Vaginal laxity: which measure of levator ani distensibility is most predictive?

OBJECTIVE

To assess the predictive value of measures of levator hiatal distension at rest and on maximum Valsalva maneuver for symptoms of vaginal laxity.

METHODS

This was a retrospective study of women seen at a tertiary urogynecological unit. All women underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound examination. Area, anteroposterior diameter (APD) and coronal diameter (CD) of the levator hiatus were measured at rest and on maximum Valsalva maneuver in the plane of minimal hiatal dimensions using the rendered volume technique, by an operator blinded to all clinical data. The association between levator hiatal measurements and vaginal laxity was assessed, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive value.

RESULTS

Data from 490 patients were analyzed. Mean age was 58 (range, 18-88) years, and vaginal laxity was reported by 111 (23%) women. Measurements obtained on maximum Valsalva were significantly larger in women who reported vaginal laxity than in those who did not, with mean levator hiatal area, APD and CD of 30.45 ± 8.74 cm² , 7.24 ± 1.16 cm and 5.60 ± 0.89 cm, respectively, in the vaginal-laxity group, compared with 24.84 ± 8.63 cm² , 6.64 ± 1.22 cm and 5.01 ± 0.97 cm in the no-laxity group (P < 0.001 for all). Measurements obtained at rest were not significantly different between the groups. Multiple logistic regression analysis controlling for age, body mass index, vaginal parity and levator avulsion confirmed these results. The best regression model for the prediction of vaginal laxity included age, vaginal parity and levator hiatal area on maximum Valsalva. ROC-curve analysis of levator hiatal measurements on maximum Valsalva in the prediction of vaginal laxity demonstrated areas under the curve of 0.68 (95% CI, 0.63-0.73) for area, 0.63 (95% CI, 0.57-0.68) for APD and 0.68 (95% CI, 0.62-0.73) for CD.

CONCLUSIONS

Levator hiatal area on maximum Valsalva seems to be the measure of levator ani distensibility that is most predictive of symptoms of vaginal laxity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Is levator trauma an independent risk factor for anal incontinence?

AIM

To determine the role of levator ani trauma in anal incontinence (AI), whilst controlling for anal sphincter injury.

METHODS

The records of 1273 patients who had attended a tertiary urogynaecology unit between 1st of January to 31st December 2016 were reviewed. AI was assessed using St Mark's score and visual analogue scale (VAS). Levator muscle and anal sphincter trauma were examined by translabial ultrasound using tomographic imaging, with archived data sets investigated blinded against all clinical data. A complete avulsion was diagnosed if at least three central tomographic slices showed an abnormal muscle insertion, rated separately for each side. A significant anal sphincter defect was diagnosed if at least four out of six slices showed a defect of ≥ 30°.

RESULTS

Avulsion was associated with St Mark's score (P = 0.005) and VAS bother of AI (P = 0.022) both on univariate analysis and when controlling for external anal sphincter (EAS) trauma on translabial imaging, forceps, body mass index (BMI) and age (P = 0.011 and P = 0.04, respectively). AI expressed as a binary variable was significantly associated with avulsion on univariate analysis (P = 0.011), although the association became nonsignificant after controlling for anal sphincter trauma, age, BMI and forceps delivery (P = 0.084).

CONCLUSION

In this retrospective observational study, we found a weak association between levator ani avulsion and measures of AI, which largely remained significant when controlling for anal sphincter trauma. However, given the large data set, any clinical effect of levator trauma on AI is likely to be minor.

Does levator ani hiatal area configuration affect pelvic organ prolapse?

OBJECTIVE

Levator ani trauma and hiatal overdistension have been shown to be associated with female pelvic organ prolapse (POP); however, the role of the shape of the levator hiatus in POP has not been examined to date. The aim of this study was to investigate the association between the configuration of the levator ani hiatus and POP.

