Social Smiles of Visually Impaired Infants

Social smiles of 10 visually impaired infants, ages 4 to 12 months, were examined longitudinally in play interactions with their mothers. Characteristics examined included the cognitive skills of the infants when the social smile was first seen, the parental behaviors that elicited and followed social smiles, and the frequency of social smiles in play interactions across the first year of life.

All infants demonstrated both the presence of social smiles and the second Piagetian stage of cognitive development at the start of the study. Social smiling appeared to increase in frequency from 6 to 12 months except for a drop at 8 months. Smiles occurred in response to social and environmental events and were consistently followed by another parental social behavior.

The addition of deep hyperthermia to gemcitabine-based chemoradiation may achieve enhanced survival in unresectable locally advanced adenocarcinoma of the pancreas

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Intensification of chemoradiation with hyperthermia was feasible in nine patients with LAPC.

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Only one grade three toxicity was reported and two tumours became resectable.

•

The 24 months median OS and 100% 1 year OS are superior to historical series.

Introduction

Driven by the current unsatisfactory outcomes for patients with locally advanced pancreatic cancer (LAPC), a biologically intensified clinical protocol was developed to explore the feasibility and efficacy of FOLFORINOX chemotherapy followed by deep hyperthermia concomitant with chemoradiation and subsequent FOLFORINOX chemotherapy in patients with LAPC.

Methods

Nine patients with LAPC were treated according to the HEATPAC Phase II trial protocol which consists of 4 cycles of FOLFORINOX chemotherapy followed by gemcitabine-based chemoradiation to 56 Gy combined with weekly deep hyperthermia and then a further 8 cycles of FOLFORINOX chemotherapy.

Results

One grade three related toxicity was reported and two tumours became resectable. The median overall survival was 24 months and 1 year overall survival was 100%.

Conclusions

Intensification of chemoradiation with deep hyperthermia was feasible in nine consecutive patients with LAPC.

Development of Object Permanence in Visually Impaired Infants

The development of object permanence skills in 20 visually impaired infants between the ages of 4 and 25 months was examined longitudinally. Other areas of development which were examined in relationship to object permanence included motor skills, various aspects of language and social adaptation, symbolic play, and stranger and separation distress. Parallels to object permanence development in sighted infants that were found included order of skill acquisition and the span of time across which the skills were mastered. The visually impaired subjects as a group were 8 to 12 months older than the sighted infants at the time of similar object permanence skills, but the greater maturity of the visually impaired subjects seemed to be demonstrated in the lack of A—B error and the ability of visually impaired infants to perform the tasks on the basis of discontinuous sensory information. No relationships between object permanence levels and either symbolic play abilities and separation or stranger distress were found.

Enhancing Low-Intensity Coaching in Parent Implemented Early Start Denver Model Intervention for Early Autism: A Randomized Comparison Treatment Trial

Short-term low intensity parent implemented intervention studies for toddlers with autism spectrum disorder (ASD) have found it difficult to demonstrate significantly improved developmental scores or autism severity compared to community treatment. We conducted a randomized comparative intent-to-treat study of a parent implemented intervention to (1) test the effects of an enhanced version on parent and child learning, and (2) evaluate the sensitivity to change of proximal versus distal measures of child behavior. We randomized 45 children with ASD, 12-30 months of age, into one of two versions of parent-implemented Early Start Denver Model (P-ESDM), the basic model, in which we delivered 1.5 h of clinic-based parent coaching weekly, and an enhanced version that contained three additions: motivational interviewing, multimodal learning tools, and a weekly 1.5-h home visit. We delivered the intervention for 12 weeks and measured child and parent change frequently in multiple settings. We found a time-by-group interaction: parents in the enhanced group demonstrated significantly greater gains in interaction skills than did parents in the non-enhanced group. Both interventions were associated with significant developmental acceleration; however, child outcomes did not differ by group. We found a significant relationship between degree of change in parental interaction skill and rate of children's improvement on our proximal measure. Parents in both groups reported satisfaction with the intervention. These findings suggest that parent skills improved more in the enhanced group than the comparison group. Children in the two groups showed similar improvements. Rate of individual parent learning was associated with greater individual child progress on a measure quite proximal to the treatment, though not on standardized assessments.

Changes in vertebral bone marrow fat and bone mass after gastric bypass surgery: A pilot study

Bone marrow fat may serve a metabolic role distinct from other fat depots, and it may be altered by metabolic conditions including diabetes. Caloric restriction paradoxically increases marrow fat in mice, and women with anorexia nervosa have high marrow fat. The longitudinal effect of weight loss on marrow fat in humans is unknown. We hypothesized that marrow fat increases after Roux-en-Y gastric bypass (RYGB) surgery, as total body fat decreases. In a pilot study of 11 morbidly obese women (6 diabetic, 5 nondiabetic), we measured vertebral marrow fat content (percentage fat fraction) before and 6 months after RYGB using magnetic resonance spectroscopy. Total body fat mass declined in all participants (mean ± SD decline 19.1 ± 6.1 kg or 36.5% ± 10.9%, p<0.001). Areal bone mineral density (BMD) decreased by 5.2% ± 3.5% and 4.1% ± 2.6% at the femoral neck and total hip, respectively, and volumetric BMD decreased at the spine by 7.4% ± 2.8% (p<0.001 for all). Effects of RYGB on marrow fat differed by diabetes status (adjusted p=0.04). There was little mean change in marrow fat in nondiabetic women (mean +0.9%, 95% CI -10.0 to +11.7%, p=0.84). In contrast, marrow fat decreased in diabetic women (-7.5%, 95% CI -15.2 to +0.1%, p=0.05). Changes in total body fat mass and marrow fat were inversely correlated among nondiabetic (r=-0.96, p=0.01) but not diabetic (r=0.52, p=0.29) participants. In conclusion, among those without diabetes, marrow fat is maintained on average after RYGB, despite dramatic declines in overall fat mass. Among those with diabetes, RYGB may reduce marrow fat. Thus, future studies of marrow fat should take diabetes status into account. Marrow fat may have unique metabolic behavior compared with other fat depots.

