The Children's Reactive Curiosity Scale

The present study reports the description of and the normative data obtained with a scale of reactive curiosity (RC Scale) for use with Grade 4, 5, and 6 children. A 90-item RC Scale and a 10-item Lie Scale are described. The RC Scale's 2-wk. test-retest reliabilities ranged from .65 to .78 for the different sex by grade classifications. At all grade levels, girls scored higher than boys on the RC Scale. The lie scores yielded high test-retest reliabilities, and the intercorrelations between the RC Scale and the Lie Scale were not significant except for fifth grade girls (.20). Intercorrelations between scores on the RC Scale and IQs based on the California Test of Mental Maturity although low and positive were not significant. However, the RC scores of Grade 6 children were positively related to originality measures that were derived from a modified Unusual Uses Test.

Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI)

BACKGROUND

There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management.

AIMS

To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment.

METHODS

A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI).

RESULTS

Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40-68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4-26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9-48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5-18.2) of CTPAs done were positive for PE.

CONCLUSION

This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.

Expression of p16, CD95, CD95L and Helix pomatia agglutinin in relapsing and nonrelapsing very thin melanoma

BACKGROUND

The incidence of malignant melanoma is increasing worldwide and patients are being diagnosed earlier with thinner primary lesions. Most patients with very thin melanoma (Breslow thickness < 0.76 mm) are cured by surgery but 2-18% relapse locally or with distant metastases.

OBJECTIVES

The objective of this study was to establish potential new prognostic markers in very thin melanoma.

METHODS

We identified a group of subjects with relapsing very thin primary cutaneous melanoma and a matched control group who had not relapsed. We investigated the expression of p16, Helix pomatia agglutinin (HPA), CD95 and CD95 ligand (CD95L) by immunohistochemistry on paraffin-embedded tissue sections from the subject group, their subsequent metastases and the control group.

RESULTS

Reduced p16 expression was significantly associated with relapse in very thin melanoma (P = 0.0129). Loss of p16 expression was also found in 76% of metastases. There was no significant association between HPA, CD95 or CD95L expression and subsequent relapse.

CONCLUSIONS

This work is the first to show a significant loss of p16 in relapsing very thin melanoma.

A phase I study (CA180021-Segment 2) of dasatinib in patients (pts) with advanced solid tumors

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Background: SPRYCEL™ is a potent, orally active, multi-targeted kinase inhibitor, active against BCR-ABL and SRC family kinases. We report the results of a Phase I dose-escalation study evaluating safety, tolerability, pharmacokinetics, and biomarkers of dasatinib in pts with advanced solid tumors. Methods: Pts with adequate hematologic, renal, cardiac and liver function received oral dasatinib once daily for 7 days per week. Three doses and schedules were examined: 90 mg BID; 140 mg QD; and 180 mg QD. Pharmacokinetics and pharmacodynamic biomarkers were collected on Days 1 and 26 of Cycle 1. Tissue biomarkers were assessed at screening. CT was performed at least every 8 weeks, and FDG-PET at weeks 4, and 8. Results: 26 pts [M=15, F=11] ECOG PS ≤ 2 with epithelial tumors (n=14) or other solid tumors (n=12) have been treated in escalating dose levels. Toxicity was generally mild; most patients came off study for progressive disease. DLTs of pleural effusions were seen in 3/9 subjects on the 180 mg cohort, 2 of whom had pre-existing effusions. Patients with pleural effusion have been excluded from future enrollment. The maximum tolerated dose has not been identified. There have been no objective responses on CT. Six patients have had stable disease with continued study treatment for 2–10 months. Conclusions: Dasatinib can be safely administered at doses of 140 and 180 mg QD. Clinical efficacy, pharmacokinetics, and correlative studies of tumor biopsy material and early FDG-PET results will be reported.

No significant financial relationships to disclose.

