801 EFFECTIVENESS OF HEARING REHABILITATION FOR CARE HOME RESIDENTS WITH DEMENTIA: A SYSTEMATIC REVIEW

Introduction

Hearing loss is common among people with dementia living in long-term care homes, leading to poorer quality of life, communication difficulties and exacerbated dementia-related symptoms. Hearing rehabilitation may improve outcomes; however, evidence suggests hearing is poorly managed in care homes.

Methods

A systematic review reporting on the effectiveness of, and barriers and facilitators to, hearing rehabilitation for residents with dementia was conducted. No restrictions on publication date or language were set and grey literature was considered. Eligible studies were critically appraised and presented via a narrative review.

Results

Sixteen studies, most of low-to-moderate quality, were identified. Hearing rehabilitation, including hearing devices, communication techniques and visual aids (e.g. flashcards), were reported to improve residents’ communication, quality of life and reduce agitation, with improvements in staff knowledge of hearing loss and job satisfaction. Residents’ symptoms of dementia presented barriers, e.g. losing or not tolerating hearing aids. Low staff prioritization of hearing loss due to time-pressures and lack of hearing-related training for staff were further barriers, particularly for residents who required assistance with hearing devices. Adopting a person-centered approach based on residents’ capabilities and preferences and involving family members facilitated hearing device use.

Conclusions

Residents with dementia can benefit from hearing rehabilitation. Identifying and implementing efficient, individualized hearing rehabilitation is necessary for those with complex cognitive needs. Increased funding and support for the social care sector is required to address systemic issues that pose barriers to hearing rehabilitation, including time-pressures, lack of training for staff and access to audiology services for residents.

69 Continuous and Regular Live Feedback is Required to Maintain An Improvement in the Quality of Discharge Summaries. Shop 75 +

Background

This quality improvement project aims to improve communication between secondary and primary care at the time of hospital discharge of older patients.

Introduction

Discharge summaries (DS) are a key component of communication between secondary and primary care. Poor quality DS are associated with poorer outcomes in terms of adverse events [1], readmissions [2] and medication errors [3]. There is NICE and AMRC guidance on what constitutes a good DS [4, 5].

Method

Prospective review of DS from a range of wards was completed in August 2017 against a detailed data tool. A random selection of DS from the same wards was audited monthly from November 2017 onwards. A novel live-feedback system was introduced to the same wards in February 2018 so that the teams completing DS received feedback on how well their summaries complied with the recommendations and what areas needed improvement. A change in staffing lead to a break in the delivery of monthly feedback to the ward teams from April to September 2019 when it was re-commenced.

Results

In the majority of areas there has been an increase in the quality of the DS from the beginning of the project until March 2019 when the regular feedback interventions were suspended. There was a decrease in the quality of summaries in July and August 2019, followed by an increase as regular feedback interventions recommenced in September 2019. The aggregate results of the four main components of DS (follow-up actions, medicines, clinical summary, and functional assessment), scored “good” in 13% of DS at baseline, 40% in March 2019, 20% in July 2019 and 31% in October 2019.

Conclusions

The suspension of regular direct interventions resulted in a significant deterioration in the quality of discharge summaries, and this improved quickly after reintroduction of PDSA cycles in key areas. Continuous quality improvement requires uninterrupted focus on regular live feedback.

References

1. Clegg et al. Lancet 2013; 381: 752–62.

2. Samra et al. Age Ageing 2017; 46: 911–9.

3. Romero-Ortuno et al. Age Ageing 2012; 41: 684–9.

The VCCC Research & Education Lead Program: Collective Leadership in Cancer Across Multiple Organisations

