Natural history of parathyroid function and calcium metabolism after kidney transplantation: a single-centre study.

BACKGROUND: The natural history of parathyroid function after successful renal transplantation (RT) and the factors predisposing to persistent hyperparathyroidism (HPT) are not well established. A better knowledge of these data may be helpful in the development of algorithms for optimal surveillance and treatment of HPT after successful RT. Our aim was to evaluate the post-transplant natural history of parathyroid function and calcium metabolism in patients with a functional renal graft and to identify risk factors for persistent HPT. METHODS: Charts of 1165 allograft kidney recipients transplanted between 1989 and 2000 were reviewed. Patients with an intact parathyroid hormone (iPTH) level available at the time of transplantation were identified. The charts of the latter patients were checked for a variety of demographic and clinical data, and all determinations of the iPTH concentration available since transplantation were recorded. Serum levels of calcium, phosphorus, alkaline phosphatases and creatinine, concurrently determined, were also registered. RESULTS: After an initial fall, iPTH levels showed a slow but steady decline towards the upper normal limit. The prevalence of persistent HPT, defined as an iPTH level > or =2.5 times the upper normal limit or the need for parathyroidectomy following transplantation, remained stable at approximately 17% up to 4 years after transplantation. Patients with persistent HPT had significantly elevated serum levels of iPTH, calcium and phosphorus at the time of RT, and had spent a longer time on dialysis. Post-transplant iPTH levels correlated significantly with transplant kidney function. CONCLUSION: Kidney transplant recipients with a high iPTH and calcium x phosphate product at the time of transplantation are at risk for persistent HPT especially when renal function is suboptimal. Therapy for persistent HPT, if considered, should be initiated 3 months post-transplantation since further spontaneous improvement of parathyroid function thereafter is limited.     

p63 expression in assessment of bronchioloalveolar proliferations of the lung.

Discrimination of well-differentiated pulmonary adenocarcinoma from reactive bronchioloalveolar epithelium can be difficult on routine histology, especially with small biopsies. Ancillary studies to help in this distinction are desirable. p63, a p53-homologous nuclear protein, is a marker of reserve cells of the bronchus and terminal lobular unit. In this study, 33 cases of adenocarcinoma (20 open lung and 13 transbronchial/percutaneous biopsies) and 43 cases of benign lungs with fibrosis and metaplasia (22 open lung and 21 transbronchial/percutaneous biopsies) were studied for nuclear p63 expression by immunohistochemistry (Dako, Carpinteria, CA, USA). Five additional cases each of atypical adenomatous hyperplasia and adenosquamous carcinoma and three cases of squamous carcinoma (all open lung biopsies) were also stained. The diagnostic categories of benign lung conditions were usual interstitial pneumonia, parenchymal scar, cryptogenic organizing pneumonia and diffuse alveolar damage. In neoplastic cases, p63 positivity was calculated as percentage of all tumor cells examined. In areas of normal lung, p63 decorated the reserve cells of large and small airways and occasional cells of the distal lobular unit. In fibrotic reactive processes, an interrupted but distinct pattern of nuclear staining was present in all cases, with staining of basal cells of the airways as well as bronchiolar- and squamous-metaplastic epithelium (43/43, 100%). p63 immunoreactivity was less uniform in areas of acute lung injury within these cases. One adenocarcinoma and two cases of atypical adenomatous hyperplasia showed strong immunoreactivity (>80%), while three adenocarcinomas highlighted only rare tumor nuclei (<5% of tumor cells). Morphologic areas where p63 immunostaining was not helpful included the junction of normal lung and lepidic growth of adenocarcinoma, and retrograde spread of adenocarcinoma into small airways. Our results highlight the differential expression of p63 across various bronchioloalveolar lesions. Moreover, p63 may be helpful in distinguishing reactive from neoplastic glandular proliferations in the lung.     

The perils of power in interpretive research.

Occupational therapy is based on core values of altruism, equality, and honoring the dignity of others. Embedded in these values is the ever-present negotiation of power. To honor the concern for the welfare of others, researchers are challenged to think about issues of power throughout the research process. This paper identifies dilemmas and raises questions researchers might ask themselves as they struggle to share power in the interpretive research process.     

Outcomes of a pilot occupational therapy wellness program for older adults.

