An evaluation of the Newcastle upon Tyne Hospitals 4Ps Programme for the development of nurses, midwives and allied healthcare professionals' research skills

BACKGROUND

Research forms an important part of clinical practice for nurses, midwives and allied healthcare professionals (NMAHPs). However, it is known there is a lack of confidence in this community in the development and use of research skills. The 4Ps Programme is a bespoke research-training programme that focuses on four areas: place, project, person and plan.

AIM

To report an evaluation of the 4Ps Programme that used a survey to record the confidence levels reported by NMAHPs.

DISCUSSION

An increase in participants' confidence was observed across all modules in the 4Ps Programme. This exceeded the standard deviation in the 'place' session, demonstrating genuine improvement. It was not possible to demonstrate a significant improvement in all cases. Low response rates affected the quality of the data obtained in the study, which would have benefitted from a more targeted approach to questions and better enabled the tracking of individuals' improvement over the course of the programme.

CONCLUSION

Participation in bespoke, targeted training related to research could lead to an increase in NMAHPs' confidence in research-related activities. Efforts need to be made to refine the evaluation approach and improve response rates.

IMPLICATIONS FOR PRACTICE

The 4Ps Programme can improve research-related confidence. Improved and further longitudinal evaluation will assess its impact in developing future clinical academics.

What is available to support pain management in Parkinson's: a scoping review protocol

OBJECTIVE

A scoping review will be undertaken to examine and map the available evidence that has been produced in relation to pain management in Parkinson's, with a focus on behavioural interventions, resources and/or how professionals support people with Parkinson's self-management of pain.

METHODS

This review will be based on the methodological framework given by Arksey and O'Malley's (2005), including enhancements by Levac et al., Peters et al. and the Joanna Briggs Institute. We will include studies from PubMed, SCOPUS, CINAHL, MEDLINE Web of Science, APA PsycINFO and ASSIA from January, 2010 onwards. Both quantitative and qualitative data will be analysed separately to identify the characteristics of support for pain management available, orientation of the approach and any identifiable behaviour change components and their outcomes. The COM-B behaviour change model and Theoretical Domains Framework will provide a theoretical framework for synthesising evidence in this review.

CONCLUSION

This scoping review will help to explore studies focusing on the evidence supporting a range of interventions relating to the management of pain experienced by people living with Parkinson's. The focus will be on describing what is available to support self-management, identify what behaviour change components have been used and their effectiveness, identify barriers and enablers to pain management and explore gaps in current provision of pain management. This review will identify implications and priorities for the follow-up phases to the larger 'Pain in Parkinson's' Project which is designed to support clinicians and individuals living with Parkinson's.

Influences on paramedic prescribing: student and prescriber perspectives

Background

Paramedic prescribing has been permitted in legislation from 2018. In 2019 one of the first cohorts of paramedic prescribers in the country was invited to share their experiences, thoughts and perceptions around the new and evolving role of paramedic prescribing practice.

Aim

To explore the opinions of student and newly qualified paramedic prescribers regarding the impact and effectiveness of paramedic independent prescribing on their clinical practice.

Design and setting

A qualitative study was undertaken within the North East of England with a group of experienced paramedics undertaking non-medical prescribing education.

Methods

A focus group and dyad interview were undertaken with a purposive sample of paramedics recruited from a higher education institution providing V300 independent and supplementary prescribing education. The focus group was undertaken with paramedics on the non-medical prescribing (NMP) programme of study. The dyad interview was undertaken with participants once qualified as prescribers, and actively prescribing. The focus group and interview were audio recorded, transcribed verbatim and subjected to thematic analysis to identify key themes.

Results

A total of n = 7 and n = 2 paramedics undertook the focus group and dyad interview, respectively. Paramedics in this sample represented a range of paramedic practice areas. Paramedic NMP students noted four key themes around role, expectations, governance and opportunities and challenges in relation to prescribing practice. The returning sample of paramedics, now practising as prescribers, noted themes of organisational and infrastructure challenges, monitoring of prescribing practice and the evolution of paramedic roles.

Conclusion

Paramedic prescribing is rapidly expanding and evolving into new clinical areas. As such, careful consideration should be given to not only the resourcing of prescribers as individuals, but also the wider organisational and technological support and structures needed to be in place to allow paramedic prescribers to fulfil their roles and utilise their advanced practice skills.

The Impact of the COVID-19 Pandemic on Informal Caregivers of People With Parkinson's Disease Residing in the UK: A Qualitative Study

Informal caregivers can experience various demands when providing care and support for People with Parkinson's disease (PwP) in their own homes. The outbreak of SARS-CoV-2 and public health strategies employed to mitigate the spread of COVID-19 have presented challenges to the general populace on a global basis. The present study used a qualitative research design to explore how the COVID-19 pandemic has impacted informal caregivers in their role of providing care for PwP in their own homes. A series of 1:1 semi-structured interviews were conducted with 11 informal caregivers of PwP (M age = 72.64 years, SD = 8.94 years). A thematic analysis indicated that 1) vulnerabilities to COVID-19, 2) home maintenance & activities of daily living and 3) engagement with healthcare services were 3 themes that provided indications on how the COVID-19 pandemic impacted informal caregivers of PwP. The present study provides illustrations of how being an informal caregiver of PwP and being identified as high risk to COVID-19 can present challenges to the process of caring for loved ones who are also vulnerable to SARS-CoV-2. The results of the present study highlights the necessity to develop strategies to ensure that informal caregivers have the necessary resources to provide care for PwP in their homes and also maintain their own well-being in the post COVID-19 era.

Understanding Caregiver Strain in Parkinsonism-A Mixed Methods Approach

BACKGROUND

Parkinsonism, including Parkinson's disease (PD) are progressive neurological conditions. As these condition progress, individuals will need more support with their care needs to maintain independent community-living. Care needs are mainly met by unpaid, informal caregivers, usually close family members or friends. Caregiver strain is thought to lead to the need for care home placement when the caregiver can no longer cope.

OBJECTIVE

To understand predictors of caregiver strain and its influence on care home placement for people with moderate to advanced Parkinsonism.

