Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers

Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.

Sustainability drivers and inhibitors for the health system performance improvement projects in selected health facilities in Kenya: a qualitative study

OBJECTIVES

To investigate the health managers perceived sustainability status of the health facilities institutional improvement projects and their experiences on factors that facilitated or constrained their maintenance, with intentions of informing relevant strategies or policies in Kenya's health sector.

METHODS

A qualitative study, nested within a quasi-experimental study. Thirty-three project-teams of health managers were purposively selected and interviewed based on their project implementation success rates post-training. The managers had previously undergone a 9-month leadership training, complimented with facility-based team coaching around the chosen projects. The training was funded by the US Agency for International Development; however, the implementation of the projects was based on how the participants could innovatively use the existing resource to create a positive change. The projects were housed within 20 public, 9 faith-based and 4 private health facilities in 19 counties in Kenya. The interviews explored the manager's experiences in sustaining the successfully implemented projects within the (24-60 months post-training period). We asked managers to describe factors they perceived enabled or hindered the sustainability of the successfully implemented institutional improvement project. The digitally audio-recorded interviews were transcribed verbatim. Data on barriers and enablers were thematically analysed.

RESULTS

Twenty-nine out of the 33 successfully implemented projects reported sustainability within periods ranging from 24 to 60 months post-training. Seven themes related to drivers of sustainability emerged, namely; programme design, stakeholder's buy-in, board members, communication, coaching, presence of change champion, devolution and political good-will. Four sustainability inhibitors identified were: human resources constraints, policy implementation, misalignment of projects with daily operations, devolution and political interference.

CONCLUSIONS

The sustainability of institutional improvement strategies such as projects implemented post-leadership training in public and private health facilities depends on the quality of board members, communication management and institutionalisation of coaching culture. These findings are pertinent for planning and implementing similar health systems strengthening intervention in low-income countries.

Pathology findings and correlation with body condition index in stranded killer whales (Orcinus orca) in the northeastern Pacific and Hawaii from 2004 to 2013

Understanding health and mortality in killer whales (Orcinus orca) is crucial for management and conservation actions. We reviewed pathology reports from 53 animals that stranded in the eastern Pacific Ocean and Hawaii between 2004 and 2013 and used data from 35 animals that stranded from 2001 to 2017 to assess association with morphometrics, blubber thickness, body condition and cause of death. Of the 53 cases, cause of death was determined for 22 (42%) and nine additional animals demonstrated findings of significant importance for population health. Causes of calf mortalities included infectious disease, nutritional, and congenital malformations. Mortalities in sub-adults were due to trauma, malnutrition, and infectious disease and in adults due to bacterial infections, emaciation and blunt force trauma. Death related to human interaction was found in every age class. Important incidental findings included concurrent sarcocystosis and toxoplasmosis, uterine leiomyoma, vertebral periosteal proliferations, cookiecutter shark (Isistius sp.) bite wounds, excessive tooth wear and an ingested fish hook. Blubber thickness increased significantly with body length (all p < 0.001). In contrast, there was no relationship between body length and an index of body condition (BCI). BCI was higher in animals that died from trauma. This study establishes a baseline for understanding health, nutritional status and causes of mortality in stranded killer whales. Given the evidence of direct human interactions on all age classes, in order to be most successful recovery efforts should address the threat of human interactions, especially for small endangered groups of killer whales that occur in close proximity to large human populations, interact with recreational and commercial fishers and transit established shipping lanes.

FRI0423 CLINICAL BURDEN OF TREATING COMMERCIALLY-INSURED OSTEOARTHRITIS PATIENTS WITH PRESCRIPTION NSAIDS

Background:

Prescription NSAIDs/Cox-2s (“NSAIDs”) are commonly prescribed by physicians to treat patients with chronic pain, and much is known about the potential negative outcomes associated with their use1. Such negative outcomes include gastrointestinal (“GI”) issues and hepatorenal toxicity.1In addition, CV risk of Cox-2s has not been completely clarified.1,2However, less is known about the extent to which these outcomes are pervasive and problematic in specific patient populations such as those diagnosed with osteoarthritis (“OA”).

Objectives:

The goal of this research is to assess the clinical burden of commercially-insured patients diagnosed with OA of the hip and/or knee before and after treatment with prescription NSAIDs, in a large, national database in recent years.