Outbreak of Legionnaires' disease on a cruise ship: lessons for international surveillance and control

A sporadic case of Legionnaires' disease was linked to travel on a cruise ship. Investigation identified two further cases of Legionnaires' Disease and one case of non-pneumonic Legionella infection. An Incident Team confirmed the source to be the ship's water system and control measures were instituted that included pasteurisation, super chlorination and chlorine dioxide dosing. The Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC), through the European Surveillance Scheme for Travel Associated Legionnaires' Disease, identified three previous cases associated with the same ship's water system including one fatality. Lessons for the international surveillance and control of Legionnaires' disease on cruise ships are discussed.

Cocaine/heroin induced rhabdomyolysis and ventricular fibrillation

A case of cardiorespiratory arrest in a 28 year old man after cocaine and heroin ingestion is described. The arrest is attributed primarily to hyperkalaemia/rhabdomyolysis-a recognised consequence of each of these drugs. The administration of naloxone may have been contributory. He developed acute renal failure, disseminated intravascular coagulopathy with consequent lower limb compartment syndrome requiring fasciotomy. Ventricular fibrillation was identified at thoracotomy.

Expression of respiratory mucins in fatal status asthmaticus and mild asthma

AIMS

The airways of patients with asthma are characterized by chronic inflammatory changes comprising mainly T-cells and eosinophils, and airway remodelling with goblet cell metaplasia and submucosal gland hyperplasia. Mucus hypersecretion is often a marked feature, particularly in status asthmaticus. The matrix of airway sputum consists of high molecular glycoproteins and mucins. In this study, the expression and distribution of the major gel-forming mucins MUC5AC and MUC5B were studied in fatal status asthmaticus tissues and bronchial biopsies of mild asthmatic patients. The effect of inhaled corticosteroids on the expression of these mucins was also investigated.

METHODS AND RESULTS

Polyclonal antibodies specific for MUC5AC and MUC5B, and a monoclonal antibody for MUC5B were used to stain lung tissues and airway mucosal biopsies obtained from patients who died of status asthmaticus (n=5) and from mild asthmatics (n=4), respectively. Immunohistochemistry for MUC5AC revealed abundant staining of goblet cells situated in the epithelial surface lining and glandular ducts of tissues from patients with fatal asthma. MUC5B immunoreactivity was restricted to mucous cells of submucosal glands and to epithelial cells. In mild asthmatics, large amounts of MUC5B, but not MUC5AC, positive extracellular mucus was found in the airway lumen as plugs, adjacent to the epithelial lining and in the necks of glandular secretory ducts of mild asthmatics. The distribution of MUC5AC and MUC5B in bronchial biopsies of mild asthmatics was similar before and after inhaled steroid treatment.

CONCLUSIONS

The expression of MUC5AC and MUC5B shares a similar distribution to normal airways in different states of asthma. The distribution is not affected by topical corticosteroid therapy.

Specialist alcohol liaison services in general hospitals improve engagement in alcohol rehabilitation and treatment outcome

OBJECTIVE

To examine the impact of providing a specialist addictions trained psychiatric nurse on outcome of alcohol treatment in patients presenting to general medical and surgical wards of a district general hospital. Before introducing the specialist alcohol liaison service, a range of staff including a consultant liaison psychiatrist, junior psychiatrists and community psychiatric nurses trained in liaison psychiatry assessed this patient group.

METHOD

A retrospective review of all alcohol liaison referrals with ICD-10 defined alcohol misuse was performed for one year. Comparison data for the first 100 referrals to the specialist alcohol liaison service were obtained prospectively. Indicators included diagnosis at referral, and engagement in and completion of alcohol rehabilitation.

RESULTS

The rates of completion of a four to six week period of alcohol rehabilitation were significantly better after introduction of the Specialist Alcohol Liaison Service. Of those who commenced alcohol rehabilitation, 88% completed, compared to 40% in the traditional assessment service (p < 0.0001).

CONCLUSION

Specialist addictions trained staff in the assessment and management of alcohol dependent patients in medical and surgical wards produce a better immediate outcome than their non-specialist colleagues. This may have implications for service design.

