Longitudinal study of immunity to SARS-CoV2 in ocrelizumab-treated MS patients up to 2 years after COVID-19 vaccination

OBJECTIVES

(1) To plot the trajectory of humoral and cellular immune responses to the primary (two-dose) COVID-19 mRNA series and the third/booster dose in B-cell-depleted multiple sclerosis (MS) patients up to 2 years post-vaccination; (2) to identify predictors of immune responses to vaccination; and (3) to assess the impact of intercurrent COVID-19 infections on SARS CoV-2-specific immunity.

METHODS

Sixty ocrelizumab-treated MS patients were enrolled from NYU (New York) and University of Colorado (Anschutz) MS Centers. Samples were collected pre-vaccination, and then 4, 12, 24, and 48 weeks post-primary series, and 4, 12, 24, and 48 weeks post-booster. Binding anti-Spike antibody responses were assessed with multiplex bead-based immunoassay (MBI) and electrochemiluminescence (Elecsys®, Roche Diagnostics), and neutralizing antibody responses with live-virus immunofluorescence-based microneutralization assay. Spike-specific cellular responses were assessed with IFNγ/IL-2 ELISpot (Invitrogen) and, in a subset, by sequencing complementarity determining regions (CDR)-3 within T-cell receptors (Adaptive Biotechnologies). A linear mixed-effect model was used to compare antibody and cytokine levels across time points. Multivariate analyses identified predictors of immune responses.

RESULTS

The primary vaccination induced an 11- to 208-fold increase in binding and neutralizing antibody levels and a 3- to 4-fold increase in IFNγ/IL-2 responses, followed by a modest decline in antibody but not cytokine responses. Booster dose induced a further 3- to 5-fold increase in binding antibodies and 4- to 5-fold increase in IFNγ/IL-2, which were maintained for up to 1 year. Infections had a variable impact on immunity.

INTERPRETATION

Humoral and cellular benefits of COVID-19 vaccination in B-cell-depleted MS patients were sustained for up to 2 years when booster doses were administered.

The CELLO trial: Protocol of a planned phase 4 study to assess the efficacy of Ocrelizumab in patients with radiologically isolated syndrome

BACKGROUND

Patients with radiologically isolated syndrome (RIS) exhibit CNS lesions suggestive of multiple sclerosis (MS) in the absence of overt neurological symptoms characteristic of the disease. They may have concurrent brain atrophy, subtle cognitive impairment, and intrathecal inflammation. At least half ultimately develop MS, cementing RIS as preclinical MS for many. However, high-quality data, including immunologic biomarkers, to guide treatment decisions in this population are lacking. Early intervention with ocrelizumab, a humanized monoclonal antibody approved for relapsing and primary progressive MS that targets CD20+ B-cells, may affect disease course and improve long-term outcomes. The objective of this study is to describe the protocol for CELLO, a clinical trial assessing the effect of ocrelizumab on RIS.

METHODS

The CELLO clinical trial, a phase 4, multicenter, randomized, double-blind, placebo-controlled study conducted as an academic-industry collaboration, aims to (1) assess the efficacy of ocrelizumab in patients with RIS and (2) identify biomarkers indicative of emerging autoimmunity as well as immune recovery after transient B-cell depletion. The study will enroll 100 participants across ≥15 sites. Participants will be aged 18 to 40 years, have RIS (defined as meeting 2017 revised McDonald criteria for dissemination in space), and have either been diagnosed with RIS within the last 5 years or have had new brain lesions identified within 5 years of study entry. A screening program of first-degree relatives of patients with MS will be used to boost recruitment. Eligible patients will be randomized 1:1 to receive 3 courses of ocrelizumab or placebo at baseline, week 24, and week 48. Patients will subsequently be followed up for ≥3 years. The primary outcome is time to development of new radiological or clinical evidence of MS. Secondary and exploratory objectives will investigate neuroimaging, serological and immunologic biomarkers, cognitive function, and patient-reported outcomes. A substudy using single-cell RNA sequencing to characterize blood and CSF immune cells will assess markers associated with conversion to clinical MS.

CONCLUSION

The CELLO study will improve the understanding of B-cell biology in early MS disease pathophysiology, characterize the emergence of CNS autoimmunity, and provide evidence to inform treatment decision-making for individuals with RIS.

CLINICALTRIALS

GOV: NCT04877457.

