The Association Between Facilitator Competent Adherence and Outcomes in Parenting Programs: a Systematic Review and SWiM Analysis

There is increasing interest about the fidelity with which interventions are implemented because it is theorized that better implementation fidelity by facilitators is associated with better participant outcomes. However, in the parenting program literature, there is mixed evidence on the relationship between implementation fidelity and outcomes. This paper provides a synthesis of the evidence on the relationship between facilitator delivery and outcomes in the parenting program literature. Following PRISMA guidelines, this paper synthesizes the results of a systematic review of studies on parenting programs aiming to reduce violence against children and child behavior problems. Specifically, it examines associations between observational measures of facilitator competent adherence and parent and child outcomes. A meta-analysis was not feasible due to study heterogeneity. As a result, Synthesis Without Meta-Analysis guidelines were followed. Searches in electronic databases, reference searching, forward citation tracking, and expert input identified 9653 articles. After screening using pre-specified criteria, 18 articles were included. The review found that most studies (n = 13) reported a statistically significant positive relationship with at least one parent or child outcome. However, eight studies reported inconsistent findings across outcomes, and four studies found no association with outcomes. The results suggest that better facilitator competent adherence is generally associated with positive parent and child outcomes. However, this finding is weakened by the methodological heterogeneity of included studies and due to the wide variety of ways in which studies conceptualized competent adherence-outcome relationships.

"Before I was like a Tarzan. But now, I take a pause": mixed methods feasibility study of the Naungan Kasih parenting program to prevent violence against children in Malaysia

BACKGROUND

Despite impressive strides in health, social protection, and education, children continue to experience high rates of child maltreatment in Malaysia. This mixed-methods study assessed the feasibility of a five-session, social learning-based parenting program delivered by government staff in a community setting to reduce violence against children.

METHODS

Parents of children from birth to 17 years were recruited from two communities near Kuala Lumpur to participate in the government-run program called the Naungan Kasih Positive Parenting Program ("Protecting through Love" in Bahasa Melayu). Quantitative data from female caregivers (N = 74) and children ages 10-17 (N = 26) were collected along with qualitative interviews and focus groups with parents, children, and facilitators. The primary outcome was child maltreatment with secondary outcomes including neglect, positive parenting, acceptability of corporal punishment, harsh parenting, positive discipline, and child behavior problems. Multilevel Poisson regression and multilevel linear regression were conducted to compare baseline and post-test outcomes. Qualitative interviews and focus groups examined how participants experienced the program utilizing a thematic analysis approach.

RESULTS

Quantitative analyses found pre-post reductions in overall child maltreatment, physical abuse, emotional abuse, attitudes supporting corporal punishment, parent sense of inefficacy, and child behavior problems. There were no reported changes on positive and harsh parenting, parental mental health, and marital satisfaction, nor were there any other significant changes reported by children. Qualitative findings suggested that the program had tangible benefits for female caregivers involved in the program, with the benefits extending to their family members.

CONCLUSIONS

This feasibility study is one of the few studies in Southeast Asia that examined the feasibility and initial program impact of a parenting program delivered by government staff to families with children across the developmental spectrum from birth to 17 years. Promising results suggest that the program may reduce child maltreatment across a range of child ages. Findings also indicate areas for program improvement prior to further delivery and testing, including additional training and content on sexual and reproductive health, parenting children with disabilities, and online child protection.

Margetuximab with retifanlimab as first-line therapy in HER2+/PD-L1+ unresectable or metastatic gastroesophageal adenocarcinoma: MAHOGANY cohort A

Background

Human epidermal growth factor receptor 2 (HER2)-positive metastatic gastric and gastroesophageal adenocarcinoma (GEA) is globally treated with chemotherapy plus trastuzumab. Novel therapeutic strategies strive to not only optimize efficacy, but also limit toxicities. In MAHOGANY cohort A, margetuximab, an Fc-engineered, anti-HER2 monoclonal antibody (mAb) was combined with retifanlimab, an anti-programmed cell death protein 1 mAb, in the first-line HER2-positive/programmed death-ligand 1 (PD-L1)-positive GEA.