One-year effects of increasingly fat-restricted, carbohydrate-enriched diets on lipoprotein levels in free-living subjects

Restriction of all dietary fat is a popular strategy for restricting saturated fat intake to lower LDL cholesterol. Some authorities advise the restriction of fat intake to the extreme of less than 10% of daily energy on the assumption that more fat restriction is better. The two studies described herein address questions relating to whether increasing fat restriction produces proportionally increasing benefit on cardiovascular risk factors in hyperlipidemic subjects. The first study is the Dietary Alternatives Study (DAS). The DAS was conducted in 531 male Boeing employees over a 2-year period. Subjects were defined as hypercholesterolemic (HC) or combined hyperlipidemic (CHL) based on age-specific 75th percentiles for plasma LDL-C and triglyceride levels. Hypothesis test analyses were performed at 1 year. HC subjects were randomized to diets taught to attain fat intakes of 30, 26, 22, and 18% (Diets levels 1-4, respectively). CHL subjects (slightly fewer in number) were randomized to Diets 1-3. After 1 year, subjects' total fat intakes were 27, 26, 25, and 22% of energy (en%), resulting in saturated fat intakes of 8, 7, 7, and 6%, respectively. In HC subjects the greatest LDL-C decrease was with Diet 2 (mean of 13.4%) and in CHL subjects with Diet 1 (7.0%). Surprisingly, plasma triglyceride concentrations rose in HC subjects 20% and 40% above baseline on Diets 3 and 4, respectively, with reciprocal reductions in HDL cholesterol of 2.5% and 3%, respectively. Furthermore, apo B reductions were attenuated below Diet 2 in HC subjects and Diet 1 in CHL subjects, and no further reductions were seen in plasma glucose and insulin concentrations, blood pressure, or body weight. Measurements of plasma total fatty acid composition showed a slight increase in plasma palmitate, whereas stearate decreased slightly, supporting the idea that de novo synthesis of palmitic acid was increased in the chronic high-carbohydrate feeding condition. The second study asked if the most effective diet in HC subjects, Diet 2, has an equivalent effect in women and men. To answer this question, men and women Boeing employees were taught the closely similar National Cholesterol Education Program (NCEP) Step II diet. After 6 and 12 months, equivalent reductions in LDL cholesterol were observed in women compared with men. HDL cholesterol levels in men were unchanged from baseline at 6 and 12 months, but were reduced 8% in HC women, with accompanying decreases of 18% in HDL2-cholesterol and 5% in apoprotein A-I (all P < 0.01). These data indicate that intakes of fat below about 25 en% and carbohydrate intake above approximately 60 en% yield no further LDL-C lowering in HC and CHL male subjects and can be counterproductive to triglyceride, HDL-C, and apo B levels. This lack of benefit appears to be explained by an enhanced endogenous synthesis of palmitic acid, which negates the benefit of further saturated fat restriction. The HDL-C decrease in HC women may have a similar cause and points to an underlying male-female difference. Alternative dietary approaches to limit saturated fat intake deserve intensive study.

Motherhood in the teens and twenties: some surprises

We report a study of the association of health and social support variables with motherhood in teenagers and older mothers. Both teenage and older mothers reported poorer physical and mental health and fewer and less frequent social contacts than their nulliparous peers. Contrary to expectation, however, older mothers reported less extensive and less adequate social support networks than did teenagers.

OASIS (Outcome and Assessment Information Set). Will HCFA know more about your agency than you do?

OASIS data will provide a host of information to the Health Care Financing Administration. Agencies should look beyond HCFA's reasons for collecting the data and capitalize on the opportunity to use OASIS to improve their own services and better understand their patients' needs.

