Enacting Treaty Rights through Restoring Shoshone Ancestral Foods on the Wind River Indian Reservation

Despite great loss in gathering and consumption of traditional foods among Indigenous communities, there is great hope for reclaiming and preserving knowledge. The Restoring Shoshone Ancestral Food Gathering (RSAFG) is a community group leading grassroots efforts on the Wind River reservation to reclaim Shoshone ancestral foods and promote food sovereignty. The story of the RSAFG promotes equitable, decolonized, and community empowered methods of reclaiming Indigenous foods by sharing three of RSAFG's acts of decolonization: 1) enacting treaty rights through gathering traditional plants, 2) demanding equitable partnerships in community-based research, and 3) sharing the story through radical authorship via layered narratives. A pesar de la gran pérdida en la recolección y el consumo de alimentos tradicionales entre las comunidades indígenas, existe una gran esperanza para recuperar y preservar el conocimiento. El Restoring Shoshone Ancestral Food Gathering (RSAFG) es un grupo comunitario que lidera los esfuerzos de base en la reserva wind river para recuperar los alimentos ancestrales shoshone y promover la soberanía alimentaria. La historia de la RSAFG promueve métodos equitativos, descolonizados y empoderados por la comunidad para recuperar los alimentos indígenas al compartir tres de los actos de descolonización de RSAFG: 1) promulgar los derechos de los tratados mediante la recolección de plantas tradicionales, 2) exigir asociaciones equitativas en la investigación basada en la comunidad, y 3) compartir la historia a través de la autoría radical a través de narrativas en capas.

Differential DNA methylation at birth associated with mental disorder in individuals with 22q11.2 deletion syndrome

Individuals with 22q11.2 deletion syndrome (DS) have an increased risk of comorbid mental disorders including schizophrenia, attention deficit hyperactivity disorder, depression, as well as intellectual disability. Although most 22q11.2 deletion carriers have the long 3-Mb form of the hemizygous deletion, there remains a large variation in the development and progression of psychiatric disorders, which suggests that alternative factors contribute to the pathogenesis. In this study we investigated whether neonatal DNA methylation signatures in individuals with the 22q11.2 deletion associate with mental disorder later in life. DNA methylation was measured genome-wide from neonatal dried blood spots in a cohort of 164 individuals with 22q11.2DS, including 48 individuals diagnosed with a psychiatric disorder. Among several CpG sites with P-value<10-6, we identified cg23546855 (P-value=2.15 × 10-7) mapping to STK32C to be associated with a later psychiatric diagnosis. Pathway analysis of the top findings resulted in the identification of several Gene Ontology pathways to be significantly enriched (P-value<0.05 after Benjamini-Hochberg correction); among them are the following: neurogenesis, neuron development, neuron projection development, astrocyte development, axonogenesis and axon guidance. In addition, we identified differentially methylated CpG sites in LRP2BP (P-value=5.37 × 10-8) to be associated with intellectual disability (F70-79), in TOP1 (P-value=1.86 × 10-7) with behavioral disorders (F90-98), in NOSIP (P-value=5.12 × 10-8) with disorders of psychological development (F80-89) and in SEMA4B (P-value=4.02 × 10-7) with schizophrenia spectrum disorders (F20-29). In conclusion, our study suggests an association of DNA methylation differences at birth with development of mental disorder later in life in 22q11.2DS individuals.

Synthesis and chemical characterization of several perfluorinated sialic acid glycals and evaluation of their in vitro antiviral activity against Newcastle disease virus

Newcastle Disease Virus (NDV), belonging to the Paramyxoviridae family, causes a serious infectious disease in birds, resulting in severe losses in the poultry industry every year. Haemagglutinin neuraminidase glycoprotein (HN) has been recognized as a key protein in the viral infection mechanism, and its inhibition represents an attractive target for the development of new drugs based on sialic acid glycals, with the 2-deoxy-2,3-didehydro-d-N-acetylneuraminic acid (Neu5Ac2en) as their backbone. Herein we report the synthesis of several Neu5Ac2en glycals and of their perfluorinated C-5 modified derivatives, including their respective stereoisomers at C-4, together with evaluation of their in vitro antiviral activity. While all synthesized compounds were found to be active HN inhibitors in the micromolar range, we found that their potency was influenced by the chain-length of the C-5 perfluorinated acetamido functionality. Thus, the binding modes of the inhibitors were also investigated by performing a docking study. Moreover, the perfluorinated glycals were found to be more active than the corresponding normal C-5 acylic derivatives. Finally, cell-cell fusion assays on NDV infected cells revealed that the addition of a newly synthesized C-4α heptafluorobutyryl derivative almost completely inhibited NDV-induced syncytium formation.

