Health service COVID-19 wellbeing and support initiatives: a mixed-methods evaluation.

BACKGROUND: Health services implemented a range of initiatives during the COVID-19 pandemic to support employee wellbeing and assist employees to manage the professional and personal challenges they experienced. However, it is not known if such initiatives were acceptable to employees or met their needs. AIMS: To evaluate the wellbeing and support initiatives implemented at an Australian health service during the COVID-19 pandemic from the perspectives of employees (both users and non-users) and key stakeholders. METHODS: A mixed-methods design (survey, interviews and data audit) to investigate employees' and key stakeholders' perceptions, experiences and use of the wellbeing and support initiatives implemented at a large tertiary metropolitan health service in Melbourne, Australia. RESULTS: Ten employees participated in an interview and 907 completed a survey. The initiatives were well used and appreciated by staff. There was no significant difference in the proportion of clinical staff who had used the initiatives compared to non-clinical staff (44% versus 39%; P=0.223). Survey respondents reported the initiatives improved their mental health (n = 223, 8%), ability to cope with COVID-19 related stress and anxiety (n = 206, 79%), do their work (n = 200, 77%) and relationships with colleagues (n = 174, 67%). Staff would like many of the initiatives (with some modifications) to continue after the COVID-19 pandemic. CONCLUSIONS: The findings suggest a high level of staff satisfaction with the implemented wellbeing and support initiatives, and confirm the need for, and importance of, developing and implementing initiatives to support health service staff during outbreaks of infectious diseases such as the COVID-19 pandemic.

Health and happiness is more important than weight': a qualitative investigation of the views of parents receiving written feedback on their child's weight as part of the National Child Measurement Programme.

BACKGROUND: The present study aimed to explore parental perceptions of overweight children and associated health risks after receiving National Child Measurement Programme (NCMP) weight feedback. METHODS: Fifty-two parents of overweight and obese children aged 4-5 years and 10-11 years enrolled in the NCMP programme in England in 2010-2011 participated in qualitative, semi-structured interviews about their perceptions of their child's weight and health risk after receiving weight feedback. Interviews were audio tape recorded and were conducted either by telephone (n = 9) or in the respondents' homes (n = 41). Interviews were transcribed verbatim and analysed using interpretative thematic analysis. RESULTS: Parents who received NCMP written feedback informing them that their child was overweight disregarded the results because they viewed 'health and happiness as being more important than weight'. The feedback was viewed as less credible because it did not consider the individual child's lifestyle.'Broad definitions of healthy' were described that did not include weight,such as reference to the child having good emotional and physical health and a healthy diet. Parents attributed weight to 'inherited/acquired factors' such as genetics or puppy fat, or did not regard their child's 'appearance' as reflecting being overweight. 'Cultural influence' also meant that being overweight was not viewed negatively by some non-white parents. CONCLUSIONS: After receiving written weight feedback, parents use methods other than actual weight when evaluating their child's weight status and health risks. Parents' conceptions of health and weight should be considered when communicating with parents, with the aim of bridging the gap between parental recognition of being overweight and subsequent behaviour change.

Rapid on-site assessment of specimens by biomedical scientists improves the quality of head and neck fine needle aspiration cytology.

OBJECTIVE: Immediate rapid on-site assessment (ROSA) of fine needle aspiration cytology (FNAC) specimens by biomedical scientists (BMS), the UK equivalent of cytotechnologists, or by pathologists may improve specimen quality and cellular adequacy rates for lymph node, head and neck and thyroid FNAC. The aim of this study was to evaluate the effect of introducing ROSA by BMS in an outpatient clinic setting. METHODS: The adequacy rate and sensitivity of histological diagnosis for lymph node, thyroid and salivary gland FNAC samples were determined before and after the introduction of BMS ROSA. The additional financial costs and time required to perform this service were also estimated. RESULTS: Thirty-one patients underwent ultrasound (US)-guided FNAC with ROSA and 151 without. ROSA reduced the number of FNAC insufficient in quality for diagnosis from 43% to 19% (P = 0.0194). The estimated additional cost for pathology per patient for ROSA was between £52.05 and £70.74, equivalent to €65.40/US $83.90 and €88.89/US $114.0, respectively, an increase of between 28% and 49% from the original cost. ROSA necessitated an additional 6 minutes clinic time per patient, reducing the number of patients that could be seen in an average clinic from 13 to 10 as well as requiring increased laboratory time for FNAC slide assessment. CONCLUSION: ROSA by suitably trained biomedical scientists and with appropriate consultant pathologist support can improve the quality of FNAC sampling for head and neck lesions. Although ROSA resulted in both additional financial and time costs, these are more than likely to be offset by a reduction in patients returning to clinic for repeat FNAC or undergoing unnecessary surgery.

