Hypokalaemia associated with excessive cola-flavoured drinks consumption

We present a case involving a male patient in his 30s who was admitted to hospital due to recurrent episodes of hypokalaemia over the past 5 years. His medical history revealed hypertension, attention deficit hyperactivity disorder (ADHD), autism, and paranoia. He was taking citalopram, ramipril, amlodipine, and pramipexole. Tests indicated normal levels of aldosterone/renin ratio and plasma metanephrines. On reviewing his dietary history, it was noted that he consumed 3 to 3.5 L of cola-flavoured drinks on a daily basis. Normal potassium levels were achieved after a significant reduction in cola-flavoured drinks intake and potassium replacement. Subsequent outpatient clinic follow-up revealed that normal potassium levels were maintained even after the patient ceased taking potassium replacement tablets. Given the rarity of hypokalaemia associated with fizzy drinks, the underlying mechanism for this association remains unclear. In this case report, we attempt to provide a possible explanation for the involved mechanisms.

Health service COVID-19 wellbeing and support initiatives: a mixed-methods evaluation

BACKGROUND

Health services implemented a range of initiatives during the COVID-19 pandemic to support employee wellbeing and assist employees to manage the professional and personal challenges they experienced. However, it is not known if such initiatives were acceptable to employees or met their needs.

AIMS

To evaluate the wellbeing and support initiatives implemented at an Australian health service during the COVID-19 pandemic from the perspectives of employees (both users and non-users) and key stakeholders.

METHODS

A mixed-methods design (survey, interviews and data audit) to investigate employees' and key stakeholders' perceptions, experiences and use of the wellbeing and support initiatives implemented at a large tertiary metropolitan health service in Melbourne, Australia.

RESULTS

Ten employees participated in an interview and 907 completed a survey. The initiatives were well used and appreciated by staff. There was no significant difference in the proportion of clinical staff who had used the initiatives compared to non-clinical staff (44% versus 39%; P=0.223). Survey respondents reported the initiatives improved their mental health (n = 223, 8%), ability to cope with COVID-19 related stress and anxiety (n = 206, 79%), do their work (n = 200, 77%) and relationships with colleagues (n = 174, 67%). Staff would like many of the initiatives (with some modifications) to continue after the COVID-19 pandemic.

CONCLUSIONS

The findings suggest a high level of staff satisfaction with the implemented wellbeing and support initiatives, and confirm the need for, and importance of, developing and implementing initiatives to support health service staff during outbreaks of infectious diseases such as the COVID-19 pandemic.

Placental volume at 11 weeks is associated with offspring bone mass at birth and in later childhood: Findings from the Southampton Women's Survey

OBJECTIVES

To investigate associations between placental volume (PV) at 11 weeks' gestation and offspring bone outcomes at birth, 6 years and 8 years.

METHODS

3D ultrasound scanning was used to assess 11 week PV in a subset (n = 236) of the Southampton Women's Survey (a prospective mother-offspring cohort). Maternal anthropometric measures and lifestyle information were obtained pre-pregnancy and at 11 weeks' gestation. Offspring dual-energy x-ray absorptiometry scanning was performed within 2 weeks postnatally and at 6 and 8 years. Linear regression was used to assess associations between PV and bone outcomes, adjusting for offspring age at DXA and sex, and maternal age, height, smoking status, walking speed and triceps skinfold thickness. β are SD change in bone outcome per SD change in PV.

RESULTS

In adjusted models, 11 week PV was positively associated with bone area (BA) at all time points, with evidence of persisting associations with increasing childhood age (birth: n = 80, β = 0.23 [95%CI = 0.03, 0.42], 6 years: n = 110, β = 0.17 [-0.01, 0.36], 8 years: n = 85, β = 0.13 [-0.09, 0.36]). Similar associations between 11 week PV and bone mineral content (BMC) were observed. Associations with size-corrected bone mineral content were weaker at birth but strengthened in later childhood (birth: n = 78, β = 0.07 [-0.21, 0.35], 6 years: n = 107, β = 0.13 [-0.08, 0.34], 8 years: n = 71, β = 0.19 [-0.05, 0.43]).

CONCLUSIONS

11 week PV is associated with DXA bone measures at birth, with evidence of persisting associations into later childhood. Further work is required to elucidate the contributions of placental morphology and function to gestational influences on skeletal development.

Health and happiness is more important than weight': a qualitative investigation of the views of parents receiving written feedback on their child's weight as part of the National Child Measurement Programme

BACKGROUND

The present study aimed to explore parental perceptions of overweight children and associated health risks after receiving National Child Measurement Programme (NCMP) weight feedback.

METHODS

Fifty-two parents of overweight and obese children aged 4-5 years and 10-11 years enrolled in the NCMP programme in England in 2010-2011 participated in qualitative, semi-structured interviews about their perceptions of their child's weight and health risk after receiving weight feedback. Interviews were audio tape recorded and were conducted either by telephone (n = 9) or in the respondents' homes (n = 41). Interviews were transcribed verbatim and analysed using interpretative thematic analysis.

