Development of a Digital Health Intervention to Support Patients on a Waitlist for Orthopedic Specialist Care: Co-Design Study

BACKGROUND

The demand for orthopedic specialist consultations for patients with osteoarthritis in public hospitals is high and continues to grow. Lengthy waiting times are increasingly affecting patients from low socioeconomic and culturally and linguistically diverse backgrounds who are more likely to rely on public health care.

OBJECTIVE

This study aimed to co-design a digital health intervention for patients with OA who are waiting for an orthopedic specialist consultation at a public health service, which is located in local government areas (LGAs) of identified social and economic disadvantage.

METHODS

The stakeholders involved in the co-design process included the research team; end users (patients); clinicians; academic experts; senior hospital staff; and a research, design, and development agency. The iterative co-design process comprised several key phases, including the collation and refinement of evidence-based information by the research team, with assistance from academic experts. Structured interviews with 16 clinicians (female: n=10, 63%; male: n=6, 38%) and 11 end users (age: mean 64.3, SD 7.2 y; female: n=7, 64%; male: n=4, 36%) of 1-hour duration were completed to understand the requirements for the intervention. Weekly workshops were held with key stakeholders throughout development. A different cohort of 15 end users (age: mean 61.5, SD 9.7 y; female: n=12, 80%; male: n=3, 20%) examined the feasibility of the study during a 2-week testing period. The System Usability Scale was used as the primary measure of intervention feasibility.

RESULTS

Overall, 7 content modules were developed and refined over several iterations. Key themes highlighted in the clinician and end user interviews were the diverse characteristics of patients, the hierarchical structure with which patients view health practitioners, the importance of delivering information in multiple formats (written, audio, and visual), and access to patient-centered information as early as possible in the health care journey. All content was translated into Vietnamese, the most widely spoken language following English in the local government areas included in this study. Patients with hip and knee osteoarthritis from culturally and linguistically diverse backgrounds tested the feasibility of the intervention. A mean System Usability Scale score of 82.7 (SD 16) was recorded for the intervention, placing its usability in the excellent category.

CONCLUSIONS

Through the co-design process, we developed an evidence-based, holistic, and patient-centered digital health intervention. The intervention was specifically designed to be used by patients from diverse backgrounds, including those with low health, digital, and written literacy levels. The effectiveness of the intervention in improving the physical and mental health of patients will be determined by a high-quality randomized controlled trial.

How does the American public interact with chaplains? Evidence from a national survey

How does the American public understand the term chaplain? What fraction interact with chaplains and in what settings? What is the content of those interactions and do care recipients find them valuable? We answer these questions with data from a nationally representative survey (N = 1096) conducted in March 2022 and interviews with a subset (N = 50) of survey recipients who interacted with chaplains. We find that people in the United States do not have a consistent understanding of the term chaplain. Based on our definition, at least 18% of Americans have interacted with a chaplain. Among those who interacted with a chaplain as defined in the survey, the majority did so through healthcare organizations. Care recipients include people who were ill and their visitors/caregivers. The most common types of support received were prayer, listening and comfort. Overall, survey respondents found chaplains to be moderately or very valuable.

The content and effects of interactions with chaplains

OBJECTIVES

Chaplains provide spiritual care in a variety of settings and are an important part of palliative and supportive care teams. This study aims to describe chaplain interactions from the perspective of the recipients of care.

METHODS

The study draws on data from a nationally representative survey conducted by the Gallup Organization in March 2022.

RESULTS

Two main groups of recipients were identified: primary recipients and visitors/caregivers. Current typologies of chaplain activities focus on primary recipients of care, but a similar proportion of chaplain interactions takes place with visitors/caregivers. Bivariate analysis was used to compare the experiences of the chaplains' primary recipients of care to other recipients of care and the experiences of visitors/caregivers to other recipients of care. Primary recipients of care were significantly more likely to have religious interactions with the chaplain and to experience the interactions as valuable and helpful.

SIGNIFICANCE OF RESULTS

This study is the first to show the groups of people - primary recipients and visitors/caregivers - who receive care from chaplains. It demonstrates how care recipients experience care differently from chaplains based on their position, which has important implications for spiritual care practice.

