Patient Characteristics and Variables Influencing Acute Medical Flow

Waiting times are the most widely used indicator of patient flow. This project aims to analyse 24-hour variation in referrals and waiting times for patients referred to the Acute Medical Service (AMS). A retrospective cohort study was conducted at the AMS of Wales' largest hospital. Collected data included patient characteristics, referral times, waiting times and adherence to Clinical Quality Indicators (CQIs). Peak referral times were found between 11:00-19:00. Peak waiting times occurred between 17:00-01:00, which was longer on weekdays in comparison to weekends. Referrals between 17:00-21:00 had the longest waiting times with > 40% of patients failing both junior and senior CQIs. Mean and median age and NEWS were higher between 17:00-09:00. Weekday evening and nights are problematic for acute medical patient flow. Interventions, including workforce, should be targeted towards these findings.

Persistent viral shedding of SARS-CoV-2 in faeces - a rapid review

AIM

In addition to respiratory symptoms, COVID-19 can present with gastrointestinal complaints suggesting possible faeco-oral transmission. The primary aim of this review was to establish the incidence and timing of positive faecal samples for SARS-CoV-2 in patients with COVID-19.

METHODS

A systematic literature review identified studies describing COVID-19 patients tested for faecal virus. Search terms for MEDLINE included 'clinical', 'faeces', 'gastrointestinal secretions', 'stool', 'COVID-19', 'SARS-CoV-2' and '2019-nCoV'. Additional searches were done in the American Journal of Gastroenterology, Gastroenterology, Gut, Lancet Gastroenterology and Hepatology, the World Health Organization Database, the Centre for Evidence-Based Medicine, New England Journal of Medicine, social media and the National Institute for Health and Care Excellence, bioRxiv and medRxiv preprints. Data were extracted concerning the type of test, number and timing of positive samples, incidence of positive faecal tests after negative nasopharyngeal swabs and evidence of viable faecal virus or faeco-oral transmission of the virus.

RESULTS

Twenty-six relevant articles were identified. Combining study results demonstrated that 53.9% of those tested for faecal RNA were positive. The duration of faecal viral shedding ranged from 1 to 33 days after a negative nasopharyngeal swab with one result remaining positive 47 days after onset of symptoms. There is insufficient evidence to suggest that COVID-19 is transmitted via faecally shed virus.

CONCLUSION

There is a high rate of positive polymerase chain reaction tests with persistence of SARS-CoV-2 in faecal samples of patients with COVID-19. Further research is needed to confirm if this virus is viable and the degree of transmission through the faeco-oral route. This may have important implications on isolation, recommended precautions and protective equipment for interventional procedures involving the gastrointestinal tract.

Persistent viral shedding of SARS-CoV-2 in faeces - a rapid review

AIM

In addition to respiratory symptoms, COVID-19 can present with gastrointestinal complaints suggesting possible faeco-oral transmission. The primary aim of this review was to establish the incidence and timing of positive faecal samples for SARS-CoV-2 in patients with COVID-19.

METHODS

A systematic literature review identified studies describing COVID-19 patients tested for faecal virus. Search terms for MEDLINE included 'clinical', 'faeces', 'gastrointestinal secretions', 'stool', 'COVID-19', 'SARS-CoV-2' and '2019-nCoV'. Additional searches were done in the American Journal of Gastroenterology, Gastroenterology, Gut, Lancet Gastroenterology and Hepatology, the World Health Organization Database, the Centre for Evidence-Based Medicine, New England Journal of Medicine, social media and the National Institute for Health and Care Excellence, bioRxiv and medRxiv preprints. Data were extracted concerning the type of test, number and timing of positive samples, incidence of positive faecal tests after negative nasopharyngeal swabs and evidence of viable faecal virus or faeco-oral transmission of the virus.

RESULTS

Twenty-six relevant articles were identified. Combining study results demonstrated that 53.9% of those tested for faecal RNA were positive. The duration of faecal viral shedding ranged from 1 to 33 days after a negative nasopharyngeal swab with one result remaining positive 47 days after onset of symptoms. There is insufficient evidence to suggest that COVID-19 is transmitted via faecally shed virus.

CONCLUSION

There is a high rate of positive polymerase chain reaction tests with persistence of SARS-CoV-2 in faecal samples of patients with COVID-19. Further research is needed to confirm if this virus is viable and the degree of transmission through the faeco-oral route. This may have important implications on isolation, recommended precautions and protective equipment for interventional procedures involving the gastrointestinal tract.

