Defining remission in childhood-onset lupus: PReS-endorsed consensus definitions by an international task force.

OBJECTIVE: To derive childhood-onset SLE (cSLE) specific remission definitions for future treat-to-target (T2T) trials, observational studies, and clinical practice. METHODS: The cSLE International T2T Task Force conducted Delphi surveys exploring paediatric perspectives on adult-onset SLE remission targets. A modified nominal group technique was used to discuss, refine, and agree on the cSLE remission target criteria. RESULTS: The Task Force proposed two definitions of remission: 'cSLE clinical remission on steroids (cCR)' and 'cSLE clinical remission off steroids (cCR-0)'. The common criteria are: (1) Clinical-SLEDAI-2 K = 0; (2) PGA score < 0.5 (0-3 scale); (4) stable antimalarials, immunosuppressive, and biologic therapy (changes due to side-effects, adherence, weight, or when building up to target dose allowed). Criterion (3) in cCR is the prednisolone dose ≤0.1 mg/kg/day (maximum 5 mg/day), whereas in cCR-0 it is zero. CONCLUSIONS: cSLE definitions of remission have been proposed, maintaining sufficient alignment with the adult-SLE definition to facilitate life-course research.

Mechanisms by which feeding synthetic zeolite A and dietary cation-anion difference diets affect feed intake, energy metabolism, and milk performance: Part II.

The objectives of this study were to assess the effects of feeding 2 different diets, a diet with low dietary cation-anion difference (DCAD) or a diet with synthetic zeolite A, to multiparous Holstein cows during the close-up period on dry matter intake (DMI) and energy metabolism, as well as to evaluate colostrum and milk production. A total of 121 multiparous Holstein cows, blocked by lactation number and expected parturition date were enrolled at 254 d of gestation and randomly assigned to 1 of 3 dietary treatments: control (CON; +190 mEq/kg; n = 40), negative DCAD (-DCAD, -65 mEq/kg; n = 41; Ultra Chlor; Vita Plus, Lake Mills, WI), or a diet containing sodium aluminum silicate zeolite (XZ; +278 mEq/kg, fed at 3.3% dry matter, targeting 500 g/d; n = 40; X-Zelit, Protekta Inc., Lucknow, ON, Canada/Vilofoss, Graasten, Denmark). Prepartum DMI was measured daily using Insentec roughage intake control (RIC) gates (RIC System, Holofarm Group, the Netherlands). All cows received the same postpartum diet. Blood and urine samples were collected daily beginning 14 d before parturition (d -14) until parturition (d 0), and on 1, 2, 3, 6, 9, 12, 15, 18, 21, 35, and 49 d postpartum. Colostrum collected within 6 h of parturition, weighed, and based on samples' Brix value, IgG concentrations, and nutrient composition were analyzed. Prepartum, cows fed the XZ diet had decreased DMI (11.70 ± 0.26, 13.88 ± 0.26, and 13.45 ± 0.25 kg/d for XZ, CON, and -DCAD, respectively) and lower rumination (487 ± 8.1, 531 ± 8.3, and 527 ± 8.5 min for XZ, CON, and -DCAD, respectively) compared with CON and -DCAD. However, rumination was not different postpartum due to treatment. No prepartum or postpartum differences were observed for glucose or BHB concentrations in blood between dietary treatments. Colostrum collected from cows fed XZ had the highest IgG concentrations (91.10 ± 2.63, 78.00 ± 2.63, and 78.90 ± 2.63 mg/mL for XZ, CON, and -DCAD, respectively), but yield did not differ between dietary treatments. Additionally, cows in their third lactation or greater fed XZ had the highest milk production (51.0 ± 1.1 kg) during the first 49 d in milk. This study demonstrates that despite a decrease in DMI and rumination in cows fed XZ prepartum, blood BHB concentrations were not altered. Additionally, cows fed XZ had higher colostral IgG concentrations and cows in their third lactation or greater fed XZ produced the most milk. These data suggest that feeding XZ prepartum may improve colostrum quality and milk yield in mature cows, and does not affect energy metabolism.

