Heterozygous Kmt2d loss diminishes enhancers to render medulloblastoma cells vulnerable to combinatory inhibition of lysine demethylation and oxidative phosphorylation

The histone H3 lysine 4 (H3K4) methyltransferase KMT2D (also called MLL4) is one of the most frequently mutated epigenetic modifiers in medulloblastoma (MB) and other types of cancer. Notably, heterozygous loss of KMT2D is prevalent in MB and other cancer types. However, what role heterozygous KMT2D loss plays in tumorigenesis has not been well characterized. Here, we show that heterozygous Kmt2d loss highly promotes MB driven by heterozygous loss of the MB suppressor gene Ptch in mice. Heterozygous Kmt2d loss upregulated tumor-promoting programs, including oxidative phosphorylation and G-protein-coupled receptor signaling, in Ptch-mutant-driven MB genesis. Mechanistically, both downregulation of the transcription-repressive tumor suppressor gene NCOR2 by heterozygous Kmt2d loss and upregulation of the oncogene MycN by heterozygous Ptch loss increased the expression of tumor-promoting genes. Moreover, heterozygous Kmt2d loss extensively diminished enhancer signals (e.g., H3K27ac) and H3K4me3 signature, including those for tumor suppressor genes (e.g., Ncor2). Combinatory pharmacological inhibition of oxidative phosphorylation and the H3K4 demethylase LSD1 drastically reduced tumorigenicity of MB cells bearing heterozygous Kmt2d loss. These findings reveal the mechanistic basis underlying the MB-promoting effect of heterozygous KMT2D loss, provide a rationale for a therapeutic strategy for treatment of KMT2D-deficient MB, and have mechanistic implications for the molecular pathogenesis of other types of cancer bearing heterozygous KMT2D loss.

Innovation in Fischer–Tropsch: Developing Fundamental Understanding to Support Commercial Opportunities

In this contribution we provide details of the BP-Johnson Matthey proprietary Fischer–Tropsch technology and the advanced CANS reactor and catalyst system. The advanced CANS catalyst carrier reactor provides superior heat transfer, reduced pressure drop and higher productivity that lead to major economic savings. Fundamental understanding of catalyst behaviour is also key to obtaining a catalyst that is stable over the lifetime of its use. Synthesis, calcination and reduction steps introduce changes in the catalyst properties prior to syngas introduction. In particular, the presence of water can affect the final catalyst performance. The activity of a good catalyst can be significantly reduced by a sub-optimal activation or start-up. Similarly, stable operation and minimising deactivation are vital for long and stable catalyst life, with years of operation without requiring regeneration. In this report we also share a fundamental study on the catalyst activation across different catalyst supports. This combines advanced in situ techniques with reactor testing to explore the role of the support on catalyst performance. The results illustrate the critical need for a logical and systematic catalyst development programme to explore these effects to optimise the whole FT process. The combination of a joint approach in development plays a key role in a long term success in a process. The fundamental catalyst understanding, optimisation and improvements in combination with the novel CANS reactor design maximise their potential and offer the potential for a world leading technology.

Vaccine administration error rates at a large academic medical center and its affiliated clinics - Familiarity matters

OBJECTIVE

The purpose of this study was to track and describe the absolute number of vaccine administration errors and corresponding error rates over time and by patient age and vaccine type.

METHODS

Total vaccines administered to patients aged 0 through 19 years 364 days from 1/1/2006 through 12/31/2017 at a large academic health system in the Midwest United States with primary, specialty and school-based clinics, and a pediatric hospital were obtained from an electronic medical record. Vaccine administration errors over the same time period for the same patient criteria were analyzed from the health system's incident reporting system and further compared to the frequency of all incidents reported. Vaccine administration error rates were calculated. Data were analyzed by patient age, vaccine type and year administered.

RESULTS

Of the 1,431,206 vaccine doses given, 552 vaccine administration errors were identified (0.04%). The highest error rates occurred in children aged 2, 3, and 19 years. Vaccine types with the highest error rate were Td, rabies and pneumococcal polysaccharide vaccines. Overall vaccine doses given and errors reported increased over the study period. However, the increase was disproportionate, resulting in an increase in the error rate initially followed by a stabilization at the end of the study period.

CONCLUSIONS

Vaccine administration errors are uncommon. The error rate appears to be stabilizing. Errors are more likely at ages when vaccines are not commonly given, with vaccines that have age-specific dosing and with vaccines that are given less often. This suggests more safety checks are needed for vaccines that are rarely used or given off-schedule, and manufacturers should avoid vaccines with age-specific dosing.

