on the basis of previous overdoses (n=14) and repetition of self-harm (self-poisoning and self-injury) during the subsequent year (n=9). Adolescents with a history of a previous overdose and/or who repeated self-harm during the following year (n=18) differed from non-repeaters in having higher scores for depression, hopelessness and trait anger, and lower scores for self-esteem, self-rated problem-solving and effectiveness of problem-solving rated on the basis of the Means End Problem Solving test, all measured at the initial assessment. These differences largely disappeared when level of depression was controlled for. Similarly, differences found between repeaters and non-repeaters in the year following the index overdoses for problem-solving were much reduced when account was taken of differences in depression scores. Depression is a key factor associated with risk of repetition of adolescent self-harm (and hence of suicide risk). In the management of adolescents who have harmed themselves, careful assessment of depression and appropriate management of those who are depressed is essential.

Evaluation of a randomised controlled trial of adult asthma education in a hospital setting

BACKGROUND

Although patient education is a key step in the Australian Asthma Management Plan, its impact has not been assessed in a hospital outpatient asthma clinic.

METHODS

A controlled trial was undertaken in 125 adults with asthma recruited from the Alfred Hospital Asthma and Allergy Clinic and randomly allocated to an intervention (n = 64) or control (n = 61) group. Subjects in the intervention group attended three education sessions, each of 90 minutes duration, spread over three successive weeks. Asthma knowledge, quality of life, self-management skills, and attitudes and beliefs about asthma were assessed by questionnaires at baseline and after six months. The intervention group was also assessed immediately after the three education sessions. The control group was evaluated after six months of usual care.

RESULTS

Asthma knowledge improved significantly in the intervention group after three education sessions (p = 0.0001) and this was retained six months later (p = 0.03). The impact of asthma on quality of life decreased significantly immediately after intervention (p = 0.03) but this was not maintained six months later (p = 0.35). On the other hand, the intervention had little impact on self-management skills or attitudes and beliefs about asthma. However, the control group had also improved their knowledge, quality of life and self-management skills after six months of usual care. The difference in mean change in knowledge score at six months between the intervention and control groups was not significant (p = 0.51).

CONCLUSIONS

In contrast to some other studies, a limited asthma education programme in a hospital outpatient setting had a positive impact on patients' knowledge of asthma, but not on their quality of life, self-management skills, or attitudes and beliefs about asthma.

A randomised controlled trial of home-based rehabilitation versus outpatient-based rehabilitation for patients suffering from chronic schizophrenia

BACKGROUND

Outpatient-based treatments for patients suffering from chronic schizophrenia inadvertently exclude a significant proportion of subjects because they are often too poorly motivated to attend for treatment. In addition there are also concerns about whether the skills that are learnt in a hospital setting will generalize to situations when the individuals are at home. This study attempted to redress some of these potential deficiencies and followed on from an earlier local study which found that a community-based team met more of the needs of patients suffering from chronic schizophrenia.

METHOD

Seventy-five patients suffering from chronic schizophrenia were allocated randomly to receive traditional outpatient-based or home-based rehabilitation from a clinical psychologist and an occupational therapist. They were assessed before and after 9 months of treatment on a range of clinical, social and quality of life outcomes. Distress to carers was also assessed. Readmission to hospital was recorded for each subject.

RESULTS

There were significant reductions in socially embarrassing behaviour (SBS), increases in interpersonal functioning and recreational activities and a trend for quality of life to improve in the home-based group. There were fewer admissions in the home-based group but the differences, although financially substantial, were not statistically significant.

CONCLUSIONS

The home-based rehabilitation service was well received by the majority of patients suffering from chronic schizophrenia and led to some improvement in social behaviour, interpersonal functioning, recreational activities and quality of life.

Decline in lung function and mortality: the Busselton Health Study

BACKGROUND

There is a direct association between level of lung function, measured by forced expiratory volume in 1 second (FEV1) and mortality rates. A low FEV may result from an increased decline in FEV1 with age, which may be an independent predictor of mortality.

OBJECTIVE

To examine the association between decline in FEV1 and mortality in a cohort from a community health study.

SETTING AND METHODS

From five cross sectional studies in Busselton between 1969 and 1981 a cohort of 751 men and 940 women was identified who had three assessments of lung function over a six year period and had other health related data collected. Each subject's average FEV1 and decline in FEV1 (litre/year) were calculated from these three measurements. Mortality follow up to December 1995 was obtained. Cause of death was taken as the certified cause of death from the death certificate using ICD9 categories.

