Participant experiences of guided self-help Acceptance and Commitment Therapy for improving quality of life in muscle disease: a nested qualitative study within the ACTMus randomized controlled trial

Introduction

In adults, muscle disease (MD) is typically a chronic long-term condition that can lead to a reduced quality of life (QoL). Previous research suggests that a psychological intervention, in particular Acceptance and Commitment Therapy (ACT), may help improve QoL for individuals living with chronic conditions such as MD.

Methods

This nested qualitative study was incorporated within a randomized controlled trial which evaluated a guided self-help ACT intervention for people living with MD to explore their experiences of the intervention. Semi-structured interviews (n = 20) were conducted with those who had received ACT. Data were analyzed via thematic analysis.

Results

There were four overarching themes. (1) Views on whether therapy sessions would help with a medical condition: participants' expectations regarding ACT varied. Some participants were skeptical about mindfulness. (2) I was able to look at things in a different way: participants described increased meaningful activity, greater awareness of thoughts and emotions and acceptance or adaptation to mobility problems. Some described improvement in the quality of relationships and a sense of feeling free. (3) Treating the body and the mind together: following the intervention participants noted that a holistic approach to healthcare is beneficial. (4) Intervention delivery: The remote delivery was generally seen as helpful for practical reasons and allowed participants to speak openly. Participants voiced a need for follow-up sessions.

Discussion

Overall, the intervention was experienced as acceptable. Suggested improvements included de-emphasizing the role of mindfulness and adding follow-up sessions.

A randomised controlled trial of acceptance and commitment therapy for improving quality of life in people with muscle diseases

Abstract.

BACKGROUND

Chronic muscle diseases (MD) are progressive and cause wasting and weakness in muscles and are associated with reduced quality of life (QoL). The ACTMuS trial examined whether Acceptance and Commitment Therapy (ACT) as an adjunct to usual care improved QoL for such patients as compared to usual care alone.

METHODS

This two-arm, randomised, multicentre, parallel design recruited 155 patients with MD (Hospital and Depression Scale ⩾ 8 for depression or ⩾ 8 for anxiety and Montreal Cognitive Assessment ⩾ 21/30). Participants were randomised, using random block sizes, to one of two groups: standard medical care (SMC) (n = 78) or to ACT in addition to SMC (n = 77), and were followed up to 9 weeks. The primary outcome was QoL, assessed by the Individualised Neuromuscular Quality of Life Questionnaire (INQoL), the average of five subscales, at 9-weeks. Trial registration was NCT02810028.

RESULTS

138 people (89.0%) were followed up at 9-weeks. At all three time points, the adjusted group difference favoured the intervention group and was significant with moderate to large effect sizes. Secondary outcomes (mood, functional impairment, aspects of psychological flexibility) also showed significant differences between groups at week 9.

CONCLUSIONS

ACT in addition to usual care was effective in improving QoL and other psychological and social outcomes in patients with MD. A 6 month follow up will determine the extent to which gains are maintained.

Do they really care? Specificity of social support issues in hoarding disorder and obsessive-compulsive disorder

OBJECTIVES

Unmet interpersonal needs may play a role in excessive emotional attachments to objects for people with hoarding disorder (HD). Previous research indicates that social support (but not attachment difficulties) may be specific to HD. The study aimed to evaluate social networks and support in HD relative to clinical controls with obsessive-compulsive disorder (OCD) and healthy controls (HC). The secondary aim was to explore the extent of loneliness and thwarted belongingness. Potential mechanisms for deficits in social support were also considered.

DESIGN

A cross-sectional between-groups design was used to compare scores on measures in those with HD (n = 37); OCD (n = 31); and HCs (n = 45).

METHODS

Participants completed a structured clinical interview by telephone (to assign diagnostic categories) followed by online questionnaires.

RESULTS

Whilst individuals with HD and OCD both report smaller social networks than HC, lower levels of perceived social support appear to be specific to HD. The HD group also showed higher levels of loneliness and thwarted belonging compared to OCD and HC. No differences were found between groups for perceived criticism or trauma.

CONCLUSIONS

The results support previous findings of lower levels of self-reported social support within HD. Loneliness and thwarted belongingness also appear significantly elevated within HD compared with OCD and HC. Further research is required to explore the nature of felt support and belonging, direction of effect and to identify potential mechanisms. Clinical implications include advocating and promoting support systems (both personal supporters and professionals) for individuals with HD.

Swarm shedding in networks of self-propelled agents

Understanding swarm pattern formation is of great interest because it occurs naturally in many physical and biological systems, and has artificial applications in robotics. In both natural and engineered swarms, agent communication is typically local and sparse. This is because, over a limited sensing or communication range, the number of interactions an agent has is much smaller than the total possible number. A central question for self-organizing swarms interacting through sparse networks is whether or not collective motion states can emerge where all agents have coherent and stable dynamics. In this work we introduce the phenomenon of swarm shedding in which weakly-connected agents are ejected from stable milling patterns in self-propelled swarming networks with finite-range interactions. We show that swarm shedding can be localized around a few agents, or delocalized, and entail a simultaneous ejection of all agents in a network. Despite the complexity of milling motion in complex networks, we successfully build mean-field theory that accurately predicts both milling state dynamics and shedding transitions. The latter are described in terms of saddle-node bifurcations that depend on the range of communication, the inter-agent interaction strength, and the network topology.

Critical transition for colliding swarms

Swarming patterns that emerge from the interaction of many mobile agents are a subject of great interest in fields ranging from biology to physics and robotics. In some application areas, multiple swarms effectively interact and collide, producing complex spatiotemporal patterns. Recent studies have begun to address swarm-on-swarm dynamics, and in particular the scattering of two large, colliding swarms with nonlinear interactions. To build on early numerical insights, we develop a self-propelled, rigid-body approximation that can be used to predict the parameters under which colliding swarms are expected to form a milling state. Our analytical method relies on the assumption that, upon collision, two swarms oscillate near a limit cycle, where each swarm rotates around the other while maintaining an approximately constant and uniform density. Using this approach we are able to predict the critical swarm-on-swarm interaction coupling, below which two colliding swarms merely scatter, as a function of physical swarm parameters. We show that the critical coupling gives a lower bound for all impact parameters, including head-on collision, and corresponds to a saddle-node bifurcation of a stable limit cycle in the uniform, constant density approximation. Our results are tested and found to agree with both small and large multiagent simulations.