Depression, lifestyle factors and cognitive function in people living with HIV and comparable HIV-negative controls

Objectives

We investigated whether differences in cognitive performance between people living with HIV (PLWH) and comparable HIV‐negative people were mediated or moderated by depressive symptoms and lifestyle factors.

Methods

A cross‐sectional study of 637 ‘older’ PLWH aged ≥ 50 years, 340 ‘younger’ PLWH aged < 50 years and 276 demographically matched HIV‐negative controls aged ≥ 50 years enrolled in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) study was performed. Cognitive function was assessed using a computerized battery (CogState). Scores were standardized into Z‐scores [mean = 0; standard deviation (SD) = 1] and averaged to obtain a global Z‐score. Depressive symptoms were evaluated via the Patient Health Questionnaire (PHQ‐9). Differences between the three groups and the effects of depression, sociodemographic factors and lifestyle factors on cognitive performance were evaluated using median regression. All analyses accounted for age, gender, ethnicity and level of education.

Results

After adjustment for sociodemographic factors, older and younger PLWH had poorer overall cognitive scores than older HIV‐negative controls (P < 0.001 and P = 0.006, respectively). Moderate or severe depressive symptoms were more prevalent in both older (27%; P < 0.001) and younger (21%; P < 0.001) PLWH compared with controls (8%). Depressive symptoms (P < 0.001) and use of hashish (P = 0.01) were associated with lower cognitive function; alcohol consumption (P = 0.02) was associated with better cognitive scores. After further adjustment for these factors, the difference between older PLWH and HIV‐negative controls was no longer significant (P = 0.08), while that between younger PLWH and older HIV‐negative controls remained significant (P = 0.01).

Conclusions

Poorer cognitive performances in PLWH compared with HIV‐negative individuals were, in part, mediated by the greater prevalence of depressive symptoms and recreational drug use reported by PLWH.

Associations between cognitive impairment and patient-reported measures of physical/mental functioning in older people living with HIV

OBJECTIVES

While cognitive impairment is frequently reported in HIV-positive individuals and has historically been associated with poorer functional outcomes, the associations between cognitive impairment and patient-reported outcome measures (PROMs) in contemporary cohorts are unclear.

METHODS

We tested cognitive function using a computerized battery (CogState^™ ) in 290 HIV-positive and 97 HIV-negative individuals aged ≥ 50 years participating in the Pharmacokinetic and Clinical Observations in People Over Fifty (POPPY) study. Participants completed questionnaires detailing physical and mental health [Short Form Health Survey (SF-36)], cognitive function [European AIDS Clinical Society (EACS) questions], activities of daily living [Lawton Instrumental Activities of Daily Living (IADL)], depression [Patient Depression Questionnaire (PHQ-9) and Centres for Epidemiologic Studies Depression scale (CES-D)], falls and sexual desire. Cognitive impairment was defined using the Frascati criteria, global deficit score (GDS) and multivariate normative comparison (MNC). In the HIV-positive group, the classification performances of the different definitions of cognitive impairment and dichotomized questionnaire results were calculated.

RESULTS

The prevalence of cognitive impairment in the HIV-positive group was 34.5% (GDS), 30.0% (Frascati) and 22.1% (MNC), with only 2% diagnosed with HIV-associated dementia. In general, the associations between cognitive impairment and PROMs were weak regardless of the definition used: mean c-statistics were 0.543 (GDS), 0.530 (MNC) and 0.519 (Frascati). Associations were similar using the global T-score to define cognitive impairment. Summary health scores (SF-36) were lower, but only significantly so for those with cognitive impairment identified using MNC, for both mental health (61.4 vs. 75.8; P = 0.03) and physical health (60.9 vs. 75.0; P = 0.03).

CONCLUSIONS

The associations between cognitive impairment and PROMs were weak, possibly because impairment was mild and therefore largely asymptomatic. Further work is needed to elucidate the clinical implications of cognitive impairment in HIV-disease.

Escherichia coli bacteraemia: how preventable is it?

Mandatory bacteraemia reporting was extended to include Escherichia coli from June 2011. The purpose of this study was to investigate whether the success seen in reducing meticillin-resistant Staphylococcus aureus infection rates could be duplicated with E. coli. All cases of E. coli bacteraemia occurring at our Trust in 2010 were reviewed. There were 216 episodes of E. coli bacteraemia, of which 63% were community-acquired. Only 19% had a potentially preventable cause identified, the majority (71%) of whom had urinary catheter-associated bacteraemia. These data must be kept in mind should targets to reduce E. coli bacteraemia be set in the future.

