LGBTQIA+ Cultural Competence in Physical Therapy: An Exploratory Qualitative Study From the Clinician's Perspective

OBJECTIVE

The purpose of this study was to understand the lesbian, gay, bisexual, transgender, queer, intersex, agender, and other gender and sexually diverse identities (LGBTQIA+) health care experience and associated cultural competence from the physical therapist perspective (physical therapist and physical therapist assistant).

METHODS

An exploratory qualitative approach implementing semi-structured focus groups and private interviews was utilized. To further anonymity, researchers allowed subjects to keep their camera off on Zoom. An interview protocol included questions guided by Campinha-Bacote domains of cultural competence (cultural awareness, skill, knowledge, encounter, and desire) to collect individual experiences, stories, discussions, thoughts, and opinions. Physical therapist clinicians were recruited from the clinical education affiliation lists of Regis University and Thomas Jefferson University. Seventy-one practicing physical therapists from the USA agreed to be part of the study.

RESULTS

Themes were organized using the Social Ecological Model Framework. Themes are in parentheses following each level of the Social Ecological Model and include intrapersonal level (psychological stress and implicit and explicit biases), interpersonal (acceptance and competency), organizational (experience), community (advocacy), and society and policy (explicit biases and policy).

CONCLUSION

Cultural competence in physical therapy is influenced by intrapersonal, interpersonal, organizational, community, and social and policy factors. Themes of psychological stress, limited awareness, decreased acceptance, and competency as well as limited exposure and experience, and a lack of advocacy and broader societal and policy issues prevent adequate LGBTQIA+ cultural competency of physical therapist providers. Further research in the physical therapist profession is needed to elaborate on the student, educator, and patient perspectives and how this information informs the LGBTQIA+ cultural competence of clinicians.

IMPACT

This project may have a significant impact on suggestions for the delivery of content for health profession education to best impact health equity goals and save lives. Implementation of this content may have a direct impact on health disparities in LGBTQIA+ populations by reducing stigma and discrimination from health care providers, thus improving quality of health care and decreasing rates of patient mortality for LGBTQIA+ individuals.

Cochlear implantation in advanced otosclerosis: utility of pre-operative radiological assessment in predicting intra-operative difficulty and final electrode position

OBJECTIVE

This study aimed to determine if pre-operative radiological scoring can reliably predict intra-operative difficulty and final cochlear electrode position in patients with advanced otosclerosis.

METHOD

A retrospective cohort study of advanced otosclerosis patients who underwent cochlear implantation (n = 48, 52 ears) was compared with a larger cohort of post-lingually deaf adult patients (n = 1414) with bilateral hearing loss and normal cochlear anatomy. Pre-operative imaging for advanced otosclerosis patients and final electrode position were scored and correlated with intra-operative difficulty and speech outcomes.

RESULTS

Advanced otosclerosis patients benefit significantly from cochlear implantation. Mean duration of deafness was longer in the advanced otosclerosis group (19.5 vs 14.3 years; p < 0.05).

CONCLUSION

Anatomical changes in advanced otosclerosis can result in increased difficulty of surgery. Evidence of pre-operative cochlear luminal changes was associated with intra-operative difficult insertion and final non-scala tympani position. Nearly all electrodes implanted in the advanced otosclerosis cohort were peri-modiolar. No reports of facial nerve stimulation were observed.

251 PREVALENCE AND CHARACTERISTICS OF SWALLOWING/COMMUNICATION IMPAIRMENTS IN FRAIL OLDER ADULTS ATTENDING THE EMERGENCY DEPARTMENT: A RETROSPECTIVE COHORT STUDY

Background

The presentation of frail older adults to the Emergency Department (ED) may be complicated by swallowing and/or communication impairment. Adults with communication impairment may experience difficulty accessing healthcare. Dysphagia is associated with frailty irrespective of age and/or number of chronic diseases [1]. This study aims to determine the prevalence and characteristics of swallowing and/or communication impairments among frail older adults attending the ED.

Methods

A retrospective cohort study of consecutive ED attendees aged ≥ 75 years assessed by an interdisciplinary Gerontological ED team between October 2021 – February 2022 was conducted. A swallow/communication screening tool determined requirement for Speech and Language Therapy (SLT) referral. Data related to demographics and SLT interventions was extracted. Data analysis was completed using STATA Version 12. Ethical approval was obtained.

Results

Among 518 patients, 118 (23%) (mean age 82.4 (+/-6.4) years, 54% male) required SLT assessment. These patients had high rates of frailty (Median CFS= 6 (IQR 5-7), suspected delirium (4AT ≥ 4 in 45%), suspected malnutrition (MNA score 0-11 in 75%), and probable sarcopenia (SARC-F= ≥ 4 in 75%). Therapy Outcome Measurement Scales and the Functional Oral Intake Scale were used in this first episode of SLT care. Oropharyngeal dysphagia was identified for 43% (27% mild, 10% moderate, 3% moderate-severe, 3% severe), with 6% presenting with signs/symptoms of oesophageal dysphagia. Changes in baseline communication was identified for 57%; cognitive communication difficulties (38%), dysarthria (11%), dysphonia (8%). SLT intervention and management approaches were initiated in the ED.

Conclusion

Findings indicate a high prevalence of swallowing/communication impairment in frail older adults attending the ED. Future research should explore SLT outcomes at point of discharge to refine these swallowing/communication presentations.

Reference

1. Bahat G et al. Association between dysphagia and frailty in community-dwelling older adults. The Journal of Nutrition, Health & Ageing. 2019:23, 571–577.

Longevity of an immunocontraceptive vaccine effect on fecundity in rats

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Increases in human-wildlife conflicts alongside cultural shifts against lethal control methods are driving the need for alternative wildlife management tools such as fertility control. Contraceptive formulations suitable for oral delivery would permit broader remote application in wildlife species.

