Genomic and global gene expression profiling in pediatric and young adult acute leukemia with PICALM::MLLT10 Fusion

PICALM

MLLT10 fusion is a rare but recurrent genetic driver in acute leukemias. To better understand the genomic landscape of PICALM::MLLT10 (PM) positive acute leukemia, we performed genomic profiling and gene expression profiling in twenty PM-positive patients, including AML (n = 10), T-ALL/LLy (n = 8), Mixed-phenotype acute leukemia (MPAL), T/B (n = 1) and acute undifferentiated leukemia (AUL) (n = 1). Besides confirming the known activation of HOXA, differential gene expression analysis compared to hematopoietic stem cells demonstrated the enrichment of genes associated with cell proliferation-related pathways and relatively high expression of XPO1 in PM-AML and PM-T-ALL/LLy. Our study also suggested PHF6 disruption as a key cooperating event in PICALM::MLLT10-positive leukemias. In addition, we demonstrated differences in gene expression profiles as well as remarkably different spectra of co-occurring mutations between PM-AML and PM-T-ALL/LLy. Alterations affecting TP53 and NF1, hallmarks of PM-AML, are strongly associated with disease progression and relapse, whereas EZH2 alterations are highly enriched in PM-T-ALL/LLy. This comprehensive genomic and transcriptomic profiling provides insights into the pathogenesis and development of PICALM::MLLT10 positive acute leukemia.

AusTraits, a curated plant trait database for the Australian flora

We introduce the AusTraits database - a compilation of values of plant traits for taxa in the Australian flora (hereafter AusTraits). AusTraits synthesises data on 448 traits across 28,640 taxa from field campaigns, published literature, taxonomic monographs, and individual taxon descriptions. Traits vary in scope from physiological measures of performance (e.g. photosynthetic gas exchange, water-use efficiency) to morphological attributes (e.g. leaf area, seed mass, plant height) which link to aspects of ecological variation. AusTraits contains curated and harmonised individual- and species-level measurements coupled to, where available, contextual information on site properties and experimental conditions. This article provides information on version 3.0.2 of AusTraits which contains data for 997,808 trait-by-taxon combinations. We envision AusTraits as an ongoing collaborative initiative for easily archiving and sharing trait data, which also provides a template for other national or regional initiatives globally to fill persistent gaps in trait knowledge.

A pre-post evaluation of a knowledge translation capacity-building intervention

BACKGROUND/AIM

Knowledge translation (KT) aims to reduce research-practice gaps. Few studies have investigated methods to build clinicians' capacity for KT. To: (i) evaluate the impact of a multifaceted KT capacity-building intervention; (ii) understand barriers and enablers to clinicians' use of KT; and (iii) identify useful strategies.

METHODS

A pre-post study to develop KT capacity amongst occupational therapy clinicians (n = 46) in a large metropolitan hospital. A customised questionaire (baseline and 18 months) identified KT-related behaviours and barriers and enablers guided by the Theoretical Domains Framework (TDF). McNemar's tests and Wilcoxon signed rank tests were completed on matched data (n = 20). At follow-up additional items explored perceptions of change and usefulness of strategies.

RESULTS

At follow-up, participants had read more clinical guidelines (10 vs. 17) and more participants reported using strategies to increase the use of recommended clinical practices (P = 0.006). The main barriers at baseline were from the TDF domains of 'attention, memory and decision processes', 'knowledge' and 'environmental context and resources', while main enablers were from 'social/professional role and identity', 'reinforcement', 'social influence' and 'beliefs about consequences' domains. At follow-up, significant improvements were seen in 'knowledge' (p < 0.001), 'environmental context & resources' (P < 0.001), 'skills' (P = 0.008) 'beliefs about consequences' (P = 0.011), 'beliefs about capabilities' (P = 0.018), and 'memory, attention & decision processes' (P = 0.048) and participants agreed that KT had become part of the departments' culture. Strategies perceived most useful included working as a team, having a dedicated staff member, mentoring meetings, department leader support, learning about KT over time, and training sessions.

CONCLUSIONS

The KT capacity-building intervention changed one clinician-reported behaviour and perceived impact of barriers across six domains. Clinicians reported perceived improvement in understanding of - and confidence in - KT, and changes in the culture to one of engaging with KT as part of clinical practice. Further research into KT capacity building is needed.

The Missing Link in the Chain

As the migrant workers of the 1960s and 1970s age in place, many countries are facing caring for increasing numbers of older migrants, many of whom have complex health and social care needs. By applying a qualitative case study approach, of a grassroots disability resource center that works with older migrants, this article critically explores the social policy debates that are focused on older migrants in the Black and Minority Ethnic community. A number of themes have emerged, including the impact of changing family structure, difficulties with accessing services, and increased isolation. In addition, there are also examples of older migrants activtly engaged in building communities and supporting others, defying the stereotypes of vulnerable older migrants being a burden on the state. This article argues for politicians and social policy makers to refocus on the new challenges that are emerging in the older migrants of the Black and Minority Ethnic community.