Methods:

The Optum Healthcare Solutions, Inc. data (1/2012-3/2017) were used to identify patients ≥18 years old with ≥2 diagnoses of hip and/or knee OA, and ≥90 days supply of NSAIDs during the three-year period from first prescription (index date) after their first OA diagnosis. Patients were required to be continuously-enrolled during the six months before (baseline period) and 36 months after (follow-up period) the index date. Selected clinical outcomes such as GI issues, CV events, and renal toxicity were compared between the baseline and follow-up periods. Costs and resource use were normalized to account for differential duration in analytic time periods.

Results:

Data for 22,435 patients (60.8% as female, with an average age of 62) with hip and/or knee OA were analyzed. On average, patients were prescribed NSAIDs for 489 days during the follow-up period. From the baseline period to follow-up period, negative clinical outcomes associated with GI issues increased by 393% (1.5% v 7.5%), driven by a 667% (0.3% v 2.3%) increase in acute GI hemorrhages. Additionally, negative clinical outcomes associated with CV events increased by 73% (40.7% v 70.6%), largely due to a 600% (0.3% v 2.1%) increase in acute myocardial infarction. Lastly, negative clinical outcomes associated with renal toxicity increased by 433% (1.5% v 8.0%), with a 740% (0.5% v 4.2%) increase in acute renal failure being the most substantial.

Conclusion:

These findings suggest that prescribing of NSAIDs among OA patients is associated with an increase in negative clinical outcomes. This suggests that new treatment options other than NSAIDs should be evaluated.

References:

[1]van Laar M, et al. Pain treatment in arthritis-related pain: beyond NSAIDs.Open Rheumatol J. 2012;6:320–330.

[2]Nissen SE, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis.NEJM2016;2519-2529.

Disclosure of Interests:

Stuart Silverman Consultant of: Pfizer and Eli Lilly for this project., Speakers bureau: Amgen, Radius, James Rice Consultant of: Pfizer and Eli Lilly have funded this project., Alan White Consultant of: Pfizer and Eli Lilly have funded this project., Nguyen Le Consultant of: Pfizer and Eli Lilly have funded this project., Michael Somma Consultant of: Eli Lilly and Pfizer have funded this project., Craig Beck Shareholder of: Pfizer, Employee of: Pfizer, Rebecca Robinson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Patricia Schepman Shareholder of: Pfizer, Employee of: Pfizer

Effect of project-based experiential learning on the health service delivery indicators: a quasi-experiment study

Background

Kenya’s new constitution passed in 2010 recognizes the right of quality care resulting in the devolution of health service delivery to the sub-national units called counties in 2013. However, the health system performance continues to be poor. The main identified challenge is poor health systems leadership. Evidence shows that addressing health system leadership challenges using different leadership intervention models has the potential to improve health outcomes. The purpose of this study is to report findings on the effect of project-based experiential learning on the health service delivery indicators addressed by 15 health management teams from 13 counties in Kenya, as compared to the non-trained managers.

Methods

A quasi-experimental design without a random sample was used to evaluate the effectiveness of the leadership program. The health managers from the 13 Counties and 15 health facilities had previously undergone a 9-month leadership training, complimented with facility-based team coaching based on 15 priority institutional service improvement projects at the Strathmore University Business School. Pre-test and post-test data were collected in three-point periods (beginning, end of the training, and 24-to-60 months post-training). The control group comprised 14 other health institutions within the same counties.

Results

Leadership training and coaching built around priority institutional health service improvement projects in the intervention institutions showed: a) skilled birth attendance increased, on average, by 71%; b) full immunization of children, increased by 52%; c) utilization of in and out-patient services, which on average, increased by 90%; d) out-patient turn-around time reduced on average by 65% and; e) quality and customer satisfaction increased by 38.8% (in all the intervention facilities). These improvements were sustained for 60 months after the leadership training. In contrast, there were minimal improvements in service delivery indicators in the comparison institution over the same period of time. Ninety-three percent of the respondents attributed team-coaching built around priority institutional health service improvement projects as a key enabler to their success.

Conclusions

The study provides support that an intervention underpinned by challenge driven learning and team coaching can improve a range of health service delivery outcome variables.