Chaplains in federal and state organizations: An institutional note

Spiritually integrated care that includes collaborations among chaplains, psychologists, and other health care professionals can have a profound effect on people's lives. To facilitate this care, scholars and policy makers need to understand where chaplains work and how they are (or are not) formally a part of institutions, particularly those funded by the state and federal government. This article offers a short history of chaplaincy and provides snapshots about where chaplains work as federal and state employees in three sample states: Massachusetts, Illinois, and California. This institutional perspective is integral to understanding where and how chaplains are staffed and where collaborations are possible. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Do We Want a Human First, and a Lawyer Second? Developing Law Student Empathy Through Clinical Legal Education

In the UK, the legal profession is increasingly acknowledging the importance of emotional intelligence and empathy in legal practice. Furthermore, research has demonstrated that soft skills such as empathy can be taught, and that these skills should be incorporated in legal education. This study uses the Basic Empathy Scale to examine whether law student participation in law clinic and tax clinic modules had any effect on students’ self-reported empathy levels. It is submitted that, in general, the students who worked in clinic experienced a statistically significant positive shift in their empathy levels. However, a few students who worked in clinic also experienced a decrease in their empathy levels, and the possible reasons for this are explored. In addition, this paper considers the impact of gender on students’ self-reported empathy levels.

Development of a reference material for analysing naturally occurring radioactive material from the steel industry

Accurate measurement of naturally occurring radionuclides in blast furnace slag, a by-product of the steel industry, is required for compliance with building regulations where it is often used as an ingredient in cement. A matrix reference blast furnace slag material has been developed to support traceability in these measurements. Raw material provided by a commercial producer underwent stability and homogeneity testing, as well as characterisation of matrix constituents, to provide a final candidate reference material. The radionuclide content was then determined during a comparison exercise that included 23 laboratories from 14 countries. Participants determined the activity per unit mass for ²²⁶Ra, ²³²Th and ⁴⁰K using a range of techniques. The consensus values obtained from the power-moderated mean of the reported participant results were used as indicative activity per unit mass values for the three radionuclides: A₀(²²⁶Ra) = 106.3 (34) Bq·kg^-1, A₀(²³²Th) = 130.0 (48) Bq·kg^-1 and A₀(⁴⁰K) = 161 (11) Bq·kg^-1 (where the number in parentheses is the numerical value of the combined standard uncertainty referred to the corresponding last digits of the quoted result). This exercise helps to address the current shortage of NORM industry reference materials, putting in place infrastructure for production of further reference materials.

Angiogenin promotes tumoral growth and angiogenesis by regulating matrix metallopeptidase-2 expression via the ERK1/2 pathway

Tumor angiogenesis is essential for tumor growth and metastasis and is dependent on key angiogenic factors. Angiogenin (ANG), a 14.2-kDa polypeptide member of the RNase A superfamily, is an angiogenic protein that has been reported to be upregulated and associated with poor prognosis in some human cancers. The mechanisms through which aberrant ANG levels promote specific steps in tumor progression are unknown. Here, we show that ANG expression in human tissues is strongly correlated with an invasive cancer phenotype. We also show that ANG induces cellular survival, proliferation, endothelial tube formation and xenograft angiogenesis and growth. Novel mechanistic investigations revealed that ANG expression stimulated matrix metallopeptidase-2 (MMP2) expression through the phosphorylation of ERK1/2. Targeting ANG in vivo with N65828, a small-molecule inhibitor of the ribonucleolytic activity of human ANG, resulted in the diminution of xenograft tumoral growth through the inhibition of angiogenesis. Our findings support an unrecognized interplay between ANG, ERK1/2 and MMP2 that can impact tumor growth and progression. The targeting of ANG and associated factors could provide a novel strategy to inhibit tumor establishment and growth.

The value of health libraries and librarians to the Irish health system

Librarians working in the Irish health sector are under threat. This is a relatively young profession in comparison with international counterparts, with a low staffing base even at its peak. The public sector moratorium has led to professionally qualified librarians and library assistants not being replaced right across the health system. Librarians are employed in the HSE, voluntary sector, and university sectors. The value that this profession brings to healthcare has been documented in systematic reviews and literature in other countries. In Ireland this group is represented by the Health Science Libraries Group (HSLG), a section of the Library Association of Ireland. The HSLG commissioned research into the status of the profession as well as Irish health libraries. This resulted in the publication of the "SHeLLI Report" in 2011. Results of the report are outlined here and selected examples of value of librarians to healthcare are described.