Liquefied gas electrolytes for electrochemical energy storage devices

Electrochemical capacitors and lithium-ion batteries have seen little change in their electrolyte chemistry since their commercialization, which has limited improvements in device performance. Combining superior physical and chemical properties and a high dielectric-fluidity factor, the use of electrolytes based on solvent systems that exclusively use components that are typically gaseous under standard conditions show a wide potential window of stability and excellent performance over an extended temperature range. Electrochemical capacitors using difluoromethane show outstanding performance from –78° to +65°C, with an increased operation voltage. The use of fluoromethane shows a high coulombic efficiency of ~97% for cycling lithium metal anodes, together with good cyclability of a 4-volt lithium cobalt oxide cathode and operation as low as –60°C, with excellent capacity retention.

Organisational support for evidence-based practice: occupational therapists perceptions

BACKGROUND

Barriers to the use of evidence-based practice extend beyond the individual clinician and often include organisational barriers. Adoption of systematic organisational support for evidence-based practice in health care is integral to its use. This study aimed to explore the perceptions of occupational therapy staff regarding the influence of organisational initiatives to support evidence-based practice on workplace culture and clinical practice.

METHODS

This study used semi-structured interviews with 30 occupational therapists working in a major metropolitan hospital in Brisbane, Australia regarding their perceptions of organisational initiatives designed to support evidence-based practice.

RESULTS

Four themes emerged from the data: (i) firmly embedding a culture valuing research and EBP, (ii) aligning professional identity with the Research and Evidence in Practice model, (iii) experiences of change: pride, confidence and pressure and (iv) making evidence-based changes to clinical practices.

CONCLUSION

Organisational initiatives for evidence-based practice were perceived as influencing the culture of the workplace, therapists' sense of identity as clinicians, and as contributing to changes in clinical practice. It is therefore important to consider organisational factors when attempting to increase the use of evidence in practice.

Vertical Si nanowire arrays fabricated by magnetically guided metal-assisted chemical etching

In this work, vertically aligned Si nanowire arrays were fabricated by magnetically guided metal-assisted directional chemical etching. Using an anodized aluminum oxide template as a shadow mask, nanoscale Ni dot arrays were fabricated on an Si wafer to serve as a mask to protect the Si during the etching. For the magnetically guided chemical etching, we deposited a tri-layer metal catalyst (Au/Fe/Au) in a Swiss-cheese configuration and etched the sample under the magnetic field to improve the directionality of the Si nanowire etching and increase the etching rate along the vertical direction. After the etching, the nanowires were dried with minimal surface-tension-induced aggregation by utilizing a supercritical CO₂ drying procedure. High-resolution transmission electron microscopy (HR-TEM) analysis confirmed the formation of single-crystal Si nanowires. The method developed here for producing vertically aligned Si nanowire arrays could find a wide range of applications in electrochemical and electronic devices.

Building capacity for knowledge translation in occupational therapy: learning through participatory action research

BACKGROUND

There has been widespread acknowledgement of the need to build capacity in knowledge translation however much of the existing work focuses on building capacity amongst researchers rather than with clinicians directly. This paper's aim is to describe a research project for developing a knowledge translation capacity building program for occupational therapy clinicians.

METHODS

Participatory action research methods were used to both develop and evaluate the knowledge translation capacity-building program. Participants were occupational therapists from a large metropolitan hospital in Australia. Researchers and clinicians worked together to use the action cycle of the Knowledge to Action Framework to increase use of knowledge translation itself within the department in general, within their clinical teams, and to facilitate knowledge translation becoming part of the department's culture. Barriers and enablers to using knowledge translation were identified through a survey based on the Theoretical Domains Framework and through focus groups. Multiple interventions were used to develop a knowledge translation capacity-building program.

RESULTS

Fifty-two occupational therapists participated initially, but only 20 across the first 18 months of the project. Barriers and enablers were identified across all domains of the Theoretical Domains Framework. Interventions selected to address these barriers or facilitate enablers were categorised into ten different categories: educational outreach; teams working on clinical knowledge translation case studies; identifying time blocks for knowledge translation; mentoring; leadership strategies; communication strategies; documentation and resources to support knowledge translation; funding a knowledge translation champion one day per week; setting goals for knowledge translation; and knowledge translation reporting strategies. Use of these strategies was, and continues to be monitored. Participants continue to be actively involved in learning and shaping the knowledge translation program across the department and within their specific clinical areas.

CONCLUSION

To build capacity for knowledge translation, it is important to involve clinicians. The action cycle of the Knowledge to Action framework is a useful guide to introduce the knowledge translation process to clinicians. It may be used to engage the department as a whole, and facilitate the learning and application of knowledge translation within specific clinical areas. Research evaluating this knowledge translation program is being conducted.

Which leaf mechanical traits correlate with insect herbivory among feeding guilds?

BACKGROUND AND AIMS

There is abundant evidence that leaf mechanical traits deter feeding by insect herbivores, but little is known about which particular traits contribute to defence across feeding guilds. We investigated the contribution of multiple mechanical traits from shear, punch and tear tests to herbivore deterrence across feeding guilds.

METHODS

Visible damage from miners and external chewers was measured and sucker feeding density estimated in mature leaves of 20 species of forest shrubs and small trees. Cafeteria trials were undertaken using a generalist chewer (larvae of Epiphyas postvittana, Lepidoptera). Damage was compared with leaf mechanical traits and associated nutrient and chemical defence traits.

