An integrated action plan to fund and support drug development for Dup15q syndrome: a patient organization perspective

Maternal 15q11.2-13.1 duplication syndrome, or Dup15q syndrome (Dup15q), is a rare neurodevelopmental disorder affecting as many as 1 in 5000 to 1 in 20,000 children worldwide. Autism and seizures are two of the most commonly observed phenotypes in Dup15q, with intellectual disability, hypotonia, gastrointestinal distress, and substantial fine and gross motor deficits also commonly reported. The community that is now known as the Dup15q Alliance started in 1994 as a small group of families raising children with chromosome 15q duplications. Originally named IsoDicentric 15 Exchange, Advocacy and Support (IDEAS), the group received official nonprofit organization status 10 years later and rebranded to its current name, Dup15q Alliance, shortly thereafter. Today, there are over 2200 families affiliated with Dup15q Alliance, with an average intake of 10 new families each month. Historically, Dup15q Alliance has provided the community with access to family and caregiver resources in addition to serving as a repository for basic educational information about Dup15q and research developments. The recent installation of a dedicated director of scientific and clinical initiatives alongside other infrastructural changes has now primed the Dup15q Alliance to expand its scientific footprint by funding cutting-edge research, supporting clinical sites and trials, and investing in novel therapeutics that have the potential to change the reality of a Dup15q syndrome diagnosis. To do this, we have developed the LEARN. TREAT. CURE. program to align initiatives, fast-track progress, and bring hope and reality into coexistence. Briefly, we seek to learn as much as we can about the syndrome through cutting-edge research, natural history studies, and patient registry utilization, identify and develop methods to treat the symptoms of our patient community, with the ultimate goal of developing a cure for the disease-causing symptoms of the syndrome.

1446Forgoing needed medical care among long-term survivors of childhood cancer: Racial/ethnic-insurance disparities

Background

Among adult childhood cancer survivors, the relationship between race/ethnicity and health insurance status, as a contributor to disparities in healthcare utilization, is poorly understood.

Methods

We examined racial/ethnic-related disparities by insurance status in “forgoing needed medical care in the last year due to finances” using 3,964 adult childhood cancer survivors (3310 non-Hispanic/Latinx White, 562 non-Hispanic/Latinx Black, and 92 Hispanic/Latinx) participating in the St. Jude Lifetime Cohort Study (SJLIFE). Multivariable logistic regression analyses, guided by Andersen’s Healthcare Utilization Model, were adjusted for “predisposing” (age, sex, childhood cancer diagnosis, cancer treatment, surgery, and treatment era) and “need” (perceived health status) factors. Additional adjustment for income/education and chronic health conditions was considered.

Results

The risk of forgoing care was highest among non-Hispanic/Latinx Blacks and lowest among Hispanics/Latinxs for each insurance status. Among privately-insured survivors, relative to non-Hispanic/Latinx Whites, non-Hispanic/Latinx Blacks were more likely to forgo care (adjusted OR: 1.82, 95% CI: 1.30–2.54): this disparity remained despite additional adjustment for income/education (adjusted OR: 1.43, 95% CI: 1.01–2.01). In contrast, publicly-insured survivors, regardless of race/ethnicity, had similar risk of forgoing care as privately-insured non-Hispanic/Latinx Whites. All uninsured survivors had high risk of forgoing care. Additional adjustment for chronic health conditions did not alter these results.

Conclusions

The findings of this study show that provision of public insurance to all childhood cancer survivors may diminish racial/ethnic disparities in forgoing care that exist among the privately-insured and reduce the risk of forgoing care among uninsured survivors to that of privately-insured non-Hispanic/Latinx Whites.

Key messages

Providing publicly funded health insurance coverage to childhood cancer survivors can reduce disparities in forgoing medical care.

Female cognitive performance and mass are correlated with different aspects of mate choice in the zebra finch (Taeniopygia guttata)

A female's cognitive ability may influence her mate preferences through various mechanisms. These mechanisms include the direct effect of cognitive ability on the information-processing skills used during mate choice, and the indirect effect of cognitive ability on quality when females mate assortatively. Here, we examined whether the ability to learn a novel foraging task, a cognitive skill which has been associated with reproductive success in other capacities, was correlated with song preferences in female zebra finches (Taeniopygia guttata). Female preferences were measured in an operant testing chamber where hops on a perch triggered song playback. Females were given the choice of (1) conspecific vs. heterospecific song and (2) high-quality male vs. low-quality male conspecific song. We found that female performance on the novel foraging task was positively correlated with preference for conspecific song, but not with preference for high-quality male song. Instead, female mass was positively correlated with preference for high-quality male song, potentially signifying that female mass is a stronger predictor of female quality in assortative mating than female cognitive performance. Female mass and cognitive performance were unrelated. Our results suggest that the particular traits of a female that affect conspecific preference do not necessarily affect preference for high-quality males.