Stability of milling patterns in self-propelled swarms on surfaces

In some physical and biological swarms, agents effectively move and interact along curved surfaces. The associated constraints and symmetries can affect collective-motion patterns, but little is known about pattern stability in the presence of surface curvature. To make progress, we construct a general model for self-propelled swarms moving on surfaces using Lagrangian mechanics. We find that the combination of self-propulsion, friction, mutual attraction, and surface curvature produce milling patterns where each agent in a swarm oscillates on a limit cycle with different agents splayed along the cycle such that the swarm's center-of-mass remains stationary. In general, such patterns loose stability when mutual attraction is insufficient to overcome the constraint of curvature, and we uncover two broad classes of stationary milling-state bifurcations. In the first, a spatially periodic mode undergoes a Hopf bifurcation as curvature is increased, which results in unstable spatiotemporal oscillations. This generic bifurcation is analyzed for the sphere and demonstrated numerically for several surfaces. In the second, a saddle-node-of-periodic orbits occurs in which stable and unstable milling states collide and annihilate. The latter is analyzed for milling states on cylindrical surfaces. Our results contribute to the general understanding of swarm pattern formation and stability in the presence of surface curvature and may aid in designing robotic swarms that can be controlled to move over complex surfaces and terrains.

Delay induced swarm pattern bifurcations in mixed reality experiments

Swarms of coupled mobile agents subject to inter-agent wireless communication delays are known to exhibit multiple dynamic patterns in space that depend on the strength of the interactions and the magnitude of the communication delays. We experimentally demonstrate communication delay-induced bifurcations in the spatiotemporal patterns of robot swarms using two distinct hardware platforms in a mixed reality framework. Additionally, we make steps toward experimentally validating theoretically predicted parameter regions where transitions between swarm patterns occur. We show that multiple rotation patterns persist even when collision avoidance strategies are incorporated, and we show the existence of multi-stable, co-existing rotational patterns not predicted by usual mean field dynamics. Our experiments are the first significant steps toward validating existing theory and the existence and robustness of the delay-induced patterns in real robotic swarms.

Torus bifurcations of large-scale swarms having range dependent communication delay

Dynamical emergent patterns of swarms are now fairly well established in nature and include flocking and rotational states. Recently, there has been great interest in engineering and physics to create artificial self-propelled agents that communicate over a network and operate with simple rules, with the goal of creating emergent self-organizing swarm patterns. In this paper, we show that when communicating networks have range dependent delays, rotational states, which are typically periodic, undergo a bifurcation and create swarm dynamics on a torus. The observed bifurcation yields additional frequencies into the dynamics, which may lead to quasi-periodic behavior of the swarm.

Unstable modes and bistability in delay-coupled swarms

It is known that introducing time delays into the communication network of mobile-agent swarms produces coherent rotational patterns, from both theory and experiments. Often such spatiotemporal rotations can be bistable with other swarming patterns, such as milling and flocking. Yet, most known bifurcation results related to delay-coupled swarms rely on inaccurate mean-field techniques. As a consequence, the utility of applying macroscopic theory as a guide for predicting and controlling swarms of mobile robots has been limited. To overcome this limitation, we perform an exact stability analysis of two primary swarming patterns in a general model with time-delayed interactions. By correctly identifying the relevant spatiotemporal modes, we are able to accurately predict unstable oscillations beyond the mean-field dynamics and bistability in large swarms-laying the groundwork for comparisons to robotics experiments.

Abstract 411: Rapid and sensitive detection of EGFR C797S mutations using a blood-based droplet digital PCR assay

The adoption of third-generation tyrosine kinase inhibitors (TKIs) to treat non-small cell lung cancer (NSCLC) for EGFR positive patient cases has led to the emergence of acquired resistance pathways. Approximately 40% of EGFRT790M-positive NSCLC cases display an acquired mutation of amino acid 797 (C797S) that mediates this resistance, which can develop after a median of 10 months following treatment. The effectiveness of treatment for patients with EGFRC797S may depend on whether the mutation is present in cis or trans with EGFRT790M, the type of sensitizing mutation (EGFRdel19 or EGFRL858R), and previous treatment(s). Patients with EGFRdel19 or EGFRL858R in conjunction with EGFRT790M and EGFRC797S remain resistant to all current targeted therapies. Several fourth-generation inhibitors are in development but have yet to be validated in clinical trials. We have developed a blood-based test that can detect two of the most common C797S nucleotide mutations (T>A and G>C) in cis or trans with EGFRT790M using the droplet digital PCR (ddPCR) technology and assays. Analytic sensitivity and specificity were assessed using synthetic DNA designed to mimic the EGFRC797S variants and their locus detected in the assay. Normal healthy donors as well as reference ddPCR positive and negative NSCLC donor samples were assessed for clinical specificity and sensitivity. Finally, the precision of the assay was evaluated with both clinical and analytical samples. Specifically, we evaluated the assay at high, medium, and low mutation frequencies over three consecutive days, including repeat runs on one day, and with multiple operators. This assay is capable of accurately and precisely detecting multiple EGFRC797S variants and their locus from blood specimens in the clinical laboratory. Consistent with other ddPCR blood-based EGFR variant assays we have developed, the limit of detection was 0.02%for C797S variants detected in both cis and trans with the T790M mutation. Once validated, the EGFR C797S assay described here may be of utility in diagnosing patients who have developed resistance to osimertinib.

Citation Format: Victoria Edwards, Leisa Jackson, Jordan Reese, Hestia S. Mellert, Gary Pestano. Rapid and sensitive detection of EGFR C797S mutations using a blood-based droplet digital PCR assay [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 411.

Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases

INTRODUCTION

In adults, muscle disease (MD) is often a chronic long-term condition with no definitive cure. It causes wasting and weakness of the muscles resulting in a progressive decline in mobility, alongside other symptoms, and is typically associated with reduced quality of life (QoL). Previous research suggests that a psychological intervention, and in particular Acceptance and Commitment Therapy (ACT), may help improve QoL in MD. ACT is a newer type of cognitive behavioural treatment that aims to improve QoL by virtue of improvement in a process called psychological flexibility. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of a guided self-help ACT programme for improving QoL in people with MD. Main secondary outcomes are mood, symptom impact, work and social adjustment and function at 9-week follow-up.

