SPTSSA variants alter sphingolipid synthesis and cause a complex hereditary spastic paraplegia

Sphingolipids are a diverse family of lipids with critical structural and signalling functions in the mammalian nervous system, where they are abundant in myelin membranes. Serine palmitoyltransferase, the enzyme that catalyses the rate-limiting reaction of sphingolipid synthesis, is composed of multiple subunits including an activating subunit, SPTSSA. Sphingolipids are both essential and cytotoxic and their synthesis must therefore be tightly regulated. Key to the homeostatic regulation are the ORMDL proteins that are bound to serine palmitoyltransferase and mediate feedback inhibition of enzymatic activity when sphingolipid levels become excessive. Exome sequencing identified potential disease-causing variants in SPTSSA in three children presenting with a complex form of hereditary spastic paraplegia. The effect of these variants on the catalytic activity and homeostatic regulation of serine palmitoyltransferase was investigated in human embryonic kidney cells, patient fibroblasts and Drosophila. Our results showed that two different pathogenic variants in SPTSSA caused a hereditary spastic paraplegia resulting in progressive motor disturbance with variable sensorineural hearing loss and language/cognitive dysfunction in three individuals. The variants in SPTSSA impaired the negative regulation of serine palmitoyltransferase by ORMDLs leading to excessive sphingolipid synthesis based on biochemical studies and in vivo studies in Drosophila. These findings support the pathogenicity of the SPTSSA variants and point to excessive sphingolipid synthesis due to impaired homeostatic regulation of serine palmitoyltransferase as responsible for defects in early brain development and function.

Bi-allelic ATG4D variants are associated with a neurodevelopmental disorder characterized by speech and motor impairment

Autophagy regulates the degradation of damaged organelles and protein aggregates, and is critical for neuronal development, homeostasis, and maintenance, yet few neurodevelopmental disorders have been associated with pathogenic variants in genes encoding autophagy-related proteins. We report three individuals from two unrelated families with a neurodevelopmental disorder characterized by speech and motor impairment, and similar facial characteristics. Rare, conserved, bi-allelic variants were identified in ATG4D, encoding one of four ATG4 cysteine proteases important for autophagosome biogenesis, a hallmark of autophagy. Autophagosome biogenesis and induction of autophagy were intact in cells from affected individuals. However, studies evaluating the predominant substrate of ATG4D, GABARAPL1, demonstrated that three of the four ATG4D patient variants functionally impair ATG4D activity. GABARAPL1 is cleaved or "primed" by ATG4D and an in vitro GABARAPL1 priming assay revealed decreased priming activity for three of the four ATG4D variants. Furthermore, a rescue experiment performed in an ATG4 tetra knockout cell line, in which all four ATG4 isoforms were knocked out by gene editing, showed decreased GABARAPL1 priming activity for the two ATG4D missense variants located in the cysteine protease domain required for priming, suggesting that these variants impair the function of ATG4D. The clinical, bioinformatic, and functional data suggest that bi-allelic loss-of-function variants in ATG4D contribute to the pathogenesis of this syndromic neurodevelopmental disorder.

Continuing a search for a diagnosis: the impact of adolescence and family dynamics

The "diagnostic odyssey" describes the process those with undiagnosed conditions undergo to identify a diagnosis. Throughout this process, families of children with undiagnosed conditions have multiple opportunities to decide whether to continue or stop their search for a diagnosis and accept the lack of a diagnostic label. Previous studies identified factors motivating a family to begin searching, but there is limited information about the decision-making process in a prolonged search and how the affected child impacts a family's decision. This study aimed to understand how families of children with undiagnosed diseases decide whether to continue to pursue a diagnosis after standard clinical testing has failed. Parents who applied to the Undiagnosed Disease Network (UDN) at the National Institutes of Health (NIH) were recruited to participate in semi-structured interviews. The 2015 Supportive Care Needs model by Pelenstov, which defines critical needs in families with rare/undiagnosed diseases, provided a framework for interview guide development and transcript analysis (Pelentsov et al in Disabil Health J 8(4):475-491, 2015. https://doi.org/10.1016/J.DHJO.2015.03.009 ). A deductive, iterative coding approach was used to identify common unifying themes. Fourteen parents from 13 families were interviewed. The average child's age was 11 years (range 3-18) and an average 63% of their life had been spent searching for a diagnosis. Our analysis found that alignment or misalignment of parent and child needs impact the trajectory of the diagnostic search. When needs and desires align, reevaluation of a decision to pursue a diagnosis is limited. However, when there is conflict between parent and child desires, there is reevaluation, and often a pause, in the search. This tension is exacerbated when children are adolescents and attempting to balance their dependence on parents for medical care with a natural desire for independence. Our results provide novel insights into the roles of adolescents in the diagnostic odyssey. The tension between desired and realistic developmental outcomes for parents and adolescents impacts if, and how, the search for a diagnosis progresses.

Detection of Academic Early Warning Signs and Effective Intervention "Takes a Village"

Early intervention for students at risk of academic difficulty can be more effectively accomplished using a team-based approach that capitalizes on the expertise of many in a pharmacy education community. Authored by members of the Big Ten Alliance Pharmacy Assessment Collaborative, this commentary advocates for better integration of assessment professionals, pharmacy faculty, and student support services to capture academic, accountability, and behavior-related data that might signal student intellectual and/or behavioral challenges and manifest as marginal academic performance. Assessment professionals can assist with creating data dashboards/monitoring systems, recognizing trends within the data, refining formulas to identify at-risk students, and measuring the impact of interventions to determine which approaches positively and significantly influence outcomes. Effective early warning and intervention takes a village and should go beyond narrowly focused attempts that fail to account for the complexity of students as individuals or fail to acknowledge the multifaceted skill set students are expected to develop to become competent and responsible pharmacists.

Plasma Exchange for Severe Immune-Related Adverse Events from Checkpoint Inhibitors: An Early Window of Opportunity?

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several advanced malignancies leading to durable remission in a subset of patients. Their rapidly expanding use has led to an increased frequency of immune-related adverse events (irAEs). The pathogenesis of irAEs is poorly understood but may involve aberrant activation of T cells leading to inflammatory cytokine release or production of pathogenic antibodies leading to organ damage. Severe irAEs can be extremely debilitating and, in some cases, life threatening. IrAEs may not always be corticosteroid responsive or may require excessively high, often toxic, corticosteroid doses. Therapeutic plasma exchange (PLEX) is a treatment modality that has shown promising results for the management of certain severe irAEs, including irAEs that are not mentioned in current treatment guidelines. PLEX may attenuate ongoing irAEs and prevent delayed irAEs by accelerating clearance of the ICI, or by acutely removing pathogenic antibodies, cytokines, and chemokines. Here, we summarize examples from the literature in which PLEX was successfully used for the treatment of irAEs. We posit that timing may be a critical factor and that earlier utilization of PLEX for life-threatening irAEs may result in more favorable outcomes. In individuals at high risk for irAEs, the availability of PLEX as a potential therapeutic mitigation strategy may encourage life-saving ICI use or rechallenge. Future research will be critical to better define which indications are most amenable to PLEX, particularly to establish the optimal place in the sequence of irAE therapies and to assess the ramifications of ICI removal on cancer outcomes.

