Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Levels of wound calprotectin and other inflammatory biomarkers aid in deciding which patients with a diabetic foot ulcer need antibiotic therapy (INDUCE study)

AIMS

Deciding if a diabetic foot ulcer is infected in a community setting is challenging without validated point-of-care tests. Four inflammatory biomarkers were investigated to develop a composite algorithm for mildly infected diabetic foot ulcers: venous white cell count, C-reactive protein (CRP) and procalcitonin, and a novel wound exudate calprotectin assay. Calprotectin is a marker of neutrophilic inflammation.

METHODS

In a prospective study, people with uninfected or mildly infected diabetic foot ulcers who had not received oral antibiotics in the preceding 2 weeks were recruited from community podiatry clinics for measurement of inflammatory biomarkers. Antibiotic prescribing decisions were based on clinicians' baseline assessments and participants were reviewed 1 week later; ulcer infection was defined by clinicians' overall impression from their two assessments.

RESULTS

Some 363 potential participants were screened, of whom 67 were recruited, 29 with mildly infected diabetic foot ulcers and 38 with no infection. One participant withdrew early in each group. Ulcer area was 1.32 cm² [interquartile range (IQR) 0.32-3.61 cm² ] in infected ulcers and 0.22 cm² (IQR 0.09-1.46 cm² ) in uninfected ulcers. Baseline CRP for mild infection was 9.00 mg/ml and 6.00 mg/ml for uninfected ulcers; most procalcitonin levels were undetectable. Median calprotectin level in infected diabetic foot ulcers was 1437 ng/ml and 879 ng/ml in uninfected diabetic foot ulcers. Area under the receiver operating characteristic curve for a composite algorithm incorporating calprotectin, CRP, white cell count and ulcer area was 0.68 (95% confidence intervals 0.52-0.82), sensitivity 0.64, specificity 0.81.

CONCLUSIONS

A composite algorithm including CRP, calprotectin, white cell count and ulcer area may help to distinguish uninfected from mildly infected diabetic foot ulcers. Venous procalcitonin is unhelpful for mild diabetic foot ulcer infection.

Erratum: iPS-derived MSCs from an expandable bank to deliver a prodrug-converting enzyme that limits growth and metastases of human breast cancers

[This corrects the article DOI: 10.1038/cddiscovery.2016.64.].

ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Using X-ray spectroscopy of relativistic laser plasma interaction to reveal parametric decay instabilities: a modeling tool for astrophysics

By analyzing profiles of experimental x-ray spectral lines of Si XIV and Al XIII, we found that both Langmuir and ion acoustic waves developed in plasmas produced via irradiation of thin Si foils by relativistic laser pulses (intensities ~10²¹ W/cm²). We prove that these waves are due to the parametric decay instability (PDI). This is the first time that the PDI-induced ion acoustic turbulence was discovered by the x-ray spectroscopy in laser-produced plasmas. These conclusions are also supported by PIC simulations. Our results can be used for laboratory modeling of physical processes in astrophysical objects and a better understanding of intense laser-plasma interactions.

Healthcare technician delivered screening of adults with diabetes to improve primary care provider recognition of depression

Purpose:

The purpose of this study was to implement a continuous quality improvement project aimed at improving primary care provider recognition of depression.

Materials and Methods:

A randomized, blinded, pre- and post-test design was implemented with 92 adults attending an academic internal medicine clinic. Subjects were assigned to an intervention where healthcare technicians (HCT) trained in the fundamentals of diabetes education delivered brief probing questions about self-care behavior and tailored talking points to encourage patients to talk to their primary care physician about their emotional health. The control group received a sham intervention that included only information on standards of diabetes care. Measures included both a paper-and-pencil screening of depression and the Primary Healthcare Questionnaire-8 (PHQ-8). Outcomes were evaluated for antidepressant and/or counseling treatment modalities once the possibility of depression was identified.