Patients and methods

MAHOGANY cohort A part 1 is a single-arm trial to evaluate margetuximab plus retifanlimab in patients with HER2 immunohistochemistry 3+, PD-L1-positive (combined positive score ≥1%), and non-microsatellite instability-high tumors. Primary objectives for cohort A were safety/tolerability and the confirmed objective response rate (ORR).

Results

As of 3 August 2021, 43 patients were enrolled and received margetuximab/retifanlimab. Nine grade 3 treatment-related adverse events (TRAEs) were reported in eight (18.6%) patients and eight serious TRAEs in seven (16.3%) patients. There were no grade 4/5 TRAEs. Three patients discontinued margetuximab/retifanlimab because of immune-related adverse events. The ORR by independent assessment was 53% [21/40 (95% confidence interval (CI) 36.1-68.5)], with a median duration of response of 10.3 months (95% CI 4.6-not evaluable); disease control rate was 73% [29/40 (95% CI 56.1-85.4)]. The study sponsor discontinued the study in advance of the planned enrollment when it became apparent that the study design would no longer meet the requirements for drug approval because of recent advances in the treatment of GEA.

Conclusions

The chemotherapy-free regimen of combined margetuximab/retifanlimab as first-line treatment in double biomarker-selected patients demonstrated a favorable toxicity profile compared with historical outcomes using chemotherapy plus trastuzumab. The ORR observed in this study compares favorably versus ORR observed with other chemotherapy-free approaches.

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The margetuximab/retifanlimab regimen has a favorable toxicity profile versus historical chemotherapy-based regimens in GEA.

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The margetuximab/retifanlimab regimen as first-line therapy for GEA met the prespecified boundary for antitumor activity.

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The 53% ORR [21/40 (95% CI 36.1-68.5)] in the combined regimen compared favorably with other chemotherapy-free approaches.

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Median duration of response was 10.3 months (95% CI 4.57-not evaluable) and disease control rate was 73% [29/40 (95% CI 56.1-85.4)].

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The study was discontinued for business reasons as chemotherapy-based regimens remain the dominant therapy for GEA.

Parenting, mental health and economic pathways to prevention of violence against children in South Africa

BACKGROUND

Parenting programs based on social learning theory have increasing empirical evidence for reducing violence against children. Trials are primarily from high-income countries and with young children. Globally, we know little about how parenting programs work to reduce violence, with no known studies in low or middle-income countries (LMICs). This study examines mechanisms of change of a non-commercialized parenting program, Parenting for Lifelong Health for Teens, designed with the World Health Organization and UNICEF. A cluster randomized trial showed main effects on parenting and other secondary outcomes. We conducted secondary analysis of trial data to investigate five potential mediators of reduced violence against children: improved parenting, adolescent behaviour, caregiver mental health, alcohol/drug avoidance, and family economic strengthening.

METHODS

The trial was implemented in rural South Africa with 40 sites, n = 552 family dyads (including adolescents aged 10-18 and primary caregivers). Intervention sites (n = 20) received the 14-session parenting program delivered by local community members, including modules on family budgeting and savings. Control sites (n = 20) received a brief informational workshop. Emotional and physical violence against children/adolescents and each potential mediator were reported by adolescents and caregivers at baseline and 9-13 months post-randomisation. Structural equation modelling was used to test simultaneous hypothesized pathways to violence reduction.

RESULTS

Improvements in four pathways mediated reduced violence against children: 1) improved parenting practices, 2) improved caregiver mental health (reduced depression), 3) increased caregiver alcohol/drug avoidance and 4) improved family economic welfare. Improved child behaviour was not a mediator, although it was associated with less violence.

CONCLUSIONS

Simultaneously bolstering a set of family processes can reduce violence. Supporting self-care and positive coping for caregivers may be essential in challenging contexts. In countries with minimal or no economic safety nets, linking social learning parenting programs with economic strengthening skills may bring us closer to ending violence against children.