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This study evaluated the contraceptive effect and immune response to two novel injectable immunocontraceptive formulations targeting the Gonadotropin Releasing Hormone (GnRH): MAF-IMX294 and MAF-IMX294P conjugates, both identified as having potential as oral contraceptives. The study also explored whether in multiparous species immunocontraceptives may either totally prevent reproduction or also affect litter size.

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Female rats, chosen as a model species, were given three doses of either MAF-IMX294 or MAF-IMX294P to compare anti-GnRH immune response and reproductive output up to 310 days post-treatment.

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Both formulations induced anti-GnRH antibody titres in 100% of rats and significantly impaired fertility compared to control animals. Following treatment with MAF-IMX294 and MAF-IMX294P 0 of 9 and 1 of 10 females respectively produced litters following the first mating challenge 45 days post-treatment, compared to 9 of 9 control animals.

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Across the whole 310 day study period 7 of 9 females from the MAF-IMX294 group and 10 of 10 females in the MAF-IMX294P group became fertile, producing at least one litter throughout six mating challenges.

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No significant differences were found between the two formulations in antibody titre response or duration of contraceptive effect, with an average time to first pregnancy of 166 days for MAF-IMX294 and 177 days for MAF-IMX294P for all females that became fertile.

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Following treatment with MAF-IMX294 and MAF-IMX294P the first litter produced post-infertility in treated females was significantly smaller than in control animals. This indicates treatment with immunocontraceptives may induce an overall suppression of fecundity extending past an initial infertility effect. This increases the potential long-term impact of these immunocontraceptives in multiparous species such as commensal rodents.

1148 Analgesia Prescribing in Acute Surgical Admissions - Dual-Centre Cross-Sectional Study

Aim

Pain is a common presenting complaint of acute surgical inpatients and has a great impact on their subjective wellbeing and the perception of care they receive if not addressed promptly and efficiently. It is also a common cause of patients’ complaints if not properly addressed. We set out to evaluate if analgesia is prescribed locally in accordance with WHO analgesia ladder and NICE CKS analgesia guidelines for mild-to-moderate pain.

Method

We performed cross-sectional studies of adults aged 16 and over, admitted under general or vascular surgery in two DGHs (2018-2020) with complaints of pain on admission. 30 patients were included in both studies with an average age 53/56 years. We undertook notes review, checked observation charts and drug charts for pain grading and analgesia prescribing following initial clinical assessment.

Results

In the first study, average pain score of 6 was obtained. Only 19/30 patients (63%) had regular analgesia prescribed. Only 2/30 (6%) were started on regular weak opioids, with further 8/30 (26%) on as required/PRN weak opioids. 17/30 (56%) patients had PRN Oramorph prescribed. Only 2/30 (6%) were started on PRN NSAIDs despite only 46% having cautions/contraindications. 5/30 patients with pain scores of 9-10 not had any regular analgesia prescribed. Comparable results were achieved in the second hospital we audited.

Conclusions

This study shows significant under-prescribing of analgesia, especially regular analgesia for surgical patients with moderate-severe pain and skipping of weaker opioids/NSAIDs in favour of Oramorph. There is significant scope for improvement following educational session implementation to junior doctors.

67 The Evolution of A Frailty Service

Introduction

In September 2017 our frailty service was started within our medium sized DGH in North Wales. Working with our management team we secured a significant clinical resource including:

We describe how resources, setting and staffing develop over a 2 year period in order to create a service which meets the needs of the local population.

Method

The service has been in a constant state of development since it has been in operation, utilising a PDSA model with regular meetings of clinical and managerial staff to analyse performance.

Results

With each new PDSA cycle the amount of patients reviewed has increased. With the move to AMU we increased the monthly number of patients reviewed from 29 to 172 patients reviewed, 97 of which were discharged directly from the unit.

Conclusion

Using QI methodology our Frailty Service has improved dramatically since its inception. We will continue to analyse how we work to improve patient outcomes and cost effectiveness.

Placing language in an integrated understanding system: Next steps toward human-level performance in neural language models

Language is crucial for human intelligence, but what exactly is its role? We take language to be a part of a system for understanding and communicating about situations. In humans, these abilities emerge gradually from experience and depend on domain-general principles of biological neural networks: connection-based learning, distributed representation, and context-sensitive, mutual constraint satisfaction-based processing. Current artificial language processing systems rely on the same domain general principles, embodied in artificial neural networks. Indeed, recent progress in this field depends on query-based attention, which extends the ability of these systems to exploit context and has contributed to remarkable breakthroughs. Nevertheless, most current models focus exclusively on language-internal tasks, limiting their ability to perform tasks that depend on understanding situations. These systems also lack memory for the contents of prior situations outside of a fixed contextual span. We describe the organization of the brain's distributed understanding system, which includes a fast learning system that addresses the memory problem. We sketch a framework for future models of understanding drawing equally on cognitive neuroscience and artificial intelligence and exploiting query-based attention. We highlight relevant current directions and consider further developments needed to fully capture human-level language understanding in a computational system.

Developing a digital data collection platform to measure the prevalence of sepsis in Wales

OBJECTIVE

To develop a secure, efficient, and easy-to-use data collection platform to measure the prevalence of sepsis in Wales over 24 hours.

MATERIALS AND METHODS

Open Data Kit was used on Android devices with Google App Engine and a digital data collection form.

RESULTS

A total of 184 students participated in the study using 59 devices across 16 hospitals, 1198 datasets were submitted, and 97% of participants found the Open Data Kit form easy to use.

DISCUSSION

We successfully demonstrated that by combining a reliable Android device, a free open-source data collection framework, a scalable cloud-based server, and a team of 184 medical students, we can deliver a low-cost, highly reliable platform that requires little training or maintenance, providing results immediately on completion of data collection.

CONCLUSION

Our platform allowed us to measure, for the first time, the prevalence of sepsis in Wales over 24 hours.

