Improving oncology first-in-human and Window of opportunity informed consent forms through participant feedback

BACKGROUND

Although patient advocates have developed templates for standard consent forms, evaluating patient preferences for first in human (FIH) and window of opportunity (Window) trial consent forms is critical due to their unique risks. FIH trials are the initial use of a novel compound in study participants. In contrast, Window trials give an investigational agent over a fixed duration to treatment naïve patients in the time between diagnosis and standard of care (SOC) surgery. Our goal was to determine the patient-preferred presentation of important information in consent forms for these trials.

METHODS

The study consisted of two phases: (1) analyses of oncology FIH and Window consents; (2) interviews of trial participants. FIH consent forms were analyzed for the location(s) of information stating that the study drug has not been tested in humans (FIH information); Window consents were analyzed for the location(s) of information stating the trial may delay SOC surgery (delay information). Participants were asked about their preferred placement of the information in their own trial's consent form. The location of information in the consent forms was compared to the participants' suggestions for placement.

RESULTS

34 [17 FIH; 17 Window] of 42(81%) cancer patients approached participated. 25 consents [20 FIH; 5 Window] were analyzed. 19/20 FIH consent forms included FIH information, and 4/5 Window consent forms included delay information. 19/20(95%) FIH consent forms contained FIH information in the risks section 12/17(71%) patients preferred the same. Fourteen (82%) patients wanted FIH information in the purpose, but only 5(25%) consents mentioned it there. 9/17(53%) Window patients preferred delay information to be located early in the consent, before the "Risks" section.  3/5(60%) consents did this.

CONCLUSIONS

Designing consents that reflect patient preferences more accurately is essential for ethical informed consent; however, a one-size fits all approach will not accurately capture patient preferences. We found that preferences differed for FIH and Window trial consents, though for both, patients preferred key risk information early in the consent. Next steps include determining if FIH and Window consent templates improve understanding.

Improving first-in-human and window-of-opportunity informed consent forms through participant feedback

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Background: Although patient advocates have created templates for standard consent forms, assessing patient preferences for First in Human (FIH) and Window of Opportunity (WO) trials consents is important given their unique risks. FIH trials are the first time a drug is tested in humans. In WO trials, treatment naïve patients receive a therapeutic agent in the window of time between diagnosis and standard of care (SOC) surgery. Our goal was to determine patient-preferred presentation of important information in FIH and WO consent forms. Methods: The study consisted of two phases: (1) analysis of consents for FIH and WO oncology trials open at a cancer center between 2019 and 2022; (2) interview patients who had reviewed consents for FIH or WO trials during the consent process. FIH consents were analyzed for the location(s) of information stating that the study drug has not been tested in humans (FIH info). The WO consents were analyzed for the location(s) of information stating the risk that trial may delay SOC surgery (WO info). Participants were asked about their preferred placement of the information in their own trial’s consent form and whether the consent was clear. Interviews were audio-recorded and double coded. Consent form analysis was compared to patients’ preferences. Results: 25 consents [20 FIH; 5 WO] were analyzed. 19/20 FIH consent forms included FIH info, and 4/5 WO consent forms included WO info. 42 patients were approached [19 FIH; 23 WO]; 34 [17 FIH; 17 WO] participated. 12/17 (71%) WO participants thought that the trial explanation in the consent form was clear. Conversely, only 9/17 (53%) FIH participants found it clear. Conclusions: Patients preferred that the important FIH and WO information be placed early in the consent, though exactly where varied. 82% of FIH participants wanted FIH information in the purpose, while only 19% of WO participants clearly preferred that WO information be in the purpose, and 41% preferred WO information to remain in the risks section. Using consent templates that reflect patient preferences accurately is essential for ethical informed consent; however, a one-size fits all approach may not accurately capture patient preferences, so multiple templates may be necessary. [Table: see text]