METHODS

This is a convergent mixed methods study. Quantitative data, following an adapted stress-appraisal model, were collected on caregiver profile, tasks performed and causes of caregiver strain. Semi-structured, in-depth interviews were conducted with caregivers of people with PD (PwP) who went into a care home during the study period, to develop a deeper understanding of the caregiver role and the factors influencing caregiver strain.

RESULTS

Quantitative data were collected from 115 patient caregiver dyads. Interviews were conducted with 10 caregivers. A model to predict caregiver strain was developed and predictors of caregiver strain were identified, such as functional disability and poor caregiver sleep.

CONCLUSION

Our findings further demonstrate the complexity of carer strain. Particular dimensions are identified that need to be addressed within clinical practice to reduce carer strain and support people with Parkinsonism to remain within their own home for as long as possible.

Exploring sexual dysfunction in care homes

Sexual needs and sexuality in older adults continues to be a neglected area of clinical intervention, particularly in longer term care settings. This is often due to older adults in long term care beds presenting with increased frailty, and often with significant neurocognitive disorders, making it difficult for care staff to evaluate the capacity of an older adult resident to participate in sexual activities or a sexual relationship. Talking about sexuality, intimacy and sexual health can be embarrassing at any age and sex is often still considered taboo for people who live in care homes. The World Health Organization recently declared that sexual health is a central aspect of life and that each individual has the right to love and be loved, to receive appropriate information and treatment, and to enable intimate relationships and personal control over sexual behavior. This chapter explores sexual behaviors, and barriers to this, in later life, and focuses on the sexual behavior of care home residents with Parkinson's disease. Reasons for sexual dysfunction, potential age-related changes to sexual functioning, along with issues such as changes to body image, intimacy and hyper sexuality, are examined for people with Parkinson's disease. Recommendations for practice are given, and acknowledge that older people may still want to be sexually active or intimate is the first step to addressing the issues and overcoming any barriers.

Covid-19 and Parkinson's disease: Nursing care, vaccination and impact on advanced therapies

The Coronavirus Disease 2019 (Covid-19) pandemic has created many challenges for the Parkinson's Disease (PD) care service delivery, which has been established over the past decades. The need for rapid adjustments to the new conditions has highlighted the role of technology, which can act as an enabler both in patient-facing aspects of care, such as clinical consultations, as well as in professional development and training. The Parkinson's Disease Nurse Specialists (PNSs) play a vital role in the effective management of people with PD (PwP). Maintaining optimum functionality and availability of device aided therapies is essential in order to ensure patients’ quality of life. PwP are particularly recommended to use vaccination as a basic protection from the virus. The long-term consequences of this pandemic on PwP are highly uncertain, and education, support and reassurance of patients and their families may help ease their burden.

Cost-effectiveness analysis of the Parkinson's KinetiGraph and clinical assessment in the management of Parkinson's disease

AIMS

The Parkinson's KinetiGraph (PKG) is a wrist-worn movement recording system that collates continuous, objective, data during daily activities in people with Parkinson's disease (PD) providing a report for clinicians. This study explores the cost-effectiveness of adding the PKG to routine PD assessments.

METHODS

A de novo Markov model of three health states: uncontrolled, controlled and death compared PKG plus routine assessment by a Movement Disease Specialist (MDS) versus routine assessment. Uncontrolled and controlled states were based on the Movement Disorder Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS) II and III scores. The transition between health states was dependent on improvement in MDS-UPDRS II and III, and transition to death state on all cause-mortality and PD-specific relative mortality risk. Markov cycle length was yearly beyond year 1 and lifetime horizon 22 years.

LIMITATIONS

PKG evidence incorporated in this analysis is based on findings from one clinical trial. Health state utilities were mapped and the probability of patients progressing from uncontrolled to controlled health state at the second visit and beyond was derived from a bootstrap method which assumed a normal distribution for MDS-UPDRS.

RESULTS

The addition of the PKG to usual PD assessments is a cost-effective intervention. PKG plus routine assessment is associated with lower total costs compared to routine assessment (£141,950 versus £159,312) and improved quality-adjusted life years (7.88 versus 7.61), resulting in an incremental cost-effectiveness ratio of -£64,978.99 and a net monetary benefit of £22,706.37 using a £20,000 threshold. Results were robust across sensitivity and scenario analyses.

CONCLUSIONS

Management of PD involves monitoring and evaluation of symptoms to assess disease progression and ensure appropriate treatment choices. Adding the PKG to clinical assessment in routine care allows for improved and objective identification of PD motor symptoms which can be used in clinical decision making to improve patient outcomes.

Driving and Parkinson's Disease: A Survey of the Patient's Perspective

BACKGROUND

Parkinson's disease (PD) is a multi-system disorder that can impact on driving ability. Little is known about how these changes in driving ability affect people with PD, making it difficult for clinicians and carers to offer appropriate support.

OBJECTIVE

To assess patient views concerning the effect of PD on their driving ability, the impact of these changes and how they manage them.

METHOD

An online survey was created by a team of clinicians, people with PD, their carers, and representatives from Parkinson's UK. People with PD throughout the United Kingdom were invited to participate through Parkinson's UK's website, newsletter and Parkinson's Excellence Network email list.

RESULTS

805 people with PD took part in the survey. We found that the loss of a driving licence had an adverse impact on employment, socialisation, travel costs and spontaneous lifestyle choices. Multiple changes in driving ability related to PD were described, including that impulse control disorders can have an adverse impact on driving. Changes in driving ability caused people to change their driving practices including taking shorter journeys and being less likely to drive at night. Participants advised managing changes in driving ability through planning, vehicle adaptions, maintaining skills and self-assessment.

CONCLUSION

This study demonstrates the impact that changes in driving ability can have on the lifestyle of people with PD and reveals the strategies that individuals adopt to manage these changes.

Exploring and understanding the scope and value of the Parkinson's nurse in the UK (The USP Project): a realist economic evaluation protocol

INTRODUCTION

There are multiple configurations of specialist nurses working in the field of Parkinson's. Parkinson's Nurse Specialists (PNSs) are recognised as playing a pivotal role; however, there is little published evidence to demonstrate their effectiveness. Further evidence is needed to establish which aspects of the PNSs provide the greatest benefit to people with Parkinson's and their families, and the cost-effectiveness of different models of care.

