Application of the Indigenous evaluation framework to a university certificate program for building cultural awareness in science, technology, engineering, and mathematics

This paper presents a case example of the Indigenous Evaluation Framework as applied to a science, technology, engineering, and mathematics (STEM) education pilot program. Indigenous methodologies include knowledge and data that are inclusive of historically marginalized groups, are highly meaningful, valid, and useful for all. A paradigm shift from Western evaluation methodologies to Indigenous evaluation is necessary when evaluating STEM programs that are committed to increasing recruitment, retention, and graduation of students from historically marginalized groups. This paper describes the use of the Indigenous Evaluation Framework during the first two years of the newly created Environmental Stewardship of Indigenous Lands program at the University of Colorado Denver. We discuss the importance of the Indigenous Evaluation Framework and how it informs the development and continued improvements to the program that also provides agency to program leads and participants.

Role of Faculty Development Programs in Medical Education at the University of Zimbabwe College of Health Sciences, Zimbabwe

Background:

Major challenges are being experienced in medical education in sub-Saharan African Universities. These include emigration of faculty, infrequent curriculum review, inadequate training in medical education, poor investments in infrastructure and lack of faculty development programs. The USA government committed funding to improve the quality of medical education and research capacity in sub-Saharan Africa through the Medical Education Partnership Initiative (MEPI).

Objectives:

This article describes the implementation of faculty development at the University of Zimbabwe College of Health Sciences (UZCHS), a recipient of a MEPI award.

Methods:

Data sources included annual surveys and reports of UZCHS MEPI activities, exit evaluation reports of faculty development workshops; results of a survey conducted in 2015 at the end of the MEPI grant. Questionnaires were developed based on the MEPI Zimbabwe evaluation plan and logic model. Surveys were administered to faculty members, postgraduate and undergraduate students. Qualitative data was collected through in-depth key informer interviews of stakeholder.

Findings:

Different faculty development activities were implemented such as workshops, exchange visits, visiting professors program, advanced leadership training and curriculum development. The implementation of the activities brought positive developments to the college as confirmed by faculty and students. The majority of faculty interviewed (96%) confirmed that faculty development programs were very helpful in enhancing their expertise and skills. A similar number, i.e. 96%, also reported satisfaction with the training.

Conclusions:

We have described how the implementation of faculty development programs at the UZCHS contributed to the improvement of medical education at the College. The short term and long-term benefits of faculty development have been analyzed. Various forms of faculty development programs were described. Limitations of this analysis were the inability to collect data on students’ performance and the demonstration of changes in teaching performance.

Medical Education Partnership Initiative (MEPI) in Zimbabwe: Outcomes and Challenges

The 5-year medical education and research strengthening initiative in Zimbabwe increased faculty retention and student enrollment, improved information technology infrastructure, provided mentoring for postgraduates and clinical training in specialty areas, instituted a competency-based curriculum reform process, and created new departments and centers to institutionalize health education and research implementation. A comprehensive review of the curriculum is still underway and uptake of technology-assisted teaching has been slower than expected.

Background:

Sub-Saharan Africa has an inadequate number of health professionals, leading to a reduced capacity to respond to health challenges, including HIV/AIDS. From 2010 to 2015, the Medical Education Partnership Initiative (MEPI)—sponsored by the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)—was enthusiastically taken up by the University of Zimbabwe College of Health Sciences (UZCHS) and 12 other sub-Saharan African universities to develop models of training to improve medical education and research capacity. In this article, we describe the outcomes and challenges of MEPI in Zimbabwe.

Methods:

UZCHS in partnership with the University of Colorado, Denver; Stanford University; University of Cape Town; University College London; and King's College London designed the Novel Education Clinical Trainees and Researchers (NECTAR) program and 2 linked awards addressing cardiovascular disease and mental health to pursue MEPI objectives. A range of medical education and research capacity-focused programs were implemented, including faculty development, research support, mentored scholars, visiting professors, community-based education, information and technology support, cross-cutting curricula, and collaboration with partner universities and the ministries of health and education. We analyzed quantitative and qualitative data from several data sources, including annual surveys of faculty, students, and other stakeholders; workshop exit surveys; and key informant interviews with NECTAR administrators and leaders and the UZCHS dean.

Findings:

Improved Internet connectivity and electronic resource availability were early successes of NECTAR. Over the 5-year period, 69% (115 of 166) of faculty members attended at least 1 of 15 faculty development workshops. Forty-one faculty members underwent 1-year advanced faculty development training in medical education and leadership. Thirty-three mentored research scholars were trained under NECTAR, and 52 and 12 in cardiovascular and mental health programs, respectively. Twelve MEPI scholars had joined faculty by 2015. Full-time faculty grew by 36% (122 to 166), annual postgraduate and medical student enrollment increased by 61% (75 to 121) and 71% (123 to 210), respectively. To institutionalize and sustain MEPI innovations, the Research Support Center and the Department of Health Professions Education were established at UZCHS.

Conclusion:

MEPI has synergistically revitalized medical education, research capacity, and leadership at UZCHS. Investments in creating a new research center, health professions education department, and, programs have laid the foundation to help sustain faculty development and research capacity in the country.