METHODS

This was a retrospective study of 547 women who attended a tertiary urogynecological center for symptoms of pelvic floor and lower urinary tract dysfunction between October 2014 and August 2016. All women underwent a standardized interview and prolapse assessment using the International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) method and four-dimensional translabial ultrasound (TLUS). Measurements of the hiatal anteroposterior diameter (APD), coronal diameter (CD) and hiatal area (HA), at rest and on maximal Valsalva maneuver, and those of organ descent were performed offline at a later date by an investigator blinded to all other data. Hiatal configuration was defined as the ratio APD/CD. Associations between HA and HA adjusted by APD/CD at rest and on maximal Valsalva and symptoms and signs of prolapse were analyzed statistically using logistic regression modelling.

RESULTS

The mean age of the women was 54 ± 13.6 (range, 16-89) years. Of the 547 women included, 241 (44%) presented with prolapse symptoms. Clinically significant POP was detected in 406 (74%) patients and significant prolapse on TLUS was detected in 331 (61%). Hiatal ballooning was observed in 310 (57%) women and this was strongly associated with signs and symptoms of POP. HA at rest and on Valsalva was associated with significant POP both on clinical examination and on TLUS. Adjusted odds ratios for hiatal shape showed no effect of the hiatal configuration on the association between HA and POP.

CONCLUSION

Hiatal shape does not seem to influence the association between HA and symptoms and signs of prolapse. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

How repeatable is assessment of external anal sphincter trauma by exoanal 4D ultrasound?

OBJECTIVE

Three-/four-dimensional translabial ultrasound (TLUS) is gaining popularity for the assessment of anal sphincter trauma, although repeatability data are lacking. This study aimed to determine the repeatability of tomographic ultrasound imaging (TUI) on TLUS for the diagnosis of external anal sphincter (EAS) trauma and compare the performance of a novice with that of an experienced investigator.

METHODS

This was a retrospective study of archived ultrasound datasets of patients who presented with symptoms of pelvic floor dysfunction and were examined twice between 2012 and 2016 at an average interval of 260 (range, 1-1100) days. All volumes were obtained using a GE Medical Systems Voluson 730 Expert or E8 ultrasound system. Post-processing of volumes was performed independently by two investigators, one with over 1 year's experience and another with no prior experience in using TUI, who were blinded to clinical data, each other's results and the results obtained at the first timepoint. Significant trauma on EAS was diagnosed if four of the six TUI slices showed a defect of ≥ 30°. Intra- and interobserver agreement were determined using Cohen's kappa (κ) and intraclass correlation coefficients.

RESULTS

During the study period, 105 women underwent two TLUS assessments of the anal sphincter. Of these, 103 patients with ultrasound volumes available for both timepoints were included in the analysis. The novice investigator demonstrated average repeatability for assessment of significant EAS trauma and single-slice defect (κ, 0.30 and 0.22, respectively) despite relatively high agreement between measurements obtained at the two timepoints (84.5% and 79.3%, respectively). The experienced investigator demonstrated good to very good repeatability for significant EAS trauma and single-slice defect (κ, 0.91 and 0.78, respectively) between the two assessments, which equates to 98.1% and 94.7% agreement, respectively.

CONCLUSION

The repeatability of TLUS measurements for diagnosis of EAS trauma seems to be very good when imaging is undertaken with state-of-the-art equipment and the analysis is performed by an experienced observer; however, the performance of a novice investigator is much poorer. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Long term subjective cure rate, urinary tract symptoms and dyspareunia following mesh augmented anterior vaginal wall prolapse repair

INTRODUCTION

The aim of this study was to assess patient-centered long term outcomes following anterior vaginal repair with mesh.

METHODS

In January 2015, we identified 124 women who underwent anterior pelvic floor repair with mesh between January 2006 and February 2009. Patient records were reviewed and demographic, clinical, intra-operative and post-operative follow-up data retrieved. Telephone interviews were conducted to access information on clinical outcomes. Associations between baseline characteristics and long term symptoms were assessed by multivariable logistic regression models.

