Evaluation of in silico pathogenicity prediction tools for the classification of small in-frame indels

BACKGROUND

The use of in silico pathogenicity predictions as evidence when interpreting genetic variants is widely accepted as part of standard variant classification guidelines. Although numerous algorithms have been developed and evaluated for classifying missense variants, in-frame insertions/deletions (indels) have been much less well studied.

METHODS

We created a dataset of 3964 small (< 100 bp) indels predicted to result in in-frame amino acid insertions or deletions using data from gnomAD v3.1 (minor allele frequency of 1-5%), ClinVar and the Deciphering Developmental Disorders (DDD) study. We used this dataset to evaluate the performance of nine pathogenicity predictor tools: CADD, CAPICE, FATHMM-indel, MutPred-Indel, MutationTaster2021, PROVEAN, SIFT-indel, VEST-indel and VVP.

RESULTS

Our dataset consisted of 2224 benign/likely benign and 1740 pathogenic/likely pathogenic variants from gnomAD (n = 809), ClinVar (n = 2882) and, DDD (n = 273). We were able to generate scores across all tools for 91% of the variants, with areas under the ROC curve (AUC) of 0.81-0.96 based on the published recommended thresholds. To avoid biases caused by inclusion of our dataset in the tools' training data, we also evaluated just DDD variants not present in either gnomAD or ClinVar (70 pathogenic and 81 benign). Using this subset, the AUC of all tools decreased substantially to 0.64-0.87. Several of the tools performed similarly however, VEST-indel had the highest AUCs of 0.93 (full dataset) and 0.87 (DDD subset).

CONCLUSIONS

Algorithms designed for predicting the pathogenicity of in-frame indels perform well enough to aid clinical variant classification in a similar manner to missense prediction tools.

Perceptions of somatic and affective symptoms and psychosocial care utilization in younger and older survivors of lung cancer

OBJECTIVE

Rates of depression identification in oncology settings and referral to psychosocial services remain low. Patients with lung cancer face an elevated risk of depression relative to patients with other cancers. This study explored perceptions of somatic and affective symptoms and psychosocial care utilization among younger and older lung cancer survivors.

METHODS

We conducted in-depth interviews with 20 adults at two academic medical centers in Boston, MA, who had received a lung cancer diagnosis in the past 24 months. A semi-structured interview guide was used to assess experiences with, and perceptions of, depression symptoms and psychosocial services. Interviews were audio-recorded, transcribed, and coded to identify themes. We also explored differences between younger (<65years; N=9) and older (>65years; N=11) patients.

RESULTS

Participants commonly described somatic symptoms (i.e., changes in appetite, sleep, or energy levels) and affective symptoms (i.e., worry, fear, sadness) as side effects of cancer treatment. Older participants more commonly contextualized these symptoms with information about how they impacted daily life. Both younger and older participants faced barriers to accessing psychosocial services, with older adults more commonly referencing stigma of service referral and utilization.

DISCUSSION

Patients with lung cancer associated both somatic and affective symptoms with their cancer and its treatment, with age differences in how symptoms were described and how psychosocial referrals may be perceived. More systematic integration of psychosocial care into cancer care may help to increase the identification of depression in lung cancer and reduce barriers to psychosocial service utilization.

Detection of iron deficiency in children with Down syndrome

PURPOSE

Current American Academy of Pediatrics guidelines for children with Down syndrome (DS) recommend a complete blood count (CBC) at birth and hemoglobin annually to screen for iron deficiency (ID) and ID anemia (IDA) in low-risk children. We aimed to determine if macrocytosis masks the diagnosis of ID/IDA and to evaluate the utility of biochemical and red blood cell indices for detecting ID/IDA in DS.

METHODS

We reviewed data from 856 individuals from five DS specialty clinics. Data included hemoglobin, mean corpuscular volume, red cell distribution width (RDW), percent transferrin saturation (TS), ferritin, and c-reactive protein. Receiver operating characteristic curves were calculated.

RESULTS

Macrocytosis was found in 32% of the sample. If hemoglobin alone was used for screening, all individuals with IDA would have been identified, but ID would have been missed in all subjects. RDW had the highest discriminability of any single test for ID/IDA. The combination of RDW with ferritin or TS led to 100% sensitivity, and RDW combined with ferritin showed the highest discriminability for ID/IDA.

CONCLUSION

We provide evidence to support that a CBC and ferritin be obtained routinely for children over 1 year old with DS rather than hemoglobin alone for detection of ID.

