Principal diagnostic features of paediatric foreign body aspiration

OBJECTIVES

The aim of this study is to identify the most common and important features within the presenting history, clinical examination and chest radiograph that are associated with foreign body (FB) aspiration in the paediatric population, to support rationalised decision making in regards to proceeding with diagnostic bronchoscopy.

METHODS

A retrospective notes review was conducted of 70 patients over a 12-year period at our tertiary referral centre. Their presenting history, clinical and radiographic signs were documented and univariate logistic regression model used to calculate odds ratios.

RESULTS

The main features identified within our cohort with a positive FB finding at bronchoscopy were history of a cough (OR 5.1, p = 0.008) and radiographic evidence of hyperinflation or air trapping (OR 7.1, p = 0.016). Zero patients with a FB presented with only a positive history in the absence of other clinical or radiological signs. History of a witnessed choking episode neither increased or decreased the likelihood of as aspirated FB (OR 1, p = 0.967).

CONCLUSIONS

We have identified two principal features, as described above, which are associated with paediatric FB aspiration. Reliance on a positive clinical history alone, but specifically the history of a witnessed choking episode, did not support the presence of a FB and other associated signs need to be considered in deciding to proceed to bronchoscopy.

The impact of primary ciliary dyskinesia on female and male fertility: a narrative review

BACKGROUND

Primary ciliary dyskinesia (PCD) is a genetic condition affecting the structure and function of sperm flagellum and motile cilia including those in the male and female reproductive tracts. Infertility is a commonly reported feature of PCD, but there is uncertainty as to how best to counsel patients on their fertility prognosis.

OBJECTIVE AND RATIONALE

This review aimed to summarize the prevalence of subfertility, possible underlying mechanisms, and the success of ART in men and women with PCD. The efficacy of ART in this patient group is relatively unknown and, hence, the management of infertility in PCD patients remains a challenge. There are no previous published or registered systematic reviews of fertility outcomes in PCD.

SEARCH METHODS

Systematic literature searches were performed in Medline, Embase, Cochrane Library, and PubMed electronic databases to identify publications between 1964 and 2022 reporting fertility outcomes in men and women with PCD. Publications were excluded if they reported only animal studies, where gender was not specified or where subjects had a medical co-morbidity also known to impact fertility. Quality of evidence was assessed by critical appraisal and application of an appraisal tool for cross-sectional studies. The primary outcomes were natural conception in men and women with PCD, and conception following ART in men and women with PCD.

OUTCOMES

A total of 1565 publications were identified, and 108 publications were included after screening by two independent researchers. The quality of available evidence was low. The exact prevalence of subfertility in PCD is unclear but appears to be higher in men (up to 83% affected) compared to women (up to 61% affected). Variation in the prevalence of subfertility was observed between geographic populations which may be explained by differences in underlying genotype and cilia function. Limited evidence suggests subfertility in affected individuals is likely caused by abnormal cilia motion in the fallopian tubes, endometrium and efferent ductules, and dysmotile sperm. Some men and women with PCD benefited from ART, which suggests its use should be considered in the management of subfertility in this patient group. Further epidemiological and controlled studies are needed to determine the predictors of fertility and optimal management in this patient group.

WIDER IMPLICATIONS

It is important that patients with PCD receive evidence-based counselling about the potential impact of their condition on their fertility prognosis and what management options may be available to them if affected. Understanding the pathophysiology and optimal management of subfertility in PCD will increase our understanding of the role of cilia and the impact of wider secondary ciliopathies on reproduction.

An international survey on nasal nitric oxide measurement practices for the diagnosis of primary ciliary dyskinesia

Nasal nitric oxide (nNO) measurements are routinely used in the assessment of patients suspected to have primary ciliary dyskinesia (PCD), but recommendations for performing such measurements have not focused on children and do not include all current practices. To guide the development of a European Respiratory Society-supported technical standard for nNO measurements in children, an international online survey was conducted to better understand current practices for measuring nNO among providers involved in PCD diagnostics.

Seventy-eight professionals responded, representing 65 centres across 18 countries, mainly located in Europe and North America. Nearly all centres measured nNO in children and more than half of them performed measurements before 5-years of age. The test was often postponed in children with signs of acute airway infection. In Europe, the electrochemical technique was more frequently used than chemiluminescence. A similar proportion of centres performed measurements during exhalation against a resistance (49/65) or during tidal breathing (50/65) with 15 centres using only exhalation against a resistance and 15 centres using only tidal breathing. The cut-off values used to discriminate PCD was consistent across centres using chemiluminescence analyzers and these centres reported results as an output (nL.min−1). However, cut-off values were highly variable across centres using electrochemical devices, and nNO concentrations were typically reported as ppb.