Mechanisms by which feeding synthetic zeolite A and dietary cation-anion difference diets affect mineral metabolism in multiparous Holstein cows: Part I.

The periparturient period is characterized by the increased demand for calcium (Ca) in dairy cows. This has resulted in the use of several different prepartal nutritional strategies to prevent hypocalcemia postpartum. The objective of our study was to determine the effects of feeding synthetic zeolite A (XZ), a diet with negative dietary cation-anion difference (-DCAD), or a positive-DCAD diet (CON) during the close-up period on peripartal mineral dynamics and hormones involved in calcium metabolism. To this end, 121 multiparous Holstein cows, blocked by lactation number and expected due date, were enrolled at 254 d of gestation and randomly assigned to 1 of 3 prepartum diets: CON (+190 mEq/kg; n = 40), -DCAD (-65 mEq/kg; n = 41), or a diet supplemented with sodium aluminum silicate (XZ; +278 mEq/kg, fed at 3.3% DM, targeting 500 g/d; n = 40; Protekta Inc.). Blood, urine, and saliva samples were collected from enrollment until parturition, with data analyzed and presented beginning 14 d before parturition (d -14) until parturition (d 0), and on d 1, 2, 3, 6, 9, 12, 15, 18, 21, 35, and 49 postpartum, to assess mineral and hormone dynamics. Total fecal collections were performed in a subset of 8 cows per treatment group to assess fecal mineral loss. Data were analyzed as a randomized complete block design in SAS. Cows fed XZ and -DCAD had higher blood Ca concentrations compared with CON-fed cows, with XZ-fed cows exhibiting the highest blood Ca concentrations pre- and postpartum. Cows fed XZ had decreased blood and salivary phosphorus (P), increased fecal water-extractable phosphate, and the highest blood calcium concentrations pre- and postpartum. Parathyroid hormone was unaffected by diet but was increased at parturition in all treatments. Serotonin concentrations were increased in -DCAD and XZ cows compared with CON during the prepartum period. Our data indicate that the XZ group's improvement in blood Ca concentrations pre- and postpartum is most likely regulated by a dietary P restriction. Taken together, these data suggest that XZ and -DCAD diets improve postpartum calcium metabolism; however, they appear to work through different mechanisms.

PReS-endorsed international childhood lupus T2T task force definition of childhood lupus low disease activity state (cLLDAS).

OBJECTIVE: To achieve a consensus-based definition of Low Disease Activity (LDA) for use in cSLE trials. METHODS: The International cSLE T2T Task Force, comprising of paediatric rheumatologists/nephrologists, and adult rheumatologists undertook a series of Delphi surveys/consensus meetings to discuss, refine, and vote upon cSLE LDA criteria. RESULTS: The Task Force agreed that LDA should be based upon the adult-SLE Lupus Low Disease Activity State definition (LLDAS), with modifications to make it applicable to cSLE (cLLDAS). They agreed upon five cLLDAS criteria: (1) SLE Disease Activity Index (SLEDAI)-2 K ≤4, with no activity in major organ systems; (2) no new features of lupus disease activity compared with the last assessment; (3) Physician Global Assessment score of ≤1 (0-3 scale); (4) prednisolone dose of ≤0.15 mg/kg/day, 7.5 mg/day/maximum; while on (5) stable antimalarials, immunosuppressives, and biologics. CONCLUSIONS: A cSLE-appropriate definition of cLLDAS has been generated, maintaining alignment with the adult-SLE definition to promote life-course research.

A Markov Multi-State model of lupus nephritis urine biomarker panel dynamics in children: Predicting changes in disease activity.