Cyanotic Congenital Heart Disease Modes of Presentation and Prenatal Detection

Prenatal detection of structural congenital heart disease (CHD) optimises cardiovascular stability pre-operatively and post-operative outcomes. We compared prenatal detection rates of critical CHD in units offering universal fetal anomaly scans with those offering imaging to selected women. One hundred and thirteen infants met inclusion criteria. The overall pre-natal detection rate for critical CHD was 57% of liveborn infants. It was 71% (57/80) in hospitals who offered a universal anomaly scan and 29% (9/31) in centres offering a limited service. Postnatal diagnosis was associated with PICU admission (p=0.016) and preoperative mechanical ventilation (p=0.001). One-year mortality was 10 fold higher in the postnatally diagnosed group 15% vs 1.55% (p=0.0066). There is a significant disparity between centres offering universal anomaly versus selective screening. Prenatal detection confers advantage in terms of pre-operative stability and one year survival. Failure to deliver an equitable service exposes infants with CHD to avoidable risk.

Evaluation of VIDAS® Immuno-Concentration Salmonella/VIDAS Salmonella Immunoassay Method for Detection of Salmonella in Selected Foods: Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS)/VIDAS Salmonella (SLM) immunoassay method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1266 of the 1440 samples. Of the 174 samples not in agreement, 69 were VIDAS ICS/SLM-positive and BAM/AOAC-negative and 105 were VIDAS ICS/SLM-negative and BAM/AOAC-positive.

Evaluation of VIDAS® Immuno-Concentration Salmonella Assay Plus Selective Plate Method (Hektoen Enteric, Bismuth Sulfite, Salmonella Identification) for Detection of Salmonella in Selected Foods: Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS) plus selective plate method (Hektoen enteric, bismuth sulfite, Salmonella identification) method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1283 of the 1440 test samples. Of the 157 test samples not in agreement, 82 were VIDAS ICS plus selective plate-positive and BAM/AOAC-negative, and 75 were VIDAS ICS plus selective plate-negative and BAM/AOAC-positive.

Salmonella in Selected Foods by VIDAS® Immuno-Concentration Salmonella Plus Selective Plate Method (Hektoen Enteric, Xylose Lysine Desoxycholate, Bismuth Sulfite): Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS) plus selective plate method (Hektoen enteric, xylose lysine desoxycholate, bismuth sulfite) method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1297 of the 1455 samples. Of the 158 samples not in agreement, 82 were VIDAS ICS plus selective plate-positive and BAM/AOAC-negative, and 76 were VIDAS ICS plus selective plate-negative and BAM/AOAC-positive.

Analysis and influence of demographic and risk factors on difficult child behaviors

This descriptive study examined the distribution of risk factors in a sample that was selected on the basis of existing potential for difficult child behaviors. We inquired into whether exposure to risk factors was distributed equally across different contexts of ethnicity, locality, and child gender. Participants included 731 mother-child dyads recruited from WIC Programs in rural, suburban, and urban localities. Cumulative risk indices were constructed using neighborhood, family, and individual risk factors. The findings generally revealed that African American children and children in urban localities were exposed to higher numbers of risk factors and cumulative risk in relation to other ethnic children and localities. On the other hand, Caucasian children expressed higher levels of vulnerabilities to risk for internalizing behaviors than did other children. The results are discussed in terms of differences in contextual specific rates of risk exposure, vulnerability, and their implications for prevention and intervention research.

Risk and protective factors for psychological well-being of children orphaned by AIDS in Cape Town: a qualitative study of children and caregivers' perspectives

By 2020, an estimated 2.3 million South African children will be orphaned by HIV/AIDS (Actuarial Society of South Africa, 2005), but little is known about risk and protective factors for their emotional and behavioural well-being. This qualitative study explores perspectives of affected families. Orphaned children (n = 60), caregivers of orphaned children (n = 42) and social care professionals (n = 20) completed semi-structured interviews and focus groups. Participants were recruited from schools, shelters and welfare services. Findings from multiple sources indicate potential risk and protective factors in a range of dimensions, including bereavement, family functioning, social support, poverty, access to education and perceived stigma. Many factors reflected international literature on children experiencing similar stressors (e.g. non HIV/AIDS-related bereavement). However, this study also identified factors which may be specific to this group, notably stigma, abuse and peer factors. Current research is quantitatively testing associations between these identified factors and psychological outcomes.