Development of a scale to determine student self-efficacy in performing key pharmacists' patient care skills

BACKGROUND

The Pharmacists' Patient Care Process (PPCP) was developed to describe a consistent process in which pharmacists in any setting provide patient care. Faculty at a midwestern university developed and refined an assessment tool which provides an indirect approach to measure student confidence in performing skills essential to the PPCP. The objective of this paper is to conduct a stepwise factor analysis to refine the PPCP survey.

METHODS

Assessing appropriateness of survey response data led to an exploratory factor analysis (EFA) on student confidence data to refine the survey instrument and examine the underlying constructs that influence student responses. Post EFA, the results were presented to the research team that collaboratively reached consensus on inclusion or exclusion of items.

RESULTS

EFA factor loadings identified a 4-factor solution suggesting elimination of 30 items from the original 53 item survey. Team discussions led to eliminating 29 items, combining two items and generation of 5 new items in order to retain important concepts. The outcome was a well-conceptualized and refined 29 item-survey model assessing 4 constructs.

CONCLUSION

To potentially improve patient outcomes, it is imperative to utilize comprehensive yet concise survey instruments, like the PPCP Skills Self-Efficacy Survey, to prepare students to translate PPCP skills to practice.

Measuring motivational interviewing self-efficacy of pre-service students completing a competency-based motivational interviewing course

Background

Improving health outcomes requires health care practitioners to work collaboratively with clients to make healthy lifestyle changes. Motivational interviewing (MI) is an evidence-based approach found to evoke and support behavior change.

Objective

The aim of this study was to examine changes over time in pre-service professional students' confidence in their MI skills after a 15-week interprofessional MI course.

Methods

Students (N = 22) completed a newly developed 24-item Motivational Interviewing Confidence Survey (MICS pre and post participation in the course). Summary statistics, initial scale reliability assessment and t-tests were carried out.

Results

MICS was a reliable measure (Cronbach's a = 0.98) and detected significant changes in students' self-perceived skill set. Using t-tests, significant differences were noted in pre- and post-assessments in students' confidence in their skills; students (p values<0.001) demonstrated significant gains in confidence on 23 of 24 MICS items.

Conclusion

After participating in the course, students' confidence in their MI skills improved significantly. Adding pre-service training in MI may increase future healthcare practitioners' confidence in their MI skills and improve their capacity to engage in individually tailored, client-driven practice.

De novo EIF2AK1 and EIF2AK2 Variants Are Associated with Developmental Delay, Leukoencephalopathy, and Neurologic Decompensation

EIF2AK1 and EIF2AK2 encode members of the eukaryotic translation initiation factor 2 alpha kinase (EIF2AK) family that inhibits protein synthesis in response to physiologic stress conditions. EIF2AK2 is also involved in innate immune response and the regulation of signal transduction, apoptosis, cell proliferation, and differentiation. Despite these findings, human disorders associated with deleterious variants in EIF2AK1 and EIF2AK2 have not been reported. Here, we describe the identification of nine unrelated individuals with heterozygous de novo missense variants in EIF2AK1 (1/9) or EIF2AK2 (8/9). Features seen in these nine individuals include white matter alterations (9/9), developmental delay (9/9), impaired language (9/9), cognitive impairment (8/9), ataxia (6/9), dysarthria in probands with verbal ability (6/9), hypotonia (7/9), hypertonia (6/9), and involuntary movements (3/9). Individuals with EIF2AK2 variants also exhibit neurological regression in the setting of febrile illness or infection. We use mammalian cell lines and proband-derived fibroblasts to further confirm the pathogenicity of variants in these genes and found reduced kinase activity. EIF2AKs phosphorylate eukaryotic translation initiation factor 2 subunit 1 (EIF2S1, also known as EIF2α), which then inhibits EIF2B activity. Deleterious variants in genes encoding EIF2B proteins cause childhood ataxia with central nervous system hypomyelination/vanishing white matter (CACH/VWM), a leukodystrophy characterized by neurologic regression in the setting of febrile illness and other stressors. Our findings indicate that EIF2AK2 missense variants cause a neurodevelopmental syndrome that may share phenotypic and pathogenic mechanisms with CACH/VWM.

Identifying High-Impact and Managing Low-Impact Assessment Practices

Those in pharmacy education who are tasked with assessment may be overwhelmed by deadlines, data collection, and reporting, leaving little time to pause and examine the effectiveness of their efforts. However, assessment practices must be evaluated for their impact, including their ability to answer important questions, use resources effectively, and contribute to meaningful educational change. Often assessments are implemented, but then attention is diverted to another assessment before the data from the former assessment can be fully interpreted or used. To maximize the impact of assessment practices, tough and uncomfortable decisions may need to be made. In this paper, we suggest an approach for examining and making decisions about assessment activities and provide guidance on building high-impact assessment practices, evolving or "sunsetting" low-impact assessment practices, and managing mandated assessment.

Orbital and chorioretinal manifestations of Erdheim-Chester disease treated with vemurafenib

Purpose

We report a patient with severe multi-organ dysfunction of unknown origin who presented with bilateral orbital and chorioretinal manifestations that led to the diagnosis of Erdheim-Chester Disease (ECD).

Observations

ECD is a rare, histiocytic, proliferative disorder characterized by multi-systemic organ involvement that has historically lacked effective therapy. Our patient underwent genetic testing that was positive for the BRAF V600E mutation; therefore, the patient was treated with vemurafenib.

Conclusions and importance

This case demonstrates the rare orbital and intraocular manifestations of ECD and the unfortunate impact of a delayed diagnosis, the importance of early gene therapy testing for management decisions, and the utilization of targeted directed therapy to improve visual outcomes and quality of life.

