Emergency treatment of peri-operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists

Peri-operative anaphylaxis is a rare but potentially catastrophic event which must be considered whenever unexpected and significant cardiovascular or respiratory compromise occurs during anaesthesia. The Resuscitation Council UK algorithm for peri-operative anaphylaxis highlights the importance of early intravenous adrenaline and fluid resuscitation and provides guidance on the treatment of refractory anaphylaxis and immediate follow-up. This algorithm is endorsed by the Royal College of Anaesthetists, Association of Anaesthetists, British Society of Allergy and Clinical Immunology and Clinical Immunology Professional Network of the British Society for Immunology. This document was produced by the Perioperative Allergy Network steering committee in collaboration with the Resuscitation Council UK.

The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice

PURPOSE

The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members.

METHODS

We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation.

RESULTS

Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN's success-in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci-is attributable to: (1) its people-the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change.

CONCLUSION

CPCRN's history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.

A scoping review of the concept of resilience among African American women

Resilience, thriving in the face of adversity, is a critical component of well-being in African American women. However, traditional definitions and approaches to operationalize resilience may not capture race- and gender-related resilience experiences of African American women. A more complete conceptualization of resilience may help facilitate future investigation of the mechanisms through which resilience influences health in this group. Our team conducted a scoping review of the literature published during twenty years, between 2000 and 2019, on resilience and health in African American women. We included a multidisciplinary set of databases (PubMed, CINAHL, PsycINFO, Scopus, Social Work Abstracts, Sociological Abstracts, Academic Search Premier). Using Covidence software a multi-step review process was conducted; 904 abstracts were initially screened for eligibility, 219 full-text studies were screened in stage two, and 22 remaining studies were reviewed for extraction. The studies reviewed revealed limitations of unidimensional approaches to conceptualizing/operationalizing resilience in African American women. The review highlighted culturally-relevant components of resilience including spirituality/religion, strength, survival, active coping, and social support. Findings highlight the importance of operationalizing resilience as a multidimensional construct so it can be optimally included in research designed to investigate the quality of life, cardiovascular risk, and other health outcomes in African American women.

Quality and safety education for nurses: A bibliometric analysis

PURPOSE

Since its origin in the United States in 2005, Quality and Safety Education for Nurses (QSEN) has guided nurses' preparation for alleviating preventable harm and improving quality safe care. QSEN's value is illustrated through specific inclusion in the competency-based 2021 American Association for Colleges of Nursing (AACN) Essentials. The purpose of this bibliometric analysis is to explore publication patterns of the extant QSEN literature to assess QSEN's spread and global penetration and to map the available knowledge and data regarding quality and safety education for nurses.

DESIGN

Bibliometric analysis.

METHOD

Two QSEN investigators and two health science librarians completed database searches to identify articles with keywords QSEN or Quality and safety education for nursing. Inclusion criteria were (1) QSEN-specific and (2) published in a peer-reviewed journal. Using PRISMA screening, the final sample included 221 articles between 2007 and 2021.

RESULTS

Average annual QSEN publications was 14.5 articles; the highest was 26 publications in 2017. Article types were 84 research, 77 descriptive/reviews, 28 quality improvement projects or case studies, 20 statements, and 12 editorials. Focus analysis revealed 165 education articles, 35 clinical practice, 17 professional development, and 4 leadership/administration. Fourteen journals published three or more; eight were education journals. Nine topic clusters indicated areas of publication focus, including clinical teaching, simulations, performance, context, and criteria of analysis, factors of efficacy, innovation and advanced practice, patient care and outcomes, academic concepts, and research frameworks.

CONCLUSIONS

Results reveal far less QSEN penetration for guiding professional practice, research measuring outcomes and impact, and global collaboration to examine cultural implications for diversity and inclusion. Results present future recommendations to assure all nurses worldwide have access to competency development to alleviate preventable healthcare harm.

CLINICAL RELEVANCE

Originating in the United States (US), the QSEN project provided the seminal framework for transforming education and practice through defining the six quality and safety competencies (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics) essential to alleviate preventable healthcare harm. Results reveal opportunities to advance QSEN penetration in developing professional practice, guiding research measuring outcomes and impact, and extending global collaboration to examine cultural implications for diversity and inclusion.

A bibliometric analysis of nursing and midwifery research in the Caribbean

PURPOSE

To determine the research output of Caribbean nurses and midwives.

