Chemical availability of fallout radionuclides in cryoconite

Atmospheric deposition on glaciers is a major source of legacy fallout radionuclides (FRNs) accumulating in cryoconite, a dark granular material with surface properties that efficiently bind FRN contaminants (specifically 137Cs; 210Pb; 241Am). Cryoconite-bound FRNs in glaciers can be released when they interact with and are transported by glacial meltwater, resulting in the discharge of amassed particulate contaminants into aquatic and terrestrial environments downstream. The environmental consequences of FRN release from the cryosphere are poorly understood, including impacts of cryoconite-sourced FRNs for alpine food chains. Consequently, there is limited understanding of potential health risks to humans and animals associated with the consumption of radiologically-contaminated meltwater. To assess the chemical availability of cryoconite-adsorbed FRNs we used a three-stage sequential chemical extraction method, applied to cryoconite samples from glaciers in Sweden and Iceland, with original FRN activity concentrations up to 3300 Bq kg-1 for 137Cs, 10,950 Bq kg-1 for unsupported 210Pb (210Pbun) and 24.1 Bq kg-1 for 241Am, and orders of magnitude above regional backgrounds. Our results demonstrate that FRNs attached to cryoconite are solubilized to different degrees, resulting in a stage-wise release of 210Pbun involving significant stepwise solubilization, while 137Cs and 241Am tend to be retained more in the particulate phase. This work provides an insight into the vulnerability of pristine glacial environments to the mobilization of FRN-contaminated particles released during glacier melting, and their potential impact on glacial-dependent ecology.

A large anterior mediastinal mass in a young infant

Funding Acknowledgements

Type of funding sources: None.

TITLE

 A large anterior mediastinal mass in a young infant

Case Report

A 4 week old male neonate, KS was referred to the emergency department with a 24 hour history of increased work of breathing, two brief episodes of apnoeas and inspiratory stridor.  There was no infective symptoms or changes to his usual feeding pattern. There was no significant past medical history and he was on no regular medications. A chest x-ray demonstrated a large mediastinal mass and suspicion of cardiomegaly. A transthoracic echocardiogram demonstrated a structurally and functionally normal heart. However, there was a large anterior homogenous soft tissue mass extending to the left ventricular apex which was separate from the pericardium. This mass did not cause any heart chamber compression or compromise. Further cross-sectional imaging with cardiac computed tomography (CT) showed a non-enhancing uniform soft tissue mass occupying the superior and anterior mediastinum without evidence of calcification or fatty components. The lesion was seen to be extending from the root of the neck down to the left cardiac apex region with the total dimensions of the mass being 5.2 x 3.5 x 5cm. There was no compression of the great arteries or the airway. Parasternal ultrasound of the chest showed a starry sky appearance compatible with normal thymic tissue. Overall, the appearances were felt to be compatible with a prominent normal thymus. 

Discussion

The differential diagnosis of an anterior mediastinal mass in young infants includes germ cell tumours (mainly teratomas), congenital thymic cysts and true thymic hyperplasia(1). These can be difficult to distinguish from the normal large neonatal thymus. The normal thymus can take on a variety of shapes and sizes and still be considered normal. One of the most important features of a normal thymus is the lack of mass effect or compression on the airway or vascular structures(2). True thymic hyperplasia is characterised by an increase in the size and shape of the thymus while preserving thymic architecture. If the anterior mass has a bipyramidal morphology with the presence of gross intercalated fat on CT, these findings are pathognomonic for thymic hyperplasia(3). Thymomas are rare in children and appear as well-defined, rounded or lobulated soft tissue density mass with mild enhancement on CT. It can demonstrate irregular borders with extension into adjacent structures and approximately 30% will have necrosis and internal cystic foci(4). The most common germ cell tumour in the mediastinum is a teratoma with the hallmark being fat, fluid and calcified components on CT(2). Lymphomas are the most common anterior mediastinal mass in children but are usually seen in children older than 5 years. They often cause mass effect with displacement of the trachea. CT scan demonstrates larger nodal areas with hypodense and cystic areas suggestive of necrosis(1). Abstract Figure 1  Abstract Figure 2

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Hepatitis B vaccination is effective by subcutaneous route in children with bleeding disorders: a universal data collection database analysis

Subcutaneous (SQ) vs. intramuscular (IM) vaccination may cause fewer injection site complications in children with bleeding disorders, but little is known about comparative immunogenicity. To compare immunogenicity of hepatitis B virus (HBV) vaccination administered SQ or IM to individuals <2 years old with bleeding disorders, we performed a retrospective analysis of HBV surface antibody titres among patients enrolled in the universal data collection database who had received three doses of HBV vaccine solely by one route (SQ or IM). Data reviewed were from an initial visit before 24 months of age, until time of hepatitis antibody titre testing. The SQ and IM study groups did not differ in demographics, haemophilia type or severity or bleeding history. The mean age at the time of HBV surface antibody (anti-HBs) testing was 56.9 ± 20.3 months. Eighty-five of 92 subjects (92.4%) who received vaccine SQ developed a positive antibody titre (>12 IU/L), compared to 101/114 (88.6%) who received IM (P = 0.30). There was no statistically significant difference in distribution of titre values. The average age of the subjects at time of testing was 53 ± 20 months in the SQ group vs. 60 ± 20 months in the IM group (P = 0.02). The average time between the last dose of vaccine and anti-HBs testing was 47.6 ± 18.5 months among SQ vaccinated subjects vs. 51.6 ± 20.5 months in the IM group (P = 0.2). Immunogenicity to hepatitis B vaccination by the SQ and IM routes is similar.

