Climatic, oceanic, freshwater, and local environmental drivers of New Zealand estuarine macroinvertebrates

Understanding the responses of organisms to different environmental drivers is critical for improving ecosystem management and conservation. Estuarine ecosystems are under pressure from multiple anthropogenic stressors (e.g. increasing sediment and nutrient loads, pollution, climate change) that are affecting the functions and services these ecosystems provide. Here, we used long-term estuarine benthic invertebrate monitoring data (∼30 year time-series) to evaluate the responses of macrobenthic invertebrate communities and indicator species to climatic, oceanic, freshwater, and local environmental drivers in New Zealand estuaries. We aimed to improve our ability to predict ecosystem change and understand the effects of multiple environment drivers on benthic communities. Our analyses showed that the abundance and richness of macrobenthic fauna and four indicator taxa (bivalves known to have differing tolerances to sediment mud content: Austrovenus stutchburyi, Macomona liliana, Theora lubrica, and Arthritica bifurca) responded to unique combinations of multiple environmental drivers across sites and times. Macrobenthic responses were highly mixed (i.e., positive and negative) and site-dependent. We also show that responses of macrobenthic fauna were lagged and most strongly related to climatic and oceanic drivers. The way the macrobenthos responded has implications for predicting and understanding the ecological consequences of a rapidly changing environment and how we conserve and manage coastal ecosystems.

Scalable Nanostructured Carbon Electrode Arrays for Enhanced Dopamine Detection

Dopamine is a neurotransmitter that modulates arousal and motivation in humans and animals. It plays a central role in the brain "reward" system. Its dysregulation is involved in several debilitating disorders such as addiction, depression, Parkinson's disease, and schizophrenia. Dopamine neurotransmission and its reuptake in extracellular space takes place with millisecond temporal and nanometer spatial resolution. Novel nanoscale electrodes are needed with superior sensitivity and improved spatial resolution to gain an improved understanding of dopamine dysregulation. We report on a scalable fabrication of dopamine neurochemical probes of a nanostructured glassy carbon that is smaller than any existing dopamine sensor and arrays of more than 6000 nanorod probes. We also report on the electrochemical dopamine sensing of the glassy carbon nanorod electrode. Compared with a carbon fiber, the nanostructured glassy carbon nanorods provide about 2× higher sensitivity per unit area for dopamine sensing and more than 5× higher signal per unit area at low concentration of dopamine, with comparable LOD and time response. These glassy carbon nanorods were fabricated by pyrolysis of a lithographically defined polymeric nanostructure with an industry standard semiconductor fabrication infrastructure. The scalable fabrication strategy offers the potential to integrate these nanoscale carbon rods with an integrated circuit control system and with other complementary metal oxide semiconductor (CMOS) compatible sensors.

Testing spatial heterogeneity with stock assessment models

This paper describes a methodology that combines meta-population theory and stock assessment models to gain insights about spatial heterogeneity of the meta-population in an operational time frame. The methodology was tested with stochastic simulations for different degrees of connectivity between sub-populations and applied to two case studies, North Sea cod (Gadus morua) and Northeast Atlantic sardine (Sardina pilchardus). Considering that the biological components of a population can be partitioned into discrete spatial units, we extended this idea into a property of additivity of sub-population abundances. If the additivity results hold true for putative sub-populations, then assessment results based on sub-populations will provide information to develop and monitor the implementation of finer scale/local management. The simulation study confirmed that when sub-populations are independent and not too heterogeneous with regards to productivity, the sum of stock assessment model estimates of sub-populations’ SSB is similar to the SSB estimates of the meta-population. It also showed that a strong diffusion process can be detected and that the stronger the connection between SSB and recruitment, the better the diffusion process will be detected. On the other hand it showed that weak to moderate diffusion processes are not easy to identify and large differences between sub-populations productivities may be confounded with weak diffusion processes. The application to North Sea cod and Atlantic sardine exemplified how much insight can be gained. In both cases the results obtained were sufficiently robust to support the regional analysis.

The DNA sequence and analysis of human chromosome 6

Chromosome 6 is a metacentric chromosome that constitutes about 6% of the human genome. The finished sequence comprises 166,880,988 base pairs, representing the largest chromosome sequenced so far. The entire sequence has been subjected to high-quality manual annotation, resulting in the evidence-supported identification of 1,557 genes and 633 pseudogenes. Here we report that at least 96% of the protein-coding genes have been identified, as assessed by multi-species comparative sequence analysis, and provide evidence for the presence of further, otherwise unsupported exons/genes. Among these are genes directly implicated in cancer, schizophrenia, autoimmunity and many other diseases. Chromosome 6 harbours the largest transfer RNA gene cluster in the genome; we show that this cluster co-localizes with a region of high transcriptional activity. Within the essential immune loci of the major histocompatibility complex, we find HLA-B to be the most polymorphic gene on chromosome 6 and in the human genome.

Production and characterization of a Tie2 agonist monoclonal antibody

The Tie2 receptor and its known ligands, the angiopoietins, play a critical role in endothelial cell differentiation during the process of angiogenesis. Recent experimental observations indicate that the agonistic ligand, angiopoietin-1, can stimulate endothelial cell sprouting and act as a chemo-attractant in vitro and induce increased and enhanced angiogenesis both alone and in conjunction with vascular endothelial growth factor (VEGF) in vivo. Here, we present a monoclonal antibody (MAb), which binds to the extracellular portion of the Tie2 receptor and elicits similar agonist effects. Upon MAb binding to the native Tie2 receptor of cultured human umblical vein endothelial cells (HUVEC), there is a rapid increase in receptor autophosphorylation with a concomitant enhancement in the recruitment and association of the signalling intermediates Grb2 and SH-PTP2. The antibody further demonstrates functional activity in vascular tissues. In vitro, the antibody promotes the survival of cultured HUVEC and elicits a dose dependent outgrowth and branching of microvessels from cultured explants of rat aorta. When administered in vivo, the antibody enhances the vascularization of subcutaneous Matrigel implants in mice. Together these data suggest that the antibody is capable of acting as a surrogate ligand for Tie2 and further confirms the role of Tie2 in the differentiation of endothelial cells during angiogenesis.