Thyroid dysfunction in patients with Down syndrome: Results from a multi-institutional registry study

The goals of this undertaking were to assess the outcomes of thyroid screening tests and adherence to thyroid screening guidelines across five Down syndrome (DS) specialty clinics in various states. Data related to thyroid screening were collected for 663 individuals across five clinics specializing in the comprehensive care of individuals with DS for a period of 1 year. Of the 663 participants, 47.7% of participants had a TSH and free T4 ordered at their DS specialty clinic visit. Approximately 19.0% (60/316) had a new thyroid disorder diagnosis made. We conclude that a sizable proportion of the patients with DS are not up-to-date on current guidelines when they present to a DS specialty clinic, while adherence to thyroid screening guidelines helps facilitate early diagnoses. Hypothyroidism is prevalent in the population, consistent with reported literature. DS specialty clinics can help patients stay current on screening guidelines.

National down syndrome patient database: Insights from the development of a multi-center registry study

The Down Syndrome Study Group (DSSG) was founded in 2012 as a voluntary, collaborative effort with the goal of supporting evidenced-based health care guidelines for individuals with Down syndrome (DS). Since then, 5 DS specialty clinics have collected prospective, longitudinal data on medical conditions that co-occur with DS. Data were entered by clinical staff or trained designees into the National Down Syndrome Patient Database, which we created using REDCap software. In our pilot year, we enrolled 663 participants across the U.S., ages 36 days to 70 years, from multiple racial and ethnic backgrounds. Here we report: (i) the demographic distribution of participants enrolled, (ii) a detailed account of our database infrastructure, and (iii) lessons learned during our pilot year to assist future researchers with similar goals for other patient populations.

Acupuncture as a Treatment Option in Treating Posttraumatic Stress Disorder-Related Tinnitus in War Veterans: A Case Presentation

Although close associations between tinnitus and posttraumatic stress disorder (PTSD) among war veterans has been documented, there is limited research that explores evidence-based, efficacious interventions to treat the condition in this particular population. This article presents a case of three war veterans with PTSD symptoms who received a series of acupuncture treatments for tinnitus with positive outcomes. Even though the article presents cases of only three veterans and was based on self-reports, there were very clear trends on how veterans with tinnitus symptoms responded to acupuncture treatments. Information generated from this case presentation is a good starting place in exploring evidence-based approaches in treating tinnitus symptoms in war veterans with PTSD.

Occurrence and Characterization of Bean common mosaic virus Strain NL1 in Iowa

A legume survey in Story County was conducted to characterize legume viruses present in Iowa and potentially problematic to soybeans. Symptomatic (chlorosis, leaf curl, or vein banding) and non-symptomic leaves were selected from Apios americana, Cyamopsis tetragonolobus, Desmodium spp., Glycine max, Lablab purpureus, Lotus japonicus, Phaseolus coccineus, Phaseolus vulgaris, Vicia faba, Vigna ungulculata, and Chenopodium quinoa (an indicator species), and sent to Agdia Inc. for their Crop Screen: "Bean (Soybean)" tests. Cowpea mosaic virus (in L. purpureus), Southern bean mosaic virus (in A. americana), Soybean dwarf virus (in L. purpureus), and Tobacco streak virus (in Desmodium spp.) were identified. In addition, P. vulgaris was found positive in the serological Potyvirus group test, and was further characterized using reverse transcription (RT)-PCR using total RNA (Qiagen RNeasy extraction kit) from symptomatic leaves. A ~1-kb fragment of virus genome was amplified using degenerate primers, forward: 5' TGYGTNGAYGAYYTYAAYAA 3' (3) and reverse: 5' TCRTARAARTCRAAIGCRTAICKIG 3' (2). The closest GenBank BLAST hits for the sequence were BCMV strain NL1 (GenBank Accession No. AY112735) and BCMV MS1 (EU761198), both at 97% identity. RNA sequencing using an Illumina HiSeq 2500 (100 base paired ends) allowed construction of a nearly complete viral sequence from positions 38 to 10,037 nt (KM023744). This showed 99% similarity to BCMV-NL1 (AY112735) and 98% similarity to BCMV MS1 (EU761198). The BCMV isolate was recovered on the P. vulgaris cv. Taos Red and tested against a panel of Phaseolus, Glycine, and other hosts. Symptomatic hosts (vein-banding, mosaic, stunting, and leaf curl) were P. vulgaris cvs. Starlight, Tohono O'odham vaya Amarillo, Black Valentine Stringless, Sutter Pink, Hidatsa red, Stringless Green Refugee, Burpees Stringless Improved Bush, Princess d'Artois, Princess Double de Holland, and Dubelle Witte. Asymptomatic hosts included P. vulgaris cvs. Sierra, Great Northern Tara, Tara, and Vigna radiata. Non-host plants were P. vulgaris cvs. Michelite 62, Great Northern UI 31, Great Northern UI 123, Pure Gold Wax, Top Crop, Redlands Greanleaf B, Red Mexican UI 34, Imuna, Monroe, Pinto UI 114, Widusa, Othello, Sacramento, Red Kidney, Provider, Black Turtle Soup, Victor, and Witte boon, G. max cv. Williams, Cucumis sativus cv. Straight 8, Solanum lycopericum cv. Reine des Hatives, Vicia faba, Pisum sativum var. macrocarpon, V. unguiculata, and A. americana. The host range of the BCMV isolate on common bean differential species concurred with pathogenicity group I (1) and agreed with assignment as strain NL1. To our knowledge, this is the first complete characterization of a pathotype I strain NL1 of BCMV in the United States, combining biological typing and whole genome sequencing. References: (1) R. E. Klein et al. Plant Dis. 76:1263, 1992. (2) H. Yamamoto et al. J. Gen. Plant Pathol. 74:97, 2008. (3) L. Zheng et al. PLoS One 3:e1586, 2008.

