Analysis of risk factors for the development of bronchiolitis obliterans syndrome

Chronic rejection after lung transplantation, manifesting as bronchiolitis obliterans syndrome (BOS), has become the dominant challenge to long-term patient and graft survival. In order to elucidate risk factors for development of BOS we utilized the 1995 revision of the working formulation for the classification of lung allograft rejection (), and devised a quantitative method to retrospectively study lung transplant biopsies from all patients who survived at least 90 d. All transbronchial biopsies were regraded 0 to 4 for acute perivascular rejection and lymphocytic bronchitis/bronchiolitis (LBB), and the grades were totaled over a period of time to give two scores, respectively, for each patient. Also examined were timing of acute rejection and LBB episodes and decreased immunosuppression defined as two or more cyclosporine A levels < 200 ng/ml. Sixty-six patients with BOS and 68 with no BOS (NBOS) satisfied our criteria for inclusion in the study. Demographics including age, sex, and primary diagnoses were similar. The mean perivascular score for BOS was 6.2 over a mean follow-up of 822 d (range, 113 to 2,146) compared with 3.2 for NBOS over 550 d (range, 97 to 1,734) mean follow-up. Airway scores were 5.3 and 1.7, respectively, for the same follow-up periods. There was no correlation between length of follow-up and rejection or LBB scores, although mean length of follow-up for the two groups was significantly different. Late acute rejection and LBB were significantly associated with BOS as was decreased immunosuppression. In addition to perivascular rejection, LBB, late acute rejection, and decreased immunosuppression are significant risk factors for the development of BOS. Analysis of the current data leads us to believe that LBB, in the absence of infection, is in fact a manifestation of acute rejection, with similar implications for graft function as acute perivascular rejection.

Parental influence and obesity prevention in pre-schoolers: a systematic review of interventions

Obesity is difficult to reverse in older children and adults and calls have been made to implement obesity prevention strategies during the formative pre-school years. Childhood obesity experts suggest that prevention of overweight in the pre-school years should focus on parents, because parental beliefs, attitudes, perceptions and behaviours appear to contribute to children's development of excessive weight gain. While evidence suggests that parental variables may be instrumental in the development of obesity, there has been no systematic evaluation of whether intervening to change such variables will positively influence the development of excess adiposity during the pre-school years. This paper is a conceptual and methodological review of the literature on the parental variables targeted in interventions designed to modify risk factors for obesity by promoting healthy eating and/or physical activity and/or reducing sedentary behaviours in families of children aged 2-6 years. There were significant methodological limitations of existing studies and the scientific study of this area is in its infancy. However, the results suggest that the modification of parental variables known to be associated with obesity-promoting behaviours in pre-school children may show promise as an obesity prevention strategy; further research is needed.

Children's fractures: a population based study

OBJECTIVE

To measure the incidence of childhood fractures in a defined population.

SETTING

Accident and emergency (A&E) departments covering the Swansea and Neath Port Talbot areas of South Wales in 1996.

METHODS

Linkage of data from A&E departments with population data to produce fracture incidence rates by anatomical site and cause in children aged 0-14 years.

RESULTS

During 1996, 2463 new fractures occurred in 2399 residents yielding a fracture rate of 36.1/1000 children. Fractures were more common in boys than girls and increased with age in both groups. Sports and leisure activities accounted for 36% of fractures, assaults for 3.5%, and road traffic accidents 1.4%. Fractures of the radius/ulna were most frequent (36%).

CONCLUSIONS

The fracture rate in South Wales children is twice the rate reported in previous studies. Further research is required to elucidate the reasons behind this high rate. Many fractures could be prevented by the use of safer surfaces in school playgrounds, and wrist protection in in-line skaters and possibly in soccer players.

