Parents' voices: "Our process of advocating for our child with autism." A meta-synthesis of parents' perspectives

BACKGROUND

Advocacy has been described by parents of children with autism as an important coping strategy, enabling them to move forward by redirecting emotions into actions. A key factor in the development of collaborative and constructive partnerships between service providers and parents is having an understanding of how parents engage in advocacy and the support needed to do so. This meta-synthesis was undertaken to consolidate in-depth qualitative data from parents' perspectives of the process that they use to advocate for their children with autism.

METHODS

A qualitative meta-synthesis was conducted, whereby 15 databases were systematically searched. Thirty-one studies were identified and appraised using an adapted version of the Critical Appraisal Skills Programme tool. Data were synthesized into themes through the steps of review, meta-aggregation, integration, and interpretation.

RESULTS

The voices of 1,662 parents are presented describing the process of advocacy in the stages of seeking a diagnosis, seeking self-education, and taking action. Taking action includes 2 subthemes: seeking, access, and use of support services and community engagement and educating others.

CONCLUSIONS

Results highlight the significant impact that positive experiences with first-line professionals have during the diagnosis process and how these experiences lay the foundation for all future relationships with other service providers. Important implications arise from this meta-synthesis for service providers in supporting parents' advocacy and hence building constructive relationships with families with a child with autism.

Parents' voices: 'why and how we advocate'. A meta-synthesis of parents' experiences of advocating for their child with autism spectrum disorder

Parenting a child with autism spectrum disorder (ASD) can be stressful, and accessing services can add to this stress. Self-efficacy, agency and advocacy are important for parents when accessing and using services. To develop insight into parental advocacy, a meta-synthesis was undertaken to consolidate the literature focussing on parents' experiences of advocating for their child with ASD. A qualitative meta-synthesis was conducted. Fifteen databases were systematically searched by using key terms related to ASD, children, parents/carers, advocacy and qualitative studies. Twenty-four studies were identified and appraised using an adapted version of the Critical Appraisal Skills Programme tool. Data were synthesized into themes through the steps of review, meta-aggregation, integration and interpretation. Two overarching concepts emerged, illustrating both the challenging nature of advocacy and the associated personal and societal benefits. These two concepts are supported by eight themes: a life-long, all-encompassing challenge; advocacy as a parental coping strategy; advocacy involving working to create a future; balancing roles and needs; isolation versus support; personal impacts of advocacy; benefits of advocacy; and the barriers to advocacy. The experience of advocacy for parents with a child with ASD is complex and intensive, presenting both personal and societal benefits, as well as challenges for parents. In supporting individuals with ASD and family well-being, service providers need to have an understanding of the advocating role of parents and ensure that opportunities exist for their voices to be heard during service delivery.

Distinct magnetic phase transition at the surface of an antiferromagnet

In the majority of magnetic systems the surface is required to order at the same temperature as the bulk. In the present Letter, we report a distinct and unexpected surface magnetic phase transition at a lower temperature than the Néel temperature. Employing grazing incidence x-ray resonant magnetic scattering, we have observed the near-surface behavior of uranium dioxide. UO2 is a noncollinear, triple-q, antiferromagnet with the U ions on a face-centered cubic lattice. Theoretical investigations establish that at the surface the energy increase-due to the lost bonds-is reduced when the spins near the surface rotate, gradually losing their component normal to the surface. At the surface the lowest-energy spin configuration has a double-q (planar) structure. With increasing temperature, thermal fluctuations saturate the in-plane crystal field anisotropy at the surface, leading to soft excitations that have ferromagnetic XY character and are decoupled from the bulk. The structure factor of a finite two-dimensional XY model fits the experimental data well for several orders of magnitude of the scattered intensity. Our results support a distinct magnetic transition at the surface in the Kosterlitz-Thouless universality class.

Weekend Arthroplasty: A Longer Inpatient Stay?

As pressures mount on efficiency, hip and knee arthroplasty surgery is increasingly being performed during weekends. Despite the growing trend for weekend orthopaedic surgery, there are virtually no published data on the effect of weekend operating on the length of hospital stay (LOS).

