Common femoral arterial access and arteriography in infants: Principles, pearls, and pitfalls

Infant femoral arterial access is an essential part of interventional procedures, hemodynamic monitoring, and support of critically ill patients. Due to small luminal diameter, superficial location, mobility, and increased risk of vasospasm, dissection, and thrombosis, femoral artery access in the infant is a technically demanding procedure. The purpose of this manuscript is to describe an approach to successful common femoral arterial access and arteriography in infants including common pearls and pitfalls.

Pedi-R-MAPP | the development, testing, validation, and refinement of a digital nutrition awareness tool

BACKGROUND & AIMS

The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments and provide practical guidance for nutritional care. R-MAPP was adapted into Pediatric Remote Malnutrition Application (Pedi-R-MAPP) using a modified Delphi consensus, with the goal of providing a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. The aim of this study was to develop and validate a digital version of Pedi-R-MAPP using the IDEAS framework (Integrate, Design, Assess and Share).

METHODS

A ten-step process was completed using the IDEAS framework. This involved the four concept processes; Stage-1, Integrate (Step 1-3) identify the problem, specify the goal, and use an evidence-based approach. Stage-2, (Step 4-7) design iteratively and rapidly with user feedback. Stage 3, (Step 8-9) Assess rigorously, and Stage 4 (Step 9-10) publish and launch of the tool.

RESULTS

Stage 1:Evidence-based development, Pedi-R-MAPP was developed using Delphi consensus methodology. Stage 2:Iteration & design, HCPs (n = 22) from UK, Europe, South Africa, and North America were involved four workshops to further develop a paper prototype of the tool and complete small-scale testing of a beta version of the tool which resulted in eight iterations. Stage 3:Assess rigorously, Small scale retrospective testing of the tool on children with congenital heart disease (n = 80) was completed by a single researcher, with iterative changes made to improve agreement with summary advice. Large scale testing amongst (n = 745) children in different settings was completed by specialist paediatric dietitians (n = 15) advice who recorded agreement with the summary advice compared with their own clinical assessment. Paediatric dietitians were in overall agreement with the summary advice in the tool 86% (n = 640), compared to their own clinical practice. The main reasons for disagreement were i) frequency of planned review 57.1% (n = 60/105), ii) need for ongoing dietetic review due to chronic condition 20.0% (n = 21/105), iii) disagreement with recommendation for discharge 16.2% (n = 17/105) and iv) concerns with faltering growth and/or need for condition specific growth charts 6.7% (7/105). Iterative changes were made to the algorithm, leading to an improvement in agreement of the summary advice on re-evaluation to 98% (p=<0.0001).

CONCLUSION

A digital version of the Pedi-R-MAPP nutrition awareness tool was developed using the IDEAS framework. The summary advice provided by the tool achieved a high level of agreement when compared to paediatric dietetic assessment, by providing a structured approach to completing a remote nutrition focused assessment, along with identifying the frequency of follow-up or an in-person assessment.

Exploring the appearance of and messaging on antibiotics to address inappropriate antibiotic use - public and pharmacists views

Introduction

The purpose of medicines labelling and packaging is to provide clear unambiguous identification of the medicine and the conditions for its safe use, allowing patients to understand and act on the information.1 Inappropriate antibiotic usage, (deviation from directions provided to the patients by the prescriber, resulting in sub-optimal treatment) may result in exposing bacteria to sub-therapeutic plasma concentrations and/or environment, which are one of the main drivers of Antibiotic Resistance.2 A recent comprehensive analysis showed the global burden associated with drug-resistant infections in 2019 was an estimated 4.95 million deaths.3

Aim

To ascertain the support from pharmacists and the public and their perceptions on the likely barriers to harmonising or standardising physical appearance and/or messaging on antibiotic packaging to reduce inappropriate antibiotic usage.

Methods

This study received ethics approval from the University of Huddersfield. In partnership with NHS England Antimicrobial Stewardship lead for North-East and Yorkshire, two questionnaires (public and pharmacist) were piloted. The final version was transferred to Qualtrics (online questionnaire format). During a 5-week period public questionnaires were distributed via posters with QR codes and social media. Pharmacist questionnaires were emailed to consenting pharmacists (community, hospital, GP practice, industry) around Huddersfield, Doncaster, Rochdale, Dewsbury and Leeds. The data underwent descriptive statistical analysis.

Results

Inappropriate antibiotic usage (saving for future use) was admitted by 23.5% of the 174 public participants, sharing with others (2.5%), throwing their antibiotics in the bin (32.7%) and other inappropriate usage was reported. This compared to 22.2% returning antibiotics to the pharmacy for disposal. 100% of pharmacists (40) think inappropriate antibiotic use needs to be addressed; the majority of pharmacists (55.5%) and the public (61.4%) think a harmonised antibiotic appearance would reduce inappropriate use. ‘Putting the word “ANTIBIOTICS” on the packaging would improve antibiotic packaging appearance’ was the top improvement selected by pharmacists (38.3%) and public (35.3%). Pharmacists (38.9%) thought antibiotic manufacturers would be the greatest obstacle to harmonised packaging. The majority of public (70.5%) and pharmacists (85.3%) think a standardised messaging system would help reduce inappropriate antibiotic use. Both pharmacists (41.1%) and public (47%) highlighted that a standard leaflet for appropriate use could improve antibiotic use. Pharmacists (47.8%) thought that multiple stakeholders (e.g., MHRA, manufacturers, etc) would be the barriers to a standardised messaging.