METHODS AND ANALYSIS

Realist approaches explain how and why programmes work (or not) through striving to answer the question: what works, for whom and under what circumstances. This research uses a realist evaluation and aims to integrate an economic analysis within the realist framework. We refer to this as 'realist economic evaluation'. It comprises four phases: (1) developing resource-sensitive initial programme theories (IPTs) using surveys to gain a better understanding of the role and impact (costs and benefits) of the PNSs; (2) testing the IPTs through qualitative interviews and quantitative data analysis; (3) evaluating the cost and resource use implications alongside the benefits associated with the role of the PNSs and (4) iteratively refining the IPTs throughout the project. The IPTs will draw on both quantitative and qualitative data. The result of the study will be a series of refined programme theories, which will explain how specialist nurses work in the field of Parkinson's in the UK, what impact they have on people with Parkinson's and their families and carers, and at what cost.

ETHICS AND DISSEMINATION

Northumbria University, the Health Research Authority and Health and Care Research Wales have approved this study. Key findings will be disseminated throughout the duration of the project online and through social media, and via annual and regional Parkinson's meetings and the Parkinson's UK Excellence Network. Academic dissemination will occur through publication and conference presentations.

What Predicts Hospital Admissions in Community-Dwelling People With Parkinsonism?

OBJECTIVES

Previous studies have looked at the reasons for hospital admission in people with parkinsonism (PwP), yet few have looked at factors that precipitate admission.

METHODS

People with parkinsonism with a diagnosis of idiopathic Parkinson disease of Hoehn and Yahr stage III-V and those with Parkinson plus syndromes were assessed for motor and nonmotor symptoms, quality of life, and functional performance. Logistic regression was used to investigate predictors of hospital admission over the subsequent 2 years.

RESULTS

Overall, 162 patients consented to be part of the study. Seventy-one PwP (43.8%) had at least 1 hospital admission, and 17 (10.5%) patients had 3 or more admissions to hospital. Poorer cognition, more nonmotor symptoms, poorer quality of life, slower timed-up-and-go test scores, and abnormal swallow predicted a subsequent hospital admission.

DISCUSSION

Our study emphasizes the importance of nonmotor symptoms in predicting admission. A cost-benefit analysis of early intervention to prevent admission should be considered.

Highlighting the goals for Parkinson's care: commentary on NICE Guidelines for Parkinson's in Adults (NG71)

Parkinson's disease is a chronic multi-system disease that can cause motor and non-motor symptoms, cognitive changes and variably effective medications. Optimal management of the condition requires a multi-disciplinary team of healthcare professionals to work closely with the patient and their carers. The National Institute for Health and Care Excellence published updated guidelines on managing Parkinson's disease in adults in 2017. Here we discuss the implications of this guidance to current healthcare professionals involved in the care of people with Parkinson's disease. The guidance highlights the importance of clear communication with people with Parkinson's disease. We discuss examples of this, including providing a point of contact with specialist services for people with Parkinson's disease and ensuring information about the risks of impulse control disorders are given to people on dopaminergic therapy. The breadth of services required by people with Parkinson's disease is also described, including the need for access to physiotherapy, occupational therapy and speech and language therapy as well as treatment monitoring services for Clozapine. In addition, we emphasise the continued importance of ensuring people with Parkinson's disease receive their medications on time when in hospital or a care home.

Impact of feeding method on overall activity of indoor, client-owned dogs

OBJECTIVE

To compare the total daily activity time, walking time and running time using food-dispensing toys versus bowls in a group of client-owned, primarily indoor dogs.

MATERIALS AND METHODS

A two-way, two period, randomised repeated measures mixed-effects crossover study performed on 26 client-owned, primarily indoor dogs.

RESULTS

Toy feeding increased average daily total activity time by 12% and walking time by 26%. Average daily total activity time and walking time were reduced by 8 and 7% respectively with each increase in year of age. Gender, body condition and muscle condition had no significant effect on average daily total activity or walking time. Toy feeding, time, their interaction, age, gender, body condition and muscle condition had no significant effect on average daily running time.

CLINICAL SIGNIFICANCE

Feeding toys may be helpful during weight loss programs to achieve the goal of increasing daily exercise duration in dogs that need to lose weight.

The role and profile of the informal carer in meeting the needs of people with advancing Parkinson's disease

BACKGROUND

Many people with Parkinson's disease (PD) (PwP) require care from either informal or formal carers, due to worsening symptoms. Carer strain is a recognised consequence of caring. However there are few data on the role and profile of informal carers and if this impacts on carer strain.

METHOD

People with moderate to advanced PD, with an informal carer were invited to participate. Data regarding motor and non-motor symptoms of the participant, along with demographics, tasks and duration of caring and health issues of the carer were collected.

RESULTS

One-hundred and fifteen participants and their carer were recruited. Mean carer age was 70.7 years, 66.1% were female caring for a median of 16 hours per day. Over 80% provided help in housework and companionship activities, 63.2% with dressing and 49.1% with feeding. There was a significant relationship between disease stage and level of strain. Participant age, physical and cognitive disability were significantly associated with greater care need. High care need was associated with poor carer quality of life.

CONCLUSIONS

The care needs of PwP are considerable. To reduce carer strain and improve quality of life, carers' needs must be considered to enable them to carry on with their vital role.

Understanding the Care Needs and Profile of People Living at Home With Moderate to Advanced Stage Parkinson Disease

BACKGROUND

In the United Kingdom, people with Parkinson disease (PD) and atypical parkinsonism will require more support with their care needs as the condition progresses. There are few data on the nature of care input required and the amount of informal and formal care needed by people with PD to enable them to remain within their own home.

METHOD

All people with moderate to advanced stage (Hoehn and Yahr III-V) idiopathic PD and atypical parkinsonism under the care of the Northumbria Healthcare NHS Foundation Trust PD service and living in their own home were invited to take part in The Northumbria Care Needs Project, a 10-year prospective longitudinal study. At baseline, data regarding formal (paid) personal and domestic care input and use of respite care, sitting services, and day centers were collected. We also collected data on patient cognitive disability, functional disability, and disease severity and informal carer tasks.

