Does a first trimester dating scan using crown rump length measurement reduce the rate of induction of labour for prolonged pregnancy? An uncompleted randomised controlled trial of 463 women

OBJECTIVE

To evaluate the effect of a first trimester ultrasound dating scan on the rate of induction of labour for prolonged pregnancy.

DESIGN

Randomised controlled trial to include 400 women in each arm of the trial.

SETTING

Participating general practices and a district general teaching hospital.

POPULATION

Women attending their general practitioner in the first trimester to confirm pregnancy, in whom a first trimester ultrasound scan was not indicated.

METHODS

Women randomised to the study group (scan group) underwent an ultrasound dating scan between 8 and 12 weeks, measuring crown-rump length. The estimated date of delivery (EDD) was changed if there was a discrepancy of more than 5 days from the gestation, calculated from the last menstrual period (LMP). For the remaining women (no-scan group), gestation was determined using the LMP.

MAIN OUTCOME MEASURES

The rate of induction of labour for prolonged pregnancy.

RESULTS

Due to circumstances beyond the researchers' control, recruitment was abandoned when 463 women had been enrolled. The EDD was adjusted in 13 (5.7%) women in the scan group and in 2 (0.9%) in the no-scan group. There was no difference in the rate of induction for prolonged pregnancy between the scan (19 [8.2%]) and the no-scan (17 [7.4%]) groups (relative risk 1.10; 95% CI 0.59-2.07).

CONCLUSIONS

Acknowledging the reduced numbers recruited for study, it is concluded that there is no evidence that a first trimester ultrasound dating scan reduces the rate of induction of labour for prolonged pregnancy and may result in a more expensive healthcare strategy.

Clonidine in horses: identification, detection, and clinical pharmacology

Clonidine is classified as a class 3 performance-enhancing agent by the Association of Racing Commissioners International and thus has the potential to influence the outcome of a race. In this study, the authors developed and validated a sensitive gas chromatograph and mass spectrometer method to determine the pharmacokinetic parameters of clonidine in equine plasma samples after IV administration of a single dose (0.025 mg/kg) of clonidine in horses. At this dose, clonidine produced rapid and profound sedation, which cold be quickly reversed with yohimbine. Clonidine was able to produce an analgesic effect but failed to provide maximal analgesia in all horses; the limited analgesic effect persisted for about 60 minutes.

Neuropsychiatric events at the time of diagnosis of systemic lupus erythematosus: An international inception cohort study

OBJECTIVE

To describe the prevalence, characteristics, attribution, and clinical significance of neuropsychiatric (NP) events in an international inception cohort of systemic lupus erythematosus (SLE) patients.

METHODS

The study was conducted by the Systemic Lupus International Collaborating Clinics (SLICC). Patients were enrolled within 15 months of fulfilling the American College of Rheumatology (ACR) SLE classification criteria. All NP events within a predefined enrollment window were identified using the ACR case definitions of 19 NP syndromes. Decision rules were derived to determine the proportion of NP disease attributable to SLE. Clinical significance was determined using the Short Form 36 (SF-36) Health Survey and the SLICC/ACR Damage Index (SDI).

RESULTS

A total of 572 patients (88% female) were recruited, with a mean +/- SD age of 35 +/- 14 years. The mean +/- SD disease duration was 5.2 +/- 4.2 months. Within the enrollment window, 158 of 572 patients (28%) had at least 1 NP event. In total, there were 242 NP events that encompassed 15 of 19 NP syndromes. The proportion of NP events attributed to SLE varied from 19% to 38% using alternate attribution models and occurred in 6.1-11.7% of patients. Those with NP events, regardless of attribution, had lower scores on the SF-36 and higher SDI scores compared with patients with no NP events.

CONCLUSION

Twenty-eight percent of SLE patients experienced at least 1 NP event around the time of diagnosis of SLE, of which only a minority were attributed to SLE. Regardless of attribution, the occurrence of NP events was associated with reduced quality of life and increased organ damage.

Visual impairment in elderly patients with hip fracture: causes and associations

AIMS

To evaluate the current visual status and ophthalmic history of a sample of elderly patients with fractured neck of femur and to study the relationship between visual status and demographic factors.

METHODS

A four-centre study of all patients admitted to hospital with fractured neck of femur. The setting was two district (Ayr, Dunfermline) and two teaching (Glasgow, Dundee) hospitals in Scotland. The study examined 537 patients aged 65 years and over admitted with acute fractured neck of femur to hospital.

RESULTS

Bilateral visual impairment (binocular visual acuity worse than 6/12) was found in 239 of 518 patients (46%). Of this group, the principal causes for visual deficit were untreated cataract (49%), macular degeneration (21%), uncorrected refractive error (17%), and glaucoma (3%). The visually impaired group were more likely to have symptomatic visual complaints (58 vs 26%), however, were less likely to be under optometric care (71 vs 85%). A higher proportion of the group with visual impairment lived in areas of social deprivation (40 vs 26%).

