Childhood steroid-sensitive nephrotic syndrome: does the histology matter?

Renal biopsy specimens from 51 children with steroid-sensitive nephrotic syndrome who were following a frequently relapsing or steroid-dependent course were reviewed by two histopathologists. In all cases the biopsy was performed prior to the commencement of an 8-week course of cyclophosphamide. The clinical courses of these patients both prebiopsy and for a minimum of 2 years after completion of cyclophosphamide therapy were analyzed using retrospective case note analyses. The distribution of histologic diagnoses differed significantly from that reported by the International Study of Kidney Disease in Children in their study of children who underwent biopsy at the time of presentation, there being an excess of focal segmental glomerulosclerosis and mild mesangial hypercellularity in this series. The prebiopsy clinical course did not predict for histologic diagnosis, and there was no correlation between prebiopsy course or histology and postcyclophosphamide course. The findings of this study support the clinical impression that steroid sensitivity rather than histology is the major determinant of prognosis in childhood nephrotic syndrome and that frequency of relapse alone is not an indication for biopsy.

Competition in a spatially heterogeneous environment: modelling the risk of spread of a genetically engineered population

In recent years regulations have been developed to address the risks of releasing genetically engineered organisms into the natural environment. These risks are generally considered to be proportional to the exposure multiplied by the hazard. Exposure is, in part, determined by the spatial spread of the organisms, a component of risk suited to mathematical analysis. In this paper we exampine a mathematical model describing the spread of organisms introduced into a hetereogeneous environment, focusing on the risk of spread and plausibility of containment strategies. Two competing populations are assumed, one the natural species and the other an engineered species or strain, both of which move randomly in a spatially heterogenous environment consisting of alternating favourable and unfavourable patches. The classical Lotka-Volterra competition model with diffusion is used. Analyses of the possible spread and invasion of engineered organisms are thus reduced to finding periodic travelling wave solutions to the model equations. We focus on whether a very small number of engineered organisms can spatially invade a natural population. Initially we investigate the problem for spatially periodic diffusion coefficients and demonstrate that, under the right circumstances and a large enough unfavourable patch, invasion does not succeed. However, if spatially periodic carrying capacities are assumed along with spatially varying diffusion rates, the situation is far more complex. In this case containment of the engineered species is no longer only a simple function of the unfavourable patch length. By using perturbation solutions to the nonuniform steady states, approximate invasion conditions are obtained.

Third generation oral contraceptives and risk of myocardial infarction: an international case-control study. Transnational Research Group on Oral Contraceptives and the Health of Young Women

OBJECTIVE

To test whether use of combined oral contraceptives containing third generation progestogens is associated with altered risk of myocardial infarction.

DESIGN

Matched case-control study.

SETTING

16 centres in Austria, France, Germany, Switzerland, and the United Kingdom.

SUBJECTS

Cases were 153 women aged 16-44 with a myocardial infarction event. Controls were 498 women (at least 3 controls per case) unaffected by myocardial infarction who were matched with their corresponding case for age and for hospital or community setting within four months of the index infarction.

MAIN OUTCOME MEASURES

Odds ratios derived with stratified analyses and unconditional logistic regression to adjust for potential confounding variables.

RESULTS

The estimated odds ratio for myocardial infarction of third compared with second generation oral contraceptives among all 651 study subjects was 0.36 (95% confidence interval 0.1 to 1.2) (P = 0.11). The odds ratio for the United Kingdom and Germany alone was 0.45 (0.1 to 1.8) (P = 0.26). Other odds ratios for the five countries were 3.1 (1.5 to 6.3) (P = 0.003) for use of second generation products v no current use and 1.1 (0.4 to 3.4) (P = 0.9) for use of third generation products v no current use. Among the confounding variables the independent contribution of smoking (for which adjustment was made in the above estimates) proved to be important (10.1 (5.7 to 17.9), P < 0.001).