A computer based, automated analysis of process and outcomes of diabetic care in 23 GP practices

The predicted prevalence of diabetes in Ireland by 2015 is 190,000. Structured diabetes care in general practice has outcomes equivalent to secondary care and good diabetes care has been shown to be associated with the use of electronic healthcare records (EHRs). This automated analysis of EHRs in 23 practices took 10 minutes per practice compared with 15 hours per practice for manual searches. Data was extracted for 1901 type II diabetics. There was valid data for >80% of patients for 6 of the 9 key indicators in the previous year. 543 (34%) had a Hba1c > 7.5%, 142 (9%) had a total cholesterol >6 mmol/l, 83 (6%) had an LDL cholesterol >4 mmol/l, 367 (22%) had Triglycerides > 2.2 mmol/l and 162 (10%) had Blood Pressure > 160/100 mmHg. Data quality and key indicators of care compare well with manual audits in Ireland and the U.K. electronic healthcare records and automated audits should be a feature of all chronic disease management programs.

Novel phage peptides attenuate beta amyloid-42 catalysed hydrogen peroxide production and associated neurotoxicity

Amyloid-beta (Abeta) peptides play a central role in the pathogenesis of Alzheimer's disease. There is accumulating evidence that supports the notion that the toxicity associated with human Abeta (both 40 and 42) is dependent on its superoxide dismutase (SOD)-like activity. We developed a novel screening method involving phage display technology to identify novel peptides capable of inhibiting Abeta's neurotoxicity. Two random peptide libraries containing 6-mer and 15-mer peptide inserts were used and resulted in the identification of 25 peptides that bound human Abeta (40 or 42). Here, we show that two of the three most enriched peptides obtained significantly reduced Abeta42's SOD-like activity. A 15-mer peptide reduced Abeta42 neurotoxicity in a dose-dependent manner as evidenced by a reduction in LDH release. These findings were confirmed in the independent MTT assay. Furthermore, comparative analysis of the 15-mer peptide with Clioquinol, a known inhibitor of Abeta's metal-mediated redox activity, showed the 15-mer peptide to be equipotent to this metal chelator, under the same experimental conditions. These agents represent novel peptides that selectively target and neutralise Abeta-induced neurotoxicity and thus provide promising leads for rational drug development.

Expression of 14 von Willebrand factor mutations identified in patients with type 1 von Willebrand disease from the MCMDM-1VWD study

BACKGROUND

Candidate von Willebrand factor (VWF) mutations were identified in 70% of index cases in the European study 'Molecular and Clinical Markers for the Diagnosis and Management of type 1 von Willebrand Disease'. The majority of these were missense mutations.

OBJECTIVES

To assess whether 14 representative missense mutations are the cause of the phenotype observed in the patients and to examine their mode of pathogenicity.

METHODS

Transfection experiments were performed with full-length wild-type or mutant VWF cDNA for these 14 missense mutations. VWF antigen levels were measured, and VWF multimer analysis was performed on secreted and intracellular VWF.

RESULTS

For seven of the missense mutations (G160W, N166I, L2207P, C2257S, C2304Y, G2441C, and C2477Y), we found marked intracellular retention and impaired secretion of VWF, major loss of high molecular weight multimers in transfections of mutant constructs alone, and virtually normal multimers in cotransfections with wild-type VWF, establishing the pathogenicity of these mutations. Four of the mutations (R2287W, R2464C, G2518S, and Q2520P) were established as being very probably causative, on the basis of a mild reduction in the secreted VWF or on characteristic faster-running multimeric bands. For three candidate changes (G19R, P2063S, and R2313H), the transfection results were indistinguishable from wild-type recombinant VWF and we could not prove these changes to be pathogenic. Other mechanisms not explored using this in vitro expression system may be responsible for pathogenicity.

CONCLUSIONS

The pathogenic nature of 11 of 14 candidate missense mutations identified in patients with type 1 VWD was confirmed. Intracellular retention of mutant VWF is the predominant responsible mechanism.

Detailed von Willebrand factor multimer analysis in patients with von Willebrand disease in the European study, molecular and clinical markers for the diagnosis and management of type 1 von Willebrand disease (MCMDM-1VWD)

BACKGROUND

Type 1 von Willebrand disease (VWD) is a congenital bleeding disorder characterized by a partial quantitative deficiency of plasma von Willebrand factor (VWF) in the absence of structural and/or functional VWF defects. Accurate assessment of the quantity and quality of plasma VWF is difficult but is a prerequisite for correct classification.

OBJECTIVE

To evaluate the proportion of misclassification of patients historically diagnosed with type 1 VWD using detailed analysis of the VWF multimer structure.

PATIENTS AND METHODS

Previously diagnosed type 1 VWD families and healthy controls were recruited by 12 expert centers in nine European countries. Phenotypic characterization comprised plasma VWF parameters and multimer analysis using low- and intermediate-resolution gels combined with an optimized visualization system. VWF genotyping was performed in all index cases (ICs).

RESULTS

Abnormal multimers were present in 57 out of 150 ICs; however, only 29 out of these 57 (51%) had VWF ristocetin cofactor to antigen ratio below 0.7. In most cases multimer abnormalities were subtle, and only two cases had a significant loss of the largest multimers.

CONCLUSIONS

Of the cases previously diagnosed as type 1 VWD, 38% showed abnormal multimers. Depending on the classification criteria used, 22 out of these 57 cases (15% of the total cohort) may be reclassified as type 2, emphasizing the requirement for multimer analysis compared with a mere ratio of VWF functional parameters and VWF:Ag. This is further supported by the finding that even slightly aberrant multimers are highly predictive for the presence of VWF mutations.

Impact of plasma von Willebrand factor levels in the diagnosis of type 1 von Willebrand disease: results from a multicenter European study (MCMDM-1VWD)

BACKGROUND

Presence of bleeding symptoms, inheritance and reduced von Willebrand factor (VWF) contribute to the diagnosis of type 1 von Willebrand disease (VWD). However, quantitative analysis of the importance of VWF antigen (VWF:Ag) and ristocetin cofactor activity (VWF:RCo) levels in the diagnosis is lacking.

