Invasive healthcare-associated (HA) environmental fungal infections (EFI) in pediatric oncology (ONC) patients (PTS) are an ever-present risk

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To reduce the risk of HA EFI, our ICUs, onc inpatient and stem cell transplant (SCT) units are centrally HEPA filtered and portable HEPA filters are used in each onc outpatient clinic room. Anticipating demolition and then construction of a new, adjacent hospital tower, infection control (IC) verified (Feb 2006) that all windows were completely sealed, provided valet parking remote to the construction and N95 respirators to be worn in all areas except the HEPA filtered locations for immunosuppressed pts to reduce exposure to construction dust; a known risk factor for HA EFI. Eleven new cases of possible HA EFI were diagnosed in 2006: 3 part of a Jan-Feb cluster related to a new construction elevator and malfunction of a door to the outside and 8 clustered July-Oct after demolition and construction began in April. This compares with only 4 cases in 2005. The primary diagnoses in 2006 were AML (6), ALL (4), and hemophagocytic lymphohistiocytosis (1) versus AML (2) and SCT (2) in 2005. Pts with AML and SCT received antifungal prophylaxis or were receiving antifungal therapy at the time of EFI diagnosis. Different isolates were identified including Aspergillus (numerous species), Scedosporium, Fusarium, and Rhizopus; sites of infection included paranasal sinuses (5), pulmonary (6), skin (2) and GI tract (1). 3 of 11 pts died; all required long term antifungal therapy, and most required altered chemotherapy. 4 of 8 pts in the Jul-Oct cluster had been in rooms later found to have faulty window caulking caused by severe weather conditions in Mar 2006. Our data suggest that despite implementation of measures to prevent HA EFI, new sources of outside air and construction dust likely led to an increase in HA EFI. The absence of HA EFI in SCT pts in 2006 may be attributed to the positive pressurization of the SCT unit, location of the unit facing away from the construction site and the antifungal prophylaxis used. The variety of fungi also support outside air as a source. After the faulty caulking was identified and repaired, no further HA EFI occurred; a case-control study is underway to identify important risk factors. Vigilance for potential new sources of contaminated air is required on units with high risk patients.

No significant financial relationships to disclose.

Loss-of-function mutations in the Nav1.7 gene underlie congenital indifference to pain in multiple human populations

Congenital indifference to pain (CIP) is a rare condition in which patients have severely impaired pain perception, but are otherwise essentially normal. We identified and collected DNA from individuals from nine families of seven different nationalities in which the affected individuals meet the diagnostic criteria for CIP. Using homozygosity mapping and haplotype sharing methods, we narrowed the CIP locus to chromosome 2q24-q31, a region known to contain a cluster of voltage-gated sodium channel genes. From these prioritized candidate sodium channels, we identified 10 mutations in the SCN9A gene encoding the sodium channel protein Nav1.7. The mutations completely co-segregated with the disease phenotype, and nine of these SCN9A mutations resulted in truncation and loss-of-function of the Nav1.7 channel. These genetic data further support the evidence that Nav1.7 plays an essential role in mediating pain in humans, and that SCN9A mutations identified in multiple different populations underlie CIP.

Kiss and tell: what do we know about pre- and early adolescent females who report dating? A pilot study

STUDY OBJECTIVE

To evaluate the implications of dating in pre- and early adolescent females.

DESIGN

Cross-sectional survey.

SETTING

Child psychiatry clinic; pediatric clinic; family clinic.

PARTICIPANTS

Pre- and early adolescent females (n = 80) aged 11-14 and their parents.

INTERVENTION

Pre- and early adolescent females aged 11-14 and a parent were recruited during a regular clinic visit. Pre- and early adolescent females completed a survey that included measures of dating; sensation seeking; lifetime individual and peer drug use; Attention Deficit Hyperactive Disorder, Oppositional Defiant Disorder and Conduct Disorder symptoms; and onset of menses. Parents were asked similar questions about their child's dating behaviors and peer relationships.

MAIN OUTCOME MEASURE

Association of early dating with individual and peer drug use, sensation seeking, aggressive behavior, and onset of menses.

