Parenting and Lead Mitigation at Home: A Multifaceted Community Partnership Model Promoting Parent Engagement in Lead Exposure Prevention

Young children are at high risk of lead poisoning, which can damage early cognitive and behavioral development and have long-lasting impacts. Home environments are persistent sources of exposure for children in urban, low-income settings. Community-academic partnerships are essential for public health intervention strategies addressing residential household lead exposure, yet community organization staff and home visitors often experience strain and burnout. We describe Parenting and Lead Mitigation at Home, a multifaceted partnership project to (a) develop and implement a community-based, peer-delivered education program for parents of young children in neighborhoods at risk for home lead exposure and (b) support the home visitors delivering programming. We developed, delivered, and initially evaluated Lead 101, a lead-exposure prevention curriculum informed by the Community Organizing and Family Issues (COFI) model. The goals were to educate parents around lead exposure risks and empower parents to reduce their child's risk. We developed a novel Reflective Practice pilot curriculum designed to provide emotional support to peer educators and community organization staff who delivered home-based programming. We trained 11 peer educators who delivered Lead 101 to 62 families. We pilot-tested the Reflective Practice curriculum with five community organization staff. The implementation process and pilot evaluation data suggest increased parent knowledge and self-efficacy regarding mitigation of home-based lead hazards, and high satisfaction with reflective practice. Using this model to develop multifaceted partnerships among universities, community-based organizations, and focal communities may facilitate community-engaged program development for families and systematic support for individuals working directly with families, thereby indirectly promoting child health and well-being.

"Virtual patch clamp analysis" for predicting the functional significance of pathogenic variants in sodium channels

OBJECTIVE

Opening of voltage-gated sodium channels is crucial for neuronal depolarization. Proper channel opening and influx of Na⁺ through the ion pore, is dependent upon binding of Na⁺ ion to a specific amino-acid motif (DEKA) within the pore. In this study we used molecular dynamic simulations, an advanced bioinformatic tool, to research the dysfunction caused by pathogenic variants in SCN1a, SCN2a and SCN8a genes.

METHOD

Molecular dynamic simulations were performed in six patients: three patients with Dravet syndrome (p.Gly177Ala,p.Ser259Arg and p.Met1267Ile, SCN1a), two patients with early onset drug resistant epilepsy(p.Ala263Val, SCN2a and p.Ile251Arg, SCN8a), and a patient with autism (p.Thr155Ala, SCN2a). After predicting the 3D-structure of mutated proteins by homology modeling, time dependent molecular dynamic simulations were performed, using the Schrödinger algorithm. The opening of the sodium channel, including the detachment of the sodium ion to the DEKA motif and pore diameter were assessed. Results were compared to the existent patch clamp analysis in four patients, and consistency with clinical phenotype was noted.

RESULTS

The Na⁺ ion remained attached to DEKA filter longer when compared to wild type in the p.Gly177Ala, p.Ser259Arg,SCN1a, and p.Thr155Ala, SCN2a variants, consistent with loss-of-function. In contrast, it detached quicker from DEKA than wild type in the p.Ala263Val,SCN2a variant, consistent with gain-of-function. In the p.Met1267Ile,SCN1a variant, detachment from DEKA was quicker, but pore diameter decreased, suggesting partial loss-of-function. In the p.Leu251Arg,SCN8a variant, the pore remained opened longer when compared to wild type, consistent with a gain-of-function. The molecular dynamic simulation results were consistent with the existing patch-clamp analysis studies, as well as the clinical phenotype.

SIGNIFICANCE

Molecular dynamic simulation can be useful in predicting pathogenicity of variants and the disease phenotype, and selecting targeted treatment based on channel dysfunction. Further development of these bioinformatic tools may lead to "virtual patch-clamp analysis".

