Negative and positive mental health characteristics of affected family members: Findings from a cross-sectional Australian general population gambling study

Despite the impact of problem gambling on affected family members (AFMs), there are limited large-scale population level studies identifying the negative mental health (NMH) and positive mental health (PMH) characteristics of AFMs. Furthermore, no study has explored whether PMH characteristics are protective in the relationships between AFM status and NMH characteristics. This study involved secondary data analysis from the Third Social and Economic Impact Study of Gambling in Tasmania. Using a subsample of 1,869 adults (48.30 % male; meanage = 48.48; 4.67 % AFMs), this study aimed to explore whether: (1) AFM status is associated with NMH (depression, anxiety, panic, post-traumatic stress disorder, social anxiety, binge drinking, tobacco use, and drug use symptoms) and PMH (quality of life [QOL], personal growth/autonomy, interpersonal/social skills, coping skills) characteristics after separately controlling for sociodemographic, problem gambling severity, and other NMH characteristics; (2) PMH characteristics moderate (buffer) the relationships between AFM status and NMH characteristics; and (3) gender influences these relationships. AFM status, defined as exposure to family member gambling problems, significantly positively predicted NMH characteristics (depression, anxiety, panic, PTSD, and tobacco use symptoms) and negatively predicted QOL (physical, social) and planning coping. The strength of these relationships generally attenuated after controlling for various covariates. Gender did not moderate these relationships. Religious coping exacerbated the relationship between AFM status and panic disorder symptoms. These findings can inform the development of intervention initiatives for family members exposed to gambling problems. Future population-representative research is required using a range of affected other types, longitudinal study designs, and more comprehensive measures.

A large outbreak of measles in the West Midlands, England, 2017-2018: descriptive epidemiology, control measures and lessons learnt

In November 2017, eight confirmed measles cases were reported to Public Health England from a hospital in the West Midlands. A multidisciplinary Incident Management Team (IMT) was established to determine the extent of the problem and coordinate an outbreak response. Between 1 November 2017 and 4 June 2018, a total of 116 confirmed and 21 likely measles cases were linked to this outbreak; just under half (43%) were aged over 15 years of age. Fifty-five of the confirmed cases were hospitalised (48%) and no deaths were reported. At the start of the outbreak, cases were mostly individuals of Romanian origin; the outbreak subsequently spread to the wider population. Over the 8-month response, the IMT conducted the following control measures: extensive contact tracing, immediate provision of post-exposure prophylaxis, community engagement amongst specific high-risk groups, MMR awareness raising including catch-up campaigns and enhanced vaccination services at selected GP surgeries. Key challenges to the effective control measures included language difficulties limiting community engagement; delays in diagnosis, notification and appropriate isolation of cases; limited resources for contact tracing across multiple high-risk settings (including GPs and hospitals) and lack of timely data on vaccine coverage in sub-groups of the population to guide public health action.

Predicting and Experimentally Validating Hot-Spot Residues at Protein-Protein Interfaces

Protein–protein interactions (PPIs) are vital to all biological processes. These interactions are often dynamic, sometimes transient, typically occur over large topographically shallow protein surfaces, and can exhibit a broad range of affinities. Considerable progress has been made in determining PPI structures. However, given the above properties, understanding the key determinants of their thermodynamic stability remains a challenge in chemical biology. An improved ability to identify and engineer PPIs would advance understanding of biological mechanisms and mutant phenotypes and also provide a firmer foundation for inhibitor design. In silico prediction of PPI hot-spot amino acids using computational alanine scanning (CAS) offers a rapid approach for predicting key residues that drive protein–protein association. This can be applied to all known PPI structures; however there is a trade-off between throughput and accuracy. Here we describe a comparative analysis of multiple CAS methods, which highlights effective approaches to improve the accuracy of predicting hot-spot residues. Alongside this, we introduce a new method, BUDE Alanine Scanning, which can be applied to single structures from crystallography and to structural ensembles from NMR or molecular dynamics data. The comparative analyses facilitate accurate prediction of hot-spots that we validate experimentally with three diverse targets: NOXA-B/MCL-1 (an α-helix-mediated PPI), SIMS/SUMO, and GKAP/SHANK-PDZ (both β-strand-mediated interactions). Finally, the approach is applied to the accurate prediction of hot-spot residues at a topographically novel Affimer/BCL-x_L protein–protein interface.

