A commentary on the healthcare transition policy landscape for youth with disabilities or chronic health conditions, the need for an inclusive and equitable approach, and recommendations for change in Canada

There is a growing number of youth with healthcare needs such as disabilities or chronic health conditions who require lifelong care. In Canada, transfer to the adult healthcare system typically occurs at age 18 and is set by policy regardless of whether youth and their families are ready. When the transition to adult services is suboptimal, youth may experience detrimental gaps in healthcare resulting in increased visits to the emergency department and poor healthcare outcomes. Despite the critical need to support youth with disabilities and their families to transition to the adult healthcare system, there is limited legislation to ensure a successful transfer or to mandate transition preparation in Canada. This advocacy and policy planning work was conducted in partnership with the Patient and Family Advisory Council (PFAC) within the CHILD-BRIGHT READYorNot™ Brain-Based Disabilities (BBD) Project and the CHILD-BRIGHT Policy Hub. Together, we identified the need to synthesize and better understand existing policies about transition from pediatric to adult healthcare, and to recommend solutions to improve healthcare access and equity as Canadian youth with disabilities become adults. In this perspective paper, we will report on a dialogue with key informants and make recommendations for change in healthcare transition policies at the healthcare/community, provincial and/or territorial, and/or national levels.

Bone marrow-derived stem/stromal cells (BMSC) 3D microtissues cultured in BMP-2 supplemented osteogenic induction medium are prone to adipogenesis

Bone marrow-derived mesenchymal stem/stromal cells (BMSC) may facilitate bone repair through secretion of factors that stimulate endogenous repair processes or through direct contribution to new bone through differentiation into osteoblast-like cells. BMSC microtissue culture and differentiation has been widely explored recently, with high-throughput platforms making large-scale manufacture of microtissues increasingly feasible. Bone-like BMSC microtissues could offer an elegant method to enhance bone repair, especially in small-volume non-union defects, where small diameter microtissues could be delivered orthoscopically. Using a high-throughput microwell platform, our data demonstrate that (1) BMSC in 3D microtissue culture result in tissue compaction, rather than growth, (2) not all mineralised bone-like matrix is incorporated in the bulk microtissue mass and (3) a significant amount of lipid vacuole formation is observed in BMSC microtissues exposed to BMP-2. These factors should be considered when optimising BMSC osteogenesis in microtissues or developing BMSC microtissue-based therapeutic delivery processes.

Head and neck cancer in South Asia: Macroeconomic consequences and the role of the head and neck surgeon

BACKGROUND

Head and neck cancer constitutes a substantial portion of the burden of disease in South Asia, and there is an undersupply of surgical capacity in this region. The purpose of this study was to estimate the economic welfare losses due to head and neck cancer in India, Pakistan, and Bangladesh in 2010.

METHODS

We used publicly available estimates of head and neck cancer morbidity and mortality along with a concept termed the value of a statistical life to estimate economic welfare losses in the aforementioned countries in 2010.

RESULTS

Economic losses because of head and neck cancer in India, Pakistan, and Bangladesh totaled $16.9 billion (2010 US dollars [USD]), equivalent to 0.26% of the region's economic output. Bangladesh, the poorest country, experienced the greatest proportional losses.

CONCLUSION

The economic consequences of head and neck cancer in South Asia are significant, and building surgical capacity is essential to begin to address this burden. © 2016 Wiley Periodicals, Inc. Head Neck 38:1242-1247, 2016.

Skull base erosion and associated complications in sphenoid sinus fungal balls

BACKGROUND

Sphenoid sinus fungal balls (SSFB) are rare entities that can result in serious orbital and intracranial complications. There are few published reports of complications that result from SSFB.

OBJECTIVE

To review the incidence of skull base erosion and orbital or intracranial complications in patients who present with SSFB.

METHODS

A retrospective review was performed of all the patients with SSFB who were treated at the Massachusetts Eye and Ear Infirmary from 2006 to 2014. Presenting clinical data, radiology, operative reports, pathology, and postoperative course were reviewed.

RESULTS

Forty-three patients with SSFB were identified. Demographic data were compared between patients with (39.5%) and those without (61.5%) skull base erosion. Two patients underwent emergent surgery for acute complications of SSFB (one patient with blindness, one patient who had a seizure). Both patients with acute complications had evidence of skull base erosion, whereas no patients with an intact skull base developed an orbital or intracranial complication (p = 0.15). All the patients were surgically managed via an endoscopic approach.

CONCLUSION

SSFBs are rare but may cause significant skull base erosion and potentially severe orbital and intracranial complications if not treated appropriately. Endoscopic sphenoidotomy is effective in treating SSFB and should be performed emergently in patients who presented with associated complications.

