A scoping review of public building accessibility

BACKGROUND

The built environment needs to be designed so that all people can participate in the activities they want and need to do. Yet, accessibility is difficult to put into practice, and accessibility issues tend to be overlooked in the building and planning processes.

OBJECTIVES

The aim of this scoping review was to summarize the research front in the area of accessibility to public buildings. Specific aims were to identify knowledge gaps, to identify access activities in relation to environmental features and to link to predominant activities in terms of the International Classification of Functioning, Disability and Health (ICF).

METHODS

A literature search was performed in PubMed, PsycINFO, Inspec, Embase and Cochrane databases. Articles in English based on original empirical studies investigating accessibility of public buildings for adults aged ≥18 years with functional limitations were considered.

RESULTS

Of the 40 articles included, ten involved study participants, while 30 only examined buildings using instruments to assess accessibility. In addition, the psychometric properties were only tested for a few of them. All articles concerned mobility and several visual limitations, while few addressed cognitive or hearing limitations. Ten main access activities were identified, from using parking/drop-off area to exiting building.

CONCLUSIONS

By using the ICF and theoretically relating the accessibility problems to activities, the results revealed that there are large knowledge gaps about accessibility to public buildings for older people and people with functional limitations and that there is a need for more methodological considerations in this area of research.

Host-specific competitiveness to form nodules in Rhizobium leguminosarum symbiovar viciae

Fabeae legumes such as pea and faba bean form symbiotic nodules with a large diversity of soil Rhizobium leguminosarum symbiovar viciae (Rlv) bacteria. However, bacteria competitive to form root nodules (CFN) are generally not the most efficient to fix dinitrogen, resulting in a decrease in legume crop yields. Here, we investigate differential selection by host plants on the diversity of Rlv. A large collection of Rlv was collected by nodule trapping with pea and faba bean from soils at five European sites. Representative genomes were sequenced. In parallel, diversity and abundance of Rlv were estimated directly in these soils using metabarcoding. The CFN of isolates was measured with both legume hosts. Pea/faba bean CFN were associated to Rlv genomic regions. Variations of bacterial pea and/or faba bean CFN explained the differential abundance of Rlv genotypes in pea and faba bean nodules. No evidence was found for genetic association between CFN and variations in the core genome, but variations in specific regions of the nod locus, as well as in other plasmid loci, were associated with differences in CFN. These findings shed light on the genetic control of CFN in Rlv and emphasise the importance of host plants in controlling Rhizobium diversity.

Effects of applying a standardized assessment and evaluation protocol in housing adaptation implementation - results from a quasi-experimental study

BACKGROUND

Standardized, research-based strategies to guide the implementation and evaluate the effects of housing adaptations (HA) on client outcomes are rare. We hypothesized that, compared to ordinary practice, a standardized assessment and evaluation protocol for HA implementation would better maintain or improve client outcomes over 1 year.

METHOD

Using a cluster design, South Swedish municipalities were recruited to an intervention or control group. Data on activities of daily living, usability of the home, health related quality of life, and participation frequency and satisfaction were collected at home visits 1 month before the HA (baseline; T1), and at 3 (T2), 6 (T3) and 12 (T4) months after. In the intervention group (n = 112) data were collected according to a standardized protocol while in the control group (n = 129) ordinary routines were applied. Changes from baseline to subsequent time points were categorized as no deterioration (i.e. improvement or no change) or deterioration, for each outcome item separately. Differences in "no deterioration" between the groups were assessed using logistic regression.

RESULTS

Little effect of using the standardized protocol was detected. For activities of daily living, statistically significant differences between the groups were found for toileting (T1-T4; OR 3.14), dressing (T1-T4; OR2.89) and cooking (T1-T3 and T1-T4; OR 3.14). For usability of the home differences were found in personal hygiene (T1-T2; OR 2.32) using a wheelchair (T1-T2 and T1-T3; OR 9.50), picking up the mail (T1-T3; OR 4.06), and in participation, helping others (T1-T3 and T1-T4; OR 2.33 and 3.36).

CONCLUSION

The applied standardized protocol for HA implementation did not show any convincing effect, possibly due to the complexity of the intervention itself, and the implementation process. A process evaluation might generate in-depth knowledge about the reasons behind the findings.

TRIAL REGISTRATION

ClinicalTrials.gov . NCT01960582.

Water use efficiency and shoot biomass production under water limitation is negatively correlated to the discrimination against 13C in the C3 grasses Dactylis glomerata, Festuca arundinacea and Phalaris arundinacea

Climate change impacts rainfall patterns which may lead to drought stress in rain-fed agricultural systems. Crops with higher drought tolerance are required on marginal land with low precipitation or on soils with low water retention used for biomass production. It is essential to obtain plant breeding tools, which can identify genotypes with improved drought tolerance and water use efficiency (WUE). In C₃ plant species, the variation in discrimination against ¹³C (Δ¹³C) during photosynthesis has been shown to be a potential indicator for WUE, where discrimination against ¹³C and WUE were negatively correlated. The aim of this study was to determine the variation in the discrimination against ¹³C between species and cultivars of three perennial C₃ grasses (Dactylis glomerata (cocksfoot), Festuca arundinacea (tall fescue) and Phalaris arundinacea (reed canary grass)) and test the relationships between discrimination against ¹³C, season-long water use WUE_B, shoot and root biomass production in plants grown under well-watered and water-limited conditions. The grasses were grown in the greenhouse and exposed to two irrigation regimes, which corresponded to 25% and 60% water holding capacity, respectively. We found negative relationships between discrimination against ¹³C and WUE_B and between discrimination against ¹³C and shoot biomass production, under both the well-watered and water-limited growth conditions (p < 0.001). Discrimination against ¹³C decreased in response to water limitation (p < 0.001). We found interspecific differences in the discrimination against ¹³C, WUE_B, and shoot biomass production, where the cocksfoot cultivars showed lowest and the reed canary grass cultivars highest values of discrimination against ¹³C. Cocksfoot cultivars also showed highest WUE_B, shoot biomass production and potential tolerance to water limitation. We conclude that discrimination against ¹³C appears to be a useful indicator, when selecting C₃ grass crops for biomass production under drought conditions.

Daily life consequences, cognitive impairment, and fatigue after transient ischemic attack

OBJECTIVES

Studies suggest that fatigue and cognitive impairment may be present after transient ischemic attack (TIA), but little is known about consequences in daily life. The main aim was to longitudinally explore the presence of fatigue, cognitive impairment, and consequences in daily life including communication after clinically diagnosed TIA at 1 and 9 months after the event.

