Tackling child health inequalities due to deprivation: using health equity audit to improve and monitor access to a community paediatric service.

BACKGROUND: Deprived children constitute a large population with high levels of ill health, and difficulty with access to healthcare contributes to their poor health outcomes. There is debate on how best to engage deprived families and the literature on differential access to paediatric care based on deprivation is limited. AIMS: To demonstrate that community paediatrics can contribute to reduction of health inequalities by providing services that are accessible to and preferentially used by children whose health is likely to be affected by deprivation. To provide a template for others to improve and monitor equity in their services. METHOD: Long-term service reconfiguration and health equity audit. We used routinely collected activity data and the Indices of Multiple Deprivation to construct equity profiles of the children using our service, and compared these with the profile of the population aged 0-16 years in the geographical area covered by the service. RESULTS: The new patient contact rate for the most deprived children in the population was more than three times that of the least deprived [odds ratio (OR) 3.29, 95% confidence interval (CI) 2.76-3.93]. Deprived children were more than twice as likely to require multi-agency meetings as part of their medical care (OR 2.28, 95% CI 1.94-2.69). Seventy per cent (3693/5312) of our total contacts were with children in the two most deprived quintiles. There was a marked socio-economic gradient in all types of contact. CONCLUSIONS: The model of care used by our community paediatric service successfully engages deprived families, thereby reducing health inequalities due to poor access. Key features are multi-agency working, removing barriers to access, raising staff awareness and use of health equity audit. Our findings provide support for tackling health inequalities via health services that are available to all, but capable of responding proportionately according to level of need, a model recently described as proportionate universalism.

Effect of congenital heart defects on language development in toddlers with Down syndrome.

BACKGROUND: Down syndrome (DS, OMIM #190685) is the most commonly identified genetic form of intellectual disability with congenital heart defect (CHD) occurring in 50% of cases. With advances in surgical techniques and an increasing lifespan, this has necessitated a greater understanding of the neurodevelopmental consequences of CHDs. Herein, we explore the impact of CHD on language development in children with DS. METHODS: Twenty-nine children with DS were observed systematically in parent-child interactions using the Communication Play Protocol to evaluate their language use; they also completed the Mullen Scales of Early Learning and MacArthur Communication Development Inventory. Mean ages were 31.2 months for children with DS and CHD (DS + CHD, n = 12) and 32.1 months for children with DS and a structurally normal heart (DS - CHD, n = 17). RESULTS: Compared with the DS - CHD controls, the DS + CHD group revealed lower scores in multiple areas, including fine motor skills and expressive and receptive vocabulary. Whereas most differences were not statistically significant, the Communication Development Inventory word count and symbol-infused joint engagement differed significantly (P < 0.01) and marginally (P = 0.09) between groups. CONCLUSIONS: Finding that CHDs may account for part of the variation in language delay allows us to consider the specific mechanisms underlying the impact of CHDs on language acquisition in children with DS. Conclusions from this first study on early language outcomes of children with DS + CHD may be useful for clinicians in providing developmental surveillance and early intervention programmes with specific emphasis on language therapy as part of long-term follow-up for children with DS + CHD.

Myeloid-derived suppressor cells impair the quality of dendritic cell vaccines.

Myeloid-derived suppressor cells (MDSC) are important regulators of the immune system and key players in tumor-induced suppression of T-cell responses. CD14+HLA-DR-/low MDSC have been detected in a great number of malignancies, including melanoma. MDSC are known to be impaired in their ability to differentiate along the myeloid lineage, e.g., into dendritic cells (DC). This is a concern for utilization of monocyte-derived DC for vaccination of patients with melanoma or other cancers exhibiting accumulation of CD14+ MDSC. When producing DC according to standard operating procedures of two currently ongoing clinical trials, we found that MDSC co-purified with monocytes isolated by elutriation. MDSC frequencies did not affect yield or viability of the produced DC, but induced a dose-dependent decrease in DC maturation, ability to take up antigen, migrate and induce T-cell IFNγ production. Changes in DC characteristics were most notable when 'pathological' frequencies of >50% CD14+HLA-DR- cells were present in the starting culture. The impaired DC quality could not be explained by altered cytokine production or increased oxidative stress in the cultures. Tracking of HLA-DR- cells throughout the culture period revealed that the observed changes were partially due to the impaired maturation and functionality of the originally HLA-DR- population, but also to their negative effects on HLA-DR+ cells. In conclusion, MDSC could be induced to differentiate into DC but, due to the impairment of overall DC vaccine quality when >50% HLA-DR- cells were present in the starting culture, their removal could be advisable.

