Fluconazole prophylaxis for prevention of invasive fungal infections in targeted highest risk preterm infants limits drug exposure.

OBJECTIVE: Previous reports suggest a benefit of fluconazole prophylaxis in extremely low birth weight (ELBW) infants <1000 g. Our aim was to evaluate if limiting fluconazole prophylaxis to targeted highest risk infants effectively prevents invasive fungal infections, has no undesired side effects and limits unnecessary drug exposure. STUDY DESIGN: This nonrandomized retrospective pre-post intervention study compared two groups of infants: (1) Infants <26 weeks gestation and/or <750 g birth weight, requiring central vascular access and admitted to the Monroe Carell Jr Children's Hospital at Vanderbilt neonatal intensive care unit (NICU) prior to 5 days of age, who received fluconazole prophylaxis and (2) a matched control group from the year prior to prophylaxis. This target population was selected for fluconazole prophylaxis based on prior infection control data from our institution and a number needed to treat of <15 to prevent one episode of fungemia. Following implementation and integration through the institution's computerized physician order entry (CPOE) system, provider adherence to the protocol was assessed during the prophylaxis period. RESULT: A total of 86 patients were included in the study, 44 in the no-prophylaxis group and 42 in the prophylaxis group. In the targeted prophylaxis group, no invasive fungal infections were observed as compared to nine infants with invasive infections in the no-prophylaxis group (P=0.004). No significant adverse effects were recorded. Targeting the highest risk infants reduced the number of infants <1000 g requiring prophylaxis from 80 to 42 (48% reduction) with no preventable infection missed. Provider compliance was 91% following implementation of this protocol through the CPOE system using a standardized order set. CONCLUSION: Targeting the highest risk infants for fluconazole prophylaxis through CPOE can effectively prevent invasive fungal infections and limit drug exposure with no unwanted side effects.

Immunohistochemical analysis of receptor tyrosine kinase signal transduction activity in chordoma.

AIMS: Currently, there are no effective chemotherapeutic protocols for chordoma. Reports of receptor tyrosine kinase (RTK) expression in chordoma suggest that these tumours may respond to kinase inhibitor therapy. However, RTK signalling activity has not been extensively investigated in chordoma. METHODS: A tissue microarray containing 21 cases of chordoma was analysed for expression of a number of proteins involved in signal transduction from RTKs by immunohistochemistry. RESULTS: Platelet-derived growth factor receptor-beta, epidermal growth factor receptor (EGFR), KIT and HER2 were detected in 100%, 67%, 33% and 0% of cases, respectively. Platelet-derived growth factor receptor-beta staining was of moderate-to-strong intensity in 20 of 21 cases. In contrast, KIT immunoreactivity was weak and focal in each of the seven positive cases. Total EGFR staining was variable; weak staining for phosphorylated EGFR was detected in nine cases. Phosphorylated isoforms of p44/42 mitogen-activated protein kinase, Akt and STAT3, indicative of tyrosine kinase activity, were detected in 86%, 76% and 67% of cases, respectively. CONCLUSIONS: Chordomas commonly express RTKs and activated signal transduction molecules. Although there were no statistically significant correlations between the expression of any of the markers studied and disease-free survival or tumour location, the results nonetheless indicate that chordomas may respond to RTK inhibitors or modulators of other downstream signalling molecules.

Equations describing percentiles for birth weight, head circumference, and length of preterm infants.

OBJECTIVE: To describe growth of prematurely born infants and create a growth chart adequate to assess growth of infants with less than 29 completed weeks of gestation. STUDY DESIGN: Birth weight, head circumference and length measurements of 7,425 liveborn preterm infants from 1985 to 1997 were retrieved from a longitudinal database maintained by the neonatology division. The 3rd, 5th, 10th, 15th, 25th, 50th, 75th, 85th, 90th, 95th and 97th percentiles of each measurement were determined and used for mathematical modeling. RESULTS: Birth weight was described with an exponential function while head circumference and length were described with linear functions. A preterm growth chart for the 10th, 50th and 90th percentiles for birth weight, weight growth, head circumference and length was generated. CONCLUSION: The mathematical models of growth provide smooth representations of the percentiles across gestational ages.