New Measurement of the π0 radiative decay width

High precision measurements of the differential cross sections for π0 photoproduction at forward angles for two nuclei, 12C and 208Pb, have been performed for incident photon energies of 4.9-5.5 GeV to extract the π0→γγ decay width. The experiment was done at Jefferson Lab using the Hall B photon tagger and a high-resolution multichannel calorimeter. The π0→γγ decay width was extracted by fitting the measured cross sections using recently updated theoretical models for the process. The resulting value for the decay width is Γ(π0→γγ)=7.82±0.14(stat)±0.17(syst)  eV. With the 2.8% total uncertainty, this result is a factor of 2.5 more precise than the current Particle Data Group average of this fundamental quantity, and it is consistent with current theoretical predictions.

Personalised learning environments – Part 1: Core development issues for construction

Purpose

This paper aims to introduce the concepts and key issues surrounding the development of personalised learning environments.

Design/methodology/approach

This is a distillation of core research material gathered from a detailed literature review covering the concepts and issues surrounding the development of personalised learning environments (PLE).

Findings

This paper finds that most e‐learning applications are rather static and represent a generic approach to tutoring. Therefore, by default, they do not fully embrace learners' needs (i.e. learning styles). This paper also highlights key issues of incorporating learning styles into a PLE; and, has identified a “roadmap” for shaping and identifying the rubrics for further work in this field.

Originality/value

This paper is a very useful source in developing a PLE incorporating learning styles for learners.

Genetic thrombophilic mutations among couples with recurrent miscarriage

BACKGROUND

Some cases of recurrent first trimester miscarriage (RM)-the loss of three or more consecutive pregnancies at <12 weeks' gestation-have a thrombotic aetiology.

METHODS

We determined (i) the prevalence of three thrombophilic mutations [factor V Leiden (FVL), prothrombin G20210A (PTG) and methylenetetrahydrofolate reductase (MTHFR) C677T] amongst 357 Caucasian couples with RM and 68 parous Caucasian couples with no history of miscarriage and (ii) the prospective outcome of untreated pregnancies amongst couples with RM in which either partner carried a thrombophilic mutation.

RESULTS

The allele frequencies of FVL (2%), PTG (2%) and MTHFR C677T (31%) were similar between cases and controls. The prevalence of multiple thrombophilic mutations (greater than one mutation) was also similar between cases and controls. Amongst couples in whom either partner carried greater than one thrombophilic allele, the relative risk of miscarriage in a future untreated pregnancy was 1.9 (95% confidence interval, 1.3-2.8) compared with those couples who carried no thrombophilic mutation.

CONCLUSION

The prevalence of thrombophilic mutations is similar in couples with RM and parous controls. In couples with RM, multiple genetic thrombophilic mutations in either partner significantly increases the risk of miscarriage in a subsequent pregnancy.

Heavy hydrides: H2Te ultraviolet photochemistry

The room-temperature ultraviolet absorption spectrum of H2Te has been recorded. Unlike other group-6 hydrides, it displays a long-wavelength tail that extends to 400 nm. Dissociation dynamics have been examined at photolysis wavelengths of 266 nm (which lies in the main absorption feature) and 355 nm (which lies in the long-wavelength tail) by using high-n Rydberg time-of-flight spectroscopy to obtain center-of-mass translational energy distributions for the channels that yield H atoms. Photodissociation at 355 nm yields TeH(2Pi1/2) selectively relative to the TeH(2Pi3/2) ground state. This is attributed to the role of the 3A' state, which has a shallow well at large R(H-TeH) and correlates to H+TeH(2Pi1/2). Note that the 2Pi1/2 state is analogous to the 2P1/2 spin-orbit excited state of atomic iodine, which is isoelectronic with TeH. The 3A' state is crossed at large R only by 2A", with which it does not interact. The character of 3A' at large R is influenced by a strong spin-orbit interaction in the TeH product. Namely, 2Pi1/2 has a higher degree of spherical symmetry than does 2Pi3/2 (recall that I(2P1/2) is spherically symmetric), and consequently 2Pi1/2 is not inclined to form either strongly bonding or antibonding orbitals with the H atom. The 3A'<--X transition dipole moment dominates in the long-wavelength region and increases with R. Structure observed in the absorption spectrum in the 380-400 nm region is attributed to vibrations on 3A'. The main absorption feature that is peaked at approximately 240 nm might arise from several excited surfaces. On the basis of the high degree of laboratory system spatial anisotropy of the fragments from 266 nm photolysis, as well as high-level theoretical studies, the main contribution is believed to be due to the 4A" surface. The 4A"<--X transition dipole moment dominates in the Franck-Condon region, and its polarization is in accord with the experimental observations. An extensive secondary photolysis (i.e., of nascent TeH) is observed at 266 and 355 nm, and the corresponding spectral features are assigned. Analyses of the c.m. translational energy distributions yield bond dissociation energies D0. For H2Te and TeH, these are 65.0+/-0.1 and 63.8+/-0.4 kcalmol, respectively, in good agreement with predictions that use high-level relativistic theory.

