Search

Aims Neonatal attendances to Children’s Emergency Departments (CED) are an increasing issue, with jaundice a common presenting problem. Assessment of the level of jaundice has traditionally been by a blood test. This not only has the disadvantages of distress, inconvenience and cost, but also exposes neonates to a busy CED for prolonged time periods. Would the introduction of a simple transcutaneous bilirubinometer into the department safely and accurately improve the delivery of our care? Methods All neonates who presented to our CED between 17/09/15 and 18/11/15 requiring investigation for jaundice had both a transcutaneous bilirubinometer (three readings taken on the sternum) and a laboratory analysis of serum bilirubin. We compared results obtained from both measurements, determined what proportion of babies could avoid a blood test (in accordance with NICE guidance on the use of transcutaneous bilirubinometers) and whether blood results changed management. The study is ongoing. Results Figure 1 19 babies presented with jaundice (two were excluded as no serum bilirubin results were available). Babies ranged from gestational ages of 36 to 41 weeks, presenting age range 1 to 28 days. 7 of these were for jaundice alone, referred from community midwives. 12 presented with both jaundice and another complaint e.g. weight loss, poor feeding. On average, the bilirubinometer result was within 12% of the serum bilirubin (mean = 12%, range 1%–30%). 12/17 (71%) had transcutaneous bilirubin readings below 250 nmol/L. In one case only, serum results changed management – initiating phototherapy. However, given transcutaneous levels were above 250nmol/L, in line with NICE guidelines, blood tests would have been initiated regardless. 3/12 (25%) were admitted immediately following high readings, improving patient flow and efficiency. Conclusion In our initial population, up to 71% of babies could have avoided the need for blood tests, offered simple advice and feeding support. Furthermore, if a community transcutaneous bilirubinometer had been available, potentially 24% of these attendances at CED could have been avoided altogether. When used in line with NICE guidance, the transcutaneous bilirubinometer is an easy to use, safe, non-invasive and accurate method of measuring jaundice in a neonate.

Introduction Major trauma is the leading cause of death and disability in children, however compared to adults, children represent a much smaller number. The Trauma Audit and Research Network (TARN) states that 65.8% of Paediatric Major Trauma does not initially present to a Children’s Major Trauma Centre (MTC), however there is little research into the role of a Paediatric Trauma Unit (PTU) in the management of paediatric major trauma (PMT). Aim To review all admitted paediatric trauma patients at a PTU, focussing on the management of PMT, to establish whether the PTU management of these patients was safe and comparable to recommended practice. Methods A retrospective review of all trauma patients age

Aims To evaluate the safeguarding assessment of “Under 2s” presenting to a Children’s Emergency Department (CED) with suspected skull fracture. Methods A retrospective study between the 1st January 2012 to 1st January 2015 for children under 2 years old who underwent radiological investigation (CT or XRAY Head) for acute head injury. Results 52 patients underwent investigation (CT head/skull x-ray) the average age was 6 months. Of these development was assessed in 40% of cases and a full body examination was documented in 67%. 22 (42%) had confirmed skull fractures (SF), with an average age of 7 months (4.6–9.5 months). Most fractures (78%) were simple, linear and parietal. 21/22 cases (95%) presented with localised head swelling, bruising or haematoma and the most common mechanisms were: fall 74%, unexplained 13% and accidentally dropped 9%. 65% were discussed with social services. 10/22 (45%) underwent skeletal survey (SS), with additional fractures (rib fractures) detected in 1 child.12/22 did not have a SS of whom half were under 6 months age. Overall 7/52 (13%) were on social service plans at time of presentation. All children who underwent skeletal survey had a strategy meeting. Only 2/52 (4%) cases were defined as definitive NAI, only one had a skull fracture. All skull fractures were admitted. 2 children were transferred to neurosurgical centres for close observation (small subdural bleed) neither were defined as NAI. Conclusion It was interesting to note the small number of SS performed in the less than 6 months age group, which on notes review appeared to be attributed to the clinicians assessment of low likelihood of NAI in that individual patient. From this limited study the presence of a skull fracture did not help predict the likelihood of NAI. The diagnosis of NAI relies on a multiagency approach; there is no gold-standard for diagnosis. This is the first UK study looking at this population of children. There is no validated decision making tool for this population of children with skull fractures to aid inclusion/exclusion of non-accidental injury. A multicentre study would allow larger numbers to draw conclusions with regards to decision making.

