Developing the public health practitioner workforce in England: lessons from theory and practice

FOCUS

The paper focuses on public health practitioners who collectively represent one of three key workforce groups identified by England's Chief Medical Officer as critical to the successful delivery of national public health policy priorities.

QUESTION

We report on two areas of work which attempt to address the following two-part question: in developing the public health practitioner workforce in England, what is needed, and how do we do it?

APPROACH

First, we describe a five-component conceptual framework for developing the public health workforce which is grounded in data derived from a national Open Space event hosted by the University of the West of England in March 2005. The five components are (i) strategic support and oversight; (ii) national technical and professional support; (iii) national career building; (iv) local organisational development, and (v) sub-regional skills development. Key elements of each component are described in the paper. Second, we describe in some detail a new multidisciplinary skills development programme which illustrates one of the framework components (sub-regional skills development). The programme, established in January 2005, is aimed at three key groups of public health practitioners: health visitors (specialist community public health nurse), school nurses and environmental health officers. Its main features and some initial evaluation findings are presented.

CONCLUSIONS

To be effective, activities aimed at supporting the development of the public health practitioner workforce should, where possible, aim to be congruent with core public health principles of self-determination and collective responsibility. We also conclude that leadership and vision at a national level, combined with local implementation of evidence-based training programme such as the one described could help to achieve much greater and more rapid progress in skilling up the existing public health practitioner workforce than has been possible up to now. But we note that this requires sustained investment, robust sector-wide delivery frameworks, and a group of committed local public health champions.

RAPD polymorphisms in spring wheat cultivars and lines with different level of Fusarium resistance

Random amplified polymorphic DNA (RAPD) markers have been used to characterize the genetic diversity among 35 spring wheat cultivars and lines with different levels of Fusarium resistance. The objectives of this study were to determine RAPD-based genetic similarity between accessions and to derive associations between Fusarium head blight (FHB) and RAPD markers. Two bulked DNA from either highly resistant lines or susceptible lines were used to screen polymorphic primers. Out of 160 screened primers, 17 primers generated reproducible and polymorphic fragments. Genetic similarity calculated from the RAPD data ranged from 0.64 to 0.98. A dendrogram was prepared on the basis of a similarity matrix using the UPGMA algorithm, which corresponded well with the results of principal component analysis and separated the 35 genotypes into two groups. Association analysis between RAPD markers and the FHB index detected three RAPD markers, H19(1000), F2(500) and B1(2400), significantly associated with FHB-resistant genotypes. These results suggest that a collection of unrelated genotypes can be used to identify markers linked to an agronomically important quantitative trait like FHB. These markers will be useful for marker-assistant breeding and can be used as candidate markers for further gene mapping and cloning.

Increased carotid intima-media thickness in children-adolescents, and young adults with a parental history of premature myocardial infarction

AIMS

The present study was designed to test whether early carotid structural changes are demonstrable (by high resolution B-mode ultrasound) in children, adolescents and young adults with a history of premature parental myocardial infarction.

METHODS AND RESULTS

One hundred and fourteen healthy young (5 to 30 years) subjects with a parental history of premature myocardial infarction and 114 age- and sex-matched control subjects were enrolled in the study. They were divided into two age groups: children and adolescents (age 5 to 18 years) (54 individuals with a parental history of premature myocardial infarction and their control subjects; mean age 12.8+/-3.8 years) and young adults (age 19 to 30 years) (60 individuals with a parental history and their controls; mean age 23.8+/-3.3 years). All subjects underwent high resolution B-mode ultrasonographic evaluation of common carotid artery intima-media thickness. Lipid profile, resting blood pressure, body mass index and smoking status were also evaluated. In both age groups, compared to controls, subjects with a parental history of premature myocardial infarction had increased intima-media thickness of common carotid arteries (mean of combined sites: age 5-18 years: 0.45+/-0.076 mm vs 0.40+/-0.066 mm in controls, P=0.008; age 19-30 years: 0.48+/-0.077 mm vs 0.45+/-0.078 mm in controls,P =0.007) Offspring of coronary patients showed an unfavourable lipid profile, however, the association between a parental history of premature myocardial infarction and carotid intima-media thickness was independent of lipids, apolipoproteins and other traditional risk factors.