Expression profiling of medulloblastoma: PDGFRA and the RAS/MAPK pathway as therapeutic targets for metastatic disease.

Little is known about the genetic regulation of medulloblastoma dissemination, but metastatic medulloblastoma is highly associated with poor outcome. We obtained expression profiles of 23 primary medulloblastomas clinically designated as either metastatic (M+) or non-metastatic (M0) and identified 85 genes whose expression differed significantly between classes. Using a class prediction algorithm based on these genes and a leave-one-out approach, we assigned sample class to these tumors (M+ or M0) with 72% accuracy and to four additional independent tumors with 100% accuracy. We also assigned the metastatic medulloblastoma cell line Daoy to the metastatic class. Notably, platelet-derived growth factor receptor alpha (PDGFRA) and members of the downstream RAS/mitogen-activated protein kinase (MAPK) signal transduction pathway are upregulated in M+ tumors. Immunohistochemical validation on an independent set of tumors shows significant overexpression of PDGFRA in M+ tumors compared to M0 tumors. Using in vitro assays, we show that platelet-derived growth factor alpha (PDGFA) enhances medulloblastoma migration and increases downstream MAP2K1 (MEK1), MAP2K2 (MEK2), MAPK1 (p42 MAPK) and MAPK3 (p44 MAPK) phosphorylation in a dose-dependent manner. Neutralizing antibodies to PDGFRA blocks MAP2K1, MAP2K2 and MAPK1/3 phosphorylation, whereas U0126, a highly specific inhibitor of MAP2K1 and MAP2K2, also blocks MAPK1/3. Both inhibit migration and prevent PDGFA-stimulated migration. These results provide the first insight into the genetic regulation of medulloblastoma metastasis and are the first to suggest a role for PDGFRA and the RAS/MAPK signaling pathway in medulloblastoma metastasis. Inhibitors of PDGFRA and RAS proteins should therefore be considered for investigation as possible novel therapeutic strategies against medulloblastoma.

Interleukin-10 inhibition of gelatinases in fetal membranes: therapeutic implications in preterm premature rupture of membranes.

OBJECTIVE: To examine the effect of interleukin-10 on production and regulation of gelatinases by amniochorion in an in vitro model of infection. METHODS: We placed amniochorionic membranes collected from eight women who had elective repeat cesareans at term in an organ explant culture system. After 48 hours in culture, the membranes were stimulated with lipopolysaccharide (50 ng/mL), and some were costimulated with interleukin-10 (500 ng/mL). Tissue and media samples were collected after 24-hour stimulation. Quantitative polymerase chain reactions and enzyme-linked immunosorbent assays were used to evaluate matrix metalloproteinase 2 and matrix metalloproteinase 9 messenger RNA and proteins, respectively. RESULTS: Lipopolysaccharide stimulation induced 55.14 transcripts of matrix metalloproteinase 9, compared with 0.83 in control tissues (P <.001). Costimulation with interleukin-10 and lipopolysaccharide significantly reduced matrix metalloproteinase 9 messenger RNA levels to 10 transcripts (P <.001). Lipopolysaccharide stimulation produced 29.25 ng/mL of immunoreactive matrix metalloproteinase 9, which was reduced to 6.3 ng/mL (P(adj) =.016) after costimulation with interleukin-10. Although not significant, matrix metalloproteinase 2 messenger RNA levels were higher in lipopolysaccharide-stimulated tissues (4.37 x 10(6) transcripts) compared with control (2.8 x 10(5) transcripts; P(adj) =.08), with a significant decrease in matrix metalloproteinase 2 messenger RNA levels in interleukin-10- costimulated tissues (2.9 x 10(6); P(adj) =.007). Interleukin-10 costimulation resulted in a significant decrease in matrix metalloproteinase 2 protein production (203.1 [lipopolysaccharide] and 149.75 [with interleukin-10]; P(adj) <.001). CONCLUSION: Interleukin-10 eliminated lipopolysaccharide induction of matrix metalloproteinase 2 and 9 in amniochorion.

MeCP2 mutations in children with and without the phenotype of Rett syndrome.