Multicentre cohort study of red blood cell use for revision hip arthroplasty and factors associated with greater risk of allogeneic blood transfusion

BACKGROUND

Revision hip arthroplasty (RHA) is associated with high rates of allogeneic blood transfusion (ABT). We aimed to determine factors associated with ABT in patients undergoing RHA in Scottish hospitals, with particular focus on perioperative cell salvage (PCS).

METHODS

A prospective observational cohort study of RHA procedures performed in 11 hospitals over 7 months was performed. We recorded predefined patient, surgery-related, and blood conservation factors that may influence perioperative ABT, together with postoperative haemoglobin (Hb) data and ABTs to day 7. We explored factors with strongest independent association with ABT during the perioperative period using multiple regression analysis.

RESULTS

Two hundred and ten cases were studied, of whom 58% received ABTs (mean 1.8 units), most of which (52%) occurred on the day of surgery. Eighty-eight (42%) patients received PCS, of whom 68 had red cells re-infused [mean re-infusion volume 312 ml (1st, 3rd quartile: 260, 363 ml)]. In unadjusted comparisons, patients receiving PCS had lower intraoperative (9% vs 40%) and total (55% vs 63%) exposure to ABTs. The mean (95% confidence interval) theatre blood loss was 1013 (899-1128) ml and was higher for combined femoral/acetabular revision and femoral revision than other categories. The mean postoperative Hb transfusion trigger was 80 g litre(-1). In multivariable models, preoperative Hb [odds ratio (OR) 0.35; P<0.001], patient weight (OR 0.96; P=0.004), operating theatre blood loss (OR 1.002; P<0.001), and re-infusion of PCS blood (OR 0.31; P=0.02) were independent predictors of ABT exposure.

CONCLUSIONS

PCS is an effective blood conservation strategy for RHA, especially for patients with preoperative anaemia, low body weight, or both.

Directives in anorexia nervosa: use of the "Ulysses Agreement"

The course of anorexia nervosa frequently has episodes of exacerbation during which motivation and insight are reduced, cognition is impaired and treatment resistance is increased. Formalizing a directive to be used during these episodes when the patient has greater motivation and insight is one way of reducing treatment resistance. We describe a form of directive, called the "Ulysses Agreement".

Quantitative trait loci for periosteal circumference (PC): identification of single loci and epistatic effects in F2 MRL/SJL mice

To test the hypothesis that periosteal circumference (PC), which is associated with bone size through cross-sectional moment of inertia (CMI), has heritable components, we performed a linkage analysis using 633 MRL/SJL F(2) mice that have 14% difference in mean PC. PC was determined in femurs by use of peripheral quantitative computerized tomography (pQCT). The genome-wide scan identified nine QTL for PC adjusted by body weight on chromosomes 1 (2 QTL), 2 (2 QTL), 8, 11, 15, 17, and X, which accounted for 38.6% of phenotype variance. QTL on chromosomes 1 (D1Mit33), 8 (D8Mit125), 15 (D15Mit 62), 17 (D17Mit176), and X (DXMit208) were unique for PC adjusted by body weight and femur length, while the remaining PC QTL were shared with body weight but not femur length. Four epistatic interactions were identified which accounted for 37.6% of phenotype variance. There was also evidence of pleiotropic effects on chromosome 11 among four size phenotypes (PC, body length, body weight, bone mineral density, and muscle size), which may represent a common genetic mechanism that may regulate bone size and body size.

Identification of wound healing/regeneration quantitative trait loci (QTL) at multiple time points that explain seventy percent of variance in (MRL/MpJ and SJL/J) mice F2 population

Studies on genetic mechanisms of wound healing in mammals are very few, although injury is a leading cause of the global burden of disease. In this study, we performed a high-density, genome-wide scan using 633 (MRL/MPJ x SJL/J) F(2) intercross at multiple time points (days 15, 21, and 25) to identify quantitative trait loci (QTL) involved in wound healing/regeneration. The hypothesis of the study was that QTL and unique epistatic interactions are involved at each time point to promote wound healing/regeneration. Ten QTL were identified from chromosomes 1, 4, 6, 7, 9, and 13. Of the 10 QTL, eight from chromosomes 1, 4, 6, and 9 were novel as compared to QTL identified in the study. The 10 QTL altogether explained 70% of variance in F(2) mice. The same QTL were identified at each time point, with simple linear correlation between days 15, 21, and 25, showing very high significant relationships (R >0.92, P <0.0001). Unique epistatic interactions were identified at each time point except those from chromosomes 4, 6, 9, and 13 that were found at all three time points, showing that some loci are involved at all the three time points of wound healing (days 15, 21, and 25). Therefore, loci-to-loci interactions may play a major role in wound healing. Information from these studies may help in the identification of genes that could be involved in wound healing/regeneration.