RESULTS

Seventy-nine women were reached and consented to participate. Patients were interviewed 79-104 months after surgery. Their mean age at the time of surgery was 62.48 ± 9.53 years; all had stage III cystocele with a mean POP Q point Ba of 5.32 ± 1.47. Twenty-four (30%) had a previous hysterectomy and 26 (33%) had a previous pelvic organ prolapse or stress urinary incontinence operation. At telephone interviews, recurrence of prolapse symptoms was reported by 11 (13.9%) patients, mostly in the posterior compartment. Only 6 needed a corrective procedure. One patient had her mesh removed due to dyspareunia. Eleven (13.9%) reported lower urinary tract symptoms other than prolapse, as follows: stress urinary incontinence (1), overactive bladder (8) and dyspareunia (2).

CONCLUSION

Long term rates of recurrent prolapse, dyspareunia and lower urinary tract symptoms were low for patients who underwent anterior vaginal wall mesh augmentation surgery for symptomatic cystoceles.

A diagnostic system using broad categories with clinically relevant specifiers: lessons for ICD-11

A diagnostic system for ICD-11 is proposed which commences with broad reorganization and simplification of the current categories and the use of clinically relevant specifiers. Such changes have implications for the positioning of diagnostic groups and lead to a range of possibilities for improving terminology and the juxtaposition of individual conditions. The development of ICD-11 provides the fi rst opportunity in almost two decades to improve the validity and reliability of the international classification system. Widespread change in broad categories and criteria cannot be justified by research that has emerged since the last revision. It would also be disruptive to clinical practice and might devalue past research work. However, the case for reorganization of the categories is stronger and has recently been made by an eminent international group of researchers (Andrews et al., 2009). A simpler, interlinked diagnostic system is proposed here which is likely to have fewer categories than its predecessor. There are major advantages of such a system for clinical practice and research and it could also produce much needed simplification for primary care (Gask et al., 2008) and the developing world (Wig, 1990; Kohn et al., 2004).

A study of self-harm in older people: mental disorder, social factors and motives

Data was collected on seventy-six older people who presented to a specialist self-harm team. Data included: diagnosis, suicide intent, motives for self-harm, social contacts and life events and difficulties. The majority of elderly who harmed themselves had high suicide intent and 69% were depressed. Patients were frequently living alone with an isolated life-style and poor physical health. Depressed self-harm subjects had higher suicide intent scores than non-depressed and to gain relief from an unbearable state of mind was a frequently recorded motive for these patients. Other motives for self-harm appear to be similar between depressed and non-depressed self-harmers. It is important that older people who self-harm receive an appropriate assessment of both risk and need by an experienced mental-health professional skilled at recognising depression in later life. The need for adequate recognition and management of depression in older people in primary care is also highlighted.

Drunken patients in the general hospital: their care and management

In Britain alcohol consumption is increasing, 1 in 4 men and 1 in 10 women drink hazardously, 1 in 3 young men, and 1 in 4 young women regularly binge drink. Mortality rates attributable to alcohol have doubled; with 1 in 5 male inpatients having an alcohol related problem. The increasing problem of managing drunken behaviour in accident and emergency departments is discussed. Although an alcohol history is recommended for all admissions, because of various reasons, hazardous drinkers continue to miss the opportunity of effective interventions. In addition to the more formal treatments for alcohol problems, there is a wealth of evidence reporting the effectiveness of brief interventions carried out by a range of health professionals can lead to long term reductions in alcohol consumption. This review discusses practical and legal issues of the assessment, screening tools, and management of intoxicated patients.

Burns and diabetes

Diabetes is often considered a risk factor for poor wound healing and increased complication rates for plastic surgery procedures. Burn injury in diabetic patients may have implications for the length of stay and number of operations required. We therefore we examined the characteristics of diabetic patients admitted to our burn unit and the impact of their condition on their hospital course. Charts of all patients with diabetes admitted to the burn unit from 1995 to 2000 were reviewed (n = 73). Demographic data, percent body surface area burned, anatomical location of the burn, number of surgical procedures required, length and cost of stay, and outcome were noted. The control population included 150 consecutive patients without diabetes treated during the same period. Diabetic patients were older and underwent a higher number of surgical procedures, with increased length of stay and increased mortality, despite an equivalent body surface area burned. They had a higher incidence of scald burns in the lower extremities than the non-diabetic population. This work shows that diabetic patients constitute a unique group. They are significantly older, have an increased rate of surgical interventions, increased hospital stay, and significantly increased mortality compared to a control group with similar surface area burns. This group is also more likely to have scald burns in the lower extremities, mostly due to diabetic neuropathy. This work emphasizes the importance of education and prevention programmes directed towards this group of patients, in order to decrease morbidity, mortality, and hospital costs.