RESULTS

The average decline in FEV1 was 0.04 litre per year (SD = 0.07) for men and 0.03 litre per year (SD = 0.06) for women. Average FEV1 was significantly associated with all cause and cardiovascular disease mortality in both sexes. In women there was a significant association between decline in FEV1 and death from all causes, after adjusting for average FEV1, age, smoking, coronary heart disease, and cardiovascular disease risk factors; a 0.05 litre per year increase in the rate of decline of FEV1 increased the risk of death for all causes by 1.23 (95% confidence interval 1.06, 1.44). In men the effect of decline in FEV1 on death rate was less; for all men the hazard ratio for a 0.05 litre/year greater decline in FEV1 was 1.19 (0.99, 1.21).

CONCLUSION

Decline in lung function, measured by FEV1 is a predictor of death, independent of average FEV1 and risk factors for cardiovascular disease.

Severe hemolytic disease from rhesus anti-C antibodies in a surrogate pregnancy after oocyte donation. A case report

BACKGROUND

Maternal sensitization with rhesus anti-C antibodies is comparatively rare and usually benign. In pregnancies conceived using donor oocytes, the mother's blood group may differ from that of both the father and the oocyte donor, making blood group incompatibility more likely.

CASE

Twins, the result of a surrogate pregnancy using donor oocytes, were born with severe hemolytic disease due to rhesus anti-C antibodies. Both infants required exchange transfusion for profound anemia at birth. Isoimmunization in the surrogate mother was not detected antenatally. The twins were delivered by emergency cesarean section due to fetal compromise, detected fortuitously when the mother attended for routine fetal assessment at 35 weeks' gestation.

CONCLUSION

Isoimmunization with anti-C antibodies is not always benign and may cause significant hemolytic disease. With the success of in vitro fertilization and oocyte donation, more infertile couples may use these methods to conceive, with or without surrogacy arrangements. In such cases, the provision of antenatal care may become a complex matter, involving several parties, and good communication between everyone involved is vital. In pregnancies conceived with donor oocytes, there may be a higher risk of blood group incompatibility, and special vigilance is warranted.

Cell behaviour as a dynamic attractor in the intracellular signalling system

We present a model of the cell signalling network based on the generic properties of interactions between protein kinases (PKs) and protein phosphatases (PPs) inside cells. The model is designed to examine the global properties and intrinsic dynamics of the phosphorylation system. A genetic algorithm (GA) is used to evolve populations of "cells". The GA selects cells and ranks them based on an analysis of the dynamics of the proteins within the networks from a series of different random starting conditions. The fittest cells are taken to be those which can generate a variety of different "behaviours" from a series of different initial conditions. During the GA, intracellular protein interactions evolve via mutation and an analogue of domain shuffling between protein types that is thought to occur during biological evolution. The dynamics of the simulated networks are presented and we discuss the hypothesis that changes in the behaviour of a cell may be interpretable as a switch between attractor basins in the intracellular signalling network.

A comparative study of the 1992 and 1997 recovery positions for use in the UK

In April 1997 the ILCOR Basic Life Support advisory statements were announced in conjunction with changes to the recovery position for use in the UK. This study compared the new and old positions by using a questionnaire to assess how well each position satisfied the ILCOR statements. The study was carried out over six different hospital trusts by eight resuscitation training officers. Each tutor alternately taught the 1992 or 1997 recommended positions. After the practical session each student completed a questionnaire on ease of learning and use of the position, as well as other factors such as spinal stability. They were also asked to score the position when they were placed in recovery by other students. Their competency was assessed using the ALS criteria. Over the duration of the study 687 forms were suitable for analysis. For every question there was a significant trend in favour of the 92 position, with students finding the technique easier to learn and use, simpler for positioning for CPR and with less spinal movement during rolling. Possible sources of bias such as previous training, tutor or staff grade made no statistical difference to the results. When performed competently the 1997 position appears to cause less brachial compression, but other problems with learning or use of the 97 position outweigh this advantage. The 1992 position currently provides the best compromise between ease of use, spinal stability and other factors, and better satisfies the ILCOR advisory statements.

Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke

OBJECTIVE

investigation of length of survival, complications, level of dependence and recovery of swallow in patients who received percutaneous endoscopic gastrostomy (PEG) feeding for dysphagia due to stroke.

DESIGN

a retrospective case note analysis of patients treated between 1991 and 1995 and telephone survey of modified Barthel index in October 1996.

SETTING

Cardiff Royal Infirmary and the University Hospital of Wales in Cardiff.

SUBJECTS

126 patients who had PEG inserted after dysphagic stroke.

MAIN OUTCOME MEASURES

complications of PEG, length of survival, duration of PEG feeding, recovery of swallow and modified Barthel index score.