METHODS

We searched the Scopus database to identify publications by Caribbean nurses and midwives during the period 2000-2020. Publications were included in the analysis if they had at least one author who was either a nurse or midwife and affiliated with a Caribbean geographic location. All publication types and languages were included in the analysis. Organization analysis and collaboration networks were created using the VOS Viewer application.

FINDINGS

The number of Scopus publications by Caribbean nurses and midwives progressively grew from 22 in 2000 to 584 in 2020. Cuba recorded the highest number of nursing research publications (319) followed by Jamaica (92), and Puerto Rico (59). Most publishing institutions were universities. The University of the West Indies (Jamaica) ranked highest with 15.2% of publications, followed by Universidad de Ciencias Médicas de La Habana with 14.4% of publications, Universidad de Puerto Rico ranked third with 9.8% of publications. The majority of publications (83.6%) were peer reviewed research articles, while review articles accounted for 9.8% of publications. Six out of the ten journals that published most research done by Caribbean nurse researchers were Cuban journals which published a total of n = 250 (75.8%) articles. All six journals had no impact factor and had low cite scores.

CONCLUSIONS

Our analysis of bibliometric indicators suggest that recent and steady growth in nursing and midwifery research in the Caribbean has had low visibility. Equipping nurses and midwives with the necessary knowledge and skills to lead, teach, and conduct high quality research through doctorate level education is an imperative for increasing research productivity among Caribbean nurses and midwives.

CLINICAL RELEVANCE

Nursing and midwifery research is critical for evidence-based nursing and midwifery practice. High quality and context specific research evidence will enable Caribbean nurses and midwives to provide quality and culturally sensitive nursing and midwifery care and contribute to evidence informed policy decisions.

A Risk Score Model for Locoregional Recurrence Following Upfront Surgery for Pancreatic Adenocarcinoma: Implications for Adjuvant Therapy

AIMS

The aims of the study were to identify predictors of locoregional failure (LRF) following surgery for pancreatic adenocarcinoma, develop a prediction risk score model of LRF and evaluate the impact of postoperative radiation therapy (PORT) on LRF.

MATERIALS AND METHODS

A retrospective review was conducted on patients with stages I-III pancreatic adenocarcinoma who underwent surgery at our institution (2005-2016). Univariable and then multivariable analyses were used to evaluate clinicopathological factors associated with LRF for patients who did not receive PORT. The risk score of LRF was calculated based on the sum of coefficients of the predictors of LRF. The model was applied to the entire cohort to evaluate the impact of PORT on the high- and low-risk groups for LRF.

RESULTS

In total, 467 patients were identified (median follow-up 22 months). Among patients who did not receive PORT (n = 440), predictors of LRF were pN+, involved or close ≤1 mm margin(s), moderately and poorly differentiated tumour grade and lymphovascular invasion. After adding patients who received PORT, the 2-year LRF in the high-risk group was 57% for patients who did not receive PORT (n = 242) and 32% among patients who received PORT (n = 22), with an absolute benefit to LRF of 25% (95% confidence interval 5-52%, P = 0.07). The 2-year overall survival for the high-versus the low-risk group was 36% versus 67% (P < 0.001).

CONCLUSION

This risk group classification could be used to identify pancreatic adenocarcinoma patients with higher risk of LRF who may benefit from PORT. However, validation and prospective evaluation are warranted.

Fatigue in people with localized colorectal cancer who do and do not receive chemotherapy: a longitudinal prospective study

BACKGROUND

Fatigue is associated with cancer and chemotherapy and may be sustained. Here, we describe a prospective longitudinal study evaluating fatigue and putative mechanisms in people with colorectal cancer (CRC).

PATIENTS AND METHODS

People with localized CRC completed the Functional Assessment of Cancer Treatment-Fatigue (FACT-F) questionnaire at baseline (before chemotherapy, if given), 6, 12, and 24 months. Healthy controls (HCs) were assessed at the first three time points. Fatigue was defined by standardized FACT-F scores ≤68/100. Quality-of-life (QoL, assessed by the FACT-G questionnaire), affective, and cognitive symptoms were evaluated. Associations were sought between fatigue, baseline factors, and blood tests (including hemoglobin, cytokines, and sex hormones). Regression analyses, Fisher's exact tests, and Wilcoxon rank-sum tests assessed levels of fatigue at each time point and change in fatigue from baseline. A repeated-measures analysis investigated prognostic factors of fatigue across all time points.