KEY RESULTS

Damage by external chewers in the field and by E. postvittana correlated negatively with mechanical traits. Hierarchical partitioning analysis indicated that the strongest independent contribution to chewing damage was by the material trait of specific work to shear, with 68 % of total variance explained by the combination of specific work to shear (alone explaining 54 %) and tannin activity in a regression model. Mining damage did not correlate with mechanical traits, probably because miners can avoid tissues that generate high strength and toughness in mature leaves. Mechanical traits correlated more strongly with chewing damage in the field than chemical defences (total phenolics and tannin activity) and nutrients (nitrogen and water), but nutrients correlated strongly with diet selection in the cafeteria trial. Surprisingly, sucker feeding density correlated positively with mechanical traits and negatively with nutrients.

CONCLUSIONS

Mechanical traits of mature leaves influenced insect feeding guilds differentially, reflecting differences in life history and feeding modes. For external chewers, energy (work) to fracture in shearing tests, at both structural and material levels, was strongly predictive of damage. Knowing which leaf mechanical traits influence insect feeding, and in which guilds, is important to our wider understanding of plant-herbivore interactions.

Sedation practices in a cohort of critically ill patients receiving prolonged mechanical ventilation

BACKGROUND

The aim of this paper was to describe type and amount of sedatives, opioid analgesics and anti- psychotics administered to critically ill patients receiving prolonged mechanical ventilation and identify patient-specific factors associated with their administration.

METHODS

Retrospective cohort study of adult patients mechanically ventilated for ≥14 days over a two-year period.

RESULTS

The majority of patients (88%) received lorazepam for sedation (median 14-day dose 168 mg, IQR 25-606). Morphine (median 14-day dose 125 mg, IQR 0-850) and fentanyl (median 14-day dose 2032 mcg, IQR 175-15346) were administered with relative equal frequency. Only 48% of the cohort received anti-psychotics during the first 14 days. Age was inversely associated with cumulative dose of lorazepam equivalents (ratio 0.97; 95% CI 0.95-0.99), propofol (ratio 0.93; 95% CI 0.89-0.96), and morphine equivalents (ratio 0.97; 95% CI 0.96-0.98). Substance abuse was associated with cumulative dose of lorazepam (ratio 3.37; 95% CI 1.14-8.21) and morphine equivalents (ratio 3.09; 95% CI 1.48-6.44). Ethanol abuse was associated with >50% lower cumulative dose of morphine equivalents (ratio 0.47; 95% CI 0.25-0.87).

CONCLUSION

In critically ill patients receiving prolonged ventilation, history of substance abuse predicted a 3-fold increase in 14-day cumulative dose of sedatives and opioids used. Conversely, older age was associated with decreased use of sedatives and opioids and history of alcohol abuse was only associated with decreased opioid use. Overall, patients receiving prolonged mechanical ventilation appeared to consume high cumulative doses of sedatives and opioids, with less frequent use of antipsychotics. Accounting for patient characteristics may help identify individuals with varying sedative needs.

Knowledge Translation in Cancer Services: Implementing the Research and Evidence in Practice Model

Occupational therapy lacks intervention effectiveness studies, which are crucial to the profession's survival. Literature also describes problems in the translation of research findings into occupational therapy clinical practice. Despite this, there is limited information regarding specific organisational models of practice to facilitate both the generation and the translation of research evidence. In 2006, occupational therapists at the Princess Alexandra Hospital, Queensland, Australia, developed and implemented the Research and Evidence in Practice model. Over the past 5 years, the model has evolved to enable a more seamless and strategic approach to the generation and translation of evidence into practice. This practice analysis describes the current model, and provides a practical example from the cancer services clinical team to demonstrate its effectiveness.

NFATc3 contributes to intermittent hypoxia-induced arterial remodeling in mice

Sleep apnea (SA) is defined as intermittent respiratory arrest during sleep and affects up to 20% of the adult population. SA is also associated with an increased incidence of hypertension and peripheral vascular disease. Exposing rodents to intermittent hypoxia during sleep mimics the cyclical hypoxia/normoxia of SA. We have previously shown that in mice and rats intermittent hypoxia induces ET-1 upregulation and systemic hypertension. Furthermore, intermittent hypoxia (IH) in mice increases nuclear factor of activated T cells isoform 3 (NFATc3) transcriptional activity in aorta and mesenteric arteries, whereas the calcineurin/NFAT inhibitor cyclosporin A prevents IH-induced hypertension. More importantly, NFATc3 knockout (KO) mice do not develop IH-induced hypertension. The goals of this study were to determine the role of NFATc3 in IH-induced arterial remodeling and whether IH-induced NFATc3 activation is mediated by ET-1. Oral administration of both a dual (bosentan) and a selective endothelin receptor type A antagonist (PD155080) during 2 days of IH exposure attenuated NFAT activation in aorta and mesenteric arteries. Rho kinase inhibition with fasudil also prevented IH-induced NFAT activation. Mesenteric artery cross-sectional wall thickness was increased by IH in wild-type (WT) and vehicle-treated mice but not in bosentan-treated and NFATc3 KO mice. The arterial remodeling in mesenteric arteries after IH was characterized by increased expression of the hypertrophic NFATc3 target smooth muscle-alpha-actin in WT but not in KO mice. These results indicate that ET-1 is an upstream activator of NFATc3 during intermittent hypoxia, contributing to the resultant hypertension and increased wall thickness.