The role of routine laboratory studies and neuroimaging in the diagnosis of dementia: a clinicopathological study

OBJECTIVE

To determine the neuropathological diagnoses of longitudinally followed patients with potentially reversible causes of dementia and to examine the results of the "dementia work-up," especially neuroimaging, by comparison with the pathological diagnosis.

DESIGN

A neuropathologic series of 61 consecutive patients, with review of clinical, laboratory, neuroimaging, and pathological results.

RESULTS

Of the 61 patients, forty-eight (79%) had a clinical diagnosis of probable or possible Alzheimer's disease (AD). Compared with the pathological diagnosis, the sensitivity and specificity of the clinical diagnosis of AD were 96% and 79%, respectively. Of the 61 patients, 9 had abnormal laboratory tests, the correction of which did not improve the subsequent course. These patients were found to have AD8 and frontotemporal dementia on pathology. In two patients, neuroimaging was helpful in the clinical diagnoses of frontotemporal dementia and progressive supranuclear palsy (PSP). Neuroimaging revealed cerebrovascular disease in 18 patients, only two of whom were suspected clinically. Pathology confirmed AD in 17 and PSP in 1 of these patients. Sensitivity and specificity for the clinical diagnosis of cerebrovascular disease in comparison with pathology were 6% and 98%, respectively. With the added information from neuroimaging, that sensitivity increased to 59% and specificity decreased to 81%.

CONCLUSIONS

All cases with abnormal laboratory or neuroimaging results had AD or some other neurodegenerative disease on pathology. The "dementia work-up" did not reveal any reversible causes for dementia in this group of patients. Neuroimaging may have a role, especially in the diagnosis of possible AD with concomitant cerebrovascular disease.

A clinicopathological comparison of community-based and clinic-based cohorts of patients with dementia

OBJECTIVES

To compare the sensitivity and specificity of the clinical diagnosis of Alzheimer disease, the distribution of pathological causes, and the demographic and clinical characteristics of 2 different groups of patients with dementia.

DESIGN

Retrospective clinicopathological study.

SETTING

A memory disorder clinic in a university hospital and a multiethnic community.

PATIENTS

Sixty-three patients from a memory disorder clinic and 26 patients from a large community-based study who underwent autopsy after clinical evaluation.

MAIN OUTCOME MEASURES

Differential distribution of clinical and pathological findings, with clinicopathological correlations.

RESULTS

Clinic patients were younger at diagnosis, more educated, and more likely to be white. Of the 63 clinic patients we evaluated, 29 (46%) had a pathological diagnosis of definite AD, 15 (24%) had a diagnosis of mixed AD, and 19 (30%) had a diagnosis of another type of dementia. The pathological diagnoses in the community patients were distributed as follows: 6 (23%) had definite AD, 6 (23%) had mixed AD, 6 (23%) had cerebrovascular disease, and 8 (31%) had another type of dementia. The difference in distribution of pathological diagnoses between these 2 groups was only significant for cerebrovascular diseases. For patients seen at the clinic, the sensitivity of the clinical diagnosis of AD was 98% and the specificity was 84%; for the community group, the sensitivity was 92% and the specificity was 79%.

CONCLUSIONS

The difference in sensitivity and specificity of clinical diagnosis was not statistically significant between the groups of clinic patients and community patients. Dementia associated with cerebrovascular disease was more prevalent in the community sample. This difference may be attributable to clinical and demographic differences between the 2 groups.

The morphogenesis of mouse vallate gustatory epithelium and taste buds requires BDNF-dependent taste neurons

The developmental absence of brain-derived neurotrophic factor (BDNF) in null mutant mice caused three interrelated defects in the vallate gustatory papilla: sparse innervation, a reduction in the area of the gustatory epithelium, and fewer taste buds. On postnatal day 7, the stunted vallate papilla of bdnf null mutant mice was 30% narrower, the trench walls 35% reduced in area, and the taste buds 75% less abundant compared with wild-type controls. Quantitative assessment of innervation density was carried out to determine if the small trench walls and shortage of taste buds could be secondary consequences of the depletion of gustatory neurons. The diminished gustatory innervation was linearly associated with a reduced trench wall area (r = +0.94) and fewer taste buds (r = +0.96). Residual taste buds were smaller than normal and were innervated by a few surviving taste neurons. We conclude that BDNF-dependent taste neurons contribute to the morphogenesis of lingual gustatory epithelia and are necessary for both prenatal and postnatal mammalian taste bud formation. The gustatory system provides a conspicuous example of impaired sense organ morphogenesis that is secondary to sensory neuron depletion by neurotrophin gene null mutation.