CONCLUSIONS

Patients with fractured neck of femur represent a frail elderly group that have poorer vision than that documented in any other elderly population. The visual defect was potentially remediable in the majority of cases but this group of individuals are not generally in touch with the ophthalmic services. Social deprivation appears to be associated with this groups' inability to access ophthalmic care.

Seed germination in response to diurnal fluctuations of temperature

Diurnal fluctuations in temperature may initiate or accelerate germination in certain flowering plants, and the effectiveness of the stimulus varies according to the amplitude of fluctuation and the presence or absence of light. Attempts to assess the adaptive significance of the phenomenon, however, have been limited by the scarcity of data for species of contrasted ecology. We report here an investigation of germination responses to fluctuating temperatures, conducted on seeds of herbaceous species collected from native populations near Sheffield. The results suggest that requirements for diurnal fluctuations in temperature are characteristic of the germination of species from particular types of habitat and provide mechanisms which cause seeds to germinate at times and in places favourable for seedling establishment.

Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment*

AIM

To describe previous contact with optometry and ophthalmic services in a group of elderly patients with and without visual impairment (VI) who had fallen and sustained a fractured neck of femur.

METHOD

A cross sectional study of 537 patients aged 65 and over who had undergone hip fracture surgery in four Scottish centres (Glasgow, Ayr, Dundee and Fife). All patients had an in-depth optometric history, ophthalmic history and examination.

RESULTS

Three hundred and ninety-three (79%) patients reported optometric contact in the 3 years preceding surgery and 107 (21%) patients had not seen an optometrist for more than 3 years. In the latter group, 64 had VI, which was due to uncorrected refractive error in 17 (27%) and untreated cataract in 20 (31%). VI (best binocular visual acuity of 6/18 or less) was found in 239 (46%) patients. A past ophthalmic history was present in 257 (50%) patients. Only 39 (16%) patients with VI were under ophthalmic care at the time of the study.

CONCLUSIONS

There was significantly poor optometric and ophthalmic contact in patients who had VI and had fallen and sustained hip fracture. A proportion of the VI (66%) was due to uncorrected refractive error and untreated cataract. Public health providers should be made aware of the fact that current optometric and ophthalmic care pathways are not accessed by this group of elderly patients with VI and at risk of falling.

Desloratadine partially inhibits the augmented bacterial responses in the sinuses of allergic and infected mice

BACKGROUND

Allergic rhinitis (AR) is considered a major predisposing factor for the development of acute bacterial rhinosinusitis. How AR augments a bacterial infection is unknown.

OBJECTIVE

Our purpose in this study was to test whether an H1 receptor antagonist, desloratadine, could reduce the augmented effect of an ongoing allergic reaction on acute bacterial rhinosinusitis.

METHODS

Three groups of infected and ovalbumin (OVA)-sensitized mice were studied: (1) infected and allergic mice treated with desloratadine, (2) infected and allergic mice treated with placebo, and (3) infected mice. A fourth group of uninfected, non-sensitized mice served as a control for the cellular changes. BALB/c mice were sensitized by two intraperitoneal injections of OVA given 8 days apart. One day after the second injection, the mice were nasally exposed daily to 6% OVA (the groups treated with desloratadine or placebo) or phosphate-buffered saline (PBS) (the infection-only group) for 5 days. After the second OVA exposure, the mice were intranasally inoculated with Streptococcus pneumoniae. Desloratadine or placebo was given daily throughout the OVA exposure period. Nasal allergic symptoms were observed by counting of nasal rubbing and sneezing for 10 min after OVA or PBS nasal challenge. On day 5 post-infection, nasal lavage culture was done, and the inflammatory cells in the sinuses were evaluated by flow cytometry.

RESULTS

Mice that were made allergic, infected, and treated with placebo showed more organisms and phagocytes than did only infect mice. They also manifested allergic nasal symptoms and eosinophil influx into the sinuses. Desloratadine treatment during allergen exposure reduced allergic symptoms and reduced sinonasal infection (P<0.05). There tended to be less myeloid cell and neutrophil influx (P=0.09 both), but not eosinophil influx (P=0.85) compared with that in the placebo-treated group.

CONCLUSION

Desloratadine treatment during nasal challenge inhibited allergic symptoms and reduced sinonasal infection, suggesting that histamine via an H1 receptor plays a role in the augmented infection in mice with an ongoing allergic reaction.

