Putting measurement-based care into action: A mixed methods study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis

Background

Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process.

Methods

We used a quasi pre-post comparison design with mixed methods to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report.

Results

People who received a personalized feedback report reported significant improvements in shared decision-making and had greater improvements over time in their intent to attend future treatment sessions. They engaged in more sessions for Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians.

Conclusions

A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase engagement in psychosocial interventions. We posit that this process facilitates strengths-focused discussions, enhances intrinsic motivation, and strengthens the therapeutic alliance.

Opportunities and Barriers to Screening and Counseling for Safe Firearm Storage

Objectives

Safety practices such as storing a firearm locked and unloaded are widely promoted although not universally applied. Educating patients about firearm safety practices is effective in increasing safe firearms storage behaviors; however, screening for safe firearm storage in practice remains low. The aim of this study was to evaluate whether our clinic population was at risk for firearm-related injuries and whether opportunities existed to study risk-mitigation interventions in future work.

Methods

The study was conducted at a suburban, midwestern academic family medicine clinic. Patients filled out paper surveys about firearm ownership and willingness to discuss firearms safety with clinicians. Health care personnel filled out paper or electronic surveys about their comfort level in discussing firearm safety with patients. Data then were collated and analyzed.

Results

We surveyed 160 patients (60% female, 80% White), and 40.6% of respondents reported living in a home with a firearm. Respondents who stored their firearm unsafely were more willing to discuss firearm safety than to change their storage behavior. Eighteen health care personnel responded to our health care personnel survey. Perceived barriers to asking about firearms included lack of time, knowledge, or educational materials. Having a screening policy was selected as the best opportunity for improvement.

Conclusions

Firearm owners appear willing to discuss firearm safety with their clinician, potentially representing an opportunity to promote risk-reduction through approaches such as motivational interviewing. In a busy outpatient setting, automating the firearm screening process could lessen the burden on clinicians.

Efficacy of hope: Analysis of organ quality and availability among deceased HIV-positive donors

BACKGROUND

Improved survival among people with human immunodeficiency virus (HIV) (PWH) has led to increased organ failure, necessitating transplantation. In 2013, the HIV Organ Policy Equity (HOPE) Act was passed, allowing PWH to donate organs to other PWH. No study has assessed organ quality and quantity among a national pool of PWH.

METHODS

CFAR Network of Integrated Clinical Systems (CNICS), a multicenter study capturing data on PWH, was used to identify 6504 deaths from 1999 to 2018. Exclusions included cause of death, chronic kidney disease, fibrosis-4 score ≥ 3.25, and opportunistic infection at the time of death. Donor quality was defined by HIV viremia and the kidney donor profile index (KDPI). The CDC Wonder database, which contains national death data, permitted the estimation of deaths among PWH nationally from 1999 to 2018. Assuming CNICS was representative of PWH nationally, percentages of potential donors were applied to the CDC Wonder cohort.

RESULTS

Within CNICS, there were 3241 (65.9%) potential kidney donors and 3536 (71.9%) potential liver donors from 1999 to 2018. Based on viremia and KDPI, 821 were lower-risk kidney donors (16.7%) and 1206 (24.5%) were lower-risk liver donors. Within CDC Wonder, we identified 12 048 potential donors from 1999 to 2018. Extrapolating from CNICS to the national cohort suggested 396 kidney donors (792 kidneys) and 433 liver donors annually, with 100 kidney donors (200 kidneys) and 147 livers being lower-risk.

CONCLUSION

A substantial number of PWH meet donation criteria, a valuable source of organs for PWH in need of transplants. Our estimates suggest there may be more available organs from PWH than current transplant numbers indicate.

Donor‐reported barriers to living kidney donor follow‐up

BACKGROUND

Despite regulations mandating follow-up laboratory testing for living kidney donors, less than half of transplant centers are in compliance. We sought to understand barriers to follow-up testing from the donors' perspective.

METHODS

We surveyed our center's living kidney donors. Binary logistic regression was used to assess factors associated with follow-up testing completion.

RESULTS

Of 185 living kidney donors, 110 (59.4%) participated. Among them, 82 (74.5%) completed 6-month laboratory testing, 76 (69.1%) completed 12-month testing, 68 (61.8%) completed both, and 21 (19.0%) completed neither. Six-month testing completion was strongly associated with 12-month testing completion (OR 9.74, 95%CI: 2.23-42.50; p = .002). Those who disagreed with the statements, "Getting labs checked wasn't a priority for me," (OR for completing 6-month testing: 15.05, 95%CI: 3.70-61.18; p < .001; OR for completing 12-month testing: 5.85, 95%CI: 1.94-17.63; p = .002); and, "I forgot to get labs drawn [until I was reminded]" (OR for completing 6-month testing: 6.93, 95%CI: 1.59-30.08; p = .01; OR for completing 12-month testing: 6.55, 95%CI: 1.98-21.63; p = .002) were more likely to complete testing.

CONCLUSIONS

To our knowledge, this is the only study providing perspective on donor insights regarding the need for follow-up testing post donation. Interventions to influence living donor attitudes toward follow-up testing may improve follow-up.