Improving consent forms for first-in-human trials through participant feedback

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Background: Risks and benefits of investigational agents that have not been tested in humans are, at best, incompletely characterized in nonclinical investigations. Despite the growing emphasis to include patient voices in clinical trial design, no published research has explored patient preferences on how best to convey the information that the agent has not been tested in humans. This study established that First in Human (FIH) consent forms present this information in different locations and queried participants for their input on the preferable FIH consent form structure. Methods: Consent forms for FIH oncology trials open to accrual at Winship Cancer Institute in 2019-2020 were analyzed for (1) the location of the mention that the study drug has not been used in humans before (FIH information), (2) the location of animal and other nonclinical data, and (3) placement of the risks section. Patients offered enrollment in a FIH trial were eligible for this study. Participants were interviewed during a clinic visit after consent was obtained. An ethics researcher asked questions about the participant’s opinions on the wording and placement of the FIH, nonclinical, and risk information in the specific trial consent form. All interviews were audio-recorded and double coded by two independent coders. The location of FIH and nonclinical data in the consent forms was compared to the patient’s suggested location for this information. Results: Saturation of themes was reached after interviewing 17 (17/19, 89% accrual) participants who were enrolled in 9 different FIH trials. Twenty FIH consents were qualitatively analyzed. Preferred placement compared to actual consent placement is listed in the table. 82% (14/17) of participants thought that nonclinical data on risks and efficacy was important to mention. 95% (19/20) of consents listed nonclinical data and most participants thought the placement in the consent was appropriate but 18% (3/17) of participants wanted the information earlier in the consent. No consent forms that were analyzed had the risks section before the study schedule; however, 47% (8/17) of participants wanted to move the risks sections before the study schedule. Conclusions: There is considerable variation in the layout of FIH consent forms that does not align with patient preferences. Standardization of FIH consent forms to better reflect patient input is essential in order to promote understandability of these important yet sometimes misunderstood clinical trials and to ensure ethical informed consent.[Table: see text]

Longitudinal observations of expected and actual library resource usage and barriers experienced by public health students

Objective:

This longitudinal observational study explored relationships between actual and expected usage of library resources as well as anticipated and encountered barriers to that usage among public health affiliates over the course of a semester.

Methods:

School of Public Health master's degree students were sent questionnaires monthly throughout a semester that asked about usage of and barriers to library resources to examine changes over time.

Results:

Most students utilized library resources less often than they predicted at the beginning of the semester and did not have accurate expectations about which library resources they would use. Although most students encountered no difficulties using library resources, those who did often had multiple problems and seldom sought library assistance.

Conclusion:

As School of Public Health master's students had unrealistically high expectations of library resource usage, librarians may need to manage students' expectations and assist in overcoming difficulties. Further studies across health sciences disciplines are needed to determine differences between different populations of users.

Residuals, sludge, and biosolids: Advancements in the field

Advancements in the field of residuals, sludge, and biosolids have been made in 2019. This review outlines the major contributions of researchers that have been published in peer-reviewed journals and conference proceedings throughout 2019 and includes brief summaries from over 125 articles. The review is organized in sections including life cycle and risk assessments; characteristics, quality, and measurement including micropollutants, nanoparticles, pathogens, and metals; sludge treatment technologies including dewatering, digestion, composting, and wetlands; disposal and reuse including adsorbents, land application and agricultural uses, nutrient recovery, and innovative uses; odor and air emissions; and energy issues.

Analyse des demandes d’appui en matière de prévention et contrôle de l’infection d’un CPias pendant la crise COVID-19

Introduction

Pendant la crise sanitaire liée au SARS-CoV-2, le Centre d’appui pour la Prévention des infections associées aux soins (CPias) a fortement été sollicité par les différents secteurs de l’offre de soins. Un outil informatique commun a été créé en 2019 pour tracer les demandes d’appui du CPias. L’objectif est d’analyser les thèmes abordés, les demandeurs et les réponses émises.

Matériels et méthodes

La saisie de ces données se fait à partir d’un formulaire en ligne. L’analyse des données est réalisée avec le logiciel statistique SAS®. Après un contrôle de la qualité des données, une analyse descriptive des conseils donnés a été réalisée. Ainsi, les variables recensées sont : la date, la fonction des appelants, le statut et le type de leurs établissements (sanitaire, ESMS, secteur libéral…) et les thèmes des demandes. Une fois la base de données exportée et les demandes étiquetées « COVID-19 » filtrées, une seconde analyse qualitative des sous-thèmes a été faite.