BACKGROUND: Rett syndrome (RTT) is a neurodevelopmental disorder caused by mutations in the X-linked methyl CpG binding protein 2 (MeCP2) gene. METHODS: One hundred sixteen patients with classical and atypical RTT were studied for mutations of the MeCP2 gene by using DHPLC and direct sequencing. RESULTS: Causative mutations in the MeCP2 gene were identified in 63% of patients, representing a total of 30 different mutations. Mutations were identified in 72% of patients with classical RTT and one third of atypical cases studied (8 of 25). The authors found 17 novel mutations, including a complex gene rearrangement found in one individual involving two deletions and a duplication. The duplication was identical to a region within the 3' untranslated region (UTR), and represents the first report of involvement of the 3' UTR in RTT. The authors also report the identification of MeCP2 mutations in two males; a Klinefelter's male with classic RTT (T158M) and a hemizygous male infant with a Xq27-28 inversion and a novel 32 bp frameshift deletion [1154(del32)]. Studies examining the relationship between mutation type, X-inactivation status, and severity of clinical presentation found significant differences in clinical presentation between different types of mutations. Mutations in the amino-terminus were significantly correlated with a more severe clinical presentation compared with mutations closer to the carboxyl-terminus of MeCP2. Skewed X-inactivation patterns were found in two asymptomatic carriers of MeCP2 mutations and six girls diagnosed with either atypical or classical RTT. CONCLUSION: This patient series confirms the high frequency of MeCP2gene mutations causative of RTT in females and provides data concerning the molecular basis for clinical variability (mutation type and position and X-inactivation patterns).

Neuroblastomas of infancy exhibit a characteristic ganglioside pattern.

BACKGROUND: Gangliosides are membrane-bound glycolipid molecules particularly prominent in neural tissue. Changes in ganglioside expression during embryologic development result from a shift in biosynthesis from the fetal b pathway to the adult a pathway. Tumor gangliosides may play a role in the clinical behavior of certain subtypes of neuroblastoma. Because neuroblastoma, which presents in infancy, has a different biologic and clinical phenotype than that which presents in older children, the authors determined whether differences in ganglioside biosynthesis exist between these two neuroblastoma subgroups. METHODS: Sixty-eight tumor specimens (25 diagnosed by screening and 43 diagnosed clinically) were obtained from the Quebec Neuroblastoma Screening Project. Gangliosides were isolated and purified by solvent partitioning, separated by high performance thin-layer chromatography, and quantitated by scanning densitometry. The sum of a and b pathway gangliosides were determined for each tumor. RESULTS: Gangliosides of the b (fetal) pathway predominated in both screened and clinically diagnosed tumors of patients younger than 1 year of age. Twenty-three of 25 screened patients (92%) and 21 of 23 patients with clinically diagnosed tumors at younger than 1 year of age (91%) had tumor b pathway ganglioside content greater than 60%. In contrast, tumors of only 8 of 20 patients 1 year or older (40%) had b pathway ganglioside predominance. Predominance of b pathway tumor gangliosides correlated with improved outcome. Event free survival was significantly higher among patients with b pathway ganglioside tumor content greater than 60% versus those with b pathway ganglioside tumor content less than 60% (118.1 +/- 3.9 months vs. 69.2 +/- 8.6 months, P < 0.01). CONCLUSIONS: Fetal patterns of ganglioside biosynthesis predominate in neuroblastoma tumors from patients younger than 1 year of age and adult patterns of ganglioside biosynthesis predominate in tumors from older children, supporting the view that neuroblastoma consists of distinct but overlapping disorders, and that gangliosides may play a biologic role in the clinical differences among these patients.

The effect of biofeedback in hypertension.

The purpose of this study was to determine the effectiveness of biofeedback in the treatment of stages 1 and 2 essential hypertension via meta-analytical methods. A utilization-focused integrative review was limited to adult randomized clinical trials, and study groups were categorized into biofeedback, active control, and inactive control. Both biofeedback and active control treatments resulted in a reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP). Only biofeedback (with related cognitive therapy and relaxation training) showed a significantly greater reduction in both SBP (6.7 mm Hg) and DBP (4.8 mm Hg) when compared with inactive control treatments. Nurses in practice settings should consider biofeedback therapy for their hypertensive clients.

Women subjects in NIH-funded clinical research literature: lack of progress in both representation and analysis by sex.