The impact of COVID-19 on recovery after heart surgery: preliminary findings from the CardiacCovid Study

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The COVID-19 pandemic has had far-reaching effects on everyday life leading to stress and anxiety, which may be heightened in those undergoing cardiac surgery. Health impacts following a traumatic event may be apparent at one month but can also present after many months.

Purpose

The aim of the CardiacCovid study was to explore the effect of the pandemic on recovery from cardiac surgery. We report the preliminary results from a single centre study in the UK during the early phase of the COVID-19 pandemic.

Methods

Patients >18 years old undergoing any form of cardiac surgery between 23rd March 2020 (UK lockdown) to 4th July 2020 (lifting of most restrictions) were recruited to this prospective observational study. Those too unwell or unable to give consent/complete study questionnaires were excluded. Participants completed a Quality of Life (QoL) (EQ-5D), impact of event (IES-R), depression (CES-D) and health service use questionnaire at baseline, 1 week after hospital discharge, and 6 weeks after surgery. Questionnaires were completed electronically on the Amplitude platform or via post. Ethics approval (20/YH/0132) was obtained and the study was registered (Clinicaltrials.gov:NCT04366167).

Results

A total of 395 patients had surgery of which 298 (91.7%) were screened and 203 (68.1%) were enrolled to the study.  Participants were mostly male (74.6%), with a mean age of 63 years, undergoing urgent/emergency (57.9%) CABG +/-valve (70.1%). Mean inpatient stay was 8.6 days and in-hospital mortality was 0.5%. No patients had Covid-19. The initial findings suggest a deterioration of QoL at 1 week post discharge with near restoration to baseline level at 6 weeks post-surgery. Mean scores for CES-D and IES-R remained within subclinical levels at all available time points. However, at 6 weeks, a proportion of patients reached levels for depression on the CES-D and had high IES-R scores indicating possible post-traumatic stress.

Conclusion

We believe that this is the largest/only study exploring the impact of the pandemic on cardiac surgery recovery, including QoL, spanning the immediate recovery phase but will continue until 1 year. The findings so far show that recovery from cardiac surgery during the Covid-19 pandemic is similar to that reported prior to the pandemic (Cromhout et al 2018) and reinforces the need for psychosocial assessments to identify patients who may require additional support during the immediate recovery phase.

Report of a Delphi exercise to inform the design of a research programme on screening for thoracic aortic disease

Objectives

To inform the design of a clinical trial of a targeted screening programme for relatives of individuals affected by thoracic aortic disease, we performed a consensus exercise as to the acceptability of screening, the optimal sequence and choice of tests, long-term patient management, and choice of trial design.

Methods

Working with the Aortic Dissection Awareness UK & Ireland patient association, we performed a Delphi exercise with clinical experts, patients, and carers, consisting of three rounds of consultation followed by a final multi-stakeholder face-to-face workshop.

Results

Thirty-five experts and 84 members of the public took part in the surveys, with 164 patients and clinicians attending the final workshop. There was substantial agreement on the need for a targeted screening pathway that would employ a combined approach (imaging + genetic testing). The target population would include the first- and second-degree adult (> 15 years) relatives, with no upper age limit of affected patients. Disagreement persisted about the screening process, sequence, personnel, the imaging method to adopt, computed tomography (CT) scan vs magnetic resonance imaging (MRI), and the specifics of a potential trial, including willingness to undergo randomisation, and measures of effectiveness and acceptability.

Conclusion

A Delphi process, initiated by patients, identified areas of uncertainty with respect to behaviour, process, and the design of a targeted screening programme for thoracic aortic disease that requires further research prior to any future trial.

Metal uptake via phosphate fertilizer and city sewage in cereal and legume crops in Pakistan

Crop irrigation with heavy metal-contaminated effluents is increasingly common worldwide and necessitates management strategies for safe crop production on contaminated soils. This field study examined the phytoavailability of three metals (Cd, Cu, and Zn) in two cereal (wheat, maize) and legume (chickpea, mungbean) crops in response to the application of either phosphatic fertilizer or sewage-derived water irrigation over two successive years. Five fertilizer treatments, i.e. control, recommended nitrogen (N) applied alone and in combination of three levels of phosphorus (P), half, full and 1.5 times of recommended P designated as N0P0, N1P0, N1P0.5, N1P1.0, and N1P1.5, respectively. Tissue concentrations of Cd, Cu, Zn, and P were determined in various plant parts, i.e., root, straw, and grains. On the calcareous soils studied while maximum biomass production was obtained with application of P at half the recommended dose, the concentrations of metals in the crops generally decreased with increasing P levels. Tissue metal concentrations increased with the application of N alone. Translocation and accumulation of Zn and Cu were consistently higher than Cd. And the pattern of Cd accumulation differed among plant species; more Cd being accumulated by dicots than monocots, especially in their grains. The order of Cd accumulation in grains was maize > chickpea > mungbean > wheat. Mungbean and chickpea straws also had higher tissue Cd concentration above permissible limits. The two legume species behaved similarly, while cereal species differed from each other in their Cd accumulation. Metal ion concentrations were markedly higher in roots followed by straw and grains. Increasing soil-applied P also increased the extractable metal and P concentrations in the post-harvest soil. Despite a considerable addition of metals by P fertilizer, all levels of applied P effectively decreased metal phytoavailability in sewage-irrigated soils, and applying half of the recommended dose of P fertilizer was the most feasible solution for curtailing plant metal uptake from soils. These findings may have wide applications for safer crop production of monocot species when irrigating crops with sewage effluent-derived waters.