The cumulative burden of surviving childhood cancer: an initial report from the St Jude Lifetime Cohort Study (SJLIFE)

BACKGROUND

Survivors of childhood cancer develop early and severe chronic health conditions (CHCs). A quantitative landscape of morbidity of survivors, however, has not been described. We aimed to describe the cumulative burden of curative cancer therapy in a clinically assessed ageing population of long-term survivors of childhood cancer.

METHODS

The St Jude Lifetime Cohort Study (SJLIFE) retrospectively collected data on CHCs in all patients treated for childhood cancer at the St Jude Children's Research Hospital who survived 10 years or longer from initial diagnosis and were 18 years or older as of June 30, 2015. Age-matched and sex-frequency-matched community controls were used for comparison. 21 treatment exposure variables were included in the analysis, with data abstracted from medical records. 168 CHCs for all participants were graded for severity using a modified Common Terminology Criteria of Adverse Events. Multiple imputation with predictive mean matching was used for missing occurrences and grades of CHCs in the survivors who were not clinically evaluable. Mean cumulative count was used for descriptive cumulative burden analysis and marked-point-process regression was used for inferential cumulative burden analysis.

FINDINGS

Of 5522 patients treated for childhood cancer at St Jude Children's Research Hospital who had complete records, survived 10 years or longer, and were 18 years or older at time of study, 3010 (54·5%) were alive, had enrolled, and had had prospective clinical assessment. 2512 (45·5%) of the 5522 patients were not clinically evaluable. The cumulative incidence of CHCs at age 50 years was 99·9% (95% CI 99·9-99·9) for grade 1-5 CHCs and 96·0% (95% CI 95·3-96·8%) for grade 3-5 CHCs. By age 50 years, a survivor had experienced, on average, 17·1 (95% CI 16·2-18·1) CHCs of any grade, of which 4·7 (4·6-4·9) were CHCs of grade 3-5. The cumulative burden in matched community controls of grade 1-5 CHCs was 9·2 (95% CI 7·9-10·6; p<0·0001 vs total study population) and of grade 3-5 CHCs was 2·3 (1·9-2·7, p<0·0001 vs total study population). Second neoplasms, spinal disorders, and pulmonary disease were major contributors to the excess total cumulative burden. Notable heterogeneity in the distribution of CHC burden in survivors with differing primary cancer diagnoses was observed. The cumulative burden of grade 1-5 CHCs at age 50 years was highest in survivors of CNS malignancies (24·2 [95% CI 20·9-27·5]) and lowest in survivors of germ cell tumours (14·0 [11·5-16·6]). Multivariable analyses showed that older age at diagnosis, treatment era, and higher doses of brain and chest radiation are significantly associated with a greater cumulative burden and severity of CHCs.

INTERPRETATION

The burden of CHCs in survivors of childhood cancer is substantial and highly variable. Our assessment of total cumulative burden in survivors of paediatric cancer, with detailed characterisation of long-term CHCs, provide data to better inform future clinical guidelines, research investigations, and health services planning for this vulnerable, medically complex population.

FUNDING

The US National Cancer Institute, St Baldrick's Foundation, and the American Lebanese Syrian Associated Charities.

Characterisation of Activated Carbons Obtained from Rice Husk

Rice husk derived activated carbons doped with nitrogen have been studied using low temperature nitrogen adsorption, scanning electron microscopy, mercury porosimetry, thermogravimetric analysis combined with mass-spectrometry, differential scanning calorimetry and X-ray photoelectron spectroscopy. It has been shown that N-doped activated carbon produced by high temperature treatment of the starting material soaked with urea, has a significantly higher anion exchange capacity than the other samples studied, which correlates with its higher adsorption capacity towards nitrate ion removal from aqueous solutions with the initial concentration of 5 and 15 ppm.