Regulation of soluble guanylyl cyclase-alpha1 expression in chronic hypoxia-induced pulmonary hypertension: role of NFATc3 and HuR

The nitric oxide/soluble guanylyl cyclase (sGC) signal transduction pathway plays an important role in smooth muscle relaxation and phenotypic regulation. However, the transcriptional regulation of sGC gene expression is largely unknown. It has been shown that sGC expression increases in pulmonary arteries from chronic hypoxia-induced pulmonary hypertensive animals. Since the transcription factor NFATc3 is required for the upregulation of the smooth muscle hypertrophic/differentiation marker alpha-actin in pulmonary artery smooth muscle cells from chronically hypoxic mice, we hypothesized that NFATc3 is required for the regulation of sGC-alpha1 expression during chronic hypoxia. Exposure to chronic hypoxia for 2 days induced a decrease in sGC-alpha1 expression in mouse pulmonary arteries. This reduction was independent of NFATc3 but mediated by nuclear accumulation of the mRNA-stabilizing protein human antigen R (HuR). Consistent with our hypothesis, chronic hypoxia (21 days) upregulated pulmonary artery sGC-alpha1 expression, bringing it back to the level of the normoxic controls. This response was prevented in NFATc3 knockout and cyclosporin (calcineurin/NFATc inhibitor)-treated mice. Furthermore, we identified effective binding sites for NFATc in the mouse sGC-alpha1 promoter. Activation of NFATc3 increased sGC-alpha1 promoter activity in human embryonic derived kidney cells, rat aortic-derived smooth muscle cells, and human pulmonary artery smooth muscle cells. Our results suggest that NFATc3 and HuR are important regulators of sGC-alpha1 expression in pulmonary vascular smooth muscle cells during chronic hypoxia-induced pulmonary hypertension.

Correlations between leaf toughness and phenolics among species in contrasting environments of Australia and New Caledonia

BACKGROUND AND AIMS

Plants are likely to invest in multiple defences, given the variety of sources of biotic and abiotic damage to which they are exposed. However, little is known about syndromes of defence across plant species and how these differ in contrasting environments. Here an investigation is made into the association between carbon-based chemical and mechanical defences, predicting that species that invest heavily in mechanical defence of leaves will invest less in chemical defence.

METHODS

A combination of published and unpublished data is used to test whether species with tougher leaves have lower concentrations of phenolics, using 125 species from four regions of Australia and the Pacific island of New Caledonia, in evergreen vegetation ranging from temperate shrubland and woodland to tropical shrubland and rainforest. Foliar toughness was measured as work-to-shear and specific work-to-shear (work-to-shear per unit leaf thickness). Phenolics were measured as 'total phenolics' and by protein precipitation (an estimate of tannin activity) per leaf dry mass.

KEY RESULTS

Contrary to prediction, phenolic concentrations were not negatively correlated with either measure of leaf toughness when examined across all species, within regions or within any plant community. Instead, measures of toughness (particularly work-to-shear) and phenolics were often positively correlated in shrubland and rainforest (but not dry forest) in New Caledonia, with a similar trend suggested for shrubland in south-western Australia. The common feature of these sites was low concentrations of soil nutrients, with evidence of P limitation.

CONCLUSIONS

Positive correlations between toughness and phenolics in vegetation on infertile soils suggest that additive investment in carbon-based mechanical and chemical defences is advantageous and cost-effective in these nutrient-deficient environments where carbohydrate may be in surplus.

Cryptococcal sepsis diagnosed by bone marrow examination

Disseminated cryptococcal disease is often associated with immunodeficient states. The diagnosis is usually made using standard antigen tests on serum and cerebrospinal fluid in patients with known immunodeficiency. Often, blood and cerebrospinal fluid cultures also yield Cryptococcus neoformans. The authors describe a child whose diagnosis remained elusive until a bone marrow aspiration, performed as part of an evaluation for suspected neoplasm, revealed the offending organism.

Irritable bowel syndrome prevalence varies enormously depending on the employed diagnostic criteria: comparison of Rome II versus previous criteria in a general population

BACKGROUND

Irritable bowel syndrome (IBS) prevalence estimates are essential for measuring the importance of the problem and the burden of the illness. However, IBS diagnosis is based on clinical criteria which have changed over time. The aim of this study was to assess how the use of different diagnostic criteria influences estimated IBS prevalence and, in particular, to compare how this prevalence varies using the new Rome II criteria and previous diagnostic criteria.

METHODS

An epidemiological survey was conducted in the general population using personal interviews in a home setting. Two thousand individuals stratified by gender, age, social class and geographic location were randomly selected from the general population of Spain. Participants were classified as 'potential IBS subjects' (n = 281) or 'non-potential IBS subjects' (n = 1719) as a result of their response to a screening question regarding the presence of abdominal pain, constipation or diarrhoea. Thus, we estimated IBS prevalence according to the following diagnostic criteria: Manning, Rome I, Rome II, Drossman, Talley and Kay & Jorgensen.