CONCLUSION

An odds ratio of 0.45 with wide confidence intervals shows that third generation oral contraceptives compared with second generation products are associated with a reduced risk of myocardial infarction or with no difference. This finding from an interim analysis should be interpreted with extreme caution. However, the excess risk of venous thromboembolism associated with the use of third generation products may be balanced by the reduced risk of myocardial infarction associated with the same products.

Third generation oral contraceptives and risk of venous thromboembolic disorders: an international case-control study. Transnational Research Group on Oral Contraceptives and the Health of Young Women

OBJECTIVE

To test whether use of combined oral contraceptives containing third generation progestogens is associated with altered risk of venous thromboembolism.

DESIGN

Matched case-control study.

SETTING

10 centres in Germany and United Kingdom.

SUBJECTS

Cases were 471 women aged 16-44 who had a venous thromboembolism. Controls were 1772 women (at least 3 controls per case) unaffected by venous thromboembolism who were matched with corresponding case for age and for hospital or community setting.

MAIN OUTCOME MEASURES

Odds ratios derived with stratified analyses and unconditional logistic regression to adjust for potential confounding variables.

RESULTS

Odds ratios (95% confidence intervals) for venous thromboembolism were: for any oral contraceptives versus no use, 4.0 (3.1 to 5.3); for second generation products (low dose ethinyl-oestradiol, no gestodene or desogestrel) versus no use, 3.2 (2.3 to 4.3); for third generation products (low dose ethinyloestradiol, gestodene or desogestrel) versus no use, 4.8 (3.4 to 6.7); for third generation products versus second generation products, 1.5 (1.1 to 2.1); for products containing gestodene versus second generation products, 1.5 (1.0 to 2.2); and for products containing desogestrel versus second generation products, 1.5 (1.1 to 2.2). Probability of death due to venous thromboembolism for women using third generation products is about 20 per million users per year, for women using second generation products it is about 14 per million users per year, and for non-users it is five per million per year.

CONCLUSIONS

Risk of venous thromboembolism was slightly increased in users of third generation oral contraceptives compared with users of second generation products.

Organizing the community to target poor Latino children with asthma

A community-university partnership to improve outcomes of care for poor Latino children (aged 6-14 years) with asthma in East Los Angeles was based on development of a community infrastructure. A family-centered educational program involved over 500 families. The Association of Latinos with Asthma and Allergy Symptoms (ALAAS) was formed. Parents report reductions in hospitalizations, emergency room, and acute care visits. Survival of the infrastructure following the end of grant funds is unlikely unless other resources offset the costs of volunteerism among poor families. Block grants to community agencies from established fund-raising groups might reduce dependency-producing practices currently employed to "help" the poor.

Outcome of pediatric cadaveric renal transplantation: a 10 year study

This report deals with 120 cadaveric renal transplants performed in 101 pediatric recipients in this Centre in two five-year periods, 1984 to 1988 (N = 65) and 1989 to 1993 (N = 55). In the first group transplants were allocated on the basis of best size (small donors for small recipients); in the second group priority was given to beneficial HLA matching. Initial immunosuppression was either cyclosporine (CsA) monotherapy (15 mg/kg/day), or triple therapy (CsA 5 mg/kg/day, prednisolone 1 mg/kg/day and azathioprine 1 mg/kg/day) if there was delayed graft function. Patient survival at one year and five years (97.5% and 92.3%, respectively) did not differ between the two groups, although there was an improvement in graft survival at one and five years in the second period relative to the first: 69.2% and 53.8% versus 78.6% and 65.6%. This did not achieve statistical significance. One year graft survival in recipients under five years did not differ significantly from older children (72%). There was a trend to improvement in one year graft survival in the < five years of age pediatric patients in Group 2, with beneficially matched kidneys and improved immunosuppressive management. Graft losses due to acute rejection were similar in both groups. Donor age < 4 years significantly reduced one year graft survival (63% vs. 85%, P = 0.01), while recipient age had no effect. Small donor kidneys were associated with a higher incidence of graft thrombosis. Transplantation resulted in the normalization or acceleration of growth velocity in (84%) of the pre-pubertal children who completed follow up. In conclusion, we have shown that excellent patient and graft survival can be achieved in children transplanted under the age of five years. Kidneys from donors under the age of four years are associated with an unacceptable rate of graft loss. Small children do not readily accept cyclosporine monotherapy. Successful early renal transplantation offers the best chance of normal growth and development.