The hip trial: psychosocial consequences for mothers of using ultrasound to manage infants with developmental hip dysplasia

BACKGROUND

The hip trial aimed to assess clinical effectiveness, economic and psychosocial costs, and benefits of ultrasound imaging (US) compared with conventional clinical assessment alone to guide the management of infants with neonatal hip instability.

OBJECTIVE

To report on psychosocial consequences for mothers and the developing mother-child relationship of US, and associations between abduction splinting and maternal psychosocial distress.

DESIGN

Multicentre randomised controlled trial.

SETTING

Thirty three hospitals in the United Kingdom and Ireland. PARTICIPANTS, INTERVENTIONS: A total of 629 infants with neonatal hip instability randomised to US examination or clinical assessment alone before treatment decision. Questionnaires were completed by 561 (89%) mothers at 8 weeks and 494 (79%) at 1 year.

MAIN OUTCOME MEASURES

Anxiety, postnatal depression, parenting stress assessed by standardised questionnaires. Maternal concerns about hip problems were assessed using the Infant hip worries inventory.

RESULTS

At 8 weeks, there were no differences between US and non-US groups of the trial in maternal anxiety (mean difference (MD) -1.2, 95% confidence interval (CI) -3.2 to 0.8), depression (MD 0.0, 95% CI -0.7 to 0.8), parenting stress (MD -1.2, 95% CI -2.8 to 0.4), or other measures. The same pattern was evident at 1 year. In an explanatory analysis, early splinting was associated with increased anxiety at 8 weeks (MD 3.8, 95% CI 1.7 to 5.9) and increased level of hip worries at 8 weeks (MD 6.8, 95% CI 5.6 to 7.9) and 1 year (MD 1.3, 95% CI 0.3 to 2.4).

CONCLUSIONS

Although early splinting is associated with maternal anxieties, US is not associated with any increase or reduction in psychosocial effects on mothers. Together with the clinical findings, this suggests that the use of US allows reduction in splinting rates without increased risk of adverse clinical or psychosocial outcomes.

Health and school performance of teenagers born before 29 weeks gestation

OBJECTIVE

To ascertain the health and school performance of teenagers born before 29 weeks gestation (extremely low gestational age (ELGA)) and to compare those in mainstream school with classroom controls.

METHODS

Three geographically defined cohorts of babies born in 1983 and 1984 were traced at the age of 15-16 years. Their health, abilities, and educational performance were ascertained using postal questionnaires to the teenagers themselves, their parents, their general practitioners, and the teachers of those in mainstream school. Identical questionnaires were sent to classroom controls.

RESULTS

Of the 218 teenagers surviving to the age of 16 years, information was obtained on 179. Of these, 29 were in special schools and 150 in mainstream school, 10 of whom had severe motor or sensory impairment. Using the Child Health Questionnaire, parents of teenagers in mainstream school reported a higher incidence of problems than controls in physical functioning (difference in mean scores 9.0 (95% confidence interval (CI) 4.9 to 13.1)) and family life (difference in mean scores for family cohesion 7.0 (95% CI 1.6 to 12.4)). In all areas of learning, teachers rated the ability of the ELGA teenagers in mainstream school lower than the control group. Parents of teenagers in special schools reported a higher rate of problems in most areas.

CONCLUSIONS

One in six ELGA survivors at age 16 years have severe disabilities and are in special schools. Most ELGA survivors are in mainstream school and are coping well as they enter adult life, although some will continue to need additional health, educational, and social services.