METHODS AND ANALYSIS

Acceptance and Commitment Therapy for Muscle Disease is an assessor-blind, multicentre, two-armed, parallel-group RCT to assess the efficacy of ACT plus standard medical care (SMC) compared with SMC alone. Individuals with a diagnosis of one of four specific MDs, with a duration of at least 6 months and with mild to moderate anxiety or depression (Hospital Anxiety and Depression Scale score ≥8) will be recruited from UK-based MD clinics and MD patient support organisations. Participants will be randomised to either ACT plus SMC or SMC alone by an independent randomisation service. Participants will be followed up at 3, 6 and 9 weeks. Analysis will be intention to treat, conducted by the trial statistician who will be blinded to treatment allocation.

ETHICS AND DISSEMINATION

The study has received full ethical approval. Study results will be disseminated via peer-reviewed publications, conference presentations and journal articles. Data obtained from the trial will enable clinicians and health service providers to make informed decisions regarding the efficacy of ACT for improving QoL for patients with MD.

TRIAL REGISTRATION NUMBER

NCT02810028.

PROTOCOL VERSION

V.11 (4 April 2017).

Rococo study: a real-world evaluation of an over-the-counter medicine in acute cough (a multicentre, randomised, controlled study)

OBJECTIVES

To investigate the efficacy and safety of CS1002, an over-the-counter cough treatment containing diphenhydramine, ammonium chloride and levomenthol in a cocoa-based demulcent.

DESIGN

A multicentre, randomised, parallel group, controlled, single-blinded study in participants with acute upper respiratory tract infection-associated cough.

SETTING

4 general practitioner (GP) surgeries and 14 pharmacies in the UK.

PARTICIPANTS

Participants aged ≥18 years who self-referred to a GP or pharmacist with acute cough of <7 days' duration. Participant inclusion criterion was cough severity ≥60 mm on a 0-100 mm visual analogue scale (VAS). Exclusion criteria included current smokers or history of smoking within the past 12 months (including e-cigarettes). 163 participants were randomised to the study (mean participant age 38 years, 57% females).

INTERVENTIONS

Participants were randomised to CS1002 (Unicough) or simple linctus (SL), a widely used cough treatment, and treatment duration was 7 days or until resolution of cough.

MAIN OUTCOME MEASURES

The primary analysis was intention-to-treat (157 participants) and comprised cough severity assessed using a VAS after 3 days' treatment (prespecified primary end point at day 4). Cough frequency, sleep disruption, health status (Leicester Cough Questionnaire (LCQ-acute)) and cough resolution were also assessed.

RESULTS

At day 4 (primary end point), the adjusted mean difference (95% CI) in cough severity VAS between CS1002 and SL was -5.9 mm (-14.4 to 2.7), p=0.18. At the end of the study (day 7) the mean difference in cough severity VAS was -4.2 mm (-12.2 to 3.9), p=0.31. CS1002 was associated with a greater reduction in cough sleep disruption (mean difference -11.6 mm (-20.6 to 2.7), p=0.01) and cough frequency (mean difference -8.1 mm (-16.2 to 0.1), p=0.05) compared with SL. There was greater improvement in LCQ-acute quality of life scores with CS1002 compared with SL: mean difference (95% CI) 1.2 (0.05 to 2.36), p=0.04 after 5 days' treatment. More participants prematurely stopped treatment due to cough improvement in the CS1002 group (24.4%) compared with SL (10.7%; p=0.02). Adverse events (AEs) were comparable between CS1002 (20.5%) and SL (27.6%) and largely related to the study indication. 6 participants (7%) in the CS1002 group reduced the dose of medication due to drowsiness/tiredness, which subsequently resolved. These events were not reported by participants as AEs.

CONCLUSIONS

Although the primary end point was not achieved, CS1002 was associated with greater reductions in cough frequency, sleep disruption and improved health status compared with SL.

TRIAL REGISTRATION NUMBER

EudraCT number 2014-004255-31.

Abstract A008: Photochemical internalization: Light-induced enhancement of MHC Class I antigen presentation, giving strong enhancement of cytotoxic T-cell responses to vaccination

For cancer vaccination and immunotherapy it is essential to stimulate cytotoxic T-cells (CTLs) to recognize and kill the tumor cells. Priming of CTLs is generally mediated through MHC Class I antigen presentation by antigen presenting cells (APCs). Since the MHC class I presentation machinery is localised in the cytosol, MHC class I presentation typically requires cytosolic delivery of the antigen. Unfortunately, this is often difficult to achieve with exogenously added peptide or protein antigens, since such antigens are primarily taken up into endocytic vesicles, and then “by default” are routed for MHC Class II presentation. Photochemical internalisation (PCI) is a technology that can help solving this problem by inducing an illumination-mediated permeabilisation of the membranes of endocytic vesicles, thereby releasing endocytosed antigens into the cytosol. This is achieved by employing a photosensitising molecule that is designed to localise specifically in endocytic membranes. Upon illumination, the photosensitiser induces photochemical reactions that make the membranes leaky, thereby releasing endocytosed molecules into the cytosol. In vitro it has been shown that the use of PCI leads to strongly increases MHC Class I presentation APCs. In vivo PCI-mediated vaccination is performed by injecting a mixture of vaccine and photosensitiser intradermally, followed by illumination of the injection site; and with this regimen, PCI substantially enhances immune responses to various types of polypeptide- based antigens. Thus, with short peptide antigens enhancement of CD8+ T-cell responses of up to 100 times have been observed when PCI is used in combination with the poly(IC) adjuvant; with a strong synergy between PCI and the adjuvant. With an HPV long peptide and with several protein antigens in addition to the CD8+ T-cell response a significant stimulation of CD4+ T-cell responses can also be observed, and in some cases also an increase in antibody production. In vivo studies with therapeutic peptide antigen vaccination in a mouse model for HPV-induced cancer show that the use of PCI strongly enhances anti-tumor responses to the vaccine, both when the vaccination is performed intradermally and when intratumoral administration is employed. The TPCS2a photosensitiser used in PCI is cheap to produce, withstands autoclavation and is stable for several years at ambient temperatures. TPCS2a is currently in clinical development for enhancement of the effect of cytotoxic anti-cancer drugs, and it has been shown that TPCS2a can be administered safely to patients in much higher doses than what is needed for the use in immunotherapy. In conclusion, PCI has a completely new mechanism of action as a vaccination enhancement technology, representing a new and potent tool for stimulation of CTL and in some cases also other types of immune responses. Preparations for a clinical study with PCI-mediated vaccination is on-going.