Associations between social cognition, skills, and function and subclinical negative and positive symptoms in 22q11.2 deletion syndrome

Background

Identification of the early signs of schizophrenia would be a major achievement for the early intervention and prevention strategies in psychiatry. Social impairments are defining features of schizophrenia. Impairments of individual layers of social competencies are frequently described in individuals with 22q11.2 deletion syndrome (22q11.2DS), who have high risk of schizophrenia. It is unclear whether and to what extent social impairments associate with subclinical negative and positive symptoms in 22q11.2DS, and which layer of social impairments are more correlated with schizophrenia-related symptoms. The aims of this study were to conduct a comprehensive investigation of social impairments at three different levels (function, skill, and cognition) and their interrelationship and to determine to what degree the social impairments correlate to subclinical levels of negative and positive symptoms, respectively, in a young cohort of 22q11.2DS not diagnosed with schizophrenia.

Methods

The level of social impairment was addressed using questionnaires and objective measures of social functioning (The Adaptive Behavior Assessment System), skills (Social Responsiveness Scale), and cognition (The Awareness of Social Inference Test and CANTAB Emotional Recognition Task), and the presence of subclinical symptoms of schizophrenia were evaluated using the Structured Interview for Prodromal Syndromes in a cross-sectional case-control study of 29 cases and 29 controls, aged 12 to 25 years. Association between social impairment and negative and positive symptoms levels was examined in cases only.

Results

Subjects with 22q11.2DS were highly impaired in social function, social skills, and social cognition (p ≤ 6.2 × 10⁻⁹) relative to control peers and presented with more negative (p = 5.8 × 10⁻¹¹) and positive (p = 7.5 × 10⁻⁴) symptoms. In particular, social functional and skill levels were highly associated with notably subclinical negative symptoms levels.

Conclusions

This study shows strong correlations between levels of social impairments and subclinical negative and positive symptoms. However, longitudinal studies are required to show if social impairments represent early disease manifestations. If parental or self-reporting suggests severe social impairment, it should advocate for clinical awareness not only to social deficits per se but also of potential subclinical psychosis symptoms.

Abstract PD08-04: Factors which affect surgical management in an underinsured, county hospital population

Background: Significant variation exists between institutions in the use of lumpectomy, mastectomy, and reconstruction. Much less is known about minorities and populations outside the large academic institutions. The current study was performed to evaluate variables that affect patient choice in surgical management in a county hospital population.

Methods: A retrospective review of all patients seen at the county, safety net institution with breast cancer from January 2010 to May 2012. Sociodemographic, clinical, and treatment variables were evaluated. Univariate analysis was performed to identify variables which were associated with type of operation. All of the variables with a p-value &lt;0.10 were included in the multivariate analysis.

Results: 403 patients were seen with mean age 53 years. 92% of the patients were insured with Medicaid or uninsured and 29% were non-Hispanic White. Only 20% of patients underwent screening mammography and therefore presentation with palpable, Stage 2A/B cancer was most common (46%). 54 patients presented with T4 tumors and 13 (24%) were found to have metastases. Only 2 of 340 (0.6%) patients who presented at Stage 3A or earlier presented with metastatic disease. Patients with operable cancer underwent lumpectomy in 65%, mastectomy in 26%, and 9% mastectomy with reconstruction. With respect to breast conservation vs mastectomy, in adjusted analysis, married patients (OR 2.59, p = 0.003) and patients with larger tumors (p = 0.003) were more likely to undergo mastectomy, while patients who were Hispanic (OR 0.38, p = 0.004), underwent preoperative chemotherapy (OR 0.25, p = 0.002), or had their operation by breast surgical oncologist (OR 0.30, p = 0.005) were more likely to undergo breast conservation. When patients who underwent mastectomy alone were compared to those who underwent reconstruction, unadjusted analysis suggested that reconstruction patients were more likely to speak English, have adequate health literacy (HL), lower clinical stage, and be seen by a breast surgical oncologist. Adjusted analysis demonstrated that having been seen by a breast surgical oncologist (OR 18.4, p = 0.007), younger age (p = 0.05) and adequate HL (OR 3.13, p = 0.06) were associated with likelihood of reconstruction compared to mastectomy alone.

Conclusions: Breast conservation and mastectomy with reconstruction can be achieved in a significant proportion (74%) of underscreened and underinsured patients. Patients who underwent preoperative chemotherapy were more likely to undergo breast conservation. Younger patients and patients with adequate HL were more likely to choose reconstruction after mastectomy. Patients treated by breast surgical oncologists were more likely to have breast conservation or mastectomy with reconstruction. Even in an underscreened population, presentation with metastatic disease is uncommon in patients with operable breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-04.

