Qualitative analysis of Coroners' data into the unnatural deaths of children and adolescents

INTRODUCTION

Unintentional injury and suicide are leading causes of death for adolescents, and reducing these is an important health priority. Coroners' records provide a valuable source of information on the events leading up to the death of an individual, and analysis of these records may help our understanding of the causal pathway, and elucidate potential areas for intervention.

METHOD

All cases of unnatural death (poisoning, violence, unintentional injury) in young people aged 8-18 between 1996 and 2002 were identified from the death registers of one region in the UK. Data from Coroners' inquests were analysed to determine cause of death and involvement of professional agencies. A thematic analysis of the transcripts of statements presented at inquests aimed to identify areas of concern in the time immediately prior to death.

RESULTS

A total of 77 cases were identified of whom 16 (20.8%) died from alcohol/drug misuse, 20 (26%) by suicide or probable suicide and 41 (53.2%) by other injuries and poisoning. Thematic analysis highlighted: bullying, teenage sexualization and pregnancy, alcohol and substance misuse, reconstituted family difficulties and out of control behaviour as being significant factors on the causal pathway.

CONCLUSION

This study based on comprehensive data from one region highlights some of the difficulties faced by young people as they negotiate how to deal with complex emotions and relationships. It also demonstrates how some parents and carers are uncertain about how to address their concerns. Finally, it shows how mortality among young people could potentially be markedly reduced if availability of alcohol and illicit and prescribed substances were reduced.

Which patients receive advice on diet and exercise? Do certain characteristics affect whether they receive such advice?

OBJECTIVE

To examine whether patients' characteristics, familiarity with the clinic, or perspectives on the quality of their care predict whether they receive advice from physicians regarding diet and exercise.

DESIGN

Secondary data analysis of responses to the Primary Care Practice Survey.

SETTING

Capital District Health Authority in Nova Scotia.

PARTICIPANTS

Residents of the Capital District Health Authority 18 years old and older (N = 1562).

MAIN OUTCOME MEASURES

Percentage of patients who reported frequently receiving advice from their family physicians regarding diet and exercise.

RESULTS

Almost 38% of respondents reported frequently receiving advice from their physicians on diet. Those more likely to receive advice on diet were male (adjusted odds ratio [AOR] 1.6, 95% confidence interval [CI] 1.2 to 2.1), were 35 to 54 years old (compared with those aged 18 to 34) (AOR 1.5, 95% CI 1.1 to 2.2), had more chronic illnesses (AOR 1.3, 95% CI 1.2 to 1.6), had good relationships with their health care providers (AOR 2.3, 95% CI 1.8 to 3.1), or reported higher scores on an enablement scale (AOR 2.2, 95% CI 1.6 to 3.1). Respondents who reported their health status as excellent were less likely to receive advice on diet (AOR 0.5, 95% CI 0.3 to 0.9). About 42% of respondents reported frequently receiving advice on exercise. Men (AOR 1.7, 95% CI 1.3 to 2.2), those older than 35 years (AOR 1.7, 95% CI 1.2 to 2.4 for those aged 35 to 54; AOR 1.6, 95% CI 1.1 to 2.3 for those 55 and older), those rating their health as good (AOR 1.6, 95% CI 1.1 to 2.4), those with more chronic illnesses (AOR 1.3, 95% CI 1.1 to 1.5), and those reporting higher scores on communication (AOR 3.2, 95% CI 2.3 to 4.4) and enablement (AOR 1.8, 95% CI 1.3 to 2.4) scales were more likely to receive advice on exercise.

CONCLUSION

Strategies to increase the number of patients who receive advice on diet and exercise would likely include enhancing communication between patients and their physicians, improving relationships between patients and their physicians, and improving physicians' ability to help their patients feel enabled to act on advice and cope with their illnesses. Physicians should be aware of their counseling practices and consider discussing healthy behaviour with patients with no obvious risk factors. This would be practising true primary prevention.