Hybrid and vaccine-induced immunity against SAR-CoV-2 in MS patients on different disease-modifying therapies

OBJECTIVE

To compare "hybrid immunity" (prior COVID-19 infection plus vaccination) and post-vaccination immunity to SARS CoV-2 in MS patients on different disease-modifying therapies (DMTs) and to assess the impact of vaccine product and race/ethnicity on post-vaccination immune responses.

METHODS

Consecutive MS patients from NYU MS Care Center (New York, NY), aged 18-60, who completed primary COVID-19 vaccination series ≥6 weeks previously were evaluated for SARS CoV-2-specific antibody responses with electro-chemiluminescence and multiepitope bead-based immunoassays and, in a subset, live virus immunofluorescence-based microneutralization assay. SARS CoV-2-specific cellular responses were assessed with cellular stimulation TruCulture IFNγ and IL-2 assay and, in a subset, with IFNγ and IL-2 ELISpot assays. Multivariate analyses examined associations between immunologic responses and prior COVID-19 infection while controlling for age, sex, DMT at vaccination, time-to-vaccine, and vaccine product.

RESULTS

Between 6/01/2021 and 11/11/2021, 370 MS patients were recruited (mean age 40.6 years; 76% female; 53% non-White; 22% with prior infection; common DMT classes: ocrelizumab 40%; natalizumab 15%, sphingosine-1-phosphate receptor modulators 13%; and no DMT 8%). Vaccine-to-collection time was 18.7 (±7.7) weeks and 95% of patients received mRNA vaccines. In multivariate analyses, patients with laboratory-confirmed prior COVID-19 infection had significantly increased antibody and cellular post-vaccination responses compared to those without prior infection. Vaccine product and DMT class were independent predictors of antibody and cellular responses, while race/ethnicity was not.

INTERPRETATION

Prior COVID-19 infection is associated with enhanced antibody and cellular post-vaccine responses independent of DMT class and vaccine type. There were no differences in immune responses across race/ethnic groups.

Cellular and humoral immunity to SARS-CoV-2 infection in multiple sclerosis patients on ocrelizumab and other disease-modifying therapies: a multi-ethnic observational study

OBJECTIVE

To determine the impact of MS disease-modifying therapies (DMTs) on the development of cellular and humoral immunity to SARS-CoV-2 infection.

METHODS

MS patients aged 18-60 were evaluated for anti-nucleocapsid and anti-Spike RBD antibody with electro-chemiluminescence immunoassay; antibody responses to Spike protein, RBD, N-terminal domain with multiepitope bead-based immunoassays (MBI); live virus immunofluorescence-based microneutralization assay; T-cell responses to SARS-CoV-2 Spike using TruCulture ELISA; and IL-2 and IFNγ ELISpot assays. Assay results were compared by DMT class. Spearman correlation and multivariate analyses were performed to examine associations between immunologic responses and infection severity.

RESULTS

Between 1/6/2021 and 7/21/2021, 389 MS patients were recruited (mean age 40.3 years; 74% female; 62% non-White). Most common DMTs were ocrelizumab (OCR) - 40%; natalizumab - 17%, Sphingosine 1-phosphate receptor (S1P) modulators -12%; and 15% untreated. 177 patients (46%) had laboratory evidence of SARS-CoV-2 infection; 130 had symptomatic infection, 47 - asymptomatic. Antibody responses were markedly attenuated in OCR compared to other groups (p≤0.0001). T-cell responses (IFNγ) were decreased in S1P (p=0.03), increased in natalizumab (p<0.001), and similar in other DMTs, including OCR. Cellular and humoral responses were moderately correlated in both OCR (r=0.45, p=0.0002) and non-OCR (r=0.64, p<0.0001). Immune responses did not differ by race/ethnicity. COVID-19 clinical course was mostly non-severe and similar across DMTs; 7% (9/130) were hospitalized.

INTERPRETATION

DMTs had differential effects on humoral and cellular immune responses to SARS-CoV-2 infection. Immune responses did not correlate with COVID-19 clinical severity in this relatively young and non-disabled group of MS patients. This article is protected by copyright. All rights reserved.