Development of a low-maintenance measurement approach to continuously estimate methane emissions: A case study

The chemical breakdown of organic matter in landfills represents a significant source of methane gas (CH₄). Current estimates suggest that landfills are responsible for between 3% and 19% of global anthropogenic emissions. The net CH₄ emissions resulting from biogeochemical processes and their modulation by microbes in landfills are poorly constrained by imprecise knowledge of environmental constraints. The uncertainty in absolute CH₄ emissions from landfills is therefore considerable. This study investigates a new method to estimate the temporal variability of CH₄ emissions using meteorological and CH₄ concentration measurements downwind of a landfill site in Suffolk, UK from July to September 2014, taking advantage of the statistics that such a measurement approach offers versus shorter-term, but more complex and instantaneously accurate, flux snapshots. Methane emissions were calculated from CH₄ concentrations measured 700m from the perimeter of the landfill with observed concentrations ranging from background to 46.4ppm. Using an atmospheric dispersion model, we estimate a mean emission flux of 709μgm^-2s^-1 over this period, with a maximum value of 6.21mgm^-2s^-1, reflecting the wide natural variability in biogeochemical and other environmental controls on net site emission. The emissions calculated suggest that meteorological conditions have an influence on the magnitude of CH₄ emissions. We also investigate the factors responsible for the large variability observed in the estimated CH₄ emissions, and suggest that the largest component arises from uncertainty in the spatial distribution of CH₄ emissions within the landfill area. The results determined using the low-maintenance approach discussed in this paper suggest that a network of cheaper, less precise CH₄ sensors could be used to measure a continuous CH₄ emission time series from a landfill site, something that is not practical using far-field approaches such as tracer release methods. Even though there are limitations to the approach described here, this easy, low-maintenance, low-cost method could be used by landfill operators to estimate time-averaged CH₄ emissions and their impact downwind by simultaneously monitoring plume advection and CH₄ concentrations.

A Pilot Study of Autism-Specific Care Plans During Hospital Admission

BACKGROUND AND OBJECTIVE

Hospital admissions can be difficult for patients with autism spectrum disorder (ASD). We created an autism-specific care plan (ACP) to help improve the hospital experience for patients with ASD, and we tested feasibility and acceptability and compared the experience of care for children with and without an ACP.

METHODS

We performed a nonrandomized, retrospective chart review of all patients with ASD and a hospital admission from January 2013 to December 2013 (n = 142) to determine feasibility of the intervention. We then mailed surveys to all 142 families to measure experience with the ACP and to compare experience of care in those who did and did not have an ACP. Using multivariable linear regression we assessed the association of experience of care with ACP use while adjusting for covariates.

RESULTS

The ACP was well tolerated by parents and used frequently by staff. Compared with parents who did not use the ACP, parents who used the ACP reported a better experience relating to their general hospital experience (B = 1.48, P < .001) and staff attention to their child's ASD-specific needs (B = 3.07, P < .001).

CONCLUSIONS

According to this pilot study, care plans are feasible and hold promise to improve the experience of care for children with ASD and their families in the hospital setting.

The needs of hospitalized patients with autism spectrum disorders: a parent survey

OBJECTIVE

This survey assessed the in-hospital needs of patients diagnosed with autism spectrum disorders (ASDs).

METHODS

Parents were recruited to complete a 21-item survey about the needs of their child with an ASD while in the hospital. ASD diagnosis was reported by parents at the time of the survey. The results of the survey were analyzed and evaluated in 3 distinct categories of need.

RESULTS

We documented a range of responses associated with ASD-specific needs during hospitalization. Common concerns included child safety and the importance of acknowledging individual communication methods.

CONCLUSIONS

In a population of children with ASDs, parents report a diverse range of needs while in the hospital. These data support the concept that a pragmatic assessment of individual communication and sensory differences is likely to be essential in the development of an appropriate inpatient care plan.

VEGF, which is elevated in the CSF of patients with hydrocephalus, causes ventriculomegaly and ependymal changes in rats

Hydrocephalus is a condition characterized primarily by excessive accumulation of fluid in the ventricles of the brain for which there is currently no effective pharmacological treatment. Surgery, often accompanied by complications, is the only current treatment. Extensive research in our laboratory along with work from others has suggested a link between hydrocephalus and vascular function. We hypothesized that vascular endothelial growth factor (VEGF), the major angiogenic factor, could play a role in the pathogenesis of hydrocephalus. We tested this hypothesis by examining two predictions of such a link: first, that VEGF is present in many cases of clinical hydrocephalus; and second, that exogenous VEGF in an animal model could cause ventricular enlargement and tissue changes associated with hydrocephalus. Our results support the idea that VEGF elevation can potentiate hydrocephalus. The clinical relevance of this work is that anti-angiogenic drugs may be useful in patients with hydrocephalus, either alone or in combination with the currently available surgical treatments.