PADMA-28, a traditional tibetan herbal preparation inhibits the respiratory burst in human neutrophils, the killing of epithelial cells by mixtures of oxidants and pro-inflammatory agonists and peroxidation of lipids

Both aqueous and methanolic fractions derived from the Tibetan preparation PADMA-28 (a mixture of 22 plants) used as an anti-atherosclerotic agent, and which is non-cytolytic to a variety of mammalian cells, were found to strongly inhibit (1) the killing of epithelial cells in culture induced by 'cocktails' comprising oxidants, membrane perforating agents and proteinases; (2) the generation of luminol-dependent chemiluminescence in human neutrophils stimulated by opsonized bacteria; (3) the peroxidation of intralipid (a preparation rich in phopholipids) induced in the presence of copper; and (4) the activity of neutrophil elastase. It is proposed that PADMA-28 might prove beneficial for the prevention of cell damage induced by synergism among pro-inflammatory agonists which is central in the initiation of tissue destruction in inflammatory and infectious conditions.

ATTAX: Randomised phase II study evaluating weekly docetaxel-based chemotherapy combinations in advanced esophago- gastric cancer, final results of an AGITG trial

4528

Background: Docetaxel (T), cisplatin (C) and 5FU(F) are active agents in esophago-gastric cancer. A recent phase III study evaluating 3-weekly TCF demonstrated a survival advantage over standard therapy, but TCF was associated with high rates of hematological toxicity (30% incidence of febrile neutropenia/neutropenic infection) as well as non-hematological side effects (Van Cutsem et al, J. Clin Oncol. 24 4991–4997 2006). Weekly docetaxel is associated with a lower incidence of hematological toxicity. This randomized phase II study aimed to test weekly docetaxel based combination chemotherapy regimens with the aim of maintaining the activity of such regimens but reducing toxicity. Methods: Eligibility included; histologically confirmed, metastatic esophageal or gastric (OG) carcinoma, measurable disease, PS0–2, adequate organ function, no prior treatment, informed consent. Patients (Pts) were randomized to receive weekly (w) T 30mg/m2 d1,8 C 60 mg/m2 d1 F 200 mg/m2/d continuously q 3w or wT 30 mg/m2 d1,d8 and capecitabine (X)1,600 mg/m2/d d1–14 q3w. The primary endpoint is confirmed response rate (RR), with each arm analyzed independently. Simon’s 2-stage design was used, with 5/21 responses required in the first stage to allow continuation to 50 pts per arm. Results: Response rates in each arm satisfied the first stage, and complete accrual of 106 pts was completed in May 2006. Demographics, toxicity and response rates are shown in the table . With a median follow-up of 14.6 months, progression free and overall survival times are 5.9 m and 12.8 m, and 4.2m and 10.1 m for wTCF and wTX, respectively. Conclusions: wTCF and wTX have encouraging activity and a far more favorable toxicity profile than TCF administered 3-weekly. Weekly docetaxel-based combination regimens should be evaluated further in this disease.

[Table: see text]

[Table: see text]

Lentiviral gene replacement therapy of retinas in a mouse model for Usher syndrome type 1B

One of the most disabling forms of retinal degeneration occurs in Usher syndrome, since it affects patients who already suffer from deafness. Mutations in the myosin VIIa gene (MYO7A) cause a major subtype of Usher syndrome, type 1B. Owing to the loss of function nature of Usher 1B and the relatively large size of MYO7A, we investigated a lentiviral-based gene replacement therapy in the retinas of MYO7A-null mice. Among the different promoters tested, a CMV-MYO7A chimeric promoter produced wild-type levels of MYO7A in cultured RPE cells and retinas in vivo. Efficacy of the lentiviral therapy was tested by using cell-based assays to analyze the correction of previously defined, MYO7A-null phenotypes in the mouse retina. In vitro, defects in phagosome digestion and melanosome motility were rescued in primary cultures of RPE cells. In vivo, the normal apical location of melanosomes in RPE cells was restored, and the abnormal accumulation of opsin in the photoreceptor connecting cilium was corrected. These results demonstrate that a lentiviral vector can accommodate a large cDNA, such as MYO7A, and mediate correction of important cellular functions in the retina, a major site affected in the Usher syndrome. Therefore, a lentiviral-mediated gene replacement strategy for Usher 1B therapy in the retina appears feasible.

