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The potential for integrated fixed film activated sludge (IFAS) processes to achieve enhanced transformation of pharmaceuticals relative to conventional activated sludge (CAS) processes was assessed. Previous studies have focused on direct comparisons of parallel reactors with and without fixed film carriers and little information is available on the impacts of how varying operating parameters impact the differences in observed pharmaceutical compound (PC) transformation capabilities between CAS reactors and those equipped with both an activated sludge (AS) and fixed film carriers. The testing was carried out using bench scale sequencing batch reactors fed with authentic municipal wastewater and operated at selected combinations of temperature and solids retention time (SRT). PC transformation efficiencies were assessed in a 22 factorial design that employed the IFAS and CAS processes, operated in parallel under identical process conditions. Nitrification rate testing that was conducted to obtain insight into the biomass activity demonstrated that IFAS consistently had improved nitrification kinetics despite lower mixed liquor volatile suspended solids levels thereby demonstrating the contribution of the biofilm to nitrification. Increased transformation of atenolol (ATEN; ranging from 10–60%) and trimethoprim (TRIM; ranging from 30–50%) in the IFAS equipped reactors relative to their respective activated sludge (AS) controls was observed under all experimental conditions. Negligible transformation of carbamazepine was observed in both reactors under all conditions investigated. More than 99% of acetaminophen was transformed in both configurations under all conditions. There was no correspondence between nitrification activity and TRIM removal in the control AS while conditions that stimulated nitrification in the control AS also resulted in enhanced removal of ATEN. The results of this study indicate that the integration of biofilms in AS processes enhances transformation of some PCs.

A significant contribution to reduced maternal mortality worldwide includes programmes of systematic surveillance and investigation of maternal deaths. However, maternal deaths represent the tip of the iceberg. Near miss events occur significantly more frequently than maternal death, presenting an opportunity for examination of approximately 8000 cases per year in the UK compared to around 80 maternal deaths in the same period. The World Health Organization defined criteria for maternal near miss: ‘a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy’. This chapter will review the identification of near misses.

Current trends, practices and related developments in the use of maps and information about geographic objects are outlined. The need for strategies including the Ordnance Survey GI Strategy, the UK Location Strategy, the Digital National Framework and INSPIRE to be better aligned to meet the growing needs of an information-based economy is discussed. Challenges to this transformation are identified.

In order to realise the full potential of photogrammetry for national map revision, photographic acquisition lead times and, where possible, costs must be significantly reduced. In this paper a review of alternative platform and camera configurations is made and tests are undertaken utilising simulated data and medium format data taken from an existing project. The results suggest that the medium format camera and helicopter combination may have much to offer while the small format camera and microlight aircraft systems have yet to be developed into an effective data acquisition and map compilation system.

Objectives. To identify epidemiological, clinical and laboratory characteristics of juvenile dermatomyositis (JDM) in a national multi-centre cohort of patients, and to review recent changes in the understanding of management and prognosis in the light of these data. Methods. All children with idiopathic inflammatory myositis recruited to the Juvenile Dermatomyositis National Registry and Repository (UK and Ireland) were included. Features at presentation, and later in disease, were assessed and evaluated. A total of 63 out of 175 children with a new diagnosis of myositis were recruited at the time of diagnosis and followed prospectively. Out of the 175 children, 122 diagnosed prior to 2000 were recruited retrospectively, with subsequent data collected prospectively. Results. One patient died (0.7%), which is equivalent to one death per 465 patient years. Data were available at the time of analysis on 151 registered patients. The most common presenting features were characteristic rash, weakness, tiredness, Gottron’s patches and myalgia. Muscle biopsy, magnetic resonance imaging and muscle enzymes were frequently, but not always, abnormal. Muscle enzymes and erythrocyte sedimentation rate were not useful markers of disease activity. Conclusions. The JDM National Registry and Repository captures data on a significant cohort of children with inflammatory myositis. The current study reports the largest European cohort of children with dermatomyositis to date. This powerful resource will help improve our understanding of this rare disease. Prospective data collection will allow a fuller analysis of poor prognostic features, impact of therapy, and variable outcome of childhood myositis.

Objective To investigate the short-term effects of exercise on muscle inflammation in children with juvenile dermatomyositis (juvenile DM). Magnetic resonance imaging (MRI), muscle strength, and blood parameters were used as outcome measures. Methods Children with active juvenile DM, inactive juvenile DM, and healthy children were assessed for muscle strength (using myometry) and function, and MRI T2-weighted relaxation time measurement; blood was obtained from patients with juvenile DM. A standardized physiotherapy-led exercise program was completed, and the MRI was performed immediately afterwards. All children were reassessed with myometry and MRI at 30 minutes and 60 minutes, and repeat blood tests were performed at 60 minutes for the patients with juvenile DM. Results Ten children with active juvenile DM, 10 with inactive juvenile DM, and 20 healthy controls completed the study. Muscle inflammation assessed by MRI, myometry, and blood parameters did not change significantly in response to exercise either immediately after or up to 60 minutes after the exercise program in any group. Conclusion In the short term, a single bout of exercise does not change the degree of inflammation within the muscles of children with active or inactive juvenile DM or in healthy children. The data suggest that, at least in this time period, there is no evidence that exercise increases the inflammation within the muscles. We propose therefore that a moderate exercise program is safe for children with juvenile DM.

Background Isolated hip disease in the context of chronic childhood inflammatory arthritis is uncommon. This paper reports 14 children who presented to the rheumatology and orthopaedic departments of our hospitals with severe hip symptoms, and who continued to have primarily hip disease throughout their clinical course. Our aim was to characterize and present the relevant demographic, clinical, investigational, treatment and outcome data from the above cohort. Methods All paediatric cases with the diagnosis of protrusio acetabuli, Otto pelvis or idiopathic chondrolysis who were seen in the past 15 yr at Great Ormond Hospital and Middlesex Hospital in London were identified and their case notes were searched retrospectively for relevant information. Results In 11 cases, the disease progressed to involve no joints other than the contralateral hip. None were considered to have a specific subtype of juvenile idiopathic arthritis (JIA) and all tested were negative for HLA-B27. Elevation of serum inflammatory markers was variable. Protrusio acetabuli was the predominant radiological feature. There were definite inflammatory changes on the gadolinium-enhanced magnetic resonance imaging study in all patients who had this procedure performed (seven cases). Microbiological investigations were all consistently negative. Severe hip disease resulted in considerable ongoing symptoms and disability. Six cases were treated with disease-modifying anti-rheumatic drugs. Total hip replacement has been required in four patients to date, with major functional improvement. Conclusions These cases represent severe and disabling primary hip disease with considerable clinical and investigational inflammatory features. Such a mode of presentation has not been described previously in the context of childhood chronic inflammatory arthritides, and may represent a separate oligoarthritis subtype of JIA.