A new method for inferring timetrees from temporally sampled molecular sequences

Pathogen timetrees are phylogenies scaled to time. They reveal the temporal history of a pathogen spread through the populations as captured in the evolutionary history of strains. These timetrees are inferred by using molecular sequences of pathogenic strains sampled at different times. That is, temporally sampled sequences enable the inference of sequence divergence times. Here, we present a new approach (RelTime with Dated Tips [RTDT]) to estimating pathogen timetrees based on a relative rate framework underlying the RelTime approach that is algebraic in nature and distinct from all other current methods. RTDT does not require many of the priors demanded by Bayesian approaches, and it has light computing requirements. In analyses of an extensive collection of computer-simulated datasets, we found the accuracy of RTDT time estimates and the coverage probabilities of their confidence intervals (CIs) to be excellent. In analyses of empirical datasets, RTDT produced dates that were similar to those reported in the literature. In comparative benchmarking with Bayesian and non-Bayesian methods (LSD, TreeTime, and treedater), we found that no method performed the best in every scenario. So, we provide a brief guideline for users to select the most appropriate method in empirical data analysis. RTDT is implemented for use via a graphical user interface and in high-throughput settings in the newest release of cross-platform MEGA X software, freely available from http://www.megasoftware.net.

Pathogen timetrees trace the origins and evolutionary histories of strains in populations, hosts, and outbreaks. The tips of these molecular phylogenies often contain sampling time information because the sequences were generally obtained at different times during the disease outbreaks and propagation. We have developed a new method for inferring divergence times and confidence intervals for phylogenies with tip dates. The new Relative Times with Dated Tips (RTDT) methods showed excellent performance in the analysis of computer-simulated datasets, producing similar or better results in several evolutionary scenarios as compared to other fast, non-Bayesian methods. The new method is available in the cross-platform MEGA software package (version 10.1 and higher) that provides a graphical user interface and allows usage via a command line in scripting and high throughput analysis (www.megasoftware.net).

Characterization of TNF-induced cell death in Drosophila reveals caspase- and JNK-dependent necrosis and its role in tumor suppression

Tumor-necrosis factor (TNF) and its superfamily members are pleiotropic cytokines. Activation of TNF can lead to distinct cellular outcomes including inflammation, cell survival, and different forms of cell death, such as apoptosis and necrosis in a context-dependent manner. However, our understanding of what determines the versatile functions of TNF is far from complete. Here, we examined the molecular mechanisms that distinguish the forms of cell death induced by Eiger (Egr), the sole homolog of TNF in Drosophila. We show that expression of Egr in the developing Drosophila eye simultaneously induces apoptosis and apoptosis-independent developmental defects indicated by cellular disorganization, both of which rely on the c-Jun N-terminal kinase (JNK) signaling activity. Intriguingly, when effector caspases DrICE and Dcp-1 are defective or inhibited, expression of Egr triggers necrosis which is characterized by loss of cell membrane integrity, translucent cytoplasm, and aggregation of cellular organelles. Moreover, such Egr-induced necrosis depends on the catalytic activity of the initiator caspase Dronc and the input from JNK signaling but is independent of their roles in apoptosis. Further mosaic analysis with mutants of scribble (scrib), an evolutionarily conserved tumor suppressor gene regulating cell polarity, suggests that Egr/JNK-mediated apoptosis and necrosis establish a two-layered defense system to inhibit the oncogenic growth of scrib mutant cells. Together, we have identified caspase- and JNK-dependent mechanisms underlying Egr-induced apoptosis versus necrosis and their fail-safe roles in tumor suppression in an intact organism in vivo.

Midwives' experience of their education, knowledge and practice around immersion in water for labour or birth

BACKGROUND

There is limited research examining midwives' education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic.

METHODS

This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia. Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire. Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth. Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts.

RESULTS

The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire. Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven. Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth. Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance. Phase two included two focus groups of seven and five midwives. Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space. Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth.

CONCLUSIONS

This research contributes to the growing knowledge base examining midwives' education, knowledge and practice around immersion in water for labour or birth. It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

Dental erosion in asthma: a case-control study from south east Queensland

BACKGROUND

Asthma medication places patients at risk of dental erosion by reducing salivary protection against extrinsic or intrinsic acids. But patterns of lesions in asthmatics may differ from patterns in non-asthmatics, because gastro-oesophageal reflux (GOR) is found in 60 per cent of asthmatics.

METHODS

The lesions in 44 asthma cases were compared to those of age and sex match controls with no history of asthma or medications drawn from the dental records of 423 patients referred concerning excessive tooth wear. The subjects were 70 males age range 15 to 55 years and 18 females age range 18 to 45. Anamnestic clinical data were compared between the two groups. Models of all 88 subjects were examined by light microscopy, and wear patterns were recorded on permanent central incisor, canine, premolar and first molar teeth.