RESULTS

median length of follow-up was 31 months (range 4-71). Median duration of PEG use was 127 days (range 1-1372). For patients with PEG inserted within 2 weeks the median duration was 52 days (range 2-1478). At follow up 36 (29%) had had PEG removed, 72 (57%) had died with PEG in use, 10 (8%) still had PEG and were nil by mouth and five (4%) had PEG in use with swallow recovered. The median survival was 305 days. Thirty-five (28%) patients died in hospital. Aspiration pneumonia was the commonest complication. Thirty-three patients were alive in October 1996. The modified Barthel index for nursing home patients was 4 (range 0-13) and for patients at home 11 (range 2-20).

CONCLUSION

PEG feeding is safe and well tolerated in patients with dysphagic stroke. Early PEG placement (within 2 weeks) is worthwhile with many going on to have long-term feeding. Although overall mortality is high, some patients have a long-term survival and a few attain a reasonable level of function in daily living activities. Late recovery of swallow occurs and patients should have follow-up swallowing assessment.

Comparative experience of a simple technique for laparoscopic chronic ambulatory peritoneal dialysis catheter placement

BACKGROUND

Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy.

METHODS

A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared.

RESULTS

Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P = 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P = 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient's death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months).

CONCLUSIONS

This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.

beta2-Adrenergic receptor haplotypes in mild, moderate and fatal/near fatal asthma

Excess beta2-agonist use in asthmatics has been associated with increased mortality and morbidity. The mechanisms responsible for these observations are unknown. We hypothesized that polymorphisms of the beta2-adrenergic receptor (beta2AR) at amino acid positions 16, 27, and 164, which are known to alter receptor functions in vitro, may predispose asthmatics to fatal/near-fatal asthma and/or modify asthma severity. In preliminary studies we found significant differences in allele frequencies due to ethnic background: Caucasian, Black, Asian Gly16 = 0.61, 0.50, 0.40 and Gln27 = 0.57, 0. 73, 0.80, respectively. beta2AR genotyping was performed on DNA from Caucasians classified as nonasthmatic/nonatopic (n = 84), fatal/near-fatal asthmatics (n = 81) and mild/moderate asthmatics (n = 86). No polymorphism or haplotype was found to be associated with fatal/near-fatal asthma. However, the Gly16/Gln27 haplotype, which undergoes enhanced downregulation in vitro, was substantially more prevalent in moderate asthmatics than in mild asthmatics (p = 0.003, odds ratio = 3.1). We conclude that the beta2AR genotype is not a major determinant of fatal or near-fatal asthma. Furthermore, allele frequency variation among ethnic groups must be considered in clinical studies of beta2AR polymorphisms in asthma.

Partial tetrasomy with triplication of chromosome (5) (p14-p15.33) in a patient with severe multiple congenital anomalies

We report on a newborn infant with a de novo triplication of the distal segment of 5p: 46,XX,trp(5) (pter-->p14::p14-->p15.33::p15.33--> qter) and multiple congenital anomalies consistent with triplication of 5p. Partial triplication was documented by fluorescence in situ hybridization with a cosmid probe specific for 5p15.2 and microdissected probes obtained from "5pter." Partial duplication of the short arm of chromosome 5 is associated with a specific phenotype that appears to be dependent on the chromosomal region duplicated. Duplication of 5p with breakpoints proximal to band p14 is generally associated with distinct craniofacial malformations, cardiac, renal, intestinal, and limb defects, and mental retardation, whereas duplications with breakpoints distal to 5p14 result in a milder phenotype characterized by minor facial anomalies, developmental delay, and seizures. The most proximal breakpoints of the partial triplication in this patient was estimated to be 5p14, suggesting that a more severe phenotype can occur with triplication of the more distal segment.

Identification of novel factors that regulate GnRH gene expression and neuronal migration

We used differential display PCR on two GnRH producing cell lines to identify genes involved in GnRH gene expression and neuronal migration. RNA from Gn10 cells (derived from a tumor in the olfactory area when GnRH neurons are migrating and make low levels of GnRH) and from GT1-7 cells (derived from a tumor in forebrain when GnRH neurons are postmigratory and make high levels of GnRH) was reverse transcribed into cDNA. The cDNA was amplified using three anchored primers and eight random primers from each cell line and products from duplicate reactions electrophoresed in parallel in a denaturing acrylamide gel. Differentially expressed cDNAs were excised, reamplified and used as probes in Northern analysis of total RNA from each cell line to confirm differentially expressed RNA. The cDNAs were sequenced and compared to the Genbank database. Four of five clones isolated from GT1-7 GnRH neurons are novel, while four of five clones isolated from Gn10 cells have homology to known DNA sequences. One clone, Gn8-01 encodes adhesion related kinase (Ark), a molecule that has an N-terminal domain characteristic of cell adhesion molecules and whose kinase domain may play a role in protection from apoptosis. Together these data support the usefulness of the technique to identify novel genes that play a role in the control of GnRH expression and neuronal migration.