Novel Wolbachia strains in Anopheles malaria vectors from Sub-Saharan Africa

Background:  Wolbachia, a common insect endosymbiotic bacterium that can influence pathogen transmission and manipulate host reproduction, has historically been considered absent from the  Anopheles (An.) genera, but has recently been found in  An. gambiae s.l. populations in West Africa.  As there are numerous  Anopheles species that have the capacity to transmit malaria, we analysed a range of species across five malaria endemic countries to determine  Wolbachia prevalence rates, characterise novel  Wolbachia strains and determine any correlation between the presence of  Plasmodium,  Wolbachia and the competing bacterium  Asaia. Methods:  Anopheles adult mosquitoes were collected from five malaria-endemic countries: Guinea, Democratic Republic of the Congo (DRC), Ghana, Uganda and Madagascar, between 2013 and 2017.  Molecular analysis was undertaken using quantitative PCR, Sanger sequencing,  Wolbachia multilocus sequence typing (MLST) and high-throughput amplicon sequencing of the bacterial  16S rRNA gene.  Results: Novel  Wolbachia strains were discovered in five species:  An. coluzzii,  An. gambiae s.s.,  An. arabiensis,  An. moucheti and  An. species A, increasing the number of  Anopheles species known to be naturally infected. Variable prevalence rates in different locations were observed and novel strains were phylogenetically diverse, clustering with  Wolbachia supergroup B strains.  We also provide evidence for resident strain variants within  An. species A.  Wolbachia is the dominant member of the microbiome in  An. moucheti and  An. species A but present at lower densities in  An. coluzzii.  Interestingly, no evidence of  Wolbachia/Asaia co-infections was seen and  Asaia infection densities were shown to be variable and location dependent.  Conclusions: The important discovery of novel  Wolbachia strains in  Anopheles provides greater insight into the prevalence of resident  Wolbachia strains in diverse malaria vectors.  Novel  Wolbachia strains (particularly high-density strains) are ideal candidate strains for transinfection to create stable infections in other  Anopheles mosquito species, which could be used for population replacement or suppression control strategies.

Novel Wolbachia strains in Anopheles malaria vectors from Sub-Saharan Africa

Background: Wolbachia, a common insect endosymbiotic bacterium that can influence pathogen transmission and manipulate host reproduction, has historically been considered absent from the Anopheles (An.) genera, but has recently been found in An. gambiae s.l. populations.  As there are numerous Anopheles species that have the capacity to transmit malaria, we analysed a range of species to determine Wolbachia prevalence rates, characterise novel Wolbachia strains and determine any correlation between the presence of Plasmodium, Wolbachia and the competing endosymbiotic bacterium Asaia. Methods: Anopheles adult mosquitoes were collected from five malaria-endemic countries: Guinea, Democratic Republic of the Congo (DRC), Ghana, Uganda and Madagascar, between 2013 and 2017.  Molecular analysis of samples was undertaken using quantitative PCR, Sanger sequencing, Wolbachia multilocus sequence typing (MLST) and high-throughput amplicon sequencing of the bacterial 16S rRNA gene.  Results: Novel Wolbachia strains were discovered in five species: An. coluzzii, An. gambiae s.s., An. arabiensis, An. moucheti and An. species ‘A’, increasing the number of Anopheles species known to be naturally infected. Variable prevalence rates in different locations were observed and novel strains were phylogenetically diverse, clustering with Wolbachia supergroup B strains.  We also provide evidence for resident strain variants within An. species ‘A’.  Wolbachia is the dominant member of the microbiome in An. moucheti and An. species ‘A’, but present at lower densities in An. coluzzii.  Interestingly, no evidence of Wolbachia/Asaia co-infections was seen and Asaia infection densities were also shown to be variable and location dependent.  Conclusions: The important discovery of novel Wolbachia strains in Anopheles provides greater insight into the prevalence of resident Wolbachia strains in diverse malaria vectors.  Novel Wolbachia strains (particularly high-density strains) are ideal candidate strains for transinfection to create stable infections in other Anopheles mosquito species, which could be used for population replacement or suppression control strategies.