RESULTS

Prevalences of IBS according to the Manning and Rome I criteria were 10.3% and 12.1%, respectively. These were higher than the prevalences obtained with the other criteria used, which varied from 2.1% to 4.9%. IBS was more prevalent in females than males irrespective of the criteria used (the female:male ratio ranged from 2.33 to 4.33). Subjects who fulfilled the Rome II, Drossman, Talley or Kay & Jorgensen criteria also fulfilled the Rome I and Manning criteria. However, between 44% and 80% of subjects who fulfilled the Rome I or Manning criteria did not fulfil the more stringent diagnostic criteria.

CONCLUSIONS

The prevalence of IBS varies enormously depending on the diagnostic criteria employed. Criteria based on the frequency of symptoms, such as the Rome II criteria, produce much lower prevalence values compared to criteria based solely on the presence of symptoms. In fact, more than two-thirds of subjects who fulfilled the Rome I criteria would not have been diagnosed with IBS if Rome II criteria had been employed.

Measuring self-efficacy in substance abuse intervention in obstetric practices

BACKGROUND

This study presents findings on the effect of an office-based obstetrics training program (given the acronym OBIWOM) on substance use assessment, management, and referral self-efficacy among obstetricians and staff of private, community-based obstetric practices.

METHODS

Participants were obstetricians and staff from 10 of 27 available community-based, private obstetric practices in the target areas, for a practice participation rate of 37%. This study used a delayed treatment design to compare self-efficacy between practice staff randomly assigned to an immediate or delayed intervention group.

RESULTS

Self-efficacy increased significantly after intervention from baseline to first follow-up for the immediate group, while no change was shown for the delayed (control) group. The impact of the intervention on self-efficacy was replicated in the assessment construct only after the intervention for the delayed group.

CONCLUSION

This research shows that education and training can effectively improve self-efficacy in obstetricians and their staff in the management of substance use and pregnancy.

Serial changes in surfactant-associated proteins in lung and serum before and after onset of ARDS

The goal of this study was to determine the changes that occur in surfactant-associated proteins in bronchoalveolar lavage fluid (BAL) and serum of patients at risk for ARDS and during the course of ARDS. We found that the concentrations of SP-A and SP-B were low in the BAL of patients at risk for ARDS before the onset of clinically defined lung injury, whereas the concentration of SP-D was normal. In patients with established ARDS, BAL SP-A and SP-B concentrations were low during the entire 14-d observation period, but the median SP-D concentrations remained in the normal range. Immunoreactive SP-A and SP-D were not increased in the serum of patients at risk for ARDS, but both increased after the onset of ARDS to a maximum on Day 3 and remained elevated for as long as 14 d. The BAL SP-A concentrations were significantly lower in at-risk patients who developed ARDS, and no patient with a BAL SP-A concentration greater than 1.2 microg/ml developed ARDS. On Days 1 and 3 of ARDS, the BAL SP-D concentration was significantly lower in patients who died, and the BAL SP-D concentration was significantly related to the PI(O(2))/FI(O(2)) ratio. Thus, surfactant protein abnormalities occur before and after the onset of ARDS, and the responses of SP-A, SP-B, and SP-D differ in important ways. The BAL SP-A and SP-D measurements can be used to classify patients as high or low risk for progression to ARDS and/or death after the onset of ARDS. Strategies to increase these surfactant proteins in the lungs of patients with ARDS could be useful to modify the onset or the course of ARDS.

Interobserver variability in applying a radiographic definition for ARDS

CONTEXT

Acute lung injury (ALI) and ARDS are currently defined by the American-European Consensus Conference (AECC) definition criteria, which contain a radiographic criterion. The accuracy or reliability of this consensus radiographic definition has not been evaluated, and no radiographic definition of ALI-ARDS has been evaluated by a large international group of experts.

OBJECTIVE

To study the interobserver variability in applying the AECC radiographic criterion for ALI-ARDS.

DESIGN

Survey.

PARTICIPANTS

A convenience sample of 21 experts selected from participants attending the 1997 Toronto Mechanical Ventilation Workshop and from members of the National Institutes of Health ARDS Network.

OUTCOME MEASURES

Participants reviewed 28 randomly selected chest radiograph from critically ill, hypoxemic (PaO(2)/fraction of inspired oxygen ratio, < 300) patients and decided whether the radiograph fulfilled the AECC definition for ALI-ARDS.

RESULTS

Interobserver agreement in applying the AECC definition for ALI-ARDS was moderate (kappa = 0.55; 95% confidence interval, 0.52 to 0.57). Thirteen radiographs (43%) showed nearly complete agreement (defined as 20 or 21 readers in agreement). Nine radiographs (32%) had more than or equal to five dissenting readers. The percentage of radiographs interpreted as consistent with ALI-ARDS by individual readers ranged from 36 to 71%. Participants commented that mild infiltrates, pleural effusions, atelectasis, isolated lower lobe involvement, radiographic technique, and overlying monitoring equipment posed the most difficulties.

CONCLUSIONS

The radiographic criterion used in the current AECC definition for ALI-ARDS showed high interobserver variability when applied by expert investigators in the fields of mechanical ventilation and ARDS. This variability may result in differences in ALI-ARDS populations at different clinical research centers and may make it difficult for clinicians to apply the results of clinical trials to their patients. Modifications to the radiographic criterion or annotated reference radiograph may improve the reliability of future definitions for ALI-ARDS.