Discussion/Conclusion

Inappropriate antibiotic use by individuals who re-use leftovers or share their antibiotics may result in a treatment failure and could to increase AMR. Improvements in antibiotic packaging and patient information leaflets with appropriate disposal instructions could help minimise AMR. Limitations of this study include the low number of practice and industrial pharmacist respondents compared to community and hospital pharmacists. Public and pharmacist respondents supported the wording “ANTIBIOTIC” on antibiotic packaging and a standardised leaflet covering increasing adherence and appropriate disposal of leftovers. This study warrants further evaluation with regulators, manufacturers and other key stakeholders.

References

1. HM Government. Best practice guidance on the labelling and packaging of medicines. Available from: https://www.gov.uk/government/publications/best-practice-in-the-labelling-and-packaging-of-medicines (Accessed: 10/09/22).

2. Gullberg, E., et al. Selection of resistant bacteria at very low antibiotic concentrations. PLoS Pathogens, 2011;7(7):e1002158. https://doi.org/10.1371/journal.ppat.1002158

3. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022. https://doi.org/10.1016/S0140-6736(21)02724-0.

351 PRIDE IN AGEING - DEVELOPING LGBTQ+ EDUCATION TO DRIVE INCLUSION IN OLDER PERSONS CARE

Background

Older LGBTQ+ people are more likely to have diminished support networks and increased health risk factors, creating a greater reliance on healthcare. Within the literature concerns are voiced that fear of discrimination leads to mistrust and therefore underutilisation of health and social services among older LGBTQ+ people, leading to a lack of understanding of the specific needs and experiences of this cohort of patients. This mistrust of healthcare professionals and systems can negatively impact upon quality of life as older LGBTQ+ people do not avail of the health and social services they need to age well.

Methods

The author attended an international workshop to hear first-hand the lived experiences of older LGBTQ+ people from five European countries. A systematic literature review was completed to gain greater understanding of the challenges and discrimination faced by older LGBTQ+ people while accessing health and social care services. The author then received training with a leading LGBTQ+ organisation in order to gain insights into the experiences and concerns of older LGBTQ+ people in Ireland. Practical learning was gained on how to foster inclusion, provide education and create change within older persons services. Staff and patient engagement, feedback and evaluation was used to establish requirements for education, training and service development.

Results

LGBTQ+ education and training was developed for all disciplines working across acute, rehabilitation and residential older persons services in a large academic teaching hospital. This education is now delivered monthly to drive inclusion in older persons care. Staff feel more equipped and confident to provide inclusive care. There has been improved staff well-being and pride as the hospital moves towards being an inclusive and safe space for all.

Conclusion

There is a need for sustained education and training to equip staff with the skills and confidence to provide inclusive care to older LGBTQ+ patients accessing health and social care services.

Genomic answers for children: Dynamic analyses of >1000 pediatric rare disease genomes

PURPOSE

This study aimed to provide comprehensive diagnostic and candidate analyses in a pediatric rare disease cohort through the Genomic Answers for Kids program.

METHODS

Extensive analyses of 960 families with suspected genetic disorders included short-read exome sequencing and short-read genome sequencing (srGS); PacBio HiFi long-read genome sequencing (HiFi-GS); variant calling for single nucleotide variants (SNV), structural variant (SV), and repeat variants; and machine-learning variant prioritization. Structured phenotypes, prioritized variants, and pedigrees were stored in PhenoTips database, with data sharing through controlled access the database of Genotypes and Phenotypes.

RESULTS

Diagnostic rates ranged from 11% in patients with prior negative genetic testing to 34.5% in naive patients. Incorporating SVs from genome sequencing added up to 13% of new diagnoses in previously unsolved cases. HiFi-GS yielded increased discovery rate with >4-fold more rare coding SVs compared with srGS. Variants and genes of unknown significance remain the most common finding (58% of nondiagnostic cases).

CONCLUSION

Computational prioritization is efficient for diagnostic SNVs. Thorough identification of non-SNVs remains challenging and is partly mitigated using HiFi-GS sequencing. Importantly, community research is supported by sharing real-time data to accelerate gene validation and by providing HiFi variant (SNV/SV) resources from >1000 human alleles to facilitate implementation of new sequencing platforms for rare disease diagnoses.