Effect of manipulation of iron storage, transport, or availability on myelin composition and brain iron content in three different animal models

Several observations suggest that iron is an essential factor in myelination and oligodendrocyte biology. However, the specific role of iron in these processes remains to be elucidated. This role could be as an essential cofactor in metabolic processes or as a transcriptional or translational regulator. In this study, we used animals models each with a unique defect in iron availability, storage, or transfer to test the hypothesis that disruptions in these mechanisms affect myelinogenesis and myelin composition. Disruption of iron availability either by limiting dietary iron or by altering iron storage capacity resulted in a decrease in myelin proteins and lipids but not the iron content of myelin. Among the integral myelin proteins, proteolipid protein was most consistently affected, suggesting that limiting iron to oligodendrocytes results not only in hypomyelination but also in a decrease in myelin compaction. Mice deficient in transferrin must receive transferrin injections beginning at birth to remain viable, and these mice had increases in all of the myelin components and in the iron content of the myelin. This finding indicates that the loss of endogenous iron mobility in oligodendrocytes could be overcome by application of exogenous transferrin. Overall, the results of this study demonstrate how myelin composition can be affected by loss of iron homeostasis and reveal specific chronic changes in myelin composition that may affect behavior and attempts to rescue myelin deficits.

An assessment of mother-to-child HIV transmission prevention in 16 pilot antenatal clinics in Jamaica

OBJECTIVES

This study aims to determine the number and age distribution of pregnant women testing positive for HIV at 16 selected clinics in Jamaica between 2001 and 2002; the utilization of therapeutic interventions to minimize the risk of mother-to-child transmission (MTCT) and the current status of the HIV-exposed infants and, finally, the number of children who received testing for detection of HIV and to calculate the incidence of MTCT in these children.

METHODS

A retrospective study was carried out at sixteen pilot clinic sites by examining the patient records for all confirmed HIV-positive pregnant mothers and the resultant infants at these facilities for the period January 2001 to December 2002.

RESULTS

One hundred and twenty-three of 8116 pregnant women newly tested positive during the period January 2001 to December 2002; however, 176 HIV+ women delivered. Fifty-three (30%) knew their HIV status prior to participating in the programme. Sixty-two (1.4%) and 61 (1.6%) tested positive in 2001 and 2002, respectively. One hundred and ten (77%) and 113 (83%) mothers and infants, respectively, received ARV therapy, (92% - nevirapine, 8% - zidovudine). Twenty-three per cent of pregnant women received no ARV Forty-four (25.0%) of the 176 infants had a documented ELISA HIV test before eighteen months of age, none had a PCR test. The health status of 40 (23%) of these children was known: 30 (75%) were alive and well, five of whom did not receive any ARV, one (2.5%) was alive and ill and nine (22.5%) were reported dead, five of whom received ARV; 28.6% of infants who did not receive ARV were reported as either dead or ill compared to 13.8% of those receiving ARV CONCLUSION: Though the majority of pregnant women discovered their HIV status during pregnancy, a significant number got pregnant knowing that they were HIV+. The majority of mothers and infants received ARV but the follow-up and testing of infants was limited. Nevirapine is clearly protective in the prevention of MTCT of HIV and should be made universally accessible. All infants delivered to HIV+ mothers should be identified and tested for HIV.

The usefulness of ultrasound assessment of amniotic fluid in predicting adverse outcome in prolonged pregnancy: a prospective blinded observational study

OBJECTIVE

To determine whether a single ultrasound scan at or beyond 40 weeks of gestation to detect a single deepest pool of amniotic fluid <2 cm and amniotic fluid index (AFI) <5 cm is clinically useful in the prediction of subsequent adverse pregnancy outcome.

DESIGN

A prospective double blind cohort study.

SETTING

A university teaching hospital delivering approximately 6000 women annually.

POPULATION

One thousand and five hundred and eighty-four pregnant women at or beyond 40 weeks of gestation.

METHODS

Ultrasound assessment of liquor to detect the single deepest pool of amniotic fluid and derive the AFI at or after 40 weeks of gestation.

MAIN OUTCOME MEASURES

Perinatal death, meconium aspiration, birth asphyxia, intervention in labour for fetal distress, a cord arterial pH <7 and admission to the neonatal unit.

RESULTS

An AFI <5 cm but not a single deepest pool <2 cm was significantly associated with birth asphyxia or meconium aspiration. An AFI <5 cm was also significantly associated with caesarean section for fetal distress in labour, a cord arterial pH <7 at delivery and low Apgar scores. Despite there being a statistically significant association with adverse outcomes the sensitivity of AFI was low at 28.6%, 12% and 11.5% for major adverse outcome, fetal distress in labour or admission to the neonatal unit, respectively.

CONCLUSIONS

The AFI is superior to a measure of the single deepest pool as an assessment of the fetus at or after 40 weeks but has a poor sensitivity for adverse pregnancy outcome. Routine use is likely to lead to increased obstetric intervention without improvement in perinatal outcomes.