Allo-immunization elicits CCR5 antibodies, SDF-1 chemokines, and CD8-suppressor factors that inhibit transmission of R5 and X4 HIV-1 in women

Studies in humans suggest that allo-immunization induces CC-chemokines, CD8-suppressor factors (SF) and anti-HIV immunity. Here we report that allo-immunization with unmatched leucocytes from partners of women with recurrent spontaneous abortion elicits specific antibodies to the CCR5 receptor. Such antibodies inhibit replication of M-tropic HIV-1 (R5) and MIP-1beta-mediated chemotaxis. These CCR5 antibodies were also found in the sera of multiparous women that were naturally immunized by semi-allogeneic fetal antigens. The specificity of these antibodies was demonstrated by adsorption with CCR5 transfected HEK-293 cells, a baculovirus CCR5 preparation and a peptide of the 2nd extra-cellular loop of CCR5. Allo-immunization also stimulated increased concentrations of the CXC chemokine, SDF-1alpha and CD8-SF that inhibit T-tropic HIV-1 (X4) replication. We suggest that allo- immunization may elicit (a) CC chemokines, CCR5 antibodies and CD8-SF that inhibit M-tropic HIV-1 infection and (b) the CXC chemokine SDF-1alpha and CD8-SF that inhibit T-tropic HIV-1 infection.

A prototype decision support system for MR spectroscopy-assisted diagnosis of brain tumours

Our objective is to develop a decision support system that improves the accuracy of non-invasive brain tumour diagnosis and grading by enabling radiologists to use data from Magnetic Resonance Spectroscopy (MRS). The system, which uses pattern recognition techniques, is trained on a validated database of spectra and associated clinical information to provide automated classification of spectra from brain tumours. An innovative user-interface presents classification results as a two-dimensional overview plot in which points representing cases of different diseases form distinct clusters. Users can inspect any cases in these plots and compare them with the new, unknown spectrum. Hence, the overview plot can both communicate the classification of a case and help provide explanation for that classification in part by supporting human case-based reasoning. This paper describes the development of a prototype system implemented in JAVA.

Allo-immunization elicits CD8+ T cell-derived chemokines, HIV suppressor factors and resistance to HIV infection in women

We assessed the potential for an allogeneic-based vaccine against HIV infection in women who were allo-immunized with their partners' mononuclear leucocytes to prevent spontaneous recurrent abortion. Within 1 month of allo-immunization, there was significant upregulation in the concentrations of CD8 cell-derived suppressor factor activity, RANTES, and macrophage inflammatory proteins 1alpha and 1beta. Allo-immunization also downregulated the proportion of cells with CCR5 and CXCR4 receptors. We also found a dose-dependent decrease in HIV infectivity of CD4+ cells in vitro after allo-immunization with both primary and T-cell line adapted HIV-1. This study provides a rational basis for an alternative or complementary strategy of allo-immunization against HIV infection.

Alzheimer's disease: correlation of the suppression of beta-amyloid peptide secretion from cultured cells with inhibition of the chymotrypsin-like activity of the proteasome

Peptide aldehyde inhibitors of the chymotrypsin-like activity of the proteasome (CLIP) such as N-acetyl-Leu-Leu-Nle-H (or ALLN) have been shown previously to inhibit the secretion of beta-amyloid peptide (A beta) from cells. To evaluate more fully the role of the proteasome in this process, we have tested the effects on A beta formation of a much wider range of peptide-based inhibitors of CLIP than published previously. The inhibitors tested included several peptide boronates, some of which proved to be the most potent peptide-based inhibitors of beta-amyloid production reported so far. We found that the ability of the peptide aldehyde and boronate inhibitors to suppress A beta formation from cells correlated extremely well with their potency as CLIP inhibitors. Thus, we conclude that the proteasome may be involved either directly or indirectly in A beta formation.