Results:

Both the control and intervention groups improved from pre-test to 3-month post-test scores on the PHQ-8 in clinically significant ways, but continued to have moderate to severe depression symptoms. There was a significant likelihood of receiving antidepressant therapy and/or counseling in those who scored high on the PHQ-8.

Conclusion:

HCT can be trained to talk to patients about emotional health issues during routine primary care visits. Depression screening measures can be administered as part of the triage routine at the start of a primary care visit, along with tasks such as vital signs. Answering a screening measure can help create awareness of symptoms and feelings that can prompt discussion during the patient–provider encounter that can result in the diagnosis and treatment of depression.

Development of a refractory gastro-oesophageal reflux score using an administrative claims database

BACKGROUND

Approximately one-third of gastro-oesophageal reflux disease (GERD) patients demonstrate refractory symptoms following treatment with proton pump inhibitor (PPI) therapy.

AIM

To develop a refractory GERD score that can be applied to predict patients' healthcare utilisation.

METHODS

We enrolled adults (≥18 years) with a diagnosis of GERD. Refractory GERD was evaluated on an 8-point scale where 1 point was given for each of the following criteria: doubling, addition, or switching of GERD medication dose, receipt of a GERD-related endoscopic procedure or surgery, or ≥3 GERD-related outpatient visits. Refractory GERD was defined as the presence of two or more points.

RESULTS

A total of 135,139 GERD patients (44% male) were analysed with a mean (±s.d.) age of 52.9 ± 15 years. The mean overall refractory GERD score was 1.12 ± 1.2 (range 0-8 on an 8-point scale); 31% of patients had refractory GERD with a mean score of 2.56 ± 0.82. Among patients with refractory GERD, 31% doubled their GERD medication, 28% added a new GERD medication, 60% switched GERD medications, 54% had a GERD-related procedure and 1% had a GERD-related surgery. Patients with refractory GERD were more likely to be female (59% vs. 55%, P < 0.001) and had a higher co-morbidity score (0.78 vs. 0.56, P < 0.001). The overall mean costs for refractory patients during the study period were significantly higher compared with treatment-responsive patients ($18,088 ± $36,220 vs. $11,044 ± $22,955, P < 0.001).

CONCLUSIONS

Refractory GERD was present in approximately one-third of the GERD patients. We created a GERD refractory score that could define need for increased anti-reflux therapy and predict higher healthcare resource utilisation.

Effects of emissions from different type of residential heating upon cyclic guanosine monophosphate (cGMP) in blood platelets of residents

We hypothesized that different types of residential heating would be associated with different levels of indoor carbon monoxide (CO) and further that this might result in a differential in the concentration of cyclic 3':5' guanosine monophosphate (cGMP) in blood platelets in exposed residents. Individuals, who were recruited from homes using different fuel for heating, donated a venous blood sample in the winter and in the summer. In the winter the median blood platelet cGMP value for the group using liquid propane gas (LPG) was 65% higher than for the group using piped natural gas for heating (p <0.001). Also in the group using LPG, the median concentration of cGMP in the winter was 39% higher than the summer median (p < 0.003). The mean indoor concentrations of CO were measured over a period of 1 week during the winter and were <1 ppm. We conclude that observed differences were associated with emissions from different types of heating but that CO exposure alone is too low to explain these.

Oral pharmacokinetic and pharmacodynamic effects of FTY720 in cats

The aim of the study was to determine pharmacokinetic and pharmacodynamic profiles of FTY720 in cats and identify any toxic side effects. Six adult cats were used for the experimental study. Single oral dosages were tested at 0.05, 0.3 and 1.0 mg/kg. Whole blood drug concentration, total white blood cell and differential counts were monitored. Flow cytometry evaluated the effects on lymphocyte subsets. A toxicity study consisted of cats receiving a dose of 0.15 mg/kg daily for 30 days. Daily observation, physical examination and bloodwork were evaluated to assess for toxicity. All single doses resulted in > or =80% reduction in circulating lymphocytes within 12 h after administration, with the duration of lymphopenia being dose dependent. CD4+ and CD5+ T cells were specifically depleted. Peripheral neutrophils declined by approximately 70% at all dosages tested. No other toxic side effects were observed. Results of this study suggest that FTY720 is effective at inducing a peripheral lymphopenia in cats without any toxic side effects. Currently, cats appear to be the only species in which FTY720 induces a neutropenia. This study provides the foundation for future clinical transplantation trials using FTY720 in cats. By using combination therapy of FTY720 and low dose cyclosporine, the incidence of serious side effects may be reduced while still preventing allograft rejection.