BDNF is required for the normal development of taste neurons in vivo

The vallate gustatory epithelium of neonatal trkB null mutant mice (-/-) lacked innervation. This prompted the evaluation of null mutant mice corresponding to the three neurotrophin ligands for tyrosine kinase receptor B (TrkB): brain-derived neurotrophic factor (BDNF), neurotrophin (NT)3, NT4. The vallate gustatory epithelium of nt3-/- mice and of nt4-/- mice appeared normal. Only bdnf-/- mice had a vallate papilla that was stunted, sparsely innervated, and lacked up to 98% of its taste buds. All three defects persisted. For example, the vallate papilla of 12-day-old bdnf-/- mice remained markedly less well innervated than the vallate of 7-day-old or newborn bdnf+/+ mice. The foliate taste papillae of neonatal bdnf-/- mice had similar defects. We conclude that the normal development of taste neurons requires BDNF.

Glycoconjugates and keratin 18 define subsets of taste cells

Sections of neonatal, normal adult and denervated adult rat tongue were examined with lectin histochemistry. Attention was focused upon intragemmal cells (cells within the taste bud) and the surrounding perigemmal cells. Informative staining patterns were observed with four of 12 lectins: Ulex europaeus (UEA-I), Bauhinia purpurea (BPA), Helix pomatia (HPA) and Lotus tetragonolobus (LTA) agglutinins. In normal adult tongues, BPA bound to those lingual epithelial cells lacking contact with the basal lamina. After they formed, vallate taste buds were laterally surrounded by distinctive BPA-positive cells. HPA reacted selectively with 28% and LTA with 23% of the intragemmal cells in vallate/foliate taste buds. In double-stained taste buds there was a statistically significant overlap of LTA-positive cells and keratin 18-positive cells. The overlap between HPA binding and keratin 18 was more marked: double-stained cells comprized 67% of all stained cells. During taste bud development in neonates keratin 18 synthesis preceded HPA binding. In contrast, during the replacement of adult taste cells, keratin 18 synthesis and HPA binding were generally concurrent. Keratin 18 and HPA probably identify the same subset of older taste receptor cells. HPA may bind to glycoconjugates on the surface of keratin 18-positive cells. In denervated adult tongue the loss of all UEA-I-positive or BPA-positive perigemmal cells suggests that perigemmal as well as intragemmal cells are nerve-dependent.

Keratin 18 is associated with a subset of older taste cells in the rat

All or nearly all intragemmal (elongated) cells of rat taste buds were immunopositive for keratins 7, 8, and 19. In contrast, keratin 18 was detected in 19 +/- 5 cells per taste bud (mean +/- sd), or about 25% of the intragemmal cells. During taste bud development keratins 7, 8, and 19 were evident initially in polygonal cells and later in elongated taste cells. Keratin 8 appeared in vallate taste cells at P0 (postnatal day 0), followed by keratins 7 and 19 at P1, and keratin 18 at P2-P3. Keratin 18 was always limited to elongated cells. The assemblage of elongated taste cells comprising a taste bud began with a single elongated cell, rather than with the synchronous elongation of a cluster of cells. Developmental errors were observed at P2-P3, e.g., some vallate taste cells had a misoriented axis. In order to study the pace of keratin differentiation during cell turnover we injected bromodeoxyuridine (BrdU) into adult rats to monitor taste cell age. Keratin-19-positive intragemmal cells differentiated within 1 day. In contrast, keratin 18 was first detected in cells aged 3 days. Hence, both in taste cell development and replacement, keratin 18 was restricted to the older cells; it was the last taste cell keratin to become expressed during differentiation.