Validation of learning assessments: A primer

The Accreditation Council for Pharmacy Education's Standards 2016 has placed greater emphasis on validating educational assessments. In this paper, we describe validity, reliability, and validation principles, drawing attention to the conceptual change that highlights one validity with multiple evidence sources; to this end, we recommend abandoning historical (confusing) terminology associated with the term validity. Further, we describe and apply Kane's framework (scoring, generalization, extrapolation, and implications) for the process of validation, with its inferences and conclusions from varied uses of assessment instruments by different colleges and schools of pharmacy. We then offer five practical recommendations that can improve reporting of validation evidence in pharmacy education literature. We describe application of these recommendations, including examples of validation evidence in the context of pharmacy education. After reading this article, the reader should be able to understand the current concept of validation, and use a framework as they validate and communicate their own institution's learning assessments.

Pharmacist Behavior Changes Following a Medication Counseling Training Program Targeting Teach-Back and Plain Language

Purpose: To evaluate whether active learning-based training in teach-back and plain language (TBPL) techniques can lead to observable changes to patient-centered practices in pharmacist-patient counseling. Methods: All pharmacists in direct patient care roles, inpatient and outpatient, were required to complete a didactic module and a workshop / webinar or small group training. The workshop / webinar and small group modalities incorporated elements of adult education theory. Following completion, pharmacists were surveyed to assess their ability, confidence and commitment to incorporating TBPL techniques into practice. Evaluation of pharmacist-patient counseling was completed pre- and post- training through direct observation. Student pharmacists were trained to evaluate pharmacists’ consultations on patients with ≥2 new medications. Students recorded completeness rates for 39 communication techniques. Results: One-hundred and eighteen pharmacists completed the TBPL training program and 59 pharmacists completed an evaluation. A total of 84 direct observations were completed (40 pre-training and 44 post-training). Skills improved included: using plain language (p Conclusion: Implementing a TBPL training program improved observable pharmacist-patient consultation skills. This approach is replicable and could be utilized as a model for other competencies.   Type: Original Research

Mistaken identity: Legionella micdadei appearing as acid-fast bacilli on lung biopsy of a hematopoietic stem cell transplant patient

Legionella micdadei is a potential cause of invasive lung infections in immunocompromised hosts. On biopsy specimens, it can appear as an acid-fast bacillus (AFB) and can be mistaken for a member of genus Mycobacterium. As Legionella requires selective media to grow in culture, and the commonly used, commercially available urine antigen test for Legionella only detects Legionella pneumophila serogroup-1, but not L. micdadei, it is important to consider this organism in the differential diagnosis for AFB in immunocompromised hosts. We report a case of L. micdadei infection, which was initially treated empirically for non-tuberculous mycobacteria based on AFB staining of biopsy tissue before the final diagnosis was made.

A nontraditional faculty development initiative using a social media platform

OBJECTIVE

To assess the outcomes from an 11-year nontraditional professional development activity implemented by female faculty members at several colleges and schools of pharmacy.

DESIGN

Within the context of an online fantasy football league, faculty members practiced community-based faculty development strategies, including peer mentoring, skills development, constructive feedback and other supportive behaviors.

ASSESSMENT

Data were extracted from curriculum vitae to characterize the academic progress of participants and to quantify scholarly work collaborations among league members. Analyses were limited to members who had participated in the league for 10 or more consecutive years. Seventy-one collaborative scholarly works occurred among team managers, including presentation of 20 posters and 2 oral presentations at national or international meetings, publication of 29 peer-reviewed articles and 15 book chapters, and funding of 5 research projects.

CONCLUSION

Social media platforms can foster nontraditional faculty development and mentoring by enhancing connectivity between pharmacy educators who share similar interests.

Educational testing and validity of conclusions in the scholarship of teaching and learning

Validity and its integral evidence of reliability are fundamentals for educational and psychological measurement, and standards of educational testing. Herein, we describe these standards of educational testing, along with their subtypes including internal consistency, inter-rater reliability, and inter-rater agreement. Next, related issues of measurement error and effect size are discussed. This article concludes with a call for future authors to improve reporting of psychometrics and practical significance with educational testing in the pharmacy education literature. By increasing the scientific rigor of educational research and reporting, the overall quality and meaningfulness of SoTL will be improved.

Safeguarding older adults from inappropriate over-the-counter medications: the role of community pharmacists

PURPOSE OF THE STUDY

To elicit the thought process or mental model that community pharmacists use when making recommendations on over-the-counter (OTC) medications to older adults and to elicit the current practices of community pharmacists in providing information, advice, and counseling to older adults about potentially inappropriate OTC medications.

DESIGN AND METHODS

Three separate focus groups with pharmacists were conducted with 5 to 8 pharmacists per group. A vignette about an elderly woman seeking an OTC sleep aid was used to elicit information that pharmacists seek to establish when making a recommendation. Focus groups were recorded, transcribed verbatim, and analyzed for themes using the initial and focused coding methods of grounded theory.

RESULTS

Community pharmacists' mental models were characterized by 2 similarities: a similarity in what community pharmacists seek to establish about patients and a similarity in when community pharmacists seek to establish it--the sequence in which they try to learn key details about patients. It was identified that pharmacists gather specific information about the patient's medication profile, health conditions, characteristics of the problem, and past treatments in order to make a recommendation. Community pharmacists recommended behavioral modifications and seeing their physician prior to recommending an OTC sleep aid, primarily due to medication safety concerns.

IMPLICATIONS

Pharmacists can play a key role in assisting older adults to select and use OTC medications.

Transitions in Care: Medication Reconciliation in the Community Pharmacy Setting After Discharge

Objective: To assess the feasibility of a workflow process in which pharmacists in an independent community pharmacy group conduct medication reconciliation for patients undergoing transitions in care. Methods: Three workflow changes were made to improve the medication reconciliation process in a group of three independent community pharmacies. Analysis of the process included workflow steps performed by pharmacy staff, pharmacist barriers encountered during the medication reconciliation process, number of medication discrepancies identified, and pharmacist comfort level while performing each medication reconciliation service. Key Findings: Sixty patient medication reconciliation services met the inclusion criteria for the study. Pharmacists were involved in all steps associated with the medication reconciliation workflow, and were the sole performer in four of the steps: verifying discharge medications with the pharmacy medication profile, resolving discrepancies, contacting the prescriber, and providing patient counseling. Pharmacists were least involved in entering medications into the pharmacy management system, performing that workflow step 13% of the time. The most common barriers were the absence of a discharge medication list (24%) and patient notpresent during consultation (11%). A total of 231 medication discrepancies were identified, with an average of 3.85 medication discrepancies per discharge. Pharmacists' comfort level performing medication reconciliation improved through the 13 weeks of the study. Conclusions: These findings suggest that medication reconciliation for patients discharged from hospitals and long term care facilities can be successfully performed in an independent community pharmacy setting. Because many medication discrepancies were identified during this transition of care, it is highly valuable for community pharmacists to perform medication reconciliation services.   Type: Original Research

Longitudinal teaching of evidence-based decision making

OBJECTIVE

To determine whether longitudinal design and delivery of evidence-based decision making (EBDM) content was effective in increasing students' knowledge, skills, and confidence as they progressed through a doctor of pharmacy (PharmD) curriculum.