BACKGROUND--Sepiolite is an absorbent clay that is used as pet litter. It forms thin crystals, which are a transition between chain and layered silicates. Inhalation studies in animals have shown no evidence of pulmonary damage. This paper reports a cross sectional study of the total work force of the largest sepiolite production plant in the world. METHODS--Two hundred and eighteen workers (210 men and eight women) were studied. Height, age, and smoking history were recorded. Chest radiographs were read according to the International Labour Office (ILO) classification by two readers. Readings were used to construct a numerical score, which was then used in statistical analyses. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were divided by the square of the height. Casella size selective personal samplers were used in randomly selected operatives to collect dust eight years before the rest of the study was carried out. These samples were evaluated gravimetrically. Total dust samples were examined by optical and electron microscopes. Results were analysed by bivariate linear regression, chi 2 tests, and analysis of variance. RESULTS--When allowance was made for smoking habit workers exposed to dry dust showed a significantly greater decline in FEV1 with age than workers with little exposure to dry dust. A similar pattern applied to FVC. Radiographic score showed deterioration with age but no clear differences from other variables. High concentrations of dust were found in the bagging department and also in the classifier shed. CONCLUSIONS--The major finding was that lung function deteriorated more rapidly in those who had had more exposure to dust, but there was no evidence of any accompanying radiographic change.

Aim To implement an effective pathway to improve the central line service offered by our hospital – a service improvement project led by a Paediatric and Anaesthetic trainee. Background Central lines (CI) are required for a variety of paediatric patients and are referred from almost every department in our hospital; and from other hospitals within our region. An recent adverse incident lead to suboptimal care for a child and illustrated major inefficiencies in our referral system. This led us to review the process of central line placement at our centre – where currently no formal pathway exists. Methods Firstly we performed a retrospective audit over a year to ascertain our current workload (1 st May 2012 and 31 st May 2013.) Data was collected from coding regarding insertion of CI. Secondly a multidisciplinary team was formed of the individual departments involved in the placement of CI. We involved senior staff who could enable and implement the reforms necessary. Results A total of 118 CI lines were inserted. In 70% (83) it was the primary (only) procedure of these 73% (61) were medical 10% (8) were trauma and orthopaedics 6% (5) were surgical 5% (4) were respiratory 2% (2) were oncology 2% (2) ENT and 1% (1) for cardiology and 30% (35) as the non-primary procedure. Implementation This data has been used to bring forward a costed business case for a dedicated central line service. This has involved A Scoping exercise for all equipment and resources requirements Establishing the training requirements needed for the team placing CI’s Liaison with the relevant departments to establish their requirements and to create a communications network. Immediate instigation of a pilot pathway in consultation with managers and our multidisciplinary team. To improve the referral pathway, efficiency and management of the patient. Also documentation and care of central lines post insertion. Conclusion This piece of work shows how trainees can influence the systems they work within leading to real change. It demonstrates how communication and collaboration across disciplines can improve not only the patient care, but improve efficiency and reduce cost.