BACKGROUND: A urine 'biomarker panel' comprising alpha-1-acid-glycoprotein, ceruloplasmin, transferrin and lipocalin-like-prostaglandin-D synthase performs to an 'excellent' level for lupus nephritis identification in children cross-sectionally. The aim of this study was to assess if this biomarker panel predicts lupus nephritis flare/remission longitudinally. METHODS: The novel urinary biomarker panel was quantified by enzyme linked immunoabsorbant assay in participants of the United Kingdom Juvenile Systemic Lupus Erythematosus (UK JSLE) Cohort Study, the Einstein Lupus Cohort, and the South African Paediatric Lupus Cohort. Monocyte chemoattractant protein-1 and vascular cell adhesion molecule-1 were also quantified in view of evidence from other longitudinal studies. Serial urine samples were collected during routine care with detailed clinical and demographic data. A Markov Multi-State model of state transitions was fitted, with predictive clinical/biomarker factors assessed by a corrected Akaike Information Criterion (AICc) score (the better the model, the lower the AICc score). RESULTS: The study included 184 longitudinal observations from 80 patients. The homogeneous multi-state Markov model of lupus nephritis activity AICc score was 147.85. Alpha-1-acid-glycoprotein and ceruloplasmin were identified to be the best predictive factors, reducing the AICc score to 139.81 and 141.40 respectively. Ceruloplasmin was associated with the active-to-inactive transition (hazard ratio 0.60 (95% confidence interval [0.39, 0.93])), and alpha-1-acid-glycoprotein with the inactive-to-active transition (hazard ratio 1.49 (95% confidence interval [1.10, 2.02])). Inputting individual alpha-1-acid-glycoprotein/ceruloplasmin values provides 3, 6 and 12 months probabilities of state transition. CONCLUSIONS: Alpha-1-acid-glycoprotein was predictive of active lupus nephritis flare, whereas ceruloplasmin was predictive of remission. The Markov state-space model warrants testing in a prospective clinical trial of lupus nephritis biomarker led monitoring.

Growing international evidence for urinary biomarker panels identifying lupus nephritis in children - verification within the South African Paediatric Lupus Cohort.

BACKGROUND: A urinary biomarker panel including alpha-1-acid-glycoprotein (AGP), lipocalin-like-prostaglandin-D-synthase (LPGDS), transferrin and ceruloplasmin demonstrates an 'excellent' ability for identifying active lupus nephritis in UK/US children. This study aimed to assess whether this panel identifies active lupus nephritis within the South African Paediatric Lupus Cohort. METHODS: Juvenile-onset-systemic lupus erythematosus (JSLE) patients aged < 19 years at diagnosis and healthy controls were recruited. Patients were categorized as having active lupus nephritis (renal BILAG score; A/B and previous histological confirmation) or inactive lupus nephritis (renal BILAG score: D/E). Urinary biomarkers were quantified by ELISA. Mann-Whitney U-test compared biomarker levels between groups. Binary logistic regression and receiver operating curve analysis assessed biomarker combinations. RESULTS: Twenty-three juvenile-onset-systemic lupus erythematosus patients were recruited with a median age of 13.5 years (interquartile range (IQR) 12.7-14.9) and disease duration of 2.6 years (IQR 1.8-4.0). Eighteen healthy controls had a median age of 11.0 years (IQR 10.0-12.0). AGP, LPGDS, transferrin, ceruloplasmin and VCAM-1 were significantly higher in active than in inactive lupus nephritis patients (corrected p-values, all pc < 0.05), with no difference between inactive lupus nephritis patients and healthy controls (all pc = 1.0). The optimal biomarker combination included AGP, ceruloplasmin, LPGDS and transferrin (area under the curve = 1.0). CONCLUSIONS: A urinary biomarker panel comprising AGP, ceruloplasmin, LPGDS and transferrin previously validated within UK/US cohorts also performed excellently within a racially distinct South African cohort which displayed more severe lupus nephritis.

Severe disease presentation and poor outcomes among pediatric systemic lupus erythematosus patients in South Africa.