Cerebral metastases from malignant fibrous histiocytoma of bone

Four patients with malignant fibrous histiocytoma of bone (MFH-B) metastasizing to brain are reported. In two cases, signs of cerebral involvement developed between 4 and 28 months after diagnosis. Both patients had known pulmonary or bony metastases. As a consequence of this experience, two further patients were subsequently identified, one with a definite cerebral metastasis and one who had an asymptomatic supratentorial lesion, possibly metastatic. It is suggested that patients with MFH-B and widespread metastatic disease at presentation or developing within a short interval should undergo cerebral imaging.

Bariatric surgery in a patient with complete MC4R deficiency

Bariatric surgery is often successful for treatment of severe obesity. The mechanisms of weight loss after bariatric surgery and the role of central energy homeostatic pathways in this weight loss process are not well understood. The study of individuals with complete loss of function of genes important in the leptin-melanocortin system may help establish the significance of these pathways for weight loss after bariatric surgery. We describe the outcome of bariatric surgery in an adolescent with compound heterozygosity and complete functional loss of both alleles of the melanocortin 4 receptor (MC4R). The patient underwent laparoscopic adjustable gastric banding and truncal vagotomy at years of age, which resulted in initial, but not long-term weight loss. Our experience with this patient suggests that complete MC4R deficiency impairs response to gastric banding and results in poor weight loss after this surgery.

Emotional responsivity in children with autism, children with other developmental disabilities, and children with typical development

Twenty six children with autism, 24 children with developmental disabilities, and 15 typically developing children participated in tasks in which an adult displayed emotions. Child focus of attention, change in facial tone (i.e., hedonic tone), and latency to changes in tone were measured and summary scores of emotional contagion were created. Group differences existed in the ratio of episodes that resulted in emotional contagion. Correlations existed between measures of emotional contagion, measures of joint attention, and indices of severity of autism. Children with autism demonstrated muted changes in affect, but these responses occurred much less frequently than in comparison groups. The findings suggest directions for early identification and early treatment of autism.

Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation

BACKGROUND

Many surgeons who perform Roux-en-Y gastric bypass (RYGB) for morbid obesity routinely obtain an upper gastrointestinal (GI) series in the early postoperative period to search for anastomotic leaks and signs of stricture formation at the gastrojejunostomy. We hypothesized that this practice is unreliable.

METHODS

We analyzed 654 consecutive RYGBs, of which 63% were completed laparoscopically. An upper GI series was obtained in 634 (97%) patients. The radiographic findings (leak or delayed emptying) were compared with clinical outcomes (leak or stricture formation) to calculate the sensitivity and specificity. Univariate analysis identified risk factors for leaks or stricture formation; events were too few for multivariate analysis.

RESULTS

Of 634 routine upper GI series, anastomotic leaks at the gastrojejunostomy were diagnosed in 5 (0.8%); 2 of these 5 were later reinterpreted as artifacts. Four leaks were not seen on the initial upper GI series, yielding an overall sensitivity of 43% and a positive predictive value (PPV) of 60%. Univariate analysis showed that cases done early (odds ratio [OR] 5.4 for the first 100 cases, p = 0.02) and prolonged operating time (OR 7.8 for cases >or= 300 min, p = 0.01) were associated with leaks. Emptying into the Roux-en-Y limb was delayed in 127 (20%) of the upper GI series. Strictures requiring dilatation developed in 16 (2.4%) patients. The PPV of delayed emptying for stricture formation was 6%. Risk factors for stricture formation included stapled anastomosis (OR 7.8, p = 0.002), surgeon inexperience (OR 2.9 for first 50 cases, p = 0.04), and delayed emptying (OR 3.3; p = 0.02).

CONCLUSIONS

Because the incidence of anastomotic complications and the sensitivity of upper GI series were both low, routine upper GI series did not reliably identify leaks or predict stricture formation. A selective approach, whereby imaging is reserved for patients with clinical evidence of a leak or stricture, may be more appropriate.

A preliminary study of screening for risk of autism in children with fragile X syndrome: testing two risk cut-offs for the Checklist for Autism in Toddlers

OBJECTIVE

Risk criteria for the Checklist for Autism in Toddlers (CHAT) and modified risk criteria (i.e. the Denver Criteria) were compared in a group of children with fragile X syndrome (FXS) and autism.

METHOD

Participants were 17 children aged 2-4 years with DNA confirmation of FXS. Four children had autism and 13 children did not.

RESULTS

Preliminary findings regarding the sensitivity and specificity of the CHAT for detecting risk for autism in children with FXS are as follows: using the original CHAT risk criteria, sensitivity and specificity were 50% and 100%, respectively; and using the Denver Criteria, sensitivity and specificity were 75% and 92%, respectively.

CONCLUSIONS

The CHAT and the Denver Criteria resulted in preliminary findings suggesting high levels of sensitivity to autism in children with FXS.