RESULTS

Of 162 people with PD included in the study, only 25.2% accessed formal domestic care and the same proportion formal personal care. In contrast, 80.2% identified an informal carer who helped with these tasks. Despite greater level of functional disability in those with an informal carer, levels of formal personal care input were similar to those with and without a formal carer. Levels of formal domestic carer input were higher in those without an informal carer.

CONCLUSIONS

Use of formal care services was relatively uncommon in our cohort and much of the burden of caring appears to be being met by informal carers.

The Pattern of Hospital Admissions Prior to Care Home Placement in People With Parkinson’s Disease: Evidence of a Period of Crisis for Patients and Carers

Objectives: We hypothesized that the number and length of hospital admissions in people with Parkinson’s disease (PD) would increase immediately prior to admission to a care home relative to those who were able to continue living at home or who died. Method: PD patients at Hoehn and Yahr Stages III to V were followed-up over two and a half years with deaths and care home placements recorded. Hospital admissions data were collected over this period. Results: Of 286 patients included in the study, 7.3% entered a care home and 28.3% died. In the final 120 days prior to the study exit point (care home placement, death, or continued living at home), longer hospital stay was significantly associated with care home placement, after adjusting for the competing risk of death. Conclusion: Our data provide evidence that, for many people with PD, a period of crisis is reached immediately prior to care home placement.

200 Years of Parkinson's disease: what have we learnt from James Parkinson?

2017 marks 200 years since James Parkinson's published his 'Essay on the Shaking Palsy'. Although now most famous for describing the condition that came to bear his name, Parkinson had a wide range of interests and his influence spread beyond medicine. In this review, we provide a biography of James Parkinson's remarkable life.Parkinson's paper not only comprehensively described the symptoms of Parkinson's disease (PD), but challenged his peers to better understand the pathophysiology of the PD. Key observation over the next 2 centuries, included the recognition of the link between the substantia nigra and PD and the discoveries of dopamine deficiency in patients with PD. We review the subsequent development of pharmacological and surgical therapies. Despite great progress over the last 200 years, Parkinson's hopes for a 'cure if employed early enough' or that 'some remedial process may ere long be discovered by which at least the progression of the disease may be stopped' remain apposite today and we reflect on the challenges ahead for the next century.

Developing an innovative online medication calculator for patients with Parkinson's disease who are nil by mouth

Missed Parkinson's disease (PD) medications when patients are admitted to hospital are associated with increased -morbidity and mortality. Swallowing difficulties in hospitalised PD patients are common and should prompt clinicians to -consider conversion of a patient's PD medications to a non-oral form - this is, however, recognised as a challenging area with potential for error. Northumbria Healthcare NHS Foundation Trust's PD service set out to address this patient safety issue through the development of an innovative online medication -calculator (pdmedcalc.co.uk). This article summarises the development process underpinning the calculator, presents numerical data on the usage of the calculator and presents survey data -relating to user experiences of the calculator. Lastly, we highlight how user feedback has been used to refine subsequent iterations of the calculator and how use of the calculator has rapidly spread beyond our trust because of it being freely accessible online.

Medication use in people with late stage Parkinson's disease and parkinsonism living at home and in institutional care in north-east England: A balance of symptoms and side-effects?

BACKGROUND

People with Parkinson's disease (PD) and parkinsonism living in care homes (residential or nursing care) in the UK represent around 10-15% of all people with PD and 3-5% of all care home residents. There are few previous data on medication use in those living in care homes with PD. In this study we aimed to compare medication use in a representative cohort of people with PD living in care homes in north-east England with those living in their own homes.

METHOD

All people with late stage (Hoehn and Yahr III-V) idiopathic PD, PD dementia, or atypical parkinsonian syndromes under the care of the Northumbria Healthcare NHS Foundation Trust PD service on 1st January 2015 were identified. Demographic, disease characteristics and medication use data were collected from an audit of medical notes of all those identified.

RESULTS

We identified 377 people who met the inclusion criteria, 91 (24.1%) of whom were living in a care home. Disease stage, age and age at disease onset were all significantly higher and levodopa equivalent dose significantly lower in those living in care homes, although disease duration and levodopa dose were not. Greater age, lower levodopa equivalent dose and higher disease stage were independently associated with being in a care home.

CONCLUSIONS

Although people in care homes had more advanced disease, they were on a significantly lower levodopa equivalent dose. This is likely to be due to the requirement to balance symptom management with drug side-effects.

Experience of care home residents with Parkinson's disease: Reason for admission and service use

AIM

The care needs of people with Parkinson's disease (PD) are poorly understood. We aimed to investigate the factors that precipitate entry to institutional care, and on-going care needs once in care, within a representative cohort of community-dwelling people with PD.

METHOD

All people with idiopathic PD, Parkinson's plus syndromes and vascular parkinsonism under the care of the Northumbria Healthcare NHS Foundation Trust PD service who were living in care homes on 1 January 2013 were included. Disease severity (Hoehn and Yahr stage) and demographic data were collected. Admissions to hospital over the previous 2 years and in the year before institutional care admission were documented.

RESULTS

A total of 90 patients (51 females) with a mean age of 81.3 years were included. During care home stay, the median number of emergency department attendances, the median number of hospital admissions and the median length of stay for those admitted per year were significantly lower than before care home admission. Both before care home admission and during care home stay, falls were the most common diagnoses in people attending emergency departments, with 32 of 65 (49.2%) admissions before and 34 of 59 (57.6%) admissions during care home stay having falls recorded as a cause of attendance.

CONCLUSIONS

Hospital attendances and admissions were relatively common, even after institutional care home placement. Events precipitating admission, such as falls, might be preventable. PD nurse specialists could be an effective way to help train staff in homes where someone is known to have PD.

Cone beam CT analysis of Haller cells: prevalence and clinical significance

OBJECTIVES

Haller cells are anterior ethmoid air cells located in the medial orbital floor immediately lateral to the maxillary infundibulum. The purpose of this study was to demonstrate the prevalence and relationship between the existence and size of these cells with ipsilateral maxillary sinusitis and orbital floor dehiscence as visualized on cone beam CT (CBCT) images.