Exogenous T3 toxicosis following consumption of a contaminated weight loss supplement

A 42-year-old male presented with a one-week history of palpitations and sweating episodes. The only significant history was of longstanding idiopathic dilated cardiomyopathy. Initial ECG demonstrated a sinus tachycardia. Thyroid function testing, undertaken as part of the diagnostic workup, revealed an un-measureable thyroid-stimulating hormone (TSH) and free thyroxine (T₄). Upon questioning the patient reported classical thyrotoxic symptoms over the preceding weeks. Given the persistence of symptoms free tri-iodothyronine (T₃) was measured and found to be markedly elevated at 48.9 pmol/L (normal range: 3.1-6.8 pmol/L). No goitre or nodular disease was palpable in the neck. Historically there had never been any amiodarone usage. Radionucleotide thyroid uptake imaging (¹²³I) demonstrated significantly reduced tracer uptake in the thyroid. Upon further questioning the patient reported purchasing a weight loss product online from India which supposedly contained sibutramine. He provided one of the tablets and laboratory analysis confirmed the presence of T₃ in the tablet. Full symptomatic resolution and normalised thyroid function ensued upon discontinuation of the supplement.

LEARNING POINTS

Free tri-iodothyronine (T₃) measurement may be useful in the presence of symptoms suggestive of thyrotoxicosis with discordant thyroid function tests.Thyroid uptake scanning can be a useful aid to differentiating exogenous hormone exposure from endogenous hyperthyroidism.Ingestion of thyroid hormone may be inadvertent in cases of exogenous thyrotoxicosis.Medicines and supplements sourced online for weight loss may contain thyroxine (T₄) or T₃ and should be considered as a cause of unexplained exogenous hyperthyroidism.

Abstract PD2-02: SFX-01 targets Wnt signalling to inhibit stem-like cells in breast cancer patient-derived xenograft tumours

Background: SFX-01 is a novel therapeutic comprising synthetic sulforaphane (SFN) stabilised within a-cyclodextrin. Breast cancer stem-like cells (CSCs) have been identified in all molecular subtypes and are likely drivers of breast cancer metastasis and treatment resistance. We recently established that CSC activity in ER+ BC, represent a source of therapeutic resistance (Simões et al, Cell Reports, 2015).

Material and methods: We investigated SFX-01 effects on breast CSC activity using mammosphere formation efficiency (MFE) and aldehyde dehydrogenase (ALDH) activity using the ALDEFLUOR assay in patient samples and patient-derived xenograft (PDX) tumours. Cells from primary (n=12) and metastatic (n=15) samples were treated with SFX-01 (5 μM) or vehicle control.Using a 2 or 8 week in vivo treatment, early (HBCx34) and metastatic (BB3RC31) ER+ PDX tumours were treated with SFX-01 (300mg/Kg/day) alone or in combination with tamoxifen (TAM, 10 mg/kg/day) or fulvestrant (FULV, 200 mg/kg/week). Tumours were dissociated and MFE and ALDH activity assessed.