The impact of instrumental feeding on children's responses to taste exposure.

BACKGROUND: In a recent study, we showed that nonfood incentives combined with taste exposure increase children's acceptance of vegetables. However, the impact of children's previous experience of receiving food rewards is unknown. The present study investigated whether the experience of food rewards affects responses to an exposure-plus-reward intervention. METHODS: One hundred and thirty-seven parents of 4-6-year-old children taking part in an exposure-based intervention study completed an instrumental feeding (IF) questionnaire aiming to assess their use of food rewards. Based on these scores, children were categorised as frequently or rarely instrumentally-fed. Intervention groups were given 12 daily tastes of a target vegetable combined with no reward, a tangible reward, (sticker) or a verbal reward (praise). A no-treatment control group received no tastings. Liking and intake of a target vegetable were measured at baseline and post-intervention. RESULTS: Irrespective of experience of IF, children in all intervention groups increased liking compared to controls (all P < 0.001) and both reward groups increased intake compared to controls (both P < 0.05). However, in the nonrewarded exposure group, only children with a limited experience with food rewards increased consumption (P < 0.05). CONCLUSIONS: Experience of IF may limit the benefits of 'mere exposure'. However, exposure with nonfood rewards can increase the acceptance of vegetables, regardless of previous experience.

Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus.

BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

The impact of flavour exposure in utero and during milk feeding on food acceptance at weaning and beyond.

An individual's experience of flavours contributes to their unique pattern of food preferences. Exposure to a specific flavour can increase familiarity and result in greater acceptance of this flavour over time. This paper describes the earliest occurrences of flavour exposure; first in utero, via amniotic fluid, and later through breast or formula milk. Evidence suggests these early experiences impact on later food preferences, but the extent to which specific flavour compounds from the mother's diet are transmitted during these pre- and early post-natal periods may vary within and between individuals. In contrast with findings with toddlers and older children, infants accept new flavours rapidly, with relatively few exposures required. Early exposure to flavour variety may improve long term dietary outcomes, highlighting the need to promote a varied diet during pregnancy and lactation.

Appetitive behaviours of children attending obesity treatment.

Associations between appetite and adiposity have not been examined in clinical samples of obese children. The Children's Eating Behaviour Questionnaire (CEBQ) was used to compare appetite in community (n=406) and clinical (n=66) samples. Clear graded patterns were seen for food responsiveness and emotional overeating; levels increased with increasing BMI SDS and the clinical sample scored highest. The reverse was seen for satiety responsiveness/slowness in eating. Differences were not solely explained by weight differences, suggesting that the clinical sample had more pronounced 'obesogenic' appetitive traits. This could make adherence to dietary guidance difficult.

Parental feeding behaviours and motivations. A qualitative study in mothers of UK pre-schoolers.

Parental feeding behaviours are considered major influences on children's eating behaviour. However, many questionnaire studies of feeding neglect subtle distinctions between specific feeding strategies and practices in favour of eliciting general feeding goals, and do not take account of the context provided by parents' motivations. These factors may be critical to understanding child outcomes and engaging parents in child obesity prevention. The present study obtained interview and diary data on specific feeding behaviours and underlying motivations from 22 mothers of predominantly healthy weight 3-5 y olds in the UK. Parents described a wide range of efforts to promote or restrict intake that were largely motivated by practical and health considerations and only rarely by concern about weight. There was also evidence for instrumental feeding, rules surrounding meal-time, child involvement, and parental flexibility in relation to feeding. Almost all parents described responding to children's appetitive traits, consistent with growing evidence for genetically influenced individual differences in children's appetite. These findings suggest that in order to engage parents of currently healthy weight children, obesity prevention advice should aim to satisfy their primary motivations (practicality, health), and be framed as helping parents to respond sensitively and appropriately to different children's characteristics.