Exploratory study of the role of knowledge brokers in translating knowledge to action following global maternal and newborn health technical meetings

OBJECTIVES

There have been increasing calls for more research on interventions to successfully translate evidence-based knowledge into improved health policy and practices. This paper reports on an exploratory study of knowledge translation interventions conducted with participants of global health meetings held in Bangladesh in 2012 and in South Africa in 2013. We measured stakeholders' uptake of evidence-based knowledge in terms of their translation of this knowledge into actions around public health policy and practice. The research sought to determine whether participants shared and used knowledge from the meetings to improve health policy and practices in their settings and the factors influencing sharing and use.

STUDY DESIGN

An exploratory study employed quantitative and qualitative methods of online surveys and in-depth interviews to collect data from all meeting participants.

METHODS

All participants in the Bangladesh and South Africa meetings were invited to complete an online survey during the meetings and over the following six weeks. Of 411 participants in the 2012 Bangladesh meeting, 148 participants from 22 countries completed the survey. Eleven of these respondents (from eight countries) were interviewed. Of the 436 participants in the 2013 South Africa meeting, 126 respondents from 33 countries completed an online survey; none of these respondents were interviewed.

RESULTS

The analysis revealed that most respondents used new knowledge to advocate for policy change (2012: 65.5%; 2013: 67.5%) or improve service quality (2012: 60.1%; 2013: 70.6%). The type of knowledge that respondents most commonly shared was clinical or scientific information (2012: 79.1%; 2013: 66.7%) and country-specific information (2012: 73.0%; 2013: 71.4%). Most 2012 respondents shared knowledge because they thought it would be useful to a co-worker or colleague (79.7%).

DISCUSSION

Findings on knowledge use and sharing suggest that most respondents saw themselves as knowledge brokers or intermediaries in a position to influence the translation of knowledge into action in health policy and practices in their countries. Results suggest that supporting knowledge brokers working in a local and regional context to spur change, as described in the paper, has the potential to improve health outcomes. Further research is needed to isolate specific interventions and their knowledge translation outcomes.

The reproductive endocrinology and behavior of Vancouver Island marmot (Marmota vancouverensis)

The Vancouver Island marmot (Marmota vancouverensis; VIM) is one of North America's most endangered species with fewer than 150 individuals remaining in the wild. A captive breeding program was established across four facilities in Canada as an insurance population and source of animals for reintroduction to the wild. The purpose of this study was to gather information about the basic reproductive biology and behavior of this species, which is essential to improve captive breeding programs. Regular fecal samples were obtained from adult female (n = 14) and male (n = 10) marmots, 2 years of age and older, over 1-3 breeding seasons (2-3 months duration posthibernation) for steroid hormone analysis. Enzyme immunoassays were validated for quantifying fecal testosterone metabolite concentrations for males, and fecal estrogen and progesterone metabolite concentrations for females. Results indicated that fecal progesterone metabolite concentrations can be used to monitor ovulation and pregnancy. Behavioral monitoring through infrared video surveillance was conducted in four breeding pairs over a 2-year period (n = 7 behavioral profiles). Breeding behaviors correlated strongly with changes in reproductive endocrine profiles. A high frequency of play behavior or "wrestling" was observed in conjunction with breeding activity before an elevation in progesterone metabolite concentrations. Impending parturition was associated with increased aggression and exclusion of the male from the maternal nestbox as well as an increase in nesting activity. Observational data combined with hormonal analysis suggest that female VIMs are induced ovulators and that multiple breeding attempts may be required for ovulation and conception. Gestation appears to be approximately 34 days from peak breeding activity (32 days from estimated ovulation). Fecal testosterone concentrations suggest that testicular activity is seasonal with the reproductive activity occurring immediately posthibernation. Monitoring breeding behavior is a useful means of indicating estrus, conception and pregnancy, which can also be supported by the hormonal analysis of daily fecal samples of individual animals.

Inventory management

A critical aspect of blood transfusion is the timely provision of high quality blood products. This task remains a significant challenge for many blood services and blood systems reflecting the difficulty of balancing the recruitment of sufficient donors, the optimal utilization of the donor's gift, the increasing safety related restrictions on blood donation, a growing menu of specialized blood products and an ever-growing imperative to increase the efficiency of blood product provision from a cost perspective. As our industry now faces questions about our standard practices including whether or not the age of blood has a negative impact on recipients, it is timely to take a look at our collective inventory management practices. This International Forum represents an effort to get a snap shot of inventory management practices around the world, and to understand the range of different products provided for patients. In addition to sharing current inventory management practices, this Forum is intended to foster an exchange of ideas around where we see our field moving with respect to various issues including specialty products, new technologies, and reducing recipient risk from blood transfusion products.