Background and context: The Victorian Comprehensive Cancer Centre (VCCC) is Australia´s first formally constituted comprehensive cancer center, based on NCI principles. It is an alliance of 10 organizations: 7 hospitals, 2 medical research institutes and a university, based in Melbourne, Australia. A key goal for the VCCC is to create meaningful collaborations across partner organizations. Aim: The VCCC established the Research & Education Lead (R & E Lead) Program to build leadership capability who can harness the critical mass of talent across the VCCC alliance to work toward optimal integration of cancer research and education into routine patient care. Strategy/Tactics: This VCCC Research & Education Lead Program manifests the foundational principles of the VCCC by systematising and normalizing collaborative activities across the VCCC alliance. The program is a vehicle that allows the VCCC to address its strategic priorities to enable: - better integration of research, education and clinical care - sharing of ideas and knowledge to improve patient outcomes - shared education and training across member organizations Program/Policy process: Clinicians-scientists were appointed to each tumor stream as VCCC R & E Leads (approx. 0.2 EFT). Their role is to build networks of expertise and to drive change that is evidence-based, strategic and agreed across the VCCC alliance, with a focus on the end goal of better outcomes for cancer patients. The program provides the basis for a model of distributed leadership, wherein champions invested in the VCCC concept are embedded in partner organizations. Outcomes: Three R & E Leads were initially appointed as a pilot for 2 years, with a further three leads appointed during this period. Following the pilot, the program has been expanded to encompass 10 tumor streams as well as leads in primary care integration and cancer nursing. Achievements to date have included the development of a Massive Online Open Course in Cancer Survivorship, conduct of numerous symposia and events that upskill the cancer workforce in niche areas identified by the leads as needs, and consensus on the clinical challenges and research priorities to be tackled collectively within each tumor stream. Overarching program benefits included increased engagement and collaboration across partner organizations, more sharing of knowledge, and more participation in collaborative efforts including VCCC strategy development and advocacy. What was learned: A key finding of an interim program evaluation identified that the appointment of clinician-scientists as the leads was an important factor in their ability to cross the boundaries between research and clinical practice and between organizations, and to work closely and cohesively with clinical service leads for the tumor streams.

Corticosteroids including ACTH for childhood epilepsy other than epileptic spasms

BACKGROUND

Epilepsy is a disorder with recurrent epileptic seizures. Corticosteroids have been used in the treatment of children with epilepsy and have significant adverse effects. Their efficacy and tolerability have not been not clearly established.

OBJECTIVES

To determine the efficacy of corticosteroids in terms of seizure control, improvements in cognition and in quality of life and tolerability of steroids compared to placebo or other antiepileptic drugs.

SEARCH STRATEGY

We searched the following databases: The Cochrane Epilepsy Group Specialized Register (September 2006); Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 2, 2006); MEDLINE (1966 - April 2004); EMBASE (1966 - December 2004); Database of Abstracts of Reviews of Effectiveness (DARE) (December 2004). We checked the reference lists of retrieved studies for additional reports of relevant studies.

SELECTION CRITERIA

All randomized controlled trials of administration of corticosteroids to children (less than 16 years) with epilepsy.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials for inclusion and extracted data. Outcomes included cessation of seizures, reduction in seizure frequency, improvement in cognition, quality of life and adverse effects of steroids.

MAIN RESULTS

A single RCT was included that recruited five patients in double blind crossover trial. One was withdrawn prematurely from the study and another had infantile spasms and hence was excluded from further analysis. ACTH 4-9 was administered. The overall reduction in seizure frequency of more than 25% and less than 50% occurred in one child at low dose and in two children at higher dose. One child did not show any reduction in seizure frequency. No adverse effects were reported.

AUTHORS' CONCLUSIONS

No evidence was found for the efficacy or safety of corticosteroids in treating childhood epilepsies. Clinicians using steroids in childhood epilepsies, other than for epileptic spasms, should take this into account before using these agents.

Posterior quadrantic dysplasia or hemi-hemimegalencephaly: A characteristic brain malformation

INTRODUCTION

Posterior quadrantic dysplasia (PQD), a developmental malformation involving the temporal, parietal, and occipital lobes of one cerebral hemisphere, leads to intractable epilepsy.

OBJECTIVE

To characterize the clinical features of 19 patients with PQD and analyze the postsurgical outcome of those who underwent resection of dysplastic tissue.

METHODS

The extent and nature of the malformation were primarily assessed with high-resolution brain imaging. Fourteen patients underwent complete or partial temporoparieto-occipital resection or temporal resection associated with parieto-occipital disconnection. Postoperative follow-up period ranged from 8 months to 7 years. The authors used the Engel classification for postoperative outcome.