From zero to thrive: A model of cross-system and cross-sector relational health to promote early childhood development across the child-serving ecosystem

Early relational health between caregivers and children is foundational for child health and well-being. Children and caregivers are also embedded within multiple systems and sectors, or a "child-serving ecosystem", that shapes child development. Although the COVID-19 pandemic has made this embeddedness abundantly clear, systems remain siloed and lack coordination. Fostering relational health amongst layers of this ecosystem may be a way to systematically support young children and families who are facing adversity. We integrate theory, examples, and empirical findings to develop a conceptual model informed by infant mental health and public health frameworks that illustrates how relational health across the child-serving ecosystem may promote child health and well-being at a population level. Our model articulates what relational health looks like across levels of this ecosystem from primary caregiver-child relationships, to secondary relationships between caregivers and child-serving systems, to tertiary relationships among systems that shape child outcomes directly and indirectly. We posit that positive relational health across levels is critical for promoting child health and well-being broadly. We provide examples of evidence-based approaches that address primary, secondary, and tertiary relational health, and suggest ways to promote relational health through cross-sector training and psychoeducation in the science of early development. This model conceptualizes relational health across the child-serving ecosystem and can serve as a template for promoting child health and well-being in the context of adversity.

Screening Children for Social Determinants of Health: A Systematic Review

CONTEXT

Screening children for social determinants of health (SDOHs) has gained attention in recent years, but there is a deficit in understanding the present state of the science.

OBJECTIVE

To systematically review SDOH screening tools used with children, examine their psychometric properties, and evaluate how they detect early indicators of risk and inform care.

DATA SOURCES

Comprehensive electronic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection.

STUDY SELECTION

Studies in which a tool that screened children for multiple SDOHs (defined according to Healthy People 2020) was developed, tested, and/or employed.

DATA EXTRACTION

Extraction domains included study characteristics, screening tool characteristics, SDOHs screened, and follow-up procedures.

RESULTS

The search returned 6274 studies. We retained 17 studies encompassing 11 screeners. Study samples were diverse with respect to biological sex and race and/or ethnicity. Screening was primarily conducted in clinical settings with a parent or caregiver being the primary informant for all screeners. Psychometric properties were assessed for only 3 screeners. The most common SDOH domains screened included the family context and economic stability. Authors of the majority of studies described referrals and/or interventions that followed screening to address identified SDOHs.

LIMITATIONS

Following the Healthy People 2020 SDOH definition may have excluded articles that other definitions would have captured.

CONCLUSIONS

The extent to which SDOH screening accurately assessed a child's SDOHs was largely unevaluated. Authors of future research should also evaluate if referrals and interventions after the screening effectively address SDOHs and improve child well-being.

Epidemiology of Obesity in Adults: Latest Trends

PURPOSE OF REVIEW

An increasing trend in obesity prevalence since the early 1980s has posed a significant population health burden across the globe. We conducted a systematic review for studies using measured anthropometry to examine trends in obesity in the USA published from 2012 to 2018 and for systematic reviews to document trends in obesity across the globe published from 2014 to 2018.

RECENT FINDINGS

For the USA, the only nationally representative data source capturing trends in obesity in this period was the National Health and Nutrition Examination Survey, which uses repeated cross-sectional data to document national trends in obesity in the USA. For global trends, the only systematic reviews of obesity across the globe were the Global Burden of Disease Obesity study and the Non-communicable Disease Risk Factor Collaboration study. In general, the population distribution of body mass index (BMI) in the USA has shifted towards the upper end of its distribution over the past three decades. The global distribution has similarly increased, albeit with large regional differences. US and global studies suggest an increasing trend in obesity since the 1980s, and there is a dearth of nationally representative longitudinal studies using measured anthropometry to capture trends in adult obesity in the USA for the same individuals over time. Greater efforts are needed to identify factors contributing to the continued increases in obesity.

How local health departments work towards health equity

BACKGROUND

Health inequities are exacerbated when health promotion programs and resources do not reach selected populations. Local health departments (LHDs)¹ have the potential to address health equity via engaging priority populations in their work. However, we do not have an understanding of what local agencies are doing on this front.

METHODS

In the summer of 2016, we collaborated with informants from thirteen LHDs across North Carolina. Via semi-structured interviews, the research team asked informants about their LHD's understanding of health equity and engaging priority populations in program planning, implementation, and evaluation.

FINDINGS

All informants discussed that a key function of their LHD was to improve the health of all residents. LHDs with a more comprehensive understanding of health equity engaged members of priority populations in their organizations' efforts to a greater extent than LHDs with a more limited understanding. Additionally, while all LHDs identified similar barriers to engaging priority populations, LHDs that identified facilitators more comprehensively engaged members of the priority population in program planning, implementation, and evaluation.