CONCLUSIONS

Vascular structural changes associated with a parental history of premature myocardial infarction are already detectable in childhood and adolescence and occur independently of several traditional cardiovascular risk factors.

Widespread bone disease in acute myeloid leukaemia

We describe a 11-year-old boy with acute myeloid leukaemia who presented with widespread bone disease. Spine X-rays revealed multiple crush fractures and there were multiple hot spots on the bone scan. The bone-mineral density was markedly reduced but there was no hypercalcaemia or hypercalcuria. Bone marrow aspirate revealed 98% blast cells and a balanced translocation between chromosomes 10 and 17 in seven of nine metaphases. Plasma interleukin-6 level before chemotherapy was high at 53 pg/ml. We postulate that the mechanism for bony destruction in this case was similar to that in the adult disease myeloma.

Fractal analysis of eye movements during reading

We present a new method for the analysis of reading eye movements based on the methods of nonlinear dynamics. In this preliminary study, the eye movements of normal and abnormal readers were analyzed for evidence of chaotic, nonlinear dynamical behavior. Both power spectral density analysis and fractal dimension determination showed evidence of nonlinearity as manifest in chaotic behavior. The computed fractal dimension of the system's presumed attractor seemed directly related to qualitative assessment of reading ability. Representative subjects did not differ in a similar analysis of pursuit movements. Although fractal analysis did not distinguish unconditionally between normal and abnormal reading in this preliminary study, it nevertheless offers a promising hitherto unused approach to the analysis of eye movements and the modeling of oculomotor behavior.

Equity in access to exercise tolerance testing, coronary angiography, and coronary artery bypass grafting by age, sex and clinical indications

OBJECTIVES

To assess whether patients with heart disease in a single UK hospital have equitable access to exercise testing, coronary angiography, and coronary artery bypass graft surgery (CABG).

METHOD

Retrospective analysis of patients' medical case notes (n = 1790), tracking each case back 12 months and forward 12 months from the patient's date of entry to the study.

SETTING

Single UK district hospital in the Thames Region.

PATIENTS

Patients (elective and emergency) with a cardiac ICD inpatient code at discharge or death, or who were referred to cardiology or care of the elderly unit over a 12 month period in 1996-7 (new episodes) were included.

RESULTS

Analysis of 1790 hospital case notes revealed that, despite having indications for intervention identical to those of younger patients, older patients (that is, those aged > 75 years) and women, independently, were significantly less likely to undergo exercise tolerance testing (exercise ECG) and cardiac catheterisation. The similar trends for age and access to CABG did not achieve significance. While clinical priority scores also independently predicted access to cardiac catheterisation and CABG, considerable numbers of patients in high clinical priority groups were not referred for either procedure.

CONCLUSIONS

The management and treatment of older patients and women with cardiac disease may be different from that of younger patients and men. Given the similarity of the indications for treatment and the lack of significant contraindications or comorbidities as a cause for these differences, one possible explanation is that these patients are being discriminated against principally because of their age and sex. Although clinical priority scores independently predicted access to catheterisation and CABG, large proportions of patients in high priority groups were not referred. This implies that the New Zealand priority scoring system may be more equitable than UK practice. The cost implications of redressing these inequities in service provision would be considerable.

Inhibition of transcription factor NF-κB reduces matrix metalloproteinase-1, -3 and -9 production by vascular smooth muscle cells

OBJECTIVE

Matrix metalloproteinases (MMPs) contribute to the destruction of the extracellular matrix at the shoulder regions of atherosclerotic plaques that leads to plaque destabilisation and triggers clinical cardiovascular disease. There is therefore considerable interest in establishing the mechanisms responsible for increased MMP production. MMPs-1, -3 and -9 are upregulated by inflammatory cytokines and growth factors that are produced by plaque resident macrophages and smooth muscle cells. Our present studies focused on NF-kappaB, which regulates numerous inflammatory genes, and is activated in plaque smooth muscle cells. Moreover, an NF-kappaB binding site is present in the promoter of the MMP-9 gene and an NF-kappaB-like element in the promoter of the MMP-1 gene.