RESULTS

Parents who received NCMP written feedback informing them that their child was overweight disregarded the results because they viewed 'health and happiness as being more important than weight'. The feedback was viewed as less credible because it did not consider the individual child's lifestyle.'Broad definitions of healthy' were described that did not include weight,such as reference to the child having good emotional and physical health and a healthy diet. Parents attributed weight to 'inherited/acquired factors' such as genetics or puppy fat, or did not regard their child's 'appearance' as reflecting being overweight. 'Cultural influence' also meant that being overweight was not viewed negatively by some non-white parents.

CONCLUSIONS

After receiving written weight feedback, parents use methods other than actual weight when evaluating their child's weight status and health risks. Parents' conceptions of health and weight should be considered when communicating with parents, with the aim of bridging the gap between parental recognition of being overweight and subsequent behaviour change.

Rapid on-site assessment of specimens by biomedical scientists improves the quality of head and neck fine needle aspiration cytology

OBJECTIVE

Immediate rapid on-site assessment (ROSA) of fine needle aspiration cytology (FNAC) specimens by biomedical scientists (BMS), the UK equivalent of cytotechnologists, or by pathologists may improve specimen quality and cellular adequacy rates for lymph node, head and neck and thyroid FNAC. The aim of this study was to evaluate the effect of introducing ROSA by BMS in an outpatient clinic setting.

METHODS

The adequacy rate and sensitivity of histological diagnosis for lymph node, thyroid and salivary gland FNAC samples were determined before and after the introduction of BMS ROSA. The additional financial costs and time required to perform this service were also estimated.

RESULTS

Thirty-one patients underwent ultrasound (US)-guided FNAC with ROSA and 151 without. ROSA reduced the number of FNAC insufficient in quality for diagnosis from 43% to 19% (P = 0.0194). The estimated additional cost for pathology per patient for ROSA was between £52.05 and £70.74, equivalent to €65.40/US $83.90 and €88.89/US $114.0, respectively, an increase of between 28% and 49% from the original cost. ROSA necessitated an additional 6 minutes clinic time per patient, reducing the number of patients that could be seen in an average clinic from 13 to 10 as well as requiring increased laboratory time for FNAC slide assessment.

CONCLUSION

ROSA by suitably trained biomedical scientists and with appropriate consultant pathologist support can improve the quality of FNAC sampling for head and neck lesions. Although ROSA resulted in both additional financial and time costs, these are more than likely to be offset by a reduction in patients returning to clinic for repeat FNAC or undergoing unnecessary surgery.

Lung function, adherence and denial in asthma patients who exhibit a repressive coping style

Lung function, adherence and denial were explored in asthma patients who possess a repressive coping style (repressors). Repressors (low trait anxiety, high defensiveness) and non-repressors were identified by their trait anxiety and defensiveness scores. Participants completed measures of self-reported adherence, denial, morbidity and demographic data. A lung function measure (FEV(1)) was obtained for a subset of patients. Repressors, who comprised 33% of the sample, had significantly worse lung function but scored significantly higher on self-reported adherence, compared to non-repressors. Age was positively correlated with adherence. Although repressive coping was positively correlated with denial, denial was significantly correlated with defensiveness but not trait anxiety. The study provides evidence that repressors are an important group to identify in future studies of asthma.

Maternal perception of the causes and consequences of sibling differences in eating behaviour

Objective

To explore mothers’ perceptions of differences between their children in the eating behaviour domain.

Methods

Twelve semi-structured interviews were carried out with mothers who had at least two children aged between 6 and 15 years, to discuss feeding experiences, particularly around healthy eating. Interviews were recorded and transcribed verbatim and analysed using Framework Analysis.

Results

Mothers frequently identified differences in appetite and food preferences between their children, which they attributed largely to genetic factors. These sibling differences meant that although feeding goals might be common, the pathways to the goals varied depending on each child’s appetitive characteristics. The overall pattern was one of flexible responsiveness to each child. In contrast to perceptions of their own children’s eating behaviours, feeding difficulties in other families were usually attributed to lack of parental control.

Conclusion

The feeding relationship is complex and interactive, resulting in parents modulating their feeding strategies to match each child’s eating behaviour. Guidance to parents on healthy feeding needs to acknowledge the nuanced and interactive nature of feeding practices.