The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians

OBJECTIVE

To assess prevalence and quality of end-of-life communication between persons with advanced AIDS and their clinicians and to identify patient and clinician characteristics associated with this communication.

DESIGN

Prospective cohort study of 57 patients with AIDS and their primary care clinicians.

SETTING

University-based and private clinics in Seattle, Washington.

PATIENTS

Patients had a prior AIDS-defining illness and a CD4 cell count of less than 100 x 10(6) cells/l.

MAIN OUTCOME MEASURES

Quality of patient-clinician communication about end-of-life care, validated against patient satisfaction and patient-clinician concordance on advance directives and treatment preferences.

RESULTS

Patients reported they had communication about end-of-life care with their clinician in 31 of 57 cases (54%) while clinicians reported they had this discussion in 36 of 57 cases (64%). Patients and clinicians gave concordant answers in 42 patient-clinician pairs. In 15 pairs (26%), patients and clinicians disagreed about whether end-of-life communication had occurred. African-American and Hispanic patients were less likely to report having communication than non-Hispanic white patients (chi-square analysis: chi2 = 4.67; P < 0.05); injection drug users and women with high-risk sexual partners were less likely to report communication than homosexual or bisexual men (chi2 = 4.67; P < 0.05). A four-item measure of patients' assessment of the quality of communication about end-of-life care had good internal consistency (Cronbach's alpha 0.81) and was significantly correlated with overall satisfaction with medical care (r2 = 0.76; P < 0.0001). Patients with lower income reported lower quality of communication (chi2 = 5.82; P = 0.05). If patients assessed quality of communication as high, their clinicians were more likely to know if the patient had a durable power of attorney for health care (chi2 = 4.95; P = 0.03) but were not more likely to predict patients' preferences for life-sustaining treatments.

CONCLUSIONS

Quality of patient-clinician communication about end-of-life care can be measured in a brief questionnaire; higher quality of this communication is associated with higher satisfaction with care and increased clinician knowledge of patients' advance directives. Since socioeconomic status and ethnicity are associated with both the occurrence and quality of this communication, future interventions in end-of-life care should assess the effect of these variables. Given the important and independent goals of improving patient-clinician communication about end-of-life care and improving the quality of care at the end of life, future studies should test interventions to improve the quality of communication and determine whether improving this communication improves the quality of care at the end of life.

Distinct alterations in mitochondrial mass and function characterize different models of apoptosis

Recent studies have shown that reduction in mitochondrial membrane potential (delta psi m) and generation of reactive oxygen species are early events in apoptosis. In this study, we present two different models of apoptotic cell death, Chinese hamster ovary (CHO) cells treated with aphidicolin and dexamethasone-treated 2B4 T-cell hybridoma cells, which display opposing mitochondrial changes. CHO cells arrested at G1/S with aphidicolin have a progressive increase in mitochondria mass and number, assessed by flow cytometry and fluorescent microscopy with mitochondria-specific probes. The increase in mitochondrial mass was not accompanied by a gain in net cellular mitochondrial membrane potential, consistent with an accumulation of relatively depolarized mitochondria. Fluorescent microscopy demonstrated an increased content of low delta psi m mitochondria in aphidicolin-treated CHO cells, but high delta psi m mitochondria were also present and remained stable in number. Mitochondrial mass correlated with decreased clonogenicity of aphidicolin-treated CHO cells. Cycloheximide prevented both the proliferation of mitochondria and subsequent cell death. In contrast, dexamethasone treatment of 2B4 T-cell hybridoma cells caused a decrease in delta psi m without mitochondrial proliferation. Cycloheximide and Bcl-2 overexpression inhibited the loss of delta psi m, as well as apoptosis. In both models, cell death was associated with a decrease in mitochondrial potential relative to mitochondrial mass, suggesting that an accumulation of damaged or dysfunctional mitochondria had occurred.

Design of "High 5": a school-based study to promote fruit and vegetable consumption for reduction of cancer risk

BACKGROUND

This paper describes the methods used in "High 5," a school-based study to increase fruit and vegetable consumption for cancer risk reduction.

METHODS

Twenty-eight elementary schools were matched and randomized to intervention or control conditions. All students were assessed based on diet and psychosocial variables at baseline and one and two years post-baseline. The intervention included classroom, parent, and environmental components.

RESULTS

The study recruited 1,698 families and retained 85%. The two conditions were equivalent at baseline; 50% female students, 81% to 84% European-American students, and 2.9 servings of fruit and vegetables per day. Good completion was achieved across the intervention components (e.g., 90% of lessons taught, 72% of parent materials read, 3.6 servings of fruit and vegetables offered in cafeterias).

CONCLUSIONS

The use of school-based programs, with strong evaluation designs, will enhance knowledge about the modification of nutrition behavior and cancer risk in children. Lessons learned from the study are reported.

