Examining State Licensing Requirements for Select Master's-Level Behavioral Health Providers for Children

OBJECTIVE

The authors examined licensing requirements for select children's behavioral health care providers.

METHODS

Statutes and regulations as of October 2021 were reviewed for licensed clinical social workers, licensed professional counselors, and licensed marriage and family therapists for all 50 U.S. states and the District of Columbia.

RESULTS

All jurisdictions had laws regarding postgraduate training and license portability. No jurisdiction included language about specialized postgraduate training related to serving children and families or cultural competence. Other policies that related to the structure, composition, and authority of licensing boards varied across states and licensure types.

CONCLUSIONS

In their efforts to address barriers to licensure, expand the workforce, and ensure that children have access to high-quality and culturally responsive care, states could consider their statutes and regulations.

"I Missed School to Take Care of Someone Else": Middle and High School Students' Caregiving Responsibilities as a Reason for Absenteeism

BACKGROUND

Middle and high school students who are involved in caregiving for aging, chronically ill, and/or disabled family members report more learning challenges compared to their non-caregiving peers. However, little is known about how many students miss school to take care of someone else, and which students are most likely to have this experience. Such knowledge could reveal an important, largely unrecognized reason for school absences and educational disparities.

METHODS

Our research-practice partnership surveyed middle-and-high schoolers across Rhode Island public schools in 2022.

RESULTS

Among 55,746 students (45% White non-Latinx; 21% Latinx; 45% girls), 13.80% reported they had missed school to take care of someone else, with up to 35% in some districts. Students who missed school for caregiving were disproportionately girls, non-binary, transgender, or preferred not to report gender, older youth, and from historically marginalized racial and ethnic groups, and from urban districts.

CONCLUSIONS

Children's experiences caregiving for others may be an important and overlooked contributor to absenteeism and achievement gaps, especially in urban areas. We suggest school policies to better serve these students.

"Caregiving Youth" and the Patchwork History of Recognition in the United States

This article examines the U.S. legislative and policy landscape and its historical and contemporary recognition of young people as caregivers and their importance to public health, both as care providers and as a category of special concern for overall wellbeing. Drawing on feminist geographies of health to situate a historical analysis, we aim to answer two key questions: First, what is the history of recognition of caregiving youth in key moments of federal action to address family caregiving needs? Second, how might we use this history to better understand and analyze the patchwork geography of caregiving youth recognition in the U.S. and other countries that similarly lack formal national policy recognition to improve and enhance public health? We use the term patchwork to describe how federal recognition of caregiving youth in broader debates about public health is uneven across both time and space, and contingent upon civil society, non-profit organizations, and researchers working in and with geographically bound communities. Our results illustrate how a focus on the relationships of recognition, both in the past and the present and at local and national scales, reveals a different perspective on caregiving youth in the U.S. with a much more complex history than previously identified. The article describes how relationships established in the absence of federal policy or legislation are sometimes directed towards building more formal recognition, and other times with the goal of changing practices in a specific location.

Child and adolescent caregiving for family: Emotional, social, physical, and academic risk and individual differences

In the United States, it is estimated that more than 5.4 million children and adolescents under age 18 provide care for adult family members who are aging or have a chronic illness, disability, or other health conditions that require assistance. However, little is known about how providing care to the family during childhood and adolescence impacts youth development. We examined whether caregiving as a youth is associated with emotional challenges, peer difficulties, course grades, and physical health risk behaviors. A large, diverse sample of middle and high school students in Florida completed the first systematic school-based survey in the U.S. to date to count caregiving youth (N = 10,880; 52% female; M_age = 14.40, 40% Latinx). Youth reported the amount of caregiving they provided to the family each week, in addition to items reflecting their emotional challenges (e.g., suicidality), peer difficulties (e.g., experiences of conflict or victimization), academic course grades, and health risk behaviors (e.g., diet, physical activity, sleep). We found that Latinx and Black youth provided higher levels of caregiving to the family compared to youth from White non-Latinx, Asian, or Other ethnicities. Caregiving was associated with more emotional challenges, more peer difficulties, and lower course grades for all groups. In addition, providing caregiving was associated with a less healthy diet among older youth and sleeping less than 8 hr per night among White non-Latinx youth. These findings highlight a need to support caregiving youth and their families via policies and institutional supports. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Emergency medicine residents spend over 7.5 months of their 3-year residency on the electronic health record