MATERIAL AND METHODS

A consecutive sample of 46 patients (23 women, 69 ± 12.3 years) was assessed at discharge from hospital and at 1 and 9 months after TIA regarding cognition, mental fatigue, tiredness, and activities of daily life. This served as basis for an interview concerning experienced changes related to the TIA.

RESULTS

Problems in daily life with probable association with the TIA were experienced by 37% (n = 45) of participants 9 months after the TIA event. Cognitive impairment was present in 40% (n = 44) after 1 month and 30% (n = 23) after 9 months. Mental fatigue was experienced by 26% (n = 42) after 1 month and 17% (n = 39) after 9 months. Communication problems were reported and increased from 7 to 14 participants between the two time points.

CONCLUSIONS

A third of the TIA patients experienced problems in performance of complex activities in daily life and often communication problems within the first 9 months. Cognitive impairment and mental fatigue could be factors influencing performance in daily life and at work, but this needs to be verified in a larger sample. The risk of activity limitations indicates need for multiprofessional support and systematic routines for TIA follow-up.

Enhancing Yields in Organic Crop Production by Eco-Functional Intensification

<p>Organic agriculture faces challenges to enhance food production per unit area and simultaneously reduce the environmental and climate impacts, e.g. nitrate leaching per unit area and greenhouse gas (GHG) emissions per unit mass produced. Eco-functional intensification is suggested as a means to reach these objectives. Eco-functional intensification involves activating more knowledge and refocusing the importance of ecosystem services in agriculture. Organic farmers manage agrobiodiversity by crop rotation (diversification in time). However, sole cropping (SC) of genetically identical plants in organic agriculture may limit resource use efficiency and yield per unit area. Intercropping (IC) of annual grain species, cultivar mixes, perennial grains, or forage species and forestry and annual crops (agroforestry) are examples of spatial crop diversification. Intercropping is based on eco-functional intensification and may enhance production by complementarity in resource use in time and space. Intercropping is based on the ecological principles of competition, facilitation and complementarity, which often increases the efficiency in acquisition and use of resources such as light, water and nutrients compared to sole crops, especially in low-input systems. Here we show that IC of cereals and grain legumes in European arable organic farming systems is an efficient tool for enhancing total grain yields compared to their respective sole crops. Simultaneously, we display how intercropping of cereals and legumes can be used as an efficient tool for weed management and to enhance product quality (i.e. cereal grain protein concentration). We discuss how intercropping contributes to efficient use of soil N sources and minimizes losses of N by nitrate leaching via <em>Ecological Precision Farming</em>. It is concluded that intercropping has a strong potential to increase yield and hereby reduce global climate impacts such as GHG kg^-1 grain. Finally, we discuss likely barriers and lock-in effects for increased use of intercropping in organic farming and suggest a roadmap for innovation and implementation of IC strategies in organic agriculture.</p>

Discrimination against 15N among recombinant inbred lines of Phaseolus vulgaris L. contrasting in phosphorus use efficiency for nitrogen fixation

Although isotopic discrimination processes during nitrogen (N) transformations influence the outcome of (15)N based quantification of N2 fixation in legumes, little attention has been given to the effects of genotypic variability and environmental constraints such as phosphorus (P) deficiency, on discrimination against (15)N during N2 fixation. In this study, six Phaseolus vulgaris recombinant inbred lines (RILs), i.e. RILs 115, 104, 34 (P deficiency tolerant) and 147, 83, 70 (P deficiency sensitive), were inoculated with Rhizobium tropici CIAT899, and hydroaeroponically grown with P-sufficient (250 μmol P plant(-1) week(-1)) versus P-deficient (75 μmol P plant(-1) week(-1)) supply. Two harvests were done at 15 (before nodule functioning) and 42 (flowering stage) days after transplanting. Nodulation, plant biomass, P and N contents, and the ratios of (15)N over total N content ((15)N/Nt) for shoots, roots and nodules were determined. The results showed lower (15)N/Nt in shoots than in roots, both being much lower than in nodules. P deficiency caused a larger decrease in (15)N/Nt in shoots (-0.18%) than in nodules (-0.11%) for all of the genotypes, and the decrease in shoots was greatest for RILs 34 (-0.33%) and 104 (-0.25%). Nodule (15)N/Nt was significantly related to both the quantity of N2 fixed (R(2)=0.96***) and the P content of nodules (R(2)=0.66*). We conclude that the discrimination against (15)N in the legume N2-fixing symbiosis of common bean with R. tropici CIAT899 is affected by P nutrition and plant genotype, and that the (15)N/Nt in nodules may be used to screen for genotypic variation in P use efficiency for N2 fixation.

Toxicity screening of produced water extracts in a zebrafish embryo assay

Produced water is the largest effluent discharge from oil and gas/condensate production facilities in the North Sea. There is concern that contaminants originating from the reservoir and chemicals used in the production process may affect marine organisms. Developmental toxicity of extractable organic compounds in produced water effluents from oil and gas/condensate production platforms in the Norwegian sector of the North Sea was assessed in a temporal and spatial manner using zebrafish (Danio rerio) embryos. Large-scale solid-phase extraction (SPE) and on-column fractionation of water-soluble fraction (WSF) and an oil/particulate fraction was used in a rapid screening bioassay for embryotoxicity. Exposure to produced water extracts increased rate of mortality and reduced pigmentation and heart rate, as well as delaying time to hatch. The oil/particulate fraction was 10-fold less toxic than WSF, indicating that toxicity was predominantly produced by moderately polar and bioavailable compounds. Large spatial and temporal variation in produced water toxicity was observed, displaying considerable variability in the reservoir, oil well, and effluent composition over time. The noted toxicity did not correlate well with either reported produced water composition or parameters such as total hydrocarbons, thus challenging chemical measurements as a reliable source of information for predicting complex effects. Although embryotoxicity was observed following exposure to the extracts, dilution and transformation of produced water in the recipient are expected to rapidly reduce the concentrations of compounds in the effluents to levels below the thresholds of observed effects.