Natural Occurrence of Phytophthora infestans Causing Late Blight on Woody Nightshade (Solanum dulcamara) in New York

Woody nightshade (Solanum dulcamara) is a common hedgerow herbaceous perennial in the United States, one of only three native Solanum spp. S. dulcamara is a known host of Phytophthora infestans (3), but infection is rarely reported. There is a U.S. record from Maryland (2); in 1947, Peterson (4) stated that this species had never been found blighted in its natural habitat, although in 1960 it was listed as a host of P. infestans in New York (1). The A2 mating type has not been reported on this host. On 2 July, 2009, leaf lesions similar to those of P. infestans on potato were found on wild S. dulcamara at Riverhead, NY. The plant was growing in a home garden within 10 m of potato and tomato plants infected with P. infestans. When two infected leaves of S. dulcamara were incubated for 24 h under high humidity, a pathogen growth developed around the lesion margins that was characterized by hyaline mycelium bearing lemon-shaped sporangia that released motile zoospores after chilling in water, which is consistent with P. infestans. The caducous and limoniform to ovoid sporangia were 39 to 50 μm (average 45 μm) × 26 to 28 μm (average 27 μm) with a length/breadth ratio of 1.66. No oospores were observed. Three isolates were obtained from this plant during July 2009. Growth on rye agar was indistinguishable from that of local tomato isolates of P. infestans. Detached leaflets of S. dulcamara and S. tuberosum, inoculated with the woody nightshade isolates and kept in a humid chamber, became infected and developed profuse sporulation within 5 days. The pathogen isolated was confirmed as P. infestans by morphological, biochemical, and molecular characteristics. Inoculations of attached leaves of potted S. dulcamara plants resulted in necrotic lesions with many sporangia; sporulation also developed on inoculated, attached, and detached tomato leaves. P. infestans was reisolated and identity confirmed as before. The three isolates were A2 mating type, metalaxyl-resistant, mitochondrial haplotype Ia. All were glucose-6-phosphate isomerase 100/122 and peptidase 100/100, as confirmed with single-spore isolates. RG57 fingerprint analysis confirmed that isolates from woody nightshade, tomato, and potato obtained from the same and nearby sites were identical. Although P. infestans in the United States belongs to the new population, which may infect a wider host range than the old US-1 clonal lineage, S. dulcamara infections have only been found when late blight is already widespread in neighboring fields and there is no evidence to suggest that woody nightshade acts as an overwintering host in the United States. References: (1) Anonymous. Index of Plant Diseases in the United States. Page 456 in: Agric. Handb. No. 165, 1960 (2) C. Cox. Phytopathology 38:575, 1948. (3) D. C. Erwin and O. K. Ribeiro. Page 190 in: Phytophthora Diseases Worldwide. The American Phytopathological Society, St. Paul, MN, 1996. (4) L. C. Peterson. Am. Potato J. 24:188, 1947.

Associations between child weight and maternal feeding styles are mediated by maternal perceptions and concerns

Objective

To determine whether controlling parental feeding practices are associated with children’s adiposity and test the hypothesis that any associations are mediated by maternal perception of their child’s weight.

Method

Children aged 7-9 yrs (n=405) were weighed and measured at school as part of the Physical Exercise and Appetite in CHildren Study (PEACHES). Adiposity was indexed with BMI SD-scores. The Child Feeding Questionnaire (CFQ) was completed by 53% of mothers of participating children (n=213). Mothers reported whether they thought their child was overweight, normal weight or underweight, and rated their concern about future overweight on a 5-point scale.

Results

Higher child adiposity was associated with lower ‘pressure to eat’ and higher ‘restriction’ scores. Restriction increased linearly with maternal concern about overweight, and maternal concern about overweight fully mediated the association between child adiposity and restriction. Use of pressure increased as mothers perceived their child to be thinner, but perceived weight did not mediate the association between child weight status and maternal pressure to eat. Monitoring was not associated with child adiposity, maternal perception of weight or concern about overweight.

Conclusion

Restriction appears to be a consequence of mothers’ concern about their child becoming overweight rather than a cause of children’s weight gain. Pressure may be a more complex response that is influenced by the desire to encourage consumption of healthy foods as well as ensure adequate energy intake and appropriate weight gain.

Do social norms affect intended food choice?

OBJECTIVE

To evaluate the effect of social norms on intended fruit and vegetable intake.

METHODS

A two-stage design to i) compare the perceived importance of normative influences vs cost and health on dietary choices, and ii) test the prediction that providing information on social norms will increase intended fruit and vegetable consumption in an experimental study. Home-based interviews (N=1083; 46% men, 54% women) were carried out as part of the Office for National Statistics Omnibus Survey in November 2008.

RESULTS

The public's perception of the importance of social norms was lower (M=2.1) than the perceived importance of cost (M=2.7) or health (M=3.4) (all p's<0.001) on a scale from 1 (not at all important) to 4 (very important). In contrast, results from the experimental study showed that intentions to eat fruit and vegetables were positively influenced by normative information (p=0.011) in men but not by health or cost information; none of the interventions affected women's intentions.

CONCLUSIONS

People have little awareness of the influence of social norms but normative information can have a demonstrable impact on dietary intentions. Health promotion might profit from emphasising how many people are attempting to adopt healthy lifestyles rather than how many have poor diets.