We have studied immune reconstitution in a patient with paediatric-onset polyarteritis nodosa treated with high-dose immunosuppressive agents followed by stem cell rescue. The patient developed several new autoimmune phenomena over the 18 months after immunosuppression and stem cell rescue. Flow cytometry, reverse transcription-polymerase chain reaction (RT-PCR) heteroduplex and isotype-specific RT-PCR analysis of immunoglobulin expression showed that the T- and B-cell repertoires were highly restricted in the first few months after treatment. The dominant T-cell clones seen after reconstitution were persistently expanded, were different from those which could be demonstrated before autologous stem cell transplantation, and were in the CD8(+) population. Our data also show that 12 months after treatment these expanded T-cell clones were within the CD45RA(+) population, suggesting that reversion from the CD45RO(+) to the CD45RA(+) phenotype had occurred in vivo.

AIMS To review the precipitating events, clinical features, treatment, and outcome of macrophage activation syndrome (MAS). METHODS Retrospective review of cases of MAS from a prospectively collected database of children with rheumatic diseases from 1980 to 2000. RESULTS Nine patients (eight girls) were considered to have evidence of MAS. The primary diagnosis was systemic onset juvenile idiopathic arthritis in seven, enthesitis related arthritis in one, and chronic infantile neurological cutaneous articular syndrome in one. Mean age of onset was 5.7 years, and duration prior to MAS, 4.2 years. No medication was identified as a trigger. Eight had infections prior to MAS; specific infectious agents were identified in four. High grade fever, new onset hepatosplenomegaly, and lymphadenopathy were common clinical features. Platelet counts fell dramatically, from an average of 346 to 99 × 10 9 /l. Mean erythrocyte sedimentation rate (in three patients) fell from 115 to 28 mm/h. Eight had abnormal liver function during the disease course, and six had coagulopathy. Bone marrow examination supported the diagnosis with definite haemophagocytosis in four of seven. All received high dose steroids (eight intravenous, one oral), five cyclosporin, two cyclophosphamide, and one antithymocyte globulin. Two of three patients with significant renal impairment died. CONCLUSION MAS is a rare and potentially fatal complication of childhood rheumatic disorders. Most of our patients were female, and most cases were preceded by infection. Bone marrow studies support the diagnosis. Deranged renal function may be a poor prognostic sign. Aggressive early therapy is essential. Key messages MAS is a rare complication of childhood rheumatic disease It is a potentially fulminant disorder, which may occur as part of the initial presentation of the rheumatic disease An infective trigger may herald the onset of this complication in predisposed patients Differentiation from a disease flare may be difficult, but is critical to ensure optimal outcome An early and dramatic fall in platelet count is characteristic, with changes in WBC and haemoglobin being more variable early and common Elevation in transaminases and coagulation abnormalities may not be present at onset of MAS Bone marrow examination is supportive, but false negative reports occur as a result of sampling errors or the subtle nature of the disease Multisystem involvement is a poor prognostic sign

The use of a touch-screen public access health information system was evaluated by monitoring system usage, by interviews with an opportunistic sample of 90 users and by other surveys. To get the largest number of users, such a system needs to be sited in a highly visible setting where there are lots of people passing. For most people, privacy does not appear to be a problem. However, some groups may require more privacy and when siting in ‘quieter’ places, such as a library this may be more important than in busier anonymous places, or in places where health is a ‘natural’ topic of interest. Waiting rooms may not be the best sites.

Objective: To describe recent trends in television tip over-related injuries among children aged 0–9 years, and to compare injury rates with sales of newer digital televisions. Methods: Digital television sales data were obtained from marketing data provided by the Television Bureau of Advertising. Data regarding television tip over-related injuries among children aged 0–9 years were obtained from the 1998–2007 National Electronic Injury Surveillance System. A Wald χ 2 test, estimated from logistic analysis, was used to determine whether the distribution of injury types differed by age group. Pearson’s correlation was used to estimate the association between digital television sales and television tip over-related injuries. Results: An estimated 42 122 (95% CI 35 199 to 49 122) injuries from television tip-overs were treated in US emergency departments from 1998 to 2007. The injury rate was highest for children aged 1–4 years (18.6/100 000). A majority of injuries (63.9%) involved the head and neck for children under 1 year of age, while a higher proportion of injuries among children aged 1–4 involved the hip and lower extremity (42.9% and 31.0%, respectively), and shoulder and upper extremity (16.8%) for children aged 5–9. A strong, positive correlation was observed between television sales and annual injury rates (r = 0.89, p Conclusion: Estimates of injury rates were similar to previously reported estimates, particularly for the increased proportion of head and neck injuries among very young children. While digital television sales were strongly correlated with increased injury rates, the lack of information regarding the type of television involved prevents inference regarding causation.