Background Systemic lupus erythematosus (SLE) is a life-threatening multisystem autoimmune disease that is more severe in patients of African ancestry and children, yet pediatric SLE on the African continent has been understudied. This study describes a cohort of pediatric SLE (PULSE) patients in South Africa. Methods Patients with a diagnosis of SLE (1997 American College of Rheumatology criteria) diagnosed prior to age 19 years in Cape Town, South Africa, were enrolled in this cross-sectional study from September 2013 to December 2014. Information on clinical and serological characteristics was extracted from medical records. Results were compared to a well-described North American pediatric SLE cohort. Results Seventy-two South African patients were enrolled in the study; mean age 11.5 years; 82% were girls. The racial distribution was 68% Coloured, 24% Black, 5% White and 3% Asian/Indian. Most patients presented with severe lupus nephritis documented by renal biopsy (61%). Of patients with lupus nephritis, 63% presented with International Society of Nephrology/Renal Pathology Society class III or IV. Patients in the PULSE cohort were more likely to be treated with cyclophosphamide, methotrexate and azathioprine. The PULSE cohort had high disease activity at diagnosis (mean Systemic Lupus Erythematosus Disease Activity Index-2K (SLEDAI-2K) 20.6). The SLEDAI-2K at enrolment in the PULSE cohort (5.0) did not differ from the North American pediatric SLE cohort (4.8). Sixty-three per cent of the PULSE cohort had end organ damage with Systemic Lupus International Collaborating Clinics Damage Index (SLICC-DI) score >0 (mean SLICC-DI 1.9), compared to 23% in a previously reported US cohort. Within the PULSE cohort, nine (13%) developed end-stage renal disease with six (8%) requiring transplant, strikingly higher than North American peers (transplant rate <1%). Conclusions The PULSE cohort had highly active multiorgan disease at diagnosis and significant disease damage at enrolment in the South African registry. South African patients have severe lupus nephritis and poor renal outcomes compared to North American peers. Our study revealed a severe disease phenotype in the PULSE cohort resulting in poor outcomes in this high-risk population.

A clinical update on paediatric lupus.

Systemic lupus erythematosus in children is a life-threatening chronic disease that is being increasingly recognised. More black African children are being diagnosed and the proportion of males affected is much higher than in adult-onset lupus. The presenting manifestations of childhood-onset lupus are variable and many systems are involved. Children with lupus often present late with severe disease, and in South African (SA) children severe lupus nephritis occurs commonly at presentation. The investigations for lupus should be performed in a three-step process ­ initial essential investigations, antibody and serological tests, and supplementary investigations. The most important factor in the management is to involve a multidisciplinary team as soon as possible. All cases of lupus in SA should be discussed with a paediatric specialist so that a tailored management plan can be made, depending on the presenting features and course of the disease.

CANDLE Syndrome: orodfacial manifestations and dental implications.

A South African girl with CANDLE Syndrome is reported with emphasis on the orodental features and dental management. Clinical manifestations included short stature, wasting of the soft tissue of the arms and legs, erythematous skin eruptions and a prominent abdomen due to hepatosplenomegaly. Generalized microdontia, confirmed by tooth measurement and osteopenia of her jaws, confirmed by digitalized radiography, were previously undescribed syndromic components. Intellectual impairment posed problems during dental intervention. The carious dental lesions and poor oral hygiene were treated conservatively under local anaesthetic. Prophylactic antibiotics were administered an hour before all procedures.Due to the nature of her general condition, invasive dental procedures were minimal. Regular follow-ups were scheduled at six monthly intervals. During this period, her overall oral health status had improved markedly.The CANDLE syndrome is a rare condition with grave complications including immunosuppression and diabetes mellitus. As with many genetic disorders, the dental manifestations are often overshadowed by other more conspicuous and complex syndromic features. Recognition of both the clinical and oral changes that occur in the CANDLE syndrome facilitates accurate diagnosis and appropriate dental management of this potentially lethal condition.