Cell-specific and efficient expression in mouse and human B cells by a novel hybrid immunoglobulin promoter in a lentiviral vector

The expression of genes specifically in B cells is of great interest in both experimental immunology as well as in future clinical gene therapy. We have constructed a novel enhanced B cell-specific promoter (Igk-E) consisting of an immunoglobulin kappa (Igk) minimal promoter combined with an intronic enhancer sequence and a 3' enhancer sequence from Ig genes. The Igk-E promoter was cloned into a lentiviral vector and used to control expression of enhanced green fluorescent protein (eGFP). Transduction of murine B-cell lymphoma cell lines and activated primary splenic B cells, with IgK-E-eGFP lentivirus, resulted in expression of eGFP, as analysed by flow cytometry, whereas expression in non-B cells was absent. The specificity of the promoter was further examined by transducing Lin(-) bone marrow with Igk-E-eGFP lentivirus and reconstituting lethally irradiated mice. After 16 weeks flow cytometry of lymphoid tissues revealed eGFP expression by CD19+ cells, but not by CD3+, CD11b+, CD11c+ or Gr-1+ cells. CD19+ cells were comprised of both marginal zone B cells and recirculating follicular B cells. Activated human peripheral mononuclear cells were also transduced with Igk-E-eGFP lentivirus under conditions of selective B-cell activation. The Igk-E promoter was able to drive expression of eGFP only in CD19+ cells, while eGFP was expressed by both spleen focus-forming virus and cytomegalovirus constitutive promoters in CD19+ and CD3+ lymphocytes. These data demonstrate that in these conditions the Igk-E promoter is cell specific and controls efficient expression of a reporter protein in mouse and human B cells in the context of a lentiviral vector.

Health visitors' role in newborn blood spot screening

New national policies and standards for newborn blood spot screening for some uncommon but serious conditions indicate that health visitors may have an increasingly important role in supporting parents. This may include offering support and guidance through times of uncertainty and hearing bad news about their baby's screening result. The U.K. Newborn Screening Programme Centre (UKNSPC) has developed resources for health professionals to support them in communicating with parents about newborn blood spot screening at different times in the screening pathway. In an era of informed choice in health care, including screening, effective communication and the provision of evidence-based information are increasingly highlighted. This paper draws attention to the importance of effective communication between health professionals and parents, and describes the resources developed specifically to support this. It outlines the communication guidelines developed by the UKNSPC, paying particular attention to the role of health visitors at critical times in parents' screening journey.

ASCIA guidelines for prevention of food anaphylactic reactions in schools, preschools and child-care centres

These guidelines have been developed by the anaphylaxis working party of the Australasian Society of Clinical Immunology and Allergy to provide advice for minimizing the risk of food-induced anaphylaxis in schools, preschools and child-care centres. The guidelines outline four steps for the prevention of food anaphylactic reactions in children at risk and food policy measures specific to school age and preschool age children.

Signal-transduction pathways involved in the hypertrophic effect of hsp56 in neonatal cardiomyocytes

Heat shock protein (hsp) 56 (hsp56) is an immunophilin that acts as a cofactor with hsp90 and exhibits both peptidyl-prolyl isomerase activity and chaperone activity. Previous studies have shown that the hypertrophic effect of cardiotrophin-1 (CT-1) in cardiac cells is dependent on hsp56 induction. CT-1 activates a number of signal-transduction pathways. Therefore, we sought to determine whether these pathways were also important for hsp56-induced hypertrophy using overexpression with transiently transfected plasmid vectors in rat neonatal cardiomyocytes. Here we show that multiple signalling pathways are involved in hsp56-induced hypertrophy, namely the Janus kinase-signal-transducer and activator of transcription, extracellular signal-regulated protein kinase and PI3-kinase/Akt signalling pathways. Dominant-negative mutants and inhibitors of these pathways were able to block the hypertrophy observed as a result of hsp56 overexpression. However, an inhibitor of the p38 mitogen-activated protein kinase (p38 MAPK) pathway was not able to block the hypertrophic effect of hsp56 overexpression. Furthermore, we show that domains I, II and IV of the hsp56 protein may be involved in its hypertrophic effect. These studies show for the first time that multiple signalling pathways are involved in the hypertrophic effect of hsp56 and that overexpression of hsp56 itself is able to activate the necessary signalling pathways, which induce hypertrophy.