Prospective assessment of symptoms and quality of life in localized rectal cancer patients receiving chemoradiotherapy

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Background: Neoadjuvant conformal chemoradiotherapy (CRT) is an important component of treatment for locally advanced rectal cancer, yet its morbidity has not been well characterized using quality of life (QOL) instruments. The present study attempts to establish a baseline distribution of QOL scores before, during, and after CRT and to correlate these changes with symptoms.

Methods: Patients undergoing 3-4 field neoadjuvant CRT for localized rectal cancer were prospectively enrolled at two institutions. Fifty patients completed the QOL instruments at three time points: pretreatment, week 4 of treatment, and 1 month post-treatment. QOL information was captured using three validated questionnaires, the EORTC QLQ-30, QLQ-38, and QLQ-29. Additionally, institutional symptom inventories and CTCAE toxicity data were collected.

Results: Average age was 59.2 years and 72% were men. During CRT, patients had a statistically significant decline in global QOL (70 to 60, p = 0.0024), which normalized (71) following completion of treatment. During therapy, patients also experienced a significant increase in GI symptoms (21 to 27, p = 0.028), urinary symptoms (16 to 30, p < 0.0001), male sexual dysfunction (23 to 34, p = 0.013), and chemotherapy related side effects (8 to 20, p = 0.0001). While these measures returned to baseline 1 month post-CRT, overall sexual function (25 vs. 37, p = 0.0062) and sexual enjoyment (53 vs. 67, p = 0.0070) remained persistently low compared to pretreatment levels. Diarrhea (27%) and proctitis (22%) were the most common grade 3 toxicities. Those patients who experienced grade 3 toxicity during treatment showed markedly decreased global QOL (mean difference = 34).

Conclusions: While rectal cancer patients experienced impaired QOL during neoadjuvant CRT, the vast majority of measures normalized one month after treatment. In contrast, significantly decreased sexual function and enjoyment persisted. This data can be used as a baseline to compare future neoadjuvant conformal CRT regimens and/or assess the toxicity and QOL of new RT modalities such as intensity modulated radiation therapy.

No significant financial relationships to disclose.

An ethnography of low-income mothers' safeguarding efforts

PROBLEM

Children living in lower-income environments are at greater risk for unintentional injuries. However, little is known about the safety practices of mothers living in low-income situations.

METHOD

This ethnographic study explored the child safeguarding experiences of low-income mothers using in-home interviews and observations.

RESULTS

Mothers' safeguarding efforts included cognitive and emotional work, child directed work, and work directed at the physical and social environments. Factors that influenced the women's safeguarding included the quality of the indoor space, availability of safe play space, traffic hazards, sibling interactions, child care supports, relationships with neighbors, and trust in community services.

DISCUSSION

These findings have implications for the conceptualization of safeguarding practices and provide insight about the experiences of mothers living on low-incomes.

IMPACT ON INDUSTRY

When developing safety interventions, program planners should consider the views and practices of mothers as well as contextual factors in the physical and social environments.

A randomized trial to assess the effectiveness of an infant home safety programme

The aim of this study was to test an intervention aimed at addressing the risk of injury in infants 2 - 12 months of age. A non-blinded, randomized controlled trial was conducted, whereby parents were randomly assigned to either a control or one of two intervention groups. Parents completed questionnaires regarding safety behaviours and injuries at the 2 (baseline), 6 and 12 month immunization visit at the community health unit. During the 2 month visit to the health unit, the two intervention groups received a home safety kit containing nine items, an instructional brochure and a risk assessment checklist. Subjects randomized to the safety kit plus home visit group also received a standardized home visit from a community health nurse. Two of the 14 parental safety behaviours showed a significant increase in use among parents in the intervention groups. Neither of the interventions was associated with a reduction in parent-reported injuries among children. It was concluded that home visitation may provide a beneficial adjunct to the provision of safety devices and may increase use by parents.

Postoperative obstructive symptoms are common after Rehbein's procedure for Hirschsprung's disease

Rehbein's procedure for Hirschsprung's disease has been questioned because several centimetres of aganglionic bowel are left behind, considered to result in obstructive symptoms. However, the reported outcome is similar to that after operations with other techniques. The purpose of this study was to review our experience of Rehbein's procedure during an 8-year period, focusing particularly on obstructive symptoms. We retrospectively studied 44 patients operated with Rehbein's procedure for biopsy-verified Hirschsprung's disease from October 1993 to October 2001. Three patients with total colonic aganglionosis and two patients who underwent total colectomy as a result of severe enterocolitis finally had a distal ileo-rectal anastomosis. Four (9 %) patients had a sphincteromyectomy before the Rehbein procedure. The patients' bowel function was evaluated by a questionnaire and an interview carried out 27 to 123 (mean 82) months after the operation. Two patients could not be traced and one patient, with total colonic aganglionosis, had an ileostomy at follow-up. Nineteen (46 %) of the 41 patients were treated with oral laxatives or enemas (12 patients), required repeated Botox injections (4 patients), or had undergone sphincteromyectomy (9 patients) due to obstructive symptoms. Eleven (27 %) of the 41 evaluated patients had soiling at least once a week at follow-up. Eleven (29 %) of 38 patients with a colorectal anastomosis had good bowel function without additional therapy. In conclusion, Rehbein's procedure for the treatment of Hirschsprung's disease is often complicated by obstructive problems.