RESULTS

In pre- and early adolescent females, dating regularly is associated with nicotine and alcohol use, sensation seeking, and aggressive behavior. Dating regularly is also associated with onset of menses and a younger age of onset of menses in those who had started menstruating. Parents under-report their child's dating practices and associated high-risk behaviors.

CONCLUSION

Early dating is associated with nicotine and alcohol use, sensation seeking, aggressive behavior, and early onset of menses in adolescent females. Questions about early dating are a simple and efficient way to open inquiry of both parents and children about high-risk behaviors in the clinic setting.

Malaria in the southern highlands of Tanzania: a review of hospital records

Outpatient attendance and inpatient admission records were examined to assess malaria situation in ten hospitals in Mbeya and Iringa Regions in southern highlands of Tanzania for a period of fifteen years from 1986-2000. Generally, records were deficient, some hospitals with entire annual records missing for one or several years. However, malaria maintained a high profile as the leading cause of admissions and deaths among hospital attendees. Of the ten hospitals, seven recorded malaria as the leading cause of admissions for at least ten years; in three of these, it was also the top ranking cause of child death. Although the respective magnitude of malaria morbidity and mortality burdens was not directly correlated with altitude (P>0.5), three hospitals (Uwemba, Bulongwa and Ikonda) at above 2,000m, had relatively lower malaria morbidity and mortality burden compared to three worst affected facilities (Ilembula, Chimala and Mbozi) in the lower range of altitude, located in the flat plains. In conclusion, malaria is the major public health problem in the highlands districts of Mbeya and Iringa Regions in Tanzania that need the attention of health authorities and immediate intervention. However, more research is required to establish the true picture of the problem among the communities.

Mutations in WNT7A cause a range of limb malformations, including Fuhrmann syndrome and Al-Awadi/Raas-Rothschild/Schinzel phocomelia syndrome

Fuhrmann syndrome and the Al-Awadi/Raas-Rothschild/Schinzel phocomelia syndrome are considered to be distinct limb-malformation disorders characterized by various degrees of limb aplasia/hypoplasia and joint dysplasia in humans. In families with these syndromes, we found homozygous missense mutations in the dorsoventral-patterning gene WNT7A and confirmed their functional significance in retroviral-mediated transfection of chicken mesenchyme cell cultures and developing limbs. The results suggest that a partial loss of WNT7A function causes Fuhrmann syndrome (and a phenotype similar to mouse Wnt7a knockout), whereas the more-severe limb truncation phenotypes observed in Al-Awadi/Raas-Rothschild/Schinzel phocomelia syndrome result from null mutations (and cause a phenotype similar to mouse Shh knockout). These findings illustrate the specific and conserved importance of WNT7A in multiple aspects of vertebrate limb development.

What primary microcephaly can tell us about brain growth

Autosomal recessive primary microcephaly (MCPH) is a neuro-developmental disorder that causes a great reduction in brain growth in utero. MCPH is hypothesized to be a primary disorder of neurogenic mitosis, leading to reduced neuron number. Hence, MCPH proteins are likely to be important components of cellular pathways regulating human brain size. At least six genes can cause this disorder and four of these have recently been identified: autosomal recessive primary microcephaly 1 (MCPH1), abnormal spindle-like, microcephaly associated (ASPM), cyclin-dependent kinase 5 regulatory subunit-associated protein 2 (CDK5RAP2) and centromere protein J (CENPJ). Whereas aberration of ASPM is the most common cause of MCPH, MCPH1 patients can be more readily diagnosed by the finding of increased numbers of "prophase-like cells" on routine cytogenetic investigation. Three MCPH proteins are centrosomal components but have apparently diverse roles that affect mitosis. There is accumulating evidence that evolutionary changes to the MCPH genes have contributed to the large brain size seen in primates, particularly humans. The aim of this article is to review what has been learnt about the rare condition primary microcephaly and the information this provides about normal brain growth.