RESULTS

All patients were sporadic. Clinical features included infantile spasms, partial seizures, mental retardation, mild hemiparesis, and visual field defects. Neuroimaging localized the malformation within the posterior cerebral quadrant contralateral to the neurologic deficit and demonstrated hemi-hemimegalencephaly in 14 of 19 patients and multilobar cortical dysplasia in 5 of 19 patients. The authors observed class I outcome in six patients. Two patients had class II and four patients had class III outcome. Class IV outcome was seen in two patients. After surgery, two patients developed mild hemiparesis, and two developed a visual field defect.

CONCLUSIONS

Widespread cortical dysplasia is more frequent in the posterior quadrant. In our series, posterior quadrantic dysplasia represents either hemi-hemimegalencephaly or multilobar cortical dysplasia. Individuals with posterior quadrantic dysplasia share a spectrum of clinical features. The intractable epilepsy in these patients may be alleviated by a large quadrantic temporoparieto-occipital resection.

Cajal-Retzius cells, inhibitory interneuronal populations and neuropeptide Y expression in focal cortical dysplasia and microdysgenesis

Focal cortical dysplasia (FCD) and microdysgenesis (MD) are likely to represent abnormalities of radial neuronal migration during cortical development. We investigated the distribution of reelin-positive Cajal-Retzius cells, known to be important in the later stages of radial neuronal migration and cortical organization, in 12 surgical cases of both MD and FCD. Quantitation revealed significantly higher numbers of these cells in MD cases compared to controls. As the majority of cortical interneurones arise via tangential rather than radial migration, we studied the distribution and morphology of inhibitory interneuronal subsets immunolabelled for calbindin, parvalbumin and calretinin within these malformations. Frequent findings were a reduction of inhibitory interneurones in the region of FCD and abnormally localised hypertrophic or multipolar calbindin-positive interneurones in both FCD and MD. Neuropeptide Y immunostaining showed a striking increase in the density of the superficial plexus of fibres in both MD and FCD cases in addition to labelling of dysplastic neurones, which may represent an adaptive anti-convulsant mechanism to dampen down seizure propagation.

Treatment of Lennox-Gastaut syndrome

BACKGROUND

The Lennox-Gastaut syndrome is an age-specific disorder, characterised by epileptic seizures, a characteristic electroencephalogram (EEG), psychomotor delay and personality disorders. It occurs more frequently in males and onset is usually before the age of eight with a peak between three and five years. Late cases occurring in adolescence and early adulthood have rarely been reported. Language is frequently affected with both slowness in ideation and expression in addition to difficulties of motor dysfunction. Severe behavioural disorders (for example hyperactivity, aggressiveness and autistic tendencies)and personality disorders are nearly always present. There is also a tendency for psychosis to develop with time. The long-term prognosis is poor; although the epilepsy often improves, complete seizure freedom is rare and conversely the mental and psychiatric disorders tend to worsen with time.

OBJECTIVES

To compare the effects of pharmaceutical therapies used to treat Lennox-Gastaut syndrome in terms of control of seizures and adverse effects. Many people who suffer from this syndrome will already be receiving other antiepileptic medications at the time of their entry into a trial. However, for the purpose of this review we will only consider the effect of the single therapeutic agent being trialed (often as add-on therapy).

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group trials register (March 2003), MEDLINE (1966 to March 2003) and EMBASE (1980 to March 2003). In addition, we contacted pharmaceutical companies and colleagues in the field to ascertain any unpublished/ongoing studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of the administration of drug therapy to patients with Lennox-Gastaut syndrome.

DATA COLLECTION AND ANALYSIS

Data was independently extracted by two reviewers. Analysis included assessing study quality, as well as statistical analysis of the effects on overall seizure rates and effects on specific seizure types (eg drop attacks), adverse effects and mortality.

MAIN RESULTS

We found five RCTs, but were unable to perform any sort of meta-analysis, because each trial looked at different populations, different therapies and considered different outcomes.