OBJECTIVES

To evaluate the relative contribution of VWF measurement to the diagnosis of VWD.

PATIENTS AND METHODS

From the MCMDM-1VWD study cohort, 204 subjects (considered as affected by VWD based on the enrolling Center diagnoses and the presence of linkage with the VWF locus) were compared with 1155 normal individuals. Sensitivity, specificity and diagnostic positive likelihood ratios (LR) of VWF:Ag and VWF:RCo were computed.

RESULTS

ABO blood group was the variable most influencing VWF levels, but adjustment of the lower reference limit for the ABO group did not improve sensitivity and specificity of VWF:Ag or VWF:RCo. The lower reference limit (2.5th percentile) was 47 IU dL(-1) for both VWF:Ag and VWF:RCo and showed similar diagnostic performance [receiver-operator curve area: 0.962 and 0.961 for VWF:Ag and VWF:RCo, respectively; P = 0.81]. The probability of VWD was markedly increased only for values below 40 IU dL(-1) (positive LR: 95.1 for VWF:Ag), whereas intermediate values (40 to 60 IU dL(-1)) of VWF only marginally indicated the probability of VWD.

CONCLUSIONS

Although the conventional 2.5 lower percentile has good sensitivity and specificity, only VWF:Ag or VWF:RCo values below 40 IU dL(-1) appear to significantly indicate the likelihood of type 1 VWD. The LR profile of VWF level could be used in a diagnostic algorithm.

A quantitative analysis of bleeding symptoms in type 1 von Willebrand disease: results from a multicenter European study (MCMDM-1 VWD)

BACKGROUND

A quantitative description of bleeding symptoms in type 1 von Willebrand disease (VWD) has never been reported.

OBJECTIVES

The aim was to quantitatively evaluate the severity of bleeding symptoms in type 1 VWD and its correlation with clinical and laboratory features.

PATIENTS AND METHODS

Bleeding symptoms were retrospectively recorded in a European cohort of VWD type 1 families, and for each subject a quantitative bleeding score (BS) was obtained together with phenotypic tests.

RESULTS

A total of 712 subjects belonging to 144 families and 195 controls were available for analysis. The BS was higher in index cases than in affected family members (BS 9 vs. 5, P < 0.0001) and in unaffected family members than in controls (BS 0 vs. -1, P < 0.0001). There was no effect of ABO blood group. BS showed a strong significant inverse relation with either von Willebrand ristocetin cofactor (VWF:RCo), von Willebrand antigen (VWF:Ag) or factor VIII procoagulant activity (FVIII:C) measured at time of enrollment, even after adjustment for age, sex and blood group (P < 0.001 for all the four upper quintiles of BS vs. the first quintile, for either VWF:RCo, VWF:Ag or FVIII:C). Higher BS was related with increasing likelihood of VWD, and a mucocutaneous BS (computed from spontaneous, mucocutaneous symptoms) was strongly associated with bleeding after surgery or tooth extraction.

CONCLUSIONS

Quantitative analysis of bleeding symptoms is potentially useful for a more accurate diagnosis of type 1 VWD and to develop guidelines for its optimal treatment.

Linkage analysis in families diagnosed with type 1 von Willebrand disease in the European study, molecular and clinical markers for the diagnosis and management of type 1 VWD

BACKGROUND

von Willebrand disease (VWD) type 1 is a congenital bleeding disorder caused by genetic defects in the von Willebrand factor (VWF) gene and characterized by a reduction of structurally normal VWF. The diagnosis of type 1 VWD is difficult because of clinical and laboratory variability. Furthermore, inconsistency of linkage between type 1 VWD and the VWF locus has been reported.

OBJECTIVES

To estimate the proportion of type 1 VWD that is linked to the VWF gene.

PATIENTS AND METHODS

Type 1 VWD families and healthy control individuals were recruited. An extensive questionnaire on bleeding symptoms was completed and phenotypic tests were performed. Linkage between VWF gene haplotypes and the diagnosis of type 1 VWD, the plasma levels of VWF and the severity of bleeding symptoms was analyzed.

RESULTS

Segregation analysis in 143 families diagnosed with type 1 VWD fitted a model of autosomal dominant inheritance. Linkage analysis under heterogeneity resulted in a summed lod score of 23.2 with an estimated proportion of linkage of 0.70. After exclusion of families with abnormal multimer patterns the linkage proportion was 0.46. LOD scores and linkage proportions were higher in families with more severe phenotypes and with phenotypes suggestive of qualitative VWF defects. About 40% of the total variation of VWF antigen could be attributed to the VWF gene.

CONCLUSIONS

We conclude that the diagnosis of type 1 VWD is linked to the VWF gene in about 70% of families, however after exclusion of qualitative defects this is about 50%.

Trial introduction of the Willis dropped ovary technique for spaying cattle in northern Australia

OBJECTIVE

To compare the Willis dropped ovary technique with traditional spaying methods in extensive beef cattle herds in northern Australia.

PROCEDURE

Three field trials were conducted simultaneously at different sites in northern Australia in 1996-97. Brahman and Brahman-Shorthorn cross heifers (n = 219, 2 years, 250 to 378 kg) and cows (n = 211, 3 to 16 years, 256 to 540 kg) were allocated by stratified randomisation to three treatments: spaying using the Willis dropped ovary technique (WDOT); spaying using traditional paralumbar and vaginal methods; and unspayed. Following these procedures, these nonpregnant, nonlactating cattle were then exposed to bulls (4 per 100 females) under extensive rangeland conditions for 12 months during which time weight, body condition, pregnancy and ovarian function were monitored and compared.