RESULTS

Clinical differences were a higher incidence of tooth hypersensitivity, xerostomia, salivary gland abnormalities, gastric complaints, and self induced vomiting in the cases. No differences were found between the cases and controls on citrus fruit and acid soft drink consumption. More occlusal erosion sites were found in cases, whereas more attrition sites were found in the controls. There were no significant differences in palatal erosion on maxillary anterior teeth found between cases and controls. Lingual erosion of the mandibular incisors, found only in GOR patients, was not observed.

CONCLUSIONS

A higher incidence of erosion was found in asthmatics. Gastro-oesophageal reflux symptoms were not associated with the sign of lingual mandibular incisor erosion. The clinical significance is that asthmatics are at risk of dental erosion from extrinsic acid, but GOR does not appear to contribute in a site-specific manner.

Dietary chromium tripicolinate supplementation reduces glucose concentrations and improves glucose tolerance in normal-weight cats

The effect of dietary chromium supplementation on glucose and insulin metabolism in healthy, non-obese cats was evaluated. Thirty-two cats were randomly divided into four groups and fed experimental diets consisting of a standard diet with 0 ppb (control), 150 ppb, 300 ppb, or 600 ppb added chromium as chromium tripicolinate. Intravenous glucose tolerance, insulin tolerance and insulin sensitivity tests with minimal model analysis were performed before and after 6 weeks of feeding the test diets. During the glucose tolerance test, glucose concentrations, area under the glucose concentration-time curve, and glucose half-life (300 ppb only), were significantly lower after the trial in cats supplemented with 300 ppb and 600 ppb chromium, compared with values before the trial. Fasting glucose concentrations measured on a different day in the biochemistry profile were also significantly lower after supplementation with 600 ppb chromium. There were no significant differences in insulin concentrations or indices in either the glucose or insulin tolerance tests following chromium supplementation, nor were there any differences between groups before or after the dietary trial.Importantly, this study has shown a small but significant, dose-dependent improvement in glucose tolerance in healthy, non-obese cats supplemented with dietary chromium. Further long-term studies are warranted to determine if the addition of chromium to feline diets is advantageous. Cats most likely to benefit are those with glucose intolerance and insulin resistance from lack of exercise, obesity and old age. Healthy cats at risk of glucose intolerance and diabetes from underlying low insulin sensitivity or genetic factors may also benefit from long-term chromium supplementation.

Perceived Health Status in African American and Caucasian Men 40 to 70 Years Old

There is limited data on the relationship between perceived health status and the demographic variables of education and income in African American men. A sample of 2,001 men (72% African Americans and 28% Caucasians) who were participating in prostate cancer screening was studied to identify predictors of men's health status. Data on the concepts of self-rated health status, age, race, education, income, living arrangements, and marital status were collected. Findings indicated that men who were more likely to report excellent health status were older Caucasians, had more than a high school education, an annual income over 25,021 dollars, were living with others, and were married. Men more likely to report fair health status were older African Americans, unmarried, had less than a high school education, had an annual income less than 9,600 dollars, were living alone, and were unmarried. Implications for targeting at-risk men are presented.

Cupped lesions of early onset dental erosion in young southeast Queensland adults

BACKGROUND

Dental erosion manifests as cupped lesions on cusp apices and in fissures of teeth in patients from southeast Queensland referred with excessive tooth wear. When found in young adults, these lesions may indicate early onset of active dental erosion. If the numbers and extent of cupped lesions increase with age, erosion may be a slow cumulative process.

METHODS

This cross-sectional study recorded the presence or absence and the relative sizes of cupped lesions from all cusps and occlusal fissures on premolar and permanent molar teeth from study models by image analysis. Type-specimens of cupped lesions were examined.

RESULTS

The incidence by tooth reflected time in the mouth, post-tooth emergence. A linear increase in lesion number and size, with age, was found. However, cupped lesions occurred on mandibular first molar cusp apices as often, and attained greater extent, in adults under 27 years compared with older subjects.

CONCLUSION

Marked differences were found between lesion number and size, between maxillary and mandibular molar sites that reflect differences in salivary protection against dental erosion. The significance of this study is that the mandibular first permanent molar indicates the age of onset and severity of dental erosion.

Determination of reference values for glucose tolerance, insulin tolerance, and insulin sensitivity tests in clinically normal cats

OBJECTIVE

To determine reference values and test variability for glucose tolerance tests (GTT), insulin tolerance tests (ITT), and insulin sensitivity tests (IST) in cats.

ANIMALS

32 clinically normal cats.