In vitro investigations of Staphylococcus aureus biofilms in physiological fluids suggest that current antibiotic delivery systems may be limited

Orthopaedic surgical site infections, especially when a hardware is involved, are associated with biofilm formation. Clinical strategies for biofilm eradication still fall short. The present study used a novel animal model of long-bone fixation with vancomycin- or gentamicin-controlled release and measured the levels of antibiotic achieved at the site of release and in the surrounding tissue. Then, using fluids that contain serum proteins (synovial fluid or diluted serum), the levels of vancomycin or gentamicin required to substantially reduce colonising bacteria were measured in a model representative of either prophylaxis or established biofilms. In the in vivo model, while the levels immediately adjacent to the antibiotic release system were up to 50× the minimal inhibitory concentration in the first 24 h, they rapidly dropped. At peripheral sites, values never reached these levels. In the in vitro experiments, Staphylococcus aureus biofilms formed in serum or in synovial fluid showed a 5-10 fold increase in antibiotic tolerance. Importantly, concentrations required were much higher than those achieved in the local delivery systems. Finally, the study determined that the staged addition of vancomycin and gentamicin was not more efficacious than simultaneous vancomycin and gentamicin administration when using planktonic bacteria. On the other hand, for biofilms, the staged addition seemed more efficacious than adding the antibiotics simultaneously. Overall, data showed that the antibiotics' concentrations near the implant in the animal model fall short of the concentrations required to eradicate biofilms formed in either synovial fluid or serum.

The V122I mutation in hereditary transthyretin-mediated amyloidosis is significantly associated with an increased incidence of polyneuropathy

Background

Hereditary transthyretin-mediated (hATTR) amyloidosis is a progressive, life-threatening disease caused by mutations in the transthyretin (TTR) gene. hATTR amyloidosis phenotypes can vary by patient and mutation. The V122I (Val122Ile; p.V142I) variant is one of the most common pathogenic TTR mutations, is primarily found in people of West African descent and has historically been associated with cardiomyopathy (CM).

Purpose

To characterize the cumulative incidence of diagnoses frequently seen with hATTR amyloidosis in V122I carriers and non-carriers in the UK Biobank (UKBB) and the Penn Medicine BioBank (PMBB).

Methods

UKBB and PMBB are prospective studies with ∼500,000 and ∼60,000 subjects, respectively. Clinical presentations frequently seen with hATTR amyloidosis were assessed using ICD10 diagnosis codes: G62–polyneuropathy (PN), I50 or I098–heart failure (HF), G560–carpal tunnel syndrome (CTS), I42–CM, and E85–amyloidosis. The cumulative incidence of diagnoses was estimated using Kaplan-Meier curves. Time to first hATTR amyloidosis-related diagnosis was compared between V122I carriers and non-carriers using Cox proportional hazards regression, controlling for age, sex, smoking, and genetic ancestry.

Results

Of the 6,062 unrelated black participants in the UKBB, 243 were V122I carriers. Only 0.8% of V122I carriers had a formal diagnosis of hATTR amyloidosis. V122I carriers were significantly more likely to have a PN diagnosis than non-carriers (p=6.35x10–5), a finding which was replicated in the PMBB. Of the ICD10 codes assessed, Cox proportional hazards regression revealed a significant association between V122I genotype and time to first diagnosis (p=2.6x10–5), with 11.1% of V122I carriers having at least one diagnosis during follow-up versus 4.9% of non-carriers. The calculated population attributable risk showed an excess risk of 16.7% for a PN diagnosis, 6.5% for HF, 4.1% for CTS, and 2.4% for CM in V122I carriers. The cumulative incidence of any hATTR amyloidosis-related diagnosis among V122I carriers by age 65 was 11.9% (95% CI=3.1–19.8%). The incidence increased to 37.4% (95% CI=20.5–50.7%) by age 75, which was significantly higher than non-carriers (13.8%, 95% CI=11.6–16%). Additionally, an assessment of the cumulative incidence of each diagnosis separately revealed that PN became more prevalent at younger ages, while HF and CM became more prevalent at older ages.

Conclusions

V122I carriers were significantly more likely to receive diagnoses frequently seen with hATTR amyloidosis than non-carriers. Although these diagnoses may not all be attributed to amyloidosis, the small fraction of patients diagnosed with hATTR amyloidosis suggests a potential underdiagnosis of disease. The V122I mutation has historically been associated with a cardiac phenotype, yet these data also suggest an increased incidence of PN. Increased vigilance for the mixed phenotype may lead to earlier diagnoses and treatment of V122I carriers.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Alnylam Pharmaceuticals

The genetic diversity of multiple sclerosis risk among Hispanic and African American populations living in the United States

BACKGROUND

Substantial progress has been made toward unraveling the genetic architecture of multiple sclerosis (MS) within populations of European ancestry, but few genetic studies have focused on Hispanic and African American populations within the United States.

OBJECTIVE

We sought to test the relevance of common European MS risk variants outside of the major histocompatibility complex (n = 200) within these populations.

METHODS

Genotype data were available on 2652 Hispanics (1298 with MS, 1354 controls) and 2435 African Americans (1298 with MS, 1137 controls). We conducted single variant, pathway, and cumulative genetic risk score analyses.

RESULTS

We found less replication than statistical power suggested, particularly among African Americans. This could be due to limited correlation between the tested and causal variants within the sample or alternatively could indicate allelic and locus heterogeneity. Differences were observed between pathways enriched among the replicating versus all 200 variants. Although these differences should be examined in larger samples, a potential role exists for gene-environment or gene-gene interactions which alter phenotype differentially across racial and ethnic groups. Cumulative genetic risk scores were associated with MS within each study sample but showed limited diagnostic capability.

CONCLUSION

These findings provide a framework for fine-mapping efforts in multi-ethnic populations of MS.