Results: SFX-01 in vitro reduced MFE of both primary (0.19%±0.02 vs control 0.52%±0.06: p<0.001) and metastatic patient samples (0.43±0.04 vs control 0.93%±0.07: p<0.001). SFX-01 treatment in vivo for 2 weeks reduced MFE of HBCx34 (0.35%±0.03 vs control 0.64%±0.09; p<0.01) and BB3RC31 (0.78%±0.04 vs control 0.89%±0.06: p<0.05) and also ALDH activity of HBCx34 (3%±0.6 vs control 6.3%±0.4: p<0.01) and BB3RC31 (1%±0.2 vs control 3%±0.6: p<0.05). TAM and FULV increased MFE and ALDH activity after 2 weeks of treatment in vivo, which was abrogated by combination with SFX-01; for example HBCx34 MFE with TAM alone: 0.81%±0.07 vs TAM+SFX-01: 0.34%±0.02 (p<0.01) and ALDH+ with TAM alone 10%±0.4 vs TAM+SFX 4.2%±0.4 (p<0.01). TAM+SFX-01 suppressed tumour growth at 8 weeks vs TAM alone in HBCx34 but not BB3RC31. FULV treatment maintained tumour growth suppression at 8 weeks and no additive effect was seen with SFX-01, although MFE and ALDH activity were suppressed. Mechanistically, SFX-01 potently inhibited the canonical Wnt pathway in MCF-7 cells and their endocrine-resistant derivatives and we are currently exploring SFX-01 activity on other CSC regulatory pathways.

SFX-01 has been shown to be well tolerated in SAD and MAD studies in normal volunteers and clinical studies designed to test tolerability and efficacy in combination with the three major classes of endocrine therapy (AI, TAM and FULV) in advanced BC will begin in Q4 2016.

Conclusions: Our data demonstrate the potential of SFX-01 for clinically meaningful improvements to endocrine therapy in ER+ breast cancer by reversing CSC mediated resistance.

Citation Format: Howell SJ, Simoes BM, Alferez D, Eyre R, Spence K, Santiago-Gomez A, Sarmiento-Castro A, Tanaka I, Howat D, Clarke RB. SFX-01 targets Wnt signalling to inhibit stem-like cells in breast cancer patient-derived xenograft tumours [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD2-02.

Stress and distress in parents of neonates admitted to the neonatal intensive care unit for cardiac surgery

BACKGROUND

Parents of infants admitted to the Neonatal Intensive Care Unit (NICU) are at risk of psychological distress and NICU-related stress. However, parents of infants admitted to NICU for cardiac surgery are an under-researched population.

AIMS

Identify levels of NICU-related stress, and levels of psychological distress, reported by parents of infants admitted to the NICU for cardiac surgery.

STUDY DESIGN

Observational study.

SUBJECTS

69 parents of infants admitted to the NICU for cardiac surgery (cardiac group) and 142 parents of healthy infants (control group).

OUTCOME MEASURES

Questionnaire packs provided to parents prior to discharge (time-point 1), and at six and 12months corrected age included: Hospital Anxiety and Depression Scale, Coping Inventory for Stressful Situations, and Family Support Scale. The Parental Stressor Scale:NICU was administered to the cardiac group at time-point 1.

RESULTS

The cardiac group reported (i) that parental role alteration was the most stressful aspect of the NICU and (ii) higher scores for anxiety and depression than the control group at all three time-points, with the highest levels reported during the NICU stay. Correlation analyses indicated (i) stress associated with the sights and sounds of the NICU, and the appearance and behaviour of the infant in the NICU, had a significant positive association with anxiety and depression, and (ii) a significant negative relationship between anxiety and task-focused coping.

CONCLUSIONS

An individualised parent-targeted intervention aimed at reducing stress associated with the NICU and enhancing task-focused coping style may help to reduce levels of anxiety and depression within this group of parents.

Epidemiologic transition in maternal mortality and morbidity: new challenges for Jamaica

OBJECTIVE

Given interventions implemented in recent years to reduce maternal deaths, we sought to determine the incidence and causes of maternal deaths for 1998-2003.

METHOD

Records of public hospitals and state pathologists were reviewed to identify pregnancy-related deaths within 12 months of delivery and determine their underlying causes.