Inkjet printing for high-throughput cell patterning

The adaptation of inkjet printing technology to the complex fields of tissue engineering and biomaterial development presents the potential to increase progress in these emerging technologies through the implementation of this high-throughput capability via automated processes to enable precise control and repeatability. In this paper, a method of applying high-throughput inkjet printing to control cellular attachment and proliferation by precise, automated deposition of collagen is presented. The results indicate that commercial inkjet printing technology can be used to create viable cellular patterns with a resolution of 350 microm through the deposition of biologically active proteins. This method demonstrates a combination of off-the-shelf inkjet printing and biomaterials and has potential to be adapted to tissue engineering and colony patterning applications. Adapting this method into the three-dimensional construction of cellular structures for eventual high-throughput tissue engineering using a bottom-up approach is possible.

A study of stereotypic behaviours in Alzheimer's disease and frontal and temporal variant frontotemporal dementia

OBJECTIVE

To document the prevalence and pattern of stereotypic behaviour in patients with Alzheimer's dementia and frontal and temporal variants of frontotemporal dementia. Secondly, to examine the relationship between stereotypic and other neuropsychiatric behaviours.

METHODS

Patients with the following were studied; Alzheimer's disease (n=28), frontal variant frontotemporal dementia (fvFTD, n=18), and semantic dementia-the temporal lobe variant of FTD (n=13). All patients were assessed using the Neuropsychiatric Inventory (NPI), the Mini-Mental State Examination, Addenbrooke's Cognitive Examination, and the Clinical Dementia Rating scale. Patients were also rated on the newly devised Stereotypic and Ritualistic Behaviour (SRB) subscale, which was designed as an addendum to the NPI.

RESULTS

There was no significant difference across diagnostic groups in terms of age, sex, or severity of cognitive deficits. The overall NPI was significantly higher in patients with fvFTD compared with the other two groups, but fvFTD and semantic dementia showed a similar, and significantly increased, prevalence of stereotypic behaviours on the SRB subscale. Within the FTD group as a whole these behaviours were more likely to be complex, whereas in Alzheimer's disease, when present, such behaviours tended to be more simple stereotypies or stimulus bound repetitive behaviours. Stereotypic behaviours were not correlated with either disease severity or the extent of cognitive impairment in the fvFTD group, but were in the other two diagnostic groups.

CONCLUSION

Complex stereotypic behaviours are a core feature of the dementing syndrome in FTD and may reflect early and specific deficits in orbitofrontal circuitry and basal ganglia involvement.

The efficacy of acquired humoral and cellular immunity in the prevention and therapy of experimental fungal infections

In the past two decades, numerous studies have documented the importance of acquired immunity for host defense against invasive fungal infections. There is widespread consensus in the field of medical mycology that cellular immunity is critical for successful host defense against fungi. However, in recent years several studies have established the potential efficacy of humoral immunity in host protection against two major fungal pathogens: Candida albicans and Cryptococcus neoformans. For C. albicans, antibodies to mannan, proteases and a heat shock proteins have been associated with protection against infection. Furthermore, anti-idiotypic antibodies to antibodies recognizing killer toxin from Pichia anomala and mimicking natural anti-killer toxin receptor antibodies can protect against C. albicans and other microorganisms. For C. neoformans, antibodies to the capsular glucuronoxylomannan have been shown to mediate protection in animal models of infection. Vaccines that induce protective antibodies have been shown to protect against experimental C. albicans and C. neoformans infection. In contrast, humoral immunity has not yet been demonstrated to mediate protection against Coccidioides immitis. For C. immitis, protection against infection is thought to rely on T cell mediated immunity, and the emphasis is on identifying the antigens that stimulate protective cellular immune responses and several candidate vaccines have been identified. These results provide encouragement for the view that acquired immune responses can be mobilized for the prevention and treatment of fungal infections.