Depression in palliative care patients--a prospective study

Psychological and psychiatric morbidity can be a major source of distress to terminally ill patients and their relatives and friends. A prospective study was carried out to determine the prevalence of undiagnosed depression in palliative care patients and to determine whether factors such as age, previous psychiatric history and perceived social support have any association with the development of depression when patients have advanced metastatic cancer. Patients aged between 18 and 70 years who had a prognosis of < or = 6 months and who were receiving palliative care only for advanced metastatic cancer were interviewed using the Present State examination interview and a semi-structured interview to determine social support, information needs and past psychiatric history. One hundred patients were recruited and the prevalence of depression according to International Classification of Diseases 10 criteria was 22%. Perceived informal social support and past psychiatric history were not associated with being a case of depression but perceived information needs had a weak association. Younger patients and patients with breast cancer were more likely to be identified as being cases of depression. Further research is necessary to explore the aetiology and outcome of depression in palliative care. A high index of suspicion for depression should be maintained for younger patients with advanced metastatic cancer.

An analysis of the validity of the Hospital Anxiety and Depression scale as a screening tool in patients with advanced metastatic cancer

Depression is difficult to diagnose in the terminally ill patient. As a result, it frequently is not treated. This has can have an adverse effect on quality of life and make the palliation of physical symptoms more difficult. In an effort to improve the detection of depression, many palliative care teams are using the Hospital Anxiety and Depression (HAD) scale as a screening tool. The HAD was devised for use in general medical settings and has not been validated for use in palliative care patients. One hundred patients receiving palliative care with an estimated prognosis of 6 months or less were invited to complete the HAD and a semi-structured psychiatric interview, the Present State Examination. The depression and anxiety subscales of the HAD showed poor efficacy for screening when used alone. The optimum threshold was at a combined cut-off of 19, which had a sensitivity of 68% and specificity of 67%. The major construct of the HAD is anhedonia, which may be present at the end of life due to increasing physical illness and may not be pathognomic of a depressive illness in this population. We recommend, therefore, that if the HAD is used as a screening tool in palliative care, it should be as a combined scale, but low sensitivity and specificity may lead to poor efficacy as a screening tool.

Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors

BACKGROUND

Social support theory and observational risk factor studies suggest that increased antenatal psychosocial support could prevent post-natal depression. We used empirical knowledge of risk and protective factors for post-natal depression not employed previously in order to develop and evaluate an antenatal preventive intervention.

METHODS

We conducted a pragmatic randomized controlled trial in antenatal clinics. We screened 1300 primiparous women and 400 screened positive, 69 screen-positive women were untraceable or not eligible. Of 292 women who completed baseline assessment, 209 consented to randomization, of these 190 provided outcome data 3 months post-natally. 'Preparing for Parenthood', a structured antenatal risk factor reducing intervention designed to increase social support and problem-solving skills, was compared with routine antenatal care only. We compared the percentage depressed at 3 months after childbirth using the self-completion General Health Questionnaire Depression scale and Edinburgh Post-natal Depression Scale (EPDS), and the Schedules for Clinical Assessment in Neuropsychiatry a systematic clinical interview.

RESULTS

Assignment to the intervention group did not significantly impact on post-natal depression (odds ratio for GHQ-Depression 1.22 (95% CI 0.63-2.39), P = 0.55) or on risk factors for depression. Forty-five per cent of the intervention group women attended sufficient sessions to be likely to benefit from intervention if effective. Attenders benefited no more than non-attenders.

CONCLUSIONS

Prevention services targeting post-natal depression should not implement antenatal support programmes on these lines until further research has demonstrated the feasibility and effectiveness of such methods. The development of novel, low cost interventions effective in reducing risk factors should be completed before further trial evaluation.

