Disabled-by-design: effects of inaccessible urban public spaces on users of mobility assistive devices - a systematic review

PURPOSE

Despite the increase of users of Mobility Assistive Devices (MobAD), there has been a lack of accessibility in urban environments in many parts of the world. We present a systematic review of how the inaccessible design of public spaces affects quality-of-life - including aspects of health and safety, independence, and social participation - of MobAD users.

MATERIALS AND METHODS

We conducted a literature search in three databases (i.e., Scopus, Web of Science, and PubMed) and initially discovered 3980 publications. We analysed 48 peer-reviewed journal articles published in English from 2005 to 2021 and assessed their quality of evidence via the Mixed Methods Appraisal Tool.

RESULTS

Findings indicated a substantial number of inaccessible elements for MobAD users in public spaces. Pathway characteristics, boarding ramps, entrance features, confined spaces, and service surfaces were deemed to be the least accessible elements. These barriers had multifaceted effects on MobAD users' quality of life with aspects of physical health, mobility, and use of public transport being most affected.

CONCLUSIONS

Notwithstanding that the reviewed studies mostly ocused on wheelchair users residing in high-income countries, this review outlines the critical role of the design of the built environment as a factor of disablement for MobAD users. We conclude by highlighting a few recommendations for future research and practice, especially inclusive approaches and adaptive techniques to assist MobAD users with performing tasks in public spaces independently.Implications for RehabilitationUsers of Mobility Assistive Devices experience a lack of accessibility provisions in public open spaces and buildings internationally.Physical barriers in public spaces substantially diminish the health and safety, autonomy, and social participation of users of Mobility Assistive Devices.There is a definite need for the adoption of inclusive strategies and adaptive techniques in placemaking processes so that users of Mobility Assistive Devices can have equitable access to public spaces.

Role of pregaming motives in accounting for links between maladaptive personality traits and drinking consequences

College students are at heightened risk of engaging in unhealthy alcohol use that leads to negative consequences (e.g., motor vehicle accidents, poor academic performance). Understanding how individual differences, such as maladaptive personality traits, contribute to that risk could improve intervention efforts. A potential pathway through which personality confers risk for consequences is by influencing students' motivation to drink. In this study of 441 college students, we investigated whether different motivations to pregame, a particularly risky and common drinking practice on college campuses, accounts for links between maladaptive traits and alcohol-related consequences. Results of bivariate analyses showed that all pregaming motives and maladaptive traits (except detachment) were strongly correlated with negative consequences. In path analytic models that adjusted for shared variance between pregaming motives and between maladaptive traits, results showed that traits had indirect effects on total drinking consequences via individual differences in pregaming motives as well as direct effects that were independent of motives. Specifically, antagonism, disinhibition, and negative affectivity predicted more drinking consequences via stronger motives to pregame for instrumental reasons over and above the general motivation to pregame, whereas detachment predicted fewer consequences via weaker instrumental pregaming motives. Antagonism and disinhibition were also associated with more drinking consequences, and detachment with fewer consequences, over and above pregaming motives and general personality problems. Our study indicates that one way maladaptive personality traits may shape alcohol-related consequences in college students is by associations with their motivations to pregame. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A system dynamics-based scenario analysis of residential solid waste management in Kisumu, Kenya

The problem of solid waste management presents an issue of increasing importance in many low-income settings, including the progressively urbanised context of Kenya. Kisumu County is one such setting with an estimated 500 t of waste generated per day and with less than half of it regularly collected. The open burning and natural decay of solid waste is an important source of greenhouse gas (GHG) emissions and atmospheric pollutants with adverse health consequences. In this paper, we use system dynamics modelling to investigate the expected impact on GHG and PM_2.5 emissions of (i) a waste-to-biogas initiative and (ii) a regulatory ban on the open burning of waste in landfill. We use life tables to estimate the impact on mortality of the reduction in PM_2.5 exposure. Our results indicate that combining these two interventions can generate over 1.1 million tonnes of cumulative savings in GHG emissions by 2035, of which the largest contribution (42%) results from the biogas produced replacing unclean fuels in household cooking. Combining the two interventions is expected to reduce PM_2.5 emissions from the waste and residential sectors by over 30% compared to our baseline scenario by 2035, resulting in at least around 1150 cumulative life years saved over 2021–2035. The contribution and novelty of this study lies in the quantification of a potential waste-to-biogas scenario and its environmental and health impact in Kisumu for the first time.

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We present a system dynamics study of solid waste management in Kisumu, Kenya.

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Scenarios involve a waste-to-biogas initiative and a ban on open burning in landfill.

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Combined scenario generates 1.1m tonnes cumulative GHG savings by 2035.

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Largest contribution (42%) is from biogas substituting traditional cooking fuels.