VEGF, PF4 and PDGF are elevated in platelets of colorectal cancer patients

Platelets sequester angiogenesis regulatory proteins which suggests an avenue for developing biomarkers to monitor disease. We describe a comparison of angiogenesis regulatory proteins found in platelets of colorectal cancer patients and normal controls. Platelet and plasma content of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), platelet derived growth factor (PDGF), platelet factor 4 (PF4), thrombospondin-1 (TSP-1) and endostatin in 35 patients with colon cancer were compared with 84 age-matched healthy controls using ELISAs. We standardized the platelet preparation procedure, introduced process controls and normalized the respective protein levels to platelet numbers using an actin ELISA. Statistically significant differences were found in the median levels of VEGF, PF4 and PDGF in platelets of patients with cancer compared to healthy individuals. Platelet concentrations in cancer patients versus controls were: VEGF 1.3 versus 0.6 pg/10(6), PF4 18.5 versus 9.4 ng/10(6), and PDGF 34.1 versus 21.0 pg/10(6). Multivariable logistic regression analysis indicated that PDGF, PF4 and VEGF were independent predictors of colorectal carcinoma and as a set provided statistically significant discrimination (area under the curve = 0.893, P < .0001). No significant differences were detected for bFGF, endostatin, or TSP-1. Reference Change Value analysis determined that the differences seen were not clinically significant. Plasma levels yielded no correlations.

Association of Clinical Cytogeneticists chorion villus sampling database 1987-2000

OBJECTIVES

To produce a fully searchable Microsoft Access database of mosaic and non-mosaic cytogenetic abnormalities, detected during diagnostic chorionic villi sampling (CVS) to aid laboratories in predicting pregnancy outcome, in particular differentiating between cases of likely genuine fetal cytogenetic abnormalities and those likely to represent confined placental mosaicism (CPM).

METHODS

Retrospective collection of referral data, initial karyotype data, follow-up karyotype data and pregnancy outcome data from almost all cytogenetically abnormal diagnostic CVS, processed in UK National Health Service laboratories, between 1987 and 2000. Collection of similar data from a published series of CVS and individual case reports.

RESULTS

A fully searchable database of abnormal CVS cases, containing over 5000 entries, has been produced. This is available to download at http://www.ncl.ac.uk/cvs/.

CONCLUSIONS

Following detection of a cytogenetic abnormality during prenatal diagnosis using CVS, use of this database allows rapid access to comparable cases from the United Kingdom and the literature. This database will improve the speed of availability and quality of information available to clinicians and patients for pregnancy management and counselling purposes. The database has been designed with future data collection in mind, and can be developed for wider research use, through more detailed registries of individual chromosome abnormalities.

Phase II study of the antiangiogenic agent SU5416 in patients with advanced soft tissue sarcomas

PURPOSE

SU5416 (semaxanib) is a small molecule inhibitor of the vascular endothelial growth factor (VEGF) receptor-2 and KIT receptor tyrosine kinases. This Phase II study was conducted to investigate the safety and efficacy of SU5416 for patients with soft tissue sarcomas.

EXPERIMENTAL DESIGN

Thirteen patients with locally advanced or metastatic soft tissue sarcomas were treated with SU5416 via intravenous infusion at a dose of 145 mg/m(2) twice weekly. In selected cases tumor biopsies were taken before and after 2 months of treatment.

RESULTS

The median progression-free survival was 1.8 months. Median overall survival was 22.8 months. No objective tumor responses were observed. There was evidence of shorter survival among patients with high baseline urine VEGF levels (P = 0.04). No grade 4 toxicities were observed. The most common grade 3 toxicities were headache and thrombosis. Other less serious toxicities included fatigue, nausea, and abdominal pain. The median systolic blood pressure increased from 118 mmHg at baseline to 133 after 1 month of treatment (P = 0.01). Post-treatment tumor biopsies showed no significant decreases in VEGF receptor phosphorylation compared with baseline in 3 evaluable patients. One patient with gastrointestinal stromal tumor who had rapid progression during SU5416 treatment was subsequently treated with another KIT inhibitor, imatinib mesylate, and had a partial response lasting >36 months.

CONCLUSIONS

SU5416 was relatively well tolerated but did not demonstrate significant antitumor activity against advanced soft tissue sarcoma. Correlative studies suggest that VEGF receptor or KIT inhibition was incomplete in at least some cases, providing a possible explanation for the observed lack of activity.

Urine vascular endothelial growth factor-A is not a useful marker for endometriosis

OBJECTIVE

To determine whether urine VEGF is elevated in women with endometriosis.

DESIGN

Prospective observational study.

SETTING

Tertiary care government and private hospitals.

PATIENT(S)

During laparoscopy for pelvic pain or infertility, urine was collected and possible endometriosis lesions were excised. Of 62 women, 40 had histology-proven endometriosis and 22 had no histological proof of the disease.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Urine VEGF-A(121, 165) was measured and compared in women with and without biopsy-proven endometriosis.

RESULT(S)

Urine VEGF levels corrected for creatinine excretion were similar in women with (83.6 +/- 11.3 pg/mg Cr) and without (88.5 +/- 10.4 pg/mg Cr) endometriosis (P =.77). The frequency distribution of urine VEGF measurements for women with and without endometriosis was similar. No significant difference was noted in urine VEGF levels when comparing endometriosis stages or in those with endometriomas compared to controls. Urine VEGF did not vary significantly over the menstrual cycle or between groups by cycle phase. No cutoff point discriminated individuals with and without the condition.