Correlation of Neo-Sensitabs tablet diffusion assay results on three different agar media with CLSI broth microdilution M27-A2 and disk diffusion M44-A results for testing susceptibilities of Candida spp. and Cryptococcus neoformans to amphotericin B, caspofungin, fluconazole, itraconazole, and voriconazole

We compared the Neo-Sensitabs tablet assay to both reference M27-A2 broth microdilution and M44-A disk diffusion methods for testing susceptibilities of 110 isolates of Candida spp. and Cryptococcus neoformans to amphotericin B, caspofungin, fluconazole, itraconazole, and voriconazole. Neo-Sensitabs assay inhibition zone diameters in millimeters on three agars (Mueller-Hinton agar supplemented with 2% dextrose and 0.5 microg/ml methylene blue [MGM], Shadomy [SHA], and RPMI 1640 [RPMI, 2% dextrose]) were obtained at 24 to 72 h. The correlation coefficient of Neo-Sensitabs results with MICs was similar to that of the disk method for most of the five agents on MGM (R, 0.80 to 0.89 versus 0.76 to 0.89, respectively). Overall, superior correlation was observed at 24 h for most agents. The exception was amphotericin B (R values of 0.68 and 0.5 for disk and tablet, respectively, at 48 h versus 0.68 and 0.48, respectively, at 24 h). In general, Neo-Sensitabs results were less consistent on SHA and RPMI agars. Although agreement by breakpoint category of Neo-Sensitabs and disk results with CLSI method M27-A2 was also similar on MGM (92.7 to 98.2% versus 95.5 to 100%, respectively), the Neo-Sensitabs method failed to identify two of the six isolates with high amphotericin B MICs. These data suggest the potential value of the Neo-Sensitabs assay for testing at least four of the five agents against yeasts evaluated in the clinical laboratory.

Randomised phase II study evaluating weekly docetaxel in combination with cisplatin and 5FU or capecitabine in metastatic oesophago-gastric cancer

4067

Background: Docetaxel (T), cisplatin (C) and 5FU (F) are active agents in oesophago-gastric cancer. A recent phase III study using TCF achieved a survival advantage but was associated with high rates of haematological toxicity (30% incidence of febrile neutropenia/neutropenic infection) as well as non-haematological side effects (Moiseyenko et al, 2005 Pr ASCO abstr 4002). Weekly docetaxel is associated with a lower incidence of haematological toxicity. This randomised phase II study aimed to test weekly docetaxel based combination chemotherapy regimens with the aim of maintaining the activity of docetaxel based combination regimens but reducing toxicity. Methods: Eligibility included; histologically confirmed, metastatic oesophageal or gastric (OG) carcinoma, measurable disease, PS0–2, adequate organ function, no prior treatment, informed consent. Pts were randomised to receive weekly (w) T 30 mg/m2 d1, 8 C 60 mg/m2 d1 F 200 mg/m2/d continuously q 3w or wT 30 mg/m2 d1, d8 and capecitabine (×)1600 mg/m2/d d1–14 q3w. The primary endpoint is confirmed response rate (RR), with each arm analysed independently. Simon’s 2 stage design was used, with 5/21 responses required in the first stage to allow continuation to 48 pts per arm. Results: 79 pts enrolled to date. Protocol specified interim analysis of efficacy after 21 pts per arm and of toxicity after 25 pts per arm ( Table ). In the first 21 pts per arm; 12 responses (11 confirmed) in wTCF arm, 6 responses (5 confirmed) in wTX arm. Trial continues accrual to target of 48 pts per arm. Complete accrual expected by April 2006. Updated data will be presented at the meeting. Conclusions: wTCF and wTX have encouraging activity and and a more favourable toxicity profile than TCF administered 3-weekly.