Increased risk of adverse events when changing intravenous immunoglobulin preparations

Intravenous immunoglobulin (IVIG) therapy has represented a major advance in the treatment of patients with primary immune deficiency disorders. In September 2000 a new IVIG formulation, Intragam P, was introduced into clinical use. Intragam P is prepared by delipidation of pooled plasma followed by an ion exchange chromatography step to eliminate immunoglobulin aggregates. It is then pasteurized for 10 h at 60 degrees C for viral inactivation before storage at pH 4.25 in 10% maltose. We report initial clinical experience with this new preparation. The details of adverse reactions of patients who received the new preparation were gathered shortly after it became apparent there was a change in IVIG formulation. Seven of 49 patients receiving Intragam P spontaneously reported adverse effects, which were temporally related to infusions. Subsequently, all seven patients have been able to tolerate the product with prophylactic use of antihistamines and paracetamol. This case series indicates that long-term tolerance of an older IVIG product does not necessarily equate to tolerance to a newer product, even if technically superior. Caution should be exercised when changing IVIG products, as they are not biologically equivalent.

Advanced age, but not anergy, is associated with altered serum polyunsaturated fatty acid levels

Unknown factors present in the serum of older adults impair lymphocyte function and may be responsible for anergy (absence of delayed-type hypersensitivity (DTH)) present in many older adults. Polyunsaturated fatty acids (PUFAs) and their metabolites are immunomodulatory and may play a role in clinical conditions of advanced age, including immune dysfunction. We hypothesized that PUFAs could be the factor(s) present in serum that contribute to impaired immune responses in older adults. Prior studies of serum PUFAs in older adults neither adequately control dietary PUFA intake, nor investigated the relationship of PUFAs and DTH responses. We determined serum PUFA concentrations in young adults with normal immune responses, and older adults with impaired (anergic elderly) or normal immunity (nonanergic elderly) before and after administering a standardized diet. After controlling for dietary intake, advancing age was associated with markedly higher serum concentrations of arachidonic acid (AA), dihomo-gamma-linoleic acid (DGLA), and eicosapentaenoic acid (EPA) and a lower AA:EPA ratio. Other serum PUFAs and the AA:DGLA ratio were unaffected by age. However, there was no difference between older adults with or without anergy. These data suggest advanced age is associated with marked alterations of serum PUFAs that are only apparent after strictly controlling dietary intake. However, there was no association of serum PUFA concentrations with DTH status among older adults.

Activation of beta-adrenoceptors opens calcium-activated potassium channels in astroglial cells

In the present study, effects of the alpha(2)- and beta-adrenoceptor agonists clonidine and isoproterenol on astrocytes in astroglial/neuronal cocultures from rat cerebral cortex were evaluated. The calcium- and potassium-sensitive dyes fura-2 and potassium-binding benzofuran isophtalate (PBFI) were used to study alterations in intracellular concentrations of calcium ([Ca(2+)](i)) and potassium ([K(+)](i)), respectively, while the perforated patch clamp technique was used to analyze transmembrane currents. Exposure to isoproterenol or clonidine elicited an immediate increase in [Ca(2+)](i) that was totally abolished in calcium-free extracellular media. Isoproterenol also decreased [K(+)](i), but clonidine did not. The reduction in [K(+)](i) was inhibited in Ca(2+)-free media. As evaluated with the perforated patch technique, isoproterenol (10(-6)-10(-4) M) induced a slowly developing and long lasting outward current that also was totally abolished in calcium-free buffer. This current was blocked by external tetraethylammonium (TEA, 10 mM) and charybdotoxin (ChTX, 10 nM), but was not affected by apamin (50 nM). The current-to-voltage (I-V) relationships for the isoproterenol-induced currents showed a markedly negative reversal potential, -96 mV+/-7, (mean+/-S.D., n=5). These results suggest that the stimulation of astroglial beta-adrenoceptors by isoproterenol opens calcium-activated potassium channels (K((Ca))). Preincubation with forskolin significantly increased the isoproterenol-induced currents compared with controls, indicating that the opening of astroglial K((Ca)) channels after beta-adrenergic stimulation not only depends on [Ca(2+)](i) but also synergistically involves the cAMP transduction system to which beta-adrenoceptors are known to be positively coupled.