Context This quality improvement project as performed in a large District General Hospital, Children’s Emergency Department (CED). It reviewed the ‘Wheeze Pathway’ used to treat children presenting with acute exacerbations of wheeze. These children initially receive “burst therapy” – 10 puffs of a Salbutamol inhaler via a spacer device every 20 min for 1 h. Problem A previous audit of the ‘Wheeze Pathway’ highlighted only 79% of children recieving burst therapy had their inhalers at the correct intervals and only 89% had appropriate observations. In a serious adverse event a child was transferred to the in-patient ward without a post burst therapy assessment, which necessitated eventual escalation to IV therapy and HDU admission. Within a busy CED it was difficult to easily establish which children were following the ‘Wheeze Pathway’ and at what time their inhalers, observations and assessments were due. Assessment of problem and analysis of its causes Wheeze is a very common presentation to CED. Following the serious adverse event, nursing staff and doctors were consulted regarding the issues they felt contributed to the problems described. Intervention Following a consultation process a ‘Pathway Checklist’ was developed (Figure 1). The checklist is a timeline of all treatments and assessments (medical and nursing) during the first 4 h of the ‘Wheeze Pathway’. It was also decided children had to remain in the CED during this time to ensure a complete assessment with timely escalation of treatment if necessary and stability prior to transfer to a definitive care bed. Strategy for change The ‘Pathway Checklist’ was developed with significant input from the nursing team to ensure strong support for the change. Upon implementation both the Pathway and Checklist were publicised to all staff and education provided at team meetings. Measurement of improvement A snap shot review of the ‘Wheeze Pathway’ and ‘Pathway Checklist’ was undertaken over a 10-day period in 2014 and 39 consecutive sets of patient notes were reviewed. The implementation achieved a near perfect number of children receiving burst therapy at the correct intervals and 100% having complete observations as well as 37 (95%) cases having timely medical reviews. Effects of changes As a consequence of its implementation there have been no further adverse incidents as children are now transferred to definitive care beds when stable and with clear plans. There is also now an unquantifiable improvement in how the department has a feeling of control and knowledge of all the children on the ‘Wheeze Pathway’, which has improved overall care of these patients. There is an allocated nurse to give all burst therapy and to provide education to families. There is also improved awareness amongst the nursing and medical teams regarding the need for escalation and which children we have greater concern for, leading to early identification of these patients. Lessons learnt Implementation requires buy-in and consensus of the whole team. Next time I would provide more regular feedback of the success of change to ensure continued motivation of users and highlight areas for improvement. Message for others An extremely simple intervention can help to improve efficiency and have a positive effect on patient care safety by prompting key points in patient management, especially in a busy environment.

Aims There is good evidence that high staff moral and satisfaction improve quality of care. The aim of this study was to assess our baseline levels of staff satisfaction within a busy Children’s Emergency Department (CED) team, to understand what the department does well and not so well and what and how could we improve. Method All staff; nursing, medical and administrative, in CED answered a brief 9 question online survey via email. This included both 1–10 rating and free text questions. Results 80 staff received the questionnaire, 38 (48%) responded. The mean ‘happiness’ rating was 6.19/10 with little difference between professions (nurses 6.6, doctors 7.0), staff rated how ‘valued’ they feel as 6.19. Staff were asked to rate the department in a number of parameters (Figure 1). The results highlighted lots of positives in the department – e.g. tea rounds, social outings, team working and communication. The main areas for improvement suggested were in the relationship and communication between medical and nursing staff. Suggested interventions included: more multidisciplinary meetings, training, and social activities, also listening without interruptions, and valuing all colleagues’ opinions. Conclusion This study has provided a number of ideas for interventions within the department to improve staff wellbeing. The anonymous feedback method allowed true reflections of staff happiness and highlighted areas for future development. Communication was particularly highlighted- e mail is used for a large amount of our interdepartmental communication and on investigation of our poor response rate it appears that staffs rarely check their hospital e mails address. Our first implementation is to improve this basic form of communication. To also implement a short simple department meeting for prior to handover thus capturing more nursing and medical staff who cannot regularly attend the department meetings. Simple service improvements were also suggested which will be considered to enhance patient care.