Decline in extractable antibiotics in manure-based composts during composting

A wide variety of antibiotics have been detected in natural water samples and this is of potential concern because of the adverse environmental effects of such antibiotic residues. One of the main sources of antibiotics effluence to the surrounding environment is livestock manures which often contain elevated concentrations of veterinary antibiotics (VAs) which survive digestion in the animal stomach following application in animal husbandry practices. In Korea, livestock manures are normally used for compost production indicating that there is potential for antibiotic release to the environment through compost application to agricultural lands. Therefore, reduction of the amount of VAs in composts is crucial. The purpose of this study was to understand the influence of the composting process and the components of the compost on the levels of three common classes of antibiotics (tetracyclines, sulfonamides, and macrolides). Composted materials at different stages of composting were collected from compost manufacturing plants and the variation in antibiotic concentrations was determined. Three different antibiotics, chlortetracycline (CTC), sulfamethazine (SMZ), and tylosin (TYL) at three different concentrations (2, 10, and 20mgkg(-1)) were also applied to a mixture of pig manure and sawdust and the mixtures incubated using a laboratory scale composting apparatus to monitor the changes in antibiotic concentrations during composting together with the physicochemical properties of the composts. During composting, in both field and lab-scale investigations, the concentrations of all three different antibiotics declined below the relevant Korean guideline values (0.8mgkg(-1) for tetracyclines, 0.2mgkg(-1) for sulfonamides and 1.0mgkg(-1) for macrolides). The decline of tetracycline and sulfonamide concentrations was highly dependent on the presence of sawdust while there was no influence of sawdust on TYL decline.

Applicability of the Charm II system for monitoring antibiotic residues in manure-based composts

The effluence of veterinary antibiotics (VAs) to aquatic and terrestrial environments is of concern due to the potential adverse effects on human health, such as the production of antibiotic resistant bacteria. One of the main pathways for antibiotics to enter the environment is via the application of manure and/or manure-based composts as an alternative organic fertilizer to agricultural lands. While a wide diversity of manure-based composts are produced in Korea, there is currently no regulatory guideline for VA residues. Hence, monitoring and limiting the concentration of VA residues in manure and/or manure-based composts prior to application to the lands is important to mitigate any environmental burden. The current study was conducted to examine the applicability of the Charm II antibiotic test system for monitoring tetracyclines, sulfonamides and macrolides in manure-based composts. The Charm II system was a highly reproducible method for determining whether VA residue concentrations in manure-based compost exceeded specific guideline values. A wide range of manure-based composts and liquid fertilizers commercially available in Korea were examined using the Charm II system to monitor the residues of the target VAs. For this, the guideline concentrations of VA residues (0.8 mg kg(-1) for tetracyclines, 0.2 mg kg(-1) for sulfonamides, and 0.1 mg kg(-1) for macrolides) stated in 'Official Standard of Feeds' under the 'Control of Livestock and Fish Feed Act' in Korea were adopted to establish control points. Of the 70 compost samples examined 12 exceeded 0.8 mg kg(-1) for tetracyclines and 21 exceeded 0.2 mg kg(-1) for sulfonamides. Of the 25 liquid fertilizer samples examined most samples exceeded these prospective guidelines.

Development and characterization of promoterless helper RNAs for the production of alphavirus replicon particle

Alphavirus-based replicon systems are frequently used as preclinical vectors and as antigen discovery tools, and they have recently been assessed in clinical vaccine trials. Typically, alphavirus replicon RNAs are delivered within virus-like replicon particles (VRP) that are produced following transfection of replicon RNA and two helper RNAs into permissive cells in vitro. The non-structural proteins expressed from the replicon RNA amplify the replicon RNA in cis and the helper RNAs in trans, the latter providing the viral structural proteins necessary to package the replicon RNA into VRP. Current helper RNA designs incorporate the alphavirus 26S promoter to direct the transcription of high levels of structural gene mRNAs. We demonstrate here that the 26S promoter is not required on helper RNAs to produce VRP and propose that such promoterless helper RNAs, by design, reduce the probability of generating replication-competent virus that may otherwise result from RNA recombination.

Alphavirus replicon approach to promoterless analysis of IRES elements

Here we describe a system for promoterless analysis of putative internal ribosome entry site (IRES) elements using an alphavirus (family Togaviridae) replicon vector. The system uses the alphavirus subgenomic promoter to produce transcripts that, when modified to contain a spacer region upstream of an IRES element, allow analysis of cap-independent translation of genes of interest (GOI). If the IRES element is removed, translation of the subgenomic transcript can be reduced >95% compared to the same transcript containing a functional IRES element. Alphavirus replicons, used in this manner, offer an alternative to standard dicistronic DNA vectors or in vitro translation systems currently used to analyze putative IRES elements. In addition, protein expression levels varied depending on the spacer element located upstream of each IRES. The ability to modulate the level of expression from alphavirus vectors should extend the utility of these vectors in vaccine development.