High and low pressure irrigation in contaminated wounds with exposed bone

BACKGROUND

Irrigation and debridement are essential in the initial management of traumatic wounds. The relative efficicacy of low pressure irrigation compared with high pressure irrigation remains unclear.

AIMS

The purpose of this study was to examine the time dependent efficacy of both high and low pressure lavage in removing adherent bacteria from traumatic wounds with exposed bone.

METHODS

Using an in-vivo model, we created bilateral Staphylococcus aureus contaminated femoral wounds in 30 mice. The wounds were incubated for 1 to 10 hours and lavaged with either high (70 psi) or low pressure lavage (1-2 psi). The mean colony forming units of bacteria were compared between groups at each time point.

RESULTS

High and low pressure lavage were effective in removing adherent bacteria from contaminated wounds up to 8 hours and 4 hours, respectively. High pressure lavage was more effective than low pressure at every time point.

CONCLUSION

The efficacy of low pressure lavage in wounds with exposed bone is questionable when irrigation is delayed beyond 4 hours.

Low molecular weight heparin for the prevention of hepatic veno-occlusive disease (VOD) after hematopoietic stem cell transplantation: a prospective phase II study

We evaluated 40 patients undergoing high-dose chemo/radiotherapy (HDCT) and hematopoietic stem cell transplantation (HSCT) (allogeneic (22), autologous (18)) to determine the safety and feasibility of administering low molecular weight heparin (LMWH) as hepatic veno-occlusive disease (VOD) prophylaxis. Patients received a once daily subcutaneous injection of dalteparin 2500 anti-Xa i.u. commencing the day prior to starting HDCT, and continuing until day +30 post HSCT or hospital discharge, whichever came first. Dosage adjustments were made for patients developing renal failure. All bleeding episodes were recorded and graded and VOD was diagnosed and graded according to Seattle criteria. At 100 days of follow-up, the overall survival and probability of regimen-related mortality were 85 and 15%, respectively. Nine patients developed VOD. The probability of developing VOD post allogeneic and autologous HSCT was 28% (95% CI, 6-45) and 17% (95% CI, 0-32), respectively. VOD was graded as moderate (n=8) and severe (n=1). VOD resolved in all cases except for one patient who died secondary to severe VOD and multiorgan failure. Clinically significant bleeding episodes occurred in three patients; 24 patients developed minor bleeding not requiring specific therapy. All bleeding episodes resolved. These results suggest that LMWH for VOD prophylaxis is safe with a low incidence of serious bleeding events. Whether it is superior to unfractionated heparin, however, is unknown and should be addressed within the context of a randomized controlled trial.

Mechanistic aspects of chiral discrimination on an amylose tris(3,5-dimethylphenyl)carbamate

The separation of [2R-[2alpha(R*),3alpha]]-5-[[2-[1-[3,5-bis-(trifluoromethyl)phenyl]ethoxy]-3(S)-4-fluorophenyl)4-morpholinyl]-methyl]-N,N-dimethyl-1H-1,2,3-triazole-4-methanamine hydrochloride from its enantiomer was achieved on an amylose tris-3,5-dimethylphenyl carbamate stationary phase. The retention of the enantiomers is dominated by weak hydrogen bonds while the enantioselectivity is governed by other kinds of interactions, e.g., inclusion in the amylose carbamate chains. Van't Hoffplots of 1nalpha vs. reciprocal temperature were non-linear and could be divided into two linear regions. One region at low temperature (5 degrees C- approximately 20 degrees C) and another one between 25 degrees C-70 degrees C with the change in slope occurring between 16 degrees C and 20 degrees C. DSC experiments suggested that the behavior can be attributed to breakage of H-bonds triggering a conformational change. Molecular simulation indicated a correlation between the interaction energies and the elution order obtained experimentally. The most retained enantiomer (R,R,S-enantiomer) interacts with the stationary phase through a hydrogen bond between the triazole proton and the C=O groups of the stationary phase, as well as through an inclusion in the cleft of the stationary phase. The other enantiomer exhibits a bifurcated H-bond between the triazolic proton and the C=O groups of the stationary phase leading to a less stable complex.

Allogeneic hematopoietic stem cell transplantation for progressive follicular lymphoma

Between 1993 and 2000, 24 patients with follicular lymphoma underwent high-dose chemo/radiotherapy and allogeneic hematopoietic stem cell transplantation (HSCT). Median age was 44 years, median interval from diagnosis to HSCT was 24 months and the median number of prior lines of treatment was three. Donor source was HLA matched sibling (23) or matched unrelated donor (one). Conditioning therapy was busulfan based in 22 patients and included total body irradiation in two. All patients received i.v. cyclosporine A and short-course methotrexate for GVHD prophylaxis. Nineteen patients are alive, a median of 2.3 years post HSCT. Death occurred due to transplant complications in four patients and one patient died of a stroke 10 months post HSCT. No patients have relapsed. The overall and progression-free survival was 78% (95% CI 63-97). Allogeneic HSCT for patients with progressive follicular lymphoma is feasible and may result in prolonged disease-free survival.

