Improving bone marrow biopsy quality through peer discussion and data comparisons: A single institution experience.

INTRODUCTION: Bone marrow biopsy (BMB) is crucial for the diagnosis, staging, and monitoring of a variety of hematologic diseases. Obtaining an adequate BMB can be challenging given the need to balance patient comfort with acquisition of high quality specimens. We had observed variable BMB quality at our institution with poor quality specimens sometimes affecting diagnosis. We thus undertook this quality improvement (QI) project to improve the quality of diagnostic BMB specimens. METHODS: We used an A3 QI process to identify factors possibly influencing BMB quality. We collected baseline data on 211 BMB, with short and long-term follow-up data on a further 382 cases. We used clinical conferences to discuss data, perform peer comparisons and identify strategies to create a sustainable improvement in BMB quality. RESULTS: Baseline data showed that BMB length was influenced most by the individual performer, with some influence of needle gauge. Other factors such as sedation, BMB indication were noncontributory. BMB lengths improved following performer education and individual performer data comparisons (15.2 mm post vs 12.8 mm baseline, P < .0001) and with use of an 8- rather than 11-gauge needle (18.3 mm 8-gauge vs 13.3 mm 11-gauge P < .0001), and were sustained over the long term. CONCLUSIONS: Education on BMB standards, sharing of performer data, and changing needle gauge are relatively straightforward methods to improve BMB quality, leading to easier pathology diagnosis.

Regulation of MEIS1 by distal enhancer elements in acute leukemia.

Aberrant activation of the three-amino-acid-loop extension homeobox gene MEIS1 shortens the latency and accelerates the onset and progression of acute leukemia, yet the molecular mechanism underlying persistent activation of the MEIS1 gene in leukemia remains poorly understood. Here we used a combined comparative genomics analysis and an in vivo transgenic zebrafish assay to identify six regulatory DNA elements that are able to direct green fluorescent protein expression in a spatiotemporal manner during zebrafish embryonic hematopoiesis. Analysis of chromatin characteristics and regulatory signatures suggests that many of these predicted elements are potential enhancers in mammalian hematopoiesis. Strikingly, one of the enhancer elements (E9) is a frequent integration site in retroviral-induced mouse acute leukemia. The genomic region corresponding to enhancer E9 is differentially marked by H3K4 monomethylation and H3K27 acetylation, hallmarks of active enhancers, in multiple leukemia cell lines. Decreased enrichment of these histone marks is associated with downregulation of MEIS1 expression during hematopoietic differentiation. Further, MEIS1/HOXA9 transactivate this enhancer via a conserved binding motif in vitro, and participate in an autoregulatory loop that modulates MEIS1 expression in vivo. Our results suggest that an intronic enhancer regulates the expression of MEIS1 in hematopoiesis and contributes to its aberrant expression in acute leukemia.

The soil flagellate Heteromita globosa accelerates bacterial degradation of alkylbenzenes through grazing and acetate excretion in batch culture.

The impact of grazing by soil flagellates Heteromita globosa on aerobic biodegradation of benzene by Pseudomonas strain PS+ was examined in batch culture. Growth of H. globosa on these bacteria obeyed Monod kinetics (mu(max), 0.17 +/- 0.03 h(-1); K(s), 1.1 +/- 0.2 x 10(7) bacteria mL(-1)) and was optimal at a bacteria/ flagellate ratio of 2000. Carbon mass balance showed that 5.2% of total [ring-U-(14)C]benzene fed to bacteria was subsequently incorporated into flagellate biomass. Growth-inhibiting concentrations (IC50) of alkylbenzenes (benzene, toluene, ethylbenzene) were inversely related with their octanol/ water partitioning coefficients, and benzene was least toxic for bacteria and flagellates with IC50 values of 4392 (+/- 167) microM and 2770 (+/- 653) microM, respectively. The first-order rate constant for benzene degradation (k1, 0.48 +/- 0.12 day(-1)) was unaffected by the presence or absence of flagellates in cultures. However, the rate of benzene degradation by individual bacteria averaged three times higher in the presence of flagellates (0.73 +/- 0.13 fmol cell(-1) h(-1)) than in their absence (0.26 +/- 0.03 fmol cell(-1) h(-1)). Benzene degradation also coincided with higher levels of dissolved oxygen and a higher rate of nitrate reduction in the presence of flagellates (p < 0.02). Grazing by flagellates may have increased the availability of dissolved oxygen to a smaller surviving population of bacteria engaged in the aerobic reactions initiating benzene degradation. In addition, flagellates may also have increased the rate of nitrate reduction through the excretion of acetate as an additional electron donor for these bacteria. Indeed, acetate was shown to progressively accumulate in cultures where flagellates grazed on heat-killed bacteria. This study provided evidence that grazing flagellates stimulate bacterial degradation of alkylbenzenes and provide a link for carbon cycling to consumers at higher trophic levels. This may have important implications for bioremediation processes.