Gefitinib (ZD1839, Iressa) as palliative treatment in recurrent or metastatic head and neck cancer

To assess the level of activity and toxicity of gefitinib (ZD1839, Iressa™) in a population of patients with locally recurrent and/or metastatic head and neck cancer. Patients were recruited into an expanded access programme through the multidisciplinary head and neck clinics at the Royal Marsden and St George's Hospitals. Patients were required to have received at least one course of standard systemic chemotherapy or radiation therapy, or be medically unfit for chemotherapy. Patients were commenced on single-agent gefitinib at a dose of 500 mg day⁻¹. Clinical, symptomatic and radiological response, time to progression (TTP), survival and toxicity were recorded. A total of 47 patients were enrolled (35 male and 12 female) with a median age of 62 years (range 18–93 years). The observed clinical response rate was 8% with a disease control rate (complete response, partial response, stable disease) of 36%. In all, 34% of patients experienced an improvement in their symptoms. The median TTP and survival were 2.6 and 4.3 months, respectively. Acneiform folliculitis was the most frequent toxicity observed (76%) but the majority of cases were grade 1 or 2. Only four patients experienced grade 3 toxicity of any type (all cases of folliculitis). Gefitinib was well tolerated and yielded symptomatic improvement in one-third of patients. However, this agent appeared to possess limited antitumour activity in this group of patients with head and neck cancer in whom the objective response rate, median TTP and survival were all lower than has been reported in a previous study.

Radiotherapy of localised intracranial germinoma: time to sever historical ties?

The optimum management of localised intracranial germinoma remains controversial. Cure rates for this rare CNS tumour, which arises mainly in adolescents, exceed 90% at 10 years, and limitation of treatment-related late morbidity is therefore essential. Craniospinal radiotherapy plus boost is perceived to be the gold-standard treatment, but there have been suggestions that reduced-volume radiotherapy could be adequate for cure. We reviewed publications since 1988 to compare patterns of disease relapse and cure rates after craniospinal radiotherapy, reduced-volume irradiation alone (i.e., whole-brain or whole-ventricular irradiation followed by a boost), and focal or localised irradiation alone. The recurrence rate after whole-brain or whole-ventricular radiotherapy plus boost was 7.6% compared with 3.8% after craniospinal radiotherapy, with no predilection for isolated spinal relapses (2.9% vs 1.2%). We challenge the consensus that craniospinal radiotherapy is the best treatment for localised germinomas and conclude that reduced-volume radiotherapy plus boost should replace craniospinal radiotherapy when a radiotherapy-only approach is used.

Can the checklist for autism in toddlers differentiate young children with autism from those with developmental delays?

OBJECTIVE

The Checklist for Autism in Toddlers (CHAT) has been demonstrated to be sensitive to the presence of autism in otherwise normally developing 18-month-old children. However, its ability to differentiate autism from other significant developmental delays is unknown. This study examined this question.

METHOD

The CHAT was applied to a group of 44 children aged 2 and 3 years, rigorously diagnosed with autism or with other developmental problems.

RESULTS

By the original CHAT authors' criteria, the sensitivity and specificity of the CHAT were 65% and 100%, respectively. Slightly altering the criteria resulted in a sensitivity of 85% in the current group of children with developmental disabilities while maintaining specificity of 100%.

CONCLUSIONS

The current study is the first to demonstrate that the CHAT successfully discriminates 2-year-old children with autism from those with other developmental disorders. In addition, the increased sensitivity of the Denver Criteria in children with developmental disabilities may improve its usefulness as a screening tool for community-based early-diagnostic teams and general practitioners.

The behavioral phenotype in fragile X: symptoms of autism in very young children with fragile X syndrome, idiopathic autism, and other developmental disorders

This study was designed to explore the behavioral phenotype of autism in a group of young children with fragile X syndrome (FXS). Twenty-four children with FXS, ages 21 to 48 months, were compared with two well-matched groups: 27 children with autism (AD) and 23 children with other developmental delays (DD), on two standardized autism instruments, as well as on measures of development and adaptive behavior. Two FXS subgroups emerged. One subgroup (n = 16) did not meet study criteria for autism. Their profiles on the autism instruments and the developmental instruments were virtually identical to the other DD group. The other FXS subgroup (n = 8, or 33% of the total FXS group) met study criteria for autism. Their profiles on the autism instruments were virtually identical to the group with autism. The finding of two FXS subgroups raises a hypothesis of additional genetic influences in the FXS autism group, warranting further genetic studies.

Understanding of others' intentions in children with autism

Many studies have shown that children with autism have difficulty understanding the thoughts and beliefs of other people. However, little research has been conducted on what these children understand about simpler mental states such as intentions. The current study tested the understanding of others' intentions in 2 1/2- to 5-year-old children with autism and a control group of children with other developmental delays. We used Meltzoff's (1995) test of understanding of others' unfulfilled intentions in an imitation context, with an additional "End State" condition. We found no significant between-group differences on any measure involving the understanding of others' intentions. Although within-group patterns suggested that children with autism may have a slightly less complex understanding of others' intentions than do other children, it was clear that any deficits these children showed in this area were not as marked as those they typically show on traditional theory of mind tasks.

Predictors of treatment outcome in young children with autism: a retrospective study

This study examined predictors of developmental outcomes in 17 children diagnosed with autism or PDD-NOS, who received generic treatment over a mean period of 37 months. Pre-treatment evaluations occurred at a mean age of 31 months with follow-up evaluations at a mean age of 69 months. Significantly different developmental trajectories were observed among the participants at follow-up, separating the participants into two distinct groups (high and low outcome). However, groups did not differ significantly in treatment intensity or other outcome prediction measures. Pre-treatment developmental intelligence levels between the two groups approached significance. The results raise questions regarding the effect of treatment intensity and type, family stress factors, and intelligence ability in very early childhood on, outcome.

Auditory evoked magnetic fields in adults with fragile X syndrome

Hyper-reactivity and anxiety to sensory stimuli have been described in patients with fragile X syndrome (FXS), and may be related to abnormal processing in afferent sensory pathways. We used magnetoencephalography (MEG) to measure auditory responses to pure tones in 11 adults with FXS and 11 non-FXS subjects. The amplitude for the N100m auditory evoked field component was significantly higher for patients with FXS than for subjects. FXS subjects also had less lateralized N100m anterior-posterior dipole locations. These data may suggest that more neurons are activated by acoustic stimuli in FXS, consistent with subjective experience of increased stimulus intensity. Anomalous cerebral lateralization may suggest an early critical window for effects on neocortical development of the fragile X mental retardation protein (FMRP) produced by the FMR1 gene in individuals with FXS.