Generation of a dendritic cell-based vaccine in chronic lymphocytic leukaemia using CliniMACS platform for large-scale production.

We previously demonstrated that dendritic cells (DC) that have endocytosed apoptotic bodies of autologous leukemic cells (Apo-DC) can boost antileukemic T-cell responses. In this study, we report a description of the production procedure and product specification of the Apo-DC vaccine preparations for clinical use. Enriched populations of CD14+ monocytic precursors and CD19+ leukaemic cells were obtained using CliniMACS technology from a single leukapheresis product. Apoptotic bodies were obtained by irradiating (5 Gy) CD19+ selected B cells. DC were generated ex vivo by culturing monocytes with granulocyte macrophage colony-stimulating factor and interleukin-4. Following coculture with apoptotic bodies, DCs were matured with tumour necrosis factor-alpha. The mean percentage of CD14+ cells in the peripheral blood as well as in the leukapheresis product of the patients (n = 10) was approximately 2% (range, 0.8-3.3). Immunomagnetic selection using the CD14 reagent yielded a CD14+ population that was 91 +/- 2.2% (mean +/- SEM) pure. Immunomagnetic selection of CD19 expressing cells yielded a population that was 100 +/- 0.03% pure. Cell viability immediately after selection was 97% and 98% after 7 days of culture. The Apo-DC cellular vaccine product showed a mature phenotype, with a high rate of endocytosis (84%) of apoptotic leukemic B-cells. In conclusion, despite significant variability in the circulating monocyte frequency of the chronic lymphocytic leukaemia patients, our method permitted the production of a DC vaccine with high reproducibility and conforming with recommended quality standards.

Effects of human plasma proteins on maturation of monocyte-derived dendritic cells.

Dendritic cells (DC) are a promising tool for vaccine therapy due to their unique properties as antigen presenting cells and their ability to prime naïve T cells. Increasing evidence suggests that maturation stage of DC critically influences the fate of the immune response. Generation of monocyte-derived DC for clinically applicable immunotherapy requires the use of well-defined components and stringent culture conditions. An alternative strategy is to use human autologous serum. However, its constituents are not stable and reflect the inflammatory condition of the donor. In order to investigate whether DC properties are influenced by proteins present in the plasma, we matured human monocyte-derived DC with four main plasma components: fibrinogen, fibronectin, plasminogen or C-reactive protein. These purified proteins were added at various concentrations on day 6 after the initial differentiation induced by IL-4 and GM-CSF. The maturation was assessed by phenotyping of maturation-associated marker (CD83) and co-stimulatory molecule CD86 as well as IL-12 production. Functional properties of DC were assessed by endocytic activity and mixed leukocyte culture. Our results indicate that fibrinogen had DC-maturation effect comparable to poly-I:C, TNF-alpha and PGE(2) as a positive control, but it failed to induce IL-12 production. The other plasma proteins had no effect on DC maturation. CRP at high concentration had rather inhibitory effect on DC induced lymphocyte function. We conclude that none of the tested plasma components and acute phase proteins sufficiently induce fully competent mature DC. This finding is important for the preparation of human DC-based vaccines supplemented by autologous sera.

Regional obstetric anesthesia and newborn behavior: effect over the first ten days of life.

This study examined the effects of carefully controlled amounts of analgesic premedications and anesthetics administered to mothers during delivery on the behavior of the newborn over the first ten days of life. The subjects were selected to minimize the synergistic effects of medication and other stress factors, such as abnormalities of pregnancy, labor, or delivery. The effects of these drugs on the behavior of these infants was small. The data provide a picture of the behavioral recovery of a group of minimally stressed newborns.

Phylogenetic analysis of multiple heterosexual transmission events involving subtype b of HIV type 1.