The programmable adult Codman Hakim valve is useful even in very small children with hydrocephalus. A 7-year retrospective study with special focus on cost/benefit analysis

INTRODUCTION

Ventriculo-peritoneal shunting is the most commonly used method for the treatment of paediatric hydrocephalus. The programmable valve with the ability to adjust the opening pressure non-invasively has made it easier to find exactly the right opening pressure for each child and reduce the risk of over- or under-drainage. The aim of this investigation was to study our clinical experience with the adult Codman Hakim programmable valve in children, with reference to complications and economic impact.

METHODS

A seven-year retrospective study of 122 hydrocephalic children (aged from children born prematurely to 15 years old) shunted with the adult Codman Hakim programmable valve was performed.

RESULTS

The programmable valve was the first shunt in 76 children and in 14 after prior ventricular drainage. The remaining 46 had different non-programmable systems as their first shunt. The most common reason for changing to a programmable valve was over-drainage. With the programmable valve, catheter-related complications, e.g. proximal (36%) or distal obstructions (30%), were the main reasons for surgical revision. Non-invasive pressure adjustment was performed in 73% of the children. Among the children with the programmable valve as their first shunt, 57 (75%) were adjusted, 12 (21%) had severe symptoms of over-drainage and would have required urgent surgical change of the valve if it had not been adjustable. A resetting of the opening pressure after MRI was found in 38% and accidental resetting occurred in 4%. Programmable valves are about twice as expensive as non-programmable valves. We estimated the increased cost of the valve and compared it with the savings from a reduction in the number of re-operations. The total cost for the programmable valve (as the primary shunt) in our study was less than that for expected re-operations due to over- or under-drainage when using non-programmable valves.

CONCLUSION

The programmable valve was easy to handle; only one size was required and the adjustment made it possible to achieve an optimal intraventricular pressure with a lower total cost, reduced hospital stay as well as an increased quality of life for the children.

Apolipoprotein D is associated with long-term outcome in patients with schizophrenia

Accumulating evidence implicates deficiencies in apolipoprotein D (ApoD) function and arachidonic acid signaling in schizophrenic disorders. We addressed two hypotheses in relation to ApoD: first, polymorphisms in the ApoD gene confer susceptibility to or are markers of disease, and, second, genetic variation in the ApoD is associated with long-term clinical outcome to antipsychotic treatment. We genotyped two single-nucleotide polymorphisms in the ApoD gene in 343 chronic patients with schizophrenia spectrum disorders (ICD-10) and 346 control subjects of Danish origin. We did not find ApoD alleles, genotypes or haplotypes to be associated with disease. However, we did find that long-term clinical outcome was associated with the ApoD polymorphism rs7659 (P = 0.041) following adjustment for lifetime clinical global impression, age at first admission and gender.

Looking for the evidence: a systematic review of prevention strategies addressing sport and recreational injury among children and youth

OBJECTIVES

To examine evidence on the effectiveness of current injury prevention strategies in selected sport and recreational activities, determine the applicability of the evidence to children and youth and discuss the implications related to policy, programming and future research.

METHODS

Research questions and relevance criteria were developed a priori. Potentially relevant studies were located through electronic and hand searches. Two independent assessors assessed articles for first relevance and then quality. Relevant articles were abstracted and synthesised for activities that had three or more relevant articles.

RESULTS

A total of 21,499 articles identified through database and manual searching yielding 117 that met inclusion criteria. The majority of the studies (93 or 89%) involved eight activities: baseball, basketball, cycling, football, ice hockey, rugby, alpine skiing and soccer. Children and youth were identified as the specific target group in 45% of the studies and another 12% included children in their sample. Studies addressed a range of intervention strategies and varied on quality of evidence.

CONCLUSIONS

Surprisingly few well-designed and controlled studies investigating strategies to prevent injuries were found and an even smaller number evaluated strategies to reduce injury in children and youth. As governments in developed countries continue to focus on increasing physical activity among children and youth, thought must be given to the issue of risk of injury and the relative lack of evidence of effective preventive measures.