Equal care ensures equal survival for African-American women with cervical carcinoma

BACKGROUND

[corrected] It was the purpose of this study to investigate whether race is an independent prognostic factor in the survival of patients with cervical carcinoma in a health care system with minimal racial bias, and few barriers to access to care.

METHODS

Records for patients with a diagnosis of invasive cervical carcinoma from 1988 to 1999 were obtained from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data including race, age at diagnosis, histology, grade, stage, socioeconomic status, treatment modality, and survival also were obtained. Survival analysis was performed with Kaplan-Meier survival curves.

RESULTS

One thousand five hundred fifty-three patients were obtained for review. Sixty-five percent of patients were Caucasian, and 35% were minorities. Of the minorities, 29% were African Americans (AAs). Mean age of diagnosis was similar among AAs and Caucasians, 44 and 42 years, respectively. There was no statistically significant difference between the distribution of age, stage, grade, or histology between Caucasians and AAs. Forty-six percent of patients were treated with surgery and 56% with radiation therapy, with no difference in type of treatment between the Caucasian and AA groups. Five- and 10-year survival rates for Caucasians and AAs were 75%, and 76%, and 64% 65% (P = 0.59), respectively.

CONCLUSIONS

In an equal access, unbiased, nonracial environment, race is not an independent predictor of survival for patients with cervical carcinoma. This study has shown, for the first time to the authors' knowledge, that when they receive equal treatment for cervical carcinoma, AA women's survival can approach that of their nonminority counterparts (75% at 10 years).

Interventions that facilitate socialization in children with autism

Social dysfunction is perhaps the most defining and handicapping feature of autism. Improved social functioning has long been considered one of the most important intervention outcomes. A variety of social interventions have been designed, empirically examined, and published in the autism literature. Children with autism have been found to be responsive to a wide variety of interventions aimed at increasing their social engagement with others, both adults and peers. Successful strategies employing peer-mediated approaches and peer tutoring have involved typically developing peers. Furthermore, several studies have demonstrated that social engagement directly affects other important behaviors like language, even when these behaviors are not specifically targeted by the teaching program. Thus, while an area of severe involvement, social behavior is also responsive to intervention.

Use of CT Hounsfield unit density to identify ablated tumor after laparoscopic radiofrequency ablation of hepatic tumors

BACKGROUND

When attempting to interpret CT scans after radiofrequency thermal ablation (RFA) of liver tumors, it is sometimes difficult to distinguish ablated from viable tumor tissue. Identification of the two types of tissue is specially problematic for lesions that are hypodense before ablation. The aim of this study was to determine whether quantitative Hounsfield unit (HU) density measurements can be used to document the lack of tumor perfusion and thereby identify ablated tissue.

METHODS

Liver spiral CT scans of 13 patients with 51 lesions undergoing laparoscopic RFA for metastatic liver tumors within a 2-year time period were reviewed. HU density of the lesions as well as normal liver were measured pre- and postoperatively in each CT phase (noncontrast, arterial, portovenous). Statistical analyses were performed using Student's paired t-test and ANOVA.

RESULTS

Normal liver parenchyma, which was used as a control, showed a similar increase with contrast injection in both pre- and postprocedure CT scans (56.4 +/- 2.4 vs 57.1 +/- 2.4 HU, respectively; p = 0.3). In contrast, ablated liver lesions showed a preablation increase of 45.7 +/- 3.4 HU but only a minimal postablation increase of 6.6 +/- 0.7 HU (p < 0.0001). This was true for highly vascular tumors (neuroendocrine) as well as hypovascular ones (adenocarcinoma).

CONCLUSIONS

This is the first study to define quantitative radiological criteria using HU density for the evaluation of ablated tissues. A lack of increase in HU density with contrast injection indicates necrotic tissue, whereas perfused tissue shows an increase in HU density. This technique can be used in the evaluation of patients undergoing RFA.

Practice parameter: screening and diagnosis of autism: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society

Autism is a common disorder of childhood, affecting 1 in 500 children. Yet, it often remains unrecognized and undiagnosed until or after late preschool age because appropriate tools for routine developmental screening and screening specifically for autism have not been available. Early identification of children with autism and intensive, early intervention during the toddler and preschool years improves outcome for most young children with autism. This practice parameter reviews the available empirical evidence and gives specific recommendations for the identification of children with autism. This approach requires a dual process: 1) routine developmental surveillance and screening specifically for autism to be performed on all children to first identify those at risk for any type of atypical development, and to identify those specifically at risk for autism; and 2) to diagnose and evaluate autism, to differentiate autism from other developmental disorders.

Latex allergy in adults with spinal cord injury: a pilot investigation

Latex allergy is a well-known complication of repeated exposure to natural rubber latex (NRL) products. The medical literature is replete with studies investigating the prevalence of NRL allergy in myelodysplastic children. However, the prevalence of NRL allergy in adults with spinal cord injury (SCI) has received little attention. Patients with a history of NRL exposure secondary to long-term indwelling urinary catheter usage were recruited as subjects. The presence of NRL allergy was established using the radioallergosorbent assay technique (RAST). Serum from 15 subjects who had been injured an average of 23.8 +/- 11.9 years and who had used an indwelling urinary catheter an average of 17.1 +/- 11.5 years was obtained. RAST for NRL was positive in 7 of the 15 (47%). Of note, serum obtained in a control group of 4 subjects who had been injured an average of 54.4 +/- 3.1 years and had no significant history of long-term indwelling urinary catheter usage were all RAST negative. This study suggests that adults with SCI and significant NRL exposure via long-term indwelling urinary catheter usage may be at risk for the development of NRL allergy.