DESIGN

Three student cohorts were followed from 2005 to 2009 (n=367), as they learned about EBDM through lectures, actively researching case-based questions, and researching and writing answers to therapy-based questions generated in practice settings.

ASSESSMENT

Longitudinal evaluations included repeated multiple-choice examinations, confidence surveys, and written answers to practice-based questions (clinical inquiries). Students' knowledge and perception of EBDM principles increased over each of the 3 years. Students' self-efficacy (10-items, p<0.0001) and perceived skills (7-items, p<0.0001) in applying EBDM skills to answer practice-based questions also increased. Graded clinical inquiries verified that students performed satisfactorily in the final 2 years of the program.

CONCLUSIONS

This study demonstrated a successful integration of EBDM throughout the curriculum. EBDM can effectively be taught by repetition, use of real examples, and provision of feedback.

A model for partnering first-year student pharmacists with community-based older adults

OBJECTIVES

To design, integrate, and assess the effectiveness of an introductory pharmacy practice experience intended to redefine first-year student pharmacists' views on aging and medication use through their work with a healthy, community-based older-adult population.

DESIGN

All students (N = 273) completed live skills training in an 8-hour boot camp provided during orientation week. Teams were assigned an independently living senior partner, completed 10 visits and reflections, and documented health-related information using an electronic portfolio (e-portfolio).

ASSESSMENT

As determined by pre- and post-experience survey instruments, students gained significant confidence in 7 skill areas related to communication, medication interviews, involving the partner in health care, and applying patient-care skills. Student reflections, in-class presentations, and e-portfolios documented that personal attitudes toward seniors changed over time. Senior partners enjoyed mentoring and interacting with students and many experienced health improvements as a result of the interaction.

CONCLUSIONS

The model for partnering first-year student pharmacists with community-based older adults improved students' skills and fostered their connections to pharmacist roles and growth as person-centered providers.

Evaluating pharmacists' ability to counsel on tobacco cessation using two standardized patient scenarios

OBJECTIVES

To evaluate the impact that role-playing two pre/post standardized patient scenarios within a tobacco cessation training program had on pharmacists' counseling skills. Second, to analyze the validity of the observation coding tool used to evaluate pharmacist's role-play performance.

METHODS

Pharmacists performed two role-playing scenarios which incorporated national guidelines, the 5A's counseling process, and the "preparation" and "action" phases of the transtheoretical model. Pharmacists' performance was evaluated with an observation coding tool.

RESULTS

Pharmacists' (n=25) counseling performance improved significantly post-training (p<0.02: Action Scenario; p<0.004: Preparation Scenario). More than 50% of pharmacists provided patient-directed tobacco consultation services in the one year following training. The observation tool score for the "action phase" scenario was highly associated with pharmacists' subsequent delivery of tobacco cessation services in community practice.

CONCLUSION

Role-playing facilitated pharmacists' skill development. The evaluation tool and Action Scenario may be powerful for predicting pharmacists' delivery of tobacco cessation services.

PRACTICE IMPLICATIONS

Incorporating role-playing and structured tools for performance evaluation can help enhance pharmacist performance during training and predict service delivery in community practice. Together they could facilitate tailored feedback to help pharmacists struggling with the difficult task of extending cognitive service roles in practice.

Development of a scale to measure pharmacists' self-efficacy in performing medication therapy management services

BACKGROUND

Measuring community pharmacists' self-efficacy in performing medication therapy management (MTM) services can be useful for tailoring interventions and predicting participation.

OBJECTIVE

To identify relevant survey constructs related to the Wisconsin Pharmacy Quality Collaborative (WPQC) MTM program and to evaluate scale validity.

METHODS

The 31-item MTM self-efficacy scale was developed using previous research, identifying critical program components, and beta testing. After administration to pharmacists in the 53 WPQC pilot sites, summary statistics and exploratory factor analysis (EFA) were conducted. Parallel analysis was used to determine the optimal number of factors. Internal consistency reliabilities were calculated.

RESULTS

Baseline participation rate was 94% (N=76). The 11-point scale (0-10) item means ranged from 2.83+/-3.05 to 7.82+/-2.19. Parallel analysis produced a 3-factor solution, accounting for 56% of the variance. Low-factor loadings or unacceptably high cross loadings resulted in 17-item deletions. The final EFA on the remaining 14 items retained the original 3-factor solution and increased the proportion of explained variance (72%). The factors relate to MTM tasks (alpha=0.92), personal interactions (alpha=0.86), and goal setting (alpha=0.84). Overall Cronbach's alpha=0.90.

CONCLUSION

Constructs for measuring self-efficacy were identified that may aid in future research predicting whether pharmacists engage in and persist in providing MTM services.

Effect of a tobacco cessation continuing professional education program on pharmacists' confidence, skills, and practice-change behaviors

OBJECTIVE

To evaluate the impact of a tobacco cessation training program on pharmacists' confidence, skills, and practice-change behaviors.

DESIGN

Quasi-experimental study.

SETTING

Wisconsin during 2002-2003.

PARTICIPANTS

25 community pharmacists.

INTERVENTION

A continuing education training program was developed and implemented using home and live training components consisting of the national tobacco cessation guidelines, including the 5A's counseling process. The home study component included lectures and readings in CD-ROM format. Consistent with self-efficacy theory, the live training was based on exercises that included modeling, rehearsal, and feedback to learners.

MAIN OUTCOME MEASURES

Knowledge assessment, pre- and post-surveys assessing confidence and skill levels, and service provision indicators.

RESULTS

Self-efficacy and perceived ability to counsel patients to quit using tobacco improved significantly after the combined program. No significant change in confidence or perceived skills occurred following home study alone, suggesting value in using a combination of teaching strategies (problem solving, modeling, rehearsal, and feedback). Of participants, 92% received a passing knowledge score and 75% attempted to implement a tobacco cessation service posttraining; more than 50% assisted patients up to 1 year post-training. A relationship between self-efficacy and service provision was found when practice settings were considered.

CONCLUSION

This program increased pharmacists' knowledge and self-efficacy to counsel patients on tobacco use. Further, the majority of pharmacy participants attempted to implement a tobacco cessation service.