Distal catheter obstruction from non-infectious cause in ventriculo-peritoneal shunted children

In hydrocephalic children, ventriculo-peritoneal shunting is the preferred treatment with few complications. However, an obviously non-infectious peritoneal reaction to the cerebrospinal fluid (CSF) may occasionally lead to shunt malfunction. In eight hydrocephalic children, shunt malfunction with distal catheter complication was found with abdominal pseudocyst formation in seven cases and accumulation of the CSF in one. All children had a normal CSF cell count and glucose concentration, and white cell count, and C-reactive protein in peripheral blood were normal. No CSF infection could be detected despite prolonged aerobic and anaerobic cultures. After initial externalisation of the shunt and subsequent routine administration of antibiotics because infection initially was suspected, ventriculo-peritoneal shunting was attempted one to three times with identical failure before successful conversion to a ventriculo-atrial system. At laparotomy the peritoneum and intestinal serosa were hyperaemic and oedematous in all patients, five of whom also had pseudocysts and two of whom also had intra-abdominal adhesions. Four children had a revision 6-24 years after the ventriculo-atrial conversion due to short atrial catheter with distal obstruction. In three of them, the distal catheter was successfully replaced into the peritoneal cavity. The fourth child, however, developed an infectious abdominal pseudocyst with adhesions due to a then undetected Propionibacterium acnes infection. After externalisation and antibiotics, a new ventriculo-atrial shunt was inserted. At follow-up between 5 months to nearly 6 years later, the three children with peritoneal catheters did not show any signs of shunt malfunction or abdominal problems. Thus hydrocephalic children may develop shunt malfunction with distal catheter obstruction due to a still unexplained, transient, non-infectious peritoneal reaction leading to abdominal pseudocyst formation or accumulation of CSF. In some children, however, it may later be possible to replace the distal catheter into the peritoneal cavity, if no infection is involved.

Strategies for prevention of soccer related injuries: a systematic review

OBJECTIVES

To examine evidence on the effectiveness of current injury prevention strategies in soccer, determine the applicability of the evidence to children and youth, and make recommendations on policy, programming, and future research.

METHODS

Standard systematic review methodology was modified and adopted for this review. Research questions and relevance criteria were developed a priori. Potentially relevant studies were located through electronic and hand searches. Articles were assessed for relevance and quality by two independent assessors, and the results of relevant articles were abstracted and synthesised.

RESULTS

A total of 44 potentially relevant articles from electronic (n = 37) and hand (n = 7) searches yielded four that met inclusion criteria. These four studies addressed a range of intervention strategies and varied with respect to results and quality of evidence.

CONCLUSIONS

Some of the strategies look promising but lack adequate evaluation or require further research among younger players. Practice, policy, and research recommendations are provided as a result of the synthesis.

Asymptomatic shunt malfunction detected fortuitously by observation of papilloedema

Significant shunt malfunction is nearly always followed by headache, nausea, vomiting, lethargy and/or visual disturbances. In many cases there are also signs of raised intracranial pressure on computed tomography (CT). In six hydrocephalic, shunt dependent children (8-14,5 years) with no or slight symptoms shunt malfunction was detected because of papilloedema. The oedema was detected in three children at routine check up, in two at regular visual check up and in one at an ophthalmological examination because of slight headache. At neurological examination five had no new symptoms, but one was ataxic. In five patients a CT scan was done, three showed slight ventricular dilatation. Splayed sutures were found in two children. At shunt revision the measured intracranial pressure was increased, varying between 25-52 cm H(2)O. In five children the oedema disappeared after shunt-revision without any visual reduction, but in one the visual deficit did not improve. Older children can have shunt malfunction leading to increased intracranial pressure, with no or discrete symptoms and no obvious ventricular dilatation but with asymptomatic papilloedema. Ophthalmoscopy can therefore be of great value at routine check up in these children.

Intrinsic DNA distortion of the bacteriophage Mu momP1 promoter is a negative regulator of its transcription. A novel mode of regulation of toxic gene expression

The momP1 promoter of the bacteriophage Mu mom operon is an example of a weak promoter. It contains a 19-base pair suboptimal spacer between the -35 (ACCACA) and -10 (TAGAAT) hexamers. Escherichia coli RNA polymerase is unable to bind to momP1 on its own. DNA distortion caused by the presence of a run of six T nucleotides overlapping the 5' end of the -10 element might prevent RNA polymerase from binding to momP1. To investigate the influence of the T(6) run on momP1 expression, defined substitution mutations were introduced by site-directed mutagenesis. In vitro probing experiments with copper phenanthroline ((OP)(2)Cu) and DNase I revealed distinct differences in cleavage patterns among the various mutants; in addition, compared with the wild type, the mutants showed an increase (variable) in momP1 promoter activity in vivo. Promoter strength analyses were in agreement with the ability of these mutants to form open complexes as well as to produce momP1-specific transcripts. No significant role is attributed to the overlapping and divergently organized promoter, momP2, in the expression of momP1 activity, as determined by promoter disruption analysis. These data support the view that an intrinsic DNA distortion in the spacer region of momP1 acts in cis as a negative element in mom operon transcription. This is a novel mechanism of regulation of toxic gene expression.