Contributions of Social Comparison and Self-Objectification in Mediating Associations Between Facebook Use and Emergent Adults' Psychological Well-Being

Although Facebook was created to help people feel connected with each other, data indicate that regular usage has both negative and positive connections to well-being. To explore these mixed results, we tested the role of social comparison and self-objectification as possible mediators of the link between Facebook use and three facets of psychological well-being: self-esteem, mental health, and body shame. Participants were 1,104 undergraduate women and men who completed surveys assessing their Facebook usage (minutes, passive use, and active use), social comparison, self-objectification, and well-being. Data were analyzed using structural equation modeling, testing separate models for women and men. Models for each gender fit the data well. For women and men, Facebook use was associated with greater social comparison and greater self-objectification, which, in turn, was each related to lower self-esteem, poorer mental health, and greater body shame. Mediated models provided better fits to the data than models testing direct pathways to the mediators and well-being variables. Implications are discussed for young people's social media use, and future directions are provided.

Use of Structured Self-Monitoring in Transplant Education

A self-assessment instrument for use at home by transplant recipients was developed to help foster partnership between patients and their healthcare provider. Self-monitoring at home has not replaced the need for close follow-up but does allow patients to provide concrete data to their healthcare provider in order to promote earlier detection of and response to adverse events. Patients are taught the essentials of self-monitoring while they are in the hospital for their transplant. Patients who perform routine self-assessment would be able to detect and provide information about problems early in the course of events. Thus, early intervention could potentially decrease the severity of the problem and prevent repeated hospitalizations. The concern that patients would not be able to perform a reliable self-assessment was unfounded; patients exceeded expectations and embraced the opportunity to communicate physical signs and symptoms effectively.

Abstract P1-09-11: Can patient navigation help overcome barriers to breast cancer treatment in patients with health care disparities?

Background: Patient navigation has been demonstrated to aid in adherence to breast cancer screening initiatives. Fewer studies have documented benefit for patients undergoing treatment, and especially among those with barriers to care. Cancer health disparities affecting low-income and minority patients are well documented. Causes of poor outcomes include treatment delays coupled with social and financial barriers. This report examines the impact of patient navigation on adherence to prescribed cancer treatment, including in patients receiving treatment in adjuvant and metastatic breast cancer settings.

Methods: This Patient Navigation project (supported by an Avon Foundation grant) was initiated at our public safety net hospital to test whether there was sufficient benefit to warrant a larger randomized trial. Health care coverage included 58% Medicaid, 7% uninsured or undocumented. This study was conducted over a 4 month period with new medical oncology practice patients. Those deemed to be at high risk for non-adherence received navigated care. Navigator duties included care coordination, appointment reminders, patient education materials, translation services, and transportation arrangement. Data collected prospectively included patient characteristics, cancer type, time from referral to first RT, and compliance with visits; this was compared with usual care controls during the 4 month period.

Results: Patient Navigation Program patient characteristics: N = 52 patients (42% breast cancer, 12% prostate cancer, 10% lung cancer and 36% with other cancers). Mean age = 55; 48% Black, 38% Hispanic, 8% Asian, 6% White. The table below gives the results of percentage of adherence to visits (and time to first RT) for all patients in the study receiving navigated care, for just the patients with breast cancer receiving navigated care, and for the usual care control (no navigated care).

Table 1. NAVIGATED CARE: ALL PATIENTS (N = 52)NAVIGATED CARE: BREAST CANCER (n = 22)USUAL CARE GROUPPhysician Visits (Medical Oncology)(141 Visits) 90% (95% CI: 84%-95%)(56 Visits) 91% (95% CI: 80%-97%)(2021 Visits) 79% (95% CI: 77%-81%)Chemotherapy Treatment(107 Treatments) 95% (95% CI: 89%-99%)(30 Treatments) 97% (95% CI: 83%-99%)(1656 Treatments) 86% (95% CI: 84%-88%)Time to first RT32 Days (n = 25)35 Days (n = 8)30 Days

Conclusions: This Patient Navigation Program is associated with observed improvements in adherence to chemotherapy and in follow up physician visits. No impact on time to first RT was shown. These results document that a Patient Navigation Program can help overcome barriers to good cancer care.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-11.