RESULTS

A total of 289 subjects with localized CRC (173 received chemotherapy) and 72 HCs were assessed. More CRC patients had fatigue than HCs at baseline (52% versus 26%, P < 0.001). Fatigue was increased in the chemotherapy (CTh) group at 6 months [CTh+ 70% versus CTh- 31% (P < 0.001), HCs 22%] and remained more common at 12 [CTh+ 44% versus CTh- 31% (P = 0.079)] and 24 months [CTh+ 39% versus CTh- 24% (P = 0.047)]. There was no significant difference between those not receiving chemotherapy and HCs at follow-up assessments. Fatigue was associated with poor QoL, affective and cognitive symptoms, but not consistently with cytokine levels. Predictors for sustained fatigue were baseline fatigue, treatment group, cognitive and affective symptoms, poorer QoL, and comorbidities.

CONCLUSIONS

CRC patients have more fatigue than HCs at baseline. Fatigue peaks immediately after adjuvant chemotherapy, but remains common for 2 years in those who receive chemotherapy. Cognitive and affective symptoms, QoL, comorbidities, chemotherapy, and baseline fatigue predict for longer term fatigue.

Assessment of functional outcomes of surgically managed acetabular fractures

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling.

Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results.

Cite this article: Bone Joint J 2016;98-B:690–5.

The "Down the PC" view - A new tool to assess screw positioning in the posterior column of the acetabulum

INTRODUCTION

Minimal-invasive placement of screws into the posterior column of the acetabulum (PC) is challenging. Due to the saddle-shaped curvature of the medial cortical border of the PC, the standard fluoroscopic views of the pelvis cannot provide the desired safety during screw insertion. The aim of this study was to define a view tangentially to the medial cortex of the PC and to evaluate its accuracy and inter-observer reproducibility.

METHODS

Radio-dense markers on the medial cortex of the PC along the axis of a PC screw were brought in line and landmarks of the new "Down the PC" view were determined. Kirschner wires were placed into the PC of a pelvis composite model and five pelvic cadaver specimens in a total of 34 different correct and incorrect positions. Based on either only the "Down the PC" view, only the standard views, or a combination of both, three fellowship-trained orthopaedic surgeons had to decide if the inserted wires were in bone in the posterior column or had exited cortex, and if they penetrated the acetabulum. Sensitivity, specificity, and the intra-class correlation coefficient were calculated.

RESULTS

A view using three radiographic landmarks (pelvic brim, medial cortical wall of the body of the ischium, ischial spine) was found. Sensitivity and specificity to detect perforation out of the bone were 1.00 and 0.97 for the "Down the PC" view, 0.46 and 0.97 if only the standard views were used, and 1.00 and 0.95 for a combination of both. Sensitivity and specificity to detect intra-articular wire placement were 1.00 and 0.96 for the "Down the PC" view, 0.72 and 0.95 if only the standard views were used, and 0.94 and 0.99 for a combination of both. Inter-observer agreement using only the "Down the PC" view was excellent with an ICC of 0.92 for perforation and ICC of 0.82 for intra-articular wire placement.

CONCLUSIONS

The "Down the PC" view is a useful addendum in the orthopaedic trauma surgeon's tool box. Using simple landmarks, it is easily to reproduce and thereby shows excellent accuracy and inter-observer agreement in order to detect medial perforation or intra-articular implant position.

Cognitive function and fatigue after diagnosis of colorectal cancer

BACKGROUND

Cognitive impairment and fatigue have been associated with cancer and its treatment. We present baseline data from a large longitudinal study that evaluates cognitive function, fatigue, and potential underlying mechanisms following diagnosis of colorectal cancer (CRC).

PATIENTS AND METHODS

We evaluated CRC patients with stage I-III disease before or after surgery, participants with limited metastatic disease and healthy controls (HC). Neuropsychological evaluation included clinical and computerised tests. Participants completed questionnaires for fatigue and quality of life (QOL)-(FACT-F), anxiety/depression, and cognitive symptoms (FACT-Cog). Ten cytokines, clotting factors, sex hormones, carcinoembryonic antigen (CEA), and apolipoprotein E genotype were evaluated. Primary end points were cognitive function on clinical tests evaluated by a Global Deficit score (GDS) and fatigue. Associations between test results, demographic, and disease related factors were explored.