Between 1996 and 1999 thirteen cases of HIV infection were detected in Doncaster, a small town in the north of England (population approximately 250,000). A complex network of shared sexual histories involving local nightclubs linked these cases, with the only known risk factor being heterosexual intercourse. A series of frozen blood samples was collected in 1998-1999 and amplified by PCR to generate full-length gp120 clones. Sequencing demonstrated that all the transmission events in this heterosexual group involved the B subtype of HIV-1. When relationships between the samples were assessed it became clear that these 13 cases represented at least three separate strains of HIV-1, indicating that HIV is well established in this community. Eleven of the 13 cases were related, forming two distinct groups. Further investigation revealed that one group contained five patients whose general health was good and who were not receiving HAART. In contrast, the second group of six patients, including the putative index case, were symptomatic, receiving HAART, and may have been infected with a CXCR-4-utilizing virus. Several of the cases that were linked by genetic criteria were not linked by contact tracing, implying that further undiagnosed cases may exist in this community. To our knowledge, this is the largest outbreak of HIV studied within the heterosexual community in the United Kingdom to date, suggesting that this route of infection is becoming more common within the United Kingdom.

Differential regulation of c-jun expression in liver and lung of mice after thermal injury.

In addition to skin injury, burns may also damage distant organs. Understanding the mechanisms of distant organ injury will substantially improve the survival of burn patients. Transcription factors are the major regulators of gene expression in response to most types of injury. C-Jun, which is a part of the activator protein-1 transcription factor complex, is one of the major immediate-early response genes, which is rapidly induced after injury. The expression of c-Jun in mouse liver and lung at different time points (3 h to 29 days) after thermal injury was examined by using Reverse Transcription-Polymerase Chain Reaction (RT-PCR), Western blot, and immunohistochemistry. Rapid induction of c-Jun mRNA and protein was observed in the liver 3 h after an 18% TBSA burn. C-Jun expression returned to basal levels within 3 days after injury. In contrast to the up-regulation observed in liver, lungs from the same mice expressed c-Jun constitutively throughout the same time points. The finding that thermal injury leads to up-regulation of c-Jun in liver but not lungs suggests that either the liver has a lower threshold for early response to injury or that different cellular events exist when each organ is stressed.

Reinstatement and spontaneous recovery of nicotine seeking in rats.

Reinstatement and spontaneous recovery of previously extinguished nicotine-taking behavior were examined in rats. Male subjects were trained to self-administer nicotine (30 microg/kg per infusion, IV; one 60-min session per day for 3 weeks). Extinction sessions were then given for 5-10 days during which saline was substituted for nicotine. Subsequently, in the first set of tests for nicotine seeking, the reinstatement of lever presses that previously delivered nicotine was examined after priming injections of saline and nicotine (75, 150 and 300 microg/kg, SC; and 30 and 60 microg/kg, IV). In the second set of tests for nicotine-seeking, rats were tested after an additional 21-day drug-free period during which they were not exposed to the self-administration chambers (a test for the spontaneous recovery of drug seeking), and after priming injections of nicotine (150 and 300 microg/kg, SC). Reinstatement of extinguished food-reinforced behavior after exposure to nicotine was also determined. Priming injections of nicotine reinstated nicotine seeking regardless of the route of administration. In addition, previously extinguished nicotine seeking recovered spontaneously after a 21-day period during which rats were not exposed to the drug-taking environment. Nicotine also reinstated extinguished food-reinforced behavior in rats with a history of nicotine self-administration, but not in drug-naive rats. The present results extend previous work with opioid and stimulant drugs on reinstatement of drug seeking by the self-administered drug. It also appears that, as with other positive reinforcers, the mere passage of time is a sufficient condition for the spontaneous recovery of extinguished nicotine seeking.

Mothers' expressed attitudes: associations with maternal depression and children's self-esteem and psychopathology.

OBJECTIVE: Mothers' expressed attitudes about their children were examined to discern whether the associations between maternal depression and children's psychopathology and self-esteem might be modified by the mother's expression of critical attitudes. METHOD: Mother-child dyads with mothers who had a history of at least one episode of unipolar major depression during the child's lifetime (N = 20) were compared to dyads with well parents (N = 19). Children's ages ranged from 8 to 10 years. Mothers' attitudes toward their children were derived from semistructured interviews. The affect expressed in each maternal statement was coded as neutral, positive, descriptive negative, or affectively charged negative. RESULTS: Affectively charged negative statements were found to be associated with mothers with a history of depressive episodes. A tendency was noted for the highest rates of psychopathology to be among children of depressed mothers who used affective-negative statements. Mothers' use of affectively charged negatives was found to modify the association between maternal depression and children's lower global self-worth. CONCLUSIONS: Clinicians attuned to mothers' expression of critical attitudes toward their children might detect children at risk for lowered self-esteem and the development of psychopathology.

The effect of maternal serum on phase-change temperature in human embryo cryopreservation.