Résultats

Entre le 1^er février et le 31 mai 2020, le CPias a répondu à 886 sollicitations sur le thème du COVID-19 contre 640 sur toute l’année 2019 (tous thèmes confondus), avec un pic visible autour de la semaine 12. Ainsi, 64 % (466) des demandes émanent d’établissements médicosociaux, 26 % (189) d’établissements sanitaires, 7 % (48) de tutelles et 3 % (22) de la médecine ambulatoire. Quarante-trois pour cent (363) de ces demandes sont faites par des professionnels de santé (à parts égales entre professionnels médicaux et paramédicaux), 26 % (217) par des personnels non soignants (dont 80 % (174) de directeurs de structures médicosociales), 21 % (175) par des hygiénistes (praticiens et infirmiers) et 10 % (90) d’autres professionnels. Les thèmes les plus souvent abordés concernent pour 30 % (264) les équipements de protection individuelle (conseils pour leur bonne utilisation, gestion de la pénurie), pour 23 % (206) l’environnement (entretien des locaux, gestion du risque environnemental) et pour 21 % (185) la conduite à tenir face à des patients/résidents suspects, positifs ou revenant d’hospitalisation. Viennent ensuite des questions sur la conduite à tenir pour les professionnels soit 14 % (123) (suspects/contact, ceux travaillant en ville ou à domicile) et 14 % (120) sur la maladie elle-même (contagiosité, symptômes, prélèvement, unité dédiée aux patients COVID ou suspects). Parfois ces questions ont été relayées aux infectiologues selon le niveau d’expertise requis. Enfin, 11 % (98) des demandes sont d’ordre organisationnel autour des flux internes et de l’organisation des consultations.

Conclusion

Le CPias a été très investi dans ses missions régionales de prévention et contrôle de l’infection pendant cette crise sanitaire. Nous en tirons que de nombreux acteurs en santé avaient besoin d’une adaptation ou d’une interprétation pratique des doctrines nationales et/ou d’être confortés dans les conduites à tenir. L’analyse montre également la diversité des appelants sortants du cadre habituel de nos interlocuteurs témoignant de l’importance de l’épidémie.

Biosolids and sludge management

The advancements in the field of sludge and biosolids have been made over the past year. This review outlines the major contributions of researchers that have been published in peer-reviewed journals and conference proceedings throughout 2018. The review is organized in sections including regulatory developments and market analysis; analysis and quantification of characteristics including microconstituents and metals; treatment advances for the conversion of sludge to biosolids including pretreatment and sludge minimization, conditioning and dewatering, digestion, composting, and innovative technologies; product development and reuse including adsorbents and thermal products, agricultural and other uses, and innovative uses; odor and air emissions; and energy factors. PRACTITIONER POINTS: Summary of advances in the field of residuals and biosolids research in 2018. This review outlines the major contributions of researchers that have been published in peer-reviewed journals and conference proceedings. Topics covered range from regulation to innovation.

Greenland records of aerosol source and atmospheric lifetime changes from the Eemian to the Holocene

The Northern Hemisphere experienced dramatic changes during the last glacial, featuring vast ice sheets and abrupt climate events, while high northern latitudes during the last interglacial (Eemian) were warmer than today. Here we use high-resolution aerosol records from the Greenland NEEM ice core to reconstruct the environmental alterations in aerosol source regions accompanying these changes. Separating source and transport effects, we find strongly reduced terrestrial biogenic emissions during glacial times reflecting net loss of vegetated area in North America. Rapid climate changes during the glacial have little effect on terrestrial biogenic aerosol emissions. A strong increase in terrestrial dust emissions during the coldest intervals indicates higher aridity and dust storm activity in East Asian deserts. Glacial sea salt aerosol emissions in the North Atlantic region increase only moderately (50%), likely due to sea ice expansion. Lower aerosol concentrations in Eemian ice compared to the Holocene are mainly due to shortened atmospheric residence time, while emissions changed little.

Past climate changes in Greenland ice were accompanied by large aerosol concentration changes. Here, the authors show that by correcting for transport effects, reliable source changes for biogenic aerosol from North America, sea salt aerosol from the North Atlantic, and dust from East Asian deserts can be derived.

Relearning of Activities of Daily Living: A Comparison of the Effectiveness of Three Learning Methods in Patients with Dementia of the Alzheimer Type

This study examined the effectiveness of three different learning methods: trial and error learning (TE), errorless learning (EL) and learning by modeling with spaced retrieval (MR) on the relearning process of IADL in mild-to-moderately severe Alzheimer's Dementia (AD) patients (n=52), using a 6-weeks randomized controlled trial design. The participants had to relearn three IADLs. Repeated-measure analyses during pre-intervention, post-intervention and 1-month delayed sessions were performed. All three learning methods were found to have similar efficiency. However, the intervention produced greater improvements in the actual performance of the IADL tasks than on their explicit knowledge. This study confirms that the relearning of IADL is possible with AD patients through individualized interventions, and that the improvements can be maintained even after the intervention.