Neurological morbidity in survivors of childhood acute lymphoblastic leukemia (ALL)

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Background: The majority of children diagnosed with ALL over the past two decades have achieved long-term survival. This remarkable success is attributed in part to intensive central nervous system (CNS)-directed therapy that effectively prevents CNS relapse. Because treatment-related neurological morbidity is recognized but poorly characterized, the objective of this cross-sectional study was to estimate the prevalence of neurological symptoms and signs in long-term survivors of childhood ALL. Methods: After obtaining IRB approval, all long-term ALL survivors (≥ 5 years since diagnosis) aged 6–28 years who remained active patients at our institution were identified. All participants completed a questionnaire consisting of independent (and when possible validated) instruments designed to identify various neurological symptoms, as well as, a comprehensive and standardized neurologic examination by a board-certified neurologist. Results: Of the 433 potentially eligible subjects, 162 (37.4%) were enrolled. Participant demographic information and previous treatment exposure were similar to those not enrolled in the study. The rates of endorsed neurological symptoms were: neuropathy (40.1%), dizziness (33%), back pain (22.8%), fatigue (19.1%), falls (15.4%), headache (14.8%), seizures (10.5%), urinary incontinence (8.6%), and stroke (1.2%). Neurological examination confirmed an underlying sensory neuropathy in 44 patients (27.3%). Otherwise, signs of chronic cranial nerve dysfunction (1.9%) and motor weakness (5.6%) were rare. Conclusions: Symptoms and signs of a chronic sensory neuropathy, presumably from previous vincristine exposure, were evident in many patients. Complaints of fatigue, dizziness, and chronic back pain were also relatively common. The number of patients who routinely fall is of concern. Whether these falls are associated with symptoms/signs of neuropathy, weakness, and/or dizziness will require further analysis. Although headache was a common complaint, its prevalence may not differ significantly from a normal age-matched population.

No significant financial relationships to disclose.

All in for mental health: a pilot study of group therapy for people experiencing anxiety and/or depression and a significant other of their choice

Background A need to provide treatment for people with anxiety and/or depression, and to provide preventive strategies for individuals who love them has been identified. In response, an innovative group therapy programme for people with anxiety and/or depression and a significant other of their choice was developed and implemented.Methods Mixed methods were employed. Five 'significant other' groups were held between May 2005 and June 2006. All group participants were requested to complete the Depression Anxiety Stress Scale (DASS), World Health Organization Quality of Life Assessment (WHOQol) and Connor-Davidson Resilience Scale (CD-RISC), pre- and post-therapy, and three months after their last therapy session. In addition, participants who attended groups between July and September 2005 were invited to provide feedback about the group therapy in an individual semi-structured interview.Results Pilot results indicate positive responses from clients, related to facilitation of knowledge and understanding and skills development. For people referred to the group significant improvements were found in the DASS scores, resilience, psychological health and living environment.Limitations Due to the small sample size, and lack of follow-up data and control group, the findings need to be considered with caution and indicate the necessity to collect further data to provide conclusive findings.Conclusions Overall, the outcome of the 'significant other' pilot programme was useful, in that it facilitated a number of positive outcomes for participants. Areas for further research have been identified including strategies to improve social relationships, the de-identification with the sick/supporter role, and testing this model with diverse populations and clinical groups.

Post-impact evaluation of an e-learning cross-infection control CD-ROM provided to all general dental practitioners in England

AIM

To carry out a post-impact evaluation of a cross-infection control CD-ROM, developed for NHS dental teams as a continuing professional development e-learning tool. The program was commissioned by the Department of Health and developed by a project team through the UK Committee of Postgraduate Dental Deans. The Dental Practice Board had originally sent one copy of the CD-ROM to each dental practice in England in 2004.

METHOD

A quantitative statistical analysis of the results of 326 online respondents to the learning package and a survey of 118 dental practitioners drawn from the Dental Practice Board database.

RESULTS

Practitioners felt the CD-ROM in this instance was well-designed and appropriate for their needs. It is inclusive and accessible to a wide range of dental professionals including nurses and hygienists.