[Table: see text]

[Table: see text]

Suicide in farmers in Scotland

INTRODUCTION

Farmers and farm workers have higher than expected rates of suicide and undetermined deaths in UK studies, and some rural areas of Scotland have higher than average male suicide rates. Firearm access seems to be an influencing factor in England and Wales. Type of farming, and farming social networks may also be important. This article describes suicide and undetermined deaths in male farmers and farm workers in Scotland from 1981-1999 using anonymised, routine data.

METHOD

Deaths of men aged 15-74 years from suicide or undetermined cause were identified from anonymised Scottish death records. Farmers and farm workers were identified using occupation codes. Methods of suicide used by farmers were compared with those of the general male population of the same age. A multiple linear regression was used to examine the influence of farm type, and the proportion of farmers in the working population of an area.

RESULTS

307 male farmers or farm workers died by suicide or undetermined cause in the time period. The overall rate was 31.4/100,000 per year (95% CI 28.1-35.1). Deaths using firearms were over-represented (29% of farming deaths compared with 3.6% in the general male population). There was no significant association between the male suicide rate in an area, and the farming suicide rate. Areas with lower proportions of farmers tended to have higher rates of farming suicide and undetermined deaths. This one factor described 85% of the variance among areas.

CONCLUSION

Deaths were substantially more likely to involve firearms than suicide and undetermined deaths in the general male population. Less use of other methods did not completely compensate for this, indicating that method availability is likely to contribute to farming suicide rates. Farmers in areas where farming is less common were more likely to die by suicide, and this described most of the differences among areas. Networks and social supports may be important protective factors for farmers.

Dendritic cell density and activation status in human breast cancer -- CD1a, CMRF-44, CMRF-56 and CD-83 expression

Low CD1a-positive putative dendritic cell numbers in human breast cancer has recently been described and may explain the apparent 'poor immunogenicity' previously reported in breast cancer. Little attention has been given to dendritic cell activation within the tumour microenvironment, which is another reason why the in-situ immune response may be severely deficient. We have therefore examined CD1a expression as a marker for dendritic cells, together with CMRF-44 and -56 as markers of dendritic cell activation status, in 40 human breast cancers. The results demonstrate few or no CD1a-positive putative dendritic cells and minimal or no expression of the dendritic cell activation markers. Both dendritic cell number and dendritic cell activation appear substantially deficient in human breast cancers, regardless of tumour histological grade.

Providing information to help Medicare beneficiaries choose a health plan

Many Medicare beneficiaries have limited knowledge of the Medicare program and related health insurance options. This is due in part to the complexity of the Medicare program and supplemental health insurance market. A recent congressional mandate through the Balanced Budget Act of 1997 called for broad dissemination of information to educate beneficiaries about their health plan options and to encourage informed health plan decision-making. In response, the Health Care Financing Administration (HCFA) launched the National Medicare Education Program (NMEP) to support the educational objectives of the BBA. This paper provides an overview of the components of the NMEP information campaign. We also review lessons learned from our experience in designing and testing a prototype consumer handbook that explains the different health plan options to Medicare beneficiaries. Through our discussion of the handbook, we highlight several ways to communicate information effectively about a complex publicly funded program to an older adult population.

A novel keratin 5 mutation (K5V186L) in a family with EBS-K: a conservative substitution can lead to development of different disease phenotypes

Epidermolysis bullosa simplex is a hereditary skin blistering disorder caused by mutations in the KRT5 or KRT14 genes. More than 50 different mutations have been described so far. These, and reports of other keratin gene mutations, have highlighted the existence of mutation "hotspots" in keratin proteins at which sequence changes are most likely to be detrimental to protein function. Pathogenic mutations that occur outside these hotspots are usually associated with less severe disease phenotypes. We describe a novel K5 mutation (V186L) that produces a conservative amino acid change (valine to leucine) at position 18 of the 1A helix. The phenotype of this case is unexpectedly severe for the location of the mutation, which lies outside the consensus helix initiation motif mutation hotspot, and other mutations at this position have been associated in Weber--Cockayne (mild) epidermolysis bullosa simplex only. The mutation was confirmed by mismatch-allele-specific polymerase chain reaction and the entire KRT5 coding region was sequenced, but no other changes were identified. De novo K5/K14 (mutant and wild-type) filament assembly in cultured cells was studied to determine the effect of this mutation on filament polymerization and stability. A computer model of the 1A region of the K5/K14 coiled-coil was generated to visualize the structural impact of this mutation and to compare it with an analogous mutation causing mild disease. The results show a high level of concordance between genetic, cell culture and molecular modeling data, suggesting that even a conservative substitution can cause severe dysfunction in a structural protein, depending on the size and structure of the amino acid involved.