REVIEWER'S CONCLUSIONS

The optimum treatment for Lennox-Gastaut syndrome remains uncertain and no study to date has shown any one drug to be highly efficacious; lamotrigine, topiramate and felbamate may be helpful as add-on therapy. Until further research has been undertaken clinicians will need to continue to consider each patient individually, taking into account the potential benefit of each therapy weighed against the risk of adverse effects.

An intensive self care training programme reduces admissions for the treatment of plantar ulcers

This paper describes, in detail, an intensive 14 day Self Care Training Programme that is conducted at Lalgadh Leprosy Services Centre in Nepal. An evaluation of the programme was undertaken in which hospital admission for infected plantar ulceration was the outcome measure. It was found that those who had undertaken the programme were less likely to have been admitted for hospital treatment in a 3-month follow-up period (chi 2 = 5.1, P = 0.02). An odds ratio of 1:1.8 (95% CI = 0.15-0.01) was also calculated. This paper presents an overview of the issues related to impairment, a description of the Self Care Training Programme, an analysis of the evaluation results and a discussion of the findings.

A possible role for gap junctions in generation of very fast EEG oscillations preceding the onset of, and perhaps initiating, seizures

PURPOSE

We propose an experimentally and clinically testable hypothesis, concerning the origin of very fast (> approximately 70 Hz) EEG oscillations that sometimes precede the onset of focal seizures. These oscillations are important, as they may play a causal role in the initiation of seizures.

METHODS

Subdural EEG recordings were obtained from children with focal cortical dysplasias and intractable seizures. Intra- and extracellular recordings were performed in rat hippocampal slices, with induction of population activity, as follows: (a) bath-applied tetramethylamine (an intracellular alkalinizing agent, that opens gap junctions); (b) bath-applied carbachol, a cholinergic agonist; and (c) focal pressure ejection of hypertonic K+ solution. Detailed network simulations were performed, the better to understand the cellular mechanisms underlying oscillations. A major feature of the simulations was inclusion of axon-axon gap junctions between principal neurons, as supported by recent experimental data.

RESULTS

Very fast oscillations were found in children before seizure onset, but also superimposed on bursts during the seizure, and on interictal bursts. In slice experiments, very fast oscillations had previously been seen on interictal-like bursts; we now show such oscillations before, between, and after epileptiform bursts. Very fast oscillations were also seen superimposed on gamma (30-70 Hz) oscillations induced by carbachol or hypertonic K+, and in the latter case, very fast oscillations became continuous when chemical synapses were blocked. Simulations replicate these data, when axonal gap junctions are included.

CONCLUSIONS

Electrical coupling between principal neurons, perhaps via axonal gap junctions, could underlie very fast population oscillations, in seizure-prone brain, but possibly also in normal brain. The anticonvulsant potential of gap-junction blockers such as carbenoxolone, now in clinical use for treatment of ulcer disease, should be considered.

The relationship between child temperament and early childhood caries

PURPOSE

Among the potential risk factors associated with nursing caries/baby bottle tooth decay--a subset of Early Childhood Caries (ECC)--is a "strong-tempered" behavioral style in the child. However, the few empirical studies that have investigated this description remain controversial. The research goal of this study was to operationalize the "strong-tempered" profile and investigate its association to parental feeding practices and ECC levels.

METHODS

In an observational-correlational study design, 58 children (ASA I), ages 18 to 70 months (M = 43 months, SD = 17), were reliably assessed for ECC levels by a clinical evaluator. A second evaluator, blind to ECC status, interviewed parents using a demographic survey, a feeding practices measure, and the EAS Temperament Survey for Children.

RESULTS

Multiple regression analyses indicated that none of the four temperament factors (Emotionality, Activity, Sociability, and Shyness) significantly predicted duration of feeding habit defined as the length of time in months that the child breast or bottle fed, whichever lasted the longest. However, the combination of greater duration of feeding habit and higher levels of Shyness predicted all three measures of ECC: the presence or absence of caries (r2 = .19, P < .001), the number of carious teeth (r2 = .23, P < .001) and the number of carious surfaces (r2 = .21, P < .001). Furthermore, the addition of Native status significantly increased the predictive value of all of three models (r2 = .37, r2 = .43, r2 = .29, respectively, Ps < .0001).