RESULTS

We assessed 291 participants with early-stage disease [median age 59 (23-75) years, 63% men], 72 with metastatic disease, and 72 HC. Using GDS, 45% (126/281) of participants with early-stage CRC had cognitive impairment versus 15% (11/72) of HC (odds ratio 4.51, 95% confidence interval 2.28-8.93; P < 0.001), with complex processing speed, attention/working memory, and verbal learning efficiency being most affected. Women with early-stage CRC had greater cognitive impairment than men [55/105 (52%) versus 71/176 (40%), P < 0.050]. Cognitive symptoms were self-reported by 21% (59/286) of early-stage patients versus 17% (12/72) of HC; fatigue by 52% (149/287) of early-stage patients and 26% (19/72) of HC (P < 0.0001). Women reported more fatigue than men (P = 0.003). Fatigue, QOL, anxiety/depression, and cognitive symptoms were associated with each other (r = 0.43-0.71), but not with neuropsychological performance. Most cytokines were elevated in cancer patients. Cognitive function was not associated with cytokines, sex hormones, clotting factors, CEA, or apolipoprotein E genotype.

CONCLUSIONS

The incidence of cognitive impairment was three to five times higher in CRC patients than HC, with women having higher impairment rates than men. The cognitive impairment profile suggests dysfunction primarily in fronto-subcortical brain systems.

TRIAL REGISTRATION

NCT00188331.

Preclinical characterisation of the GM-CSF receptor as a therapeutic target in rheumatoid arthritis

Objective

Previous work has suggested that the granulocyte macrophage colony stimulating factor (GM-CSF)–GM-CSF receptor α axis (GM-CSFRα) may provide a new therapeutic target for the treatment of rheumatoid arthritis (RA). Therefore, we investigated the cellular expression of GM-CSFRα in RA synovial tissue and investigated the effects of anti-GM-CSFRα antibody treatment in vitro and in vivo in a preclinical model of RA.

Methods

We compared GM-CSFRα expression on macrophages positive for CD68 or CD163 on synovial biopsy samples from patients with RA or psoriatic arthritis (PsA) to disease controls. In addition, we studied the effects of CAM-3003, an anti-GM-CSFR antibody in a collagen induced arthritis model of RA in DBA/1 mice. The pharmacokinetic profile of CAM-3003 was studied in naïve CD1(ICR) mice (see online supplement) and used to interpret the results of the pharmacodynamic studies in BALB/c mice.

Results

GM-CSFRα was expressed by CD68 positive and CD163 positive macrophages in the synovium, and there was a significant increase in GM-CSFRα positive cells in patients in patients with RA as well as patients with PsA compared with patients with osteoarthritis and healthy controls. In the collagen induced arthritis model there was a dose dependent reduction of clinical arthritis scores and the number of F4/80 positive macrophages in the inflamed synovium after CAM-3003 treatment. In BALB/c mice CAM-3003 inhibited recombinant GM-CSF mediated margination of peripheral blood monocytes and neutrophils.

Conclusions

The findings support the ongoing development of therapies aimed at interfering with GM-CSF or its receptor in various forms of arthritis, such as RA and PsA.

Abstract P6-09-02: Pre-treatment cognitive function (CF) in women with locally advanced breast cancer (LABC) and in healthy controls

Background: Several studies have reported that women with breast cancer may have cognitive dysfunction prior to chemotherapy (ChT), and that cognitive dysfunction may be related to the cancer itself or to the psychological impact of a cancer diagnosis. Previous studies assessing CF in breast cancer patients pre-ChT have done so after surgery. Women with LABC receive ChT prior to surgery, and therefore provide a unique opportunity to assess CF without the confounding factor of surgery. This study reports CF in women with newly diagnosed LABC compared to healthy controls.

Methods: Baseline information including participant demographics, smoking/alcohol history, co-morbidities, and medications were collected. Women with LABC underwent a 2-hour battery of CF tests prior to neoadjuvant ChT. Six cognitive domains using standardized, validated, and reliable neuropsychological tests were assessed: verbal, visual-spatial, memory, attention, processing speed, and executive function. Performance on each test was transformed to z-scores using normative data (average range z-score = −1 to 1). Participants also completed self-report questionnaires for CF (FACT-COG3 and PAOFI), fatigue (FACIT-F subscale) and affect (HADS). Data obtained were compared to those for age-matched healthy women who were administered the same battery of tests and measures.