Updating a patient-level ART database covering remote health facilities in Zomba district, Malawi: lessons learned

SETTING

A non-governmental organization, Dignitas International, working in partnership with the Ministry of Health in Malawi, adopted innovative, low-technology methods to collect, capture, and manage patient-level antiretroviral therapy (ART) data in a district database covering 26 remote low-resource facilities in Zomba District, Malawi.

OBJECTIVE

To establish a longitudinal, observational database of routinely collected program data that could serve as a program monitoring and evaluation tool as well as a platform to conduct effective operational research.

DESIGN

This article describes the processes developed for digital capture of paper-based ART clinical records at health facilities and updating them in a central electronic database. It documents and focuses on lessons learned during the implementation and review of processes.

CONCLUSIONS

Data quality can only be ensured with regular review of, and compliance with, clearly delineated workflow protocols and adequate staffing and supervision. Through the implementation of this procedure, we expect to improve data quality, completeness, and use of routine ART clinical data in low-resource settings.

Oxygen storage capacity and structural flexibility of LuFe2O4+x (0≤x≤0.5)

Combining functionalities in devices with high performances is a great challenge that rests on the discovery and optimization of materials. In this framework, layered oxides are attractive for numerous purposes, from energy conversion and storage to magnetic and electric properties. We demonstrate here the oxygen storage ability of ferroelectric LuFe2O4+x within a large x range (from 0 to 0.5) and its cycling possibility. The combination of thermogravimetric analyses, X-ray diffraction and transmission electron microscopy evidences a complex oxygen intercalation/de-intercalation process with several intermediate metastable states. This topotactic mechanism is mainly governed by nanoscale structures involving a shift of the cationic layers. The ferrite is highly promising because absorption begins at a low temperature (~=200 °C), occurs in a low oxygen pressure and the uptake of oxygen is reversible without altering the quality of the crystals. The storage/release of oxygen coupled to the transport and magnetic properties of LnFe2O4 opens the door to new tunable multifunctional applications.

Effectiveness of mammography screening in reducing breast cancer mortality in women aged 39-49 years: a meta-analysis

BACKGROUND

Mammography screening of women >50 years of age significantly reduces breast cancer mortality in randomized controlled trials (RCTs). We sought to evaluate the effectiveness of mammography screening in women aged 39-49 years in reducing breast cancer mortality and to discuss previously published meta-analyses.

METHODS

PubMed/MEDLINE, OVID, COCHRANE, and Educational Resources Information Center (ERIC) databases were searched, and extracted references were reviewed. Dissertation abstracts and clinical trials databases available online were assessed to identify unpublished works. All assessments were independently done by two reviewers. All trials included were RCTs, published in English, included data on women aged 39-49, and reported relative risk (RR)/odds ratio (OR) or frequency data.

RESULTS

Nine studies were identified: the Kopparberg, Ostergotland (The Two-County study), Health Insurance Plan (HIP), Canada, Stockholm, Gothenburg, Edinburgh, Age, and Malmo trials. The individual trials were quality assessed, and the data were extracted using predefined forms. Using the DerSimonian and Laird random effects model, the results from the seven RCTs with the highest quality score were combined, and a significant pooled RR estimate of 0.83 (95% confidence interval [CI] 0.72-0.97) was calculated. Post hoc sensitivity analyses excluding studies with randomization before 1980 caused a loss of statistical significance (RR 0.87, 95% CI: 0.56, 1.13).

CONCLUSIONS

Mammography screenings are effective and generate a 17% reduction in breast cancer mortality in women 39-49 years of age. The quality of the trials varies, and providers should inform women in this age group about the positive and negative aspects of mammography screenings.

Pressure-induced structural transition in LuFe2O4: towards a new charge ordered state

The electronic ferroelectric lutetium ferrite (LuFe(2)O(4)) was studied by x-ray diffraction as a function of pressure. Pressure is shown to induce an irreversible rhombohedral to orthorhombic transition leading to a supercell determined by the combination of electron and synchrotron x-ray diffraction. This new configuration is proposed to be charge ordered in agreement with the results of resistivity measurements.