This survey represents the first to determine real-world use of nNO measurements worldwide and revealed remarkable variability in methodology, equipment, and interpretation. These findings will be useful to standardise methods and training.

Clinical utility of NGS diagnosis and disease stratification in a multiethnic primary ciliary dyskinesia cohort

BACKGROUND

Primary ciliary dyskinesia (PCD), a genetically heterogeneous condition enriched in some consanguineous populations, results from recessive mutations affecting cilia biogenesis and motility. Currently, diagnosis requires multiple expert tests.

METHODS

The diagnostic utility of multigene panel next-generation sequencing (NGS) was evaluated in 161 unrelated families from multiple population ancestries.

RESULTS

Most (82%) families had affected individuals with biallelic or hemizygous (75%) or single (7%) pathogenic causal alleles in known PCD genes. Loss-of-function alleles dominate (73% frameshift, stop-gain, splice site), most (58%) being homozygous, even in non-consanguineous families. Although 57% (88) of the total 155 diagnostic disease variants were novel, recurrent mutations and mutated genes were detected. These differed markedly between white European (52% of families carry DNAH5 or DNAH11 mutations), Arab (42% of families carry CCDC39 or CCDC40 mutations) and South Asian (single LRRC6 or CCDC103 mutations carried in 36% of families) patients, revealing a striking genetic stratification according to population of origin in PCD. Genetics facilitated successful diagnosis of 81% of families with normal or inconclusive ultrastructure and 67% missing prior ultrastructure results.

CONCLUSIONS

This study shows the added value of high-throughput targeted NGS in expediting PCD diagnosis. Therefore, there is potential significant patient benefit in wider and/or earlier implementation of genetic screening.

A re-examination of the relationship between Steller sea lion (Eumetopias jubatus) diet and population trend using data from the Aleutian Islands

Prey diversity and energy density have been linked to each other and to population trends in many studies of bird and mammal diets. We re-examined these relationships in Steller sea lions (Eumetopias jubatus (Schreber, 1776)) using data collected from the Aleutian Islands, where there has been a strong longitudinal gradient in population trend. Diet diversity and energy density metrics were similar in the western Aleutians, where sea lion counts declined consistently, and in the easternmost Aleutian area, where population trends improved significantly. We compared traditional deterministic diet diversity metrics with diversity scores based on an occupancy model that accounts for differences in sample size and uncertainty in prey group detection. This analysis indicated that there was no significant change in diet diversity over the 23-year study period or any significant differences across the Aleutian Islands. These results are consistent with prey abundance data from nine groundfish bottom trawl surveys conducted over the same period. While diet studies detail what Steller sea lions eat and provide an estimate of their energy intake, they provide only limited information on the energy expended to obtain their food or the consequences of their diet and foraging ecology on individual or population fitness.

Burden of Uterine Fibroids: An African Perspective, A Call for Action and Opportunity for Intervention

Black women carry the burden of uterine fibroids, (AKA uterine leiomyomas), at a much higher rate than their racial counterparts. Thus, increasing awareness and discovering a solution to an endemic problem that plagues Sub-Saharan Africa is of critical importance, not only for the region itself, but also for the medical community globally. A collaborative, patient oriented, cost effective, and culturally sensitive approach must be at the forefront of this endeavor. While the exact pathogenesis of uterine fibroid development remains elusive, the racial disparity is well documented. Moreover, in the developed world, women are able to seek treatment through surgical and non-surgical means; however, sub-Saharan regions face their own challenges that, if not addressed, can ultimately extinguish the lives of many suffering women. Unfortunately, the literature is scarce on how to prevent fibroid development, which may be critical for women who do not have access to effective interventions. Recent research from our group and others has shown that vitamin D deficiency plays an important role in fibroid development and may be a preventable risk factor. Daily vitamin D supplementation is a low cost, effective intervention that could be implemented throughout the Sub-Saharan region. Similarly, education and increased awareness as to the nature and symptoms of uterine fibroids could improve the quality of life, remove negative social stigma, and reduce morbidity and mortality rates in women who seek medical care with advanced uterine fibroids.