Citation Format: Tone Otterhaug, Markus Haug, Gaute Brede, Monika Håkerud, Anne Grete Nedberg, Victoria Edwards, Pål Kristian Selbo, Pål Johansen, Øyvind Halaas, Anders Høgset. Photochemical internalization: Light-induced enhancement of MHC Class I antigen presentation, giving strong enhancement of cytotoxic T-cell responses to vaccination [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A008.

Evaluating the effectiveness of guided versus non-guided interpretation in the Kruger National Park, South Africa

In the face of growing pressure placed on the natural environment, the study on which this article is based considered the effectiveness of interpretive provision in mitigating the harmful effects of tourism on the environment. The aim of this research was to determine whether guided or non-guided interpretation is most effective in reaching the stated goals of interpretation. The four key goals of interpretation, namely visitor satisfaction, knowledge gain, attitude change and modification of behaviour intent, were used in the assessment of the relative effectiveness of guided and non-guided interpretation in the Kruger National Park, South Africa. Through comparing responses to questionnaires from post-visit samples and observing both guided and non-guided interpretation, the research found that guided interpretation was only marginally more effective in reaching the four key goals of interpretation than the non-guided interpretive media. Guided interpretation was found to be more effective in terms of visitor satisfaction, whilst guided and non-guided interpretation had only marginal differences in effectiveness in relation to knowledge gain, attitude change and intent to modify behaviour.Conservation implications: The necessity of implementing an appropriate interpretation programme within protected areas cannot be overemphasised. The interpretation programme should be designed to include elements of both guided and non-guided interpretation in order to achieve a predetermined goal. The effectiveness of the programme should be evaluated periodically and amended where appropriate.

The experience of disabled children as inpatients: a structured review and synthesis of qualitative studies reporting the views of children, parents and professionals

Disabled children are a broad group that includes those with complex, special or additional health needs as a result of chronic physical, cognitive, communication or behavioural problems. These children are more frequently admitted to hospital than other children; however, there appears to be relatively little research on their experience as inpatients. The aim of this structured review and synthesis was to integrate findings from qualitative studies reporting the experience of disabled children when they are hospital inpatients. Inclusion criteria were: qualitative studies that focused on the experience of children less than 18 years old, with a chronic health condition or neurodisability, during an inpatient stay. Studies of outpatient episodes or intensive care units were excluded. A systematic search identified relevant abstracts, selected papers were reviewed and data were extracted. The synthesis involved elucidating and integrating common themes. Eight relevant papers were identified; data were gathered from children, parents and staff. Communication between children and staff was a dominant theme and comprised giving the child information about their condition and appropriate involvement of the child/young person in discussions and decision making that affected them. Also important was communication between parents and staff, particularly around the division of care for their child. Other themes included emotions, particularly fears, the ward environment and confidence in staff. The review suggests that disabled children's experience as inpatients is not always optimal. Improving the communication skills of ward staff and providing information to disabled children and their families would improve disabled children's experience when they are inpatients.

Directed blood donor program decreases donor exposure for children with sickle cell disease requiring chronic transfusion

In children with sickle cell disease (SCD), primary and secondary prevention of strokes require indefinite regular blood transfusion therapy. The risks associated with repeated transfusions include alloimmunization and increased donor exposure. The Charles Drew Program is a directed blood donor program designed to lower donor exposure, decreasing the associated complications of transfusion; however, no evidence exists demonstrating the magnitude of the benefit to the recipient. Further, the use of extended red blood cell (RBC) antigen matching for C, E, and K has been well documented in a clinical trial setting but not extensively evaluated in a standard care setting. The goal of this study is to assess the effectiveness in reducing alloimmunization when matching for C, E, and K and the magnitude of the decrease in donor exposure in a directed blood donor program. The rate of alloimmunization and reduction of donor exposure were determined during the course of 1 year in a cohort of children with SCD who received regular directed donor blood transfusions. A total of 24 recipients were in the program, 16 females and 8 males, 4 to 20 years of age. During 2008, alloimmunization was 0 percent and donor exposure was reduced by 20 percent, compared with usual care. Extended RBC antigen matching has the same benefit as in a clinical trial setting for patients with SCD receiving blood transfusion therapy. Despite significant effort, we only achieved a modest decrease in donor exposure and cannot determine the immediate benefit of a directed blood donor program.

A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of inpatient compared with outpatient treatment and general (routine) treatment in Child and Adolescent Mental Health Services (CAMHS) against specialist treatment for young people with anorexia nervosa. In addition, to determine young people's and their carers' satisfaction with these treatments.

DESIGN

A population-based, pragmatic randomised controlled trial (RCT) was carried out on young people age 12 to 18 presenting to community CAMHS with anorexia nervosa.

SETTING

Thirty-five English CAMHS in the north-west of England co-ordinated through specialist centres in Manchester and Liverpool.

PARTICIPANTS

Two hundred and fifteen young people (199 female) were identified, of whom 167 (mean age 14 years 11 months) were randomised and 48 were followed up as a preference group.

INTERVENTIONS

Randomised patients were allocated to either inpatient treatment in one of four units with considerable experience in the treatment of anorexia nervosa, a specialist outpatient programme delivered in one of two centres, or treatment as usual in general community CAMHS. The outpatient programmes spanned 6 months of treatment. The length of inpatient treatment was determined on a case-by-case basis on clinical need with outpatient follow-up to a minimum of 6 months.

MAIN OUTCOME MEASURES

Follow-up assessments were carried out at 1, 2 and 5 years. The primary outcome measure was the Morgan-Russell Average Outcome Scale (MRAOS) and associated categorical outcomes. Secondary outcome measures included physical measures of weight, height, body mass index (BMI) and % weight for height. Research ratings included the Health of the National Outcome Scale for Children and Adolescents (HoNOSCA). Self report measures comprised the user version of HoNOSCA (HoNOSCA-SR), the Eating Disorder Inventory 2 (EDI-2), the Family Assessment Device (FAD) and the recent Mood and Feelings Questionnaire (MFQ). Information on resource use was collected in interview at 1, 2 and 5 years using the Child and Adolescent Service Use Schedule (CA-SUS). Satisfaction was measured quantitatively using a questionnaire designed for the study and qualitative (free) responses on it. The questionnaire data were supplemented by qualitative analysis of user and carer focus groups.