RESULTS

Pregnancy rates varied from 60 to 90% for entire heifers and 80 to 100% for entire cows depending on site. The traditional spay methods were 100% successful in preventing pregnancy; the WDOT was 92 to 97% effective, depending on operator experience. The number of deaths was the same or higher in Willis spayed animals than other groups. Weight changes were similar in all groups at the three sites over the trial period. The time taken to spay using the WDOT was similar to or less than that required for the traditional methods. Uterine abnormalities were not observed in animals spayed with the WDOT, there were however 30 (12.4%) animals where excision of the ovary was incomplete; the still-attached ovarian remnant presumably accounting for the three pregnant animals in this group.

CONCLUSION

The WDOT suffers from requiring a high degree of skill in transrectal ovarian manipulation. There were more deaths and more pregnancies than with traditional spay methods. More experienced operators can be expected to achieve lower mortalities, better contraception and higher processing rates. Pregnancy will occur as a consequence of ovarian remnants unless care is taken to ensure removal of the entire ovary.

Detection of structural and numerical chromosomal abnormalities by ACM-FISH analysis in sperm of oligozoospermic infertility patients

BACKGROUND

Modern reproductive technologies are enabling the treatment of infertile men with severe disturbances of spermatogenesis. The possibility of elevated frequencies of genetically and chromosomally defective sperm has become an issue of concern with the increased usage of ICSI, which can enable men with severely impaired sperm production to father children. Several papers have been published reporting aneuploidy in oligozoospermic patients, but relatively little is known about chromosome structural aberrations in the sperm of these patients.

METHODS

We examined sperm from infertile, oligozoospermic individuals for structural and numerical chromosomal abnormalities using a multicolour ACM fluorescence in situ hybridization (FISH) assay that utilizes DNA probes specific for three regions of chromosome 1 to detect human sperm that carry numerical chromosomal abnormalities plus two categories of structural aberrations: duplications and deletions of 1pter and 1cen, and chromosomal breaks within the 1cen-1q12 region.

RESULTS

There was a significant increase in the average frequencies of sperm with duplications and deletions in the infertility patients compared with the healthy concurrent controls. There was also a significantly elevated level of breaks within the 1cen-1q12 region. There was no evidence for an increase in chromosome 1 disomy, or in diploidy.

CONCLUSIONS

Our data reveal that oligozoospermia is associated with chromosomal structural abnormalities, suggesting that oligozoospermic men carry a higher burden of transmissible, chromosome damage. The findings raise the possibility of elevated levels of transmissible chromosomal defects following ICSI treatment.

Expression of the amino-terminal domain of platelet glycoprotein Ib alpha: exploitation of a calmodulin tag for determination of its functional activity

Platelet glycoprotein (GP) Ibalpha is a component of the GPIb-IX receptor complex, which is involved in multiple physiological and pathological processes, including platelet adhesion at sites of vascular injury, thrombin binding, Bernard-Soulier syndrome, platelet-type von Willebrand disease, and immune-mediated thrombocytopenias. The amino-terminal domain of approximately 300 residues of GPIbalpha mediates both normal biological function (by providing the sites for direct ligand interaction) and aberrant function (through amino acid substitutions). To investigate the molecular interactions mediated by this region of GPIbalpha, we have developed a recombinant baculovirus to facilitate its expression as a calmodulin fusion protein from insect cells. By employing the calmodulin tag, the fusion protein could be obtained at >90% purity after a single isolation step at yields of 8 mg/L of insect cell medium (purified fusion protein). The recombinant GPIbalpha fragment was shown to be posttranslationally sulfated and glycosylated, although its glycosylation differed from that of the equivalent GPIbalpha fragment isolated from human platelets. The differential glycosylation, however, did not affect the function of the recombinant GPIbalpha fragment in either von Willebrand factor (vWf) or thrombin binding as these were both found to be identical to those of the same-length GPIbalpha fragment derived from human platelets. The calmodulin tag was also exploited in the development of assays to measure directly vWf and thrombin binding, since it did not interfere with either, demonstrating the feasibility for the use of this soluble receptor fusion protein in detailed biophysical assays to investigate the molecular mode of binding of platelet glycoprotein Ibalpha to these ligands.

Bisensory augmentation: a speechreading advantage when speech is clearly audible and intact

Reisberg, McLean, and Goldfield (1987) have shown that vision plays a part in the perception of speech even when the auditory signal is clearly audible and intact. Using an alternative method the present study replicated their finding. Clearly audible spoken messages were presented in audio-only and audio-visual conditions, and the adult participants' resulting comprehension was measured. Stories were presented in French (Expt 1), in a Glaswegian accent (Expt 2), and by presenting spoken information that was semantically and syntactically complex (Experiment 3). Three separate groups of 16 adult female participants aged 19-21 participated in the three experiments. In all three experiments, comprehension improved significantly when the speaker's face was visible.

Determinants of outcome after intensified therapy of childhood lymphoblastic leukaemia: results from Medical Research Council United Kingdom acute lymphoblastic leukaemia XI protocol

The single most important prognostic determinant in childhood acute lymphoblastic leukaemia (ALL) is effective therapy and changes in therapy may influence the significance of other risk factors. The effect of intensified therapy on the importance of currently recognized phenotypic and genotypic determinants of outcome was assessed in 2090 children enrolled on the Medical Research Council United Kingdom acute lymphoblastic leukaemia XI (MRC UKALL XI) protocol. Treatment allocation was not determined by risk factors. Multivariate analysis confirmed the dominant influence on prognosis of age, sex and presenting white cell count (WCC). After allowing for these features, blast karyotype, d 8 marrow blast percentage and remission status at the end of induction therapy were the only remaining significant predictors of outcome. Organomegaly, haemoglobin concentration, French--American--British type, body mass index, presence of central nervous system disease at diagnosis, immunophenotype and presence of TEL/AML1 fusion gene (examined in a subset of 659 patients) either had no significant effect on outcome or were significant only in univariate analysis. Among karyotype abnormalities with an independent influence on prognosis, high hyperdiploidy (> 50 chromosomes) was shown to be favourable, whereas near haploidy (23--29 chromosomes), presence of the Philadelphia chromosome, t(4;11) and abnormalities affecting the short arm of chromosome 9 [abn (9p)] were adverse risk factors. Early responders to therapy, determined by residual marrow infiltration after 8 d of induction therapy, had a good outcome, while the small proportion of patients who did not achieve a complete remission by the end of induction therapy had a poor outcome. A third block of late intensification was shown to improve event-free survival by 8% at 5 years. The effect of these risk factors was not significantly different between those randomized to the third intensification block and those not randomized to a third block.