Private payers of health care in Brazil: characteristics, costs and coverage

The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation.

Drugs, poverty, pregnancy, and foster care in Los Angeles, California, 1989 to 1991

To determine the characteristics and childbearing histories of women whose infants entered foster care in Los Angeles County, we examined the cases of 1,155 drug-using women whose infants were removed from them at birth and 236 non-drug-using women whose infants were also removed at birth by court order (July 1989 through March 1991). All of the women were indigent, and less than half had graduated from high school. The drug-using women frequently had criminal records, and more than a quarter were homeless. Many comparison women had mental health problems, and some (16.7%) were teenagers under court custody. Overall, 80% of all the children born to both groups of women were under court jurisdiction. Data obtained after study infants' births on 926 drug-using women observed for 18 months revealed that 22% had borne another infant who was placed in foster care; half of these infants had a positive drug immunoassay. Of the 185 non-drug-using women with 18-month follow-ups, 7.6% had borne another child who was in foster care. The magnitude of the repeated childbearing recorded among both groups of women in this study shows that preventive programs including family planning, mental health services, and drug prevention or rehabilitation programs have not reached this population.

Lhermitte-Duclos disease associated with Cowden's disease

The twelfth patient in the known literature with Lhermitte-Duclos disease (dysplastic gangliocytoma) occurring in association with Cowden's disease is described. The investigation, aetiology, and management of the case are discussed.

Identification of Candida species by PCR and restriction fragment length polymorphism analysis of intergenic spacer regions of ribosomal DNA

The PCR was used to amplify a targeted region of the ribosomal DNA from 84 Candida isolates. Unique product sizes were obtained for Candida guilliermondii, Candida (Torulopsis) glabrata, and Candida pseudotropicalis. Isolates of Candida albicans, Candida tropicalis, Candida stellatoidea, Candida parapsilosis, and Candida krusei could be identified following restriction digestion of the PCR products.

Multicystic renal dysplasia diagnosed in the antenatal period: a note of caution

OBJECTIVE

To document the urological problems associated with multicystic renal dysplasia (MCRD), to assess the efficacy of radiological methods for following the natural history of MCRD and to review current experience in the light of historical data regarding this condition.

PATIENTS AND METHODS

From January 1982 to December 1992 data were obtained prospectively on 62 patients (41 boys and 21 girls, age range 1-11 years) who had a diagnosis of MCRD suspected on antenatal ultrasonography. All patients had the diagnosis confirmed with radioisotope scans and micturating cystograms. Serum creatinine was measured in each patient and repeated clinically as indicated. Follow-up was from 1 to 11 years, with a clinical review and an annual ultrasonogram. The natural history of these patients was compared with those in other published studies.

RESULTS

Of the 62 patients, 12 had associated vesicoureteric reflux. Four patients developed impaired renal function during the course of observation and 10 patients required urological surgery for other pathologies. In the patients managed conservatively, 38% underwent no resolution on sequential ultrasonograms during the 2-year follow-up, and in four children, where complete resolution of the MCRD had occurred on ultrasonography, significant cellular renal masses were excised at subsequent surgery.

CONCLUSION

Patients with MCRD have significant associated urological malformations and the natural history in such patients is unpredictable. We do not regard MCRD as an entirely benign condition and feel that all patients require appropriate investigation of their urinary tract and long-term follow-up where conservative treatment is instituted. From the natural history of these patients, reviewed in conjunction with the literature, we recommend that decisions for management can only be taken with the full informed consent of the parents and that surgical excision is offered as part of that process.