RESULTS

Maternal mortality declined (p=0.023) since surveillance began in 1981-83. The fall in direct mortality (p=0.0003) included 24% fewer hypertension deaths (introduction of clinical guidelines, reorganization of antenatal services) and 36% fewer hemorrhage deaths (introduction of plasma expanders). These improvements were tempered by growing indirect mortality (p=0.057), moving to 31% of maternal deaths from 17% in 1993-95.

INTERPRETATION

Declines in direct mortality may be associated with surveillance and related improvements in obstetric care. Increased indirect deaths from HIV/AIDS, cardiac disease, sickle cell disease and asthma suggests the need to improve collaboration with medical teams to implement guidelines to care for pregnant women with chronic diseases.

Discovery of a granulovirus of Pandemis pyrusana (Lepidoptera: Tortricidae), a leafroller pest of apples in Washington

Pandemis pyrusana (Kearfott) is an important leafroller pest of apples in Washington. Surveys for natural enemies discovered a pathogen infecting Pandemis leafrollers in an apple orchard in central Washington. The pathogen was propagated in the laboratory and light microscopy using an azan stain demonstrated that it infected fat body, epidermis, and tracheal matrix cells. The virus was identified morphologically as a granulovirus using electron microscopy and designated PpGV. Rates of infection were determined for each generation in an apple orchard for three years. Infection rates were variable and ranged from 2.6 to 67% of individuals collected from each generation.

Gastroschisis: determinants of neonatal outcome

This retrospective study elicits information regarding the dependence of neonatal outcome in gastroschisis upon: (1) the mode of delivery, (2) place of birth, (3) time for birth to surgery, (4) method of closure, (5) time from operation to commencement of first enteral feeds. The neonatal intensive care database from five major tertiary centres was used to identify 181 neonates with gastroschisis from 1990 to 2000. There were 8 deaths. There were no significant differences in outcome for infants delivered vaginally (102) versus Caesarean section (79), those born near the tertiary centre (133) as compared to infants born away (48), ones operated within 7 hours (125) compared with those operated after 7 hours (56), with delayed closure (30) versus primary closure (151). Neonates fed within 10 days of operation (85) had significantly lower incidence of sepsis, duration of TPN and hospital stay when compared to those fed after 10 days (96). Early commencement of feeds decreases the incidence of sepsis, duration of total parenteral nutrition (TPN) and hospital stay. Place of delivery, mode of delivery, time to surgery and type of closure do not influence neonatal outcome.

Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants

BACKGROUND

Mechanical ventilation is commonly used in Neonatal Intensive Care Units to assist breathing in a variety of conditions. Mechanical ventilation is achieved through the placement of an endotracheal tube (ETT) which is left in-situ. The ETT is suctioned to prevent a build-up of secretions and therefore blockage of the airway. Methods of suctioning the endotracheal tube vary according to institutional practice and the individual clinician performing the task. The depth of suctioning is one of these variables. The catheter may be passed to the tip of the ETT or beyond the tip into the trachea or bronchi to facilitate removal of secretions. However, trauma to the lower airways may result from the suction catheter being passed into the airway beyond the tip of the endotracheal tube.

OBJECTIVES

To compare the effectiveness and complications of deep (catheter passed beyond the tip of the ETT) versus shallow (catheter passed to length of ETT only) suctioning of the endotracheal tube in ventilated infants.

SEARCH STRATEGY

Using text words and subject headings relevant to endotracheal suctioning, searches were made of the Oxford Database of Perinatal Trials, Cochrane Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (from January 1966 to December 2002, all languages), CINAHL (from 1982 to 2002). In addition, a call was placed on the list servers, NICU-NET and Neonatal-Talk for unpublished trials, conference presentations and current trials.

SELECTION CRITERIA

Controlled trials using random or quasi-random allocation of neonates receiving ventilatory support via an endotracheal tube to either deep or shallow endotracheal suctioning.