Context This quality improvement project was carried out at a large general paediatric hospital. The project was performed on our medical and surgical inpatient wards, involving all prescribing healthcare professionals. Problem There had been numerous minor and moderate prescribing errors identified via DATIX and CPSQ meetings, the majority not affecting patient care and were identified prior to administration of medication, thus avoiding serious incidents. However, they caused delays in treatment and sub-optimal, timely patient care. This inefficient practice wastes time and resources of nurses, doctors and pharmacists in identification of errors and re-prescribing of medication. Assessment of problem and analysis of its causes This problem had already been identified at CPSQ meetings and the medication errors were ongoing despite improvement in prescribing training at staffing induction. A multidisciplinary meeting involving doctors, senior nursing clinicians and the pharmacy lead was held to identify common errors. The prescribing errors were primarily illegible handwriting, inaccurate history taking, confusion with drug names, inappropriate use of decimal points, incorrect completion of drug charts and use of verbal orders and abbreviations. Clinicians were often unaware of errors, with colleagues amending drug charts, with no direct feedback to the person making the error. Intervention Our quality improvement intervention was to implement a “zero tolerance policy” of prescribing errors, such that no medication would be given until correctly prescribed. No verbal orders were accepted. All errors once identified were photographed by paediatric pharmacists. All photographic evidence was then communicated to the consultant who directly discussed it with the individual responsible, either face-to-face, or via email. Individuals’ results were published monthly. The intervention was timed so that it would there would be no staff change over. The information was relayed back to the multi-disciplinary team in a teaching session, highlighting the numbers and types of errors using graphical evidence. Strategy for change The implementation was simple once agreement had been reached with the pharmacy team who wished to prioritise a reduction in prescribing errors. The main stakeholders involved were the pharmacy team, senior nurses and consultants. Results were disseminated as previously described. It was expected that change would occur slowly initially, with the project needing to be ongoing as medical staff rotate every four months. Measurement of improvement A total of 204 errors were identified in the four months prior to the zero tolerance policy being implemented, and assigned according to staffing posts. These included 26 errors at consultant level, 53 at registrar, 74 SHO errors, and 51 for other prescribing posts. In the first month of our project being initiated, there were a recorded 74 errors, with the biggest reduction being between this and the second month (34), with a further 34 errors in the third month, reducing to only 10 by the fourth month. This demonstrated a clear trend in reduction of prescribing errors. Effects of changes There was a dramatic decrease by 81% in total errors. Additionally there has been a generalised perceived but unmeasurable improvement in efficiency of distribution of medication. Lessons learnt This was a surprisingly simple intervention with excellent results. However it has been hard to maintain momentum at continuing this analysis. Message for others This was a simple project to implement and to demonstrate improvement. It improves individual accountability and self-awareness. There is potential to develop a phone application capturing errors and sending feedback to prescribers, producing a league table. Since incorrect medical prescribing has been identified as being the single most preventable cause of patient harm (previous studies identifying errors in one in eight charts), this could form part of a formal assessment in the e-portfolio, with doctors providing annual error reports.

Aims To review the practice, usefulness and interpretation of electrocardiogram (ECG) in a Children’s Emergency Department (CED), following a clinical risk incident due to the lack of formal review process of all ECGs in the CED. Methods All ECGs performed in the CED (25,000 annual attendances) over a 4-month period were analysed retrospectively. Data collected included a) patient data recorded on the ECG printout (name, date of birth, hospital number), b) automatic machine report on the ECG printout, c) interpretation of the ECG by the attending physician, and d) documentation of the results in the case notes. Results 71 ECGs were performed during the study period. Eight cases were excluded (3 duplicate, 5 lost notes). The 63 patients (M: F 1:1.5) were further analysed. Ages ranged from 21 days to 16 years (mean 10.6 yrs). The main indications for the test were chest pain (33%), syncope (32%), seizure or life threatening event (15%), drug overdose (10%) and miscellaneous (10%). The automatic reporting system on the ECG machine identified 15 (23%) ECGs as showing a prolonged corrected QT interval (QTc). Manual measurement and computation (Bazet’s formula) however, showed all these records have a normal QTc. There were 9 (2%) abnormal ECGs, which included supraventricular tachycardia (1), left axis deviation (2), left ventricular hypertrophy by voltage criteria (3), left bundle branch block (1), right bundle branch block (1), ST elevation (1). Conclusion The study showed widespread deficiencies in the performing, interpretation and documentation of ECGs in the CED. A guideline for interpretation of ECG has been introduced and a proforma designed to guide a detailed reporting of all ECGs. There is now a process for a formal review of all ECGs performed in the department which will prevent any unnecessary cardiology referral and prevent any abnormal ECGs being missed.

Aims To analyse the epidemiological characteristics, presenting complaints and outcomes of all neonatal presentations to a Children’s Emergency Department. Methods A retrospective review of neonates (aged ≤28 days) who presented to the Children’s Emergency Department (CED) (25,000 annual attendances) over a 6 month period (1 st November 2012 to 30 th April 2013). Study data was collected from case notes using a standardised proforma and analysed. Results 358 presentations were made by 284 neonates during the 6 month study period, making up 3% of all CED presentations. Only 1 was excluded from the study. 53% were self-presentations, 25% referred by midwives and 10% from the GP. The commonest presenting complaints were jaundice (22%), difficulty in breathing (14%), feeding problems (8%) and weight loss (8%). Of the jaundiced patients, only 45% were admitted, with 18% required phototherapy. Of the patients presenting with feeding problems, 84% were admitted. Most neonates (31%) were given a diagnosis of “normal baby”, and 34% of all presentations were labelled as being primary care problems. The majority of mothers (45%) were primaparous. 42% of all presentations were admitted (25% short stay unit, 65% ward, 7% HDU and 2% NICU). For admitted patients, the main diagnoses were feeding problems (22%), jaundice (17%), infection (17%) and normal (15%). The average duration of stay was 17 hrs in the short stay unit and 74 hrs on the ward. Conclusion Our study shows that there is a large group of neonates who are inappropriately attending the CED and who could be better managed elsewhere in the community. These patients consume a great deal of time and resources and are often medicalised and over investigated. We have identified jaundice, feeding problems and primparous mothers as the most important areas that could be targeted by all the stakeholders involved in neonatal care. We are using this data to work with our clinical commissioning group and stakeholders within the hospital trust to enable redirection of these patients away from the CED.