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Combined scenario may save 1,150 cumulative life years by 2035, plus ~220 more p.a.

Joint range of motion entropy changes in response to load carriage in military personnel

BACKGROUND

Overuse accounts for 82% of injuries in military personnel, and these occur predominantly in the spine and lower limbs. While non-linear analyses have shown changes in overall stability of the movement during load carriage, individual joint contributions have not been studied. The concept of entropy compensation between task, organism and environmental constraints is studied at a joint level.

RESEARCH QUESTION

The aim of this study was to investigate whether using different methods of loading by military personnel would have an effect on the sample entropy of the joint ranges of motion.

METHODS

Eleven male reserve infantry army soldiers (age: 22 ± 2 years; height: 1.80 ± 0.06 m; mass: 89.3 ± 14.4 kg) walked an outdoor, 800 m course under 5 load conditions: unloaded, 15 kg backpack, 25 kg backpack, 15 kg webbing and backpack and 25 kg webbing and backpack. Kinematic data was recorded at 240 Hz using the Xsens motion capture system. The ranges of motion (ROM) of the spine, hips and knee were calculated for each gait cycle. Mean ROM, coefficient of variation (CV) of the ROM and the sample entropy of the ROM were compared between conditions.

RESULTS

Spine side flexion ROM decreased significantly from the control condition in all loaded conditions, while sample entropy of the spine side flexion ROM increased in some conditions with no significant change in CV. Conversely, the hip flexion ROM increased significantly from the control, while sample entropy of the hip flexion ROM decreased.

SIGNIFICANCE

These results suggest that entropy compensation may propagate at a joint level. Understanding that a decrease in certainty with which a joint angle is selected, may be accompanied by an increase at a neighbouring joint. This could be significant in monitoring injuries as a result of environmental or task constraints.

Objective assessment of thirst recovery in patients with adipsic diabetes insipidus

Adipsic diabetes insipidus (ADI) is characterised by impaired thirst and defective AVP secretion. We have assessed the thirst response to graded osmotic stimulation using a visual analog scale (VAS) in patients with a history of ADI following surgery for a craniopharyngioma. The patients were thought to be regaining their thirst response but we wanted to confirm that this was the case objectively before relaxing their strict fluid balance regimen. Three patients with adipisa in the presence of hypernatremia following surgery for a craniopharyngioma are described. Their median age at surgery was 13 years (range 11-15 years). All patients had previously demonstrated no desire to drink despite a serum osmolality in excess of 300 mOsmol/kg. Fluid balance was maintained postoperatively with a regimen involving a fixed daily fluid intake and DDAVP dose together with daily weights and regular assessment of capillary sodium concentrations. Patients were thought to be regaining thirst sensation and so were assessed by hypertonic saline infusion (HSI) with thirst measured using a VAS. Patients underwent a HSI test 4, 6 and 9 months post surgery. All had abnormally low AVP production at raised plasma osmolalities but the visual analogue scale confirmed partial or complete thirst recovery. The intensive regimen used to maintain stable serum sodium concentrations was relaxed without the patients subsequently developing a significant hyperosmolar state. We have shown objective recovery of thirst perception in patients with adipsia within 9 months of surgery, despite persistence of cranial diabetes insipidus. These observations indicate that both osmoreceptors regulating thirst and their efferent pathways demonstrate more plasticity than those regulating AVP production. The HSI and thirst VAS are an objective way of assessing patients known to have ADI who are thought to be recovering thirst perception.

Pregnancy IFN-gamma responses to foetal alloantigens are altered by maternal allergy and gravidity status

BACKGROUND

During pregnancy, variations in maternal-foetal cellular interactions may influence immune programming. This study was carried out to determine if maternal responses to foetal alloantigens are altered by maternal allergic disease and/or previous pregnancies.

METHODS

For this cohort study, peripheral blood was collected from allergic (n = 69) and nonallergic (n = 63) pregnant women at 20, 30, 36-week gestation and 6-week postpartum (pp). Cord blood was collected at delivery. Mixed lymphocyte reactions were used to measure maternal cytokine responses [interleukin-6 (IL-6), IL-10, IL-13 and (interferon-gamma) IFN-gamma] at each time point towards foetal mononuclear cells.

RESULTS

Maternal cytokine responses during pregnancy (20, 30 and 36 weeks) were suppressed compared to the responses at 6-week pp. The ratio of maternal IFN-gamma/IL-13 and IFN-gamma/IL-10 responses were lower during pregnancy. Allergic mothers had lower IFN-gamma responses at each time-point during pregnancy with the greatest difference in responses observed at 36-week gestation. When allergic and nonallergic women were further stratified by gravidity group, IFN-gamma responses of allergic multigravid mothers were significantly lower than nonallergic multigravid mothers during pregnancy.