Law, ethics and epidemiology: the case of the cervical screening audit

This paper provides a legal and ethical analysis of some controversial aspects of a recent proposal for an independent audit of New Zealand's National Cervical Screening Programme. The analysis reveals the difficulties likely to arise between investigators and ethics committees when the interests served by important public health research compete with the rigorous protection of patients' privacy.

Letter writing as a therapeutic tool

A novel method of family therapy for persons suffering from eating disorders, therapeutic letter writing (TLR), is presented. The protocol used for letter writing, its advantages and limitations, and a variety of applications are reviewed. The concept of TLR grew out of the study of narrative therapy, and was strongly influenced by ideas of Lorraine Wright and Maureeen Leahey about nurses and families, as well as the work of W.R. Miller around stages of change. This article will review: the process of TLR; therapeutic uses of eating disorders linked to TLR, including those relevant to families divided by distance or understanding; and the advantanges and disadvantages of TLR. Finally, a case study is discussed.

Detection of lysozyme in llama, sheep, and cattle tears

OBJECTIVE

To determine whether the tears of llamas, sheep, and cattle contain lysozyme and compare lysozyme concentrations in tears among these species.

ANIMALS

40 llamas, 5 sheep, and 36 cattle.

PROCEDURE

Electrophoresis, western blot immunoassay for lysozyme, a spectrophotometric assay to detect tear lysozyme by its ability to lyse a suspension of Micrococcus lysodeiticus, and a microtiter plate colorometric assay were performed.

RESULTS

A 13.6-kd protein band was detected by use of electrophoresis and western blot immunoassay in llama and sheep tears but not cattle tears. Results of spectrophotometric assay suggested that llama and sheep tears had high concentrations of lysozyme, whereas cattle tears had low concentrations. Results of the microtiter plate colorometric assay suggested that llama tears had high concentrations of lysozyme, whereas concentrations in sheep and cattle tears were lower.

CONCLUSIONS AND CLINICAL RELEVANCE

Lysozyme concentrations in tears may vary among species and this variability may contribute to differing susceptibilities to ocular diseases such as infectious keratoconjunctivitis.

The effects of increasing incentives on adherence to tuberculosis directly observed therapy

SETTING

Six New York State Department of Health tuberculosis (TB) directly observed therapy (DOT) programs in public, private and community facilities in New York City.

OBJECTIVE

A key feature of the TB DOT program was provision of incentives to motivate patients and increase adherence to therapy. The study hypothesis was that adherence will improve as the value of incentives increases and bonuses are added in a schedule of increasing rewards.

DESIGN

The study population consisted of 365 patients in six inner city TB DOT programs. Interviews, clinical data and attendance records for 3+ years were analyzed.

RESULTS

Patients who adhered (attending 80% of prescribed DOT visits each month of treatment) and those who did not were similar on seven demographic factors (e.g., age and sex), but were significantly different on clinical and social variables. Previous TB, resistance to rifampin, human immunodeficiency virus infection, psychiatric illness, homelessness, smoking and drug use were related to non-adherence. High adherence was significantly associated with fewer months in treatment (P < 0.016). Logistic regression showed that the odds that a patient would adhere to therapy were greater with increased incentives. Odds of adherence were significantly lower with rifampin resistance and psychiatric illness.

CONCLUSION

Increasing incentives is associated with improved adherence to therapy in inner city TB populations.

Genomic sequence analysis of Fugu rubripes CFTR and flanking genes in a 60 kb region conserving synteny with 800 kb of human chromosome 7

To define control elements that regulate tissue-specific expression of the cystic fibrosis transmembrane regulator (CFTR), we have sequenced 60 kb of genomic DNA from the puffer fish Fugu rubripes (Fugu) that includes the CFTR gene. This region of the Fugu genome shows conservation of synteny with 800-kb sequence of the human genome encompassing the WNT2, CFTR, Z43555, and CBP90 genes. Additionally, the genomic structure of each gene is conserved. In a multiple sequence alignment of human, mouse, and Fugu, the putative WNT2 promoter sequence is shown to contain highly conserved elements that may be transcription factor or other regulatory binding sites. We have found two putative ankyrin repeat-containing genes that flank the CFTR gene. Overall sequence analysis suggests conservation of intron/exon boundaries between Fugu and human CFTR and revealed extensive homology between functional protein domains. However, the immediate 5' regions of human and Fugu CFTR are highly divergent with few conserved sequences apart from those resembling diminished cAMP response elements (CRE) and CAAT box elements. Interestingly, the polymorphic polyT tract located upstream of exon 9 is present in human and Fugu but absent in mouse. Similarly, an intron 1 and intron 9 element common to human and Fugu is absent in mouse. The euryhaline killifish CFTR coding sequence is highly homologous to the Fugu sequence, suggesting that upregulation of CFTR in that species in response to salinity may be regulated transcriptionally.