Contraceptive efficacy of an intra-uterine device in Brahman cattle

The contraceptive efficacy of an intra-uterine device was evaluated using 218 heifers and 212 cows on three north Australian cattle stations. The heifers were aged approximately 2 years and weighed 250-378 kg; the cows were aged 3-16 years and weighed 256-540 kg. All cattle were non-pregnant, non-lactating Brahmans. At the end of the monsoon (wet) season (April-June 1997), the cattle were allocated by stratified randomisation to the three treatments which were untreated controls (n=59), surgical ovariectomy (n=105), or implantation with a bovine intra-uterine device (BIUD; n=266). All cattle grazed and were managed as one group within each station. They were exposed to bulls (4 per 100 females) from soon after treatment until slaughter approximately 12 months later. The BIUD could not be implanted in 25% of heifers and 8% of cows due to narrow or twisted cervices. Correct placement of the BIUDs appeared to be achieved in 57% of heifers and 72% of cows. At slaughter, the devices were incorrectly positioned in 73% of heifers and 49% of cows into which BIUDs had been inserted and that remained non-pregnant. Uterine perforations by the BIUD were observed in 35 and 45% of these heifers and cows, respectively; most perforations appeared to occur during implantation. Low-grade endometritis was observed at slaughter in most BIUD-implanted animals; 2% had pyometra.BIUD animals did not have significantly different growth to that of control or ovariectomised animals, other than when ovariectomy suppressed growth following surgery. Most animals implanted with BIUDs appeared to have normal ovarian function and animals were observed mating. All ovariectomised animals remained non-pregnant. Over 80% of controls were pregnant within 8 months of exposure to bulls, except heifers at one station where pregnancy rate was restricted to 25% as a result of severe nutritional conditions. Pregnancy was diagnosed in 21% of heifers and 33% of cows with implanted BIUDs. The device remained correctly positioned and with no pregnancy diagnosed in the year following implantation in only 2% of heifers and 14% of cows originally allocated. Because of the difficulties of implanting BIUDs, the high frequency of associated uterine injury, the high pregnancy rate in implanted animals, and that growth was unaffected by the presence of a BIUD, it was concluded that the device had poor contraception efficacy and no growth-promotant effect in Brahman cattle.

Identification of a new Leu354Pro mutation responsible for factor XIII deficiency

We report a new homozygous CTG-->CCG (Leu-->Pro) mutation at codon 354 in the factor XIIIA gene of a patient suffering from FXIII deficiency. Leu354 lies in a pocket within the core domain of the FXIIIA molecule, with its side chain pointing into the structure of the barrel 1 domain. Replacement of leucine with a proline residue gives rise to steric hindrance between the proline ring and the surrounding residues, and rearrangement of these residues would be necessary for proline to be accommodated at this position. Using PCR-RFLP, we have demonstrated the absence of this mutation from 220 normal alleles. Together, these data suggest that Leu354Pro is likely to be the disease-causing mutation in this factor XIII deficient family.

From minichaperone to GroEL 3: properties of an active single-ring mutant of GroEL

The next step in our reductional analysis of GroEL was to study the activity of an isolated single seven-membered ring of the 14-mer. A known single-ring mutant, GroEL(SR1), contains four point mutations that prevent the formation of double-rings. That heptameric complex is functionally inactive because it is unable to release GroES. We found that the mutation E191G, which is responsible for the temperature sensitive (ts) Escherichia coli allele groEL44 and is located in the hinge region between the intermediate and apical domains of GroEL, appears to function by weakening the binding of GroES, without destabilizing the overall structure of GroEL44 mutant. We introduced, therefore, the mutation E191G into GroEL(SR1) in order to generate a single-ring mutant that may have weaker binding of GroES and hence be active. The new single-ring mutant, GroEL(SR44), was indeed effective in refolding both heat and dithiothreitol-denatured mitochondrial malate dehydrogenase with great efficiency. Further, unlike all smaller constructs of GroEL, the expression of GroEL(SR44) in E. coli that contained no endogenous GroEL restored biological viability, but not as efficiently as does wild-type GroEL. We envisage the notional evolution of the structure and properties of GroEL. The minichaperone core acts as a primitive chaperone by providing a binding surface for denatured states that prevents their self-aggregation. The assembly of seven minichaperones into a ring then enhances substrate binding by introducing avidity. The acquisition of binding sites for ATP then allows the modulation of substrate binding by introducing the allosteric mechanism that causes cycling between strong and weak binding sites. This is accompanied by the acquisition by the heptamer of the binding of GroES, which functions as a lid to the central cavity and competes for peptide binding sites. Finally, dimerization of the heptamer enhances its biological activity.