Laser-induced photodynamic therapy with aluminum phthalocyanine tetrasulfonate as the photosensitizer: differential phototoxicity in normal and malignant human cells in vitro.

Photodynamic therapy (PDT) involves the use of laser or noncoherent light energy with photosensitizing dyes to induce a cytotoxic reaction in the target cells, resulting in cell injury and/or death. In this study, we have examined laser-induced phototoxicity in normal human skin fibroblasts and HT-1080 fibrosarcoma cells incubated with aluminum phthalocyanine tetrasulfonate (AlPcS) in vitro. The culture, laser, and photosensitizer parameters were varied in attempts to establish the conditions for differential cytotoxicity between normal and malignant human fibroblasts. Biochemical assays, as a measure of cytotoxicity, included [3H]thymidine incorporation (an index of DNA replication), [35S]methionine incorporation (a measure of protein synthetic activity), and the MTT assay (an indirect index of mitochondrial activity). In the absence of laser irradiation, AlPcS was non-toxic to both cell lines in concentrations up to 25 micrograms/ml. Laser light alone at 675 nm (the absorption maximum of AlPcS) had no effect on the cells at energy densities up to 16 J/cm2. In the presence of 3 or 10 micrograms/ml of AlPcS, both cell lines demonstrated marked energy-dependent toxicity. If an 8-h or a 24-h "efflux" period in AlPcS-free medium was allowed to take place prior to laser irradiation, normal fibroblasts were much less sensitive to PDT, whereas fibrosarcoma cells still exhibited a marked degree of toxicity. The results indicate that, under appropriate treatment conditions, AlPcS is capable of preferentially sensitizing a malignant mesenchymal cell line, while sparing its non-malignant normal cell counterpart.

Twin relationships and depression.

The authors investigated closeness and other variables measuring depression in 22 identical and 13 fraternal twin pairs. Each twin rated him/herself on a two-part questionnaire; part 1 included questions on demographic characteristics and the twin relationship, and part 2, the Zung Self-Rating Depression Scale, measured depressive symptoms. There was a high degree of agreement across all variables for the total sample, and degrees of depression were comparable to that in the general population. Closeness was found to be inversely correlated with depression. The authors suggest that future studies include other groups (siblings, spouses, etc.) and follow-up data.

Monoclonal antibodies to bovine platelet factor 4: species interactions to platelets and megakaryocytes using indirect immunocytofluorescence.

Murine monoclonal antibodies (mAb) were raised to a purified product of bovine PF-4, a 9,500 dalton protein with heparin neutralization activity comparable to that of human PF-4. Using a non-radioactive slide immunoenzymatic assay, four major classes of mAb could be identified when comparisons were made between purified antigens of PF-4 and beta-TG-like protein from both bovine and human species. Type 1 cross-reacted with all four antigens; type 2 reacted with PF-4s; type 3 reacted with only bovine PF-4 and beta-TG-like protein; and type 4 reacted only with bovine PF-4. Differences in immunoreactivities of types 1, 2 and 3 were retained throughout the growth of succeeding clones and in ascitic fluids. Using a modified factor Xa, S-2222 chromogenic substrate-heparin inhibition assay, no mAb was found to block PF-4's ability to neutralize heparin. mAbs representative of types 1, 2 and 3 were successfully raised in stable cell lines from at least second generation clones. These were purified with protein A agarose and found to be IgG1. By indirect immunocytofluorescence a purified type 2 mAb, 2E7, was found to specifically stain granules of human platelets and megakaryocytes, as well as masses (putative platelets within late stage megakaryocytes) without staining other cellular types in either bone marrow or peripheral blood. Species comparisons displayed positive staining for human, rat, and rabbit platelets and megakaryocytes, and negative staining for mouse, guinea pig and dog platelets and megakaryocytes. It seems likely that mAb, 2E7, is directed against an epitope, common to PF-4 of bovine, human, rabbit and rat.