Transferring public-health nursing research to health-system planning: assessing the relevance and accessibility of systematic reviews

A descriptive study was designed to gain an understanding of the research needs, perceptions of barriers to research utilization, and attitudes towards systematic reviews of decision-makers in public health at the level of systems planning. Public-health consultants and managers in Ontario were surveyed about barriers to research utilization and awareness of and attitudes towards systematic reviews as a method of/vehicle for research transfer. Access to 5 completed reviews was provided in summary, abstract, and full form, and on diskette, hard copy, and Internet. A follow-up survey at 3 months assessed use, relevance, application, and further dissemination of the reviews. A total of 242 people in positions of public-health policy and decision-making participated. Respondents reported a great, largely unmet, need for research evidence. They viewed systematic reviews as likely to overcome the barriers to research use related to critical appraisal, time, timeliness, availability, cost and credibility, but not the barriers related to policy climate, authority, or implementation resources. Three months after requesting a review, 93% said they would follow it up; 91% remembered receiving it, and 71% of these had read it while 23% stated it played a part in program planning or decision-making.

Mucosal inflammation in severe glucocorticoid-dependent asthma

To improve our understanding of the inflammatory mechanisms underlying severe disease, a biopsy study was performed comparing 15 clinically unstable glucocorticoid-dependent asthmatics, 10 mild asthmatics, and 10 control subjects. Compared with mild asthma, severe asthma was characterized by reduced mucosal eosinophilia. Whilst no significant differences were found in the numbers of mast cells, neutrophils, CD3+ and CD4+ T-cells between the three groups, up to a 4-fold increase In the numbers of activated T-lymphocytes bearing the interleukin (IL)-2 receptor (IL-2R) was found in the mucosa in severe asthma compared to mild asthma (p = 0.03) and control subjects (p = 0.003). Compared to control subjects, the mucosa of severe asthmatics contained significantly (p = 0.02) higher numbers of IL-5+ cells, with no differences between mild and severe disease. In contrast, staining for the anti-IL-4 monoclonal antibody 3H4 revealed that biopsies from mild asthmatics contained more IL4+ cells than biopsies from severe asthmatics and control subjects (p = 0.0008). In the severe asthmatics, a close correlation (r(s) = 0.76, p = 0.005) was found between the numbers of IL-2R-bearing cells and the variability in peak expiratory flow. In conclusion, persistent T-cell activation is a prominent feature of severe asthma. These results also indicate that interleukin-5, and not interleukin-4, is upregulated in severe disease.

Proteolytic fragments of Alzheimer's disease-associated presenilin 1 are present in synaptic organelles and growth cone membranes of rat brain

Previous studies have demonstrated the molecular linkage of three causative genes for early-onset Alzheimer's disease: the presenilin 1 gene on chromosome 14, the presenilin 2 gene on chromosome 1, and the amyloid precursor protein gene on chromosome 21. In the present study, we have investigated the distributions of the approximately 20-kDa C-terminal and approximately 30-kDa N-terminal fragments of presenilin 1 and the amyloid precursor protein in rat brain and compared them with the distribution of several marker proteins. The fragments of presenilin 1 are present in synaptic plasma membranes, neurite growth cone membranes, and small synaptic vesicles of rat brain. Both proteolytic fragments are coenriched in the corresponding tissue fractions. Based on this observation, it seems likely that N- and C-terminal presenilin 1 fragments form a functional unit while remaining associated. In contrast to a predominant subcellular localization of presenilin 1 to the endoplasmic reticulum and Golgi apparatus in different cell lines, our results indicate that rat brain presenilin 1 fragments exit from these biosynthetic compartments to reach synaptic organelles in neurons.

Surviving social assistance: 12-month prevalence of depression in sole-support parents receiving social assistance

BACKGROUND

Although it is generally recognized that poverty and depression can coexist among single parents receiving social assistance, there is insufficient research on this topic. The goals of this study therefore were to investigate the prevalence, correlates and health care expenditures associated with depression among sole-support parents receiving social assistance.

METHODS

Sole-support parents who had applied for social assistance in 2 regions of southwestern Ontario were included in the study. Depression was diagnosed with the 1994 University of Michigan Composite International Diagnostic Interview short forms.

RESULTS

The 12-month prevalence rate of depressive disorder among the parents interviewed was 45.4% (345/760). A total of 247 (32.5%) had major depressive disorder alone, 19 (2.5%) had dysthymia, and 79 (10.4%) had both major depressive disorder and dysthymia ("double depression"). Those with major depressive disorder, particularly double depression, had significantly higher rates of coexisting psychiatric disorder than those without depressive disorders. Parents with depression reported higher rates of developmental delay and behaviour problems in their children than parents without depression. Expenditures for health care services were higher for parents with depression and for their children than for parents without depressive disorder and their children.

INTERPRETATION

Single parents receiving social assistance have high rates of depression. Such parents with depression also have higher rates of other psychiatric disorders and higher expenditures for health care services, and their children have higher rates of developmental delay and behaviour problems.