Vitamin B(1) status assessed by direct measurement of thiamin pyrophosphate in erythrocytes or whole blood by HPLC: comparison with erythrocyte transketolase activation assay

BACKGROUND

The concentration of thiamin diphosphate (TDP) in erythrocytes is a useful index of thiamin status. We describe an HPLC method for TDP and its results in patients at risk of thiamin deficiency.

METHODS

We used reversed-phase HPLC with postcolumn derivatization with alkaline potassium ferricyanide and fluorescence detection. Samples were deproteinized and injected directly onto a C(18) column. TDP concentrations in erythrocytes were compared with those in whole blood. Reference intervals for erythrocyte TDP (n = 147; 79 males and 68 females; mean age, 54 years) and whole blood TDP (n = 124; 68 males and 56 females; mean age, 54 years) were determined in an apparently healthy population. We compared erythrocyte TDP with results of the erythrocyte transketolase activation test in 63 patients who were considered at risk of thiamin deficiency.

RESULTS

The method was linear to at least 200 microgram/L. The between-run CV was <8%. The lower limit of quantification for both whole blood and packed erythrocytes was 300 pg on column with a detection limit of 130 pg on column. Recovery of TDP from blood samples was >90%. TDP in erythrocytes correlated strongly with that in whole blood (r = 0.97). Reference intervals for erythrocyte and whole blood TDP were 280-590 ng/g hemoglobin and 275-675 ng/g hemoglobin, respectively. Of the 63 patients suspected of thiamin deficiency, 46 were normal by both TDP and activation tests, 13 were deficient by both tests, 1 was deficient by the activation test but had normal erythrocyte TDP concentrations, and 4 were normal by the activation test but had low TDP.

CONCLUSIONS

The HPLC method is precise and yields results similar to the erythrocyte activation assay.

Differences in visual attention and task interference between males and females reflect differences in brain laterality

Two cognitive tasks (a letter memory task and a spatial memory task) designed to selectively activate the left or right hemisphere were combined with attentional probe tasks to measure how hemispheric activation affects attention to left and right hemifields. The probe task in Experiment 1 required the identification of digits in the left and right hemifield. During the letter task, male subjects identified more probes from the left hemifield than from the right. Their accuracy varied little across the two hemifields during the dots task. Experiment 2 tested whether this pattern is due to either spatial attention or interference in character processing. Instead of identifying digits, the probe task required subjects to respond to a black square that appeared in the periphery of the screen. For male subjects, the pattern was opposite of that from Experiment 1. During the letter task they responded faster to the probe in the right hemifield than in the left. Their response times were equivalent across the two hemifields during the dots task.These results indicate two separate effects of laterality in male subjects. The activation of one hemisphere produced more attention to the contralateral hemifield in Experiment 2, and the letter memory task interfered with the processing of other characters in the right visual field more than those in the left visual field in Experiment 1. Neither of these effects appeared in female subjects, corroborating earlier claims that female brains are less lateralized than male brains.

Patient satisfaction with care at directly observed therapy programs for tuberculosis in New York City

OBJECTIVES

This study examined patients' satisfaction with New York State's tuberculosis (TB) directly observed therapy (DOT) programs in New York City.

METHODS

A survey was conducted of 435 patients at 19 public, private, and community-based TB DOT clinics about their satisfaction with various aspects of the programs.

RESULTS

Patients identified the opportunity to receive good medical care as the most important aspect of TB DOT. Also significant was the supportiveness of DOT staff. Receiving incentives to encourage participation was statistically less important. Half of the patients reported being better off with DOT than with self-supervised care.

CONCLUSIONS

This study confirms the value of patient-focused care among inner-city TB patients.

Insertion of natural intron 6a-6b into a human cDNA-derived gene therapy vector for cystic fibrosis improves plasmid stability and permits facile RNA/DNA discrimination

BACKGROUND

The gene therapy vector pCMV-CFTR containing human CFTR cDNA shows high segregational instability during growth in Escherichia coli.

METHODS

By host strain screening and optimization of fermentation, satisfactory levels of pCMV-CFTR production were achieved. However, the vector was also vulnerable to structural instability manifested by the appearance during fermentation of a more stable mutant form in which the bacterial insertion sequence IS1 had transposed into exon 7 of plasmidborne CFTR. The instability of pCMV-CFTR is attributable to transcription from an upstream cryptic promoter leading to the production of CFTR peptide fragments known to be toxic when expressed in E. coli. To address this, we inserted the 1.1 kb natural human 6a-6b intron into pCMV-CFTR.

RESULTS

The new vector pCMV-CFTR-int6ab is more stable in E. coli than either pCMV-CFTR or the IS1 mutant, grows to high cell density giving higher DNA yields and expresses CFTR appropriately in transfected cells. Thus, the intron has a stabilizing effect comparable to the IS1 insertion yet retains full functionality for gene therapy. We describe a PCR assay using primers directed to sequences flanking the intron that allows differentiation between DNA and mature mRNA. The T936C mutation present only in vector DNA has also been exploited to allow transgene CFTR to be distinguished and its dose-dependent expression to be detected in human cellular backgrounds.