Are routine chest X-rays for students entering university worthwhile?

Mass radiographic screening for tuberculosis has lost favour in many countries. The aim of this study was to determine whether the continued practice of such screening of prospective students at the University of the West Indies was warranted by assessing the yield and the cost of the programme in our setting. In a cross- sectional retrospective study, 12,662 chest X-ray reports collected over the period 1989-1997 were studied. No active case of tuberculosis was detected. Three students reported a previous history of tuberculosis and 10 students had a positive family history of tuberculosis. Three hundred and ninety-nine clinically insignificant abnormalities were reported, such as mild scoliosis and calcified foci. Routine radiological screening of prospective students at the University of the West Indies for tuberculosis has an extremely low yield, places the students at unnecessary risk of radiation exposure and should be discontinued.

Sexual trauma and personality: developmental vulnerability and additive effects

Two types of sexual trauma, sexual abuse in childhood and rape in adulthood, were investigated in terms of possible effects on personality. Four groups of participants were studied: women who had experienced sexual abuse in childhood, women who had experienced rape as adults, women who had experienced both of these sexual traumas, and a control group of women who had experienced no sexual trauma. Personality functioning was assessed using the Dimensional Assessment of Personality Pathology. Groups who had experienced childhood sexual abuse displayed the highest degree of personality disturbance; however, the additive effects of repeated sexual trauma were limited. These findings may reflect the outcome of specific adversity in childhood on the psychobiological constructs underlying personality.

Allergic inflammation enhances bacterial sinusitis in mice

BACKGROUND

Although it is not proven, one factor considered important in the development of sinusitis is allergic rhinitis.

OBJECTIVE

The purpose of this study was to determine whether ongoing allergic rhinitis enhances the infection and inflammation associated with Streptococcus pneumoniae acute sinus infection.

METHODS

BALB/c mice were sensitized to ovalbumin by intraperitoneal injection. After infection of the sinuses by S pneumoniae, either with or without concomitant administration of ovalbumin to induce allergic inflammation, mice were killed at various times and their heads were prepared for histologic evaluation of the sinuses.

RESULTS

Mice became allergic to ovalbumin and developed eosinophilia in the sinus and lung cavities in response to ovalbumin administration to each of the respective cavities. In comparison with controls, the mice with ongoing nasal allergic inflammation that were inoculated with S pneumoniae had significantly more bacteria recovered at sacrifice and had significantly more inflammation, as indicated by neutrophil, eosinophil, and mononuclear influx into the sinus mucosa. The percentage of the sinus area occupied by neutrophil clusters was also increased after infection in the allergic mice in comparison with the control mice.

CONCLUSION

Our data demonstrate that mice can be sensitized to ovalbumin and develop a localized allergic reaction in the skin, nose, or lung. An ongoing local allergic response augments bacterial infection in these animals. We also demonstrate that allergic sensitization alone, allergen exposure alone, or an allergic response at a distal site, the lung, does not augment the sinus infection.

C57Bl/6 and BALB/c mice have similar neutrophil response to acute Streptococcus pneumoniae sinus infections

BACKGROUND

Previous investigations have shown that mice with a tendency toward a T(H)1 or T(H)2 lymphocyte response manifest different reactions to inoculation with the parasite Leishmania major. BALB/c mice (with a tendency for a T(H)2 response) showed evidence of systemic infection, whereas C57Bl/6 mice (with a tendency for a T(H)1 response) showed only a local reaction.

OBJECTIVE

To investigate whether BALB/c and C57Bl/6 mice respond differently to acute bacterial infection of the sinuses.

METHODS

We inoculated the nasal cavities of C57Bl/6 and BALB/c mice with Streptococcus pneumoniae (type ATCC59), or with broth as a control. The mice were humanely killed 2, 5, 10, and 14 days after inoculation. Their heads were fixed, decalcified, and embedded in paraffin blocks. Sections were stained with hematoxylin and eosin, and the degree of inflammation was quantified by the number of neutrophils per square millimeter of the sinus mucosa and the percentage of the sinus cavity occupied by neutrophil clusters.

RESULTS

Both groups of mice showed evidence of inflammation that was significantly greater than controls (P =.01), with no difference between groups. There was a correlation between the number of neutrophils per square millimeter in the sinus mucosa and the percentage of neutrophil clusters (C57Bl/6 mice, r = 0.37, P<.001; BALB/c mice, r = 0.20, P<.001). In the infected mice, the number of infiltrating neutrophils was significantly greater (P<.001) in anatomically lower (dependent) areas of the sinuses compared with the upper areas.