OBJECTIVES: Joint hypermobility (JH) or "ligamentous laxity" is felt to be an underlying risk factor for many types of musculoskeletal presentation in paediatrics, and joint hypermobility syndrome (JHS) describes such disorders where symptoms become chronic, often more generalized and associated with functional impairment. Clinical features are felt to have much in common with more severe disorders, including Ehlers-Danlos syndrome (EDS), osteogenesis imperfecta and Marfan syndrome, although this has not been formally studied in children. We defined the clinical characteristics of all patients with joint hypermobility-related presentations seen from 1999 to 2002 in a tertiary referral paediatric rheumatology unit. METHODS: Patients were identified and recruited from paediatric rheumatology clinic and ward, and a dedicated paediatric rheumatology hypermobility clinic at Great Ormond Street Hospital. Data were collected retrospectively on the patients from the paediatric rheumatology clinics (1999-2002) and prospectively on patients seen in the hypermobility clinic (2000-2002). Specifically, historical details of developmental milestones, musculoskeletal or soft tissue diagnoses and symptoms, and significant past medical history were recorded. Examination features sought included measurements of joint and soft tissue laxity, and associated conditions such as scoliosis, dysmorphic features, cardiac murmurs and eye problems. RESULTS: One hundred and twenty-five children (64 females) were included on whom sufficient clinical data could be identified and who had clinical problems ascribed to JH present for longer than 3 months. Sixty-four were from the paediatric rheumatology clinic and 61 from the hypermobility clinic. No differences were found in any of the measures between the two populations and results are presented in a combined fashion. Three-quarters of referrals came from paediatricians and general practitioners but in only 10% was hypermobility recognized as a possible cause of joint complaint. The average age at onset of symptoms was 6.2 yr and age at diagnosis 9.0 yr, indicating a 2- to 3-yr delay in diagnosis. The major presenting complaint was arthralgia in 74%, abnormal gait in 10%, apparent joint deformity in 10% and back pain in 6%. Mean age at first walking was 15.0 months; 48% were considered "clumsy" and 36% as having poor coordination in early childhood. Twelve per cent had "clicky" hips at birth and 4% actual congenital dislocatable hip. Urinary tract infections were present in 13 and 6% of the female and male cases, respectively. Thirteen and 14%, respectively, had speech and learning difficulties diagnosed. A history of recurrent joint sprains was seen in 20% and actual subluxation/dislocation of joints in 10%. Forty per cent had experienced problems with handwriting tasks, 48% had major limitations of school-based physical education activities, 67% other physical activities and 41% had missed significant periods of schooling because of symptoms. Forty-three per cent described a history of easy bruising. Examination revealed that 94% scored > or =4/9 on the Beighton scale for generalized hypermobility, with knees (92%), elbows (87%), wrists (82%), hand metacarpophalangeal joints (79%), and ankles (75%) being most frequently involved. CONCLUSIONS: JHS is poorly recognized in children with a long delay in the time to diagnosis. Although there is a referral bias towards joint symptoms, a surprisingly large proportion is associated with significant neuromuscular and motor development problems. Our patients with JHS also show many overlap features with genetic disorders such as EDS and Marfan syndrome. The delay in diagnosis results in poor control of pain and disruption of normal home life, schooling and physical activities. Knowledge of the diagnosis and simple interventions are likely to be highly effective in reducing the morbidity and cost to the health and social services.

Objective. The aim of the study was to examine the validity and reliability of a quantifiable measure of inflammation using magnetic resonance imaging (MRI) in children with juvenile dermatomyositis (JDM). Methods. Children with active JDM, inactive JDM and healthy children received detailed assessments of recognized measures of muscle inflammation including muscle strength (manual muscle testing and myometry) and function (Childhood Myositis Assessment Scale, Childhood Health Assessment Questionnaire), the muscle enzymes lactate dehydrogenase (LDH) and creatine kinase (CK) and T 2 -weighted MRI scans of the thigh muscles, and these values were correlated with each other. Results. Ten children with active JDM, 10 with inactive JDM and 20 healthy children completed the study. There was no significant difference in ages between the three groups. The MRI T 2 relaxation times were significantly increased in active JDM compared with inactive JDM and healthy children (P=0.05), indicating a detectable increase in inflammation within the muscles. There were also good correlations between the MRI scores and the measures of muscle strength and function; however, there was no correlation between the MRI and muscle enzymes. Conclusions. The MRI T 2 relaxation time can be used as a quantitative measure of muscle inflammation and it has good correlations with other measures of disease activity.

Objectives. To assess the efficacy and safety of intravenous cyclophosphamide (CYP) used in severe and refractory juvenile dermatomyositis (JDM). Methods. Retrospective case note review of the outcome of 12 patients. Results. Assessment at 6 months of therapy in 10 of the 12 patients showed a significant improvement in muscle function as assessed by the Childhood Myositis Assessment Scale (CMAS) (P ¼ 0.012), muscle strength (P ¼ 0.008), global extramuscular disease score (P ¼ 0.008), skin disease severity (P ¼ 0.015) and lactate dehydrogenase (P ¼ 0.028). There were reductions in creatine kinase, alanine aminotransferase, prednisolone dose and ESR, but these did not reach statistical significance. Clinical improvement was maintained after CYP until the most recent follow-up (between 6 months and 7 yr) and no severe side-effects were seen. Reversible complications included lymphopenia, herpes zoster infections and alopecia. The median cumulative dose was 4.6 g/m 2 (range 3–9 g/m 2 ). The available evidence suggests that, at the doses required, risks of malignancy, infertility and gonadal failure are low. Two patients with severe treatment-resistant disease died after one dose of CYP, both of whom were ventilated prior to commencement of CYP and were thought to have died as a result of their severe disease process, and too early for clinical benefit to be obtained from the drug. Conclusions. In this cohort of children with severe and refractory JDM, CYP appeared to have provided major clinical benefit with no evidence of serious toxicity in the short term.

There is a need for a simple rule based on the sort of clinical data generated by annual review examinations, which predicts those at risk of foot ulcers with reasonable specificity and sensitivity. We have used data on 5, 153 patients free of ulcer or amputation at registration who were followed up at University Hospital Nottingham for between one and 12.4 years. A ‘sensitive’ rule using neuropathy and pulse ‘scores’ and HbA1 predicted 95% of those who developed an ulcer and missed only one person out of 39 who worsened to amputation. The rule seemed fairly effective when tested on data from Nottingham City Hospital, and although developed and tested on outpatient attenders, the rule should be relevant in primary care.

Central nervous system (CNS) complications are rarely reported in either juvenile or adult onset inflammatory myositides, such as dermatomyositis and polymyositis. We report two children, aged 4 and 10 yr respectively, with a diagnosis of juvenile dermatomyositis, both of whom subsequently developed clinical features of severe CNS involvement, possibly consistent with cerebral vasculopathy. One child died from apparent brainstem involvement; the other developed seizures, pseudoseizures and clinical depression which responded to aggressive immunosuppression. Although the vasculopathy or vasculitis underlying this disorder is known to have a systemic distribution, CNS involvement has rarely been reported and may be under-recognized.