Quantification of homozygosity in consanguineous individuals with autosomal recessive disease

Individuals born of consanguineous union have segments of their genomes that are homozygous as a result of inheriting identical ancestral genomic segments through both parents. One consequence of this is an increased incidence of recessive disease within these sibships. Theoretical calculations predict that 6% (1/16) of the genome of a child of first cousins will be homozygous and that the average homozygous segment will be 20 cM in size. We assessed whether these predictions held true in populations that have preferred consanguineous marriage for many generations. We found that in individuals with a recessive disease whose parents were first cousins, on average, 11% of their genomes were homozygous (n = 38; range 5%-20%), with each individual bearing 20 homozygous segments exceeding 3 cM (n = 38; range of number of homozygous segments 7-32), and that the size of the homozygous segment associated with recessive disease was 26 cM (n = 100; range 5-70 cM). These data imply that prolonged parental inbreeding has led to a background level of homozygosity increased approximately 5% over and above that predicted by simple models of consanguinity. This has important clinical and research implications.

Quantification of homozygosity in consanguineous individuals with autosomal recessive disease

Individuals born of consanguineous union have segments of their genomes that are homozygous as a result of inheriting identical ancestral genomic segments through both parents. One consequence of this is an increased incidence of recessive disease within these sibships. Theoretical calculations predict that 6% (1/16) of the genome of a child of first cousins will be homozygous and that the average homozygous segment will be 20 cM in size. We assessed whether these predictions held true in populations that have preferred consanguineous marriage for many generations. We found that in individuals with a recessive disease whose parents were first cousins, on average, 11% of their genomes were homozygous (n = 38; range 5%-20%), with each individual bearing 20 homozygous segments exceeding 3 cM (n = 38; range of number of homozygous segments 7-32), and that the size of the homozygous segment associated with recessive disease was 26 cM (n = 100; range 5-70 cM). These data imply that prolonged parental inbreeding has led to a background level of homozygosity increased approximately 5% over and above that predicted by simple models of consanguinity. This has important clinical and research implications.

Validation of the Maltese version of the Edinburgh Postnatal Depression Scale

This paper reports the validation of the Maltese translated Edinburgh Postnatal Depression Scale against Diagnostic Criteria for Research (DCR-10) diagnosis for severe, moderate and mild depression during pregnancy (antenatally) and at 8 weeks postnatally. A random sample of 239 pregnant women were interviewed at booking and at 8 weeks postnatally using a detailed sociodemographic history, the Revised Version of the Clinical Interview Schedule (CIS-R) and Maltese translation of the Edinburgh Postnatal Depression Scale (EPDS). The Maltese translated EPDS had good face validity and had satisfactory sensitivity and specificity for identifying depression both antenatally and postnatally. Cut-off scores of 13/14 antenatally and 11/12 postnatally are recommended when using the Maltese EPDS. Controversial issues surrounds the use of the EPDS in clinical practice. However, introducing the EPDS in pregnancy will help to identify women who are at high risk of depression so as to treat appropriately and early in the antenatal period.

3q29 microdeletion syndrome: clinical and molecular characterization of a new syndrome

We report the identification of six patients with 3q29 microdeletion syndrome. The clinical phenotype is variable despite an almost identical deletion size. The phenotype includes mild-to-moderate mental retardation, with only slightly dysmorphic facial features that are similar in most patients: a long and narrow face, short philtrum, and high nasal bridge. Autism, gait ataxia, chest-wall deformity, and long and tapering fingers were noted in at least two of six patients. Additional features--including microcephaly, cleft lip and palate, horseshoe kidney and hypospadias, ligamentous laxity, recurrent middle ear infections, and abnormal pigmentation--were observed, but each feature was only found once, in a single patient. The microdeletion is approximately 1.5 Mb in length, with molecular boundaries mapping within the same or adjacent bacterial artificial chromosome (BAC) clones at either end of the deletion in all patients. The deletion encompasses 22 genes, including PAK2 and DLG1, which are autosomal homologues of two known X-linked mental retardation genes, PAK3 and DLG3. The presence of two nearly identical low-copy repeat sequences in BAC clones on each side of the deletion breakpoint suggests that nonallelic homologous recombination is the likely mechanism of disease causation in this syndrome.