The National Institutes of Health (NIH) issued guidelines in 1990 requiring the inclusion of women and minorities in all NIH-sponsored clinical research and revised these guidelines in 1994 to require analysis of clinical trial outcomes by sex of the subjects. To ascertain whether these guidelines are yet reflected in the scientific literature, we performed a survey of research articles published in major medical journals. All original research articles in the New England Journal of Medicine, the Journal of the American Medical Association, the Journal of the National Cancer Institute, and Circulation from the years 1993, 1995, 1997, and 1998 were examined. Articles were assessed for use of human subjects, source of funding, type of study (clinical trial or not), sex-relatedness of the disease or condition, inclusion of women as study subjects, and analysis of outcomes by sex of the subjects. Among NIH-funded, non-sex-specific studies, approximately one fifth of the studies published each year failed to include women as research subjects. This number did not improve significantly over the 5-year period analyzed. Only one quarter to one third of the studies that included women analyzed data by sex of the subjects, with no significant change over the time period studied. Although most clinical trials included women as study subjects, in only a small percentage of the trials were results analyzed by sex of the subjects, with no significant improvement over time. These data clearly show the need for increased awareness and monitoring of recruitment and retention of women in clinical research and for analysis of data by sex of the subjects to be carried out consistently.

Use of a live attenuated varicella vaccine to boost varicella-specific immune responses in seropositive people 55 years of age and older: duration of booster effect.

Varicella-zoster virus (VZV)-specific T cell immunity was measured in 130 persons > or = 55 years of age 6 years after they received a live attenuated VZV vaccine. Circulating T cells, which proliferated in vitro in response to VZV antigen, were enumerated (VZV responder cell frequency assay). Six years after the booster vaccination, the VZV-responding cell frequency (1/61,000 circulating cells) was still significantly (P < .05) improved over the baseline measurements (1/70,000) and appears to have diminished the expected decline in frequency as these vaccinees aged (to 1/86,000). Ten herpes-zoster--like clinical events were recorded. Although the frequency of these events, approximately 1/100 patient-years, is within the expected range of such events for this age cohort, the number of lesions was small, there was very little pain, and there was no postherpetic neuralgia. These results support the development of a vaccine to prevent or attenuate herpes zoster.

The increased incidence on Mondays of work-related sprains and strains.

Insurance-industry researchers have shown an increase on Mondays of lost-time sprain and strains said to be work-related, but thought to be fraudulent claims for off-the-job weekend injuries. We examined this issue among civilian employees of the Department of the Navy, using data from claims for injuries occurring between 1989 and 1994. We found that the rate of Monday sprains and strains significantly exceeded the expected rate and that such claims were significantly more likely to be made by claimants who were craftsmen and mechanics, who reported an injury to the back or trunk, who were supervisors, or who did not have college degrees. We estimate that 22% of claims for Monday-occurring sprains and strains are possibly fraudulent and that their cost to the Department of the Navy during the 6 years studied was $38 million. For the entire federal government, cost for such claims during this period may have exceeded $250 million.

Predictors of gender differences in sunscreen use and screening outcome among skin cancer screening participants.

This study identified predictors of sunscreen use in males and females and examined the extent to which gender differences in sunscreen use were associated with skin cancer screening outcomes. Subjects were 351 adult Southern California residents who participated in one of five free skin cancer screenings. Logistic regression models showed that sunscreen use was significantly associated with sex, personal and family history of skin cancer, and a sun sensitivity index. The latter three factors were found to be confounders of the sex-sunscreen use relationship. Whereas female use of sunscreen was best predicted by her sun sensitivity, male use of sunscreen was best predicted by a family history of skin cancer. Screening outcomes also varied by sex, suggesting that the interrelationships among gender, family history of skin cancer, and sun sensitivity have important implications for sunscreen use, which may in turn impact clinical outcomes.

Psychosocial implications of service dog ownership for people who have mobility or hearing impairments.

Service dogs for people with mobility impairments and hearing ear dogs for persons with hearing impairments have grown in popularity because the important practical tasks these dogs perform enhance the independence of their owners. Little is known about the psychosocial impact of service dog ownership, however. The results of a survey of 24 owners and seven trainers on the psychosocial benefits and liabilities of service dog ownership are presented and the implications for social work practice are discussed.