PROCEDURE

GTT, ITT, and IST were performed on consecutive days. Tolerance intervals (ie, reference values) were calculated as means +/- 2.397 SD for plasma glucose and insulin concentrations, half-life of glucose (T1/2 glucose), rate constants for glucose disappearance (Kglucose and Kitt), and insulin sensitivity index (Si). Tests were repeated after 6 weeks in 8 cats to determine test variability.

RESULTS

Reference values for T1/2glucose, Kglucose, and fasting plasma glucose and insulin concentrations during GTT were 45 to 74 minutes, 0.93 to 1.54 %/min, 37 to 104 mg/dl, and 2.8 to 20.6 microU/ml, respectively. Mean values did not differ between the 2 tests. Coefficients of variation for T1/2glucose, Kglucose, and fasting plasma glucose and insulin concentrations were 20, 20, 11, and 23%, respectively. Reference values for Kitt were 1.14 to 7.3%/min, and for SI were 0.57 to 10.99 x 10(4) min/microU/ml. Mean values did not differ between the 2 tests performed 6 weeks apart. Coefficients of variation for Kitt and SI were 60 and 47%, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

GTT, ITT, and IST can be performed in cats, using standard protocols. Knowledge of reference values and test variability will enable researchers to better interpret test results for assessment of glucose tolerance, pancreatic beta-cell function, and insulin sensitivity in cats.

Exhaled nitric oxide levels correlate with measures of disease control in asthma

BACKGROUND

Asthma guidelines emphasize maintaining disease control. However, objective measures of asthma disease control are lacking.

OBJECTIVE

We sought to examine the relationship between exhaled nitric oxide (NO) levels and measures of asthma disease control versus asthma disease severity.

METHODS

We performed a cross-sectional study of 100 patients (age range, 7-80 years) with asthma. We administered a questionnaire to identify characteristics of asthma, performed spirometric testing before and after administration of a bronchodilator, and measured exhaled NO levels in all participants.

RESULTS

Exhaled NO was significantly correlated with the following markers of asthma disease control: asthma symptoms within the past 2 weeks (P =.02), dyspnea score (P =. 02), daily use of rescue medications (P =.01), and reversibility of airflow obstruction (P =.02). Exhaled NO levels were not correlated with the following markers of asthma disease severity: history of respiratory failure (P =.20), health care use (P =.08), fixed airflow obstruction (P =.91), or a validated asthma severity score (P =.19). Markers with relevance to both disease control and severity showed either a weak correlation (FEV(1) and FEV(1) percent predicted) or no correlation (controller drug use) with exhaled NO.

CONCLUSION

We conclude that exhaled NO levels are correlated predominantly with markers of asthma control rather than asthma severity. Monitoring of exhaled NO may be useful in outpatient asthma management.

Antibody response in goats vaccinated with liposome-adjuvanted Clostridium perfringens type D epsilon toxoid

A trial was performed using 20 goats to evaluate the antibody responses to a liposome-adjuvanted Clostridium perfringens epsilon toxoid vaccine (LIPV). The antibody response was compared with those produced by epsilon toxoid vaccines prepared using aluminium hydroxide (ALV) and incomplete Freud's adjuvant (FAV). The animals were allocated to four groups at the beginning of the trial. The animals in group 1 were vaccinated with ALV, while the animals in group 2 received FAV and those in groups 3 and 4 were vaccinated with LIPV. The animals in groups 1 to 3 received three doses of the corresponding vaccine at intervals of three weeks, while those in group 4 received only 1 dose of vaccine at the beginning of the trial. A blood sample was obtained from all the goats at the beginning of the trial and then weekly for 8 weeks. The samples were analysed for epsilon toxoid antibodies by an indirect ELISA technique. No major clinical abnormalities were observed in the animals after vaccination, with the exception of those that received the FAV, which experienced transient lameness. The highest antibody response was observed in the animals vaccinated with FAV, but they presented moderate to severe inflammatory tissue reactions at the injection site. Moderately high antibody responses were obtained with the ALV, with which only minor local reactions were observed. No significant antibody responses were obtained with the LIPV, nor were local reactions observed.

Newcastle satisfaction with nursing scales: an instrument for quality assessments of nursing care

OBJECTIVES

To test the validity and reliability of scales for measuring patients' experiences of and satisfaction with nursing care; to test the ability of the scales to detect differences between hospitals and wards; and to investigate whether place of completion, hospital, or home influences response.

DESIGN

Sample survey.

SETTING

20 wards in five hospitals in the north east of England.

PATIENTS

2078 patients in general medical and surgical wards.

MAIN MEASURES

Experiences of and satisfaction with nursing care.