Five patients with the 22q11 deletion syndrome (velocardiofacial syndrome) developed chronic inflammatory polyarticular arthritis. These new cases add to 8 previously reported and confirm the association. The arthritis in all cases was moderate to severe, but at least partially responsive to methotrexate and/or corticosteroids, and was clinically indistinguishable from juvenile idiopathic arthritis (JIA). Analysis of the total 13 patients indicates that 2 are rheumatoid factor positive, 6 are antinuclear antibody positive, 5 have subtle T cell deficiencies, and 6 have hypergammaglobulinemia. Of particular interest is the occurrence of IgA deficiency in 4 patients, including 2 from our own series. Although IgA deficiency is seen in both JIA (2-4%) and 22q11 deletion syndrome (2-4%), the prevalence of low IgA in this series (31%) is much greater than expected. This phenomenon and the true association of inflammatory arthritis and a chromosome deletion disorder provides further evidence of important genetic factors in the pathogenesis of JIA.

We describe 2 pediatric patients with sickle cell disease (SCD) who developed seropositive juvenile rheumatoid arthritis (JRA). Both patients have severe joint damage, the compound effect of both disease processes. The bone and cartilage destruction, which poses serious therapeutic challenges, highlights the difficulty of making a diagnosis of chronic inflammatory disease in the setting of SCD. There may be a correlation between increased levels of tumor necrosis factor-alpha in the synovial tissue of joints damaged by arthritis and local sickling. The resultant ischemia and corresponding inflammatory infiltrates could in turn worsen existing synovial proliferation and cartilage destruction as well as trigger further sickling.

To define the onset and duration of effect of the HLA alleles that are associated with disease susceptibility and protection in juvenile rheumatoid arthritis (JRA) and 2 of its subtypes.We typed 680 patients with JRA and 254 ethnically matched unrelated controls for HLA class I and II genes. The frequency of each allele was calculated for each of the age-at-onset, onset type, and sex categories and plotted against the allele frequency in the control population. Survival analysis (with onset of disease as the terminating event) was used to calculate the age by which 50% (St0.5) and 80% (St0.2) of the children with particular alleles and combinations of alleles develop disease. This allele-specific survival analysis also allowed for the comparison of the overall survival functions for the various JRA subtype and sex categories.Certain alleles are strongly associated with early susceptibility to pauciarticular JRA, including HLA-A2, DR8, DR5, and DPB1*0201. Fifty percent of the children carrying at least 1 of these alleles had disease onset prior to their third birthday. Among children who carried HLA-A2 and any 2 HLA-DR alleles (DR3, DR5, DR6, or DR8), the median age at the onset of pauciarticular disease was 2.7 years. Combinations of A2 and DPB1*0201 and one DR allele narrowed the window further to a median age at onset of 2.4 years. B27 and DR4 were associated with protection early in life but with increased risk later in childhood, with St0.5 values of 7.3 and 6.6 years, respectively, for pauciarticular JRA and St0.5 values of 10.2 and 10.7 years, respectively, for polyarticular JRA. Sex strongly influenced the age at which many of the alleles have their effect.These data define at what age and for how long various HLA alleles influence susceptibility and protection (window-of-effect) in patients with JRA. In addition, these data establish more clearly the boundaries of ages-at-onset for 2 of the subtypes of the disease.

To identify features of the T cell receptors (TCRs) present on clonally expanded T cells in the joints of patients with similar types of childhood rheumatic disease. Vbeta8 and Vbeta20 TCRs were selected as prototypic for polyarticular juvenile rheumatoid arthritis (JRA) and pauciarticular/juvenile spondylarthropathy (SpA), respectively.The portion of the TCR beta chain involved in antigen recognition in the synovial tissue, synovial fluid, and peripheral blood from patients with JRA and juvenile SpA was cloned and sequenced. The frequency of expanded clonotypes, size of expansions, the Jbeta region, and sequence motifs were determined for2,000 sequences.The majority of Vbeta20 and Vbeta8 clonal expansions were found in the joint rather than the peripheral blood. While instances of both Vbeta8 and Vbeta20 clonal expansion were detected in all disease types, the features of these expanded clonotypes were specific for disease type and Vbeta family. For example, Vbeta20 clonal expansion was characterized by many small expanded clonotypes in samples from patients with pauciarticular JRA and juvenile SpA while single large Vbeta8-specific expansions were found only in patients with polyarticular disease. Motifs specific to individual patients were identified, and for Vbeta20 clonotypes, a motif was found in synovial tissue samples.Identification of common TCR features in oligoclonal expansions within individual patients and between patients with the same type of JRA suggests the recognition of a common or limited group of antigens in these diseases.

To study the frequency of autoantibodies to the 45 kDa DEK nuclear antigen, a putative oncoprotein, in a sample of patients with juvenile rheumatoid arthritis (JRA), and to make correlations with disease subtype and complications such as iridocyclitis. Class I and Class II HLA associations with reactivity to the antigen were also sought.Sera from 146 HLA typed patients with JRA representing all subtypes were analyzed for reactivity with the 45 kDa DEK protein by immunoblotting. The antigen was purified to near homogeneity from nuclei of HeLa cells.Antibodies to DEK were found in 57% of all patients with JRA compared to 3% of controls (p0.0001). Antibodies were detected more frequently in pauciarticular onset (78%) than in polyarticular onset patients (29%; p0.01) and controls (3%; p0.0001). 97% of patients with JRA (regardless of onset subtype) and iridocyclitis had anti-DEK antibodies compared to 47% of patients without eye disease (p0.0001). Anti-DEK antibodies were found more frequently in females compared to males in the pauciarticular onset disease group (84 vs 42%; p0.01). The occurrence of anti-DEK antibodies was closely associated with positive antinuclear antibody serology, and a strong association with the Class I gene HLA-A2 was also observed.Antibodies to the 45 kDa DEK protein are characteristic of the pauciarticular onset subtype of JRA, particularly in patients with a history of iridocyclitis. The occurrence of anti-DEK antibodies is significantly but paradoxically associated with the presence of the HLA-A2 allele in such patients.