Natural Occurrence of Phytophthora infestans Causing Late Blight on Woody Nightshade (Solanum dulcamara) in New York.

Woody nightshade (Solanum dulcamara) is a common hedgerow herbaceous perennial in the United States, one of only three native Solanum spp. S. dulcamara is a known host of Phytophthora infestans (3), but infection is rarely reported. There is a U.S. record from Maryland (2); in 1947, Peterson (4) stated that this species had never been found blighted in its natural habitat, although in 1960 it was listed as a host of P. infestans in New York (1). The A2 mating type has not been reported on this host. On 2 July, 2009, leaf lesions similar to those of P. infestans on potato were found on wild S. dulcamara at Riverhead, NY. The plant was growing in a home garden within 10 m of potato and tomato plants infected with P. infestans. When two infected leaves of S. dulcamara were incubated for 24 h under high humidity, a pathogen growth developed around the lesion margins that was characterized by hyaline mycelium bearing lemon-shaped sporangia that released motile zoospores after chilling in water, which is consistent with P. infestans. The caducous and limoniform to ovoid sporangia were 39 to 50 µm (average 45 µm) × 26 to 28 µm (average 27 µm) with a length/breadth ratio of 1.66. No oospores were observed. Three isolates were obtained from this plant during July 2009. Growth on rye agar was indistinguishable from that of local tomato isolates of P. infestans. Detached leaflets of S. dulcamara and S. tuberosum, inoculated with the woody nightshade isolates and kept in a humid chamber, became infected and developed profuse sporulation within 5 days. The pathogen isolated was confirmed as P. infestans by morphological, biochemical, and molecular characteristics. Inoculations of attached leaves of potted S. dulcamara plants resulted in necrotic lesions with many sporangia; sporulation also developed on inoculated, attached, and detached tomato leaves. P. infestans was reisolated and identity confirmed as before. The three isolates were A2 mating type, metalaxyl-resistant, mitochondrial haplotype Ia. All were glucose-6-phosphate isomerase 100/122 and peptidase 100/100, as confirmed with single-spore isolates. RG57 fingerprint analysis confirmed that isolates from woody nightshade, tomato, and potato obtained from the same and nearby sites were identical. Although P. infestans in the United States belongs to the new population, which may infect a wider host range than the old US-1 clonal lineage, S. dulcamara infections have only been found when late blight is already widespread in neighboring fields and there is no evidence to suggest that woody nightshade acts as an overwintering host in the United States. References: (1) Anonymous. Index of Plant Diseases in the United States. Page 456 in: Agric. Handb. No. 165, 1960 (2) C. Cox. Phytopathology 38:575, 1948. (3) D. C. Erwin and O. K. Ribeiro. Page 190 in: Phytophthora Diseases Worldwide. The American Phytopathological Society, St. Paul, MN, 1996. (4) L. C. Peterson. Am. Potato J. 24:188, 1947.

Placental volume at 11 weeks is associated with offspring bone mass at birth and in later childhood: Findings from the Southampton Women's Survey.

OBJECTIVES: To investigate associations between placental volume (PV) at 11 weeks' gestation and offspring bone outcomes at birth, 6 years and 8 years. METHODS: 3D ultrasound scanning was used to assess 11 week PV in a subset (n = 236) of the Southampton Women's Survey (a prospective mother-offspring cohort). Maternal anthropometric measures and lifestyle information were obtained pre-pregnancy and at 11 weeks' gestation. Offspring dual-energy x-ray absorptiometry scanning was performed within 2 weeks postnatally and at 6 and 8 years. Linear regression was used to assess associations between PV and bone outcomes, adjusting for offspring age at DXA and sex, and maternal age, height, smoking status, walking speed and triceps skinfold thickness. ß are SD change in bone outcome per SD change in PV. RESULTS: In adjusted models, 11 week PV was positively associated with bone area (BA) at all time points, with evidence of persisting associations with increasing childhood age (birth: n = 80, ß = 0.23 [95%CI = 0.03, 0.42], 6 years: n = 110, ß = 0.17 [-0.01, 0.36], 8 years: n = 85, ß = 0.13 [-0.09, 0.36]). Similar associations between 11 week PV and bone mineral content (BMC) were observed. Associations with size-corrected bone mineral content were weaker at birth but strengthened in later childhood (birth: n = 78, ß = 0.07 [-0.21, 0.35], 6 years: n = 107, ß = 0.13 [-0.08, 0.34], 8 years: n = 71, ß = 0.19 [-0.05, 0.43]). CONCLUSIONS: 11 week PV is associated with DXA bone measures at birth, with evidence of persisting associations into later childhood. Further work is required to elucidate the contributions of placental morphology and function to gestational influences on skeletal development.