DATA COLLECTION AND ANALYSIS

No studies were found meeting the criteria for inclusion in this review

MAIN RESULTS

No studies were found meeting the criteria for inclusion in this review

REVIEWER'S CONCLUSIONS

There is no evidence from randomised controlled trials concerning the benefits or risks of deep versus shallow suctioning of endo-tracheal tubes in ventilated neonates and infants. Further high quality research would be required to conclusively establish whether there are any benefits to deep or shallow suctioning. However, as it may be considered unethical to conduct a trial of deep suctioning given anecdotal evidence regarding possible damage to the airway, it is proposed that a randomised controlled trial comparing deep with shallow suctioning may be considered in a NICU where the standard practice includes a deep suctioning technique.

Excision duodenoplasty: a new technique for congenital duodenal obstruction

Slow anastomotic function is a common problem in the management of congenital duodenal obstruction. We describe a simple technique of excision duodenoplasty (ED) that results in a fixed open anastomosis, which facilitates early commencement of feeds and discharge from hospital. A retrospective case-note review (1981-2000) was undertaken to compare the results of ED with side-to-side duodenoplasty (SSD) and diamond-shaped anastomosis (DD). The outcome measures were days to commencement of feeds, duration of total parenteral nutrition (TPN), and length of hospital stay. In ED a 1.0 to 1.5-cm elliptical segment of dilated duodenum is excised. A longitudinal incision is made in the smaller distal duodenum. A side-to-side one-layer anastomosis is performed. The wall of the proximal duodenal stump is thick, and excision of the ellipse keeps the anastomosis open by preventing apposition of the opposing walls. This facilitates good drainage across the anastomosis. The time to onset of feeding was longer after SSD (median 7 days) compared to ED (5 days) and DD (5 days). The total duration of TPN was also longer for SSD (9 days) in comparison to ED (7 days) and DD (7 days). Although the duration of hospital stay was more for SSD (18 days) than ED (13 days) and DD (16 days), this difference was not statistically significant. The ED technique thus gives an equally good result as DD and a better result than SSD. It is simple to perform and to teach.

Ancient Egyptian chronology and the astronomical orientation of pyramids

The ancient Egyptian pyramids at Giza have never been accurately dated, although we know that they were built approximately around the middle of the third millennium BC. The chronologies of this period have been reconstructed from surviving lists of kings and the lengths of their reigns, but the lists are rare, seldom complete and contain known inconsistencies and errors. As a result, the existing chronologies for that period (the Old Kingdom) can be considered accurate only to about +/-100 years, a figure that radiocarbon dating cannot at present improve. Here I use trends in the orientation of Old Kingdom pyramids to demonstrate that the Egyptians aligned them to north by using the simultaneous transit of two circumpolar stars. Modelling the precession of these stars yields a date for the start of construction of the Great Pyramid that is accurate to +/-5 yr, thereby providing an anchor for the Old Kingdom chronologies.

The best interest principle as a standard for decision making in the care of neonates

In neonatal care, decisions are made on behalf of newborn infants by their parents or, in some instances, health professionals. This paper examines how the best interest standard is the most appropriate focus for decision-making concerning neonates. The components of surrogate decision-making are discussed from the perspective of the neonate's interests and the contribution of the various persons involved in caring for neonates. An argument is presented for the use of best interests when making decisions and the interpretation of best interests is explored. By examining the ethical approaches using best interests, an argument is put forward for caring as an expression of best interests. How some nurses use the best interest standard in their practice is described. The unique perspective nurses may have because of their philosophy, circumstances, experience and concern for neonates is discussed. Examples are used from the literature to support the argument for nurses being in roles and relationships where the neonate's interests are the basis of practice. How nurses classify infants on the basis of their future outcome is used to illustrate how nurses can apply the best interest standard. Ethical approaches of care and cure are used to show the best interest standard as applied to neonates. Caring as an expression of best interests is recommended for nursing decisions and actions using infant outcomes as a focus for caring and best interests.