Boys do it the right way: sex-dependent amygdala lateralization during face processing in adolescents

Previous studies have observed a sex-dependent lateralization of amygdala activation related to emotional memory. Specifically, it was shown that the activity of the right amygdala correlates significantly stronger with memory for images judged as arousing in men than in women, and that there is a significantly stronger relationship in women than in men between activity of the left amygdala and memory for arousing images. Using a large sample of 235 male adolescents and 235 females matched for age and handedness, we investigated the sex-specific lateralization of amygdala activation during an emotional face perception fMRI task. Performing a formal sex by hemisphere analysis, we observed in males a significantly stronger right amygdala activation as compared to females. Our results indicate that adolescents display a sex-dependent lateralization of amygdala activation that is also present in basic processes of emotional perception. This finding suggests a sex-dependent development of human emotion processing and may further implicate possible etiological pathways for mental disorders most frequent in adolescent males (i.e., conduct disorder).

The IMAGEN study: reinforcement-related behaviour in normal brain function and psychopathology

A fundamental function of the brain is to evaluate the emotional and motivational significance of stimuli and to adapt behaviour accordingly. The IMAGEN study is the first multicentre genetic-neuroimaging study aimed at identifying the genetic and neurobiological basis of individual variability in impulsivity, reinforcer sensitivity and emotional reactivity, and determining their predictive value for the development of frequent psychiatric disorders. Comprehensive behavioural and neuropsychological characterization, functional and structural neuroimaging and genome-wide association analyses of 2000 14-year-old adolescents are combined with functional genetics in animal and human models. Results will be validated in 1000 adolescents from the Canadian Saguenay Youth Study. The sample will be followed up longitudinally at the age of 16 years to investigate the predictive value of genetics and intermediate phenotypes for the development of frequent psychiatric disorders. This review describes the strategies the IMAGEN consortium used to meet the challenges posed by large-scale multicentre imaging-genomics investigations. We provide detailed methods and Standard Operating Procedures that we hope will be helpful for the design of future studies. These include standardization of the clinical, psychometric and neuroimaging-acquisition protocols, development of a central database for efficient analyses of large multimodal data sets and new analytic approaches to large-scale genetic neuroimaging analyses.

The characterization of a promising new optical source for use with a radiotherapy treatment simulator

We report on an experimental examination of a new powerful optical source with potential application in radiotherapy treatment simulation. The illuminance, effective source position, and source size have been measured for this new source and, for comparison, for conventional sources on a simulator and a linear accelerator. This new source is considerably brighter than those in common use in radiotherapy. Its effective optical source size is larger than that on the linear accelerator tested but comparable with that on a conventional simulator.

Successful therapy of a human lung cancer xenograft using MAb RS7 labeled with residualizing radioiodine

We have recently reported that a radioiodinated, DTPA-appended peptide, designated IMP-R1, is a residualizing iodine label that overcomes many of the limitations that have impeded the development of residualizing iodine for clinical use. In this study the potential of 131I-IMP-R1-RS7, an internalizing anti-EGP-1 monoclonal antibody, was evaluated by performing preclinical therapy studies in nude mice bearing Calu-3 human non-small cell carcinoma of the lung xenografis. Elimination of 6 of 9 established tumors (mean tumor volume=0.3 cm(3)) was observed using a single dose of 350 microCi/mouse of 131I-IMP-R1-RS7, with all animals tolerating the dose. At the same dose and specific activity of 131I-RS7, labeled using the conventional chloramine-T method, there were four deaths, and one complete remission in nine treated mice. At the maximum tolerated dose of conventionally 131I-labeled RS7, 275 microCi, mean stable disease for approximately 5 weeks was observed, with no complete responses. Specificity of the therapeutic effect was shown in an isotype-matched control experiment, where 131I-IMP-R1-RS7 was markedly more effective than the (131)I-IMP-R1-labeled control antibody. These studies demonstrate that (131)I-IMP-R1-RS7 provides a therapeutic advantage in comparison to conventional 131I-labeled RS7, as predicted by the increased tumor accretion observed previously in targeting studies. A direct comparison of the maximum tolerated doses of (131)I-IMP-R1-RS7 (350 microCi) and 90Y-DOTA-RS7 (105 microCi) was performed in this tumor model using large established tumors (mean tumor volume=0.85 cm(3)). Anti-tumor efficacy and toxicity of the two treatments were comparable.