CONCLUSION

Unlike leishmaniasis, acute bacterial sinusitis is not affected by the tendency of the host to favor either a T(H)1 or T(H)2 response.

Fibrinogen naples I (B beta A68T) nonsubstrate thrombin-binding capacities

Fibrinogen Naples I (Bbeta A68T) is characterized by defective thrombin binding and fibrinopeptide cleavage at the fibrinogen substrate site in the E domain. We evaluated the fibrinogen of three homozygotic members of this kindred (II.1, II.2, II.3) who have displayed thrombophilic phenotypes and two heterozygotic subjects (I.1, I.2) who were asymptomatic. Electron microscopy of Naples I fibrin networks showed relatively wide fiber bundles, probably due to slowed fibrin assembly secondary to delayed fibrinopeptide release. We evaluated 125I-thrombin binding to the fibrin from subjects I.1, I.2, II.1, and II.2 by Scatchard analysis with emphasis on the high-affinity site in the D domain of fibrin(ogen) molecules containing a gamma chain variant termed gamma'. Homozygotic subjects II.1 and II.2 showed virtually absent low-affinity binding, consistent with the Bbeta A68T mutation, whereas heterozygotes I.1 and I.2 showed only moderately reduced low-affinity binding. The homozygotes also showed impaired high-affinity thrombin binding, whereas that of the heterozygotes was nearly the same as normal. Genomic sequencing of the gamma' coding sequence (I.2, II.2), ELISA measurements of two gamma' chain epitopes (L2B, gamma'409-412, and IF10, gamma'417-427) (I.2, II.1, II.2, II.3), and mass spectrometry of Naples I fibrinogen (II.2) showed no differences from normal, thus indicating that there were no abnormal structural modifications of the gamma' chain residues in Naples I fibrinogen. However, thrombin reportedly utilizes both of its available exosites for binding to high- and low-affinity sites on normal fibrin, suggesting that binding is cooperative. Thus, reduced high-affinity thrombin binding to homozygotic Naples I fibrin may be related to the absence of low-affinity binding sites.

A qualitative investigation of perceptions of violence risk factors in low-income African American children

Conducted a qualitative investigation to identify the perceptions of risk factors for violence in a sample of inner-city African American youth. Using ethnographic analyses, themes emerging from these data included concerns about the reciprocity between drugs and violence, familial quality of life issues, gender differences in the experience of violence and risk for violence, community safety concerns, and fears about managing peer relationships specific to violence. These data are interpreted relative to the risk factors the violence prevention literature has identified among youth residing in urban environments. Findings are discussed in terms of their potential contribution to generating hypotheses for the development of theory and effective violence prevention practice.

Nutrition during and after cancer treatment: a guide for informed choices by cancer survivors

Many studies have been conducted about dietary interventions aimed at preventing cancer. The American Cancer Society has published guidelines on diet, nutrition and cancer prevention, which are updated periodically as new evidence emerges, and other groups, too, have issued statements or guidelines about nutritional strategies to prevent cancer. Much less is known, however, about optimal nutrition for cancer survivors. This report looks at the different phases of cancer survivorship, from active treatment to advanced disease, and presents existing evidence from which informed decisions can be made regarding dietary choices. Popular complementary and alternative methods related to dietary intervention are reviewed. Nutrition information is also provided according to common cancer sites. As this is an area that requires survivors and health care providers to communicate effectively, a special section on "frequently asked questions" is provided for use as a patient education handout.

Praxis lateralization: errors in right and left hemisphere stroke

Whereas the representations of skilled movements in most right handers are stored in the left hemisphere, the right hemisphere's contribution to action planning remains unclear. We investigated error patterns in left (LHD) and right hemisphere damaged (RHD) subjects as well as normal control subjects (C) to determine if specific components of action programs may be processed by the right hemisphere or bilaterally represented. We had these subjects perform gestures to verbal command with the ipsilesional limb. Although the LHD group made significantly more qualitative errors than the C and RHD groups, the RHD subjects produced a number of apraxic errors. Specifically, the LHD group produced a wide range of spatiotemporal and conceptual errors for both transitive and intransitive gestures, while the RHD group made specific spatial and temporal errors primarily when performing transitive gestures. These findings support the postulate that the left hemisphere stores the spatiotemporal and conceptual representations of learned skilled movements, while several specific components of action programs, such as external configuration (limb orientation) and timing, may have bihemispheric representations.

Pathways mediating sexual abuse and eating disturbance in children

OBJECTIVE

To examine the relationship between childhood maltreatment and eating disorders in a sample of children.

METHOD

Twenty 10-15-year-old female children who were receiving treatment following reported childhood sexual abuse and 20 age-matched controls were compared on a series of measures assessing eating disorder behaviors, body image concerns, substance use, mood, impulsive behavior, and self-concept.