Limb hypoplasia resulting from intrauterine infection with herpes simplex virus: a case report

Intrauterine infection with herpes simplex virus, although very rare, has devastating effects on multiple organ systems in the fetus and can lead to in utero fetal demise. Neonates born following intrauterine herpes simplex virus infection commonly manifest with cutaneous lesions, ocular damage and/or brain abnormalities. We describe the case of a dichorionic, diamniotic twin gestation complicated by intrauterine herpes simplex virus infection. This infection led to the fetal demise of twin A and a very uncommon presentation of limb hypoplasia in twin B.

Race by sex differences in depression symptoms and psychosocial service use among non-Hispanic black and white patients with lung cancer

PURPOSE

This study examined race by sex differences in depression symptoms and psychosocial service use (pastors, social workers, mental health workers, support groups) among patients with lung cancer.

PATIENTS AND METHODS

The multiregional Cancer Care Outcomes Research and Surveillance study surveyed black and white adults with stages I to III lung cancer (n = 1,043) about depression symptoms, interest in help for mood, and psychosocial service use. Multivariable logistic regression was used to evaluate race/sex differences in depression symptoms (modified Center for Epidemiologic Studies Depression Scale ≥ 6) and psychosocial service use, independent of demographic, clinical, psychosocial, and behavioral covariates.

RESULTS

A total of 18.2% screened positive for depression symptoms. This proportion was highest among black men (24.7%), followed by white women (20.6%), black women (15.8%), and white men (15.0%). In adjusted analyses, white women showed greater risk for depression symptoms relative to black women (P = .01) and white men (P = .002), with no other differences among groups. Black patients were less likely than white patients to receive desired help for mood from their doctors (P = .02), regardless of sex. Among all patients, black women were most likely to have contact with pastoral care and social work.

CONCLUSION

Race and sex interacted to predict risk of depression symptoms. Covariates accounted for elevated risk among black men. White women showed greater risk than black women and white men, independent of covariates. Black patients may experience greater barriers to receiving help for mood from their doctors. Race by sex differences in contact with psychosocial services highlight potential differences in the extent to which services are available, acceptable, and/or sought by patients.

Depression and undertreatment of depression: potential risks and outcomes in black patients with lung cancer

In the United States, Black men are at higher risk than White men for lung cancer mortality whereas rates are comparable between Black and White women. This article draws from empirical work in lung cancer, mental health, and health disparities to highlight that race and depression may overlap in predicting lower treatment access and utilization and poorer quality of life among patients. Racial barriers to depression identification and treatment in the general population may compound these risks. Prospective data are needed to examine whether depression plays a role in racial disparities in lung cancer outcomes.

Disparities between blacks and whites in tobacco and lung cancer treatment

Racial disparities exist in lung cancer incidence, morbidity, and mortality. Smoking is responsible for the majority of lung cancers, and racial disparities also exist in smoking outcomes. Black smokers are less likely than white smokers to engage in evidence-based tobacco treatment, and black smokers are less likely than white smokers to stop smoking. Continued smoking following a lung cancer diagnosis is a potential indicator of poor lung cancer treatment outcomes, yet lung cancer patients who smoke are unlikely to receive evidence-based tobacco treatment. The risks from continued smoking after diagnosis deserve attention as a modifiable factor toward lessening racial disparities in lung cancer outcomes.