A randomized trial of local anesthesia with intravenous sedation vs general anesthesia for the vaginal correction of pelvic organ prolapse

The purpose of this study is to compare the feasibility of local anesthesia with IV sedation versus general anesthesia for vaginal correction of pelvic organ prolapse. Patients with pelvic organ prolapse who were scheduled for an anterior or posterior colporrhaphy, or an obliterative procedure, and who did not have a contraindication or preference to type of anesthesia were randomized to one of the two anesthesia groups. Nineteen patients were randomized to the general group and 21 patients were randomized to the local group. Mean operating room, anesthesia, and surgical time were similar in each group, and 10 patients in the local group bypassed the recovery room. Requests and doses of antiemetics, postoperative verbal numerical pain scores and length of hospital stay were similar between the two groups. Mean recovery room and total hospital costs were significantly lower in the local group. Local anesthesia with IV sedation is a feasible alternative for vaginal surgery to correct pelvic organ prolapse.

Rapsyn mutations in hereditary myasthenia: distinct early- and late-onset phenotypes

Rapsyn mutations in 16 unrelated patients with a congenital/hereditary myasthenic syndrome were identified, and a mutation (N88K) common to each of them was found. Two distinct phenotypes were noted: early and late onset. The former is frequently associated with arthrogryposis multiplex congenita and life-threatening crises. The late-onset phenotype developed in adolescence or adulthood and was initially mistaken for seronegative myasthenia gravis. Recognition of this late-onset phenotype should prevent inappropriate immunotherapy.

Potent thyrotrophin receptor-blocking antibodies: a cause of transient congenital hypothyroidism and delayed thyroid development

OBJECTIVE

We describe an infant with surprisingly severe neonatal hypothyroidism due to transplacental passage of thyrotrophin receptor (TSH-R)-blocking antibodies (TBAb).

DESIGN AND METHODS

TBAb were detected using a cell line which stably expresses the human TSH-R and a cAMP-responsive luciferase reporter by their ability to inhibit TSH-stimulated luciferase expression. Potent TBAb were detected in maternal serum and initially in the infant's serum but, in the latter, TBAb decreased over time to within the reference range by 3-4 months of age, illustrating the transient nature of this condition.

RESULTS

The thyroid function of this child did not return to normal on withdrawal of thyroxine therapy at 16 months of age when he developed transient compensated hypothyroidism.

CONCLUSIONS

We propose that the presence of potent TBAb in utero and in the first weeks of life may have implications for the development of a normally sized thyroid gland. We have demonstrated the presence of TBAb in the mother's milk and, as far as we are aware, this is the first such report. However, the TBAb in the milk probably did not contribute significantly to hypothyroidism in the child, given the reducing antibody titre in his circulation.

Chemistry of chromium in soils with emphasis on tannery waste sites

Worldwide chromium contamination of soils has arisen predominantly from the common practice of land-based disposal of tannery wastes under the assumption that the dominant species in the tannery waste would be the thermodynamically stable Cr(III) species. However, significant levels of toxic Cr(VI) recently detected in surface water and groundwater in India, China, Australia, and elsewhere raise critical questions relating to current disposal criteria for Cr-containing wastes. It now appears that despite the thermodynamic stability of Cr(III), the presence of certain naturally occurring minerals, especially Mn oxides, can enhance oxidation of Cr(III) to Cr(VI) in the soil environment. This factor is of public concern because at high pH, Cr(VI) is bioavailable, and it is this form that is highly mobile and therefore poses the greatest risk of groundwater contamination. A review of the current literature indicates that extensive research has been performed on the speciation of Cr in soil, the effect of pH on soil solution concentrations of Cr(III) and Cr(VI), soil adsorption phenomenon of Cr species, redox reactions, and transformation of Cr(II) and Cr(VI) together with remediation strategies to decontaminate Cr-contaminated soils. Most of the studies were conducted using an uncontaminated soil artificially spiked with Cr, and very limited research has been conducted in the contaminated soil environment. Furthermore, studies on tannery waste contaminated soils are limited, and obviously a serious gap of knowledge exists in understanding the influence of long-term tannery waste contamination on Cr behavior in soil.

In utero gene delivery by intraamniotic injection of a retroviral vector producer cell line in a nonhuman primate model

In utero gene therapy (IUGT) offers the promise of treating a wide variety of genetic diseases before the development of disease manifestations. The most convenient and potentially easiest method of targeting the fetus is through injection into the amniotic cavity. For long-term correction of genetic defects, retroviral vectors have great potential as a tool for gene therapy strategies. However, retroviral vectors are limited by growth to low titers. In an attempt to increase the amount of vector particles delivered and assess the potential of intraamniotic administration, we injected a retroviral vector producer cell line encoding the lacZ gene into the amniotic fluid of a nonhuman primate model. After birth the infants were analyzed for vector-mediated transduction. Two of four fetuses were successfully transduced, with transgene expression detected in the esophagus, trachea, and stomach. In some sections of tissue, nearly 100% of the cells lining the lumen of these tissues were positive for transduction. Although successful, the limited number of tissues in which transduction was observed led to an in vitro analysis of the effects of amniotic fluid (AF). The presence of amniotic fluid inhibited transduction by 99%. AF affected both the transducing activity of the vector and the health of the packaging cells. The negative effects of AF were gestational age dependent; greater inhibition was observed from AF collected at later stages of pregnancy. The fact that transduction was successful despite these negative effects indicates that this approach is a promising strategy for gene therapy.