RESULTS

Sexually abused children reported higher levels of eating disorder behaviors, impulsive behaviors, and drug abuse than controls. Furthermore, behavioral impulsivity provided the strongest mediational effect between a history of childhood sexual abuse and purging and restrictive dieting behavior. Drug use proved to be a significant secondary mediator of the childhood sexual abuse eating disorder behavior association.

DISCUSSION

These data support the hypothesis that childhood sexual abuse is related to disordered eating in children, and extend similar findings that have been previously reported with adults. Behavioral impulsivity and drug use appear to be significant mechanisms that influence eating disorder behavior following childhood sexual abuse.

Structure-activity relationships for inhibition of farnesyl diphosphate synthase in vitro and inhibition of bone resorption in vivo by nitrogen-containing bisphosphonates

It has long been known that small changes to the structure of the R(2) side chain of nitrogen-containing bisphosphonates can dramatically affect their potency for inhibiting bone resorption in vitro and in vivo, although the reason for these differences in antiresorptive potency have not been explained at the level of a pharmacological target. Recently, several nitrogen-containing bisphosphonates were found to inhibit osteoclast-mediated bone resorption in vitro by inhibiting farnesyl diphosphate synthase, thereby preventing protein prenylation in osteoclasts. In this study, we examined the potency of a wider range of nitrogen-containing bisphosphonates, including the highly potent, heterocycle-containing zoledronic acid and minodronate (YM-529). We found a clear correlation between the ability to inhibit farnesyl diphosphate synthase in vitro, to inhibit protein prenylation in cell-free extracts and in purified osteoclasts in vitro, and to inhibit bone resorption in vivo. The activity of recombinant human farnesyl diphosphate synthase was inhibited at concentrations > or = 1 nM zoledronic acid or minodronate, the order of potency (zoledronic acid approximately equal to minodronate > risedronate > ibandronate > incadronate > alendronate > pamidronate) closely matching the order of antiresorptive potency. Furthermore, minor changes to the structure of the R(2) side chain of heterocycle-containing bisphosphonates, giving rise to less potent inhibitors of bone resorption in vivo, also caused a reduction in potency up to approximately 300-fold for inhibition of farnesyl diphosphate synthase in vitro. These data indicate that farnesyl diphosphate synthase is the major pharmacological target of these drugs in vivo, and that small changes to the structure of the R(2) side chain alter antiresorptive potency by affecting the ability to inhibit farnesyl diphosphate synthase.

Pediatric patients with bleeding dyscrasias: what is the cause of delays in initiating replacement therapy?

INTRODUCTION

The objectives of this study were to (a) evaluate the emergency department management of pediatric patients with bleeding disorders, specifically regarding time intervals from triage to administration of replacement therapy, and (b) to review resultant patient outcomes.

METHODS

A retrospective review was performed of charts from June 1996 to June 1998 for all patients with known bleeding disorders whose course was followed by the hematology clinic. Records were reviewed for all emergency department visits that required replacement therapy. Time intervals from triage to initiation of therapy were evaluated.

RESULTS

Eleven of 24 patients required administration of factor or desmopressin acetate. The mean time from triage to therapy administration was 103 minutes (range, 7 to 175 minutes; SD +/- 38). The mean time from triage to placement in a room was 34.3 minutes (SD +/- 32.6). The mean time to order replacement therapy was 26.7 minutes (SD +/- 27.4). The mean time from physician evaluation to administration of replacement therapy was 34.2 minutes (SD +/- 15.9). These intervals were believed to be suboptimal, and a new nursing driven protocol was established to expedite patient care.

DISCUSSION

Simple delays in time to replacement therapy may result in increased patient morbidity. We present an easy-to-follow algorithm that can be implemented to expedite the care of pediatric patients with a known bleeding disorder.

A comparison of an international experience for nursing students in developed and developing countries

Theoretical perspectives and approaches to transcultural nursing have been developed and there are different options for teaching transcultural care. The opportunity for nursing students to gain healthcare experience in another country is one option. This article reports a study undertaken in Northern Ireland to evaluate outcomes of a 3-month international experience for undergraduate nursing students (n=74) and to assess differences between the experiences in developed and developing countries. Data were collected by questionnaire. The findings indicate a high impact on students' international perspective and career development. Students' understanding of cultural and political issues within Northern Ireland was enhanced.

A randomized trial of magnesium in the emergency department treatment of children with asthma

STUDY OBJECTIVE

Magnesium sulfate has been shown to benefit asthmatic children and adults with poor responses to initial beta(2)-agonist therapy in the emergency department. We sought to determine whether the routine early administration of high-dose magnesium would benefit moderate to severely ill children with acute asthma.