CONCLUSION(S)

It is unlikely that urine VEGF-A(121, 165), as measured in this study, will be a useful non-invasive marker for endometriosis.

Phase I clinical trial of recombinant human endostatin administered as a short intravenous infusion repeated daily

PURPOSE

To perform a phase I trial of recombinant human endostatin (rhEndostatin; EntreMed, Rockville, MD) given as a daily 20-minute intravenous (IV) injection in adult patients with refractory solid tumors.

PATIENTS AND METHODS

The daily dose was increased from 15 to 240 mg/m(2) by a factor of 100% in cohorts of three patients. In the absence of dose-limiting toxicity, uninterrupted treatment was continued until the tumor burden increased by more than 50% from baseline. Correlative studies included dynamic contrast-enhanced magnetic resonance imaging of tumor blood flow, urinary vascular endothelial growth factor and basic fibroblast growth factor levels, rhEndostatin serum pharmacokinetics, and monitoring of circulating antibodies to rhEndostatin.

RESULTS

There were no notable treatment related toxicities among 15 patients receiving a total of 50 monthly cycles of rhEndostatin. One patient with a pancreatic neuroendocrine tumor had a minor response and two patients showed disease stabilization. Linearity in the pharmacokinetics of rhEndostatin was indicated by dose-proportionate increases in the area under the curve for the first dose and the peak serum concentration at steady state. Daily systemic exposure to rhEndostatin in patients receiving 240 mg/m(2)/d was approximately 50% lower than that provided by the therapeutically optimal dose in preclinical studies.

CONCLUSION

rhEndostatin administered as a 20-minute daily IV injection at doses up to 240 mg/m(2) showed no significant toxicities. Evidence of clinical benefit was observed in three patients. Due to high variability between the peak and trough serum concentrations associated with the repeated short IV infusion schedule, daily serum drug levels only briefly exceeded concentrations necessary for in vitro antiangiogenic effects.

Successful antiangiogenic therapy of giant cell angioblastoma with interferon alfa 2b: report of 2 cases

We describe 2 cases of angioblastoma, a rare, destructive pediatric tumor, treated with interferon alfa 2b (IFNalpha2b). The first patient is a 10-month-old male who presented with an ulcerated palatal neoplasm that could not be completely resected. The second is a male neonate with a congenital tumor of the right hand that invaded the hypothenar eminence, destroying the fourth and fifth metacarpals. Biopsy in both patients was interpreted as giant cell angioblastoma. Angioblastoma is rare; there is only 1 reported case that necessitated amputation of an upper extremity, also initially recommended for our patient. Because there is little experience with chemotherapy, permission was granted to employ an antiangiogenic regimen of IFNalpha2b. The angiogenic protein, basic fibroblast growth factor (bFGF), was abnormally elevated in both patients. Both patients received IFNalpha2b. In the first child, it was used after incomplete resection, because biopsy-proven tumor was present at the margin and in the nasopharynx. Biopsies 15 months after initiation of IFN2alphab were negative for tumor. Therapy was stopped after 3 years. Eighteen months later, the patient remains disease-free. In the second child, IFNalpha2b was started after debridement of the ulcerated tumor. Over 11 months, the tumor completely regressed and there was bony regeneration of the metacarpals. The fifth digit was amputated because of damage to the metacarpophalangeal joint by the tumor. IFNalpha2b therapy was discontinued after 1 year of treatment, and the child remains disease-free 2 years and 8 months later. In conclusion, this report demonstrates that: 1) a bFGF-overexpressing low-grade tumor can respond to IFNalpha2b in a manner similar to life-threatening infantile hemangiomas, 2) urinary bFGF levels can help guide IFNalpha dosage in such patients, and 3) although bFGF-mediated tumor angiogenesis is inhibited by IFNalpha, physiologic angiogenesis seems to be unaffected.

Urinary basic fibroblast growth factor: a noninvasive marker of progressive cystic renal disease in a child

Autosomal recessive polycystic kidney disease (ARPKD) is a hereditary condition with an estimated incidence of 1 in 20,000 live births. Various growth factors have been implicated in the causation of this disease. We describe a child with ARPKD whose levels of urinary basic fibroblast growth factor (bFGF) were markedly elevated. The concentrations of bFGF increased further following right nephrectomy, in response to the compensatory growth of the remaining kidney. We hypothesize that measurement of urinary bFGF may be useful as a noninvasive marker to assess progression of cystic renal development.

Pigeon fanciers' lung: the mucin antigen is present in pigeon droppings and pigeon bloom

BACKGROUND

Pigeon intestinal mucin has been implicated as an important antigen pigeon fanciers' lung. This study investigated whether mucin is detectable in pigeon droppings and bloom, the likely antigenic sources in disease.

METHODS

Soluble extracts of a number of materials found in a pigeon loft were prepared and specific IgG subclass antibodies to these antigens were measured in 14 antibody-positive pigeon fanciers. Cross-reactivity between these materials and purified pigeon intestinal mucin was investigated by inhibition of anti-mucin ELISA. Mucin was purified from the soluble extracts of these crude antigen mixtures by CsCl density gradient centrifugation.