Do social norms affect intended food choice?

OBJECTIVE: To evaluate the effect of social norms on intended fruit and vegetable intake. METHODS: A two-stage design to i) compare the perceived importance of normative influences vs cost and health on dietary choices, and ii) test the prediction that providing information on social norms will increase intended fruit and vegetable consumption in an experimental study. Home-based interviews (N=1083; 46% men, 54% women) were carried out as part of the Office for National Statistics Omnibus Survey in November 2008. RESULTS: The public's perception of the importance of social norms was lower (M=2.1) than the perceived importance of cost (M=2.7) or health (M=3.4) (all p's<0.001) on a scale from 1 (not at all important) to 4 (very important). In contrast, results from the experimental study showed that intentions to eat fruit and vegetables were positively influenced by normative information (p=0.011) in men but not by health or cost information; none of the interventions affected women's intentions. CONCLUSIONS: People have little awareness of the influence of social norms but normative information can have a demonstrable impact on dietary intentions. Health promotion might profit from emphasising how many people are attempting to adopt healthy lifestyles rather than how many have poor diets.

Adiposity is not associated with children's reported liking for selected foods.

It is often assumed that heightened liking for energy-dense foods contributes to the development of obesity, however previous findings on the association between adiposity and liking among common foods are inconclusive in adults and there is limited research in children. Therefore the present study assessed the association between adiposity and liking for fatty or sugary foods, fruits and vegetables in children. A community sample of children aged 7-9 years (N=366) were recruited as part of the Physical Exercise and Appetite in CHildren Study (PEACHES). Anthropometric measurements (BMI- and waist-SD scores, fat mass index) were taken alongside self-reported liking for a list of fatty or sugary foods, fruits and vegetables. Regression analyses were used to predict liking from continuous adiposity measures (BMI- and waist-SD score, fat mass index). Linear trend analysis was used to assess the patterning of liking across weight categories. Vegetables were liked less than fatty or sugary foods or fruit, but there was no difference between liking for fruit and for fatty or sugary foods. Boys had a higher liking for fatty or sugary foods than girls, although sex-by-adiposity interactions were not significant for any of the food categories. There was no association between liking for any of the food categories and adiposity. This suggests that overweight in children is not reflective of differences in liking for selected common foods. Variation in appetitive responsiveness to food with increasing adiposity may be more salient in the development of obesity.

Mothers' views on portion sizes for children.

BACKGROUND: Childhood obesity has increased steadily over recent years and has coincided with a general trend towards larger portions of foods consumed both inside and outside the home. A causal link between portion size and weight gain has not been established, although there is evidence of an association between larger portions and greater energy intake. The present study aimed to investigate parent's attitudes, knowledge, practices, and concerns about appropriate portions for children. METHODS: Four focus groups with a total of 14 volunteer mothers of 8-11-year-old children taking part in a larger school-based study. Mothers were asked their views about portion sizes for their children and were asked to demonstrate typical servings that they would offer their children, by weighing five common foods provided. Conversations were tape-recorded and transcribed for thematic analysis. RESULTS: Participants were unconcerned about portion sizes and would not welcome official guidance, particularly if it involved weighing foods. Mothers fed their children the amount that they believed they would eat and felt that this varied across children and across occasions. The weighing task revealed a wide variation in portion sizes served to children, with portions of the more energy-dense foods being smaller on average than those of less energy-dense foods. CONCLUSIONS: There was little understanding of age-appropriate serving sizes amongst mothers in this study. Education campaigns should be mindful of the need to make portion information clear and simple because parents may not be prepared to weigh the food that they serve to their children.