CONCLUSIONS

During normal pregnancy, peripheral T-cell cytokine responses to foetal alloantigens may be altered by both allergic status of the mother and previous pregnancies. These factors could influence the cytokine milieu experienced by the foetus and will be further explored in the development of allergic disease during early life.

Fluorescent resonance energy transfer based detection of biological contaminants through hybrid quantum dot-quencher interactions

A nanoscale sensor employing fluorescent resonance energy transfer interactions between fluorescent quantum dots (QDs) and organic quencher molecules can be used for the multiplexed detection of biological antigens in solution. Detection occurs when the antigens to be detected displace quencher-labelled inactivated (or dead) antigens of the same type attached to QD-antibody complexes through equilibrium reactions. This unquenches the QDs, allowing detection to take place through the observation of photoluminescence in solution or through the fluorescence imaging of unquenched QD complexes trapped on filter surfaces. Multiplexing can be accomplished by using several different sizes of QDs, with each size QD labelled with an antibody for a different antigen, providing the ability to detect several types of antigens or biological contaminants simultaneously in near real-time with high specificity and sensitivity.

Supplementation with vitamins C, E, beta-carotene and selenium has no effect on anti-oxidant status and immune responses in allergic adults: a randomized controlled trial

BACKGROUND

Anti-oxidants are of growing interest in early treatment and prevention of allergic diseases in early life, but the effects on allergen-specific immune responses need to be documented further before intervention studies in infants are undertaken. The aim of this study in adults was to determine the effects of dietary anti-oxidants on allergen-specific immune responses in sensitized individuals.

METHODS

In a randomized controlled trial, 54 allergic adults received an anti-oxidant supplement (n=36) comprising beta-carotene (9 mg/day), vitamin C (1500 mg/day), vitamin E (130 mg/day), zinc (45 mg/day), selenium (76 microg/day) and garlic (150 mg/day) or a placebo (n=18) for 4 weeks. Anti-oxidant capacity (AC), serum levels of vitamin C, vitamin E, beta-carotene and selenium, peripheral blood responses, exhaled nitric oxide (eNO), as a marker of airway inflammation, and plasma F(2) isoprostanes, as a measure of oxidative stress, were measured before and after supplementation.

RESULTS

Anti-oxidant supplementation resulted in significant increases in serum levels of vitamin C, vitamin E, beta-carotene and selenium levels, compared with the placebo group (P<0.001). There was no change in serum AC, plasma F(2)-isoprostanes, eNO or immune responses following supplementation with anti-oxidants compared with placebo.

CONCLUSION

Supplementation with anti-oxidants resulted in significantly increased levels of vitamin C, vitamin E, beta-carotene and selenium but no change in immune responses, serum AC or plasma F(2)-isoprostanes.

Associations between antioxidant status, markers of oxidative stress and immune responses in allergic adults

BACKGROUND

There has been growing interest in the role of antioxidant function in controlling inflammatory disease states, such as allergy. This study investigated the relationship between antioxidant status, markers of airways inflammation [exhaled nitric oxide (eNO)], oxidative stress (F(2) isoprostanes) and immune responses in allergic adults.

METHODS

Antioxidants (vitamins C, E, beta-carotene and selenium) and total antioxidant capacity (tAC) in serum were examined in relation to eNO, plasma F(2) isoprostanes and peripheral blood mononuclear cell (PBMC) cytokine and lymphoproliferative response to house dust mite (HDM) allergen, Staphylococcus enterotoxin B (SEB), phytohaemaglutinin (PHA) and lipopolysaccharide (LPS) in 54 allergic adults.

RESULTS

Firstly, levels of specific vitamins did not correlate with tAC. Secondly, we did not see any evidence that specific vitamin levels (or tAC) were associated with either polarization or attenuation of in vitro immune responses. If anything, there were positive correlations between antioxidant (vitamin C and selenium) levels and HDM allergen responses [lymphoproliferation (selenium; r=0.35, P=0.013) and both Th2 IL13 (vitamin C; tau=0.254, P=0.028) and Th1 IFN-gamma (vitamin C; tau=0.302, P=0.009) responses]. There were also significant positive relationships between antioxidant levels and IL-10 responses to polyclonal stimulation by SEB (r=0.292, P=0.036) and LPS (r=0.34, P=0.015) (beta-carotene) and PHA (r=0.34, P=0.021) (tAC). Thirdly, although airways inflammation (eNO) was associated with both in vitro and in vivo (skin test reactivity) to HDM, we did not see any correlation between eNO and oxidative stress (F(2)-isoprostanes). Finally, there were no consistent relationships between oxidative stress and immune responses.

