Parenting children with neurodevelopmental disorders and/or behaviour problems

BACKGROUND

Parenting behaviours influence child well-being and development. However, much of the research on parenting behaviours and their correlates has focused on caregivers of healthy, typically developing children. Relatively less is known about the parenting behaviours of caregivers of children with chronic health conditions.

OBJECTIVE

To examine and compare three parenting behaviours (positive interactions, consistency and ineffective parenting) among caregivers of children with neurodevelopmental disorders and/or externalizing behaviour problems, before and after accounting for child and family socio-demographic characteristics.

METHODS

Participants (n= 14 226) were drawn from the National Longitudinal Survey of Children and Youth, a long-term study of Canadian children that follows their development and well-being from birth to early adulthood. Children (and their caregivers) were divided into four groups according to the presence of a neurodevelopmental disorder (NDD; n= 815), the presence of an externalizing behaviour problem (EBP; n= 1322), the presence of both conditions (BOTH; n= 452) or neither of these conditions (NEITHER; n= 11 376).

RESULTS

Caregivers of children in the NEITHER group reported significantly higher positive interaction scores and lower ineffective parenting behaviours than caregivers of children in any of the other three groups. Caregivers of children in the EBP and BOTH groups reported similar levels of consistency, but significantly lower levels than caregivers of NDD or NEITHER children. These associations largely remained after accounting for child and family socio-demographic characteristics, with two exceptions: caregivers' reports of positive interactions were no longer significantly associated with child's NDD and BOTH conditions.

CONCLUSIONS

Parenting children with multiple health conditions can be associated with less positive, less consistent and more ineffective parenting behaviours. Understanding the factors that are associated with the challenges of caring for these children may require additional research attention.

Primary anti-vascular endothelial growth factor (VEGF)-refractory metastatic renal cell carcinoma: clinical characteristics, risk factors, and subsequent therapy

BACKGROUND

A subset of patients treated with initial anti-vascular endothelial growth factor (VEGF) therapy exhibit progressive disease (PD) as the best response per RECIST criteria.

METHODS

Data from patients with metastatic renal cell carcinoma (mRCC) treated with anti-VEGF therapy were collected through the International mRCC Database Consortium from 12 centers.

RESULTS

One thousand and fifty-six assessable patients received initial VEGF inhibitors and 272 (26%) of these patients had PD as best response. Initial treatment included sunitinib (n = 203), sorafenib (n = 51), or bevacizumab (n = 18). Six percent of patients were at favorable risk, 55% at intermediate risk, and 39% at poor risk. On multivariable analysis, predictors of PD were Karnofsky performance status < 80% [odds ratio (OR) = 2.3, P < 0.0001], diagnosis to treatment < 1 year (OR = 2.1, P < 0.0001), neutrophilia (OR = 1.9, P = 0.0021), thrombocytosis (OR = 1.7, P = 0.0068), and anemia (OR = 1.6, P = 0.0058). Median progression-free survival (PFS) in patients with PD versus without PD was 2.4 versus 11 months (P < 0.0001) and overall survival (OS) was 6.8 versus 29 months (P < 0.0001), respectively. One hundred and eight (40%) VEGF-refractory patients proceeded to receive further systemic therapies. Response rate, PFS, and OS for subsequent therapy were 9%, 2.5 months, and 7.4 months, respectively, with no statistical differences between patients who received VEGF versus mammalian target of rapamycin (mTOR) inhibitors.

CONCLUSIONS

Primary anti-VEGF-refractory mRCC patients have a dismal prognosis. Second-line anti-mTOR and anti-VEGF agents produce similar outcomes.

Normal urine output after elective caesarean section: an observational study

BACKGROUND

When monitoring postoperative urine output there is no guidance specific to obstetrics. Factors such as peri-operative oxytocin infusions add further complexity. Our aim was to determine a normal range for urine output after elective caesarean section under neuraxial anaesthesia.

METHODS

Sixty women were recruited and for 24h from the time of urethral catheterisation, we recorded urine output and fluid input. We also measured intra-operative blood loss, use of prophylactic oxytocin infusion and markers of renal function. Data were compared with Mann-Whitney U-tests or paired t tests.