BACKGROUND

Use of the electronic health record (EHR) is a standard component of modern patient care. Although EHRs have improved since inception, cumbersome workflows decrease the time for residents to spend on clinical and educational activities. This study aims to quantify the time spent interacting with the EHR during a 3-year emergency medicine (EM) residency.

METHODS

System records of time spent actively engaged in EHR use were analyzed for 98 unique EM residents over a period of 5 years from July 2015 to June 2020. Time spent on the EHR was totaled to give a career time, with a "work month" defined as a 4-week period of 70.5 h per week, based on Accreditation Council for Graduate Medical Education work hour restrictions for EM residents. Engagement in specific activities such as chart review, documentation preparation, and order entry were separately analyzed.

RESULTS

Over their 3-year training, a resident interacted with the EHR for 2,171 continuous hours. This amounts to 30.8 work weeks or 7.7 work months. Chart review was the most time-intensive activity at 11.42 weeks. Documentation accounted for 9.91 weeks, with an average career total of 7,280 notes created. Additionally, each resident spent 4.57 weeks on order entry, with 46,347 orders entered during training. While the number of charts opened increased after first year of residency, average time spent on each activity per patient decreased.

CONCLUSIONS

This unique study quantifies the total time an EM resident spends on the EHR during a 3-year residency. Use of the EHR accounted for over 7.5 work months or nearly 21% of their training. Residents spend a substantial portion of their training interacting with the EHR and workflow improvements to reduce EHR time are critical for maximizing training time.

Evaluation of the Clinical Performance of 7 Serological Assays for SARS-CoV-2 for Use in Clinical Laboratories

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological assays have emerged as a response to the global pandemic, warranting studies evaluating their clinical performance. This study investigated seven commercially available SARS-CoV-2 serological assays in samples from non-infected individuals and hospitalized patients.

Methods

SARS-CoV-2 qualitative serological assays by Abbott (IgG), Beckman (IgG), DiaSorin (IgG), EUROIMMUN (IgG and IgA), Roche and Bio-Rad (Total) were evaluated using specimens collected pre-December 2019 (n=393), from nucleic acid amplification testing (NAAT) negative patients (n=40), and from 53 patients with COVID-19 by NAAT collected 3-21 days post-onset of symptoms (POS) (N=83). Negative agreement (NA), positive agreement (PA), and positive and negative predictive values (PPV and NPV) at prevalences of 5% and 10% were calculated.

Results

The overall %NA;95% CI in the negative samples were: Roche 99.8%; 99.3-100.2, Beckman 99.8%; 98.7-100.0, Abbott and Bio-Rad 99.3%; 98.0-99.9, DiaSorin 98.4; 97.2-99.6, EUROIMMUN IgG 97.5%; 95.5-98.7, and EUROIMMUN IgA 79.7%; 75.9-83.5), accounting for positive/equivocal results as false positives. The %PA; 95% CI in samples collected 14+days POS (n=24) were: Bio-Rad 83.3%; 68.4-98.2, Abbott and Roche 79.2%; 62.9-95.4, EUROIMMUN IgA 70.8%; 52.6-89.0, Beckman 58.3%; 38.6-78.1, DiaSorin 54.2; 34.2-74.1, and EUROIMMUN IgG 50.0%; 30.0-70.0, accounting for negative/equivocal results as false negatives. NPVs ranged from 97.4-98.9% and 94.7-97.7% for prevalences 5% and 10%, respectively. PPVs ranged from 15.5-94.8% and 27.9-97.4% for prevalences 5% and 10%, respectively.