METHODS

CBCT image volumes of 50 patients were retrieved and analysed. All CBCT images were acquired with a 9-inch field of view scan. χ(2) and Cochran-Mantel-Haenszel tests were used for statistical analysis of the obtained data, and p-values of <0.05 were considered to be statistically significant.

RESULTS

There was no statistically significant association between the existence and size of Haller cells and maxillary sinusitis. There was a significant association between Haller cells and orbital floor dehiscence.

CONCLUSIONS

The explanation of maxillary sinusitis on the basis of mechanical obstruction is unlikely. This study provides evidence for the usefulness of CBCT scan in delineation of the sinonasal anatomy.

Developing an information prescription service

BACKGROUND

Availability and accessibility of high-quality information is inconsistent nationally and improving information is central to Department of Health policy. This article outlines an information prescription (IP) pilot.

AIM AND METHOD

Using a quality-improvement cycle, feedback was gathered from stakeholders to develop an IP service for people with Parkinson's disease and their relatives/carers.

RESULTS AND DISCUSSION

Generally, service users were satisfied with the information and felt it enabled them to better understand, manage and be in control of their condition. Despite initial concerns, health staff identified benefits to themselves and patients. Barriers to implementing IPs were discussed.

The metric properties of a novel non-motor symptoms scale for Parkinson's disease: Results from an international pilot study

Non-motor symptoms (NMS) in Parkinson's disease (PD) are common, significantly reduce quality of life and at present there is no validated clinical tool to assess the progress or potential response to treatment of NMS. A new 30-item scale for the assessment of NMS in PD (NMSS) was developed. NMSS contains nine dimensions: cardiovascular, sleep/fatigue, mood/cognition, perceptual problems, attention/memory, gastrointestinal, urinary, sexual function, and miscellany. The metric attributes of this instrument were analyzed. Data from 242 patients mean age 67.2 +/- 11 years, duration of disease 6.4 +/- 6 years, and 57.3% male across all stages of PD were collected from the centers in Europe, USA, and Japan. The mean NMSS score was 56.5 +/- 40.7, (range: 0-243) and only one declared no NMS. The scale provided 99.2% complete data for the analysis with the total score being free of floor and ceiling effect. Satisfactory scaling assumptions (multitrait scaling success rate >95% for all domains except miscellany) and internal consistency were reported for most of the domains (mean alpha, 0.61). Factor analysis supported the a prori nine domain structure (63% of the variance) while a small test-retest study showed satisfactory reproducibility (ICC > 0.80) for all domains except cardiovascular (ICC = 0.45). In terms of validity, the scale showed modest association with indicators of motor symptom severity and disease progression but a high correlation with other measures of NMS (NMSQuest) and health-related quality of life measure (PDQ-8) (both, rS = 0.70). In conclusion, NMSS can be used to assess the frequency and severity of NMS in PD patients across all stages in conjunction with the recently validated non-motor questionnaire.

Prevalence of nonmotor symptoms in Parkinson's disease in an international setting; Study using nonmotor symptoms questionnaire in 545 patients

2006, there was, no single instrument (questionnaire or scale) for attempting a comprehensive assessment of the wide range of nonmotor symptoms (NMS) of Parkinson's disease (PD). The PD nonmotor group, a multidisciplinary group of experts including patient group representatives developed and validated the NMS screening questionnaire (NMSQuest) comprising 30 items. The NMSQuest is a self completed screening tool designed to draw attention to the presence of NMS. In this paper, we present the results gathered from 545 patients using the definitive version of the NMSQuest highlighting the prevalence of the wide range of NMS flagged in the NMSQuest from consecutive PD patients in an international setting.

Effective distribution of domestic wastewater effluent between percolation trenches in on-site treatment systems

On-site treatment systems discharging to groundwater rely on the effective distribution of effluent across a percolation area to provide an appropriate loading rate for the subsoil. In Ireland, this is achieved in a distribution box which splits the effluent evenly between the requisite number of percolation pipes. The flow regime experienced at four different distribution boxes was monitored continuously over twelve month periods which established that the most common flow rates at the distribution unit were in the range 1-4 litres/minute for a four to five person dwelling. In addition, the average flow rate from the four sites was only 100 litres per person per day, compared to recommended design value of 180 litres per person per day. Two distribution boxes were also tested in the laboratory to assess their distribution efficiency over a range of loading rates. The most commonly installed unit was found to significantly favour two out of the four trenches and both units were shown to perform particularly poorly at a range of different off-level installation angles. Modifications to the boxes were also tested, involving plastic V-notch inserts which were shown to greatly improve the hydraulic distribution and make the unit much less sensitive to off-level installation or subsidence.

Cerebrospinal fluid levels of nitric oxide metabolites predict response to methylprednisolone treatment in multiple sclerosis and optic neuritis

The role of nitric oxide (NO) in multiple sclerosis (MS) is not clear. We found increased cerebrospinal fluid concentrations of the NO degradation products nitrate (NO(x)) in clinically definite MS but not in clinically isolated syndromes. High CSF concentrations of NO(x) correlated with long attack duration. Patients carrying the truncated CC chemokine receptor allele CCR5 Delta32 had lower serum concentration of NO(x) at later attack stages. NO(x) concentrations did not change after methylprednisolone treatment but high concentrations were associated with more pronounced treatment responses. These findings suggest an association of high CSF levels of NO(x) with more severe disease activity in relapsing-remitting MS.