Fluid consumption, exercise, and cognitive performance

Laboratory evidence supports the notion that dehydration degrades exercise performance and impairs certain cognitive processes. The purpose of this study is to examine the effect of a voluntary versus a dictated drinking condition on exercise and cognitive performance. The study used a double-blind and paired design. Twenty male and female college students (10 women, 10 men) participated in an exercise protocol consisting of 1 hr of treadmill running followed by a high intensity portion continuing until voluntary exhaustion. The dictated drinking condition consisted of 900 ml of water equally distributed in 4 pre-prepared opaque bottles. At 15 min intervals the subject was instructed to drink the entire contents until the end of the 1 hr treadmill protocol. The voluntary drinking condition consisted of 225 ml of water within arm's reach of the subjects while on the treadmill. Exercise performance was significantly better (longer duration and faster speed) in the voluntary condition compared with the dictated condition. Cognitive test outcomes were not significantly different between drinking conditions. A difference in fluid absorption is a potential source of exercise impairment seen in the dictated fluid condition. The higher fluid consumption rate presumably would cause greater gastric and esophageal distention resulting in the diversion of blood flow from working muscles to the gastrointestinal system. In situations where dehydration is likely, drinking to recommended guidelines may protect individuals from dehydration and its negative effects. However, when dehydration is not likely, allowing an individual to follow voluntary drinking behavior is preferable for exercise performance.

Thirteen Patients with MAT1A Mutations Detected Through Newborn Screening: 13 Years' Experience

BACKGROUND

Methionine adenosyltransferase I/III (MATI/III) deficiency is the most common genetic cause of persistent isolated hypermethioninemia. Patients and Methods : This is a retrospective data analysis of 62 newborns with elevated methionine detected by newborn screening between January 2000 and June 2013. The clinical, biochemical, and molecular findings of a subset of these children with MAT1A mutations associated with MATI/III deficiency are presented.

RESULTS

Of the 62 newborns with elevated methionine, 12 were identified as having classical homocystinuria; 37 were false-positives; and 13 were found to have isolated persistent hypermethioninemia in the absence of biochemical markers of homocystinuria, abnormal liver function studies, or other causes of elevated methionine. These 13 individuals underwent genetic testing for changes in the MAT1A gene, associated with MATI/III deficiency. Three of 13 were found to have the common autosomal dominant R264H mutation, one was found to be a compound heterozygote for two novel pathogenic mutations, and three were found to be heterozygotes for previously reported mutations shown to cause autosomal recessive MATI/III deficiency when present in homozygous or a compound heterozygous configuration. The remaining six patients had variants of unknown clinical significance or novel mutations. For the majority of individuals, methionine persisted above the normal range but trended downward over time. None of these 13 individuals was started on a low-methionine diet, and all have age-appropriate growth and development.

CONCLUSION

These cases show that individuals with even single changes in the MAT1A gene may have elevations in methionine identified by newborn screening, which may persist for months after birth without any clinical consequences.

Opioid consumption following outpatient upper extremity surgery

PURPOSE

After elective outpatient upper extremity surgery, patients' need for opioid analgesic medication may be considerably less than typically dispensed. Our goal for this study was to evaluate pain control and quantify the amount of leftover pain medication.

METHODS

We recruited patients scheduled for elective outpatient upper extremity surgery, who met the inclusion criteria, to participate in a phone interview 7 to 14 days after surgery. Information collected included age, gender, procedure performed, analgesic medication and regimen prescribed, satisfaction with pain control, number of tablets remaining, reasons for not taking medication, other analgesic medications used, payer classification, and any adverse drug reactions.

RESULTS

A total of 287 eligible subjects consented to participate. Of these, 36 patients failed phone contact and 1 patient canceled surgery, which left 250 patients who completed the study. Oxycodone, hydrocodone, and propoxyphene accounted for over 95% of the prescription medications, with adequate pain control reported by 230 (92%) patients. Patients most frequently received 30 pills. Patients undergoing bone procedures reported the highest medication use (14 pills), whereas patients undergoing soft tissue procedures reported the lowest use (9 pills). Over half of the subjects reported taking the opioid medication for 2 days or less. Medicare patients consumed significantly less medication (7 pills, P < .05) than patients covered by all other types of insurance. Overall, patients consumed a mean of 10 opioid pills, whereas 19 pills per subject were reported unused, which resulted in 4,639 leftover tablets for the entire cohort.

CONCLUSIONS

Our data show that excess opioid analgesics are made available after elective upper extremity surgery and could potentially become a source for diversion. A prescription of 30 opioid pills for outpatient surgery appears excessive and unnecessary, especially for soft tissue procedures of the hand and wrist.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Fluvastatin and lovastatin inhibit granulocyte macrophage-colony stimulating factor-stimulated human eosinophil adhesion to inter-cellular adhesion molecule-1 under flow conditions

BACKGROUND

Eosinophil accumulation in the lung is an important feature of airway inflammation in asthma. There is therefore much interest in developing novel therapies to prevent this process. Accumulating evidence suggests that statins have anti-inflammatory properties, including inhibition of leucocyte accumulation. We therefore assessed the ability of five statins to inhibit human eosinophil adhesion to recombinant human inter-cellular adhesion molecule (rhICAM)-1 under physiologically relevant flow conditions.