Consultation interactions between special education teachers and child psychiatrists.

Characteristics were investigated for 169 special education students referred to a child psychiatrist consultant. There was a common occurrence of learning or language disorders, predominance of attention deficit/hyperactivity disorder, severity and complexity of psychopathology, and undertreatment. The teachers especially asked about diagnosis, behavioral management, and medication and also about issues involving learning and language disorders.

The predatory soil flagellate Heteromita globosa stimulates toluene biodegradation by a Pseudomonas sp.

A model food chain was established to investigate the influence of grazing by flagellates on bacteria degrading toluene in batch culture. The rate of toluene consumed by a Pseudomonas sp. strain PS+ (max. 0.37 fmol cell(-1) h(-1)) was significantly higher in the presence of the bacterivorous flagellate Heteromita globosa (max. 1.38 fmol cell(-1) h(-1)). A maximum increase of up to 7.5 times was observed in the rate of toluene consumed by these bacteria during exponential growth of this flagellate. Carbon conversion efficiency (CCE) of bacteria to flagellate biomass was estimated to be 33.4% based on measured biovolumes and published values for carbon contents. However, the CCE for toluene-derived carbon was lower (max. 4.9%) when calculations were based on incorporation of [ring-U-(14)C]toluene into biomass of flagellates grazing on labelled bacteria. The findings suggest a potential role for flagellates in bioremediation processes.

School consultation: a review of research on issues unique to the school environment.

OBJECTIVE: To provide clinicians with current information to assist in their consultations to schools on 4 major topics that are unique to the school environment and of serious concern to educators: absenteeism, disciplinary referrals, retention (non-promotion), and dropping out. METHOD: Computer literature searches and the major journals of the various school disciplines were used to identify empirically based articles with sound methodology. Information on each of the 4 issues is presented as general characteristics, characteristics of psychopathology, prevention and treatment, and implications for consultation. RESULTS: Findings are largely general, with little specific information on level of intelligence, learning disorders, psychopathology, or family stressors. Students under each topic have varied presentations. However, many pupils with absenteeism, disciplinary referrals, or retention appear to be characterized by chronic and serious academic and/or behavior problems, all of which can predate dropping out. CONCLUSIONS: Considerable research is still needed on all 4 school issues, especially psychopathology. Nevertheless, consultants can reasonably first help schools to identify students at risk for the 4 outcomes, followed by appropriate screening/evaluation to indicate more clearly their true intervention needs. The ongoing process can further educate school staff about psychiatric disorders in their most problematic students.

Use of psychotropic medications in special education students with serious emotional disturbance.

The three-year usage of psychotropic medication was investigated for the first time in elementary school students classified by the special education category serious emotional disturbance. Almost 40% of the original 89 students were on a medication at baseline, primarily stimulants (26%), and multiple medications were not common (17%). Over the three time points of followup, 52% of the constant 54 students used a medicine at least once, principally stimulants followed by, in descending order, antipsychotics, antidepressants, and Clonidine. The order of distribution was constant at each point of follow-up. Only 24% received a medication at all three time points (rarely the same specific medicine), and only 9% received therapy at each time. Overall, 41% of the ongoing students received no medication or therapy over the course of the study. The medication needs, as well as the therapy needs, of this highly dysfunctional group of students appear unmet.