Oral bacterial community dynamics in paediatric patients with malignancies in relation to chemotherapy-related oral mucositis: a prospective study

The role of oral bacteria in the development of chemotherapy-related oral mucositis has not been fully elucidated. This study aimed to investigate oral bacterial community diversity and dynamics in paediatric patients with malignancies in relation to the occurrence of oral mucositis. Patients with malignancies (n = 37) and reference individuals without known systemic disorders (n = 38) were recruited. For patients, oral bacterial samples were taken from mucosal surfaces both at the time of malignancy diagnosis and during chemotherapy. If oral mucositis occurred, samples were taken from the surface of the mucositis lesions. Oral mucosal bacterial samples were also taken from reference individuals. All samples were assessed using a 16S ribosomal RNA gene 454 pyrosequencing method. A lower microbial diversity (p < 0.01) and a higher intersubject variability (p < 0.001) were found in patients as compared with reference individuals. At the time of malignancy diagnosis (i.e. before chemotherapy) patients that later developed mucositis showed a higher microbial diversity (p < 0.05) and a higher intersubject variability (p < 0.001) compared with those without mucositis. The change of bacterial composition during chemotherapy was more pronounced in patients who later developed mucositis than those without mucositis (p < 0.01). In conclusion, we found a higher microbial diversity at the time of malignancy diagnosis in patients who later develop oral mucositis and that these patients had a more significant modification of the bacterial community by chemotherapy before the occurrence of mucositis. These findings may possibly be of clinical importance in developing better strategies for personalized preventive management.

The decline of fertility: Innovation or adjustment process

Abstract In Western society the process of fertility decline is often regarded as an innovation process. The assumptions behind this approach seem rather questionable, and the diffusion lags or gradients of limited importance. Both Swedish and other European data are used as illustrations. It is suggested that the decline be treated within the wider sociological perspective of a time-consuming adjustment or change process, not necessarily starting from a position of completely uncontrolled fertility within marriage. The situation in to-day's high fertility populations is briefly discussed against this background.

A topological paradigm for hippocampal spatial map formation using persistent homology

An animal's ability to navigate through space rests on its ability to create a mental map of its environment. The hippocampus is the brain region centrally responsible for such maps, and it has been assumed to encode geometric information (distances, angles). Given, however, that hippocampal output consists of patterns of spiking across many neurons, and downstream regions must be able to translate those patterns into accurate information about an animal's spatial environment, we hypothesized that 1) the temporal pattern of neuronal firing, particularly co-firing, is key to decoding spatial information, and 2) since co-firing implies spatial overlap of place fields, a map encoded by co-firing will be based on connectivity and adjacency, i.e., it will be a topological map. Here we test this topological hypothesis with a simple model of hippocampal activity, varying three parameters (firing rate, place field size, and number of neurons) in computer simulations of rat trajectories in three topologically and geometrically distinct test environments. Using a computational algorithm based on recently developed tools from Persistent Homology theory in the field of algebraic topology, we find that the patterns of neuronal co-firing can, in fact, convey topological information about the environment in a biologically realistic length of time. Furthermore, our simulations reveal a "learning region" that highlights the interplay between the parameters in combining to produce hippocampal states that are more or less adept at map formation. For example, within the learning region a lower number of neurons firing can be compensated by adjustments in firing rate or place field size, but beyond a certain point map formation begins to fail. We propose that this learning region provides a coherent theoretical lens through which to view conditions that impair spatial learning by altering place cell firing rates or spatial specificity.

A phase I/II study of neoadjuvant chemotherapy with Pemetrexed (Alimta) in rectal cancer

AIM

The aim was to assess the feasibility of preoperative chemotherapy and possible tumour response using Pemetrexed (Alimta) in rectal cancer.

METHOD

The study was a prospective, non-randomized, single-centre phase I/II feasibility trial. 37 patients with resectable rectal cancer were recruited and given three 3-week cycles of preoperative Pemetrexed therapy. Tumour size and stage were assessed by MRI scans before and after chemotherapy. Treatment tolerability and response such as changes in tumour size and symptoms were assessed.

RESULTS

All patients completed the chemotherapy. Whilst mild side effects were frequent (grade 1, 34/37), the risk of severe effects was limited (grade 3 or 4, 4/37). Overall, there was a significant reduction in tumour size (p < 0.001). By RECIST criteria, one patient had tumour progression, 23/36 had stable disease and 12 patients had a response of up to 65%. There was also a significant decrease in the number of pre-treatment symptoms (p < 0.018) including reduction of bleeding and diarrhoea/constipation.

CONCLUSION

Preoperative (Neoadjuvant) treatment with Pemetrexed was feasible in studied patients. Serious side effects were limited and a radiological tumour response or stable disease was seen in a majority of patients.

Phosphorous deficiency decreases nitrogenase activity but increases proton efflux in N2-fixing Medicago truncatula

Effects of Sinorhizobium strain and P nutrition on N(2)-dependent growth, nitrogenase activity and proton efflux by nodulated roots were investigated in the model legume Medicago truncatula cultivar Jemalong grown in hydroaeroponic culture in symbioses with Sinorhizobium meliloti strains 102F51 and 2011. Sinorhizobium strain had strong effects on nitrogenase activity and N(2)-dependent growth, with S. meliloti 102F51 being the more efficient strain. Apparent and total nitrogenase activities, measured by hydrogen evolution in air and argon, respectively, were drastically reduced in plants supplied with 5 μmol P plant(-1) week(-1) as compared with 15 μmol P plant(-1) week(-1). There was a net proton efflux as soon as 2 weeks after inoculation and, in contrast to the effect of P nutrition on nitrogenase activity, P deficiency increased total and specific proton effluxes, irrespective of Sinorhizobium strain.

Hematopoietic stem cell transplantation in severe congenital neutropenia

BACKGROUND

Severe congenital neutropenia (SCN) is an immunodeficiency characterized by disturbed myelopoiesis and an absolute neutrophil count (ANC) <0.5 × 10(9)/L. SCN is also a premalignant condition; a significant proportion of patients develop myelodysplastic syndrome or leukemia (MDS/L). Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative treatment for SCN.

PROCEDURE

Since 2004, eight HSCT have been performed in seven patients at our center. The indications were transformation to MDS/L (n = 2), granulocyte colony-stimulating factor receptor (CSF3R) mutation(s) (n = 2), granulocyte colony-stimulating factor (G-CSF) resistance (n = 2), and at the patient's own request (n = 1).

RESULTS

The mean age at transplantation was 13 years (2.8-28 years) (mean follow-up 32 months, range 21-60). Three patients harbored ELANE mutations, three HAX1 mutations, and in one patient no causative mutation was identified. Two of the ELANE mutations were novel mutations. Three patients initially received myeloablative conditioning and four had reduced intensity conditioning (RIC). Three grafts were from HLA-identical siblings, three from matched unrelated donors and two were cord blood units. Engraftment occurred in all patients. Two of seven (29%) patients died; both had MDS/L and both were among the three that underwent myeloablative conditioning. One patient has chronic GVHD 2 years post-transplant.

CONCLUSIONS

The role of HSCT should be explored further in patients with SCN. In particular, the influence of the conditioning regime needs to be evaluated in a larger cohort of patients.