Psychometric testing in bacterial meningitis: results of a long-term prospective study of infants and children treated between 1973 and 1977

Acute bacterial meningitis can result in structural damage to the nervous system with associated functional derangements. Neurologic abnormalities can be transient, although some sequelae, including lasting impairment in cognition and behavior, may be permanent. 1,2 In this brief report, we present the results of psychometric testing of patients conducted over a 5-year period in our prospective study of acute bacterial meningitis begun in 1973.

Antibody responses to bovine parainfluenza virus type 3 (PIV3) vaccination and human PIV3 infection in young infants

A phase 2 clinical trial was conducted to evaluate the antibody responses to bovine parainfluenza virus type 3 (bPIV3) vaccination in young infants. Three groups were tested as follows: placebo (n=66) and 10(5) (n=64) or 10(6) (n=62) TCID(50) of bPIV3. The vaccine or placebo was administered intranasally at ages 2, 4, 6, and 12-15 months, and serum specimens were collected at ages 2, 6, 7, 12-15, and 13-16 months. Serum hemagglutination inhibition (HI) and IgA antibody titers against bPIV3 and human PIV3 (hPIV3) were measured. The results indicate that antibody responses to bPIV3 vaccination are more likely to be detected by the bPIV3 IgA and HI assays than by the hPIV3 IgA and HI assays, that bPIV3-induced antibody response can be differentiated from hPIV3-induced antibody response most reliably by comparing bPIV3 and hPIV3 HI titers, and that bPIV3 vaccine prevents vaccine recipients from developing antibody profiles of hPIV3 primary infection.

Safety of a trivalent live attenuated intranasal influenza vaccine, FluMist, administered in addition to parenteral trivalent inactivated influenza vaccine to seniors with chronic medical conditions

We conducted a randomized, double-blind trial to evaluate the safety and tolerability of a live attenuated cold adapted trivalent intranasal influenza vaccine, FluMist, compared with intranasal placebo when given in addition to a licensed trivalent injected inactivated influenza vaccine (TIV). The study population consisted of persons 65 years of age and older with chronic cardiovascular or pulmonary conditions or diabetes mellitus. During the 7 days post-vaccination, sore throat was reported on at least one day by 15% (15/100) of FluMist recipients compared with 2% (2/100) of intranasal placebo recipients (p = 0.001). No other reactogenicity symptom was statistically associated with receipt of FluMist. Among this group, FluMist was safe and well tolerated when administered with TIV.

Long-term change in the bone mineral density of adults with adult onset growth hormone (GH) deficiency in response to short or long-term GH replacement therapy

OBJECTIVE

Only two previous studies have assessed the effects of long-term GH replacement therapy on bone mineral density (BMD) in patients with adult onset GH deficiency. To date no study has looked at the long-term impact on BMD after a short course (6-12 months) of GH replacement. In two groups of patients with adult onset GH deficiency we have studied BMD either (a) after 3 years of continuous GH replacement or (b) 2 years after completion of a short course of GH.

DESIGN

An open GH therapeutic study in which patients were recruited from a previous double-blind placebo-controlled study. The BMD status of all patients was unknown to the physician and patient at the time of recruitment.

PATIENTS

Group A (n = 7, three females) all received GH replacement continuously for 3 years. Group B (n = 8, five females) included six patients who received GH replacement for 6 months and two who received GH replacement for 12 months with BMD being measured at 6-monthly intervals.

METHODS

Single photon absorptiometry (SPA) and later single X-ray absorptiometry (SXA) were used to measure forearm cortical BMD. Dual-energy X-ray absorptiometry (DXA) was used to measure lumbar spine, trochanteric, femoral neck and Ward's area BMD.

RESULTS

In group A lumbar spine and trochanter BMD had increased significantly from baseline by 3.7% (DXA: median change = 0.045 g/cm2; P = 0.028) and 4.0% (DXA: median change = 0.031 g/cm2; P = 0.046), respectively. There were non-significant decreases in femoral neck (1.9%) (DXA: median change = -0.02 g/cm2; P = 0.39), Ward's area (6.5%) (DXA: median change = -0.06 g/cm2; P = 0.09) and forearm (2.6%) (SPA/SXA: median change = -0.013 g/cm2; P = 0.18). In group B, compared with baseline, only trochanter BMD changed significantly, increasing by 5.9% (DXA: median change = 0.0485 g/cm2; P = 0.049). Lumbar spine (DXA: median change = -0.001 g/cm2) Ward's area (DXA: median change = 0.0135 g/cm2), femoral neck (DXA: median change = -0.005 g/cm2) and forearm cortical (SPA/SXA; median change = -0.01 g/cm2) BMD did not change significantly (P = 0.67, P = 0.57, P = 0.86 and P = 0.31, respectively). Median percentage changes compared with baseline were -0.1%, 1.8%, -0.5% and -2.1%, respectively. From the time of completion of GH therapy however, BMD increased significantly at lumbar spine, (median change = 0.023 g/cm2), Ward's area (median change = 0.03 g/cm2) and trochanter (median change = 0.056 g/cm2) (P = 0.036, P = 0.049 and P = 0.012, respectively) but not at the femoral neck (median change = 0.017 g/cm2; P = 0.31) or forearm (median change = 0 g/cm2; P = 0.75).

CONCLUSION

Long-term GH replacement therapy for three years appears to have beneficial effects on bone in patients with adult onset GH deficiency particularly at the lumbar spine and trochanter; the effects on femoral neck and forearm cortical BMD, however, are less impressive. A short course (6-12 months) of GH replacement therapy results in an increase in trochanter BMD several years later, and after an initial decline in BMD whilst on GH replacement, lumbar spine and Ward's area BMD return towards their baseline values. These results emphasize that not all types of bone and skeletal sites respond to GH therapy identically. Furthermore a short course of GH replacement over 6-12 months may result in significant changes in BMD several years later.

Review of recommendations of the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention, on varicella vaccine

After US licensure of the Merck varicella vaccine for immunocompetent persons on 17 March 1995, the Advisory Committee on Immunization Practices finalized draft recommendations for varicella prevention in the public health sector. These recommendations call for routine vaccination of children at age 12-18 months with a single dose of the vaccine. Varicella vaccine preferably should be given to children at the same time they receive measles-mumps-rubella vaccine and may be given at the same time as other vaccines recommended at this age. Children ages 18 months to 12 years who have not been vaccinated as part of the routine schedule and who lack a reliable history of varicella should be vaccinated. Vaccination is desirable for persons > or = 13 years old without a reliable history of varicella. Special efforts should be made to assess the immunity of and to vaccinate susceptible persons who have close contact with persons at high risk for complications, including family contacts of immunocompromised individuals and health care workers.