CONCLUSIONS

LHDs are ideally situated between the research and practice worlds to address health equity locally. To promote this work, we should ensure LHDs hold an understanding of health equity, have the means to realize facilitators of health equity work, and recognize the complex context in which health equity work exists.

Variability in self-rated health trajectories from adolescence to young adulthood by demographic factors

Self-rated health (SRH) is a robust measure of general health status and an indicator of where and when to target disease prevention efforts-especially in adolescent populations when clinical endpoints are rare. This study's purpose was to model SRH trajectories from ages 13 to 31 and identify whether and when differences between demographic groups emerge. We employed a conditional latent growth model of SRH in December 2016 using a nationally representative sample of 11,512 adolescents from the National Longitudinal Study of Adolescent to Adult Health data collected in 1994-2008. The average SRH trajectory is curvilinear: SRH increases until age 21 and then decreases. This trajectory contains significant between-individual variability in the intercept and linear slope. Males and self-identified non-Hispanic Blacks had higher SRH at age 13 but experienced steeper linear declines than their demographic counterparts. Individuals who grew up in households without two parents and whose parents did not graduate college had consistently lower SRH compared to those living in households with two parents and whose parents graduated college. Self-rated health is not stable over the span of early adolescence to young adulthood; demographic factors account for differences in individual variability around the starting point and overtime changes in SRH. Because these differences are apparent as early as age 13years, prevention efforts targeting demographic-based disparities should occur early in life.

Peer Support for the Hardly Reached: A Systematic Review

BACKGROUND

Health disparities are aggravated when prevention and care initiatives fail to reach those they are intended to help. Groups can be classified as hardly reached according to a variety of circumstances that fall into 3 domains: individual (e.g., psychological factors), demographic (e.g., socioeconomic status), and cultural-environmental (e.g., social network). Several reports have indicated that peer support is an effective means of reaching hardly reached individuals. However, no review has explored peer support effectiveness in relation to the circumstances associated with being hardly reached or across diverse health problems.

OBJECTIVES

To conduct a systematic review assessing the reach and effectiveness of peer support among hardly reached individuals, as well as peer support strategies used.

SEARCH METHODS

Three systematic searches conducted in PubMed identified studies that evaluated peer support programs among hardly reached individuals. In aggregate, the searches covered articles published from 2000 to 2015.

SELECTION CRITERIA

Eligible interventions provided ongoing support for complex health behaviors, including prioritization of hardly reached populations, assistance in applying behavior change plans, and social-emotional support directed toward disease management or quality of life. Studies were excluded if they addressed temporally isolated behaviors, were limited to protocol group classes, included peer support as the dependent variable, did not include statistical tests of significance, or incorporated comparison conditions that provided appreciable social support.

DATA COLLECTION AND ANALYSIS

We abstracted data regarding the primary health topic, categorizations of hardly reached groups, program reach, outcomes, and strategies employed. We conducted a 2-sample t test to determine whether reported strategies were related to reach.

RESULTS

Forty-seven studies met our inclusion criteria, and these studies represented each of the 3 domains of circumstances assessed (individual, demographic, and cultural-environmental). Interventions addressed 8 health areas, most commonly maternal and child health (25.5%), diabetes (17.0%), and other chronic diseases (14.9%). Thirty-six studies (76.6%) assessed program reach, which ranged from 24% to 79% of the study population. Forty-four studies (94%) reported significant changes favoring peer support. Eleven strategies emerged for engaging and retaining hardly reached individuals. Among them, programs that reported a strategy of trust and respect had higher participant retention (82.8%) than did programs not reporting such a strategy (48.1%; P = .003). In 5 of the 6 studies examining moderators of the effects of peer support, peer support benefits were greater among individuals characterized by disadvantage (e.g., low health literacy).

CONCLUSIONS

Peer support is a broad and robust strategy for reaching groups that health services too often fail to engage. The wide range of audiences and health concerns among which peer support is successful suggests that a basis for its success may be its flexible response to different contexts, including the intended audience, health problems, and setting.

PUBLIC HEALTH IMPLICATIONS

The general benefits of peer support and findings suggesting that it may be more effective among those at heightened disadvantage indicate that peer support should be considered in programs intended to reach and benefit those too often hardly reached. Because engendering trust and respect was significantly associated with participant retention, programs should emphasize this strategy.