CONCLUSION

Temperament did not predict the duration of feeding habit but together, shyness and duration of feeding habit was associated with ECC.

The mitosis of fibroblasts in cell culture is enhanced by binding GP IIb-IIIa of activated platelets on fibrinogen

A fibroblast cell culture model enables us to measure the mitogenic ability mediated by growth factors released from stimulated platelets under different conditions. Simultaneously the growth factors secreted in the culture medium were determined. Cell mitotic rate was measured by incorporation of 3H-thymidine on days 3, 5 and 7 of culture. PDGF, TGF-beta, EGF and IGF-I were determined by Western blot. When fibroblasts were grown on surfaces precoated with a mixture of fibrinogen and thrombin-stimulated platelets, the 3H-thymidine uptake (196,645 +/- 56,864 cpm/ml) was increased, in comparison to fibroblasts grown on uncoated surfaces, in medium supplemented with FBS (28,855 +/- 7329 cpm/ml). Neither thrombin-stimulated platelets without fibrinogen nor fibrinogen alone had positive effects on the mitogenic activity of fibroblast. Growth factors were identified only in a culture medium in which the cells were grown on surfaces precoated with fibrinogen and thrombin-stimulated platelets. Blocking the platelet integrin GP IIb-IIIa inhibited the release of growth factors from thrombin-stimulated platelets and consecutively the stimulation of mitosis by fibrinogen and activated platelets was absent. Antibodies against the growth factors added to the medium suppressed the stimulation of cell mitosis. These results show that delivery of growth factors from platelets' secretory granules is dependent on binding of fibrinogen to GP IIb-IIIa.

Paradoxic reaction to lamotrigine in a child with benign focal epilepsy of childhood with centrotemporal spikes

A girl aged 5 years developed nocturnal seizures (mouth twitching, salivation, anarthria, with right arm jerking and occasional secondary generalisation), with frequent focal sharp waves over the left centrotemporal region in her EEG, suggesting benign childhood epilepsy with centrotemporal spikes (BECTS). Seizures became diurnal and frequent, not modified by carbamazepine (CBZ) or valproate (VPA) but responding to VPA and lamotrigine (LTG) with recommended dosage schedules for this combination. Her school performance then deteriorated insidiously, with poor memory and concentration, clumsiness, stuttering, and emotional lability. After 4 months, new episodes, < or =10 per day, occurred. These lasted a few seconds; she stared into space, her jaw dropped, her head dropped to the right, and her eyelids flickered. She usually maintained awareness. Attacks were often provoked by blowing or sneezing. Ictal EEG showed anterior-predominant 3/s sharp-slow wave complexes lasting < or =8 s, with bilateral rolandic discharges interictally. Withdrawal of LTG resulted in rapid improvement in cognitive function and gradual remission of the new attacks.

CONCLUSIONS

This appears to be a paradoxic reaction to LTG in the setting of BECTS.

The significance of bilateral EEG abnormalities before and after hemispherectomy in children with unilateral major hemisphere lesions

The rate of seizure relief following hemispherectomy varies between 50 and more than 80%. There has been particular debate concerning the significance of bilateral electroencephalography (EEG) abnormalities in influencing prognosis. This study was set out to determine the frequency of bilateral EEG abnormalities and their relationship to underlying pathology and outcome. We investigated 28 children with unilateral hemisphere lesions, who underwent hemispherectomy. Interictal and ictal EEGs before and after hemispherectomy were reviewed. Post-operative outcome with respect to seizures was noted. Bilateral EEG abnormalities were seen in 75%, but were more common in children with malformations of cortical development than in patients with acquired cerebral lesions, and were found more often in interictal than in ictal records. Post-operative EEG abnormalities were variable and did not consistently predict outcome. Short-term outcome was similar, irrespective of aetiology. With longer term follow-up, only 47% of children with developmental abnormalities were still seizure-free in contrast to 77% of children with acquired abnormalities. Although the incidence of bilateral EEG abnormalities in patients with major unilateral hemisphere lesions is high, these findings alone should not preclude further consideration for hemispherectomy. Our findings emphasise that the aetiology of the lesion plays a major role in determining outcome.

