Exploration of sleep disturbances in children and adolescents with and without autism in a paediatric sample referred for polysomnography

AIMS

The purpose of the study was to increase the body of knowledge related to sleep in children with autism. The specific aims were to (i) identify the subgroup of children with autism, ages 3-17 years, referred for polysomnography and (ii) describe types and frequency of clinical encounters for sleep problems in a sample of children ages 3-17 with and without the diagnosis of autism.

METHODS

The authors performed a secondary data analysis of the de-identified Nationwide Children's Hospital Sleep DataBank, a collection of encounters with children referred for polysomnography. The data were filtered for ages 3-17 years at the time of the participant's first sleep study, and further filtered for the presence of an autism diagnosis.

RESULTS

In the sample, there were 2838 unique participants (M = 10.5 years) with a total of 172 167 encounters between 2017 and 2019. Of these, 198 (7%) were diagnosed with Autism Spectrum Disorder, Asperger's Syndrome, or Pervasive Developmental Disorder. Among all participants, the most common sleep problems were apnea, snoring, non-specified sleep disorders (including restless sleeper), circadian rhythm disorder (CRD), and insomnia. The subgroup of patients diagnosed with autism was noted to have higher frequency of several types of sleep problems, especially restless sleep, CRD and insomnia, compared to those without an autism diagnosis.

CONCLUSIONS

Findings elucidate the increased presence of sleep problems in paediatric patients with autism, and the need for purposeful sleep evaluation and research given the potential impact on daytime function for these individuals and their families.

Health-related behaviors, self-rated health, and predictors of stress and well-being in nursing students

BACKGROUND

Nursing students are at increased risk for the consequences of stress on wellbeing. Little is known about nursing students' health promoting behaviors and how these relate to health, stress, and well-being.

PURPOSE

The purpose was to describe perceived stress and measures of well-being (self-compassion, happiness, and life satisfaction) along with self-reported health promoting behaviors and health status in order to identify factors that could affect stress and well-being in nursing students.

METHODS

A multi-site team employed cross-sectional research methods to explore well-being, stress, and potential physical and emotional health-relevant factors in undergraduate nursing students. Baccalaureate Nursing students from three nursing programs in North Texas participated in a web-based survey. Undergraduate students (n = 417) reported being junior or senior level in a traditional (74.1%) or an alternative nursing training program (on-line, fast-track, or weekend nursing program; 24.9%) in the fall of 2019. Recruitment fliers went to a total of 2264 potential participants via university e-mail. Consenting students completed online surveys collecting demographic and health related factors as well as measures of well-being and stress.

RESULTS

More than half (56.6%) of students reported worsening health since starting nursing school. Exercise and meditation were related to higher measures of well-being and lower stress, but this relationship diminished in the multivariate model when considering individual demographic and health related factors. Our multivariate model suggests that self-rated health status remains a main potential predictor of reduced stress and improved well-being.

CONCLUSIONS

Self-reported health factors are related to wellbeing in nursing students. Targeted interventions to improve well-being among nursing students may be necessary and would fit with national recommendations for nursing education programs. Resiliency skills training with mindfulness practices may help nursing students reduce stress, improve overall well-being, and equip students to avoid burnout and stress-related illness once in the workforce.

Abnormal weight gain with fatigue and stress in early survivorship after childhood brain tumor diagnosis

BACKGROUND

Diagnosis and treatment for individuals with brain tumors during childhood involves sequelae, including abnormal weight gain. This symptom is commonly clustered with fatigue and increased risk for cardiovascular disease. Children's Oncology Group recommendations include annual surveillance of body mass index (BMI) and cardiometabolic comorbidities; however, there has been little emphasis on individualized screening early in survivorship.

PURPOSE

The primary purpose of this paper is to describe the findings of abnormal weight gain and its correlates in a sample of young childhood brain tumor survivors during early survivorship.

DESIGN AND METHODS

This cross-sectional multi-site study included brain tumor survivors of ages 8-12 years who were less than 6 years posttreatment. Convenience sampling from two pediatric cancer centers in the southern United States was utilized. Data collected included BMI, parent report of sleep, and child report of fatigue and stress.

RESULTS

The sample (N = 21) consisted of children who had received chemotherapy, radiation treatment, and surgery for childhood brain tumor. BMI in overweight and obese categories exceeded normative samples with 38% at or above the 85th percentile. There were clinically significant relationships with fatigue, stress about weight, tumor location, cranial radiation, chemotherapy, and recurrence PRACTICE IMPLICATIONS: Screening for abnormal weight gain and related factors, such as fatigue should begin early in survivorship after childhood brain tumor treatment completion with the aim of health promotion and disease prevention. Adiposity measurement techniques should be utilized in future clinical and research settings to improve assessment of cardiometabolic risk.

0045 Biobehavioral Markers for Sleep/Wake Disturbance and Fatigue in Young Childhood Brain Tumor Survivors

Introduction

Survivors of childhood and adolescent brain tumors and subsequent treatment may experience many neurological processes involving the forebrain, brainstem, and hypothalamus as well as the symptom cluster of stress, sleep, and fatigue. As a result, the impact of brain tumor treatment (chemotherapy/biotherapy, radiotherapy, and surgery) may have lasting biobehavioral effects. Description of symptoms during early survivorship is not always evident in the literature.

Methods

Convenience sampling and the following inclusion criteria were utilized: brain tumor survivors ages 8–17 years; ≥6 months, <6 years from completion of treatment; disease free or stable disease. Participants completed polysomnography (PSG) followed by a multiple sleep latency test (MSLT), and subjective measures of sleep, fatigue, stress, and pubertal status. Collection of salivary biomarkers for stress (cortisol) and sleep (melatonin) was completed the evening of and morning after the PSG.

Results

Analysis of the first 12 participants (5 males; 3 Hispanic/Latino; average age 14 years; 9–72 months post treatment) revealed mean (minutes) total sleep time (TST) 442, sleep latency (SL) 42 and waking (WASO) 88; sleep efficiency (SE) mean 83%, There were large magnitude correlations between several variables of interest, notably PM Cortisol with fatigue, TST (r= .472; -.453); AM Cortisol with SL (r=.479); AM Melatonin with SE, SL, WASO (r= -.459; .692; .458). Average AM melatonin level (26.6 pg/dl) was higher than PM (6.66 pg/dl). Seven participants were diagnosed with clinical sleep disorders, including one with narcolepsy and two with hypersomnia.