Maternal response to paternal trophoblast antigens

PROBLEM

What is the function of the immunoglobulin (Ig) G antibody bound to trophoblast in normal pregnancy, and what is the antigen?

METHOD

IgG was acid eluted from term human placental microvesicles and reacted with the antigen, R80K, left on the vesicles. The eluted antibody was used to detect the antigen on monocytes, lymphocytes, and lymphoblastoid cell lines. The eluted antibody is highly polymorphic, but monoclonal antibodies (mAbs) were made against conserved regions of the molecule. These also reacted with the murine equivalent of the human R80K and were used in inhibition studies of natural killer (NK) cell killing and the mouse abortion models, CBA x DBA2 F1 resorption in CBA females, the endotoxin-induced resorption model, and a sonic stress-induced murine resorption model.

RESULTS

All 600 syncytiotrophoblast microvesicle preparations of human term placenta had IgG antibody bound, elutable at pH 3.0. The eluted antibody reacted with about 15% of unrelated human placentae. In horses mares make detectable antibody early in pregnancy, at about the time of implantation. The IgG antibody was bound to an 80-kDa protein (R80K) also detected on B lymphocytes and monocytes. In HLA homozygous lymphoblastoid B cell lines, which reacted with one or more eluted antibodies, had a pattern of cytotoxicity independent of HLA Class I; and as a single 80-kDa peptide chain, R80K did not resemble HLA molecules. Genetic studies in horses show that of the two paternal allotypes of R80K detectable by placental alloantibodies, only one, usually the grandpaternal one, is present in all the placentae of a sibship. Two of 26 eluted human antibodies had affinity for K562 and inhibited killing by human peripheral blood NK cells. One mAb, BA11, against a conserved site on R80K inhibited killing of K562, and also reacted with the murine R80K homologue. BA11 inhibited murine NK cell killing and virtually completely inhibited three NK cell-dependent mouse resorption models.

CONCLUSION

R80K protein is a target molecule for NK cell activity expressed on all placentae. It has a polymorphic alloantigenic determinant completely covered with maternal antibody in all successful term pregnancies. In murine NK cell-dependent models of abortion, a mAb against a monomorphic determinant present in human and murine R80K prevents abortion very effectively. It seems that the R80K molecule must be covered with antibody to prevent NK attacks on trophoblast.

Collection and normal levels of the amyloid precursor protein in plasma

The amyloid precursor protein is contained in platelet alpha granules and released with degranulation. Methods are described to control for amyloid precursor protein release from platelets during blood collection and processing. In normal subjects (n = 97; age range, 44-84 years), the average plasma level of amyloid precursor protein was 6.5 +/- 1.8 ng/ml.

Identification of a novel cis-acting element participating in maximal induction of the human low density lipoprotein receptor gene transcription in response to low cellular cholesterol levels

In this paper, we present both in vivo and in vitro evidence for the presence of a novel cis-acting regulatory element that is required for maximal induction of the human low density lipoprotein (LDL) receptor gene following depletion of cellular sterols in HepG2 cells. First, in vivo dimethyl sulfate footprinting of the human LDL receptor promoter before and after transcriptional induction in HepG2 cells revealed protection from -145 to -126, 5'-GAGCTTCACGGGTTAAAAAG-3' (referred to as FP1 site). Second, transient transfections of HepG2 cells with promoter luciferase reporter constructs containing the FP1 site resulted in significant enhancement (approximately 375%) of reporter gene expression in response to low levels of sterols compared with parallel plasmid without the FP1 site. In addition, this response was markedly attenuated on nucleotide substitutions within the FP1 site. Third, by electrophoretic mobility shift assays, the FP1 sequence was found to bind protein(s) from HepG2 nuclear extracts in a sequence-specific manner. In vitro binding of the FP1 mutants paralleled the results obtained for their in vivo transcription. On the basis of competition profiles, the FP1-binding factor is different from the known transcription factors binding to the AT-rich CArG and GArC motifs. Furthermore, the FP1-binding protein is not specific to HepG2 cells because nuclear factor(s) with the same specificity was observed in nuclear extracts of non-hepatic HeLa cells. We conclude that transcriptional induction of the LDL receptor gene in response to sterol depletion is mediated, in part, by an highly conserved novel cis-acting element through the binding of specific nuclear protein(s).