Midodrine hydrochloride and the treatment of orthostatic hypotension in tetraplegia: two cases and a review of the literature

STUDY DESIGN

A report of two cases of orthostatic hypotension in acute tetraplegia that were resistant to classic treatment interventions.

OBJECTIVE

To discuss the use of midodrine hydrochloride for the treatment of orthostatic hypotension in early tetraplegia.

SETTING

Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, Texas, USA.

METHODS

Presentation of two cases.

RESULTS

Midodrine hydrochloride successfully treated two cases of orthostatic hypotension that had been refractory to classic treatment interventions.

CONCLUSION

Midodrine hydrochloride should be included in the armamentarium of the physician treating orthostatic hypotension in spinal cord injury.

The screening and diagnosis of autistic spectrum disorders

The Child Neurology Society and American Academy of Neurology recently proposed to formulate Practice Parameters for the Diagnosis and Evaluation of Autism for their memberships. This endeavor was expanded to include representatives from nine professional organizations and four parent organizations, with liaisons from the National Institutes of Health. This document was written by this multidisciplinary Consensus Panel after systematic analysis of over 2,500 relevant scientific articles in the literature. The Panel concluded that appropriate diagnosis of autism requires a dual-level approach: (a) routine developmental surveillance, and (b) diagnosis and evaluation of autism. Specific detailed recommendations for each level have been established in this document, which are intended to improve the rate of early suspicion and diagnosis of, and therefore early intervention for, autism.

A comparison of the bactericidal efficacy of 18 disinfectants used in the food industry against Escherichia coli O157:H7 and Pseudomonas aeruginosa at 10 and 20 degrees C

A number of proprietary disinfectant products (18) used in the food industry were tested for their bactericidal efficacy against Pseudomonas aeruginosa and Escherichia coli O157:H7 at 20 and 10 degrees C according to the BS EN 1276 (1997) quantitative suspension test for the evaluation of bactericidal activity of chemical disinfectants and antiseptics used in food, industrial, domestic and institutional areas. At 20 degrees C, 13 products passed at their in-use concentration (under clean and dirty conditions) against Ps. aeruginosa and 15 passed against E. coli O157:H7. The number of products passing the test at 10 degrees C was 11 and 14 for Ps. aeruginosa and E. coli O157:H7, respectively. The products exhibiting reduced efficacy at the lower temperature were amphoterics and quaternary ammonium compounds although some of these types of products were effective at both temperatures. Products that passed against Ps. aeruginosa generally also passed against E. coli O157:H7. Taking all the results together, only 11 of the total of 18 products achieved a pass result under all the parameters tested. This work demonstrates the need for final verification of disinfectant efficacy by undertaking field trials in the food-processing environment in which the product is intended for use.

Local excision of rectal carcinoma

HYPOTHESIS

Selected clinicopathologic characteristics of locally treated rectal cancers are predictive of recurrence.

DESIGN

Case series review with median follow-up of 6 years.

SETTING

University medical center.

PATIENTS

Fifty-eight patients with rectal cancer who underwent local excisions from February 1, 1982, to December 31, 1998.

MAIN OUTCOME MEASURES

Local and distant recurrence rates and overall survival.

RESULTS

Overall local recurrence rate was 14% (8 patients). There were no local recurrences among patients treated with chemotherapy or radiation. Of patients not treated, local recurrence rates were 33%, 5%, 45%, and 25% for T0, T1, T2, and T3 tumors, respectively. No clinicopathologic factor predicted local recurrence. Two patients developed distant recurrence. Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively.

CONCLUSION

In selected patients, outcomes for local excision combined with additional therapy may be equivalent to those for radical resection.

Executive functions in young children with autism

The executive dysfunction hypothesis of autism has received support from most studies of older people with autism; however, studies of young children have produced mixed results. Two studies are presented that compare the performance of preschoolers with autism (mean = 51 months/4.3 years of age) to a control group matched on age, and verbal and nonverbal ability. The first study (n = 18 autism and 17 control) found no group differences in performance on 8 executive function tasks (A not B, Object Retrieval, A not B with Invisible Displacement, 3-Boxes Stationary and Scrambled, 6-Boxes Stationary and Scrambled, and Spatial Reversal), but did find that children with autism initiated fewer joint attention and social interaction behaviors. The second (longitudinal) study of a subset of the children (n = 13 autism and 11 control) from the first study found that neither groups' performance on Spatial Reversal changed significantly over the course of a year. The results of these studies pose a serious challenge to the executive dysfunction hypothesis of autism.

The efficacy of nursing education as an intervention in the treatment of recurrent urinary tract infections in individuals with spinal cord injury

Urinary tract infection (UTI) continues to be the most frequent secondary medical complication experienced by persons with spinal cord injury (SCI). We developed a carepath designed to minimize recurrent UTIs in patients identified as at risk. Data were collected in a prospective fashion for 1,000 consecutive days at an outpatient SCI clinic. The number of UTIs decreased to below threshold in 65 percent of the patients when the nurse clinician counseled them regarding proper technique and hygiene related to clean intermittent catheterization. Of the patients who responded to this intervention, 73 percent required multiple counseling sessions. We conclude that educational intervention by a clinic nurse is a simple, cost-effective means of decreasing the risk of UTIs in individuals with SCI who are identified as at risk.

Primary angiosarcoma of the ovary: a case report and review of the literature

INTRODUCTION

Gynecological sarcomas are rare and have a poor prognosis. Uterine sarcomas are most common accounting for 4% of all uterine tumors. Ovarian sarcomas are less frequent and are usually carcinosarcomas.