CONCLUSION

There was no evidence that higher antioxidant levels were associated with reduced allergen responsiveness in allergic adults. If anything, antioxidant status was associated with increased immune responsiveness. The significance of this needs to be addressed in future intervention studies.

The role of similarity in human associative learning

In 2 experiments, humans received sequences of patterns that were similar (AX-->BX, AY-->BY, AZ-->BZ) or dissimilar (CX-->DY, CY-->DZ, CZ-->DX). The patterns were portrayed as bugs that could be eliminated with 2 insecticide sprays (red or blue). Either spray eliminated bugs with Features A and C, and participants learned by trial and error to use one spray (e.g., red) to eliminate bugs with Feature B and the other spray (e.g., blue) to eliminate those with Feature D. In Experiment 1, participants' spray choice for bugs with Feature A came to match that used to eliminate bugs with Feature B, but there was no such associative transfer between Features C and D. That is, similarity promoted associative transfer of responding between paired patterns when the features used to manipulate similarity (i.e., X, Y, and Z) were irrelevant. In Experiment 2, in which X, Y, and Z were relevant to the solution of configural discrimination, similarity hindered such associative transfer. These results complement those found in pigeons (R. A. Rescorla & D. J. Gillan, 1980) and indicate that similarity should not be accorded independent status as a principle of associative learning.

Non-small cell lung carcinoma metastatic to the kidney

INTRODUCTION

Renal metastasis by non-small cell lung cancer is uncommon and usually described at autopsy.

CASE PRESENTATION

We report the rare case of a 77-year-old man with localized non-small cell lung carcinoma who underwent extirpative surgery and 2 years later presented with gross hematuria and was noted to have a large infiltrating renal mass on computed tomography.

CONCLUSIONS

In patients with a prior history of resected localized non-small cell lung carcinoma, presence of a renal lesion should prompt the clinician to consider the possibility of metastasis. Further evaluation should consider this scenario.

Evaluation of the effects of probiotic supplementation from the neonatal period on innate immune development in infancy

BACKGROUND

Activation of the innate immune system by microbial stimulation is believed to be critical for normal immune maturation, and there has been speculation that these pathways are important for inhibiting allergic-immune responses.

OBJECTIVE

To assess innate immune function following a 6-month supplementation with probiotic bacteria.

METHODS

Two hundred and thirty-one allergic, pregnant women were recruited into a randomized, controlled trial. The infants received either a probiotic (Lactobacillus acidophilus LAVRI-A1; Probiomics) or placebo (maltodextrin alone) daily for the first 6 months of life. Mononuclear cell samples were available from 118 infants. Functional responses to toll-like receptor (TLR) were assessed using ligands for TLR2 (Pansorbin) and TLR4/CD14 [lipopolysaccharide (LPS)] and measuring cytokine responses in the supernatants. Antigen-presenting cell function, as well as capacity for cytokine production (IL-12p70 and IL-10) was assessed.

RESULTS

Infants in the probiotic group did not demonstrate differences in innate immune function compared with those in the control group. No differences were seen when cytokine responses were examined following stimulation with Pansorbin (TLR2) or LPS (TLR4). Similarly, no differences were seen in the antigen-presenting capacity of these infants. The mean fluorescence intensities of human leucocyte antigen-DR (HLA-DR) on monocytes, B cells and dendritic cells (DC) subsets were not affected, nor were the percentage of circulating DC subsets affected by a 6-month supplementation with L. acidophilus LAVRI-A1.

CONCLUSIONS

Probiotic supplementation with L. acidophilus for the first 6 months of life did not alter early innate immune responses in this population at high risk of developing allergic disease.

Effects of probiotic supplementation for the first 6 months of life on allergen- and vaccine-specific immune responses

BACKGROUND

A reduction in microbial burden during infancy when allergen-specific memory is evolving has become a prominent explanation for the allergy epidemic.

OBJECTIVE

We sought to determine whether probiotic dietary supplementation in the first 6 months of life could modify allergen- and vaccine-specific immune responses.

METHODS

Two hundred and thirty-one pregnant women with a history of allergic disease and positive allergen skin prick test (SPT) were recruited into a randomized-controlled trial. The infants received either a probiotic (3 x 10(9)Lactobacillus acidophilus LAVRI-A1; Probiomics) or placebo (maltodextrin alone) daily for the first 6 months of life, given independent of feeding methods. One hundred and seventy-eight children completed the study; blood samples were available from 60 children in the placebo group and 58 children in the probiotic group. Infant cytokine (IL-5, IL-6, IL-10, IL-13, TNF-alpha or TGF-beta) responses to tetanus toxoid (TT), house dust mite (HDM), ovalbumin (OVA), beta-lactoglobulin (BLG), Staphylococcus enterotoxin B (SEB) and phytohaemaglutinin (PHA) were measured at 6 months of age.

