Building cultural responsiveness in a mainstream health organisation with '8 Aboriginal Ways of Learning': a participatory action research study

OBJECTIVE

Despite much effort and goodwill, the gap in health status between Aboriginal and non-Aboriginal Australians persists. Bringing Aboriginal cultural protocols and teaching strategies into healthcare could improve the fit between healthcare services provided and Aboriginal peoples. This approach to making healthcare more accessible has not been tested in mainstream health settings. This study aimed to introduce '8 Aboriginal Ways of Learning' to a mainstream health organisation and observe how learning about Aboriginal perspectives and processes shaped work-related project or program design.

METHODS

Program and network coordinators (n=18) employed in a state-wide health organisation joined in-person workshops and virtual sessions. Participatory Action Research methods guided the process and framework analysis transformed data.

RESULTS

Introducing '8 Ways' generated conversations which went beyond deficits in Aboriginal health. Learning about cultural processes provided scaffolding to show how services and models of care can change.

CONCLUSIONS

This strategy demonstrated potential to improve approachability, acceptability and appropriateness of mainstream healthcare for Aboriginal peoples.

IMPLICATIONS FOR PUBLIC HEALTH

Introduction of Aboriginal pedagogies were welcomed by mainstream healthcare workers as they provided scaffolding and support to plan and work in new ways. Future studies could examine outcomes on program design and access to services for Aboriginal peoples.

Modeling of an SCN5A founder mutation in iPSC-derived cardiomyocytes

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation - Flanders (FWO)

Introduction

SCN5A encodes the α-subunit of voltage-gated cardiac sodium channel Nav1.5. Mutations in SCN5A are identified in about 20% of patients with Brugada syndrome (BrS), an inherited cardiac arrhythmia. We have identified an SCN5A founder mutation (c.4813+3_4813+6dupGGGT), leading to a loss-of-function of Nav1.5 in 25 different families. Mutation carriers show variable expression of the phenotype: from asymptomatic to syncopes and sudden cardiac death. We used induced pluripotent stem cell derived cardiomyocytes (iPSC-CM) to investigate the underlying pathophysiology.

Material & Methods

Dermal fibroblasts of six patients with different disease severity, and two unrelated healthy control individuals were reprogrammed using a commercially available reprogramming kit. iPSC-CMs were differentiated following a published protocol. We performed several differentiation rounds and investigated expression of cardiac markers using qPCR and immunocytochemistry and electrophysiological properties using patch-clamping.

Results

All iPSC-CMs expressed the tested markers. We observed reduction in sodium current density in patient iPSC-CMs compared to the control cells. However, our data display variability in AP characteristics between the differentiation batches, as well as between clones generated from one donor.

Conclusions

We established iPSC-CM models for a unique Belgian SCN5A founder mutation. Despite the observed variability, we could detect expected differences in electrophysiological properties of patient cells compared to controls.

Targeted therapies for ROS1-rearranged non-small cell lung cancer

ROS1 gene fusions account for approximately 1-2% of all cases of non-small cell lung cancer (NSCLC). Similarly to anaplastic lymphoma kinase (ALK)-positive NSCLC, patients with ROS1+ NSCLC tend to have minimal smoking and be of the female sex. In most cases, adenocarcinoma is the dominant histology. The ROS1 gene has homology to ALK and this structural similarity formed the basis for utilizing ALK inhibitors for ROS1+ NSCLC. On the basis of impressive progression-free survival of 19.2 months from the PROFILE 1001 trial, crizotinib obtained Food and Drug Administration (FDA) approval as first-line therapy for treatment of ROS1+ NSCLC. Since then, there has been a growing appreciation of the incidence of brain metastases in ROS1+ NSCLC and rates of central nervous system progression on crizotinib. Additionally, appreciation of novel resistance mechanisms to crizotinib has led to the development of newer tyrosine kinase inhibitors (TKIs). In this review, we highlight known and emerging TKIs for the management of ROS1+ NSCLC.