CASE REPORT

A previously healthy 40-year-old G2P2 presented for evaluation of 72 h of right upper quadrant pain and shortness of breath. A malignant right pleural effusion, ascites, and adnexal mass were found. Surgical staging and suboptimal debulking revealed pure angiosarcoma of the ovary Stage IV.

DISCUSSION

There are 12 cases of ovarian angiosarcoma reported in the literature. Ten of these cases presented in advanced stages with survivals of 2-30 months. Various chemotherapy regimens have been tried on these tumors including the most recent recommendation of MAID (mesna, doxorubicin, ifosfamide, and dacarbazine) and prognosis remains poor. Our patient underwent elective right pleurodesis via video-assisted thorascopic surgery under local anesthesia for an early recurrent right pleural effusion and subsequently began MAID chemotherapy.

Pilot evaluation of a nurse-administered carepath for successful colonoscopy for persons with spinal cord injury

Due to ongoing improvements in medical care, the life expectancy of persons with spinal cord injury (SCI) continues to improve and approach that of the able-bodied population. As the SCI population ages, cancer would be expected to increase as a cause of death. When a patient presents with occult fecal blood and anemia, colonscopy to the cecum is often pursued. It has been our experience that 80 percent of patients are found to have inadequate bowel preps resulting in suboptimal colonoscopy when the prep is attempted at home. Because of this, we developed a nurse-administered carepath necessitating a 48-hour admission for bowel prep and colonoscopy. The bowel prep consists of magnesium citrate, polyethylene glycol-electrolyte solution, and sodium phosphate/biphosphate enemas. Throughout hospitalization, the patient receives a clear liquid diet. Eighteen patients have been placed on the carepath. At the time of colonoscopy, all 18 were noted to have received an acceptable bowel prep allowing vizualization to the cecum. A description of the carepath and its benefits is presented.

Partner notification with HIV-infected drug users: results of formative research

The authors conducted formative research on the use of partner notification with HIV-infected drug users (i.e. those who use/abuse injectable drugs, crack or cocaine) in order to guide the development of an effective intervention for this population in New York City. Structured focus group and personal interviews were conducted with 25 in- and out-of-treatment drug users, 23 counsellors from a sexually transmitted disease (STD) clinic and a methadone maintenance treatment programme (MMTP), and nine experts in the field of HIV partner notification and/or substance abuse prevention and treatment. Results revealed factors associated with HIV-positive disclosure, the strengths and barriers of existing partner notification programmes and issues that should be considered in designing an effective intervention with HIV-infected drug users. Further research and planning activities are recommended before piloting and evaluating such a programme.

Empirically supported comprehensive treatments for young children with autism

Describes treatment of autism, a severe, chronic developmental disorder that results in significant lifelong disability for most persons, with few persons ever functioning in an independent and typical lifestyle. Within the past decade, a number of studies have reported significant changes in the outcomes of very young children with autism following intensive comprehensive treatment. The criteria for empirically supported treatments, as described by Lonigan, Elbert, and Johnson (this issue), were applied to reports of eight treatment efficacy studies published in peer-reviewed journals. Whereas positive outcomes are reported in every case, the field does not yet have a treatment that meets the present criteria for well-established or probably efficacious treatment. Hypothesized variables affecting outcomes that need to be rigorously tested include age at start of treatment, type of treatment used, intensity of treatment, and IQ and language levels at the start of treatment.

Laparoscopic thermal ablation of hepatic neuroendocrine tumor metastases

BACKGROUND

Neuroendocrine tumor metastases to the liver are generally slow growing, but patients suffer from hormone hypersecretion despite aggressive multimodality therapy. A minimally invasive method of tumor ablation affords symptomatic improvement with minimal morbidity.

METHODS

Radiofrequency electrical energy is delivered to tissues via a 4-prong catheter resulting in tissue heating to 60 to 70 degrees C and cell death. Porcine studies were conducted to define appropriate parameters for energy delivery and then applied to patients using laparoscopic techniques.

RESULTS

In the porcine model 3.5 to 4 cm lesions were reproducibly created in 15 minutes using 30 to 50 W of power. The ablation process was monitored via temperature feedback from thermocouples in the catheter tips and by a hyperechoic blush noted on ultrasonography. Laparoscopic thermal ablation of 13 tumors in six patients with carcinoid (two patients), gastrinoma, insulinoma, nonsecreting islet cell cancer, or medullary thyroid cancer was performed. There were no intraoperative complications, and all patients were discharged the next day. Successful ablation was confirmed by spiral-computed tomography and by symptomatic improvement in patients with secreting tumors.

CONCLUSIONS

Laparoscopic thermal ablation of hepatic tumors is a novel, minimally invasive method of providing effective cytoreduction of neuroendocrine tumors metastatic to the liver.

An ovine model of acute myocardial infarction and chronic left ventricular dysfunction

In order to develop and validate an ovine model of myocardial infarction with subsequent impairement of left ventricular function, 15 instrumented sheep underwent selective microembolization of the left coronary arteries with 0.5 mL 90 microns polystyrene beads. Hemodynamics and plasma hormones were measured preembolization (baseline) and then at hours 2, 4, 6, and 12 and days 1, 2, 3, 5 and 7 postembolization. Of the 15 sheep studied, 2 (13%) died on the day of embolization from arrhythmias. In the remaining sheep, left ventricular systolic pressure and stroke work (both P < 0.001) were reduced promptly and remained below basal levels. Mean arterial pressure (P < 0.001) increased initially, then decreased to below basal levels by hour 6. Heart rate (P < 0.001) and left atrial pressure (P < 0.05) were increased while cardiac output was decreased (P < 0.05). Left ventricular ejection fraction at day 7 was reduced (38.8 +/- 3.5 vs 46.0 +/- 3.9% preembolization; P < 0.05). The cardiac enzymes creatine kinase (P < 0.001) and troponin-T (P < 0.001) were increased following microembolization and returned to basal levels by days 2 and 5 respectively. Plasma atrial and brain natriuretic peptides (both P < 0.001) and plasma renin activity (P < 0.005) were all increased following embolization. This ovine model mimics the hemodynamic and neurohumoral features of acute myocardial infarction, resulting in left ventricular dysfunction, and should prove suitable for the study of interventions in a number of these conditions.