Head and neck cancer in South Asia: macroeconomic consequences and the role of surgery

BACKGROUND

Head and neck cancer, for which the diagnosis and treatment are often surgical, comprises a substantial proportion of the burden of disease in South Asia. Further, estimates of surgical volume suggest this region faces a critical shortage of surgical capacity. We aimed to estimate the total economic welfare losses due to the morbidity and mortality of head and neck cancer in India, Pakistan, and Bangladesh for 1 year (2010).

METHODS

We used publicly available estimates from the Institute for Health Metrics and Evaluation regarding the morbidity and mortality of head and neck cancer in India, Pakistan, and Bangladesh, along with an economic concept termed the value of a statistical life, to estimate total economic welfare losses due to head and neck cancer in the aforementioned countries in the year 2010. The counterfactual scenario is absence of disease. Sensitivity analyses were done with regard to how the value of a statistical life changes with income.

FINDINGS

In 2010, the most conservative estimate of economic welfare losses due to head and neck cancer in the three studied countries is US$16·9 billion (2010 USD, PPP), equivalent to 0·26% of their combined gross domestic product (GDP). The welfare losses experienced by the population younger than 70 years of age accounted for US$15·2 billion (90% of the total losses). When adjusted for the size of their respective economies, Bangladesh, the poorest of the three countries, incurred the greatest loss (US$930 million), equivalent to 0·29% of its GDP. India and Pakistan experienced welfare losses of US$14·1 billion and US$1·9 billion, respectively. These figures are equivalent to 0·26% of the GDP for both countries. Oropharyngeal and hypopharyngeal cancer made up the largest share of the total burden at 39% (US$6·6 billion), followed closely by oral cavity cancer at 34% (US$5·7 billion).

INTERPRETATION

The burden of non-communicable diseases, to which cancer contributes greatly, is growing at a rapid pace in South Asia. Head and neck cancer is a leading cause of cancer-related mortality in this region, and this study suggests that the associated economic welfare losses, estimated to be US$16·9 billion in 2010 alone, are substantial. A number of strategies are available to address this burden. Surgery, as part of a multidisciplinary approach that includes radiation therapy and chemotherapy, plays a central part in the diagnosis and treatment of head and neck cancer, and building surgical capacity, which offers large economies of scope and scale, can not only address the burden of head and neck cancer, but also create a platform for beginning to confront the rising tide of non-communicable diseases.

FUNDING

None.

Stellar dynamics. The fastest unbound star in our Galaxy ejected by a thermonuclear supernova

Hypervelocity stars (HVSs) travel with velocities so high that they exceed the escape velocity of the Galaxy. Several acceleration mechanisms have been discussed. Only one HVS (US 708, HVS 2) is a compact helium star. Here we present a spectroscopic and kinematic analysis of US 708. Traveling with a velocity of ~1200 kilometers per second, it is the fastest unbound star in our Galaxy. In reconstructing its trajectory, the Galactic center becomes very unlikely as an origin, which is hardly consistent with the most favored ejection mechanism for the other HVSs. Furthermore, we detected that US 708 is a fast rotator. According to our binary evolution model, it was spun-up by tidal interaction in a close binary and is likely to be the ejected donor remnant of a thermonuclear supernova.

Delayed Endovascular Coil Extrusion following Internal Carotid Artery Embolization

Internal carotid artery injury is a rare and devastating complication of endoscopic sinus and skull base surgery that has an associated mortality rate of 15%. This case describes a patient who developed massive epistaxis following routine sinus surgery and was eventually diagnosed with a pseudoaneurysm of the cavernous internal carotid artery. Endovascular coiling and Onyx (Covidien, Irvine, California, United States) liquid embolization were ultimately used to completely occlude the internal carotid artery with resolution of bleeding; however, the patient had an unexpected late complication of coil extrusion through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. The endoscopic skull base team safely excised the coils endoscopically without recurrent bleeding. We describe the multidisciplinary operative management of this case of endovascular coil extrusion to increase awareness of this potentially life-threatening complication.