Estimating medium- and long-term trends in malaria transmission by using serological markers of malaria exposure

The implementation and evaluation of malaria control programs would be greatly facilitated by new tools for the rapid assessment of malaria transmission intensity. Because acquisition and maintenance of antimalarial antibodies depend on exposure to malaria infection, such antibodies might be used as proxy measures of transmission intensity. We have compared the prevalence of IgG antibodies with three Plasmodium falciparum asexual stage antigens in individuals of all ages living at varying altitudes encompassing a range of transmission intensities from hyper- to hypoendemic in northeastern Tanzania, with alternative measures of transmission intensity. The prevalence of antibodies to merozoite surface protein-1(19) was significantly more closely correlated with altitude than either point-prevalence malaria parasitemia or single measures of hemoglobin concentration. Analysis of age-specific seroprevalence rates enabled differentiation of recent (seasonal) changes in transmission intensity from longer-term transmission trends and, using a mathematical model of the annual rate of seroconversion, estimation of the longevity of the antibody response. Thus, serological tools allow us to detect variations in malaria transmission over time. Such tools will be invaluable for monitoring trends in malaria endemicity and the effectiveness of malaria control programs.

Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy

We have reviewed imaging findings of 32 female patients with a proven haematological malignancy in the breast and axilla presenting to two breast units over a 13-year period. Nineteen patients had screen-detected lesions, and 13 presented to symptomatic services. The most common histological diagnosis was of non-Hodgkins lymphoma. Of the 12 patients who presented with disease in the breast, six (all with primary breast lymphoma) presented with a well-defined mass on mammography. The range of radiological appearances is, however, highly variable.

HIV status of sexual partners is more important than antiretroviral treatment related perceptions for risk taking by HIV positive MSM in Montreal, Canada

OBJECTIVE

To examine the role of antiretroviral treatment related perceptions relative to other clinical and psychosocial factors associated with sexual risk taking in HIV positive men who have sex with men (MSM).

METHODS

Participants were recruited from ambulatory HIV clinics in Montreal. Information on sociodemographic factors, health status, antiretroviral treatment related perceptions, and sexual behaviours was collected using a self administered questionnaire. At-risk sexual behaviour was defined as at least one occurrence of unprotected insertive or receptive anal intercourse in the past 6 months. Multivariate logistic regression was performed to evaluate the associations between at-risk sexual behaviour and covariates.

RESULTS

346 subjects participated in the study. Overall, 34% of subjects were considered at risk; 43% of sexually active subjects (n=274). At-risk sexual behaviour was associated with two antiretroviral treatment related perceptions: (1) taking antiretroviral treatment reduces the risk of transmitting HIV (adjusted odds ratio (OR), 2.10; 95% confidence interval (CI), 1.16 to 3.80); and (2) there is less safer sex practised by MSM because of HIV treatment advances (OR, 1.82; CI, 1.14 to 2.90). Other factors, however, were more strongly associated with risk. These were: (1) safer sex fatigue (OR, 3.23; CI, 1.81 to 5.78); (2) use of "poppers" during sexual intercourse (OR, 6.28; CI, 2.43 to 16.21); and (3) reporting a greater proportion of HIV positive anal sex partners, compared with reporting no HIV positive anal sex partners: (a) <50% HIV positive (OR, 16.79; CI, 4.70 to 59.98); (b) > or =50% HIV positive (OR, 67.67; CI, 15.43 to 296.90).

CONCLUSION

Despite much emphasis on HIV treatment related beliefs as an explanation for sexual risk taking in MSM, this concern may play a relatively minor part in the negotiation of risk by HIV positive MSM. Serosorting, safer sex fatigue, and the use of poppers appear to be more important considerations in understanding the sexual risk behaviours of HIV positive MSM.