METHODS

Purified eosinophils were pre-treated with a panel of statins before elucidation of the adhesion profiles of resting and granulocyte macrophage-colony stimulating factor (GM-CSF)-stimulated cells to rhICAM-1-coated microchannels at a flow rate of 0.5 dynes/cm(2). Images were recorded in real-time at 1 min intervals and analysed using Ducocell software.

RESULTS

Fluvastatin and lovastatin (both 10 nm) significantly inhibited GM-CSF-stimulated eosinophil adhesion to rhICAM-1 after 2 min (34.4+/-3.0% inhibition and 37.8+/-12.6% inhibition, respectively, n=4, P<0.05) but had no significant inhibitory effect on unstimulated eosinophil adhesion. Mevastatin, simvastatin, and pravastatin (all 10 nm) had no significant effect on GM-CSF-stimulated eosinophil adhesion to rhICAM-1. A concentration range of fluvastatin and lovastatin inhibited GM-CSF stimulated eosinophil adhesion with significant (P<0.05) inhibition observed at low concentrations of 1 nm for both drugs. Mevalonate (100 nm) reversed fluvastatin-mediated but not lovastatin-mediated inhibition of eosinophil adhesion.

CONCLUSIONS

Inhibition of eosinophil adhesion to ICAM-1 by fluvastatin and lovastatin under physiological shear stress represent novel actions by these drugs that may inform the development of anti-inflammatory therapy for allergic disease.

Impact of emergency admissions on elective surgical workload

BACKGROUND

Day case surgery is the most cost-effective approach for all minor, most intermediate and some major surgery.

AIMS

To examine the effect of the current 'escalation' policy of opening the surgical day ward to A&E admissions at the expense of planned surgery.

PATIENTS AND METHODS

A retrospective study was carried out on all elective general surgical operations planned for January through March 2003. The number of cases cancelled and the reasons for cancellation were documented.

RESULTS

The total number of patients booked for surgery was 836, 66.6% of which were day cases (557 patients). Overall 338 patients accounting for 40.4% of all planned cases were cancelled. Day case cancellations accounted for 68.9% of all cancellations (233 patients). Bed unavailability was the main reason due to the overflow of A&E admissions, accounting for 92% of cancelled patients and 73.8% of day ward cancellations.

CONCLUSIONS

The cancellation of surgery creates untold hardship for patients who plan their working and family lives around the proposed operation date. Most are cancelled at less than 24 hours notice. The cost implications to the community are immense but have not been calculated. The separation of emergency and planned surgery is essential through adequate observation ward access.

Lessons for increasing awareness and use of booster seats in a Latino community

OBJECTIVES

Latino children are more likely to be unrestrained passengers in motor vehicles than non-Latino children, but little is known about the use of booster seats in Latino families. This study investigates Latino parents' knowledge, attitudes and beliefs about booster seats, barriers to booster seat use, and effective strategies for message delivery in the Latino community.

METHODS

Two focus groups were conducted with Spanish speaking parents. Information was obtained through a written survey and moderated discussions.

RESULTS

Parents were widely misinformed about recommended guidelines for booster seat use, and the majority of participants did not own a booster seat. Parents identified a lack of information, the cost of booster seats, resistance to use by the child or the father, limited space in the vehicle, and unavailability of shoulder belts as barriers to booster seat use. Participants felt that learning more about the new Washington state booster seat law and its consequences would increase booster seat use. Public health messages felt to be effective were those in Spanish, delivered by credible spokespeople such as physicians and teachers, and utilizing the Spanish media.

CONCLUSIONS

Campaigns to promote booster seats in the Latino community should be culturally specific, and clear guidelines for booster seat use should be given in Spanish. Legislation may be an important incentive for using booster seats, though reducing their cost and providing strategies to address child resistance and physical constraints of some vehicles are also important.

Isolation of a murine homologue of the Drosophila neuralized gene, a gene required for axonemal integrity in spermatozoa and terminal maturation of the mammary gland

The Drosophila neuralized gene shows genetic interactions with Notch, Enhancer of split, and other neurogenic genes and is thought to be involved in cell fate specification in the central nervous system and the mesoderm. In addition, a human homologue of the Drosophila neuralized gene has been described as a potential tumor suppressor gene in malignant astrocytomas. We have isolated a murine homologue of the Drosophila and human Neuralized genes and, in an effort to understand its physiological function, derived mice with a targeted deletion of this gene. Surprisingly, mice homozygous for the introduced mutation do not show aberrant cell fate specifications in the central nervous system or in the developing mesoderm. This is in contrast to mice with targeted deletions in other vertebrate homologues of neurogenic genes such as Notch, Delta, and Cbf-1. Male Neuralized null mice, however, are sterile due to a defect in axoneme organization in the spermatozoa that leads to highly compromised tail movement and sperm immotility. In addition, female Neuralized null animals are defective in the final stages of mammary gland maturation during pregnancy.