Background Most women with endometriosis receive unnecessary antibiotics for “P.I.D.” because both conditions present with pelvic pain and dyspareunia. We used negative chlamydial antibody titre and laparoscopy to confirm diagnoses in women identified by dysmenorrhea symptom scoring (DSS) as more probably having endometriosis than PID. Methods Retrospective review of women meeting CDC diagnostic criteria for “acute P.I.D.” who completed a pain history questionnaire identifying symptoms strongly suggestive of endometriosis, namely: Severe dysmenorrhoea interfering with schooling or work Cyclical use of painkillers or heat application Improvement on hormonal contraception Cyclical dyschezia Family history Those who scored > 50% and whose symptoms failed to respond to hormonal treatment, were assessed by laparoscopy. Results Of 149 women with high DSS, all tested negative for chlamydia by AptimaCombo2. 41 were referred to gynaecology, and 36 (aged 16–39, median 24y) had laparoscopy. Of these, 23 had chlamydial antibody titre (CAT) measured, 4 were raised. 26/36 (72%) had endometriosis confirmed at laparoscopy including the four with raised CAT. 10/36 (28%) had no obvious signs of endometriosis or PID nor any other diagnosis. Scores were similar in those with mild, moderate or severe endometriosis and the apparently disease-free group (mean score 87% & 85% respectively). Conclusions DSS is a simple means of excluding PID in women with acute pelvic pain and filtering appropriate referrals to gynaecology with high rates of endometriosis disease finding. Laparoscopy may not identify exclusively uterine or rectovaginal endometriosis and negative cases remain under review. DSS cannot predict disease extent due to “high end failure” as genuinely severe endometriosis is uncontrolled by hormonal contraception. Dysmenorrhoea symptom scoring reliably identifies women who are likely to be given antibiotics for PID when they actually require hormones for endometriosis, and could improve specificity in patient selection for PID research.

Bronchial hyper-responsiveness is a particular feature of asthma, but also occurs in normal subjects after a viral upper respiratory tract infection or ozone inhalation. Such stimuli would be expected to result in the release of chemical mediators of inflammation. In this study, the effects of one of these, prostaglandin F2 alpha (PGF2 alpha), on the response of normal subjects to inhaled histamine has been investigated. Nine normal volunteers took 10 inhalations of increasing concentrations of PGF2 alpha at 15-minute intervals from a Wright's nebuliser under standard conditions until a change in sGaw could be detected. The next lowest serial dilution of PGF2 alpha was subsequently inhaled by each subject every 15 min for 90 min to ensure the absence of a cumulative effect. Inhalation dose-response curves to histamine diphosphate were constructed on two separate occasions using the same standardised technique. Doses were administered every 15 min and sGaw determined five minutes after each. On one occasion each dose of histamine was immediately preceded by the non-active test dose of PGF2 alpha and on the second by saline as placebo. The study was performed double-blind and in random order. After pretreatment with PGF2 alpha the histamine dose-response curve was significantly shifted to the left in a parallel fashion (p less than 0.001). There was a significant decrease in the doses of histamine required to cause a 20% fall in sGaw (p less than 0.0015) but no significant change in the slopes of the dose-response regression lines, indicating that bronchial muscle sensitivity rather than reactivity had been predominantly affected.