Long-term stability of Child Behavior Checklist profile types in a child psychiatric clinic population.

OBJECTIVE: To study the long-term stability of Child Behavior Checklist (CBCL) profile types, which represent children's overall patterns of single and comorbid scale elevations. METHOD: Profile types were determined for 623 outpatient children at referral and then at mean follow-up 4.8 years later, and their continuity was determined. RESULTS: At baseline 37.5% of the children were classified by a profile type, and 41.9% of these originally classified children continued to be classified at follow-up. The average odds ratio for a child continuing as a specific CBCL profile type from baseline to follow-up was 8.2. When children changed from one specific profile type to another, they usually continued in the same broad externalizing or internalizing category. Children who were not classified by a profile type at baseline generally remained unclassified. CONCLUSIONS: Stability findings for CBCL profile types appeared good and were similar to past longitudinal results for CBCL scales and DSM diagnoses. These profile types may prove an important empirical method for addressing the problem of comorbid clinical pictures.

The Diagnostic Interview Schedule for Children (PC-DISC v.3.0): parents and adolescents suggest reasons for expecting discrepant answers.

To identify reasons for discrepancies between parent and child reports of child/adolescents's psychiatric symptoms, parents and adolescents (51 pairs) were asked to guess what the other would answer to questions from the PC-DISC about the adolescent's psychiatric symptoms, and to explain why they expected disagreement when the answer they provided for the other was different from their own. Adolescents' explanations for expecting (1) parental denial of symptoms the adolescent reported were: the parent was unaware of, forgot about, assumed the adolescent could not have, or trivialized the symptom; and (2) parental report of symptoms the adolescent denied were: the parent misread or exaggerated the adolescent's symptom, had too high expectations for the adolescent's behavior, put a negative label on or did not trust the adolescent. Parents' reasons for expecting their children to (1) deny symptoms the parents reported were: the adolescent did not remember how s/he felt, lied, did not recognize or minimized the importance or frequency of the symptom; and (2) report symptoms the parents denied were: the adolescent lied, exaggerated the importance of or interpreted the symptom differently.

Methylphenidate and ADHD: influence of age, IQ and neurodevelopmental status.

Sixty-nine children with attention deficit hyperactivity disorder (ADHD) underwent blind methylphenidate trials. 36 had ADHD alone (with or without a learning disability) and 33 had additional neurodevelopmental disorders. Of the children with ADHD alone, 88 per cent improved significantly on methylphenidate. This did not differ significantly from the 69 per cent response rate for children with ADHD and other neurodevelopmental disorders. The results confirm and add to the research literature indicating that ADHD children who are of preschool age and/or who have co-existing neurological disorders may benefit from methylphenidate.

Ultrastructure and histochemistry of the tegument of juvenile paramphistomes during migration in Indian ruminants.

The tegument of juvenile Paramphistomum epiclitum and Fischoederius elongatus (Paramphistomidae: Digenea) resembles those of other digeneans. Seven types of papillae were observed, mostly on the oral and acetabular surfaces, and increase in number during migration. Also evident are two types of secretory body (T1 and T2) which are synthesized separately in tegumental cytons underlying the syncytium. Exocytosis of T2 bodies occurs at the apical membrane and appears to contribute to a fibrous glycocalyx. The tegumental syncytium lining the pharynx and acetabulum is thinner and has a higher capacity for vacuolation than the general tegument. These may represent important sites for osmoregulation. The absence of mitochondria from the tegument in migrating juveniles suggests limited involvement in energy demanding processes. Pigmentation of the subtegument is first evident in mature cercariae and is progressively eliminated during migration.

Adolescent schoolboys in SED classes: implications for child psychiatry.