From minichaperone to GroEL 2: importance of avidity of the multisite ring structure

Structural studies on minichaperones and GroEL imply a continuous ring of binding sites around the neck of GroEL. To investigate the importance of this ring, we constructed an artificial heptameric assembly of minichaperones to mimic their arrangement in GroEL. The heptameric Gp31 co-chaperonin from bacteriophage T4, an analogue of GroES, was used as a scaffold to display the GroEL minichaperones. A fusion protein, MC(7), was generated by replacing a part of the highly mobile loop of Gp31 (residues 23-44) with the sequence of the minichaperone (residues 191-376 of GroEL). The purified recombinant protein assembled into a heptameric ring composed of seven 30.6 kDa subunits. Although single minichaperones (residues 193-335 to 191-376 of GroEL) have certain chaperone activities in vitro and in vivo, they cannot refold heat and dithiothreitol-denatured mitochondrial malate dehydrogenase (mtMDH), a reaction that normally requires GroEL, its co-chaperonin GroES and ATP. But, MC(7) refolded MDH in vitro. The expression of MC(7) complements in vivo two temperature-sensitive Escherichia coli alleles, groEL44 and groEL673, at 43 degrees C. Although MC(7) could not compensate for the complete absence of GroEL in vivo, it enhanced the colony-forming ability of cells containing limiting amounts of wild-type GroEL at 37 degrees C. MC(7 )also reduces aggregate formation and cell death in mammalian cell models of Huntington's disease. The assembly of seven minichaperone subunits on a heptameric ring significantly improves their activity, demonstrating the importance of avidity in GroEL function.

Treatment of children with haemophilia in Europe: a survey of 20 centres in 16 countries

A survey was made of the current status of treatment of haemophilic boys at 20 centres in 16 European countries and includes approximately 1500 of the estimated 6500 haemophiliacs in the participating countries. Many mild haemophiliacs are not seen, or seen infrequently, at haemophilia centres and this requires study. Nine of 18 centres provide continuous prophylaxis to 80-100% of their patients, five centres provide it to 55-80% and the remaining four centres to 15-40% of the boys. The median dose given was 6240 U kg-1 year-1 (range 3120-7800). Four centres administered only recombinant concentrates to children with severe haemophilia A, while seven centres administered recombinant concentrates to 75-90% and the remaining centres to less than 50% of the boys (two centres < 10%). When asked for the choice of concentrate for a newly diagnosed boy with severe haemophilia A, all but one centre preferred recombinant concentrate. Most boys below 6 years received concentrates via a peripheral vein but three centres preferred a central venous line for 80-100% of the boys. Thirteen of 18 centres applied home treatment to 84-100% of the boys and the remaining five centres to 57-77% of the boys.

An estimate of large-scale sequencing accuracy

The accuracy of large-scale DNA sequencing is difficult to estimate without redundant effort. We have found that the mobile genetic element IS10, a component of the transposon Tn10, has contaminated a significant number of clones in the public databases, as a result of the use of the transposon in bacterial cloning strain construction. These contaminations need to be annotated as such. More positively, by defining the range of sequence variation in IS10, we have been able to determine that the rate of sequencing errors is very low, most likely surpassing the stated aim of one error or less in ten thousand bases.

Deeply Penetrating Banded Zonal Flows in the Solar Convection Zone

Helioseismic observations have detected small temporal variations of the rotation rate below the solar surface that correspond to the so-called "torsional oscillations" known from Doppler measurements of the surface. These appear as bands of slower- and faster-than-average rotation moving equatorward. Here we establish, using complementary helioseismic observations over 4 yr from the GONG network and from the MDI instrument on board SOHO, that the banded flows are not merely a near-surface phenomenon: rather, they extend downward at least 60 Mm (some 8% of the total solar radius) and thus are evident over a significant fraction of the nearly 200 Mm depth of the solar convection zone.

Dynamic variations at the base of the solar convection zone

We have detected changes in the rotation of the sun near the base of its convective envelope, including a prominent variation with a period of 1.3 years at low latitudes. Such helioseismic probing of the deep solar interior has been enabled by nearly continuous observation of its oscillation modes with two complementary experiments. Inversion of the global-mode frequency splittings reveals that the largest temporal changes in the angular velocity Omega are of the order of 6 nanohertz and occur above and below the tachocline that separates the sun's differentially rotating convection zone (outer 30% by radius) from the nearly uniformly rotating deeper radiative interior beneath. Such changes are most pronounced near the equator and at high latitudes and are a substantial fraction of the average 30-nanohertz difference in Omega with radius across the tachocline at the equator. The results indicate variations of rotation close to the presumed site of the solar dynamo, which may generate the 22-year cycles of magnetic activity.

Benefit of intensified treatment for all children with acute lymphoblastic leukaemia: results from MRC UKALL XI and MRC ALL97 randomised trials. UK Medical Research Council's Working Party on Childhood Leukaemia

Treatment of children with acute lymphoblastic leukaemia (ALL) aims to cure all patients with as little toxicity as possible and, if possible, to restrict further intensification of chemotherapy to patients with an increased risk of relapse. However in Medical Research Council (MRC) trial UKALL X two short myeloablative blocks of intensification therapy given at weeks 5 and 20 were of benefit to children in all risk groups. The successor trials, MRC UKALL XI and MRC ALL97, tested whether further intensification would continue to benefit all patients by randomising them to receive, or not, an extended third intensification block at week 35. After a median follow-up of 4 years (range 5 months to 8 years), 5 year projected event-free survival was superior at 68% for the 894 patients allocated a third intensification compared with 60% for the 887 patients who did not receive one (odds ratio 0.75, 95% CI 0.63-0.90, 2P = 0.002). This difference was almost entirely due to a reduced incidence of bone marrow relapses in the third intensification arm (140 of 891 in the third intensification arm vs. 171 of 883 in the no third intensification, 2P = 0.02). Subgroup analysis suggests benefit of the third intensification for all risk categories. Overall survival to date is no different in the two arms, indicating that a greater proportion of those not receiving a third intensification arm and subsequently relapsing can be salvaged. These results indicate that there is benefit of additional intensification for all risk subgroups of childhood ALL.

BAC trimming: minimizing clone overlaps

Bacterial vectors containing large inserts of genomic DNA are now the standard substrates for large-scale genomic sequencing. Long overlaps between some clones lead to considerable redundant effort. A method for deleting defined regions from bacterial artificial chromosome (BAC) inserts, using homologous recombination, was applied to minimize the overlap between successive BAC clones. This procedure, called trimming, was carried out in the recA(-) BAC host. We have precisely deleted up to 70 kb of DNA from BACs that were to be sequenced. This method requires minimal prior characterization of the clones: collections of BAC end sequences or STS-based maps will accelerate the process. BAC trimming will be useful in both small and large genome sequencing projects and will be of particular utility for gap closure in finishing phases.