Mitochondrial proliferation and paradoxical membrane depolarization during terminal differentiation and apoptosis in a human colon carcinoma cell line

Herbimycin A, a tyrosine kinase inhibitor, induces cellular differentiation and delayed apoptosis in Colo-205 cells, a poorly differentiated human colon carcinoma cell line. Cell cycle analysis in conjunction with end labeling of DNA fragments revealed that G2 arrest preceded apoptotic cell death. Ultrastructural examination of herbimycin-treated cells demonstrated morphologic features of epithelial differentiation, including formation of a microvillar apical membrane and lateral desmosome adhesions. A marked accumulation of mitochondria was also observed. Fluorometric analysis using the mitochondrial probes nonyl-acridine orange and JC-1 confirmed a progressive increase in mitochondrial mass. However these cells also demonstrated a progressive decline in unit mitochondrial transmembrane potential (DeltaPsim) as determined by the DeltaPsim-sensitive fluorescent probes rhodamine 123 and JC-1 analyzed for red fluorescence. In concert with these mitochondrial changes, Colo-205 cells treated with herbimycin A produced increased levels of reactive oxygen species as evidenced by oxidation of both dichlorodihydrofluorescein diacetate and dihydroethidium. Cell-free assays for apoptosis using rat-liver nuclei and extracts of Colo-205 cells at 24 h showed that apoptotic activity of Colo-205 lysates requires the early action of mitochondria. Morphological and functional mitochondrial changes were observed at early time points, preceding cleavage of poly (ADP-ribose) polymerase. These results suggest that apoptosis in differentiated Colo-205 cells involves unrestrained mitochondrial proliferation and progressive membrane dysfunction, a novel mechanism in apoptosis.

Pulmonary and systemic inflammatory responses in rabbits with gram-negative pneumonia

The major goals of this study were to define the relationships between intrapulmonary and systemic inflammatory responses in animals with gram-negative pneumonia. We treated rabbits with intrapulmonary Escherichia coli (1 x 10(7) to 1 x 10(10) cfu/ml), and then measured physiologic, cellular, and molecular events in the lungs and systemic circulation for 24 h. The treatment protocols resulted in groups of animals that mimicked the stages of the septic inflammatory response in humans. Animals treated with low inocula had systemic changes consistent with systemic inflammatory response syndrome and cleared the bacteria and inflammatory products from the lungs. Animals treated with high inocula failed to clear bacteria from the lungs, had severe intrapulmonary inflammatory responses, and developed septic shock. Intrapulmonary leukocyte recruitment was directly related to the size of the bacterial inoculum, but lung protein accumulation was not. Tumor neurosis factor-alpha (TNF-alpha), interleukin-8 (IL-8), and GRO were detectable in lung lavage fluid at 4 h and declined by 24 h in animals that cleared intrapulmonary E. coli. In contrast, lavage TNF-alpha, IL-8, and GRO increased over 24 h in animals that failed to clear intrapulmonary bacteria. MCP-1 increased between 4 h and 24 h in the lungs of all of the animals as the histologic response evolved from neutrophilic to mononuclear cell predominance. Thus, the intensity of systemic inflammatory and physiologic responses to intrapulmonary gram-negative infection depends on the inoculum size and whether the bacteria are cleared from or proliferate in the lungs. The results provide experimental support for the recently proposed classification of septic responses in humans.

Sufficient conditions for effective treatment of substance abusing homeless persons

Treatment efficacy for homeless substance abusers (primarily crack cocaine) was studied in a randomized control design with subjects (n = 176) assigned to usual care (UC) or an enhanced day treatment program plus abstinent contingent work therapy and housing (EC). Subjects met DSM-III-R criteria for Substance Use Disorder and McKinny Act criteria for homelessness. UC involved weekly individual and group counseling. EC involved a day treatment program consisting of daily attendance, transportation, lunch, manualized psychoeducational groups, and individual counseling. A total of 131 (74.4%) subjects (62 UC and 69 EC) were treated and followed. UC subjects attended 28.5% and EC attended 48.4% of expected treatment during the first 2 months. After 2 months, EC subjects experienced up to 4 months of abstinent contingent work therapy (44.9% of EC subjects) and housing (37.7% of EC subjects), with day treatment available two afternoons per week. Longitudinal Wei-Lachin analyses of medians (reported alcohol use, days homeless and employed) and proportions (cocaine toxicologies) were conducted across 2-, 6-, and 12-month follow-up points. EC had 36% fewer positive cocaine toxicologies at 2-months and 18% fewer at 6-months than UC with regression toward baseline at 12-months. EC had 8 days fewer days of reported alcohol use in the past 30 days, 52 fewer days homeless in the past 60 days, and 10 more days employed in the past 30 days from baseline to the 12-months. UC showed no changes except a temporary increase in employment at 6-months. This is one of the first demonstrations that homeless cocaine abusers can be retained and effectively treated.

Treatment outcome as a function of treatment attendance with homeless persons abusing cocaine

This research examines the influence of treatment attendance at two substance abuse outpatient treatment programs of the Birmingham Substance Abuse Homeless Project on substance abuse, homelessness, and unemployment outcomes with homeless persons abusing primarily crack cocaine. Results revealed that significant reductions across a one year period in alcohol use, cocaine use, and homelessness were more likely to occur in clients who attended an average of 4.1 treatment days per week (High attendance or Enhanced Care group) than clients who attended less than one day a week on the average (Low attendance or Usual Care and Medium attendance groups). These results are consistent with the literature suggesting that more intensive contact early in treatment results in better long-term outcome with cocaine abusers, but has now been demonstrated with homeless cocaine abusers who have additional problems associated with housing and employment.