Proximal humeral replacement using a fixed-fulcrum endoprosthesis

Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%). Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18). Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.

Local recurrence of osteosarcoma after 17 years

The recurrence of osteosarcoma is rare. Local recurrence occurs in 4-10% of patients following effective treatment. So far, recurrences as late as 15 years have been reported in the literature. We report a unique case of local recurrence of intramedullary osteosarcoma 17 years from initial diagnosis and treatment. Regular long-term follow-up of patients with this diagnosis is crucial to ensure early detection and treatment of potential recurrences.

Peri-acetabular resection and endoprosthetic reconstruction for tumours of the acetabulum

We treated 98 patients with peri-acetabular tumours by resection and reconstruction with a custom-made pelvic endoprosthesis. The overall survival of the patients was 67% at five years, 54% at ten years and 51% at 30 years. One or more complications occurred in 58.1% of patients (54), of which infection was the most common, affecting 30% (28 patients). The rate of local recurrence was 31% (29 patients) after a mean follow-up of 71 months (11 to 147). Dislocation occurred in 20% of patients (19). Before 1996 the rate was 40.5% (17 patients) but this was reduced to 3.9% (two patients) with the introduction of a larger femoral head. There were six cases of palsy of the femoral nerve with recovery in only two. Revision or excision arthroplasty was performed in 23.7% of patients (22), principally for uncontrolled infection or aseptic loosening. Higher rates of death, infection and revision occurred in men.

This method of treatment is still associated with high morbidity. Patients should be carefully selected and informed of this pre-operatively.

Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects: implications for prevention of travel-related deep vein thrombosis

BACKGROUND

Venous stasis is an important contributing factor in the development of travel-related deep vein thrombosis. This study examined factors affecting popliteal venous blood flow in order to determine the most effective exercise regimen to prevent venous stasis.

METHODS

Twenty-one healthy subjects were randomly assigned to various activities over a 9-week period. Subjects remained seated throughout the investigation and 3660 duplex ultrasound examinations were performed by a single examiner using a SonoSite 180 Plus handheld ultrasound. Baseline popliteal vein blood flow velocity, cross-sectional area and volume flow in subjects sitting motionless were assessed in the first 3 weeks.The remaining 6 weeks involved subjects performing airline-recommended activities, foot exercises, foot exercises against moderate resistance and foot exercises against increased resistance in order to determine the most beneficial method for enhancing popliteal venous flow. Sitting with feet not touching the floor and the effect of sleeping were also assessed.

RESULTS

The median age of the subjects was 22 years (range: 18-25.5 years), height 171 cm (162.5-180.5 cm) and body mass index 25.3 kg m(-2) (23.2-26.3 kg m(-2)). Blood volume flow in the popliteal vein was reduced by almost 40% with immobility of seated subjects and by almost 2-fold when sitting motionless with feet not touching the floor. Foot exercises against increased resistance positively enhanced volume flow (P < 0.0001).

CONCLUSION

Leg exercise regimens enhanced popliteal venous flow during prolonged immobility of seated subjects, reinforcing the importance of regular leg movement to prevent venous stasis during prolonged sitting, such as in long-distance travel.

Kystes anévrismaux des phalanges et des métacarpiens. À propos de six cas et revue de la littérature

Aneurysmal bone cysts arising from tubular bones of the hand occur very rarely and require particular diagnostic and therapeutic management techniques. The authors report the diagnostic and surgical management of a monocentric case series of six aneurysmal bone cysts involving the phalangeal and metacarpal bones. In addition to hightlighting the use of diagnostic MRI and biopsy prior to surgical intervention, the authors describe the favourable outcome of curetage with and without the use of bone graft. An aggressive treatment approach such as cryotherapy or resection with reconstruction should only be used in cases when the articular surface is involved, when full bone invasion of the phalanx or metacarpal has occurred, or in case of more than one recurrence.