Conclusions

The Roche and Beckman assays resulted in fewer false positives followed by the Bio-Rad and Abbott assays. While the Bio-Rad assay demonstrated higher antibody detection in COVID-19-positive patients, PA claims cannot be established with a high level of confidence in our sample population.

Mycoplasma genitalium infection in women reporting dysuria: A pilot study and review of the literature

Mycoplasma genitalium (MG) infection, a sexually transmitted infection (STI), causes cervicitis and may cause reproductive sequelae and adverse pregnancy outcomes. Some MG-infected women report dysuria, a symptom frequently attributed to urinary tract infection (UTI). Given potential MG-associated morbidity and the likelihood that UTI treatment would be ineffective in eradicating MG, an improved understanding of MG infection frequency and clinical significance in young women reporting dysuria is needed. We conducted MG testing on stored urogenital specimens collected in a pilot study on frequency of STIs in young women presenting to an emergency department for dysuria evaluation and performed a literature review on MG infection frequency in women reporting dysuria. Among 25 women presenting for dysuria evaluation in our pilot study, 6 (24.0%) had MG detected and one-third had co-infection with chlamydia and one-third with trichomoniasis; half with MG detected did not receive an antibiotic with known efficacy against MG, while the other half received azithromycin. In five studies identified in the literature review, dysuria was reported by 7%-19% of women and MG detected in 5%-22%. MG infection is common in young women with dysuria and empiric UTI treatment may not be effective against MG. Studies evaluating the clinical significance of MG infection in women reporting dysuria are needed.

Polycystic Ovary Syndrome, Affective Symptoms, and Neuroactive Steroids: a Focus on Allopregnanolone

PURPOSE OF REVIEW

To provide an overview of existing studies on alterations in gonadal and neuroactive steroids (NASs) and mood symptoms among women with polycystic ovary syndrome (PCOS).

RECENT FINDINGS

Recent studies have demonstrated a previously underappreciated association between PCOS and comorbid depression and anxiety. However, most studies on affective symptoms among women with PCOS have been cross-sectional, limiting our knowledge about fluctuations in symptoms over the menstrual cycle and reproductive lifespan for women with PCOS, as well as the potential interplay between NAS alterations and mood symptoms. Changes in the NAS allopregnanolone (ALLO) have been implicated in several reproductive-related psychiatric disorders (e.g., premenstrual dysphoric disorder (PMDD) and postpartum depression (PPD)) as well as in normal reproductive functioning, warranting further investigation for its potential role in the psychiatric symptoms observed in women with PCOS. Prospective studies evaluating associations between psychiatric symptoms and NAS are needed to elucidate the biological causes of the increased rates of psychiatric symptoms among women with PCOS and inform clinical treatment. ALLO, with its role in normal reproductive function, menstrual dysregulation among women with PCOS, and reproductive-related psychiatric conditions, makes it a particularly intriguing candidate for future investigation.

Standardized outcome measures for pregnancy and childbirth, an ICHOM proposal

BACKGROUND

Value-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families.

METHODS

An interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set.

RESULTS

The Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined.

CONCLUSIONS

We propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care.

Abstract P1-09-08: BCL2L1 (BCL-XL) expression and MYC super-enhancer positivity predict sensitivity to the covalent CDK7 inhibitor SY-1365 in triple negative breast cancer (TNBC) cell lines

Effective therapies for TNBC remain elusive. As such, TNBCs are associated with a high risk of relapse and short progression free- and overall-survival. Recent studies showed that TNBC cells are highly dependent on the transcriptional regulator CDK7, and suggest that the mitochondrial apoptosis pathway is important in mediating cell survival in CDK7-dependent cells. Further, TNBC has been shown to have a distinct epigenetic and transcriptional program, with super-enhancers (SE) mediating the expression of key oncogenic drivers such as MYC. SY-1365, a covalent and selective inhibitor of CDK7, was developed to exploit dysregulated programs thought to drive SE-mediated transcriptional-dependencies in TNBC and other cancers. To identify potential biomarkers predictive of sensitivity to SY-1365, we evaluated SY-1365 inhibitory activity in a large panel of human tumor cell lines, including TNBC lines, and correlated sensitivity with RNA expression and epigenetic profiles.