METHODS

We used adenovirus mediated overexpression of its inhibitor, I kappaBalpha to investigate the role of NF-kappaB in regulation of MMP-1, -3 and -9 by isolated, cytokine stimulated rabbit aortic and human saphenous vein VSMC.

RESULTS

IL-1alpha potently activated NF-kappa B in VSMCs and acted synergistically with growth factors to upregulate expression of MMP-1, -3 and -9. Overexpression of I kappaBalpha, almost completely inhibited expression of MMP-1, -3 and -9 in response to IL-1alpha alone or in combination with bFGF and PDGF.

CONCLUSION

NF-kappaB is required for cytokine upregulation of MMP-1, -3 and -9 in VSMCs, which suggests that NF-kappaB inhibition may promote plaque stabilisation.

Structural and functional characterization of B-domain deleted recombinant factor VIII

A new high-purity recombinant factor VIII preparation has been developed for the treatment of hemophilia A. Structurally, this factor VIII preparation, B-domain deleted recombinant factor VIII (BDDrFVIII), differs from other recombinant and plasma-derived factor VIII preparations in that most of the B-domain has been deleted. To ensure that BDDrFVIII contains the requisite structural and functional features, it has been subjected to detailed biochemical and biophysical characterization in comparison to the plasma-derived form of factor VIII. Laboratory studies have shown that the primary, secondary, and tertiary structures of BDDrFVIII and the posttranslational modifications are similar to those of the [80 + 90]-kd form of plasma-derived factor VIII. In addition, BDDrFVIII has full biologic activity compared with full-length factor VIII preparations.

A national evaluation of specialists' clinics in primary care settings

BACKGROUND

Encouraged by the increased purchasing power of general practitioners (GPs), specialist-run clinics in general practice and community health care settings (known as specialist outreach clinics) have increased rapidly across England. The activities of local commissioning schemes within primary care groups are likely to accelerate this trend.

AIM

To evaluate the costs, processes, and benefits of specialists' outreach clinics held in GPs' surgeries, compared with hospital outpatient clinics.

DESIGN OF STUDY

A case-referent (comparative) study comparing the characteristics of outreach clinics (cases) with matched outpatient control clinics.

SETTING

Thirty-eight outreach clinics, compared with 38 matched outpatient clinics as controls, covering 14 hospital trust areas across England.

METHOD

Self-administered questionnaires were given to patients in both clinic settings. These covered processes, satisfaction, personal costs, and health status, with postal follow-up at six months to assess health outcomes. Self-administered questionnaires were also given to the specialists and GPs whose clinics were included in the study (individual patient clinical sheet and an attitude questionnaire), practice managers, and trust accountants (process and costs questionnaire). Evaluation of the costs, processes, and benefits of specialist outreach clinics versus hospital outpatient clinics was carried out by comparing questionnaire responses.

RESULTS

In comparison with outpatients, outreach clinic patients spent less time on the waiting lists for appointments to see the specialist, they had shorter waiting times in clinics, fewer follow-up appointments, and were more likely to be completely discharged after the sampled attendance. Outreach patients were more satisfied than outpatients with the range of clinic process items asked about. Most doctors felt that the outreach clinic was 'worthwhile'. While patients' personal costs were lower in outreach than in outpatients clinics, NHS costs were more expensive per patient in outreach. The benefits of outreach clinics on patients' health status at six months' follow-up were relatively small.

CONCLUSIONS

Outreach clinics are a means of improving access to specialist services for patients, in addition to improving the efficiency and quality of health care. Most results were similar across specialties and areas. The benefits of the outreach service need to be weighed against their substantially higher NHS costs, in comparison with outpatients clinics. Outreach clinics are unlikely to be financially justifiable for NHS funding given that the impact on patients' health status was small.