Doxorubicin and cisplatin chemotherapy in high-grade spindle cell sarcomas of the bone, other than osteosarcoma or malignant fibrous histiocytoma: a European Osteosarcoma Intergroup Study

There are limited data that define the role of chemotherapy in the treatment of high-grade spindle cell sarcomas of bone, other than osteosarcoma or malignant fibrous histiocytoma (MFH-B). This prospective study evaluates the effect of doxorubicin and cisplatin on these tumours. Thirty-seven patients, age 65 years, with spindle cell sarcoma of bone, except osteosarcoma or MFH-B, were included. Chemotherapy consisted of doxorubicin and cisplatin every 3 weeks for six cycles. Resection was performed after three cycles. In 15 patients with metastases, response assessment showed three complete responses (CR), four stable disease (SD), five progression; three were not evaluable. Median time to progression was 30 months (95% Confidence Interval (CI), 8-51 months) for the operable non-metastatic patients; median survival 41 months (95% CI, 16-82 months). Median time to progression in the metastatic group was 10 months (95% CI, 0-18 months) and median survival was 14 months (95% CI, 4-45 months). This study suggests a limited role for doxorubicin and cisplatin in metastatic high-grade spindle cell sarcoma of bone, other than osteosarcoma or MFH-B cases.

Single center experience of a new intensive induction therapy for ewing's family of tumors: feasibility, toxicity, and stem cell mobilization properties

PURPOSE

To examine the feasibility, tolerability, and toxicity of an intensified induction regimen (vincristine, ifosfamide, doxorubicin, and etoposide [VIDE]) in patients with newly diagnosed Ewing's family of tumors (EFT); to assess ability to maintain dose-intensity, and predictability of peripheral-blood stem cell mobilization.

PATIENTS AND METHODS

Thirty patients were treated with vincristine 1.4 mg/m2 (maximum 2 mg) on day 1, doxorubicin 20 mg/m2, ifosfamide 3 g/m2 plus mesna and etoposide 150 mg/m2 on days 1 to 3. Cycles were given every 21 days for up to six cycles.

RESULTS

One-hundred and seventy cycles of VIDE were given. The median treatment interval was 21 days (21 to 42) and nadir count: hemoglobin 8.3 (6.3 to 11.9), neutrophils 0.045 (0.0 to 2.1), and platelets 45 (3 to 343). There were 96 episodes of infection requiring hospitalization (56%). Growth factor support reduced infectious complications by 34%. Etoposide dose was reduced, or omitted, in 24% of cycles. Four patients did not complete six cycles due to unacceptable toxicity and one patient progressed on treatment. Twenty patients underwent peripheral-blood stem cell harvesting, 15 after cycle 3, and five after cycle 4. Median CD34+ yield was 4.6 x 106/kg per patient (1.8 to 14.5). Overall response to treatment, measured in 24 patients, was 88%. Seven of 11 patients undergoing surgery achieved greater than 90% necrosis of tumor (64%).

CONCLUSION

VIDE is an effective induction regimen with substantial but acceptable toxicity that allows predictable mobilization of stem cells. Maintenance of dose-intensity is feasible in the majority of patients. Growth factors play a role in maintaining dose-intensity and reduce infectious complications.

Posture-related tachycardia in older patients with hyponatremia

Hyponatremia (HN) is the commonest electrolyte abnormality in elderly patients. Its etiology in this setting is poorly understood. In this study, the authors aim to compare the hemodynamic and hormonal responses of a group of older patients with a predisposition to HN with a group of age-matched controls. We assessed hemodynamic and hormonal responses to postural challenge in 15 patients over age 65 with serum sodium concentrations of less than 130 mM (mean 128.7 mM) and 15 age-matched controls with normal sodium concentrations. Patients remained recumbent for 1 h and stood for the second. Blood was drawn at baseline and at 15 min intervals. Blood pressure (BP) and pulse rates (PR) were monitored electronically. Plasma arginine vasopressin (AVP), atrial natriuretic peptide (ANP), renin and aldosterone were determined periodically during the study period. No difference in BP between groups was noted. PR increased significantly in the HN group only within 3 min of standing (from 71 +/- 4 to 86 +/- 5, P<0.01) and remained significantly higher than controls until 90 min (87 +/- 5 vs. 69 +/- 4, P<0.01). While plasma AVP levels increased significantly following 30 min standing and remained elevated for both HN and control groups, it did not differ significantly between the two. Baseline plasma ANP levels were significantly higher in HN patients compared with controls and remained significantly higher (P<0.05) throughout the study. There was no significant difference in plasma renin or aldosterone levels between groups during the study period. We have demonstrated differing autonomic and hormonal responses to orthostatic challenge between HN patients and age-matched controls. Water retention due to the syndrome of inappropriate anti-diuretic hormone secretion (with reset osmostat) may lead to raised ANP levels in this older cohort of patients. Further physiological studies are required to clarify the precise mechanism of these varying responses.

