Reversing immunosuppression in the tumor microenvironment of fibrolamellar carcinoma via PD-1 and IL-10 blockade

Fibrolamellar carcinoma (FLC) is a rare liver tumor driven by the DNAJ-PKAc fusion protein that affects healthy young patients. Little is known about the immune response to FLC, limiting rational design of immunotherapy. Multiplex immunohistochemistry and gene expression profiling were performed to characterize the FLC tumor immune microenvironment and adjacent non-tumor liver (NTL). Flow cytometry and T cell receptor (TCR) sequencing were performed to determine the phenotype of tumor-infiltrating immune cells and the extent of T cell clonal expansion. Fresh human FLC tumor slice cultures (TSCs) were treated with antibodies blocking programmed cell death protein-1 (PD-1) and interleukin-10 (IL-10), with results measured by cleaved caspase-3 immunohistochemistry. Immune cells were concentrated in fibrous stromal bands, rather than in the carcinoma cell compartment. In FLC, T cells demonstrated decreased activation and regulatory T cells in FLC had more frequent expression of PD-1 and CTLA-4 than in NTL. Furthermore, T cells had relatively low levels of clonal expansion despite high TCR conservation across individuals. Combination PD-1 and IL-10 blockade signficantly increased cell death in human FLC TSCs. Immunosuppresion in the FLC tumor microenvironment is characterized by T cell exclusion and exhaustion, which may be reversible with combination immunotherapy.

Identification of pan-cancer/testis genes and validation of therapeutic targeting in triple-negative breast cancer: Lin28a-based and Siglece-based vaccination induces antitumor immunity and inhibits metastasis

BACKGROUND

Cancer-testis (CT) genes are targets for tumor antigen-specific immunotherapy given that their expression is normally restricted to the immune-privileged testis in healthy individuals with aberrant expression in tumor tissues. While they represent targetable germ tissue antigens and play important functional roles in tumorigenesis, there is currently no standardized approach for identifying clinically relevant CT genes. Optimized algorithms and validated methods for accurate prediction of reliable CT antigens (CTAs) with high immunogenicity are also lacking.

METHODS

Sequencing data from the Genotype-Tissue Expression (GTEx) and The Genomic Data Commons (GDC) databases was used for the development of a bioinformatic pipeline to identify CT exclusive genes. A CT germness score was calculated based on the number of CT genes expressed within a tumor type and their degree of expression. The impact of tumor germness on clinical outcome was evaluated using healthy GTEx and GDC tumor samples. We then used a triple-negative breast cancer mouse model to develop and test an algorithm that predicts epitope immunogenicity based on the identification of germline sequences with strong major histocompatibility complex class I (MHCI) and MHCII binding affinities. Germline sequences for CT genes were synthesized as long synthetic peptide vaccines and tested in the 4T1 triple-negative model of invasive breast cancer with Poly(I:C) adjuvant. Vaccine immunogenicity was determined by flow cytometric analysis of in vitro and in vivo T-cell responses. Primary tumor growth and lung metastasis was evaluated by histopathology, flow cytometry and colony formation assay.

RESULTS

We developed a new bioinformatic pipeline to reliably identify CT exclusive genes as immunogenic targets for immunotherapy. We identified CT genes that are exclusively expressed within the testis, lack detectable thymic expression, and are significantly expressed in multiple tumor types. High tumor germness correlated with tumor progression but not with tumor mutation burden, supporting CTAs as appealing targets in low mutation burden tumors. Importantly, tumor germness also correlated with markers of antitumor immunity. Vaccination of 4T1 tumor-bearing mice with Siglece and Lin28a antigens resulted in increased T-cell antitumor immunity and reduced primary tumor growth and lung metastases.

CONCLUSION

Our results present a novel strategy for the identification of highly immunogenic CTAs for the development of targeted vaccines that induce antitumor immunity and inhibit metastasis.

Emerging interleukin targets in the tumour microenvironment: implications for the treatment of gastrointestinal tumours

The effectiveness of antitumour immunity is dependent on intricate cytokine networks. Interleukins (ILs) are important mediators of complex interactions within the tumour microenvironment, including regulation of tumour-infiltrating lymphocyte proliferation, differentiation, migration and activation. Our evolving and increasingly nuanced understanding of the cell type-specific and heterogeneous effects of IL signalling has presented unique opportunities to fine-tune elaborate IL networks and engineer new targeted immunotherapeutics. In this review, we provide a primer for clinicians on the challenges and potential of IL-based treatment. We specifically detail the roles of IL-2, IL-10, IL-12 and IL-15 in shaping the tumour-immune landscape of gastrointestinal malignancies, paying particular attention to promising preclinical findings, early-stage clinical research and innovative therapeutic approaches that may properly place ILs to the forefront of immunotherapy regimens.