Preventing excessive gestational weight gain: a systematic review of interventions

Women who gain excessive weight during pregnancy have an increased risk of post-partum obesity, and retention of gestational weight gain (GWG) post birth is a strong predictor of maternal overweight/obesity a decade or more after the birth. The aim of the current review was to identify, and evaluate the effect of key variables designed to modify risk factors for excessive weight gain in pregnant women that have been targeted in interventions over the last decade. The 10 interventions focused primarily on behavioural changes in relation to physical activity and/or to eating. While six studies reported significantly less weight gain in the intervention women, only three showed that women in the intervention were significantly more likely to gain within recommended guidelines. GWG was reduced in only normal-weight, low-income, obese, or overweight women, or not at all. Only one study reported a reduction in GWG in women with body mass indexes spanning the normal, overweight and obese categories. The findings were inconsistent in relation to what factors need to be targeted in intervention programmes to reduce GWG. Consideration of psychological factors relevant to pregnancy, in addition to behavioural changes in relation to eating and physical activity, is suggested for future intervention studies.

Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review

Hantavirus cardiopulmonary syndrome (HCPS) is a rare but frequently lethal acute zoonotic viral infection in rural North America. The rapidity of progression from febrile prodrome to cardiogenic shock and noncardiogenic pulmonary edema requiring intensive care creates high diagnostic urgency and a need for a rapid screening tool. In this retrospective cohort study, 2 pathologists scored blinded peripheral blood smears from 52 patients with HCPS and 128 seronegative patients referred for diagnosis of suspected hantavirus infection. During the prodromal phase, thrombocytopenia was the only consistent abnormality and could be used to indicate hantavirus serologic testing. After the onset of pulmonary edema detected radiographically, the presence of 4 of 5 findings (thrombocytopenia, myelocytosis, hemoconcentration, lack of significant toxic granulation in neutrophils, and more than 10% of lymphocytes with immunoblastic morphologic features) has a sensitivity for HCPS of 96% and a specificity of 99% and missed no patients with HCPS who required intensive care. While each abnormality is commonly seen, the combination of at least 4 of these CBC count data and peripheral blood smear findings can guide early treatment and patient transport decisions until rapid, specific, serologic testing becomes widely available.

Predictors of success in electroejaculation of spinal cord injured men

Rectal probe electroejaculation was attempted in 48 spinal cord injury men and greater than 10 million sperm were obtained in 71%. Patient age and interval since injury had no effect on outcome. The best performance was seen in thoracic paraplegics and in those using intermittent catheterization for bladder management. Indwelling urethral catheters and high pressure reflex voiding had a negative impact on electroejaculation results.

Sexual and emotional variables influencing sexual response to erotica

This study was designed to evaluate the relative contribution of attention and emotional responses to the sexual response to erotica. Self reported levels of sexual arousal, attention, and emotional responses were measured after 20 men and 20 women viewed a series of erotic film segments. Men and women reported greater sexual arousal to erotica when they became absorbed in the activities portrayed in the film and when they experienced the erotic encounters as appetitive, than when they were distracted and perceived the encounters as aversive. Subjective sexual arousal also correlated positively with the degree to which subjects experienced entertainment and curiousity to the erotic film segments, but negatively with boredom. The level of sexual arousal reported by subjects did not correlate significantly with trait measures of absorption (as indexed by the Tellegen Absorption Scale) and vividness of imagery (as assessed by the Betts Questionnaire upon Mental Imagery). The multidimensional nature of the sexual response was demonstrated by the fact that the magnitude of subjective sexual arousal was predicted by the separate groupings of state assessed attentional and emotional variables, trait indexed absorption and appetitive feelings, and demographic information. These findings applied to both men and women, with the exception that men experienced greater sexual arousal than women, and women reported more disgust to the stimulus materials. Future directions for studying the basis for differences in sexual arousal between men and women are outlined, with an emphasis on a psychophysiological exploration of these phenomena.

Nifedipine pretreatment for autonomic dysreflexia during electroejaculation

Ten spinal-cord-injured males who exhibited autonomic dysreflexia during electroejaculation were given sublingual calcium channel blocker nifedipine pretreatment to prevent this complication. Nifedipine was successful in decreasing peak systolic, diastolic, and mean blood pressures during the procedure. The use of nifedipine resulted in fewer aborted trials and allowed higher energy delivery during the procedure.