Criterion validation of the Edinburgh postnatal depression scale as a screening tool for depression in patients with advanced metastatic cancer

It is estimated that 25% of palliative care patients will have identifiable symptoms of depression. Near the end of life, the distinction between what can be called "appropriate sadness" and depression may be difficult. Many palliative care units use rating scales to help identify patients who may be depressed. It is believed that symptoms such as guilt, worthlessness, and hopelessness may be more discriminating than other symptoms for depression within this population. The Edinburgh postnatal depression scale (EPDS) was devised for use in women in the postnatal period and does not contain any somatic-type symptoms. It consists of 10 items, each rated on a four-point scale, and includes items on guilt, thoughts of self-harm, and hopelessness. It has not previously been used for screening in cancer patients. In a study of 100 inpatients receiving palliative care, a cutoff of 13 on the EPDS had a sensitivity of 81% and a specificity of 79% for detecting cases of depression. There was a low rate of misclassifications. This study suggests that the EPDS may be useful as a screening instrument for palliative care patients.

Early screening for amblyogenic risk factors lowers the prevalence and severity of amblyopia

PURPOSE

To evaluate the efficacy of a mass screening program for amblyopia and amblyogenic risk factors in infants.

METHODS

Since 1968, children between the ages of 1 and 2(1/2) years in the city of Haifa, Israel, have been systematically screened for amblyopia and amblyogenic risk factors. The screening is performed by the Ophthalmology Department of Bnai-Zion Medical Center (formerly known as Rothchild Hospital). In 1995, we compared the prevalence and severity of amblyopia in two populations of 8-year-old children in elementary school: one group was a cohort of 808 children from the city of Haifa and its vicinity, who had been screened in infancy (between 1988 and 1990); and the second group, the control group, was a cohort of 782 children from Hadera and its vicinity, where this early screening program is not conducted. Amblyopia was defined as corrected visual acuity of < or =5/10 (20/40), or >1 line difference in corrected visual acuity between the two eyes. Referral rate, treatment rate, sensitivity, specificity, and positive predictive value and negative predictive value of the screening test in detecting factors that later resulted in the development of amblyopia were examined.

RESULTS

The prevalence of amblyopia in the 8-year-old population screened in infancy was found to be 1.0% compared with 2.6% in the 8-year-old population that had not been screened in infancy (P =.0098). The prevalence of amblyopia with visual acuity of < or =5/15 (20/60) in the amblyopic eye was 0.1% in the screened population compared with 1.7% in the non-screened population (P =.00026). In the screened infant population, 3.6% were referred from the screening examination to a confirmatory examination and 2.2% were treated. The screening examination had a sensitivity of 85.7% and a specificity of 98.6% for amblyopia. The positive predictive value of the screening examination was 62.1% and the negative predictive value was 99.6%.

CONCLUSIONS

The screening program for amblyopia and amblyogenic risk factors in infants, followed by appropriate treatment, is effective in significantly reducing the prevalence and severity of amblyopia in children.

Modifier genes of hereditary hearing loss

Phenotypic variation between individuals with the same disease alleles may be attributable to the genotype at another locus, which is referred to as a modifier gene. Recent functional studies of modifier genes of hearing-loss loci have begun to refine our understanding of hearing processes and will guide the rational design of medical therapies for hearing loss.

p53 and WAF1 polymorphisms in Jewish-Israeli women with epithelial ovarian cancer and its association with BRCA mutations

OBJECTIVE

To investigate whether polymorphic p53 and WAF1 alleles are associated with clinical, demographic and histopathological features and BRCA mutation in women with ovarian cancer.

DESIGN

A cross-sectional study.

POPULATION

Two hundred and twenty-one nonselected Israeli women with epithelial ovarian cancer.

METHODS

DNA was analysed for known polymorphisms in intron 3 (a 16 nucleotide single repeat) and intron 6 (a G to A change at nucleotide 13,494) of the p53 gene, the S31R polymorphism in the WAF1 gene, and for three predominant Jewish mutations in the BRCA genes (185delAG and 5382insC in BRCA1, and 6174delT in BRCA2).

MAIN OUTCOME MEASURE

The rate of polymorphic p53 and WAF1 alleles and their association with BRCA mutation, ethnic origin, age and stage at diagnosis, and family history of cancer.