RESULTS

The patterns of IgG subclass responses to purified pigeon intestinal mucin and to the four materials collected from the pigeon loft were similar. Subclass differences between symptomatic and asymptomatic individuals, demonstrable against purified mucin, were similarly seen against pigeon droppings and pigeon bloom. Both pigeon droppings and pigeon bloom were capable of inhibiting IgG binding to purified pigeon mucin, and mucin inhibited substantially the binding of IgG to these materials. Glycoprotein with a density similar to that described for pigeon intestinal mucin was purified from each source.

CONCLUSION

Pigeon intestinal mucin is present in a variety of materials found in the environment of the pigeon loft in a form capable of reacting with anti-mucin antibodies in the sera of exposed individuals. Reduction in exposure to these materials may decrease the likelihood of developing pigeon fanciers' lung and minimise reactions in sensitised individuals.

Basic fibroblast growth factor: a missing link between collagen VII, increased collagenase, and squamous cell carcinoma in recessive dystrophic epidermolysis bullosa

BACKGROUND

Patients with recessive dystrophic epidermolysis bullosa (RDEB) have deficiencies of collagen type VII and have elevated levels of fibroblast collagenase, and a greatly increased risk of cutaneous squamous cell carcinoma. Patients with other genetic blistering disorders do not have elevated collagenase or an increased risk of squamous cell carcinoma, despite chronic wounding. The connection between collagen type VII deficiency, increased collagenase, and squamous cell carcinoma is not understood.

MATERIALS AND METHODS

Urine from 81 patients with RDEB (39 patients), junctional epidermolysis bullosa (JEB; 12 patients), and epidermolysis bullosa simplex (EBS; 30 patients), as well as unaffected family members of RDEB patients (33 patients), was tested for the presence of basic fibroblast growth factor (bFGF) using a sensitive radioimmunoassay. These patients included many who were enrolled in the Epidermolysis Bullosa Registry and others who were referred by their physicians.

RESULTS

Fifty-one percent of patients with RDEB had elevated levels (> 5000 pg/g) of urinary bFGF. In contrast, none of the patients with JEB had elevated levels of bFGF. Twenty-one percent of clinically unaffected family members had elevated levels of bFGF, and 13% of patients with EBS had elevated levels of bFGF. The frequency of elevated bFGF values among all groups was statistically significant (p = 0.002), and the levels of bFGF in RDEB patients were significantly elevated compared with those of other groups (p < 0.05).

CONCLUSIONS

We have found that patients with RDEB have elevated levels of bFGF, which may contribute to increased fibroblast collagenase and the development of squamous cell carcinoma. These results suggest a novel treatment for RDEB, namely, angiogenesis inhibitors, which may antagonize the effects of bFGF in this disorder. There are currently no other means of treatment for this disorder, which has a high morbidity and mortality rate.

Urinary basic fibroblast growth factor. A biochemical marker for preosseous fibroproliferative lesions in patients with fibrodysplasia ossificans progressiva

Angiogenesis is a prominent histopathologic feature of preosseous fibroproliferative lesions in patients who have fibrodysplasia ossificans progressiva. Basic fibroblast growth factor is an extremely potent in vivo stimulator of angiogenesis, and has been implicated in the growth of solid tumors. An enzyme linked immunosorbent assay for basic fibroblast growth factor was performed on urine samples from patients who had active (n = 28) and inactive (n = 39) fibrodysplasia ossificans progressiva, and compared with urine samples from normal age and gender matched control subjects (n = 54). Median basic fibroblast growth factor levels were 2705 pg/g of creatinine in the normal control group, 5058 pg/g of creatinine in patients with inactive fibrodysplasia ossificans progressiva (no significant difference), and 8793 pg/g of creatinine in patients with active fibrodysplasia ossificans progressiva. Female subjects, both normal and with fibrodysplasia ossificans progressiva, had higher levels of urinary basic fibroblast growth factor than did male subjects. There was no correlation of urinary basic fibroblast growth factor levels with age or severity of preexisting disability. These data document an elevation of urinary basic fibroblast growth factor during acute flareups of fibrodysplasia ossificans progressiva and provide a biochemical basis for considering antiangiogenic therapy for inhibiting endochondral osteogenesis in this disorder.

Elevation of cerebrospinal fluid levels of basic fibroblast growth factor in moyamoya and central nervous system disorders