Electroejaculation following retroperitoneal lymphadenectomy

Transrectal electroejaculation was performed in 24 men who were anejaculatory from retroperitoneal lymphadenectomy. Of the men 23 had undergone retroperitoneal lymphadenectomy because of testis cancer. Seminal emission was achieved in all patients. In 21 patients greater than 10 x 10(6) progressively motile sperm with normal morphology were obtained. The average sperm count and motilities obtained were 289 x 10(6) and 18%, respectively, for the antegrade fractions, and 2,051 x 10(6) and 13%, respectively, for the retrograde fractions. Of the 3 azoospermic failures 2 had chemotherapy-induced testicular damage and 1 had carcinoma in situ of the remaining testis. A total of 19 couples underwent artificial insemination with electroejaculated sperm. There were 7 pregnancies achieved in 74 insemination cycles (36.8% of the couples conceived for a 9% cycle fecundity). Routine semen parameters could not predict which couples would be successful in achieving pregnancy. There were 2 first trimester spontaneous abortions. Five healthy children have been born. Electroejaculation is an excellent treatment for anejaculation that persists following retroperitoneal lymph node dissection.

Phase I/II study of 72-hour infusional paclitaxel and doxorubicin with granulocyte colony-stimulating factor in patients with metastatic breast cancer

PURPOSE

We conducted a phase I/II trial of concurrently administered 72-hour infusional paclitaxel and doxorubicin in combination with granulocyte colony-stimulating factor (G-CSF) in patients with previously untreated metastatic breast cancer and bidimensionally measurable disease.

PATIENTS AND METHODS

We defined the maximum-tolerated dose (MTD) of concurrent paclitaxel and doxorubicin administration and then studied potential pharmacokinetic interactions between the two drugs. Forty-two patients who had not received prior chemotherapy for metastatic breast cancer received 296 total cycles of paclitaxel and doxorubicin with G-CSF.

RESULTS

The MTD was determined to be paclitaxel 180 mg/m2 and doxorubicin 60 mg/m2 each by 72-hour infusion with G-CSF. Diarrhea was the dose-limiting toxicity (DLT) of this combination, with three of three patients developing abdominal computed tomographic (CT) scan evidence of typhlitis (cecal thickening) at the dose level above the MTD. All patients developed grade 4 neutropenia (absolute neutrophil count [ANC] < 500 microL), generally less than 5 days in duration. This combination was generally safely administered at dose levels at or below the MTD. The overall response rate was 72% (28 of 39 patients; 95% confidence interval [CI], 55% to 85%), with 8% complete responses (CRs) (three of 39; 95% CI, 2% to 21%) and a median response duration of 9 months. The median overall survival time for all patients is 23 months, with a median follow-up duration of 28 months. Pharmacokinetic studies showed that administration of paclitaxel and doxorubicin together by 72-hour infusion did not affect the steady-state concentrations of either drug.

CONCLUSION

Concurrent 72-hour infusional paclitaxel and doxorubicin can be administered safely, but is associated with significant toxicity. The overall response rate of this combination in untreated metastatic breast cancer patients is similar to that achieved with other doxorubicin-based combination regimens. The modest complete response rate achieved suggests that this schedule of paclitaxel and doxorubicin administration does not produce significant additive or synergistic cytotoxicity against breast cancer.

Body shape perception and its disturbance in anorexia nervosa

The perception of body shape was studied in 15 female patients with anorexia nervosa and 15 age matched controls. A lens was used which could be manipulated to cause a horizontal distortion of an image projected onto a video monitor. The patients showed a greater tendency to over- and under-estimate their present body shape than did the controls. Further, the patients' desired body shape was significantly thinner than that of controls, as was their estimation of what constitutes a normal body shape. These findings are discussed in relation to the literature and it is suggested that they may have important implications for treatment.