CONCLUSIONS

Instability of a plasmid vector for gene therapy has been minimized by rational modification. The introduction of an intron for this purpose offers the additional advantage of providing a discriminatory RT-PCR assay.

pSURF-2, a modified BAC vector for selective YAC cloning and functional analysis

A modified bacterial artificial chromosome (BAC) vector, pSURF-2, adapted for the selective subcloning of yeast artificial chromosome (YAC) sequences was constructed. DH10B-U, a pyrF derivative of the highly transformable E. coli strain DH10B was also constructed and used for the detection of Ura+ recombinants carrying DNA linked to YAC right arms. The vector's properties were illustrated in two main ways. (i) An intact 25-kb YAC containing a mouse tyrosinase minigene was cloned into pSURF-2. Appropriately spliced tyrosinase RNA was detected by reverse transcription (RT)-PCR in extracts of cells transiently lipofected with the cloned YAC. (ii) Cells expressing human cystic fibrosis transmembrane conductance regulator (CFTR) from an integrated pSURF-2 recombinant containing a cDNA expression cassette were selected using the hygromycin-resistance (HyTK) marker of the vector and characterized by RT-PCR and immunoprecipitation. The unique I-SceI site and HyTK marker of pSURF-2 are designed to facilitate subsequent functional studies of cloned DNA.

Elimination of contaminant Escherichia coli chromosomal DNA from preparations of P1 artificial chromosome recombinants facilitates directed subcloning

The subcloning of large inserts (>50 kbp) from P1-derived artificial chromosomes (PACs) was found to be hindered by the presence of contaminating Escherichia coli chromosomal fragments which, because of their smaller median size, are recovered preferentially as unwanted subclones. A significant fraction of contaminating DNA was seen to persist after conventional plasmid purification methods. We describe a rigorous protocol for eliminating the bulk of contamination that involves plasmid isolation on commercially available silica-based columns followed by three pulsed field gel electrophoresis steps. Using this, we were able to subclone 55, 85 and 90 kbp PAC inserts but failed to subclone a 195 kbp PAC insert. After surveying a range of DNA purification methods, we devised an optimised protocol that allowed us to subclone the 195 kbp insert. The optimised protocol, which reliably yields DNA with essentially no contaminating material, consists of plasmid isolation on silica-based columns followed by treatment with highly purified DNaseI and retrieval by electroelution of restriction-digested DNA electrophoresed on a single pulsed field gel. By inference it is applicable to the purification of large inserts from other single-copy plasmid vectors such as bacterial artificial chromosomes (BACs).

The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses

OBJECTIVES

Among the consequences of downsizing and cost containment in hospitals are major changes in the work life of nurses. As hospitals become smaller, patient acuity rises, and the job of nursing becomes more technical and difficult. This article examines the effects of changes in the hospital environment on nurses' job satisfaction and voluntary turnover between 1993 and 1994.

METHODS

Data were collected in a longitudinal survey of 736 hospital nurses in one hospital to examine correlates of change in aspects of job satisfaction and predictors of leaving among nurses who terminated in that period.

RESULTS

Unadjusted results showed decline in most aspects of satisfaction as measured by Hinshaw and Atwood's and Price and Mueller's scales. Multivariate analysis indicated that the most important determinants of low satisfaction were poor instrumental communication within the organization and too great a workload. Intent to leave was predicted by the perception of little promotional opportunity, high routinization, low decision latitude, and poor communication. Predictors of turnover were fewer years on the job, expressed intent to leave, and not enough time to do the job well.

CONCLUSIONS

The authors conclude that although many aspects of job satisfaction are diminished, some factors predicting low satisfaction and turnover may be amenable to change by hospital administrators.

Help clients develop hopes for the future

The purposes of this article are (a) to examine cognitive, emotional, and spiritual aspects of hope as reflected in the literature; (b) to describe three clinical approaches that have been used in occupational therapy to engage clients in development of hopes for the future; and (c) to consider practical issues that have been raised by therapists seeking to incorporate development of hopes in their practice. Literature from health care and the social sciences indicates that cognitive, emotional, and spiritual aspects of hope are interwoven in a complex process that evolves over time after major loss. Three alternative clinical strategies for collaborating with clients in developing hopes are reviewed, including a goal-setting and goal-attainment approach, an occupational change approach, and a life history approach. These clinical strategies are illustrated by the stories of an elderly mental health client, an adult rehabilitation client, and an adolescent orthopedic client, which are drawn from research in which the authors have been involved. Discussion of issues involved in incorporating hope work into daily practice is based on the experiences of practicing therapists who participated in a workshop. These include pragmatic issues of documentation and reimbursement of this aspect of practice as well as clinical issues of how to develop hopes among clients who appear hopeless.