Use of structured self-monitoring in transplant education

A self-assessment instrument for use at home by transplant recipients was developed to help foster partnership between patients and their healthcare provider. Self-monitoring at home has not replaced the need for close follow-up but does allow patients to provide concrete data to their healthcare provider in order to promote earlier detection of and response to adverse events. Patients are taught the essentials of self-monitoring while they are in the hospital for their transplant. Patients who perform routine self-assessment would be able to detect and provide information about problems early in the course of events. Thus, early intervention could potentially decrease the severity of the problem and prevent repeated hospitalizations. The concern that patients would not be able to perform a reliable self-assessment was unfounded; patients exceeded expectations and embraced the opportunity to communicate physical signs and symptoms effectively.

Radioimmunotherapy of a human lung cancer xenograft with monoclonal antibody RS7: evaluation of (177)Lu and comparison of its efficacy with that of (90)Y and residualizing (131)I

Tumor targeting and therapeutic efficacy of (177)Lu-labeled monoclonal antibody (mAb) RS7 (antiepithelial glycoprotein-1) was evaluated in a human nonsmall cell lung carcinoma xenograft model. The potential of (177)Lu-labeled RS7 was compared with that of RS7 labeled with (90)Y and a residualizing form of (131)I.

METHODS

A 1,4,7,10-tetraazacyclododecane-N,N',N",N"'-tetraacetic acid (DOTA) conjugate of RS7 was used for radiolabeling with (177)Lu-acetate or (88/90)Y-acetate. Biodistribution and therapy studies were conducted in nude mice with subcutaneous Calu-3 xenografts. Therapy studies were performed using the maximal tolerated doses (MTDs) of (90)Y-DOTA-RS7 (3.9 MBq [105 microCi]) and (177)Lu-DOTA-RS7 (10.2 MBq [275 microCi]) and compared with the data obtained using the MTD (13.0 MBq [350 microCi]) of a residualizing form of (131)I-RS7.

RESULTS

Radiolabeling of RS7-DOTA conjugate with (177)Lu-acetate was facile. (177)Lu-DOTA-RS7 displayed biodistribution results that were nearly identical to that of the (88)Y analog in a paired-label study. The mean percentage injected doses per gram (%ID/g) for (177)Lu-RS7 and (88)Y-RS7 (in parentheses) in tumor were 38.3 %ID/g (39.1 %ID/g), 63.0 %ID/g (66.0 %ID/g), 63.0 %ID/g (65.8 %ID/g), and 34.0 %ID/g (34.9 %ID/g) on days 1, 3, 7, and 14, respectively. Elimination of established tumors, with an initial mean tumor volume of 0.24 cm(3), was shown using doses of (177)Lu-DOTA-RS7 ranging from 5.6 to 9.3 MBq (150--250 microCi) per nude mouse, with no significant difference in response rate noted between the doses in this range. Specificity of the therapeutic effect was shown in an isotype-matched control experiment, in which (177)Lu-DOTA-RS7 was markedly more effective than the (177)Lu-DOTA control antibody. A comparison of the therapeutic efficacies of (177)Lu-DOTA-RS7 and (90)Y-DOTA-RS7, using mice with established tumors with an initial mean tumor volume of 0.85 cm(3), indicated similar tumor growth inhibition and similar tumor regrowth profiles. The therapy data were similar to those obtained with residualizing (131)I-RS7 obtained at the same time.

CONCLUSION

(177)Lu-RS7 is an effective radioimmunoconjugate for radioimmunotherapy. With its radiophysical properties similar to those of (131)I, coupled with its facile and stable attachment to mAb, (177)Lu promises to be an alternative to (131)I, and a complement to (90)Y, in radioimmunotherapy.

Changes in foot function with the use of Root and Blake orthoses

This study examined the effects of two designs of rigid foot orthoses on plantar pressure measurements and identified differences between the devices. While wearing modified Root- and Blake-style orthoses, 27 subjects were examined with the Electrodynogram (EDG) in-shoe pressure measurement system. Reliability testing was performed on the EDG data. Significant changes were observed in the temporal parameters of gait when subjects wore the orthoses. When the devices were used, the duration of some of the components of stance phase was altered, and the initiation of loading beneath the medial forefoot was delayed. A reduction in the total duration of loading at discrete sites beneath the heel and forefoot was also observed. The effects of the two orthoses were similar, with only small differences observed between the devices.

Integrating the Internet into health administration education: a report from AUPHA's Faculty Internet integration task force

HRSA funded a survey to determine what Internet resources would be most useful to AUPHA membership. This manuscript describes the Internet-intensive survey methodology, reports the survey results, and lists the task force recommendations. The task force used sequential questionnaires posted on the Web to gather both potentially useful Internet resource ideas and membership perceptions of the importance of each idea. Resources recommended by survey participants and the Task Force members emphasized potential improvements to the AUPHA and AUPHA-member Web pages.