Recruiting patients to clinical trials: lessons from studies of growth hormone treatment in renal failure

Issues raised by the recruitment of children to trials of growth hormone treatment for short stature in chronic renal failure are reported. Information needs of parents and children are discussed, the latter should take account of the children's developmental level and anticipated involvement in decision making. When the incidence of certain side effects is low and probably unquantifiable there are particular problems; failure to include these in information sheets may compromise informed consent but inclusion will, at least for some families, make an already difficult decision even more complicated. A process of recruitment is described which attempts to protect against bias and which balances the requirement to impart neutral information with appropriate clinical involvement in the decision to enter the study. Other functions of the recruitment process are identified. Analysis of understanding and decision making demonstrates that good understanding is neither necessary nor sufficient for ease of decision making. The recruitment process was time consuming and needs planning and funding in future studies. Many of these issues are of general importance for trials of treatment in children.

Prevalence of penicillin resistant bacteria in acute suppurative oral infection

Pus aspirated from acute suppurative oral infections in 78 patients (age range 13-76 years) yielded a total of 331 bacterial strains consisting of 143 facultative anaerobes (predominantly Streptococcus spp.) and 188 strict anaerobes (predominantly Prevotella spp.). Seventy-five isolates (23%) were resistant to penicillin (MIC > 1 mg/L), 37 (11%) were resistant to ampicillin (MIC > 2 mg/L) and 16 (5%) isolates were resistant to amoxycillin/clavulanic acid (MIC > 2 mg/L). Samples from 43 (55%) of the patients yielded at least one penicillin resistant isolate and within this group 30 samples (73%) contained at least one strain which produced beta-lactamase. A history of antibiotic therapy during the 6 months before enrollment in the study did not influence the isolation of penicillin resistant bacteria. It is concluded that penicillin resistant bacteria are often present in the microflora of acute dental infection.

Ecological chaos in the wake of invasion

Irregularities in observed population densities have traditionally been attributed to discretization of the underlying dynamics. We propose an alternative explanation by demonstrating the evolution of spatiotemporal chaos in reaction-diffusion models for predator-prey interactions. The chaos is generated naturally in the wake of invasive waves of predators. We discuss in detail the mechanism by which the chaos is generated. By considering a mathematical caricature of the predator-prey models, we go on to explain the dynamical origin of the irregular behavior and to justify our assertion that the behavior we present is a genuine example of spatiotemporal chaos.

Use of freshwater plants for phytotoxicity testing: a review

Phytotoxicity data for aquatic plants have served a relatively minor role in regulatory decisions concerning the environmental hazard of most potential contaminants. A variety of phytotoxicity tests have been conducted with freshwater green algae, duckweed, blue-green algae, diatoms and rooted macrophytes (whole plants and seeds). Several test methods have been standardized for microalgae which are used primarily with chemicals, effluents, contaminated sediment elutriates and hazardous waste leachates. Current scientific understanding concerning the phytotoxic effects of these contaminants is based mostly on results for a few green algae. The greatest limitation of these results is their uncertain environmental relevance due to the large interspecific variation in response of standard algal test species and the unrealistic experimental test conditions. Results of the few field validation toxicity tests conducted to resolve this uncertainty have been chemical-specific and unpredictable. Aquatic vascular plants have been used less frequently than algae as test species. Duckweeds have been used more often than rooted submersed species but the uncertain nature of their sensitivities relative to animal and other plant species has limited their use. Regulatory interest in wetland protection, contaminated sediment evaluations and sediment quality criteria development will result in increased use of whole rooted plants and their seeds as test species. Overall, regardless of the test species, if phytotoxicity data are to be more available and effective in the hazard assessment process, additional information concerning species sensitivity, and environmental relevance of the results will be needed.