Results: Forty-seven women with LABC and 22 controls were assessed. All women completed the CF tests and questionnaires within 2 hours. There were no significant differences between patients and controls in age (pts median age=49; controls=48), education (median years in school=16 for both), smoking or alcohol history, co-morbidities, mood disorders (anxiety, depression), previous history of concussion, or current medication for mood or sleep problems. Objective CF testing demonstrated no significant difference in the mean performance of women with LABC vs that of controls in any objective domain, nor were there statistically significant differences in the frequency of deficits (e.g., 96% of pts had &lt; 2 deficits; 86% of controls had &lt; 2 deficits). Women with LABC did not report worse CF, fatigue, or depressive symptoms compared to controls. Anxiety was the only self-reported measure where patients had more symptoms (mean HADS 7.6 vs 5.4, p &lt; .036). Consistent with the literature, only weak to no association was observed between any of the objective measures of CF and the self-reported measures. Multivariate regression analyses found for both patients and controls, low education level (≤12 years), smoking history (≥10 pack year), alcohol intake (≥10 drinks/week), and currently taking medication for anxiety, depression, or sleep to be associated with poorer CF as measured on at least one objective domain.

Conclusion: When assessed prior to ChT and surgery, no significant difference in objectively assessed or self-reported CF was observed between women with LABC and healthy controls. The effects of cancer treatment will be evaluated as part of a longitudinal study.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-09-02.

A randomized double-blind placebo-controlled cross-over trial of the impact on quality of life of continuing dexamethasone beyond 24 h following adjuvant chemotherapy for breast cancer

Uncertainty remains about the optimal anti-emetic regimen for control of delayed nausea and vomiting after adjuvant chemotherapy for breast cancer. Many patients receive dexamethasone but complain of insomnia, anxiety/agitation, and indigestion. The aim was to determine if patients receiving chemotherapy for breast cancer prefer treatment with dexamethasone or placebo for prophylaxis against delayed nausea and vomiting, and to compare quality of life (QOL) between the two treatments. In this randomized, double-blind, cross-over trial, we compared oral dexamethasone (4 mg twice daily for 2 days) versus placebo for chemotherapy-naïve patients with breast cancer. All patients received intravenous granisetron and dexamethasone pre-chemotherapy and oral granisetron on day 2. Primary endpoints were: (i) patient preference; (ii) difference between cycles in change of QOL from days 1 to 8. Median age of the 94 women was 51 years (range 27-76): 79 received fluorouracil/epirubicin/cyclophosphamide and 15 received doxorubicin/cyclophosphamide. Thirteen withdrew pre-cycle 2 with no differences between arms. Of 80 patients stating a preference, 31 preferred placebo (39 %, 95 % CI: 28-50 %) and 37 (46 %, 95 % CI: 35-58 %) preferred dexamethasone; 12 had no preference. There were no differences in intensity of vomiting, nausea, or time to onset of vomiting. There was greater decrease in global QOL (p = 0.06) when patients received dexamethasone. No other symptom/QOL domains differed significantly. In conclusion, no significant difference was found in patient preference, QOL, or symptoms regardless of whether dexamethasone or placebo was used after adjuvant chemotherapy.

Cognitive function and fatigue in colorectal cancer (CRC) patients: Baseline assessments prior to chemotherapy

9557

Background: A subset of women with breast cancer have cognitive impairment &/or fatigue before and after chemotherapy (CTh). We evaluated these symptoms and potential mechanisms prior to CTh in patients with CRC. Methods: Chemo-naïve patients with stage I-III CRC (Group 1) and pts with limited stage IV CRC prior to 1st line metastatic CTh (Group 2) were evaluated. Neuropsychological (NP) performance was assessed by classical and computerized (CANTAB) test batteries, with cognitive impairment defined using a global deficit score approach, and concurrent questionnaires for fatigue & quality of life (FACT-F), anxiety/depression (GHQ), and perceived cognitive function (FACT-COG). Group 1 had blood tests to evaluate 10 cytokines, clotting factors, sex hormones, CEA and apoE genotype. Primary endpoints were cognitive function (classical tests) and fatigue in group 1. Associations between test results, demographic and disease-related factors were sought. Results: We assessed 326 patients: Group 1, 253 (post-surgery [median 56 days] 174; pre-surgery 79); Group 2, 73. Median age was 59 (23–75); 61% were male. In group 1, 36% had cognitive impairment on classical tests & 29% on CANTAB; 32% and 30% in group 2. No differences were seen by disease stage or surgery status. Men had more cognitive impairment than women on classical tests (p=.001). Self-reported cognitive symptoms was 10%; higher in women (p=.08). Fatigue, QOL, anxiety/depression & self-reported cognitive symptoms were strongly associated with each other (r=.45-.76, p<.0001), but not with NP test performance. Fatigue was 52% in Group 1 vs 66% in Group 2 (p=.03); and greater in women (p=.002). All cytokines were elevated compared to healthy volunteers (p<.001). Cognitive function and fatigue prior to CTh were not associated with cytokines, sex hormones, clotting factors, CEA or apoE genotype. Symptoms of anxiety/depression were reported by 13% of group 1 pts vs 25% in group 2 (p=.02). Conclusions: Cognitive impairment was present in 36% of CRC patients prior to adjuvant CTh, with 10% self-reporting impairment and 52% reporting fatigue. Cytokine levels were elevated but were not associated with cognitive function or fatigue. The etiology of cognitive impairment prior to cancer treatment remains unknown.