Brain trauma in aged transgenic mice induces regression of established abeta deposits

Traumatic brain injury (TBI) increases susceptibility to Alzheimer's disease (AD), but it is not known if TBI affects the progression of AD. To address this question, we studied the neuropathological consequences of TBI in transgenic (TG) mice with a mutant human Abeta precursor protein (APP) mini-gene driven by a platelet-derived (PD) growth factor promoter resulting in overexpression of mutant APP (V717F), elevated brain Abeta levels, and AD-like amyloidosis. Since brain Abeta deposits first appear in 6-month-old TG (PDAPP) mice and accumulate with age, 2-year-old PDAPP and wild-type (WT) mice were subjected to controlled cortical impact (CCI) TBI or sham treatment. At 1, 9, and 16 weeks after TBI, neuron loss, gliosis, and atrophy were most prominent near the CCI site in PDAPP and WT mice. However, there also was a remarkable regression in the Abeta amyloid plaque burden in the hippocampus ipsilateral to TBI compared to the contralateral hippocampus of the PDAPP mice by 16 weeks postinjury. Thus, these data suggest that previously accumulated Abeta plaques resulting from progressive amyloidosis in the AD brain also may be reversible.

Changes in patterns of 24-hr heart rate variability after kidney and kidney-pancreas transplant

BACKGROUND

Transplantation has been shown to improve cardiorespiratory reflex measures of autonomic function. However, there are limited data on how kidney or kidney-pancreas transplantation influence continuous autonomic modulation of heart rate and the clinical utility of 24-hr heart rate variability (HRV) monitoring.

METHODS

Ninety nondiabetic kidney and 30 diabetic kidney-pancreas transplant recipients underwent 24-hr Holter monitoring before and again at 6 and 12 months posttransplantation. Tapes were submitted for determination of HRV including interbeat variability (the proportion of adjacent R-R intervals having a difference <50 msec, the SD of all R-R intervals for the entire recording, and the SD of the averages of R-R intervals calculated over 5-min blocks for the entire recording) which is associated with vagal function, sudden death, and circadian function, respectively. Power spectral analysis quantified total neural, sympathetic, and parasympathetic modulation of the heart in ln(msec2).

RESULTS

Nondiabetic kidney recipients showed improvement (P< or =0.05) in the SD of the averages of R-R intervals calculated over 5-min blocks (83.2 vs. 95.7 msec) and the SD of all R-R intervals (94.5 vs. 104.4 msec) by 6 months and all groups showed improvement by 12 months. Kidney-pancreas recipients also showed improved total neural (4.35 vs. 4.64) and sympathetic modulation (2.70 vs. 3.13). Kidney-pancreas recipients had significantly poorer values for each measure (P< or =0.05) at all time points.

CONCLUSIONS

Cardiac autonomic neuropathy arises in the presence of uremia and diabetes, with severe dysfunction seen when these conditions occur concomitantly. Improvement in cardiac autonomic function follows both kidney and kidney-pancreas transplantation with more pronounced improvement in the circadian measures. Therefore, circadian measures of 24-hr HRV could be used to monitor the restoration of cardiac autonomic function.

Assessment of lead toxicity to the marine bacterium, Vibrio fischeri, and to a heterogeneous population of microorganisms derived from the Pearl River in Jackson, Mississippi, USA

Microorganisms are known to be excellent test organisms because of the relative ease for handling and suitability for analysis related to their small size, large number and convenient growing conditions. In this research, we tested the toxic effects of lead against a marine bacterium (Vibrio fischeri), and a heterogeneous population of bacteria derived from the Pearl River in Jackson, Mississippi. Using the level of bioluminescence in the Microtox Assay (V. fischeri), and the kinetics of dissolved oxygen uptake and growth (mixed bacterial population) as measures of toxicity, lead concentrations effecting a 50% reduction in these parameters (EC50) were determined as the toxic end-points. The activity quotients were also computed to determine the degrees of toxicity. Optical density (measure of growth) and oxygen uptake were measured over an extended period of time (20 h). EC50 values of 0.34 +/- 0.03, 3.10 +/- 0.01, and 3.80 +/- 0.02 mg/L were recorded for bioluminescence, growth, and oxygen uptake, respectively. As expected, the results indicated that the sensitivity to lead toxicity of V. fischeri was about one order of magnitude (10 times) greater than that of the mixed population of Pearl River microorganisms. Reductions in bioluminescence, growth, and oxygen uptake were directly correlated to lead concentrations, with toxic levels ranging from slightly toxic in lower concentrations to extremely toxic in higher concentrations. Upon 20 h of exposure, the times required to produce 50% reduction in dissolved oxygen uptake were (TD50S) 8.01 +/- 0.44, 9.60 +/- 0.46, 11.29 +/- 0.46, 13.03 +/- 0.57, 17.32 +/- 0.95, and 20.00 +/- 0.00 h in 0, 1, 2, 3, 4, 5, and 6 mg/L of lead, respectively, indicating a time-response relationship with respect to lead toxicity.