Outcomes of laparoscopic-assisted transhiatal esophagectomy for adenocarcinoma of the esophagus and esophago-gastric junction

Esophagectomy is associated with substantial morbidity and mortality, yet it is the only modality that offers the possibility of cure for esophageal and gastroesophageal junction (E-GEJ) adenocarcinoma. Several minimally invasive techniques have been developed to decrease the morbidity of the operation, but to date, the results have not led to its wide adoption in part due to their complexity. We developed a technique of laparoscopic-assisted transhiatal esophagectomy (LA-THE) with the idea of preserving some of the advantages of the minimally invasive approach while eliminating the degree of complexity and the time required to complete the operation solely using laparoscopy. The course of all patients who underwent LA-THE for E-GEJ adenocarcinoma at the University of Washington Medical Center was determined by analysis of all hospital records to determine perioperative variables, complications, and survival. Patients were also given a follow-up survey in order to assess long-term health-related quality of life (Gastrointestinal Quality of Life Index or GIQLI). Seventy-two patients underwent LA-THE between 1995 and 2007. Median age was 64 years (range, 42-83 years), and the median body mass index was 28 (range 17-35). Twenty-eight tumors (39%) were categorized as Siewert I, 41 (57%) as Siewert II, and 3 (4%) as Siewert III. Median operative time was 299min (range, 212-700min). All the resections were R-0. The median number of lymph nodes harvested was 11 (range, 2-32). Using the Dindo-Clavien classification of surgical complication, we had a total of 48 postoperative complications in 37 patients: 26 (53%) grade I, 20 (41%) grade II, 1 (2%) grade IIIb, 1 (2%) grade IVb, and 1 (2%) grade V complications. Median length of hospital stay was 9 days (range, 7-58 days). One patient (1.4%) died within 30 days. Overall, 3- and 5-year survival (calculated Kaplan-Meier) was 68% and 63%, respectively. Forty-nine patients (90% of those still alive) answered the GIQLI survey. Median follow-up was 26 months (range, 6-144 months). The mean GIQLI score was 108 (range, 74-138) from a maximum possible value of 144. Our study shows that LA-THE is feasible, safe, and effective in the treatment of adenocarcinoma of the esophagus and GEJ and should probably be considered an alternative to open esophagectomy and other minimally invasive techniques in the treatment of this disease.

Polarized fluid movement and not cell death, creates luminal spaces in adult prostate epithelium

There are two predominant theories for lumen formation in tissue morphogenesis; cavitation driven by cell death, and membrane separation driven by epithelial polarity. To define the mechanism of lumen formation in prostate acini we examined both theories in several cell lines grown in 3D Matrigel culture. Lumen formation occurred early in culture and preceded the expression of cell death markers for apoptosis (active caspase 3) and autophagy (LC-3). Active caspase 3 was expressed by very few cells and inhibition of apoptosis did not suppress lumen formation. Despite LC-3 expression in all cells within a spheroid, this was not associated with cell death. However, expression of the prostate secretory protein coincided with lumen formation and subsequent disruption of polarized fluid movement led to significant inhibition of lumen formation. This work indicates that lumen formation is driven by the polarized movement of fluids and proteins in 3D prostate epithelial models and not by cavitation.

Serum fibrosis markers can predict rapid fibrosis progression after liver transplantation for hepatitis C

Although recurrent hepatitis C virus (HCV) after liver transplantation (LT) is universal, a minority of patients will develop cirrhosis within 5 years of surgery, which places them at risk for allograft failure. This retrospective study investigated whether 2 serum fibrosis markers, serum hyaluronic acid (HA) and YKL-40, could be used to predict rapid fibrosis progression (RFP) post-LT. These markers were compared with conventional laboratory tests, histological assessment, and hepatic stellate cell activity (HSCA), a key step in fibrogenesis, as assessed by immunohistochemical staining for alpha-smooth muscle actin. Serum and protocol liver biopsy samples were obtained from 46 LT recipients at means of 5 +/- 2 (biopsy 1) and 39 +/- 6 (biopsy 2) months post-LT, respectively. RFP was defined as an increase in the fibrosis score >or= 2 from biopsy 1 to biopsy 2 (a mean interval of 33 +/- 6 months). The ability of parameters at biopsy 1 to predict RFP was compared with the areas under receiver operating characteristic curves (AUROCs). Of the 46 subjects, 15 developed RFP. Serum HA and YKL-40 performed significantly better than conventional parameters and HSCA in predicting RFP post-LT for HCV at biopsy 1, with AUROCs of 0.89 and 0.92, respectively. The accuracy of serum HA >or= 90 microg/L and YKL-40 >or= 200 microg/L in predicting RFP at biopsy 1 was 80% and 96%, respectively. In conclusion, we found that elevated levels of serum HA and YKL-40 within the first 6 months after LT accurately predicted RFP. Larger studies evaluating the role of serum HA and YKL-40 in post-LT management are warranted.