RESULTS

Of the 167 patients randomised, 65% adhered to the allocated treatment. Adherence was lower for inpatient treatment (49%) than for general CAMHS (71%) or specialist outpatient treatment (77%) (p = 0.013). Every subject was traced at both 1 and 2 years, with the main outcome measure completed (through contact with the subject, family members or clinicians), by 94% at 1 year, 93% at 2 years, but only 47% at 5 years. A validated outcome category was assigned for 98% at 1 year, 96% at 2 years and 60% at 5 years. There was significant improvement in all groups at each time point, with the number achieving a good outcome being 19% at 1 year, 33% at 2 years and 64% (of those followed up) at 5 years. Analysis demonstrated no difference in treatment effectiveness of randomisation to inpatient compared with outpatient treatment, or, specialist over generalist treatment at any time point, when baseline characteristics were taken into account. Generalist CAMHS treatment was slightly more expensive over the first 2 years of the study, largely because greater numbers were subsequently admitted to hospital after the initial treatment phase. The specialist outpatient programme was the dominant treatment in terms of incremental cost-effectiveness. Specialist treatments had a higher probability of being more cost-effective than generalist treatments and outpatient treatment had a higher probability of being more cost-effective than inpatient care. Parental satisfaction with treatment was generally good, though better with specialist than generalist treatment. Young people's satisfaction was much more mixed, but again better with specialist treatment, including inpatient care.

CONCLUSION

Poor adherence to randomisation (despite initial consent to it), limits the assessment of the treatment effect of inpatient care. However, this study provides little support for lengthy inpatient psychiatric treatment on clinical or health economic grounds. These findings are broadly consistent with existing guidelines on the treatment of anorexia nervosa, which suggest that outpatient treatments should be offered to the majority, with inpatient treatment offered in rare cases, though our findings lend little support to a stepped-care approach in which inpatient care is offered to outpatient non-responders. Outpatient care, supported by brief (medical) inpatient management for correction of acute complications may be a preferable approach. The health economic analysis and user views both support NICE guidelines, which suggest that anorexia nervosa should be managed in specialist services that have experience and expertise in its management. Comprehensive general CAMHS might, however, be well placed to manage milder cases. Further research should focus on the specific components of outpatient psychological therapies. Although family-based treatments are well established, trials have not established their effectiveness compared with good-quality individual psychological therapies and the combination of individual and family approaches is untested. Further research is needed to establish which patients (if any) might respond to inpatient psychiatric treatment when unresponsive to outpatient care, the positive and negative components of it and the optimum length of stay.

TRIAL REGISTRATION

NRR number (National Research Register) N0484056615; Current Controlled Trials ISRCTN39345394.

Ultrastructure of Lamellar Bodies in Congenital Surfactant Deficiency

Congenital surfactant deficiency (CSD) is a newly identified neonatal lung disorder associated with a variety of molecular defects affecting surfactant synthesis and secretion in alveolar type II cells. The authors present ultrastructural findings of abnormal lamellar bodies in lung biopsies from 4 infants with CSD. All were term infants presenting shortly after birth with severe respiratory failure that was unresponsive to conventional therapy and all died within the first month of life. Lung biopsies were performed between 8 and 25 days of age. Biochemical and molecular studies in 2 unrelated male infants identified SP-B deficiency, one case with 121 ins 2 mutation and the second with a 209 + 4 A > G mutation. Light microscopy in both cases showed features of alveolar proteinosis. Ultrastructurally, alveolar type II cells lacked mature lamellar bodies, and their cytoplasm contained numerous pleomorphic inclusions with membranous and vesicular structures not seen in normal type II cells. The other 2 infants were a pair of siblings in whom molecular studies identified mutations in ABCA3 transporter gene. Light microscopy showed features of acinar dysplasia and desquamative interstitial pneumonitis. TEM studies revealed absence of mature lamellar bodies in type II cells and instead showed a mixture of cytoplasmic electron-dense inclusions with concentric membranes and distinctive electron dense aggregates. The ultrastructural changes in alveolar type II cells correlated well with specific gene defect. In SP-B deficiency, the absence of mature lamellar bodies is consistent with the postulated role for this protein in the formation of lamellar bodies. The lack of mature lamellar bodies in the ABCA3 gene mutations is due to the dysfunction of this endogenous lipid transporter that targets surfactant lipid moieties to the lamellar bodies. The findings demonstrate the importance of TEM studies of lung biopsies from infants with CSD as it is a critical adjunct in the diagnosis of neonatal lung disease and in defining the underlying cellular defects.

In the company of wolves: the physical, social, and psychological benefits of dog ownership

OBJECTIVE

The increase in aging populations has implications for the provision of health and social services. A preventative approach is taken to address this problem by examining a mechanism that can enhance physical health and reduce minor ailments.

METHODS

Participants in 10 focus groups discussed physical, psychological, and social benefits associated with human-dog interactions.

METHOD

RESULTS

Interaction between humans and dogs is a mechanism that can enhance the physical and psychological health of elderly citizens and promote a social support network between dog owners. In turn, dependence and impact on health and social services are alleviated.

DISCUSSION

The social and community consequences of promoting dog ownership in the elderly are addressed, and it is concluded that the benefits of dog ownership should be promoted among the elderly and acknowledged by relevant agencies.

Mapping Ds insertions in barley using a sequence-based approach

A transposon tagging system, based upon maize Ac/Ds elements, was developed in barley (Hordeum vulgaresubsp. vulgare). The long-term objective of this project is to identify a set of lines with Ds insertions dispersed throughout the genome as a comprehensive tool for gene discovery and reverse genetics. AcTPase and Ds-bar elements were introduced into immature embryos of Golden Promise by biolistic transformation. Subsequent transposition and segregation of Ds away from AcTPase and the original site of integration resulted in new lines, each containing a stabilized Ds element in a new location. The sequence of the genomic DNA flanking the Ds elements was obtained by inverse PCR and TAIL-PCR. Using a sequence-based mapping strategy, we determined the genome locations of the Ds insertions in 19 independent lines using primarily restriction digest-based assays of PCR-amplified single nucleotide polymorphisms and PCR-based assays of insertions or deletions. The principal strategy was to identify and map sequence polymorphisms in the regions corresponding to the flanking DNA using the Oregon Wolfe Barley mapping population. The mapping results obtained by the sequence-based approach were confirmed by RFLP analyses in four of the lines. In addition, cloned DNA sequences corresponding to the flanking DNA were used to assign map locations to Morex-derived genomic BAC library inserts, thus integrating genetic and physical maps of barley. BLAST search results indicate that the majority of the transposed Ds elements are found within predicted or known coding sequences. Transposon tagging in barley using Ac/Ds thus promises to provide a useful tool for studies on the functional genomics of the Triticeae.