The impact of telephone follow up on adverse events for Aboriginal people with chronic disease in new South Wales, Australia: a retrospective cohort study

BACKGROUND

Chronic diseases are more prevalent and occur at a much younger age in Aboriginal people in Australia compared with non-Aboriginal people. Aboriginal people also have higher rates of unplanned hospital readmissions and emergency department presentations. There is a paucity of research on the effectiveness of follow up programs after discharge from hospital in Aboriginal populations. This study aimed to assess the impact of a telephone follow up program, 48 Hour Follow Up, on rates of unplanned hospital readmissions, unplanned emergency department presentations and mortality within 28 days of discharge among Aboriginal people with chronic disease.

METHODS

A retrospective cohort of eligible Aboriginal people with chronic diseases was obtained through linkage of routinely-collected health datasets for the period May 2009 to December 2014. The primary outcome was unplanned hospital readmissions within 28 days of separation from any acute New South Wales public hospital. Secondary outcomes were mortality, unplanned emergency department presentations, and at least one adverse event (unplanned hospital readmission, unplanned emergency department presentation or mortality) within 28 days of separation. Logistic regression models were used to assess outcomes among Aboriginal patients who received 48 Hour Follow Up compared with eligible Aboriginal patients who did not receive 48 Hour Follow Up.

RESULTS

The final study cohort included 18,659 patients with 49,721 separations, of which 8469 separations (17.0, 95% confidence interval (CI): 16.7-17.4) were recorded as having received 48 Hour Follow Up. After adjusting for potential confounders, there were no significant differences in rates of unplanned readmission or mortality within 28 days between people who received or did not receive 48 Hour Follow Up. Conversely, the odds of an unplanned emergency department presentation (Odds ratio (OR) = 0.92; 95% CI: 0.85, 0.99; P = 0.0312) and at least one adverse event (OR = 0.91; 95% CI: 0.85,0.98; P = 0.0136) within 28 days were significantly lower for separations where the patient received 48 Hour Follow Up compared with those that did not receive follow up.

CONCLUSIONS

Receipt of 48 Hour Follow Up was associated with both a reduction in emergency department presentations and at least one  adverse event within 28 days of discharge, suggesting there may be merit in providing post-discharge telephone follow up to Aboriginal people with chronic disease.

Misdiagnosis of asthma in schoolchildren

BACKGROUND

A correct diagnosis of asthma is the cornerstone of asthma management. Few pediatric studies have examined the accuracy of physician-diagnosed asthma.

OBJECTIVES

We determined the accuracy of parent reported physician-diagnosed asthma in children sampled from a community cohort.

METHODS

Nested case-control study that recruited 203 children, aged 9-12, from a community-based sample. Three groups were recruited: asthma cases had a parental report of physician-diagnosed asthma, symptomatic controls had respiratory symptoms without a diagnosis of asthma, and asymptomatic controls had no respiratory symptoms. All participants were assessed and assigned a clinical diagnosis by one of three study physicians, and then completed spirometry, methacholine challenge, and allergy skin testing. The reference standard of asthma required a study physician's clinical diagnosis of asthma and either reversible bronchoconstriction or a positive methacholine challenge. Diagnostic accuracy, sensitivity and specificity were calculated for parent-reported asthma diagnosis compared to the reference standard.

RESULTS

One hundred two asthma cases, 52 controls with respiratory symptoms but no asthma diagnosis, and 49 asymptomatic controls were assessed. Physician agreement for the diagnosis of asthma was moderate (kappa 0.46-0.81). Compared to the reference standard, 45% of asthma cases were overdiagnosed and 10% of symptomatic controls were underdiagnosed. Parental report of physician-diagnosed asthma had 75% sensitivity and 92% specificity for correctly identifying asthma.

CONCLUSIONS

There is significant misclassification of childhood asthma when the diagnosis relies solely on a clinical history. This study highlights the importance of objective testing to confirm the diagnosis of asthma. Pediatr Pulmonol. 2017;52:293-302. © 2016 Wiley Periodicals, Inc.