The effect of complete excision on stage III neuroblastoma: a report of the European Neuroblastoma Study Group

Current opinion is divided about the value of excisional surgery in Evans stage III neuroblastoma.

AIMS

To evaluate and correlate the survival of patients with stage III neuroblastoma with the effectiveness of the surgical excision, as assessed by (1) the surgeon (resection data) at the time of operation and (2) the pathologist (excision data).

METHODS

The ENSG (European Neuroblastoma Study Group) database of 202 patients from 29 centres with proven stage III were analysed. The data include all patients with neuroblastoma diagnosed between 1982 and 1992 and their subsequent follow-up.

RESULTS

Patients were grouped according to the extent of resection (100%, 75% to 99%, and < 75%) and the completeness of excision (complete, microscopic residual, macroscopic residual). There were 123 with resection data, a subgroup of 104 with excision data, and 27 with no excision. There was no statistically significant difference (log rank test) in overall survival (p = 0.11) or event-free survival between the resection subgroups, even when the data from patients without resection were included. Complete excision was associated with a highly significant survival advantage, in terms of overall survival (P = .007) and event-free survival (P = .006). This effect is most obvious among patients with the worst prognosis: older children and those with an abdominal tumour.

CONCLUSION

Histological confirmation of complete excision confers a significant survival advantage for patients with stage III neuroblastoma and justifies a painstaking attempt at complete resection.

Neurosurgery in a patient with Creutzfeldt-Jakob disease after pituitary derived growth hormone therapy in childhood

The case of a young man who had previously received pituitary derived growth hormone for treatment of radiation induced growth hormone deficiency is reported. He underwent neurosurgery for presumed recurrence of a posterior fossa tumour but was subsequently shown to have Creutzfeldt-Jakob disease, confirmed on necropsy. The risk of transmission of Creutzfeldt-Jakob disease by neurosurgical instruments is discussed. Since the occurrence of this case the Department of Health have issued guidelines concerning neurosurgery and ophthalmic surgery in patients who have previously received treatment with pituitary derived growth hormone and may therefore be at risk of developing Creutzfeldt-Jakob disease. Surgical instruments used on such patients should under no circumstances be reused, and should be destroyed after use.

Role of growth hormone and sex steroids in achieving and maintaining normal bone mass

It is now established that adults with growth hormone (GH) deficiency, of childhood or adult onset, have reduced bone mass. GH deficiency is believed to interfere with acquisition of bone mass, although an alternative mechanism is required to explain the reduction in bone mass present in adults who acquire GH deficiency after peak bone mass has been achieved. GH replacement increases bone turnover and may increase bone mass in the longer term, although short-term studies show a decrease in bone mass which can be explained by an increase in bone resorption before new bone formation occurs. Abnormalities of GH secretion have also been implicated in the development of osteoporosis, but the effect of GH treatment on bone mass in such patients is disappointing. Sex steroids have an important role to play in the acquisition of bone mass, and reduced sex steroid levels during adolescence have a deleterious effect on bone mass. The importance of sex steroids in the maintenance of bone mass is illustrated by the development of osteopenia in men and women with hypogonadism, and by the preservation of bone mass by restoration of normal endogenous sex steroid levels, or by treatment with exogenous sex steroid. Sex steroids also influence circulating levels of GH and insulin-like growth factor-1, and the inter-action between these hormones is likely to be important in the acquisition and maintenance of normal bone mass.

Adult growth hormone deficiency and bone mass

Bone mineral density (BMD) is reduced in adults with growth hormone (GH) deficiency and the decrease in BMD appears more marked if the GH deficiency is childhood onset rather than adult onset. Recent epidemiological studies suggest an increased fracture rate in GH-deficient adults. The skeletal response to GH therapy depends on the variety of GH deficiency, the type of bone studied and the duration of therapy. In the childhood-onset, GH-deficient adult there is either no change or a reduction in cortical and integral bone mass over the first 6 months, whereas at 6 months there is an increase in vertebral trabecular BMD. Subsequently there is a steady rise in BMD at all sites over the next 12-18 months. In the adult-onset, GH-deficient adult, the long-term results are more contentious. It is too early to determine whether GH therapy modifies fracture risk.

Child-care practices: effects of social change on the epidemiology of infectious diseases and antibiotic resistance

The increasing number of mothers of young children in the work force and the resultant escalated use of child-care facilities has had a marked effect on the epidemiology of infectious diseases in young children. Children attending child care are at high risk for respiratory and gastrointestinal tract illnesses. The high prevalence of infectious diseases in the child-care setting is accompanied by high usage of antibiotics, which in turn has resulted in spread of antibiotic-resistant organisms. The infectious disease standards of the American Public Health Association/American Academy of Pediatrics guidelines were developed to prevent and limit transmission of infectious diseases in the child-care setting. Adherence to these standards is essential but will not completely eliminate the increased risk of infectious diseases in child-care settings. New challenges need to be addressed to assure that optimal health promotion and disease prevention is practiced in child-care settings. We approach the 21st century with a vast amount of medical knowledge, molecular technology, highly effective vaccines, and powerful antimicrobial agents. However, at the same time we face many unsolved serious problems, such as preventing or controlling the emergence and spread of antibiotic-resistant organisms that adversely affect our ability to treat infectious diseases. Further research is needed concerning the relations between child care, the use of antibiotics, and transmission of antibiotic-resistant organisms in order to design and implement the most effective strategies for preventing or controlling antibiotic resistance. The potential risk for transmission of HIV in the child-care setting also needs to be recognized, and procedures to prevent transmission of blood-borne pathogens need to be followed. Monitoring compliance with national standards for child-care facilities, dissemination of information concerning infectious diseases and use of antibiotics, and development and use of new vaccines are strategies which should be used to help protect the health of children in child-care environments.

Mumps surveillance--United States, 1988-1993

PROBLEM/CONDITION

CDC monitors the incidence of mumps in the United States through the passive reporting of cases to its National Notifiable Disease Surveillance System (NNDSS).