RESULTS

Oxytocin infusions were used in 45 women (75%). Median (95% CI) urine output in the first 6h was 0.8 (0.4-1.9) mL kg(-1)h(-1) in women receiving oxytocin compared to 1.4 (0.7-2.2)mL kg(-1)h(-1) in those who did not (P=0.02). Urine output for all women at 12 and 18 h was 2.0 (0.7-5.7) and 1.9 (0.5-4.5)mL kg(-1)h(-1). Blood loss was 0.4 (0.2-0.8)L in women with oxytocin infusions and 0.3 (0.1-0.4)L in those without (P=0.003). Mean (SD) pre- and postoperative urine osmolality was 622.5 (185.7) and 293.0 (135.1) mosm/kg, respectively (P<0.0001).

CONCLUSIONS

Urine output varied widely between subjects, especially after the first 6h and was further reduced by the use of oxytocin infusion. This may have been a direct effect or related to increased blood loss in this group. Oxytocin use should be accounted for when setting a minimum postoperative urine output. We also found high pre-operative urine osmolalities suggesting significant dehydration.

Cardiovascular events (CVEs) associated with tyrosine kinase inhibitor (TKI) therapy in patients with metastatic renal cell carcinoma (mRCC) at a regional cancer center

e16040

Background: Recent studies suggest the incidence of CVEs associated with TKIs has been underestimated. Phase III trials have reported low incidences of heart failure, cardiac ischemia and hypertension. A recent observational study reported that one third of patients taking sunitinib or sorafenib experienced a cardiovascular event often without symptoms. We assessed the incidence of CVEs in mRCC patients who received TKIs at our centre. Methods: Eligible mRCC patients were identified from a mRCC database between January 2006 and November 2008. Data was retrospectively extracted including age, sex, diagnosis, histology, past cardiac history, cardiac risk factors, number and type of TKI regimens, and CVEs. A CVE was defined as unexplained death, acute coronary syndrome (ACS), heart failure, or arrhythmia requiring intervention. We also identified any new or exacerbated cases of hypertension after the start of TKI therapy, as a CVE. Results: Eighty-five eligible patients were identified. Average age was 61 years (range, 23–78), 72% were male and 80% were clear cell in origin. A total of 31 CVEs occurred in 28 patients (33%). These events occurred at a median of 5 weeks of TKI therapy (range, 1 - 64 weeks). There were 8 cases of ACS, 2 of heart failure, 2 of arrhythmia, and 3 unknown causes of death. Only 2 of these particular CVEs were associated with new or increased hypertension. There were 16 cases of hypertension alone. Those who had CVEs had a higher mean number of cardiac risk factors. They were also more likely to have an echocardiogram during treatment, and less likely to receive sorafenib following sunitinib. Conclusions: Our study suggests a lower rate of CVEs than recent studies, but the true rate may be underestimated, as routine cardiac studies were not performed in all patients. Rational surveillance strategies for patients receiving TKI therapies should be developed. Prospective trials should address predictive and prognostic factors for CVEs. [Table: see text]

[Table: see text]

A Phase II study of 3-aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP) and gemcitabine in advanced pancreatic carcinoma. A trial of the Princess Margaret hospital Phase II consortium

3-Aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP, Triapine, Vion Pharmaceuticals, New Haven, CT) is an inhibitor of the M2 subunit of ribonucleotide reductase (RR). Preclinical testing demonstrates synergy between 3-AP and gemcitabine. Phase I studies of the combination have suggested tolerability and some initial evidence of efficacy. Therefore, a phase II study of gemcitabine plus 3-AP in advanced pancreatic carcinoma was undertaken. In this two-step phase II trial, patients with advanced pancreatic adenocarcinoma who had not received prior chemotherapy for advanced disease were treated with 3-AP 105 mg/m(2) given over 2 h. Four hours after the 3-AP infusion was completed, gemcitabine 1,000 mg/m(2) was given over 30 min. Both drugs were given on days 1, 8 and 15 of a 28-day cycle.Twenty-six patients were enrolled to the study. One patient withdrew consent prior to receiving any treatment and is excluded from all further analyses. Four patients discontinued treatment due to adverse effects. Grade 3/4 hematological adverse events included neutropenia, thrombocytopenia, lymphopenia, leukopenia and anemia and the most frequent non-hematological adverse events were fatigue and pain. No objective responses were observed. Eleven patients had stable disease (SD). In five of these eleven patients, SD lasted for more than 6 months. The median time to progression was 4.1 months and the 6 month progression-free survival rate was 29%. The median survival was 9.0 months with a 1-year survival of 28.0%. The combination of 3-AP and gemcitabine is associated with moderate toxicity in patients with advanced pancreatic cancer. This two-stage trial was stopped after stage I due to lack of antitumour activity. On the basis of this clinical trial, the combination of gemcitabine and 3-AP at this dose and schedule does not warrant further study in this patient population.