RESULTS

Children who received the probiotics showed reduced production of IL-5 and TGF-beta in response to polyclonal (SEB) stimulation (P=0.044 and 0.015, respectively). They also demonstrated significantly lower IL-10 responses to TT vaccine antigen compared with the placebo group (P=0.03), and this was not due to any differences in vaccination. However, there were no significant effects of probiotics on either Type 1 (Th1) or Type 2 (Th2) T helper cell responses to allergens or other stimuli. The only other effects observed were for reduced TNF-alpha and IL-10 responsiveness to HDM allergens in children receiving probiotics (P=0.046 and 0.014, respectively).

CONCLUSIONS

In summary, although we did not see any consistent effects on allergen-specific responses, our study suggests that probiotics may have immunomodulatory effects on vaccine responses. The significance and clinical relevance of this need to be determined in further studies.

Hypercalcaemia in relapsed medulloblastoma 8 years post-diagnosis; evidence to support PTHrP production by medulloblastoma cells

BACKGROUND

A 19-year-old male presented with symptomatic hypercalcaemia as the first manifestation of relapsed metastatic medulloblastoma. Management at the time of the initial presentation 8 years earlier was with surgical excision and craniospinal radiotherapy. His biochemistry at the time of relapse and studies of medulloblastoma cell lines provide an insight into the pathogenesis of his hypercalcaemia.

METHODS

Parathyroid hormone-related protein (PTHrP) was measured by immunoradiometric assay in blood, and in conditioned and control media from three medulloblastoma cell lines following 72 h growth.

RESULTS

The histology at initial presentation (11 years of age) and at the time of relapse (with bone marrow infiltration and widespread bony metastases) demonstrated medulloblastoma. Ionised calcium concentrations at relapse were 2.89 mmol/l and serum PTHrP levels were increased at the same time (2.7 pmol/l; normal range: 0.7-1.8 pmol/l). There was evidence of PTHrP production by one cell line (MHH-MED-8A) while results for both other lines tested were below the limit of detection.

CONCLUSIONS

Relapse 8 years after diagnosis is unusual in medulloblastoma and for this relapse to manifest as hypercalcaemia is also very uncommon. Our investigations suggest that the clinical picture was a reflection of PTHrP production by medulloblastoma cells.

Maternal smoking is associated with impaired neonatal toll-like-receptor-mediated immune responses

Infants of smokers have much higher rates of respiratory infection, asthma and airway disease. The current study assessed the effects of maternal smoking in pregnancy on neonatal toll-like-receptor (TLR)-mediated immune responses as a possible contributing factor to the elevated rates of respiratory illness. In a prospective birth cohort, the cord blood immune responses of neonates of smoking and nonsmoking mothers were compared. Maternal and cord serum cotinine were measured to confirm the level of cigarette smoke exposure. Neonatal cytokine responses were assessed to optimal doses of TLR2, TLR3, TLR4 and TLR9 ligands. Cotinine levels confirmed maternal reporting of cigarette smoking in pregnancy, with significantly higher cotinine levels in maternal and cord blood compared with the nonsmoking group. Infants of smoking mothers showed significantly attenuated innate TLR-mediated responses compared with infants of nonsmokers. The current findings indicate that in addition to effects on developing airways, maternal smoking also has significant immunological effects in pregnancy, which could contribute to the well recognised, subsequent increased risk of respiratory infections and asthma. These effects appear to be mediated through effects on toll-like receptor-mediated innate response pathways, which also promote regulatory pathways in the inhibition of allergic immune responses in the postnatal period, suggesting that other environmental interactions are highly relevant to the "hygiene hypothesis".

Atopic dermatitis in young children is associated with impaired interleukin-10 and interferon-gamma responses to allergens, vaccines and colonizing skin and gut bacteria

BACKGROUND

A significant proportion of children with food allergy and more severe forms of atopic dermatis (AD) go on to develop persistent forms of allergic disease such asthma. Defining immune dysregulation in these children will be of great value in understanding disease pathogenesis.

OBJECTIVE

In this study we characterized the immune responses of young infants (6-18 months of age) with moderate-to-severe AD (a modified SCORAD>or=25) and compared these (n=53) with responses of non-allergic children with no history of dermatitis or sensitization of the same age (n=20).

METHODS

Mononuclear cell cytokine responses to allergens (egg ovalbumin (OVA), beta-lactoglobulin (BLG), house dust mite (HDM)), vaccines (tetanus toxoid (TT), diphtheria toxoid (DT)), intestinal flora (heat-killed Lactobacillus species (HKLB)), heat-killed Staphylococcus aureus (HKSA), S. aureus enterotoxin B (SEB) and mitogen (phytohaemaglutinin (PHA)) were compared in children with AD with unaffected children.