No significant financial relationships to disclose.

The use of melatonin to treat sleep disorder in adults with intellectual disabilities in community settings - the evaluation of three cases using actigraphy

BACKGROUND

Sleep disorders are known to be very prevalent in adults with intellectual disabilities (ID) but to date there has been limited objective assessment of either sleep disorders or of interventions such as the use of melatonin.

METHODOLOGY

A protocol-driven assessment and intervention procedure was followed with three people with moderate to severe ID identified as having a possible sleep disorder. Actigraphic assessment was used to determine the nature of the sleep disorder, after which sleep hygiene advice and then individual treatment with melatonin were provided, following which further actigraphic assessment was carried out. Behavioural disturbance was formally assessed before and after the intervention phase.

RESULTS

Following treatment with melatonin, changes in circadian rhythm were noted, together with improvements in challenging behaviour, but no significant effects were noted with regard to either quantity or quality of sleep.

CONCLUSIONS

A standardised procedure for assessment and treatment of sleep disorders in people with ID was established. Although no apparent effects on sleep quantity or quality were noted, this may reflect factors inherent in the sample, rather than the relative efficacy of melatonin treatment per se.

The conceptualisation of dreams by adults with intellectual disabilities: relationship with theory of mind abilities and verbal ability

BACKGROUND

Empirical studies suggest that individuals with intellectual disabilities (ID) have difficulties in conceptualising dreams as perceptually private, non-physical, individuated and potentially fictional entities. The aim of the current study was to replicate the results found by Stenfert Kroese et al. using a comparative sample size, and to examine putative cognitive correlates of accurate dream conceptualisation [receptive language and 1st order theory of mind (ToM) abilities].

METHOD

Conceptualisation of dreams, real objects and photographs was assessed with a structured closed-question interview schedule, together with receptive language, and ToM abilities.

RESULTS

Findings from the current study replicated those of previous research, finding that many adults with ID tend to think that dreams take place around them, can be witnessed by others, can be touched and manipulated, can be shared by others and are about real events. The ability to accurately conceptualise dreams was found to increase along with receptive language ability, and there was a non-significant association between ToM ability and the ability to understand that dreams can be about potentially fictional entities.

CONCLUSIONS

Some individuals with ID have a different understanding of mental phenomena such as dreams, which has implications for several aspects of care and support, particularly relating to mental health and therapeutic work.

Dystrophin in adult zebrafish muscle

Mutations in the human dystrophin gene are implicated in the fatal muscle wasting disease Duchenne Muscular Dystrophy (DMD). This gene expresses a sarcolemmal-associated protein that is evolutionarily conserved, underpinning its important role in the architecture of muscle. In terms of DMD modelling, the mouse has served as a suitable vertebrate species but the pathophysiology of the disease in the mouse does not entirely mimic human DMD. We have examined the zebrafish in order to expand the repertoire of vertebrate species for muscle disease modelling, and to dissect further the functional interactions of dystrophin. We report here the identification of an apparent zebrafish orthologue of the human dystrophin gene that expresses a 400-kDa protein that is localised to the muscle membrane surface. These data suggest that the zebrafish may prove to be a beneficial vertebrate model to examine the role and functional interactions of dystrophin in disease and development.

Zebrafish: bridging the gap between development and disease

The zebrafish has been the model of choice amongst developmental biologists for many years. This small freshwater species offers many advantages to the study of organ and tissue development that are not provided by other model systems. Against this background, modern molecular genetic approaches are being applied to expand the physical and genetic mapping of the zebrafish genome. These approaches complement the large-scale mutagenic screens that have led to the isolation of mutant phenotypes. Some of the phenotypes have been found to resemble human disease states, while mapping and sequencing data have revealed zebrafish genes with significant homology to human disease-causing genes. It is the realization that the zebrafish offers an amenable system for understanding disease, as opposed to development, that underpins this review. The adventitious identification of disease phenotypes amongst zebrafish mutants and the important area of deliberate disease modelling using transgenesis and gene targeting should lead to a better application of the zebrafish as a vertebrate model of human diseases.