Keratins as markers of differentiated taste cells of the rat

Cytokeratins in taste buds were immunocytochemically evaluated with monoclonal antibodies. In each of six different epithelial sites in the rat oral cavity, intragemmal cells of taste buds were immunoreactive for keratin polypeptides 8, 18, and 19, as well as for keratin 7, which has not been previously reported in taste buds. Keratin-18-like immunoreactivity was present in fewer than half of the intragemmal cells, whereas all intragemmal cells were immunopositive for keratins 7, 8, and 19. Apart from some salivary duct cells, no other cells in the tongue were immunoreactive for any of these four keratins. Morphological and immunocytochemical profiles indicate that taste buds are islets of simple epithelium embedded in an expanse of stratified squamous epithelium. These simple epithelial cells and their keratins are nerve-dependent, since denervation eliminated all four keratins and replaced elongated taste cells of the vallate papilla with stratified squamous epithelium. We conclude that antibodies against keratins 7, 8, or 19 are useful markers for intragemmal cells in studies of taste bud development, degeneration, regeneration, turnover and tissue culture.

Keratin 19-like immunoreactivity in receptor cells of mammalian taste buds

Three monoclonal antibodies, 4.62, LP2K and 170.2.14, were used to evaluate keratin 19-like immunoreactivity in gustatory epithelia. Keratin 19-like immunoreactivity was restricted to the intragemmal cells for all types of mammalian taste buds examined. These taste buds included fungiform, foliate and vallate taste buds in rat, gerbil and rabbit, and nasopalatine, epiglottal and palatine taste buds in rat. There was no keratin 19-like immunoreactivity in basal cells or in perigemmal cells lateral to the immunoreactive taste receptor cells. Denervation of the rat vallate papilla eliminated all taste buds, as well as all immunoreactive taste cells. That the immunoreactive material in the taste cells was keratin 19 was supported by the comparable staining of rat taste buds with each of three monoclonal antibodies specific for keratin 19. Furthermore, as predicted, these antibodies selectively stained luminal cells of rat bile ducts, bladder, salivary ducts, trachea, ureter and uterus. It was concluded that monoclonal antibodies against keratin 19 can usefully distinguish intragemmal taste receptor cells from keratinocytes, and from the perigemmal and basal cells of gustatory epithelia. Anti-keratin 19 antibodies may serve to identify differentiated taste cells in gustatory epithelia undergoing taste bud development, renewal, degeneration or regeneration.

Novel splicing, missense, and deletion mutations in seven adenosine deaminase-deficient patients with late/delayed onset of combined immunodeficiency disease. Contribution of genotype to phenotype

We examined the genetic basis for adenosine deaminase (ADA) deficiency in seven patients with late/delayed onset of immunodeficiency, an underdiagnosed and relatively unstudied condition. Deoxyadenosine-mediated metabolic abnormalities were less severe than in the usual, early-onset disorder. Six patients were compound heterozygotes; 7 of 10 mutations found were novel, including one deletion (delta 1019-1020), three missense (Arg156 > His, Arg101 > Leu, Val177 > Met), and three splicing defects (IVS 5, 5'ss T+6 > A; IVS 10, 5'ss G+1 > A; IVS 10, 3'ss G-34 > A). Four of the mutations generated stop signals at codons 131, 321, 334, and 348; transcripts of all but the last, due to delta 1019-1020, were severely reduced. delta 1019-1020 (like delta 955-959, found in one patient and apparently recurrent) is at a short deletional hot spot. Arg156 > His, the product of which had detectable activity, was found in three patients whose second alleles were unlikely to yield active ADA. The oldest patient diagnosed was homozygous for a single base change in intron 10, which activates a cryptic splice acceptor, resulting in a protein with 100 extra amino acids. We speculate that this "macro ADA," as well as the Arg156 > His, Arg101 > Leu, Ser291 > Leu, and delta 1019-1020 products, may contribute to mild phenotype. Tissue-specific variation in splicing efficiency may also ameliorate disease severity in patients with splicing mutations.