Evaluation of an EIA method for measuring serum levels of the estrogen metabolite 2-hydroxyestrone in adults

Two-hydroxyestrone (2OHE-1) and 16alpha-hydroxyestrone (16OHE-1) are two estrogen metabolites that may play important roles in the development or promotion of breast cancer. Our study assessed the reliability of a newly developed kit procedure for measuring 2OHE-1. Although under certain conditions the assay would not distinguish 2OHE-1 from estriol, or possibly 2-methoxyestrone, steroids such as 17beta-estradiol, estrone and 16OHE-1 should not interfere with the test. Our study evaluated the precision of this enzyme immunoassay (EIA) kit for measuring 2OHE-1 levels in serum obtained from healthy men and women. As a result of several replicate analyses of specimens obtained from 18 men and 20 women, we found that the within-run coefficients of variation (CVs) were approximately 20% and the among run CVs, 30%. Because the SD for the procedure is high, the limit of detection (LOD) was also high (130 ng/l). Nonetheless the assay could distinguish between 2OHE-1 levels in men (128 ng/l) and women (332 ng/l) because we performed a large number of analyses on each specimen. Improving the reproducibility of the assay would reduce the: 1. LOD; number of replicates needed to obtain reliable estimates of 2-OHE-1 levels; amount of time, effort, and cost for each analysis; and greatly improve the reliability of the method. Because the within-run variability is relatively smaller than the total variability (among run + within run), use of the assay for determining differences among groups could be justified only when measurements were made in a single run.

Methodological issues in the direct observation of parent-child interaction: do observational findings reflect the natural behavior of participants?

This review examines evidence for the utility and validity of direct observational techniques for answering particular research and clinical questions. Observational techniques often involve recording behavior in settings that are relatively unnatural for families. However, it is argued that construct validity of observational methods depends partly on whether the findings are representative of participants' typical everyday behavior. Evidence is reviewed concerning whether observational findings are affected by the presence of the observer, and by two factors which have been neglected in the literature, namely the type of task imposed by the observer (e.g., directing parent and child to play rather than observing spontaneous interaction) and the location of the observations (e.g., clinic or laboratory rather than home). The review suggests that the presence of an observer does not necessarily distort the nature of interactions. However, the small number of studies in this area suggest that interactions in structured or artificial settings are not necessarily representative of those normally taking place at home.

Design evaluation: illuminating social work practice for better outcomes

One of the difficulties in social work lies in finding forms of evaluation that suit the various kinds of work people actually do. There is a need for methods that allow a valid and rigorous evaluation of process as well as outcomes, particularly in new areas of work. A valuable example of such evaluation evolved at St. Luke's, a voluntary agency in Victoria, Australia, that used design evaluation to articulate a new model of practice. Design evaluation involved having the evaluator work with staff to describe work practices as a series of stages with associated principles. This process of documenting, clarifying, and illuminating the model led to its progressive refinement and concurrent improved services delivery to clients. Testing the program model with clients provided some valuable feedback about its effectiveness. This form of evaluation is complementary to outcomes evaluation and can also provide the information needed for a subsequent outcomes evaluation.

Serum S-100 protein release and neuropsychologic outcome during coronary revascularization on the beating heart: a prospective randomized study

OBJECTIVES

Our purpose was to establish whether coronary revascularization on the beating heart without cardiopulmonary bypass is less harmful to the brain than conventional surgery with cardiopulmonary bypass as indicated by measures of cognitive function or by changes in serum concentrations of S-100 protein, a recognized biochemical marker of cerebral injury.

METHODS

We conducted a prospective randomized trial in which the assessors of the outcome measures were blind to the treatment received. Sixty patients without known neurologic abnormality, undergoing coronary revascularization, were prospectively randomized to 1 of 2 groups: (1) cardiopulmonary bypass (32 degrees C-34 degrees C) and cardioplegic arrest (on pump) with intermittent antegrade warm blood cardioplegia or (2) surgery on the beating heart (off pump). Neuropsychologic performance was assessed before and 12 weeks after the operation. Serum S-100 protein concentration was measured at intervals up to 24 hours after the operation.

RESULTS

The groups had similar preoperative characteristics. There were no deaths or major neurologic complications in either group, nor was there any difference between groups in the chosen index of neurologic deterioration. Serum S-100 protein concentrations were higher in the on-pump group at 30 minutes, but any such difference between groups had disappeared 4 hours later. The extent of the changes in S-100 protein was unrelated to the index of neuropsychologic deterioration.