A two year global evaluation of the susceptibility of Candida species to fluconazole by disk diffusion

The in-vitro activity of fluconazole against 46,831 yeast isolates collected over a two-year period from 57 laboratories in 33 countries worldwide was assessed using a disc diffusion method. Candida albicans was the organism isolated most frequently, accounting for 68.6% of the total number of isolates. C. glabrata, C. tropicalis, C parapsilosis and C. krusei and Cryptococcus neoformans represented 9.9, 4.7, 4.3, 1.9, and 1.4% of isolates respectively during the 2 year period and rates varied markedly between countries. In 1999 data blood isolates represented 4.9% of all isolates and intensive care unit isolates represented 9.9%. In both the 1998 and 1999 data, 99% of C. albicans were fully susceptible (S) to fluconazole, and 95.6% of all species of yeasts tested were S or susceptible-dose dependent (S-DD) to fluconazole. No emerging trends of resistance were noted with any of the Candida spp. tested as 96% of all isolates retained susceptibility (S or S-DD) to this agent.

X-Ray anomalous scattering study of a charge-ordered state in NaV2O5

Charge ordering of V4+ and V5+ in NaV2O5 has been studied by an x-ray diffraction technique using anomalous scattering near a vanadium K-absorption edge to critically enhance a contrast between the two ions. A dramatic energy dependence of the superlattice intensities is observed below T(C) = 35 K. The charge ordering pattern is the fully charged zigzag-type ladder with the unit cell 2ax2bx4c, but not the chain-type originally proposed for the spin-Peierls state. Charge disproportionation suggested in our model as the average valence V(4.5+/-delta(c)/2) is observed below T(C), showing continuous variation of delta(c) as a function of temperature.

Spin dynamics and orbital state in LaTiO3

A neutron scattering study of the Mott-Hubbard insulator LaTiO3 ( T(N) = 132 K) reveals a spin wave spectrum that is well described by a nearest-neighbor superexchange constant J = 15.5 meV and a small Dzyaloshinskii-Moriya interaction ( D = 1.1 meV). The nearly isotropic spin wave spectrum is surprising in view of the absence of a static Jahn-Teller distortion that could quench the orbital angular momentum, and it may indicate strong orbital fluctuations. A resonant x-ray scattering study has uncovered no evidence of orbital order in LaTiO3.

A global evaluation of the susceptibility of Candida species to fluconazole by disk diffusion. Global Antifungal Surveillance Group

An improved fluconazole 25-mg disk diffusion method was used to test the susceptibility of 20,900 consecutively isolated clinical strains of Candida species from 40 hospital laboratories in 26 countries. The procedure is similar to the National Committee for Clinical Laboratory Standards (NCCLS) M2-A6 method for testing bacteria, except Mueller-Hinton agar is supplemented with 2% glucose and 0.5 mcg/mL methylene blue. Plates were incubated at 35 degrees C and read after 18 to 24h. Tentative zone interpretive criteria were based on the correlation by regression analysis with the NCCLS M27-A Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts: > =19mm Susceptible, < = 12mm Resistant, and 13-18 mm Susceptible-Dose Dependent. Of 14,368 isolates of Candida albicans, 2,073 C. glabrata, 869 C. tropicalis, 752 C. parapsilosis, and 351 C. krusei, 99%, 67%, 90%, 94%, and 26%, respectively, were susceptible in vitro to fluconazole. All study sites used the BIOMIC System to electronically read zones on plates, interpret, record test results and verify quality control data. This is the largest study to date that evaluated a broad range of sequentially collected yeasts from various infections and different types of hospitals. The modified disk testing procedure is facile and economical to perform and offers a reproducible and accurate means to assess the in vitro susceptibility of Candida species to fluconazole.