Morphometric and immunocytochemical assessment of fungiform taste buds after interruption of the chorda-lingual nerve

Unilateral interruption of the chorda-lingual nerve led to a loss of most epithelial axons and to the deterioration of fungiform taste buds in the anterior portion of the tongue of albino rats, mongolian gerbils, and golden hamsters. By three weeks after surgery the following percentages of fungiform taste buds had completely disappeared: 71% in gerbils, 28% in rats, and 26% in hamsters. Residual taste buds were classified into two groups: atrophic taste buds and taste bud remnants. Atrophic taste buds were smaller than normal and typically had no visible taste pore, although they retained the characteristic oval shape of a taste bud and numerous elongated cells. Taste bud remnants were non-oval fragments of taste buds with few elongated cells. Specific markers for elongated taste cells (monoclonal antibodies to keratin 19) confirmed that atrophic taste buds, as well as some taste bud remnants, had elongated taste cells. By 180 days after chorda-lingual nerve transection, 44% of rat fungiform taste buds had disappeared; morphometric analysis of the 311 residual taste buds established that 241 atrophic taste buds and 69 taste bud remnants were, respectively, 50% and 75% smaller than the average volume of 480 normal taste buds. The aggregate loss of gustatory tissue, calculated from the shrinkage of residual taste buds and the volume lost by the outright disappearance of many taste buds, was 88% for gerbils, 72% for rats, and 65% for hamsters. Evaluation in gerbils of the co-occurrence of taste buds and axons suggests residual taste buds were neurotrophically supported. Every gerbil fungiform papilla that lacked axons lacked a taste bud.(ABSTRACT TRUNCATED AT 250 WORDS)

Double-blind parallel design pilot study of acetyl levocarnitine in patients with Alzheimer's disease

Acetyl levocarnitine hydrochloride has been reported to retard dementia in patients with Alzheimer's disease. In a double-blind, parallel design, placebo-controlled pilot study of 30 mild to moderately demented patients with probable Alzheimer's disease, tests of memory, attention, language, visuospatial, and constructional abilities were administered, and the level of acetyl levocarnitine was measured in the cerebrospinal fluid. Patients were then randomly assigned to receive acetyl levocarnitine hydrochloride (2.5 g/d for 3 months followed by 3 g/d for 3 months) or placebo. After 6 months, the acetyl levocarnitine group demonstrated significantly less deterioration in timed cancellation tasks and Digit Span (forward) and a trend toward less deterioration in a timed verbal fluency task. No differences were found in any other neuropsychological test results. A subgroup with the lowest baseline scores, receiving acetyl levocarnitine, had significantly less deterioration on the verbal memory test and a significant increase in cerebrospinal fluid acetyl levocarnitine levels compared with those receiving placebo. These results suggest that acetyl levocarnitine may retard the deterioration in some cognitive areas in patients with Alzheimer's disease and stress the need for a larger study of this drug.

Tritiated imipramine binding. A peripheral marker for serotonin in Parkinson's disease

Tritiated imipramine binding in platelets has been used to evaluate serotonin activity in depression in previous studies. This article examined this marker as a possible measure of central nervous system serotonergic activity for depression in patients with Parkinson's disease (PD). The number of binding sites was significantly lower in depressed patients with PD than in a healthy control group. Patients with PD who were not depressed had lower values than the comparison group, but this difference was not significant. We also found a significant correlation between the receptor site values in platelets and cerebrospinal fluid levels of the serotonin metabolite, 5-hydroxyindoleacetic acid (r = .59), but this was independent of a diagnosis of depression. Receptor site values were examined to identify appropriate cutoff scores to predict depression in the group of patients with PD. A maximum sensitivity of 50% was achieved with a specificity of 64%. Our results strongly support a generalized alteration in serotonin metabolism in depressed patients with PD, but tritiated imipramine binding in platelets is not a useful diagnostic tool for depression.

Neural control of ectopic filiform spines in adult tongue

The tongue surface directly above a fungiform taste bud is flat, thinly keratinized, and free of filiform spines. We examined fungiform papillae in serial sections of rat and gerbil tongues after unilateral transection of the chorda-lingual nerve had caused many fungiform taste buds to degenerate. Such empty fungiform papillae often formed a solitary keratinized outgrowth that closely resembled the spine of an ordinary filiform papilla. By six months an ectopic spine was found on 61% of empty fungiform papillae, but never on fungiform papillae that contained a taste bud. Experimental innervation of the tongue reduced the incidence of ectopic filiform spines in proportion to the cross-sectional area of the trigeminal nerve branches tested (the mylohyoid nerve, the lingual nerve, lingual + mylohyoid or lingual + auriculotemporal nerves). The chorda tympani nerve was 60 times more effective than trigeminal nerves in preventing ectopic filiform spines. We suggest that positive and negative trophic actions are normal characteristics of taste axons, for they promote the formation of taste buds and prevent the expression of ectopic filiform spines. By preventing the outgrowth of ectopic spines on fungiform papillae, taste axons maintain a thinly keratinized apical surface that can be breached by the taste receptor cells.