Paediatric consultation patterns in general practice and the accident and emergency department

The age, sex, source of referral and diagnosis of children brought to a paediatric accident and emergency department by their parents were compared to those consulting their general practitioner. A simultaneous, prospective review of these consultations was carried out over a six-week period in an inner-city paediatric teaching hospital and a group practice in a socially deprived urban area. 730 children less than 13 years of age who presented for a new consultation were seen. 629 (86%) presented initially to the general practitioner, who dealt with all but 25 (4.0%) without onward referral to the accident and emergency department. 127 consultations took place at the accident and emergency department, of which 104 (82%) were parental referrals. There was no sex difference in children seen by the general practitioner. There was a decreasing trend with increasing age in the proportion of children who consulted the general practitioner, perhaps due to the higher frequency of injury in the older children. Over three quarters (77%) of injured children were brought directly to the accident and emergency department, compared with only 4% of children without injuries (p < 0.001). Of 22 children with injuries who presented to the general practitioner, only 4 (18%) required onward referral. General practitioners met the great majority of the paediatric workload generated by the practice. Audit between primary and secondary care gives a more reliable picture than data from only one source. Injured children are more likely to be taken to the accident and emergency department. Further study of the severity of injury in children is required to determine if there is potential to reduce parental referrals to accident and emergency departments.

Repairs by trephination and suturing of longitudinal injuries in the avascular area of the meniscus in goats

Trephination may encourage healing of a tear in the avascular area of the meniscus, but healing may not be complete in unstable tears. We studied trephination with suture of longitudinal injuries in the avascular area of the medial meniscus in 20 goats; samples were studied at 3, 8, and 25 weeks. All 20 tears treated by trephination and suture were completely (4 samples) or partly (16 samples) healed. The average tensile strength of the healed repair was 40.4 kg/cm2 at 25 weeks. The level of DNA synthesis and tissue ingrowth decreased with time; DNA synthetic activity was also found in the chondrocytes of the menisci treated by suture alone. Only three of the menisci treated by suture alone were partly healed, and the remainder showed no gross evidence of healing. The addition of trephination to the sutured meniscus appears to promote healing of longitudinal injuries in the avascular area and is recommended rather than suturing or trephination alone. Meniscal suture alone may stabilize the tear and stimulate cell proliferation for healing, but it appears to be significantly restricted without an adequate blood supply.

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinic Foundation

BACKGROUND

Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation.

METHODS

The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment.

STUDY DESIGN

We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period.

RESULTS

Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges.

CONCLUSION

Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.

Circular ruffle formation and closure lead to macropinocytosis in hepatocyte growth factor/scatter factor-treated cells

Treatment with hepatocyte growth factor/scatter factor (HGF/SF) rapidly induced the formation of conspicuous circular ruffles on the apical surfaces of two kidney cell lines, MDCK and PtK2. The ruffles were found to contain significant amounts of F-actin and myosin as judged by immunofluorescence microscopy. Time-lapse photomicroscopy demonstrated that the ruffles constrict, closing over, and were followed by the formation of phase bright structures. That these structures were macropinocytotic vesicles was confirmed using fluorescein isothiocyanate (FITC)-dextran as a marker for fluid uptake. It is hypothesized that the constriction of the ruffles followed by membrane fusion causes the vesicles to form. Treatment with suramin blocked both circular ruffle formation and scattering, suggesting that ligand binding was the causal agent for ruffle formation. The drugs amiloride and SITS (4-acetamido-4'-isothiocyanatostilbene-2,2'-disulfonic acid) also completely inhibited ruffle formation, suggesting that ion transport was an early consequence of HGF/SF binding and that these transport effects had a major role in the cytoskeletal changes leading to circular ruffle formation. The appearance of macropinocytotic vesicles was also blocked by amiloride treatment. Surprisingly though, subsequent scattering was not blocked by amiloride treatment, although suramin and SITS both entirely inhibited scattering.

The presence of scatter factor in patients with metastatic spread to the pleura

Pleural effusion fluid obtained from eleven patients with metastatic spread to the pleura was screened for the ability to cause the dispersal--'scattering'--of MDCK colonies in vitro. Four of these samples proved to be positive using this assay. Of these two had titres high enough to warrant further purification on a cation exchange Mono S column. Active material from both lung samples, eluted at the same positions as factor from cultured human lung fibroblasts (MRC-5) and human placenta but in a slightly different position to murine scatter factor. In both cases the semi-purified active agent was identified as hepatocyte growth factor/scatter factor (HGF/SF) using an ELISA detection system specific for human HGF/SF. This is the first report identifying the presence of significant amounts of HGF/SF in the pleura of patients where malignant spread has occurred.