CONCLUSIONS

This form of continuing professional development is popular with dental practitioners, although it should not be the only form of continuing professional development available. However, whilst the project was generally regarded as successful, there were problems with the distribution of the CD-ROM. This suggests that an online resource should be made available in the future.

Cardiovascular toxicity due to venlafaxine poisoning in adults: a review of 235 consecutive cases

AIMS

Venlafaxine may increase the risk of arrhythmia in certain patients. We sought to characterize the cardiovascular effects of venlafaxine overdose in adults.

METHODS

A retrospective casenote review of patients admitted to the Royal Infirmary of Edinburgh between January 2000 and June 2006. Haemodynamic and electrocardiographic data were examined in the whole group and a subset that ingested venlafaxine alone.

RESULTS

Two hundred and thirty-five patients (65 men) with median (interquartile range) age 34 years (27-43 years) had ingested venlafaxine 1500 mg (919-2800 mg). Tachycardia (40.0%), high blood pressure (28.4%) and mydriasis (36.6%) were common. Corrected QT >450 ms occurred in seven men (11.1%) and 17 women (10.5%) and transient arrhythmia in three patients. There was a positive correlation between stated quantity of venlafaxine ingested and heart rate [rho = 0.195, 95% confidence interval (CI) 0.054, 0.328] and QTc (rho = 0.314, 95% CI 0.089, 0.509).

CONCLUSIONS

Venlafaxine overdose is associated with sympathomimetic cardiovascular effects and prolonged QTc, irrespective of coingested drugs. These mechanisms might pose an increased risk of arrhythmia and require further exploration.

Compton-scattering cross section on the proton at high momentum transfer

Cross-section values for Compton scattering on the proton were measured at 25 kinematic settings over the range s=5-11 and -t=2-7 GeV2 with a statistical accuracy of a few percent. The scaling power for the s dependence of the cross section at fixed center-of-mass angle was found to be 8.0+/-0.2, strongly inconsistent with the prediction of perturbative QCD. The observed cross-section values are in fair agreement with the calculations using the handbag mechanism, in which the external photons couple to a single quark.

VENLAFAXINE INGESTION IS ASSOCIATED WITH RHABDOMYOLYSIS IN ADULTS: A CASE SERIES

Rhabdomyolysis has been reported after venlafaxine ingestion. We wished to characterize the prevalence of this adverse effect in a realistic clinical setting. Therefore, a retrospective casenote review was performed, including 235 patients admitted to the Royal Infirmary of Edinburgh due to venlafaxine overdose between January 2000 and June 2006. Seizures occurred in 8.9% of the study population. Patients who suffered seizures had ingested larger quantities of venlafaxine than those who did not develop seizures; median (interquartile range) 2800 mg (2006-4350 mg) versus 1500 mg (900-2700 mg, p = 0.001). Raised CK values were more prevalent in those with seizures than those without seizures (61.1% versus 25.7% respectively, p = 0.004). Nonetheless, a positive correlation was found between the quantity of venlafaxine ingested and CK across the whole group (rho = 0.201, 95% confidence interval 0.045-0.347), and in patients who had not developed seizures (rho = 0.174, 95% confidence interval 0.009-0.331). Venlafaxine overdose is associated with a high prevalence of acute muscle injury, both in patients who develop seizures and in those who do not. The clinical significance of this association merits further consideration.

Survey of the implementation of the recommendations in the Health Service Circular 2002/009 'Better Blood Transfusion'

This report describes the results of questionnaire surveys in 2003 and 2004 on the implementation of the recommendations of the Health Service Circular (HSC) 'Better Blood Transfusion' 2002/009 for improving transfusion practice. These followed a similar survey in 2001 to determine the progress with the implementation of recommendations in the previous Health Service Circular (HSC) 'Better Blood Transfusion' 1998/224. There was a disappointing response rate (47%) to the 2003 survey and evidence for incomplete compliance with the action plan. It was repeated in April 2004 with a systematic approach to encouraging returns, and the response rate was 95%. The results indicate progress in the implementation of Better Blood Transfusion between 2001 and 2004 in relation to increases in the proportion of hospitals with Hospital Transfusion Committees, the training of some staff groups, the number of hospitals with transfusion practitioners, the development of protocols for the use of blood and audit activity. However, the results also indicate the need for further progress in the training of some staff groups, particularly nurses and doctors, the development of Hospital Transfusion Teams, the development of protocols for the appropriate use of blood, the provision of information to patients and the use of peri-operative cell salvage. This information should be used to plan further local, regional and national initiatives to implement the Better Blood Transfusion action plan and improve transfusion practice.