Conclusion

During early survivorship after pediatric brain tumor treatment, survivors may be at high risk for sleep/wake disturbance (SWD). Morning melatonin and biomarker correlations with sleep and fatigue in this sample warrant further exploration and may be related to first night effect versus circadian rhythm differences or clinical sleep disorder. Recommendations for future practice include developmentally matched protocols and routine screening of biobehavioral markers to assess risk for stress, SWD, and fatigue.

Support

1. Center for Oncology Education and Research Harris College of Nursing & Health Sciences Texas Christian University 2. Neuro-Oncology Program Hematology/Oncology Center Cook Children’s Health Care System 3. Nursing Research and Evidence-Based Practice James A. “Buddy” Davidson Endowed Fund

Gender Disparities in Financial Relationships Between Industry and Orthopaedic Surgeons

BACKGROUND

Recent studies in a number of surgical subspecialties have demonstrated that financial relationships with industry differ between men and women. This study aimed to determine if gender disparities exist in industry relationships with orthopaedic surgeons.

METHODS

This retrospective study utilized publicly available data from the Centers for Medicare & Medicaid Services (CMS) at OpenPayments.cms.gov. Data were extracted for payments made to orthopaedic surgeons from industry for royalties, licensing, or consulting fees from 2016 to 2017. A physician's profile was used to determine name, gender, practice location, and subspecialty. Years of experience were recorded from publicly available websites. Total number of payments and amounts were compared among men and women, subspecialties, and locations. Multivariable linear regression models were used to determine predictors of total payments and number of payments.

RESULTS

Royalties and consulting fees were paid to 3,418 individual physicians (11% of 29,996 physicians in the American Academy of Orthopaedic Surgeons [AAOS] census) and accounted for 88% of total payments. The majority of the total payment amount (99.6%) was made to men, while only 0.4% went to women. Male gender was a predictor of total number of payments (β = 5.17, p < 0.001), as were years of experience (β = 0.15 [95% confidence interval (CI): 0.10 to 0.20], p < 0.001), Mountain region (β = 2.77 [95% CI: 0.37 to 5.17], p = 0.02), and adult reconstructive subspecialty (β = 4.07 [95% CI: 1.89 to 6.25], p < 0.001). Years of experience (β = 0.046 [95% CI: 0.039 to 0.052], p < 0.001), male gender (β = 1.09 [95% CI: 0.67 to 1.51], p < 0.001), Mountain region (β = 0.35 [95% CI: 0.020 to 0.68], p = 0.04), and adult reconstructive subspecialty (β = 0.33 [95% CI: 0.030 to 0.63], p = 0.03) were associated with higher payments.

CONCLUSIONS

Male gender, years of experience, Mountain region, and adult reconstructive subspecialty are independent predictors of a higher number of industry payments and payment amount. These disparities in industry payments may contribute to continued inequities in scholarship, academic rank, and leadership opportunities.

Climate and red spruce growth and decline in the northern Appalachians

Between the mid-1960s and mid-1980s, red spruce (Picea rubens Sarg.) died at unusual rates on the mountains of New York and western New England. We determined the relationship between standardized tree ring widths and monthly climate data for calibration and verification periods from 1856 to 1981 and found that after about 1960, there was a distinct shift in the temperature variables related to standardized ring widths in vigorous spruce. The beginning of widespread spruce mortality, regionwide growth decreases, and the shift in response to climate in the early 1960s corresponds to the onset of a decade of unusually cold winters and several consecutive years when severe winter damage was noted across the Northeast in this species. We suggest that the episodes of winter damage are an important initiating and synchronizing factor in the red spruce decline.

Off-Therapy Headaches in Pediatric Brain Tumor Patients: A Retrospective Review

To determine the incidence, timing, and characteristics of headaches in a population of off-therapy pediatric brain tumor patients, a retrospective chart review was conducted on 3 subpopulations of children followed in a multidisciplinary neuro-oncology clinic in the Southeastern United States. Data collected included tumor type and location, treatment, associated symptoms, and description and timing of headaches. In all, 81 charts were reviewed from which headaches in 3 subtypes of tumors were identified (29 medulloblastomas, 36 cerebellar juvenile pilocytic astrocytomas [JPAs], and 16 craniopharyngiomas). Off-therapy headaches were noted in 6 (21%) of medulloblastomas, 10 (28%) of JPAs, and 19 (56%) of craniopharyngiomas. Almost half of those patients with prediagnosis headaches had recurrent off-therapy headaches. Given the incidence of this symptom, headache must be highlighted in posttreatment and late effects monitoring.Whether provided by the oncology team or primary care provider, headache assessment, treatment, and prevention counseling can be improved through utilization of newly developed tools and written educational materials. Experienced nurses can play key roles in this aspect of posttreatment pediatric care of brain tumor patients.

HLA type of EBV-transformed human B cell lines

This appendix lists reference Epstein-Barr virus (EBV)-transformed B lymphoblastoid cell lines (B-LCL) and the HLA types expressed by these cell lines. These B-LCL are useful for studies of cellular immunity (e.g., restriction of antigen-specific responses), biochemical characterization of histocompatibility molecules, and as controls for DNA-based typing methods.

Randomised trial of high frequency oscillatory ventilation or conventional ventilation in babies of gestational age 28 weeks or less: respiratory and neurological outcomes at 2 years

BACKGROUND

The long term outcome of children entered into neonatal trials of high frequency oscillatory ventilation (HFOV) or conventional ventilation (CV) has been rarely studied.

OBJECTIVE

To evaluate respiratory and neurodevelopmental outcomes for children entered into the United Kingdom Oscillation Study, which was designed to evaluate these outcomes.

METHODS

Surviving infants were followed until 2 years of age corrected for prematurity. Study forms were completed by local paediatricians at routine assessments, and parents were asked to complete a validated neurodevelopmental questionnaire.

RESULTS

Paediatricians' forms were returned for 73% of the 585 surviving infants. Respiratory symptoms were common in all infants, and 41% had received inhaled medication. Mode of ventilation had no effect on frequency of any symptoms. At 24 months of age, severe neurodevelopmental disability was present in 9% and other disabilities in 38% of children, but the prevalence of disability was similar in children who received HFOV or CV (relative risk 0.93; 95% confidence interval 0.74 to 1.16). The prevalence of disability did not vary by gestational age, but boys were more likely to have overall disability. Developmental scores were unaffected by mode of ventilation (relative risk 1.13; 95% confidence interval 0.78 to 1.63) and were lower in infants born before 26 weeks gestation compared with babies born at 26-28 weeks.