Hospital-acquired Clostridium difficile infection: determinants for severe disease

Risk factors of severity (need for surgical intervention, intensive care or fatal outcome) were analysed in hospital-acquired Clostridium difficile infection (CDI) in a 777-bed community hospital. In a prospective analytical cross-sectional study, age (≥ 65 years), sex, CDI characteristics, underlying diseases, severity of comorbidity and PCR ribotypes were tested for associations with severe CDI. In total, 133 cases of hospital-acquired CDI (mean age 74.4 years) were identified, resulting in an incidence rate of 5.7/10,000 hospital-days. A recurrent episode of diarrhoea occurred in 25 cases (18.8%) and complications including toxic megacolon, dehydration and septicaemia in 69 cases (51.9%). Four cases (3.0%) required ICU admission, one case (0.8%) surgical intervention and 22 cases (16.5%) died within the 30-day follow-up period. Variables identified to be independently associated with severe CDI were severe diarrhoea (odds ratio [OR] 3.64, 95% confidence interval [CI] 1.19-11.11, p=0.02), chronic pulmonary disease (OR 3.0, 95% CI 1.08-8.40, p=0.04), chronic renal disease (OR 2.9, 95% CI 1.07-7.81, p=0.04) and diabetes mellitus (OR 4.30, 95% CI 1.57-11.76, p=0.004). The case fatality of 16.5% underlines the importance of increased efforts in CDI prevention, in particular for patients with underlying diseases.

Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review

BACKGROUND

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. A number of guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis.

OBJECTIVES

We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), MEDLINE (Ovid) (1966 to September 2009), EMBASE (Ovid) (1988 to September 2009), CINAHL (EBSCOhost) (to September 2009) and The Science Citation Index Expanded (SCI-EXPANDED) (1945 to September 2009). We also searched the UK National Research Register and websites listing ongoing trials and contacted international experts in anaphylaxis in an attempt to locate unpublished material. We sought to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). Two authors independently assessed articles for inclusion.

RESULTS

None of the 2496 reports identified satisfied the inclusion criteria.

CONCLUSIONS

We conclude that there is no evidence from high-quality studies for the use of steroids in the emergency management of anaphylaxis. Therefore, we can neither support nor refute the use of these drugs for this purpose.

Implementing and optimising an Electronic Library of Health Care in Belgium: results of a pilot study

Health care practitioners are expected to incorporate results from the best available, scientific information into their daily clinical decision-making process. Useful formats of evidence for practitioners include selected reviews, abstracts in which research results are discussed, "quick answer", evidence-based website including for example diagnostic and therapeutic algorithms, drugs prescription and non-drug therapy. An increasing amount of practitioners has access to the World Wide Web, either at home or at the office. However, easy and cheap access to objective and high quality research results is limited. Many practitioners lack the skills to efficiently navigate complicated medical databases. In 2003 an 'Electronic Library of Health Care' was introduced in Belgium. The main goal of the electronic library is to provide a gateway to scientific evidence to Belgian health care practitioners from different disciplines. This paper presents the results of a pilot project to implement the library in the field. It also describes recent developments and adjustments that increased the efficacy of this gateway to evidence.

Helicobacter cinaedi bacteremia presenting as macules in an afebrile patient with X-linked agammaglobulinemia

We describe a 54-year-old man with X-linked agammaglobulinemia (XLA) and Helicobacter cinaedi bacteremia, who presented with tender, hyper-pigmented skin macules without increased local warmth or fever. We propose that this presentation may be a characteristic early sign of bacteremia caused by H. cinaedi and related organisms in otherwise healthy immunocompromised patients. This case demonstrates the importance of a high index of suspicion for H. cinaedi bacteremia in immunocompromised patients with unexplained skin lesions.