CONCLUSIONS

The changes in S-100 protein concentration suggest that the brain and/or blood-brain barrier may be more adversely affected during coronary artery surgery with cardiopulmonary bypass than during surgery on the beating heart, but that this may not be reflected in detectable neuropsychologic deterioration at 12 weeks.

Intermittent running: muscle metabolism in the heat and effect of hypohydration

PURPOSE

This study reports two studies that investigated the reason for a poorer intermittent supramaximal running performance previously found in the heat (Maxwell et al., The effect of climatic heat stress on intermittent supramaximal running performance in humans. Exp. Physiol. 81:833-845, 1996). The first study tested the hypothesis that it was due to different rates of substrate metabolism. The second study tested whether a greater level of hypohydration led to an earlier exhaustion time.

METHODS

A maximal anaerobic running test (MART) was the exercise model used. This involved repeated 20-s runs, each at increasing intensities, with 100 s of passive recovery between runs.

RESULTS

In study 1, eight male subjects performed the MART on two occasions at either 32.8+/-0.3 degrees C, 80.5+/-1.6% relative humidity (RH), or 21.3+/-0.4 degrees C, 48.8+/-2.2% RH. Needle biopsy samples were taken from the vastus lateralis muscle before and immediately after the MART. In study 2, 11 male subjects performed the MART in a moderately hypohydrated (HYPO) and euhydrated (EUH) state while in a cool environment. In study 1, performance was significantly worse in the hot compared with the cool environment (138+/-7 vs. 150+/-6 s, respectively, P<0.05). No differences were observed in the change in muscle glycogen (100.3+/-15.1 vs. 107.0+/-15.6 mmol glucosyl units x kg dry muscle(-1)) or muscle lactate (102.9+/-18.2 vs. 100.5+/-16.6 mmol x kg dry muscle(-1)) between the hot and cool environments, respectively. In study 2, performance was worse in the HYPO (148+/-9 s) compared with the EUH (154+/-9 s) trial (P<0.05).

CONCLUSIONS

These results indicate that a reduced intermittent supramaximal running performance in the heat is not caused by greater muscle glycogenolysis or lactate accumulation. Further, a poorer intermittent sprinting performance is experienced in a hypohydrated compared with a euhydrated state.

The effects of cardiopulmonary bypass temperature on neuropsychologic outcome after coronary artery operations: a prospective randomized trial

The effect of systemic perfusion temperature on postoperative cognitive function was investigated in 96 adult patients undergoing elective coronary revascularization with cardiopulmonary bypass at 28 degrees C, 32 degrees C, or 37 degrees C. Neuropsychologic performance was assessed 1 day before the operation and 6 weeks after the operation. Five tests were adapted from the Wechsler Adult Intelligence Scale and two from the Wechsler Memory Scale.

RESULTS

No patients had major neurologic complications. Ninety-three patients completed the five Wechsler Adult Intelligence Scale tests, but only 70 went on to complete the Wechsler Memory Scale tests as well. In these, there was an effect of cardiopulmonary bypass temperature on the number of neuropsychologic tests in which there was a preoperative to postoperative deterioration (p = 0.021), the number with bypass at 37 degrees C being significantly greater than the number with bypass at 32 degrees C (p = 0.015). Subsidiary analyses using a multivariate linear model examined the effect of cardiopulmonary bypass temperature on the magnitude of change, with or without allowing for other possible confounding influences. There was an adverse effect of normothermic (37 degrees C) versus moderately hypothermic (32 degrees C) perfusion---more convincingly displayed in the analyses of all seven scores rather than just the Wechsler Adult Intelligence Scale scores. Further cooling to 28 degrees C conferred no additional benefit in terms of cognitive function. The importance of the deterioration is open to question.