Involving research participants in a pan-European research initiative: the EPAD participant panel experience

BACKGROUND

Including participants in patient and public involvement activities is increasingly acknowledged as a key pillar of successful research activity. Such activities can influence recruitment and retention, as well as researcher experience and contribute to decision making in research studies. However, there are few established methodologies of how to set up and manage participant involvement activities. Further, there is little discussion of how to do so when dealing with collaborative projects that run across countries and operate in multiple linguistic and regulatory contexts.

METHODS

In this paper we describe the set-up, running and experiences of the EPAD participant panel. The EPAD study was a pan-European cohort study with the aim to understand risks for developing Alzheimer's disease and build a readiness cohort for Phase 2 clinical trials. Due to the longitudinal nature of this study, combined with the enrolment of healthy volunteers and those with mild cognitive impairments, the EPAD team highlighted participant involvement as crucial to the success of this project. The EPAD project employed a nested model, with local panels meeting in England, France, Scotland, Spain and The Netherlands, and feeding into a central study panel. The local panels were governed by terms of reference which were adaptable to local needs.

RESULTS

The impact of the panels has been widespread, and varies from feedback on documentation, to supporting with design of media materials and representation of the project at national and international meetings.

CONCLUSIONS

The EPAD panels have contributed to the success of the project and the model established is easily transferable to other disease areas investigating healthy or at-risk populations.

Enumeration of Total Aerobic Microorganisms in Foods by SimPlate® Total Plate Count–Color Indicator Methods and Conventional Culture Methods: Collaborative Study

The relative efficacy of the SimPlate® Total Plate Count–Color Indicator (TPC–CI) method (SimPlate 35°C) was compared with the AOAC Official Method 966.23 (AOAC 35°C) for enumeration of total aerobic microorganisms in foods. The SimPlate TPC–CI method, incubated at 30°C (SimPlate 30°C), was also compared with the International Organization for Standardization (ISO) 4833 method (ISO 30°C). Six food types were analyzed: ground black pepper, flour, nut meats, frozen hamburger patties, frozen fruits, and fresh vegetables. All foods tested were naturally contaminated. Nineteen laboratories throughout North America and Europe participated in the study. Three method comparisons were conducted. In general, there was &lt;0.3 mean log count difference in recovery among the SimPlate methods and their corresponding reference methods. Mean log counts between the 2 reference methods were also very similar. Repeatability (sr) and reproducibility (sR) standard deviations were similar among the 3 method comparisons. The SimPlate method (35°C) and the AOAC method were comparable for enumerating total aerobic microorganisms in foods. Similarly, the SimPlate method (30°C) was comparable to the ISO method when samples were prepared and incubated according to the ISO method.

From strategy to action: a qualitative study on salient factors influencing knowledge transfer in project-based experiential learning in healthcare organisations in Kenya

OBJECTIVES

Knowledge transfer is recognised as a key determinant of organisational competitiveness. Existing literature on the transfer of knowledge and skills imply diminutive return on investment in training and development due to the low application of learnt knowledge. Following devolution of health services provision to new counties in Kenya in 2013, Strathmore Business School designed an experiential facility improvement project-based leadership training programme for healthcare managers in the new counties. Selected healthcare management teams participated in the leadership training to improve health systems performance in the devolved counties in Kenya. Despite similar training, the projects implementation contexts were different, leading to different implementation completion rates. The aim of this study was to investigate the reasons for this disparity and then recommend solutions.

DESIGN

A qualitative study using semi-structured interviews. A thematic framework approach was used in data analysis.

SETTING AND PARTICIPANTS

Thirty-nine projects teams constituting; 33 successful and 6 unsuccessful project teams, were purposively selected based on their project implementation success rates at the end of the leadership training. The managers had undertaken a team-based institutional improvement project. The prioritised projects were housed within; 23 public, 10 faith-based and 6 private health facilities in 19 counties in Kenya.

RESULTS

Our findings indicate projects completion rates were influenced by (training design, work environment climate, trainee characteristics, team-based coaching and leveraging on occurring opportunities). Transfer barriers were (inadequate management support, inadequate team and staff support, high staff turnover, misalignment of board's verses manager's priorities, missing technical expertise, endemic strikes, negative politics and poor communication). Recommendations were (need-driven curriculum, effective allocation and efficient utilisation of resources, proper prioritisation, effective communication, longitudinal coaching and work-teams recruitment).

CONCLUSION

The findings reveal that unless training interventions are informed by a need-driven curriculum customised to real-world work teams, the potential knowledge and skill transfer can be thwarted.