CONCLUSIONS

Initial mode of ventilation in very preterm infants has no impact on respiratory or neurodevelopmental morbidity at 2 years. HFOV and CV appear equally effective for the early treatment of respiratory distress syndrome.

The mechanical joint score: a new clinical index of joint damage in rheumatoid arthritis

OBJECTIVES

To evaluate the mechanical joint score (MJS) in terms of its reliability between observers and over time, its ease of use and its relationship with conventional measures of rheumatoid arthritis (RA) disease activity, severity and functional outcome.

METHODS

The MJS was evaluated in 103 patients with reference to the following joints: total proximal interphalangeal (PIP) joints, total metacarpophalangeal (MCP) joints, wrists, elbows, shoulders, hips, knees, ankles and total metatarsophalangeal (MTP) joints. The score was based on the appearance of the joints on a scale of 0-3, 0 representing no abnormality and 3 severe abnormality or previous surgery. The MJS was evaluated in terms of its intra- and inter-observer variability and its content, construct and criterion validities. A subset of 29 patients were re-evaluated after 5 yr to examine change in MJS over time.

RESULTS

The MJS performed well in terms of inter-observer and intra-observer reliability. The MJS showed strong correlation with the Larsen X-ray score of hands and feet (Spearman correlation coefficient 0.74) and with the modified Health Assessment Questionnaire (Spearman correlation coefficient 0.56) and only weak correlation with indices of disease activity, such as the Ritchie index and erythrocyte sedimentation rate. The MJS showed highly significant positive change over time.

CONCLUSION

The MJS is a reliable clinical index of joint damage and may be a useful new outcome measure in RA.

A Dendroctonus bark engraving (Coleoptera: Scolytidae) from a middle Eocene Larix (Coniferales: Pinaceae): early or delayed colonization?

An engraving made by a scolytid bark beetle, assigned to the genus Dendroctonus of the tribe Tomicini, has been identified on a mummified, middle Eocene (45 Ma) specimen of Larix altoborealis wood from the Canadian High Arctic. Larix altoborealis is the earliest known species of Larix, a distinctive lineage of pinaceous conifers that is taxonomically identifiable by the middle Eocene and achieved a broad continental distribution in northern North America and Eurasia during the late Cenozoic. Dendroctonus currently consists of three highly host-specific lineages that have pinaceous hosts: a basal monospecific clade on Pinoideae (Pinus) and two sister clades that consist of a speciose clade associated exclusively with Pinoideae and six species that breed overwhelmingly in Piceoideae (Picea) and Laricoideae (Pseudotsuga and Larix). The middle Eocene engraving in L. altoborealis represents an early member of Dendroctonus that is ancestral to other congeneric species that colonized a short-bracted species of Larix. This fossil occurrence, buttressed by recent data on the phylogeny of Pinaceae subfamilies and Dendroctonus species, indicates that there was phylogenetically congruent colonization by these bark-beetle lineages of a Pinoideae + (Piceoideae + Laricoideae) host-plant sequence. Based on all available evidence, an hypothesis of a geochronologically early invasion during the Early Cretaceous is supported over an alternative view of late Cenozoic cladogenesis by bark beetles onto the Pinaceae. These data also suggest that host-plant chemistry may be an effective species barrier to colonization by some bark-beetle taxa over geologically long time scales.

The current status of Balint groups in US family practice residencies: A 10-year follow-up study, 1990-2000

BACKGROUND AND OBJECTIVES

In 1990, the first and, to date, only objective study of Balint groups in US family practice residencies was conducted to measure their prevalence, composition, leadership, and function. The study reported here collected similar information about Balint groups.

METHODS

Surveys were sent to all 464 US family practice residency program directors, with a 1-month follow-up to nonrespondents. The survey included questions about the existence, leadership, meeting frequency, and objectives of Balint training.

RESULTS

A total of 298 (64%) residencies responded. Almost half (48%) of US responding residences reported conducting Balint groups, and 40% of those residencies have more than one group. The frequency of Balint group meetings has shifted in the past 10 years. In 1990, 55% of groups met weekly; in 2000, only 15% of groups met weekly. Sixty-five percent of residencies require Balint participation. One third of Balint groups are conducted without a coleader and the number of physicians leading groups is 22%, a decrease of 10% from 10 years ago. Forty-four percent of groups are led by psychologists, an increase of 19% from 10 years ago. Respondents indicated uncertainly about whether their groups were true Balint groups or simply resident support groups.

CONCLUSIONS

About half of US family practice residencies operate groups described as Balint groups. They meet less frequently then 10 years ago and are less likely to have a physician involved in group leadership. Some of the groups may actually be support groups rather than Balint groups.

Gastric antral vascular ectasia in systemic sclerosis: complete resolution with methylprednisolone and cyclophosphamide

A case of severe, transfusion dependent anaemia in a 72 year old woman, which on endoscopy was found to be due to gastric antral vascular ectasia (GAVE), is reported. Repeated endoscopic sclerotherapy was ineffective. She subsequently developed Raynaud's phenomenon and on further investigation was found to have classical systemic sclerosis with lung involvement. Treatment with pulses of intravenous methylprednisolone and cyclophosphamide resulted in significant improvement in her pulmonary function tests and skin score. Coincidentally, her haemoglobin stabilised and further endoscopic examinations were normal. This is the first report of cyclophosphamide and methylprednisolone leading to complete and sustained resolution of GAVE in association with systemic sclerosis.

HLA-DR and -DQ polymorphism in Cameroon

HLA-DRB1, -DQA1 and -DQB1 allele frequencies were determined by high-resolution polymerase chain reaction using sequence-specific oligonucleotide probes (PCR-SSOP) and/or DNA sequencing in 126 healthy individuals in Cameroon. Eighteen DRB1, 11 DQA1, and 18 DQB1 alleles were observed. The most common alleles at each locus were DRB1*1503 (29%), DRB1*1301 (13%); DQA1*0102 (38%), DQA1*0302 (11%), DQA1*0401 (11%); and DQB1*0602 (31%), DQB1*0301 (13%), DQB1*0501 (12%). Forty-four different haplotypes were identified including 12 novel haplotypes demonstrating the HLA class II diversity resulting from allele combinations in this population. A single predominant DRB1*1503-DQA1*0102-DQB1*0602 haplotype was observed with a frequency of 27%. In summary, this study of HLA class II polymorphism in Cameroon demonstrates the extent of diversity in this population.