Dissociation of social cognition and executive function in frontal variant frontotemporal dementia

In this paper, we adopt a neurodevelopmental stance to examining frontal variant frontotemporal dementia (fv-FTD) by using experimental procedures from the literature on the growth of social behaviour in children to examine the deficits in social reasoning which may underpin behavioural disturbance in fv-FTD. We present the case of a 47-year-old man with a diagnosis of fv-FTD and severe antisocial behaviour. Tests of general neuropsychology and of executive function were performed. In addition, the patient, JM, was assessed on tasks which test theory of mind. Theory of mind develops in distinct stages through childhood and is a core ability to represent the thoughts and feelings of others, independent of the level of intellectual ability. The results indicate relatively intact general neuropsychological and executive function, but extremely poor performance on tasks of theory of mind. This indicates a dissociation of social cognition and executive function suggesting that in psychiatric presentations of fv-FTD there may be a fundamental deficit in theory of mind independent of the level of executive function. The implications of this finding for diagnostic procedures and possible behavioural management are discussed.

Two "senior citizen" headhunters provide counsel to recruiters

Two long-term recruiting executives examine important missteps of medical recruiters. Remedies include seeking authority to perform optimally, recognizing recruiting and decision-making role differences, gaining knowledge of medical specialties, using creative techniques, letting searches dictate the possible and assuming the mantle of both hiring and out-placement resource.

Substance abuse intervention for health care workers: a preliminary report

The Workplace Managed Care Cooperative Agreement project targets 3,300 health care professionals in hospital, specialty clinic, and primary care settings located in metropolitan New Mexico communities. This project will evaluate whether enhancements to existing substance abuse prevention/early intervention programs can prevent the onset of risky drinking, reduce prevalence of risky drinking, better identify employees who abuse alcohol and drugs, and improve employee wellness. This article describes one such enhancement (Project WISE [Workplace Initiative in Substance Education]), implemented at Lovelace Health Systems. Project WISE includes relatively low-cost elements such as substance abuse awareness training, information on how to reduce drinking, and brief motivational counseling. Evaluation will consist of baseline comparisons of the intervention and comparison sites, a process evaluation, a qualitative analysis using focus groups, and an outcome evaluation using health and work records. Methodological challenges, solutions, and implications for researchers undertaking similar projects are presented.

The differentiation of semantic dementia and frontal lobe dementia (temporal and frontal variants of frontotemporal dementia) from early Alzheimer's disease: a comparative neuropsychological study

The authors compared age-matched groups of patients with the frontal and temporal lobe variants of frontotemporal dementia (FTD; dementia of frontal type [DFT] and semantic dementia), early Alzheimer's disease (AD), and normal controls (n = 9 per group) on a comprehensive neuropsychological battery. A distinct profile emerged for each group: Those with AD showed a severe deficit in episodic memory with more subtle, but significant, impairments in semantic memory and visuospatial skills; patients with semantic dementia showed the previously documented picture of isolated, but profound, semantic memory breakdown with anomia and surface dyslexia but were indistinguishable from the AD group on a test of story recall; and the DFT group were the least impaired and showed mild deficits in episodic memory and verbal fluency but normal semantic memory. The frontal and temporal presentations of FTD are clearly separable from each other and from early AD.

Possible hemolytic uremic syndrome in three cats after renal transplantation and cyclosporine therapy

OBJECTIVE

To describe the clinical history of 3 cats with possible hemolytic uremic syndrome (HUS) after renal transplantation.

STUDY DESIGN

This case series documents historical findings, physical examination findings, clinical pathologic features, necropsy and histopathologic findings of 3 cats with possible HUS.