Hypothalamo-pituitary-adrenal axis response to coronary artery embolization: an ovine model of acute myocardial infarction

Although previous studies have described the hypothalamo-pituitary-adrenal (HPA) response to the stress of acute myocardial infarction, it is not possible to study the hormone changes immediately after infarction in humans. Accordingly, we have examined the HPA response to microembolization of coronary arteries in 13 sheep compared with 5 sham control sheep. Plasma vasopressin (AVP; P < 0.001), ACTH (P = 0.005) and cortisol (P = 0.005) were all increased 2 h (first sample time) after embolization. Plasma ACTH and cortisol levels returned to baseline levels by 6 h but plasma AVP levels did not return to baseline levels until more than 12 h after embolization. Plasma corticotrophin-releasing hormone (CRH) showed no significant change in response to embolization. In a subset of six animals which were sampled more frequently, the peak responses for plasma AVP, ACTH and cortisol occurred at 40 min after embolization. The maximum responses in any individual sheep observed at this time point were 744 pmol/l for AVP, 144 pmol/l for ACTH and 492 nmol/l for cortisol. CRH levels tended to increase across the first hour but these changes were not statistically significant. In conclusion, the stress hormone responses to microembolization of the coronary arteries have been defined in an ovine model of myocardial infarction. This model is suitable for studying the effects of novel treatments to reduce the stress of myocardial infarction.

Evaluating HIV prevention community planning

To improve human immunodeficiency virus (HIV) prevention efforts nationwide, the Centers for Disease Control and Prevention (CDC) has funded HIV Prevention Community Planning, an initiative that promotes parity, representativeness, and inclusion of community and the application of scientific principles for decision making. This initiative was welcomed enthusiastically in New York City, an AIDS epicenter with limited prevention resources. In the first year of implementation, the New York City Department of Health (NYCDOH) supported a comprehensive evaluation of the planning initiative. This article reviews the evaluation design, including its process and outcome components, the study findings, and its strengths and limitations. It provides overall guidance for those who are assessing prevention planning in HIV as well as other health areas.

Imitation and pantomime in high-functioning adolescents with autism spectrum disorders

A study was designed to test 2 alternative hypotheses--a symbolic hypothesis and an executive function hypotheses--for the imitation and pantomime deficits found in previous studies of autism. The subjects were 17 adolescent high-functioning subjects with autism spectrum disorders and 15 clinical comparison subjects who were matched on chronological age and verbal IQ. Meaning and sequence were manipulated in facial and manual imitation tasks. Sequence was manipulated in the pantomime and control tasks. Recognition memory and motor control tasks were matched to the experimental tasks. The results provided no support for the symbolic deficit hypothesis; meaning aided rather than hindered the performance of the group with autism. Partial support for the executive deficit hypothesis was found. There were no group differences on motor control tasks, and few on the memory control tasks, arguing against deficits in motor initiation, basic motor coordination, or visual recognition memory.

Intact and impaired memory functions in autism

This study examined memory functions in individuals with autism. Based on previous evidence of executive function (EF) deficits, we hypothesized that subjects with autism would demonstrate a pattern of intact and impaired memory functions similar to that found in other groups with EF deficits, such as patients with frontal lobe pathology. We compared the performance of high-functioning children and adolescents with autism (n = 19) and clinical comparison subjects (n = 19) matched on sex, CA, and VIQ on measures of memory and EF. The group with autism performed significantly worse than comparison subjects on measures of temporal order memory, source memory, supraspan free recall, working memory, and EF, but not on short- and long-term recognition, cued recall, or new learning ability, consistent with the predictions of the EF theory. The cognitive measures were significantly more intercorrelated in the autism group than the comparison group, consistent with a limit in central cognition.

Glycine-induced hyponatremia in the rat: a model of post-prostatectomy syndrome

Post-prostatectomy syndrome (PPS) is characterized by hyponatremia after absorption of glycine irrigant. To study the pathogenesis of this syndrome, adult male rats with ligated ureters were infused over 15 minutes with 7.5 ml/100 g body weight of isosmotic glycine (N = 9) or mannitol (N = 9) and were compared to non-infused, ureter-ligated controls (N = 9). Immediately post-infusion, plasma sodium had decreased similarly in glycine- and mannitol-infused animals (111 +/- 2 vs. 106 +/- 1 mmol/liter), but plasma osmolality remained at control levels in both groups (285 +/- 1 vs. 288 +/- 1 mOsm/kg). Two hours post-infusion, hyponatremia was stable in the mannitol group (108 +/- 1 mmol/liter), but in the glycine group plasma sodium increased significantly (to 120 +/- 1 mmol/liter). Plasma osmolality two hours post-infusion was maintained in both the glycine (287 +/- 2) and mannitol (292 +/- 2) groups. Brain water in glycine-infused animals (3.90 +/- 0.01 liter/kg dry wt) was not significantly different from the mannitol-infused group (3.85 +/- 0.01) and only 1.8% higher than non-infused controls (3.83 +/- 0.02). Brain tissue glycine did not differ between the three groups. In contrast, muscle water two hours post-infusion in the glycine group was 6% higher than mannitol-infused and 13% higher than non-infused animals. Muscle glycine content in the glycine group (67 +/- 4 mM/kg dry tissue) was increased when compared to both mannitol-infused (25 +/- 1) and non-infused (20 +/- 1) groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged paralysis due to nondepolarizing neuromuscular blocking agents and corticosteroids