Regulation of fibroblast growth factor 2 and fibroblast growth factor receptors by transforming growth factor beta in human osteoblastic MG-63 cells

Fibroblast growth factor 2 (FGF-2) and its receptors (FGFRs) are important regulators of bone cell function. Although FGF-2 is a major modulator of bone cell function, its expression and regulation in human osteoblasts have not been investigated. We examined FGF-2 messenger RNA (mRNA) expression and regulation in the human osteosarcoma MG-63 cells. Northern analysis revealed that MG-63 cells expressed FGF-2 mRNA transcripts of 7, 4, 2.2, and 1.3 kilobases (kb). In the absence of serum, treatment with transforming growth factor beta (TGF-beta; 0.1-10 ng/ml) increased all FGF-2 mRNA transcripts. Maximal increase was seen with 1 ng/ml of TGF-beta. TGF-beta increased FGF-2 mRNA expression within 2 h and this was sustained for 24 h. Phorbal myristate acetate (PMA; 1 microM) also increased FGF-2 mRNA at 6 h. Time course studies showed that TGF-beta did not significantly alter FGFR1 or FGFR2 mRNA expression in MG-63 cells. Western blotting with anti-human FGF-2 revealed that MG-63 cells synthesize three isoforms of FGF-2 protein of approximately 18, 22/23, and 24 kDa, which were increased after either 6 h or 24 h of treatment with TGF-beta. Increased FGF-2 mRNA and protein expression in response to TGF-beta was markedly reduced by the protein kinase A (PKA) inhibitor H-89. Immunogold labeling of MG-63 cells treated with TGF-beta showed increased labeling for FGF-2 and FGFR2 in the nuclei. In contrast, TGF-beta treatment significantly decreased FGFR1 labeling in the nuclei. These data show that TGF-beta regulates FGF-2 gene expression in human osteosarcoma cells. Furthermore, TGF-beta modulates the cellular localization of FGF-2 and its receptors.

Sympathectomy decreases and adrenergic stimulation increases the release of tissue plasminogen activator (t-PA) from blood vessels: functional evidence for a neurologic regulation of plasmin production within vessel walls and other tissue matrices

Our recent morphologic studies indicated that peripheral nervous system (PNS) adrenergic neurons synthesize, transport, and store the serene protease, tissue plasminogen activator (t-PA) in axon terminals, many of which innervate vessel walls. Sympathoadrenal stimulation induces a surge of t-PA from vessel walls into the blood. The vascular endothelium, which constitutively secretes t-PA into blood also has long been widely assumed to be the principal source of this stress-induced release, but has not been verified as such. A neurologically regulated release from adrenergic stores could thus augment the known constitutive endothelial release. To functionally test this possibility, we quantitated the effects of guanethidine-induced systemic sympathectomy on the basal and stimulated release of t-PA from isolated vessel explants in superfused organ cultures. Moment-to-moment changes in the release rate were plotted from serial assays of the t-PA free activity. The effects of endothelial and adventitial nerve plexus ablations were also tested. Sympathectomy induced 30-50% reductions in t-PA release from both arterial and microvascular explants. An acute release induced by alpha-1 adrenergic receptor stimulations was also strongly suppressed, as were basal levels of the circulating enzyme in vivo. Adventitial and endothelial ablations from normal large vessel explants produced greater reductions than small vessel endothelial ablations. Ganglion electrical stimulation also induced an acute microvascular release in vivo. These and past morphologic findings indicate a physiological infusion of t-PA into the vessel walls, blood, and other innervated matrices by sympathetic neurons.

Trafficking, assembly, and function of a connexin43-green fluorescent protein chimera in live mammalian cells

To examine the trafficking, assembly, and turnover of connexin43 (Cx43) in living cells, we used an enhanced red-shifted mutant of green fluorescent protein (GFP) to construct a Cx43-GFP chimera. When cDNA encoding Cx43-GFP was transfected into communication-competent normal rat kidney cells, Cx43-negative Madin-Darby canine kidney (MDCK) cells, or communication-deficient Neuro2A or HeLa cells, the fusion protein of predicted length was expressed, transported, and assembled into gap junctions that exhibited the classical pentalaminar profile. Dye transfer studies showed that Cx43-GFP formed functional gap junction channels when transfected into otherwise communication-deficient HeLa or Neuro2A cells. Live imaging of Cx43-GFP in MDCK cells revealed that many gap junction plaques remained relatively immobile, whereas others coalesced laterally within the plasma membrane. Time-lapse imaging of live MDCK cells also revealed that Cx43-GFP was transported via highly mobile transport intermediates that could be divided into two size classes of <0.5 microm and 0.5-1.5 microm. In some cases, the larger intracellular Cx43-GFP transport intermediates were observed to form from the internalization of gap junctions, whereas the smaller transport intermediates may represent other routes of trafficking to or from the plasma membrane. The localization of Cx43-GFP in two transport compartments suggests that the dynamic formation and turnover of connexins may involve at least two distinct pathways.

Biologically active Fas antigen and its cognate ligand are expressed on plasma membrane-derived extracellular vesicles

Exfoliation of plasma membrane components is a directed process that consumes energy and requires active cell metabolism. Proteins involved in regulating the survival and proliferation of eukaryotic cells are released on exfoliated vesicles. We examine here whether the Fas receptor and its cognate ligand (FasL) are present on vesicles shed from high metastatic potential CX-1 cells and low metastatic potential MIP-101 cells and from HuT 78 cells, respectively. Rates of exfoliation at 2 hours and cumulative levels of extracellular vesicles in serum-free medium conditioned by CX-1 cells are increased by 1.8-fold and 1.6-fold, respectively, relative to that in medium conditioned by MIP-101 cells. Although vesicles shed from both cancer cell lines contain Fas antigen, the amount of Fas per vesicle and the percentage of vesicles containing Fas are increased for vesicles isolated from MIP-101 cells, relative to those from CX-1 cells, as determined by immunogold particle labeling and electron microscopy and by immunofluorescence microscopy and flow cytometry. Results of metabolic labeling with 35S-methionine indicate that Fas biosynthesis is reduced by up to 3.3-fold for CX-1 cells, relative to that of MIP-101 cells, consistent with the finding of decreased Fas on vesicles shed from the plasma membrane of CX-1 cells. Although mRNA for soluble Fas receptor is detectable in both cell lines, depletion of shed vesicles from serum-free medium by ultracentrifugation removes all detectable biological activity. FasL is detected on vesicles exfoliated from HuT 78 cells by immunoelectron microscopy and Western blot analysis. FasL-bearing vesicles induce apoptosis of Fas-expressing cancer cells at the same level as observed by treatment with monoclonal anti-Fas antibody. Furthermore, Fas-bearing extracellular vesicles from MIP-101 but not from CX-1 cells protect the CX-1 cell line from FasL-induced and anti-Fas-mediated apoptosis, indicating that Fas present on shed vesicles is biologically active. We conclude that the Fas antigen and its cognate ligand are exfoliated from the cell surface in a bioactive configuration. Exfoliation may provide a mechanism for long-range signal-directed apoptosis while maintaining Fas/FasL on a membrane surface.