RESULTS

75% of patients approached to complete the questionnaires did so. Construct validity and internal consistency were both satisfactory. Both the experience and satisfaction scales were found to detect differences between randomly selected wards and hospitals. A sample of patients (102) were sent a further questionnaire to complete at home. 73% returned this; no significant differences were found in either experience or satisfaction scores between questionnaires given in hospital or at home.

CONCLUSION

Scales to measure patients' experiences of and satisfaction with nursing in acute care have been developed and found to be valid, reliable, and able to detect differences between hospitals and wards. Questionnaires can be given before patients leave hospital or at home without affecting scores, but those given at home have a lower response rate.

The impact of primary nursing on patient satisfaction

Primary nursing is considered by some to be an appropriate vehicle for meeting the named-nurse standard of the Patient's Charter. The study reported here set out to determine whether patients identifying one nurse as being in charge of their care would express more positive experiences of and greater satisfaction with nursing care. Patients who could identify a nurse in charge of their care reported more positive experiences of that care. However, in the wards studied, primary nursing did not appear to be any more successful than team nursing in encouraging this process. Given the limited resources to implement primary nursing, the authors advise increased efforts to ensure each patient has one nurse responsible for their care, and that they know who this nurse is.

Tail docking in dogs: a sample of attitudes of veterinarians and dog breeders in Queensland

One hundred veterinarians and 100 breeders of traditionally docked dogs from Queensland were surveyed by telephone to determine their attitudes towards tail docking. Eighty-four percent of the breeders surveyed were in favour of docking, whereas 83% of veterinarians were opposed to the practice. Most pups were docked between 1 and 3 days of age. All veterinarians surgically amputated the tail, whereas 16% of breeders applied rubber bands to the tail. Seventy-six percent of the veterinarians, but only 18% of the breeders believed that docking caused significant to severe pain. No veterinarians, but 25% of the dog breeders believed that docking was painless. Although recent changes to the Queensland Canine Control Council's rulings allow dogs with intact tails to be shown in traditionally docked classes, the requirement of breed standard was cited as the major reason for tail docking by both breeders and veterinarians.

Echocardiographic evaluation of the effects of medetomidine and xylazine in dogs

The echocardiographic effects of medetomidine and xylazine were evaluated in 6 healthy dogs. Values for echocardiographic variables were significantly different from pre-treatment values after administration of both drugs. The effects of medetomidine were similar to that of xylazine. Because of their cardiac depressant effects, both drugs should be used with care in sick dogs.

Monosomy 7 and activating RAS mutations accompany malignant transformation in patients with congenital neutropenia

Individuals with severe forms of congenital neutropenia suffer from recurrent infections. The therapeutic use of recombinant human granulocyte colony-stimulating factor (rhG-CSF) to increase the neutrophil count is associated with fewer infections and an improved quality of life. However, the long-term effects of this new therapy are largely unknown. In particular, it is unclear if myeloid leukemia, a known complication of some forms of congenital neutropenia, will occur with increased frequency among patients who receive long-term treatment with hematopoietic growth factors. We report 13 patients with congenital disorders of myelopoiesis who developed leukemic transformation with either myelodysplastic syndrome (MDS) or acute myelogenous leukemia (AML) and 1 who acquired a clonal cytogenetic abnormality without evidence of MDS or AML while receiving rhG-CSF. The bone marrows of 10 patients showed monosomy 7 and 5 had activating RAS mutations. These abnormalities were not detected in pretreatment bone marrows and cessation of rhG-CSF was not associated with either clinical improvement or cytogenetic remission. We conclude that patients with severe forms of congenital neutropenia are at relatively high risk of developing MDS and AML. The occurrence of monosomy 7 and RAS mutations in these cases suggests that the myeloid progenitors of some patients are genetically predisposed to malignant transformation. The relationship between therapeutic rhG-CSF and leukemogenesis in patients with severe chronic neutropenia is unclear.

Nurse involvement in cardiac rehabilitation prior to hospital discharge

Interviews were undertaken with 202 men admitted to five hospitals in northeast England following an uncomplicated first myocardial infarction. The likelihood of patients speaking to a nurse about recovery or seeing a physiotherapist, dietician or specialist rehabilitation nurse, varied considerably between hospitals. Whilst virtually all patients received written information concerning some aspect of life-style change or cardiac rehabilitation, the quality and range of information, particularly with regard to information about stress or anxiety, was frequently limited. Instructions about seeing a general practitioner following discharge were often vague; formal rehabilitation programmes, where they existed, excluded some patients. The study suggests that much patient education is dependent on the provision of written information alone, and that further evaluation of the effectiveness of self-help material supported by nursing input is desirable.