OBJECTIVE: The purpose of this study was to evaluate a pilot occupational therapy wellness program designed to teach elders the importance of participation in meaningful social and community occupations to their quality of life. METHOD: Sixty-five older adults participated in this pilot wellness program held at each of three senior apartment complexes. Measures of health-related quality of life using the SF-36 Health Survey and frequencies of social and community participation from a program-specific intake form were completed by 39 participants before and after the 6-month program. Participants also evaluated components of the program through a satisfaction survey. RESULTS: Scores on the SF-36 Health Survey were significantly higher in vitality, social functioning, and the mental health summary scores following participation in the program. Participants reported an increased frequency of socialization and community participation with an average of 55% participating in at least three or more activities per week before the program to an average of 66% participating after the program. Participants who benefited the most attended more classes, were older, and were nondrivers. Eighty percent of those polled rated the pilot program as good or excellent. CONCLUSION: This pilot study provides additional support for prevention efforts for elders in the community. Wellness programs for seniors may be most effective if targeted to those who are older and nondrivers.     

Homeless Shelter Policies for Women in an Urban Environment

A survey of shelters serving women in Chicago (N = 43) identified admission criteria, policies and services, estimated the number of homeless women in childbearing years served by the shelters, the number who were pregnant or mothers with children, and identified unmet health needs and health services provided. The majority (64%) of the women using shelters were African American and there was great variability in shelter policies. Women with male children more than seven years old, pregnant women and substance abusers were less likely to be admitted.     

The concept of self-management of type 1 diabetes in children and adolescents: an evolutionary concept analysis

AIM: An evolutionary concept analysis was undertaken to clarify the concept of self-management of type 1 diabetes in children and adolescents. BACKGROUND: Several problems exist in the literature on self-management of type 1 diabetes in children and adolescents. There is no uniform terminology and there is no uniform definition of the concept. Also, there is no differentiation in the literature between self-management of diabetes in children and adults. METHODS: Ninety-nine references were reviewed and analysed in the disciplines of nursing, medicine, and psychology. After separate analyses revealed no significant differences across disciplines, the analyses were combined to describe the attributes, antecedents, consequences, and surrogate and related concepts. RESULTS: The three essential attributes of the concept were identified as process, activities, and goals. Self-management of type 1 diabetes in children and adolescents is an active and proactive process; it is daily, lifelong, and flexible, and it involves shifting and shared responsibility for diabetes care tasks and decision-making between child and parent. It is a process that involves collaboration with health care providers. Self-management of type 1 diabetes in children and adolescents also consists of varied and many activities related to giving insulin, monitoring metabolic control, regulating diet and exercise, to name just a few. The concept also involves goals, which may differ from one parent/child dyad to another. A working definition of the concept is suggested. CONCLUSIONS: It is hoped that a more uniform definition of the concept will enable researchers to continue investigating antecedents and consequences of the concept in a way that allows for aggregating results.     

Rapid Inpatient Behavioral Treatment for Choking Phobia in Children

Six children with acquired choking phobia who failed outpatient intervention were treated in a rapid, behaviorally based inpatient program that integrated in vivo exposure with contingency management. Motivation to eat feared foods was increased via the manipulation of appetite and hospital privileges (e.g., visits, TV). Children were required to eat small quantities of feared food to receive privileges, and failure to meet these requirements resulted in privilege suspension. Elimination of the choking phobia occurred within 3 days. This approach is appropriate for cases in which outpatient treatment fails, in which parents have made legitimate attempts at home-based treatment, or in which the child's medical condition warrants it.     

Depression in the elderly

Received from the Geriatric Medicine/Gerontology Division of General Internal Medicine, and the Department of Psychiatry. Medical College of Ohio, C. S. # 10008, Toledo, OH 43699.     

Natural history of atopic dermatitis and its relationship to serum total immunoglobulin E in a population-based birth cohort study

We investigated the natural history of atopic dermatitis (AD) in a population-based birth cohort and assessed whether children at risk of visible eczema at 5 years of age can be identified from total immunoglobulin E (IgE) levels measured at 8, 12 and 18 months. AD data collected included a whole body examination for visible eczema at 49 months (4 years) and 61 months (5 years) of age and parent completed questionnaire data throughout their early lives. Children were divided into four groups based on their natural history of early AD: persistent (AD at 1, 6, 18, 30 and 42 months, n  = 34), intermittent early onset (before 18  months of age, n  = 495), intermittent late onset (18–42 months of age, n  = 273) and unaffected ( n  = 429). Visible eczema at 5 years of age was present in 12.2% (117/957) (95% confidence interval [CI] 10.1–14.3%) of the children. Levels of total IgE at 8, 12 and 18 months of age were associated with early onset of AD, but not with AD of later onset. For all four natural history groups, the geometric mean total IgE at 12 months was higher in those who subsequently had visible eczema than those who did not. However, the degree of overlap was such that total IgE at 12 months of age was a poor predictor of eczema at age five. A cutoff point of 78 kU/l had the highest positive predictive value for visible eczema at 5 years of age of 28.6%, with a sensitivity of 12% and specificity of 95%.