RESULTS

Two cats had chronic renal failure; 1 cat had acute renal failure secondary to ethylene glycol toxicity. A renal transplant was performed in each of the 3 cats without obvious problems. Complications that would support a diagnosis of HUS, including anemia, thrombocytopenia, and azotemia occurred within 24 hours in 1 cat, within 8 days in a second cat, and 2 months after transplantation in the third cat. In 2 cats, HUS was likely secondary to cyclosporine immunosuppression. In the third cat, HUS may have been secondary to allograft rejection. Renal biopsies from all 3 cats were suggestive of HUS.

CONCLUSION AND CLINICAL RELEVANCE

In human beings, HUS in transplant recipients may occur secondary to immunosuppressive drugs, vascular rejection, or recurrence of original disease. Graft loss occurred in all 3 cats in this study and the mortality rate was 100%. Clinicians caring for these patients need to be aware of this disorder because early recognition and treatment is critical in the management of post-transplant HUS.

Targeted intervention programs: creating a customized practice model to improve the treatment of allergic rhinitis in a managed care population

OBJECTIVE

To develop an intervention program to improve health outcomes among patients with allergic rhinitis in a managed care environment.

STUDY DESIGN

The Episodes of Care (EOC) team at Lovelace Health Systems selected allergic rhinitis for an intervention program because it was identified as one of the top 10 reasons for visits to primary care clinics. The intervention program was based on a multidisciplinary team process designed to create a customized provider and patient education program to alter inconsistence or deficiencies in the treatment of allergic rhinitis.

PATIENTS AND METHODS

The EOC team researched literature and current practices and then identified inconsistencies in diagnostic and treatment patterns. Based on this research, the team developed guidelines and a provider education program. Intervention strategies were structured around decision points in a treatment protocol. More than 500 patients were monitored throughout the allergy season by using written and telephone surveys, symptom diaries, and encounter data. Measurable outcomes were established for provider and patient behavior. Patient outcomes were derived from a preventive behavior index and administrative data reporting usage of 5 classes of medication.

RESULTS

Approximately 50% of providers altered their practice patterns as a result of the intervention program. Patient outcomes showed a decrease in the use of rescue medications, particularly antibiotics, and an increase in preventive measures in the treatment group compared with the control group.

CONCLUSION

The EOC model resulted in positive changes in provider and patient behavior. The multidisciplinary approach resulted in broad provider participation.

Diagnosis and treatment of allergic rhinitis: primary care in an integrated health system setting

The first point of contact for many patients presenting with allergy symptoms is the primary care physician. And in the managed care system, this initial primary care visit is essential. Guidelines for the primary care physician in diagnosing and treatment rhinitis as well as referring patients to allergy specialists are described. In addition, optimal medication usage for treating mild, moderate, and severe rhinitis is detailed.

Economic outcomes of a targeted intervention program: the costs of treating allergic rhinitis patients

OBJECTIVES

To determine the annual costs of treating allergic rhinitis patients in a managed care environment and to assess the effect of a treatment intervention program on direct and indirect costs.

DESIGN

Two arms of an economics study were designed to calculate annual costs of treating allergic rhinitis in Lovelace Health Systems. Direct and indirect costs were also reviewed for patients participating in an intervention program designed to improve patient outcomes during the 1996 fall allergy season.

PATIENTS AND METHODS

Annual medical costs of treating allergic rhinitis within the Lovelace system were reviewed using a patient database. A total of 7936 patients with allergic rhinitis symptoms were identified in the database using a case-finding algorithm. An equal number of patients without allergy conditions were selected for the comparison group. In addition to calculating annual costs of treating allergic rhinitis, direct and indirect costs were reviewed for patients participating in a rhinitis intervention program to determine differences in cost between the treatment and control groups. An intervention group of 247 patients was selected to receive care at clinics randomized to use practice guidelines to improve treatment, while 255 patients were treated in the control group clinics, which did not alter treatment practices.