When a cane was the necessary complement of a physician

Although Dr John Radcliffe's gold-headed cane, presented to the Royal College of Physicians in 1825, became well-known following the publication two years later of Dr William Macmichael's book, The gold-headed cane, little consideration has previously been given either to medical canes, or to the custom of cane-carrying by doctors in the 18th century. This article makes a brief assessment of medical canes within the social and historical framework of the period, and views Macmichael's book in its literary context, with mention of other relevant examples of books in this genre.

Organ and tissue donation: are minorities willing to donate?

The Task Force on Organ Transplantation (DHHS,1986) addressed the issue of increasing organ donation. The Report of the Task Force recommended that "educational efforts aimed at increasing organ donation among minority populations be developed and implemented, so that the donor population will more closely reflect the ethnicity of potential transplant recipients, in order to gain the advantage of improved donor and recipient immunologic matching (DHHS,1986). Donor rates for minorities has increased as follows: 16% in 1988 to 23% in 1995 among cadaveric donors and 24% in 1988 to 28% in 1995 among living donors. The improvement in donor rates among minorities may positively affect the transplantation success rate experienced by organ recipients of the same race. Strategies must be implemented that will increase the effectiveness and frequency of communication between minority patients and the medical community. An increase in the effectiveness of communication between potential minority donor families and the health care community will contribute to the process of Consciousness Raising as discussed by Prochasksa. The result of increased awareness of the organ donation and transplantation process may have a favorable impact on organ donation. The media has, through public service announcements, paid advertising and entertainment programming, attempted to promote discussion of organ donation in the community and within families. Johnson et al. discussed Mexican-American and Anglo-American Attitudes Toward Organ Donation. The primary impediment contributing to the disparity of consent rates between Mexican-American and Anglo-American population occurs with regard to the donation of organs of relatives. Johnson stated that this impediment to organ donation can be effectively addressed by promoting family discussion. Communication within families will inform surviving next of kin of the desire of the deceased to be an organ donor and hence improve the likelihood of the donor family consenting to organ donation (Johnson et al., 1988). The promotion of communication within families must continue to be a goal of the transplant community regardless of race/ethnicity. Despite the efforts of the government, the transplant community, the media and the corporate sector to address the critical shortage of donors in the United States, the reality is that no community has the supply of donor organs suitable to meet the need.

Fluconazole orally dispersible tablets for the treatment of patients with oropharyngeal candidiasis

The efficacy and tolerability of fluconazole orally dispersible tablets (ODT) in the treatment of oropharyngeal candidiasis was evaluated in this multicentre non-comparative study. A total of 89 adults with signs and symptoms of oropharyngeal candidiasis were enrolled; 70 of whom completed therapy with fluconazole ODT 100 mg once daily for 7 - 14 days. Acquired immunodeficiency syndrome (AIDS)/ AIDS-related complex was an underlying illness in 69% of patients (61). An antimicrobial and corticosteroid therapy was given in 52% (46) and 20% (18) of patients, respectively. Of the 60 patients who had baseline signs and symptoms of infection and a culture positive for Candida albicans, 90% (54) were cured or had improved at the end of therapy, and the fungal pathogen was eradicated in 19/57 (33%) patients. At the 4-week posttreatment follow-up, signs and symptoms of oropharyngeal candidiasis were absent in 73% (27/37) patients. The adverse events and laboratory abnormalities recorded during the study period were attributable to underlying illnesses rather than to fluconazole therapy. These results indicate that this novel dosage form of fluconazole is effective and well tolerated in the treatment of oropharyngeal candidiasis.

Ganciclovir implant exchange. Timing, surgical procedure, and complications

BACKGROUND

The ganciclovir implant is effective for the treatment of cytomegalovirus (CMV) retinitis. The device eventually runs out of drug, however, and must be replaced. We report our experience with exchanging ganciclovir implants during the course of a randomized clinical trial.