Evidence for safety and efficacy of DOTAP cationic liposome mediated CFTR gene transfer to the nasal epithelium of patients with cystic fibrosis

In cystic fibrosis (CF), mutation of the cystic fibrosis transmembrane conductance regulator (CFTR) gene results in defective transepithelial ion transport, leading to life shortening inflammatory lung disease. Before lung studies, we tested the safety and efficacy of gene delivery to the nasal epithelium of CF patients using pCMV-CFTR-DOTAP cationic liposome complex. A single dose of 400 micrograms pCMV-CFTR:2.4 mg DOTAP was administered in a randomised, double-blinded fashion to the nasal epithelium of eight CF patients, with a further eight receiving buffer only. Patients were monitored for signs and symptoms for 2 weeks before treatment and 4 weeks after treatment. Inflammatory cells were quantified in a nasal biopsy taken 3 days after treatment. There was no evidence for excess nasal inflammation, circulating inflammatory markers or other adverse events ascribable to active treatment. Gene transfer and expression were assayed by the polymerase chain reaction. Transgene DNA was detected in seven of the eight treated patients up to 28 days after treatment and vector derived CFTR mRNA in two of the seven patients at +3 and +7 days. Transepithelial ion transport was assayed before and after treatment by nasal potential difference during drug perfusion and by SPQ fluorescence halide ion conductance. Partial, sustained correction of CFTR-related functional changes toward normal values were detected in two treated patients. The level of gene transfer and functional correction were comparable to those reported previously using adenoviral vectors or another DNA-liposome complex, but here were sustained and uncompromised by false positives. These results justify further studies with pCMV-CFTR-DOTAP aimed at treating CF lung disease.

Laboratory and clinical studies in support of cystic fibrosis gene therapy using pCMV-CFTR-DOTAP

The first phase I study of cystic fibrosis gene therapy using cationic liposomes to deliver the cystic fibrosis conductance regulator gene to the nose reported partial and transient correction of the nasal transepithelial ion transport defect, While encouraging, further improvements will be required if this form of treatment is to be of therapeutic value. We tested a new formulation, pCMV-CFTR-DOTAP. The complex is stable for 10 days and effective at correcting the electrophysiological deficit in the trachea of CF mutant mice at 8 or 9 days after intratracheal instillation. Reliable protocols for consistent detection of as few as 10 molecules of CFTR mRNA and DNA in nasal brushing samples are described, Both vector and DNA have been produced to Good Manufacturing Practice standard, Nasal potential difference measurements developed at the National Heart and Lung Institute to assess the CFTR ion channel activity in CF patients replicated well at the Scottish Adult Cystic Fibrosis Service. The SPO fluorescence assay for halide ion conductance in nasal brushings has also been tested. These establish baseline conditions in the Scottish CF cohort from which evidence for correction can be judged under clinical trial conditions. These studies formed the basis for regulatory approval of a randomised, placebo controlled double-blind phase I research study.

Medicaid-funded home care for the frail elderly and disabled: evaluating the cost savings and outcomes of a service delivery reform

OBJECTIVES

In response to rising demand and increased costs for home care services for frail elderly and disabled Medicaid clients, New York City implemented cluster care, a shared-aide model of home care. Our objective: to evaluate the effects of cluster care on home care hours and costs, client functioning, depressive symptoms, and satisfaction.

DATA SOURCES

Client interviews, conducted prior to implementation and again 16 months later; Medicaid claims records; home attendant payroll files; and vendor agency records.

STUDY DESIGN

The study employed a pretest/posttest design, comparing 229 clients at the first seven demonstration sites to 175 clients at four comparison sites before and after cluster care implementation. Regression methods were used to analyze pre and post-intervention data.

PRINCIPAL FINDINGS

Cluster care reduced costs by about 10 percent. Most savings occurred among the more vulnerable clients (those with five or more ADL/IADL limitations). Clients at cluster care sites who started out with fewer than five limitations appeared to decline somewhat more slowly than similarly impaired clients at comparison sites, while those with more than five ADL/IADLs tended to decline more rapidly. This difference was small-less than one limitation per year. Cluster care is associated with a significant decline in satisfaction but appears unrelated to depressive symptoms.

CONCLUSIONS

Cluster care appears benign for home care clients with fewer limitations. For the more vulnerable, we recommend experimentation with low-cost interventions that might augment service and improve outcomes without reverting to traditional one-on-one care.

Effects of changes in acid base and calcium concentration on fasting serum insulin, proinsulin, and glucose concentrations

AIMS

To test the hypothesis that alterations in acid base or calcium concentration may affect proinsulin processing or the insulin secretion mechanism.

METHODS

Changes in proinsulin secretion or cleavage were assessed by measuring serum intact proinsulin and immunoreactive insulin concentrations in three models of acid base and calcium disturbance: (1) subacute changes in acid base status in six volunteers who received oral placebo, ammonium chloride, or sodium bicarbonate for three five day periods; (2) acute changes in calcium concentration in eight subjects who received 25 mmol oral calcium; (3) chronic changes in calcium concentration in seven patients with primary hyperparathyroidism and five with pseudohypoparathyroidism.