Solid-phase synthesis of an arylsulfone hydroxamate library

Synthesis of an arylsulfone hydroxamate lead optimization library is presented. Biological activity of representative examples is given to demonstrate the value of this approach for lead optimization.

Mutations in the adrenoleukodystrophy gene

Adrenoleukodystrophy (ALD) is a peroxisomal disorder that commonly manifests as demyelination of the central nervous system (CNS). The isolation of the ALD gene by positional cloning has led to the identification of a variety of mutations in the ALD gene. One hundred and ten mutations have been identified to date, of which approximately 50% are missense mutations. While rapid DNA-based diagnoses of ALD is now possible, there appears to be no simple correlation between genotype and phenotype.

DNA-based diagnostics for adrenoleukodystrophy in a large New Zealand family

AIM

To develop a DNA-based diagnostic test for adrenoleukodystrophy (ALD) in a large New Zealand family.

METHODS

Mutation screening of the X chromosome-linked ALD gene was undertaken by direct sequencing of PCR amplified products encompassing defined exons of the ALD gene. The identification of a mutation led to the development of a simple restriction enzyme digestion protocol of a PCR amplified product to identify those individuals with the mutation.

RESULTS

A nonsense mutation, resulting in deduced premature termination of translation of the ALD gene product, was detected in exon 4 of the ALD gene in an affected male. This mutation was found in three obligate gene carriers in the same ALD family. A DNA-based test was established to identify this mutation by Bgl II digestion of a PCR amplified product encompassing exons 3 and 4 of the ALD gene. The DNA-based test was applied to a chorionic villus sampling for prenatal diagnosis.

CONCLUSIONS

A simple DNA-based test has been developed for ALD in a large New Zealand family. This test provides a rapid means of determining carrier status and for undertaking prenatal diagnosis for ALD in this family.

Structure and location of the murine adrenoleukodystrophy gene

X-linked adrenoleukodystrophy (ALD) is a degenerative neurological disease characterized by the accumulation of very long chain fatty acids in various tissues and demyelination of the central nervous system. The human gene responsible for the disease encodes a membrane-bound ATP-binding transporter protein that is located in peroxisomes. We isolated the mouse adrenoleukodystrophy gene, determined its structure, and mapped it both cytogenetically and genetically. The mouse gene is very similar in structure to the human gene, consisting of 10 exons arranged over a 22-kb genomic region. We localized it in band B of the mouse X chromosome by fluorescence in situ hybridization analysis and, using a new microsatellite repeat polymorphism, determined the map location as 47 cM from the X centromere. We found evidence for other sequences in the mouse genome related to the 3' end of Aldgh. This study paves the way for the construction of gene-targeting plasmids that may be used to develop an animal model of ALD.

Ontogeny of ovine fetal renal atrial natriuretic factor receptors

Ovine fetal renal responses to ANF decrease during the last third of gestation, although circulating fetal plasma atrial natriuretic factor (ANF) levels are higher than in the maternal circulation, and do not change with gestation. This study examined whether previously reported maturational changes in fetal renal responses to ANF are due to changes in renal ANF receptor numbers and/or affinity during gestation. ANF receptor numbers (Bmax) and dissociation constants (Kd) were measured in isolated renal glomeruli from early (95 and 110 day; mean 103 +/- 2) and late gestation (131 and 145 day; mean 138 +/- 2) fetal and maternal sheep. Fetal renal ANF receptor Bmax values significantly increased between 103 and 138 days gestation (13 +/- 3 to 29 +/- 4 fmol/mg protein) but were significantly lower than maternal values (60 +/- 13 fmol/mg protein). Fetal ANF receptor Kd values also increased significantly (245 +/- 34 to 370 +/- 36 pM), with early gestation values significantly lower than maternal values (470 +/- 69 pM). Thus, the blunted fetal renal response to ANF in late as compared to early gestation is not due to reduced ANF receptor numbers. Rather, an increased proportion of ANF clearance receptors, reduced post-receptor function and/or altered intrarenal hemodynamics may contribute.