[Anti-reflux surgery is possible also in children with multiple disabilities. Good results after Nissen fundoplication in 10-years experience]

82 children with gastroesophageal reflux, 43 of whom were seriously neurologically impaired, were operated according to Nissen. A retrospective study compares the results, complications and recurrences between children with and children without neurological disability. There were no major differences between the groups; four of the neurologically impaired children and one without impairment had died from unrelated causes. In 62 children, 31 of whom were neurologically impaired, the operation was completely successful, 13 children (six of whom were neurologically impaired) had minor problems, two (both neurologically impaired) had major problems. The conclusion is that serious neurological impairment can not be considered a contraindication to antireflux surgery.

From vision to reality: how to actualize the vision of discharging patients from a hospital, with an increased focus on prevention

Experiences in creating dialogue possibilities to stimulate interdisciplinary and intersectoral collaboration in hospital discharge and prevention are presented. Time is often a major constraint that persuades decision-makers to avoid using qualitative methodologies in research and development. Quick results are demanded of today's health-care system, not allowing ideas to be implemented or visions owned by professionals. Action-orientated research is used and recommended, despite its time-demanding methodology. A multidisciplinary management team and the authors, over a 2-year period, worked with the development and implementation of 'Preventive Discharge' in a Danish hospital clinic. The empirical starting point, developmental processes, piloting and implementation of the project are described. Earlier research from a literature review on discharge is referenced. The results show that while there are many barriers to dialogue between professions and between organizational levels, it is possible to frame such opportunities and improve interdisciplinary and intersectoral collaboration for health. External supervision may be an effective tool for stimulating dialogue. The testing phase afforded a valuable lesson when pilot-site collaborators, initially not involved in the development of the process tools, reformulated the project to suit their cultural climate while maintaining the project's original aims. Finally, a discussion is presented on actualizing the vision for 'Preventive Discharge'.

Pressure-flow studies: short-time repeatability

The within and between examination variation in selected test parameters and test results in repeated pressure-flow studies was determined in a prospective study of consecutive pressure-flow examinations in 22 patients. The patients were pressure-flow tested twice within a month. Furthermore, it was evaluated whether there was a systematic change in the measured parameters during retesting. By using the Abrams-Griffiths nomogram, patients were classified as obstructed, equivocal, or unobstructed. Within and between examination variations in classification were evaluated. We found a systematic variation in P(det.Qmax) during testing, which in the absence of statistically significant systematic variations in P(det.Close) and Qmax, indicates a physiological effect of repeated pressure-flow studies, resulting in a less-obstructed second voiding. Supporting this, we found that all patients who changed group of classification of bladder outlet obstruction in the first examination shifted to a group of less obstruction, as did 66% of the patients who changed group of classification of bladder outlet obstruction in the second examination. Still, 80, respectively 85%, of the patients remained in the same group of classification of bladder outlet obstruction during retesting in the first and second examinations, respectively. Classifying the degree of bladder outlet obstruction by Qmax, P(det.Qmax), and P(det.Close) 85% of the patients reproduced their test results accurately in both examinations and taking only the first voiding in both examinations into account 95% reproduced their test results.

Pressure-flow studies: an evaluation of within-testing reproducibility--validity of the measured parameters

The within-examination variation in selected test parameters in repeated pressure-flow studies was determined in a retrospective study of consecutive pressure-flow examinations in 105 patients. It was further evaluated to see whether there was a systematic change in the measured parameters during retesting. To see if variation and reproducibility were influenced by the procedure of investigation, i.e., transurethral or suprapubic, patients were grouped according to the method employed. Finally, the effect of detrusor instability on the measurements was evaluated. Using the Abrams-Griffiths nomogram, patients were classified as obstructed, equivocal, or unobstructed. The test-retest variations in classification were evaluated. We found a systematic variation in Pdet.Qmax' Pdet.Open' and Qmax during testing, indicating a physiological effect of repeated pressure-flow studies resulting in a less obstructed second voiding. Accordingly, 69% of the patients who shifted group of classification during retesting shifted to a group of lesser obstruction at the second voiding. Still, 88% of patients remained in the same group of classification of bladder outlet obstruction. Within- and between-patient variations and reproducibility of the test results were not influenced by the procedure of investigation, i.e., the transurethral or suprapubic method. However, we found variations suggesting a decrease in urethral resistance and bladder contractility from test to test in the transurethral group, whereas variations suggesting an isolated decrease in bladder contractility were seen in the suprapubic group. Detrusor instability per se does not seem to cause any systematic changes during repeated testing.