Glucose-free medium exacerbates microvesicular steatosis in cultured skin fibroblasts of genetic defects of fatty acid oxidation. A novel screening test

Skin fibroblasts from patients with various fatty acid oxidation defects (FAOD) and four normal controls were subcultured in standard glucose-containing medium or in glucose-free medium simulating fasting. The FAOD fibroblasts developed microvesicular steatosis, which was greatly exacerbated in glucose-free medium. 'Rescue treatment' with glucose-containing medium was performed in the short-chain L-3-hydroxyacyl-CoA dehydrogenase-deficient (SCHADD) fibroblasts and resulted in a partial resolution of the steatosis and improved cellular viability. Transmission electron microscopy of autopsy specimens from the SCHADD patient demonstrated that most renal interstitial fibroblasts and approximately 50% of fibroblasts in the heart had microvesicular steatosis. The demonstration of microvesicular steatosis in parenchymal and/or cultured skin fibroblasts may provide important and cost-effective screening tools for the detection of genetic defects of fatty acid oxidation.

Health care utilization among young adult injection drug users in Harlem, New York

PURPOSE

This cross-sectional study investigated the predictors for and patterns of health care utilization among young adult injection drug users (IDUs).

METHODS

The subjects were 206 IDUs, ages 18-29, who were street-recruited from Harlem, New York. Participants were interviewed about their drug use, health conditions, and use of services such as health care, needle exchange programs (NEPs), and drug treatment in the preceding 6 months. Data were analyzed using logistic regression.

RESULTS

Health insurance was associated with use of health care both among NEP users [AOR (adjusted odds ratio) 10.66] and non-NEP users (AOR 2.45). Use of health care was independently associated with drug treatment (AOR 2.58), being gay/bisexual (AOR 3.86), and negatively associated with injecting cocaine (AOR 0.56). Half the participants (49%) had used health care in the previous 6 months; 48% were uninsured. Many participants who did not use health services reported a condition that would have warranted medical care.

IMPLICATIONS

Health insurance was strongly associated with use of health care, particularly among those who attend NEPs. Young adult IDUs may benefit from increased efforts to help them arrange and maintain health insurance coverage, potentially at NEPs. NEPs may be connecting young IDUs with health insurance to medical care through referrals.

Raffinose improves 24-hour lung preservation in low potassium dextran glucose solution: a histologic and ultrastructural analysis

BACKGROUND

We have previously shown that the addition of raffinose to low potassium dextran (LPD) preservation solution improves transplanted rat lung function after 24 hours of storage. The mechanisms by which raffinose acts are unclear. The aim of this study was to examine the histologic and ultrastructural correlates of this enhanced pulmonary function after preservation with raffinose.

METHODS

In a randomized, blinded study, rat lungs were flushed with LPD, or LPD containing 30 mmol/L of raffinose, and stored for 24 hours at 4 degrees C. Control lungs were flushed with LPD but not stored (n = 5 each group). Changes in postpreservation edema were determined. In addition, lungs were flushed with a trypan blue solution to quantify cell death, and examined using both light and electron microscopy.

RESULTS

The LPD lungs gained significantly more weight (25.5%+/-5.5%) compared with raffinose-LPD lungs (5.2%+/-5.3%; p < 0.0001). There were higher percentages of dead cells in the LPD lungs (29%+/-0.3% of total cells) compared with raffinose-LPD lungs (14%+/-1.4%; p < 0.001) and control lungs (0.2%+/-5%; p < 0.001). Control lungs maintained normal ultrastructure, whereas LPD lungs showed a decreased number of intact type II pneumocytes and significant cellular necrosis. Interstitial and alveolar edema with interstitial macrophage infiltration was also observed. Alveolar capillaries were collapsed. In contrast, raffinose-LPD lungs showed only mild alterations such as minimal interstitial edematous expansion, fewer damaged cells, and minimal capillary injury.

CONCLUSIONS

Raffinose exerts a cytoprotective effect on pulmonary grafts during preservation, which explains the previously documented improved function. This simple modification of LPD with raffinose may provide clinical benefit in extended pulmonary preservation.

Factors associated with prevalent hepatitis C: differences among young adult injection drug users in lower and upper Manhattan, New York City

OBJECTIVES

This study examined correlates of prevalent hepatitis C virus (HCV) infection among young adult injection drug users in 2 neighborhoods in New York City.

METHODS

Injection drug users aged 18 to 29 years were street recruited from the Lower East Side and Harlem. Participants were interviewed about drug use and sex practices; venipuncture was performed for hepatitis B virus (HBV), HCV, and HIV serologies.

RESULTS

In both sites, testing positive for HCV antibody (anti-HCV) was associated with having injected for more than 3 years. Additionally, HCV infection was positively associated with injecting with someone known to have had hepatitis (but the association was significant only in the Lower East Side) and with sharing cotton (but the association was statistically significant only in Harlem). Being in drug treatment and older than 24 years were associated with HCV in the Lower East Side but not in Harlem. Receiving money for sex was associated with anti-HCV positivity in Harlem but not in the Lower East Side.

CONCLUSIONS

Several differences in factors associated with prevalent HCV infection existed among 2 populations of young injection drug users from the same city. Indirect transmission of HCV may occur.

Development of a questionnaire (OPQ) to assess patient's knowledge about osteoporosis

OBJECTIVE

to develop a self-administered questionnaire (OPQ) to assess the patient's knowledge about osteoporosis.

METHODS

An initial item pool of 71 questions was developed with input from clinicians involved in the management of patients with osteoporosis. It was piloted in ten patients for face validity and comprehension. The questionnaire was then administered to 50 first-time attendees at a specialist osteoporosis unit. After item analysis using index of difficulty and index of discrimination, 20 items were selected for the final questionnaire (OPQ). These were in the areas of general information (5), risk factors (7), consequences and treatment (four each).

RESULTS

the average index of difficulty and index of discrimination (D) of the 20 items was 0.56 (>0.75 is suggestive of a poor discriminator) and 54.8% (D value of 50% is associated with highest level of item discrimination) respectively. This means that all the items actively discriminated between high and low scorers. The Flesch readability index was 74.3 (a score between 70 and 100 means a document is easily understood) and the reliability coefficient was 0.84 (acceptable range 0.8-0.9). Criterion validity (verification that the scale measures what it claims to measure) was confirmed by the method of contrasted groups where members of an osteoporosis awareness charity had a significantly higher score than the first time attendees (13.6 +/- 4.3 vs. 8.5 +/- 5.4; P=0.003).