Identification of pan-cancer/testis genes and validation of therapeutic targeting in triple-negative breast cancer: Lin28a- and Siglece-based vaccination induces anti-tumor immunity and inhibits metastasis

Background

Cancer-testis (CT) genes are targets for tumor antigen-specific immunotherapy given that their expression is normally restricted to the immune-privileged testis in healthy individuals with aberrant expression in tumor tissues. While they represent targetable germ-tissue antigens and play important functional roles in tumorigenesis, there is currently no standardized approach for identifying clinically relevant CT genes. Optimized algorithms and validated methods for accurate prediction of reliable CT antigens with high immunogenicity are also lacking.

Methods

Sequencing data from the Genotype-Tissue Expression (GTEx) and The Genomic Data Commons (GDC) databases was utilized for the development of a bioinformatic pipeline to identify CT exclusive genes. A CT germness score was calculated based on the number of CT genes expressed within a tumor type and their degree of expression. The impact of tumor germness with clinical outcome was evaluated using healthy GTEx and GDC tumor samples. We then used a triple-negative breast cancer mouse model to develop and test an algorithm that predicts epitope immunogenicity based on the identification of germline sequences with strong MHCI and MHCII binding affinities. Germline sequences for CT genes were synthesized as long synthetic peptide vaccines and tested in the 4T1 triple-negative model of invasive breast cancer with Poly(I:C) adjuvant. Vaccine immunogenicity was determined by flow cytometric analysis of in vitro and in vivo T cell responses. Primary tumor growth and lung metastasis was evaluated by histopathology, flow cytometry and colony formation assay.

Results

We developed a new bioinformatic pipeline to reliably identify CT exclusive genes as immunogenic targets for immunotherapy. We identified CT genes that are exclusively expressed within the testis, lack detectable thymic expression, and are significantly expressed in multiple tumor types. High tumor germness correlated with tumor progression but not with tumor mutation burden, supporting CT antigens as appealing targets in low mutation burden tumors. Importantly, tumor germness also correlated with markers of anti-tumor immunity. Vaccination of 4T1 tumor bearing mice with Siglece and Lin28a antigens resulted in increased T cell anti-tumor immunity and reduced primary tumor growth and lung metastases.

Conclusion

Our results present a novel strategy for the identification of highly immunogenic CT antigens for the development of targeted vaccines that induce anti-tumor immunity and inhibit metastasis.

Blockade of interleukin 10 potentiates antitumour immune function in human colorectal cancer liver metastases

OBJECTIVE

Programmed cell death protein 1 (PD-1) checkpoint inhibition and adoptive cellular therapy have had limited success in patients with microsatellite stable colorectal cancer liver metastases (CRLM). We sought to evaluate the effect of interleukin 10 (IL-10) blockade on endogenous T cell and chimeric antigen receptor T (CAR-T) cell antitumour function in CRLM slice cultures.

DESIGN

We created organotypic slice cultures from human CRLM (n=38 patients' tumours) and tested the antitumour effects of a neutralising antibody against IL-10 (αIL-10) both alone as treatment and in combination with exogenously administered carcinoembryonic antigen (CEA)-specific CAR-T cells. We evaluated slice cultures with single and multiplex immunohistochemistry, in situ hybridisation, single-cell RNA sequencing, reverse-phase protein arrays and time-lapse fluorescent microscopy.

RESULTS

αIL-10 generated a 1.8-fold increase in T cell-mediated carcinoma cell death in human CRLM slice cultures. αIL-10 significantly increased proportions of CD8⁺ T cells without exhaustion transcription changes, and increased human leukocyte antigen - DR isotype (HLA-DR) expression of macrophages. The antitumour effects of αIL-10 were reversed by major histocompatibility complex class I or II (MHC-I or MHC-II) blockade, confirming the essential role of antigen presenting cells. Interrupting IL-10 signalling also rescued murine CAR-T cell proliferation and cytotoxicity from myeloid cell-mediated immunosuppression. In human CRLM slices, αIL-10 increased CEA-specific CAR-T cell activation and CAR-T cell-mediated cytotoxicity, with nearly 70% carcinoma cell apoptosis across multiple human tumours. Pretreatment with an IL-10 receptor blocking antibody also potentiated CAR-T function.

CONCLUSION

Neutralising the effects of IL-10 in human CRLM has therapeutic potential as a stand-alone treatment and to augment the function of adoptively transferred CAR-T cells.