Obtaining patients' views of nursing care to inform the development of a patient satisfaction scale

Patient satisfaction is increasingly being measured as an indication of the effectiveness of nursing care. At present, however, there are no validated UK scales available specifically addressed to nursing. The aim of the present study was to develop a sensitive, valid and reliable measure of patient satisfaction. This paper describes the first phase of the study, the development of a multidimensional concept of satisfaction from the patients' perspective. Using qualitative methods, patients were interviewed both in hospital and following discharge. Eleven main concepts were identified: nurses' manner, attentiveness, availability, reassurance, individual treatment, openness/informality, information, professionalism, ward organization, nurses' knowledge and ward environment. Beginning with customer-defined values has provided the starting point for the development of a scale to measure patients' satisfaction with nursing using concepts important to patients, rather than hospital personnel or research teams.

A gene for Crouzon craniofacial dysostosis maps to the long arm of chromosome 10

Crouzon craniofacial dysostosis (CFD) is an autosomal dominant craniofacial disorder characterized by premature craniosynostosis, shallow orbits and hypoplastic maxilla. To map the gene responsible, we have used a mapping strategy of testing for linkage to known developmental genes. Analysis of a large kindred established linkage between CFD and three loci (D10S190, D10S209 and D10S216) that span a 13 cM region on chromosome 10q. A maximum pairwise lod score of 4.42 (theta = 0) at D10S190 was obtained and the addition of a second kindred produced a combined pairwise lod score of 5.32 (theta = 0) at the same locus. The developmental gene, PAX2, located within this region, is an attractive candidate gene.

Antithymocyte globulin, cyclosporine, and prednisone for the treatment of severe aplastic anemia in children. A pilot study

PURPOSE

The aim of the therapeutic trial was to try to optimize the treatment of severe and moderate aplastic anemia in children who lack a suitable bone marrow donor using the most successful available drugs, with the least amount of side effects.

PATIENTS AND METHODS

A pilot study for the treatment of severe aplastic anemia in children was conducted by four institutions. The treatment protocol included antithymocyte globulin (ATG), prednisone, and cyclosporine A. Twelve patients were enrolled, and 11 were evaluable. All patients had severe aplastic anemia (SAA); three had hepatitis-induced severe aplastic anemia (HI-SAA).

RESULTS

Of 11 evaluable patients, eight have responded with normalization of their blood counts. Two of the three patients with HI-SAA responded to the therapy.

CONCLUSION

The results of our pilot study compare favorably with previous therapeutic trials. All the patients who responded achieved complete response, i.e., restoration of blood counts to within the normal range.

Cook obstetrics and gynecology catheter multicenter chorionic villus sampling trial: comparison of birth defects with expected rates

OBJECTIVE

The null hypothesis was that offspring of women undergoing first-trimester chorionic villus sampling do not experience a rate of birth defects exceeding background rates.

STUDY DESIGN

Follow-up information regarding major malformations was prospectively sought on offspring of 4105 women undergoing first-trimester chorionic villus sampling from nine centers participating in a collaborative study with the Cook obstetrics and gynecology catheter. These data were compared with data from the Collaborative Perinatal Project and other registries.

RESULTS

A total of 84 offspring with major malformations was identified (2.36%). Compared with background rates, there was no increase in the incidence of total malformations or specific malformations (including limb reduction defects) in the subjects. One institution experienced all three limb reduction defects in this series; the probability of this occurring by chance alone is < 1%.

CONCLUSION

Chorionic villus sampling was not found to result in an increase in major birth defects or in specific categories of birth defects in this series.

Restaurant wheelchair accessibility

This study was designed to determine the compliance of restaurants to the wheelchair accessibility standards set forth in the Uniform Federal Accessibility Standards. The standards that were operationalized in this study are also found in Title III of the Americans With Disabilities Act of 1990. The data were collected at 120 sites in three midwestern states. For one who uses a wheelchair, parking the car is often an obstacle to eating out. Only 53% of the restaurants surveyed provide handicapped parking. Entering the building may also be a problem. Of the restaurants that required a ramp, only 66% provided them. Inside the restaurant, the key problems were accessible rest-rooms and the height of tables. The study provided comparisons between restaurants in rural and urban settings, as well as comparisons between conventional restaurants and fast food restaurants. No notable differences emerged for these comparisons.