RESULTS

Annual expenditures were nearly $2 million more for the allergic rhinitis group than for the control group. In the intervention study, treatment and control groups expended the same in direct costs, but the intervention group showed a trend toward decreased indirect costs.

CONCLUSION

Costs of allergic rhinitis are not trivial to a managed care organization; a specifically designed intervention program shows potential for minimizing the costs associated with the ailment.

The differentiation of semantic dementia and frontal lobe dementia (temporal and frontal variants of frontotemporal dementia) from early Alzheimer's disease: a comparative neuropsychological study

The authors compared age-matched groups of patients with the frontal and temporal lobe variants of frontotemporal dementia (FTD; dementia of frontal type [DFT] and semantic dementia), early Alzheimer's disease (AD), and normal controls (n = 9 per group) on a comprehensive neuropsychological battery. A distinct profile emerged for each group: Those with AD showed a severe deficit in episodic memory with more subtle, but significant, impairments in semantic memory and visuospatial skills; patients with semantic dementia showed the previously documented picture of isolated, but profound, semantic memory breakdown with anomia and surface dyslexia but were indistinguishable from the AD group on a test of story recall; and the DFT group were the least impaired and showed mild deficits in episodic memory and verbal fluency but normal semantic memory. The frontal and temporal presentations of FTD are clearly separable from each other and from early AD.

Apoptosis-specific protein (ASP) identified in apoptotic Xenopus thymus tumor cells

A novel apoptosis-specific protein (ASP) has recently been identified in the cytoplasm of apoptotic mammalian cells. This paper investigates whether ASP is found in Xenopus thymus tumor-derived lymphoid cell lines undergoing apoptosis and also in apoptotic, nontransformed splenocytes. Cultured Xenopus tumor lymphoid cells induced to undergo apoptosis by serum deprivation or treatment with the calcium ionophore, ionomycin, displayed altered morphology typical of apoptotic cells, as judged by flow cytometric light-scatter characteristics and by fluorescence microscopy of acridine-orange-stained cells. Flow cytometry of permeabilized cells and fluorescence microscopy of acetone-fixed cytospins revealed that apoptotic Xenopus tumor cells, especially those displaying loss or condensation of DNA, displayed increased expression of epitopes recognized by a rabbit polyclonal antibody against ASP. Flow cytometry confirmed that ASP is also expressed in splenocytes induced to apoptose by culture in ionomycin or following concanavalin A stimulation. No increased expression of ASP was seen when lymphoid tumor cells or splenocytes were induced into necrosis by overdose with the antifungal agent amphotericin B. Western blotting with antibody against ASP identified the emergence of several protein bands in cell lysates from apoptotic, but not necrotic, Xenopus tumor cells. The new and simple methodology for identifying apoptotic cells described here is likely to be of value to those studying immune system development and associated programmed cell death in Xenopus.

Effect of ursodeoxycholic acid therapy on hepatic function in children with intrahepatic cholestatic liver disease

BACKGROUND

Ursodeoxycholic acid (UDCA) has been shown to improve pruritus, alanine aminotransferase (ALT), and cholesterol levels in children with intrahepatic cholestatic liver disease. However, the effect of UDCA on quantitative tests of hepatic function in children is uncertain.

METHODS

A 2.5-year, open label, crossover study, was designed to determine the effect of UDCA (15-20 mg/kg per day for 12 months, off for 6 months, and on again for 12 months) on clinical symptoms, biochemical test results, galactose and caffeine elimination half-lives (t1/2), and quantitative hepatic scintigraphy in 13 subjects aged 13.1 +/- 2.1 years (10 of whom completed the entire study), with intrahepatic cholestasis.