An ecotoxicological approach for hazard identification of energy ash

Within the EU, ash should be classified by its inherent hazardous effects under criterion H-14 (ecotoxic) in the Directive on waste (2008/98/EC). Today, however, there are no harmonized quantitative criterions for such a classification, but it is stated that biological test systems can be used. In this study seven ash materials were leached and characterized, both biologically and chemically. The objectives were to evaluate if (a) clear concentration-response relationships could be achieved for the selected toxicity tests (bacteria, algae, crustacean and fish), (b) some test(s) are generally more sensitive and (c) the toxic responses were consistent with the chemical analyzes. Interestingly, our results indicate that high concentrations of non-hazardous components (Ca, K) influenced the toxicity of almost all ash eluates, whereas hazardous components (e.g. Zn, Pb) only influenced the toxicity of the eluates ranked as most hazardous. If considering both hazardous and non-hazardous substances, the observed toxic responses were relatively consistent with the chemical analyzes. Our results further showed that the (sub)chronic tests were much more sensitive than the acute tests. However, the use of extrapolation factors to compensate for using the less sensitive acute tests will likely lead to either over- or underestimations of toxicity. Our recommendation is therefore that classification of waste according to H-14 should be based on (sub)chronic test data. Finally, given that treatment of the eluates prior to toxicity testing has a major significance on the concentration and speciation of released substances, further studies are needed in order to propose a relevant testing scheme.

Feasibility of treatment of resectable rectal cancer with neoadjuvant treatment with pemetrexed

e15121

Background: Multimodality strategies of chemo- and radiotherapy (RT) in the neoadjuvant setting of resectable rectal cancer are a challenge to optimize surgery outcome. Pemetrexed (P) has shown efficacy in colorectal cancer. This phase II trial evaluated its feasibility as neo-adjuvant monotherapy for patients (pts) with resectable rectal cancer. Methods: Between June’ 06 and January’ 08, 37 pts with a histologically proven diagnosis of operable rectal adenocarcinoma were enrolled. P was dosed at 500 mg/m2 every 3 weeks, during 3 cycles with standard co-medication (vitamin B12, folic acid, and dexamethasone) on an outpatient base. If RT was given, minimum interval between start of RT and last dose of P was 2 weeks, preferably 5 consecutive days of RT occurred from day 17 to day 21 in cycle 3 or after completion of cycle 3. The feasibility hypothesis was that at least 85% of pts would be able to receive the chemotherapy as planned. Secondary endpoints were evaluation of qualitative and quantitative toxicities including rate of postoperative complications, proportion of pts with sphincter saving surgery, proportion of pts with complete tumor resection rate and pathological response rate. Results: All patients were able to receive 3 cycles of chemotherapy. 33 patients (89.2%, CI: 74.6 to 97) completed their planned dosage in time. The reason for delay was inadequate vitamin supply for 1 pt and 3 pts due to other reasons. No dose reduction or study-drug related SAE was seen. The only grade 3 and 4 toxicities (neutropenia) occurred in 7 pts (18.9%). 28 pts received RT following chemotherapy. All pts underwent R0 resection. One pathological proven complete response was evaluated. 12 out of 13 planned pts had a rectum amputation. All others received sphincter saving surgery. Postoperative complications occurred in 54% of the pts. All events were considered related to study procedure (operation) and not to study drug. Conclusions: This explorative study suggests that the administration of 3 cycles of pemetrexed is feasible and well tolerated within a multimodality treatment strategy.

[Table: see text]

Central nervous system involvement in severe congenital neutropenia: neurological and neuropsychological abnormalities associated with specific HAX1 mutations

OBJECTIVES

Homozygous mutations in the HAX1 gene were recently identified in severe congenital neutropenia patients belonging to the original Kostmann family in northern Sweden. Our observations suggested that these patients also develop neurological and neuropsychological symptoms.

METHODS

Detailed clinical studies and mutation analyses were performed in the surviving patients belonging to the Kostmann kindred and in two patients not related to this family, along with studies of HAX1 splice variant expression in normal human tissues.

RESULTS

Five of six Kostmann family patients and one other patient from northern Sweden harboured homozygous HAX1 mutations (568C-->T, Q190X) and one carried a heterozygous ELA2 gene mutation. One Swedish patient of Kurdish extraction carried alternative homozygous HAX1 mutations (131G-->A, W44X). All the three patients with Q190X mutations who were alive and available for evaluation developed neurological disease with decreased cognitive function, and three of four patients who reached 10 years developed epilepsy. In contrast, the patients with the ELA2 and W44X HAX1 mutations, respectively, showed no obvious neurological abnormalities. Moreover, two alternative HAX1 splice variants were identified in normal human tissues, including the brain. Both transcripts contained exon 5, harbouring the Q190X mutation, whereas the 5' end of exon 2 containing the W44X mutation was spliced out from the second transcript.

CONCLUSIONS

We describe neurological and neuropsychological abnormalities for the first time in Kostmann disease patients. These central nervous system symptoms appear to be associated with specific HAX1 mutations.

The natural history of gross motor development in children with cerebral palsy aged 1 to 15 years

The aim of this study was to explore motor development in children with cerebral palsy (CP) using developmental curves for CP, subtypes, and the five severity levels of the Gross Motor Function Classification System (GMFCS). The Gross Motor Function Measure (GMFM) and the GMFCS were applied to 317 children (145 females, 172 males) with CP, aged between 1 and 15 years. The CP type distribution was spastic diplegia in 157 (49%), spastic hemiplegia in 101 (33%), spastic tetraplegia in 11 (3%), dyskinesia in 38 (12%), and ataxia in 10 (3%). Forty-five physiotherapists were trained in the GMFM and intra- and interrater reliability was tested. The GMFM was measured prospectively every 6 months up to the age of 4 years and once a year thereafter. Developmental curves were constructed for 258 children with spastic CP. About three-quarters of the children at GMFCS Level I reached 90% of the maximum GMFM score at 5 years of age. The performance peaked at 7 years of age. Children at GMFCS Level II reached 90% at a median age of 5 years, which was also the upper limit, reached by about three-quarters at 7 years of age. The majority of children at GMFCS Level III reached 80% of the GMFM by 7 years of age and most of the children at GMFCS Level IV reached 30% at 5 years and remained there. The median score for children at GMFCS Level V was 20%. The intra- and interrater reliability for the GMFM 88 among physiotherapists were Spearman's rank correlation coefficient 0.91 and 0.99 respectively. There were 931 measurements with a median of 2 (1-11) per child. The gross motor development was demonstrated for the five GMFCS levels in children with spastic CP. These kind of curves may be useful for monitoring and predicting motor development, for planning treatment, and for evaluating outcome after interventions.