A novel tyrosine kinase switch is a mechanism of imatinib resistance in gastrointestinal stromal tumors.

KIT or alpha-platelet-derived growth factor receptor (alpha-PDGFR) activating mutations are the pathogenic mechanisms that characterize gastrointestinal stromal tumors (GIST). Despite excellent responses to imatinib mesylate (IM), patients are relapsing. We developed an IM-resistant GIST cell line (GIST-R) from the IM-sensitive GIST882 cell line (GIST-S) by growing these cells in IM. Gene expression profiling (GEP) of GIST-S, GIST-R cells and two IM resistant GIST patients demonstrated that KIT is downregulated implying a major role in IM resistance. Instead, GIST-R cells have acquired IM resistance by overexpressing the oncogenic receptor tyrosine kinase - AXL - in a 'kinase switch'. Further, the two IM resistant GIST patients express AXL and not c-Kit, seen by immunohistochemistry (IHC). Real time reverse transcriptase-polymerase chain reaction and Western blotting of the GIST-S and GIST-R cells confirmed the switch from Kit to AXL. In GIST-R, AXL is tyrosine phosphorylated and its ligand growth-arrest-specific gene 6 is overexpressed implying autocrine activation. The kinase switch is associated with a morphological change from spindle to epithelioid. Molecular modeling of the kinase domain of mutant c-Kit (V654A) and AXL showed no binding to IM but efficient binding to MP470, a novel c-Kit/AXL kinase inhibitor. MP470 synergizes with docetaxel (taxotere) and is cytotoxic to GIST cells.

First Report of the A2 Mating Type of Phytophthora infestans on Tomato Crops in Taiwan, Republic of China.

In a study of the Phytophthora infestans population in Taiwan, samples with symptoms typical of late blight were collected from field crops in an important potato- (Solanum tuberosum) and tomato-(Lycopersicon esculentum) production area in the central highlands region. Isolates were obtained by surface disinfecting leaf sections and plating them onto antibiotic-amended rye A agar (1). After subculturing, the pathogen was confirmed as P. infestans on the basis of morphological characters (2). Mating type was determined by co-inoculating unamended rye agar plates with mycelial plugs of the test isolate and a reference P. infestans isolate of either the A1 or A2 mating type (four plates per test isolate, two with different A1, and two with different A2 reference isolates). After incubation (15°C darkness, 7 to 14 days), plates were examined microscopically for the presence of oospores where the colonies interacted. In 2004, one isolate of 200 tested, and in 2006, one isolate of 102 tested, produced oospores only with A1 reference isolates and were concluded to be A2 mating type. In vitro testing showed the two A2 isolates were metalaxyl-resistant (ED50 values >100 mg of metalaxyl per liter on rye grain agar), which is typical of recent P. infestans isolates from potato and tomato in this area (2). Twenty-one single-sporangial isolates from each of the two A2 strains were tested for mating type against two different A1 isolates of P. infestans and confirmed as A2. These isolates were characterized using the techniques described by Deahl et al. (1) and had the allozyme genotype 100/100/111, 100/100 at the loci coding for glucose-6-phosphate isomerase and peptidase, respectively, and were mitochondrial haplotype IIb. This multi-locus genotype is characteristic of recent P. infestans isolates from tomato and potato in Taiwan, but all previous such isolates were A1 mating type and attributed to the US-11 clonal lineage (1). When evaluated on differential hosts, both A2 isolates were tomato race PH-1 and complex potato race R 0,1,2,3,4,7,9,11. RG57 fingerprinting showed that the A2 isolates had fingerprints identical to each other and to A1 P. infestans isolates of the US-11 clonal lineage from tomato in Taiwan (101 011 100 100 110 101 011 001 1). Koch's postulates were completed and the two A2 isolates were found to be highly aggressive on cultivars of potato and tomato. To our knowledge, this is the first report of A2 mating type strains of P. infestans in the field in Taiwan, but currently, their incidence is very low (<1%). One crop from which an A2 isolate was obtained also yielded an A1 isolate, while A1 isolates were obtained from crops in the vicinity of the other. The concurrent presence of the two mating types of P. infestans poses a risk of sexual reproduction and oospore formation in tomato or potato in Taiwan. References: (1) K. L. Deahl et al. Pest Manag. Sci. 58:951, 2002. (2). D. C. Erwin and O. K. Ribeiro, Page 346 in: Phytophthora Diseases Worldwide. The American Phytopathological Society. St. Paul, MN, 1996.