Interferon-induced growth arrest is mediated by membrane structural changes

Interferon-gamma (IFN-gamma) is an immunomodulator shown to augment the expression of major histocompatibility (MHC) class I/class II antigens on the cell surface. In previous studies, we have demonstrated that the enhanced expression of these antigens on the cell surface is in part due to IFN-gamma-mediated abrogation of antigen shedding. In this study, we demonstrate that IFN-gamma induces structural changes in the cell membrane by altering the cholesterol/phospholipid ratio. Furthermore, such changes not only mediate enhanced expression of antigen on the cell surface but may drive the cells to growth arrest and apoptosis. These results were obtained by employing x-ray diffraction, electron microscopy, and DNA analysis.

Structure-activity studies of rapamycin analogs: evidence that the C-7 methoxy group is part of the effector domain and positioned at the FKBP12-FRAP interface

BACKGROUND

Rapamycin is an immunosuppressant natural product, which blocks T-cell mitogenesis and yeast proliferation. In the cytoplasm, rapamycin binds to the immunophilin FKBP12 and the complex of these two molecules binds to a recently discovered protein, FRAP. The rapamycin molecule has two functional domains, defined by their interaction with FKBP12 (binding domain) or with FRAP (effector domain). We previously showed that the allylic methoxy group at C-7 of rapamycin could be replaced by a variety of different substituents. We set out to examine the effects of such substitutions on FKBP12 binding and on biological activity.

RESULTS

Rapamycin C-7-modified analogs of both R and S configurations were shown to have high affinities for FKBP12, yet these congeners displayed a wide range of potencies in splenocyte and yeast proliferation assays. The X-ray crystal structures of four rapamycin analogs in complexes with FKBP12 were determined and revealed that protein and ligand backbone conformations were essentially the same as those observed for the parent rapamycin-FKBP12 complex and that the C-7 group remained exposed to solvent. We then prepared a rapamycin analog with a photoreactive functionality as part of the C-7 substituent. This compound specifically labeled, in an FKBP12-dependent manner, a protein of approximately 250 kDa, which comigrates with recombinant FRAP.

CONCLUSIONS

We conclude that the C-7 methoxy group of rapamycin is part of the effector domain. In the ternary complex, this group is situated in close proximity to FRAP, at the interface between FRAP and FKBP12.

Interferon (IFN)-alpha and IFN-gamma in combination with methotrexate: in vitro sensitivity studies in four human mesothelioma cell lines

Mesothelioma is a malignant tumor of the serous surfaces in the thorax and abdomen, which has proved exceptionally resistant to treatment. A recent phase II trial of a high-dose methotrexate regime on 63 Norwegian patients has, however, achieved a response rate of 37%. Some responses have also been achieved using interferon (IFN)-gamma administered intrapleurally or recombinant (r) IFN-alpha administered subcutaneously. Our earlier in vitro sensitivity studies of mesothelioma cell lines showed that IFN augments the response to chemotherapeutic agents in mesothelioma. The aim of this study was to assess the response of four mesothelioma cell lines, derived from diffuse asbestos-related pleural malignant mesothelioma, to methotrexate alone and in combination with recombinant IFN-alpha and IFN-gamma. Anti-proliferative effects were assayed by vital dye exclusion. A combination of IFN-alpha and IFN-gamma consistently augmented the response of the cell lines to methotrexate, by as much as 75% for one cell line, although the response to the individual IFNs was variable. We were also able to compare the effects of natural IFN-beta with those of IFN-alpha and IFN-gamma. The IFN-beta sensitivity profile for each of the four cell lines was similar to that of IFN-alpha. In two cell lines, the combination of IFN-beta and IFN-gamma produced a similar effect to the IFN-alpha and IFN-gamma combination.

Human macrophage colony-stimulating factor is expressed at and shed from the cell surface

Surface membrane-associated growth factors are being recognized as important for developmental processes, including cell assembly, differentiation, and growth. To investigate the role of membrane-bound macrophage colony-stimulating factor (M-CSF) in myelopoiesis, and whether this factor is released from the cell surface in association with shed membrane-derived vesicles, COS-1 cells were transfected with cDNAs for M-CSF-tau (containing the transmembrane domain) or a soluble mutant form of the molecule lacking the transmembrane domain ([s]M-CSF-alpha). COS-1 cells transfected with either cDNA released activity into the spent culture medium. Conditioned medium was separated by centrifugation into supernatants and pellets were found to contain plasma membrane-derived vesicles by transmission electron microscopy. When medium fractions were assayed in marrow cultures, activity was localized to shed plasma membrane-derived vesicles in medium conditioned by cells transfected with cDNA for M-CSF-tau and in the vesicle-free supernatants of medium conditioned by cells transfected with cDNA for [s]M-CSF-alpha. In addition, nuclear, mitochondrial, and plasma membrane subfractions of stably transfected cells were prepared and assayed for activity. Concentration-dependent stimulation of macrophage colony formation was observed with purified plasma membranes (but not nuclear or cytosolic proteins) from cells transfected with cDNA for M-CSF-tau. By contrast, membranes from untransfected cells and cells transfected with cDNA for [s]M-CSF-alpha or control DNA expressed no activity. Together, the data indicate that human M-CSF is expressed at the cell surface and exfoliated in association with surface membrane-derived vesicles.

Interferon-alpha and interferon-gamma combined with chemotherapy: in vitro sensitivity studies in non-small cell lung cancer cell lines

Non-small cell lung cancers (NSCLC) are often resistant to chemotherapy. Cisplatin has shown the most activity against all the histological subtypes and is now used in most combined treatment programmes. Interferon (IFN)-alpha has been shown to potentiate cisplatin and other drugs experimentally and in clinical trials involving NSCLC. We are looking at the responses of different NSCLC cell lines to cisplatin (P), etoposide (VP-16) and IFN [recombinant human IFN-alpha 2c (IFN-alpha) and IFN-gamma 1b (IFN-gamma)], individually and in combination. We then compare the results with those from a clinical trial of etoposide and cisplatin with interferon in advanced NSCLC. We report here the results from the first of our cell lines, established from a large cell anaplastic carcinoma. We have confirmed earlier findings that NSCLC cell lines are not sensitive to either IFN-alpha or IFN-gamma alone. However a combination of IFN-alpha and IFN-gamma does reduce cell proliferation in our cell lines. This IFN combination potentiates the response of the cells to etoposide far more than to cisplatin. There is a trend towards greater activity when a combination of cisplatin and etoposide is used, compared with the activity of either drug alone. This effect is further increased by the interferon combination.