Validity of self-reported crack cocaine use among homeless persons in treatment

The validity of self-reported crack cocaine use among 131 homeless persons participating in an outpatient substance abuse treatment research demonstration project was assessed by comparing the concordance of self-report and urinalysis results. The subjects were participants in either a Usual Care outpatient program or an Enhanced Care day treatment program that included drug free contingent work therapy and housing. For all subjects across four evaluation points, the false negative classification by self-report (i.e., denied verified use) rate for crack cocaine use was 32.0%. Denied verified use was greater in Usual Care (34.9%) than in Enhanced Care clients (23.7%) and greater at follow-up as compared to treatment entry for all clients. The findings are explained in terms of social desirability and the influence of treatment contingencies and greater accountability specific to the Enhanced Care program. The need for validation of self-reported cocaine use data among homeless persons in settings where contingencies are present and in other drug treatment or research settings is recommended.

Preliminary study of two methods of treatment for laryngeal nodules

To date, a limited number of formal studies have assessed the efficacy of voice therapy for laryngeal nodules. The present study represents a preliminary stage of inquiry in a series of planned studies on this topic. Thirteen women with nodules participated as paid subjects. Some subjects received "confidential voice therapy," some received "resonant voice therapy," and some received no therapy (control condition) over a period of approximately 2 weeks. Pre- and post-therapy measures of phonatory effort, auditory-perceptual status of voice, and laryngeal appearance provided evidence of a benefit from therapy. Baseline measures were then repeated 2 weeks after therapy was terminated. The final results indicated that, for auditory-perceptual and phonatory effort measures, the likelihood of benefiting from therapy directly covaried with compliance scores (reflecting the reported extraclinical utilization of the therapy technique), but not with therapy type (confidential vs. resonant voice therapy). At this level, the results point to the importance of assessing not only therapy type but also compliance in future, larger studies. A series of other positive and negative factors in the present research design were identified based on the results. These should be considered in future studies.

Long-term patient satisfaction following reduction mammoplasty

This study documents that reduction mammoplasty is a procedure with excellent long-term patient satisfaction. This has not been previously well documented. One hundred nine patients after reduction mammoplasty were surveyed by questionnaire. Results of the questionnaire indicated that the majority of patients were pleased with their breast size and breast shape. The majority had equal-sized breasts. Most were comfortable after surgery and had an easier time buying clothes. Ninety-four percent of patients would have the procedure again. Multiple techniques for reduction mammoplasty were used and there were no significant differences with the exception of a change in nipple sensation. Nipple sensation was best preserved by using the inferior pedicle technique.

A comparison of conventional and low-bleed implants in augmentation mammaplasty

We conducted a double-blind, retrospective comparison between low-bleed and non-low-bleed (conventional) mammary implants because no controlled study has shown a difference in the degree of capsular contracture between the two types of implants. Twenty-five patients had conventional implants and form group A; twenty-eight patients had low-bleed implants and form group B. All patients had submuscular augmentation. The mean Baker score was 1.51 for group A and 1.04 for group B for the entire patient population and 1.65 for group A and 1.07 for group B for patients with more than 1 year of follow-up. For the entire population, 34 percent of group A and 3.6 percent of group B had a Baker score of 2 or greater. For the population with more than 1 year of follow-up, 42 percent of group A and 7 percent of group B had a Baker score of 2 or greater. There was significantly (p less than 0.007) less contracture with the low-bleed implants for the entire population as well as for those patients with greater than 1 year of follow-up (p less than 0.015).

Herpes simplex virus infection of the placenta. The role of molecular pathology in the diagnosis of viral infection of placental-associated tissues

Herpes simplex infections of the placenta and its associated tissues are rarely seen and, consequently, the pathologic features are not well understood. We describe the occurrence of herpes simplex virus infection of the placenta that was limited to maternal-derived cells of the subchorionic tissue. The microscopic findings were remarkable for both the absence of inflammation and characteristic viral inclusions. However, in situ DNA hybridization, as well as immunohistochemistry using antibody to herpes simplex virus type 2, revealed herpes virus infection of decidualized cells in the decidua capsularis. The significance of this finding, and the importance of molecular techniques for the diagnosis of herpes virus infection in placental pathology, are discussed.

Nocturnal oxygen desaturation in patients with sickle cell anemia

The sleep of two patients with sickle cell disease was punctuated by periods with notably reduced arterial O2 saturation despite simultaneous normal respiratory rates. The O2 levels returned to baseline during intermittent wakefulness. Gas exchange patterns during sleep may contribute to the morbidity of sickle cell disease.

Studies of the pain produced by mafenide acetate preparations in burns

In a double-blind triple cross-over clinical study, 37 patients were exposed to several formulations of mafenide acetate (Sulfamylon Cream) and their pain responses were recorded and converted to a semiquantitative pain index. The 11.2% concentration in cream was two to three times more painful than the 5% concentration. Hypertonicity and not the pH level appears to be the cause of the pain produced by the high (11.2%) concentration. The tonicity of the cream carrier and 11.2% mafenide acetate are 1,080 mOsm/kg and 1,100 mOsm/kg, respectively, for a total of 2,180 mOsm/kg. The carrier cream without glycerol and a 5% concentration of mafenide cream were much less painful than the 11.2% concentration of mafenide. Both afforded a great deal of relief to the patients who received the medications.