REPORTING PERIOD COVERED

1988-1993.

DESCRIPTION OF SYSTEM

Weekly reports to the NNDSS from 48 states and the District of Columbia were used to calculate incidence rates for mumps. State immunization requirements were obtained from the U.S. Department of Health and Human Services.

RESULTS

After the licensure of mumps vaccine in the United States in December 1967 and the subsequent introduction of state immunization laws in an increasing number of states, the reported incidence of mumps decreased substantially. The 1,692 cases of mumps reported for 1993 represent the lowest number of cases ever reported to NNDSS and a 99% decrease from the 152,209 cases reported for 1968. During 1988-1993, most cases occurred in children 5-14 years of age (52%) and in persons > or = 15 years of age (36%). Although the incidence decreased in all age groups, the largest decreases (> 50% reduction in incidence rate per 100,000 population) occurred in persons > or = 10 years of age. Overall, the incidence of mumps was lowest in states that had comprehensive school immunization laws requiring mumps vaccination and highest in states that did not have such requirements.

INTERPRETATION

Because of the extensive use of mumps vaccine and the increased number of states that had enacted mumps immunization laws, the number of reported mumps cases decreased further since the marked decline that began during the early 1970s. The earlier shift in incidence from children of school ages to older persons that was noted during 1985-1988 continued until 1992, when the proportion of cases occurring in children of school ages increased and exceeded the proportions occurring in other age groups.

ACTIONS TAKEN

All health-care providers are encouraged to a) report mumps cases to their local and state health departments for transmission to NNDSS and b) enact school immunization laws requiring mumps vaccination.

Which adults develop side-effects of growth hormone replacement?

OBJECTIVE

Although the nature of the side-effects of GH replacement in adults are well described, the factors influencing their development are ill understood. The aim of this study was to determine whether there were any characteristics of adults with GH deficiency that predicted whether or not they developed side-effects of GH replacement.

DESIGN

A 12-month study (double blind placebo controlled for the first 6 months and open for the second 6 months) of GH replacement (0.125 IU/kg/week for the first month and 0.25 IU/kg/week thereafter) in adults.

PATIENTS

Sixty-three adults (27 men, 36 women, aged 34.9 +/- 1.4 (mean +/- SE, range 20.1-59.5 years)) with GH deficiency (peak serum GH response to provocative testing of less than 10 mU/l) who took part in a 12-month study of GH replacement. Twenty-five patients (40%) did not develop side-effects, 19 patients (30%) developed side-effects which did not necessitate a reduction in dose of GH, and 19 patients (30%) required a reduction in dose of GH because of side-effects.

MEASUREMENTS

The three groups of patients were compared according to age, height, weight and body mass index (BMI) at entry into the study and to pretreatment peak serum GH response to provocative testing. They were also compared according to serum concentration of insulin-like growth factor (IGF)-I and IGF binding protein-3, and age-adjusted serum IGF-I standard deviation score (SDS), at entry into the study and by change in these measurements after 6 months of GH replacement. The patient's sex, whether GH deficiency was of childhood or adult onset, estimated duration of GH deficiency, presence or absence of additional pituitary hormone deficiencies, underlying pathological disorder and previous therapeutic interventions were also compared in the three groups of patients.

RESULTS

Those patients who required a reduction in dose of GH because of side-effects were more likely to have a peak serum GH response of greater than 1 mU/l (P = 0.005) and to have adult onset GH deficiency (P = 0.04) than those who did not develop side-effects or who did not require a reduction in dose of GH because of side-effects. In addition, those who needed a reduction in GH dose were older (P = 0.002), heavier (P = 0.04) and had a greater BMI (P = 0.003) than those who did not develop side-effects. Those who developed side-effects but did not require a reduction in dose of GH had a greater increment in IGF-I SDS after 6 months of GH replacement than those who did not develop side-effects (P = 0.03).

CONCLUSION

Side-effects of GH replacement are more likely to occur in older patients, in those with a peak serum GH response to provocative testing of greater then 1 mU/l, in those with a greater increment in serum IGF-I SDS whilst receiving GH replacement, in those with greater weight and BMI, and those with adult onset GH deficiency.

Factors influencing the desire for long-term growth hormone replacement in adults

OBJECTIVE

Growth hormone replacement in adults may be considered beneficial by clinicians, but patients may not perceive any benefits. The purpose of this study was to determine whether there were any factors which influenced whether an adult wished to continue on long-term GH replacement after taking part in a study of GH replacement.

DESIGN

A 12-month study (double-blind placebo controlled for the first 6 months and open for the second 6 months) of GH replacement (0.125 IU/kg/week for the first month and 0.25 IU/kg/week thereafter) in adults.

PATIENTS

Sixty-three adults (27 men, 36 women, aged 34.9 +/- 1.4 (mean +/- SE, range 20.1-59.5) years) with GH deficiency (peak serum GH response to provocative testing less than 10 mU/l) who entered a 12-month study of GH replacement. Thirty patients (48%) wished to continue on GH replacement and 33 patients (52%) did not wish to continue on GH replacement after the study.

MEASUREMENTS

Biochemical, anthropometric and demographic characteristics, and well-being, were compared in those patients who wished to continue on long-term GH replacement and in those who did not. In the two groups of patients the age, height, weight, body mass index, serum insulin-like growth factor (IGF)-I, IGF binding protein (IGFBP)-3 and IGF-I age matched standard deviation score (SDS) were compared at entry into the study, and changes in IGF-I, IGFBP-3 and IGF-I SDS were compared after 6 months of GH replacement. The patients were compared according to pretreatment peak serum GH response to provocative testing, sex, estimated duration of GH deficiency, whether GH deficiency was of childhood or adult onset, presence or absence of additional pituitary hormone deficiencies, underlying pathological disorder, previous therapeutic interventions, employment status, marital status and living arrangement, and according to development of side-effects of GH replacement and the requirement for reduction in dose of GH because of side-effects during the study. Scores on two questionnaire measures of well-being or distress, the Nottingham Health Profile (NHP) and the Psychological General Well-Being Schedule (PGWBS), were compared at entry into the study in the two groups, as were change in scores on these questionnaires after 6 months of GH replacement.