Moyamoya syndrome is a vaso-occlusive disease involving the intracranial vessels of the circle of Willis which is accompanied by an intense compensatory recruitment of new vessels. Angiogenic substances such as basic fibroblast growth factor (bFGF) present in the cerebrospinal fluid (CSF) have been proposed as possible mediators of the neovascular response. We analyzed CSF samples collected intraoperatively from predominantly pediatric patients with moyamoya and other conditions such as Chiari malformation (Ch), tethered cord (TC), arteriovenous malformation (AVM), brain tumor (BT) and hydrocephalus (HCP). We found that CSF bFGF was significantly elevated in patients with moyamoya (141 pg/ml, n = 37), Ch (56.7 pg/ml, n = 22), TC (55.1 pg/ml, n = 23), AVM (354 pg/ml, n = 5), and BT (208 pg/ml, n = 5) compared to patients with HCP (5.5 pg/ml, n = 7) and controls (1.6 pg/ml, n = 25; p < 0.05). There was no dependence of CSF bFGF on patient age or gender. Although CSF bFGF in the moyamoya group showed no correlation with the Suzuki radiographic stage at either pre- or post-operative (1-year follow-up) angiography, it showed a trend with the Matsushima angiographic score with increasing collateral vascularization from the synangiosis developing at higher levels of CSF bFGF. Our findings suggest that CSF bFGF may be playing a wide-ranging role in a number of central nervous system conditions associated with ischemia and hypervascularity. Although not a specific marker for moyamoya, elevated CSF bFGF may serve as a weak predictor of the extent of angiogenesis to be expected in indirect revascularization procedures.

Spectrum of tumor angiogenesis in the bone marrow of children with acute lymphoblastic leukemia

It has been shown that solid tumors progress in concert with an induction of tumor angiogenesis. It is not known, however, whether a similar phenomenon occurs in leukemia. Angiogenesis was characterized immunohistochemically by factor VIII staining of bone marrow biopsies and quantified by assessment of microvessel density using previously described techniques. We evaluated bone marrow biopsies from 40 children with newly diagnosed, untreated acute lymphoblastic leukemia. In 22 of the patients, we also evaluated angiogenesis after the completion of remission induction chemotherapy. Control specimens were obtained from children undergoing staging evaluations at the time of diagnosis of solid tumors and lymphomas. Microvessels were counted throughout the entire core specimen in consecutive x 200 fields, and a median count per field (cpf) was calculated. In addition, the number of microvessels in the single x 200 field with the highest microvessel density was designated as the "hot spot." Biopsies from children with leukemia and from controls showed median microvessel densities of 42 and 6 counts per field, respectively (P < or = 0.0001). Microvessel density of the hot spots of leukemia specimens and controls were also significantly different, 51 and 8, respectively (P < or = 0.0001). A computer-aided three-dimensional reconstruction model of bone marrow vascularity showed a complex, arborizing branching of microvessels in leukemic specimens compared with single, straight microvessels without branching in controls. Urinary basic fibroblast growth factor, a potent angiogenic factor, was measured in 22 of the children with newly diagnosed leukemia and in 39 normal, age-matched controls. Urinary basic fibroblast growth factor levels were increased in all 22 patients before treatment, were variable during induction chemotherapy, and demonstrated statistically insignificant decreases at the time of complete remission. These findings suggest that leukemia cells induce angiogenesis in the bone marrow and that leukemia might be angiogenesis dependent and raise the possibility for a role of antiangiogenic drugs in the treatment of leukemia.

Management of supraventricular tachycardia in the emergency department

While supraventricular tachycardia is a common condition and seldom leads to serious consequences, it can be challenging to treat. Optimal management requires an accurate diagnosis, especially in the distinction between regular and irregular tachycardias; as well as an understanding of the mechanism responsible for the arrhythmia. In this article, the acute management of supraventricular tachycardias as they present in the emergency department is discussed, based on the underlying electrophysiological principles of arrhythmias.

The Community Medical Alliance: an integrated system of care in Greater Boston for people with severe disability and AIDS

The Community Medical Alliance in Boston has adapted principles of prepaid managed care to redesign service delivery for people with severe physical disability and with late-stage AIDS. Experience to date suggests that the flexibility of capitation can be used to substantially shift care from its usual hospital focus to clinicians in home and community settings, especially nurse practitioners, with a high degree of patient satisfaction and without apparent compromise in quality. Instead of limiting access, managed care can use prepayment to support early interventions, coordination, and the development of services specifically designed to meet the needs of the target population.

The biotransformation of the ergot derivative CQA 206-291 in human, dog, and rat liver slice cultures and prediction of in vivo plasma clearance

Liver slice cultures from humans, dogs, and rats were used to investigate the biotransformation of the dopaminergic ergot agonist CQA 206-291 and to predict pharmacokinetic values for hepatic intrinsic clearance and plasma clearance. CQA 206-291 was extensively metabolized in the liver slice cultures and in vivo. The HPLC metabolite patterns from the liver slice cultures were similar for all three species, indicating the occurrence of the same metabolic pathways for CQA 206-291 biotransformation. The rate of formation of CQ 32-084, a pharmacologically active N-deethylated metabolite, exceeded that of metabolite d, a primary metabolite, by 1.4 fold in human liver slices, and by 1.7 fold in rat liver slices. In dog liver slice cultures, metabolite d formation exceeded CQ 32-084 formation by 1.3 fold and was formed at a statistically significantly greater rate (3 fold) than in either human or rat liver slices. The metabolism of ergots like CQA 206-291 by human fetal liver was also demonstrated in this study. However, the prominent metabolite from fetal and adult human liver microsomes was metabolite d with minor amounts of CQ 32-089 being formed. A major route of excretion for the metabolites of CQA 206-291 is the kidney, yet the kidney does not contribute to the metabolism of CQA 206-291. Kidney slices derived from humans, rats, and dogs did not metabolize CQA 206-291 within 24 hr. CQA 206-291 intrinsic clearance was derived from the half-life of parent drug disappearance in the liver slice and hepatocyte cultures, and from the ratio of Vmax/Km of human and rat liver microsomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclosporin A metabolism in human liver, kidney, and intestine slices. Comparison to rat and dog slices and human cell lines