Nursing scripts and the organizational influences on critical thinking: report of a study of neonatal nurses' clinical reasoning

During 1995-1997 a study was undertaken to explore the extent to which theoretical knowledge acquired through a distance education programme in neonatal nursing was brought to bear in the real-world clinical reasoning of course participants. The study utilized a think aloud technique and included both concurrent (on-the-job) and retrospective verbal reports at 0, 6 and 12 months into the programme. Participants (n=4) were also interviewed individually on completion of the study. Results indicated that important inconsistencies existed between participants' theoretical knowledge and their practice; they also pointed to some organizational influences on these theory-practice inconsistencies. Script (or schema) theory provided a useful explanatory framework for these results. The paper includes a brief description of data collection and analysis techniques; its main emphasis, however, is on these theory-practice inconsistencies and their explanation in terms of the nature and acquisition of nursing practice scripts. The implications of nursing scripts for the promotion of critical thinking and evidence-based practice are discussed.

Nasal versus oral intubation for mechanical ventilation of newborn infants

BACKGROUND

This section is under preparation and will be included in the next issue.

OBJECTIVES

The purpose of the review was to compare the complications associated with intubation by the nasal route with those associated with intubation by the oral route for mechanical ventilation in newborn infants.

SEARCH STRATEGY

The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Register of Controlled Trials, MEDLINE and CINAHL. A call was placed on the list servers, NICU-NET and Neonatal Talk for unpublished trials, conference presentations and current trials.

SELECTION CRITERIA

All trials using random or quasi-random allocation of patients to either the nasal or oral route of intubation were included. Study quality and eligibility were assessed independently by each author.

DATA COLLECTION AND ANALYSIS

The standard method of the Cochrane Collaboration and the Neonatal Review Group was used to assess the methodological quality of the included studies. The methodological quality of each study was reviewed by the second author blinded to study authors and institutions. Each reviewer extracted data separately before comparison and resolution of differences. The standard method of the Neonatal Review Group was used to measure the effect of the different routes of intubation, using Relative Risk (RR) and 95% Confidence Intervals (CI).

MAIN RESULTS

Only two eligible randomized trials were found. Data from these two trials failed to show significant differences between the oral and nasal route of intubation for mechanically ventilated neonates. The rate of failure to intubate using the nasal route was higher in one study. One study found post extubation atelectasis occurred more frequently in nasally intubated infants who weighed less than 1500 grams. The rates of malposition of the tube at the initial intubation, accidental extubation, tube blockage, re-intubation after extubation, septicaemia, clinical infection and local trauma (nasal erosion or palatal groove) were not significantly different for the two groups.

REVIEWER'S CONCLUSIONS

Post extubation atelectasis may be more frequent after nasal intubation, particularly in very low birth weight infants. One route of intubation does not seem to be preferable to the other. There is a need for further randomized controlled trials containing larger numbers of infants.

Ethical issues for neonatal nurses

This article examines the involvement of neonatal nurses in ethical issues, achieved through a survey of Australian neonatal nurses. The aim was to discover if nurses were involved in ethical decisions, to examine various categories of neonates and the concerns that nurses felt about them, and to determine the extent to which nurses saw themselves as advocates. A response rate of 65% was achieved from nurses in two states who worked in intensive care and special care nurseries. The findings show that nurses were more likely to be involved in clinical decision making than in ethical decision making, showed the greatest concern for infants who had an uncertain prognosis, and saw themselves as advocates for their patients. The issues surrounding these findings are examined.

Differential influence of TGFbeta1 and TGFbeta3 isoforms on cell cycle kinetics and postirradiation recovery of normal and malignant colorectal epithelial cells

PURPOSE

A clonogenic assay was used to determine the effects of the growth factors TGFbeta1 and TGFbeta3 on the radiation responses of a normal rat epithelial cell line (IEC6) and a human colonic carcinoma epithelial cell line (Widr).

METHODS AND MATERIALS

The radiation sensitivity and ability to recover from potentially lethal damage (PLD), of preconfluent monolayer cultures, was assessed in the presence of the growth factors for 24 h prior to, during, and after irradiation.