To characterize synovial T cell infiltrate, in terms of CD4/CD8 ratio and level of activation of T cells, in juvenile rheumatoid arthritis (JRA) and juvenile spondyloarthropathy(JSpA), to correlate these findings with clinical outcomes of the different forms of disease, and to compare them with findings in adult RA synovium.We studied synovial tissue specimens from 22 individuals with childhood onset of chronic arthritis (12 polyarticular JRA, 5 pauciarticular JRA, 5 JSpA) and 4 with adult RA. Specimens were selected from an initial bank from 40 patients on the basis of significant inflammation on hematoxylin and eosin and CD3 and CD68 monoclonal antibody staining (T cells and macrophages, respectively). Indirect immunohistochemistry was used with monoclonal antibodies to CD3, CD4, CD8, and interleukin 2 receptor alpha to determine CD4/CD8 ratios and the levels of activation within the T cell subsets. The distribution of gamma delta T cells was also studied.Two patterns of T cell infiltration were seen. The majority of patients had lymphocytic aggregates associated with diffuse infiltrates; a few tissue specimens had diffuse infiltrates without aggregates. The CD4/CD8 ratio was significantly lower in pauciarticular course JRA than polyarticular JRA (p0.01) and RA (p0.05). Similarly patients with JSpA had a significantly lower CD4/CD8 ratio than patients with polyarticular JRA (P0.05). The level of T cell activation (CD3+IL-2R+) was significantly higher in pauciarticular compared with both polyarticular JRA (P0.01) and RA (p0.05). In general, higher levels of activation of CD8 cells than CD4 cells were seen, particularly in the pauciarticular JRA and JSpA groups. gamma delta T cells were prominent in 2 patients.Demonstrated differences in T cell subset distribution between types of childhood chronic arthritis at a histopathological level may reflect different pathogenic mechanisms.

Efforts to improve local control and survival by increasing the dose of once-daily radiation therapy beyond 70 Gray (Gy) for patients with malignant gliomas has yet been unsuccessful. Hyperfractionated radiation therapy (HF) should allow for delivery of a higher total dose without increasing normal tissue late effects, whereas accelerated hyperfractionated radiation therapy (AHF) may minimize tumor repopulation by shortening overall treatment time. The Radiation Therapy Oncology Group (RTOG) conducted a randomized Phase I/II study of escalating doses of HF and AHF either carmustine (bis-chlorethyl nitrosourea [BCNU]) fro adults with supratentorial glioblastoma multiforme (GBM) or anaplastic astrocytoma (AA). Primary study endpoints were overall survival and acute and chronic treatment-related toxicity.From 1983 to 1989, 786 patients with supratentorial gliomas (81% with GBM and 19% with AA) were stratified by histology, age, and performance status and randomized to receive partial brain irradiation, utilizing either HF (1.2 Gy twice daily to doses of 64.8, 72, 76.8, or 81.6 Gy) of AHF (1.6 Gy twice daily to doses of 48 or 54.4 Gy). All patients received carmustine. The distinction of pronistic factors was similar on all arms.There were 747 eligible and analyzable patients among 786 enrolled patients (95%). Two patients had a Grade 5 and 65 patients had a Grade 4 chemotherapy toxicity. Two patients in the 81.6 Gy arm experienced late Grade 4 radiation toxicity and there was 1 late radiation-associated death in the 54.4 Gy arm. The rate of Grade 3 of worse radiation toxicity at 5 years, calculated by the delivered does level, was 3% in the lowest total dose arms (48 and 54.4 Gy), 4% in the intermediate dose arms (64.8 and 72 Gy), and 5% in the highest dose arms (76.8 and 81.6 Gy) (p = 0.54). Survival rates at 2 and 5 years were: 21% and 11%, and 4%, respectively, for GBM patients. There were no significant differences between the treatment arms with regard to median survival time (MST), when analyzed by the originally assigned dose. The MST for all patients varied between 10.8 months and 12.7 months (P = 0.59); between 9.6 months and 11 months for patients with GBM (P = 0.43); and between 30.4 months and 85.8 months for patients with AA (P = 0.78). Analysis of the survival rates for all patients by dose received rather than by dose assigned revealed a 14% 5-year survival rate for the lower HF doses (64.8 and 73 Gy), 11% for the higher doses (76.8 and 81.6 Gy), and 10% for the AHF doses (48 and 54.4 Gy) (P = 0.1). The subgroup a AA patients had a better MST (49.9 months) in the lower received HF doses than in the higher HF doses (34.6 months) (P = 0.35). In contrast, GM patients who received the higher HF doses had survival superior to the patients in the AHF arms (MST of 11.6 months and 10.2 months, respectively, P = 0.04).The use of HF with BCNU and dose escalation up to 81.6 Gy is both feasible and tolerable, although late toxicity increases slightly with increasing dose. The best MST with the least toxicity were observed for AA in the lower received HF doses (72 and 64.8 Gy). Accordingly, 72 Gy in two 1.2 Gy fractions was used as the investigational arm of a completed Phase III trial (RTOG 90-06). In contrast, for GBM patients, longer survival times were noted in the higher received HF doses (78.6 and 81.6 Gy), suggesting the role for further dose escalation. The low toxicity rate with AHF arms suggest that further dose escalation is possible and is currently occurring in RTOG 94-11.

To determine the potential contribution of the MHC class II region proteasome subunit gene, LMP2, to disease susceptibility, severity, and phenotype in patients with juvenile rheumatoid arthritis (JRA).A CfoI restriction site polymorphism in the coding region of the LMP2 gene was evaluated in 279 patients with JRA and 107 healthy controls of similar ethnicity. Patients were divided into 5 groups on the basis of clinical presentation; 46% had early onset pauciarticular disease, 10% early onset polyarticular, 10% late onset pauciarticular, 20% late onset polyarticular, and 11% systemic onset arthritis. The influence of this LMP2 polymorphism on susceptibility to disease, clinical subtype of disease at onset (age and number of joints involved), progression and severity of joint disease (pauci to polyarticular course and radiographic changes), and occurrence of inflammatory eye disease was evaluated.Comparison of genotypes revealed a significantly increased prevalence of homozygosity for the LMP2 B allele (LMP2 BB genotype) in patients who were older (or = 6 years) at onset of disease (65%, p0.05), particularly in those with pauciarticular (71%) involvement at presentation (p0.05), compared to controls (51%). The BB genotype was also more prevalent in patients with a polyarticular course, either from onset (63%) or those who progressed from pauciarticular disease (69%), compared with controls, (p = 0.05 and0.05, respectively). Stratification for HLA-B27 and DR4, the HLA alleles most frequently associated with late onset pauciarticular and late onset polyarticular JRA, respectively, revealed a persistent effect of LMP2 BB homozygosity on disease susceptibility and phenotype that remained statistically significant in HLA-B27 positive children, and was not due to linkage disequilibrium.We show that homozygosity of the B allele of the proteasome subunit LMP2 increases susceptibility to certain subgroups of JRA, and influences the phenotype of disease, predisposing to more progressive and severe articular disease.