Cloning of the 18S rDNA gene, an internal transcribed spacer, and the 5' region of the 28S rDNA gene of Cope's gray treefrog, Hyla chrysoscelis

The location of rDNA genes on the chromosomes of most species is identical within that species, usually occurring on the same chromosome or chromosomes. This is not the case in Cope's gray treefrog, Hyla chrysoscelis, where the rDNA genes are polymorphic for chromosome location. The occasions leading to this polymorphism have yet to be determined. The first step in understanding the nature of the polymorphism is the characterization of the ribosomal gene array. Here we describe the cloning, sequencing, and confirmation, by fluorescence in situ hybridization, of the 18S rDNA gene, a region which includes the end of the 18S rDNA gene, an internal transcribed spacer, and a portion of the 5' end of the 28S rDNA gene in H. chrysoscelis.

The redox-sensitive transcriptional activator OxyR regulates the peroxide response regulon in the obligate anaerobe Bacteroides fragilis

The peroxide response-inducible genes ahpCF, dps, and katB in the obligate anaerobe Bacteroides fragilis are controlled by the redox-sensitive transcriptional activator OxyR. This is the first functional oxidative stress regulator identified and characterized in anaerobic bacteria. oxyR and dps were found to be divergently transcribed, with an overlap in their respective promoter regulatory regions. B. fragilis OxyR and Dps proteins showed high identity to homologues from a closely related anaerobe, Porphyromonas gingivalis. Northern blot analysis revealed that oxyR was expressed as a monocistronic 1-kb mRNA and that dps mRNA was approximately 500 bases in length. dps mRNA was induced over 500-fold by oxidative stress in the parent strain and was constitutively induced in the peroxide-resistant mutant IB263. The constitutive peroxide response in strain IB263 was shown to have resulted from a missense mutation at codon 202 (GAT to GGT) of the oxyR gene [oxyR(Con)] with a predicted D202G substitution in the OxyR protein. Transcriptional fusion analysis revealed that deletion of oxyR abolished the induction of ahpC and katB following treatment with hydrogen peroxide or oxygen exposure. However, dps expression was induced approximately fourfold by oxygen exposure in DeltaoxyR strains but not by hydrogen peroxide. This indicates that dps expression is also under the control of an oxygen-dependent OxyR-independent mechanism. Complementation of DeltaoxyR mutant strains with wild-type oxyR and oxyR(Con) restored the inducible peroxide response and the constitutive response of the ahpCF, katB, and dps genes, respectively. However, overexpression of OxyR abolished the catalase activity but not katB expression, suggesting that higher levels of intracellular OxyR may be involved in other physiological processes. Analysis of oxyR expression in the parents and in DeltaoxyR and overexpressing oxyR strains by Northern blotting and oxyR'::xylB fusions revealed that B. fragilis OxyR does not control its own expression.

A comparative study of the clinical efficacy of nedocromil sodium and placebo. How does cromolyn sodium compare as an active control treatment?

Nedocromil sodium and cromolyn sodium are the only two currently available nonsteroid anti-inflammatory agents for treatment of asthma. Clinical differences between the two agents remain under continuous investigation with reports differentiating the two on the basis of atopy of the patient and reversibility of bronchoconstriction. This study investigated the efficacy of nedocromil sodium (4 mg, qid) for treatment of mild-to-moderate asthma in comparison to placebo using cromolyn sodium (2 mg, qid) as an active control treatment. Patients were primarily allergic asthmatics (with at least 15% reversibility) previously maintained on a regimen of regular bronchodilator therapy. During a 2-week run-in period, the patient's slow-release theophylline therapy was removed, and the patients were randomized to treatment after deterioration of asthma control (asthma symptom summary score of 3 for 7 of the 14 days). After 8 weeks of treatment, patients were returned to as occasion requires bronchodilator therapy, as per the 2-week baseline period. The results demonstrate that patients treated with nedocromil sodium showed statistically significant improvements during the primary time period (mean weeks 3 through 8) over placebo-treated patients as evidenced by all indexes of asthma symptoms, pulmonary function measures, and decreased bronchodilator reliance (p<0.05). Patients treated with cromolyn sodium demonstrated similar improvements over placebo-treated patients. Comparisons between nedocromil sodium and cromolyn sodium showed the two agents to be comparable in this group of primarily allergic patients with reversible disease. Between-group differences were noted for 3 of the 13 variables (nighttime asthma, FEV1, and forced expiratory flow rate between 25 % and 75% of the FVC) in favor of cromolyn sodium when the data were pooled during the primary time period. The number of patients missing 1 or more days from work/school/regular activity due to asthma was significantly fewer compared with placebo, and favoring nedocromil sodium over cromolyn sodium. No differences were observed among the three treatments for adverse events. This study demonstrated that in primarily allergic patients with reversible airways disease, nedocromil sodium and cromolyn sodium are both significantly more effective than placebo for treatment of mild-to-moderate asthma.