OBJECTIVE: The primary purpose of this study was to determine basic psychosocial characteristics for adolescent socially and emotionally disturbed (SED) boys. METHODS: Boys aged 12 to 16 years who were recommended for SED placement were compared with same-aged boys recommended for other educational intervention. The main measures were the Kiddie SADS-E interview and Achenbach's parent Child Behavior Checklist and Teacher Report Form scales. RESULTS: The adolescent SED boys were found to have normal intelligence, high rates of family stressors, predominantly DSM-III externalizing disorders, serious dysfunction according to checklist ratings by both teachers and parents, and little current community mental health intervention. They were significantly different from the comparison group on several variables: lower socioeconomic status, more abuse experience, greater diagnostic comorbidity, higher Axis V clinician ratings, and higher teacher ratings on externalizing scales. CONCLUSIONS: Findings are similar to those for other age-gender groups of SED students. One implication is the need for more private child psychiatrists to become involved in the collaborative treatment of this complex and seriously ill group of special education students. Consequently, a second implication is to increase the experience of child psychiatry trainees in dealing with the many consultative needs of SED students and staff.

Ultrastructure and histochemistry of the digestive tract of juvenile Paramphistomum epiclitum (Paramphistomidae: Digenea) during migration in Indian ruminants.

The digestive tract of juvenile Paramphistomum epiclitum consists of a foregut with a highly muscular terminal pharynx and an oesophagus, which leads to a pair of unbranched and blind-ending intestinal caeca. A syncytium lining the foregut is continuous with the external tegument and displays similar sensory papillae and secretory bodies (T1 and T2). A third type of secretory body (T3) is confined to the oesophageal cytons of newly excysted juveniles and is first evident in the syncytium by day 14 of migration. An epithelium lining the caeca is composed of a single layer of morphologically uniform cells whose apical surface is amplified by microvilli. Dense secretions synthesized in the caecal epithelium of mature cercariae are released during migration by a mechanism resembling modified apocrine discharge. The caecal epithelium of migrating juveniles undergoes a 10-fold increase in surface amplification (irrespective of growth) during its transition from a primarily secretory tissue to one apparently specialized for absorption.

Ultrastructure and histochemistry of the protonephridial system of juvenile Paramphistomum epiclitum and Fischoederius elongatus (Paramphistomidae: Digenea) during migration in Indian ruminants.

The protonephridial system of juvenile Paramphistomum epiclitum and Fischoederius elongatus consists of a bilaterally symmetrical arrangement of primary, secondary and tertiary ducts which connect individual flame cells with a simple common bladder. Primary and secondary ducts are formed from columns of adjoining cells which provide an epithelial lining, whose luminal surface is elaborated with either short tubercles or lamellae. Groups of cilia project from the luminal surface at frequent intervals along secondary ducts. By contrast, the tertiary ducts and bladder are lined with a nucleated syncytium which ends at a junctional complex formed with the terminal canal. The latter is continuous with the tegumental syncytium and opens at a nephridiopore on the postero-dorsal surface. Tertiary ducts of mature cercariae contain concretions which are voided by migrating juveniles in whose tertiary ducts lipids are progressively accumulated. Evidence for the role of protonephridia in excretion and possibly in osmoregulation and ionic balance is currently examined.

Ultrastructure and histochemistry of the lymph system and parenchyma of juvenile paramphistomes (Paramphistomidae: Digenea) during migration in Indian ruminants.