Determination of the pH of the Cryptococcus neoformans vacuole

We have previously demonstrated the antifungal activity of the weak bases chloroquine and quinacrine against Cryptococcus neoformans. Quinacrine, being fluorescent, was seen to be concentrated within a complex vacuolar structure within the cryptococcal cell. Here we determined the pH of this compartment using the pH-sensitive fluorescent dye, 5-(and 6-) carboxy-2',7'-dichlorofluorescein diacetate (carboxy-DCFDA). Carboxy-DCFDA was concentrated within the cryptococcal vacuole, giving a pattern of fluorescence similar to that previously observed with quinacrine. For each experiment, a standard curve of fluorescence ratio against pH was generated using buffers of defined pH containing a mixture of ionophores and inhibitors to equilibrate vacuolar pH with that of the medium. The pH of the cryptococcal vacuole of five strains was calculated to range from 5.3 to 5.9 with a mean of 5.6. This acidic pH is consistent with a model in which weak bases such as chloroquine and quinacrine are accumulated, by ion trapping within the fungal vacuole. Antifungal activity may result from the consequent disruption of pH-dependent processes as well as effects on other as yet undefined fungal targets.

Mont Blanc with oxygen: the first rotters

After a brief outline of some early theories about the effects of thin air, the attempt of Joseph Ch. Hamel on Mont Blanc in 1820 is described. The Russian physician had postulated that lack of oxygen was responsible for muscular weakness at altitude and therefore had planned to study the oxygen content of air and blood on the summit and to administer oxygen to see if it improved performance. During the ascent he observed "pneumatic flatulence," shortness of breath, and fatigue. Shortly before the summit, an avalanche, which killed three of his guides, stopped and terminated the expedition. Although Hamel may have lacked the necessary equipment, he was among the first to try to test his hypothesis on altitude effects by experiments.

A role for hyaluronan in macrophage accumulation and collagen deposition after bleomycin-induced lung injury

Elevated concentrations of hyaluronan (HA) are associated with the accumulation of macrophages in the lung after injury. We have investigated the role of HA in the inflammatory and fibrotic responses to lung injury using the intratracheal instillation of bleomycin in rats as a model. After bleomycin-induced lung injury, both HA content in bronchoalveolar lavage (BAL) and staining for HA in macrophages accumulating in injured areas of the lung were maximal at 4 d. Increased HA in BAL correlated with increased locomotion of isolated alveolar macrophages. HA-binding peptide was able to specifically block macrophage motility in vitro. Importantly, systemic administration of HA-binding peptide to rats before injury not only decreased alveolar macrophage motility and accumulation in the lung, but also reduced lung collagen alpha (I) messenger RNA and hydroxyproline contents. We propose a model in which HA plays a critical role in the inflammatory response and fibrotic consequences of acute lung injury.

Targeted disruption of guanosine diphosphate-dissociation inhibitor for Rho-related proteins, GDID4: normal hematopoietic differentiation but subtle defect in superoxide production by macrophages derived from in vitro embryonal stem cell differentiation

The Rho subfamily of small guanosine triphosphate (GTP)-binding proteins, through their role in cytoskeletal organization, is involved in diverse cellular functions, including cell motility and morphologic changes during differentiation. Rac also has a special role in the production of superoxide, a key component in phagocytic antimicrobial function. Guanosine diphosphate (GDP)-dissociation inhibitors (GDIs) belong to one of three classes of proteins that regulate the critical cycling of GTP-binding proteins between the inactive and active states. Two homologous GDIs for the Rho subfamily have been identified. GDID4 is preferentially expressed in hematopoietic cells, while RhoGDI is ubiquitously expressed. Whether different physiologic functions are subserved by the two GDIs is unknown. We have derived embryonal stem (ES) cells with targeted disruption of both alleles of the GDID4 gene and examined hematopoiesis and phagocytic functions of macrophages derived from in vitro ES-cell differentiation. GDID4-/- ES cells develop like wild-type cells into colonies that contain heterogeneous populations of progenitor cells and differentiated erythromyeloid cells. GDID4-/- cells express no GDID4 protein, but have normal levels of RhoGDI. GDID4-/- macrophages phagocytose yeasts and antibody-opsonized erythrocytes as effectively as wild-type macrophages. However, a slight but consistent reduction in their capacity to generate superoxide was observed, which suggests new insight into the cellular role of GDID4. The minimal phenotypic effect of a loss of function of GDID4 also indicates a significant redundancy of function between GDID4 and RhoGDI. Their functional repertoire may be better revealed by a disruption of both genes. The use of hematopoietic cells derived in vitro from genotypically altered ES cells avoids the difficulties inherent in generating knockout animals and is a useful complementary approach for evaluating the gene function.