High-dose cyclophosphamide in refractory myasthenia gravis with MuSK antibodies

We describe a 48-year-old woman with seronegative myasthenia gravis (MG) and high-titer of anti-MuSK antibody. She had severe bulbar and respiratory weakness with minimal limb weakness for 2 years. Her disease responded poorly to all the conventional immunosuppressive regimens. Treatment with immunoablative dose of cyclophosphamide led to dramatic and sustained remission of her symptoms. High-dose cyclophosphamide is an effective alternative in patients with unusually refractory disease.

Reproductive status of western mosquitofish inhabiting selenium-contaminated waters in the Grassland water district, Merced county, California

This study was implemented to determine if western mosquitofish (Gambusia affinis) populations in the Grassland Water District suffer from impaired reproduction because of seleniferous inflows of agricultural drainwater from the Grassland Bypass Project. During June to July 2001, laboratory trials with pregnant female fish collected from two seleniferous treatment sites exposed to selenium-laden drainwater and two nonseleniferous reference sites yielded fry that averaged > 96% survival at birth. In addition, none of the newborn fry exhibited evidence of teratogenesis, a typical consequence of selenium toxicity. Chemical analysis of postpartum female fish and their newborn fry indicated that mosquitofish from seleniferous sites accumulated relatively high body burdens of selenium (3.96 to 17.5 microg selenium/g in postpartum female fish and 5.35 to 29.2 microg selenium/g in their fry), whereas those from nonseleniferous sites contained lower body burdens (0.40 to 2.72 microg selenium/g in postpartum female fish and 0.61 to 4.68 microg selenium/g in their fry). Collectively, these results strongly suggest that mosquitofish inhabiting selenium-contaminated waters are not experiencing adverse reproductive effects at current levels of selenium exposure.

Test-retest reliability of cortical evoked potentials using naturally produced speech sounds

OBJECTIVE

To determine if naturally produced speech stimuli evoke distinct neural response patterns that can be reliably recorded in individuals.

DESIGN

Auditory cortical evoked potentials were obtained from seven normal-hearing young adults in response to four naturally produced speech tokens (/bi/, /pi/, /[U0283]i/, and /si/). Stimuli were tokens from the standardized UCLA version of the Nonsense Syllable Test (NST) ( Dubno & Schaefer, 1992). Using a repeated measures design, subjects were tested and then retested within an 8-day period.

RESULTS

Auditory cortical evoked potentials elicited by naturally produced speech sounds were reliably recorded in individuals. Also, naturally produced speech tokens, representing different acoustic cues, evoked distinct neural response patterns.

CONCLUSIONS

1) Cortical evoked potentials elicited by naturally produced speech sounds can be reliably recorded in individuals. 2) Naturally produced speech tokens, representing different acoustic cues, evoke distinct neural response patterns. 3) Given the reliability of the response, this work has potential application to the study of neural processing of speech in individuals with communication disorders as well as changes over time after various types of auditory rehabilitation.

Risk for osteoporosis in elderly nuns: need for better recognition and treatment

BACKGROUND

The risk for osteoporosis in Catholic sisters (nuns) may be even higher than that of the general female population given their longer life expectancy (82.0 to 89.0 years vs 79.6 years for the average white woman) and the use of a traditional habit as a young adult, resulting in limited sun exposure (ie, exposure to vitamin D).

OBJECTIVES

The aim of this study was to determine, in a group of elderly nuns attending an annual health screening day (Health Forum), how many met National Osteoporosis Foundation (NOF) treatment criteria using peripheral bone mineral density (BMD) measurements and risk factors; what proportion received adequate vitamin D; whether BMD was related to length of time that nuns wore a habit; and whether BMD measurement led to medical interventions. In addition, we compared the usefulness of calcaneal BMD with that of BMD at central sites for identification of those at risk for osteoporosis.

METHODS

This cross-sectional study assessed BMD by calcaneal dual energy X-ray absorptiometry (DXA) and, for some participants, central DXA. A baseline questionnaire and follow-up mail survey also were included.

RESULTS

Of the 230 nuns attending the Health Forum, 146 (63%) (mean age, 70 years; range, 48-90 years) participated in the study. Of these, 14% had calcaneal osteoporosis (T-score <-2.5) and 32% met NOF treatment criteria, indicating risk comparable to that of other postmenopausal American women. Sixty-four percent were receiving less than the recommended amount of vitamin D (≥400 IU/d for those aged <71 years and ≥600 IU/d for those aged ≥71 years). Calcaneal BMD was inversely related to the length of time nuns had worn a habit. Fifty-six women subsequently underwent central DXA. Using a calcaneal T-score of -1.2 to identify those with central osteoporosis, sensitivity and specificity of 78% and 76%, respectively, were obtained. According to the mail survey, 11 of 42 respondents who had met NOF treatment criteria started new medications for osteoporosis.

CONCLUSIONS

Elderly nuns are at substantial risk for osteoporosis. Most receive inadequate vitamin D. For nuns and others who may have limited access to central DXA measurement, peripheral measurements may help identify those in need of further intervention. Further efforts, in addition to BMD measurements, are necessary to ensure appropriate therapy for those who meet treatment criteria.

Ca(2+)- and myristoylation-dependent association of calcineurin with phosphatidylserine

It has been proposed that N-terminal myristoylation of calcineurin B is necessary for the membrane association of calcineurin. We tested the effects of Ca(2+) and myristoylation on the binding of calcineurin B alone or heterodimeric calcineurin to phosphatidylserine or phosphatidylcholine vesicles. In the presence of excess phosphatidylserine, 50-60% of total calcineurin associated with phosphatidylserine in a Ca(2+)-sensitive manner. Calcineurin did not associate with phosphatidylcholine. Calcineurin containing both the alpha and beta catalytic subunit isoforms bound to phosphatidylserine. Calmodulin interfered with the association of calcineurin with phosphatidylserine. In the presence of Ca(2+), myristoylated calcineurin B alone did not bind to phosphatidylcholine but did bind to phosphatidylserine, although to a lesser extent than the calcineurin heterodimer. Non-myristoylated calcineurin B alone, or calcineurin containing non-myristoylated calcineurin B did not associate with phosphatidylserine in the presence of Ca(2+). These results indicate: (i) Both isoforms of calcineurin bind to phosphatidylserine. (ii) A phospholipid binding site is located on the calcineurin B subunit. (iii) Calcineurin B myristoylation is required for the Ca(2+)-sensitive binding of calcineurin to phosphatidylserine vesicles in vitro.