Occupational injury in a fishmonger with a macular rash, hepatosplenomegaly and pancytopenia.

A 47-year-old fishmonger presented with a history of weight loss and lethargy. On investigation he was found to have myeloma. He presented again before follow up, with a 3-day history of fever and a maculopapular rash. He was admitted to the haematology ward and treated with broad-spectrum antibiotics. Blood cultures were found to be positive for Erysipelothrix rhusiopathiae. Penicillin treatment was given, and he made a good recovery. The importance of occupational illness in an already immunocompromised patient and of taking a proper social and occupational history from patients on admission is illustrated through this case.

Primary central nervous system lymphoma: a single-centre experience of 55 unselected cases.

AIMS: Current treatment for primary central nervous system lymphoma (PCNSL) involves high-dose methotrexate (HDMTX) with or without radiotherapy. Many published studies describing this approach include a highly selected group of patients. We report a single-centre experience of unselected cases of PCNSL. MATERIALS AND METHODS: We retrospectively reviewed the case notes of 55 consecutive patients diagnosed with biopsy-proven PCNSL between 1995 and 2003 at Addenbrooke's Hospital Cambridge, UK. We describe the treatment and outcome, including survival, treatment-related toxicity and long-term functional disability. RESULTS: At diagnosis, 45% of patients were considered unfit to receive treatment with HDMTX, owing to poor performance status or comorbidity. These patients had a median survival of 46 days and may not have been included in other published studies. The remaining patients were treated with a chemotherapy regimen, which included HDMTX. Patients who received at least one cycle of a chemotherapy containing HDMTX had a median survival of 31 months. Forty per cent did not complete planned chemotherapy owing to toxicity, disease progression or death. The median survival of patients treated with HDMTX aged 60 years compared with patients aged under 60 years was 26 months vs 41 months (P = 0.07), respectively. Younger patients treated with HDMTX, who achieved complete remission with chemotherapy, had a median survival of 56 months. We identified a high incidence of functional disability among survivors, resulting from a combination of the tumour itself, the neurosurgical procedure required for diagnosis and the late neurotoxicity of combined chemoradiotherapy. CONCLUSION: The treatment of PCNSL is associated with significant early and late toxicity. Further attempts to improve treatment should address mechanisms to reduce this toxicity. In particular, the benefit of radiotherapy in patients who achieve complete remission with HDMTX will remain uncertain until it is addressed in a multicentre, randomised trial.

Liver transplantation for children: Red Cross Children's Hospital experience.

BACKGROUND: The liver transplant program for infants and children at the Red Cross Children's Memorial Hospital is the only established pediatric service in sub-Saharan Africa. Since 1985, 250 infants and children have been assessed and 155 accepted for transplantation. METHODS: Since 1987, 76 children (range 6 months to 14 years) have had 79 liver transplants, with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (n = 44), metabolic (n = 7), fulminant hepatic failure (n = 10), redo transplants (n = 3), and other (n = 15). Three combined liver/kidney transplants have been performed. Forty-nine were reduced-size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1, and 29 children weighed < 10 kg. RESULTS: Fifty-six (74%) patients survived 3 months to 12 years posttransplant. Cumulative 1- and 5-year patient survival data are 79% and 70%, respectively. However, with the introduction of prophylactic intravenous gancyclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the projected 5-year pediatric survival has been >80%. Early (<1 month) post-liver-transplant mortality was low, but included: primary malfunction (n = 1); inferior vena cava thrombosis (n = 1); bleeding esophageal ulcer (n = 1); and sepsis (n = 1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths); Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disease (12 patients, 7 deaths); and cytomegalovirus disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in three patients was complicated by chronic rejection (n = 1) and TB drug-induced subfulminant liver failure (n = 1). CONCLUSIONS: Despite limited resources, a successful pediatric program has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors due to HBV and human immunodeficiency virus (HIV) leads to significant waiting list mortality and infrequent transplantation.