Gap junction formation in human myometrium: a key to preterm labor?

OBJECTIVE

The purpose of this study was to determine if gap junctions are a necessary component of the human laboring uterus and if their presence in myometrium is a prerequisite for both term and preterm labor.

STUDY DESIGN

We obtained 27 human myometrial samples at cesarean section or nongravid hysterectomy. Gap junction formation was analyzed in a blind fashion by freeze fracture and indirect immunofluorescence. Six samples were obtained from term patients with no labor, six from term patients in labor, six from preterm patients with no labor, six from patients in preterm labor, and three from nongravid hysterectomy specimens.

RESULTS

Gap junction structures were identified in the human myometrium of patients in term and in preterm labor but not in the other patient samples. In addition, evidence was obtained for the expression of (alpha 1) gap junction ribonucleic acid and (alpha 1) gap junction protein in term samples of human myometrium.

CONCLUSION

Gap junctions are a necessary component of the human myometrium during term and preterm labor. The formation of gap junctions may be a final common event for the development of labor, and inhibition of gap junction activity could be a novel approach for the treatment of preterm labor.

Pyridinyl imidazoles inhibit IL-1 and TNF production at the protein level

The mechanism by which SK&F 86002 and other pyridinyl imidazoles inhibit the production of IL-1 and TNF from LPS-stimulated human monocytes was examined. Inhibition of IL-1 and TNF production was found to depend on the time of addition of SK&F 86002, with diminishing effect when added more than 2 h after LPS stimulation. Analysis of Western blots confirmed that both intracellular IL-1 beta and extracellular TNF were significantly reduced in response to SK&F 86002, but these reductions were not paralleled by changes in IL-1 and TNF mRNA. 35S methionine pulse and pulse-chase studies on IL-1 biosynthesis suggest that significant inhibition by SK&F 86002 and related compounds occurs at the translational level.

Regulation of ICAM-1 expression and function in human dermal fibroblasts by IL-4

ICAM-1 is found on the surface of many hematopoietic and nonhematopoietic cells and can function as an adhesive ligand for the integrin, leukocyte function-associated molecule-1 (LFA-1, CD11a/CD18). ICAM-1/leukocyte function-associated molecule-1 interaction has been shown to be of importance in many immune-mediated cell-cell adhesion reactions. In vitro, unstimulated human fibroblast cell cultures express low levels of ICAM-1. Using ELISA, cytofluorography, electron microscopy, Northern analysis, and an in vitro cell adherence assay, we demonstrate that treatment of human dermal fibroblasts with the cytokine IL-4 leads to an increase in cell surface ICAM-1 expression that is under transcriptional control as well as increased fibroblast adhesion to LFA-1-bearing T lymphocytes. The kinetics of increased ICAM-1 expression induced by IL-4 paralleled the increase in ICAM-1-dependent T lymphocyte adhesion. The increase in T cell adhesion was determined to be due to the effects of IL-4 on the fibroblasts and not the adhering T cells. Treatment of fibroblasts with IL-4 also resulted in enhanced binding of human rhinovirus, a recently reported additional ligand for ICAM-1. Virus binding was IL-4 dose dependent and could be inhibited with mAb to ICAM-1. Both the expression of ICAM-1 and the ICAM-1-dependent increase in T lymphocyte adhesion that was induced by IL-4 could be inhibited by preexposure of the fibroblasts to either IL-1 or IL-6, suggesting that multiple cytokines can have both positive and negative effects on human fibroblast ICAM-1 expression and function.

Regulation of ICAM-1 expression and function in human dermal fibroblasts by IL-4

ICAM-1 is found on the surface of many hematopoietic and nonhematopoietic cells and can function as an adhesive ligand for the integrin, leukocyte function-associated molecule-1 (LFA-1, CD11a/CD18). ICAM-1/leukocyte function-associated molecule-1 interaction has been shown to be of importance in many immune-mediated cell-cell adhesion reactions. In vitro, unstimulated human fibroblast cell cultures express low levels of ICAM-1. Using ELISA, cytofluorography, electron microscopy, Northern analysis, and an in vitro cell adherence assay, we demonstrate that treatment of human dermal fibroblasts with the cytokine IL-4 leads to an increase in cell surface ICAM-1 expression that is under transcriptional control as well as increased fibroblast adhesion to LFA-1-bearing T lymphocytes. The kinetics of increased ICAM-1 expression induced by IL-4 paralleled the increase in ICAM-1-dependent T lymphocyte adhesion. The increase in T cell adhesion was determined to be due to the effects of IL-4 on the fibroblasts and not the adhering T cells. Treatment of fibroblasts with IL-4 also resulted in enhanced binding of human rhinovirus, a recently reported additional ligand for ICAM-1. Virus binding was IL-4 dose dependent and could be inhibited with mAb to ICAM-1. Both the expression of ICAM-1 and the ICAM-1-dependent increase in T lymphocyte adhesion that was induced by IL-4 could be inhibited by preexposure of the fibroblasts to either IL-1 or IL-6, suggesting that multiple cytokines can have both positive and negative effects on human fibroblast ICAM-1 expression and function.

Saliva secretion from the rat submandibular gland after retrograde infusion of radiographic contrast media

Rat submandibular saliva was collected at various times after retrograde infusion of water-soluble (Renografin 60%) or lipid-soluble (Lipiodol UF) radiographic contrast medium. Significant alterations in flow rate occurred following heavy parenchymal filling with both types of contrast media. Occasional changes in protein concentration, lactoperoxidase activity, and K+ levels were also noted. These changes were relatively mild and transient, and gland function had generally returned to normal by one wk after infusion. No alterations in glandular function were detected after infusion of contrast medium to a degree (ductal filling) comparable to that usually employed in clinical sialography.