METHODS

This was a randomized, double-blind, placebo-controlled trial of 54 children 1 to 18 years of age who presented to the ED of a tertiary care children's hospital with a moderate to severe asthma exacerbation. After receiving a nebulized albuterol treatment (0.15 mg/kg) and methylprednisolone (1 mg/kg), patients were randomly assigned to receive either 75 mg/kg of magnesium sulfate (maximum 2.5 g) or placebo. Thereafter, all patients were treated with frequent nebulized albuterol following a structured protocol. The main outcome was degree of improvement as assessed by Pulmonary Index scores over 120 minutes. Secondary outcomes included hospitalization rates and time required to meet discharge criteria.

RESULTS

The mean change in Pulmonary Index score from baseline to 120 minutes was 2.83 for the magnesium group compared with 2.66 for the placebo group (95% confidence interval -1. 24 to 1.60). Eleven (46%) of 24 magnesium-treated patients were hospitalized compared with 16 (53%) of 30 in the placebo group (95% confidence interval -19% to 34%). There were no statistically significant differences between the groups with respect to time required to meet discharge criteria.

CONCLUSION

The routine administration of high-dose magnesium to moderate to severely ill children with asthma, as an adjunct to initial treatment with albuterol and corticosteroids, was not efficacious.

MLL amplification in acute leukaemia: a United Kingdom Cancer Cytogenetics Group (UKCCG) study

The MLL gene, located at 11q23, is frequently rearranged in acute leukaemia as either chimaeric fusion genes or partial tandem duplications. We report a series of 12 acute leukaemia cases with apparent amplification of the MLL gene ascertained using fluorescence in situ hybridisation (FISH). Seven cases showed intrachromosomal amplification of MLL, four cases showed extrachromosomal amplification as double minute chromosomes (dmin) and one case had separate subclones with dmin and homogenously staining region (hsr). Southern blot analysis of the MLL gene showed MLL gene rearrangement in three of the 10 successful cases. These cases do not naturally fall into either of the two recognised categories of MLL rearrangement and may represent a third variety of MLL gene abnormalities.

Sensitivity of FISH in detection of MLL translocations

Fluorescence in situ hybridisation (FISH) detection of MLL translocations is now commonplace in cytogenetics laboratories. One of the most widely used probes is the Oncor MLL probe (Oncor, Gaithersburg, MD) that theoretically demonstrates the presence of an MLL rearrangement by a splitting of the FISH signal between the two derivative chromosomes generated by a translocation. Recently, another commercial probe has been made available from Vysis (Vysis, Downers Grove, IL) that uses a dual colour system. We examined material from 29 patients and 4 cell lines, all with recognised MLL translocations by G-banding, that were confirmed using Southern blot analysis of the MLL breakpoint cluster region. Both Oncor and Vysis MLL FISH probes were applied to these cases to compare their performance in detection of the MLL translocations. Thirty of the 33 cases demonstrated a clear splitting of Oncor MLL FISH signal in concordance with the Southern blot analysis and cytogenetics. Three cases failed to demonstrate a split MLL FISH signal. Therefore, we conclude that the Oncor MLL FISH probe has a 9.1% false negative rate, i.e., 90.9% sensitivity in detection of classic MLL translocations. Vysis MLL FISH detected the rearrangement in all 33 cases.

Utility of laboratory testing for infants with seizures

OBJECTIVES

Study objectives were to 1) determine the frequency with which laboratory studies are obtained, 2) determine the proportion of results that are clinically significantly abnormal, and 3) define the clinical characteristics of those with abnormal results, among infants with nonfebrile seizures (NFSz).

METHODS

A retrospective consecutive cohort study of infants < or = 12 months old presenting to the ED of a tertiary care, children's hospital following a seizure. A 2-year review was performed. Serum chemistry results were classified as "normal," "outside of the normal range," or "clinically significantly abnormal."

RESULTS

Sixty-seven of 134 (50%) with a NFSz were tested compared to 19/80 (24%) with a febrile seizure (FSz, P < 0.001). Nine (5 with hyponatremia and 4 with hypocalcemia) of the 67 (13%) tested NFSz infants had a clinically significant abnormality, as did 9 of 21 (43%) NFSz infants who seized in the ED compared to 0/46 (0%) without ED seizure activity (P < 0.0001). Hypothermia (T < 36.5 degrees C) and age less than 1 month were common characteristics of infants with clinically significant abnormalities.

CONCLUSIONS

This is one of the only studies to have assessed the utility of laboratory testing for infants with seizures. Abnormal serum chemistries accounted for a greater proportion of seizures among this cohort compared to that reported previously for older children. Laboratory testing is recommended for NFSz infants who 1) are actively seizing in the ED, 2) have a temperature below 36.5 degrees C, or 3) are less than 1 month of age.