Use of a low pressure liquid chromatography system for haemoglobinopathy screening

A closed low pressure liquid chromatography system (LPLC) is described which is suitable for haemoglobinopathy screening. The system (Glycomat) was originally developed for the quantitation of the glycated haemoglobin (HbA1). The same biochemical principles have been applied to the separation of haemoglobin A2 (HbA2) and haemoglobin variants. The instrument offers three modes of use including a fast haemoglobin elution, a variant screen and a HbA2 assay for thalassaemia screening. The fast screen isolates all of the common haemoglobin variants except HbE which elutes with HbA. This mode is a more rapid alternative to the Sickledex test. The variant screen produces a wider separation of abnormal variants giving an identification and quantitation for each. The HbA2 assay separates this minor fraction from all other haemoglobins giving an accurate percentage. Abnormal variants are also separated. To validate the HbA2 assay 252 samples were assayed by the cellulose acetate electrophoresis/elution method and LPLC with a correlation of 0.932. The system provides an accurate and sensitive alternative to traditional manual chromatography and electrophoresis methods. The automated sampler allows batches from 1-99 samples to be processed with significant savings in operator time.

Diagnostic accuracy of self collected vaginal specimens for human papillomavirus compared to clinician collected human papillomavirus specimens: a meta-analysis

BACKGROUND/OBJECTIVES

Providing summary recommendations regarding self collection of vaginal specimens for human papillomavirus (HPV) testing is difficult owing to the wide range of published estimates for the diagnostic accuracy of this approach. To determine summary estimates from analyses of reported findings of the sensitivity, specificity and summary receiver operating characteristic curves (SROC) for self collected vaginal specimens for HPV testing compared to the reference standard, clinician collected HPV specimens.

METHODS

Standard search criteria for a diagnostic systematic review were employed. Eligible studies were combined using a random effects model and summary ROC curves were derived for overall and for specific subgroups.

RESULTS

Summary measures were determined from 12 studies. Six studies where patients used Dacron or cotton swabs or cytobrushes to obtain samples were pooled and had an overall sensitivity of 0.74 (95% CI 0.61 to 0.84) and specificity of 0.88 (95% CI 0.83 to 0.92), with diagnostic odds ratio of 22.3 and an area under the curve of 0.91. Self specimens using Dacron or cotton swabs or cytobrushes collected by women enrolled at referral clinics had an overall sensitivity of 0.81 (95% CI 0.65 to 0.91) and specificity of 0.90 (95% CI 0.80 to 0.95). Sensitivity and specificity of tampons ranged from 0.67-0.94 and 0.80-0.85 respectively.

CONCLUSIONS

Our findings indicate that the combined sensitivity for HPV-DNA is more than 70% when patients use Dacron swabs, cotton swabs, or cytobrushes to obtain their own vaginal specimens for HPV-DNA evaluation. Self collected HPV-DNA swabs may be an appropriate alternative for low resource settings or in patients reluctant to undergo pelvic examinations.

Clinical outcomes that fetal surgery for myelomeningocele needs to achieve

INTRODUCTION

The development of techniques to close open neural tube malformations prior to birth has generated great interest and hope for fetal interventions and their outcomes. To plan a randomized trial, as is being discussed at three centres in the United States, the determination of what constitutes a clinically significant improvement in outcome is critical. To date, preliminary observations from two centres suggest that improvements may occur, not in spinal cord function as originally postulated, but in the extent of the hindbrain hernia and the frequency that shunting is required to control hydrocephalus.

PURPOSE

The determination of what outcome would constitute an important and clinically significant difference in outcome to be achieved by fetal intervention for myelomeningocele.

METHOD

Parents of patients and patients treated in our myelomeningocele clinic were surveyed using a structured and validated tool. From the perspective of a recommendation to a close friend or family member, the interviewees were asked to quantify on a scale from 0 to 100 the chance of specific outcomes (need for a shunt, need for a wheelchair, change of urinary incontinence) that a fetal operation would need to predictably achieve.

RESULTS

Responses were obtained from 77 patients/families. The fifty percentile response in each study dimension was as follows: the chance of needing a shunt was 12 % (range 0 - 50 %), the chance of needing a wheelchair was 8 % and the chance of being incontinent was 5 % (range 0 - 25 %).

CONCLUSIONS

Fetal interventions will have to achieve significant improvements in the control of hydrocephalus, mobilization and continence over postnatal treatment to be justified.