Deliberating performance targets workshop: Potential paths for emerging PM2.5 and O3 air sensor progress

The United States Environmental Protection Agency held an international two-day workshop in June 2018 to deliberate possible performance targets for non-regulatory fine particulate matter (PM_2.5) and ozone (O₃) air sensors. The need for a workshop arose from the lack of any market-wide manufacturer requirement for Ozone documented sensor performance evaluations, the lack of any independent third party or government-based sensor performance certification program, and uncertainty among all users as to the general usability of air sensor data. A multi-sector subject matter expert panel was assembled to facilitate an open discussion on these issues with multiple stakeholders. This summary provides an overview of the workshop purpose, key findings from the deliberations, and considerations for future actions specific to sensors. Important findings concerning PM_2.5 and O₃ sensors included the lack of consistent performance indicators and statistical metrics as well as highly variable data quality requirements depending on the intended use. While the workshop did not attempt to yield consensus on any topic, a key message was that a number of possible future actions would be beneficial to all stakeholders regarding sensor technologies. These included documentation of best practices, sharing quality assurance results along with sensor data, and the development of a common performance target lexicon, performance targets, and test protocols.

In situ wavelength calibration system for the X-ray Imaging Crystal Spectrometer (XICS) on W7-X

An in situ wavelength calibration system for the X-ray Imaging Crystal Spectrometer (XICS) on W7-X has been developed to provide routine calibration between plasma shots. XICS is able to determine plasma flow profiles by measuring the Doppler shift of x-ray line emission from highly charged impurity species. A novel design is described that uses an x-ray tube with a cadmium anode placed in front of the diffracting spherically bent crystal. This arrangement provides calibration lines over the full detector extent for both the Ar¹⁶⁺ and Ar¹⁷⁺/Fe²⁴⁺ spectrometer channels. This calibration system can provide a relative wavelength accuracy of 3 × 10^-7 Å across the full spatial extent of the detector, which corresponds to 50 m/s in the W7-X system. An absolute wavelength calibration of 1 × 10^-5 Å is expected, corresponding to 1 km/s, based on the current known accuracy of the calibration wavelength and the achievable measurement of the absolute positioning of the hardware. This calibration system can be used to independently calibrate XICS systems on both stellarators and tokamaks, without the need for special plasma conditions often used for calibration, such as locked modes on tokamaks. Experimental and simulated results are shown along with expected results, and the complete design of the calibration hardware that is to be installed in the W7-X XICS system.

Special care dentistry: how prepared are we?

AIM

To assess and evaluate the confidence of the undergraduate dental team in Irish dental schools regarding their training in the field of special care dentistry (SCD).

METHOD

A questionnaire was distributed amongst the undergraduate dental teams within Cork University Dental School and Hospital (CUDSH) and Dublin Dental University Hospital (DDUH). The data were analysed to assess for differences between the median responses of the various groups.

RESULTS

A total of 139 students participated in the study; 82 from DDUH (59 dental science students, seven dental hygiene students and 16 dental nursing students) and 57 from CUDSH (43 dental science students and 14 dental hygiene students). Twenty-two per cent (n = 30) of respondents agreed that their training had been sufficient in providing treatment or assistance for patients requiring SCD. Seventy-five per cent agreed that more emphasis should be placed on clinical training in SCD (n = 76). Thirty-one per cent of students anticipated a high level of confidence in treating patients requiring SCD upon graduation (n = 43), with dental science students feeling the least prepared amongst the dental team.

CONCLUSION

Confidence levels of the undergraduate dental team were low with regard to SCD. The existing hands-on clinical training in SCD was deemed insufficient by the respondents. Students believed more emphasis should be placed on SCD training in the undergraduate curriculum.