Abnormal vitamin levels in patients receiving home total parenteral nutrition

The administration of multivitamins to patients receiving home parenteral nutrition (HPN) was decreased from once daily to three times weekly during the parenteral multivitamin shortage in 1997. Blood vitamin levels were measured to examine whether the decrement in the infused vitamins affected the levels. Six patients with normal renal and liver function, receiving HPN for 6 months to 10 years, were studied 6 months after the institution of 10 mL of multivitamins thrice weekly. Two patients with renal insufficiency who required hemodialysis and HPN were also studied. Multivitamin administration was eliminated in one patient and was reduced to once weekly when elevated pyridoxine levels were found in association with possible neurotoxicity. Five of the six patients with normal renal function had low serum ascorbic acid levels. Serum riboflavin levels were found to be low in one patient, serum pyridoxine was low in one, serum retinoids were low in three, and serum niacin was low in one. There were no clinically obvious untoward effects caused by the vitamin deficiencies. Each of the dialysis patients had elevated serum pyridoxine levels and had some neurologic disturbance (peripheral neuropathy, involuntary movements). The serum pyridoxine levels fell to normal in each after the cessation or decrease of the multivitamin preparation. Ascorbic acid levels were low in one patient and fell into abnormally low levels in the other when the parenteral multivitamins were reduced, but they corrected with the separate administration of intravenous vitamin C. In conclusion, the reduced administration of multivitamins in 1997 resulted in diminished ascorbic acid levels in seven of eight patients receiving total parenteral nutrition. Less often, low levels of retinoids, niacin, pyridoxine, and riboflavin were seen. Patients with chronic renal failure receiving HPN with multivitamins may develop elevated pyridoxine levels, which might result in neurologic sequelae.

Growth and development in preterm infants fed long-chain polyunsaturated fatty acids: a prospective, randomized controlled trial

OBJECTIVES

A randomized, masked, controlled trial was conducted to assess effects of supplementing premature infant formulas with oils containing the long-chain polyunsaturated fatty acids, arachidonic acid (AA; 20:4 n6), and docosahexaenoic acid (DHA; 22:6 n3) on growth, visual acuity, and multiple indices of development.

METHODS

Infants (N = 470) with birth weights 750 to 1800 g were assigned within 72 hours of the first enteral feeding to 1 of 3 formula groups with or without long-chain polyunsaturated fatty acids: 1) control (N = 144), 2) AA+DHA from fish/fungal oil (N = 140), and 3) AA+DHA from egg-derived triglyceride (egg-TG)/fish oil (N = 143). Infants were fed human milk and/or Similac Special Care with or without 0.42% AA and 0.26% DHA to term corrected age (CA), then fed human milk or NeoSure with or without 0.42% AA and 0.16% DHA to 12 months' CA. Infants fed exclusively human milk to term CA (EHM-T; N = 43) served as a reference.

RESULTS

Visual acuity measured by acuity cards at 2, 4, and 6 months' CA was not different among groups. Visual acuity measured by swept-parameter visual-evoked potentials in a subgroup from 3 sites (45 control, 50 AA+DHA [fish/fungal]; 39 AA+DHA [egg-TG/fish]; and 23 EHM-T) was better in both the AA+DHA (fish/fungal; least square [LS] means [cycle/degree] +/- standard error [SE; octaves] 11.4 +/- 0.1) and AA+DHA (egg-TG/fish; 12.5 +/- 0.1) than control (8.4 +/- 0.1) and closer to that of the EHM-T group (16.0 +/- 0.2) at 6 months' CA. Visual acuity improved from 4 to 6 months' CA in all but the control group. Scores on the Fagan test of novelty preference were greater in AA+DHA (egg-TG/fish; LS means +/- SE, 59.4 +/- 7.7) than AA+DHA (fish/fungal; 57.0 +/- 7.5) and control (57.5 +/- 7.4) at 6 months' CA, but not at 9 months' CA. There were no differences in the Bayley Mental Development Index at 12 months' CA. However, the Bayley motor development index was higher for AA+DHA (fish/fungal; LS means +/- SE, 90.6 +/- 4.4) than control (81.8 +/- 4.3) for infants </=1250 g. When Spanish-speaking infants and twins were excluded from the analyses, the MacArthur Communicative Development Inventory revealed that control infants (LS means +/- SE, 94.1 +/- 2.9) had lower vocabulary comprehension at 14 months' CA than AA+DHA (fish/fungal) infants (100.6 +/- 2.9) or AA+DHA (egg-TG/fish) infants (102.2 +/- 2.8). There were no consistent differences in weight, length, head circumference, or anthropometric gains.

CONCLUSION

These results showed a benefit of supplementing formulas for premature infants with AA and DHA from either a fish/fungal or an egg-TG/fish source from the time of first enteral feeding to 12 months' CA.

The small GTPase Rab4A interacts with the central region of cytoplasmic dynein light intermediate chain-1

Rab4 belongs to the Rab family of small GTPases involved in the regulation of intracellular transport, and has been localized to early endosomes. We have employed the yeast two-hybrid system to identify proteins that specifically interact with Rab4AQ67L, a GTPase-deficient mutant form of Rab4A. Screening a mouse embryo cDNA library identified a clone (M449) that interacted with Rab4A in a nucleotide-dependent fashion. Data base searches identified this clone as the mouse cytoplasmic dynein light intermediate chain-1 (LIC-1). Based on this finding, the full-length equivalent human cytoplasmic dynein LIC-1 was isolated by PCR. When Rab4A was overexpressed together with either M449 or dynein LIC-1 in HeLa cells, the proteins were found to colocalize in the perinuclear region. We characterize the localization of both overexpressed human dynein LIC-1 and the endogenous protein with respect to microtubules and show that it concentrates to the microtubule-organizing center and mitotic spindle. Additionally, GFPRab4A endosomes localize to microtubules and are redistributed by nocodazole treatment. This is the first described interaction between cytoplasmic dynein, a retrograde motor protein, and a Rab protein.