In adults, sensorineural hearing loss (SNHL) resulting from megavoltage temporal bone radiation therapy (RT) is dose dependent. A review of the literature reveals only two cases of pediatric SNHL after RT without chemotherapy. This report presents four cases of late onset, asymmetric SNHL after RT in children treated for posterior fossa tumors. The children were treated with surgical resection of the tumor, followed by RT of 50 to 54 gray and no chemotherapy. These children, without evidence of tumor recurrence, developed severe SNHL 18 to 36 months after the completion of RT. Although no definite audiometric pattern was seen, most of the patients had a predominately high frequency SNHL in the poorer hearing ear, and fluctuant hearing in the better ear, without evidence of osteoradionecrosis or otitic infection. A review of the literature suggests that injury to the outer hair cells and cochlear neurons of the basal turn of the cochlea are possible sources for the hearing loss. Pretreatment audiologic evaluation as well as a minimum of 3 years of evaluations following RT would be prudent.

Four children with prolonged emesis during brain tumor therapy were diagnosed with pancreatitis.All were exposed to medications or radiotherapy that potentially contributed to pancreatitis.Because recognition of pancreatitis may necessitate changes in supportive care, pancreatitis should be included in the differential diagnosis of vomiting in this population.

Meeting the demands of patients and the public for health information is now a recognised aim. Healthpoint is a community-based touch-screen public-access health information system which aims to make health information easily accessible by the public and to provide feedback information on this demand. We have assessed Healthpoint in an experiment in three parts. Part one was a survey of 13 Healthpoints for several weeks in various community sites in Glasgow, such as a shopping centre, supermarket, library, and pub, as well as health service sites such as out-patient department and general practice. The number of users and the topics chosen were recorded by the systems. Part two was a survey of ten Healthpoints in one town (Clydebank) over five months, which examined routine information recorded by the system, and interviews with an opportunistic sample of 300 weekday shoppers in the street and a random sample of 271 by telephone. Part three was a survey of one Healthpoint in a general practice for 36 weeks using routine recording by the system and a postal survey of a systematic sample of 250 attenders. Seventy five (25%) out of 300 in the street survey and 45 (22%) of the telephone sample who had visited a site where there was a Healthpoint had used it. Overall, 17% of the telephone sample had used it. Seventy three (27%) out of 200 general practice attenders had used Healthpoint.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1972 to 1986, 354 patients with local and locoregional adenocarcinoma of the prostate were treated with curative intent at the Medical College of Wisconsin. Fifty-six of these patients were found to have Stage D1 disease (evidence of pelvic lymph node involvement). Using external beam irradiation alone, these patients were treated aggressively to the pelvis followed by a boost to the prostate. The median dose to the prostate was 6800 cGy, and to the pelvis, it was 5040 cGy. The median period of observation after treatment was 9 years. Actuarial survival was 76% at 5 years, and disease-free survival was 61% at 5 years. Twenty-three patients had biopsy-proved pelvic lymph node involvement; the other 33 were considered to have Stage D1 disease based on abnormal computed tomographic scans, lymphangiograms, or both. Actuarial survival and disease-free survival were calculated for both groups separately, and there was no statistical difference in the results. Major complications occurred in 3.6% (two patients) of this group with Stage D1 disease. These results support the continued use of aggressive external beam irradiation in patients with locoregional adenocarcinoma of the prostate.

Seven hundred fifty-nine patients with Stage I/II breast cancer who were treated with mastectomy alone (558 patients) or breast-conserving surgery and tangential irradiation (201 patients) were evaluated. Median follow-up time was 34 months. Axillary node status showed differences between treatment groups. Seventy-two percent of patients undergoing lumpectomy and radiation therapy (Lx) versus 35% of patients in the mastectomy group were pathologically node-negative, 18% Lx versus 30% mastectomy alone had one to three nodes positive, and four or more positive axillary nodes were seen in 35% of mastectomy alone patients. Reflecting this trend, overall survival (P less than 0.007), time to locoregional failure (P less than 0.0005), and time to any failure (P less than 0.0001) favored Lx patients. Correcting for axillary node status, significant differences persisted only for node-negative patients. Median actuarial survival time was 73 months for the mastectomy alone group (196 patients) versus 120 months for the Lx group (144 patients) (P less than 0.02), with significant differences also noted in time to local failure (P less than 0.003) and time to any failure (P less than 0.001). Stratification according to primary tumor size in patients who were node-negative yielded marked differences in time to locoregional failure in T1 (less than 2 cm) (P less than 0.0006) presentations, with analysis approaching significance for T2 (2 to 5 cm) lesions (P less than 0.06). Disease-free interval was greater in node-negative Lx patients for both T1 (P less than 0.007) and T2 (P less than 0.05) presentations. Overall survival was not significantly different in node-negative Lx patients when primary tumor size was considered. Improved prognosis was identified in node-negative patients undergoing breast-conserving surgery and radiation therapy over mastectomy alone. Theoretical considerations included eradication of occult microscopic disease within the chest wall by tangential irradiation.

Until recently long-term renal toxicity has not been considered a major late complication of bone marrow transplantation (BMT). Late renal dysfunction has been described in a pediatric population status post-BMT which was attributable to the radiation in the preparatory regimen. A thorough review of adults with this type of late renal dysfunction has not previously been described. Fourteen of 103 evaluable adult patients undergoing allogeneic (96) or autologous (7) bone marrow transplantation, predominantly for leukemia and lymphomas, at the Medical College of Wisconsin (Milwaukee, WI) have had a syndrome of renal insufficiency characterized by increased serum creatinine, decreased glomerular filtration rate, anemia, and hypertension. This syndrome developed at a median of 9 months (range, 4.5 to 26 months) posttransplantation in the absence of specific identifiable causes. The cumulative probability of having this renal dysfunction is 20% at 1 year. Renal biopsies performed on seven of these cases showed the endothelium widely separated from the basement membrane, extreme thickening of the glomerular basement membrane, and microthrombi. Previous chemotherapy, antibiotics, and antifungals as well as cyclosporin may add to and possibly potentiate a primary chemoradiation marrow transplant renal injury, but this clinical syndrome is most analogous to clinical and experimental models of radiation nephritis. This late marrow transplant-associated nephritis should be recognized as a potentially limiting factor in the use of some intensive chemoradiation conditioning regimens used for BMT. Some selective attenuation of the radiation to the kidneys may decrease the incidence of this renal dysfunction.