HLA-B allele frequencies in Côte d'Ivoire defined by direct DNA sequencing: identification of HLA-B*1405, B*4410, and B*5302

Direct automated DNA sequencing was used to analyze exons 2 and 3 of HLA-B alleles present in forty-four unrelated individuals residing in the village of Adiopodoume, Côte d'Ivoire (Ivory Coast). Of the 23 HLA-B alleles observed, the most frequently detected allele was HLA-B*5301 (22.7%), which is believed to confer resistance to severe Plasmodium falciparum malaria. B*4501 (9.1%), B*1503 (8.0%), B*0705 (5.7%), B*1510 (5.7%) and B*3501 (5.7%) occurred frequently in the population. A second allele of B53 was identified; B*5302 contains a single amino acid variation at residue 171 (Y-->H). Two additional novel alleles, B* 1405 (a single amino acid variant of B*1402) and B*4410 (a five amino acid variant of B*4403) were characterized.

The Balint movement in America

Michael Balint's (1896-1970) career evolultion from general practitioner (1918) to psychoanalyst (1926) and subsequently to general practitioner educator (1950) began at his home in Budapest and then moved from London to sites in the United States. His frequent visits to America, together with his wife Enid, were an influential force in promoting and training US-based Balint group leaders. Michael and Enid Balint's influence, together with the support of US physicians, South African physicians who became US citizens, and behavioral scientists, laid the foundation for the formation of an American Balint Society in 1990. The Society's educational and research efforts occurred primarily in family practice residencies and have grown over the past 10 years. The Society, is presently working to standardize credentialing of Balint group leaders to assure continued quality growth in the American Balint movement.

The epidemiology of Plasmodium falciparum malaria in two Cameroonian villages: Simbok and Etoa

In support of ongoing immunologic studies on immunity to Plasmodium falciparum, demographic, entomologic, parasitologic, and clinical studies were conducted in two Cameroonian villages located 3 km apart. Simbok (population = 907) has pools of water present year round that provide breeding sites for Anopheles gambiae, whereas Etoa (population = 485) has swampy areas that dry up annually in which A. funestus breed. Results showed that individuals in Simbok receive an estimated 1.9 and 1.2 infectious bites per night in the wet and dry season, respectively, whereas individuals in Etoa receive 2.4 and 0.4 infectious bites per night, respectively. Although transmission patterns differ, the rate of acquisition of immunity to malaria appears to be similar in both villages. A prevalence of 50-75% was found in children < 10 years old, variable levels in children 11-15 years old, and 31% in adults. Thus, as reported in other parts of Africa, individuals exposed to continuous transmission of P. falciparum slowly acquired significant, but not complete, immunity.

Diversity is demonstrated in class I HLA-A and HLA-B alleles in Cameroon, Africa: description of HLA-A*03012, *2612, *3006 and HLA-B*1403, *4016, *4703

To examine the genetic diversity in west Africa, class I HLA-A and HLA-B alleles of 92 unrelated individuals from two areas in the Cameroon, the capital Yaoundé and the village of Etoa, were identified by direct automated DNA sequencing of exons 2 and 3 of the HLA-B locus alleles and sequence-specific oligonucleotide probe (SSOP) and/or sequencing of the HLA-A locus alleles. HLA-A*2301 (18.7%), A*2902 (10.4%), B*5301 (10.9%), and B*5802 (10.9%) were the most frequently detected alleles, present in at least 10% of the population. A total of 30 HLA-A locus and 33 HLA-B locus alleles, including six novel alleles, were detected. The novel alleles were HLA-A*03012, A*2612, A*3006 and HLA-B*1403, B*4016, and B*4703. HLA-B*4703 contains a novel amino acid sequence that is a combination of the first 5 amino acids of the Bw6 epitope and the last 2 residues of the Bw4 epitope. The addition of 6 alleles to the ever-expanding number of known class I HLA alleles supports our hypothesis that extensive genetic diversity, including previously undescribed alleles, would be observed in this African population. In the Yaoundé population, the allele frequency distribution at the HLA-A locus is consistent with distributions indicative of balancing selection. Extensive HLA-A-B haplotypes were observed in this population suggesting that only a fraction of the Cameroon HLA-A-B haplotype diversity has been observed.

Characterization of conserved T- and B-cell epitopes in Plasmodium falciparum major merozoite surface protein 1

Vaccines for P. falciparum will need to contain both T- and B-cell epitopes. Conserved epitopes are the most desirable, but they are often poorly immunogenic. The major merozoite surface protein 1 (MSP-1) is currently a leading vaccine candidate antigen. In this study, six peptides from conserved or partly conserved regions of MSP-1 were evaluated for immunogenicity in B10 congenic mice. Following immunization with the peptides, murine T cells were tested for the ability to proliferate in vitro and antibody responses to MSP-1 were evaluated in vivo. The results showed that one highly conserved sequence (MSP-1#1, VTHESYQELVKKLEALEDAV; located at amino acid positions 20 to 39) and one partly conserved sequence (MSP-1#23, GLFHKEKMILNEEEITTKGA; located at positions 44 to 63) contained both T- and B-cell epitopes. Immunization of mice with these peptides resulted in T-cell proliferation and enhanced production of antibody to MSP-1 upon exposure to merozoites. MSP-1#1 stimulated T-cell responses in three of the six strains of mice evaluated, whereas MSP-1#23 was immunogenic in only one strain. Immunization with the other four peptides resulted in T-cell responses to the peptides, but none of the resulting peptide-specific T cells recognized native MSP-1. These results demonstrate that two sequences located in the N terminus of MSP-1 can induce T- and B-cell responses following immunization in a murine model. Clearly, these sequences merit further consideration for inclusion in a vaccine for malaria.