Tracking the Development of Muscular Myoglobin Stores in Mysticete Calves

For marine mammals, the ability to tolerate apnea and make extended dives is a defining adaptive trait, facilitating the exploitation of marine food resources. Elevated levels of myoglobin within the muscles are a consistent hallmark of this trait, allowing oxygen collected at the surface to be stored in the muscles and subsequently used to support extended dives. In mysticetes, the largest of marine predators, details on muscular myoglobin levels are limited. The developmental trajectory of muscular myoglobin stores has yet to be documented and any physiological links between early behavior and the development of muscular myoglobin stores remain unknown. In this study, we used muscle tissue samples from stranded mysticetes to investigate these issues. Samples from three different age cohorts and three species of mysticetes were included (total sample size = 18). Results indicate that in mysticete calves, muscle myoglobin stores comprise only a small percentage (17–23%) of conspecific adult myoglobin complements. Development of elevated myoglobin levels is protracted over the course of extended maturation in mysticetes. Additionally, comparisons of myoglobin levels between and within muscles, along with details of interspecific differences in rates of accumulation of myoglobin in very young mysticetes, suggest that levels of exercise may influence the rate of development of myoglobin stores in young mysticetes. This new information infers a close interplay between the physiology, ontogeny and early life history of young mysticetes and provides new insight into the pressures that may shape adaptive strategies in migratory mysticetes. Furthermore, the study highlights the vulnerability of specific age cohorts to impending changes in the availability of foraging habitat and marine resources.

Factors Influencing Consumption of Fruits and Vegetables in Older Adults in New Orleans, Louisiana

BACKGROUND

OBJECTIVES

The objective of this study was to identify demographic, social and structural factors associated with intake of fruit and vegetables in older adults in New Orleans, Louisiana.

DESIGN

A cross-sectional randomly sampled, address-based telephone survey of households in Orleans Parish, Louisiana was conducted with the household's main grocery shopper.

SETTING

All participants were in the New Orleans metro area and were surveyed in 2011.

PARTICIPANTS

Participants were 2,834 residents identified as the households' main grocery shopper in Orleans Parish, Louisiana. Participants were primarily female (75%), African-American (53%), approximately 10 percent of the sample reported receipt of government assistance. Approximately 37% of the sample was age 65 and older.

MEASUREMENTS

Measures included a telephone administered survey assessing demographic characteristics, food intake, access to supermarkets and other food sources, transportation, self-reported health, and frequency of grocery shopping.

RESULTS

Older adults consumed fewer fresh fruits and vegetables (FV) than younger adults (p<0.01). Bivariate associations with decreased FV included older age, receipt of government assistance, African American race, use of mobility aid, and poorer health. Multivariate factors associated with lower consumption include age, African American race, and poorer self-reported health. Women reported more fruit and vegetable consumption than men.

CONCLUSIONS

FV consumption is associated with improved health and reduced mortality. Older adults are less likely to consume fruits and vegetables, therefore addressing reduced FV consumption in older adults is a potential target for improving health outcomes in older adults. Specifically targeting African Americans and those with poorer health, as well as males may be an important focus for interventions.

Enrichment of cis-regulatory gene expression SNPs and methylation quantitative trait loci among bipolar disorder susceptibility variants

We conducted a systematic study of top susceptibility variants from a genome-wide association (GWA) study of bipolar disorder to gain insight into the functional consequences of genetic variation influencing disease risk. We report here the results of experiments to explore the effects of these susceptibility variants on DNA methylation and mRNA expression in human cerebellum samples. Among the top susceptibility variants, we identified an enrichment of cis regulatory loci on mRNA expression (eQTLs), and a significant excess of quantitative trait loci for DNA CpG methylation, hereafter referred to as methylation quantitative trait loci (mQTLs). Bipolar disorder susceptibility variants that cis regulate both cerebellar expression and methylation of the same gene are a very small proportion of bipolar disorder susceptibility variants. This finding suggests that mQTLs and eQTLs provide orthogonal ways of functionally annotating genetic variation within the context of studies of pathophysiology in brain. No lymphocyte mQTL enrichment was found, suggesting that mQTL enrichment was specific to the cerebellum, in contrast to eQTLs. Separately, we found that using mQTL information to restrict the number of single-nucleotide polymorphisms studied enhances our ability to detect a significant association. With this restriction a priori informed by the observed functional enrichment, we identified a significant association (rs12618769, P(bonferroni)<0.05) from two other GWA studies (TGen+GAIN; 2191 cases and 1434 controls) of bipolar disorder, which we replicated in an independent GWA study (WTCCC). Collectively, our findings highlight the importance of integrating functional annotation of genetic variants for gene expression and DNA methylation to advance the biological understanding of bipolar disorder.

Molybdenum emission from impurity-induced m = 1 snake-modes on the Alcator C-Mod tokamak

A suite of novel high-resolution spectroscopic imaging diagnostics has facilitated the identification and localization of molybdenum impurities as the main species during the formation and lifetime of m = 1 impurity-induced snake-modes on Alcator C-Mod. Such measurements made it possible to infer, for the first time, the perturbed radiated power density profiles from which the impurity density can be deduced.