Mothers' views on portion sizes for children

BACKGROUND

Childhood obesity has increased steadily over recent years and has coincided with a general trend towards larger portions of foods consumed both inside and outside the home. A causal link between portion size and weight gain has not been established, although there is evidence of an association between larger portions and greater energy intake. The present study aimed to investigate parent's attitudes, knowledge, practices, and concerns about appropriate portions for children.

METHODS

Four focus groups with a total of 14 volunteer mothers of 8-11-year-old children taking part in a larger school-based study. Mothers were asked their views about portion sizes for their children and were asked to demonstrate typical servings that they would offer their children, by weighing five common foods provided. Conversations were tape-recorded and transcribed for thematic analysis.

RESULTS

Participants were unconcerned about portion sizes and would not welcome official guidance, particularly if it involved weighing foods. Mothers fed their children the amount that they believed they would eat and felt that this varied across children and across occasions. The weighing task revealed a wide variation in portion sizes served to children, with portions of the more energy-dense foods being smaller on average than those of less energy-dense foods.

CONCLUSIONS

There was little understanding of age-appropriate serving sizes amongst mothers in this study. Education campaigns should be mindful of the need to make portion information clear and simple because parents may not be prepared to weigh the food that they serve to their children.

Changing perceptions of weight in Great Britain: comparison of two population surveys

OBJECTIVES

To examine changes in public perceptions of overweight in Great Britain over an eight year period.

DESIGN

Comparison of data on self perceived weight from population surveys in 1999 and 2007.

SETTING

Household surveys of two representative samples in Great Britain.

PARTICIPANTS

853 men and 944 women in 1999, and 847 men and 989 women in 2007.

MAIN OUTCOME MEASURES

Participants were asked to report their weight and height and classify their body size on a scale from "very underweight" to "obese."

RESULTS

Self reported weights increased dramatically over time, but the weight at which people perceived themselves to be overweight also rose significantly. In 1999, 81% of overweight participants correctly identified themselves as overweight compared with 75% in 2007, demonstrating a decrease in sensitivity in the self diagnosis of overweight.

CONCLUSIONS

Despite media and health campaigns aiming to raise awareness of healthy weight, increasing numbers of overweight people fail to recognise that their weight is a cause for concern. This makes it less likely that they will see calls for weight control as personally relevant.

The importance of exposure for healthy eating in childhood: a review

Children's food preferences are strongly associated with their consumption patterns. Identifying the factors that influence preferences is therefore crucial to the development of effective interventions to improve children's diets. Perhaps the most important determinant of a child's liking for a particular food is the extent to which it is familiar. Put simply, children like what they know and they eat what they like. From the very earliest age, children's experiences with food influence both preferences and intake, and research suggests that the earlier and broader that experience, the healthier the child's diet. Laboratory studies of children's food acceptance have indicated that repeated opportunities to taste unfamiliar foods results in increased liking and consumption. In order to investigate whether these results can be replicated in real-world situations, a series of naturalistic studies testing the efficacy of exposure-based interventions have been carried out. In a school-based study large increases in liking and intake of raw red pepper were seen in 5- to 7-year olds and two further studies, in which mothers used exposure techniques to increase children's acceptance of vegetables, achieved similar results. If future large-scale interventions prove to be successful, training could be offered to health professionals or directly to parents themselves.

Humanized anti-CEACAM6 PEGylated scFv: A promising novel therapy for pancreatic cancer

3042

Background: Novel Therapies for pancreatic cancer (PC) based on biological insight are urgently needed. CEACAM6, a member of the carcinoembryonic antigen (CEA) family, is a cell surface oncogene on PC cells. It is a glycoprotein composed of 3 Ig-like domains (Mr ∼35.2kD) and is linked to the plasma membrane via a glycophospholipid linked anchor. It is over-expressed on ≥95% PC patients’ found irrespective of stage of disease and represents a target for antibody therapy. Methods: Murine anti-CEACAM6 monoclonal antibody (Mab) 13–1 was humanized by a structure-based approach and single chain variable fragments (scFv) designed consisting of a Gly/Ser-linker which includes a cysteine residue for PEGylation. Murine scFv and 4 humanized scFv fragments (Version.1, 2, 7, 8) were bacterially expressed, purified, PEGylated and evaluated for activity alone or in combination with gemcitabine in human PC cell lines and mouse xenograft tumors. Cell viability, apoptosis and in-cell Westerns were done for efficacy and binding. Mouse xenograft tumors were treated with scFv or PEGylated scFv or combination with gemcitabine. Tumors (treated Vs untreated) were analyzed by immunohistochemistry for Ki-67, CD31, CEACAM6 and Caspase 3 Results: Mab 13–1, murine and 4 humanized scFvs’ were cytotoxic to CEACAM6 expressing PC cells (BxPC-3, HPAF-2) and not to PC cells that lack CEACAM6 (CaPan-2) with increased PARP-cleavage that was dose dependent (IC50=10μg/mL). Western blotting of culture media and serum from xenograft mice showed that CEACAM6 is not shed. In-cell Western confirmed humanized V.7 to be the best binder (KD=1–10μg/mL) confirming protein-protein interaction studies performed in silico with homology models of murine and humanized scFvs’ and CEACAM6. The murine scFv alone or the humanized scFV (V.8) in combination with gemcitabine delayed tumor growth by >50%. This tumor reduction correlated well with the immunohistochemical markers of response. Conclusions: We have demonstrated that CEACAM6 is a clinically relevant target in PC and that a PEGylated humanized scFv is a novel effective therapy alone and/or in combination with gemcitabine. Humanized scFv V.7 is undergoing mouse xenograft evaluation and expect will be the most effective agent to take forward into clinical development.