Identifying Those Whom Health Promotion Hardly Reaches: A Systematic Review

To understand what circumstances lend groups to be recognized as hardly reached by health services and research, we systematically reviewed studies that identified their priority populations as hard to reach. We classified attributes of hardly reached groups into cultural/environmental, individual, and demographic domains. Of the 334 identified studies, 78.74% used attributes that were classified into the cultural/environmental, 74.85% the individual, and 50% the demographic domain to identify those hardly reached. Of all possible combinations of domains, the most common was the use of all three domains (28.74%). Overall, papers were more likely to use attributes to identify their hardly reached population that fell into more than one domain (74.85%) compared to only one domain (25.15%; χ(2), p < .0001). Through this review, we identified the attributes of those who have been identified as hardly reached in published research. No single attribute is used to identify those who are hardly reached. This reflects a socioecological perspective, emphasizing that both intrapersonal and external elements may cause interventions to fail to reach those intended. Moreover, the focus not on populations hardly reached but on the attributes of those hardly reached suggests objectives for interventions to reach them better.

European biliary atresia registries: summary of a symposium

Biliary atresia (BA) is a rare but potentially devastating disease. The European Biliary Atresia Registry (EBAR) was set up to improve data collection and to develop a pan-national and interdisciplinary strategy to improve clinical outcomes. From 2001 to 2005, 100 centers from 22 countries registered with EBAR via its website (www.biliary-atresia.com). In June 2006, the first meeting was held to evaluate results and launch further initiatives. During a 5-year period, 60 centers from 19 European countries and Israel sent completed registration forms for a total of 514 BA patients. Assuming the estimated incidence of BA in Europe is 1:18,000 live births, 35% of the expected 1488 patients from all EBAR participating countries were captured, suggesting that reporting arrangements need improvement. At the meeting, the cumulative evaluation of 928 BA patients including patients from other registries with variable follow-up revealed an overall survival of 78% (range from 41% to 92%), of whom 342 patients (37%) have had liver transplants. Survival with native liver ranged from 14% to 75%. There was a marked variance in reported management and outcome by country (e.g., referral patterns, timing of surgery, centralization of surgery). In conclusion, EBAR represents the first attempt at an overall evaluation of the outcome of BA from a pan-European perspective. The natural history and outcome of biliary atresia is of considerable relevance to a European population. It is essential that there is further support for a pan-European registry with coordination of clinical standards, further participation of parent support groups, and implementation of online data entry and multidisciplinary clinical and basic research projects.

Liver transplantation in mitochondrial respiratory chain disorders

Mitochondrial respiratory chain disease may lead to neonatal or late onset liver failure, requiring liver transplantation. In rare cases, the disease is restricted to the liver and the patient is cured after surgery. More frequently, other organs are simultaneously involved and neuromuscular or other extra-hepatic symptoms may pre-exist, or appear in the post-transplant follow up. Pre-transplant evaluation should aim to rule out neurological disease, which may be difficult to differentiate from signs accompanying liver insufficiency. Cerebrospinal fluid lactic acid levels, compared to blood lactate, may be suggestive of central nervous system involvement. Of 11 cases with respiratory chain disorders who had liver transplantation in various centres, 4 are alive and well on follow up, and 6 died, three of them having developed neurological disease post orthotopic liver transplantation. All three patients with initial liver and gastro-intestinal disease died early after transplantation, indicating that these may be poor candidates for this procedure.

CONCLUSION

Liver transplantation is feasible in hepatic respiratory chain disorders, but extra-hepatic disease should be ruled out before transplantation. Extra-hepatic manifestations may, however, appear and cause patient death despite successful transplantation.

[Complications of colostomy--how to avoid them]

According to data in the literature complications develop in association with colostomy in 20-66% of patients, occlusion of the colostomy occurs in 10-17%. The authors analyze their own group of 122 patients where in 1994-1998 a colostomy was made. Sixty-two patients were operated with developed ileus, 19 colostomies were later abolished and the passage per vias naturales was reconstructed. The authors recorded 38.5% complications, they were most frequent in axial transversostomies and sigmostomies, wound infections were most frequent. For prevention of complications the authors emphasize that stricter indications for colostomy should be used. The same applies to the selection of the type and site of colostomy and exact surgical technique, ATB prophylaxis and lavage, use of modern stomic appliances, perspectives of using the laparoscopic technique.