The long-term use of nondepolarizing neuromuscular blocking agents (ND-NMBA) has recently been implicated as a cause of prolonged muscle weakness, although the site of the lesion and the predisposing factors have been unclear. We report 3 patients (age 37-52 years) with acute respiratory insufficiency who developed prolonged weakness following the discontinuation of ND-NMBAs. Two patients also received intravenous corticosteroids. Renal function was normal but hepatic function was impaired in all patients, and all had acidosis. Electrophysiologic studies revealed low amplitude compound motor action potentials, normal sensory studies, and fibrillations. Repetitive stimulation at 2 Hz showed a decremental response in 2 patients. The serum vecuronium level measured in 1 patient 14 days after the drug had been discontinued was 172 ng/mL. A muscle biopsy in this patient showed loss of thick, myosin filaments. The weakness in these patients is due to pathology at both the neuromuscular junction (most likely due to ND-NMBA) and muscle (most likely due to corticosteroids). Hepatic dysfunction and acidosis are contributing risk factors.

Domains of the Childhood Autism Rating Scale: relevance for diagnosis and treatment

The Childhood Autism Rating Scale (CARS) was factor analyzed. Three factors emerged: Social Impairment (SI), Negative Emotionality (NE), and Distorted Sensory Response (DSR). Unit-weight factor scales showed moderate-to-good internal consistency. Cross-sectional analyses demonstrated that autistic (AUT) subjects were distinguished from subjects with pervasive developmental disorders (PDD) and nonpervasive developmental disorders (NPDD) by higher scores on SI. An SI cutoff score of 26 classified individuals as autistic vs. nonautistic with 78% accuracy. Longitudinal analyses showed that DSR was stable over 6 months of treatment, with little indication of symptom reduction. SI decreased over time across the diagnostic groups, but still showed significant continuity over the period. NE was most malleable and apparently sensitive to the effects of treatment.

Developmental aspects of attachment behavior in young children with pervasive developmental disorders

OBJECTIVE

The present study applied a continuous, clinically based rating system to compare predictions about attachment behavior in autism resulting from three different theoretical views and to characterize differences in attachment behavior of young autistic children.

METHOD

The attachment behaviors of 32 young children with autism or pervasive developmental disorder were examined in a modified "strange situation." Attachment behaviors were rated on a continuous scale and on the Ainsworth subscales. Attachment ratings were compared with several developmental variables, including chronological age, mental age, language level, and social level.

RESULTS

The continuous rating scale distinguished signs of security from signs of insecurity, allowing for behavioral idiosyncracies in the expression of attachment behavior seen in autistic children. The study found that 50% of the children demonstrated some behaviors indicative of secure attachment, that no children were unattached, and that developmental level rather than severity of autism was the strongest predictor of attachment security.

CONCLUSIONS

Autism does not preclude the development of secure attachment relationships in young children, but rather it delays the development of secure attachment and may alter the behavioral patterns that express attachment security.

Can standard measures identify subclinical markers of autism?

This study compared the executive function and theory-of-mind abilities of siblings of autistic individuals to those of siblings of learning-disabled controls. Three different analyses of the dependent measures provided convergent support for a potential subclinical marker in the executive function domain. No group differences in theory-of-mind abilities were found. However, power analyses revealed that the measures employed in this study, which are typically used with autistic individuals, were not sufficiently sensitive to detect any group differences that might exist in "unaffected" family members. Suggestions for future research are provided, including the need to develop more sensitive tasks that produce larger effects and measure more elementary cognitive operations.

Pathophysiology and treatment of acute ischemic stroke

Risk factors, pathogenesis, clinical manifestations, diagnosis, and surgical and pharmacological treatment of ischemic stroke are reviewed. Risk factors play an important part in the pathogenesis of ischemic stroke. Knowledge of the complex metabolic and cellular changes that occur during ischemic stroke is rapidly growing. Choosing the correct treatment is dependent upon obtaining a thorough and accurate clinical assessment of the patient. Diagnostic tests help in determining the size, location, etiology, and characteristics of the lesion. Currently no single agent or mode of therapy appears to be most efficacious. Many drugs are still in the human clinical testing stage; promising agents include thrombolytics, low-molecular-weight heparin, and heparinoids. Hemodilution, pentoxifylline, epoprostenol, nimodipine, naloxone, and GM1 therapy have had mixed results in clinical trials, partly because some of these agents were not tested in enough patients to provide an accurate assessment of their efficacy. Atenolol and propranolol are ineffective. Ticlopidine and aspirin decrease the incidence of subsequent stroke but have not been tested in acute ischemic stroke. Heparin may be effective in preventing further cardioembolic stroke or in treating stroke in progress. Nondrug therapies include carotid endarterectomy and surgical decompression for cerebellar stroke. No single agent can be recommended for treatment of ischemic stroke at this time. Promising regimens include ancrod, low-molecular-weight heparin and heparinoids, or thrombolytics.

Executive function and social communication deficits in young autistic children

Preschool-aged, autistic children were compared with both developmentally delayed children of similar non-verbal mental age and normally developing children of similar verbal skill on measures of executive function and social communication skills. Autistic children exhibited significantly more perseverative responses on a test of executive function when compared to both comparison groups. Autistic children also exhibited significantly fewer joint attention and social interaction behaviors. Moreover, a significant relationship was found between executive function skill and the two social communication skills, which was independent of group membership or verbal ability. Competing hypotheses to account for the relationship between executive function deficits and social communication deficits in autism are discussed.