Phase II study of the angiogenesis inhibitor AZD2171 in first line, progressive, unresectable, advanced metastatic renal cell carcinoma (RCC): A trial of the PMH Phase II Consortium

5093

Background: AZD2171 is an oral, highly potent inhibitor of VEGFR1, VEGFR2, with activity also against cKit, PDGFRβ and Flt-4. We conducted a two-stage, phase II trial of AZD 2171 in first line advanced RCC, with a planned sample size of 37 pts, and a primary endpoint of tumor control rate (PR+SD). Methods: Pts had progressive, unresectable, advanced RCC, measurable disease, a performance status of ≤ 2 and no prior cytokine or antiangiogenic therapy. Pts received AZD2171 45 mg orally, daily, continuously (1cycle = 4wks) as monotherapy. Disease was evaluated with cross-sectional imaging every 8 wks. Functional DCE-MRI imaging was performed at baseline, 24h and 28d after the first dose. Pharmacokinetic studies were performed on day 8, 15 and 28. Results: From January- November 2006, 24 pts median (range) age 62 (44–80), were entered on study. Sixteen pts evaluable for response, 7 too early; 23 pts evaluable for toxicity; 1 pt inevaluable due to withdrawal. There have been 6 confirmed PR (6/16=38%), 1 unconfirmed PR, 5 SD, 4 PD. Tumor control rate 12/16=75%. Seventeen patients remain on treatment, 6 now off due to PD and 1 off due to consent withdrawal. Eighteen patients had dose reductions due to toxicity. Most common toxicities (any grade) were fatigue (21pts), voice alteration (14pts), hypertension (12pts), diarrhea (15pts), and increased creatinine (10pts). Common (>5% of cycles) grade 3+ adverse events were hypertension (5pts), joint pain (4pts), fatigue (7pts), dyspnea (2pts), increased ALT (2pts) and anorexia (3pts). Preliminary pK analysis is available on 6 patients: median (range) Tmax: 2hr (2- 6hr), Cmax: 107.8± 29.8 ng/ml, T1/2: 12.1 ± 2.2hr. Conclusion: AZD2171 is an active agent in first line, progressive, unresectable, advanced RCC with a partial response rate of 38% and tumor control rates of 75%. Accrual is ongoing with pharmacokinetics, functional imaging, and correlative studies. This agent warrants further investigation.

No significant financial relationships to disclose.

Anaesthetic management of labour and caesarean delivery of a patient with hyperkalaemic periodic paralysis

We describe a parturient with hyperkalaemic periodic paralysis who presented for induction of labour and subsequently, caesarean section. Epidural analgesia and anaesthesia were used successfully in a multidisciplinary plan aimed at avoiding a peripartum attack and providing safe delivery. Management of this rare condition is discussed along with a review of the available literature.

A comparative analysis of pressure sore treatment modalities in community settings

The management of pressure sores in community settings, poses a clinical problem which challenges the patient’s tolerance and the clinician’s diligence and ingenuity. Pressure sores can be painful, lead to infection and are associated with considerable morbidity and increased mortality (Patterson & Bennett, 1995:919; Bale, Banks, Hagelstein & Harding, 1998:65). Treatment costs of these wounds are high in terms of resources (Colin 1995:65; Wood, Griffiths & Stoner, 1997:256). However, since there are untold cost in terms of pain and suffering to the patient, it is impossible to calculate the true cost of pressure sores (Dealey, 1994:87).

A cytogenetic and molecular reappraisal of a series of patients with Turner's syndrome

The results of a cytogenetic and molecular reinvestigation of a series of 52 patients with Turner's syndrome are reported. No evidence of Y chromosome material was found among the patients with a 45,X constitution but two patients were found to have a cell line with a r(Y) chromosome which was previously thought to be a r(X). The parental origin of the single X in the 45,X patients was maternal in 69% and paternal in 31%, a similar ratio to that seen among spontaneously aborted 45,X conceptuses. This suggests that X-chromosome imprinting is not responsible for the two grossly different phenotypes associated with a 45,X chromosome constitution. Approximately half of the structurally abnormal X chromosomes were maternal in origin and half paternal. This observation is consistent with either a meiotic or post-zygotic mitotic origin and at variance with the predominantly paternal origin reported for autosome structural abnormalities.