RESULTS

Of the tested women, 72 (32.6%) were either BRCA1 (n = 57) or BRCA2 (n = 15) mutation carriers. Sixty-eight of 213 (31.9%) were heterozygous for intron 3 polymorphism, 67/193 (34.7%) for intron 6 polymorphism, and 22/154 (14.3%) for S31R of the WAF1 gene. The p53 and WAF1 polymorphism rate did not differ between BRCA mutation carriers and noncarriers. No significant association between specific p53 or WAF1 genotypes, and clinical, histopathological or demographic variables was observed.

CONCLUSION

In Jewish-Israeli women with sporadic and familial ovarian cancer, p53 or WAF1 polymorphisms do not seem to affect the phenotype.

A critical role for human CD4+ T-cells in rejection of porcine islet cell xenografts

T-cell-mediated rejection is likely to present a significant barrier to porcine islet xenotransplantation. Little is known, however, about human anti-porcine islet rejection because no suitable model exists to study this process. To address this problem, we have developed an immunodeficient mouse model to study rejection of fetal porcine islet cell clusters (ICCs) by human lymphocytes. Transplantation of porcine ICCs into hyperglycemic recombinase activating gene-deficient (R-) mice restores normal blood glucose levels within 5 weeks. Adoptive transfer of in vitro-stimulated human peripheral blood mononuclear cells into R- mice before islet cell transplantation leads to acute cellular rejection of porcine ICCs. The first human cells observed to infiltrate rejecting grafts are CD4+ T-cells. Although CD8+ T-cells are observed within the grafts at later time points, CD4+ T-cells predominate until the graft is destroyed. Adoptive transfer of purified human CD4+ T-cells before ICC transplantation is sufficient to cause acute cellular rejection. These data demonstrate that human CD4+ T-cells play a critical role in porcine ICC xenograft rejection.

General hospital services for deliberate self-poisoning: an expensive road to nowhere?

This study was designed to investigate the clinical and economic aspects of deliberate self-poisoning services in four teaching hospitals in Leeds, Leicester, Manchester and Nottingham. We investigated the management of the current self-harm episode, including direct in-hospital costs, in 456 individuals who presented to hospital on a total of 477 occasions with deliberate self-poisoning during a 4-week period in 1996. Fewer than half of the patients received specialist psychosocial assessment or follow-up. Patients were more likely to receive an assessment if they were already in contact with psychiatric services, had a history of previous overdoses, if they presented during working hours, or if they lived near the hospital. Patients who were admitted were nearly twice as likely to receive specialist assessment, and those who received a specialist assessment were nearly three times as likely to be offered follow-up. In-patient days and days on the intensive care unit accounted for 47% and 8% of the total costs, respectively. This study suggests that general hospital services are disorganised, with evidence of inequitable access to specialist assessment and after-care. This state of affairs cannot be justified on financial or clinical grounds.

Costs of antidepressant overdose: a preliminary study

There is ongoing debate regarding the relative cost effectiveness of different classes of antidepressants. Although factors such as tolerability and discontinuation rates have been taken into account, there has been little consideration of the cost of overdose. In the current study we examined the cost of antidepressant overdose at four teaching hospitals over a four-week period and found that the cost of selective serotonin reuptake inhibitor overdose was less than half that of tricyclic anti-depressant overdose. The cost of overdose is often ignored and should be considered in future analyses of the cost effectiveness of different antidepressant prescribing policies in primary care.

A survey of antidepressant prescribing in the terminally ill

Depression is a symptom in a quarter of patients admitted to a palliative care unit, but little is known of how depression in terminally ill patients is treated. We reviewed 1046 consecutive patient admissions, of whom 106 (10%) were prescribed antidepressant medication while under the care of a palliative care team. Of these patients, 21 were prescribed antidepressants when under the care of the home care team, but 80 patients (76%) were started on medication during the final 2 weeks of life. There was consequently insufficient time for the medication to have any therapeutic effect. Seventeen patients were discharged home on antidepressant medication. Three patients were referred for a psychiatric assessment. Patients prescribed antidepressants were significantly younger (P = 0.002) than those who were not. There were no prescriptions for psychostimulants. Although the numbers of patients prescribed antidepressant medication were low in all disease groups, it was notable that patients with breast cancer were prescribed antidepressant medication more frequently than any other patient group. We conclude that there appears to be a need for a coordinated approach to both the assessment and the treatment of depression in terminally ill patients.