A cluster of basic amino acid residues in calcineurin b participates in the binding of calcineurin to phosphatidylserine vesicles

Interactions between phospholipid membranes and the acyl chain and specific amino acid residues of myristoylated proteins are necessary for membrane association. In the present study we tested the effects of mutations of calcineurin B subunit amino acid residues K(20)K(21), K(24)R(25), K(27)K(28) to Glu on the interactions between calcineurin and phosphatidylserine vesicles. Calcineurin-phosphatidylserine interactions were measured using binding assays and assays of phosphatidylserine-stimulated calcineurin phosphatase activity. The reverse-charge calcineurin B subunit mutant had a slower mobility in SDS-PAGE relative to wild-type calcineurin B. In addition, the myristoylated calcineurin B reverse-charge mutant had a slower mobility in SDS-PAGE compared to the non-myristoylated form, in contrast to the faster mobility of myristoylated wild-type calcineurin B relative to non-myristoylated calcineurin B. The reverse-charge mutations had no apparent effect on N-terminal myristoylation, Ca(2+)-binding, or calcineurin heterodimer formation and stimulation of Ca(2+)/calmodulin-dependent phosphatase activity. However, in contrast to the results obtained using native calcineurin, phosphatidylserine vesicles did not bind to or activate the phosphatase activity of calcineurin containing the calcineurin B reverse-charge mutant. These results indicate that calcineurin B contains an amino terminal basic residue cluster that is involved in the binding of calcineurin to acidic phospholipids.

The Clarke Institute experience with completed suicide: 1966 to 1997

OBJECTIVES

To describe the caseload of completed suicides at a single psychiatric facility and to review the perceived deficiencies in the care of those patients.

METHOD

Demographic and diagnostic data, clinical circumstances, and the deficiencies in care and documentation or both were extracted from medical records and post-suicide audit reports.

RESULTS

There were 276 completed suicides over the period reviewed, yielding suicide rates of 206 per 100,000 registered patients and 123.5 per 100,000 inpatient discharges. The male to female ratio was 2:1, and patients with schizophrenia or depression accounted for 63.7% of the caseload. Only 18% of inpatients were involuntary, and only 10% were under individual observation at the time of suicide. Individual psychiatrists had up to 15 suicides in their caseloads. Deficiencies and recommendations pursuant to case audits are summarized.

CONCLUSION

This is the first report of the entire cumulative experience with completed suicide, including audited deficiencies in the care and documentation of that caseload, at a single Canadian psychiatric facility.

Cortical, auditory, evoked potentials in response to changes of spectrum and amplitude

The acoustic change complex (ACC) is a scalp-recorded negative-positive voltage swing elicited by a change during an otherwise steady-state sound. The ACC was obtained from eight adults in response to changes of amplitude and/or spectral envelope at the temporal center of a three-formant synthetic vowel lasting 800 ms. In the absence of spectral change, the group mean waveforms showed a clear ACC to amplitude increments of 2 dB or more and decrements of 3 dB or more. In the presence of a change of second formant frequency (from perceived /u/ to perceived /i/), amplitude increments increased the magnitude of the ACC but amplitude decrements had little or no effect. The fact that the just detectable amplitude change is close to the psychoacoustic limits of the auditory system augurs well for the clinical application of the ACC. The failure to find a condition under which the spectrally elicited ACC is diminished by a small change of amplitude supports the conclusion that the observed ACC to a change of spectral envelope reflects some aspect of cortical frequency coding. Taken together, these findings support the potential value of the ACC as an objective index of auditory discrimination capacity.

Having children after cancer. A pilot survey of survivors' attitudes and experiences

BACKGROUND

Although the prevalence of infertility after cancer treatment and the health of the offspring of survivors have been studied, little information has been available about survivors' attitudes, emotions, and choices with regard to having children.

METHODS

A questionnaire was received by 283 patients from the Cleveland Clinic Foundation tumor registry who were diagnosed before age 35 years, were age 18 years or older at the time of the survey, and were free of disease. The SF-36, a measure of health-related quality of life, was included, as well as questions about demographic and medical background, reproductive and fertility history, and a variety of concerns about having children after cancer.

RESULTS

The response rate to the survey was 47%, yielding a sample of 43 men and 89 women who had had cancer at various sites. Their mean age at diagnosis was 26 years and the mean time since diagnosis was 5 years. Before cancer, 35% had at least 1 child, compared with 46% currently. Of those currently childless, 76% want children in the future. Although about half of the entire sample view themselves as having impaired fertility, only 6% have undergone infertility treatment. Nineteen percent have significant anxiety that their cancer treatment could impact negatively on their children's future health. Of women, 18% fear that a pregnancy could trigger a cancer recurrence. Only 57% received information from their health care providers about infertility after cancer. Other reproductive concerns were discussed less often. Only 24% of childless men banked sperm before treatment. SF-36 scores were very similar to normative data for healthy Americans of similar age. About 80% of the sample viewed themselves positively as actual or potential parents. Feeling healthy enough to be a good parent after cancer was the strongest predictor (P < 0.001) of emotional well-being as measured by the Mental Component Score of the SF-36.

CONCLUSIONS

The great majority of younger cancer survivors see their cancer experience as potentially making them better parents. Those who are childless want to have children in the future. Many, however, are left with significant anxieties and insufficient information about reproductive issues.

Having children after cancer. A pilot survey of survivors' attitudes and experiences

BACKGROUND

Although the prevalence of infertility after cancer treatment and the health of the offspring of survivors have been studied, little information has been available about survivors' attitudes, emotions, and choices with regard to having children.

METHODS

A questionnaire was received by 283 patients from the Cleveland Clinic Foundation tumor registry who were diagnosed before age 35 years, were age 18 years or older at the time of the survey, and were free of disease. The SF-36, a measure of health-related quality of life, was included, as well as questions about demographic and medical background, reproductive and fertility history, and a variety of concerns about having children after cancer.

RESULTS

The response rate to the survey was 47%, yielding a sample of 43 men and 89 women who had had cancer at various sites. Their mean age at diagnosis was 26 years and the mean time since diagnosis was 5 years. Before cancer, 35% had at least 1 child, compared with 46% currently. Of those currently childless, 76% want children in the future. Although about half of the entire sample view themselves as having impaired fertility, only 6% have undergone infertility treatment. Nineteen percent have significant anxiety that their cancer treatment could impact negatively on their children's future health. Of women, 18% fear that a pregnancy could trigger a cancer recurrence. Only 57% received information from their health care providers about infertility after cancer. Other reproductive concerns were discussed less often. Only 24% of childless men banked sperm before treatment. SF-36 scores were very similar to normative data for healthy Americans of similar age. About 80% of the sample viewed themselves positively as actual or potential parents. Feeling healthy enough to be a good parent after cancer was the strongest predictor (P < 0.001) of emotional well-being as measured by the Mental Component Score of the SF-36.