Hyperfractionated radiotherapy for children with brainstem gliomas: a pilot study using 7,200 cGy

Brainstem gliomas, constituting approximately 10% of all childhood central nervous system tumors, remain the most resistant of all brain tumors to therapy. A subgroup of high-risk patients with tumors that diffusely involve the brainstem or that microscopically demonstrate foci of anaplasia on biopsy specimens rarely survive after treatment. Conventional doses of radiotherapy result in temporary clinical improvement in the majority of these high-risk patients; however, few if any remain alive 18 months after treatment. Hyperfractionated radiotherapy, with delivery of larger numbers of smaller fractions of radiotherapy, is a possible way to increase tumor control without increasing neurological toxicity. In 1985, a multiinstitutional phase I/phase II trial, using 100 cGy of radiation therapy twice daily to a total dose of 7,200 cGy, was undertaken for patients with high-risk brainstem gliomas. At the time of writing, 24 (69%) had developed progressive disease and 11 remained in continuous progression-free remission. Actuarial progression-free survival at 20 months is approximately 30%. Twenty-three of 31 evaluable patients had an objective radiographic response to therapy. In comparison to both historical control patients and patients treated in a previous trial using 6,480 cGy of hyperfractionated radiation therapy, there was a statistically significant improvement in progression-free survival rate for patients treated with 7,200 cGy of hyperfractionated radiation therapy (p less than 0.01). To date no patient has died as a result of treatment. Six patients developed transient neurological deterioration or cystic intralesional changes, as demonstrated on magnetic resonance imaging, within 6 weeks of the completion of radiotherapy. Postmortem examination performed in 7 patients did not disclose significant radiation necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality assurance and clinical dietetics

A comprehensive Quality Assurance Programme has been developed in the Department of Dietetic Services at Waikato Hospital. It involves the evaluation of personal performance and of the services provided by the Department. Performance Appraisal and Dietetic Record Audit. The programme has become an established aspect of the service. It has been modified from time to time, but always with the intent to improve performance. Significant gains have accrued to the Department and to the services it provides as a result of the Quality Assurance Programme.

Dicentric chromosome 13 and centromere inactivation

The karyotype of a child with dysmorphic findings suggestive of both trisomy 13 and the 13q--syndrome was found to have cells with one of two different dicentric chromosomes: one bearing a duplication of chromosome 13q [46,XX,-13, + psu dic (13)t(13;13)(pter leads to cen leads to q34::q34 leads to pter)] and the other a deletion of 13q [46,XX,-13, + psu dic (13)t(13;13)(pter leads to cen leads to q22::q11 leads to pter]. Longitudinal cytogenetic studies in leukocytes demonstrated a loss of those cells possessing the small dicentric [psu dic(13)(q22;q11)], whereas fibroblasts from two separate skin biopsies contained only this marker. Q-band polymorphisms indicated that both dicentrics were of paternal origin, with the smaller dicentric derived from the larger via the bridge-breakage-fusion cycle. The presence of two active centromeres could not be confirmed in either dicentric.

PLasma half-life and urinary excretion of cyclophosphamide in children

The plasma half-life and urinary excretion of cyclophosphamide were determined in 13 children who had various malignancies and/or who were being prepared for bone marrow transplantation. Disappearance from the plasma following iv infusion over a 1-2 hour period was first-order. Urinary excretion was maximal during the first 8 hours after administration and was essentially complete in 24 hours. The plasma half-life in children not receiving known inducers of hepatic microsomal mixed-function oxygenase activity or cyclophosphamide in the 3-week period prior to each determination ranged from 145 to 390 minutes. These values are lower than those ordinarily found in adult patients. The fraction of the total dose excreted in the urine as the parent compound ranged from 4% to 27%. Repeated administration of cyclophosphamide at approximately 30-60 day intervals did not appear to alter its plasma half-life but did appear to increase its urinary excretion. Daily administration of cyclophosphamide (approximately 50 mg/kg/day x 2 or 4) significantly decreased its plasma half-life and urinary excretion suggesting that it may reversibly induce its own metabolism.

The management of hyperkinetic children: a trial of dietary therapy

The standard techniques in the management of hyperkinetic children are not uniformly successful. Recently, there has been considerable interest in dietary therapy. The diet, low in artificial colours, and flavours and in naturally occurring salicylates has been adapted for use in New Zealand. Ten hyperkinetic children have been treated with the diet, five of whom improved dramatically and are now off all other therapy. Their response to accidental and deliberate challenge supports the hypothesis that the dietary regime described has been responsible for their improvement.