Expression of leukaemia inhibitory factor during the development of the human enteric nervous system

Leukaemia inhibitory factor (LIF) is a neuropoietic cytokine, which promotes the development of enteric neurons in vitro, particularly when administered together with neurotrophin-3 (NT-3). The purpose of this study was to map the LIF immunoreactivity in the human enteric nervous system in foetuses, children, adults, and in patients with Hirschsprung's disease. Normal bowel specimens were obtained at postmortem examination of 13 foetuses, at 13-31 weeks of gestation, and at surgery in five children and two adults. Bowel resected in seven patients with Hirschsprung's disease was also investigated. Immunohistochemical analysis was performed on material fixed in formalin and embedded in paraffin. The specimens were exposed to antibodies raised against LIF. The ABC-complex method was used to visualise binding of antibodies to the corresponding antigen. LIF immunoreactivity was disclosed in the myenteric and submucous ganglion cells at 13-31 weeks of gestation, in childhood cases, and adults. LIF-immunoreactive ganglion cells were absent in aganglionic bowel, where the ganglia in the intermuscular layer were replaced by hypertrophic nerve bundles. These morphological findings indicate that LIF may play a role in the development of the enteric nervous system.

[Circumcision of boys--a child's right versus parents' right]

Male circumcision was practiced long before Abraham established a covenant with God to the effect that he should circumcize himself and all male members of his house. Thereafter it has become a potent religion-ethnic commandment also in the Islamic world, although it is not mentioned in the Koran. Several million boys are circumcised yearly in for instance traditional Africa and the USA (in the USA originally as prophylaxis against masturbation). In Sweden the yearly figure is some 3000 boys. A comprehensive review of the literature reveals that there are no or only marginal medical benefits of the operation, particularly in view of the fact that up to 10% suffer complications, and also that newborns both experience pain and will respond more strongly to new pain stimuli for years to come. There are two opposing interests--those related to the religious tradition and those related to the welfare of the child as expressed in the United Nations Convention on the Rights of the Child.

Genetic Differentiation and Host Specificity Among Populations of Alternaria spp. Causing Brown Spot of Grapefruit and Tangerine x Grapefruit Hybrids in Florida

ABSTRACT Alternaria spp. were sampled from brown spot lesions in several geographically separated citrus groves and different grapefruit and tangerine x grapefruit hybrid cultivars in Florida and screened for variation at 16 putative random amplified polymorphic DNA loci. Populations of the pathogen on two hybrids, Minneola and Orlando, in five locations throughout Florida were moderately differentiated (Nei's coefficient of gene differentiation [G(ST)] = 0.12) among locations. The hypothesis that host-specialized forms of Alternaria spp. cause brown spot on different Citrus spp. and cultivars was tested by estimating genetic differentiation among isolates sampled from different hosts and by pathogenicity assays. Isolates sampled from grapefruit and the hybrid cv. Nova were genetically distinct from isolates sampled from other hybrid cultivars including Robinson, Sunburst, Minneola, Orlando, and Murcott. No differentiation could be detected among isolates sampled from this latter group of hybrids. Quantitative pathogenicity assays on leaves using spray inoculation revealed that 'Nova' isolates were not significantly more pathogenic on 'Nova' compared with isolates from 'Minneola' and 'Orlando'. Similarly, grapefruit isolates were not significantly more pathogenic on grapefruit compared with isolates from 'Minneola'. Isolates from all hosts had similar disease rankings on each inoculated cultivar, with 'Minneola' the most susceptible, followed in decreasing order of susceptibility by 'Orlando', 'Sunburst', 'Nova', and 'Duncan' grapefruit. Rough lemon was generally immune to all isolates tested; however, occasional brown spot lesions were observed on leaves of this host with isolates from grapefruit. No evidence was found to support the hypothesis that unique genotypes of the pathogen, which are more virulent on 'Sunburst' or grapefruit, have been introduced to Florida. Populations of Alternaria spp. causing brown spot of citrus on grapefruit and 'Nova' in Florida are genetically distinct from isolates on other cultivars, and we speculate that these populations are in the early stages of adaptation to and possible speciation on these hosts.

Attention-deficit hyperactivity disorder in children and youth: a quantitative systematic review of the efficacy of different management strategies

OBJECTIVE

To obtain estimates of the relative efficacy of 3 main treatment strategies for attention-deficit hyperactivity disorder (ADHD) in children and youth (age < 18 years).