The value of community mental health nurses based in primary care teams: 'switching the light on in a cellar'

This paper explores the impact of placing Community Mental Health Nurses (CMHNs) at two primary care practices in South Staffordshire. Data were collected by means of a questionnaire which was sent to primary care personnel at these practices, to ascertain their opinions with respect to the contribution of practice-based CMHNs. Overall, primary care personnel were satisfied with the quality of the service received from the CMHNs, especially in terms of improved communication. They felt that the new arrangements enabled a quicker and more efficient access to the services of the CMHN. The results are discussed in terms of the value of having CMHNs within the primary care setting, and in terms of service planning and future recommendations for mental health services within primary care.

Prescribing practices and attitudes toward giving children antibiotics

OBJECTIVE

To investigate whether overprescribing is common in treatment of pediatric upper respiratory infections and to examine factors that influence prescribing antibiotics for children.

DESIGN

A random, stratified sample of practising family physicians was surveyed with a mailed questionnaire. Initial nonresponders were mailed a second questionnaire.

SETTING

British Columbia.

PARTICIPANTS

A total of 608 general and family physicians. Response rate was 64%; 392/612 surveys were completed.

MAIN OUTCOME MEASURES

Physicians' self-reported prescribing practices and knowledge of and attitudes toward using antibiotics for children's upper respiratory tract infections.

RESULTS

Relative to treatment guidelines developed for the study, most physicians responded appropriately to the cough (94%) and lobar pneumonia (99.1%) vignettes. More than half the physicians (56.5%) reported they would immediately prescribe antibiotics for tympanic membrane dysfunction, and 79.4% indicated they would prescribe antibiotics for pharyngitis without obtaining a laboratory culture. Approximately 25% of physicians in the study did not believe that prior antibiotic use increased personal risk for acquiring drug-resistant infection, and 23.1% did not believe that antibiotic use was an important factor in promoting resistance in their communities.

CONCLUSION

Education in current treatment of pediatric upper respiratory tract illnesses and antimicrobial drug resistance is required. The high response to the questionnaire (64%) and the many requests from physicians to receive the project's educational materials (45%) indicate a high level of interest in this subject.

Divergent effects of 4-1BB antibodies on antitumor immunity and on tumor-reactive T-cell generation

4-1BB is an inducible receptor-like protein expressed rapidly by both CD4 and CD8 T-cells after activation. 4-1BB cross-linking, either by binding to 4-1BBL or by antibody ligation, delivers a costimulatory signal to enhance T-cell activation and proliferation. Previous studies have demonstrated that the administration of 4-1BB monoclonal antibodies (mAbs) induces antitumor immune responses. In the current study using several murine tumors, we examined the systemic effects of 4-1BB mAb on the growth of s.c., intracranial (i.c.), and pulmonary metastases. In addition, the effects of 4-1BB mAb on the generation of antitumor effector T cells were examined. Treatment of 3-day i.c. MCA 205 sarcoma and GL261 glioma with the antibody resulted in prolongation of survival and cure of disease in some mice, whereas only minimal therapeutic effects were observed in established s.c. and pulmonary tumors. No antitumor effects against the poorly immunogenic B16/D5 melanoma were observed. Interestingly, successful treatment of i.c. tumors induced concomitant regression of s.c. tumors. Experiments using severe combined immunodeficient mice and mice depleted of either CD4 or CD8 T cells demonstrated T-cell dependence of the antitumor effects. For generation of effector T cells in the tumor-draining lymph nodes (LNs), administration of 4-1BB mAb had adverse effects, despite the apparent hypertrophy of the LNs. During in vitro activation of tumor-draining LN T cells with anti-CD3 and interleukin 2, the 4-1BB mAb augmented proliferation, resulting in an increase in CD8 T cells. However, they were less therapeutic than not treated LN cells. In adoptive immunotherapy, the coadministration of 4-1BB mAb enhanced the therapeutic efficacy. These results thus demonstrate the limits and potential advantages of 4-1BB antibody interactions with antitumor T cells in vivo and in vitro and suggest that therapeutic interactions of the antibody may be used in a variety of immunotherapeutic approaches.

Separation of nicotine metabolites by capillary zone electrophoresis and capillary zone electrophoresis/mass spectrometry

The use of capillary zone electrophoresis (CZE) and capillary zone electrophoresis/mass spectrometry (CZE/MS) has been demonstrated, in principle, for the separation of nicotine and nicotine metabolites. The buffer system developed for separation and detection by CZE/UV was modified for use in CZE/MS analysis. Several of the metabolites are isobaric and tandem mass spectrometric (MS/MS) techniques have been used to differentiate such analytes.