Transcriptomic diversity in human medullary thymic epithelial cells

The induction of central T cell tolerance in the thymus depends on the presentation of peripheral self-epitopes by medullary thymic epithelial cells (mTECs). This promiscuous gene expression (pGE) drives mTEC transcriptomic diversity, with non-canonical transcript initiation, alternative splicing, and expression of endogenous retroelements (EREs) representing important but incompletely understood contributors. Here we map the expression of genome-wide transcripts in immature and mature human mTECs using high-throughput 5' cap and RNA sequencing. Both mTEC populations show high splicing entropy, potentially driven by the expression of peripheral splicing factors. During mTEC maturation, rates of global transcript mis-initiation increase and EREs enriched in long terminal repeat retrotransposons are up-regulated, the latter often found in proximity to differentially expressed genes. As a resource, we provide an interactive public interface for exploring mTEC transcriptomic diversity. Our findings therefore help construct a map of transcriptomic diversity in the healthy human thymus and may ultimately facilitate the identification of those epitopes which contribute to autoimmunity and immune recognition of tumor antigens.

Impact of serological and PCR testing requirements on the selection of COVID-19 convalescent plasma donors

BACKGROUND

Convalescent plasma is undergoing randomized trials as a potential therapeutic option for COVID-19 infection. Little empirical evidence exists regarding the determination of donor eligibility and experiences with donor selection.

STUDY DESIGN AND METHODS

This prospective study was conducted at a tertiary care hospital in New York to select plasma donors for a randomized, double-blind, controlled convalescent plasma trial. Clearance for donation required successful completion of an online questionnaire and an in-person screening visit, which included (a) completion of a Donor Health Questionnaire (DHQ), (b) Immunoglobulin G (IgG) antibody testing using an immunochromatographic anti- severe acute respiratory coronavirus 2 (SARS-CoV-2) test, (c) Polymerase chain reaction (PCR) testing if <28 days from symptom resolution, and (d) routine blood bank testing.

RESULTS

After receiving 3093 online questionnaires, 521 individuals presented for in-person screening visits, with 40.1% (n = 209) fully qualifying. Subjects (n = 312) failed to progress due to the following reasons: disqualifying answer from DHQ (n = 30, 9.6%), insufficient antibodies (n = 198, 63.5%), persistent positive PCR tests (n = 14, 4.5%), and blood donation testing labs (n = 70, 22.4%). Importantly, 24.6% and 11.1% of potential donors who reported having PCR-diagnosed infection had low or undetectable SARS-CoV-2 antibody levels, respectively. Surprisingly, 62.9% (56/89) of subjects had positive PCR tests 14-27 days after symptom resolution, with 13 individuals continuing to be PCR positive after 27 days.

CONCLUSION

It is feasible for a single site to fully qualify a large number of convalescent plasma donors in a short period of time. Among otherwise qualified convalescent plasma donors, we found high rates of low or undetectable antibody levels and many individuals with persistently positive PCR tests.

Bayesian Inference of Allelic Inclusion Rates in the Human T Cell Receptor Repertoire

A small population of αβ T cells is characterized by the expression of more than one unique T cell receptor (TCR); this outcome is the result of "allelic inclusion," that is, inclusion of both α- or β-chain alleles during V(D)J recombination. Limitations in single-cell sequencing technology, however, have precluded comprehensive enumeration of these dual receptor T cells. Here, we develop and experimentally validate a fully Bayesian inference model capable of reliably estimating the true rate of α and β TCR allelic inclusion across two different emulsion-barcoding single-cell sequencing platforms. We provide a database composed of over 51,000 previously unpublished allelic inclusion TCR sequence sets drawn from eight healthy individuals and show that allelic inclusion contributes a distinct and functionally important set of sequences to the human TCR repertoire. This database and a Python implementation of our statistical inference model are freely available at our Github repository (https://github.com/JasonACarter/Allelic_inclusion).

Single T Cell Sequencing Demonstrates the Functional Role of αβ TCR Pairing in Cell Lineage and Antigen Specificity

Although structural studies of individual T cell receptors (TCRs) have revealed important roles for both the α and β chain in directing MHC and antigen recognition, repertoire-level immunogenomic analyses have historically examined the β chain alone. To determine the amount of useful information about TCR repertoire function encoded within αβ pairings, we analyzed paired TCR sequences from nearly 100,000 unique CD4+ and CD8+ T cells captured using two different high-throughput, single-cell sequencing approaches. Our results demonstrate little overlap in the healthy CD4+ and CD8+ repertoires, with shared TCR sequences possessing significantly shorter CDR3 sequences corresponding to higher generation probabilities. We further utilized tools from information theory and machine learning to show that while α and β chains are only weakly associated with lineage, αβ pairings appear to synergistically drive TCR-MHC interactions. Vαβ gene pairings were found to be the TCR feature most informative of T cell lineage, supporting the existence of germline-encoded paired αβ TCR-MHC interaction motifs. Finally, annotating our TCR pairs using a database of sequences with known antigen specificities, we demonstrate that approximately a third of the T cells possess α and β chains that each recognize different known antigens, suggesting that αβ pairing is critical for the accurate inference of repertoire functionality. Together, these findings provide biological insight into the functional implications of αβ pairing and highlight the utility of single-cell sequencing in immunogenomics.