Plasma P-selectin is elevated in the first trimester in women who subsequently develop pre-eclampsia

OBJECTIVE

To report plasma concentrations of the adhesion cell molecule P-selectin during pregnancy to determine the effect of subsequent development of hypertension and pre-eclampsia.

DESIGN

A longitudinal study.

METHODS

A longitudinal study involving 70 women followed up from early pregnancy; 20 who subsequently developed pre-eclampsia were compared with 24 who developed gestational hypertension and 26 normotensive women with normal obstetric outcome. The determination of citrate plasma soluble P-selectin levels throughout pregnancy was performed using a commercial quantitative sandwich immunoassay kit. The temporal course of plasma P-selectin in the three groups of subjects was analysed.

RESULTS

There was no significant difference in mean plasma P-selectin concentration between normotensive and gestational hypertensive subjects at any stage of pregnancy. Using a cutoff level of 60 ng/mL, P-selectin concentration at 10-14 weeks had a negative predictive value for pre-eclampsia of almost 99%. Mean plasma P-selectin concentrations were significantly elevated by 10-14 weeks in women who later developed pre-eclampsia (P < 0.001).

CONCLUSIONS

Our data support an inflammatory model for pre-eclampsia whereby endothelial cell activation may be secondary to a primary inflammatory response. Plasma P-selectin has significant potential as a first trimester clinical marker of pre-eclampsia.

Plasma P-selectin is elevated in the first trimester in women who subsequently develop pre-eclampsia

OBJECTIVE

To report plasma concentrations of the adhesion cell molecule P-selectin during pregnancy to determine the effect of subsequent development of hypertension and pre-eclampsia.

DESIGN

A longitudinal study.

METHODS

A longitudinal study involving 70 women followed up from early pregnancy; 20 who subsequently developed pre-eclampsia were compared with 24 who developed gestational hypertension and 26 normotensive women with normal obstetric outcome. The determination of citrate plasma soluble P-selectin levels throughout pregnancy was performed using a commercial quantitative sandwich immunoassay kit. The temporal course of plasma P-selectin in the three groups of subjects was analysed.

RESULTS

There was no significant difference in mean plasma P-selectin concentration between normotensive and gestational hypertensive subjects at any stage of pregnancy. Using a cutoff level of 60 ng/mL, P-selectin concentration at 10-14 weeks had a negative predictive value for pre-eclampsia of almost 99%. Mean plasma P-selectin concentrations were significantly elevated by 10-14 weeks in women who later developed pre-eclampsia (P < 0.001).

CONCLUSIONS

Our data support an inflammatory model for pre-eclampsia whereby endothelial cell activation may be secondary to a primary inflammatory response. Plasma P-selectin has significant potential as a first trimester clinical marker of pre-eclampsia.

Evaluating the self-assessed support needs of women with breast cancer

AIMS OF THE STUDY

The first aim of the study was to identify the self-assessed support needs of women with breast cancer at various points of illness and, secondly, to establish if these needs formed clusters which could provide the basis for developing a standardized scale of needs for use by breast care teams in the evaluation of care.

BACKGROUND

It has been found that support given to women with breast cancer has a positive effect upon their reactions to the illness and may even prolong their survival. Given that breast cancer affects a large number of women it is obviously important that those affected receive, in addition to the best available medical treatment, the type of support that best meets their needs. This study aimed to provide information on the impact of breast cancer and the need for various types of support by examining women's own assessment of their needs at different stages of their illness.

DESIGN AND METHODS

A purposive sample of 12 women with a diagnosis of breast cancer was selected in one health authority in England, United Kingdom (UK). Women selected represented a wide age range (between 26 and 58), were married or in long-term cohabiting relationships and were at different points on the illness trajectory. Women were invited to take part in a semi-structured interview about their experiences of breast cancer. The data from these interviews were analysed using the software package Qualitative Solutions and Research, Nonnumerical Data Indexing, Searching and Theorizing (QSR*NUDIST). Following this content analysis, a questionnaire was formulated which divided statements into seven categories: diagnosis, treatment, support, femininity and body image, family and friends, information and after care, to be rated on a Likert scale ranging from "of no importance" to "extremely important". Questionnaire data were analysed by means of a one-way analysis of variance (for three independent variables) or t-test for two independent variables. Results. The questionnaire was sent to 971 women and achieved a response rate of 50.4%. The mean score for statements of need reached the level of point 4 on the Likert scale (important) with three exceptions: having professional help with family problems and domestic upheaval, coping with feelings of anger and dealing with the question "why me?"