Depressive disorder moderates the effect of the FTO gene on body mass index

There is evidence that obesity-related disorders are increased among people with depression. Variation in the FTO (fat mass and obesity associated) gene has been shown to contribute to common forms of human obesity. This study aimed to investigate the genetic influence of polymorphisms in FTO in relation to body mass index (BMI) in two independent samples of major depressive disorder (MDD) cases and controls. We analysed 88 polymorphisms in the FTO gene in a clinically ascertained sample of 2442 MDD cases and 809 controls (Radiant Study). In all, 8 of the top 10 single-nucleotide polymorphisms (SNPs) showing the strongest associations with BMI were followed-up in a population-based cohort (PsyCoLaus Study) consisting of 1292 depression cases and 1690 controls. Linear regression analyses of the FTO variants and BMI yielded 10 SNPs significantly associated with increased BMI in the depressive group but not the control group in the Radiant sample. The same pattern was found in the PsyCoLaus sample. We found a significant interaction between genotype and affected status in relation to BMI for seven SNPs in Radiant (P<0.0057), with PsyCoLaus giving supportive evidence for five SNPs (P-values between 0.03 and 0.06), which increased in significance when the data were combined in a meta-analysis. This is the first study investigating FTO and BMI within the context of MDD, and the results indicate that having a history of depression moderates the effect of FTO on BMI. This finding suggests that FTO is involved in the mechanism underlying the association between mood disorders and obesity.

Parents Empowering Parents (PEP) Program: understanding its impact on the bleeding disorders community

The Parents Empowering Parents (PEP) Program gives parents tools to improve the lives of children with bleeding disorders. The aim of this study was to evaluate the efficacy of PEP. Eleven haemophilia treatment centres (HTC) participated in the study and 301 participants completed the survey. Parents who did not attend PEP were divided into three groups based on their reasons for not attending: (Not Offered, Bad Time and Don't Need). Those who attended (Attended) PEP reported less use of yelling, spanking, slapping and giving-in after attending PEP. The Not Offered group used Praising (P = 0.016), Natural Consequences (P = 0.002), Being Consistent (P = 0.016), Ignoring (P = 0.006), Distracting (P = 0.002), Setting Limits (P=0.009), Giving Choices (P = 0.049), Being Consistent (P = 0.014) and Distracting (P = 0.019) less than all other groups. The Bad Time group used Time-Out (P = 0.037) and Ignoring (P = 0.019) more than the other groups that did not attend PEP. The Don't Need group used Spanking (P = 0.008) and Time-Out (P = 0.003) and Yelling (P = 0.014) less than all other groups. Attending PEP seems to decrease the use of negative parenting techniques. Those who reported PEP was not offered to them used positive parenting techniques less than all other participants.

Hip displacement and overall function in severe cerebral palsy

OBJECTIVE

The aim of this study was to investigate the relationship between hip displacement (HD) in individuals with severe cerebral palsy with function and quality of life (QOL). The second aim was to identify differences in these outcomes when comparing surgical and non-surgical management for HD.

DESIGN

Cross-sectional study of 26 participants born between 1988 and 1998 who had hip displacement on their most recent hip radiograph.

METHOD

Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD©) questionnaire. Hip migration percentage and a validated hip classification were used.

RESULTS

Significant positive correlation coefficients (CC) were found for mobility and comfort (CC=0.620, ρ = 0.001) as well as for QOL and comfort (CC=0.683, ρ < 0.001). Orthopedic hip surgery was associated with better scores for mobility (median [95% CI]); surgery vs. none; (36.1 [27.7, 44.4]) vs. (25.6 [22.2, 29.8]) and personal care, (32.1 [27.1, 43.2]) vs. (25.9 [22.7, 30.8]). Severity of HD had no significant association with comfort or QOL.

CONCLUSION

Mobility and personal care scores were significantly better in children who had undergone reconstructive hip surgery. However, QOL and pain scores were not associated with the severity of hip displacement or undertaking reconstructive hip surgery.