Effect of application of benzyl benzoate on house dust mite allergen levels

BACKGROUND

Several acaricides have become available for reducing house dust mite allergen levels.

OBJECTIVE

The purpose of this study was to assess whether the use of benzyl benzoate (Acarosan) provides additional benefit to the usual mite control measures including encasement of mattress and pillows with vinyl covers.

METHODS

A randomized controlled trial was carried out in 26 homes (14 control versus 12 treatment) of asthmatic patients in two cities (Vancouver and Winnipeg). The control group had the usual house dust mite control measures including the use of vinyl covers for mattresses and pillows while the treatment group had application of benzyl benzoate to mattresses and carpets in the bedroom and the most commonly used room, in addition to the above control measures. Mite allergen levels were measured 3 months and immediately before, 1 week, and 1 and 3 months after the application of house dust mite control measures. Patients kept diary cards on asthma symptoms and peak expiratory flow rates morning and evening one month before and three months after the onset of mite allergen control measures.

RESULTS

A reduction of mite allergen level was found in mattress samples in both groups, statistically significant at all times in the treatment group and at one and three months in the control group. Mite allergen levels on floor carpets also showed progressive reduction in both groups, but were significantly different in the treatment group (compared with controls) at 1 week, and were lower compared with baseline in the treatment group up to 3 months. No significant changes in asthma symptoms, peak expiratory flow rates, spirometric measurements, or bronchial hyperresponsiveness were observed among treatment or control group subjects.

CONCLUSION

The addition of benzyl benzoate to conventional house dust mite control measures resulted in a significant reduction in floor carpet dust mite levels that persisted for 3 months. The results of this study should be confirmed in a larger and longer study.

Mite and cat allergen levels in homes and severity of asthma

The relationships between mite and cat allergen levels in the home, skin test reactivity, and severity of asthma were explored in 120 asthmatic subjects, 57 in Vancouver and 63 in Winnipeg. Patients in the two cities were similar in age, gender distribution, and severity of asthma. Skin tests were performed using 13 common allergens, including D. pteronyssinus, D. farinae, and cat dander, as well as control subjects. Patients recorded their asthma symptoms, medication requirement, and twice daily peak expiratory flow rate for 1 yr. Dust samples were collected every 3 mo during each season of 1992 through 1993 in both cities. Mite and cat allergen levels were determined with an ELISA using monoclonal antibodies against Der p I, Der f I, and Fel d I. There was no relationship between skin test reactivity and levels of mite and cat allergens. In children with positive skin tests to either mite allergen, total mite (sum of Der p I and Der f I) allergen level was positively related to the mean daily symptom score and negatively related to the daily mean PEF (% of predicted). There was no such relationship among adult asthmatic patients with positive skin tests to either mite allergen. No relationship was found between cat allergen level and the severity of asthma.

Major cat allergen (Fel d I) levels in the homes of patients with asthma and their relationship to sensitization to cat dander

BACKGROUND

Exposure and sensitization to the major cat allergen, Felis domesticus allergen I (Fel d I), significant causes of allergic respiratory disease. Many patients who are allergic to cats, however, do not own a cat and there is not an obvious source of allergen in their home environment.

OBJECTIVE

We investigated the levels of Fel d I in dust from homes of 120 subjects with asthma in two climatologically diverse Canadian cities (Vancouver and Winnipeg). Fel d I levels were related to exposure to cats as well as to skin reactivity to cat dander.

METHODS

Dust samples from bedroom floors and mattresses were collected in four different seasons and Fel d I content was determined by 2-site monoclonal antibody based-ELISA.

RESULTS

Although only 18 patients (15%) were cat owners, detectable levels of Fel d I were found on at least one occasion in all homes. The geometric mean concentration of Fel d I on floors was 1.15 micrograms/g of dust (range 0.07 to 26.3 micrograms/g) and on mattresses 0.89 micrograms/g (range 0.01 to 17.4 micrograms/g). Seasonal variation of Fel d I levels was only observed in Winnipeg, where Fel d I concentrations were highest in the winter and spring compared with either summer (P < .05) or autumn (P < .005). The highest Fel d I levels were found in homes with a cat (P < .05), however, rather high levels were also found in homes of patients who did not have a cat but visited others with cats. Cat dander was the most frequent sensitizer (60%) in these patients but no correlation was found between the size of the wheal induced by cat dander extract and Fel d I levels in dust samples.