Prognostic factors for disease progression after high-dose chemotherapy and autologous hematopoietic stem cell transplantation for recurrent or refractory Hodgkin's lymphoma

Our purpose was to study the risk factors associated with disease progression after high-dose chemotherapy followed by autologous stem cell transplantation in patients with recurrent or refractory Hodgkin's lymphoma (HL). We analyzed the long-term outcome of 184 patients with recurrent or refractory HL who underwent autologous hematopoietic stem cell transplantation. At the time of transplantation, 82 patients were in first relapse or second remission, 46 patients were refractory to the primary induction chemotherapy, and 56 patients were beyond first relapse or second remission. In 64 patients, the disease had proved refractory to the chemotherapy regimen administered immediately prior to transplantation. The median follow-up of patients who were alive and free of disease at the time of this report was 8.9 years (range, 0.1-19.0 years). At 10 years, the overall and disease-free survival rates were 34% (95% CI 27-42) and 29% (95% CI 22-36) respectively. The major cause of treatment failure was disease relapse. Chemotherapy resistance prior to transplantation, advanced stage, and higher number of chemotherapy regimens administered prior to transplantation were adverse prognostic factors for disease progression. We conclude that autologous transplantation is an effective salvage treatment for recurrent HL.

Neutron capture cross section measurement of 151Sm at the CERN neutron time of flight facility (n_TOF)

The151Sm(n,gamma)152Sm cross section has been measured at the spallation neutron facility n_TOF at CERN in the energy range from 1 eV to 1 MeV. The new facility combines excellent resolution in neutron time-of-flight, low repetition rates, and an unsurpassed instantaneous luminosity, resulting in rather favorable signal/background ratios. The 151Sm cross section is of importance for characterizing neutron capture nucleosynthesis in asymptotic giant branch stars. At a thermal energy of kT=30 keV the Maxwellian averaged cross section of this unstable isotope (t(1/2)=93 yr) was determined to be 3100+/-160 mb, significantly larger than theoretical predictions.

Postnatal blues: a risk factor for postnatal depression

Postnatal blues have been regarded as brief, benign and without clinical significance. However, several studies have proposed a link between blues and subsequent depression but have methodological problems. We report a prospective, controlled study of postpartum women with severe blues which uses systematically devised and validated instruments for that purpose which tests the hypothesis that severe blues increases the risk of depression in the six months following childbirth. 206 first-time mothers were recruited in late pregnancy. Blues status was defined using the Blues Questionnaire and those with severe blues and their controls who had no blues (matched for age, marital status and social class) were followed for 6 months with postal Edinburgh Postnatal Depression Scale. RDC diagnoses were made following SADS-L interview at the end of the protocol. Backwards stepwise Cox regression analysis found severe blues and past history of depression to be independent predictors each raising the risk by almost 3 times. Depression in those with severe blues onset sooner after delivery and lasted longer. The difference was largely accounted for by major depression. Severe postpartum blues are identified as an independent risk factor for subsequent postpartum depression. Screening and intervention programs could be devised.

Cloning, genomic organization, alternative splicing and expression analysis of the human gene WNK3 (PRKWNK3)

We report the isolation of a full length coding WNK3 cDNA from human fetal brain. The WNK3 transcript has an open reading frame of 5403 nucleotides and encodes a putative protein of 1800 amino acids. The human WNK3 gene comprises 24 exons and lies within a 559 kb genomic segment on chromosome Xp11.22 which has conserved synteny with a 705 kb genomic segment of human chromosome 9q22.31 which contains WNK2. The WNK3 transcript is expressed in several human fetal and adult tissues and has at least two splice isoforms generated by the alternative splicing of exon 18 and exon 22 which maintain the open reading frame. Usage of exon 18b is restricted to brain and introduces an additional 47 amino acids into the predicted protein. The predicted WNK3 protein has a similar structural organization to the other human WNK kinases. Significant homology between these proteins is confined to three conserved regions of their amino acid sequences which we have designated CR1, CR2 and CR3. CR1 and CR3 contain highly conserved residues which have been shown to be important for the normal function of WNK1 and WNK4, and CR2 contains a highly conserved 22 amino acid motif specific to chordate species. WNK3 lies within the critical linkage interval for several human monogenic disorders, including X-linked mental retardation. The function of mammalian WNK3 kinase remains to be investigated.