RESULTS

Those who continued on GH replacement tended to have a greater severity of GH deficiency (median peak serum GH concentration 0.7 vs 2.3 mU/l, P = 0.06), tended to have greater distress in terms of energy (NHP, P = 0.06) and vitality (PGWBS, P = 0.06) at entry into the study and showed an improvement in energy during the study compared with no change in those who did not wish to continue on GH replacement (NHP, P = 0.06).

CONCLUSION

Those adults who wished to continue on GH replacement tended to have a greater severity of GH deficiency, to experience more distress in terms of energy and vitality at entry into the study and to experience an improvement in energy after 6 months treatment with GH.

Effect of growth hormone replacement on bone mass in adults with adult onset growth hormone deficiency

OBJECTIVE

Previous studies of the effect of GH replacement on bone mass in adults with GH deficiency have produced conflicting results. We have studied the effect of 6 and 12 months of GH replacement on bone mass in adults with adult onset GH deficiency.

DESIGN

Double blind placebo controlled study of GH replacement (0.125 IU/kg/week for the first month and 0.25 IU/kg/week thereafter) for 6 months and an open study for a further 6 or 12 months.

PATIENTS

Twenty-two adults (10 men, 12 women), aged 41.5 +/- 2.1 years (mean +/- SE, range 23.6-59.5), with adult onset GH deficiency.

MEASUREMENTS

Single-energy quantitative computed tomography was used to measure vertebral trabecular bone mineral density (BMD), single-photon absorptiometry (SPA) was used to measure forearm cortical and integral bone mineral content and BMD and dual-energy X-ray absorptiometry (DXA) was used to measure lumbar spine, femoral neck, trochanteric and Ward's triangle integral BMD.

RESULTS

After 6 months of GH replacement (n = 21) there was a significant decrease in forearm cortical BMD (SPA: median change -0.009 g/cm2, P = 0.01), forearm integral BMD (SPA: median change -0.016 g/cm2, P = 0.03), lumbar spine BMD (DXA: median change -0.22 g/cm2; P = 0.003) and femoral neck BMD (DXA: median change -0.029 g/cm2, P = 0.006). After 12 months of GH replacement (n = 13) there was a significant decrease in lumbar spine BMD (DXA: median change -0.035 g/cm2, P = 0.002) from baseline. There was no significant increase in bone mass at any site after 6 or 12 months of GH replacement. Change in bone mass was not influenced by sex of the patient or by presence or absence of additional pituitary hormone deficiencies.

CONCLUSION

The response of bone mass to 6 and 12 months of GH replacement in adults with adult onset GH deficiency is disappointing. Longer-term studies are required to determine whether prolonged GH replacement has a beneficial effect on bone mass.

Characteristics of adults who wish to enter a trial of growth hormone replacement

OBJECTIVE

It is possible that the degree of perceived well-being may influence the decision of an adult with GH deficiency to receive GH replacement. We have therefore sought factors which influenced whether or not such a patient wished to enter a study of GH replacement.

DESIGN

Biochemical, anthropometric and demographic characteristics, and well-being, of patients who chose to enter a 12-month study of GH replacement at Christie Hospital NHS Trust were compared with those of patients who declined to enter the study.

PATIENTS

Sixty-five adults with GH deficiency who entered a study of GH replacement and 33 adults with GH deficiency who were approached but who declined to enter the study.

MEASUREMENTS

The two groups of patients were compared according to sex, age, height, weight, body mass index, peak serum GH response to provocative testing, estimated duration of GH deficiency, whether GH deficiency was of childhood or adult onset, presence or absence of additional pituitary hormone deficiencies, aetiology of GH deficiency, previous therapeutic interventions, employment status, marital status and living arrangement (65 entered vs 33 declined to enter). Well-being or distress was measured using the Nottingham Health Profile (NHP) (65 entered vs 20 declined to enter) and the Psychological General Well-being Schedule (PGWBS) (33 entered vs 19 declined to enter).

RESULTS

Those who entered the study had significantly higher scores on the energy (P = 0.03) and emotional reaction (P = 0.02) subsections and on the total score (P = 0.04) of the NHP, indicating greater distress, and had a significantly lower score (P = 0.009) on the vitality subsection of the PGWBS, again indicating greater distress. Those who entered the study had a significantly lower prevalence of non-functioning pituitary adenoma (P = 0.02) but there was no other difference in biochemical, anthropometric or demographic characteristics between the two groups.

CONCLUSION

Adults who enter a study of GH replacement exhibit greater distress on questionnaire assessment than those who decline to enter such a study. This bias must be considered when interpreting studies of the effect of GH replacement on well-being in adults.

Intestinal dilatation in the fetus

Images

Further increase in forearm cortical bone mineral content after discontinuation of growth hormone replacement

OBJECTIVE

Growth hormone replacement of adults with childhood onset GH deficiency results in an increase in bone mineral density (BMD) after 6-12 months of GH replacement. By measuring BMD 12 months after discontinuation of GH replacement we aimed to investigate whether there is an effect of GH replacement on BMD persisting after GH has been withdrawn.

DESIGN

BMD was measured 13 +/- 1 (mean +/- SE, range 11-16) months after discontinuation of GH replacement.

PATIENTS

Ten adults, age 23.2 +/- 1.4 (range 18.8-32.4) years, with childhood onset isolated GH deficiency (2 idiopathic, 8 irradiation induced) who had previously completed a study of the effect of 12 months of GH replacement on BMD.

MEASUREMENTS

Forearm cortical bone mineral content (BMC) was measured using single-photon absorptiometry at the proximal site of the distal forearm. Forearm integral BMC at the ultradistal site of the forearm and bone width at both proximal and ultradistal sites of the distal forearm were measured by the same technique. Vertebral trabecular BMD was measured using quantitative computed tomography.

RESULTS

Forearm cortical BMC was significantly greater than that measured at the time of discontinuation of GH (1.48 +/- 0.04 vs 1.44 +/- 0.05 g/cm). There was no significant change in forearm integral BMC or in vertebral trabecular BMD after discontinuation of GH. There was no significant change in bone width at proximal and ultradistal sites of the distal forearm after discontinuation of GH.