Emerging issues in AIDS: variant strains of human immunodeficiency virus and its subtypes

The emergence of variant strains of HIV has triggered the need for active local, national, and global surveillance. Some new strains identified in the US cannot be detected reliably with current test kits--a problem with important implications for blood safety and for diagnosis and prevention of AIDS.

Temperament and trait anxiety as predictors of child behavior prior to general anesthesia for dental surgery

Children's individual styles of interaction with the environment (temperament) influence stable tendencies towards distress (trait anxiety) and context-specific manifestations of distress (state anxiety). Measures of temperament and trait anxiety were examined as predictors of state anxiety (i.e., disruptive behaviors) in the presurgical setting. During a 2-month period, 51 nonpremedicated, healthy children (M = 3 years of age) were consecutively studied-as they presented to a hospital setting for dental treatment under general anesthesia (GA). Using correlation and backward multiple regression analyses, one temperament category (shyness), but not trait anxiety (the revised CMAS), predicted disruptive behaviors (the revised MBPRS) during preseparation (r2 = .16, P = .0038) and separation (r2 = .09, P = .0281) from parents. Shyness, age, and gender best predicted disruptive behaviors during preseparation (multiple R2 = .31, P = .0005). Temperament (a) predicts children's distress in the presurgical setting, and (b) appears to be moderated by age, gender, and interpersonal factors. Awareness of temperamental influences can help predict children's behavior and aid in the presurgical care of children.

Bilateral parasagittal parietooccipital polymicrogyria and epilepsy

We describe 9 patients with a bilateral malformation of cortical development, centered around the parasagittal and mesial aspects of the parietooccipital cortex, with magnetic resonance imaging findings suggestive of polymicrogyria. No familial distribution or etiologic factors were identified. Location in a watershed area between anterior and posterior cerebral arteries suggests postmigratory perfusion failure as the underlying cause. In most patients the malformation was detected by magnetic resonance imaging after computed tomography scans with 10-mm-thick sections were considered normal. Seizures, present in all, had started between the ages of 20 months and 15 years (mean, 9 years) and were intractable in 7. Complex partial seizures with or without minor automatisms were the most frequent ictal pattern. In only 4 patients these were preceded by symptoms indicating posterior onset. Interictal electroencephalograms showed both diffuse and bilateral parietooccipital or temporal abnormalities. The range of IQ scores indicated average intelligence to mild retardation. Several patients presented deficits on neuropsychological tasks requiring performance under time constraints, suggesting that the malformation may result in cognitive slowing. Early diagnosis of this malformation may be difficult because of the lack of neurological signs, relatively late seizure onset, difficulty in localizing seizure onset, and inability to recognize the cortical abnormality on computed tomography scans.

Plantar ulceration in patients with leprosy

A controlled trial was implemented to investigate the hypothesis that plantar ulcer sites associated with leprosy, in subjects who were supplied with foot orthoses, would heal more quickly than those in a control group. The population was comprised of individuals with impairments associated with leprosy, living near a leprosy hospital in India. Ulcer area was compared in the two groups and assessed at three-monthly intervals from July 1993 to March 1994. At the March 1994 assessment 58% of ulcers in the experimental group had healed but only 14% in the control group. At this point patients in the control group were supplied with orthoses and three months later, in June 1994, 60% of the ulcers in the experimental group and 62% of ulcers in the control group had healed. The results of this study demonstrate that orthotic intervention can significantly reduce the duration of ulceration.

The efficacy of podiatric orthoses as an adjunct to the treatment of plantar ulceration in leprosy

This study examines the outcome of a management approach to plantar ulceration secondary to leprotic neuropathy. Locally-available resources were used to produce podiatric orthoses which were supplied to an experimental group. The effects on healing time and quality of healing were compared with a control group. Both groups were ambulant (the programme sought not to interfere with socioeconomic independence). Using standard nonparametric methods of analysis, it was demonstrated that the effects on healing rate, attributed to the experimental intervention, were highly significant. Over a 7-month period, 57% of the experimental group ulcers healed, while only 12.5% of the control group ulcers healed. The experimental intervention also demonstrated a positive effect on the quality of ulcer healing. This effect was not reflected in the control group.