RESULTS

Pruritus improved with UDCA in the 6 patients with pruritus on entry into the study. At 12 months, there was a significant decline in ALT, gamma-glutamyl transpeptidase, and plasma levels of copper and manganese, with no further decline in these levels at 24 months. There were no changes in bilirubin or cholylglycine levels. After therapy was discontinued at 12 months, UDCA was restarted within 1 month in 9 of 12 patients in response to a doubling of ALT (n = 6) or worsening pruritus (n = 3). Galactose t1/2 increased after 12 months, with no further increases after 24 months of UDCA therapy, whereas caffeine t1/2 did not change. There were no significant changes in hepatic scintigraphy throughout the study.

CONCLUSIONS

These data suggest that although UDCA therapy improves pruritus and results in a reduction in ALT and gamma-glutamyl transpeptidase, UDCA therapy did not improve quantitative measures of hepatic function in children with intrahepatic cholestasis.

Effect of ketoconazole on cyclosporine dose in healthy dogs

OBJECTIVE

To determine the degree to which the dose of oral cyclosporine (CyA), in healthy dogs, can be decreased by concurrent oral administration of ketoconazole. Dogs in this study were observed for physical or biochemical side effects that might have been caused by the administration of CyA and ketoconazole.

STUDY DESIGN

Prospective research study.

SAMPLE POPULATION

Five healthy, intact female Beagle dogs.

METHODS

CyA was administered orally twice daily to achieve stable whole blood trough levels of 400 to 600 ng/mL. Ketoconazole was added at a low therapeutic dose (average dose: 13.6 mg/kg/d) then at a subtherapeutic dose (average dose: 4.7 mg/kg/d). CyA whole blood trough levels were monitored every 3 to 4 days and maintained at 400 to 600 ng/mL by adjusting CyA doses accordingly. Physical examination, CBC, biochemical profile, and urinalysis were performed at 2-week intervals throughout the study period.

RESULTS

The initial mean dose of CyA required to achieve target blood levels was 14.5 mg/ kg/d. With concurrent ketoconazole (low therapeutic dose, average dose: 13.6 mg/kg/d) and CyA administration, the CyA dose declined to 3.4 mg/kg/day (range: 1.2 to 5.2 mg/kg/d), representing a 75% reduction in CyA dose and monetary savings of 57.8%. At a subtherapeutic dose of ketoconazole (average dose: 4.7 mg/kg/d), combination therapy resulted in a CyA dose of 10.1 mg/kg/day (4.9 to 10.6 mg/kg/d), representing a 38% reduction in CyA dose and monetary savings of 23.8%. Weight loss and transient hypoalbuminemia of unknown clinical significance were observed. Other physical and biochemical evaluations were unremarkable over the 12-week study period.

CONCLUSIONS

The oral administration of ketoconazole can be used to reduce substantially the oral CyA dose needed to maintain selected blood levels in healthy dogs.

CLINICAL RELEVANCE

The oral administration of ketoconazole can result in substantial cost savings to owners of dogs receiving CyA after renal allograft transplantation or for the treatment of autoimmune disease.

Geriatric occupational therapy: the uncertain ideology of long-term care

The search for the good life is used as a framework for understanding the meaning of geriatric practice to occupational therapists. Data consisted of a subset of phenomenological interviews drawn from a nationwide study of 148 occupational therapists in all areas of practice. Narratives of satisfying and dissatisfying experiences with older clients were analyzed to understand the uniqueness of therapists' lived experiences in geriatrics. The realities of practice with older clients--the settings, the meanings and symbols of continuity in old age, and the older client's uncertain future--merge to create an uncertain ideology in geriatric occupational therapy. We suggest that a fundamental task of occupational therapists in geriatrics, as they seek the good life for themselves and their older clients, is to reconcile the realities of practice with traditional rehabilitation ideologies by redefining themselves and their roles in practice.