Clinical onset of celiac disease after an episode of Campylobacter jejuni enteritis

The present report describes a young woman with no previous gastrointestinal complaints who was initially diagnosed with postinfective irritable bowel syndrome (IBS) after a confirmed case of Campylobacter jejuni enteritis. However, because of persistent diarrhea, new-onset bloating and the development of iron and vitamin deficiencies, serological markers for celiac disease (CD) were evaluated. A positive tissue transglutaminase immunoglobulin A antibody test and repeat endoscopy with duodenal biopsy showing a Marsh IIIa lesion confirmed the diagnosis of CD. Infectious gastroenteritis is a well-established risk factor for the development of IBS, and there is recent evidence that it could play a role in the initiation and exacerbation of inflammatory bowel disease. The present case suggests that the clinical expression of CD can be unmasked by an acute gastrointestinal infection and supports the hypothesis that environmental factors other than gliadin may play a role in the clinical onset of CD in a genetically susceptible host. The increasing availability of serological testing and upper endoscopy has led to increasingly frequent diagnoses of CD and recognition that it may mimic IBS. The present case findings suggest that CD should be considered in the differential diagnosis of persistent IBS-like symptoms after an episode of infectious gastroenteritis.

Genetic Analysis of a Scytho-Siberian Skeleton and Its Implications for Ancient Central Asian Migrations

The excavation of a frozen grave on the Kizil site (dated to be 2500 years old) in the Altai Republic (Central Asia) revealed a skeleton belonging to the Scytho-Siberian population. DNA was extracted from a bone sample and analyzed by autosomal STRs (short tandem repeats) and by sequencing the hypervariable region I (HV1) of the mitochondrial DNA. The resulting STR profile, mitochondrial haplotype, and haplogroup were compared with data from modern Eurasian and northern native American populations and were found only in European populations historically influenced by ancient nomadic tribes of Central Asia.

Continuous insulin infusion in hyperglycaemic very-low-birth-weight infants receiving parenteral nutrition

Continuous infusion of insulin was used to improve glucose tolerance in 30 premature (26.4+/-1.4 weeks) very-low-birth-weight (750+/-211.3 g) hyperglycaemic infants receiving parenteral nutrition. Infusion of insulin was started at 159.1+/-67 h of life; while glycaemia was 12.1+/-3.3 mmol/l. Normoglycaemia was restored within 31.4h (range 2-134 h). A maximum insulin dose of 0.4 (range 0.07-4.2)IU/kg/h was required to control the blood glucose, the mean cumulative doses of insulin required was 3.27 IU/kg (range 0.09-18.1). The mean glucose infusion rate during insulin treatment was 20.3+/-1.7 g/kg/day; lipid was 4.6+/-1.1 g/kg/day and non-protein caloric intake 121.7+/-16.5 kcal/kg/day. Infants reach 85 kcal/kg/day of non-protein energy intake at 179.5+/-71.2 h after birth. During continuous insulin infusion, enteral feeding was started in all infants at 124.9+/-75.8 h of life. Insulin was continued for 317.7+/-196.6 h. Only two infants lost weight during the first week of treatment, the remaining infant gained weight steadily. In conclusion, continuous insulin infusion can rapidly and safely improve intravenous glucose tolerance, allowing higher caloric intake and growth in very-low-birth-weight infants who develop hyperglycaemia during total parenteral nutrition.

Pulmonary fluorodeoxyglucose uptake in infants of very low birth weight with and without intrauterine inflammation

OBJECTIVE

We compared early pulmonary (18)fluorodeoxyglucose ((18)FDG) uptake in infants who had very low birth weight with and without exposure to intrauterine inflammation by using positron emission tomography (PET). A secondary goal was to correlate (18)FDG uptake with later death or bronchopulmonary dysplasia.

METHODS

Within 72 hours of birth, 22 singleton infants between 25 and 30 weeks of gestation had a thoracic PET scan after intravenous (18)FDG. Influx constants (K(i)) for (18)FDG were determined. Placental histology assessed exposure to intrauterine inflammation.

RESULTS

Chorioamnionitis was found in 13 infants. Seven of these infants also had evidence of funisitis. No inflammation was detected in the remaining nine infants. Median (minimum, maximum) thoracic K(I) was 0.008 (0.006, 0.011) mL/min/mL in infants with funisitis, 0.006 (0.002, 0.008) in infants with chorioamnionitis only, and 0.006 (0.001, 0.015) in infants with no evidence of intrauterine inflammation (P=.16). No relation was found between K(i) and later death or bronchopulmonary dysplasia. Cord blood interleukin-6 was elevated in newborns with placental inflammation (P=.014).