Dynamics of Mouth Opening in Hydra

Hydra, a simple freshwater animal famous for its regenerative capabilities, must tear a hole through its epithelial tissue each time it opens its mouth. The feeding response of Hydra has been well-characterized physiologically and is regarded as a classical model system for environmental chemical biology. However, due to a lack of in vivo labeling and imaging tools, the biomechanics of mouth opening have remained completely unexplored. We take advantage of the availability of transgenic Hydra lines to perform the first dynamical analysis, to our knowledge, of Hydra mouth opening and test existing hypotheses regarding the underlying cellular mechanisms. Through cell position and shape tracking, we show that mouth opening is accompanied by changes in cell shape, but not cellular rearrangements as previously suggested. Treatment with a muscle relaxant impairs mouth opening, supporting the hypothesis that mouth opening is an active process driven by radial contractile processes (myonemes) in the ectoderm. Furthermore, we find that all events exhibit the same relative rate of opening. Because one individual can open consecutively to different amounts, this suggests that the degree of mouth opening is controlled through neuronal signaling. Finally, from the opening dynamics and independent measurements of the elastic properties of the tissues, we estimate the forces exerted by the myonemes to be on the order of a few nanoNewtons. Our study provides the first dynamical framework, to our knowledge, for understanding the remarkable plasticity of the Hydra mouth and illustrates that Hydra is a powerful system for quantitative biomechanical studies of cell and tissue behaviors in vivo.

An Innovative Approach to Pharmacy Law Education Utilizing a Mock Board of Pharmacy Meeting

A thorough understanding of pharmacy law by students is important in the molding of future pharmacy practitioners but a standardized template for the best way to educate students in this area has not been created. A mock Board of Pharmacy meeting was designed and incorporated into the Pharmacy Law course to meet the ACPE accreditation standards at the University of Tennessee College of Pharmacy. Students acted as Board of Pharmacy members and utilized technology to decide outcomes of cases and requests addressed in a typical 2 day Tennessee Board of Pharmacy meeting. The actual responses to those cases, as well as similar cases and requests addressed over a 5 year period, were revealed to students after they made motions on mock scenarios. Student participation in this interactive learning experience resulted in good understanding of the rules and regulations of pharmacy practice and the consequences associated with violating regulations. Such mock Board of Pharmacy meeting is recommended for future pharmacy law education.

Furosemide as a potential unintended urine drug screen confounder during methadone maintenance treatment

Patients receiving chronic methadone maintenance treatment (MMT) for addiction are closely monitored for signs of relapse. Urine drug screen (UDS) comprises a major component of ongoing patient assessment. As patients continue with MMT, developing medical conditions may necessitate addition of medications that interfere with UDS. Although widely accepted as masking agents, little guidance is available regarding management of patients receiving MMT with legitimate medical need for diuretics. The following describes a case in which furosemide clinically interfered with UDS interpretation for a patient receiving MMT. Potential management strategies are also discussed.

Cost effectiveness of zoledronic acid in the management of skeletal metastases in hormone-refractory prostate cancer patients in France, Germany, Portugal, and the Netherlands

OBJECTIVE

Zoledronic acid (ZOL) reduces the risk of skeletal related events (SREs) in hormone-refractory prostate cancer (HRPC) patients with bone metastases. This study assessed the cost effectiveness of ZOL for SRE management in French, German, Portuguese, and Dutch HRPC patients.

METHODS

This analysis was based on the results of a randomized phase III clinical trial wherein HRPC patients received up to 15 months of ZOL (n = 214) or placebo (n = 208). Clinical inputs were obtained from the trial. Costs were estimated using hospital tariffs, published, and internet sources. Quality adjusted life-years (QALYs) gained were estimated from a separate analysis of EQ-5D scores reported in the trial. Uncertainty surrounding outcomes was addressed via univariate sensitivity analyses.

RESULTS

ZOL patients experienced an estimated 0.759 fewer SREs and gained an estimated 0.03566 QALYs versus placebo patients. ZOL was associated with reduced SRE-related costs [net costs] (-€2396 [€1284] in France, -€2606 [€841] in Germany, -€3326 [€309] in Portugal and -€3617 [€87] in the Netherlands). Costs per QALY ranged from €2430 (Netherlands) to €36,007 (France).

CONCLUSIONS

This analysis is subject to the limitations of most cost-effectiveness analyses: it combines data from multiple sources. Nevertheless, the results strongly suggest that ZOL is cost effective versus placebo in French, German, Portuguese, and Dutch HRPC patients.

Treatment of the first known case of king cobra envenomation in the United Kingdom, complicated by severe anaphylaxis

We report the first known case of envenomation following snake bite by a king cobra in the UK. The patient required tracheal intubation and ventilation. Treatment with king cobra antivenom resulted in anaphylaxis (bronchospasm and hypotension), requiring adrenaline infusion. The patient's trachea was extubated 11 h after administration of antivenom.