Epidural versus non-epidural or no analgesia in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

OBJECTIVES

To assess the effects of all modalities of epidural analgesia (including combined -spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (June 2005).

SELECTION CRITERIA

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. Data were entered into RevMan and double checked. Primary analysis was by intention-to-treat; sensitivity analyses excluded trials with > 30% of women receiving un-allocated treatment.

MAIN RESULTS

Twenty-one studies involving 6664 women were included, all but one study compared epidural analgesia with opiates. For technical reasons, data on women's perception of pain relief in labour could only be included from one study which found epidural analgesia to offer better pain relief than non-epidural analgesia (weighted mean difference (WMD) -2.60, 95% confidence interval (CI) -3.82 to -1.38, 1 trial, 105 women). However, epidural analgesia was associated with an increased risk of instrumental vaginal birth (relative risk (RR) 1.38, 95% CI 1.24 to 1.53, 17 trials, 6162 women). There was no evidence of a significant difference in the risk of caesarean delivery (RR 1.07, 95% CI 0.93 to 1.23, 20 trials, 6534 women), long-term backache (RR 1.00, 95% CI 0.89 to 1.12, 2 trials, 814 women), low neonatal Apgar scores at five minutes (RR 0.70, 95% CI 0.44 to 1.10, 14 trials, 5363 women), and maternal satisfaction with pain relief (RR 1.18 95% CI 0.92 to 1.50, 5 trials, 1940 women). No studies reported on rare but potentially serious adverse effects of epidural analgesia.

AUTHORS' CONCLUSIONS

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

Measurement of the generalized polarizabilities of the proton in virtual Compton scattering at Q2=0.92 and 1.76 GeV2

We report a virtual Compton scattering study of the proton at low c.m. energies. We have determined the structure functions P(LL)-P(TT)/epsilon and P(LT), and the electric and magnetic generalized polarizabilities (GPs) alpha(E)(Q2) and beta(M)(Q2) at momentum transfer Q(2)=0.92 and 1.76 GeV2. The electric GP shows a strong falloff with Q2, and its global behavior does not follow a simple dipole form. The magnetic GP shows a rise and then a falloff; this can be interpreted as the dominance of a long-distance diamagnetic pion cloud at low Q2, compensated at higher Q2 by a paramagnetic contribution from piN intermediate states.

Dynamics of the 16O(e, e'p) reaction at high missing energies

We measured the cross section and response functions for the quasielastic 16O(e,e'p) reaction for missing energies 25< or =E(m)< or =120 MeV at missing momenta P(m)< or =340 MeV/c. For 25<E(m)<50 MeV and P(m) approximately 60 MeV/c, the reaction is dominated by a single 1s(1/2) proton knockout. At larger P(m), the single-particle aspects are increasingly masked by more complicated processes. Calculations which include pion exchange currents, isobar currents, and short-range correlations account for the shape and the transversity, but for only half of the magnitude of the measured cross section.

A comparison of molecular and enzyme-based assays for the detection of thiopurine methyltransferase mutations

S-Methylation by thiopurine methyltransferase (TPMT) is an important route of metabolism for the thiopurine drugs. About one in 300 individuals are homozygous for a TPMT mutation associated with very low enzyme activity and severe myelosuppression if treated with standard doses of drug. To validate the use of molecular genetic techniques for the detection of TPMT deficiency, we have determined red blood cell TPMT activity in 240 adult blood donors and 55 normal children. Genotype was determined by restriction fragment length analysis of polymerase chain reaction products in a cohort of 79 of the blood donors and five cases of azathioprine-induced myelosupression, and this confirmed a close relationship between genotype and phenotype. In 17 of the 24 cases in which mutations were found, DNA was also available from remission bone marrow. In one of these cases, DNA from the remission marrow sample indicated the presence of a non-mutated allele that had not been seen in the blast DNA sample obtained at presentation. These results indicate that polymerase chain reaction-based assays give reliable and robust results for the detection of TPMT deficiency, but that caution should be exercised in relying exclusively on DNA obtained from lymphoblasts in childhood leukaemia.