CONCLUSION

Early thoracic PET scanning for metabolically active inflammatory cells does not differ between infants with and without exposure to intrauterine inflammation. Evidence of early intrapulmonary sequestration of inflammatory cells in some infants without chorioamnionitis points to the complex etiology of postnatal inflammation.

[Blood transfusion despite early use of erythropoietin: failure or limit of therapy? Annual cohort study of premature infants weighing less than 1500 g]

STUDY

Prospective, observative study.

SETTING

Neonatal intensive care unit in a university tertiary care hospital.

AIMS

1) Assessment of blood transfusion requirement. 2) Demonstration of haematocrit and hemoglobin level difference at birth between transfused and non-transfused infants. 3) Assessment of iron mass before and after early iron supplementation.

POPULATION

All premature infants without cardiopathy, surgical diseases, hemolysis or haemorrhage, at less than 30 weeks of gestational age or less than 32 weeks, weighing less than 1,500 grams, with respiratory distress syndrome admitted into the unit during the year 1998, were included in the study. Each received erythropoietin (750 U.kg-1.wk-1) with intravenous iron supplements from day 5 (0.017 mmol.kg-1.d-1), then orally (0.17 mmol.kg-1.d-1).

RESULTS

Seventy-nine premature infants were included in this study. 1) Sixty-seven percent of the transfusions occurred during the first 14 days of life. 2) Haematocrit and hemoglobin levels at birth were significantly different between transfused and non-transfused infants (P < 0.001) and remained different for infants of less than 28 weeks (P < 0.01). 3) After six weeks of iron supplementation (mean 0.31 mmol/kg), the ferritin level had significantly decreased in the non-transfused (P < 0.001) and transfused population (P < 0.01).

CONCLUSION

Increasing the haematocrit and the hemoglobin levels at birth, for example by placentofetal transfusion, could decrease the number of early transfusion. Early intravenous iron supplementation had no side effects but did not maintain iron levels.

[Outcome of 249 premature infants, less than 29 weeks gestational age]

The aim of this paper was to report the vital and neurological outcome of 249 preterm infants of less than 29 weeks born between 1990 and 1996, and included in a prospective study until two years of age.

RESULTS

The initial mortality rate was 19%. This was related to gestational age and severe transfontanellar ultrasonographically (TFU) detected abnormalities. The rate of follow-up at two years of age was 98%. Neurological sequelae amounted to 12.8%, including four cases of deafness. The possibility of survival without neurological sequelae increased from 52% at 24-25 weeks to 72% at 26-28 weeks of gestational age (p < 0.005). The presence of sequelae was significantly related to severe cranial ultrasonographically-detected abnormalities, to parental social level, and to early neonatal anemia. Normal TFU and/or isolated periventricular hyperechogenicity could not exclude the presence of neurological sequelae which, however, appeared to be less severe than at the onset.

CONCLUSION

Gestational age, severe TFU abnormalities and neonatal anemia play a major role in the rate of mortality and in the neurological sequelae in preterm infants, and can influence the decisions concerning the treatment of this pediatric population.

Manganese superoxide dismutase levels are elevated in a proportion of amyotrophic lateral sclerosis patient cell lines

The most frequent genetic causes of amyotrophic lateral sclerosis (ALS) determined so far are mutations occurring in the gene for copper/zinc superoxide dismutase (CuZnSOD). The mechanism may involve inappropriate formation of hyroxyl radicals, peroxynitrite or malfunctioning of the SOD protein. We hypothesized that undiscovered genetic causes of sporadically occurring amyotrophic lateral sclerosis might be found in the mechanisms that create and destroy oxygen free radicals within the cell. After determining that there were no CuZnSOD mutations present, we measured superoxide production from mitochondria and manganese superoxide dismutase (MnSOD), glutathione peroxidase, NFkappaB, Bcl-2 and Bax by immunoblot. Of the ten sporadic patients we tested we found three patients with significantly increased concentrations of MnSOD. These patients also had lower levels of superoxide production from mitochondria and decreased expression of Bcl-2. No mutations were found in the cDNA sequence of either MnSOD in any of the sporadic patients. A patient with a CuZnSOD mutation (G82R) used as a positive control showed none of these abnormalities. The patients displaying the MnSOD aberrations showed no specific distinguishing features. This result suggests that the cause of ALS in a subgroup of ALS patients (30%) is genetic in origin and can be identified by these markers. The alteration in MnSOD and Bcl-2 are likely epiphenomena resulting from the primary genetic defect. It suggests also that the oxygen free radicals are part of the cause in this subgroup and that dysregulation of MnSOD or increased endogenous superoxide production might be responsible.