Nephrotoxic effects of immunosuppressant therapy in pediatric liver transplant recipients.

Drugs used for immunosuppression have been implicated in causing numerous long-term side effects including nephrotoxicity, glucose intolerance, and hyperlipidemia. In this study, we reviewed our pediatric liver transplant recipients in terms of glomerular filtration rate (GFR) as well as fasting glucose and lipid profiles. To date, 79 pediatric liver transplantations have been performed at our center: 24 transplantations of at least 5 months to a maximum of 7.3 years posttransplant are reviewed herein. The mean time posttransplantation was 2.1 years. Nine boys and 15 girls showed a distribution of 19 mixed race, 3 black, and 2 white patients. The mean age at the time of transplantation was 6.6 years (0.8-13.3 years) with 8 cases under the age of 3 years. All recipients started with Cyclosporine Neoral (CSA) as first line, but, at the time of testing, immunosuppression included 5 children on CSA and 19 on Tacrolimus. Radionuclide 51 Cr-EDTA Glomerular Filtration Rates (GFR) showed a range from 21 to 220 mL/min/1.73 m2 (mean 96.1, median 89.8). Seven cases had a GFR less than 75 mL/min/1.73 m2. Twenty-one children were on antihypertensives agents: 15 children on 1 agent and 6 children on 2 agents. On full fasting lipid profiles, the total cholesterol ranged from 2 to 7.9 mmol/L (mean 4.4). Only 1 child is currently on statin therapy. Fasting glucose ranged from 3.2 to 5.9 mmol/L (mean 4.1) No difference was observed in glucose values between CsA and Tacrolimus. Thus, immunosuppressive therapies, such as the calcineurin inhibitors, are known to cause nephrotoxicity, which is of concern in pediatric liver transplant recipients. Almost all our patients currently require antihypertensive therapy. At present, the renal function is adequate in the majority of the group, but this study needs to be extended to other pediatric liver transplant recipients with particular emphasis on those who are more than 5 years posttransplantation.

Chinook winds and migraine headache.

OBJECTIVE: To determine the effects of chinook weather conditions on probability of migraine headache onset. BACKGROUND: Many migraineurs believe weather to be a trigger factor for their headaches; however, there is little supportive evidence in the literature. Migraineurs in the southern part of the Canadian province of Alberta frequently report that chinooks, warm westerly winds specific to the region, trigger their headaches. METHOD: Weather data from Environment Canada were used to designate each calendar day during the study period as a chinook, prechinook, or nonchinook day. Headache data were collected from 75 patient diaries from the University of Calgary Headache Research Clinic. Individual and multiple logistic regression models were used to determine if the weather conditions affected the probability of migraine onset. RESULTS: The probability of migraine onset was increased on both prechinook days (odds ratio 1.24; 95% CI 1.08 to 1.42) and on days with chinook winds (1.19; 1.02 to 1.39) compared with nonchinook days. Analysis of chinook wind velocities revealed that for chinook days, the relative risk of migraine onset was increased only on high-wind chinook days (velocity > 38 km/h) (odds ratio 1.41; 95% CI 1.06 to 1.88). A subset of individuals was sensitive to high-wind chinook days, and another subset was only sensitive to prechinook days. Only two patients were sensitive to both weather conditions, and the majority of patients was not sensitive to either. Neither weather condition had a protective effect. Increasing age was associated with high-wind chinook sensitivity (p = 0.009) but not prechinook sensitivity (p = 0.389). CONCLUSIONS: Both prechinook and high-wind chinook days increase the probability of migraine onset in a subset of migraineurs. Because few subjects were found to be sensitive to both weather types, the mechanisms for these weather effects may be independent. This is supported by the presence of an age interaction for high-wind chinook days but not for prechinooks day.