When are dysphoric individuals distressing to others and vice versa? Effects of friendship, similarity, and interaction task

Interpersonal relationships present difficulties for dysphoric individuals, but the specific contexts in which these difficulties arise remain poorly understood. The authors examined several factors hypothesized to affect how dysphoric and nondysphoric individuals react to each other. Female college students interacted with either a friend or stranger who had a similar or dissimilar dysphoria status in three tasks: a causal conversation, disclosure of a personal problem to the partner, and response to the partner's disclosure of a personal problem. Ss' moods, evaluations of their partners, and verbal behaviors were assessed. Dysphoric Ss exhibited characteristic negative mood and verbal content but did not elicit negative reactions from their partners. Negative reactions were most evident in dysphoric Ss' responses to dissimilar (nondysphoric) strangers, underscoring the need for greater attention to dysphoric individuals' perspective on their social interactions.

Investigative techniques and renal parenchymal damage in children with spina bifida

The case records of 72 patients attending a multidisciplinary spina bifida clinic were reviewed to discover the prevalence of renal parenchymal damage. 19.4% of the total population had such damage. More detailed analysis of the group according to age showed that the prevalence of parenchymal damage in the over ten year olds (27.3%), was twice that of the under five year olds (13.3%) but the same as the prevalence of "at risk" patients (26.6%) in this group. On the basis that most renal parenchymal damage occurs early we conclude that the current approach to investigation and treatment is reducing the incidence of renal parenchymal damage in this population. Further reduction would require the early identification of the high risk bladder before the onset of hydronephrosis.

Cutaneous T-cell lymphoma presenting as facial swelling: report of a case and review of the literature

This paper describes the case of a primary cutaneous T-cell lymphoma (CTCL) which presented on the cheek of a 69-year-old man. Contemporary theories of the pathogenesis and immunologic basis of CTCL are discussed along with recent advances in its diagnosis, classification, and treatment.

When are dysphoric individuals distressing to others and vice versa? Effects of friendship, similarity, and interaction task

Interpersonal relationships present difficulties for dysphoric individuals, but the specific contexts in which these difficulties arise remain poorly understood. The authors examined several factors hypothesized to affect how dysphoric and nondysphoric individuals react to each other. Female college students interacted with either a friend or stranger who had a similar or dissimilar dysphoria status in three tasks: a causal conversation, disclosure of a personal problem to the partner, and response to the partner's disclosure of a personal problem. Ss' moods, evaluations of their partners, and verbal behaviors were assessed. Dysphoric Ss exhibited characteristic negative mood and verbal content but did not elicit negative reactions from their partners. Negative reactions were most evident in dysphoric Ss' responses to dissimilar (nondysphoric) strangers, underscoring the need for greater attention to dysphoric individuals' perspective on their social interactions.

The termination of a randomized clinical trial for poor Hispanic children

OBJECTIVE

To conduct a randomized clinical trial of the Spanish version of an educational program designed to be an adjuvant to adequate medical care of children with asthma.

DESIGN

Randomized, clinical trial.

SETTING

Los Angeles County, Calif.

PARTICIPANTS

One hundred thirty-eight Hispanic children, ages 7 to 12 years, from disadvantaged families. All had used emergency facilities of major local hospitals in the previous year. MEASUREMENT/MAIN RESULTS: As the study proceeded, it became apparent that subjects were receiving inadequate medical and nursing care and had numerous barriers to applying knowledge and self-care skills gained from the program. Realizing this, we considered it unethical to allow the control children to suffer for the duration of the trial (1 year). Therefore, all children received "adequate" care from the research staff, and the randomized clinical trial, as originally designed, was ended. The emergency department/hospital use by both groups was significantly reduced compared with previous experience.

CONCLUSION

Those researchers conducting randomized trials involving poor children should be aware of the potential ethical problems inherent in such ventures.