Ras pathway signals are required for notch-mediated oncogenesis

The Notch genes of C. elegans, Drosophila melanogaster and vertebrates encode receptors responsible for cell fate decisions during development. These Notch receptors and their ligands, Delta and Jagged, have been implicated in several human diseases. Truncated, constitutively active mutant forms of the Notch receptor appear to be involved in human T-cell leukemia, mammary carcinomas in mice, and a tumorous germline phenotype in C. elegans. Since activated Notch induces solitary tumors in transgenic mice, it is highly likely that collaborating genetic events are required for tumor formation. We have assessed four signal transduction pathways to determine which might play additional roles in malignant transformation in concert with activated Notch4. Our results suggest that transformation by Notch does not, as might have been expected, depend on the Src-like kinases Lck and Fyn, nor upon signals from protein kinase A and C (PKA, PKC). Rather, transformation by Notch requires active signals from the Erk/MAP kinase and PI-3 kinase pathways downstream of Ras. Oncogene (2000) 19, 4191 - 4198

Electroretinography is necessary for spasmus nutans diagnosis

The purpose of the present study was to determine whether that which clinically appeared to be spasmus nutans could actually represent retinal sensory deficits diagnosable by electroretinography. Eight patients clinically thought to have spasmus nutans underwent electroretinography according to international standards. Five had normal electroretinograms and represented cases of true spasmus nutans. Three patients had abnormal electroretinograms, indicating that they did not have spasmus nutans. The clinical findings used to diagnose spasmus nutans can be simulated by retinal dystrophies. A normal electroretinogram is needed to confirm the diagnosis of spasmus nutans.

Hypermanganesemia in patients receiving total parenteral nutrition

BACKGROUND

Manganese is one of the trace elements that is routinely administered to total parenteral nutrition (TPN) patients. The recommended daily IV dosage ranges from 100 to 800 MICROg. We have used 500 microg daily. Recent reports have suggested neurologic symptoms seen in some patients receiving home parenteral nutrition (HPN) may be due to hypermanganesemia. Therefore, HPN patients and some short-term inpatients receiving TPN were studied to ascertain the relationship between dose and blood levels.

METHODS

Red blood cell manganese levels were obtained by atomic absorptiometry.

RESULTS

The levels in 36 hospitalized, short-term patients obtained within 48 hours of initiating TPN were all normal. The 30 patients receiving TPN from 3 to 30 days had levels that ranged from 4.8 to 28 microg/L (normal, 11 to 23 microg/L). Two patients had abnormal levels, at days 14 and 18. Fifteen of the 21 patients receiving inpatient TPN or HPN for 36 to 5075 days had elevated Mn levels. Only one patient with hypermanganesemia, an inpatient, had abnormal biochemical liver tests (bilirubin and alkaline phosphatase). One of the patients with a high level had some vestibular symptoms attributed to aminoglycoside use and had increased signal density in the globus pallidus on T1-weighted images on magnetic resonance imaging (MRI). A second patient with Mn levels twice normal had no neurologic symptoms, but had similar MRI findings. A third had some basal ganglia symptoms, confirmed by a neurologic evaluation, seizures, and very high Mn levels. The MRI showed no signal enhancement, but motion artifacts limited the study technically.

CONCLUSIONS

Hypermanganesemia is seen in HPN patients receiving 500 microg manganese daily and may have resulted in some neurologic damage in three patients. Hypermanganesemia is sometimes seen after a short course of TPN in inpatients, as early as 14 days. Patients should be monitored for hypermanganesemia if they receive Mn in their TPN for >30 days. A 500 microg/d dose of Mn is probably excessive, and 100 microg/d should probably never be exceeded. Mn should be eliminated from the solution if the Mn level is elevated and should not be readministered unless the level returns to normal or subnormal. Mn should not be supplemented if the patient has liver disease with an elevated bilirubin.

Association of compartment defects in pelvic floor dysfunction

OBJECTIVE

Dynamic cystoproctography was used to determine the frequency of associated urinary, genital, and anorectal abnormalities in women with pelvic floor dysfunction.

SUBJECTS AND METHODS

We categorized, by pelvic floor compartments, the symptoms at presentation of 100 consecutive female patients who had been referred for dynamic cystoproctography. We then analyzed the compartment defects seen on dynamic cystoproctography relative to those detected on clinical presentation.