Human CD4+ T cells mediate rejection of porcine xenografts

It has previously been demonstrated that xenograft rejection in rodents is dependent on CD4+ T cells. However, because of the lack of an appropriate in vivo model, little is known about the cellular basis of human T cell-mediated rejection of xenografts. In this study, we have evaluated the ability of human T cells to mediate rejection of porcine skin grafts in a novel in vivo experimental system using immunodeficient mice as recipients. Recombinase-activating gene-1-deficient mice (R-) lacking mature B and T cells were grafted with porcine skin and received human lymphocytes stimulated in vitro with irradiated porcine PBMC. Skin grafts on mice given either unseparated, activated human lymphocytes, or NK cell-depleted lymphocyte populations were rejected within 18 days after adoptive cell transfer. In contrast, skin grafts on mice given T cell-depleted human lymphocytes or saline showed no gross or histologic evidence of rejection up to 100 days after adoptive transfer. Purified CD4+ T cells were also able to mediate rejection of porcine skin grafts. These data suggest that human CD4+ T cells are sufficient to induce rejection of porcine xenografts. Thus, strategies directed toward CD4+ T cells may effectively prevent cellular rejection of porcine xenografts in humans.

Xenotransplantation--state of the art--update 1999

Organ transplantation is limited by the number of cadaveric human donor organs that become available. Xenotransplantation - the transplantation of organs and tissues between animal species - would supply an unlimited number of organs and offer many other advantages. The pig has been identified as the most suitable donor animal. Pig organs, when transplanted into humans or nonhuman primates, are, however, rejected hyperacutely within minutes by antibody-mediated complement activation. Human anti-pig antibodies have been identified as being directed against galactose alpha 1-3galactose (alpha Gal) epitopes on pig vascular endothelium. Methods have been successfully developed to prevent hyperacute rejection. These include (i) depletion or inhibition of recipient antibodies or complement and (ii) development of transgenic pigs that express a human complement-regulatory protein (e.g. hDAF). The persistence or return of anti-pig antibody, however, even following the use of hDAF pig organs, eventually leads to what has been variously termed "acute vascular rejection" or "delayed xenograft rejection", which is again believed to be largely antibody-dependent. Nevertheless, experimental pig-to-primate organ xenotransplantation now results in transplant function for days and weeks rather than minutes. Little is yet known of the nature of the acute cellular rejection response that is anticipated to follow, and of any subsequent chronic rejection that may develop. Tolerance to both the alpha Gal epitope and to swine leukocyte antigens (SLA) is being explored using gene therapy techniques and by the induction of hematopoietic cell chimerism. The development of genetically engineered pigs that do not express the alpha Gal epitope is also being pursued. Considerable progress has been made in recent years, but experimental results do not yet warrant the initiation of a clinical trial of organ xenotransplantation. However, trials are already underway of pig cell transplants in patients with diabetes and neurodegenerative conditions, such as Parkinson's disease.

Gene therapy for pediatric brain tumors

There have been impressive surgical, radiotherapeutic, and chemotherapeutic advances in treating cancer. However, the outlook for patients with malignant brain tumors is still dismal. Gene therapy offers hope of replacing defective genes, amplifying the immune response to cancer, and sensitizing tumor cells to systemic therapies (suicide gene therapy). The insertion of the thymidine kinase gene from herpes virus (HSV-TK) into glioma cells can sensitize them to intravenous ganciclovir. Pivotal to the HSV-TK strategy is the "bystander effect," which results in a larger number of tumor cells being killed than those that have been genetically altered. The presence of gap junctions between tumor cells and immunocompetence are required experimentally to observe the "bystander effect." At present, clinical trials using suicide gene therapy in newly diagnosed and recurrent gliomas are underway. Suicide gene therapy faces many challenges in neuro-oncology until p53 gene replacement and immunomodulatory strategies become feasible.