CONCLUSIONS

we have developed a self-report, 20-item questionnaire (OPQ) to assess the patient's knowledge about osteoporosis. Psychometric analysis has shown that the items have a satisfactory index of difficulty and discrimination. The OPQ is internally reliable, valid and easily understandable. It can be used to identify individuals in need of educational interventions as well as assess the effectiveness of education efforts as a part of management of osteoporosis.

Selection of viable cardiomyocytes for cell transplantation using three-dimensional tissue culture

BACKGROUND

We developed a three-dimensional cardiac tissue culture system to select viable and contractile cells for the purpose of cardiomyocyte transplantation. In this study we will show that reaggregation of cardiomyocytes in culture is an active process indicative of cardiomyocyte viability and functionality.

METHODS

Myocardial tissue from newborn mice has been enzymatically digested, incubated in culture inserts, and studied by phase contrast microscopy, conventional histology, immunohistochemistry, electron microscopy, and TUNEL assay.

RESULTS

Cells that are plated on nonadhesive surfaces, reaggregate to spontaneously contracting cell aggregates. The capacity to reaggregate was significantly dependent from the age of the tissue donor (P<0.0001) and on the method of enzymatic dissociation (P<0.0001). The majority of cells within the aggregates consisted of cardiomyocytes. After 24 hr incubation, significant amounts of laminin and fibronectin had been deposited between the cells. Ultrastructural analysis revealed viable cardiomyocytes attached to each other by tight junctions. The apoptotic rate within the aggregates was 11.4+/-4.6 vs. 44.5+/-10.5% immediately after dissociation (P<0.05).

CONCLUSIONS

The capacity to form spontaneously contracting aggregates is an inherent characteristic of viable cardiomyocytes in 3-dimensional cultures, which could be successfully exploited for cellular cardiomyocyte transplantation.

The effect of polyethylene particle chemistry on human monocyte-macrophage function in vitro

Osteolysis remains the most important problem in orthopedic implant failure. Wear debris from the implant contains polyethylene (PE) particulate which has been shown to activate monocyte-derived macrophages (MDM). Although the response of MDM has been shown to be influenced by the size, shape, and chemical type of PE, the effect of chemically altered PE on MDM has not been studied. In this study, human MDM were seeded onto glass coverslips coated with virgin high density (HD)PE and chemically modified HDPE (impregnated with ppm levels of CoCl(2) and oxidized by heat) mixed with type I collagen and cultured for 96 h. Light microscopic evaluation demonstrated consistent phagocytosis of the HDPE particulate that was confirmed by scanning electron and transmission electron microscopy with little evidence of cytotoxicity. Evaluation of pro-inflammatory mediator secretion by MDMs in response to the virgin and chemically modified HDPE revealed significant differences in interleukin (IL)-1, tumor necrosis factor (TNF)-alpha, and IL-6 secretion. A significant elevation of IL-1 secretion was observed after initial exposure to virgin HDPE particles compared with controls (p = 0.001). IL-1 secretion was also elevated in the low oxidized particle groups (p = 0.001), whereas the highly oxidized particles were not different than controls. Secretion of both IL-6 (p = 0.03) and TNF-alpha (p = 0.007) were significantly elevated by the low oxidized HDPE particles whereas the virgin and highly oxidized groups showed no difference. The different effects on MDM activation when HDPE surface chemistry was altered, highlight the importance of defining the particle properties when studying the role of MDM activation in in vitro systems and extrapolating these observations to the in vivo situation.

An ultrastructural study of the intimal hyperplasia in healing microarterial anastomoses

The purpose of the study was to investigate the ultrastructure of intimal hyperplastic cells. End-to-end microarterial anastomoses were studied in a rabbit free-tissue-transfer model. There were five experimental groups, with 1, 3, 7, 14, or 28 days follow-up. At sacrifice the anastomoses were tested for patency and then examined by light and electron microscopy. At days 1 and 3 the repaired intima was covered with macrophages and extravasated erythrocytes. At day 7 spindle-shaped fibroblasts with copious rough endoplasmic reticulum were seen. Some of these cells also contained pinocytotic vesicles, filaments with focal densities, and subplasmalemmal attachment sites, the features of smooth muscle cells. At day 14, more cells contained smooth muscle features and these features were also more pronounced. These young myofibroblasts were plumper than adjacent fibroblasts. At day 28 mature myofibroblasts with a full complement of organelles were present. The results, therefore, supported the hypothesis that myofibroblasts are present in the intimal hyperplasia of healing microarterial anastomoses.

Cell death in human lung transplantation: apoptosis induction in human lungs during ischemia and after transplantation

OBJECTIVE

To examine the presence and extent of apoptosis as well as the affected cell types in human lung tissue before, during, and after transplantation.

SUMMARY BACKGROUND DATA

Apoptosis has been described in various human and animal models of ischemia-reperfusion injury, including heart, liver, and kidney, but not in lungs. Therefore, the presence of apoptosis and its role in human lungs after transplantation is not clear.

METHODS

Lung tissue biopsies were obtained from 20 consecutive human lungs for transplantation after cold ischemic preservation (1-5 hours), after warm ischemia time (during implantation), and 30, 60, and 120 minutes after graft reperfusion. To detect and quantify apoptosis, fluorescent in situ end labeling of DNA fragments (TUNEL assay) was used. Electron microscopy was performed to verify the morphologic changes consistent with apoptosis and to identify the cell types, which were lost by apoptosis.

RESULTS

Almost no evidence of apoptosis was found in specimens after immediate cold and warm ischemic periods. Significant increases in the numbers of cells undergoing apoptosis were observed after graft reperfusion in a time-dependent manner. The mean fraction of apoptotic cells at 30, 60, and 120 minutes after graft reperfusion were 16.6%, 22.1%, and 34.9% of total cells, respectively. Most of the apoptotic cells appeared to be alveolar type II pneumocytes, as confirmed by electron microscopy.

CONCLUSIONS

Programmed cell death (apoptosis) appears to be a significant type of cell loss in human lungs after transplantation, and this may contribute to ischemia-reperfusion injury during the early phase of graft reperfusion. This cell loss might be responsible for severe organ dysfunction, which is seen in 20% of patients after lung transplantation. Therefore, this work is of importance to surgeons for the future development of interventions to prevent cell death in transplantation.