The highly conserved COOH terminus of troponin I forms a Ca2+-modulated allosteric domain in the troponin complex

The primary structure of the COOH-terminal region of troponin I (TnI) is highly conserved among the cardiac, slow, and fast skeletal muscle TnI isoforms and across species. Although no binding site for the other thin filament proteins is found at the COOH terminus of TnI, truncations of the last 19-23 amino acid residues reduce the activity of TnI in the inhibition of actomyosin ATPase and result in cardiac muscle malfunction. We have developed a specific monoclonal antibody (mAb), TnI-1, against the conserved COOH terminus of TnI. Using this mAb, isolation of the troponin complex by immunoaffinity chromatography from muscle homogenate and immunofluorescence microscopic staining of myofibrils indicate that the COOH terminus of TnI forms an exposed structure in the muscle thin filament. Binding of this mAb to the COOH terminus of cardiac TnI induced extensive conformational changes in the protein, suggesting an allosteric role of this region in the functional integrity of troponin. In the absence of Ca2+, the binding of troponin C and troponin T to TnI had very little effect on the conformation of the COOH terminus of TnI as indicated by the unaffected mAb affinity for the TnI-1 epitope. However, Ca2+ significantly increased the accessibility of the TnI-1 epitope on TnI in the presence of troponin C and troponin T. The results provide evidence that the COOH terminus is an essential structure in TnI and participates in the allosteric switch during Ca2+ activation of contraction.

AKAP-mediated targeting of protein kinase a regulates contractility in cardiac myocytes

Compartmentalization of cAMP-dependent protein kinase A (PKA) by A-kinase anchoring proteins (AKAPs) targets PKA to distinct subcellular locations in many cell types. However, the question of whether AKAP-mediated PKA anchoring in the heart regulates cardiac contractile function has not been addressed. We disrupted AKAP-mediated PKA anchoring in cardiac myocytes by introducing, via adenovirus-mediated gene transfer, Ht31, a peptide that binds the PKA regulatory subunit type II (RII) with high affinity. This peptide competes with endogenous AKAPs for RII binding. Ht31P (a proline-substituted derivative), which does not bind RII, was used as a negative control. We then investigated the effects of Ht31 expression on RII distribution, Ca(2+) cycling, cell shortening, and PKA-dependent substrate phosphorylation. By confocal microscopy, we showed redistribution of RII from the perinuclear region and from periodic transverse striations in Ht31P-expressing cells to a diffuse cytosolic localization in Ht31-expressing cells. In the presence of 10 nmol/L isoproterenol, Ht31-expressing myocytes displayed an increased rate and amplitude of cell shortening and relaxation compared with control cells (uninfected and Ht31P-expressing myocytes); with isoproterenol stimulation we observed decreased time to 90% decline in Ca(2+) but no significant difference between Ht31-expressing and control cells in the rate of Ca(2+) cycling or amplitude of the Ca(2+) transient. The increase in PKA-dependent phosphorylation of troponin I and myosin binding protein C on isoproterenol stimulation was significantly reduced in Ht31-expressing cells compared with controls. Our results demonstrate that, in response to beta-adrenergic stimulation, cardiomyocyte function and substrate phosphorylation by PKA is regulated by targeting of PKA by AKAPs.

Early transference interventions with male patients in psychotherapy

Transcripts of early sessions for 7 personality-disordered male subjects participating in an ongoing naturalistic long-term dynamic psychotherapy project were rated for therapist interventions and alliance. Early transference interpretations were followed by increased defensiveness even when there was a solid alliance. Omitting transference interpretations in the face of an early negative transference was equally problematic. However, the rapid sequence of early transference and defense interpretations, or early defense interpretations alone, enhanced therapeutic work without increasing defensiveness. Caretaking of the alliance after early interpretive work was also investigated. Two different styles of handling affect emerged from the sample.

Localization of the death domain of tissue inhibitor of metalloproteinase-3 to the N terminus. Metalloproteinase inhibition is associated with proapoptotic activity

The tissue inhibitors of metalloproteinases (TIMPs) are a family of four secreted inhibitors of matrix metalloproteinases (MMPs). Recently, additional functions have been attributed to the TIMPs, including cell growth and inhibition of angiogenesis. In particular, we demonstrated that TIMP-3 overexpression using gene transfer induces apoptosis in a variety of cell types and can inhibit vascular neointima formation in vivo. However, little is know about the mechanisms underlying TIMP-3-mediated apoptosis. Here, using both purified recombinant proteins and novel adenoviral vectors we demonstrate that the prodeath domain of TIMP-3 is located within the N-terminal three loops of TIMP-3. Although both wild type and N-terminal TIMP-3 proteins promoted apoptosis, a T-2/T-3 chimera, in which the N-terminal three loops of TIMP-3 are replaced by those of TIMP-2, failed to induce cell death. Furthermore, a point mutation at residue 1 of TIMP-3 totally abolished MMP-inhibitory activity of TIMP-3 and also failed to promote apoptosis. This study demonstrates, using multiple apoptosis assays, that the prodeath function of TIMP-3 is located within the N-terminal three loops and the presence of functional metalloproteinase-inhibitory activity is associated with the induction of apoptosis.