Response to Comment on "Tropical forests are a net carbon source based on aboveground measurements of gain and loss"

The Hansen et al critique centers on the lack of spatial agreement between two very different datasets. Nonetheless, properly constructed comparisons designed to reconcile the two datasets yield up to 90% agreement (e.g., in South America).

Haemoglobinaemia and Haemoglobinuria Following the Administration of Neodymium 3-Sulpho-Isonicotinate (Thrombodym)

Nine of thirteen patients receiving daily intravenous injections of 375 mg. 3-sulpho-isonicotinate for four to eight days developed haemoglobinaemia, accompanied in one case by haemoglobinuria and methaemalbuminaemia. In addition to haemoglobinaemia, a rise in blood cholesterol was observed in rabbits given larger doses.

High prevalence of CCDC103 p.His154Pro mutation causing primary ciliary dyskinesia disrupts protein oligomerisation and is associated with normal diagnostic investigations

RATIONALE

Primary ciliary dyskinesia is a genetically heterogeneous inherited condition characterised by progressive lung disease arising from abnormal cilia function. Approximately half of patients have situs inversus. The estimated prevalence of primary ciliary dyskinesia in the UK South Asian population is 1:2265. Early, accurate diagnosis is key to implementing appropriate management but clinical diagnostic tests can be equivocal.

OBJECTIVES

To determine the importance of genetic screening for primary ciliary dyskinesia in a UK South Asian population with a typical clinical phenotype, where standard testing is inconclusive.

METHODS

Next-generation sequencing was used to screen 86 South Asian patients who had a clinical history consistent with primary ciliary dyskinesia. The effect of a CCDC103 p.His154Pro missense variant compared with other dynein arm-associated gene mutations on diagnostic/phenotypic variability was tested. CCDC103 p.His154Pro variant pathogenicity was assessed by oligomerisation assay.

RESULTS

Sixteen of 86 (19%) patients carried a homozygous CCDC103 p.His154Pro mutation which was found to disrupt protein oligomerisation. Variable diagnostic test results were obtained including normal nasal nitric oxide levels, normal ciliary beat pattern and frequency and a spectrum of partial and normal dynein arm retention. Fifteen (94%) patients or their sibling(s) had situs inversus suggesting CCDC103 p.His154Pro patients without situs inversus are missed.

CONCLUSIONS

The CCDC103 p.His154Pro mutation is more prevalent than previously thought in the South Asian community and causes primary ciliary dyskinesia that can be difficult to diagnose using pathology-based clinical tests. Genetic testing is critical when there is a strong clinical phenotype with inconclusive standard diagnostic tests.

The acceptability and tolerability of nasal douching in children with allergic rhinitis: A systematic review

BACKGROUND

Allergic rhinitis (AR) is a significant issue in children. Treatment options include allergen avoidance, pharmacotherapy and immunotherapy. The use of nasal saline douching (NSD) in children has recently gained acceptability. However, there is limited data regarding the acceptability and tolerability of NSD in children with AR.

METHODS

A search was conducted using Medline and Embase databases from January 1946 until June 2015 on the use of NSD in children aged 4-12 years with AR. All publications identified that assessed the beneficial effects, acceptability and tolerability were included.

RESULTS

40 studies were analyzed. Data varied considerably in terms of saline solutions used, modality of application, participant numbers, study design, follow up and outcomes. Factors that appear to influence the acceptability and tolerability of NSD include parental and health professionals' preconceptions, and characteristics of the solution.

CONCLUSIONS

Nasal saline douching appears to be effective, being accepted and tolerated in the majority of children (78-100%). NSD has a significant positive impact on the quality of life in children with allergic rhinitis. When used as an adjunctive treatment having mainly a cleansing property, NSD potentiates the effects and may reduce the dose required of AR medications. Among the principal factors that influence the acceptability and tolerability of NSD are the child's age, delivery system and method, and tonicity. Nasal saline douching provides an accessible, low cost, low morbidity, easy to use treatment in children with allergic rhinitis.

Nasal nitric oxide screening for primary ciliary dyskinesia: systematic review and meta-analysis

Nasal nitric oxide (nNO) concentrations are low in patients with primary ciliary dyskinesia (PCD) providing a noninvasive screening test.

We conducted a systematic review of the literature to examine the utility of nNO in screening for PCD, in particular 1) different respiratory manoeuvres during sampling (velum closure, tidal breathing, etc.), 2) accuracy in screening young/uncooperative children, 3) stationary versus portable analysers, and 4) nNO in “atypical” PCD.