DESIGN

quantitative systematic review of randomized trials.

SUBJECTS

999 patients with ADHD from 26 randomized trials.

INTERVENTIONS

medications alone, behavioural interventions alone, and a combination of these 2 modalities.

MAIN OUTCOME MEASURE

differences in scores between treatment groups on commonly used teacher- and parent-completed behaviour rating scales.

RESULTS

Medication-only therapy was efficacious in ADHD. Behavioural therapies used alone appeared not to be efficacious in ADHD. Combination therapy was more efficacious than placebo or no treatment for parent but not teacher ratings, not more efficacious than drug therapy alone, and more efficacious than behavioural treatments alone based on parent but not teacher ratings.

CONCLUSION

Though stimulant medications were found to be an effective treatment strategy for ADHD in children and youth, it proved difficult to assess the relative benefits of behavioural interventions alone and combined medication and behavioural therapy because of the paucity of treatment studies other than medication-only treatment studies and heterogeneity of various kinds that exist in relation to ADHD studies and treatments.

Expression of bcl-2 in enteric neurons in normal human bowel and Hirschsprung disease

OBJECTIVE

The bcl-2 protein has the functional role of blocking apoptosis, ie, programmed cell death. This protein is widely expressed in the developing central and peripheral nervous systems. The purpose of this study was to map bcl-2 expression in the human enteric nervous system, as this has not previously been done.

METHODS

Rectal specimens were obtained at autopsy of 13 fetuses at 13 to 31 weeks of gestation. Normal colon was also obtained from 5 children and 2 adults, and, in addition, ganglionic and aganglionic bowel resected in 11 patients with Hirschsprung disease was examined. Specimens were fixed in formalin, embedded in paraffin, and analyzed with immunohistochemical methods, using antibodies raised against bcl-2 and neuron-specific enolase (NSE).

RESULTS

The bcl-2 protein was expressed in myenteric and submucous ganglion cells in fetuses, children, and adults. Nerve fibers of the enteric plexuses that were bcl-2 immunoreactive were few compared with the number of NSE-immunoreactive nerve fibers. In aganglionic bowel no bcl-2-or NSE-immunoreactive ganglion cells were revealed. Results of NSE immunohistochemistry showed clearly stained hypertrophic nerve bundles, known to be of extrinsic origin, which were only weakly bcl-2 immunoreactive.

CONCLUSION

Expression of bcl-2 in enteric ganglion cells of the myenteric and submucous plexuses is displayed in the fetus and during childhood and is also retained in adult bowel. Immunohistochemical analysis of bcl-2 provides a good marker for identification of ganglion cells in Hirschsprung disease and may also be valuable for the diagnosis of disorders characterized by hypoganglionosis or hyperganglionosis.

Population Genetic Structure and Host Specificity of Alternaria spp. Causing Brown Spot of Minneola Tangelo and Rough Lemon in Florida

ABSTRACT Alternaria spp. were sampled from two rough lemon (RL) and two Minneola tangelo (MIN) groves in a limited geographic area in central Florida to test for host-specialized forms of the pathogen. Isolates of Alternaria spp. were scored for variation at 16 putative random amplified polymorphic DNA (RAPD) loci and for pathogenicity on both hosts. Subpopulations on each host were differentiated genetically and pathogenically, which was consistent with the hypothesis of host specialization. Highly significant genetic differentiation was detected among all four subpopulations (Nei's coefficient of gene differentiation [G(ST)] = 0.292, P = 0.000); most of the differentiation occurred between hosts (G(ST) = 0.278, P = 0.000). Phenograms of qualitative similarities among isolates within subpopulations revealed two or three distinct clusters of isolates within each subpopulation. The majority of isolates sampled from RL were pathogenic on RL and not on MIN, although a few RL isolates were able to induce disease on MIN, and 44% were nonpathogenic on either host. In contrast, isolates from MIN were pathogenic only on MIN, never on RL, and only 3% of the isolates were nonpathogenic. Overall, three genetically distinct clusters of isolates were detected on both hosts. One of the clusters (cluster A) sampled from RL was pathogenic on RL and not on MIN and consisted almost entirely of one RAPD genotype. This cluster also contained two isolates that were 93% similar to the majority genotype but were pathogenic on MIN and not RL. In isolates from MIN, two distinct clusters of isolates were found in one subpopulation (clusters B and C), and three distinct clusters were found in another subpopulation (clusters A, B, and C). Clusters A and B were found on both hosts, while cluster C was limited to MIN. Populations of Alternaria spp. sampled from RL and MIN showed a high degree of host specificity; however, the specificity obscured a high level of genetic variation within subpopulations.