Risk factors for persisting neurological and cognitive impairments following cerebral malaria

BACKGROUND

Persisting neurological and cognitive impairments are common after cerebral malaria. Although risk factors for gross deficits on discharge have been described, few studies have examined those associated with persistent impairments.

METHODS

The risk factors for impairments following cerebral malaria were determined by examining hospital records of 143 children aged 6-9 years, previously admitted with cerebral malaria, who were assessed at least 20 months after discharge to detect motor, speech and language, and other cognitive (memory, attention, and non-verbal functioning) impairments.

RESULTS

The median age on admission was 30 months (IQR 19-42) and the median time from discharge to assessment was 64 months (IQR 40-78). Thirty four children (23.8%) were defined as having impairments: 14 (9.8%) in motor, 16 (11.2%) in speech and language, and 20 (14.0%) in other cognitive functions. Previous seizures (OR 5.6, 95% CI 2.0 to 16.0), deep coma on admission (OR 28.8, 95% CI 3.0 to 280), focal neurological signs observed during admission (OR 4.6, 95% CI 1.1 to 19.6), and neurological deficits on discharge (OR 4.5, 95% CI 1.4 to 13.8) were independently associated with persisting impairments. In addition, multiple seizures were associated with motor impairment, age <3 years, severe malnutrition, features of intracranial hypertension, and hypoglycaemia with language impairments, while prolonged coma, severe malnutrition, and hypoglycaemia were associated with impairments in other cognitive functions.

CONCLUSIONS

Risk factors for persisting neurological and cognitive impairments following cerebral malaria include multiple seizures, deep/prolonged coma, hypoglycaemia, and clinical features of intracranial hypertension. Although there are overlaps in impaired functions and risk factors, the differences in risk factors for specific functions may suggest separate mechanisms for neuronal damage. These factors could form the basis of future preventive strategies for persisting impairments.

Persistent neurocognitive impairments associated with severe falciparum malaria in Kenyan children

OBJECTIVES

There is little information on the characteristics of persisting impairments associated with severe forms of falciparum malaria. Previous work has suggested the existence of a group of children with particularly poor performance on neurocognitive assessments in the context of average group performance. The aim of this study was to provide a detailed characterisation of impairments in this subgroup.

METHODS

Three groups of children were recruited: children admitted up to nine years earlier with cerebral malaria (CM) (n = 152), malaria and complicated seizures (M/S) (n = 156), or those unexposed to either condition (n = 179). Each child underwent a series of developmental assessments. Standard definitions were used to classify impairment.

RESULTS

Twenty-four percent of the CM and M/S groups had at least one impairment in the major domains assessed in the study, compared with 10% of the unexposed group. CM was associated with a higher proportion of multiple impairments and an increased risk of mortality in the first year after recovery in those identified with impairments on discharge.

CONCLUSIONS

After severe malaria, some children have neurocognitive impairments that are evident as long as nine years later. Impairments may become more evident as children progress and face more complex cognitive and linguistic demands, socially and educationally. The child's neurological status at discharge was not a good predictor of later neurocognitive impairment. This highlights the importance of follow up for children with severe malaria and the involvement of therapists and educators in the provision of services for this population.

Validity and Reliability of the ‘Ten Questions’ Questionnaire for Detecting Moderate to Severe Neurological Impairment in Children Aged 6–9 Years in Rural Kenya

BACKGROUND

The 'Ten Questions' Questionnaire (TQQ) is used to detect severe neurological impairment in children living in resource-poor countries. Its usefulness has been established in Asia and the Caribbean, but there are a few published studies from Africa. We evaluated the TQQ as part of a larger study of neurological impairment in a rural community, on the coast of Kenya.

METHODS

The study was conducted in two phases from June 2001 to May 2002; in phase one, a community household screening of 10,218 children aged 6-9 years using the TQQ was performed. Phase two involved a comprehensive clinical and psychological assessment of all children testing positive on the TQQ (n = 810) and an equivalent number of those testing negative (n = 766). Data were interpreted using the impairment-specific approach.

RESULTS

Overall, the sensitivity rates for screening the different impairments were: cognitive (70.0%), motor (71.4%), epilepsy (100%), hearing (87.4%) and visual (77.8%). All the specificity rates were greater than 96%. However, the positive predictive values were low, and ranged from 11 to 33%.

CONCLUSIONS

These results are similar to those from other continents and provide evidence that the TQQ can be used to compare the epidemiology of moderate/severe impairment in different parts of the world. Furthermore, the TQQ can be used to screen for moderately/severely impaired children in resource-poor countries; however, the low positive predictive values mean that other assessments are required for confirmation.