Photosynthetic energy storage efficiency, oxygen evolution and chloroplast movement

When there is a saturating supply of dissolved carbon available, photosynthetic energy storage efficiency (ES) varies linearly with light fluence rate (I) for both Vallisneria americana and Pisum sativum leaves. The frequently reported hyperbolic relationship between ES and I occurs only when low levels of dissolved carbon are present in the medium. The linear relationship has its origin in intracellular events and implies that two heat-producing processes limit the value of ES. The rate of one process varies as I and the other varies as I(2). The rates of both processes were changed after a 2 hour exposure to 400 mumol photons m(-2) s(-1) of red light, speeding up the process that depends linearly on I and slowing the other. Illumination for 1 hour with 100 mumol photons m(-2) s(-1) of blue (but not red) light moves many chloroplasts from the periclinal to the anticlinal cell walls [Inoue and Shibata (1973) Planta 114: 341-358]. Blue light exposure of V. americana leaf sections (a) reduced the rate of oxygen evolution under light-limiting conditions by about 22%; (b) increased the value of ES by an amount dependent on the light fluence rate; and (c) decreased the slope of (ES v I). The slope change indicated that light absorption had fallen by 26% after blue light exposure. The rate of oxygen evolution (V) was measured under light-limiting conditions with leaf sections in which the chloroplasts had been immobilised after blue or red light exposure. With both red and blue-exposed leaf sections, V fell by about 50% after exposure to 1 hour of 1250 mumol photons m(-2) s(-1) of white light. Thus accumulation of chloroplasts on anticlinal walls did not protect the leaf from photoinactivation by a high light fluence rate.

Temperature quantitation and mapping of frozen tissue

A method was developed for quantitating the temperature within frozen tissue with the magnetic resonance (MR) parameter R2*. The pulse sequence uses half-pulse excitation and a short spiral readout to achieve echo times as short as 0.2 msec. Fiber-optic temperature sensors were inserted into bovine liver tissue. The tissue was frozen at one end while being held warm at the other end. Once steady state was reached, the parameter R2* was measured. A linear dependence of R2* on temperature was demonstrated. R2* is independent of freeze number and of the orientation of the temperature gradient with respect to the main magnetic field. Feasibility in a canine prostate during cryosurgery is demonstrated. J. Magn. Reson. Imaging 2001;13:99-104.

Astroglia and glutamate in physiology and pathology: aspects on glutamate transport, glutamate-induced cell swelling and gap-junction communication

Astroglia have the capacity to monitor extracellular glutamate (Glu) and maintain it at low levels, metabolize Glu, or release it back into the extracellular space. Glu can induce an increase in astroglial cell volume with a resulting decrease of the extracellular space, and thereby alter the concentration of extracellular substances. Many lines of evidence show that K(+) can be buffered within the astroglial gap-junction-coupled network, and recent results show that gap junctions are permeable for Glu. All these events occur dynamically: the astroglial network has the capacity to interfere actively with neurotransmission, thereby contributing to a high signal-to-noise ratio for the Glu transmission. High-quality neuronal messages during normal physiology can then be maintained. With the same mechanisms, astroglia might exert a neuroprotective function in situations of moderately increased extracellular Glu concentrations, i.e., corresponding to conditions of pathological hyper-excitability, or corresponding to early stages of an acute brain injury. If the astroglial functions are failing, neuronal dysfunction can be reinforced.