96 papers were assessed according to modified PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and 22 were included in this review.

Meta-analysis of 11 studies comparing nNO during a velum closure breath hold gave a mean±sd nNO of 19.4±18.6 nL·min-1 in PCD (n = 478) and 265.0±118.9 nL·min-1 in healthy controls (n = 338). Weighted mean difference for PCD versus healthy controls was 231.1 nL·min-1 (95% CI 193.3–268.9; n = 338) and 114.1 nL·min-1 (95% CI 101.5–126.8; n = 415) for PCD versus cystic fibrosis. Five studies of nNO measurement during tidal breathing demonstrated that this is an acceptable manoeuvre in young children where velum closure is not possible, but the discriminatory value was reduced. Four small studies of portable NO analysers suggest these are reliable tools for screening for PCD. However, nNO must be interpreted alongside clinical suspicion. Future studies should focus on standardising sampling techniques and reporting.

Reversible anionic redox chemistry in high-capacity layered-oxide electrodes

Li-ion batteries have contributed to the commercial success of portable electronics and may soon dominate the electric transportation market provided that major scientific advances including new materials and concepts are developed. Classical positive electrodes for Li-ion technology operate mainly through an insertion-deinsertion redox process involving cationic species. However, this mechanism is insufficient to account for the high capacities exhibited by the new generation of Li-rich (Li(1+x)Ni(y)Co(z)Mn(1-x-y-z)O₂) layered oxides that present unusual Li reactivity. In an attempt to overcome both the inherent composition and the structural complexity of this class of oxides, we have designed structurally related Li₂Ru(1-y)Sn(y)O₃ materials that have a single redox cation and exhibit sustainable reversible capacities as high as 230 mA h g(-1). Moreover, they present good cycling behaviour with no signs of voltage decay and a small irreversible capacity. We also unambiguously show, on the basis of an arsenal of characterization techniques, that the reactivity of these high-capacity materials towards Li entails cumulative cationic (M(n+)→M((n+1)+)) and anionic (O(2-)→O₂(2-)) reversible redox processes, owing to the d-sp hybridization associated with a reductive coupling mechanism. Because Li₂MO₃ is a large family of compounds, this study opens the door to the exploration of a vast number of high-capacity materials.

Drug advertising in medical journals

One hundred different drug advertisements from each of seven leading medical journals have been assessed. Information about drug interactions, adverse reactions, mode of action, absorption, distribution, metabolism, excretion and cost was seldom provided in UK journals. A requirement should exist that drug advertisements include such clinically important information. Only a few pharmaceutical companies are attempting to educate doctors through their marketing and promotional material in advertisements in medical journals.

Control of Cimex lectularius using heat combined with dichlorvos resin strips

Successful management of the bed bug, Cimex lectularius L. (Hemiptera: Cimicidae), is difficult because of its pesticide resistance, which can allow a reduction in population, but not elimination. We evaluated the effect of heat and/or air circulation on the efficacy of dichlorvos resin strips in the control of bed bugs. Treatments were performed in unoccupied dormitory rooms and consisted of dichlorvos resin strips containing 18.6% active ingredient, the same strips + fan, and strips + fan + heat. The mortality of recently fed bed bugs and weight loss of the dichlorvos strips were evaluated over 7 days. Dichlorvos resin strips killed bed bugs and eggs in just over 7 days. The addition of a fan or a fan + heat decreased time to 100% mortality to 3 days and 36 h, respectively. Eggs located in treated rooms did not hatch. Resin strips in the strips + fan treatment and the strips + fan + heat treatment volatilized 10 and 70 times, respectively, faster than strips in the strips-only treatment. The addition of heat in treatments with dichlorvos resin strips enhances the overall efficacy of the volatile insecticide and reduces the time required to eliminate live bed bugs and eggs.

Update on the causes, investigation and management of empyema in childhood

Despite being recognised for over two millennia and having an increasing incidence in many countries, the management of childhood empyema remains controversial. This review examines the recent literature on its causes and investigation then focuses on its treatment. Following a trial of appropriate intravenous antibiotics, the evidence would currently support the use of chest drain insertion with urokinase instillation as first line treatment with video-assisted thoracoscopic surgery to be used for failure of medical management. A treatment algorithm is proposed to guide clinical practice.