No significant financial relationships to disclose.

A novel tyrosine kinase switch is a mechanism of imatinib resistance in gastrointestinal stromal tumors

KIT or alpha-platelet-derived growth factor receptor (alpha-PDGFR) activating mutations are the pathogenic mechanisms that characterize gastrointestinal stromal tumors (GIST). Despite excellent responses to imatinib mesylate (IM), patients are relapsing. We developed an IM-resistant GIST cell line (GIST-R) from the IM-sensitive GIST882 cell line (GIST-S) by growing these cells in IM. Gene expression profiling (GEP) of GIST-S, GIST-R cells and two IM resistant GIST patients demonstrated that KIT is downregulated implying a major role in IM resistance. Instead, GIST-R cells have acquired IM resistance by overexpressing the oncogenic receptor tyrosine kinase - AXL - in a 'kinase switch'. Further, the two IM resistant GIST patients express AXL and not c-Kit, seen by immunohistochemistry (IHC). Real time reverse transcriptase-polymerase chain reaction and Western blotting of the GIST-S and GIST-R cells confirmed the switch from Kit to AXL. In GIST-R, AXL is tyrosine phosphorylated and its ligand growth-arrest-specific gene 6 is overexpressed implying autocrine activation. The kinase switch is associated with a morphological change from spindle to epithelioid. Molecular modeling of the kinase domain of mutant c-Kit (V654A) and AXL showed no binding to IM but efficient binding to MP470, a novel c-Kit/AXL kinase inhibitor. MP470 synergizes with docetaxel (taxotere) and is cytotoxic to GIST cells.

Liver Transplantation for Children: Red Cross Children's Hospital Experience

BACKGROUND

The liver transplant program for infants and children at the Red Cross Children's Memorial Hospital is the only established pediatric service in sub-Saharan Africa. Since 1985, 250 infants and children have been assessed and 155 accepted for transplantation.

METHODS

Since 1987, 76 children (range 6 months to 14 years) have had 79 liver transplants, with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (n = 44), metabolic (n = 7), fulminant hepatic failure (n = 10), redo transplants (n = 3), and other (n = 15). Three combined liver/kidney transplants have been performed. Forty-nine were reduced-size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1, and 29 children weighed < 10 kg.

RESULTS

Fifty-six (74%) patients survived 3 months to 12 years posttransplant. Cumulative 1- and 5-year patient survival data are 79% and 70%, respectively. However, with the introduction of prophylactic intravenous gancyclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the projected 5-year pediatric survival has been >80%. Early (<1 month) post-liver-transplant mortality was low, but included: primary malfunction (n = 1); inferior vena cava thrombosis (n = 1); bleeding esophageal ulcer (n = 1); and sepsis (n = 1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths); Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disease (12 patients, 7 deaths); and cytomegalovirus disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in three patients was complicated by chronic rejection (n = 1) and TB drug-induced subfulminant liver failure (n = 1).

CONCLUSIONS

Despite limited resources, a successful pediatric program has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors due to HBV and human immunodeficiency virus (HIV) leads to significant waiting list mortality and infrequent transplantation.

Nephrotoxic Effects of Immunosuppressant Therapy in Pediatric Liver Transplant Recipients

Drugs used for immunosuppression have been implicated in causing numerous long-term side effects including nephrotoxicity, glucose intolerance, and hyperlipidemia. In this study, we reviewed our pediatric liver transplant recipients in terms of glomerular filtration rate (GFR) as well as fasting glucose and lipid profiles. To date, 79 pediatric liver transplantations have been performed at our center: 24 transplantations of at least 5 months to a maximum of 7.3 years posttransplant are reviewed herein. The mean time posttransplantation was 2.1 years. Nine boys and 15 girls showed a distribution of 19 mixed race, 3 black, and 2 white patients. The mean age at the time of transplantation was 6.6 years (0.8-13.3 years) with 8 cases under the age of 3 years. All recipients started with Cyclosporine Neoral (CSA) as first line, but, at the time of testing, immunosuppression included 5 children on CSA and 19 on Tacrolimus. Radionuclide 51 Cr-EDTA Glomerular Filtration Rates (GFR) showed a range from 21 to 220 mL/min/1.73 m2 (mean 96.1, median 89.8). Seven cases had a GFR less than 75 mL/min/1.73 m2. Twenty-one children were on antihypertensives agents: 15 children on 1 agent and 6 children on 2 agents. On full fasting lipid profiles, the total cholesterol ranged from 2 to 7.9 mmol/L (mean 4.4). Only 1 child is currently on statin therapy. Fasting glucose ranged from 3.2 to 5.9 mmol/L (mean 4.1) No difference was observed in glucose values between CsA and Tacrolimus. Thus, immunosuppressive therapies, such as the calcineurin inhibitors, are known to cause nephrotoxicity, which is of concern in pediatric liver transplant recipients. Almost all our patients currently require antihypertensive therapy. At present, the renal function is adequate in the majority of the group, but this study needs to be extended to other pediatric liver transplant recipients with particular emphasis on those who are more than 5 years posttransplantation.