SY-1365 dose-response curves were measured using the ATP-lite assay in a panel of 406 human tumor cell lines, including 19 TNBC cell lines. Clustering of growth-rate adjusted dose response curves of cell-lines treated with SY-1365 allowed the classification of cell-lines into low and high response groups. An unbiased genome wide approach was used to compare response classification to RNA expression data across all cell lines to identify gene expression markers predictive of sensitivity to SY-1365. Furthermore, a hypothesis driven approach was followed to interrogate whether the MYC SE predicted sensitivity to SY-1365.

Twenty-five genes were differentially expressed between SY-1365-sensitive and -insensitive tumor lines (FDR<0.05). Lower expression of BCL2L1, which encodes the mitochondrial apoptosis regulator BCL-XL, was identified as the most predictive expression biomarker of sensitivity across all profiled cell lines, strongly separating the two classes of sensitivity (Accuracy=70%, FDR<0.005). Further, this predictive power of lower BCL2L1 expression was maintained in an analysis restricted to the subset of TNBC cell-lines (Accuracy=73%).

Expanding beyond expression analysis, we also found that the strength of the MYC SE (as defined by H3K27Ac) was predictive of response to SY-1365 in TNBC (Accuracy=86%, FDR<0.05).

In this study, we show for the first time that SY-1365 induced differential responses across a large panel of human tumor cell lines derived from multiple indications. We also show that in this panel of cell lines the response could be predicted in an “indication agnostic” manner by the level of expression of BCL2L1. Finally, in line with prior reports, in TNBC cell lines, MYC SE was significantly associated with sensitivity to SY-1365. These observations have generated strong hypotheses for selection strategies aimed at identifying patients with tumors particularly sensitive to CDK7 inhibition with SY-1365, and warrant further investigation with respect to predictive biomarkers of response in patients. SY-1365 is currently being assessed in a phase 1 trial in adult patients with advanced solid tumors, including a planned expansion cohort enriching for patients with TNBC (NCT03134638).

Citation Format: Rajagopal N, Hodgson G, Hu S, McKeown M, Bush A, Fritz C, Orlando D, Olson E, di Tomaso E. BCL2L1 (BCL-XL) expression and MYC super-enhancer positivity predict sensitivity to the covalent CDK7 inhibitor SY-1365 in triple negative breast cancer (TNBC) cell lines [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-09-08.

Development of a core set of outcome measures for OAB treatment

INTRODUCTION AND HYPOTHESIS

Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).

METHODS

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.

RESULTS

The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.

CONCLUSIONS

The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

Abstract P5-18-03: Clinicopathological features among patients with HER2-positive breast cancer with prolonged response to trastuzumab based therapy

Background: HER2-positivity is a predictor of benefit from trastuzumab (TRZ), but fails to depict the observed interpatient variability in terms of treatment (tx) duration. In this study we described the relationship between clinicopathological features and TRZ tx duration.

Methods: A retrospective consecutive series of 343 HER2+ breast cancer (BC) patients (pts) treated with TRZ at the Dana-Farber Cancer Institute from 1999–2008 was identified. 139 pts treated with 1st line TRZ-based tx were selected for analysis. Pts who received any non-TRZ prior tx for metastatic disease were excluded. TRZ tx duration was defined as time from start of 1st line therapy to the 1st day of 2nd line therapy or death. Central nervous system (CNS) progression with TRZ maintenance was not considered change of tx. Pts were divided equally into 3 groups based on the duration of 1st line tx distribution. Short-term responders (STR) were on the 1st line tx for <7 months (m), intermediate responders (IR) 7–15m and long responders (LTR) for >15m. An additional group of extremely LTR (ELTR) was defined as being in the 90th percentile of tx duration (>37m). Descriptive analysis was performed; fisher exact test, Kruskal-Wallis and logistic regression methods were used to compare groups.