Selectivity and regulation of A-kinase anchoring proteins in the heart. The role of autophosphorylation of the type II regulatory subunit of cAMP-dependent protein kinase

Downstream regulation of the cAMP-dependent protein kinase (PKA) pathway is mediated by anchoring proteins (AKAPs) that sequester PKA to specific subcellular locations through binding to PKA regulatory subunits (RI or RII). The RII-binding domain of all AKAPs forms an amphipathic alpha-helix with similar secondary structure. However, the importance of sequence differences in the RII-binding domains of different AKAPs is unknown, and mechanisms that regulate AKAP-PKA affinity are not clearly defined. Using surface plasmon resonance (SPR) spectroscopy, we measured real-time kinetics of RII interaction with various AKAPs. Base-line equilibrium binding constants (K(d)) for RII binding to Ht31, mAKAP, and AKAP15/18 were 10 nm, 119 nm, and 6.6 microm, respectively. PKA stimulation of intact Chinese hamster ovary cells increased RIIalpha binding to AKAP100/mAKAP and AKAP15/18 by approximately 7- and 82-fold, respectively. These results suggest that differences in primary sequence of the RII-binding domain may be responsible for the selective affinity of RII for different AKAPs. Furthermore, RII autophosphorylation may provide additional localized regulation of kinase anchoring. In cardiac myocytes, disruption of RII-AKAP interaction decreased PKA phosphorylation of the PKA substrate, myosin-binding protein C. Thus, these mechanisms may be involved in adding additional specificity in intracellular signaling in diverse cell types and under conditions of cAMP/PKA activation.

Decreased SLIM1 expression and increased gelsolin expression in failing human hearts measured by high-density oligonucleotide arrays

BACKGROUND

Failing human hearts are characterized by altered cytoskeletal and myofibrillar organization, impaired signal transduction, abnormal protein turnover, and impaired energy metabolism. Thus, expression of multiple classes of genes is likely to be altered in human heart failure.

METHODS AND RESULTS

We used high-density oligonucleotide arrays to explore changes in expression of approximately 7000 genes in 2 nonfailing and 2 failing human hearts with diagnoses of end-stage ischemic and dilated cardiomyopathy, respectively. We report altered expression of (1) cytoskeletal and myofibrillar genes (striated muscle LIM protein-1 [SLIM1], myomesin, nonsarcomeric myosin regulatory light chain-2 [MLC(2)], and ss-actin); (2) genes responsible for degradation and disassembly of myocardial proteins (alpha(1)-antichymotrypsin, ubiquitin, and gelsolin); (3) genes involved in metabolism (ATP synthase alpha-subunit, succinate dehydrogenase flavoprotein [SDH Fp] subunit, aldose reductase, and TIM17 preprotein translocase); (4) genes responsible for protein synthesis (elongation factor-2 [EF-2], eukaryotic initiation factor-4AII, and transcription factor homologue-HBZ17); and (5) genes encoding stress proteins (alphaB-crystallin and mu-crystallin). In 5 additional failing hearts and 4 additional nonfailing controls, we then compared expression of proteins encoded by the differentially expressed genes, alphaB-crystallin, SLIM1, gelsolin, alpha(1)-antichymotrypsin, and ubiquitin. In each case, changes in protein expression were consistent with changes in transcript measured by microarray analysis. Gelsolin protein expression was also increased in cardiomyopathic hearts from tropomodulin-overexpressing (TOT) mice and rac1-expressing (racET) mice.

CONCLUSIONS

Altered expression of the genes identified in this study may contribute to development of the heart failure phenotype and/or represent compensatory mechanisms to sustain cardiac function in failing human hearts.