Evaluation of a health promotion program for reducing depression, anxiety and stress in community-dwelling older adults

Aim

Health education programs that address risk factors for depression and promote positive mental health are approaches that can improve mental wellbeing. We investigated the effectiveness of a health promotion program for reducing levels of depression, anxiety and stress and for promoting appropriate help-seeking behaviour.

Methods

Fifty-five adults 55+years (43 female, 12 male) self-selected to attend the Healthy & Wise program - a group-based, 8 × 2hr session health-literacy program for promoting positive physical, mental and social functioning in a rural setting. A questionnaire was administered at base-line and post-intervention which included the DASS-21 to measure depression, anxiety and stress levels.

Results

No significant change in depression scores (mean = 3.60pre-3.51post). Anxiety scores increased (mean 2.92pre-3.51post) (p = .036) correlating with age (p = .029) and change in physical health status (p = .002).

Stress scores increased (mean 4.81pre-5.59post) (p = .05) correlating with age (p = .033) and change in physical health status (p = .016).

Most participants (pre = 96.36%, post = 98%) indicated they would be likely to seek help from a GP if depressed. Men who mainly rely on their spouse for support were more likely to seek help from a psychologist or psychiatrist (p = .038).

Conclusions

There was no significant change in DASS-21 scores for depression. There was an increase in anxiety and stress levels which may be attributable to older participants experiencing a decline in physical health during the program. Participants remained firm in their preference for seeking help from their GP for depression. Further evaluation is needed to determine whether: at-risk-populations need to be targeted; the intervention has an impact at 12-month follow-up.

A 3.6 V lithium-based fluorosulphate insertion positive electrode for lithium-ion batteries

Li-ion batteries have contributed to the commercial success of portable electronics, and are now in a position to influence higher-volume applications such as plug-in hybrid electric vehicles. Most commercial Li-ion batteries use positive electrodes based on lithium cobalt oxides. Despite showing a lower voltage than cobalt-based systems (3.45 V versus 4 V) and a lower energy density, LiFePO(4) has emerged as a promising contender owing to the cost sensitivity of higher-volume markets. LiFePO(4) also shows intrinsically low ionic and electronic transport, necessitating nanosizing and/or carbon coating. Clearly, there is a need for inexpensive materials with higher energy densities. Although this could in principle be achieved by introducing fluorine and by replacing phosphate groups with more electron-withdrawing sulphate groups, this avenue has remained unexplored. Herein, we synthesize and show promising electrode performance for LiFeSO(4)F. This material shows a slightly higher voltage (3.6 V versus Li) than LiFePO(4) and suppresses the need for nanosizing or carbon coating while sharing the same cost advantage. This work not only provides a positive-electrode contender to rival LiFePO(4), but also suggests that broad classes of fluoro-oxyanion materials could be discovered.

The effects of Donepezil on traumatic brain injury acute rehabilitation outcomes

PRIMARY OBJECTIVE

To evaluate the effects of administering Donepezil during inpatient rehabilitation for individuals with TBI.

RESEARCH DESIGN

Retrospective, age and injury severity matched, mixed between-within subjects analysis.

METHODS AND PROCEDURES

Thirty-six patients with moderate-to-severe TBI admitted to acute rehabilitation within 90 days of injury. Main outcome measures included FIM cognitive total scores and rehabilitation lengths of stay.

INTERVENTION

Initiation of Donepezil administration beginning at 5 mg daily. Dose titration and continuation based on perceived clinical response.

MAIN OUTCOMES AND RESULTS

No differences in cognitive improvement were observed between the Donepezil treatment group and the matched control group. Sub-set analyses suggested that administration of Donepezil early in the rehabilitation stay was significantly related to higher rates of cognitive improvement.

CONCLUSIONS

Preliminary evidence suggests that Donepezil administration early in the rehabilitation stay may have advantageous treatment effects. A prospective, randomized, placebo-controlled clinical trial with standard timing, dosage and treatment duration is recommended to further evaluate treatment efficacy.