Mutation-specific functional impairments in distinct tau isoforms of hereditary FTDP-17

Tau proteins aggregate as cytoplasmic inclusions in a number of neurodegenerative diseases, including Alzheimer's disease and hereditary frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17). Over 10 exonic and intronic mutations in the tau gene have been identified in about 20 FTDP-17 families. Analyses of soluble and insoluble tau proteins from brains of FTDP-17 patients indicated that different pathogenic mutations differentially altered distinct biochemical properties and stoichiometry of brain tau isoforms. Functional assays of recombinant tau proteins with different FTDP-17 missense mutations implicated all but one of these mutations in disease pathogenesis by reducing the ability of tau to bind microtubules and promote microtubule assembly.

Pathogenic implications of mutations in the tau gene in pallido-ponto-nigral degeneration and related neurodegenerative disorders linked to chromosome 17

Pallido-ponto-nigral degeneration (PPND) is one of the most well characterized familial neurodegenerative disorders linked to chromosome 17q21-22. These hereditary disorders are known collectively as frontotemporal dementia (FTD) and parkinsonism linked to chromosome 17 (FTDP-17). Although the clinical features and associated regional variations in the neuronal loss observed in different FTDP-17 kindreds are diverse, the diagnostic lesions of FTDP-17 brains are tau-rich filaments in the cytoplasm of specific subpopulations of neurons and glial cells. The microtubule associated protein (tau) gene is located on chromosome 17q21-22. For these reasons, we investigated the possibility that PPND and other FTDP-17 syndromes might be caused by mutations in the tau gene. Two missense mutations in exon 10 of the tau gene that segregate with disease, Asn279(Lys) in the PPND kindred and Pro301(Leu) in four other FTDP-17 kindreds, were found. A third mutation was found in the intron adjacent to the 3' splice site of exon 10 in patients from another FTDP-17 family. Transcripts that contain exon 10 encode tau isoforms with four microtubule (MT)-binding repeats (4Rtau) as opposed to tau isoforms with three MT-binding repeats (3Rtau). The insoluble tau aggregates isolated from brains of patients with each mutation were analyzed by immunoblotting using tau-specific antibodies. For each of three mutations, abnormal tau with an apparent Mr of 64 and 69 was observed. The dephosphorylated material comigrated with tau isoforms containing exon 10 having four MT-binding repeats but not with 3Rtau. Thus, the brains of patients with both the missense mutations and the splice junction mutation contain aggregates of insoluble 4Rtau in filamentous inclusions, which may lead to neurodegeneration.

Frequency of 22q11 deletions in patients with conotruncal defects

OBJECTIVES

This study was designed to determine the frequency of 22q11 deletions in a large, prospectively ascertained sample of patients with conotruncal defects and to evaluate the deletion frequency when additional cardiac findings are also considered.

BACKGROUND

Chromosome 22q11 deletions are present in the majority of patients with DiGeorge, velocardiofacial and conotruncal anomaly face syndromes in which conotruncal defects are a cardinal feature. Previous studies suggest that a substantial number of patients with congenital heart disease have a 22q11 deletion.

METHODS

Two hundred fifty-one patients with conotruncal defects were prospectively enrolled into the study and screened for the presence of a 22q11 deletion.

RESULTS

Deletions were found in 50.0% with interrupted aortic arch (IAA), 34.5% of patients with truncus arteriosus (TA), and 15.9% with tetralogy of Fallot (TOF). Two of 6 patients with a posterior malalignment type ventricular septal defect (PMVSD) and only 1 of 20 patients with double outlet right ventricle were found to have a 22q11 deletion. None of the 45 patients with transposition of the great arteries had a deletion. The frequency of 22q11 deletions was higher in patients with anomalies of the pulmonary arteries, aortic arch or its major branches as compared to patients with a normal left aortic arch regardless of intracardiac anatomy.