Vascular pathology in galactosialidosis

This article immunohistochemically and ultrastructurally examines a brain with galactosialidosis, focusing on the structure of blood vessel endothelium. Lysosomes were observed in the expanded cytoplasm of the endothelial cells, which were vacuolated by light microscopy. Immunoreactivity for CD31, one of the vascular cell adhesion molecules, was minimal to faint in endothelial cells with vacuolations. The loss of CD31 immunoreactivity and breakdown of vascular cell adhesion molecules in vacuolated endothelial cells seem to promote the development of brain infarctions. Moreover, diffuse and various degrees of axonal damage, most likely caused by vascular disorder in cerebral or cerebellar white matter, was reported using the amyloid precursor protein (APP) immunohistochemical method.

A comparison of cell phenotypes in hemimegalencephaly and tuberous sclerosis

Hemimegalencephaly, an uncommon sporadic nonfamilial congenital dysplastic abnormality of the central nervous system, constitutes a pathological spectrum of neuronal migration disorders, but consistently includes abnormal large neurons similar to those in the cortical tubers of tuberous sclerosis. Microscopically, there are also cells with homogeneous and weakly eosinophilic cytoplasm with a single eccentric nucleus, sometimes called balloon cells (likewise prominent in tuberous sclerosis). We looked for immunohistochemical and ultrastructural differences in the large neurons and balloon cells between hemimegalencephaly and tuberous sclerosis. Microtubule-associated protein 1B and 2, phosphorylated and non-phosphorylated neurofilament and synaptophysin identify the large neurons and distinguish them from balloon cells in both entities. Balloon cells in hemimegalencephaly showed no immunoreactivity for TSC2 gene product, tuberin, and vimentin, but similar cells in tuber tissue showed consistent immunoreactivity. Balloon cells in hemimegalencephaly showed no immunoreactivity for glial fibrillary acidic protein, but some cells in tubers showed such immunoreactivity. Ultrastructurally, balloon cells in hemimegalencephaly contained very few lysosomes, microfilaments, and microtubules, but abundant lipofuscin granules. Similar cells in tubers had prominent lysosomes, more microfilaments and microtubules, and very few lipofuscin granules. The resemblance between abnormal cells in hemimegalencephaly and tuberous sclerosis is superficial; their immunohistochemistry and electron microscopic profiles show distinct differences.

Analysis of chromosome 22q as an aid to the diagnosis of rhabdoid tumor: a case report

Malignant rhabdoid tumor is a highly aggressive tumor of childhood that may present as a soft-tissue primary tumor. We report a soft-tissue neoplasm that was polyphenotypic by immunohistochemical expression of epithelial, mesenchymal, and neural markers and did not meet the criteria for any of the usual pediatric small round-cell tumors. The findings raised the diagnosis of rhabdoid tumor, leading to testing for WT1 mRNA and protein expression, which were positive, as has been reported for renal rhabdoid tumor. This tumor had the typical clinical behavior of rhabdoid tumor with therapy resistance and early tumor-related death. Multicolor spectral karyotyping of this neoplasm showed a balanced translocation between chromosomes 1 and 22 with breakpoints at 1p36 and 22q11-12. The latter region is commonly involved in rhabdoid tumor. This change was also identified by fluorescence in situ hybridization. This case suggests that studies of chromosome 22 may be required to distinguish rhabdoid tumor from other soft-tissue tumors.

PCR-RFLP analysis of the coagulase gene of Staphylococcus aureus: application to the differentiation of epidemic and sporadic methicillin-resistant strains

Preventing cross-infection with epidemic strains of methicillin-resistant Staphylococcus aureus (MRSA) requires effective control measures. These call for simple, rapid, discriminatory and reproducible methods for typing this pathogen. In this study 140 isolates/strains from 105 hospitals in England and Wales, representing 72 diverse phage types, were analysed by bacteriophage typing and PCR coagulase (coa) gene restriction fragment length polymorphism (RFLP). Isolates gave a coa gene PCR product that was either 660 base pairs (bp), 603 bp or 547 pb in size. The PCR products were digested with Alu I and Cfo I, and the fragments separated by gel electrophoresis. Eight coa gene RFLP patterns, numbered 1 to 8, were observed. Pattern 3 was most common (N = 25 isolates), followed by patterns 2 and 5 (18 isolates each), pattern 1 (14 isolates), pattern 4 (11 isolates), pattern 7 (10 isolates), pattern 8 (eight isolates) and pattern 6 (six isolates). Isolates of the same phage type often gave different coa gene RFLP patterns, and the patterns within the epidemic types EMRSA-03, EMRSA-15 and EMRSA-16 were heterogeneous. Thus, representatives of EMRSA-03 were subtyped to coa RFLP patterns 1 and 2, those of EMRSA-05 to coa RFLP patterns 1, 2, 7 and 8, and those for EMRSA-16 to coa RFLP patterns 2, 3, 4, 5 and 6. The range of patterns within single phage types of S. aureus could help to discriminate between isolates/strains, and in a hierarchical approach coa gene RFLP could occupy an intermediate position between phage typing and pulsed-field gel electrophoresis (PFGE).

Rhabdomyosarcoma metastasizing as a malignant ectomesenchymoma

Rhabdomyosarcoma is a common childhood malignancy that may occasionally occur as a component of a mixed mesenchymal tumor, e.g., a triton tumor or malignant ectomesenchymoma. A case is reported of a 13-year-old boy who had resection of a paratesticular embryonal rhabdomyosarcoma with subsequent radiation and chemotherapy. Two years later, a retroperitoneal metastasis was resected. Histology showed a mixture of rhabdomyoblasts, ganglion cells, and a third population of cells with combined features of these two distinct cell types. Electron microscopy confirmed the presence of rhabdomyoblasts with characteristic bundles of myofilaments and Z-band material, and ganglion cells with prominent nuclei and nucleoli, rough endoplasmic reticulum, dense core granules, filaments, and tubules. Notably, the third cell population showed features of both rhabdomyoblasts and ganglion cells. Immunohistochemistry confirmed the mixed population of rhabdomyoblasts (positive for vimentin, desmin, negative for S-100, NSE), ganglion cells (positive for S-100 and NSE, negative for vimentin and desmin), and the third population expressing all test antigens. The features of this metastatic lesion are those of a malignant ectomesenchymoma with combined rhabdomyosarcoma and ganglioneuroma components. It is postulated that this lesion results from biphenotypic expression of tumor cells that previously expressed only rhabdomyoblastic differentiation. The role of prior chemotherapy and radiotherapy in this particular case is unclear.