Prenatal cocaine exposure and child behavior

OBJECTIVE

The aim of this study was to evaluate previous teacher reports that children exposed to cocaine prenatally have more problem behaviors.

METHODS

A historical, prospective design was used. Maternal subjects (n = 116) of 6-year-old singleton, term (>/=36 weeks) children, and the children's first-grade teachers (n = 102) agreed to participate. The child's first-grade teacher, blinded to study design and exposure status, rated the child's behavior with the Conners' Teacher Rating Scales (CTRS) and an investigator-developed scale, the Problem Behavior Scale (PROBS 14), measuring behaviors reported by educators to be specific to cocaine exposure. Mothers were interviewed by telephone regarding demographic and socioeconomic factors.

RESULTS

Although the cocaine-exposed group had higher (more problem behaviors) for each of the CTRS subscales, the overall multivariate analysis of variance for the CTRS was not significant. Children exposed to cocaine prenatally had higher scores (more problem behaviors) for 11 of the 14 PROBS items and the overall multivariate analysis of variance relating prenatal cocaine exposure to the PROBS was significant (Wilkes' lambda =.775), even after controlling for gender and prenatal exposure to alcohol and cigarettes.

CONCLUSIONS

This pilot study supports that teachers blinded to exposure status of early elementary students did rate the cocaine-exposed group as demonstrating significantly more problem behaviors than control children. Although an important first step, postnatal factors that also may influence behavior were not evaluated; hence, causation is not addressed.

Prenatal coke: what's behind the smoke? Prenatal cocaine/alcohol exposure and school-age outcomes: the SCHOO-BE experience

Despite media reports and educators' concerns, little substantive data have been published to document or refute the emerging reports that children prenatally exposed to cocaine have serious behavioral problems in school. Recent pilot data from this institution have indeed demonstrated teacher-reported problem behaviors following prenatal cocaine exposure after controlling for the effects of prenatal alcohol use and cigarette exposure. Imperative in the study of prenatal exposure and child outcome is an acknowledgement of the influence of other control factors such as postnatal environment, secondary exposures, and parenting issues. We report preliminary evaluation from a large ongoing historical prospective study of prenatal cocaine exposure on school-age outcomes. The primary aim of this NIDA-funded study is to determine if a relationship exists between prenatal cocaine/alcohol exposures and school behavior and, if so, to determine if the relationship is characterized by a dose-response relationship. A secondary aim evaluates the relationship between prenatal cocaine/alcohol exposures and school achievement. Both relationships will be assessed in a black, urban sample of first grade students using multivariate statistical techniques for confounding as well as mediating and moderating prenatal and postnatal variables. A third aim is to evaluate the relationship between a general standardized classroom behavioral measure and a tool designed to tap the effects thought to be specific to prenatal cocaine exposure. This interdisciplinary research team can address these aims because of the existence of a unique, prospectively collected perinatal Database, funded in part by NIAAA and NICHD. The database includes repeated measures of cocaine, alcohol, and other substances for over 3,500 births since 1986. Information from this database is combined with information from the database of one of the largest public school systems in the nation. The final sample will be composed of over 600 first grade students for whom the independent variables, prenatal cocaine/alcohol exposures, were prospectively assessed and quantified at the university maternity center. After informed consent, the primary dependent variable, school behavior, is assessed, using the PROBS-14 (a teacher consensus developed instrument), the Child Behavior Check List, and the Conners' Teacher Rating Scale. The secondary dependent measure, school achievement, is measured by the Metropolitan Achievement Text and the Test of Early Reading Ability. Control variables, such as the environment and parenting, are measured by several instruments aimed at capturing the child and family ecology since birth. All analyses will be adjusted as appropriate for prospectively gathered control variables such as perinatal risk, neonatal risk, and other prenatal drug and cigarette exposures. Further adjustment will be made for postnatal social risk factors which may influence outcome. Of particular concern are characteristics of the home (adaptation of HOME), parent (depression, stress), and neighborhood (violence exposure). Finally, postnatal exposure to lead and other drugs is being considered.

[Bile leak after surgery of the gallbladder and bile ducts]

The authors present a brief review of the most frequent complications of operations of the gallbladder and biliary pathways and demonstrate a group of patients of the Department of Surgery of the hospital and policlinic Ruzinov in Bratislava treated during the last six years. They emphasize conservative treatment of escape of bile except cases of acute biliary peritonitis or peroperatively revealed lesions of the biliary pathways. In the conclusion they submit an algorithm of treatment of escape of bile after surgery of the gallbladder and biliary pathways.