14N Nuclear Magnetic Resonance Relaxation of the Nitrate Ion and Ion Pairing in Aqueous Solution

14 N n.m.r. spin-lattice relaxation times of four metal nitrate salts were measured as a function of concentration in aqueous solution. The concentration dependence of T1 was attributed to the formation of ion pairs with increasing concentration in these solutions. The T1 data, allowing for viscosity corrections, were treated by a two-state model of 'free' and 'bound' nitrate ions and to both possibilities of slow and fast exchange between the two states. In the equilibrium expressions estimates of the relevant activity coefficients were included. The slow nitrate exchange mechanism was favoured and the values obtained for this particular mechanism compared well with those derived from alternative measurements.

Nitrate Selectivity of Ion-Exchange Resins and of Their Model Compounds. II. Viscosity and Density of Benzyltrialkylammonium Salts in Aqueous Solution and 14N N.M.R. Relaxation of the Nitrate Ion

The densities and viscosities of benzyltrialkylammonium chlorides and nitrates were determined in aqueous solution; the alkyl substituents were methyl, ethyl, propyl , butyl and pentyl . The concentration dependence of the 14N nuclear spin relaxation of the nitrate ion was used to find ion pair association constants for comparison with those derived from conductivity measurements (Part I). Density measurements were used to determine partial molar volumes, and viscosity measurements to find hydrodynamic volumes of the solutes. With the assumption of additivity of ionic volumes, cationic volumes calculated from the two series of chloride and nitrate salts agreed well. The increase in the ratio of hydrodynamic to partial ionic volumes with increasing chain length of the alkyl substituent was interpreted as a corresponding increase in hydrophobic hydration.

Varicella-zoster virus (VZV) transcription during latency in human ganglia: construction of a cDNA library from latently infected human trigeminal ganglia and detection of a VZV transcript

The entire varicella-zoster virus (VZV) genome appears to be present in latently infected human ganglia, but the extent of virus DNA transcription is unknown. Conventional methods to study virus gene transcripts by Northern (RNA) blotting are not feasible, since ganglia are small and VZV DNA is not abundant. To circumvent this problem, we prepared radiolabeled cDNA from ganglionic RNA, hybridized it to Southern blots containing VZV DNA, and demonstrated the presence of a transcript within the SalI C fragment of the virus genome (R. Cohrs, R. Mahalingam, A. N. Dueland, W. Wolf, M. Wellish, and D. H. Gilden, J. Infect. Dis. 166:S24-S29, 1992). To further map VZV transcripts, in the work described here we constructed a cDNA library from poly(A)+ RNA obtained from latently infected human ganglia. Phage DNA isolated from the library was used in PCR amplifications to detect VZV-specific inserts. The specificity of the PCRs was provided by selection of a primer specific for VZV gene 17, 18, 19, 20, or 21 and a second vector-specific primer. VZV gene 21-specific sequences were identified by PCR amplification. The PCR product contained the XhoI cloning site and poly(A)+ sequences between vector and VZV gene 21 sequences. The sequence motif at the 3' end of VZV gene 21, determined by cloning and sequencing of the PCR product, consisted of 49 to 51 nucleotide bases of 3'-untranslated DNA, the termination codon for the VZV gene 21 open reading frame, and DNA sequences reading into the VZV gene 21 open reading frame.

Inhibition of IL-1 release from human monocytes and suppression of streptococcal cell wall and adjuvant-induced arthritis in rats by an extract of Tripterygium wilfordii Hook

1. It was investigated whether an extract of Tripterygium wilfordii Hook f (TW) inhibits IL-1 production by monocytes and suppresses the development of IL-1-dependent arthritis induced in rats with streptococcal cell wall and adjuvant. 2. TW preferentially inhibited IL-1 alpha and IL-1 beta production by bacterial lipopolysaccharide (LPS)-stimulated human monocytes with IC50 of approximately 1 microgram/ml. 3. Oral administration of TW dose-dependently suppressed joint swelling and structural damage in streptococcal cell wall-induced arthritis (ED50 = 20 mg/kg/day) and in adjuvant-induced arthritis (ED50 = 46 mg/kg/day for developing and 8 mg/kg/day for established arthritis).

The ETO portion of acute myeloid leukemia t(8;21) fusion transcript encodes a highly evolutionarily conserved, putative transcription factor

The 8;21 translocation, t(8;21)(q22;q22.3), is seen only in acute myelogenous leukemia and is characteristically associated with the M2 subtype. Subsequent to our identification of the t(8;21) breakpoint region on chromosome 21, we reported that the translocation results in the fusion of the AML1 gene on chromosome 21 with a novel gene on chromosome 8 which we called ETO (for eight twenty-one). Recently, the AML1 portion of the fusion protein has been shown to correspond to the DNA-binding and dimerization domains of the mouse gene, polyoma enhancer binding protein 2 alpha B (pebp 2 alpha B). We report here the complete sequence of the ETO portion of the fusion transcript as compiled from complementary DNAs from a t(8;21) AML patient and compare this with the ETO sequence from a mouse brain transcript. The deduced amino acid sequences are 99% identical. ETO has several features consistent with it being a transcription factor. The ETO sequence is different from the portion of PEBP 2 alpha B it replaces in the AML1/ETO fusion protein, except for their common high content of proline, serine, and threonine residues. Because neither the putative zinc fingers nor the TAF110 homology domain of ETO is present in PEBP2 alpha B, one might expect functional differences in the ability of AML1/ETO protein to affect the levels of transcription of genes normally regulated to some degree by AML1 (PEBP2 alpha B) during myeloid differentiation. The relatively high levels of ETO in developing brain suggest that it could be involved in the regulation of some aspect of neural proliferation or differentiation.