Functional characteristics of sperm obtained by electroejaculation

Sperm obtained by electroejaculation in 32 anejaculatory men were examined for functional characteristics. Raw specimens showed high sperm counts but motility averaged only 11%. Average viability was 10% for antegrade and 5% for retrograde fractions. Bovine cervical mucus penetration was normal (30 mm. or more in 30 minutes) in only 24% of the electroejaculation samples but it was normal in all of the donor samples tested. Processed sperm motility averaged 30% with 71% forward progression. At 20 hours patient samples retained 46% of the original motility, while donor controls retained 81%. In the hamster egg penetration assay patient sperm penetrated 14% of the oocytes while donor sperm penetrated 40%. Therefore, we identified 4 characteristics of sperm obtained by electroejaculation: 1) low viability, 2) poor survival after overnight incubation, 3) moderately impaired cervical mucus penetration and 4) moderately poor fertilizing capability as measured by the hamster egg penetration assay. Poor sperm survival and impaired function may explain the low pregnancy rates from insemination with electroejaculated sperm.

A parent-based intervention to promote healthy eating and active behaviours in pre-school children: evaluation of the MEND 2-4 randomized controlled trial

BACKGROUND

There is a paucity of studies evaluating targeted obesity prevention interventions in pre-school children.

OBJECTIVES

We conducted a randomized controlled trial to evaluate the efficacy of a parent-based obesity prevention intervention for pre-schoolers - MEND (Mind, Exercise, Nutrition … Do It!) 2-4 on child diet, eating habits, physical activity/sedentary behaviours, and body mass index (BMI).

METHODS

Parent-child dyads attended 10 weekly 90-min workshops relating to nutrition, physical activity and behaviours, including guided active play and healthy snack time. Assessments were conducted at baseline, immediately post-intervention, and 6 and 12 months post-intervention; child intake of vegetables, fruit, beverages, processed snack foods, fussiness, satiety responsiveness, physical activity, sedentary behaviour and neophobia were assessed via parent proxy report. Parent and child height and weight were measured.

RESULTS

Two hundred one parent-child dyads were randomized to intervention (n = 104) and control (n = 97). Baseline mean child age was 2.7 (standard deviation [SD] 0.6) years, and child BMI-for-age z-score (World Health Organization) was 0.66 (SD 0.88). We found significant positive group effects for vegetable (P = 0.01) and snack food (P = 0.03) intake, and satiety responsiveness (P = 0.047) immediately post-intervention. At 12 months follow-up, intervention children exhibited less neophobia (P = 0.03) than controls.

CONCLUSION

Future research should focus on additional strategies to support parents to continue positive behaviour change. ACTRN12610000200088.

Fertility of spinal cord injured males: effect of genitourinary infection and bladder management on results of electroejaculation

Thirty-eight men undergoing electroejaculation (EEJ) procedures for anejaculatory infertility were examined for the presence or absence of infection in urine and semen. In 29 spinal cord injury patients, a high incidence of infected urine and infected semen (41% and 56%, respectively) was seen, in contrast to patients with normal bladder function (0% and 11%). Urinary infection was associated with slightly lower sperm quality and lower pregnancy rates (10% vs 30% in the presence of sterile urine). Semen infection had no effect on sperm counts or pregnancy rates. If intermittent self-catheterization (ISC) was used to empty the neurogenic bladder, slightly better sperm quality was seen, the total failure rate was less, and much better pregnancy rates (44%) resulted than for patients using an alternative bladder management (7%). Antibiotics did not reduce the incidence of urine or semen infection, but did improve sperm counts slightly. Continuous prophylaxis was associated with bacterial resistance to many oral antibiotics and had no advantage over a short course of antibiotics prior to the procedure. Despite the above associations, the sperm quality in our patient population was never normal compared with that of men who ejaculate normally. We conclude that the low sperm quality seen in electroejaculation specimens from spinal cord injured males is not due entirely to infection or to the type of bladder management. Short courses of antibiotics, instead of continuous antibiotic prophylaxis, may be beneficial. Intermittent catheterization is superior to other methods of neurogenic bladder management in maintaining the fertility of spinal cord injured men.