CONCLUSIONS

The great majority of younger cancer survivors see their cancer experience as potentially making them better parents. Those who are childless want to have children in the future. Many, however, are left with significant anxieties and insufficient information about reproductive issues.

The effects of decreased audibility produced by high-pass noise masking on N1 and the mismatch negativity to speech sounds /ba/and/da

This study investigated the effects of decreased audibility produced by high-pass noise masking on the cortical event-related potentials (ERPs) N1 and mismatch negativity (MMN) to the speech sounds /ba/ and /da/, presented at 65 dB SPL. ERPs were recorded while normal listeners (N = 11) ignored the stimuli and read a book. Broadband masking noise was simultaneously presented at an intensity sufficient to mask the response to the speech sounds, and subsequently high-pass filtered. The conditions were QUIET (no noise); high-pass cutoff frequencies of 4000, 2000, 1000, 500, and 250 Hz; and broadband noise. Behavioral measures of discrimination of the speech sounds (d' and reaction time) were obtained separately from the ERPs for each listener and condition. As the cutoff frequency of the high-pass masker was lowered, ERP latencies increased and amplitudes decreased. The cutoff frequency where changes first occurred differed for N1 and MMN. N1 showed small systematic changes across frequency beginning with the 4000-Hz high-pass noise. MMN and behavioral measures showed large changes that occurred at approximately 1000 Hz. These results indicate that decreased audibility, resulting from the masking, affects N1 and the MMN in a differential manner. N1 reflects the presence of audible stimulus energy, being present in all conditions where stimuli were audible, whether or not they were discriminable. The MMN is present only for those conditions where stimuli were behaviorally discriminable. These studies of cortical ERPs in high-pass noise studies provide insight into the changes in brain processes and behavioral performance that occur when audibility is reduced, as in hearing loss.

Molecular and metabolic evidence for the restricted expression of inducible nitric oxide synthase in healing wounds

Tissue injury initiates a temporally ordered sequence of local cellular and metabolic responses presumably necessary for successful repair. Previous investigations demonstrated that metabolic evidence for nitric oxide synthase (NOS) activity is detectable in wounds only during the initial 48 to 72 hours of the repair process. Present results identify the cell types contributing inducible NOS (iNOS) to experimental wounds in rats. iNOS antigen was expressed in most macrophages present in wounds 6 to 24 hours after injury, and these cells exhibited NAPDH diaphorase and NOS activity. Polymorphonuclear leukocytes contained little iNOS antigen and no NADPH diaphorase activity and were minimally able to convert L-arginine to L-citrulline. The frequency of iNOS-positive macrophages declined on days 3 and 5 after wounding. By day 10, most macrophages in the wound were negative for iNOS. These cells, however, acquired iNOS antigen and activity in culture. Wound fluids, but not normal rat serum, suppressed the induction of iNOS during culture. Findings indicate that the expression of iNOS in healing wounds is restricted to macrophages present during the early phases of repair and that components of wound fluid suppress the induction of iNOS in macrophages in late wounds. Polymorphonuclear leukocytes contribute little iNOS activity to the healing wound.

Cortical, auditory, event-related potentials in response to periodic and aperiodic stimuli with the same spectral envelope

OBJECTIVE

1) To determine whether the N1-P2 acoustic change complex is elicited by a change of periodicity in the middle of an ongoing stimulus, in the absence of changes of spectral envelope or rms intensity. 2) To compare the N1-P2 acoustic change complex with the mismatch negativity elicited by the same stimuli in terms of amplitude and signal to noise ratio.

DESIGN

The signals used in this study were a tonal complex and a band of noise having the same spectral envelope and rms intensity. For elicitation of the acoustic change complex, the signals were concatenated to produce two stimuli that changed in the middle (noise-tone, tone-noise). Two control stimuli were created by concatenating two copies of the noise and two copies of the tone (noise-only, tone-only). The stimuli were presented using an onset-to-onset interstimulus interval of 3 sec. For elicitation of the mismatch negativity, the tonal complex and noise band stimuli were presented using an oddball paradigm (deviant probability = 0.14) with an onset-to-onset interstimulus interval of 600 msec. The stimuli were presented via headphones at 80 dB SPL to 10 adults with normal hearing. Subjects watched a silent video during testing.

RESULTS

The responses to the noise-only and tone-only stimuli showed a clear N1-P2 complex to the onset of stimulation followed by a sustained potential that continued until the offset of stimulation. The noise-tone and tone-noise stimuli elicited an additional N1-P2 acoustic change complex in response to the change in periodicity occurring in the middle. The acoustic change complex was larger for the tone-noise stimulus than for the noise-tone stimulus. A clear mismatch negativity was elicited by both the noise band and tonal complex stimuli. In contrast to the acoustic change complex, there was no significant difference in amplitude across the two stimuli. The acoustic change complex was a more sensitive index of peripheral discrimination capacity than the mismatch negativity, primarily because its average amplitude was 2.5 times as large.

CONCLUSIONS

These findings indicate that both the acoustic change complex and the mismatch negativity are sensitive indexes of the neural processing of changes in periodicity, though the acoustic change complex has an advantage in terms of amplitude. The results support the possible utility of the acoustic change complex as a clinical tool in the assessment of peripheral speech perception capacity.

Quality improvement in an integrated urban healthcare system: a necessary journey

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

Cortical evoked response to acoustic change within a syllable

OBJECTIVE

To investigate whether the evoked potential to a complex naturally produced speech syllable could be decomposed to reflect the contributions of the acoustic events contained in the constituent phonemes.

DESIGN

Auditory cortical evoked potentials N1 and P2 were obtained in eight adults with normal hearing. Three naturally produced speech stimuli were used: 1) the syllable [sei]; 2) the sibilant [s], extracted from the syllable; 3) the vowel [ei] extracted from the syllable. The isolated sibilant and vowel preserved the same time relationships to the sampling window as they did in the complete syllable. Evoked potentials were collected at Fz, Cz, Pz, A1, and A2, referenced to the nose.

RESULTS

In the group mean waveforms, clear responses were observed to both the sibilant and the isolated vowel. Although the response to the [s] was weaker than that to [ei], both had N1 and P2 components with latencies, in relation to sound onset, appropriate to cortical onset potentials. The vowel onset response was preserved in the response to the complete syllable, though with reduced amplitude. This pattern was observable in six of the eight waveforms from individual subjects.

CONCLUSIONS

It seems likely that the response to [ei] within the complete syllable reflects changes of cortical activation caused by amplitude or spectral change at the transition from consonant to vowel. The change from aperiodic to periodic stimulation may also produce changes in cortical activation that contribute to the observed response. Whatever the mechanism, the important conclusion is that the auditory cortical evoked potential to complex, time-varying speech waveforms can reflect features of the underlying acoustic patterns. Such potentials may have value in the evaluation of speech perception capacity in young hearing-impaired children.