Patient simulation using seamless digital video

This manuscript describes a method for using digital-video technology to create patient simulations in which the simulated patient is always active on the computer screen. We outline the technical method we have developed, and we present the lessons learned in applying the method to develop a prototype patient simulation.

Isolated diffusing capacity reduction in systemic sclerosis

OBJECTIVE

To determine the long-term outcome of patients with systemic sclerosis (SSc) and an isolated reduction in the diffusing capacity for carbon monoxide (DLCO) at the time of initial evaluation.

METHODS

Patients with an isolated reduction in DLCO (i.e., normal forced vital capacity [FVC] and normal ratio of the forced expiratory volume in one second [FEV1] to the FVC) on initial evaluation were identified from among 815 patients with SSc who were carefully followed up throughout their illness. We requested that patients have repeat pulmonary function testing (PFT), and the outcomes of these tests, as well as cardiopulmonary and survival outcomes, were determined.

RESULTS

An isolated reduction in DLCO, with a normal FVC was detected in 152 (19%) of the 815 patients. A subset of those with an isolated reduction in DLCO (11%) developed isolated pulmonary hypertension and had severely reduced survival rates. Pulmonary hypertension was strongly associated with an initial DLCO of less than 55% of predicted normal and a FVC (% predicted)/DLCO (% predicted) ratio of greater than 1.4. Among all patients in whom this ratio was greater than 1.4, 22% developed isolated pulmonary hypertension, compared with only 2% of those whose ratio was less than 1.4 (P less than 0.01). Of the 152 patients with isolated DLCO reduction, 73 (48%) underwent PFTs a mean of 5.4 years (range 2.0-13.2) after the initial PFT. Only 6 (8%) of these 73 patients ever had serious pulmonary disease: 5 had isolated pulmonary hypertension, and 1 had severe pulmonary fibrosis. Half of the patients with a low initial DLCO demonstrated a significant improvement (greater than 20%) at followup testing that could not be explained by the demographic, clinical, or laboratory findings at the first visit.

CONCLUSION

Isolated reduction in DLCO is a frequent abnormality in SSc. Overall, it is associated with a good prognosis for survival and for pulmonary morbidity. A small subset of patients (11%) who have a very low DLCO (less than 55% of predicted) have developed isolated pulmonary hypertension, all of whom had limited scleroderma.

Studies of the initiation of myelination by Schwann cells

The rapid morphologic changes in Schwann cells and in their relationships to axons during the transition from the premyelinating to the myelinating state have been known for more than 15 years. The sorting of axons by dividing Schwann cells, the establishment of a 1:1 relationship between a postmitotic Schwann cell, and the onset of myelin sheath formation have all been described in detail. However, the chain of molecular events and mechanisms by which these morphologic changes are regulated has not been elucidated. In this chapter we have reviewed results that strongly suggest that the adhesion molecule L1 is one of the important determinants that mediate the elongation of the Schwann cell along the axon, and the extension of Schwann processes to engulf axons. Thus, L1 functions to promote the spreading of the Schwann cell process over the surface of the axon. L1 does not appear to be exclusively involved in the adhesion of Schwann cells to axons, in the activation of Schwann cell proliferation by axons, or in the induction of synthesis of extracellular matrix proteins. The results from the anti-L1 blocking experiments further provided clues for an understanding of how the expression of GalC and MAG, which are both likely to be involved in the initiation of myelination, are regulated. These results imply that the overall regulation of expression of these early myelin components could require controls other than a single signaling mechanism derived from contact with axons. We propose that the deposition of basal lamina or one of its components could also be involved. Finally, the results from anti-GalC-blocking experiments indicated that GalC is involved in the mechanism of early growth of the myelin spiral.

Mechanisms of injury in unilateral testis torsion

We investigated the mechanisms of injury involved in unilateral testis torsion as well as the interventional effects of orchiectomy at 48 h and immunosuppression with corticosteroids in rats. Torsion was associated with abnormal contralateral testis histology and raised antilymphocytes and antisperm antibody titers. Both orchiectomy and steroid administration lessened these findings, suggesting that an immunological process underlies the abnormality seen in this experiment model.

Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery

Within three weeks of definitive surgical intervention, 467 patients with histologically proved malignant glioma were randomized to receive one of four treatment regimens: semustine (MeCCNU), radiotherapy, carmustine (BCNU) plus radiotherapy, or semustine plus radiotherapy. We analyzed the data for the total randomized population and for the 358 patients in whom the initial protocol specifications were met (the valid study group). Observed toxicity included acceptable skin reactions secondary to radiotherapy and reversible leukopenia and thrombocytopenia due to chemotherapy. Radiotherapy used alone or in combination with a nitrosourea significantly improved survival in comparison with semustine alone. The group receiving carmustine plus radiotherapy had the best survival, but the difference in survival between the groups receiving carmustine plus radiotherapy and semustine plus radiotherapy was not statistically significant. The combination of carmustine plus radiotherapy produced a modest benefit in long-term (18-month) survival as compared with radiotherapy alone, although the difference between survival curves was not significiant at the 0.05 level. This study suggests that it is best to use radiotherapy in the post-surgical treatment of malignant glioma and to continue the search for an effective chemotherapeutic regimen to use in addition to radiotherapy.