Stage migration in colorectal cancer related to improved lymph node assessment

AIM

The aim of the study was to evaluate the clinical impact of improved cooperation between the treating surgeons and pathologists in a high volume surgical unit. As a measure we used the staging process with special focus on lymph node assessment.

FINDINGS

Comparing two periods 5 years apart, we found a significant increase in the number of nodes examined and also an increase in the number of metastasis-positive nodes. Concurrently, we observed a trend in stage migration from stage I/II towards stage III, whilst stage IV remained unchanged. This was one factor that contributed to an increase in the number of patients treated with adjuvant chemotherapy. We also found that the number of assessed nodes had an impact on survival in stage II. The major change in practise was the implementation of a multidisciplinary team conference and the associated possibility of reciprocal feedback.

CONCLUSION

Lymph node status has a key role in cancer staging and in the selection of further therapy. The quality and the standard of the assessment can be improved through multidisciplinary cooperation and it has an impact on the clinical decisions and can affect long-term survival. A correct node status should be mandatory in the evaluation of prognostic factors.

Delayed start of adjuvant 5-FU/leucovorin based chemotherapy in colon cancer is safe up to 12 weeks postoperatively

4056

Background: Postoperatively adjuvant chemotherapy with 5-Fluorouracil modulated by leucovorin alone or in combination with Oxaliplatin significantly reduce the risk of recurrence and prolong the disease free survival (DFS) in patients with a radical resection for colonic carcinoma. In all reported studies the chemotherapy has started within 6–8 weeks after surgery. Due to complications following surgery it is not always possible to start adjuvant chemotherapy within this time frame. The aim of the present retrospective study was to investigate the effect on risk of recurrence and effect on DFS in patients treated in clinical routine practice in one single institution. Methods: Between 1992 and 2004, 234 patients (121 females, 113 males) with a median age of 66 years (range 25–84 years) received weekly bolus 5-FU/leucovorin postoperatively for 6 months. 211 (90.2%) had a Dukes′ C tumour and 23 (9.8%) high risk Dukes′ B tumour. The median time from surgery and start of adjuvant therapy was 71 days (range 30–190 days). Patients were divided in three groups, where chemotherapy started within 6 weeks, 8 weeks and 12 weeks after surgery and the frequency of recurrent disease and DFS were compared between these groups. Results: Medium follow-up was 35.6 months (range 2,7- 140.6 months). Five patients (21.7%) with Dukes′ B tumours and 76 patients (36.0%) with Dukes′ C tumours recurred during the follow-up period. There were no differences in the proportion of Dukes′ B and C tumours between the three groups. Recurrent disease was more frequent but no significant difference in patients that started within 6 weeks (52.6%) compared with patients that started within 8 weeks (45.5%) and 12 weeks (35.5%). In all three groups there was a tendency to better DFS in patients that started later than 6 or 8 weeks, but these differences were not significant. Conclusions: Starting adjuvant 5-Fluorouracil/leucovorin alone later than 6–8 weeks do not negatively effect the risk of recurrent disease or DFS.

No significant financial relationships to disclose.

Large genotypic variation but small variation in N2fixation among rhizobia nodulating red clover in soils of northern Scandinavia

AIMS

To analyse the symbiotic variations within indigenous populations of rhizobia nodulating red clover (Trifolium pratense L.) in soils of northern Norway and Sweden at different times of the growing season.

METHODS AND RESULTS

A total of 431 nodule isolates sampled under field conditions in summer and autumn, were characterized genetically by targeting both chromosomal and symbiotic genes. The Enterobacterial Repetitive Intergenic Consensus polymerase chain reaction (PCR) fingerprinting of chromosomal DNA revealed considerable variation within the isolated populations that was more influenced by geographical origin than sampling time. Analysis of PCR amplified nodEF gene on the symbiotic plasmid by restriction fragment length polymorphism revealed a high proportion of nod types common to the two studied sites. The symbiotic efficiency of the isolates, representing both dominating and rare nodEF genotypes, showed high N(2) fixation rates in symbiosis with the host plant in a greenhouse experiment using the (15)N isotope dilution method.

CONCLUSIONS

Effective N(2)-fixing strains of Rhizobium leguminosarum bv. trifolii nodulating red clover are common and genetically diverse in these northern Scandinavia soils.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides information on the variability, stability and dynamics of resident populations of rhizobia nodulating red clover in Scandinavian soils which has practical implications for applying biological nitrogen fixation in subarctic plant production.

Assignment of the gene locus for severe congenital neutropenia to chromosome 1q22 in the original Kostmann family from Northern Sweden

Autosomal recessive severe congenital neutropenia (SCN) or Kostmann syndrome is characterised by reduced neutrophil counts and subsequent recurrent bacterial infections. The disease was originally described in a large consanguineous pedigree from Northern Sweden. A genome-wide autozygosity scan was initiated on samples from four individuals in the original pedigree using high density single nucleotide polymorphism (SNP) genotyping arrays in order to map the disease locus. Thirty candidate regions were identified and the ascertainment of samples from two additional patients confirmed a single haplotype with significant association to the disorder (p<0.01) on chromosome 1q22. One affected individual from the original Kostmann pedigree was confirmed as a phenocopy. The minimal haplotype shared by affected individuals spans a candidate region of 1.2 Mb, containing several potential candidate genes.

Worse survival for TP53 (p53)-mutated breast cancer patients receiving adjuvant CMF

BACKGROUND

TP53 has been described as a prognostic factor in many malignancies, including breast cancer. Whether it also might be a predictive factor with reference to chemo- and endocrine therapy is more controversial.

PATIENTS AND METHODS

We investigated relapse-free (RFS), breast cancer-corrected (BCCS) and overall survival (OS) related to TP53 status in node-positive breast cancer patients that had received polychemotherapy [cyclophosphamide, methotrexate, 5-fluorouracil (CMF)] and/or endocrine therapy (tamoxifen). Sequence analyses of the whole TP53 coding region was performed in 376 patients operated on for primary breast cancer with axillary lymph node metastases between 1984 and 1989 (median follow-up time 84 months).

RESULTS

TP53 mutations were found in 105 patients (28%). We found 90 (82%) of the 110 mutations in the more frequently analysed exons 5-8, while the other 20 (18%) were located in exons 3-4 and 9-10, respectively. Univariate analyses showed TP53 to be a significant prognostic factor with regard to RFS, BCCS and OS in patients who received adjuvant CMF.

CONCLUSIONS

TP53 mutations might induce resistance to certain modalities of breast cancer therapy. Sequence-determined TP53 mutation was of negative prognostic value in the total patient population and in the CMF treated patients.