CONCLUSION

After discontinuation of GH replacement the further increase in forearm cortical bone mineral content without a significant increase in forearm bone width suggests that the increase in cortical bone mineral content is due to a persisting effect of previous GH replacement, and not to further spontaneous attainment of bone mass before peak bone mass is reached. These findings emphasize the importance of continuing to monitor bone mass after the stimulus to increase bone turnover has been withdrawn.

Benign chest wall lipoblastoma of infancy producing underlying bone enlargement

We report a case of a chest wall lipoblastoma first presenting in a 6-month-old infant. Clinical presentation was with a posterior chest wall mass. Chest X-ray showed expansion of the posterior ribs on the left, a feature not previously described in this condition. CT scanning delineated a mass of predominantly fat attenuation, which was invading between the ribs to line the extra-pleural space, and was causing compression and atrophy of muscles locally. There were two recurrences requiring further surgery. Histology showed a well-differentiated lipoblastoma.

Effect of carrier protein priming on antibody responses to Haemophilus influenzae type b conjugate vaccines in infants

OBJECTIVE

To assess the effect of priming with diphtheria and tetanus toxoid vaccine (DT) at 1 month of age on the anticapsular polyribosylribitol phosphate (PRP) antibody responses of infants vaccinated with Haemophilus influenzae type b polysaccharide-tetanus toxoid conjugate (PRP-T) or PRP oligosaccharide-cross-reactive mutant diphtheria toxin conjugate (HbOC).

DESIGN

Randomized controlled trial with serum samples assayed blindly.

PARTICIPANTS AND SETTING

Healthy infants enrolled in private pediatric practices; 94 (91%) of 103 infants had prevaccination and postvaccination serum samples available for analysis.

INTERVENTIONS

Two groups received DT vaccination at 1 month of age and subsequent injections of PRP-T or HbOC conjugate vaccines at 2, 4, and 6 months of age. The control groups were not vaccinated with DT but received PRP-T or HbOC at the same ages as the carrier-primed groups. Infants in all groups were given a booster injection of unconjugated PRP at 12 months of age to assess induction of immunologic memory.

MAIN OUTCOME MEASURE

Concentrations of serum antibody to PRP.

MAIN RESULTS

The DT-primed infants given PRP-T had twofold to threefold higher geometric mean anti-PRP antibody responses after one (P < or = .01), two (P < or = .01), or three (P = .06) doses of conjugate vaccine than the infants of the unprimed group. The primed infants also had threefold higher memory antibody responses to the booster PRP injection given at 12 months of age (concentration of 24.4 vs 8.4 micrograms/mL in infants not primed with DT; P < .01). The DT-primed infants given HbOC had twofold to threefold higher antibody responses after one (P = .07) or two (P < .01) doses of conjugate vaccine than the unprimed HbOC group, but there were no significant differences after the third dose of conjugate vaccine or after the PRP booster injection.

CONCLUSIONS

Vaccination with DT at 1 month of age increases the magnitude of the anti-PRP antibody responses to conjugate vaccination. With HbOC, the effect of carrier priming was present for up to 6 months of age, whereas in infants vaccinated with PRP-T, enhanced immunity was present for at least 12 months.

Reduced bone mineral density in men following chemotherapy for Hodgkin's disease

We have measured bone mineral density (BMD) in 29 men, mean age 35.0 (range 19.7-58.0) years, with testicular damage following MVPP or hybrid chemotherapy for Hodgkin's disease. Forearm cortical bone mineral content (BMC) and lumbar spine and femoral neck integral BMD were measured 3.4 (1.1-6.8) years after completion of chemotherapy, and results expressed as Z (standard deviation) scores. There was a significant reduction in forearm cortical BMC (median BMC 1.727 g cm-1, median Z-score -0.8, P < 0.0005), in lumbar spine integral BMD (median BMD 1.141 g cm-2, median Z-score -0.6, P < 0.0005) and in femoral neck integral BMD (median BMD 0.991 g cm-2, median Z-score -0.4, P < 0.05). There was no significant correlation between Z-score and time elapsed since completion of chemotherapy, and no significant difference in Z-score according to type of chemotherapeutic regimen or number of cycles of chemotherapy received. In conclusion, men who are in complete remission following treatment of Hodgkin's disease have reduced cortical and trabecular BMD. Possible causes include mild hypogonadism secondary to chemotherapy-induced impairment of Leydig cell function, a direct effect of chemotherapy on bone, an effect of high-dose glucocorticoid on bone or an effect of Hodgkin's disease per se.

Plasma interleukin-6 and tumour necrosis factor levels as predictors of disease severity and outcome in necrotizing enterocolitis

Plasma tumour necrosis factor (TNF) and interleukin-6 (IL-6) levels of 18 infants with necrotizing enterocolitis (NEC) were measured at the time of diagnosis or on transfer to a paediatric surgical unit. Whereas TNF levels were similar for infants managed medically (stage II, n = 8) and surgically (stage III, n = 7), IL-6 levels were significantly higher in stage III cases (mean, 3,127 pg/mL [95% CI, 1,809 to 4,445 pg/mL]) than in stage II (mean, 127 pg/mL [95% CI, 10 to 329 pg/mL]; P = .001). Neither TNF nor IL-6 level predicted eventual outcome. Plasma IL-6 may be useful as an indication for operation in NEC.

Human chorionic gonadotrophin and laparoscopy in the treatment of impalpable testes

The object of this preliminary retrospective study was to assess the use of human chorionic gonadotrophin (HCG) in the treatment of impalpable testes. Eleven children were found to have an impalpable testis, and in two cases neither testis was palpable. After HCG injections, 10 testes were palpable (67%), two of which were in the scrotum. During laparoscopy, three testes were found to be absent (20%) and two were found to be intraabdominal (13%). During surgery, seven testes were found in the inguinal canal, close to the deep ring (47%). The other was found at the superficial ring. The authors conclude that HCG injections are valuable in the treatment of impalpable testes; the treatment resulted in palpable testes in 83% of their cases in which one testis was present.