Human cytomegalovirus mediates cell cycle progression through G(1) into early S phase in terminally differentiated cells

Terminal differentiation of embryonal carcinoma cells and monocytes has been shown to be important for their permissiveness for human cytomegalovirus (HCMV) infection, even though such terminally differentiated cells have withdrawn from the cell cycle and are, essentially, in G(0) arrest. Recently, data from a number of laboratories have shown that productive infection with HCMV of quiescent fibroblasts held reversibly in G(0) of the cell cycle can result in cell cycle progression, which results eventually in cycle arrest. In contrast to quiescent fibroblasts, the effect of HCMV on cells that have withdrawn irreversibly from the cell cycle due to terminal differentiation has not, so far, been addressed. Here, it is shown that, in cells that have arrested in G(0) as a result of terminal differentiation, HCMV is able to induce cell functions associated with progression of the cell cycle through G(1) into early S phase. This progression is correlated with a direct physical and functional interaction between the HCMV 86 kDa major immediate-early protein (IE86) and the cyclin-dependent kinase inhibitor p21(Cip1).

Spatio-temporal profile of DNA fragmentation and its relationship to patterns of epileptiform activity following focally evoked limbic seizures

The specific electrographic activity responsible for seizure-induced DNA damage remains little explored. We therefore examined the regional and temporal appearance of DNA fragmentation and cell death and its relationship to specific electrographic seizure patterns in a rat model of focally evoked limbic epilepsy. Animals received intra-amygdaloid injection of kainic acid (KA) to induce seizures for 45 min during continuous electroencephalographic (EEG) monitoring, after which diazepam (30 mg/kg) was administered. DNA polymerase I-mediated biotin-dATP nick translation (PANT) and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) were used to detect single- and double-stranded DNA breaks, respectively. Injection of 0.01 microg KA induced seizures characterized by ictal fast activity but without consequent brain injury. By contrast, 0.1 microg KA induced an additional pattern of seizure activity characterized by bursts of high frequency polyspike paroxysmal discharges. In these animals, there was a significant reduction in numbers of pyramidal neurons within the ipsilateral and contralateral CA3 subfield of the hippocampus, detectable as little as 4 h following seizures. PANT- and TUNEL-positive cells appeared in similar numbers 16 h following seizure cessation within the CA3, declining after 72-96 h. Varying the duration of polyspike paroxysmal discharges determined that as little as 30 s elicited maximal injury. These data suggest single- and double-stranded DNA breaks are generated during the cell death process and are consequent on a specific component of seizure activity electrographically determined.

The effects of the hole in the ozone layer on health

Depletion of the ozone layer is a factor in global climate change. This article focuses on its potential detrimental effects on health.

Relationship between seizure-induced transcription of the DNA damage-inducible gene GADD45, DNA fragmentation, and neuronal death in focally evoked limbic epilepsy

We investigated the temporal and spatial profile of mRNA transcription for the growth arrest and DNA damage-inducible gene GADD45, DNA fragmentation, and neuronal death in rat brain following focally evoked limbic seizures. GADD45 mRNA was detected by in situ hybridization, whereas fragmented DNA was detected using in situ nick end-labeling by the large (Klenow) fragment of DNA polymerase I. Kainic acid (0.1 microg) was injected into the right amygdala of rats to induce seizures for 45 min, after which diazepam (30 mg/kg) was administered. GADD45 mRNA, DNA fragmentation, and cell death were quantified bilaterally within six limbic brain regions 0-96 h following seizure cessation. All animals underwent seizures of equivalent severity and duration as determined electrographically. In situ hybridization detected bilateral up-regulation of GADD45 mRNA throughout the CA1, CA3, and dentate gyrus of the hippocampus, the piriform and retrosplenial cortices, and the thalamus within 1 h of seizure termination. GADD45 mRNA levels remained elevated for up to 6 h, declining to baseline within all structures by 16 h. Klenow-positive cells were only found within the CA3 pyramidal layer of the ipsilateral hippocampus and appeared 16-72 h following seizure cessation. Morphologic cell death was also restricted to the CA3 subfield. These data demonstrate that focally evoked limbic seizures trigger early bihemispheric GADD45 mRNA transcription within connected limbic structures, whereas subsequent DNA fragmentation and cell death are restricted to selectively vulnerable brain regions.