Ovine fetal swallowing and behavioral state responses to sublingual water

Ovine fetal swallowing primarily occurs in bouts of activity associated with low voltage electrocorticogram activity and breathing movements. Despite similar rates of electromyographic swallowing activity, there are significant differences in the net esophageal fluid flow among fetuses. To determine if variations in the volume of fluids accessible to the fetus (amniotic fluid, lung fluid, salivary secretions) affect fetal swallowing, we studied the effects of sublingual distilled water infusions on ovine fetal swallowing rates and esophageal flow. Seven pregnant ewes at 127 +/- 2 days gestation were chronically instrumented with maternal and fetal vascular catheters, fetal electrocortical, electro-ocular and electromyograph electrodes, an esophageal flow probe and a sublingual infusion catheter. Following a 2-hour control period, consecutive sublingual infusions of room temperature distilled water (10 and 20 ml/kg/h) were administered for 2 h each. In response to sublingual infusions, fetal plasma sodium (142.5 +/- 0.5 to 140.8 +/- 0.8 mEq/l), chloride concentrations (109.2 +/- 0.4 to 107.7 +/- 0.7 mEq/l) and osmolality (302 +/- 2 to 298 +/- 2 mOsm/kg) decreased significantly. Swallowing activity and esophageal flow did not change significantly from basal values (47 +/- 9 swallows/h, 19.2 +/- 4.2 ml/h) during the sublingual infusions. However, fetal low-voltage electrocortical activity increased significantly during both infusion periods (42 +/- 3 to 56 +/- 6%). Sublingual distilled water infusion decreases fetal plasma osmolality and alters fetal behavioral state without affecting swallowing frequency or esophageal flow.

Dehydration increases the renal response to atrial natriuretic peptide in fetal sheep

OBJECTIVE

In sheep, maternal water deprivation results in urinary natriuresis in spite of suppression of plasma atrial natriuretic factor levels. Near-term fetal sheep also have a urinary natriuresis without change in plasma atrial natriuretic factor during maternal dehydration. This study was designed to explore the role of plasma atrial natriuretic factor levels in fetal dehydration-natriuresis.

STUDY DESIGN

Eight chronically instrumented preterm (113 +/- 1 days) ovine fetuses received two atrial natriuretic factor infusions (3 and 15 ng/kg/min) in a euhydrated state and after 48 +/- 1 hours of maternal water deprivation.

RESULTS

Dehydration significantly increased maternal plasma osmolality (302 +/- 2 to 313 +/- 2 mOsm/kg water), sodium (148.1 +/- 0.8 to 154.3 +/- 0.4 mEq/L), chloride (112.4 +/- 0.6 to 116.8 +/- 0.9 mEq/L), and arginine vasopressin (4.2 +/- 1.2 to 23.0 +/- 4.0 pg/ml) and significantly decreased plasma atrial natriuretic factor (36 +/- 6 to 19 +/- 4 pg/ml) concentrations. Fetal plasma osmolality (296 +/- 1 to 308 +/- 2 mOsm/kg), atrial natriuretic factor (128 +/- 16 to 241 +/- 36 pg/ml), and arginine vasopressin (3.5 +/- 0.8 to 12.3 +/- 4.8 pg/ml) concentrations and urine osmolality (170 +/- 10 to 253 +/- 10 mOsm/kg), osmolar clearance (0.80 +/- 0.02 to 0.14 +/- 0.02 ml/kg/min), and fractional sodium excretion (3.3% +/- 1.7% to 8.5% +/- 2.1%) increased significantly with dehydration, whereas the plasma atrial natriuretic factor clearance decreased from 127 +/- 27 to 63 +/- 10 ml/kg/min. Dehydration had no effect on fetal hematocrit, vascular pressures, glomerular filtration rate, urine flow, or free water clearance. In euhydrated fetuses plasma atrial natriuretic factor increased from 128 +/- 16 to 287 +/- 46 pg/ml with sequential atrial natriuretic factor infusion, and no significant increases were observed in urine flow, fractional sodium excretion, and glomerular filtration rate. In contrast, atrial natriuretic factor infusion to dehydrated fetuses significantly increased urine flow (0.17 +/- 0.03 to 0.32 +/- 0.07 ml/kg/min), osmolar clearance (0.14 +/- 0.02 to 0.28 +/- 0.06 ml/kg/min), and fractional sodium excretion (8.5% +/- 2.1% to 14.8% +/- 4.0%).

CONCLUSION

These results demonstrate that in the fetus at 113 days' gestation plasma atrial natriuretic factor levels increase with dehydration, probably a result of decreased plasma atrial natriuretic factor clearance, and the fetal renal responsiveness to atrial natriuretic factor infusion increases during maternal dehydration.