Use of radiation therapy in posttransplant lymphoproliferative disorder (PTLD) after liver transplantation

Posttransplant lymphoproliferative disorder (PTLD) is a common and life-threatening complication of immunosuppression used to prevent rejection of solid organ and bone marrow transplants. There is no standardized treatment algorithm, but numerous management strategies are available. We describe a patient who developed a solitary lymphoproliferative lesion in the porta hepatis 9 months after orthotopic liver transplant. Following reduction in immunosuppression with no response, she was treated with involved field radiotherapy utilizing CT-based treatment planning. A partial radiographic response was obtained, and she has not developed disease in the engrafted liver or systemically. Based on the present case report, involved field radiotherapy seems to be a reasonable treatment option for patients with localized PTLD. Int. J. Cancer (Radiat. Oncol. Invest.) 90:104-109, 2000.

Evaluation of Cobe Trima for the collection of blood components with particular reference to the in vitro characteristics of the red cell and platelet concentrates and the clinical responses to transfusion

This study evaluated Cobe Trima for donor and operational acceptability, the quality and storage stability of the blood components collected, and the clinical responses to transfusion. The study was carried out in 2 phases; phase 1 assessed the efficiency of red cells and platelet collection, and the characteristics of the components collected before and after storage. Phase 2 was an evaluation of operational issues and the in vitro characteristics of the red cells and platelet concentrates at the time of transfusion in respect to their cellular content, and leucocyte (interleukin IL-6 and IL-8) and platelet-derived (Rantes) cytokine levels. Cytokine levels were also measured in the donors before and after the collection procedure and in patients both before and after transfusion. The clinical responses to a small number of transfusions were assessed. The Cobe Trima was found to be straightforward to use by the operators, although additional operator training was required to manage occasional uncertainty with alarm messages. It was acceptable to the donors except for the occurrence of citrate reactions in 3/6 donors in phase 1; this problem persisted in phase 2 (6/15 donors), and needs to be addressed in the future. All blood components met UK product specifications apart from 2 platelet concentrates, 2 red cell concentrates, and one unit of FFP; the red cell and platelet concentrates had good storage characteristics. The 2 procedures, which resulted in low platelet yields, were due to occlusion of the plasma line; the method for installation of the harness has been subsequently modified to prevent this. 2 red cell concentrates showed haemolysis; the reason for this was not established. The Factor VIII level was satisfactory in plasma and the cellular content was low. The responses to 12 platelet transfusions were expected as in a group of haematology patients, and no immediate adverse effects were reported with any of the transfusions. Leucocyte-associated (IL-8 and IL-6) and platelet-associated (Rantes) cytokine levels were not elevated in donor samples taken before or after the collection procedure, or in the red cell and platelet concentrates at the time of issue. Pre- and post-transfusion IL-8 levels were raised in one patient with non-immune platelet refractoriness, and normal in 2 patients with excellent or almost satisfactory responses to platelet transfusions raising the question as whether IL-8 could be used as a laboratory marker for non-immune platelet refractoriness due to infection.

Low intensity laser therapy for chronic venous leg ulcers

Ulceration of the lower extremities is one of the most important medicosocial problems (Skobelkin et al 1990). In this article, two case studies show that it is the length of time that laser therapy is used that can have a significant impact on ulcer size.

The relationship between thiopurine methyltransferase activity and genotype in blasts from patients with acute leukemia

The level of expression of the enzyme thiopurine methyltransferase (TPMT) is an important determinant of the metabolism of thiopurines used in the treatment of acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). Studies in red blood cells (RBC) have shown that TPMT expression displays genetic polymorphism with 11% of individuals having intermediate and one in 300 undetectable levels. The genetic basis for this polymorphism has now been elucidated and polymerase chain reaction (PCR)-based assays described for the most common mutations accounting for reduced activity. In previous studies, genotype has been correlated with red blood cell activity. In this report, we describe the relationship between genotype and TPMT activity measured directly in the target of drug action, the leukemic cell. We have demonstrated that the TPMT activity in lymphoblasts from 38 children and adults found by PCR to be homozygotes (*1/*1) was significantly higher than that in the five heterozygotes (*1/*3) detected (median, 0.25 v 0.08, P < .002, Mann-Whitney U). Similar results were obtained when results from children were analyzed separately. However, comparison of activity in blasts from AML and ALL showed a higher level in the former (0.35 v 0.22 nU/mg, P < .002, n = 17, 35), suggesting that factors other than genotype may also influence expression.