Visual attention in young adulthood after cardiopulmonary resuscitation at birth or being born small for gestational age

The Posner cue-target paradigm for the study of shifts in visual attention was used to assess focused attention and shifts in attention in 43 young adults, 19 to 28 years of age, who had been in need of cardiopulmonary resuscitation at birth because of perinatal asphyxia (n=31) or who were born small for gestational age (n= 12). Their performances were compared to that of 18 control subjects. The subjects resuscitated at birth were divided into two groups, mild and moderate, according to neurological symptoms during the neonatal course. An expected significant main effect by block of trials and conditions was found, with general decrease in reaction times from Blocks 1 to 5 and with slowest reaction times to an invalid cue and fastest to a valid one. No group differences were statistically significant, but the moderate asphyxia and the groups small for gestational age had longer average reaction times on all test conditions than control subjects, implying that those who showed the most severe pre- or neonatal complications also were most affected in attentional functions.

Synthetic musk toxicity to early life stages of zebrafish (Danio rerio)

Synthetic musk substances have been found in a number of environmental samples. Some of these chemicals have been detected in concentrations above 1 microg/L in water, which raises concern about possible effects on aquatic life. The toxicity of four synthetic musks, 4-tert-butyl-2,6-dimethyl-3,5-dinitrophenylethanone (musk ketone), 1-tert-butyl-3,5-dimethyl-2,4,6-trinitrobenzene (musk xylene), 1-(5,6,7,8-tetrahydro-3,5,5,6,8,8-hexamethyl-2-naphthalenyl)ethanone (AHTN, tonalide) and 1,3,4,6,7,8-hexahydro-4,6,6,7,8,8-hexamethylcyclopenta-[g]-2-benzopyrane (HHCB, galaxolide), were studied in zebrafish by the use of two different early life-stage methods. In the first method, specific developmental characteristics during the first 48 hours were studied. In the second method, hatching and survival times were studied on eggs and larvae. The results on heart rate in the first test gave the following LOECs: musk ketone 10 microg/L, musk xylene and AHTN 33 microg/L, and HHCB showed no effect up to 1000 microg/L. In the study of survival time, LOEC for musk ketone was 100 microg/L, for musk xylene 33 microg/L, and AHTN gave no effect on survival time up to 100 microg/L. The LOECs for musk ketone, musk xylene, and AHTN in this study are in the range of what has been measured in sewage effluents and recipients, and consequently these substances may have adverse impact on wild fish.

Large variability in performance IQ associated with postnatal morbidity, and reduced verbal IQ among school-aged children born preterm

AIM

To assess cognitive ability in a population-based group of prematurely born school-aged children and to relate these findings to postnatal morbidity.

METHOD

The study group consisted of a cohort of 51 children born preterm, 43 (26 boys, 17 girls) of whom were available for psychological evaluation At evaluation, their median age was 10 y (range 8-11 y). They were all born between 1988 and 1991, with gestational age less than 29 wk (median 27, range 24-28). Their median birthweight was 1060g (range 450-1450). The Wechsler Intelligence Scale for Children (WISC-III) was used, and the test results were compared with those of a standardized, age-matched, normative group of children.

RESULTS

Thirteen children (30%) performed below average [intelligence quotient (IQ) < 80] for Full Scale IQ (FSIQ). Thirty-six children had a Verbal IQ (VIQ) below the mean value of 100 [84%, 95% confidence interval 73-95%], p < 0.0001. The Performance IQ (PIQ) was within the expected range of a normal population, although a large variability was observed. Discrepancies between VIQ and PIQ of more than 15 IQ units were found in 42% of the children. High postnatal morbidity (days with assisted ventilation, number of blood transfusions) and low birthweight standard deviation scores (SDS) were associated with lower PIQ than VIQ, while low postnatal morbidity and high birthweight were associated with higher PIQ than VIQ.

CONCLUSION

This cohort of preterm children had reduced overall verbal capacity independent of morbidity, and a large variability in performance capacity that was associated with postnatal morbidity. The findings suggest that there are different mechanisms influencing the outcome of verbal and performance capacity in preterm children.

Follow-up into young adulthood after cardiopulmonary resuscitation in term and near-term newborn infants. I. Educational achievements and social adjustment

AIM

Long-term sequelae after perinatal asphyxia have generally been assessed at preschool or school age. The aim of the study was to confirm the hypothesis that there could be impairment of cognitive and memory functions that does not become apparent until education and adult life impose special demands.

METHODS

Seventy-one term or near-term newborns in need of cardiopulmonary resuscitation because of presumed perinatal asphyxia were investigated with evoked EEG potentials during the first week of life and were investigated at a follow-up clinic until 18 mo of age. At that time 12 subjects showed signs of neuro-developmental impairment. The remaining 59 were considered healthy. They were contacted at young adult age and given a questionnaire containing questions about type of education, need for extra support at school, present activity/employment, living conditions, spare-time activities and self-estimation of health.

RESULTS

Thirty-five control subjects were approached at the same time. From the group that was resuscitated at birth, 53 questionnaires were returned and 30 from the control group. Although the resuscitated subjects had signs of both encephalopathy and pathologic evoked responses during their neonatal period, the questionnaire revealed that they had coped with school equally as well as their peers, that the rate of entering university studies was the same and that living conditions were similar between the groups.

CONCLUSION

These individuals who were resuscitated at birth and who demonstrated various degrees of neonatal encephalopathy suffered either brain injury that could be diagnosed at 18 mo of age or managed as well as their non-resuscitated peers in terms of educational achievement and social adjustment at young adult age.

Follow-up into young adulthood after cardiopulmonary resuscitation in term and near-term newborn infants. II. Neuropsychological consequences

AIM

Brain injury after neonatal cardiopulmonary resuscitation in the term baby is often described as an all-or-nothing phenomenon, but little is known about possible late cognitive consequences. The aim of this study was therefore to investigate whether children who needed cardiopulmonary resuscitation because of presumed mild and moderate intra-partum asphyxia with no evidence of neurological impairments at 18 mo of age may display neuropsychological impairments later in life.

METHODS

A long-term follow-up of young adults was carried out. A blinded comprehensive neuropsychological assessment of the main aspects of cognitive functions was made. The subjects who were resuscitated were divided into two groups according to the clinical course: 20 cases with mild asphyxia and 11 cases with moderate asphyxia, all followed prospectively and compared with 18 healthy controls. The 31 subjects were born at term or near-term and selected randomly from 59 infants born in 1969-1978 at Sahlgren's Hospital, Göteborg. All infants with early neurological impairments were excluded.