CONCLUSIONS

A substantial proportion of patients with IAA, TA, TOF and PMVSD have a deletion of chromosome 22q11. Deletions are more common in patients with aortic arch or vessel anomalies. These results begin to define guidelines for deletion screening of patients with conotruncal defects.

Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review

OBJECTIVE

The authors' objective was to resolve the current controversies surrounding the diagnosis and management of blunt pancreatic trauma (BPT).

SUMMARY BACKGROUND DATA

The diagnosis of BPT is notoriously difficult: serum amylase has been claimed to be neither sensitive nor specific, and recent anecdotal reports have suggested a role for computed tomography. The therapy of BPT has been controversial, with some suggesting selective observation and others advocating immediate exploration to prevent a delay-induced escalation in morbidity and death.

METHODS

The authors conducted a retrospective chart review of documented BPT from six institutions, using a standardized binary data form composed of 187 items and 237 data fields.

RESULTS

A significant correlation between pancreas-specific morbidity and injury to the main pancreatic duct (MPD) was noted. Patients requiring delayed surgical intervention after an unsuccessful period of observation demonstrated notably higher pancreas-specific mortality and morbidity rates, principally because of the incidence of unrecognized injuries to the MPD. Although detection of MPD injuries by computed tomography was no better than flipping a coin, endoscopic pancreatography was accurate in each of the five cases in which it was used.

CONCLUSIONS

The principal cause of pancreas-specific morbidity after BPT is injury to the MPD. Parenchymal pancreatic injuries not involving the ductal system rarely result in pancreas-specific morbidity or death. Delay in recognizing MPD injury leads to increased mortality and morbidity rates. CT is unreliable in diagnosing MPD injury and should not be used to guide therapy. Initial selection of patients with isolated BPT for observation or surgery can be based on the determination of MPD integrity.

Adverse patient occurrences as a measure of nursing care quality

OBJECTIVE

The purpose of this study was to describe relationships among adverse patient occurrences aggregated at the unit level of measurement. Relationships between adverse occurrences and a patient acuity measure were also described.

BACKGROUND

Adverse patient occurrence data have been traditionally a major indicator of quality care in hospitals; however, few studies have examined relationships among these indicators or the usefulness of these indicators for assessing the quality of nursing care.

METHODS

A correlational design was used to examine and describe patterns of relationships among in-patient units in a tertiary care hospital. The results demonstrated positive correlations between medication error rates and patient falls; these adverse occurrences correlated negatively with pressure ulcers, infections, patient complaints, and death. Pressure ulcers, infections, patient complaints and death intercorrelated positively and also related positively to patient acuity levels.

RESULTS

An examination of these same rates for a subset of units with similar patient acuity levels revealed that most of the interrelationships among the entire set of adverse occurrence indicators were positive. When patient acuity was taken into account, these adverse outcomes appeared to indicate some common underlying characteristic of the units, such as quality of nursing care.

CONCLUSIONS

This study suggests a relationship between the adverse occurrences that were correlated (pressure ulcers, patient complaints, infection, and death) and the severity of patient illness. Medication error rates and patient fall rates were not correlated with patient acuity and are more likely to indicate quality of nursing care across all types of units.

Pharmaceutical practice management

BACKGROUND

Being accomplished in the short span of 21 years the number of states granting therapeutic optometric privileges has now reached 50. Since health care reform is also expanding, optometrists' prescribing responsibilities will probably increase in proportion to their clinical demands.

PURPOSE

In addition to clinical expertise, optometrists should possess practical knowledge about pharmaceutical industry practices and the effects of managed care. This article addresses issues such as drug pricing and distribution, reimbursement, and patient costs, which can affect pharmaceutical dispensing.

CONCLUSION

Optometrists should become aware of "nonclinical" prescribing influences that can affect patients. By doing so, they can make informed decisions about the products they prescribe, to ensure optimum patient care and compliance.

Nurse staffing and patient outcomes

BACKGROUND

Nursing studies have shown that nursing care delivery changes affect staff and organizational outcomes, but the effects on client outcomes have not been studied sufficiently.

OBJECTIVE

To describe, at the level of the nursing care unit, the relationships among total hours of nursing care, registered nurse (RN) skill mix, and adverse patient outcomes.

METHODS

The adverse outcomes included unit rates of medication errors, patient falls, skin breakdown, patient and family complaints, infections, and deaths. The correlations among staffing variables and outcome variables were determined, and multivariate analyses, controlling for patient acuity, were completed.