A hypertext information system for standard operating procedures in haematological intensive care

In times of cost reduction efforts the role of standard operating procedures for both medical and nursing procedures gets increasing importance. Such standards are necessary if the quality of patient care shall not suffer but even improve. While some sophisticated approaches are coming up with generation of clinical processes from formal protocol models in connection with documentation systems the clinical practice actually looks quite different: Paper-based "operating standards" are used in day-to-day work, if any. In this paper a simple and powerful WWW-based hypertext information system for easy provision and maintenance of nursing standards is presented.

[Personal experience with the Lichtenstein surgical method in recurrent abdominal hernia]

The authors present a group of 21 patients treated with the method of Lichtenstein with the use of polypropylene mesh Prolen. They used the method of an "inlay" mesh for recurrent groin and epigastric hernias, mostly by men. The men:women ratio was 19:2. They emphasise better healing, early recovery to work and almost no wound infection by use of this method.

Translocation of apolipoprotein B across the endoplasmic reticulum is blocked in abetalipoproteinemia

Abetalipoproteinemia (ABL) is an autosomal recessive disease characterized by the inability of the liver and intestine to secrete apolipoprotein B (apoB). Mutations in the microsomal triglyceride transfer protein (MTP) gene, but not the apoB gene, are responsible for the ABL phenotype. It is not clear how loss of MTP in ABL patients leads to a complete, but specific, block in the secretion of apoB. It is to this question that our work is directed. In cultured cells lacking MTP, translocation of apoB is completely arrested, leading to the hypothesis that apoB requires MTP in order to completely enter the lumen of the endoplasmic reticulum, the site of lipoprotein assembly. We examined this hypothesis by determining the presence in plasma of distinct N-terminal apoB peptides, produced exclusively from translocation arrested apoB, in the plasma of six ABL patients and six normal subjects. The data show that N-terminal apoB peptides are present in the plasma of six ABL patients, whereas intact apoB-100 was barely detectable. Moreover, the plasma of all six ABL patients displayed a 2000-fold increase in the amount of an 85 kDa N-terminal apoB peptide relative to apoB-100. These data provide the first in vivo data supporting the essential role that MTP plays in apoB translocation. In normal humans, varied expression of MTP may be responsible for the post-transcriptional regulation of apoB secretion.

Erythrocyte insulin and insulin-like growth factor-I receptor tyrosine kinase activity in hypertension in pregnancy

We have shown that preeclampsia is associated with insulin resistance. In the present study, we examined young normal, preeclamptic (PE), and gestational hypertensive (GH) nulliparous African-American women at term to investigate cellular determinants of this resistance and insulin and insulin-like growth factor-I (IGF-I) binding to partially purified erythrocyte receptors and receptor tyrosine kinase activity (TKA). Blood pressure was significantly elevated in PE and GH subjects as compared with controls. Insulin binding was similar in number and affinity in the three groups (femtomoles per microgram). IGF-I binding was increased in PE subjects as compared with either normals or GH subjects (0.2 +/- 0.02, 0.15 +/- 0.01, and 0.14 +/- 0.02 fmol/microgram protein). Insulin receptor TKA was increased in PE subjects as compared with normals when assessed either per microgram protein or per femtomole insulin binding (P < .01). In contrast, IGF-I-potentiated TKA was elevated in PE subjects only when assessed per microgram protein (P < .03). Thus, the increased number of IGF-I receptors in erythrocytes of PE subjects yields a net increase in receptor tyrosine kinase. Also, there is an augmentation of insulin receptor TKA in PE subjects. Together, these two alterations may be a compensatory mechanism for the insulin resistance associated with hypertensive diseases of pregnancy.

Ataxia with isolated vitamin E deficiency is caused by mutations in the alpha-tocopherol transfer protein

Ataxia with isolated vitamin E deficiency (AVED) is an autosomal recessive neurodegenerative disease which maps to chromosome 8q13. AVED patients have an impaired ability to incorporate alpha-tocopherol into lipoproteins secreted by the liver, a function putatively attributable to the alpha-tocopherol transfer protein (alpha-TTP). Here we report the identification of three frame-shift mutations in the alpha TTP gene. A 744delA mutation accounts for 68% of the mutant alleles in the 17 families analysed and appears to have spread in North Africa and Italy. This mutation correlates with a severe phenotype but alters only the C-terminal tenth of the protein. Two other mutations were found in single families. The finding of alpha TTP gene mutations in AVED patients substantiates the therapeutic role of vitamin E as a protective agent against neurological damage in this disease.