RESULTS

Acid base changes were confirmed by rises in serum bicarbonate concentrations (p < 0.01). No changes in serum insulin, intact proinsulin, or the proinsulin:insulin molar ratio were found. Serum calcium concentrations increased (2.49 v 2.38 mmol/l; p < 0.05) and parathyroid hormone concentrations decreased (1.1 v 1.9 pmol/l; p < 0.01) two hours after acute calcium loading. There were no significant differences in serum glucose, insulin, or intact proinsulin concentrations. Fasting proinsulin concentrations were significantly lower in the hyperparathyroid group (1.1 v 2.1 pmol/l; p < 0.05) and increased significantly after parathyroidectomy (2.1 v 1.1 pmol/l; p < 0.05).

CONCLUSIONS

The results indicate that subacute acid base changes do not affect proinsulin cleavage. Although acute calcium loading has no demonstrable effect, chronic hypercalcaemia may influence the mechanism of insulin secretion.

Measuring depressive symptoms in the frail elderly

To determine the usefulness of the Center for Epidemiological Studies Depression Scale (CES-D) as a measure of depressive symptoms among frail and disabled elderly, we conducted a first- and second-order confirmatory factor analysis testing the four-factor structure of the CES-D and the existence of a single underlying second-order factor. We also examined the relative contribution of the somatic factor of the total symptom score, and relationships of age, race, functional status, and health with the four factors. We found that the factor structure is replicated when used with frail elderly, and scores are not distorted by the disproportionate influence of somatic items. Age and health do not affect the somatic subscale more than the other three subscales. Functional limitations are associated with higher somatic scores. We conclude that the CES-D is an appropriate tool to measure depressive symptoms in frail elderly.

The role of general hospitals in the privatization of inpatient treatment for serious mental illness

For almost three decades, many have regarded general hospital psychiatric units as the most appropriate setting for acute treatment of persons with serious mental illness who were once treated mostly in state hospitals. The extent to which this transfer has taken place and the differences between public and private general hospitals have been unclear. Using data from the 1988 National Mental Health Facilities Study and published data from the 1970s, the authors found that nearly half of all general hospitals providing psychiatric services treat persons with serious mental illness. Significant differences in case and payer mix were observed between public and private general hospitals, although these differences were smaller than in the 1970s. The findings suggest increased involvement by private general hospitals in treating patients reimbursed by public payers, but the findings also indicate that persons with serious mental illness and those using Medicaid are still more prevalent in public general hospitals than in private ones.

Consolidation hemibody radiotherapy following induction combination chemotherapy in high-tumor-burden multiple myeloma

PURPOSE

Curative therapy for multiple myeloma continues to be an elusive goal. This report discusses the Northern California Oncology Group (NCOG) phase I and II trial in high-tumor-burden disease that used a strategy that consisted of induction chemotherapy (vincristine, melphalan, cyclophosphamide, and prednisone [VMCP]) for eight cycles followed by sequential hemibody radiation therapy (RT) and subsequent chemotherapy for an additional eight cycles.

PATIENTS AND METHODS

Seventy-two previously untreated stage III myeloma patients were entered onto the study. Sixty-nine received induction chemotherapy, 40 received induction chemotherapy and hemibody RT, and 23 received induction chemotherapy, hemibody RT, and consolidative chemotherapy.

RESULTS

Twenty-two complete responses (CRs) were obtained by induction chemotherapy, with four additional CRs after RT and consolidative chemotherapy. Nineteen patients developed grade 4 hematologic toxicity primarily after upper hemibody RT. Eight of these developed long-standing neutropenia or thrombocytopenia. Median survival of the group was 134 weeks, which was not significantly different from other approaches.

CONCLUSIONS

Hemibody RT can be combined with chemotherapy as induction therapy and can be safely administered in a community setting. However, as administered here no survival advantage was demonstrated.

Treatment of malignant Leydig cell tumor

Malignant Leydig cell tumors (LCT) are rare. Only 32 cases of malignant LCT (as evidenced by metastatic spread) were reported. Generally metastatic spread occurs within 2 years of the primary LCT, and the patient dies within 2 years of the discovery of metastatic disease. The tumor is highly resistant to both radiation and chemotherapy. It also has a great propensity for recurring after surgical resection. A case is reported of a patient whose metastatic disease occurred 8 years after his primary LCT had been resected. He was treated with doxorubicin and mitotane without response. The clinical features of this case are highlighted, and a review of the literature describing treatment of this rare disease is presented.

Contracting between public agencies and private psychiatric inpatient facilities

Purchasing human services through contracts with private providers has become an increasingly common practice over the past 20 years. Using data from a national survey of psychiatric inpatient facilities, this paper examines the extent to which psychiatric units in privately controlled general hospitals and private psychiatric specialty hospitals (N = 611) participate in contractual arrangements to provide services to governmental bodies. It also examines how the likelihood of such a practice is affected by hospital characteristics (general or specialty, for profit or nonprofit) and features of hospitals' environments, including the competitiveness of the market for psychiatric inpatient care and the population's need for services in the hospital's county. The findings indicate that nonprofit psychiatric specialty hospitals were more likely than other types of hospitals to enter into such contracts, and that forces such as local competition and need for services were not predictors of such involvement. Contracting was shown to have a significant impact on the level of referrals a hospital accepted, but these levels were also affected by competition and need. Among hospitals with public contracts, referral acceptance from public agencies was unaffected by these factors, but they did have a significant effect on referral acceptance by hospitals without public contracts. These data suggest that public agencies contracting for services with private hospitals may represent a means by which "public sector" patients may gain access to private providers. Further, this mechanism may impose sufficient structure and regulation on the acceptance of such patients that many concerns of hospital administrators regarding patients who are costly and difficult to treat and discharge can be allayed.