Process-Oriented Critical Pathways in Inpatient Psychiatry: Our First Year

The critical pathway methodology of assigning and timing staff interventions and expected patient outcomes has developed worldwide recognition, but is less likely to be used in psychiatry than in other medical fields. At St. Mary's in Rochester, New York, an interdisciplinary team adapted the critical pathway concept to meet the needs of an acute inpatient population with relative success. Although staff education needs continue and plans to modify the pathway are in progress, all staff feel that the critical pathway is a viable tool for enhancing patient care and optimizing resources use. Benefits, obstacles, and suggestions are discussed.

Epoxybutene-hemoglobin adducts in rats and mice: dose response for formation and persistence during and following long-term low-level exposure to butadiene

Measurement of specific adducts to hemoglobin can be used to establish the dosimetry of electrophilic compounds and metabolites in experimental animals and in humans. The purpose of this study was to investigate the dose response for adduct formation and persistence in rats and mice during long-term low-level exposure to butadiene by inhalation. Adducts of 3,4-epoxy-1-butene, the primary metabolite of butadiene, with N-terminal valine in hemoglobin were determined in male B6C3F1 mice and male Sprague-Dawley rats following exposure to 0, 2, 10, or 100 ppm of 1,3-butadiene, 6 h/day, 5 days/week for 1, 2, 3, or 4 weeks. Blood samples were collected from groups of five mice and three rats at the end of each week during the 4 weeks of exposure and weekly for 3 weeks following the end of the 4-week exposure period. The increase and decrease, respectively, of the adduct levels during and following the end of the 4-week exposure followed closely the theoretical curve for adduct accumulation and removal for rats and mice, thereby demonstrating that the adducts are chemically stable in vivo and that the elimination follows the turnover of the red blood cells. The adduct level increased linearly with butadiene exposure concentration in the mice, whereas a deviation from linearity was observed in the rats. For example, after exposure to 100 ppm butadiene, the epoxybutene-hemoglobin adduct levels were about four times higher in mice than in rats; at lower concentrations of butadiene, the species difference was less pronounced. Blood concentrations of epoxybutene, estimated from hemoglobin adduct levels, were in general agreement with reported concentrations in mice and rats exposed by inhalation to 62.5 ppm. These studies show that adducts of epoxybutene with N-terminal valine in hemoglobin can be used to predict blood concentration of epoxybutene in experimental animals.

A pre-discharge ward for acute medical patients

We describe and evaluate a ward developed to facilitate the discharge planning of general medical patients.

DESCRIPTION

A 15-bed pre-discharge ward (PDW) with a ward coordinator was established in 1995, as a counterpoise to a medical assessment unit (MAU).

METHOD

Data, analysed after the first year, included diagnosis, physiotherapy and occupational therapy referrals, length of stay and discharge destination.

RESULTS

During its first year, 810 patients were admitted to the PDW; 39% were male, their mean age was 75 years (range, 16-99; standard deviation, 11.3). Respiratory illness (24%) was the commonest diagnosis, 62% required physiotherapy, 51% occupational therapy and 35% needed increased social support. Discharge was as follows: 681 (84.1%) patients were discharged to their admission address, 34 (4.2%) were taken over by the department for care of the elderly, 29 (3.6%) discharged to relatives, 23 (2.8%) to residential or nursing homes, 22 (2.7%) returned to acute medical beds, 12 (1.5%) to general practitioner beds and nine patients (1.1%) died. The average length of stay during a three-month period (October-December) for all acute medical patients was 7.47 days before the MAU and PDW were opened and 7.32 days afterwards.

CONCLUSIONS

The PDW provides multidisciplinary assessment and focused discharge planning for patients of general physicians. This did not prolong their stay in acute medical beds.

The clinical skills of community psychiatric nurses working with patients who have severe and enduring mental health problems: an empirical analysis

This study describes the use of reliable scales to rate the clinical skills of mental health nurses when working with individuals and families with severe mental health problems. The Cognitive Therapy Scale and the Schizophrenia Family Work Scale were adapted for the study and were shown to have good inter-rater reliability when assessing audio-taped interviews carried out by mental health nurses during their usual course of work with patients with severe mental health problems and their families. The sample of mental health nurses studied were shown to have significantly better general therapy skills than specific cognitive therapy technical skills. The implications for training are discussed.