Rapid flow cytometric test for the diagnosis of membrane cytoskeleton-associated haemolytic anaemia

The flow cytometric test measures the fluorescence intensity of intact red cells labelled with the dye eosin-5-maleimide, which reacts covalently with Lys-430 on the first extracellular loop of band 3 protein. In this study, red cells from patients with hereditary spherocytosis (HS), congenital dyserythropoietic anaemia type II, South-east Asian ovalocytosis and cryohydrocytosis have produced a greater degree of reduction of mean channel fluorescence readings than those for other patient groups and normal controls. The predictive value of this test for membrane abnormality was compared with the results obtained from the sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) method, which is currently the reference laboratory test for the identification of membrane protein deficiencies in hereditary spherocytosis and for the detection of spectrin variants in hereditary elliptocytosis. The dye method is a reliable, speedy diagnostic test (2 h from sample collection to result) for HS with a sensitivity of 92.7% and a specificity of 99.1%. Thus, it will serve well as a first-line screening test for the diagnosis of hereditary spherocytosis in routine haematology.

A genetic linkage map of the baboon (Papio hamadryas) genome based on human microsatellite polymorphisms

A first-generation genetic linkage map of the baboon (Papio hamadryas) genome was developed for use in biomedical and evolutionary genetics. Pedigreed baboons (n = 694) were selected from the breeding colony maintained by the Southwest Foundation for Biomedical Research. To facilitate comparison with the human genome, the baboon linkage map consists primarily of human microsatellite loci amplified using published human PCR primers. Genotypes for 325 human microsatellites and 6 novel baboon microsatellites were used in linkage analyses performed with the MultiMap expert system. The resulting sex-averaged meiotic recombination map covers all 20 baboon autosomes, with average spacing among loci of 7.2 cM. Direct comparison among homologous (orthologous) loci reveals that, for 7 human autosomes, locus order is conserved between humans and baboons. For the other 15 autosomes, one or more rearrangements distinguish the two genomes. The total centimorgan distances among homologous markers are 28.0% longer in the human genome than in the baboon, suggesting that rates of recombination may be higher in humans. This baboon linkage map is the first reported for any nonhuman primate species and creates opportunities for mapping quantitative trait loci in baboons, as well as for comparative evolutionary analyses of genome structure.

Validity of the visual function index (VF-14) in patients with retinal disease

OBJECTIVE

To test the validity of the Visual Function Index (VF-14) in patients with retinal disease.

DESIGN

A self-administered questionnaire package in association with clinical examination findings.

PARTICIPANTS

Consecutive patients attending the Vancouver General Hospital Eye Care Centre, Vancouver, British Columbia, retina clinic between May 1 and August 15, 1998.

MAIN OUTCOME MEASURES

Responses to the questionnaire package as they relate to global self-assessment scales and visual acuity. In addition, correlations were calculated between the VF-14, the 36-Item Short-Form Health Survey, a Weighted Comorbidity Scale, and visual acuity scores.

RESULT

Five hundred forty-seven patients were given the questionnaire package to complete. The VF-14 demonstrated a moderately strong positive association with patient self-rating of amount of trouble, satisfaction, and overall quality of vision. Correlations between the 36-Item Short-Form Health Survey, visual acuity, and the global scales were mild to moderate. The VF-14 was moderately correlated with visual acuity in the better and the worse eyes.

CONCLUSIONS

This study provides support for the validity of the VF-14 as a measure of functional impairment in patients with retinal disease. Once responsiveness has been measured and an analysis of disease subtypes has been carried out, the VF-14 will be ready for inclusion in clinical trials to evaluate patients' functional ability. Further implementation and development of this outcome measure will better our understanding of the utility of the functional assessment format for patients with retinal disease.

Action leadership: the development of an approach to leadership enhancement for grassroots community leaders in children's mental health

The last decade has seen the development of a number of interagency systems for children with serious emotional disturbances and their families. Many public sector agencies, however, continue to have inadequate or fragmented services. It is believed that effective systems of care for children and families will not be adequate until more parents and community residents are involved in all phases of systems development. Consequently, the need for the development of leadership models that enhance the involvement of grassroots community leaders is crucial. This article summarizes a research team's preliminary experience in developing an "action leadership" model that empowers grassroots community leaders toward action. The team discovered that leadership enhancement and development of grassroots community leaders is not a static skill attribute of an individual but rather is acquired through a dynamic process in which both the facilitator of a community leadership initiative and its natural leaders are active participants in a shared learning and change experience.