Splenic lymphoma with circulating villous lymphocytes

This report describes the occurrence of splenic lymphoma with villous lymphocytes (SLVL) in a 56 year old white female with a family history of chronic lymphocytic leukaemia. Other unusual features included a marked lymphocytosis with counts up to 224 x 10(9)/l and marked clumping of lymphocytes in EDTA anticoagulated blood. The neoplastic cells were CD19+, CD20+, CD22+, CD22+, IgM+, lambda+, kappa-, CD5-, and CD10-. The spleen had nodular infiltrates of B lymphocytes in the region of the white pulp with minimal red pulp involvement. Electron microscopy of peripheral blood lymphocytes revealed cells with polar cytoplasmic processes. This report underlines the need for detailed analysis, including morphology and immunophenotyping, for each patient with a small B cell lymphoproliferative disorder.

A multicenter trial of antithymocyte globulin in aplastic anemia and related diseases

One hundred fifty patients with bone marrow failure were treated in three groups with antithymocyte globulin (ATG; Upjohn, Kalamazoo, MI) in a multicenter trial. Patients were assessed at 3, 6, and 12 months after initiation of treatment by three criteria: transfusion independence, clinical improvement, and blood counts. Group I consisted of 77 patients with acute severe aplastic anemia, randomized to receive either ten or 28 days of ATG. There was no significant difference between the two arms of this protocol: 47% of all patients were clinically improved and 31% were transfusion independent at 3 months. Of the severely affected patients, 27% died before 3 months; most deaths occurred early in treatment. Factors associated with survival in severely affected patients included male sex, age less than 40 years, absolute neutrophil count greater than 200/microL, and idiopathic etiology. Neutrophil counts generally increased by 8 weeks after treatment, but patients continued to show improvement to 1 year posttreatment. In Group II, 44 patients with moderate or chronic severe aplastic anemia were randomized to receive either ten days of ATG or 3 months of high-dose nandrolone decanoate. No patient initially treated with androgens recovered, but 28% of ATG-treated cases achieved transfusion independence at 3 months. Group III consisted of patients with a variety of bone marrow failure syndromes. Patients with pancytopenia and cellular bone marrow showed response rates similar to those of patients with chronic or moderate aplastic anemia.

Chromosome studies in "preleukemia". III. Myelofibrosis

Cytogenetic studies were done on 18 patients with myelofibrosis or the closely related syndrome, undifferentiated myeloproliferative disorder (MPD). Clones of cells with chromosome abnormalities were demonstrated in the blood of eight individuals, including two with a history of radiation therapy and two with "acute myelofibrosis". Trisomy 8 was present in the latter two patients, but otherwise, there was no consistent cytogenetic pattern or correlation with specific hematologic findings. Sixteen of these patients have been followed for more than 1 year or until death; none has progressed to leukemia. The results indicate that chromosome abnormalities are relatively common in this disorder, but as with polycythemia vera, and unlike some other "preleukemic" states, the aberrant clones in myelofibrosis do not appear to indicate that clinical leukemia is imminent.

Two complex translocations in chronic granulocytic leukemia involving chromosomes 22, 9, and a third chromosome

Among 13 Ph-positive cases of chronic granulocytic leukemia (CGL), banding studies revealed two with complex rearrangements involving translocation of the long arm of number 22 to another autosome and a segment of that chromosome translocated to the long arm of number 9. In a patient with both CGL and sickle cell anemia, the 3-way rearrangement involved chromosomes 5, 9, and 22; and he also had a second Philadelphia chromosome and two constitutional variants: pericentric inversion of the other number 9 chromosome and satellite polymorphism in the G group. The karyotype of the leukemic cells was interpreted as: 47,XY,inv(9) (p11q13),t(5;9;22)(q13;q34;q11)+del(22)(q11). In the second patient, the complex translocation in the Ph-positive cells involved chromosomes 3, 9, and 22, resulting in a karyotype interpreted as: 46,XX,t(3;9;22)(p21;q34;q11). Several reports indicate that an abnormality of chromosome 9 is not essential for the development of Ph-positive CGL, but the very high frequency of its involvement (including these unusual translocations) suggests that some type of non-random somatic association may exist between 9q and 22q which makes simultaneous breakage likely. Attempts to correlate specific types of pH chromosome rearrangements with the clinical course of CGL must await the identification of more cases and longer follow-up.

SILENT DISSECTION OF THE AORTA

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