A systematic overview of adolescent suicide prevention programs

The purpose of this systematic overview was to summarize evidence about the effectiveness of adolescent suicide prevention curricula programs. A comprehensive search of published and unpublished literature resulted in retrieval of 11 relevant studies. The findings, of this overview indicate that there is currently insufficient evidence to support curriculum-based suicide prevention programs. The evidence suggests that there may be both beneficial and harmful effects of the programs on students. In most studies, knowledge related to suicide improved as a result of the programs. However, studies found both beneficial and harmful effects on attitudes related to suicide. One study found in increase in hopelessness and maladaptive coping for males following the intervention. The literature suggests that more broadly based comprehensive school health programs should be evaluated for their effectiveness in addressing the determinants of adolescent risk behaviour.

A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions

The purpose of this systematic overview was to assess the evidence for the effectiveness of public health nursing interventions when carried out by the strategy of home visiting. A search of published and unpublished literature resulted in retrieval of 108 articles; 77 articles were judged to be relevant. Validity criteria included method of allocation to the study groups, level of agreement to participate in the study, control for confounders, method of data collection (pretesting of data collection tools, blinding of data collectors to group allocation of study participants), quantitative measure of effect and percentage of participants available at follow-up. Using these criteria, 9 articles were judged to be strong, 5 moderate and 63 weak. There were no reported negative effects of home visiting in the 9 strong articles. Positive outcomes included improvement in children's mental development, mental health and physical growth; reduction in mother's anxiety, depression, and tobacco use; improvement in maternal employment, nutrition and other health habits; government cost saving; and reduced level of care required for the elderly.

Changing nursing practice--trisectoral collaboration in decision making

In an age of cost containment, agency partnerships have become an essential element for future planning and program implementation. This paper describes a trisectoral collaboration of a hospital, health department, university and school of nursing to compare the efficacy and efficiency of referral decisions of hospital staff nurses to those of the public health liaison nurses (LNs). A process to identify decision criteria was undertaken and an educational programme was designed to assist the staff nurses with the referral process and to assure consistency of decision making. The two groups were then compared. The results of the study found staff nurses, using the decision criteria, identified more patients who required public health nursing visits than did the liaison nurses, refusal rate of the patients to participate was no different, staff nurses cost less than LNs and job satisfaction was not significantly altered for either group. In addition to providing information to guide administrative and clinical decision making, the project also provided a learning experience for the staff of three agencies in conducting research and in using evidence-based practice to change traditional practice.

A subset of patients with recurrent spontaneous abortion is deficient in transforming growth factor beta-2-producing "suppressor cells" in uterine tissue near the placental attachment site

PROBLEM

To determine if patients with unexplained recurrent miscarriage have a deficiency of decidual immunosuppressor cells that produce transforming growth factor beta type 2, as has been found in mice with abortion due to rejection and/or trophoblast failure.

METHODS

Decidual biopsy specimens were taken as near to the placental attachment site as possible under ultrasound guidance from first trimester legal termination (control) patients with recurrent miscarriage and non-viable pregnancy, and from patients with sporadic missed abortion. The tissue was tested for TGF beta-2+ suppressor cells by in situ hybridization, immunohistochemistry, and analysis of supernatants.

RESULTS

TGF beta-2-related suppressor molecules similar but not identical to those identified in pregnant mice were released by decidual lymphoid cells. Fifty percent of 14 recurrent miscarriage patients showed a lack of suppressor cells and 59% were subnormal in comparison to 20 controls and 5 sporadic miscarriage patients, where 80-85% of the patients had detectable suppressor cells.

CONCLUSIONS

Suppressor cell deficiency is compatible with a role for rejection and/or trophoblast failure in some patients with recurrent miscarriage. Presence of suppressor cells in most patients with missed abortion (4/5) is compatible with an alternative cause of fetal death, similar to findings reported in genetic fetal death mice.

Public health nursing clientele shared with social assistance: proportions, characteristics and policy implications

This study was designed to determine (1) the extent to which public health nursing visits and social services income programs serve the same population (shared clientele), (2) whether shared and unshared clientele differ in their characteristics, and (3) whether those who use both these services are high users of other health and social services. A computerized record linkage showed that 17% of individual public health nursing clients were shared with social services. Shared clientele had more social, perinatal, emotional and mental health problems. It is these characteristics, rather than the simultaneous use of both services, that were associated with more public health nursing visits, days in care, and use of all other health providers. The trend away from in-home nursing visits may create a situation of unmet need. While health and social resources are expended on persons with children with greater risk circumstances, the question remains about the efficacy and efficiency of this mix of service for parents and children receiving social assistance.