Sex differences in male-typical copulatory behaviors in response to androgen and estrogen treatment in rats

The present experiment was performed to test the hypothesis that gender differences in the capacity for brain estrogen synthesis could constitute a sexually dimorphic mechanism that limits the activational effects of testosterone (T) in females, and enhances them in males. We determined the effects of treatments with equivalent levels of either T or estradiol (E2) on olfactory behavior and mounting in age-matched heterosexually naive gonadectomized male and female rats that were genitally ansthetized with lidocaine paste in order to minimize the contribution of sexually dimorphic somatosensory inputs to the expression of copulatory behavior. We found that T stimulated mounting to a greater extent in males than in females, but had equivalent effects on mount latency and genital investigation in the two sexes. On the other hand, E2 stimulated equivalent levels of mounting in males and females and reduced mount latency to a similar extent in males and females. However, E2 had a pronounced effect on the levels of genital investigation in males but not in females. Serum steroid levels and the levels of nuclear steroid receptor occupation in the brain were not different between males and females, suggesting that the behavioral differences between males and females cannot be attributed to differences in peripheral steroid metabolism or brain uptake. The results obtained corroborate previous studies suggesting that female rats normally undergo considerable male-typical behavioral masculinization during fetal development. However, such male-typical features of normal development in female rats do not extend to the regulation of preoptic aromatase activity or to the capacity of females to display olfactory behaviors in response to adult E2 exposure, functions which are sexually dimorphic even in the rat. The present results support the view that gender differences in the capacity for brain estrogen synthesis contribute to the sexually dimorphic display of T-stimulated male-typical sexual motivation and copulatory behavior in rats.

Clinical utility of a portable ultrasound device in intermittent catheterization

OBJECTIVE

To evaluate the clinical utility of a new portable ultrasound device (PUD) in the management of intermittent catheter programs in patients with neuropathic bladder.

DESIGN

Intervention study using randomized control trial.

SETTING

Tertiary care center providing inpatient and ambulatory rehabilitation services to persons with neurologic disabilities.

PARTICIPANTS

Thirty-eight inpatients and outpatients with neuropathic bladders requiring intermittent catheterization.

MAIN OUTCOME MEASURES

Mean frequency of intermittent catheterization, mean number of episodes of overdistension, and patient satisfaction as measured with a Patient Satisfaction Questionnaire.

RESULTS

The mean frequency of catheterization per day was reduced in the PUD group in comparison with controls (2.99 vs 4.12, p = .026). The number of episodes of overdistension was also reduced in the PUD group but did not reach statistical significance (12.45 vs 14.76, p = .61). Subjects generally expressed satisfaction with the PUD, with 16 of 18 patients at least somewhat satisfied with the device.

CONCLUSION

The PUD is a useful tool for clinicians in patients undergoing intermittent catheterization programs that can reduce the number of required catheters. It is associated with a high degree of patient satisfaction.

A primatized MAb to human CD4 causes receptor modulation, without marked reduction in CD4+ T cells in chimpanzees: in vitro and in vivo characterization of a MAb (IDEC-CE9.1) to human CD4

A Primatized anti-CD4 monoclonal antibody (MAb), CE9.1, with V-domain from cynomolgus macaque (showing 92% homology with human consensus sequence V-domains), and a human IgG1 constant region, was characterized in vitro and in vivo in chimpanzees. This MAb binds human CD4 with Kd of 1.0 nM and was also able to bind to human IgG Fc receptors (Fc gamma R). However, despite being of the IgG1 subclass, CE9.1 did not bind to complement component C1q, nor did it mediate complement-dependent cytotoxicity. Examination of T cells from a number of species showed restricted reactivity for CE9.1, recognizing only human and chimpanzee CD4. In both human and chimpanzee MLRs, it had an IC50 of about 10.0 ng/mL. Therefore, a chimpanzee in vivo model was used to characterize CE9.1, CE9.1 caused transient decrease in the number of lymphocytes bearing the CD4 receptor starting at doses of 0.3 mg/kg in an in vivo dose ranging study in one chimpanzee. This effect was reversed within approximately 7 days. In a multiple high-dose study in which 10.0 mg/kg of CE9.1 was administered at intervals of 1-3 months, there was a dramatic loss of CD4 marker with a reciprocal increase in the number of CD3+ CD8- CD4- cells. The CD4 receptor was totally undetectable on these lymphocytes for 1-2 weeks, with a gradual, but complete, reversal within 4 weeks. We interpret these observations as receptor modulation because, although there was apparent loss of CD4+ lymphocytes, an equivalent number of CD3+CD8- T lymphocytes were present in circulation in all four chimpanzees treated with 10.0 mg/kg CE9.1. Even at this high dose, only limited reduction of CD4+ T lymphocytes was observed in these animals. These observations are in sharp contrast to what has been reported in rodents or in human clinical studies using other IgG1 mAbs to human CD4. CD8 counts, although variable, remained unaffected by CE9.1 treatment. No adverse events were observed following administration of CE9.1 to chimpanzees, and there was no detectable host immune responses to the Primatized MAb.