Results: Median follow-up time since metastatic diagnosis was 4 years (y) (range 0–11). Median age at diagnosis was 47y (22–83), 25% of stage I-III pts at diagnosis received adjuvant/neoadjuvant TRZ. The median disease free interval (DFI) was 20m (0–172), median number of metastatic sites was 2(1–5), 68% of pts had visceral disease. Median duration of 1st line tx was 10m (2–105). TRZ was given with CT in 86%, hormone tx in 6% and as monotherapy in 9%. 25% of pts developed CNS progression and continued tx. There were only small absolute differences for clinicopathological characteristics among STR, IR and LTR.

The Relationship Between Performance-based Visual Acuity Screening, Self-reported Visual Acuity, and Neuropsychological Performance

Despite frequent cautions in the literature concerning the importance of visual acuity in neuropsychological testing, there are few published empirical investigations of what constitutes "sufficient" visual acuity, nor are there published guidelines for performance-based visual screening techniques. The current study attempted to validate the utility of a visual acuity screening technique by examining individuals with varying visual ability on neuropsychological measures. Results revealed declines on neuropsychological measures associated with reduced visual acuity, as well as discrepancies between self-reported and measured visual acuity, with neuropsychological performance being more closely related to a performance-based measure of visual acuity than to self-reported visual acuity. Clinical implications are discussed.

Prostate-cancer (CaP) screening decision aid for black men designed to enhance shared decision-making

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Background: The high CaP incidence and mortality of black men combined with their relatively low rate of CaP screening and their elevated risk of presenting with advanced disease has led to their being identified as a high-priority group for screening. The benefit of screening, however, is uncertain. Most guidelines recommend that men make an individualized screening decision in consultation with their doctor. Motivating and preparing men to actively participate in this difficult decision remains a challenge. This is particularly relevant regarding black Americans given their historical alienation from the health care system. Methods: A CaP screening decision aid designed to promote shared decision-making was tested in 5 small group sessions of black men at community sites in Boston. The decision aid was preceded by a brief didactic presentation on CaP screening. The decision aid included a graphical depiction of all potential major outcomes that may follow a decision for or against screening. Vignettes about the decision-making and outcomes of hypothetical men with different life circumstances and priorities were presented to enhance values clarification by the participants. Endpoints measured before and after the intervention included self efficacy (SE)[Decision Self Efficacy Scale], decisional conflict (DC) [Decisional Conflict Scale], desire for autonomy (DFA) [Control Preferences Scale], and prostate cancer knowledge (PCK) [Prostate Cancer Knowledge and Prostate Cancer Screening Knowledge scales]. Pre- and post-intervention scores were compared using a Wilcoxon Matched-Pairs Signed Rank test. Results: 64 men were accrued over 4 months during 2005. Significant changes were seen in all measures. Average scores improved 16% on SE (p<.001) and 17% on DC (p<.004). DFA increased, with the proportion of men wanting to play a dominant role in health care decisions rising from 62% to 81% (p<.001). PCK more than doubled on both scales (p<.001). Focus groups held after the intervention reinforced these findings. Conclusions: Men were better informed, felt better prepared to actively participate in CaP screening decisions, and wanted to play a stronger role in decisions about their health care following exposure to our decision aid.

No significant financial relationships to disclose.