CONCLUSION

Cat allergen was universally found in homes of asthmatic patients and this may explain the high frequency of cat sensitization among patients with asthma in these two cities. A seasonal variation in cat allergen was observed in Winnipeg with no variation in Vancouver.

House dust mite allergen levels in two cities in Canada: effects of season, humidity, city and home characteristics

The homes of 120 patients with asthma, 57 in Vancouver and 63 in Winnipeg, were studied. The characteristics of the homes were assessed by a questionnaire. Dust samples were collected and the indoor relative humidity was measured four times during the year covering all four seasons in both cities. Mite allergen levels were determined using monoclonal antibodies against Der p I and Der f I by the ELISA method. The mean levels of both mite allergens in mattress and floor samples in the homes in Vancouver and in Winnipeg were relatively low for all seasons. Mite allergen levels were found to be associated with city, season and individual home differences. They were significantly higher in Vancouver than in Winnipeg. Der p I and Der f I in mattress samples in both cities and Der f I in floor samples in Vancouver, varied by season. The indoor relative humidity level in the homes in Vancouver were also significantly higher than those in Winnipeg. There was, however, no significant association between the levels of indoor relative humidity and the levels of mite allergens after adjusting for variations in city, season and individual home. Although individual home differences were highly associated with mite allergen levels, only a few home characteristics were found to be related to mite allergen levels such as the type and the age of the home, the type of heating, the use of feather pillows and the number of occupants in the homes. Whether low levels of mite allergens are partially responsible for the relatively low prevalence of childhood asthma in Canada remains to be investigated.

Decreasing calreticulin expression lowers the Ca2+ response to bradykinin and increases sensitivity to ionomycin in NG-108-15 cells

It has been suggested that the multifunctional protein, calreticulin, is a major calcium sequestering protein in the inositol 1,4,5-trisphosphate receptor-containing endoplasmic reticulum subcompartment. In neuroblastoma X glioma NG-108-15 cells, bradykinin can effectively stimulate the release of inositol 1,4,5-trisphosphate and cause a cytosolic calcium transient. To explore the function of calreticulin as an intracellular calcium sequestering protein, we investigated calcium dynamics in NG-108-15 cells after treatment with an antisense oligonucleotide against calreticulin, CrtAS1. Cells treated with either CrtAS1 or the corresponding sense oligonucleotide CrtPS1 were examined for their calreticulin content by Western blotting, the amplitude of their calcium transient in response to bradykinin, and their sensitivity toward the calcium ionophore, ionomycin. Treatment with CrtAS1 decreased the amount of calreticulin in comparison to CrtPS1-treated and untreated control cells. At the same time, CrtAS1-treated cells had a significantly reduced calcium response to bradykinin and were more sensitive to ionomycin-induced cell death. These data show that the level of calreticulin expression is directly related to the calcium storage capacity of the inositol 1,4,5-trisphosphate-sensitive calcium pool and indicate a direct relationship between the level of calreticulin and the protection against cytotoxic calcium overload.

Sensory and autonomic innervation of the rat eyelid: neuronal origins and peptide phenotypes