[Respiratory distress in three newborns after mask disinfection with Endosporine. Probable role of glutaraldehyde]

BACKGROUND

Disinfectants for medical devices are uncommonly a cause of iatrogenic adverse effects. Nevertheless, when misused, they can induce severe complications. Three cases of acute respiratory distress in newborns probably induced by glutaraldehyde are reported.

CASE REPORTS

Three children born by Caesarean section between 8 and 19 May 1999 in the same hospital presented acute respiratory distress requiring hospitalization in the neonatal intensive care unit; one child was premature. The clinical appearance, which was initially normal, deteriorated with a respiratory distress in 30 to 60 minutes. Recovery was uneventful in all cases. The diagnosis considered was a hyaline membrane disease. The enquiry conducted after this cluster onset identified, as a main contributing factor, the disinfection procedure recently introduced in the surgical theater.

CONCLUSION

Review of toxicologic data on glutaraldehyde shows this is a highly irritating chemical for the respiratory tract, even at low concentrations. Clinical and radiologic features in these three neonates are compatible with a pulmonary sub-edema on an immature alveolar setting. The hypothesis proposed is that glutaraldehyde, the active ingredient of the biocidal formula used to disinfect the respiratory masks, was massively desorbed from the rubber and foam of which masks are made.

Naproxen does not alter indices of muscle damage in resistance-exercise trained men

PURPOSE

Unaccustomed exercise is associated with an elevated plasma creatine kinase (CK), myofibrillar inflammation, and delayed onset muscle soreness (DOMS). Nonsteroidal antiinflammatory drugs (NSAID) may attenuate DOMS and indirect indices of inflammation in humans.

METHODS

We studied the effects of an NSAID (naproxen sodium (500 mg, 2 times a day for 48 h)) taken before and after resistance exercise in eight healthy, moderately trained men in a randomized, double-blind trial. The exercise consisted of unilateral knee concentric/eccentric weight lifting with 6 sets x 10 repetitions at 80-85% of the 1 repetition maximal contraction. Muscle biopsies of each vastus lateralis (EX = exercised/REST = control) were taken 24 h after exercise for immunohistochemical staining of inflammatory cells (leukocyte common antigen). At 24 and 48 h postexercise, we also determined DOMS, plasma CK activity, and knee extensor muscle torque.

RESULTS

Exercise resulted in an increased CK activity at +24 and +48 h (vs preexercise: P < 0.01), with no treatment effect. There were no treatment effects for any of the measured variables except for a return of voluntary knee extension torque to baseline by +48 h postexercise for NSAID treatment (P < 0.05).

CONCLUSIONS

NSAID administration did not alter CK rise, muscle force deficit at 24 h postexercise, nor perceived muscle pain. In addition, the increased CK at 24 h postexercise was not associated with an acute myofibrillar inflammatory cell infiltrate in moderately trained men after resistance exercise.

A new neonatal case of N-acetylglutamate synthase deficiency treated by carbamylglutamate

N-Acetylglutamate synthase (NAGS) deficiency is a rare, autosomal recessive urea-cycle disease. Its clinical presentation is not different from the other hereditary hyperammonaemias. We report a new neonatal case with hyperammonaemic coma. A test by carbamylglutamate was performed at 25 days of life. Since then, the child was treated by carbamylglutamate three or four times a day with a total dose of 80-100 mg/kg per day. Today, the boy is 1 year old. He receives carbamylglutamate 200 mg four times a day. He has normal somatic and neurological development and good metabolic balance.

Coexisting calcified inferior vena cava thrombus and adrenal hemorrhage in the neonate: report of three cases

Coexisting calcified inferior vena cava (IVC) thrombus and adrenal hemorrhage are uncommon in children. We present three such cases diagnosed by ultrasound in three boys who were born after 41-, 38-, and 38-week gestations, respectively. In all cases the pregnancy and delivery were unremarkable. The birthweight was 3,630 g, 3,210 g, and 3,390 g, respectively. Left adrenal hemorrhage occurred in all cases. Associated left renal vein thrombus occurred in two cases. The mean followup was 8.5 years. In two cases ultrasound showed persistence of a calcified thrombus and residual stenosis of the IVC. In the third case the IVC thrombus had almost disappeared.