CONCLUSION

With the above three exceptions, women experienced a high level of need associated with a diagnosis of breast cancer. Studies of this kind should enable resources to be targeted to areas of highest need.

Experiences of women with a diagnosis of breast cancer: a clinical pathway approach

The study presented in this paper formed the first part of a large survey of breast cancer patients in one health authority in England, UK looking at individual needs expressed by women with a diagnosis of breast cancer. The paper provides an account of the experiences of 12 women with a diagnosis of breast cancer. The women represent a wide age range and different stages of illness. The transcribed accounts of the women were analysed by means of Qualitative Solutions and Research, Non-Numerical Unstructured Data Indexing Searching and Theorising (QSR*NUDIST). The study examined the individual experiences of women with a diagnosis of breast cancer and its aftermath as they passed through different stages related to it. The women's experiences are presented within the conceptual framework of the clinical pathway and their accounts represent their journey along the pathway. Various significant points in this journey are portrayed representing the women's reactions to diagnosis, treatment, femininity and body image, support, family and friends, information and after care.

Can we predict who will return to a genitourinary clinic?

One hundred and eighty-eight first-time attenders at a genitourinary (GU) clinic were monitored to establish who returned following discharge after treatment. Thirty-six (19%) returned within 2 years with a new infection. The re-attenders did not differ significantly from the rest of the cohort by age, gender or occupation, nor did they differ in their sexual history and psychological variables. Re-attenders were significantly more likely to have consulted their general practitioner (GP) in the 6 months prior to their first clinic attendance.

Factors influencing delay in treatment seeking by first-time attenders at a genitourinary clinic

We examined treatment-seeking behaviours amongst a consecutive sample of 188 first-time attenders at a busy genitourinary (GU) clinic in a general hospital. Participants were interviewed and completed a battery of questionnaires prior to receiving diagnosis or treatment. Delay in treatment seeking was measured in 3 ways: utilization delay, illness behaviour delay and appraisal delay. Appraisal delay and illness behaviour were significantly related, but were unrelated to utilization delay. Substantial delays were reported before seeking treatment, with a median of 30 days elapsing between first noticing symptoms and attending the clinic. Analysis of age groups indicated that the oldest groups--45 and above were likely to delay longest, on all 3 measures of delay.

Multiregional evaluation of the SimPlate heterotrophic plate count method compared to the standard plate count agar pour plate method in water

A new SimPlate heterotrophic plate count (HPC) method (IDEXX Laboratories, Westbrook, Maine) was compared with the pour plate method at 35 degrees C for 48 h. Six laboratories tested a total of 632 water samples. The SimPlate HPC method was found to be equivalent to the pour plate method by regression analysis (r = 0. 95; y = 0.99X + 0.06).

Chondromyxoid fibroma of the sacrum

A 30-year-old man with a 7-month history of mild sacral pain and intermittant left sciatica was found to have an expansile lesion in the sacrum on a plain radiograph. Biopsy confirmed a chondromyxoid fibroma which was removed surgically. A 1-year follow-up showed no recurrence. The case is the fifth to be reported. Plain film and MRI appearances, histology and treatment are described. The previously reported cases are reviewed and the current literature is discussed.

Local therapy and other factors influencing site of relapse in patients with localised Ewing's sarcoma. United Kingdom Children's Cancer Study Group (UKCCSG)

Relapse patterns have been documented in 191 children with localised Ewing's sarcoma treated with the United Kingdom Children's Cancer Group (UKCCSG) Ewing's Tumour regimen ET2. All received chemotherapy comprising ifosfamide, vincristine, doxorubicin and actinomycin D. Local treatment modality was excision and or radiotherapy depending on tumour site and response to primary chemotherapy. Although not strictly comparable, due to the clinical indications used for each modality, local relapse rates were very low and were similar, irrespective of the type of local treatment modality: radiotherapy (3/56), surgery (7/114) or a combination (0/20). Combined relapse (local + distant) rates were similarly low irrespective of the type of local therapy: radiotherapy (4/56), surgery (4/114) or a combination (0/20). Overall survival was lower in females (P = < 0.04), older children (P = < 0.002) and those with primaries at sites other than long bones (P = < 0.02). It is concluded that with effective intensive chemotherapy combined with either radiotherapy or surgery, local control in this study was excellent at sites other than the pelvis. Preventing distant relapse, predominantly to lung and bone, remains the major challenge.