The chest radiograph appearances of very premature infants at 36 weeks post-conceptional age

The chest radiograph of very premature infants at 36 weeks post-conceptional age (PCA) was evaluated with regard to the degree of hyperinflation and cardiomegaly, and the presence of fibrosis/interstitial shadowing, cystic elements, air bronchograms and opacification. The evolution of abnormalities was assessed by comparing the radiograph appearance at 36 weeks PCA with that at 28 days post-natal age (PNA). Three scoring systems were used to determine how any abnormalities present could be best quantified to reflect disease severity as determined by chronic dependency upon supplementary oxygen status. Chest radiographs at 36 weeks PCA from 60 infants (median gestational age 26 weeks (range 24-28)) were studied. 47 infants also had radiographs at 28 days PNA. Only three infants had no chest radiograph abnormalities at 36 weeks PCA, although 24 infants were not dependent upon supplementary oxygen. The most common abnormalities were interstitial shadowing and hyperinflation, while cystic elements and cardiomegaly were rare. The radiographic appearance had deteriorated from 28 days PNA to 36 weeks PCA (p < 0.05); more infants at 36 weeks PCA were hyperinflated (p < 0.01). The chest radiograph appearances of infants who were dependent upon supplementary oxygen scored higher than those who were not (p < 0.01) using all three scoring systems. The system that assessed only the presence of interstitial shadowing, cystic elements and hyperinflation had the highest specificity in identifying oxygen dependency beyond 36 weeks PCA and had the highest area under the respective receiver operator characteristic curve. In conclusion, the majority of very immature infants have an abnormal chest radiograph appearance at 36 weeks PCA. The appearance can, however, be meaningfully scored by evaluating only three abnormalities.

Assessing the binding of four Plasmodium falciparum T helper cell epitopes to HLA-DQ and induction of T-cell responses in HLA-DQ transgenic mice

A subunit vaccine for Plasmodium falciparum malaria will need to contain well-defined T helper cell epitopes that induce protective immune responses to the parasite. One major barrier to the use of subunit vaccines is the requirement for T helper cell epitopes to be presented by the HLA class II molecules that are present in the population being vaccinated. Since the majority of malaria studies have focused on HLA-DR, little information on the role of HLA-DQ in the binding and immune response to malarial epitopes is available. This study used an in vitro peptide-binding assay to predict the extent of HLA-DQ binding of four conserved T helper cell epitopes identified from asexual-stage malaria vaccine candidate antigens. Epstein-Barr virus (EBV)-transformed human B-cell lines expressing 14 different DQ molecules (DQ2.1, -2.2, -4.1, -4.2, -5.1 to -5.3, -6.1, -6.2, -6.4, -7.1, -7.3, -8, and -9) representing all broad serological specificities, including common DQ molecules present in populations in areas where malaria is endemic, were used in the binding assay. Moreover, an HLA-DQ transgenic mouse model was employed to evaluate the correlation between the in vitro DQ binding of the peptides and the generation of in vivo immune responses following peptide immunization. This study identified two broad DQ-binding peptides, ABRA#14 and SERA#9. ABRA#14 also induced T-cell proliferation and Th1-associated cytokine production in DQ8(+) transgenic mice. The combination of peptide binding to EBV-transformed cell lines and DQ transgenic mice provides a method for identifying additional T-cell epitopes for inclusion in a vaccine.

Balint group observations: the white knight and other heroic physician roles

BACKGROUND

This article reports a typology of five roles that resident family physicians on occasion assume when relating to troubling patients presented in Balint group seminars. The five roles include the white knight (my way or no way), the Pogo look-alike (I feel your pain), the missing link (you made me do it), the surrogate (I can help), and the revolutionary (let me show you). Each role reflects a particular physician's coping behavior in the context of a specific troubling relationship and is driven, in large part, by unrealistic professional expectations. The roles intend to perform a heroic function in rescuing or protecting the patient, the family, or the physician from a distressing medical situation. Balint group work provides participants with the opportunity to derive clinically useful meaning from their presentations. Residents begin to imagine a variety of therapeutic (helpful) roles to replace the ones they were induced to fill. This process has implications for practicing physicians and physician teachers for improving patient and doctor satisfaction and well-being.

A simple chest radiograph score to predict chronic lung disease in prematurely born infants

A simple scoring system has been evaluated with regard to its ability to characterize the pre-term infant's chest radiograph appearance at 28 days and predict oxygen dependency beyond 36 weeks post-conceptional age (PCA). Chest radiographs taken at approximately 1 month of age in 42 infants (median gestational age 28 weeks) were assessed by the scoring system for the presence of fibrosis/interstitial shadows, cystic elements and degree of hyperinflation (maximum score 8). The system's results were then compared with those obtained using two previously published scoring systems. Using all three systems, there were significant differences in the scores of infants who were and were not oxygen dependent at 28 days (p < 0.001) and 36 weeks PCA (p < 0.001). For the three systems, the positive predictive values of a score of 3 or more to predict oxygen dependency at 36 weeks (PCA) were between 67% and 80% and similar receiver operating characteristic curves were obtained. We conclude that scoring only three abnormalities of the 28 day chest radiograph appearance of pre-term infants gives useful predictive information.

Death in the PICU: caring for the "other" families

This article discusses the care of Pediatric Intensive Care Unit (PICU) families who are present during the death of a child other than their own. "Other" families witness bereavement and experience grief, and there is no literature available to evaluate and describe their needs. Many PICU families are exposed to the death of a child. Nursing interventions to ameliorate self-awareness skills, validate the significance of the event, eliminate unnecessary fears, and cultivate effective coping strategies are necessary to decrease the stress of the experience. Research is needed to specify the needs of "other" families and to improve care for everyone present during the death of a child.