Plasma cytokine levels in necrotizing enterocolitis

Plasma concentrations of tumour necrosis factor (TNF) and interleukin-6 (IL-6) were measured by ELISA in samples taken from 24 infants with necrotizing enterocolitis (NEC) between 0 and 306 h from diagnosis. TNF was detected (> 10 pg/ml) in 71% samples with a mean of 48 pg/ml (95% CI 42 to 55 pg/ml) and did not vary with either time from diagnosis or severity of disease. IL-6 was raised during the first 48 h with a significant difference between stage II (mean 127 pg/ml, 95% CI 10 to 329 pg/ml) and stage III (mean 3127 pg/ml, 95% CI 1809 to 4445 pg/ml, p = 0.001). Postoperative plasma IL-6 concentration fell to similar levels seen in stage II (mean 150 pg/ml, 95% CI 37 to 283 pg/ml, p = 0.79). We conclude that plasma concentration of IL-6 rather than TNF reflects the clinical severity of necrotizing enterocolitis and that the relative level of these cytokines has important implications for the use of anti-cytokine therapy in NEC.

Reduced bone mineral density in patients with adult onset growth hormone deficiency

We have demonstrated previously that adults with isolated GH deficiency of childhood onset have a reduced bone mineral density (BMD) of vertebral trabecular bone [quantitative computed tomography (QCT): median Z score -1.3, P < 0.01, n = 12] and of cortical bone in the forearm [single photon absorptiometry (SPA): median Z score -2.9, P = 0.001, n = 7]. We have now examined BMD in 26 patients (13 men, 13 women), aged between 23.6 and 59.5 (mean 42.4) yr, with adult onset GH deficiency, defined as a GH response of less than 5 micrograms/L to provocative testing, of at least two years duration. BMD was measured using QCT for vertebral trabecular bone, dual energy x-ray absorptiometry (DXA) in the lumbar spine and femoral neck, and SPA in the forearm. There was a highly significant reduction in QCT (median Z score -1.07, P < 0.00005), in DXA of the lumbar spine (median Z score -0.76, P = 0.0001) and in SPA of the forearm (median Z score -0.86, P = 0.0001) but not in DXA of the femoral neck (median Z score -0.38, P = 0.35). There were no significant differences in Z scores between those patients with isolated GH deficiency and those with GH and gonadotrophin deficiency. There was a significant positive correlation between age at which BMD was measured and Z score (the older the patient, the higher the Z score) for QCT (r = 0.38, P < 0.05) and SPA (r = 0.48, P < 0.01) with a trend to a positive correlation for DXA of the lumbar spine and femoral neck. Patients were grouped according to estimated duration of GH deficiency (less than 5 yr, n = 7; 5-10 yr, n = 10; greater than 10 yr, n = 9). These groups did not show a significant difference in BMD at any site. We conclude that patients with adult onset GH deficiency (isolated or in conjunction with other pituitary hormone deficiencies) have a reduced BMD. Age at development of GH deficiency may be more important than duration of GH deficiency in determining the degree of reduction in bone mass. The impact of GH treatment on BMD in adults with adult onset GH deficiency requires investigation.

Bone mineral density is reduced in female but not male subjects with Addison's disease

AIMS

Bone mineral density (BMD) may be potentially reduced in Addison's disease as a result of excessive glucocorticoid replacement, loss of adrenal androgens or concomitant gonadal or thyroid disease. We have examined clinical and biochemical parameters, and BMD in a group of subjects with Addison's disease.

METHODS

Fourteen patients (9 female mean age 56 years, 5 male mean age 56.6 years) with primary adrenocortical failure (median duration 8.5 yrs) on replacement therapy were studied. Four had hypothyroidism on thyroxine doses (0.1 to 0.15 mg/d). Seven of the 9 females were post menopausal. Mean plasma cortisol levels were calculated from at least five samples in each subject drawn between 3 and 5 hours post dose, and the cortisol replacement dose calculated per unit body mass (mg/kg). BMD was measured by dual energy X-ray absorptiometry (DEXA) at femoral neck and lumbar spine (L2-4) and compared with local reference data.

RESULTS

For women (n = 9) at L2-4 the mean Z score was -1.21 (95% CI -1.69, -0.73), and at femoral neck -0.57 (95% CI -1.15, 0.00). For men (n = 5) at L2-4, the mean Z score was 1.32 (95% CI -0.86, 3.50) and at femoral neck 0.62 (95% CI -0.18, 1.42). For all patients, there was no significant correlation between mean plasma cortisol and Z scores at L2-4 and femoral neck, r = -0.003 and -0.095 respectively; and between duration of Addison's disease and mean Z scores at L2-4 and femoral neck r = -0.043 and 0.143 respectively.

CONCLUSIONS

Women with Addison's disease therefore have a greater than expected reduction in BMD. We postulate that this may be related to loss of adrenal androgens.

Cost-effectiveness of a routine varicella vaccination program for US children

OBJECTIVE

To evaluate the economic consequences of a routine varicella vaccination program that targets healthy children.

METHODS

Decision analysis was used to compare the costs, outcomes, and cost-effectiveness of a routine vaccination program with no intervention. Clinical outcomes were based on a mathematical model of vaccine efficacy that relied on published and unpublished data and on expert opinion. Medical utilization rates and costs were collected from multiple sources, including the Kaiser Permanente Medical Care Program and the California Hospital Discharge Database.

RESULTS

A routine varicella vaccination program for healthy children would prevent 94% of all potential cases of chickenpox, provided the vaccination coverage rate is 97% at school entry. It would cost approximately $162 million annually if one dose of vaccine per child were recommended at a cost of $35 per dose. From the societal perspective, which includes work-loss costs as well as medical costs, the program would save more than $5 for every dollar invested in vaccination. However, from the health care payer's perspective (medical costs only), the program would cost approximately $2 per chickenpox case prevented, or $2500 per life-year saved. The medical cost of disease prevention was sensitive to the vaccination coverage rate and vaccine price but was relatively insensitive to assumptions about vaccine efficacy within plausible ranges. An additional program for catch-up vaccination of 12-year-olds would have high incremental costs if the vaccination coverage rate of children of preschool age were 97%, but would result in net savings at a coverage rate of 50%.

CONCLUSIONS

A routine varicella vaccination program for healthy children would result in net savings from the societal perspective, which includes work-loss costs as well as medical costs. Compared with other prevention programs, it would also be relatively cost-effective from the health care payer's perspective.

Necrotizing enterocolitis--multisystem organ failure of the newborn?