Suppression subtractive hybridization identifies high glucose levels as a stimulus for expression of connective tissue growth factor and other genes in human mesangial cells

Accumulation of mesangial matrix is a pivotal event in the pathophysiology of diabetic nephropathy. The molecular triggers for matrix production are still being defined. Here, suppression subtractive hybridization identified 15 genes differentially induced when primary human mesangial cells are exposed to high glucose (30 mM versus 5 mM) in vitro. These genes included (a) known regulators of mesangial cell activation in diabetic nephropathy (fibronectin, caldesmon, thrombospondin, and plasminogen activator inhibitor-1), (b) novel genes, and (c) known genes whose induction by high glucose has not been reported. Prominent among the latter were genes encoding cytoskeleton-associated proteins and connective tissue growth factor (CTGF), a modulator of fibroblast matrix production. In parallel experiments, elevated CTGF mRNA levels were demonstrated in glomeruli of rats with streptozotocin-induced diabetic nephropathy. Mannitol provoked less mesangial cell CTGF expression in vitro than high glucose, excluding hyperosmolality as the key stimulus. The addition of recombinant CTGF to cultured mesangial cells enhanced expression of extracellular matrix proteins. High glucose stimulated expression of transforming growth factor beta1 (TGF-beta1), and addition of TGF-beta1 to mesangial cells triggered CTGF expression. CTGF expression induced by high glucose was partially suppressed by anti-TGF-beta1 antibody and by the protein kinase C inhibitor GF 109203X. Together, these data suggest that 1) high glucose stimulates mesangial CTGF expression by TGFbeta1-dependent and protein kinase C dependent pathways, and 2) CTGF may be a mediator of TGFbeta1-driven matrix production within a diabetic milieu.

Differential effects of protein kinase A on Ras effector pathways

Ras mutants with the ability to interact with different effectors have played a critical role in the identification of Ras-dependent signaling pathways. We used two mutants, RasS35 and RasG37, which differ in their ability to bind Raf-1, to examine Ras-dependent signaling in thyroid epithelial cells. Wistar rat thyroid cells are dependent upon thyrotropin (TSH) for growth. Although TSH-stimulated mitogenesis requires Ras, TSH activates protein kinase A (PKA) and downregulates signaling through Raf and the mitogen-activated protein kinase (MAPK) cascade. Cells expressing RasS35, a mutant which binds Raf, or RasG37, a mutant which binds RalGDS, exhibited TSH-independent proliferation. RasS35 stimulated morphological transformation and anchorage-independent growth. RasG37 stimulated proliferation but not transformation as measured by these indices. TSH exerted markedly different effects on the Ras mutants and transiently repressed MAPK phosphorylation in RasS35-expressing cells. In contrast, TSH stimulated MAPK phosphorylation and growth in cells expressing RasG37. The Ras mutants, in turn, exerted differential effects on TSH signaling. RasS35 abolished TSH-stimulated changes in cell morphology and thyroglobulin expression, while RasG37 had no effect on these activities. Together, the data indicate that cross talk between Ras and PKA discriminates between distinct Ras effector pathways.

Training staff to prevent aggressive behavior of cognitively impaired elderly patients during bathing and grooming

1. Cognitively impaired elderly patients often become aggressive toward caregivers who are providing assistance with bathing and grooming, but caregivers can learn methods to prevent or reduce some of the aggression. 2. The R.E.S.P.E.C.T. model describes key practices caregivers can use to better meet patient needs and reduce aggression, increasing their understanding and skill. 3. In addition to training, observation of performance and consultation are important steps in enabling caregivers to apply and maintain their skills.

Predictive value of objective esophageal insufflation testing for acquisition of tracheoesophageal speech

This prospective study was undertaken to assess the predictive value of esophageal insufflation on the acquisition of tracheoesophageal (TE) speech. Fourteen total laryngectomy patients were evaluated prior to tracheoesophageal puncture (TEP) using objective esophageal pressure measurements. These patients then were followed prospectively for 6 to 13 months. Speech was assessed at the time of prosthesis fitting, at 1 month, at less than 6 months, and at greater than 6 months post-TEP. No patient underwent pharyngeal myotomy. Pre-TEP esophageal insufflation pressure was associated (P = .065) with successful TE speech at the time of prosthesis fitting, but was not associated with successful TE speech acquisition after 6 months. This study's results suggest that patients with poor pre-TEP esophageal insufflation test results will usually obtain successful TE speech given adequate time and training, even without pharyngeal myotomy.