Innate Immune Responses in Swine Resuscitated from Severe Traumatic Hemorrhagic Shock with Hemoglobin-Based Oxygen Carrier-201

Hemoglobin-based oxygen carrier-201 transports oxygen and improves survival in swine with hemorrhagic shock, but has potential to be immune activating. Herein, we evaluated HBOC-201's immune effects in swine with more severe hemorrhagic shock due to soft tissue injury and 55% blood volume catheter withdrawal over 15 minutes followed by fluid resuscitation at 20 minutes with HBOC-201, Hextend, or no treatment (NON) before hospital arrival. Survival rates were similar with HBOC-201 and Hextend (p > 0.05), but were higher than in (p = 0.007). There were no significant group differences in blood cell count, percentages of leukocyte sub-populations and immunophenotype (CD4:CD8 ratio), adhesion markers expression (neutrophil CD11b; monocyte or neutrophil CD49d) and apoptosis. There was a trend to higher plasma IL-10 in HBOC-201 and groups vs. Hextend. We conclude that in swine with severe controlled HS and soft tissue injury, immune responses are similar with resuscitation with HBOC-201 and Hextend.

Depression, migraine with aura and migraine without aura: their familiality and interrelatedness

Migraine is frequently comorbid with depression. There appear to be common aetiological factors for both disorders, but the aetiology of migraine within depressed patients, in particular the significance of aura, has been little studied. A large sample of concordantly depressed sibling pairs [the Depression-Network (DeNT) sample] was assessed as having migraine with aura (MA), migraine without aura (MoA), probable migraine or no migraine according to International Headache Society guidelines. Correlations between siblings' migraine status were used to assess the nature of familial liability to migraine. A multiple threshold isocorrelational model fit best, in which different syndromes are conceptualized as different severities of one underlying dimension rather than as having separate aetiologies. Thus, MA and MoA were found to be different forms of the same disorder, with MA occupying the more extreme end of the spectrum of liability. Implications for our understanding of the relationship between migraine and depression are discussed.

Mutations in CHD7 in patients with CHARGE syndrome cause T-B + natural killer cell + severe combined immune deficiency and may cause Omenn-like syndrome

More than 11 genetic causes of severe combined immunodeficiency (SCID) have been identified, affecting development and/or function of T lymphocytes, and sometimes B lymphocytes and natural killer (NK) cells. Deletion of 22q11.2 is associated with immunodeficiency, although less than 1% of cases are associated with T-B + NK + SCID phenotype. Severe immunodeficiency with CHARGE syndrome has been noted only rarely Omenn syndrome is a rare autosomal recessive form of SCID with erythroderma, hepatosplenomegaly, lymphadenopathy and alopecia. Hypomorphic recombination activating genes 1 and 2 mutations were first described in patients with Omenn syndrome. More recently, defects in Artemis, RMRP, IL7Ralpha and common gamma chain genes have been described. We describe four patients with mutations in CHD7, who had clinical features of CHARGE syndrome and who had T-B + NK + SCID (two patients) or clinical features consistent with Omenn syndrome (two patients). Immunodeficiency in patients with DiGeorge syndrome is well recognized--CHARGE syndrome should now be added to the causes of T-B + NK + SCID, and mutations in the CHD7 gene may be associated with Omenn-like syndrome.

Immune effects of decreasing low-molecular weight hemoglobin components of hemoglobin-based oxygen carriers (HBOC) in a swine model of severe controlled hemorrhagic shock

Hemoglobin-based oxygen carriers (HBOCs) show potential as safe, efficacious, pre-hospital resuscitation fluids. The major criticism of HBOC-201 is its vasoactive property, attributed partially to low-molecular weight (low-MW) tetrameric/dimeric (TD) hemoglobin (Hb) in HBOC solution. Here we sought to determine whether resuscitation with decreasing concentrations of low-MW Hb component of HBOC affects immune responses in hemorrhagic swine. 28 anesthetized swine underwent a soft muscle crush and controlled hemorrhage of 55% blood volume, followed by resuscitation with HBOC containing 31%, 2%, or 0.4% low-MW Hb in four 10 ml/kg infusions at 20, 30, 45 and 60 minutes before hospital arrival at 75 minutes. IL-10, cell activation and adhesion markers and CD4:CD8 ratio remained unchanged in all 3 groups compared to baseline. Leukocyte apoptosis was equally elevated across all groups. Purification from 31% to 0.4% low-MW Hb in HBOC solution did not alter immune effects in a swine model of severe controlled hemorrhagic shock.