RESULTS

Children with AD had significantly lower spontaneous (unstimulated) production of regulatory cytokine IL-10 (P<0.001), as well as IFN-gamma (P<0.001) and TNF-alpha (P<0.001) compared with the unaffected children. After allowing for differences in baseline levels IL-10 responses to virtually all stimuli (food allergens (P=0.003), vaccines P=0.01, intestinal flora (heat-killed Lactobacillus species (HKLB), P=0.005) and skin flora (heat-killed Staphylococcus aureus (HKSA), P=0.003)) were also significantly attenuated in children with AD. The only exception was HDM, to which responses were stronger in children with AD [P=0.05]. Although there were no significant correlations between HDM IgE and HDM cytokine responses at this age, T-helper type 2 (Th2) IL-5 (P=0.014) and IL-13 (P=0.004) responses to HDM were significantly more frequent in the children with AD. However, while children with AD showed significantly attenuated Th1 IFN-gamma responses to food allergens (OVA, P=0.007 and BLG, P<0.001) and vaccines (DT, P=0.008 and TT, P<0.001), these children showed no difference in Th1 IFN-gamma responses to HDM or microbial agents (HKSA and HKLB).

CONCLUSION

A increase in propensity for Th2 responses to aeroallergens in children with AD is associated with early impaired production of IL-10 regulatory cytokine to a broad range of environmental stimuli including foods, intestinal flora, S. aureus, and vaccines.

Clinical effects of probiotics are associated with increased interferon-γ responses in very young children with atopic dermatitis

BACKGROUND

We recently demonstrated that administration of probiotics resulted in significant clinical improvement in very young children with moderate-to-severe atopic dermatitis (AD). The purpose of this study was to determine the underlying immunological effects that are associated with these apparent clinical benefits.

METHODS

Peripheral blood mononuclear cells (PBMC) were isolated from children (n = 53) at baseline and at the end of an 8-week supplementation period during which they received a probiotic (Lactobacillus fermentum PCCtrade mark) (n = 26) or a placebo (n = 27). A further sample was collected at 16 weeks (8 weeks after ceasing the supplement). Cytokine (IL-5, IL-6, IL-10, IL-13, IFN-gamma and TNF-alpha) responses to allergens (egg ovalbumin (OVA), beta lactoglobulin (BLG), house dust mite (HDM)), vaccines (tetanus toxoid (TT)), diphtheria toxoid (DT)), intestinal flora (heat-killed Lactobacillus (HKLB)), heat-killed Staphylococcus aureus (HKSA), Staphylococcus aureus enterotoxin B (SEB) and mitogen (phytohaemaglutinin (PHA)) were compared.

RESULTS

The administration of probiotics was associated with a significant increase in T-helper type 1(Th1-type) cytokine IFN-gamma responses to PHA and SEB at the end of the supplementation period (week 8: P = 0.004 and 0.046) as well as 8 weeks after ceasing supplementation (week 16: P = 0.005 and 0.021) relative to baseline levels of response. No significant changes were seen in the placebo group. The increase in IFN-gamma responses to SEB was directly proportional to the decrease in the severity of AD (r = -0.445, P = 0.026) over the intervention period. At the end of the supplementation period (week 8) children receiving probiotics showed significantly higher TNF-alpha responses to HKLB (P = 0.018) and HKSA (P = 0.011) but this was no longer evident when supplementation ceased (week 16). Although IL-13 responses to OVA were significantly reduced in children receiving probiotics after 8 weeks (P = 0.008), there were no other effects on allergen-specific responses, and this effect was not sustained after ceasing supplementation (week 16). There were no effects on vaccine-specific responses, or on responses to any of the stimuli assessed.

CONCLUSION

The improvement in AD severity with probiotic treatment was associated with significant increases in the capacity for Th1 IFN-gamma responses and altered responses to skin and enteric flora. This effect was still evident 2 months after the supplementation was ceased. The lack of consistent effects on allergen-specific responses suggests that the effects of probiotics may be mediated through other independent pathways, which need to be explored further.

Immune responses to the 105AD7 human anti-idiotypic vaccine after intensive chemotherapy, for osteosarcoma

105AD7 is a human monoclonal antibody that mimics the complement regulatory protein, CD55, overexpressed by many solid tumours including osteosarcoma. This study was designed to assess the toxicity and efficacy of this vaccine in a young age group of patients within 1–6 months of myleosuppressive chemotherapy. Out of 28, 20 (71%, 95% CI 51–87%) patients showed a significant T-cell proliferation response in vitro to the 105AD7 protein but not to human IgG. Furthermore, 13 out of 22 (59%, 95% CI 36–79%) patients showed antigen-specific γIFN secretion (range 20–370 U/ml). Nine out of 28 (32%, 95% CI 16–52%) patients made weak antibody responses to CD55. This study showed that 105AD7 was well tolerated in younger patients with osteosarcoma. In addition, two patients with possible clinical responses were given compassionate permission to continue immunisation quarterly for 2 years. They both remain alive and disease free 5.8 and 6.5 years from original diagnosis of osteosarcoma and showed no adverse effects of repeated immunisation. In conclusion, the majority of patients showed measurable T helper responses when vaccination was commenced within a 6-month window of intensive chemotherapy with no clinically significant toxicity. Future clinical trials incorporating immune stimulation strategies should include early introduction of vaccines during the highest risk period for relapse.