The lymph system of juvenile Paramphistomum epiclitum and Fischoederius elongatus consists of a single pair of longitudinal primary vessels from which sub-dividing branches extend laterally to associate with most major tissues and organs. The system originates shortly after excystation in the definitive host and is fully developed in day 14 juveniles. Lymph vessels are syncytial and membrane limited, with a matrix which contains autophagic-like inclusions, clusters of SER and free nuclei. Similar organelles are evident in the matrix of parenchyma and specialized cells juxta-posing the pharynx (JP cells). These tissues are intimately associated and perhaps functionally integrated. Parenchyma represents a major site for carbohydrate storage and turnover, whilst the lymph appears to perform a similar role for proteins. The JP cells of juveniles display prolific autophagic-like activity only during migration, which coincides with the depletion of carbohydrate reserves in parenchyma. Key mitochondrial enzymes were histochemically demonstrated in the lymph despite the apparent absence of mitochondria from this system in post-day 14 juveniles. Succinate dehydrogenase activity was cytolocalized in mitochondria, whilst attempts to perform a similar localization of this enzyme in lymph were unsuccessful. The possibility of non-enzymatic interference in the histochemical demonstration of dehydrogenase is examined.

Facial video image processing: standard facial image capturing, software modification, development of a surgical plan, and comparison of presurgical and postsurgical results.

Video imaging is a maturing technology that will challenge the 35-mm photograph in its usefulness to the plastic surgeon. Computer modification of a patient image communicates to the patient a reconstructive plan. A comparison of the presurgical and postsurgical images keenly sensitizes the surgeon to the results of surgical technique. The equipment required for video imaging also provides a powerful tool for creation of presentation graphic prints (for publication), 35-mm slides, and, with additional software, educational video tapes. I describe here a video method for standard alignment of patients. The preoperative and modified patient image (surgical plan) is compared with the postoperative image to determine the degree of success in achieving the reconstructive goals. Comparison of standardized presurgical and postsurgical images offers the surgeon greater objectivity in his analysis of the surgical technique than is possible by comparison of clinical photographs. The value of video imaging to the reconstructive surgeon magnifies the success (or disappointment) of surgical technique.

Child behavior profile types in a general population sample of boys 6 to 11 years old.

Characteristics of Child Behavior Profile (CBP) types were studied in a general population sample of 202 boys aged 6 to 11 years. Parents completed the Child Behavior Checklist and teachers simultaneously rated the Teacher's Report Form. Overall, 39.7% of the boys were classified within a CBP type: 28.8% Internalizing and 10.9% Externalizing. The most common specific type was Somatic Complaints. Teachers rated the Externalizing CBP boys as showing robust externalizing behaviors in school. Also, boys with Externalizing profile types showed severe degrees of psychopathology in both home and school environments. An intraclass correlation of .35 or greater was found to identify boys with sufficiently severe psychopathology to warrant further clinical evaluation. Findings in this general population sample appear consistent with previous results in outpatient samples, and extend our understanding of the validity and clinical value for CBP types.

Pediatric management of anxiety disorders.

The first step in the pediatric management of anxiety disorders is to determine whether a child or adolescent has acute, situational anxiety symptoms or a pervasive, chronic anxiety disorder. Such anxiety symptoms can most frequently be handled with reassurance and practical advice to the child and the parents, and followed by monitoring. However, if an anxiety disorder is suspected, then referral to a mental health professional is in order for confirmation of the diagnosis and institution of comprehensive treatment. Medication currently has a limited role in the treatment of any anxiety disorder, although psychopharmacologic treatment may become part of the overall care of obsessive-compulsive disorder in the future. Pediatricians may wish to learn more about behavioral-cognitive treatment approaches used by mental health professionals in the treatment of anxiety symptoms and disorders in children and adolescents. An excellent general text has been edited by R. Gittelman, Anxiety Disorders of Childhood.

Suicide and other consequences of childhood and adolescent anxiety disorders.

The increasing risk of suicide among children and adolescents makes imperative the development of a set of appropriate and clinically significant predictors of suicide risk for that group. Of particular concern is the need to understand the role of anxiety psychopathology in suicidal children and the occurrence of suicidal behaviors in children with anxiety disorders. The author reviews the recent investigations assessing childhood and adolescent suicide risk and emphasizes the need to update our current methods in assessing both suicidal behavior and anxiety. Furthermore, he points out the need for prospective studies of anxiety disorders in children and adolescents to identify those children at risk for suicide and other psychopathology as they mature.