Meta-analysis of cognitive-behavioral treatment studies for bulimia.

A meta-analysis was performed to systematically assess the effect of cognitive-behavioral treatments for bulimia. To protect against past criticisms of meta-analyses, this study focused on well-defined hypotheses with clearly articulated conceptual foundations. Twenty-six studies of the cognitive-behavioral treatment of bulimia were selected through computer searches. Effect sizes were calculated for changes in behavioral outcome measures (25 independent hypothesis tests) and cognitive-attitudinal outcome measures (17 independent hypothesis tests). Additionally, two effect sizes were generated for within and between group comparisons. The analysis revealed an effect size of average r = 0.69 for behavioral outcome measures (average r = 0.64 for between group and average r = 0.74 for within group) and average r = 0.67 for cognitive-attitudinal outcome measures (average r = 0.64 for between group and average r = 0.69 for within group). Follow-up effect sizes were less favorable; however, the diversity of time spans and outcome measures used to calculate follow-up effect sizes limit their utility. Overall, results suggest that the use of a cognitive-behavioral therapy will result in favorable treatment outcomes and implications for future research are discussed.

Mental and physical health effects of intimate partner violence on women and children.

The battering of female partners and the concomitant emotional abuse that is almost always part of the coercive control have significant mental and physical health consequences for the women who experience this type of violence. Children who live in households fraught with the conflict, violence, and unpredictable danger of domestic violence often witness the battering of their mothers and may also be victims of child abuse themselves. This article highlights current knowledge regarding the mental and physical health effects of intimate partner violence on women and their children, and discusses needed directions for screening, intervention, research, and changes in the health care system.

PIP: This article reviews the literature on the effects of domestic violence on women and children. The introduction notes that domestic violence affects millions of women in the US each year, significantly increasing their health problems and their use of the health care system. The next sections review the incidence of mortality related to such abuse and women's physical health sequelae from battering. Consideration of women's mental health consequences focuses on the traumatic response framework that has been developed to conceptualize the psychological effects of domestic violence. The article then considers studies of abuse during pregnancy. Next, the article turns to the children of battered women, noting how they often fit the description of traumatized children but that there have been no studies to date of the existence among them of post-traumatic stress disorder. After looking at studies that marked children's responses to traumatic events and the effects of domestic violence on the children, the review examines work that revealed developmental differences in children from violent homes. The article then points to several limitations in prior research in the area of domestic violence and highlights the lack of experimental evaluation of treatments or interventions. Next, research into possible opportunities for routine screening and intervention is considered. The article concludes by documenting the need for a change in the health care system so that it can respond appropriately to the needs of battered women.

Anomalous dominance in Down syndrome young adults.

The ear advantages of groups of Down Syndrome and developmentally retarded (NonDown) young adults, and normal youngsters matched for mental age were compared on dichotic listening performance. The paradigm employed strings of single, double, and triple digits presented to each ear under both free and cued recall conditions. The developmentally retarded and normal groups demonstrated the typical right ear advantage (REA), whereas the Down Syndrome group produced a significant left ear advantage (LEA) in four of the six experimental conditions. In addition, for the cued as compared to free recall conditions, all three groups demonstrated relatively better right ear performance. These results indicate anomalous dominance in Down Syndrome young adults which is consistent across varying memory load and attentional demands. Furthermore, these results are not likely due to a maturational lag phenomenon, but more likely related to genetic, biologic, and neurologic, factors as suggested by Geschwind and Galaburda (1985).

Cell cycle and apoptosis in tumours of oral cavity estimated by image cytometry.