Neuronal origins, peptide phenotypes and target distributions were determined for sensory and autonomic nerves projecting to the eyelid. The retrograde tracer, Fluoro-Ruby, was injected into the superior tarsal muscle and meibomian gland of Sprague-Dawley rats. Labelled neurons were observed within the pterygopalatine (31 +/- 6 of a total of 8238 +/- 1610 ganglion neurons), trigeminal (173 +/- 43 of 62,082 +/- 5869) and superior cervical ganglia (184 +/- 35 of 21,900 +/- 1741). Immunostaining revealed vasoactive intestinal polypeptide immunoreactivity (VIP-ir) in nearly all Fluoro-Ruby-labelled pterygopalatine ganglion neurons (86 +/- 5%) but only rarely in trigeminal (0.3 +/- 0.3%) or superior cervical (1.4 +/- 1.4%) ganglion neurons. Calcitonin gene-related peptide (CGRP)-ir was not observed in pterygopalatine or superior cervical ganglion somata, but was present in 24 +/- 4% of trigeminal neurons. Bright dopamine beta-hydroxylase (DBH) immunofluorescence was observed in the majority of eyelid-projecting neurons within the superior cervical ganglia (65 +/- 5%) and lighter staining was detected in pterygopalatine neurons (63 +/- 3%), but no DBH-ir was observed in trigeminal neurons. Examination of eyelid sections revealed dense VIP-ir innervation of meibomian gland acini and vasculature and modest distribution within tarsal muscle. CGRP-ir fibers surrounded ductal and vascular elements of the meibomian gland and the perimeter of tarsal muscle. DBH-ir fibers were associated with meibomian gland blood vessels and acini, and were more densely distributed within tarsal muscle. This study provides evidence for prominent meibomian gland innervation by parasympathetic pterygopalatine ganglion VIP-ir neurons, with more restricted innervation by sensory trigeminal CGRP-ir and sympathetic neurons. Tarsal muscle receives abundant sympathetic innervation, as well as moderate parasympathetic and sensory CGRP-ir projections. The eyelid contains substantial non-CGRP-ir sensory innervation, the targets of which remain undetermined. The distribution of identified autonomic and sensory fibers is consistent with the idea that meibomian gland function, as well as that of the tarsal muscle, is regulated by peripheral innervation.

Sensory nerves impair sympathetic reinnervation and recovery of smooth muscle function

Neuronal populations projecting to a common target may compete for neurotrophic substances. To determine if competition impairs target reinnervation, we examined the effect of capsaicin-induced sensory denervation on sympathetic nerve ingrowth to the sympathectomized rat superior tarsal smooth muscle. In tarsal muscles with intact sympathetic innervation, capsaicin injection on Day 2 reduced numbers of perimuscular CGRP-ir sensory nerves by 68% at 3-4 months; however, it did not alter dopamine-beta-hydroxylase-ir nerve density, response to nerve stimulation, or tarsal muscle adrenoceptor-mediated contraction. Tarsal muscles denervated by ipsilateral superior cervical ganglionectomy on Postnatal Day 4 were partially reinnervated by fibers from the contralateral ganglion, as noted in previous studies. Sensory denervation by capsaicin improved sympathetic reinnervation, as evidenced by a 174% increase in numbers of DBH-ir nerves and a 62% increase in neurally mediated smooth muscle contraction evoked by electrical stimulation of the contralateral pathway relative to reinnervated muscles of vehicle-injected rats; smooth muscle function was also influenced, as indicated by a decrease toward normal in adrenoceptor sensitivity. Tarsal muscles denervated at 30 days were not reinnervated in either vehicle-injected or capsaicin-treated rats, indicating that sensory denervation does not extend the developmental window during which contralateral reinnervation can occur. Both the vehicle-injected and capsaicin-treated preparations with sustained juvenile sympathectomy showed sensory hyperinnervation as adults; thus, a chronic reduction in competition from sympathetics is a sufficiently powerful stimulus to overcome the decreased nerve density induced by neonatal capsaicin treatment. We conclude that sensory nerves limit the extent of sympathetic reinnervation and functional recovery that can occur following neonatal sympathetic denervation.

Analysis of 1071 gift procedures--the case for a flexible approach to treatment

An analysis of the outcome of first gamete intrafallopian transfers for 1071 women indicates that for those aged 40 years or more all the oocytes had to be transferred to obtain a 19.2% pregnancy rate. In this age-group pregnancy rate and multiple pregnancy rate were significantly lower than those for younger women. Success rate, but not multiple pregnancy rate, was significantly higher in the group of women from whom 11 or more oocytes were recovered and transferred after ovulation induction than when only 1-4 oocytes were recovered and transferred. The findings suggest that the number of oocytes transferred should depend on clinical circumstances.