The effect of addition of maternal serum to cryomedium on the phase-change temperature for embryo cryopreservation has been investigated. No effect on the eutectic point (i.e., earliest seeding temperature) was found within patients because of serum concentration or the time in the ovarian cycle when the serum was collected. However, the optimum seeding temperature did vary between patients, which suggests that self-seeding devices for embryo cryopreservation may be practically beneficial.

An evaluation of peripheral blood platelet enumeration as a monitor of fertilization and early pregnancy.

This paper reports our data that confirm the existence of early pregnancy-associated thrombocytopenia (EPAT) in the mouse and illustrate that the phenomenon is independent of age, parity, and strain differences. This paper also provides evidence that the EPAT phenomenon is induced by a soluble factor (EPAT-factor) released by the fertilized ovum. EPAT-factor was produced in vitro by mouse embryos from the 1-cell stage to the expanded blastocyst stage. The human study involved a "blind" analysis of serum samples, collected from in vitro fertilization-treated patients, for the presence of thrombocytopenic activity. Results suggest that measurement of this thrombocytopenic activity might be useful as an index of embryo viability and might be clinically applicable for the monitoring of implantation success in in vitro fertilization programs.

Factor XIII catalyzed formation of fibrinogen-fibronectin oligomers--a thiol enhanced process.

Fibrinogen and plasma fibronectin were shown to interact in the presence of factor XIIIa. The reaction was enhanced by dithiothreitol and was accompanied by an increase in the turbidity of the solution and the formation of particulate matter and gel structures. At a constant concentration of fibrinogen the turbidity increase was dependent on the fibronectin concentration and at a constant concentration of fibronectin, on the fibrinogen concentration. Kinetic experiments showed that an initial step in the reaction between fibrinogen and fibronectin was the formation of a transient intermediate containing 1 mole of fibrinogen and 1 mole of fibronectin. Transient intermediates of larger molecular weight and containing both fibrinogen and fibronectin were also formed. These heterooligomers eventually reached huge molecular sizes and at early times formed particulate matter that sedimented on centrifugation. The predominant molecular species formed in an equimolar mixture of fibrinogen and fibronectin were heteropolymers. Small amounts of homopolymers composed of fibrinogen and possibly also homopolymers of fibronectin were detected. The results are discussed in terms of reaction mechanism and potential importance of this novel oligomerization pathway in haemostasis, thrombosis and tissue repair.

FXIII induced gelation of human fibrinogen--an alternative thiol enhanced, thrombin independent pathway.

Factor XIII induced gelation of human fibrinogen in the presence of calcium ions. At the end of this reaction between 95 and 100% of the fibrinogen was incorporated into the gel matrix. The gelation was dramatically enhanced by DTT. Cysteine and beta-mercaptoethanol also enhanced the reaction, but less efficiently. Thrombin activated factor XIII led to shortened gelation time and increased the rate of gelation. The reaction was inhibited by p-chloromercuribenzoate and iodoacetamide. Neither fibrinopeptide A, nor fibrinopeptide B were released during gelation, while quantitative release of FPA by thrombin was demonstrated from preformed gel matrices. SDS-PAGE showed the presence of gamma-dimers and alpha-polymers in the gel matrix. In the clot supernatants gamma-dimers were observed already before the gel point. We also observed that the clotting of fibrinogen by thrombin was perturbed by DTT. Preincubation of fibrinogen with calcium ions prevented this effect of DTT.

Application of an enzyme-linked immunosorbent assay (ELISA) to von Willebrand factor (vWF) and its derivatives.

Sandwich ELISA systems were developed to measure human von Willebrand factor (vWF). In one system the microtitre plates were coated with goat F(ab')2 to vWF. The F(ab')2 different molecular forms in the soluble phase. VWF antigen bound by the F(ab')2 antibody was subsequently determined by using horse-radish peroxidase labeled goat Fab' to vWF. In plasma 3 X 10(-4) units of vWF per ml could be detected with this system. In a different approach the antigen bound by the F(ab')2 antibody was probed by monoclonal antibodies to multimeric as well as to the reduced and carboxymethylated (RCM) form of vWF. Using these monoclonals and RCM-as well as native plasma as antigen, the total antigen and the relative proportion of multimeric forms in the sample were estimated.

Mechanistic studies of early pregnancy associated thrombocytopenia (EPAT) in the mouse.