CT findings of perforated rectal carcinoma presenting as Fournier's gangrene in the emergency department

We report a case of a perforated rectal adenocarcinoma presenting as Fournier's in the emergency department. CT findings in this case confirmed the clinical diagnosis, established the extent of disease, and suggested the presence of an underlying rectal neoplasm as the primary source of infection.

Primary hyperaldosteronism with normokalaemia secondary to an adrenal adenoma (Conn's syndrome) in a 12 year-old boy

A 12-1/2 year-old boy presented to the Accident Department following an episode of dizziness and was found to be hypertensive. Investigations revealed primary hyperaldosteronism secondary to an adrenal adenoma (Conn's syndrome). He had normal electrolytes during the period of investigation and potassium concentrations were > or = 4.2 mmol/l on all but one occasion. The hypertension resolved following excision of the adrenal tumour. Normokalaemia with potassium >4.0 mmol/l is very unusual in patients with Conn's syndrome and has not been described in childhood before. Primary hyperaldosteronism needs to be considered in hypertensive children even when potassium concentrations are well within the laboratory reference range.

Immune cell regulation and cardiovascular effects of sphingosine 1-phosphate receptor agonists in rodents are mediated via distinct receptor subtypes

Sphingosine 1-phosphate (S1P) is a bioactive lysolipid with pleiotropic functions mediated through a family of G protein-coupled receptors, S1P(1,2,3,4,5). Physiological effects of S1P receptor agonists include regulation of cardiovascular function and immunosuppression via redistribution of lymphocytes from blood to secondary lymphoid organs. The phosphorylated metabolite of the immunosuppressant agent FTY720 (2-amino-2-(2-[4-octylphenyl]ethyl)-1,3-propanediol) and other phosphonate analogs with differential receptor selectivity were investigated. No significant species differences in compound potency or rank order of activity on receptors cloned from human, murine, and rat sources were observed. All synthetic analogs were high-affinity agonists on S1P(1), with IC(50) values for ligand binding between 0.3 and 14 nM. The correlation between S1P(1) receptor activation and the ED(50) for lymphocyte reduction was highly significant (p < 0.001) and lower for the other receptors. In contrast to S1P(1)-mediated effects on lymphocyte recirculation, three lines of evidence link S1P(3) receptor activity with acute toxicity and cardiovascular regulation: compound potency on S1P(3) correlated with toxicity and bradycardia; the shift in potency of phosphorylated-FTY720 for inducing lymphopenia versus bradycardia and hypertension was consistent with affinity for S1P(1) relative to S1P(3); and toxicity, bradycardia, and hypertension were absent in S1P(3)(-/-) mice. Blood pressure effects of agonists in anesthetized rats were complex, whereas hypertension was the predominant effect in conscious rats and mice. Immunolocalization of S1P(3) in rodent heart revealed abundant expression on myocytes and perivascular smooth muscle cells consistent with regulation of bradycardia and hypertension, whereas S1P(1) expression was restricted to the vascular endothelium.

Influence of cellular factors and pharmacokinetics on the formation of platinum-DNA adducts in leukocytes of children receiving cisplatin therapy

The formation of platinum (Pt)-DNA adducts is thought to be crucial to the antitumor activity of cisplatin, and relationships between adduct formation in peripheral blood leukocytes (PBLs) and response to cisplatin therapy have been reported. The current study directly tests, for the first time, whether pharmacokinetic or other factors predominantly determine the drug-target interaction of cisplatin in a pediatric patient population. Cisplatin pharmacokinetics and Pt-DNA adduct formation in PBLs were determined in 10 children in parallel with measurement of adduct levels after incubation of pretreatment blood samples with cisplatin in vitro. Total and unbound plasma Pt concentrations were determined by atomic absorption spectrophotometry and adduct measurements performed by competitive ELISA. Pt-DNA adduct levels determined after cisplatin treatment showed considerable interindividual variation (peak levels at 24 h ranged from 0.15 to 1.31 nmol/g DNA) and correlated strongly with adduct levels determined after incubation of pretreatment whole blood with cisplatin (r = 0.92; P = 0.0002). No significant correlation was observed between in vivo adduct formation and either unbound or total cisplatin plasma concentrations (r = 0.14 and 0.18, respectively). A correlation was also observed between the degree of myelosuppression, as determined by WBC nadirs measured over a 14-day period after cisplatin treatment, and the extent of adduct formation, with greater WBC toxicity observed in patients with higher levels of Pt-DNA adducts (P = 0.010). These preliminary results provide evidence that interpatient variation in formation of Pt-DNA adducts in PBLs of children is determined by host-specific factors other than cisplatin pharmacokinetics. These results imply that analysis of adducts in PBLs after incubation of pretreatment blood samples with cisplatin may be used to predict in vivo adduct levels, leukopenia, and, potentially, response to cisplatin therapy.