Evidence of failure of organ system other than the gastrointestinal tract was reviewed in a series of 46 infants treated for necrotizing enterocolitis (NEC) at a regional combined medical and surgical neonatal unit. Respiratory failure was identified in 42 infants (91%), renal failure in 39 (85%), cardiovascular failure in 15 (33%) and hepatic failure in 7 (15%). The number of systems involved correlated with both severity of disease and outcome. Onset of failure in the above systems was closely related to the diagnosis of NEC and 29 cases predated the clinical onset. We conclude that NEC is part of a syndrome of multisystem failure and that this has important implications for the treatment of NEC.

Follow-up after inguinal herniotomy or surgery for hydrocele in boys

A retrospective review of 556 boys who had undergone inguinal herniotomy or surgery for hydrocele was carried out to assess the value of early routine postoperative follow-up. Of 386 children given an appointment, 319 (82.6 per cent) attended. The testis was no longer palpable in the normal scrotal position in 12 boys; eight were normal on further review and four required orchidopexy. Six hydroceles, all of which resolved, and four contralateral hernias were detected. Nineteen boys (4.9 per cent) were referred later with recurrent hernia (two patients), ipsilateral high testis (two), or contralateral hernia or hydrocele (15). Of 170 children not given a routine appointment, ten (5.9 per cent) were subsequently referred back with a transient hydrocele (two) or a contralateral hernia (eight). After a total of 440 appointments, eight boys (1.8 per cent) were found to have a significant abnormality. The rate of referral back to hospital was similar in both groups. Early discharge would make more efficient use of outpatient resources without significantly affecting overall outcome.

Metyrapone induced increase in plasma corticotropin is not associated with changes in peripheral venous arginine vasopressin or corticotropin releasing factor

The responses of the "stress hormones" cortisol, 11-deoxycortisol, ACTH, vasopressin (AVP), and corticotropin releasing factor (CRF) were studied in 6 normal males in response to acute cortisol deficiency induced by the 11-beta-hydroxylase inhibitor, metyrapone. A 750 mg dose was administered orally at 08:00 h on day 1 and at 4 hourly intervals over a 24-h period. A 20 mg tablet of hydrocortisone or placebo was then given at 08:00 h on day 2, according to a randomized cross-over design. Each subject was restudied after an interval of at least one month. Blood samples were taken for all hormones at 08:00 h on day 1 and at 04:00 h on day 2. Thereafter ACTH and AVP were sampled at 10-min intervals, CRF at 20-min intervals, and cortisol and 11-deoxycortisol at hourly intervals until 12:00 h on day 2. Cortisol (mean +/- SE) fell from 628 +/- 218 nmol/l at 08:00 h (day 1) to a minimum of 230 +/- 78 nmol/l at 05:00 h on day 2. Plasma 11-deoxycortisol rose from 14.0 +/- 0.8 nmol/l to a maximum of 622 +/- 36 nmol/l and plasma ACTH rose from 8.71 +/- 1.64 pmol/l to a maximum of 166.2 +/- 57.5 pmol/l. Diurnal rhythmicity of plasma ACTH was maintained. There was no detectable change in plasma levels of AVP or CRF from baseline (AVP 2.5 +/- 0.8 pmol/l, CRF 3.4 +/- 0.5 pmol/l).(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of immunologic memory in infants primed with Haemophilus influenzae type b conjugate vaccines

The ability of different Haemophilus influenzae type b conjugate vaccines to induce immunologic memory was compared in 381 infants who were vaccinated with one of three conjugate vaccines beginning at 2 months of age. All infants were vaccinated with unconjugated type b capsular polysaccharide, polyribosylribitol phosphate (PRP), at 12 months. In each group, high antibody responses were detected by 6-9 days after vaccination. One month after receiving PRP, infants primed with PRP conjugated to the outer membrane protein of Neisseria meningitidis or PRP oligomers conjugated to the cross-reactive mutant diphtheria protein, CRM197, had twofold higher total anti-PRP antibody concentrations than did infants primed with PRP conjugated to tetanus toxoid (P < .005). After the conjugate and the PRP boost, notable differences were present among vaccine groups with respect to the magnitude of the IgG anti-PRP antibody concentrations and light chain variable region usage as determined by idiotypic analysis. Thus, each of the conjugate vaccines primed infants for the ability to evoke memory antibody responses to PRP, but qualitative and quantitative differences in priming induced by different vaccines may affect their ability to confer protection against disease.

Immunogenicity of Haemophilus influenzae type b polysaccharide-tetanus toxoid conjugate vaccine in infants

OBJECTIVE

To compare the safety and immunogenicity of three investigational lots of Haemophilus influenzae type b polysaccharide-tetanus toxoid (PRP-T) conjugate vaccine in infants.

DESIGN

A multicenter, randomized immunogenicity trial. Infants were vaccinated at 2, 4, and 6 months of age with one of three lots of PRP-T. A control group received H influenzae type b oligomers conjugated to CRM197 (HbOC). Serum was obtained before each injection and 1 month after the third dose, and assayed blindly for antibody in one laboratory.

SUBJECTS

Four hundred eighty-four infants from private pediatric practices located in five geographic areas.

MEASUREMENTS AND RESULTS

There were no significant differences in the number of adverse events reported for infants receiving PRP-T or HbOC, and the rates did not exceed those observed previously in infants given diphtheria-tetanus-pertussis vaccine alone. Total serum anti-PRP antibody responses were analyzed in 336 infants who met strict inclusion criteria. After one, two, or three doses, the respective antibody responses to each of the three lots of PRP-T and to HbOC vaccine were similar. The only exception was one lot of PRP-T, which after one or two injections elicited significantly higher geometric mean antibody responses than the other two lots or the HbOC vaccine. After a third injection, there were no significant lot differences. Combining the data from the different lots, there were no significant differences in the geometric mean antibody concentration after three doses of PRP-T or HbOC (8.3 vs 7.7 micrograms/mL), and 95% and 91%, respectively, of infants had greater than 1.0 microgram/mL of antibody. There were no significant differences in the magnitudes of the respective IgG1-, IgG2-, and IgM-specific antibody concentrations between infants given PRP-T or HbOC.

CONCLUSIONS

The three investigational lots of PRP-T tested were safe and were as immunogenic as or more so than the licensed HbOC conjugate vaccine.