Speech and language sequelae of severe malaria in Kenyan children

PRIMARY OBJECTIVE

To conduct a preliminary investigation into the occurrence of speech and language impairments following severe malaria in Kenyan children.

RESEARCH DESIGN

Cohort study comparing the prevalence of impairments in children exposed or unexposed to severe malaria.

METHODS AND PROCEDURES

The study recruited 25 children who had previously been admitted to hospital with severe falciparum malaria and 27 unexposed to the disease. Assessments of comprehension, syntax, lexical semantics, higher level language abilities, pragmatics and phonology were administered to each child at 8-9 years of age, at least 2 years after admission to hospital in children exposed to severe malaria.

MAIN OUTCOMES AND RESULTS

Exposed children were found to have lower scores on each assessment and significantly lower scores on four aspects of language ability: comprehension (p = 0.02); syntax (p = 0.02); content words (p = 0.02) and function words (p = 0.004) components of lexical semantics.

CONCLUSIONS

These data suggest that speech and language deficits may be an important and under-recognized sequela of severe falciparum malaria.

Seizure disorders among relatives of Kenyan children with severe falciparum malaria

PURPOSE

The cause of seizures in children with falciparum malaria is unclear. In malaria endemic areas, children who develop severe falciparum malaria with seizures may have a genetically higher risk of epilepsy or febrile seizures. We used the history of seizures in relatives of children previously admitted with malaria to determine if there is evidence for a familial predisposition of seizures in children admitted with malaria and seizures or cerebral malaria.

METHODS

Family history of seizures were obtained from the parents/guardians of 81 children (35 children previously admitted with severe malaria and 46 children matched for age who had not been admitted with severe malaria). Data were collected on frequency, duration, age of onset, presence of fever and causes of seizures.

RESULTS

The prevalence of seizures in the relatives of children not admitted with severe malaria was 4.3%, of whom 2.2% had a history of seizures compatible with febrile seizures, and 1.1% with epilepsy. Overall the odds ratio (OR) for relations of children admitted with malaria, to have a seizure disorder was 1.41 [95% confidence interval (CI) 1.06-1.88]. There was a significant risk of the relatives dying if they had epilepsy [relative risk 1.88 (95% CI 1.11-3.19)], but not for other seizure disorders (i.e. febrile, single or unclassifiable seizures).

CONCLUSION

Relatives of children admitted with severe falciparum malaria are more likely to have a seizure disorder compared with controls, but it is unclear if this is because of a genetic propensity or caused by exogenous factors such as malaria.

Formative evaluation of a multimedia program for patients about the side effects of cancer treatment

Formative evaluation of multimedia programs can prevent costly and time-consuming revisions and result in more effective programs. Yet systematic formative evaluation is seldom conducted. This paper reviews the basic principles of formative evaluation and describes how we applied those principles to the formative evaluation of a multimedia program for patients about the side effects of cancer treatment. It discusses the challenges of developing multimedia programs for patients and provides guidance to other health professionals interested in developing programs on other topics.

Short-term stability of NEO-PI-R personality trait scores in opioid-dependent outpatients

The present study examined the short-term stability of personality trait scores from the Revised NEO Personality Inventory (NEO-PI-R) among 230 opioid-dependent outpatients. The NEO-PI-R is a 240-item empirically developed measure of the five-factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness). Participants completed the NEO-PI-R at admission and again approximately 19 weeks later. Results indicated fair to good stability for all NEO-PI-R factor domain scores, with coefficients ranging from .68 to .74. Stability of NEO-PI-R scores was decreased among potentially invalid response patterns but was not significantly affected by drug-positive versus drug-negative status at follow-up.

Influence of antisocial personality subtypes on drug abuse treatment response

This methodological study examined the impact of antisocial personality disorder (APD) and other psychiatric comorbidity on drug use and treatment retention in 513 new admissions to methadone maintenance treatment. Patients were classified into one of four groups: APD ONLY, APD plus other psychiatric disorder (APD MIXED), other psychiatric disorder, and no psychiatric disorder. Patients completed research assessments and were then followed for 1 year of treatment. Patients with APD had longer histories of heroin and cocaine use than non-APD patients and were more likely to meet criteria for cocaine dependence. Distinct clinical profiles emerged that differentiated APD ONLY from APD MIXED. APD ONLY patients exhibited higher rates of cocaine and heroin use, whereas those with APD MIXED exhibited higher rates of benzodiazepine use. Self-report measures supported urinalysis results, but group differences did not affect treatment retention. These differences in clinical profiles should be considered when evaluating treatment performance in substance abusers with APD.