Prediction of persistent immunodeficiency in the DiGeorge anomaly

To assess the natural history of the immune defect in DiGeorge anomaly, we reviewed serial immunologic studies in 18 patients. The diagnosis was made with criteria based on the concept of the DiGeorge anomaly as a field defect. Initial or early follow-up laboratory examination suggested moderate to normal T cell function in 14 patients. None of these patients have lost T cell capability; they have never had infections characteristic of T cell deficiency. Four patients had clinical and laboratory evidence of profound immunodeficiency. A decreased number of CD4+ cells (less than 400/microliters) and a decrease in phytohemagglutinin responsiveness (stimulation index less than 10) may be useful in discriminating patients with immunodeficiency; absolute lymphocyte count and immunoglobulin values were not informative. At the time of surgery, the thymus was not found in 11 of 14 patients; however, only two of these patients had immunodeficiency. Patients with a persistently low number of CD4+ cells and decreased phytohemagglutinin response are candidates for immunologic reconstitution.

Modulation of cell nucleotide levels of isolated kidney tubules

The mechanisms responsible for the large increases of intracellular ATP levels seen after isolated rabbit proximal tubules are treated with exogenous adenine nucleotides were studied. Exogenous ATP was rapidly degraded via adenosine as far as hypoxanthine. Degradation of AMP to adenosine was substantially inhibited by beta-glycerol phosphate. In studies of the ability of individual exogenous purines to increase intracellular ATP levels, single large doses of adenosine were less effective than equimolar doses of exogenous ATP but were substantially more effective than exogenous inosine or hypoxanthine. Exogenous guanine derived compounds increased only cell GTP. Incremental delivery of smaller doses of adenosine to maintain medium levels greater than 5 microM or inhibition of adenosine deaminase with erythro-9-[3-(2-hydroxynonyl)]adenine or 2'-deoxycoformicin enhanced the nucleoside's effectiveness. However, the initial increase of cell ATP was still greater after treatment with exogenous ATP than after adenosine and, in the presence of adenosine deaminase inhibition, larger increases of cell ATP were produced by 50 microM adenosine than by 250 microM adenosine. These observations are most consistent with substrate inhibition of adenosine kinase by adenosine. Furthermore, the adenosine kinase inhibitor, 5-iodotubercidin, prevented the increases of cell ATP resulting from exogenous adenosine or exogenous ATP. These studies demonstrate how the differential uptake and utilization characteristics of nucleosides and bases can fully account for the increases of intracellular nucleotides produced in isolated tubules by exogenous purines.

Characterization of site-specific antibodies to the erbB gene product and EGF receptor: inhibition of tyrosine kinase activity

Site-specific antibodies were generated against the erbB protein and epidermal growth factor (EGF) receptor by immunizing rabbits with a synthetic peptide corresponding to amino acid residues 285-296 of the predicted AEV-H erbB protein sequence. This peptide region lies within the tyrosine kinase domain of erbB and EGF receptor. Antibodies directed against this region readily identified native and denatured forms of the erbB gene product and EGF receptor as demonstrated by immuneprecipitation and immunoblot analysis. The anti-peptide antibody immuneprecipitated a functional EGF binding receptor molecule. Scatchard analysis demonstrated a KD for 125I-labeled EGF binding of 40 nM, a value consistent with that of detergent solubilized EGF receptor. Immuneprecipitates, though able to bind EGF, were unable to transfer phosphate from gamma-labeled ATP in a standard phosphorylation reaction. In detergent solubilized extracts of crude A431 microsomes, the anti-peptide antibody inhibited in a dose dependent manner the autophosphorylation of EGF receptor as well as receptor mediated phosphorylation of exogenously added substrates. In addition, this anti-peptide antibody reduced the overall level of tyrosine kinase activity present in microsomes prepared from AEV-transformed erythroblasts. This site-specific antisera should be useful for understanding the role of EGF receptor and erbB tyrosine kinase activity and their link with cell proliferation.