The aim of investigations was to examine whether diploid and aneuploid tumours of oral cavity differ in frequencies of occurrence of individual phases of cell cycle and of apoptosis. Investigations were carried out on 53 tumours using techniques of image cytometry. The studies were performed on properly isolated cells of tumours, which were stained using Feulgen method and analysed by image cytometry. Using a suitable computer programme, the percentages of cells present in individual phases of cell cycle and in apoptosis were estimated. No respective differences could be disclosed between diploid and aneuploid tumours. In addition, the ratios of the fraction of cells in S phase of the cell cycle and those in apoptosis were calculated and were found to carry certain prognostic significance in patients with squamous cell carcinomas of oral cavity.

Left-hemisphere dysfunction in autism: what are we measuring?

This study sought to investigate the left hemisphere deficit hypothesis regarding autism. A group of 15 autistic youngsters between the ages of 8 and 13 years was compared with a group of 15 mentally retarded youngsters matched for age and IQ on a set of measures presumed to be sensitive to neuropsychological dysfunction. The results suggested that this sample of autistic youngsters is best characterized by bilateral neuropsychological involvement, affecting left-hemisphere functioning predominantly but not exclusively. The findings of this and other such studies seem to be somewhat determined by the varied samples and assessments employed in the research. The practice of selecting tests which presumably tap left or right cerebral functions is highly inferential, and warrants concern, particularly when assessing complex cognitive functioning in autistic individuals.

Sleep alterations in cancer patients.

This multi-institutional sleep study involved two phases aimed at investigating sleep alterations in patients with any stage of breast and lung cancer. The first phase of this study used an 82-item, 20-minute telephone survey to elicit information regarding the impact of sleep disturbances on a convenience sample of 150 patients. Of these patients, 44% reported a sleep problem during the month before the interview. Significant relations included these: report of sleep problems prediagnosis over the past month (x = 5.82; p = 0.02), duration of sleep medication use and frequency of sleep problem (r = 0.58; p = 0.05), age and severity of sleep problems (r = 0.38; p = 0.05), and frequency and severity of the sleep problem over the past month (r = 0.21; p < 0.10). Communication with health care providers occurred in 16.6% of patients reporting a sleep disturbance. The second phase of this study explored the type, frequency, and severity of sleep problems and perceptions of causation, support, and methods of coping with the sleep problem. A qualitative approach to the problem was used in this phase. A one-time telephone interview of 42 patients, derived from a convenience sample, revealed a 45% prevalence of sleep problems a month before the interview. A qualitative analysis of the responses suggested that sleep problems are related to experiences of other symptoms and perceptions of cancer and treatment. Content analysis of the responses identified the following categories: figuring out the reason, seeking help, seeking support and relation to the overall cancer experience.

Critical care nurses' role with families: a descriptive study.

The purpose of this descriptive study was to explore the topic of families of critically ill patients from the critical care nurse's perspective. Two hundred twenty-six critical care nurses from one Midwest and three New England hospitals participated in the study. Critical care nurses' responses to questions about family visiting demonstrated variation in their interpretation and enforcement of visiting policies within units and among hospitals. There was overall consensus that family members should play a supportive, although nonparticipative role in the provision of care of their sick family member. More than 75% of the critical care nurses became involved with families in need of emotional support although more than one third of the respondents did not believe they had the requisite knowledge to meet families' psychosocial needs. Among the factors that most influenced critical care nurses' involvement with families were situations relating to the patient's actual or impending death and the nurses' subjective feelings (likes or dislikes) for the patient and family.

Training with o (observing) and T (treatment) teams in live supervision: reflections in the looking glass*.

Working with a treatment and observing team at the same time, behind the oneway mirror, offers a variety of ways to: (a) generate multiple realities; (b) work with two different models of family therapy simultaneously; and (c) provide feedback on the teams' own roles, rules and group process. The process that 6 trainees and two supervisors used with T and O teams to examine their own coevolution as a therapeutic system using the Milan model of family therapy and Ericksonian hypnotherapy is described. The article concludes with a discussion of the advantages and pitfalls of this type of dual supervision.