Autoantibodies to oxidized low density lipoprotein: the relationship to low density lipoprotein fatty acid composition in diabetes

Autoantibodies to oxidized low density lipoprotein have been shown to be an independent predictor of the progression of carotid atherosclerosis. This study examines the relationship between low density lipoprotein fatty acid composition and autoantibodies to both malondialdehyde-modified and copper-oxidized low density lipoprotein in non-diabetic patients with (n = 17), and without (n = 18), definite evidence of previous myocardial infarction. The third group were non-insulin-dependent diabetic patients with no evidence of atherosclerosis (n = 15) and the fourth group were patients with non-insulin-dependent diabetes (n = 17) who had definite evidence of previous myocardial infarction. Fatty acids were measured by gas-liquid chromatography. Antibodies to malondialdehyde-modified low density lipoprotein and copper-oxidized low density lipoprotein were determined by an ELISA method. Autoantibodies to copper-oxidized low density lipoprotein were significantly higher in the non-diabetic patients with heart disease when compared to any other group (p < 0.05). Autoantibodies to malondialdehyde-modified low density lipoprotein were significantly higher in the non-diabetic subjects with heart disease and in both diabetic groups compared to non-diabetic subjects without coronary heart disease (p < 0.05). Linoleic acid (%) in low density lipoprotein did not differ between groups groups but arachidonic acid (%) was significantly lower in both diabetic and non-diabetic patients with coronary heart disease (p < 0.05). The diabetic patients with low antibodies had 39.6 +/- 2.2% polyunsaturated fatty acids in their low density lipoprotein while diabetic patients with high antibodies had 46.7 +/- 1.2% polyunsaturates in their low density lipoprotein (p < 0.01). This study confirms the association between antibodies to oxidized low density lipoprotein and coronary heart disease and shows raised low density lipoprotein antibody levels in diabetic patients with and without demonstrable atherosclerosis. In the diabetic patients, those with high antibody levels had high polyunsaturated fatty acid levels in their LDL suggesting a possible role for dietary intervention.

Crystallization and preliminary X-ray studies of rhamnogalacturonase A from Aspergillus aculeatus

Recombinant rhamnogalacturonase A from Aspergillus aculeatus has been crystallized and X-ray diffraction data has been collected. Crystals were grown by the hanging-drop vapour-diffusion technique, under the conditions 10% PEG 8000, 0.05 M KH(2)PO(4) and 0.1 M sodium acetate buffered at pH 3.5. The crystals diffract beyond 2.0 A resolution and belong to one of the orthorhombic space groups I2(1)2(1)2(1) or I222, with the unit-cell parameters a = 62.9, b = 125.4 and c = 137.0 A. There is one molecule in the asymmetric unit and a solvent content of approximately 54%. The enzyme is highly glycosylated corresponding to 5.9 kDa.

Heavy metals in Jamaican surface soils

A regional survey of Jamaican surface soils has been conducted in which more than 200 samples were collected at a sample density of 1 per 64 km(2) across the island and analysed for total concentrations of 31 elements by instrumental neutron activation analysis (INAA), energy dispersive X-ray fluorescence (EDXRF) analysis and atomic absorption spectrophotometry (AAS). The aim of the survey was to begin the construction of a high-precision geochemical database to provide information on elemental levels in soils for application to environmental studies, agriculture, and human and animal health. Results on the regional scale are presented for As, Cd, Cu, Hg and Pb. Although Jamaican surface soils are enriched in several heavy metals compared with world soil means and crustal abundances, lead is of particular importance at this stage because of its occurrence in residential areas. Except for Cu, the distribution maps of these elements are highly correlated with bauxite which in Jamaica is associated with white limestone geology and residualterra rossa soils.

Novel HLA-B alleles, B*8201, B*3515 and B*5106, add to the complexity of serologic identification of HLA types

Three class I alleles, B*8201, B*3515 and B*5106, have been described using DNA and cDNA sequencing. The B*8201 allele is most structurally related to B*5602, differing from it by 14 nucleotide substitutions resulting in 5 amino acid differences. The other two alleles, B*3515 and B*5106, differ from their most closely related HLA-B alleles by 2-3 nucleotide substitutions resulting in 1-2 amino acid substitutions, respectively. The majority of nucleotide substitutions marking these new alleles are observed in other HLA-B alleles suggesting that gene conversion and/or reciprocal recombination have created this diversity. All of the amino acid substitutions are predicted to alter the antigen binding site of the HLA-B molecule. The newly defined HLA-B allelic products were originally defined by their unusual serologic reactivity patterns. The B*8201 allelic product is serologically typed as a B "blank" or as a variant of B22 or B45. These patterns and the serologic reactivity of the other newly described allelic products are consistent with the protein sequence homology among specific HLA-B molecules. While serology remains a powerful tool for detecting HLA diversity, alleles generated by events resulting in the sharing of HLA sequence polymorphisms among alleles at a locus will continue to create complexity in the interpretation of typing results.

Cellular crossreactivity. Implications for solid organ transplantation matching

This study evaluates the cellular crossreactivity among DR11, DR13, and DR8 molecules using TLC reagents generated in reciprocal priming combinations where the responder and stimulator cells express different microvariants of DR11. The large majority of T lymphocyte clones (TLC) derived from such stimulation detect not only the product of the specific DR11 allele expressed by the stimulator but also detect subsets of DR molecules that span serologic specificities. Thus, TLC generated in response to DR(alpha,beta1*1102) detect DR(alpha,beta1*1103) and products of specific DR13, DR8, DR2 and DR4 alleles. Whereas, TLC generated in response to DR(alpha,beta1*1104) detect DR(alpha,beta1*1101), DR(alpha,beta1*1103), and products encoded by specific DR8 and DR2 but not DR13 or DR4 alleles. Since DR11 microvariants cannot be identified serologically, this type of mismatch certainly occurs frequently between DR11 serologically matched donors and recipients. Particularly affected are populations, such as the African American population, that exhibit extensive HLA diversity and exhibit different frequencies of HLA alleles compared with those of the majority of serologically matched cadaveric donors. Rapid methods of DNA-based HLA typing now makes it feasible to utilize this methodology for allele level identificaiton of recipient and donor alleles. Based on the strength of the alloproliferative responses and on the recognition patterns of the TLC reported here, we suggest that retransplant patients might benefit by excluding subsequent donors expressing DR molecules that in vitro demonstrate strong cellular crossreactivity with DR molecules expressed by the previous donor(s) as well as those DR molecules shared with the previous donor(s). Since such a matching schema has the potential to improve retransplant allograft survival, particularly in patients from minority population groups, it should be evaluated clinically.