Selective inhibitors of the cyclic nucleotide phosphodiesterase (PDE) isoenzymes have been studied to assess the potential for such agents in the treatment of asthma. A novel selective PDE V inhibitor, SKF 96231, reversed the bronchoconstriction induced in anaesthetised guinea pigs by histamine, a thromboxane-mimetic or by ovalbumin challenge. There was no effect of SKF 96231 on heart rate or blood pressure in conscious dogs. Siguazodan (SKF 94836, a selective PDE III inhibitor) caused bronchodilation but also had cardiovascular effects in conscious dogs. Studies on the PDE profile of various inflammatory cells have indicated that inhibition of PDE IV would be beneficial in the treatment of the inflammatory aspects of asthma and this is briefly reviewed.

The gas phase photodissociation spectra of four protonated β-diketones were obtained and compared with the absorption spectra of the corresponding ions in solution. Protonated 2,4-pentanedione was observed to undergo the photodissociation process [C5H9O2]+ +hν [CH3CO]+ +C3H6O with a λmax at 276±10 nm compared with a solution absorption maximum at 286 nm. Protonated 2,4-hexanedione was observed to undergo the photodissociation processes [C6H11O2]+ +hν [CH3CO]+ +C4H8O and [C6H11O2]+ +hν [C2H5CO]+ +C3H6O with a λmax at 279±10 nm compared with a solution absorption maximum at 288 nm. Protonated 3-methyl-2,4-pentanedione was observed to undergo the photodissociation process [C6H11O2]+ +hν [CH3CO]+ +C4H8O with a λmax at 295±10 nm compared with a solution absorption maximum at 305 nm. Protonated 1,1,1-trifluoro-2,4-pentanedione was observed to undergo the photodissociation process [C5H6F3O2]+ +hν CF3H+[C4H5O2]+ with a λmax at 273±10 nm compared with a solution absorption maximum at 288 nm. The [CH3CO]+ and [C2H5CO]+ produced photochemically with the first three ions react to regenerate the protonated β-diketone leading to a photostationary state. Photodissociation of the protonated alkyl β-diketones is believed to occur from the protonated keto form, whereas photodissociation of protonated 1,1,1-trifluoro-2,4-pentanedione is believed to occur from the protonated enol form. Mechanisms for the observed photodissociation processes are proposed and comparisons with results from related techniques are presented.

1. The cell-attached and excised inside-out configurations of the patch-clamp technique were employed to probe isolated enterocytes of Necturus maculosus for the presence of Cl(-)-selective channels. 2. Chloride-selective channels were rarely observed unless cells were previously stimulated by agonists that raise cyclic AMP. In cell-attached patches forskolin (20 microM) or dibutyryl cyclic AMP 2 mM) evoked single-channel activity that reversed, depending on the cell, between 9 and 27 mV positive to the spontaneous membrane potential. This is close to the Cl- equilibrium potential in those cells; the single-channel current-voltage relationship was linear with a unitary slope conductance between 17 and 25 pS (pipettes filled with 100 mM-NaCl). 3. Large depolarizing voltage steps also activated Cl- channels in excised inside-out membrane patches that were previously quiescent. This mode of activation produced a distinctive single-channel current-voltage relationship with strong outward rectification at depolarizing membrane potentials. Single-channel cord conductance at negative potentials was 15-18 pS and increased to 45 pS at + 100 mV. 4. Altering the Cl- concentration in the bathing solution of excised inside-out patches displaced the observed reversal potential (Erev) to values predicted for Cl- equilibrium potential. Replacement of K+ for Na+ was without effect. 5. The effect of different anions upon Erev was used to determine the channel anion selectivity in excised inside-out patches. The permeability sequence was SCN- greater than I- greater than Br- greater than Cl- greater than F- greater than HCO3- greater than gluconate which corresponds to Eisenman's sequence 1. Neither ionic size nor diffusion rates determine the permeation of ions through the channel. 6. In channels activated by depolarization the open probability (Po) was insensitive to changes in the Ca2+ concentration (less than 10(-8)-10(-3) M) bathing the cytoplasmic face of excised inside-out patches. Depolarization was also without marked effect on Po. 7. Chloride channels in excised inside-out patches were inhibited by stilbene and diphenylamine-2-carboxylate derivatives. 4-Acetamido-4'-isothiocyanatostilbene-2,2'-disulphonic acid (SITS, 5 x 10(-5) M) and 5-nitro-2-(3-phenylpropylamino) benzoic acid (NPPB, 1 x 10(-5) M) caused an irreversible 'flickery' blockade without altering single-channel current. 3'5-Dichlorodiphenylamine-2-carboxylic acid (DDPC, 5 x 10(-5) M) reduced the currents at every voltage without apparent effects on gating properties of the channel.(ABSTRACT TRUNCATED AT 400 WORDS)

Rat liver 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase catalyzes exchange reactions between ADP and ATP and between fructose-6-P and fructose-2,6-P2 at histidyl residues. Limited proteolysis of the enzyme with thermolysin yielded an enzyme core with a subunit molecular weight of 35,000-38,000. This enzyme core had no kinase activity and a 2-fold activated bisphosphatase activity whose sensitivity to the product inhibitor fructose-6-P was unchanged. The thermolysin-treated enzyme also did not catalyze the fructose-6-P/fructose-2,6-P2 exchange reaction but did catalyze the ADP/ATP exchange. These results suggest that 1) the enzyme's reactions may be catalyzed at two active sites, 2) there are at least two fructose-6-P binding sites, 3) the fructose-6-P/fructose-2,6-P2 exchange is catalyzed only at the kinase site, and 4) inactivation of the exchange and kinase reactions by thermolysin digestion is due to the loss of the fructose-6-P binding site of the kinase. Also consistent with these conclusions was the finding that oxidation of the enzyme with ascorbate/Fe3+ or H2O2 resulted in complete loss of the kinase activity as well as the fructose-6-P/fructose-2,6-P2 exchange but did not affect the bisphosphatase activity or the ADP/ATP exchange. Dithiothreitol could completely reactivate the ascorbate/Fe3+-inactivated enzyme, suggesting that oxidation occurred at a sulfhydryl group(s) essential for fructose-6-P binding in the kinase reaction. In addition, the kinase and fructose-6-P/fructose-2,6-P2 exchange reactions were more sensitive to inactivation by diethylpyrocarbonate than was the bisphosphatase. The different responses of the kinase and bisphosphatase reactions to the action of these various protein-modifying agents and to thermolysin digestion support the existence of a separate site for each reaction and an essential role for sulfhydryl groups at the sugar-phosphate-binding site(s) of the kinase.