METHODS

During our study, patients with newly diagnosed peripheral CMV retinitis were treated with a ganciclovir implant. The implant was scheduled for exchange at 32 weeks. It was exchanged earlier if progression of CMV retinitis occurred. Patient examinations and standard fundus photography were performed at 2-week intervals after the exchange procedure.

RESULTS

Twenty-six exchange procedures were performed. Twenty-two eyes in 15 patients received a second implant and 4 eyes in 4 patients later received a third implant. Cytomegalovirus retinitis was rendered or maintained inactive in 22 of 23 cases with more than 1 month of follow-up after the second or third implants. Complications after the second implant procedure included transient vitreous hemorrhage in 5 eyes, postoperative inflammation in 1 eye, and retinal detachment in 1 eye. Median visual acuity returned to 20/25 by 28 days and to 20/20 by 42 days. Complications after the third implant procedure included dense vitreous hemorrhage in 3 of 4 eyes. Median survival time after a second implant procedure was 89 days.

CONCLUSIONS

The initial ganciclovir implant exchange procedure is well tolerated with continued long-term control of CMV retinitis. Multiple reentries through the same wound may be associated with an increased risk for vitreous hemorrhage.

The college suspended

A satirical account of the raising of the Royal College of Physicians and its suspension from a balloon for three months is included among Baron Munchausen's later surprising adventures. Portrayals by artists of this flight of fancy involving the College are not widely known. Three pictorial representations of the raising of the College are shown and some of the historical context of the tall tale is given.

Hemoperitoneum due to spontaneous rupture of the umbilical vein

Portal hypertension often leads to collateralization of blood flow via variceal vessels that shunt blood from the portal to the systemic circulation. Rupture of an intra-abdominal varix is an unusual complication of portal hypertension that can lead to life-threatening hemoperitoneum. We describe a patient with portal hypertension secondary to liver cirrhosis who presented with acute intra-abdominal hemorrhage. At laparotomy, she was found to have a rupture of the umbilical vein. The vessel was ligated, and the patient recovered uneventfully. The causes of hemoperitoneum in cirrhosis are discussed, and the previously reported cases of intra-abdominal variceal bleeding are reviewed.

Fluconazole treatment of neonates and infants with severe fungal infections not treatable with conventional agents

Fluconazole was evaluated prospectively in 40 neonates and infants between the ages of 2 days and 3 months in whom conventional antifungal therapy was ineffective or contraindicated. The patients received therapy on an individual compassionate request basis for microbiologically documented or presumed fungal infection. The mean fluconazole dosage was 5.3 mg/kg/day (range 1-16 mg/kg/day) and the mean duration of therapy was 26 days (range 2-80 days). Efficacy was evaluated in neonates with proven fungal infection as documented by the presence of a pathogen at baseline. A positive clinical response was achieved in 97% (31/32) of the clinically evaluable patients; eradication of the fungal organism was achieved in 97% (30/31) of evaluable patients. Adverse events occurred in two patients (5%); therapy was not discontinued in either patient. These favorable safety and efficacy data are similar to results obtained with fluconazole in older children and adults.

Fluconazole treatment of children with severe fungal infections not treatable with conventional agents

Fluconazole was evaluated prospectively in 173 children aged between 4 months and 16 years in whom conventional antifungal therapy was ineffective or contraindicated. Children entered the study on an individual compassionate request basis for treatment of confirmed or presumed fungal infection or for prophylaxis of fungal infections. Sixty-two children had cancer, 40 had undergone transplantation, 14 had AIDS and 52 had other conditions. The mean fluconazole dosage was 3.4 mg/kg/day (range 0.16-11.1 mg/kg/day) and the mean duration of therapy was 36 days (range 1-340 days). Efficacy was evaluated in 63 children with confirmed fungal infection as documented by the presence of a fungal pathogen at baseline; clinical cure or improvement was achieved in 83% (52/63), pathogen eradication in 73% (43/59). All 173 children were assessed for safety. Related or possibly related adverse events occurred in 6% (11/173) of patients; seven children were withdrawn from therapy because of adverse events. Results of this study demonstrate that the clinical efficacy and safety profile of fluconazole in the treatment of fungal infections in children are favorable, results being similar to those obtained in adults.