Increased esterification of cholesterol and transfer of cholesteryl ester to apo B-containing lipoproteins in Type 2 diabetes: relationship to serum lipoproteins A-I and A-II

This study examines the activity of two key enzymes of reverse cholesterol transport, cholesterol ester transfer protein (CETP) and lecithin:cholesterol acyl transferase (LCAT) in 21 patients with non-insulin dependent diabetes mellitus (NIDDM) and 21 control subjects. Serum CETP was assessed by measuring plasma-mediated cholesteryl ester transfer between pooled exogenous lipoprotein with endogenous LCAT inhibited--an estimate of CETP mass. CETP activity was determined as cholesteryl ester transfer in the presence of the patients' lipoproteins and LCAT (endogenous assay). LCAT activity was determined in the same assay. There was no significant difference in CETP mass between the diabetic and non-diabetic subjects and there was no correlation between CETP mass and LCAT activity. Using the endogenous lipoprotein assay, CETP was elevated in serum from diabetic patients compared to control subjects (10.05 +/- 1.89 vs. 5.50 +/- 0.53 nmol/ml/h P < 0.05). LCAT was also increased in the diabetic patients (53.63 +/- 4.70 vs. 41.22 +/- 3.40 nmol/ml/h P < 0.05). Serum free cholesterol from diabetic and control subjects correlated with CETP activity measured using endogenous lipoprotein assay (r = 0.77, P < 0.001 and r = 0.82, P < 0.001), and also with LCAT activity (r = 0.76, P < 0.01 and r = 0.79, P < 0.01). There was a negative correlation between CETP activity with the endogenous lipoprotein assay and serum high density lipoprotein (HDL) cholesterol in the diabetic patients (r = -0.38, P < 0.01), but not in control subjects. In a subgroup of 10 control subjects, there was a positive correlation between LCAT activity and apolipoprotein (apo) A-I (r = 0.49, P < 0.05) and apo A-II (r = 0.51, P < 0.05) and also between CETP activity (endogenous assay) and apo A-I (r = 0.87, P = 0.001) and apo A-II (r = 0.63, P < 0.05). No relationship was observed between CETP activity and apo A-I or apo A-II in the diabetic subjects. Thus, serum CETP mass was normal in Type 2 diabetes but CETP activity (endogenous assay) was increased and was related to free cholesterol levels and LCAT activity in both diabetic and non-diabetic subjects.

Molecular and serological characterization of HLA-B71 in association with different class I haplotypes or in different ethnic groups

The HLA-B70 antigen is among the most common antigens present in African Americans; however, monospecific serologic reagents defining B70 and its subtypes, B71 and B72, are rare. We have recently reported the molecular characterization of a B71 allele (B*1510) from an African American individual carrying the haplotype HLA-A30, Cw3, B71(w6). In order to better define the degree of polymorphism of molecules carrying the B71 serological specificity in the human population, we have used serology, cDNA sequencing, and PCR/SSOP typing to characterize B71 alleles from additional individuals from different ethnic populations and carrying different class I haplotypes. All carried either B*1510 or B*1518 alleles. Other HLA-B alleles isolated from these individuals (B*5001, B*4901, B*3501, B*3701) were identical to previously reported sequences except for a novel B41 allele (B*4102) identified in one Hispanic individual. This allele has concurrently been identified by Rufer and colleagues in Caucasian individuals. The B*4102 allele differs from B*4101 at codons 95 (Leu/Trp) and 97 (Ser/Arg). In addition, the B*4102 allele differs from B*4101 by two silent substitutions at codons 94 (ACC/ACT) and 99 (TAC/TAT). Since the polymorphic sequence present in B*4102 is also present in other HLA-B alleles (e.g.., B*2707, B*4002, B*0702), it may represent a gene conversion cassette. The allelic diversity at the class I loci and the scarcity of monospecific alloantisera support the importance of the application of molecular based methods to identify HLA class I alleles in matching unrelated donor/recipient pairs for bone marrow transplantation.

T cell responses to the paramyxovirus simian virus 5: studies in multiple sclerosis and normal populations

A recent study suggested that a significant portion of the oligoclonal IgG found in multiple sclerosis (MS) cerebrospinal fluid may be removed by absorption with simian virus 5 (SV5). We have now evaluated the proliferative responses to SV5 generated by peripheral blood mononuclear cells from normal adult subjects and from patients with MS. Positive responses were detected in 16 of 16 subjects in each group. The magnitude of the response was not significantly different in the two groups. There was no correlation between the level of response and the presence or absence of HLA-DR2. No cross-reactivity with SV5 was demonstrated by panels of human T cell clones directed against myelin basic protein or measles virus. More than 60% of normal individuals between 10 and 16 years of age also generated positive T cell proliferative responses to SV5, while fewer than 25% of subjects below the age of 6 generated positive responses. Intermediate percentages of positive responders were detected in subjects 6-9 years of age. We conclude that the adult human population has been widely exposed to this organism and that initial exposure generally occurs in the early to middle school-age years.

Cerebral perfusion pressure: management protocol and clinical results

Early results using cerebral perfusion pressure (CPP) management techniques in persons with traumatic brain injury indicate that treatment directed at CPP is superior to traditional techniques focused on intracranial pressure (ICP) management. The authors have continued to refine management techniques directed at CPP maintenance. One hundred fifty-eight patients with Glasgow Coma Scale (GCS) scores of 7 or lower were managed using vascular volume expansion, cerebrospinal fluid drainage via ventriculostomy, systemic vasopressors (phenylephrine or norepinephrine), and mannitol to maintain a minimum CPP of at least 70 mm Hg. Detailed outcomes and follow-up data bases were maintained. Barbiturates, hyperventilation, and hypothermia were not used. Cerebral perfusion pressure averaged 83 +/- 14 mm Hg; ICP averaged 27 +/- 12 mm Hg; and mean systemic arterial blood pressure averaged 109 +/- 14 mm Hg. Cerebrospinal fluid drainage averaged 100 +/- 98 cc per day. Intake (6040 +/- 4150 cc per day) was carefully titrated to output (5460 +/- 4000 cc per day); mannitol averaged 188 +/- 247 g per day. Approximately 40% of these patients required vasopressor support. Patients requiring vasopressor support had lower GCS scores than those not requiring vasopressors (4.7 +/- 1.3 vs. 5.4 +/- 1.2, respectively). Patients with vasopressor support required larger amounts of mannitol, and their admission ICP was 28.7 +/- 20.7 versus 17.5 +/- 8.6 mm Hg for the nonvasopressor group. Although the death rate in the former group was higher, the outcome quality of the survivors was the same (Glasgow Outcome Scale scores 4.3 +/- 0.9 vs. 4.5 +/- 0.7). Surgical mass lesion patients had outcomes equal to those of the closed head-injury group. Mortality ranged from 52% of patients with a GCS score of 3 to 12% of those with a GCS score of 7; overall mortality was 29% across GCS categories. Favorable outcomes ranged from 35% of patients with a GCS score of 3 to 75% of those with a GCS score of 7. Only 2% of the patients in the series remained vegatative and if patients survived, the likelihood of their having a favorable recovery was approximately 80%. These results are significantly better than other reported series across GCS categories in comparisons of death rates, survival versus dead or vegetative, or favorable versus nonfavorable outcome classifications (Mantel-Haenszel chi 2, p < 0.001). Better management could have improved outcome in as many as 35% to 50% of the deaths.