RESULTS

Units with higher average patient acuity had lower rates of medication errors and patient falls but higher rates of the other adverse outcomes. With average patient acuity on the unit controlled, the proportion of hours of care delivered by RNs was inversely related to the unit rates of medication errors, decubiti, and patient complaints. Total hours of care from all nursing personnel were associated directly with the rates of decubiti, complaints, and mortality. An unexpected finding was that the relationship between RN proportion of care was curvilinear; as the RN proportion increased, rates of adverse outcomes decreased up to 87.5%. Above that level, as RN proportion increased, the adverse outcome rates also increased.

CONCLUSIONS

The higher the RN skill mix, the lower the incidence of adverse occurrences on inpatient care units.

Perceptual and behavioral manifestations of the Chronic Illness and Recovery models among clinical transplant coordinators

This descriptive, qualitative study examines manifestations of the Chronic Illness and Recovery models among clinical transplant coordinators. Data collected through focused group interviews revealed that the Chronic Illness model fosters patient dependency, education about the illness itself, a perception that transplantation does not change the chronic nature of illness, a view of patients as socioeconomically disadvantaged and dependent on the transplant center, and the use of reactive approaches to care. In contrast, the Recovery model encourages patient independence, limits coordinators' protective feelings toward patients, provides education for life tasks, perceives patients as socioeconomically advantaged people capable of managing their own lives, and conducts patient care in a proactive manner.

Juvenile rheumatoid arthritis-like polyarthritis in chromosome 22q11.2 deletion syndrome (DiGeorge anomalad/velocardiofacial syndrome/conotruncal anomaly face syndrome)

OBJECTIVE

To investigate the association of polyarthritis and chromosome 22q11.2 deletions.

METHODS

Eighty patients with chromosome 22q11.2 deletion syndrome followed up at The Children's Hospital of Philadelphia were examined for evidence of arthropathy or arthritis. Patients with chromosome 22q11.2 deletion syndrome and polyarthritis underwent laboratory evaluations of immunologic function to determine the relationship of their immunodeficiency to the polyarthritis.

RESULTS

The prevalence of polyarthritis in patients with chromosome 22q11.2 deletion syndrome was markedly increased over the prevalence of polyarticular juvenile rheumatoid arthritis (JRA) in the general population. All 3 patients with polyarthritis had evidence of impaired T cell function. Two of the patients with polyarthritis also had IgA deficiency.

CONCLUSION

The chromosome 22q11.2 deletion syndrome represents a primary T cell disorder which can be associated with a JRA-like polyarthritis. All 3 patients with polyarthritis had evidence of more extensive immunoregulatory derangements than those typically seen in patients with chromosome 22q11.2 deletion, and these derangements may have predisposed to the development of polyarthritis.

Cerebral amyloid angiopathy presenting as a nonhemorrhagic, infiltrating mass

We present a case of biopsy-proven cerebral amyloid angiopathy mimicking a unilateral, non-hemorrhagic, infiltrating, intra-axial mass on MRI. The patient was treated with steroids, with clinical improvement and significant resolution of the MRI abnormalities.

Who should give lifestyle advice in general practice and what factors influence attendance at health promotion clinics? Survey of patients' views

BACKGROUND

Health promotion activity in general practice has increased greatly since 1990. A large proportion of this work is undertaken by practice nurses. Little is known about patients' views about the providers of health promotion or their views about general practice health promotion clinics.

AIM

A study was carried out in 1992 to determine patients' views about the provision of health promotion advice by general practitioners and practice nurses and their views about attending health promotion clinics.

METHOD

A postal questionnaire was sent to a random sample of 1750 patients aged 16 years and over from five general practices in south Tyneside. The questionnaire explored patients' preferences regarding health promotion advice from the general practitioner or practice nurse in relation to four areas of lifestyle advice and factors that might encourage patients to attend a health promotion clinic.

RESULTS

A response rate of 75% was obtained from 1639 eligible patients. Receiving health promotion advice from either the general practitioner or the practice nurse was the most commonly preferred option expressed by patients overall. The ability of health promotion clinic staff to deal with patients' concerns about their illness and short waiting times were more likely to influence patients' attendance at health promotion clinics than the presence of a general practitioner or practice nurse.

CONCLUSION

In the present study, many patients found health advice received from practice nurses and general practitioners equally acceptable. However, it was the ability of health professionals to respond to patients' health concerns in the health promotion clinic rather than the type of health professional running the clinic that was important for patients.