Prolonged ventilatory support after open-heart surgery

OBJECTIVES

To characterize the course of open-heart surgery patients who require prolonged (greater than 72 hrs) mechanical ventilation and to define the role and timing of tracheostomy.

DESIGN

Retrospective review.

SETTING

Cardiac surgery ICU and surgery wards at a university hospital.

PATIENTS

All open-heart surgery patients during an 18-month period from January 1988 to July 1989 (n = 581). From this group, 58 patients (9.9%) required prolonged mechanical ventilation.

INTERVENTIONS

Study patients (n = 58) were followed through the course of intubation and/or tracheostomy until they were extubated, left the hospital on ventilation, or died.

MEASUREMENTS AND MAIN RESULTS

End-points for mortality and complications were determined. Overall mortality rate was 43% in the patients who required prolonged mechanical ventilation. Twenty-eight percent of the 58 patients died within the first 14 days. Of those patients who survived, 55% required an endotracheal tube only and were extubated in less than 14 days; 45% of the patients required tracheostomy. Of those patients who required tracheostomy, five (26%) were eventually extubated, seven (37%) remained mechanically ventilated, and seven (37%) died. The complication rate for endotracheal tubes was 65%; the complication rate for tracheostomy was 37%.

CONCLUSIONS

Open-heart surgery patients requiring prolonged mechanical ventilation are a desperately ill subset of cardiac surgery patients. Those patients who survive are either extubated in less than 14 days or require prolonged mechanical ventilation beyond that point. In our opinion, patients should be given 1 wk to recover and one trial of weaning from the ventilator. If this approach fails, then they should undergo elective tracheostomy.

Hypnotic susceptibility and its relationship to outcome in the behavioral treatment of asthma: some preliminary data

12 subjects from an experiment on relaxation therapy for asthma were given the Harvard Group Scale of Hypnotic Susceptibility, Form A. Full scale hypnotic susceptibility scores were positively correlated, at a borderline significance, with improvement in the methacholine challenge test, a measure of asthma severity. Performance on the amnesia item of the Harvard Group Scale was correlated with improvement in self-reported symptoms of asthma.

Relaxation decreases large-airway but not small-airway asthma

Eleven asthmatic subjects were each offered sixteen sessions of relaxation therapy, consisting of progressive relaxation, desensitization, and EMG biofeedback to the trapezius and frontalis areas, while 9 subjects were offered a complex placebo. Subjects in the relaxation condition showed greater improvement than subjects in the placebo condition in performance on a methacholine challenge test which, as a measure of airway reactivity, reflects degree of asthma. Subjects in both conditions showed improvements in various self-report measures of asthma symptoms and psychopathology. Subject in the relaxation condition reported a significantly greater decrease in frequency of emotional precursors to asthma attacks than subjects in the control condition. Overall improvement on the methacholine challenge test was predicted almost perfectly by heliox spirometry. Only subjects showing predominant large-airway obstruction obstruction improved on the methacholine challenge test. The relative contribution of large airway obstruction to asthma was found to correlate with psychopathology.

Net delay of next conception by contraception: A highly simplified case

Abstract A probability model, building on the work of Perrin and Sheps, is presented and applied. The model makes it possible to follow a cohort of women from a pregnancy outcome to next conception. Principal simplifying assumptions are homogeneity among women and constant fecundity. Cases treated include no contraception; a single contraceptive method practised; and a second contraceptive method practised following a first one. Expected durations to next conception may be calculated in relation to the following factors: outcome of previous pregnancy, length of anovulation, natural fecundability, time first contraceptive method is initiated, characteristics of first contraceptive (effectiveness and continuation rate), characteristics of second contraceptive, and gap between termination of first and commencing second contraceptive. By suitably pairing runs of the model, one can construct experiments in which the only differentiating factor is use and non-use of a specified contraceptive, and, by differencing the corresponding mean durations to next conception, compute the net delay of next conception produced by that contraceptive.