Medical treatment of Rasmussen's syndrome (chronic encephalitis and epilepsy): effect of high-dose steroids or immunoglobulins in 19 patients

We treated 19 patients with Rasmussen's syndrome (chronic encephalitis and epilepsy)--a rare progressive disorder of unknown etiology causing focal epilepsy, hemiparesis, and intellectual deterioration--with intravenous immunoglobulins, high-dose steroids, or both, to control seizures and improve the end point of the disease. Ten of 17 patients receiving steroids, and eight of nine patients receiving immunoglobulins, had some reduction of seizure frequency in the short term. Improvement in hemiparesis was slight. The effect of these drugs in ameliorating the end point of the disease in the long term remains unknown, and further multicenter studies with standardized protocols are warranted.

Effects of 1,1-dichloroethene and of some of its metabolites on the functional viability of mouse hepatocytes

1,1-Dichloroethene (DCE) is hepatotoxic in rodents, and the expression of its toxicity involves probably its metabolism. In this study the role of DCE metabolites in the generation of the hepatotoxic lesion was investigated. Hepatocytes from male BALB/c mice in suspension were used as the experimental model. Cells were incubated with DCE for up to 5 hr and cellular viability was assessed by measurement of the release of lactate dehydrogenase into the medium and by alterations in the reduction of the dye 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide. After incubation for 3 hr DCE at 0.5 mM caused maximal toxicity, whereas at 0.1 mM DCE was only marginally toxic. Cytotoxicity was exacerbated by pretreatment of mice with buthionine sulfoximine (1.6 g/kg), an inhibitor of glutathione biosynthesis, given 4 hr prior to hepatocyte isolation. Inclusion of N-acetylcysteine (10 mM) into the incubate protected cells against DCE-induced cytotoxicity. Coincubation with octylamine (0.5 mM), an inhibitor of cytochrome P450, abolished the cytotoxic potential of 0.5 mM DCE during incubation for 3 hr. DCE toxicity was increased in hepatocytes from mice which had received ethanol or acetone in their drinking water, both of which induce levels of the hepatic cytochrome P450 isozyme P450 2E1. Incubation of cells with the P450 2E1 inhibitors N,N-dimethylformamide (10 mM) or diethyldithiocarbamate (100 microM) protected liver cells against the detrimental effect of DCE. Pretreatment of animals with phenobarbital, which induces the P450 2B subfamily, or 3-methylcholanthrene, which induces P450 1A1, did not affect the degree of hepatocytotoxicity elicited DCE.(ABSTRACT TRUNCATED AT 250 WORDS)

N-alkylformamides are metabolized to N-alkylcarbamoylating species by hepatic microsomes from rodents and humans

Hepatotoxic formamides such as N-methylformamide (NMF) and N,N-dimethylformamide (DMF) are metabolized in vivo to N-acetyl-S-(N-methylcarbamoyl)cysteine via oxidation at the formyl carbon, which yields a reactive intermediate. The hypothesis was tested that this biotransformation route can be studied in vitro with hepatic fractions. NMF was incubated with microsomes or cytosol obtained from BALB/c mice, and metabolically generated N-methyl-carbamoylating species were analyzed after derivatization with ethanol in base to furnish ethyl N-methylcarbamate. Generation of metabolite was catalyzed by microsomes, but not by cytosol. Detection of the N-methylcarbamoylating species was dependent on the presence in the incubation mixture of NMF, viable microsomes, NADPH, and a thiol-containing agent such as glutathione. Metabolite formation was inhibited by SKF 525-A (3 mM) and abolished when the incubation atmosphere consisted of an air/carbon monoxide mixture (1:1) instead of air. Metabolism was not induced by pretreatment of mice with phenobarbital or beta-naphthoflavone. N-Ethylformamide and the DMF metabolite N-(hydroxymethyl)-N-methylformamide, but not DMF, were metabolized by microsomes to the N-alkylcarbamoylating metabolite at a measurable rate. NMF metabolism was also observed with liver microsomes from Sprague-Dawley rats or from humans. In the case of rat microsomes the rate of metabolism was half of that measured with murine microsomes. The results suggest that (i) the metabolic toxification of NMF can be studied in hepatic microsomes and (ii) the oxidation of the formyl moiety in N-alkylformamides is catalyzed by cytochrome P-450.