RESULTS

No major differences could be established between the two clinical groups and normal controls in any aspects of cognitive function or intelligence. All the groups performed within the normal range in all tests. A tendency toward minor deficits in verbal ability in the mild group compared to the controls was found. Only one subject had a clear, defined memory deficit.

CONCLUSIONS

Infants who underwent cardiopulmonary resuscitatation at birth without neurological deficits at 18 mo of age did not show any cognitive deficits or neuropsychological impairments in adulthood even though inferior performance on some verbal subtests was observed compared to the control group.

Age effects in dichotic listening to consonant-vowel syllables: interactions with attention

A relatively large sample of individuals (N = 240) ranging from 7 to 70 years were studied with the dichotic listening (DL) technique as a measure of language lateralization. Two questions were asked: (a) Is there a developmental effect for the right-ear advantage (REA) with age? (b) Is there a developmental effect for attentional modulation of the REA? The participants were all right-handed, healthy individuals tested in Sweden and Norway. The stimuli were dichotic presentations of consonant-vowel (CV) syllable pairs. There were 3 different attentional conditions: nonforced (NF) attention, with no specific instructions about focusing of attention; forced-right (FR) attention, with instructions to focus attention on the right-ear stimulus; and forced-left (FL) attention, with instructions to focus attention on the left-ear stimulus. The results showed a REA in all age groups, except for the 9-year-olds, in the NF condition. In the FR condition, all age groups showed a REA. The youngest age groups did not, however, increase the REA to the same degree as the older age groups, as indicated by the significant age x ear interaction. In the FL condition, all age groups, with the exception of the youngest groups, showed a left-ear advantage (LEA). It is concluded that the REA effect in DL is subject to developmental effects and that attentional effects on laterality also develop with increasing age.

The effect of desmopressin on short-term memory in children with primary nocturnal enuresis

PURPOSE

The use of desmopressin in patients with primary nocturnal enuresis is based on the hypothesis of a nocturnal lack of endogenous arginine vasopressin. However, in addition to the kidney, other targets of desmopressin are known. Therefore, we examined whether the administration of desmopressin influences central nervous function in children with primary nocturnal enuresis.

MATERIALS AND METHODS

Our prospective, randomized, double-blind, placebo controlled cross-over study was performed on 40 children with nocturnal enuresis. Patients were randomly assigned to receive either 20 microg. desmopressin intranasally or 0.9% saline solution. Each group comprised 19 and 21 to children, respectively. After 2 weeks the groups were switched. The children were tested for short-term memory and reaction time to both treatments. Statistical analysis was done using the Wilcoxon matched pairs test.

RESULTS

Median patient age was 8.0 years (range 6 to 13). During desmopressin treatment children in both groups had a significant decrease of wet nights (5.3 to 3.2 per week). In contrast to reaction time, short-term memory was significantly different between both groups (p <0.05).

CONCLUSIONS

Our results demonstrate an increase in short-term memory after desmopressin treatment in children with nocturnal enuresis. This finding indicates the central nervous system as a target involved in the pathogenesis of nocturnal enuresis as well as the therapeutic benefit of desmopressin treatment.

Effects of 5-fluorouracil on mitogen-induced costimulatory capacity of accessory cells from rat oral mucosa and dental pulp

The present study was designed to investigate the effect of the antimetabolite 5-fluorouracil (5-FU) on the capacity of the oral epithelium and the dental pulp to induce a mitogen-driven T-cell proliferation. Inbred Lewis rats were given 6 i.v. injections of 5-FU (30 mg/kg or 50 mg/kg) over a period of 8 days. Suspensions of oral epithelial and dental pulpal cells were prepared. The costimulatory capacity of the accessory cells from treated animals was monitored by their ability to induce a mitogen (ConA)-mediated proliferation of T cells isolated from regional lymph nodes of untreated animals. Accessory epithelial cells from rats treated with the high dose of 5-FU, but not the low dose, induced a decreased T-cell proliferation compared to controls. Accessory pulpal cells from rats, treated with 30 mg/kg or 50 mg/kg of 5-FU, induced a lower T-cell proliferation. When MHC class II molecule depleted T-cell suspensions from lymph nodes of 5-FU-injected animals were incubated with ConA, a significant proliferative response was observed. This finding correlated with an increase of MHC class II molecule expressing cells detected after incubation, although no such cells were observed immediately following the initial purification step of T cells. This finding demonstrates that the accessory cells could partly restore their expression of MHC class II molecules during incubation. The results of the study suggest that the function of immunocompetent cells of the oral mucosa and dental pulp is influenced by treatment with 5-FU and that the function of accessory cells of the pulp is affected more than the function of accessory cells derived from the oral mucosa.

Infantile genetic agranulocytosis, morbus Kostmann: presentation of six cases from the original "Kostmann family" and a review

In 1956 Rolf Kostmann reported on six children with severe neutropenia associated with a block in myelopoiesis at the promyelocyte/myelocyte stage and an autosomal recessive inheritance. He named the new syndrome infantile genetic agranulocytosis. Today it is known as Kostmann's syndrome or severe congenital neutropenia. In 1975 an additional 10 cases from northern Sweden were published. This article reports on the only long-term survivor from the 1975 report plus another five patients born after 1975 who belong to the original "Kostmann family". Treatment and survival have changed dramatically since Kostmann's first publication. In the pre-antibiotic era, Kostmann's syndrome was inevitably fatal during the first year of life.

CONCLUSION

Since the introduction of recombinant human granulocyte colony-stimulating factor (G-CSF) about 10 y ago, most patients now enjoy a normal life span and a greatly improved quality of life. Although the threat of death has disappeared, patients still have problems with infections, especially chronic gingivitis and periodontitis. In other groups of severe neutropenia, not related to the original "Kostmann family", an increased incidence of myeloid leukaemia has been observed. However, in this small cohort none of the children on chronic G-CSF therapy have developed malignancies.

Neuropsychological long-term outcome of rolandic EEG traits

BACKGROUND

Long-term outcome of rolandic epilepsy (RE) is associated with a diversity of neuropsychological deficits in childhood, although RE is historically considered as a benign epileptic disorder. Dyslexia and other developmental disorders are associated with rolandic EEG traits.

AIM

To investigate if there is an association between the manifestation of a specific EEG trait of RE and dyslexia. If the EEG traits are causing dyslexia, the cognitive deficits are supposed to be normalised after the EEG trait have resolved.

METHOD

Thirty adolescents and young adults, who had previously received a diagnosis of dyslexia by standard criteria, were included. Fifteen probands (mean age = 15.9) with dyslexia and rolandic EEG traits were compared with 15 age- and sex-matched controls (mean age = 16.0) with normal EEG.