The preimplantation period of uterine pregnancy is associated with the transient (first 4 days of gestation) expression of a state of early pregnancy-associated thrombocytopenia (EPAT), a phenomenon shown to be mediated by the embryo-derived EPAT factor, which presumably causes platelet activation and subsequent removal. We previously investigated the time course of production of EPAT factor in mouse embryo culture medium and found a correlation between the production of this factor and the in vivo platelet alterations in pregnant mice. The present paper supports the postulation that the EPAT factor and PAF-acether (a phospholipid platelet-activating factor) are related by providing data showing that PAF-acether may be responsible for the thrombocytopenia. Finally, data are presented to suggest that platelet activation, though not affecting the rate of ovulation, is important for successful ongoing pregnancy. Results suggest that the EPAT factor, produced by the fertilized egg, might act to signal uterine decidualization and/or modulate maternal immunological rejection of the implanting conceptus.

Release of anti-PAF activity from PAF-binding human ovarian cancer cells in culture.

The human ovarian cancer cell line EFO-27 in culture spontaneously produced anti-PAF activity, which eluted from HPLC in the range of synthetic PAF. The activity therefore appears to be due to an antagonistic PAF-analogue. It was detected by a suppressed PAF-induced platelet aggregation in vitro. EFO-27 cells were found to be able to bind synthetic PAF with saturable binding kinetics. This binding led to reduced cell proliferation. The production of anti-PAF activity by EFO-27 cells resembles an autocrine growth regulation in the light of recent findings that other malignant transformed cell lines produce PAF-like activity in vitro if stimulated appropriately.

Social referencing by young chimpanzees (Pan troglodytes).

Social referencing is the seeking of information from another individual and the use of that information to evaluate a situation. It is a well-documented ability in human infants but has not been studied experimentally in nonhuman primates. Seventeen young nursery-reared chimpanzees (14 to 41 months old) were observed in a standard social referencing paradigm in which they received happy and fear messages concerning novel objects from a familiar human caregiver. Each chimpanzee looked referentially at their caregiver, and the emotional messages that they received differentially influenced their gaze behavior and avoidance of the novel objects. It is concluded that chimpanzees can acquire information about their complex social and physical environments through social referencing and can use emotional information to alter their own behavior.

General practitioner screening for melanoma: sensitivity, specificity, and effect of training.

OBJECTIVE: To measure the performance of trained and untrained general practitioners (GPs) in screening men and women aged 50 or more for melanomas. METHODS: GPs trained in melanoma diagnosis, untrained GPs, and skin cancer specialists examined groups of volunteers, each of which included a small number of subjects with prediagnosed suspicious pigmented lesions (SPLs) that were subsequently excised for histopathological examination. RESULTS: Trained and untrained GPs achieved mean sensitivities of 0.73 and 0.71, and mean predictive values of 0.40 and 0.37, respectively, for the detection of prediagnosed SPLs. When the SPLs had been excised and examined histopathologically, reanalysis showed mean sensitivities of 0.98 and 0.95, mean specificities of 0.52 and 0.49, and mean positive predictive values of 0.24 and 0.22 for the detection of subjects with melanomas by trained and untrained GPs respectively. Trained GPs were significantly better than untrained GPs at diagnosing as melanomas SPLs that subsequently proved to be melanomas (p = 0.04). CONCLUSIONS: GPs in this study achieved high sensitivities in screening older Australian men and women for melanomas, but at the cost of low specificities and positive predictive values. Training in melanoma diagnosis had no significant effect on sensitivity, specificity, and positive predictive value for screening. Data from the study were tested in a model of population screening for melanomas, and costs per life year saved for men aged 50-70 ranged from $A11,852 to $A40,259 depending upon the screening interval and whether the GPs excised the SPLs diagnosed, or referred all patients to skin cancer specialists; this would be as cost effective as cervical cancer screening.

Joint attention in preverbal children: autism and developmental language disorder.

For preverbal children, episodes of joint attention are contexts for communication with responsive adults. This study describes the joint attention of 3- to 5-year-old children, 15 with autistic disorder (AD) and 15 with developmental language disorder (DLD), during play sessions with unfamiliar adults. Adults used fewer conventional than literal bids for joint attention with AD children and vice versa with DLD children. Children with AD were less likely to engage in joint attention than children with DLD. In the allocation of attention, AD children monitored the channel of communication with the adult 37% less often than DLD children. We discuss how perturbations in reciprocal interactions permeate the sharing situation and the implications of this problem for the mastery of cultural conventions.