Propofol anesthesia, seizure duration, and ECT: a case report and literature review

Propofol is a nonbarbiturate anesthetic induction agent known to have anti-convulsant properties. When used as an anesthetic for electroconvulsive therapy (ECT), it can reduce seizure duration to a significant degree, which may not be fully appreciated. A case is presented in which propofol caused a 63.1% reduction in mean seizure duration compared with preceding and subsequent treatments with thiopental anesthesia. The literature on the use of propofol for ECT was reviewed with specific reference to its effect on seizure duration and any evidence of superiority to the barbiturate induction agents. It is concluded that propofol may have only very circumscribed indications as an anesthetic for ECT. If used, psychiatrists and anesthetists must be aware of its potency as an anticonvulsant.

The effects of broadband noise masking on cortical event-related potentials to speech sounds /ba/ and /da/

OBJECTIVE

To systematically investigate in normal-hearing listeners the effects of decreased audibility produced by broadband noise masking on the cortical event-related potentials (ERPs) N1, N2, and P3 to the speech sounds /ba/ and /da/.

DESIGN

Ten normal-hearing adult listeners actively (button-press response) discriminated the speech sounds /ba/ and /da/ presented in quiet (no masking) or with broadband masking noise (BBN), using an ERP oddball paradigm. The BBN was presented at 50, 60, and 70 dB SPL when speech sounds were presented at 65 dB ppe SPL and at 60, 70 and, 80 dB SPL when speech sounds were presented at 80 dB ppe SPL.

RESULTS

On average, the 50, 60, 70, and 80 dB SPL BBN maskers produced behavioral threshold elevations of 18, 25, 35, and 48 dB (average for 250 to 4000 Hz), respectively. The BBN maskers produced significant decreases (relative to quiet condition) in ERP amplitudes and behavioral discriminability. These decreases did not occur, however, until the noise masker intensity (in dB SPL) was equal to or greater than the speech stimulus intensity (in dB ppe SPL), that is, until speech to noise ratios (SNRs) were < or = 0 dB. N1 remained present even after N2, P3, and behavioral discriminability were absent. In contrast to amplitudes, ERP and behavioral latencies showed significant decreases at higher (better) SNRs. Significant latency increases occurred when the noise maskers were within 10 to 20 dB of the stimuli (i.e., SNR < or = 20 dB). The effects of masking were greater for responses to /da/ compared with /ba/. Latency increases occurred with less masking for N1 than for P3 or behavioral reaction time, with N2 falling in between.

CONCLUSIONS

These results indicate that decreased audibility as a result of masking affects the various ERP peaks in a differential manner and that latencies are more sensitive indicators of these masking effects than are amplitudes.

Effect of stromal cell coculture on progenitor cell expansion and myeloid effector function in vitro

Stimulation of CD34(+)-enriched marrow or light density marrow with various growth factor combinations can generate granulocyte progenitors and mature neutrophils in vitro. In this work, we have examined the influence of irradiated marrow stromal layers on growth factor-induced myeloid and early multipotential progenitor expansion from enriched marrow CD34+ progenitors. We have also explored whether the addition of early-acting growth factors known to enhance myelopoiesis in long-term culture, such as fibroblast growth factor (b-FGF), insulin growth factor (IGF-1), c-kit ligand or stem cell factor (SCF), and flk-2flt-3 ligand (FL), can lengthen survival of CD34+ progenitors in these cultures. Stromal cell coculture resulted in greater numbers of total cells and CFU-GM at day 7 and day 14, but with the addition of multiple growth factors, these effects of stromal cell coculture were diminished. At day 14, generally < 1% of the expanded cells over stromal coculture conditions were CD34+, with up to 90% demonstrating CD15 positivity. Culture of CD34+ cells in the presence of early-acting growth factors did not cause significant expansion of CD34+ cells over a 14-day life span, even in the presence of marrow stromal cells. These data suggest that although stromal cell coculture for a period up to 14 days can enhance expansion of total cell numbers and CFU-GMs, stromal cell presence does not lead to expansion of CD34+ cells in these cultures and may diminish the number of clonogenic cells present when growth factors with differentiating capacity are present. Mature neutrophils harvested from such cultures are capable of chemotaxis, actin polymerization, and migration, suggesting a replete functional status.

Tetracycline-induced steatosis in primary canine hepatocyte cultures

Primary hepatocyte cultures prepared from male beagle dog liver were used to determine susceptibility of the canine liver to tetracycline-induced steatosis. The effects of the drug on mitochondrial lipid metabolism and intracellular triglyceride accumulation were monitored at the same time that steatosis was detected by light microscopy and quantitated using lipid-specific stains. Exposure of primary canine hepatocyte cultures to tetracycline for 24-48 h resulted in concentration-dependent, significant increases in the Oil Red O-stained lipid inclusions. Microscopic examination of the total stained areas suggested that increases over control levels were due primarily to the increase in the size of the lipid inclusions rather than in the number. Biochemical analyses for triglyceride content and histological staining with Nile red, another neutral lipid-specific dye, confirmed a specific increase in intracellular triglyceride following a 24-h exposure to noncytotoxic levels of tetracycline beta-oxidation studies based on the oxidation of [14C]palmitic acid or [14C]palmitoyl carnitine demonstrated a concentration-dependent inhibition of mitochondrial but not peroxisomal beta-oxidation in hepatocytes after a 24-h exposure to tetracycline. In vitro incubation of tetracycline with mitochondria isolated from dog liver showed similar concentration-dependent inhibition. This study clearly indicates that the canine hepatocyte is susceptible to tetracycline-induced steatosis. Triglyceride accumulation was concomitant with the inhibition of mitochondrial lipid metabolism, indicating that this is a primary mechanism leading to steatosis in dog hepatocytes following tetracycline exposure.

Primary care of adults with mental retardation living in the community

An increased number of adults with mental retardation are living in the community and seeking health care from family physicians. When mentally retarded patients are enrolled in a medical practice, guardianship status should be determined, but these patients should be involved in their own care to as great an extent possible. Since a verbal history may be difficult to obtain, a systematic, thorough physical examination is important. Certain Illnesses, such as hepatitis B, recurrent aspiration syndrome, leukemia and atlantoaxial instability, are much more common in adults with Down syndrome then in adults with mental retardation from other causes. Seizures and mental illness are equally common in all mentally retarded adults. The behavior management and pharmacologic therapy of patients with mental retardation are best handled in close association with caregivers, as well as psychiatrists and neurologists who are familiar with the special needs of this population.