RESULTS

Of the 20 patients with symptoms of anterior compartment (urinary) defect, dynamic cystoproctography revealed that 45% had vaginal vault prolapse of more than 50% and that 90% had rectoceles. Of the 45 patients with symptoms of middle compartment (genital) defect, dynamic cystoproctography revealed that 91% had cystoceles, 56% had a hypermobile bladder neck, 82% had rectoceles, 58% had enteroceles, 11% had sigmoidoceles, 20% had rectoanal intussusception, and 16% had anal incontinence. Of the 17 patients with symptoms of posterior compartment (anorectal) defect, dynamic cystoproctography showed that 71% had cystoceles, 65% had a hypermobile bladder neck, and 35% had vaginal vault prolapse of more than 50%. Of the 18 patients with symptoms of defects from a combination of compartments, dynamic cystoproctography revealed that 89% had cystoceles, 56% had a hypermobile bladder neck, 39% had vaginal vault prolapse exceeding 50%, 100% had rectoceles (of which 45% were large), 6% had enteroceles, 6% had sigmoidoceles, 22% had rectoanal intussusception, and 6% had anal incontinence.

CONCLUSION

Although patients may present with symptoms that involve only one compartment, a multicompartment prolapse is usually revealed on dynamic cystoproctography. Of the patients with pelvic floor dysfunction, 95% had abnormalities in all three compartments.

Clinical benchmarking: implications for perinatal nursing

Health care is a dynamic environment where expectations of quality must be balanced with appropriateness of treatment and cost of care. Managers often have inadequate information on which to base decisions, policy, and practice. Clinical benchmarking is a tool and a process of continuously comparing the practices and performances of one's operations against those of the best in the industry or the focused area of service and then using that information to enhance and improve performance and productivity. The article discusses the advantages and disadvantages of benchmarking as well as the factors influencing the need for such tools in health care and in perinatal nursing.

GATA-6 stimulates a cell line-specific activation element in the human lactase promoter

Lactase-phlorizin hydrolase (LPH) synthesis is restricted to differentiated small intestinal enterocytes and is highly regulated during development. Analysis of expression of LPH promoter segments fused with luciferase transfected in Caco-2 cells, a line that uniquely expresses LPH mRNA, mapped an 18-base pair (bp) segment 100 bp upstream of the transcription start site that is required for transactivation. Remarkably, the LPH upstream element (LUE) has no stimulatory activity in both human intestinal and nonintestinal lines in which LPH mRNA is absent. Electrophoretic analysis of sequence-specific DNA-nuclear protein complexes demonstrated the presence of a Caco-2 cell-specific protein(s) (CCP), which is uniformly absent in LPH nonproducer cell lines. Mutational analysis of the LUE demonstrated that bases contained within a GATA consensus motif are critical for both CCP binding and transcription from the LPH promoter. Caco-2 cells express high levels of GATA-6 mRNA in a cell line-specific manner, suggesting that GATA-6 is a CCP that complexes with the LUE. When expressed by a plasmid, GATA-6 transactivated the LPH promoter. The stimulation was abrogated with mutations in the GATA consensus motif as well as mutations in a flanking downstream element. These studies are consistent with an important role of an intestinal GATA binding protein in cell type-specific transactivation of the LPH promoter.

The safety of ranitidine in over a decade of use

BACKGROUND

Ranitidine hydrochloride (Zantac) is one of the most extensively studied and widely used drugs of all time. This has provided an excellent opportunity to define its safety profile.

METHODS

Data from 189 controlled clinical trials in which more than 26,000 patients received daily doses of ranitidine for 4 weeks or more were reviewed. More than 80% of patients were treated with up to 300 mg ranitidine daily; the remaining patients received doses of up to 1200 mg daily. Eighty-seven trials were placebo controlled. Analyses of post-marketing surveillance and a database of all spontaneously reported adverse events were also evaluated.

RESULTS

Overall in the clinical trial programme adverse events were reported by 20% of those receiving ranitidine compared with 27% of those receiving placebo. The pattern of events was similar in all treatment groups with no evidence of dose-related toxicity in regimens encompassing an eightfold range of therapeutic doses. Similarly in a programme of studies designed to evaluate a dose of ranitidine of 75 mg for non-prescription (over-the-counter) use in the treatment of heartburn, ranitidine was not associated with an adverse event profile distinct from that of placebo. Analysis of spontaneously reported adverse event data allowed identification of rare idiosyncratic events.

CONCLUSIONS

Review of data from a large population of controlled clinical trials with analyses of postmarketing surveillance studies and spontaneously reported adverse events confirmed the excellent safety profile of ranitidine.

Interchangeability of Caenorhabditis elegans DSL proteins and intrinsic signalling activity of their extracellular domains in vivo

Ligands of the Delta/Serrate/lag-2 (DSL) family and their receptors, members of the lin-12/Notch family, mediate cell-cell interactions that specify cell fate in invertebrates and vertebrates. In C. elegans, two DSL genes, lag-2 and apx-1, influence different cell fate decisions during development. Here we show that APX-1 can fully substitute for LAG-2 when expressed under the control of lag-2 regulatory sequences. In addition, we demonstrate that truncated forms lacking the transmembrane and intracellular domains of both LAG-2 and APX-1 can also substitute for endogenous lag-2 activity. Moreover, we provide evidence that these truncated forms are secreted and able to activate LIN-12 and GLP-1 ectopically. Finally, we show that expression of a secreted DSL domain alone may enhance endogenous LAG-2 signalling. Our data suggest ways that activated forms of DSL ligands in other systems may be created.