Intracranial haemorrhage associated with ingestion of 'ecstasy'

A case of a patient with intracranial haemorrhage thought to have been associated with ingestion of 'Ecstasy' [3-4 methylenedioxymethamphetamine (MDMA)] is presented. The case illustrates the importance of drug analysis in cases involving illicit drug use.

Symptom experiences of lung transplant recipients: comparisons across gender, pretransplantation diagnosis, and type of transplantation

PURPOSES

To investigate symptom experiences of patients who have single and bilateral-sequential lung transplantation and to determine whether differences exist according to gender, pretransplantation diagnosis, and type of transplantation procedure.

DESIGN AND METHODS

In the context of a descriptive, comparative survey design, surviving recipients of single and bilateral-sequential lung transplants (n = 56) were mailed a symptom frequency and distress questionnaire. The response rate was 85.7% (n = 48). The average time since the recipients' lung transplantations was 1.5 +/- 0.7 years.

RESULTS

Recipients of lung transplants reported that several symptoms (eg, muscle weakness, shortness of breath with activity, and changed appearance) were both frequently occurring and quite distressing. Other symptoms were identified as being distressing, but not frequently occurring, or vice versa. Significant (P <.05) differences were found for symptom experiences among pretransplant diagnostic groups and between genders and types of transplant procedures.

CONCLUSIONS

These findings elucidate the symptom experiences of recipients of lung transplants and suggest that subgroup differences exist. The data provide a basis for strengthening patient and family education and for developing symptom management strategies. Further investigation of the symptom experiences of the recipients of lung transplants is needed, especially in relation to subgroups.

Integrating partners into erectile dysfunction treatment: improving the sexual experience for the couple

INTRODUCTION

Erectile dysfunction (ED) is a common condition estimated to affect more than 150 million men worldwide. ED should be regarded as a shared sexual problem which has significant detrimental effects both on the men who experience this condition and on their partners.

EVIDENCE TO SUPPORT PARTNER INVOLVEMENT IN ED THERAPY

Evidence shows that the partner plays a key supportive role in the man's ED treatment and in successful long-term ED therapy. Including the partner in consultations may highlight discordant attitudes and communication problems between couple members which may indicate treatment acceptance or rejection, or realistic or unrealistic treatment expectations.

OPTIONS FOR PARTNER INVOLVEMENT IN ED THERAPY

Most patients with ED consult their physician in the absence of their partner. Therefore, involving the partner in therapy can be challenging. Two options which physicians should consider are: encouraging the patient to bring the partner into the office and, often more realistically, seeking information about, and providing information to, the partner, via the patient.

OBJECTIVES

The objective of these recommendations is to provide practical guidance on treating couples affected by ED, and suggest techniques that may be helpful in integrating the partner into the process of ED treatment.

Efficacy of tetrahydrocannabinol in patients refractory to standard antiemetic therapy

Oral delta-9-tetrahydrocannabinol (THC), 15 mg/m2, was compared to prochlorperazine (PCZ), 10 mg. for the control of cancer chemotherapy-related emesis. Thirty-six patients whose vomiting was refractory to standard antiemetic therapy were entered in this randomized comparative cross-over study. THC decreased nausea and vomiting in 23 of 36 (64%) patients compared to 1 of 36 receiving PCZ. THC efficacy was not dependent on the class of antineoplastic-agent inducing the emetic symptoms, age of patients or type of sensorial change experienced. Using the 15 mg/m2 dose, all patients experienced transient sensorial changes, characterized as a pleasant "high" in 19 or a variable state of dysphoria in 17 cases. This study confirms the usefulness of THC in patients whose chemotherapy-induced nausea and vomiting is refractory to other standard antiemetics. While excellent antiemetic control was achieved at the dosage 15 mg/m2, dysphoria was encountered at this dose level and we recommend that an initial dose of 5 mg/m2 which, if necessary, can be carefully increased to achieve maximum antiemetic benefit.