Rat liver 6-phosphofructo-2-kinase/fructose 2,6-bisphosphatase was phosphorylated by [gamma-32P]ATP plus fructose-6-P or [2-32P]fructose-2,6-P2. The radioactivity co-migrated with homogeneous 6-phosphofructo-2-kinase/fructose 2,6-bisphosphatase during sodium dodecyl sulfate-disc gel electrophoresis and the phosphoenzyme was acid-labile and base-stable. Hydrolysis of the phosphate group from phosphoenzyme prepared with either donor and the hydrolysis of their tryptic phosphopeptides depended on pH similarly. The pH dependence suggested that phosphate was linked to the N3 of a histidine residue. Co-electrophoresis and co-chromatography of alkaline hydrolysates of the labeled phosphoenzyme prepared from either substrate allowed the definitive identification of 3-phosphohistidine in the degradation products. Modification of the enzyme with diethylpyrocarbonate inactivated both the phosphotransferase and phosphohydrolase activities and suppressed the phosphorylation of the enzyme by ATP and fructose-6-P or by fructose-2,6-P2. Trypsin digestion of the phosphoenzyme formed upon incubation with ATP or fructose-2,6-P2 yielded an identical phosphopeptide after high pressure liquid chromatography. All the above data are consistent with this enzyme catalyzing both phosphohydrolase and phosphotransferase reactions with the mediation of phosphohistidine in the reaction scheme(s).

The stimulant effects of adrenaline and noradrenaline on contractile force and adenylate cyclase, mediated through beta 1 and beta 2-adrenoceptors, are analysed in isolated atrial and ventricular myocardium of man. The tissues were obtained from patients without advanced heart failure undergoing heart surgery. Usually, both adrenaline and noradrenaline stimulated adenylate cyclase predominantly through ventricular and atrial beta 2-adrenoceptors. Because the relative density of beta 2-adrenoceptors is usually smaller than that of beta 1-adrenoceptors, stimulation of one beta 2-adrenoceptor leads to the production of up to 10 times more cyclic AMP molecules than does stimulation of one beta 1-adrenoceptor. Adrenaline and noradrenaline maximally enhance contractile force through both atrial and ventricular beta 1-adrenoceptors. Adrenaline can also maximally enhance contractile force through atrial beta 2-adrenoceptors. In the ventricle, adrenaline increases force via beta 2-adrenoceptors by up to 60% of its maximal beta 1 response. Noradrenaline can increase atrial and ventricular contractile force through beta 2-adrenoceptors but only at high concentrations. Unexpectedly, in atria from patients treated with the beta 1-selective antagonist atenolol, contractile responses to adrenaline are markedly and selectively augmented through activation of beta 2-adrenoceptors. In atria from atenolol-treated patients equi-inotropic concentrations of adrenaline and noradrenaline acting through beta 2 and beta 1-adrenoceptors, respectively, cause similar increases of cyclic AMP and of cyclic AMP-dependent protein kinase activity.

6-Phosphofructo-2-kinase/fructose-2,6-bisphosphatase from rat liver was phosphorylated by cyclic AMP-dependent protein kinase and [gamma-32P]ATP. Treatment of the 32P-labeled enzyme with thermolysin removed all of the radioactivity from the enzyme core and produced a single labeled peptide. The phosphopeptide was purified by ion exchange chromatography, gel filtration, and reverse phase high pressure liquid chromatography. The sequence of the 12-amino acid peptide was found to be Val-Leu-Gln-Arg-Arg-Arg-Gly-Ser(P)-Ser-Ile-Pro-Gln. Correlation of the extent of phosphorylation with activity showed that a 50% decrease in the ratio of kinase activity to bisphosphate activity occurred when only 0.25 mol of phosphate was incorporated per mol of enzyme subunit, and maximal changes occurred with 0.7 mol incorporated. The kinetics of cyclic AMP-dependent protein kinase-catalyzed phosphorylation of the native bifunctional enzyme was compared with that of other rat liver protein substrates. The Km for 6-phosphofructo-2-kinase/fructose-2, 6-bisphosphatase (10 microM) was less than that for rat liver pyruvate kinase (39 microM), fructose-1,6-bisphosphatase (222 microM), and 6- phosphofructose -1-kinase (230 microM). Comparison of the initial rate of phosphorylation of a number of protein substrates of the cyclic AMP-dependent protein kinase revealed that only skeletal muscle phosphorylase kinase was phosphorylated more rapidly than the bifunctional enzyme. Skeletal muscle glycogen synthase, heart regulatory subunit of cyclic AMP-dependent protein kinase, and liver pyruvate kinase were phosphorylated at rates nearly equal to that of 6-phosphofructo-2-kinase/fructose-2, 6-bisphosphatase, while phosphorylation of fructose-1,6-bisphosphatase and 6-phosphofructo-1-kinase was barely detectable. Phosphorylation of 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase was not catalyzed by any other protein kinase tested. These results are consistent with a primary role of the cyclic AMP-dependent protein kinase in regulation of the enzyme in intact liver.

Twenty-three patients underwent craniotomies for brain malignancies. One hundred eleven fluorescein-stained and 75 nonstained tissue biopsies were obtained for histopathological examination using a special arc-lighting system connected to a conventional surgical headlight. Of the 75 nonstained specimens, 71 (94.7%) were negative for tumor and 4 demonstrated the presence of tumor. Ninety-four (84.7%) of the fluorescent tissues obtained were reported as having neoplasia and the remaining 17 showed characteristics consistent with necrotic tissue debris. All stained tissues obtained in this study demonstrated visible fluorescence within neoplastic tissue margins harboring abnormally permeable blood-brain barriers.