[Evaluation of a new intravenous device]

Problems associated with intravenous (IV) admixture preparation include contamination by microorganisms, human error and expense. To solve some of these problems, the Vialink system was developed by Travenol, Israel. This device enables enhanced sterility in clinical settings, since in the preparation of the admixture there is only a single penetration of the rubber seal of the vial. The dilution is performed immediately prior to administration, thereby reducing the possibility of wastage due to unused admixture. In addition, Vialink offers a means of double-checking the contents of the admixtures, since the emptied vial remains attached to the infusion bag. Results of our evaluation of this new system indicate that it offers substantial savings in preparation time and expense. It was suitable for 58.2% of all IV admixtures routinely hospital-prepared. The Vialink system may be a useful strategy, as it improves the quality of the service provided by the health service team and hospital pharmacists to their patients, and results in savings in budget and manpower.

Vitamin E supplementation reduces the incidence of diabetes but not insulitis in NOD mice

The incidence of diabetes was reduced in non-obese diabetic (NOD) mice fed a diet containing 1000 IU/kg of vitamin E. Histologic examination of the islets of these mice, however, disclosed a frequency of insulitis that approximated the frequency found in animals fed conventional diets. The vitamin E-treated mice were not immunosuppressed, as judged by normal T cell subsets in the spleen and normal T cell proliferative responses to concanavalin A. NOD mice deprived of vitamin E were also protected from diabetes. However, these mice had delayed growth, reduced T cell numbers in the spleen, and impaired proliferative responses to mitogens, which is indicative of secondary immunodeficiency. The data are consistent with the view that antioxidant treatment may limit immunologically mediated damage to islet beta cells.

Prenatal alcohol exposure and cognitive development in the preschool years

The teratogenic effects of drinking during pregnancy on cognitive development were investigated in a cohort of disadvantaged mother-infant pairs. Three indices associated with maternal alcohol use were related to comprehensive cognitive measures obtained during five in-home assessments through age four years, ten months. Birth weight and a tally of craniofacial anomalies were also evaluated as early indicators of fetal alcohol damage. Multiple analyses relating the alcohol and cognitive measures provided no evidence of an adverse alcohol effect on cognitive development in the absence of Fetal Alcohol Syndrome. Assessments based on confidence intervals indicated that an average decrement of more than two points (IQ equivalent) on the five cognitive measures is unlikely for relatively heavy levels of maternal alcohol use or alcohol-related problems. Marginal relationships were observed between cognitive measures and the neonatal indicators, but depended heavily on the influence of a child exhibiting signs consistent with Fetal Alcohol Syndrome. This case therefore received special attention. The implications of the relationships involving the neonatal indicators were investigated using arguments based on path analysis.

A randomized controlled trial of early amniotomy

OBJECTIVE-To determine if a policy of early amniotomy resulted in a reduction in mean labour duration when compared to a policy of conservation of the membranes. DESIGN-A single-centre randomized controlled trial. SETTING-A tertiary care teaching hospital in Alberta, Canada. SUBJECTS-Ninety-seven term nulliparae in spontaneous labour, baby in cephalic presentation. INTERVENTION-Early amniotomy versus intent to keep membranes intact. MAIN OUTCOME MEASURES-Interval from randomization to delivery, rate of abnormalities of fetal heart rate tracings, cord artery blood pH, Apgar scores. RESULTS-The mean interval from randomization to delivery was 390.9 (SE 29.1) min in the amniotomy group and 442.9 (SE 34.1) min in the control group (P = 0.251). There were no differences between groups in the occurrence of fetal heart rate tracing abnormalities, nor was there a difference in the proportion of babies with abnormal Apgar scores, or abnormal cord pH (less than 7.20). CONCLUSION-The results of the study fail to support the long held belief that early amniotomy is an effective method for reducing labour duration.