The United Kingdom Children's Cancer Study Group's second germ cell tumor study: carboplatin, etoposide, and bleomycin are effective treatment for children with malignant extracranial germ cell tumors, with acceptable toxicity

PURPOSE

To evaluate carboplatin, etoposide, and bleomycin (JEB) in children with malignant extracranial germ cell tumors (GCTs).

PATIENTS AND METHODS

Malignant GCTs in children aged 0 to 16 years were excised without major morbidity or otherwise biopsied. Stage I testicular and some ovarian GCTs were resected and monitored with alpha-fetoprotein (AFP) ("watch-and-wait" approach). Patients with recurrent stage I disease and all other patients received JEB (etoposide 120 mg/m(2) on days 1 through 3, carboplatin 600 mg/m(2) on day 2, and bleomycin 15 mg/m(2) on day 3). Courses were administered every 3 to 4 weeks until remission, and then two more courses were given. Chemotherapy toxicities were assessed using World Health Organization or Brock grading.

RESULTS

Between January 1989 and December 1997, 192 patients were registered. Eight were excluded because either there was no histologic diagnosis (n = 3) or chemotherapy was given off-study (n = 5). The remaining 184 patients had germinoma (n = 20), malignant teratoma (n = 55), embryonal carcinoma (n = 1), yolk sac tumor (n = 107), or choriocarcinoma (n = 1). Forty-seven patients were treated with surgery alone, and 137 patients received JEB. The 5-year survival rate in March 1999 for all 184 patients was 93.2% (95% confidence interval [CI], 87.9% to 96.3%); for the 137 JEB-treated patients, it was 90.9% (95% CI, 83.9% to 95.0%), with an event-free survival rate of 87.8% (95% CI, 81.1% to 92.4%). The median follow-up after JEB treatment was 53 months (range, 0 to 109 months); the median number of courses was five (range, three to eight). Site, stage, and AFP level had prognostic significance. Nonfatal hematologic toxicity was common, but deafness and pulmonary and renal toxicities were rare. One child died of a thoracic tumor and bronchopulmonary dysplasia, and another died of acute myeloid leukemia.

CONCLUSION

Conservative surgery, a watch-and-wait approach after complete excision, and JEB for those requiring chemotherapy produced high cure rates and few serious complications.

Laparoscopic renal cryoablation in 32 patients

OBJECTIVES

Laparoscopic renal cryoablation is a developmental minimally invasive nephron-sparing treatment alternative for highly select patients with small renal tumors. We present our evolving experience with this procedure.

METHODS

Thirty-two patients (34 tumors) with a mean tumor size of 2.3 cm on preoperative computed tomography underwent laparoscopic renal cryoablation. As dictated by the tumor location, cryoablation was performed by either the retroperitoneal (n = 22) or the transperitoneal (n = 10) laparoscopic approach using real-time ultrasound monitoring. A double freeze-thaw cycle was routinely performed.

RESULTS

The mean surgical time was 2.9 hours, cryoablation time 15.1 minutes, and blood loss 66.8 mL. For a mean intraoperative ultrasonographic tumor size of 2 cm, the mean cryolesion size was 3.2 cm. The hospital stay was less than 23 hours in 22 (69%) of 32 patients. Sequential magnetic resonance imaging scans demonstrated a gradual contraction in the mean diameter of the cryolesions. Of the 20 patients who underwent a 1-year follow-up magnetic resonance imaging scan, the cryoablated tumor was no longer visible in 5. Of note, 23 patients have now undergone a 3 to 6-month follow-up computed tomography-directed biopsy of the cryoablated tumor site; the biopsy was negative for cancer in all 23 patients. No evidence of local or port-site recurrence was found during a mean follow-up of 16.2 months.

CONCLUSIONS

Critical long-term data regarding laparoscopic renal cryoablation, a developmental technique, are awaited. However, our initial experience is cautiously optimistic. Despite its significant potential for false-negative results, it is encouraging that the follow-up computed tomography-directed needle biopsies at 3 to 6 months were negative for cancer in 23 of 23 patients.