This study assesses the contribution of cyclosporin A (CsA) metabolism at sites of CsA-induced toxicity: kidney and liver, and a site of absorption, the intestine. With organ slice cultures (8 mm phi), it has been possible to demonstrate that the extrahepatic metabolism of CsA is significant. Both human kidney and colonic mucosal tissue metabolize CsA (1 microM, 24 hr) as analyzed by HPLC. The major metabolite M17 was formed in the kidney at an initial rate of 3 pmol/hr/mg slice protein, which was comparable to M17 formation in the liver slices (5 pmol/hr/mg slice protein). The rate of total CsA metabolism by human kidney slices represents about 42% the rate in liver slices. The metabolism of CsA to M17 was the same in the human kidney cell line 293; however, CsA metabolism was not detectable using human kidney microsomes, nor was metabolism clearly evident in either rat or dog kidney slice cultures. The metabolism of CsA by human colonic mucosal slices to at least three metabolites and the metabolism of CsA by the human intestinal cell line FHs74 Int indicates that the intestinal metabolism of CsA contributes to the first-pass effect of the drug. The liver proved to be the major site of CsA biotransformation in terms of the complexity of metabolites produced, whereas the human liver HepG2 cell line proved not to be a suitable model for CsA metabolism. A time course revealed that the first metabolites formed in the liver slice cultures were the monohydroxylated, M1 and M17, and N-demethylated, M21, followed by the secondary metabolites (including M8, M13, and M18).(ABSTRACT TRUNCATED AT 250 WORDS)

Conversion of ionization measurements to radiation absorbed dose in non-water density material

The radiation absorbed dose to non-water equivalent materials of interest in radiotherapy is the dose to lung and the dose to bone. The measurement and calculation of dose to the lung has been of great interest and much effort has gone into the development of accurate lung dose calculation methods. The radiation absorbed dose to the bone is usually not calculated and most absorbed dose calculations have been done without correcting for the presence of bone. For the lower megavoltage photon beams this may be appropriate, however, as the energy of the photon beam increases, the region of electronic disequilibrium becomes larger and pair production which depends on the atomic number of the material becomes significant. Therefore the bone will produce greater perturbations of the dose distribution. The dose to lung-equivalent material is uniquely obtained from ionization measurements. However, in bone-equivalent materials two different calculations of absorbed dose are possible: the absorbed dose to soft tissue plastic (polystyrene) within bone-equivalent material and the dose to the bone-equivalent material itself. Both can be calculated from ionization measurements in phantoms. These two calculations result in significantly different doses in a heterogeneous phantom composed of polystyrene and aluminium (a bone substitute). The dose to a thin slab of polystyrene in aluminium is much higher than the dose to the aluminium itself at the same depth in the aluminium. Monte Carlo calculations confirm that the calculation of dose to polystyrene in aluminium can be accurately carried out using existing dosimetry protocols. However, the conversion of ionization measurements to absorbed dose to high atomic number materials cannot be accurately carried out with existing protocols and appropriate conversion factors need to be determined.

The influence of lung and bone dosimetry on the choice of radiation energy for total body irradiation

The radiation absorbed dose to lung and bone is of importance for total body irradiation performed prior to bone marrow transplantation for hematologic malignancies. The measurement and calculation of radiation absorbed dose to low density materials such as lung has been discussed in several publications and most total body irradiation procedures account for the increased radiation dose to the lung. However, radiation absorbed dose to bone and soft tissues within bone is not calculated and is assumed to be the same as the dose to soft tissues. Because the bone is different in both density and atomic number from soft tissues, radiation dose calculations are more complex for bone than for lung. As the energy of the radiation beam changes, the dose to heterogeneous tissue varies. This variation of the radiation dose is investigated for radiation beams ranging in energy from 60Cobalt to x-ray beams produced at 18 MV. The radiation absorbed dose to soft tissues within bone is found to increase relative to the dose to soft tissue for higher megavoltage radiations, while at the same time there is a decrease in lung dose. Therefore, since for total body irradiation procedures the target tissues are the soft tissues within bone, a higher dose to those tissues would be an advantage.

The use of an universal wedge for asymmetric fields

Beam collimators on newer linear accelerators may be collimated asymmetric to the central axis. The asymmetric beam has a non-flat profile adjusted to yield fields whose half widths are not symmetric about the central axis. While some treatment planning systems modify their programs to mimic the nonuniformity, ideally it is preferred to have a flat profile under the open beam. We have developed a universal wedge that can be used to flatten the field for a variety of jaw sizes and positions and energies for the Varian 2100C. The wedge flattens the field to +/- 3% over 80% of the field.