Planimetry study of the percent of body surface represented by the hand and palm: sizing irregular burns is more accurately done with the palm

Sizing irregular burns is commonly done with use of the patient's hand as a template representing 1% of the body surface. To verify that this is accurate over a broad range of ages or to see if the surface of the palm is a more consistent template, a planimetry study was done. This revealed that the surface area of the palm averaged 0.52% total body surface area (+/- 0.07) and the palmar surface of the hand 0.85% total body surface area (+/- 0.08). The surface of the palm was a more consistent template and represented 0.5% of the body surface over a broad range of ages.

A survey of basic resuscitation knowledge among resident paediatricians

A telephone questionnaire was undertaken to evaluate the knowledge of resident paediatricians on the subject of the basic resuscitation of the acutely sick child. The questionnaire was targeted at 88 resident paediatricians in hospitals accepting paediatric emergencies in four health regions. Outcome was measured as a correct response to questions based on several emergency scenarios and on the confidence expressed of basic resuscitation knowledge. The subject of emergency management of the child with a compromised upper airway was poorly answered with 40/73 (55%) resident paediatricians suggesting an incorrect endotracheal tube size for an 8 year old child. Fluid management was also deemed unsatisfactory with only 36/73 (49%) providing adequate transfusion secondary to haemorrhagic shock. In addition only 19/73 (26%) mentioned the intraosseous route as a means of obtaining vascular access in a child in extremis. Confidence of the knowledge of basic resuscitation of children was low among resident paediatricians with only 30/73 (41%) expressing confidence and 69/73 (94%) expressing a desire for more formal training in paediatric resuscitation. Resident paediatricians are usually the key personnel in the management of very sick children. This survey demonstrates a low level of basic resuscitation knowledge among resident paediatricians of all grades that must be remedied at a local and national level.

Epidermal growth factor and platelet-derived growth factor-BB induce a stable increase in the activity of low density lipoprotein receptor-related protein in vascular smooth muscle cells by altering receptor distribution and recycling

Low density lipoprotein receptor-related protein (LRP) is a multifunctional receptor, expressed by vascular smooth muscle cells (VSMCs) in normal arteries and in atherosclerotic lesions. In this investigation, we demonstrate a novel mechanism for the regulation of LRP activity in cultured rat aortic VSMCs. Cells that were treated with platelet-derived growth factor-BB (PDGF-BB) or epidermal growth factor (EGF) for 24 h bound increased amounts of the LRP ligand, activated alpha2-macroglobulin (alpha2M), at 4 degrees C. The Bmax for activated alpha2M was increased from 56 +/- 5 to 178 +/- 24 and 143 +/- 11 fmol/mg cell protein by PDGF-BB and EGF, respectively, while the KD was unchanged. Northern and Western blot analyses demonstrated that neither PDGF-BB nor EGF increase LRP mRNA or protein levels. Instead, LRP was redistributed to the cell surface and remained localized primarily in coated pits, as determined by surface protein biotinylation, affinity labeling, and immunoelectron microscopy studies. The increase in cell-surface LRP was partially explained by a 50% decrease in receptor endocytosis rate; however, at 37 degrees C, PDGF-BB- and EGF-treated VSMCs still bound/internalized increased amounts of activated alpha2M and subsequently released increased amounts of trichloroacetic acid-soluble radioactivity. The cytokine-induced shifts in LRP subcellular distribution were stable when VSMCs were challenged with a saturating concentration of ligand and then incubated, in the absence of cytokine, for 2.5 h at 37 degrees C. Regulation of LRP distribution and activity may be an important aspect of the VSMC response to the atherogenic cytokines, PDGF-BB and EGF.