Differences between rodents and humans in the metabolic toxification of N,N-dimethylformamide

The widely used industrial solvent N,N-dimethylformamide (DMF) causes liver damage in occupationally exposed persons and is suspected of involvement in the generation of certain occupational malignancies. Here the extent of the biotransformation of DMF to three urinary metabolites has been compared in humans and rodents. The metabolites, which were quantified by gas chromatography (GC) are N-(hydroxymethyl)-N-methylformamide (HMMF), which yielded N-methylformamide on GC analysis, a species which decomposed to formamide on GC analysis, and N-acetyl-S-(N-methylcarbamoyl) cysteine (AMCC), measured after derivatization with ethanol to give ethyl N-methylcarbamate. Ten volunteers who absorbed between 28 and 60 mumol/kg DMF during an 8-hr exposure to DMF in the air at 60 mg/m3 excreted in the urine within 72 hr between 16.1 and 48.7% of the dose as HMMF, between 8.3 and 23.9% as formamide, and between 9.7 and 22.8% as AMCC. AMCC, together with HMMF, was also detected in the urine of workers after occupational exposure to DMF. The portion of the dose (0.1, 0.7, or 7.0 mmol/kg given ip) which was metabolized in mice, rats, or hamsters to HMMF varied between 8.4 and 47.3% of the dose; between 7.9 and 37.5% were excreted as formamide and only between 1.1 and 5.2%, as AMCC. The results suggest that there is a quantitative difference between the metabolic pathway of DMF to AMCC in humans and rodents. It is argued that the hepatotoxic potential of DMF may be linked to the extent of its metabolic conversion to AMCC.

Systemic histiocytosis: an unusual cause of perianal disease in a child

A male child first presented with chronic perianal skin disease at 33 months of age and later developed gingival disease and loose teeth associated with alveolar bone erosion. Biopsy of gingival and perianal lesions showed histiocytic proliferation. Following therapy with vinblastine, prednisone, methotrexate, and cyclophosphamide, the lesions healed but disease recurred in the mastoid and was successfully treated with vinblastine alone. Although the perianal area is an unusual site of skin involvement in systemic histiocytosis, this disorder should be considered in any child with chronic unexplained perianal disease, and biopsy of these lesions should be obtained.

The relationship between level of adjustment and expectations for therapy

Investigated Goldstein's (1962) hypothesis of a curvilinear relationship between client expectancy and psychotherapy outcome, based partly on a similar relationship between client expectancy and adjustment. One hundred and ten new clients at a university counseling center completed self-assessments and were rated on an adjustment scale by their therapists at the beginning and end of therapy. There was no curvilinear relationship between adjustment and expectancy, but a linear relationship between expectancy and self-assessed outcome was found. Because no relationship was obtained between expectancy and therapist-defined outcome, method variance may account for the association between expectancy and outcome from the client's perspective.

In utero Epstein-Barr virus (infectious mononucleosis) infection

A male infant infected in utero with Epstein-Barr virus (EBV) demonstrated a syndrome of multiple congenital anomalies (micrognathia, cryptorchidism, central cataracts), hypotonia, thrombocytopenia, persistent monocytosis, proteinuria, and multiple areas of metaphysitis at birth. Lymphocytes were Epstein-Barr nuclear antigen (EBNA) positive (18%) and persisted in culture for three months. He had antibody to early antigen (anti-EA), IgM-viral capsid (anti-VCA), and EBNA (anti-EBNA) detectable at 22 days of age. All attempts to isolate infectious agents or to serologically identify other infectious causes for his syndrome were negative.