Prospective evaluation of the value of direct referral hearing aid clinic in management of young patients with bilateral hearing loss

The purpose of this study was to evaluate the value and effectiveness of a direct referral hearing aid clinic (DRHAC) in providing appropriate hearing aids to young patients aged 18-60 years while at the same time identifying patients with significant ear disease who need an otologist's opinion. The patients were referred to a tertiary referral hearing assessment clinic. A total of 137 patients (18-60 years) met the criteria to be included in the study to be assessed in the clinic by both an audiometrician and an otologist. The main outcome measures were hearing evaluation and audiometrician's management. Of them, 114 patients attended the research clinic (83%), 23 patients (17%) did not attend the clinic and 57 patients (51%) did not need any treatment or further investigation as their hearing was normal or near normal. Thirty patients (27%) were given hearing aids. Twenty-five patients (22%) failed the audiometrician assessment and were referred to the otologist. Only 13 (18%) of the 25 patients referred for an otological opinion actually required further investigations, medical or surgical treatment. DRHAC is as viable a system in the younger as in the elderly population.

Modifying children's food preferences: the effects of exposure and reward on acceptance of an unfamiliar vegetable

OBJECTIVE

The aim of this study was to evaluate two interventions (one reward-based and one exposure-based) for increasing children's acceptance of an unfamiliar vegetable compared with a no-treatment control. It was predicted that the exposure condition would increase liking for, and consumption of, the vegetable relative to either the reward or control group.

DESIGN

Using a randomized controlled design, participants were assigned to one of two intervention groups (exposure or reward) or to a no-treatment control condition, for a 2 week period. Liking for, and consumption of, red pepper was assessed before and after the treatment period.

SETTING

The study was conducted in three primary schools in London.

SUBJECTS

Parental consent was obtained for 49 out of a possible 72 children.

INTERVENTIONS

Interventions comprised eight daily sessions during which participants in the exposure group were offered a taste of sweet red pepper and told that they could eat as much as they liked. Participants in the reward group were shown a sheet of cartoon stickers and told that they could choose one of them on condition that they ate at least one piece of the pepper.

RESULTS

The exposure-based intervention significantly increased both liking (P=0.006) and consumption (P=0.03) compared with the control group. The outcome of the reward intervention was intermediate and did not differ significantly from the exposure or control conditions.

CONCLUSIONS

Repeated exposure to the taste of unfamiliar foods is a promising strategy for promoting liking of previously rejected foods in children.

Indomethacin for asymptomatic patent ductus arteriosus in preterm infants

BACKGROUND

Patent Ductus Arteriosus (PDA remains a significant cause of mortality and morbidity in premature infants. Indomethacin is an effective treatment to close a PDA, and has been used for many years with several treatment regimes, including prophylactic use in all at risk premature infants. There are however concerns regarding adverse side effects of indomethacin. By targeting a group of infants with an asymptomatic PDA, rather than treating all VLBW infants prophylactically, indomethacin use would be restricted, limiting the possibility of significant side effects to those with greater chance of benefit.

OBJECTIVES

To assess whether in premature neonates with asymptomatic PDA, treatment with indomethacin improves short and long term outcomes; in particular: incidence of symptomatic PDA, mortality, chronic neonatal lung disease (CLD), intraventricular haemorrhage (IVH), retinopathy of prematurity (ROP), neurodevelopmental outcome, length of ventilation.

SEARCH STRATEGY

Standard strategies of the Cochrane Neonatal Review Group were used. Searches were made of the Oxford Database of Perinatal Trials, MEDLINE and EMBASE from 1966 to September 2002, CINAHL from 1982 to September 2002, and the Cochrane Controlled Trials Register (CENTRAL/CCTR) in The Cochrane Library, Issue 3, 2002. Searches were also made of previous reviews including cross-referencing, abstracts, and conference and symposia proceedings published in Pediatric Research.

SELECTION CRITERIA

All randomised controlled trials of indomethacin compared with placebo or no intervention for the treatment of asymptomatic PDA in premature infants were eligible.