Transplantation of unrelated placental blood cells in children with high-risk sickle cell disease

The lack of healthy HLA-identical sibs limits the use of allogeneic hematopoietic cell transplantation in children with high-risk sickle cell disease (SCD). We evaluated unrelated placental blood cell transplantation (UPBCT) after a preparative regimen of busulfan, cyclophosphamide and antithymocyte globulin in three children with SCD who had cerebrovascular accidents (CVAs) and did not have HLA-matched sib donors. The placental blood cell units were matched with the recipients at four of six HLA-A, HLA-B and HLA-DRB1 antigens. Neutrophil levels above 0.5 x 10(9)/l occurred at 23, 38 and 42 days after UPBCT, and platelet levels above 50 x 10(9)/l without transfusions occurred at 62, 81 and 121 days after UPBCT. All patients developed acute graft-versus-host disease (GVHD; two grade II, one grade III), and one developed extensive chronic GVHD. One patient had graft failure and autologous hematopoietic recovery. Two patients have complete donor hematopoietic chimerism without detectable hemoglobin S or symptoms of SCD at 40 and 61 months, respectively, after UPBCT. These observations demonstrate the feasibility of UPBCT in children with SCD. Further studies of UPBCT for SCD are needed but, because of risks of procedure-related morbidity and graft rejection, should be restricted to pediatric patients with high-risk manifestations of SCD.

Audiovisual speech facilitates voice learning

In this research, we investigated the effects of voice and face information on the perceptual learning of talkers and on long-term memory for spoken words. In the first phase, listeners were trained over several days to identify voices from words presented auditorily or audiovisually. The training data showed that visual information about speakers enhanced voice learning, revealing cross-modal connections in talker processing akin to those observed in speech processing. In the second phase, the listeners completed an auditory or audiovisual word recognition memory test in which equal numbers of words were spoken by familiar and unfamiliar talkers. The data showed that words presented by familiar talkers were more likely to be retrieved from episodic memory, regardless of modality. Together, these findings provide new information about the representational code underlying familiar talker recognition and the role of stimulus familiarity in episodic word recognition.

Evidence for a unimodal somatosensory attention system

Extinction is generally viewed as a disorder of selective attention for spatial locations. Recent physiologic, behavioral and lesion studies view spatial locations as a complex construct in which multiple modalities and motor systems are integrated. Accordingly, cross-modal and sensory-motor conditions often modify extinction. In a patient with tactile extinction, we tested the hypothesis that attentional deficits can also be confined to a specific sensory modality. Using objectively and subjectively balanced tactile stimuli and signal detection analysis, we found that our patient's contralesional tactile discrimination was not modulated by proprioceptive or visual input or by movement. By contrast, increasing the salience of the contralesional tactile stimuli did improve her contralesional tactile discrimination, consistent with our hypothesis that she suffered from a modality-specific attentional deficit. Additionally, she did not have any evidence of visual extinction, again bolstering our claim that her extinction was confined to touch. These data suggest that in addition to polymodal and sensory-motor attentional systems, spatial attention also operates on specific sensations. We also advocate the use of signal detection analysis, a method that has been surprisingly neglected in extinction research.

Biogeography and ecological setting of Indian Ocean hydrothermal vents

Within the endemic invertebrate faunas of hydrothermal vents, five biogeographic provinces are recognized. Invertebrates at two Indian Ocean vent fields (Kairei and Edmond) belong to a sixth province, despite ecological settings and invertebrate-bacterial symbioses similar to those of both western Pacific and Atlantic vents. Most organisms found at these Indian Ocean vent fields have evolutionary affinities with western Pacific vent faunas, but a shrimp that ecologically dominates Indian Ocean vents closely resembles its Mid-Atlantic counterpart. These findings contribute to a global assessment of the biogeography of chemosynthetic faunas and indicate that the Indian Ocean vent community follows asymmetric assembly rules biased toward Pacific evolutionary alliances.