RESULTS

There were no statistical differences between the groups according to intelligence (Verbal IQ, Performance IQ and Arithmetical IQ) or spelling ability. However, there was a significant difference between the groups in reading ability of non-related words with the group without RE performing better than the group with RE (p < 0.01). Attentional shifts in dichotic listening with forced or directed attention are generally found in 50-60% in normative samples. However, the present date suggest an impaired attentional shift in dichotic listening test for both groups. Only one third was able to modulate their ear-preference. There were no group differences.

CONCLUSION

In general, both dyslectic groups did not show significant neuropsychological deficits as compared to standard controls. However, there were more reading errors and a tendency to attention impairments in the group with rolandic EEG trait as compared to the dyslectic group with normal EEG. Possible pathogenic factors are discussed.

A pharmacokinetic study of 5-FU/leucovorin and alpha-interferon in advanced cancer

The present study was designed to study 5-FU pharmacokinetics after interferon. Weekly bolus 5-FU (500 mg/m2), immediately followed by leucovorin (60 mg/m2) was given in 14 weekly cycles to 55 gastrointestinal and breast cancer patients. Interferon-alpha was given on days 2, 4 and 6, starting from cycle 2 at a dose of 0.5 million units (MU) and stepwise increased to 12 MU in cycles 12 and 13. Five patients could not tolerate the treatment even at the lowest dose of interferon and 22 patients were unavailable for the pharmacokinetic analysis because of dose reductions of 5-FU. Five patients were able to follow the protocol to 12 MU, whereas most patients were unable to continue owing to toxicity. 5-FU pharmacokinetics was analysed every second cycle. Peak concentration and AUC were increased after 12 MU of interferon, but no other significant influence of interferon on pharmacokinetic parameters of 5-FU was observed.

Evaluation of solid-phase microextraction for the study of protein binding in human plasma samples

Solid-phase microextraction (SPME) in combination with capillary gas chromatography and a nitrogen-phosphorous detector is used to study protein binding in human plasma samples. Local anesthetics of the amide-type (ropivacaine, bupivacaine, mepivacaine, prilocaine, and lidocaine) are used as model compounds in this evaluation. Carbowax/divinylbenzene (CW/DVB), polyacrylate, and polydimethylsiloxane fibers are tested. Sampling on CW/DVB fibers give the highest recovery in plasma samples compared with other fibers. Ultrafiltrate spiked with each of the substances is used for the construction of calibration curves. The protein binding is investigated at four different total concentrations from 0.5 to 15.0 microM. The degree of protein binding increases when the solute concentration decreases. Protein binding of the five solutes is investigated at four pH levels (6.4, 7.4, 8.4, and 9.4). It is found that protein binding increased with increasing pH. The influence of temperature variation (from 32 degrees C to 40 degrees C) on protein binding is also investigated. The protein binding decreases when the temperature increases. The methodology is validated and good correlation and precision are obtained. Back-calculated quality control samples give accuracy within 20% of theoretical values for all five substances. This study shows that SPME as a sample-preparation method gives the same protein binding for the studied local anesthetics as that achieved using earlier presented methods.

The impact of musk ketone on reproduction in zebrafish (Danio rerio)

Nitro musks are a group of nitrated benzenes mainly used by the fragrance industry as a substitute for natural musk. Two of the most common nitro musks, musk xylene and musk ketone, have been detected in water, fish, human adipose tissue, as well as in human breast milk. In this study, female zebrafish were dietary-exposed to musk ketone, prior to spawning with unexposed males. The fish were exposed for 8 weeks at two different dose levels. Accumulation of the compound in the fish as well as reproductive success were studied. Exposed females had reduced body weight and length, as well as reduced liver- and gonad somatic index. The results from the reproduction study showed a dose-dependent reduction in fecundity. Early life-stage mortality was increased and the median survival time was reduced. In addition, an embryo/larvae toxicity test was performed, using newly fertilized zebrafish eggs from unexposed parental fish. Eggs were exposed to a series of different concentrations of musk ketone via the surrounding water. A NOEC value of 10 micrograms/l and a LOEC value of 33 micrograms/l was determined. Conclusively, the present study clearly shows that musk ketone negatively affects reproduction and early life-stage survival in zebrafish.

Encountering violence and aggression in mental health nursing: a phenomenological study of tacit caring knowledge

Violence is a growing psychosocial problem in the health care working environment. Literature shows that nurses are physically assaulted, threatened, and verbally abused more often than other professionals. However, some nurses are able to relate to clients in a way that produces positive resolution. This study explored the phenomenon of positive encounters with aggressive and violent clients. Guided by a phenomenological method, data were analyzed within a lifeworld perspective. The essential meaning of the phenomenon of caregivers' experiences of encountering violent clients is described as an "embodied moment," which is explicated by seven themes of meaning, "respecting one's fear and respecting the client," "touch," "dialogue," "situated knowledge," "stability," "mutual regard," and "pliability." The authors discuss the meaning of the outcome and propose both theory and praxis-oriented activities toward decreasing aggression and violence in health care.

Efficacy of pamidronate in breast cancer with bone metastases: a randomized, double-blind placebo-controlled multicenter study

PURPOSE

To evaluate the efficacy of pamidronate 60 mg i.v. q 4 weeks in women with advanced breast cancer with skeletal metastases.

PATIENTS AND METHODS

404 woman with skeletal metastases from breast cancer in Sweden and Norway were included in a randomized, placebo-controlled, multicenter study. Except for the study medication, other palliative treatment was chosen at the discretion of the physician. Skeletal related events, i.e. increased pain, treatment of hypercalcemia, pathologic fractures of long bones or pelvis, paralyses due to vertebral compression, palliative radiotherapy for skeletal metastases, surgery on bone and change of antitumor therapy were recorded every third month as well as a self-estimated pain-score using visual Analog Scales and analgesic consumption.

RESULTS

There was a significantly increased time to progression of pain (p < 0.01), to hypercalcemic events (p < 0.05) as well as for the cumulative number of skeletal related events (p < 0.01) in favor for the pamidronate group. No statistically significant reduction of pathologic fractures of long bones or pelvis, or pareses due to vertebral compression occurred. No statistically significant differences were found for the need of radiotherapy and surgery on bone. The pamidronate group faired better regarding performance status (p < 0.05). There was a statistically not significant lower consumption of opioid analgesics in the pamidronate group (p = 0.14).

CONCLUSION

Pamidronate 60 mg i.v. q 4 weeks reduces skeletal events and improves the quality of life in women with bone metastases from breast cancer.