DATA COLLECTION AND ANALYSIS

Standard methods of the Cochrane Neonatal Review Group were used. Trials identified by the search strategy were independently reviewed by each author and assessed for eligibility and trial quality. Data were then extracted independently by each author and compared, with any differences resolved following discussion. Any additional information required was requested from trial authors. Only published data was available for review. Results are expressed as typical relative risk and typical risk difference for dichotomous outcomes, and weighted mean difference for continuous variables.

MAIN RESULTS

Three small trials involving a total of 97 infants were included. Meta analysis of combined data was possible for seven outcomes. Treatment of an asymptomatic PDA with indomethacin significantly reduced the incidence of symptomatic PDA (RR 0.36, 95% CI 0.19, 0.68) and duration of supplemental oxygen (WMD -12.5, 95% CI -23.8, -1.26). There was no evidence of effect on mortality (RR 1.32, 95% CI 0.45, 3.86), CLD (RR 0.91, 95% CI 0.62, 1.35), IVH (RR 1.21, 95% CI 0.62, 2.37), ROP (RR 0.68, 95% CI 0.26, 1.78), or length of ventilation (WMD -7.00 days, 95%CI -17.33, 3.34). Long term neurodevelopmental outcomes were not reported. One trial reported a significant reduction in the duration of supplemental oxygen following treatment with indomethacin in the subgroup of infants with birth weight less than 1000g.

REVIEWER'S CONCLUSIONS

This review demonstrates a significant decrease in the incidence of symptomatic PDA following treatment of an asymptomatic PDA with indomethacin. There is also a small but statistically significant decrease in the duration of requirement for supplemental oxygen. There are no reported long term outcomes in the included trials, and so it is not possible to comment on possible long term effects. Further studies are required to determine the long term benefits or harms of closing a PDA prior to the onset of symptoms.

Doctors' professional values: results from a cohort study of United Kingdom medical graduates

OBJECTIVES

To examine young doctors' views on a number of professional issues including professional regulation, multidisciplinary teamwork, priority setting, clinical autonomy and private practice.

METHOD

Postal survey of 545 doctors who graduated from United Kingdom medical schools in 1995.

RESULTS

Questionnaires were returned by 95% of the cohort (515/545). On issues of professional regulation, teamwork and clinical autonomy, the majority of doctors held views consistent with current General Medical Council guidance. The majority supported the right of doctors working in the NHS to engage in private practice. Most respondents thought that public expectations of doctors, medicine and the NHS were too high, and that some form of rationing was inevitable. On many issues there was considerable variation in attitudes on the basis of sex and intended branch of medicine.

CONCLUSIONS

The results highlight the heterogeneity of the profession and the influence of specialty and gender on professional values. Doctors' attitudes had also been shaped by broader social changes, especially debates surrounding regulation of the profession, rising public expectations and the need for rationing of NHS care.

Doctors' professional values: results from a cohort study of United Kingdom medical graduates

OBJECTIVES

To examine young doctors' views on a number of professional issues including professional regulation, multidisciplinary teamwork, priority setting, clinical autonomy and private practice.

METHOD

Postal survey of 545 doctors who graduated from United Kingdom medical schools in 1995.

RESULTS

Questionnaires were returned by 95% of the cohort (515/545). On issues of professional regulation, teamwork and clinical autonomy, the majority of doctors held views consistent with current General Medical Council guidance. The majority supported the right of doctors working in the NHS to engage in private practice. Most respondents thought that public expectations of doctors, medicine and the NHS were too high, and that some form of rationing was inevitable. On many issues there was considerable variation in attitudes on the basis of sex and intended branch of medicine.

CONCLUSIONS

The results highlight the heterogeneity of the profession and the influence of specialty and gender on professional values. Doctors' attitudes had also been shaped by broader social changes, especially debates surrounding regulation of the profession, rising public expectations and the need for rationing of NHS care.

Searching for one versus two identical targets: when visual search has a memory

A recent study has suggested that observers' visual explorations of the external world can proceed unimpaired when the visual environment precludes the operation of memory processes (as, for instance, when the display elements change locations every 100 ms). One theoretical limitation of this study was that distractors were the only elements that had the potential to be tagged during visual search. The present study sought to clarify the amnesic-search hypothesis by investigating whether memory processes can guide search in other contexts in which targets also have the potential to be tagged. Accordingly, the experimental conditions of the previous study were repeated using a different search task in which observers had to decide whether one target or two were present among a variable number of similar distractors. Under these search conditions, the present findings provided strong evidence that memory processes can guide visual search.

Education and training in the senior house officer grade: results from a cohort study of United Kingdom medical graduates

INTRODUCTION

This paper shows the findings from a survey of 439 senior house officers undertaken as part of the British Medical Association cohort study of 1995 medical graduates. The aim of the study was to assess the quality of senior house officer training in the United Kingdom.

METHOD

In July 1997 a postal questionnaire was sent to a sample of 545 doctors who graduated from medical school in 1995. Responses were received from 515 (95%). Only those doctors who had worked as a senior house officer in the previous 12 months were included in the analysis (n = 439).