Once-daily trandolapril compared with the twice-daily formulation in the treatment of mild to moderate essential hypertension: assessment by conventional and ambulatory blood pressures

A double-blind, crossover study was carried out to compare the antihypertensive efficacy of the long-acting ACE inhibitor trandolapril 1 mg administered once daily and 0.5 mg twice daily in 31 patients with mild to moderate essential hypertension. After randomization, patients entered a single-blind placebo period of 4 weeks. After a double-blind treatment of 4 weeks with either of the dosage regimens, patients were then crossed over to the alternate regimen for the last 4 weeks of the study. Conventional BP and heart rate were measured on each visit and ambulatory BP monitoring was done at baseline and at the end of each treatment phase. Conventional as well as 24-hour and awake ambulatory systolic and diastolic BPs were significantly (P < 0.001) and almost identically decreased by both once- and twice-daily formulations. Moreover, the clinical response rates (reduction in seated diastolic BP > or = 10% or diastolic BP < or = 90 mm Hg) were similar with both treatment regimens (42% vs. 45% with the once- and twice-daily formulations, respectively). However, trandolapril twice daily exerted a significantly (P = 0.03) greater antihypertensive effect on systolic BP during sleep as compared with the once-daily formulation. Due to the fact that the minimal effective dose was used in this trial, further studies with higher doses should demonstrate effective 24-hour control of BP as described with other long-acting ACE inhibitors. In addition, our results suggest that ambulatory BP measurements should be done in dose-response studies.

A Tsunami Deposit at the Cretaceous-Tertiary Boundary in Texas

At sites near the Brazos River, Texas, an iridium anomaly and the paleontologic Cretaceous-Tertiary boundary directly overlie a sandstone bed in which coarse-grained sandstone with large clasts of mudstone and reworked carbonate nodules grades upward to wave ripple-laminated, very fine grained sandstone. This bed is the only sandstone bed in a sequence of uppermost Cretaceous to lowermost Paleocene mudstone that records about 1 million years of quiet water deposition in midshelf to outer shelf depths. Conditions for depositing such a sandstone layer at these depths are most consistent with the occurrence of a tsunami about 50 to 100 meters high. The most likely source for such a tsunami at the Cretaceous-Tertiary boundary is a bolidewater impact.

[Neonatal bilateral interstitial emphysema. Surgical treatment. Apropos of 1 case]

The authors report a case of respiratory distress secondary to inhalation of meconial amniotic fluid treated by mechanical ventilation, which was complicated by severe interstitial emphysema. Treatment by pleurotomy allowed a favorable evolution. The various therapies of interstitial emphysema of the neonate, in particular surgical technics are described.

Effects of prematurity and dysmaturity on growth at age 5 years

Forty-two term and 106 preterm appropriate for gestational age (AGA), and 43 term and 31 preterm small for gestational age (SGA) children were observed from birth to age 5 years. Parents' weight and height were also measured in 193 subjects including 97 couples. The percentage of short children was higher in SGA (17%) than in AGA (3.4%) children (P less than 0.01). This difference was significant in the preterm but not in the term children, suggesting that early failure of growth in utero can result in reduced growth in children. The findings were similar for weight and head circumference, but microcephaly was more frequent in term SGA (30%) than in preterm SGA (6.4%) children (P less than 0.05), suggesting that late impaired growth in utero can result in poor growth of the head. Height at the age of 5 years correlated with the parents' height only in AGA children, and with length at birth in SGA children. Weight of the 5-year-old children correlated with the mother's weight only in AGA children. Multivariate analysis in 66 couples and their children confirmed a greater tendency toward the influence of parental factors in AGA children and a more significant relationship with perinatal factors in SGA children.

[Anatomical study of the kidneys of newborn infants dying after a septic state]

Over a 6 years period, 51 autopsies have been performed in infants dead after severe sepsis. One third of them had renal damages, consisting mainly in haemorrhagic infiltration. Pathological and clinical data are not always well correlated, but some parameters may enhance a poorer renal prognosis, such as the duration of shock and anuria, or exchange transfusion. The clinical presentation of the infection and the encountered germs are the same in both groups, with or without renal damage. A better management of intensive haemodynamic cares in these neonates increases their survival rate and raises the problem of chronic renal failure or hypertension in this situation. It seems very useful to state precisely the surveillance and protection of the renal function in such patients.