Prenatal spinal evaluation and functional outcome of patients born with myelomeningocele: information for improved prenatal counselling and outcome prediction

OBJECTIVE

Prenatal ultrasonography can localize the level of the spinal cord malformation, allowing prediction of the potential postnatal neurological deficit and functional prognosis.

METHODS

This study has two evaluations: (a) a retrospective prenatal review of 26 fetuses with spinal dysraphism (1987-1991), and (b) a follow-up descriptive study of patients (1971-1981) who underwent closure of the spinal lesion and ventricular shunting in the neonatal period.

RESULTS

Prenatal ultrasound evaluation enabled the accurate definition of the last intact vertebral level which allows separation of fetuses into three functional groups (last intact level L2, L3-4, L5-sacral). Patterns of ambulation, urinary and bowel continence, and school performance vary according to level of spinal lesion and the neurological deficit. The need for ventricular shunts, the incidence of other spinal malformations and surgical interventions did not vary with the level of the spinal lesion.

CONCLUSIONS

The functional outcome for patients with myelomeningocele is variable; however, distinct patterns emerge based on the level of spinal dysraphism and the resultant neurological deficit. By relating the level of the fetal spinal lesion to outcome data, more precise functional prognoses can be given to families.

The Christensen prosthesis. A retrospective clinical study

The objective of this study was to determine if the Christensen temporomandibular joint prosthesis system in an effective alternative in treating patients with severe temporomandibular joint disorders. A total of 69 patients who were not responsive to either nonsurgical or prior surgical treatments were placed into one of three treatment groups depending on the following diagnoses: (1) placement of a glenoid fossa-eminence prosthesis with meniscus retention (22 patients, 40 joints); (2) placement of a glenoid fossa-eminence prosthesis without retention of the meniscus (26 patients, 49 joints); (3) total joint replacement (21 patients, 34 joints). Patients were evaluated immediately before surgery and at regular intervals after surgery for an average of 3.1 years. Success was measured as a significant improvement of function and decrease in pain as measured on a visual analogue scale, as well as improved incisor opening as measured with a Therabite Scale (Lorenz Surgical, Jacksonville, Fla.). Comparison of mean and average pre- and postsurgical values for all groups and criteria showed significant improvement. Results of this study indicate that the Christensen temporomandibular joint prosthesis system may offer a viable method for the treatment of severe temporomandibular joint disease with a high degree of success.

The correlation of multichannel urodynamic pressure-flow studies and American Urological Association symptom index in the evaluation of benign prostatic hyperplasia

PURPOSE

We correlated multichannel pressure-flow urodynamics and the American Urological Association (AUA) symptom index in the evaluation of benign prostatic hyperplasia.

MATERIALS AND METHODS

We evaluated 121 consecutive, symptomatic patients older than 55 years with the AUA symptom score and multichannel pressure-flow urodynamic studies. Testing was performed during a single session and the data obtained from 103 patients were plotted on the Schäfer nomogram for assessment of outflow obstruction. Linear regression statistical analysis was used to determine correlations.

RESULTS

There was no significant correlation between uroflowmetry and Schäfer curves (r = 0.173 to 0.326), uroflowmetry and AUA symptom scores (r = 0.134 to 0.153) and, most importantly, AUA symptom scores and Schäfer curves (r = 0.025 to 0.137).

CONCLUSIONS

We conclude that these modalities measure independent variables, and should not be linked in the evaluation and treatment decision of the patient with prostatism.

Use of pedicled fat pad graft as an adjunct in the reconstruction of palatal cleft defects

The purpose of this article is to provide the rationale for the use of pedicled buccal fat pad grafts as an adjunct to the reconstruction of palatal or dentoalveolar clefts in cases when healing by secondary intention may need to be considered and integrated into the initial treatment plan because of the size of the defect or qualitative or quantitative tissue constraints. Four representative cases are presented in which a pedicled buccal fat graft was adjunctively used in conjunction with pedicled mucosal flaps to gain closure of large oroantral or oronasal cleft deformity.

Automated quantitative microcolumn chromatography of haemoglobin A2

Automated cation exchange microcolumn chromatography of haemoglobins has been modified for the analysis of haemoglobin A2. It provides the quantitative data of sufficient precision and specificity for the investigation of potential heterozygotes for beta-thalassaemia. Results have been compared with an established method of electrophoresis followed by densitometry of the eluted bands.