Dose escalated, hypofractionated radiotherapy using helical tomotherapy for inoperable non-small cell lung cancer: preliminary results of a risk-stratified phase I dose escalation study

To improve local control for inoperable non-small cell lung cancer (NSCLC), a phase I dose escalation study for locally advanced and medically inoperable patients was devised to escalate tumor dose while limiting the dose to organs at risk including the esophagus, spinal cord, and residual lung. Helical tomotherapy provided image-guided IMRT, delivered in a 5-week hypofractionated schedule to minimize the effect of accelerated repopulation. Forty-six patients judged not to be surgical candidates with Stage I-IV NSCLC were treated. Concurrent chemotherapy was not allowed. Radiotherapy was delivered via helical tomotherapy and limited to the primary site and clinically proven or suspicious nodal regions without elective nodal irradiation. Patients were placed in 1 of 5 dose bins, all treated for 25 fractions, with dose per fraction ranging from 2.28 to 3.22 Gy. The bin doses of 57 to 80.5 Gy result in 2 Gy/fraction normalized tissue dose (NTD) equivalents of 60 to 100 Gy. In each bin, the starting dose was determined by the relative normalized tissue mean dose modeled to cause < 20% Grade 2 pneumonitis. Dose constraints included spinal cord maximum NTD of 50 Gy, esophageal maximum NTD < 64 Gy to < or = 0.5 cc volume, and esophageal effective volume of 30%. No grade 3 RTOG acute pneumonitis (NCI-CTC v.3) or esophageal toxicities (CTCAE v.3.0 and RTOG) were observed at median follow-up of 8.1 months. Pneumonitis rates were 70% grade 1 and 13% grade 2. Multivariate analysis identified lung NTD(mean) (p=0.012) and administration of adjuvant chemotherapy following radiotherapy (p=0.015) to be independent risk factors for grade 2 pneumonitis. Only seven patients (15%) required narcotic analgesics (RTOG grade 2 toxicity) for esophagitis, with only 2.3% average weight loss during treatment. Best in-field gross response rates were 17% complete response, 43% partial response, 26% stable disease, and 6.5% in-field thoracic progression. The out-of-field thoracic failure rate was 13%, and distal failure rate was 28%. The median survival was 18 months with 2-year overall survival of 46.8% +/- 9.7% for this cohort, 50% of whom were stage IIIB and 30% stage IIIA. Dose escalation can be safely achieved in NSCLC with lower than expected rates of pneumonitis and esophagitis using hypofractionated image-guided IMRT. The maximum tolerated dose has yet to be reached.

Role of transesophageal echocardiography in the clinical management of a patients with a giant coronary artery aneurysm

Transthoracic echocardiography (TTE) has substantial limitations for the study of abnormalities of the coronary tree. Transesophageal echocardiography (TEE) allows a more complete examination of the coronary arteries, particularly the proximal segments. This report describes the use of TEE after cardiac catheterization in the clinical management of a patient with unstable angina. While angiography first showed the giant aneurysm of the left circumflex coronary artery. TEE, by revealing an active thrombus of the lumen, prompted an immediate surgical resolution.

A genome-wide linkage scan for genes controlling variation in urinary albumin excretion in type II diabetes

The main hallmark of diabetic nephropathy is elevation in urinary albumin excretion. We performed a genome-wide linkage scan in 63 extended families with multiple members with type II diabetes. Urinary albumin excretion, measured as the albumin-to-creatinine ratio (ACR), was determined in 426 diabetic and 431 nondiabetic relatives who were genotyped for 383 markers. The data were analyzed using variance components linkage analysis. Heritability (h2) of ACR was significant in diabetic (h2=0.23, P=0.0007), and nondiabetic (h2=0.39, P=0.0001) relatives. There was no significant difference in genetic variance of ACR between diabetic and nondiabetic relatives (P=0.16), and the genetic correlation (rG=0.64) for ACR between these two groups was not different from 1 (P=0.12). These results suggested that similar genes contribute to variation in ACR in diabetic and nondiabetic relatives. This hypothesis was supported further by the linkage results. Support for linkage to ACR was suggestive in diabetic relatives and became significant in all relatives for chromosome 22q (logarithm of odds, LOD=3.7) and chromosome 7q (LOD=3.1). When analyses were restricted to 59 Caucasian families, support for linkage in all relatives increased and became significant for 5q (LOD=3.4). In conclusion, genes on chromosomes 22q, 5q and 7q may contribute to variation in urinary albumin excretion in diabetic and nondiabetic individuals.

The management and outcome of patients with germ-cell tumours treated in the Edinburgh Cancer Centre between 1988 and 2002

AIMS

The aim of this retrospective analysis was to review the outcome of patients with germ-cell tumours treated in the Edinburgh Cancer Centre over the past 15 years, and to see whether there had been any changes over three 5-year cohorts.