Effects of mist acidity and ambient ozone removal on montane red spruce

Recent forest studies have established that high-elevation (> 900 m) populations of red spruce (Picea rubens Sarg.) in the northeastern USA are declining. Because it has been suggested that changes in air quality are responsible for the decline, we examined the effects of acidic mists and ozone on several biochemical and growth parameters in mature montane red spruce. We used branch-sized environmental chambers to introduce mists of controlled composition and exclude ambient clouds and ozone from individual branches within a tree. Mists consisting of distilled water increased the end-of-season pigment concentration and shoot length of enclosed branches relative to ambient or artificial mists. Needle and twig weights and starch concentrations were not significantly altered by the acidic mist treatments. Removal of ambient ozone had no apparent effect on the variables measured.

The nurse practitioner's role in a pediatric sleep clinic

The assessment and management of pediatric sleep disorders frequently involves a multidisciplinary approach that includes many practice opportunities for the pediatric nurse practitioner. This article discusses the approach used in The Children's Sleep Clinic at The Children's Hospital of Alabama, where nurse practitioner involvement begins with telephone triage and progresses to collaborative management. Recommendations for future research include investigation of pediatric sleep disorders and research involving the outcome of nurse practitioner case management.

Microvariation creates significant functional differences in the DR3 molecules

Two DR3 molecules differ by four amino acids whose side chains point into the DR antigen-binding groove. To begin to assess the role of microvariation on DR3 function, DRB1*0302 residues were replaced with DRB1*0301 residues at beta-chain positions 26, 47, 86, and 47 plus 86. Murine fibroblast cell lines expressing DR(alpha, beta 1*0301), DR(alpha, beta 1*0302), and the four mutant 0302 molecules were examined for alloproliferative DR(alpha, beta 1*0302)-specific TLC stimulation and peptide binding. Changing position 26 had the most profound effect on T-cell recognition (seven of nine TLCs did not respond). Two TLCs did not respond to the mutant 0302V86 molecule and four TLCs that did respond to this mutant lost responsiveness when positions 47 and 86 were mutated together. These data suggest that each of these variant residues, including position 47, influence T-cell recognition. Surprisingly, none of the mutations had an effect on the absolute binding of HA 307-319 (DR[alpha, beta 1*0302] specific) and HSP 3-13 (DR[alpha, beta 1*0301] specific); however, the mutant 0302 molecules changed at position 86 (glycine to valine) consistently bound HA 307-319 at significantly higher levels than DR(alpha, beta 1*0302). These data for position 86 are in contrast to other DR molecules and indicate that peptide contact residues for a specific DR molecule cannot be predicted based on binding results obtained with other DR molecules. These data suggest that each of these variant groove residues, although not accessible to the TCR, contribute to the significant functional differences between the DR3 microvariants through subtle influences on the DR3-peptide complex.

Effect of elevated temperatures on carbon dioxide exchange in Picea rubens

We examined some of the physiological reasons that may underlie past and expected future migrations of red spruce (Picea rubens Sarg.) by evaluating the effects of high temperatures on photosynthesis and respiration of trees growing on Whiteface Mountain, NY. At temperatures of 35-40 degrees C, the trees exhibited a zero or negative carbon balance. Higher temperatures resulted in cellular disorganization and death. Temperatures around 30 degrees C resulted in reduced CO(2) uptake, a condition that could decrease future reproductive output and competitive stature. We conclude that thermal intolerance explains, at least in part, the absence of red spruce at low elevations and latitudes where temperatures of >/= 30 degrees C occur. We suggest that the thermosensitivity of this species is important with respect to global climate trends and migration patterns.

Detection of malignancy-associated metabolites in the sera of cancer patients by electron capture gas chromatography

A reliable test that detects malignancy and indicates response to therapy is needed. Frequency-pulsed electron-capture gas-liquid chromatography (FPEC-GLC), a selective analytical technique that is sensitive to 15 fmol quantities of metabolites, was used to analyse derivatised acidic chloroform extracts of sera from patients with biopsy-proven cancer, non-malignant infectious and non-infectious disease, and healthy controls. Two peaks designated P1 and P10, not found in serum from healthy controls (n = 7) or patients with non-malignant disease (n = 85), were detected in biopsy-proven samples (n = 52) from cancer patients. P1 and P10 were later shown by chemical and mass spectral studies to be carboxylic acids. When one or both of these peaks were detected in the sera of non-treated patients they were always associated with malignancy. In patients responding to therapy, a reduction or disappearance of these peaks was observed. Further, it was noted that P10 persisted or increased in sera of patients with progressive cancer not responding to therapy. We conclude that this test has potential in diagnosis and for following the response of the disease to therapy.

Survey of family medicine residents evaluation methods

BACKGROUND

Family medicine residents are evaluated to ensure mastery of required practice skills by a variety of methods. The objective of this paper is to report the results of a sample of the 394 accredited family practice residencies to determine the evaluation methods used and their corresponding value to the program.

METHODS

Questionnaires were sent to program directors and chief residents of all accredited family practice residency programs.

RESULTS

Responses were received from the director or chief resident of 354 (90%) programs. For 195 programs, both the chief resident and program director responded. The five most common evaluation methods were the American Board of Family Practice In-Training Examination, formative review sessions, resident chart review, list of procedures performed, and family medicine conference attendance. Of 195 programs for which directors and chief residents both responded, directors and chief residents differed significantly in the reported number of evaluation methods but not in perceived value of those evaluation methods. Neither geographic region, community or university affiliation, class size, nor age of program was associated with differences in numbers of evaluation methods or perceived value of those methods.

CONCLUSION

Many highly rated resident evaluation methods are being utilized by less than one-third of the programs. The most prevalent forms of evaluation appear to be auditing medical practices and behaviors.