Use of alternative therapies for children with cancer

OBJECTIVE

To compare the use of alternative therapy (AT) in families of children with cancer with its use in those with routine pediatric conditions.

BACKGROUND AND RATIONALE

AT refers to healing practices such as therapeutic massage, acupuncture, and use of medicinal herbs that have become increasingly popular with the general public, but are not widely accepted by the medical profession. Although studies have investigated the use of AT in the families of both healthy children and children with cancer, no comparison of the incidence of its use between these two populations has been published. We hypothesized that AT was used more frequently among the families of children with cancer.

METHODS

Using a prevalence survey design, we interviewed 81 parents of children with cancer attending a pediatric hematology/oncology clinic and 80 parents of children attending a continuity care clinic for routine check-ups and acute care. We explored the types of AT being used, the reasons for its use, and the frequency with which it was discussed with the patient's physician.

RESULTS

1) Overall, 65% of the cancer group were using AT, compared with 51% of the control group. This was not statistically significant. 2) Prayer, exercise, and spiritual healing were three AT practices most often used by the cancer group, and prayer, massage, and spiritual healing by the control group. 3) Discussion of AT with the physician varied according to group, with 53% of the cancer patients discussing its use; income level, with 59% of parents in the higher income group discussing its use; and ethnicity, with 47% of whites discussing its use.

CONCLUSION

Use of AT is not limited to the families of children with life-challenging illnesses, but is commonly used by those of children with routine pediatric problems. Pediatricians need to be aware that their patients may not tell them about AT practices they are using in addition to prescribed treatment.

An examination of the accident and emergency management of deliberate self harm

OBJECTIVE

To examine the adequacy of assessment and management of deliberate self harm (DSH) undertaken by accident and emergency (A&E) medical staff.

METHODS

The records for attendances to the Leicester Royal Infirmary A&E department with a diagnosis of "self inflicted" injury for the 12 month period April 1994 to March 1995 were scrutinised. If the episode was identified as DSH, then assessment and management were examined, using an instrument based on the Royal College of Psychiatrists' standards of service for the general hospital management of adult DSH.

RESULTS

There were 934 episodes of DSH involving 854 patients. The mean age was 32 (SD 14.2), with an even sex distribution. Overdose was by far the most common method of DSH (91.5%). Information concerning suicide intent was documented in 70% of cases, and psychiatric history in 67%. Less information was recorded for medical history (50%), mental state (51%), recent stress (55%), or previous DSH (47%), and only 23% had an assessment of risk of further DSH. Very little was recorded concerning alcohol or substance misuse. In 291 cases (31%), the patient was discharged directly home by A&E medical staff, and 50 of these were referred for psychiatric outpatient follow up; 210 (23%) were referred for specialist assessment in the department and 423 (45.5%) were admitted to medical/surgical wards. The frequency with which information was recorded varied significantly between outcome groups. At night A&E staff were far more likely to discharge a patient home themselves than refer for specialist assessment (P << 0.001).

CONCLUSIONS

With over half the sample not admitted, the responsibility for the initial risk assessment lies with A&E medical staff. The study reveals a need for improved planning and delivery of services.

Sensitization of rhabdo-, lenti-, and spumaviruses to human serum by galactosyl(alpha1-3)galactosylation

Vesicular stomatitis virus, human immunodeficiency virus type 2, and human foamy virus, which were produced by cell lines expressing galactosyl(alpha1-3)galactosyl (alphaGal) sugars, were found to be less stable in human serum than those from alphaGal-negative cells, indicating that galactosyl(alpha1-3)galactosylation sensitizes these viruses as well as mammalian type C oncoviruses (Rother et al., J. Exp. Med. 182:1345-1355, 1995; Takeuchi et al., Nature (London) 379:85-88, 1996) to complement killing via natural anti-alphaGal antibodies. Thus, virus killing mediated by anti-alphaGal antibodies may play a role as a barrier to animal-to-human infection of various enveloped viruses. Virus vectors for human in vivo gene therapy based on the viruses mentioned above should be produced from alphaGal-negative cells.