Methemoglobinemia associated with dapsone treatment in solid organ transplant recipients: a two-case report and review

Dapsone, a sulfone antibiotic, has been increasingly used in solid-organ transplant recipients for the primary prevention of Pneumocystis carinii pneumonia, especially in patients with documented sulfa allergy. A known side effect of dapsone therapy, however, is methemoglobinemia, a condition leading to impaired tissue oxygen delivery. This report documents two cases of dapsone-induced methemoglobinemia in patients after solid organ transplantation with emphasis on the importance of clinical recognition and benefits of treatment. Further, the pathophysiology and causes of this condition are extensively reviewed.

Conservative management of pediatric pancreatic pseudocyst using octreotide acetate

Pancreatic pseudocysts in children are rare. A total of 213 cases have been reported in the literature, the majority secondary to trauma (65%). Treatment options range from conservative, non-operative management to operative drainage. Octreotide acetate, a long-acting analog of somatostatin, is a synthetic peptide with a variety of endocrine and gastrointestinal functions. Octreotide has been successfully used following pancreatic surgery to reduce exocrine function and most recently in the management of adult pancreatic pseudocysts. We report the efficacy of octreotide, as an adjunct to treatment, in two children with pancreatic pseudocyst. Each child was treated conservatively with bowel rest, hyperalimentation, and octreotide acetate (2.5 micrograms/kg SQ QD). Complete resolution of the pseudocysts occurred within 5 weeks. We conclude that octreotide acetate is a safe and potentially effective adjunct in the treatment of pediatric pancreatic pseudocyst, and should be added to the management of pseudocyst before drainage procedures.

Ramifications of late luteal phase dysphoric disorder diagnosis

This article examines the major clinical, sociological, and research implications associated with the diagnosis of late luteal phase dysphoric disorder (LLPDD) as currently defined in the DSM-III-R Appendix A, the diagnostic handbook used to define psychiatric disorders. Evidence supports use of this diagnosis, albeit with strict adherence to the criteria. The recognition, use, and impact of the LLPDD diagnosis as a women's health care issue is discussed.

Dialysis access via a right ventricular assist device

In this report, we describe the successful utilization of an external right ventricular assist device as vascular access for hemodialysis and continuous arteriovenous hemodialysis in a critically ill patient on biventricular mechanical assist support. Utilization of the right ventricular assist device lines provided relatively easy and safe dialysis access and temporarily reduced the risks associated with the conventional vascular access techniques.

Hiding and healing: resolving the suicide of a parent or sibling

The purpose of this study was to describe the long-term effects of suicide of a parent or sibling during childhood or young adulthood. A grounded theory approach was used to discover the respondents' perceptions of the meaning of the event and the effects that it had on them. The themes that emerged from the data were experiencing the pain, hiding the pain, and healing the pain. The need to hide the pain often interfered with the process of healing the pain. Findings indicate that many survivors of suicide during childhood experience painful, unresolved grief that affects their well-being in adulthood.

Cardiovascular screening programs: implications for school nurses

Programs directed toward the identification, prevention, and intervention of blood pressure variations in children and their implications for school nurses are detailed.

The Mother-Infant Transaction Program. The content and implications of an intervention for the mothers of low-birthweight infants

A brief, economic neonatal intervention based on the transactional model of development and influenced predominantly by the conceptual design of the Neonatal Behavioral Assessment Scale was implemented in an intensive care nursery with the mothers of a group of low-birthweight infants. The development of the intervention group was compared with that of a similar group of low-birthweight infants who did not receive the intervention and contrasted with that of a group of normal-birthweight infants. The intervention had a significant effect on maternal adjustment and perception of the infant at 6 months. No significant effect on infant cognitive development was apparent until 36 months (that is, 31 months after the intervention had ceased). The intervention effect was even more significant at 48 months. It appeared that the two low-birthweight groups had progressively diverged after 12 months, the intervention group rising until it approximated the normal-birthweight group in cognitive development, whereas the low-birthweight control group deteriorated. The economical nature of the MITP, its unique (although delayed) benefits, and the apparent durability of the intervention effect, suggest that this intervention program has important theoretical and practical implications and potentially far-reaching applications.