Temporal and spatial overlap between monarch larvae and corn pollen

To assess the likelihood that monarch larvae will be exposed to Bacillus thuringiensis (Bt) pollen, we studied milkweed and monarch densities in habitats which comprise much of the land available to breeding monarchs, e.g., cornfields, cornfield edges, other agricultural fields, and nonagricultural areas, in four regions of the monarch breeding range. We found that monarchs use milkweed in cornfields throughout their breeding season, and that per plant densities are as high or higher in agricultural habitats as in nonagricultural habitats. As a result of the prevalence of agricultural land, most of the monarchs produced in the upper Midwest are likely to originate in cornfields or other agricultural habitats. There was a greater temporal overlap between susceptible monarchs and corn anthesis in the northern than the southern part of the summer breeding range, because of earlier pollen shed in the south. The importance of agricultural habitats to monarch production suggests that, regardless of the impact of genetically modified crops, agricultural practices such as weed control and foliar insecticide use could have large impacts on monarch populations.

Surrogate decision makers' attitudes towards tube feeding in the nursing home

In the nursing home, a widely accepted medical practice is to recommend the initiation of long term tube feeding in residents with eating difficulties. However, frequently the nursing home resident has dementia, lacks decision-making capacity, and has no advance directives to guide the physician and the family member(s). Therefore, the family member or another surrogate decision maker has to make the difficult decision of whether or not to consent to the placement of a feeding tube. We surveyed 50 English speaking surrogates of nursing home residents who were on a feeding tube for at least 6 months. Each surrogate was contacted by telephone and was administered a 16-item structured questionnaire. Statistical analyses included frequency distributions, and the Wilcoxon signed rank test for two related samples. Most surrogates rated the residents' quality of life as poor or extremely poor. Yet, 78% of the surrogates perceived tube feeding to be beneficial, 62% would repeat their initial decision to initiate tube feeding, and 68% would not consider removal of the feeding tube. Their leading concerns were medical complications, tube feeding's impact on each resident's quality of life, and adequacy of nursing care. The surrogates were satisfied with their initial decision for the placement of a feeding tube despite their perception that there was no improvement in the quality of life of the residents. The surrogates may have viewed tube feeding as a life prolonging measure.

Drinking water contaminants and childhood leukemia

We conducted a population-based case-control study to evaluate the relation between exposure to drinking water contaminants (total and specific trihalomethanes and certain metals and nitrates) and childhood acute lymphoblastic leukemia. We compared 491 cases 0-9 years of age with 491 controls. We developed a municipality-exposure matrix based on municipal and provincial historical data, a tapwater survey in 227 homes, and information about residential history. We used average level of exposure and cumulative average over the period as exposure indices, and we measured risk for the pregnancy period as well as for the postnatal period. We show that risks were generally not increased for the prenatal period nor with average levels of exposure. Postnatal cumulative exposure for total trihalomethanes at above the 95th percentile of the distribution for cases and controls was associated with an odds ratio of 1.54 (95% confidence interval = 0.78-3.03); for that same period, risk associated with exposure to chloroform was increased (odds ratio = 1.63; 95% confidence interval = 0.84-3.19) as well as that for exposure to zinc (odds ratio = 2.48; 95% confidence interval = 0.99-6.24). Risks were also increased for exposure to cadmium and arsenic, but not for other metals nor for nitrates.

Markers of infection, breast-feeding and childhood acute lymphoblastic leukaemia

Infections are suspected to play a role in the aetiology of childhood leukaemia. In 1989-95, we evaluated the relation between childhood acute lymphoblastic leukaemia and pre- and postnatal markers of exposure to infection, as well as breast-feeding. A population-based case-control study was carried out in certain regions of Québec, Canada, in 1989-95 including 491 incident cases diagnosed between 1980 and 1993 and aged between 0 and 9 years. An identical number of healthy controls matched for age, sex and region of residence at the date of diagnosis was included. Having older siblings, mother's use of antibiotics during pregnancy, and being born second or later were all associated with increased risk of leukaemia while early day-care attendance (odds ratio (OR) = 0.49; 95% CI 0.31-0.77), and breast-feeding (OR = 0.68; 95% CI 0.49-0.95) were significantly protective. A marker of population mixing was not a risk factor. When including all variables defining family structure in a model, having older siblings at time of diagnosis was a risk factor among children diagnosed before 4 years of age (OR = 4.54; 95% CI 2.27-9.07) whereas having older siblings in the first year of life was protective among children diagnosed at 4 years of age or later (OR = 0.46; 95% CI 0.22-0.97).