Prenatal alcohol exposure and language development

The effects of fetal alcohol exposure on language and speech acquisition were investigated in a cohort of socioeconomically disadvantaged urban children. Language development was assessed by instruments derived from the Expressive and Receptive Scales of the Sequenced Inventory of Communication Development (SICD) at 1, 2, and 3 years, and by indices constructed from a taped speech sample at age 2 years. Three indices of maternal drinking were supplemented with birth weight and a tally of craniofacial anomalies as early indicators of fetal alcohol damage. No statistically significant relationships were found between the alcohol and language indices after statistical control for confounding variables. The anomalies tally was marginally related to reduced language scores. The statistical significance of this relationship, depended, however, on a single child with the characteristics of fetal alcohol syndrome. The pattern of results suggested that the anomalies tally, and to a lesser extent birth weight, are more sensitive indicators of fetal alcohol exposure than subsequent language development.

Stability of the MCMI among depressed psychiatric outpatients

The Millon Clinical Multiaxial Inventory (MCMI) is a promising, yet somewhat unproven psychometric inventory developed to identify clinical syndromes and personality traits consonant with the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. [DSM-III]; American Psychiatric Association, 1980). The stability of its measures for both the theoretically more stable personality characteristics and the clinical syndromes was investigated in a group of depressed psychiatric outpatients. In this test-retest design with a 3-month interval between tests, clinical syndrome scales of relevance changed significantly as expected. However, many of the personality scales also changed significantly. Only four of the personality scales met a two-fold test of stability. Findings are discussed in terms of characteristics of self-report inventories such as the MCMI, the uniqueness of the depressed population, and characteristics of personality disorders.

Personality disorders among depressed outpatients as identified by the MCMI

Personality disorders frequently are seen among depressed psychiatric inpatients. In a group of 73 depressed psychiatric outpatients, this study identified 85% whose response to the Millon Clinical Multiaxial Inventory (MCMI) suggested a personality disorder. On retest 12 weeks later, only 64% manifested a response style consistent with the DSM-III personality disorders. These findings are discussed in relation to methodology, characteristics of the MCMI, and the response style of the depressed patient, which may lead to an overidentification of personality disorders on a self-report measure. Related aspects of the diagnostic criteria for personality disorders also are discussed.

Does intravenous ritodrine therapy cause capillary endothelial damage?

The effects of intravenous (IV) ritodrine therapy on capillary endothelial damage and colloid osmotic pressure were examined in 15 patients in premature labor. Plasma fibronectin, a marker for capillary endothelial damage, did not change significantly after IV ritodrine therapy. Plasma colloid osmotic pressure was lowered following ritodrine therapy (P less than 0.05). Pretreatment plasma fibronectin levels in the study and control groups were similar. Interestingly, pretreatment colloid osmotic pressure in the study group was significantly lower than that of the control group (P less than 0.05). Our data suggest that there is no evidence of capillary endothelial damage following ritodrine therapy. Lower levels of plasma colloid osmotic pressure in patients with preterm labor, which are further reduced with IV ritodrine therapy, may predispose these patients to pulmonary edema.

Friedreich's disease: V. Variant form with vitamin E deficiency and normal fat absorption

A 30-year-old woman was thought to have Friedreich's disease because of progressive ataxia, dysarthria, and titubation from age 3 years. Her diet was normal, and there were neither symptoms nor laboratory evidence of liver disease or fat malabsorption. Serum vitamin E content and the ratio of serum vitamin E to total serum lipid were very low, but serum vitamin A, cholylglycine, and lipid levels were normal, as was an oral vitamin E tolerance test. Muscle biopsy showed the lysosomal inclusions of vitamin E deficiency. Mitochondria had normal oxidative phosphorylation using polarographic assays. The cause of her vitamin E deficiency was unknown.

Selenium: childhood poisoning and cystic fibrosis

Two cases of selenium ingestion in children are described; one child with severe cystic fibrosis died. Both children had cystic fibrosis and both had low serum chloride in association with selenium usage. Neither child was exposed to excessive heat or cold weather, factors known to salt-deplete children were cystic fibrosis, although one child was dehydrated during a summer month on initial presentation. One child had protein-calorie malnutrition, a condition known to enhance selenium toxicity in animals. We conclude that selenium is a potential hazard in its use as a health food fad for children with cystic fibrosis and in overdose ingestions. Thus selenium supplementation may have contributed to the morbidity and mortality reported here.