VH and VL gene analysis in sporadic Burkitt's lymphoma shows somatic hypermutation, intraclonal heterogeneity, and a role for antigen selection

Tumor cell lines and one tumor biopsy from seven cases of Epstein-Barr virus (EBV) genome-negative sporadic Burkitt's lymphoma (BL) have been investigated for usage and mutational pattern of Ig variable region genes. The VH genes were derived from the VH 3 (one) and VH4 (six) families and both the IgM-positive (six) and the IgA-positive (one) were all mutated from their germline counterparts. The VL genes were derived from V kappa 1 (one), V kappa 3 (one), V lambda 1 (four), and V lambda 2 (one) families and were also somatically hypermutated. Biopsy material from one of the IgM-positive cases showed VH and VL sequences that matched the derived cell line, with additional intraclonal sequence heterogeneity, indicating that the tumor cells had undergone posttranformation somatic mutation. Mutational patterns in V(H) genes did not show a conventional role for antigen in selecting tumor cell sequences. In contrast, patterns in VL sequences were consistent with a role for antigen in five of seven cases. The pattern of extensive scattered somatic hypermutation and intraclonal variation is similar to that in VH sequences of EBV genome-positive endemic BL, although the degree of mutational activity is less. These common features indicate that B cells involved in the two variants of BL may share a common clonal history.

The "Lactation Game": an innovative teaching method for health care professionals

The "Lactation Game" is a teaching tool designed to provide breastfeeding education to physician residents in an obstetrics and gynecology program. The game format encourages a participatory learning experience while providing information in a non-threatening environment.

Dependent care, caregiver burden, hardiness, and self-care agency of caregivers

This is a partial replication of a descriptive correlation study that examined the relationship between dependent care, caregiver burden, health-related hardiness, and self-care agency of caregivers. Data from this replication were compared with those of the previously reported study. Data were collected from a home health agency and a radiation-oncology unit. A moderate significant negative correlation was found between objective burden and dependent care. Moderate significant positive correlations were found between self-care agency scores and the commitment/challenge and control subscales of health-related hardiness scores. The major difference between this study and the previous one was in the level of subjective burden. Even though caregivers reported greater levels of subjective burden, the correlation with self-care agency and hardiness was nonexistent. The small subsample of male caregivers (n = 14) prevented a statistical comparison with the previous data; however, in the pooled sample previous findings were supported.

Pharmacological management of schizophrenia in older patients

Although antipsychotic drugs are the mainstay of treatment in older patients with schizophrenia, much of the theoretical work underpinning their use is based on evidence gained from younger patients. With respect to dosages, there has been little work comparing plasma concentrations of antipsychotics in older patients with those of younger patients. However, there are well documented changes in the pharmacokinetics of these drugs in the elderly, particularly in their hepatic metabolism and renal excretion. There is also evidence that older patients experience more adverse effects from antipsychotics than younger patients. Such effects include extrapyramidal symptoms, postural hypotension and falls. For these reasons it is recommended that starting doses of antipsychotic drugs in older patients should be in the region of 25 to 50% of that recommended for younger patients, and should be slowly increased. Selection of a particular antipsychotic agent is best made on the basis of individual patient characteristics and the adverse effect profiles of particular drugs.

User-definable bull's-eye database analysis

Several quantitative bull's-eye database programs have been developed and employed successfully, but generally they restrict the user to limited types of quantitative analysis. We developed a type of bull's-eye analysis which facilitates user-defined processing, and then explored the effects of various types of processing on the comparisons of patient information with that of reference databases. Male and female bull's-eye database were generated from 32 normal patients using unweighted 2D prefiltering, ramp backprojection, unweighted 3D postfiltering, and peak value circumferential plotting (base method). The data from each patient were then reprocessed and compared to the databases by means of three different approaches: (1) using the base method, (2) using average as opposed to peak value profiles, and (3) using a resolution recovery prefilter instead of a smoothing prefilter. Significant differences in the number of apparently abnormal regions were found between the three methods. In other words, the type of single-photon emission tomography (SPET) processing affected the accuracy of comparisons between patient and database information. Because even sophisticated analysis can now be performed on personal computers, we conclude that, rather than a preprocessed data file, clinical "normal reference" information should consist of original SPET data (in a standard format, e.g., Interfile) from a series of documented normal patients. Each user could then generate reference bull's-eye database by applying his or her own clinical processing procedures to the data.