MATERIALS AND METHODS

Patients referred with gonadal and extra-gonadal primary germ-cell tumours, between 1988 and 2002, were identified from the departmental database, and survival by stage and prognostic group was analysed.

RESULTS AND CONCLUSIONS

The proportion of patients with stage I seminoma has significantly increased. The good prognosis of patients with early stage disease is confirmed, with the outcome for some groups of patients being better than expected. There is a non-significant trend to improved results over the three 5-year cohorts. The outcome for patients with stage IV seminoma is worse than would be expected, but numbers are small. The poor prognosis of patients with non-seminomatous germ-cell tumours who fall into the International Germ Cell Consensus Classification (IGCCC) poor-prognostic group is confirmed. Failure of patients with metastatic non-seminomatous germ-cell tumours to achieve a complete response to initial therapy is shown to be a poor prognostic indicator.

Analysis of leukocyte binding to depletion filters: role of passive binding, interaction with platelets, and plasma components

Since limited knowledge exists on the mechanisms which regulate cell binding to leukocyte removal filter surfaces, we investigated the binding patterns of leukocytes to individual layers of leukocyte depletion filters. After passage of 1 unit of whole blood, blotting of isolated filter layers on glass slides or elution of cells from filter layers revealed that most leukocytes were located within the first 10 of a total of 28 filter layers, peaking at layers 6 to 8, with granulocytes binding on average to earlier filter layers than lymphocytes. Leukocytes preincubated with inhibitors of actin activation showed unchanged distribution between filter layers, suggesting that cytoskeletal activation does not significantly contribute to their binding. When leukocytes were directly incubated with single filter layers, binding of up to 30% of input cells was recorded in the absence of Ca(2+). Immunohistological analyses showed colocalization of platelets and leukocytes, with co-clustering of platelets and leukocytes. Monocytes and to some degree lymphocytes but not granulocytes competed with platelets for filter binding. Precoating of filter layers with individual plasma components showed that hyaluronic acid, plasma type fibronectin, and fibrinogen all increased the binding of leukocytes compared with albumin coating. In conclusion, leukocytes can bind passively to filters in a process which does not require Ca(2+), which is independent of cytoskeletal activation and which may depend on individual plasma components. These results are of importance when new selective cell enrichment or depletion strategies through specific filters are envisaged.

Comprehensive critical care education is critical to success

Intensive and high-dependency care is currently receiving considerable attention, not least since the Department of Health review of adult critical care nursing and subsequent proposals for the development of a consistent and comprehensive critical care service (DoH 2000). The report highlights the need for policy changes at all levels and across all disciplines and makes several recommendations that are deemed essential for the future organization and delivery of critical care. Central to the proposed reforms is the availability of a skilled workforce, adequately prepared and appropriately trained to provide specialist care in a variety of settings where acutely ill patients are found. This paper considers the implications of 'comprehensive critical care' for pre- and post-registration nurse education and offers insight into programmes of learning that are tailored to meet the needs of the service and individuals. The paper draws upon three influential and timely publications, namely the Audit Commission report into critical care services, the English National Board (ENB) review of adult intensive/critical and high-dependency care programmes and the United Kingdom Central Council (UKCC) Commission for Education recommendations regarding 'fitness for practice'.

Sex-associated hormones and immunity to protozoan parasites

Numerous epidemiological and clinical studies have noted differences in the incidence and severity of parasitic diseases between males and females. Although in some instances this may be due to gender-associated differences in behavior, there is overwhelming evidence that sex-associated hormones can also modulate immune responses and consequently directly influence the outcome of parasitic infection. Animal models of disease can often recreate the gender-dependent differences observed in humans, and the role of sex-associated hormones can be confirmed by experimentally altering their levels. Under normal circumstances, levels of sex hormones not only differ between males and females but vary according to age. Furthermore, not only are females of reproductive age subject to the regular hormonal cycles which control ovulation, they are also exposed to dramatically altered levels during pregnancy. It is thus not surprising that the severity of many diseases, including those caused by parasites, has been shown to be affected by one or more of these circumstances. In addition, infection with many pathogens has been shown to have an adverse influence on pregnancy. In this article we review the impact of sex-associated hormones on the immune system and the development and maintenance of immunity to the intracellular protozoan parasites Toxoplasma gondii, Plasmodium spp., and Leishmania spp.