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Controversy continues over a proposed moratorium on elective genital surgery in childhood for disorders/differences of sex development (DSD). Empirical evidence on patient preference is needed to inform decision-making. We conducted a multicentre survey by cross-sectional questionnaire in 14 specialized clinics in six European countries. The sample comprised 459 individuals (≥ 16 years) with a DSD diagnosis, including individuals with congenital adrenal hyperplasia (CAH) (n = 192), XY DSD with prenatal androgen effect (A) (n = 150), and without (nA) (n = 117). Main outcome measures were level of agreement with given statements regarding genital surgery, including clitoris reduction, vaginoplasty, and hypospadias repair. A total of 66% of individuals with CAH and 60% of those with XY DSD-A thought that infancy or childhood were the appropriate age for genital surgery. Females with XY DSD were divided on this issue and tended to prefer vaginoplasty at a later age (XY DSD-A 39%, XY DSD-nA 32%). A total of 47% of males preferred early hypospadias surgery. Only 12% (CAH), 11% (XY DSD-A), and 21% (XY DSD-nA) thought they would have been better off without any surgery in childhood or adolescence. Individuals who had early genital surgery were more likely to approve of it. Outcome data failed to support a general moratorium on early elective genital surgery. Participant perspectives varied considerably by diagnostic category, gender, history of surgery, and contact with support groups. Case-by-case decision-making is better suited to grasping the ethical complexity of the issues at stake.Trial registration: German Clinical Trials Register DRKS00006072.

Increasingly, work schedules in retail sales are generated by software that takes into account variations in predicted sales. The resulting variable and unpredictable schedules require employees to be available, unpaid, over extended periods. At the request of a union, we studied schedule preferences in a retail chain in Québec using observations, interviews, and questionnaires. Shift start times had varied on average by four hours over the previous week; 83 percent had worked at least one day the previous weekend. Difficulties with work/life balance were associated with schedules and, among women, with family responsibilities. Most workers wanted: more advance notice; early shifts; regular schedules; two days off in sequence; and weekends off. Choices varied, so software could be adapted to take preferences into account. Also, employers could give better advance notice and establish systems for shift exchanges. Governments could limit store hours and schedule variability while prolonging the minimum sequential duration of leave per week.

The patient with Guillain-Barré syndrome (GBS) presents a complex clinical picture. Depending on the degree of paralysis, problems with communication can be significant. The patient's inability to express fears, needs and frustrations coupled with the lengthy recovery process makes GBS one of the most difficult diseases for nurses to manage. Nursing interventions, based on Orem's self-care theory, can ease the frustration and feelings of powerlessness a patient with GBS experiences.

The interrelationships between histomorphologic classification, cell surface marker phenotype and prognosis were prospectively studied in 130 adults with non-Hodgkin's lymphomas. Within each of the classification schemes used there were certain histologic variants that exhibited heterogeneity of cell lineage as well as those that were extremely uniform. Diffuse lymphomas with cell populations consisting of large cells, or mixtures of large and small cells were the most heterogeneous phenotypically and were most resistant to precise definition of immunologic cell lineage. The new Working Formulation for Clinical Usage likewise exhibited considerable heterogeneity of phenotype even within well defined histomorphologic categories. Two immunologic phenotypic variables that conferred a significant favorable prognosis were the expression of surface membrane immunoglobulin (B derivation) and the simultaneous expression of a membrane mu and delta immunoglobulin heavy chain. The results of this study suggest that cell surface marker phenotypic determinations have well defined and potentially useful correlations with histomorphologic classification schemes, and are useful in predicting biologic behavior and prognosis. It is suggested that a knowledge of both immunologic phenotype and histomorphologic characteristics is necessary in formulating therapeutic decisions.

We appreciate the letter from Dr Castaneda and his group regarding our article on pulmonary hemorrhage (PH) in systemic lupus erythematosus (SLE). Several of their points merit comment. In retrospect, we agree that our patient's initial presentation of dyspnea, pulmonary infiltrates, and scant blood-tinged sputum quite possibly represented an undiagnosed episode of PH rather than mycoplasma pneumonia. This diagnosis was entertained at the time but not pursued because of her rapid improvement on receiving oral antibiotics. As for the utility of carbon monoxide diffusion as a means of diagnosing PH, we would add that the test depends on a fully cooperative patient. Often, the severity of a patient's dyspnea renders the test results uninterpretable. Regarding the pathogenesis of PH in SLE, the conclusions by Dr Castaneda and colleagues, like others in the literature, are drawn from finding immune complexes (IC) and electron-dense deposits in postmortem lungs, which had undoubtedly suffered