RESULTS

The surviving fractions of both cell lines assessed immediately following irradiation were unaffected by TGFbeta1 or TGFbeta3. However, TGFbeta3 (but not TGFbeta1) significantly reduced the amount of PLD recovery in the Widr cells (but not in the IEC6 cells). This was associated with a reduction in the shoulder region of the survival curve, rather than a change in slope. A comparative analysis of the effects of TGFbetas 1 and 3 on cell cycle events in the two cell lines demonstrated significantly more Widr cells in the S phase, in the presence of TGFbeta3 only, compared to the controls. This remained constant both before and immediately following irradiation. In the IEC6 cell line TGFbeta3 produced an increase in the numbers of G1 phase cells, characteristic of a G1 arrest.

CONCLUSION

It seems likely that TGFbeta3-induced radiosensitisation in Widr cells, 6 h after a single dose of irradiation, is related to its effects on cell cycle events such that the failure of these cells to arrest in G1, either before or after irradiation, results in significantly reduced recovery from DNA damage. This, however, may not be the only mechanism by which this growth factor produces this effect. Indeed, it will also be necessary to investigate these effects in in vivo models and to determine the response to fractionated irradiation before the potential therapeutic benefit of both the differential effects observed between the two TGFbeta isoforms and also between the malignant and normal cell lines can be fully assessed.

Continuous infusion therapy with very high purity von Willebrand factor concentrate in patients with severe von Willebrand disease

Five patients with severe (type III) von Willebrand disease received, by continuous infusion, a solvent-detergent treated von Willebrand factor high purity concentrate to control haemostasis. The clinical indications for treatment included prophylaxis prior to orthopaedic, abdominal and tympanic membrane surgery, and treatment of epistaxis and trauma-related bleeding. Plasma vWf antigen and activity were normalized sooner than factor VIII:C levels after initial bolus followed by infusion of the concentrate. Haemostasis was established in all five patients. The degree of shortening of the bleeding time correlated with concentrate infusion rate and, therefore, with administered dose of high molecular weight multimers. Concentrate clearance decreased over time with continued infusion. The product was shown to be stable and sterile at 24 h after reconstitution with no evidence of neoantigen expression. This report illustrates the effectiveness of high purity vWf concentrate administered by continuous infusion and shows that high-molecular-weight multimers are required to shorten the bleeding time to within the normal range.

Mutation spectrum of copper-induced DNA damage

The ability of metal ions to damage DNA and cause mutagenesis has been analyzed with reversion and forward mutation assays using single-stranded DNA templates. We previously reported that incubation of phi X174 am3 DNA with Fe2+ in vitro results in mutagenesis when the treated DNA is transfected into Escherichia coli spheroplasts (Loeb, L. A., James, E. A., Waltersdorph, A. M., and Klebanoff, S. J. (1988) Proc. Natl. Acad. Sci. U.S.A. 85, 3918-3922, 1988). We now extend these studies to other metal ions. Of the metal ions tested, copper ions were the most mutagenic; the frequency of mutants produced was equal to or greater than that produced by Fe2+. Mutagenesis by Cu+ was diminished by catalase, mannitol, and superoxide dismutase suggesting the involvement of H2O2, hydroxyl ions, and superoxide, respectively. However, the findings that Cu+ and Cu2+ are nearly equally mutagenic and that the mutagenic activities are not completely inhibited by oxygen free radical scavengers make it unlikely that the mechanism for mutagenesis is simply the production of hydroxyl free radicals. The spectra of mutations produced by either copper ion using the lacZ gene as a target are very similar and differ from those reported with other agents. The predominant mutagenic sequence changes are single-base substitutions, the most frequent being replacement of a template C by a T. This transition presumably results from mispairing of an altered C with deoxyadenosine. Copper-induced mutations are not randomly distributed. Instead, they are found predominantly in clusters suggesting direct interaction of copper ions with specific nucleotide sequences in DNA. Evidence is considered that the high frequency of C----T transitions may be a common manifestation of DNA damage by oxygen radicals.