Rheumatoid arthritis: treatment which controls the C-reactive protein and erythrocyte sedimentation rate reduces radiological progression

One hundred and fifty consecutive patients with active, rheumatoid arthritis were assessed and treated with gold, D-penicillamine, chloroquine or dapsone. Four groups were selected from these patients. Group I consisted of 60 patients who did not complete 12 months' therapy. Group II consisted of patients in whom ESR and C-reactive protein (CRP) fell to less than 30 mm/h and less than 20 mg/l, respectively, and remained at these levels between 6 and 12 months. In group IV the ESR and CRP fell but remained greater than 30 and greater than 20, respectively, during the same period. Group III patients had variable ESRs and CRPs between 6 and 12 months. In groups II, III and IV there was a significant deterioration (p less than 0.01) in the hand and foot radiographs from 0 to 6 months. Between 6 and 12 months the radiographs in groups III and IV continued to show significant radiological progression (p less than 0.01), but those of group II did not alter. These results suggest radiological deterioration continues during the first 6 months regardless of clinical response but thereafter, further deterioration is less likely to occur when the ESR and CRP are consistently controlled.

Studies on the glutathione S-transferase of human platelets

The glutathione S-transferases of human platelets have been compared with those of erythrocytes. Although wide variations in activity were found, in individual subjects, the activity in these cell types was significantly correlated. The enzymes demonstrated similar isoelectric points and electrophoretic mobilities and it appears that the platelet enzyme is also a product of the GST3 locus. There was no correlation between platelet enzyme activity and plasma concentrations of retinol and cholesterol, but in men, the relationship between activity and carotene was significant. It is suggested that GST3 isoenzyme activity depends on vitamin A.

Report on chloroquine and dapsone in the treatment of rheumatoid arthritis: a 6-month comparative study

A controlled study compared 6 months' treatment of 60 patients with rheumatoid arthritis (RA). Half were randomly allocated to treatment with chloroquine 250 mg daily, the other half dapsone 100 mg daily (50 mg/day for the first 7 days) following a one-month run-in assessment period. All patients had active or progressing disease. Both treatment groups showed significant improvement in morning stiffness, number of painful joints, pain scores, Ritchie index, and proximal interphalangeal joint size, and the chloroquine group alone in grip strength. Laboratory tests showed significant decreases in erythrocyte sedimentation rate, C-reactive protein, and total serum protein levels, with significant increase in serum albumin in the dapsone group, where there was a significant mean drop in haemoglobin (less than 1 g/dl) and a rise in serum bilirubin, associated with its haemolytic effect. X-ray erosion scores were not significantly affected. The clinical and laboratory responses became evident by the time of the 2-month assessment. Criteria for clinical and laboratory improvement were defined, according to which there were 21/26 improvers in the chloroquine group and 12/29 in the dapsone group. It is concluded that although both are effective preparations, chloroquine showed a significantly higher improvement rate and was certainly better tolerated. It is the preferred treatment for patients with active or progressive disease not controlled by nonsteroidal anti-inflammatory drugs, with dapsone as an alternative for patients who fail to respond to or cannot tolerate chloroquine.

Exercise after myocardial infarction: a controlled trial

Six weeks after acute myocardial infarction, 303 men were randomly divided into exercise and control groups. The exercise group attended the hospital gymnasium twice weekly for a three-month supervised exercise course. Both groups were exercise tested before and after the course and at subsequent follow-up. The exercise group increased their physical fitness greatly compared with the control group. Eight per cent of the exercise group died during the period of follow-up, compared with 14 per cent of the control group; this difference is not significant. There was an apparent improvement in mortality in those with inferior MI who completed the exercise course, which was not seen in those with MI in other sites. For many patients after MI progressive exercise is safe, improves physical fitness and may reduce mortality for those after inferior MI.

Studies on the variability of glutathione S-transferase from human erythrocytes

Glutathione S-transferase activity has been measured in erythrocytes from 101 subjects. Specific activity in the female subjects was significantly greater than that in the males, but there was no relationship in either sex between enzyme activity and age or between enzyme activity and the most common erythrocyte antigens. Separation of erythrocytes by age using isopycnic centrifugation showed that enzyme activity was constant during the life of the cell.