The role of histamine H1 and H2 receptors in the lung is not clear. H1 receptor blockade results in bronchodilatation and inhibition of histamine induced bronchoconstriction. H2 receptor blockade in vitro prevents the normal negative feedback of histamine on further mediator release in antigen challenge. Bronchospasm in guinea pigs given antigen challenge is enhanced by previous administration of metiamide or burimamide but not of cimetidine. These findings suggest the possible deleterious effect of H2 receptor antagonists in asthmatic subjects. The effects of H2 receptor blockade with cimetidine on bronchial hyperreactivity to histamine were studied in 10 asthmatic volunteers by whole body plethysmography. Cimetidine 800 mg and placebo were administered orally on two separate days, eight hours and two hours before study. No significant difference in baseline levels of airways obstruction was seen with the two agents. Inhalational challenge with increasing concentrations of histamine revealed no significant difference in bronchial hyperreactivity to histamine between cimetidine and placebo treatment days. H2 receptor blockade with cimetidine does not appear to affect ventilatory function or bronchial hyperreactivity to histamine in asthmatic subjects. It has been suggested that cimetidine may have H1 as well as H2 receptor blocking properties which prevent this effect.

To determine whether airway receptors are responsible for the rapid, shallow breathing pattern seen in hypercapnic chronic obstructive lung disease, 10 patients underwent upper airway anaesthesia with inhaled lignocaine in a placebo controlled study. There was a significant reduction in breathing frequency after lignocaine (p less than 0.001) that was due to an increase in expiratory time (p less than 0.001). The inspiratory time remained unchanged, but tidal volume increased significantly (p less than 0.02). It is concluded that, while airway receptors may have a role in determining the frequency of breathing in chronic obstructive lung disease, other factors are responsible for the reduced inspiratory time.

Twenty patients with haematological malignancies who developed Clostridium difficile bowel infection or colonisation are described. All isolates of C difficile were toxigenic in vitro and faecal cytotoxin (toxin B) was detected in 20/26 episodes. Ten of 20 episodes with detectable faecal cytotoxin were associated with typical antibiotic associated diarrhoea. In the other 10 episodes (nine patients), there was a severe unusual illness which was associated with detection of C difficile. The unusual features of the illness were pronounced jaundice (total bilirubin greater than or equal to 44 mumol/l), abdominal pain and distension, and initial constipation followed either by diarrhoea or by large bowel stasis. Four of these patients died within seven days. Bacteraemia was often a presenting feature in neutropenic patients subsequently shown to have C difficile. This was not the case in non-neutropenic patients. Bacteraemia was commonly polymicrobial and in two cases C difficile was isolated from blood culture. The clinical implications of recognition of this atypical C difficile associated syndrome are discussed.

A survey was undertaken among adults aged 20-44 years in a South Wales town. Persons with a history of wheezing with breathlessness and in the absence of a cold were identified by postal questionnaires and seen at a clinic, together with a sample of subjects without these symptoms. The response rates for the first and second stages of the survey were 99.6% and 91.0% respectively, and 574 subjects were ultimately seen. Asthmatic patients (those receiving treatment within the previous year) had some airways obstruction at rest, which increased after exercise. They also had strong allergic tendencies, as shown by personal and family history, skin tests, and serum IgE levels. The ex-asthmatics (those not receiving treatment within the previous year) showed these tendencies to a lesser extent. A larger group gave a history of wheezing but stated that they had never had asthma; in their response to exercise and allergic traits they resembled the control group rather than the asthmatics, and appeared to have the features of chronic bronchitis. Asthma and chronic bronchitis would therefore seem to be distinct entities within the population studied.

Karyotypes of bone marrow cells from 24 patients with multiple myeloma (MM) and two patients with de novo plasma cell leukaemia (PCL) were analysed by Giemsa banding (G banding). Chromosome aberrations were found in 13 patients with MM and both patients with PCL. Hyperdiploid and hypodiploid lines were present in eight and five of the patients with MM, respectively. Marker chromosomes derived from structural rearrangements were present in all eight cases of MM with hyperdiploid lines, although markers of uncertain origin were rare in those patients with hypodiploid lines. Chromosome 1 participated most often, and chromosomes 5 and 9 often played a part in the structural rearrangements. Chromosomes 3, 5, 7, 9, 11, 15, 19, and 21 were subject to numerical aberrations. In the two patients with PCL one had a hypodiploid line with a 14q + marker derived from a t(11;14) and the other a hyperdiploid line. The breakpoints on the chromosomes participating in the structural rearrangements in myeloma showed a good correlation with known fragile sites and oncogene locations on the corresponding chromosomes.