MEF2: a transcriptional target for signaling pathways controlling skeletal muscle growth and differentiation

Skeletal muscle development involves a multistep pathway in which mesodermal precursor cells are selected, in response to inductive cues, to form myoblasts that later withdraw from the cell cycle and differentiate. The transcriptional circuitry controlling muscle differentiation is intimately linked to the cell cycle machinery, such that muscle differentiation genes do not become transcribed until myoblasts have exited the cell cycle. Members of the MyoD and MEF2 families of transcription factors associate combinatorially to control myoblast specification, differentiation and proliferation. Recent studies have revealed multiple signaling systems that stimulate and inhibit myogenesis by altering MEF2 phosphorylation and its association with other transcriptional cofactors.

Factors that increase the risk of leakage during surgical removal of benign cystic teratomas

The contents of mature cystic teratomas can be a potent irritant resulting in chemical peritonitis. Using a retrospective cohort, we examined the various risk factors for leakage of benign cystic teratomas during laparoscopy and laparotomy. Cyst leakage of the benign cystic teratoma contents was the primary endpoint. In all, 158 women underwent surgery for a total of 178 ovarian benign cystic teratomas. Statistical analysis was performed using chi(2), Mann-Whitney U and multivariate logistic regression analysis. A total of 115 benign cystic teratomas was successfully removed without intra-operative leakage and 63 underwent intra-operative leakage either at laparoscopy or laparotomy. The likelihood of success of removing the benign cystic teratoma intact was unrelated to age, pre-operative size or surgical technique. There was no difference among cystectomies performed by laparotomy in surgeon experience or the presence of adhesions. However, surgeons with more laparoscopic experience (>35 laparoscopies/year) were less likely to have intra-operative leakage (relative risk: 0.5, 95% confidence interval: 0.2, 1.2) compared to surgeons with less experience (<20/year) at cystectomy (26.1 versus 51.2% respectively). Oophorectomy significantly reduced the frequency of intra-operative leakage at both laparoscopy and laparotomy (14.7%). These findings suggest that laparoscopic experience can reduce the risk of leakage at cystectomy. At laparotomy, lack of surgeon postgraduate years of experience was not a risk factor for leakage.

Immunomagnetic recovery of human neutrophil defensins from the human gingival crevice

The human neutrophilic protein defensins are cationic, antimicrobial, cytotoxic, corticostatic chemotactic, opsonic peptides found in azurophilic granules and constitute about 5% of the total protein in human neutrophils. In the present study, defensins were recovered from the human gingival crevice using paramagnetic microspheres (beads), coated with anti-defensin antibodies. The bead-bound defensins were assayed using an enzyme-linked immunosorbent assay developed in this laboratory. Twenty sites were sampled; defensin was found in 100% of the sites and ranged in amount from 270-2000 ng/site. The large local concentrations of defensins, estimated in the mg/ml range, may have major effects on the microbiology of the gingival crevice.

Broad spectrum antimicrobial biocides target the FabI component of fatty acid synthesis

The broad spectrum antibacterial properties of 2-hydroxydiphenyl ethers have been appreciated for decades, and their use in consumer products is rapidly increasing. We identify the enoyl-acyl carrier protein reductase (fabI) component of the type II fatty acid synthase system as the specific cellular target for these antibacterials. Biologically active 2-hydroxydiphenyl ethers effectively inhibit fatty acid synthesis in vivo and FabI activity in vitro. Resistant mechanisms include up-regulation of fabI expression and spontaneously arising missense mutations in the fabI gene. These results contradict the view that these compounds directly disrupt membranes and suggest that their widespread use will select for resistant bacterial populations.