Cocaine hepatotoxicity in cultured liver slices: a species comparison

Studies were carried out in order to find a sensitive in vitro model with which to investigate cocaine-mediated hepatotoxicity. Precision-cut liver slices were prepared from: human, domestic pig, New Zealand white rabbit, Sprague-Dawley (S/D) rat, and two mouse strains (DBA/2Ha and ICR). The rationale for the choice of these species was that information on in vivo effects of cocaine was available in the literature. Slices were cultured for up to 6 h in the presence of 0-5 mM cocaine. Indices of toxicity consisted of K+ retention and Ca2+ uptake. Minimal effects and no clear dose-response relationships were observed. In addition to the studies with non-pretreated animals, liver slices were prepared from DBA/2Ha and ICR mice, both induced by housing on pine shavings, and phenobarbital pretreated Sprague-Dawley rats. The induced ICR mouse and rat were approximately 3 times more sensitive to cocaine-mediated hepatotoxicity. The following order of sensitivity to cocaine-mediated hepatotoxicity was established: induced rat = induced ICR mouse much greater than induced DBA/2Ha mouse = rabbit = uninduced ICR mouse = uninduced DBA/2Ha mouse = uninduced rat greater than pig = human.

Development of a translating bed for total body irradiation

Total body irradiation is used to prepare a patient for bone marrow transplantation. Traditional techniques often sacrifice dose uniformity for patient comfort and ease of treatment. A method has been developed using a translational bed under a Cobalt 60 photon beam. The bed and controller were designed and built on site. A bolused patient lying in the bed is moved at constant speed through the beam. Using this technique, dose homogeneity is optimized by the use of bolus, extended source-skin distance, adequate field size and use of anterior/posterior fields. The dose rate represents a compromise between a value high enough to keep treatment times tolerable by the patient and one that is sufficiently low to avoid treatment complications. The value of 50 cGy/min which was used meets these requirements. Extensive phantom measurements have shown that the dose homogeneity can be obtained to within an acceptable limit of +/- 5%.

Coregulation of C3-hydroxyl versus C17-hydroxyl glucuronidation of beta-estradiol in pregnancy and after treatment with phenobarbital or ethinyl-estradiol

The glucuronidation of [3H]estradiol-17 beta at the C3 vs. the C17 hydroxyl groups was determined in female Sprague-Dawley rat liver microsomes. A high-performance liquid chromatography method was developed to resolve the glucuronide conjugates which were then quantitated by liquid scintillation counting. The rates of formation of 17 beta-estradiol 3-(beta-D-glucuronide) (E(2)3G) and 17 beta-estradiol 17-(beta-D-glucuronide) (E(2)17G) were 0.49 +/- 0.03 and 0.40 +/- 0.02 nmol/min/mg of protein, respectively. The apparent Km and Vmax of estradiol glucuronidation were determined in control, pregnant (day 19 of gestation), phenobarbital-treated (80 mg/kg/day i.p. for 5 days) and ethinylestradiol-treated (5 mg/kg/day i.p. for 5 days) female rats. The least-squares estimates of Km and Vmax values as well as the confidence contours of the joint sums of squares for the parameter spaces were calculated. The Vmax (nanomoles per minute per milligram of protein) for E(2)3G was significantly decreased from 0.94 to 0.57 in pregnancy and to 0.47 as a result of ethinylestradiol treatment. The Vmax values for E(2)17G were significantly different in control (0.43), pregnant (0.31) and ethinylestradiol-treated (0.27) rats. Phenobarbital treatment slightly increased the Vmax to 0.51 for E(2)17G whereas the Vmax for E(2)3G was unchanged (0.90) compared to controls. The Km (micromolar) for E(2)3G was 144 in the controls, 112 in pregnancy and 86 and 92 as a result of treatment with ethinylestradiol and phenobarbital, respectively. The Km for E(2)17G was 60 in the controls, 40 in pregnancy, 43 and 68 as a result of ethinylestradiol and phenobarbital treatment, respectively. None of the changes in Km were statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

An all-glass apparatus for liver perfusion of lipophilic substrates. I. Construction and physical characteristics

An all-glass apparatus for perfusing isolated rat livers was constructed for use in studies of the metabolism by, or action on, the liver of lipophilic substrates. Other designs, which generally include plastic connections or cannulae, can have unnecessarily complicated kinetics because of adsorption of the agent to the plastic parts. Two versions of an all-glass perfusion apparatus are described in detail. Both instruments operate on the same basic principle, but differ in size, total recirculating volume, pump rate, perfusion head pressures, maximum perfusate flow rate, maximum linear velocity in the perfusion head, and oxygenation efficiency. Although the maximum protein handling capacity differs for the two apparatuses, this capacity is so limited that it disallows the use of albumin in the perfusate.

Children's understanding of monosyllabic nouns in quiet and in noise

A four-alternative, forced choice adaptive procedure was used to measure the lowest intensity at which children could identify monosyllabic nouns that had been standardized to be understandable (at comfortable listening levels) to inner city, 3-year-old children. Results showed no age-related performance changes when the words were presented against a 12-talker babble or against filtered noise. In quit, however, performance improved between the ages of 5 and 10 years. Performance of children with learning problems was poorer than performance of children achieving normal school progress, even though clinical measures of auditory sensitivity showed no differences. Results are discussed in terms of "semantic closure" skills of children.