RESULTS

Encouraging results are that 69% of the senior house officers surveyed had discussed their progress directly with their consultant, and 24% rated their supervision by their consultant as 'excellent'. Of concern are the findings that 47% of respondents did not receive protected teaching time and 16% were unable to take study leave.

DISCUSSION

The study revealed wide variability in the quality of training received by senior house officers in the United Kingdom. Whilst some respondents - notably those in general practice, accident and emergency, paediatrics and psychiatry - had enjoyed a high standard of education and training, it was clear that a minority of posts continue to offer little if any educational value to the post holder. The results point to a need for a more systematic approach to maintaining standards in senior house officer training with greater incentives for under-performing trusts.

Changes in the referral pattern of child patients from the GDS to the CDS following the introduction of capitation in October 1990. General Dental Services. Community Dental Services

OBJECTIVE

To observe the changes in the criteria for, rate of, and pattern of, referral of child patients from the General Dental Services (GDS) to the Community Dental Services (CDS) which may have occurred following the introduction of capitation as the method of remuneration for general dental practitioners (GDPs) for the treatment of child patients in The new contract 1990.

DESIGN

GDP referral criteria and attitude to capitation were assessed in two districts (North Downs and Weybourne Trusts) using a questionnaire distributed to 179 GDPs. Reasons for referral, and treatment received within the CDS, were collated from the dental records of referred children, before and after the introduction of capitation.

RESULTS

The response rate from the GDPs was 87%, of whom 82% had referred child patients to the CDS. The results showed that 65% of GDPs indicated a preference for treatment of children under a fee per item system, whereas only 17% favoured capitation. Although 60% believed that their referral of patients to the CDS had not changed following capitation, an analysis of the referred children's dental records revealed that there had actually been a 57% increase in the number of referrals from GDPs to CDS following the introduction of capitation. The GDPs considered the most important referral criteria were for non cooperation or general anaesthesia. More cooperative children had been referred and more routine restorative procedures, less inhalation sedation and deciduous extractions were carried out following the introduction of capitation.

CONCLUSIONS

This study has shown that following the introduction of capitation there had been an increase in the number of referrals from the GDS to the CDS.

Papillon-Lefèvre syndrome: a case report

This case report discusses a very rare condition; Papillon-Lefèvre Syndrome. This is an autosomal recessive condition in which the main features are hyperkeratosis of the palms and the soles and severe periodontal destruction.

Is erythrocyte alkaline phosphatase activity a marker of zinc status in humans?

The identification of an enzyme activity that responds to changes in Zn intake may serve as a useful biomarker for Zn status. Alkaline phosphatase (ALP) is a dimeric protein with each subunit containing two Zn atoms. The activity of ALP in erythrocytes (E) decreases as a result of a low Zn diet, which suggests that this enzyme may be a marker of Zn status. To investigate this further, we determined the response of E-ALP in six healthy subjects following supplementation with 50 mg Zn (4.2 x RDI) daily for 4 wk. A small but significant increase in plasma Zn was observed with supplementation (p < 0.05), whereas there was no significant change in E-Zn over the same period. Plasma and E-Cu showed no change. Conversely, the activity of E-ALP increased in all subjects from 1.7 +/- 0.5 to 5.9 +/- 0.7 U/g protein (mean +/- SE) (p < 0.0001). The small change observed in plasma Zn is not biologically significant in view of the many documented factors that influence its concentration. Our data support the hypothesis that E-ALP is a marker of Zn status in humans.

Differences in beta adrenergic receptor agonist affinity between cardiac myocytes and coronary arterioles in canine heart

Beta adrenergic receptors (beta AR) are localized in several tissue compartments of the heart, including cardiac myocytes, coronary arteries and coronary arterioles, but it is unclear whether there are differences between tissues in beta AR coupling to G protein. The goal of these studies was to use receptor autoradiography to analyze beta receptor agonist binding characteristics in different tissue compartments of dog heart, including ventricular myocytes (predominantly beta-1) and coronary arterioles (predominantly beta-2). Frozen sections were incubated in [125I]-pindolol with the beta agonist isoproterenol in the absence and presence of 0.1 mM sodium 5'-guanylylimidodiphosphate (GppNHp, a nonhydrolyzable GTP analog) and analyzed by gamma counting or autoradiography. Nonlinear curve-fitting analyses of ventricular section radioactivity indicated that in the absence of GppNHp, the data were consistent with a two-site fit, with 88% of the receptors in the high-affinity state. In autoradiographic analyses, GppNHp displaced the agonist binding curve to a greater extent in arterioles (approximately 100-fold) than in myocytes (approximately 10-fold). This suggests that beta receptors on arterioles are more tightly coupled to G protein than are beta receptors on myocytes. Thus these studies suggest that 1) beta AR on arterioles are coupled more tightly to G protein than are beta AR on myocytes, possibly because of differences in beta receptor subtype, and 2) more beta AR are in the high-affinity state than has been reported previously in more traditional analyses on membrane preparations.