Background ionizing radiation plays a minor role in the production of chromosome translocations in a control population

PURPOSE

To obtain a relationship between background chromosome translocation frequency and age with translocation frequency measured to a high statistical precision, and to identify the role of background ionizing radiation in the production of chromosome translocations in a control population.

MATERIALS AND METHODS

Lymphocytes from 35 healthy control individuals (15 females and 20 males) were scored, using fluorescence in situ hybridization, for the presence of chromosomal translocations. Translocation frequencies were measured to a high statistical precision (s.d. 25% or less for each individual). These control subjects were of varying ages, ranging from 0 (cord blood) to 98 years.

RESULTS

In a total of 521,492 metaphases (203,754 genome equivalent cells) scored, an average of 5,822 genome equivalent cells per individual, 764 translocations were observed in the 35 individuals. The translocation frequencies ranged from 0 (for cord blood) to 0.0167 (for a 98 year old) translocations per cell. The average age and translocation frequency was 50 years and 0.004 translocations per cell, respectively. The best fit of the relationship between translocations and age was: Y=7x10(-4)+6.9x10(-6)A+1.35x10(-6)A2, which does not obey the linear relationship expected from chronic background radiation alone. The curvilinear relationship observed clearly shows that other endogenous and exogenous clastogens or clastogenic events, in addition to radiation, serve to generate chromosome translocations in control populations.

CONCLUSION

The background translocation frequency in control individuals follows a curvilinear relationship with age. No significant variation was observed between individuals of the same age. Clastogenic processes of normal aging and physiological factors in additional to ionizing radiation play a major role in the production of chromosome translocations in a control population. Background radiation, however, appears to play a minor role in chromosome translocation production in control individuals living near sea level.

Food affordability in air stage communities

In 1991 and 1992, changes were made to the rate structure and eligibility requirements of the Northern Air Stage Program. To determine the effect of these changes on the affordability of a nutritious diet, food price surveys were conducted in 20 isolated communities, staging points, and selected southern cities and used to cost a 46-item Northern Nutritious Food Basket (NFB), which meets the nutrient requirements of a reference family of four. Food affordability was calculated as the percentage of "after-shelter" social assistance income required to purchase the NFB. In the Northwest Territories (NWT), from 100% to 123% of income was required in Air Stage communities in 1990-1991 and from 86% to 125% in 1993. In the provinces, from 65% to 83% of income was needed in 1990-1991 and from 56% to 98% in 1993. In Kangiqsujuaq and Nain, the amount of "after-shelter" income needed increased by as much as 6% and 15%, respectively. Changes to the Northern Air Stage Program reduced the cost of perishable foods and improved the affordability of a nutritious diet in the NWT. Affordability is also affected by social assistance income. In most isolated communities, families would still find it difficult to afford a nutritious diet.

Food mail: the Canadian alternative to food stamps

PURPOSE

To describe the impact of a selective transportation subsidy on food costs in isolated communities in Northern Canada, and the government's proposal to refine the "food mail" program to promote better nutrition.

METHOD

The cost of various components of a Northern Food Basket has been monitored since 1990. An assessment of the probable impact and acceptability of program refinements was made through surveys of merchants and health and social service providers and focus group sessions. Decisions expected following consultations with stakeholders in March and April 1996 are also described.

RESULTS

Costs of nutritious perishable food have been reduced in the Northwest Territories, and consumption of these foods in the Baffin region doubled within three years. Program refinements were proposed, with the objective of increasing intakes of calcium, folacin, and vitamin A, reducing dependency on convenience perishable foods, and reducing the cost of a healthy diet.

Food consumption patterns of Inuit women

To evaluate nutrient intake and food consumption patterns of Inuit women of child-bearing age, a 24-hour diet recall and general health and food frequency questionnaire was administered to 688 Inuit women aged 15-44 in six isolated communities. Data were analyzed using the 1991 Canadian Nutrient File. Mean intakes of essential nutrients were expressed as percentages of Health Canada's 1990 Recommended Nutrient Intakes (RNI). Chi-square tests were used to determine relationships between categorical variables. Folacin intake ranged from 49% to 95% of the RNI in most communities (median = 76%) and was only 37% of the RNI for pregnant and 54% for lactating women. Mean calcium intake for pregnant and lactating women averaged 55% and 47% of the RNI, respectively. Average vitamin A intakes ranged from 26% to 87% of the RNI (median = 65%), with intake for pregnant Inuit women and lactating women 79% and 54% of the RNI, respectively. Country food was the major source of protein and iron, and store foods the major source of calories, calcium, folacin, and vitamin A. Low intakes of folacin, calcium, and vitamin A, especially among pregnant and lactating women, place Inuit women of childbearing age at risk. Women on social assistance are nutritionally vulnerable.

An encyclopedia of mouse genes

The laboratory mouse is the premier model system for studies of mammalian development due to the powerful classical genetic analysis possible (see also the Jackson Laboratory web site, http://www.jax.org/) and the ever-expanding collection of molecular tools. To enhance the utility of the mouse system, we initiated a program to generate a large database of expressed sequence tags (ESTs) that can provide rapid access to genes. Of particular significance was the possibility that cDNA libraries could be prepared from very early stages of development, a situation unrealized in human EST projects. We report here the development of a comprehensive database of ESTs for the mouse. The project, initiated in March 1996, has focused on 5' end sequences from directionally cloned, oligo-dT primed cDNA libraries. As of 23 October 1998, 352,040 sequences had been generated, annotated and deposited in dbEST, where they comprised 93% of the total ESTs available for mouse. EST data are versatile and have been applied to gene identification, comparative sequence analysis, comparative gene mapping and candidate disease gene identification, genome sequence annotation, microarray development and the development of gene-based map resources.