Evaluation of a treatment-appropriate cognitive intervention for challenging alcohol outcome expectancies

The current study evaluated an alcohol expectancy challenge (EC) that did not require alcohol administration and could therefore be implemented in a treatment setting. Participants in the treatment group directly challenged alcohol expectancies endorsed on an expectancy questionnaire. A total of 62 male and female undergraduates completed the study (32 control participants, 30 EC participants). Self-report questionnaires were collected pre- and post-intervention, and alcohol logs were kept during the study. The EC resulted in significant reductions in alcohol expectancies across multiple expectancy dimensions. Although the analysis for alcohol consumption was not significant, there was a trend toward better outcomes for male participants in the EC condition. In contrast to study hypotheses, women in the EC condition increased their alcohol consumption from pre to post-test to a greater degree than did control participants.

The feasibility of a kinematic measure of lip closure during meaningful speech

PURPOSE

Assessment of dysarthria has traditionally been based on perceptual methods. The purpose of this study was to examine the feasibility of using 2D kinematic analysis to measure lip closure during normal speech.

METHOD

Retroflective markers (4 mm diameter) were placed on the midline of each lip of three healthy male, caucasian volunteers aged 69 years who repeated the sentence 'My mother made me an apple and blackberry pie' six times. Videorecordings were analysed using the Ariel Performance Analysis System to calculate the distance between the lips before, during and after the sentence.

RESULTS

The graphs produced from the data objectively measured the distance between the lips and identified the eight bilabial sounds. However, in spite of stringent study criteria to minimize differences linked to age, gender and race, differences were found between participants.

CONCLUSION

Kinematic 2D analysis may have potential for the objective measurement of lip closure in dysarthria in the context of meaningful speech. These results justify further pilot work to explore: the possible variability within defined populations; and the usefulness of 2D kinematic analysis in the measurement of disordered lip closure in dysarthria.

Gender differences related to heterosexual condom use: the influence of negotiation styles

The present study had three primary goals. The first was to identify gender differences related to negotiation styles associated with condom use. We hypothesized that women would report engaging in more negotiation behaviors associated with condom use than men. The second goal was to determine whether the relationships between intentions to use condoms and past condom use for women and men were moderated by negotiation behaviors. The third goal was to examine gender differences in responses to an open-ended question inquiring why participants did not use condoms. Male and female college students (N = 219) anonymously completed a series of measures. The results indicated that women and men have unique roles in the negotiation process; women play a more active role in negotiation of condom use, while men play a more reactive role. The relationship between intentions to use condoms and past condom use increased for men when their partners were more active in the process of deciding whether to use condoms. Responses to the open-ended item revealed that women identified perceptions of low risk as the most common reason for not using condoms, while men identified the inconvenience or unavailability of condoms as the most common reason. The implications of these results are discussed as they relate to health efforts to increase condom use.

Effects of priming positive and negative outcomes on drinking responses

The purpose of this investigation was to study the effects of priming positive and negative expectancy outcomes on the drinking responses of college students. Men and women (N = 64) were randomly assigned to 1 of 3 priming conditions: a positive expectancy outcome condition, a negative expectancy outcome condition, and a neutral (control) condition. Participants were exposed to a series of semantic primes corresponding to their condition and then asked to complete a beer taste-rating task. Planned comparisons revealed that the average ratio of beer consumed to body weight in the positive condition was significantly greater than the average ratio in the neutral condition, and the average ratio of beer consumed to body weight was significantly less in the negative condition than the average ratio in the neutral condition. These findings are discussed as they relate to cognitive models of alcohol use.

Self-esteem, gender, and alcohol use: relationships with HIV risk perception and behaviors in college students

The present study examined the confluence of alcohol use and self-esteem on risky sexual behavior and perceptions of risk for female and male college students. It was predicted that higher levels of self-esteem, female gender, and lower alcohol consumption would be associated with greater condom use and lower perceptions of risk for self and partner. Results indicated that for low drinking students, those with high self-esteem reported greater condom use. In addition, low rates of alcohol use were associated with greater frequency of past condom use. Women and students low in self-esteem indicated greater perceptions of risk for themselves and their partners. These findings are discussed in terms of their implications for developing interventions aimed at reducing risky sexual behavior.

Delayed paraplegia following spinal anaesthesia. Spinal subdural haematoma following dural puncture with a 25 G pencil point needle at T12-L1 in a patient taking aspirin

We report an extremely rare complication of regional anaesthesia, a spinal subdural haematoma, which resulted in permanent neurological damage occurring 8 days after dural puncture at T12-L1. Although spinal subdural haematoma following spinal anaesthesia and lumbar puncture has been described before, this is the first report of this complication occurring after dural puncture using a 25 G atraumatic pencil point (Whitacre) needle. Contributory factors might have been the perioperative intermittent low dose aspirin therapy and the fact that spinal anaesthesia was performed at the T12-L1 level.