Pathologic flail chest complicating multiple myeloma

Pathologic flail chest complicated the initial presentation of multiple myeloma in two patients. Both had severe hypercalcemia and diffuse bone disease. Atelectasis and pulmonary edema preceded the appearance of flail chest in one patient; atelectasis complicated the flail chest in the second patient and increased the severity of the flail. Both were treated with radiotherapy and chemotherapy. However, delay in stabilizing the first patient's chest wall with positive airway pressure was followed by extension of the flail chest and irreversible respiratory failure. On the other hand, prolonged stabilization of the chest wall in the second patient until a chemotherapy-induced remission occurred was associated with resolution of the flail chest.

Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas. A cooperative clinical trial

A controlled, prospective, randomized study evaluated the use of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and/or radiotherapy in the treatment of patients who were operated on and had histological confirmation of anaplastic glioma. A total of 303 patients were randomized into this study, of whom 222 (73%) were within the Valid Study Group (VSG), having met the protocol criteria of neuropathology, corticosteroid control, and therapeutic approach. Patients were divided into four random groups, and received BCNU (80 mg/sq m/day on 3 successive days every 6 to 8 weeks), and/or radiotherapy (5000 to 6000 rads to the whole brain through bilateral opposing ports), or best conventional care but no chemotherapy or radiotherapy. Analysis was performed on all patients who received any amount of therapy (VSG) and on the Adequately Treated Group (ATG), who had received 5000 or more rads radiotherapy, two or more courses of chemotherapy, and had a minimum survival of 8 or more weeks (the interval that would have been required to have received either the radiotherapy or chemotherapy). Median survival of patients in the VSG was, best conventional care: 14 weeks (ATG: 17.0 weeks); BCNU: 18.5 weeks (ATG: 25.0 weeks); radiotherapy: 35 weeks (ATG: 37.5 weeks); and BCNU plus radiotherapy: 34.5 weeks (ATG: 40.5 weeks). All therapeutic modalities showed some statistical superiority compared to best conventional care. There was no significant difference between the four groups in relation to age distribution, sex, location of tumor, diagnosis, tumor characteristics, signs or symptoms, or the amount of corticosteroid used. An analysis of prognostic factors indicates that the initial performance status (Karnofsky rating), age, the use of only a surgical biopsy, parietal location, the presence of seizures, or the involvement of cranial nerves II, III, IV, and VI are all of significance. Toxicity included acceptable, reversible thrombocytopenia and leukopenia.

Evaluation of mithramycin in the treatment of anaplastic gliomas

A controlled, prospective, randomized study evaluated the use of mithramycin in the treatment of anaplastic glioma compared to a similar group of patients receiving best conventional care. From a total of 116 patients in the study, 96 were within the valid study group. All patients were operated on, had histological confirmation of anaplastic glioma, and received radiotherapy at the discretion of the principal investigator. Fifty-two patients received mithramycin at a dose of 25 mug/kg/day for 21 days, while 44 patients were in the control group. There was no significant difference in the median survival from time of randomization in those receiving mithramycin (21 weeks) as compared to those not receiving mithramycin (26 weeks). There was no significant difference between the two groups in relation to age distribution, sex, location, diagnosis, tumor characteristics, signs or symptoms, or radiotherapy received. Duration of symptoms correlates positively with survival and was also significantly longer in the control group than in the treated group. This, however, did not account for the failure of mithramycin to be found an effective agent. Although the study was not designed to evaluate the efficacy of radiotherapy, patients who were so treated had a significant improvement in survival. The toxic complications of mithramycin included gastrointestinal symptoms, dermatological involvement, anemia, and liver dysfunction, indicating the need for close supervision.

[Intraocular and cerebral reticular sarcoma]

An anatomo-clinical study is presented of a reticulum cell sarcoma (or lymphosarcoma), limited to the eye-ball and the brain. The eye disease developed as a chronic, diffused hypertensive uveitis. The diagnosis of the nature of the brain tumour was made by cytological study of the cerebro-spinal fluid.

Myocardial perfusion and metabolism at normothermic and hypothermic levels

Changes in intramyocardial carbon dioxide tension (Pco2) and arterial oxygen tension (Po2) were recorded in dogs with a mass spectrometer after temporary occlusion of the aorta and the proximal part of the anterior descending coronary artery at normothermic and hypothermic levels. Patterns of hypoxic and hypercapnic changes and their recovery were favorably modified with moderate hypothermia. Deep levels of hypothermia seemed to enhance this protective effect and progressively slow the myocardial metabolism. Occlusion of the proximal part of the anterior descending coronary artery for 30 minutes had a regional effect similar to the general myocardial changes recorded after aortic clamping, while the posterior myocardial probe showed stable control values. These data support previous studies showing that moderate hypothermia halves the oxygen consumption and doubles the "safe" period of anoxic arrest.