A national study of psychiatric hospital care

BACKGROUND

The delivery system for psychiatric inpatient services in the United States has changed dramatically over the past 30 years, undergoing a marked privatization.

METHOD

To assess the effect of changes in ownership and types of inpatient settings on the structure of the mental health services system, the authors surveyed a national sample of nonfederal mental health facilities in 1988.

RESULTS

Comparing their data to those of earlier surveys, they found that a decline in the number of patients per staff occurred in most settings over the last decade, suggesting that this aspect of quality of care may have improved. They observed important ownership-related differences in 1988 in diagnostic mix (e.g., more schizophrenia treated in public facilities than in private ones) and in payer source (e.g., more third-party revenues in public facilities than occurred in the past).

CONCLUSIONS

There was a significant interaction between ownership form and type of facility, suggesting that the type of inpatient setting, ownership, and the relation between the two should be considered in assessing the impact of privatization on the accessibility of health care available for the mentally ill. The authors found that the increase in private psychiatric hospitals has widened the availability and choice of treatment facilities for those with private funding sources (especially children and adolescents) but has not had a similar effect in increasing sources of care for the seriously mentally ill dependent upon public financing.

Physical symptoms and the interplay of work and family roles

The paradigm underlying research on the relationship between work and physical-health symptoms in men has focused on workplace stressors and has ignored men's family roles. Research on women, work, and health suggests several necessary additions to this paradigm, including (a) a focus on job rewards and job concerns and (b) attention to the impact of family roles on the relationship between job rewards and concerns and physical health. We included these variables in a study of a disproportionate random sample of 403 employed 25- to 55-year-old women. Major findings are that (a) work rewards (e.g., helping others at work) are related to reports of low levels of physical symptoms; (b) work concerns (e.g., overload) are associated with reports of high levels of physical symptoms; (c) particular work rewards, which may be different for women than for men, mitigate the negative health effects of work concerns; (d) among employed mothers, satisfaction with salary is negatively related to physical-health symptoms; and (e) women in positive marriages or partnerships were more likely to reap physical-health benefits from the rewards of helping others at work and from supervisor support.

Cryosurgery for treatment of recurrent proliferative keratoconjunctivitis in five dogs

Cryosurgery was used for treatment of recurrent proliferative keratoconjunctivitis in 5 dogs that had been treated with combined medical and surgical procedures without success. Four dogs recovered completely after one application of cryosurgery. The fifth dog did not respond to cryosurgery until after oral administration of corticosteroids was stopped, indicating a possible immune-mediated mechanism of action of cryosurgery on proliferative keratoconjunctivitis.

Spinal computed tomography and computed tomographic metrizamide myelography in the early diagnosis of metastatic disease

New lesions were shown by Tc99m bone scans to have developed in sixty patients with known metastatic cancer or high-risk primary cancer and normal neurologic examinations; they were further evaluated with plain radiographs, spinal computed tomography (CT), and CT myelography (CT-M) according to an algorithm. Three groups were identified based on plain radiographs: group 1 (normal radiograph), group 2 (compression fracture as indicated by radiograph), group 3 (evidence of metastasis as indicated by radiograph). In group 1 (n = 18), spinal CT revealed that 33% of the patients had benign disease and 67%, metastases; epidural compression was seen in 25% of the patients with metastasis as indicated by CT-M. In group 2 (n = 26), CT-M disclosed that 38% had a benign compression fracture and 62% had metastases and that 63% of the patients with metastases had an epidural compression. In group 3 (n = 16), spinal CT revealed that 15 patients had metastases (one patient had benign disease). Epidural cord compression was seen in 47% of the patients with metastatic disease. In all groups, the presence of cortical bone discontinuity around the neural canal (seen in 31 patients) was highly associated with epidural compression (seen in 20 patients). Our approach allowed the early and accurate diagnosis of spinal metastasis and epidural tumor as well as the diagnosis of benign disease and was useful in planning optimal local therapy.

Lack of comparability between CEA analyses using three different methods

Three different methods for the assay of carcinoembryonic antigen were investigated--radioimmunoassay, enzyme-linked immunoassay, and a commercial immunoradiometric assay. Two standard preparations of CEA were used: the 1st British Standard (73/601) and a commercial preparation obtained as a component of the IRMA kit. Serum samples were assayed by each method against each standard material. Significant differences between results were obtained when the different methods were compared. When using the two standards in the same assay system no significant differences were found between results. A possible explanation and the implications of these findings for the routine assay of CEA are discussed.