Intubation with propofol: evaluation of pre-treatment with alfentanil or lignocaine

The effect of lignocaine or alfentanil pre-treatment on conditions at orotracheal intubation following induction with propofol, but without the use of muscle relaxants, were compared in a prospective, controlled, double-blind study. Forty five healthy patients undergoing elective surgery were randomly allocated to receive either 0.9% saline (control), alfentanil 20 micrograms/kg-1, or lignocaine 1.5 mg kg-1 prior to induction with propofol 2.5 mg kg-1. Ease of intubation was scored on a four point scale from 'excellent' = 1 to 'not possible' = 4. Alfentanil pre-treatment allowed intubation in 93% of patients compared to 60% in each of the groups pre-treated with lignocaine or saline. Intubation scores of 1 or 2 were obtained in 14 out of 15 patients (93%) in the alfentanil group and this was significantly better than the lignocaine group (33%) or control group (20%). No difference was detected between the scores of the latter two groups.

The ophthalmopathy of Graves' disease

Ophthalmopathy is an integral component of Graves' disease. It usually appears at the same time as hyperthyroidism, and is characterized by proptosis (exophthalmos), periorbital and conjunctival edema, eye muscle dysfunction, and on occasion corneal ulceration or optic neuropathy. Graves' ophthalmopathy, like Graves' hyperthyroidism, is an autoimmune disease, but the mechanisms that initiate and maintain it are not known. Most patients can be treated conservatively, but a few require anti-inflammatory or surgical therapy to relieve symptoms and preserve vision.

Cardiovascular changes at antagonism of atracurium. Effects of different doses of premixed neostigmine and glycopyrronium in a ratio of 5:1

The cardiovascular changes in the 10 minutes following antagonism of an atracurium-induced block were studied in 32 patients. A 5:1 ratio combination of either 15, 35, 55 or 75 micrograms/kg neostigmine, with a corresponding dose of 3, 7, 11, or 15 micrograms/kg of glycopyrronium was used for antagonism. The least change in heart rate was with neostigmine 15 micrograms/kg with an increase of more than 15 beats/minute found in only one patient. Antagonism with 35, 55 and 75 micrograms/kg neostigmine mixture produced the greatest increase in heart rate at one minute and this was significantly different from the effect of the 15 micrograms/kg dose. Twenty out of 24 patients given the larger doses had heart rate increases in excess of 15 beats/minute and in nine patients this ranged from 30 to 52 beats/minute, representing increases of 46-80% above baseline values. Arterial pressure increases after antagonism were statistically significant in all four groups, with no between-group difference; these were clinically unimportant. When antagonising an atracurium-induced block with clinically useful doses of neostigmine, the standard 5 : 1 ratio combination with glycopyrronium will result in an initial tachycardia.

Antagonism of atracurium with neostigmine. Effect of dose on speed of recovery

In 36 patients in whom anaesthesia was maintained with nitrous oxide and 0.5% isoflurane an atracurium-induced neuromuscular block was either allowed to recover spontaneously or antagonised with one of four doses of neostigmine (15 micrograms/kg, 35 micrograms/kg, 55 micrograms/kg or 75 micrograms/kg). The recovery times to a train-of-four ratio of 0.5, 0.75 and 0.9 were recorded. In patients given neostigmine, antagonism was at an average T1 of between 8.8% and 14.9%. There was no difference in the recovery times between the patients given neostigmine 35 micrograms/kg, 55 micrograms/kg or 75 micrograms/kg. Recovery after neostigmine 15 micrograms/kg was significantly slower than after the higher doses. One patient given neostigmine 75 micrograms/kg showed an unusual bimodal pattern of recovery. There appears to be no benefit in giving a larger dose than 35 micrograms/kg of neostogmine as a single bolus.

Resedation after bolus administration of midazolam to an infant and its reversal by flumazenil

A 4-month-old infant was sedated with bolus doses of midazolam, and after initial apparent complete arousal, became unresponsive and hypotonic. Administration of flumazenil enabled differentiation of a residual drug effect from an intracerebral event.

Contralateral tension pneumothorax during thoracotomy for lung resection

A patient underwent right thoracotomy and upper lobectomy for a mass found on routine chest radiography. He became profoundly cyanosed with a bradycardia and severe reduction in oxygen saturation at completion of surgery. The diagnosis of tension pneumothorax on the contralateral side to surgery was made and treatment instituted. The causes, treatment and implications of such an event during general anaesthesia for lung resection are discussed.

An evaluation of the incentive spirometer to improve lung function after cholecystectomy

Forty patients who underwent elective cholecystectomy were allocated randomly to one of two groups. Patients in one group used an incentive spirometer as part of their postoperative chest physiotherapy; those in the other received routine postoperative physiotherapy as dictated by their needs. Each group contained equal numbers of smokers and nonsmokers, and the data from each group were analysed separately. The use of the incentive spirometer did not confer any benefits as judged by clinical evidence of pulmonary complications, pulmonary function tests or length of hospital stay.