Comprehensive T-cell epitope mapping of HIV-1 env antigens reveals many areas recognized by HIV-1-seropositive and by low-risk HIV-1-seronegative individuals

Peripheral blood mononuclear cells from 12 asymptomatic human immunodeficiency virus (HIV)-1-seropositive and nine HIV-1-seronegative donors were screened for proliferative T-lymphocyte responses to peptides derived from a consensus sequence of the HIV-1 env gene products from 25 HIV-1 isolates. Two hundred seventy-eight overlapping 17mer peptides, incremented by three residues each, were pooled into groups, each containing eight sequential peptides, for use in proliferation tests. Thirty-eight additional peptides containing variant amino acid residues also were tested. Proliferation data were analyzed using an algorithm that reduced subjective bias and estimated the responding cell frequencies. Peripheral blood mononuclear cells from a majority of donors, regardless of HIV-1 status, recognized peptides within two pools derived from the gp120 sequence and peptides from one pool in gp41. Pool 25 peptides from gp41 (centered around residue 600 of the gp160 consensus sequence) were recognized most frequently. The observed inability to differentiate between responses of HIV-1-seropositive and HIV-1-seronegative individuals implies either a lack of HIV-1 disease-related immunodominant env epitopes or functional abrogation of HIV-1 env-specific T-helper lymphocyte responses soon after infection. The observed proliferation of T lymphocytes from noninfected, low-risk individuals questions the origin of the responses to HIV-1 env-derived peptides and suggest that preexisting, cross-reactive immunity could influence responses to HIV-1.

Public health nurses' quality of worklife: responses to organizational changes

The Nursing Division of a local health unit in Ontario reorganized its nursing teams into target population based programs. Nurses involved in this reorganization were asked to report their perceptions of job satisfaction, job design and role stress using standardized instruments before the reorganization and at three points in time after the reorganization. No administratively significant differences in these variables were reported by the nurses through the four time periods. The one exception was an unpredicted decrease in their perception of their task identity, that is, their perception of the significance or importance of their work. Major changes in the organization of a nursing division may be possible with minimal impact on perceptions of job satisfaction, job design and role stress. We caution that further assessment of the measurement tools used in this study should be undertaken.

Development of a temporary living skin replacement composed of human neonatal fibroblasts cultured in Biobrane, a synthetic dressing material

BACKGROUND

Preferred coverings for excised burn wounds when sufficient autograft skin is not available are fresh or cryopreserved cadaveric skin. Problems with supply, preservation, immune rejection, and potential infection transmission accompanying the use of allograft skin underscore the need for effective alternative temporary skin replacements.

METHODS

We cultured human neonatal fibroblasts (HF) for 4 to 6 weeks in nylon mesh of Biobrane, a synthetic dressing consisting of a thin layer of silicone bonded to nylon mesh. Secreted matrix proteins were identified by immunostaining and quantitated, and growth factor-specific messenger RNAs were identified by reverse transcription-polymerase chain reaction. Living grafts (Biobrane/HF) were sutured to full-thickness, excised wounds on athymic mice; control animals received Biobrane alone. Wounds were observed and biopsy specimens were obtained at intervals during the subsequent 40 days.

RESULTS

After 3 to 6 weeks of culture in Biobrane the HF proliferated and secreted matrix proteins including type I collagen, fibronectin, and decorin, as well as messenger RNA for several growth factors (acidic fibroblast growth factor, basic fibroblast growth factor, and keratinocyte growth factor). Biobrane/HF grafts were transferred to full-thickness wounds, resulting in rapid fibrovascular ingrowth from the wound and effective wound closure for up to 40 days with minimal inflammatory responses. Biobrane control grafts adhered initially to wounds, but within several days many grafts developed subgraft exudates; histologic sections revealed marked inflammatory responses in these wounds. By 20 days, most BB grafts were separating from the underlying wounds that were closing by epithelialization and contraction.

CONCLUSIONS

The Biobrane/HF living skin replacement provides long-term biologic coverage of full-thickness wound defects in mice with rapid incorporation of a living tissue matrix into the wound bed. Because HF have been found to be relatively nonantigenic when transferred to allogeneic hosts, Biobrane/HF grafts could replace the use of cadaveric allograft skin for achieving temporary wound closure after burn wound excision. Biobrane/HF grafts may persist on human wounds for weeks or months, with long-term persistence perhaps primarily dependent on durability of the silicone rubber layer.

1992 Ontario Survey of Public Health Nurses: perceptions of roles and activities

A survey of public health nurses (PHNs) who work in official public health units in Ontario was undertaken to determine whether their perceptions of their roles and activities concurred with a 1990 Canadian Public Health Association report which describes the roles and qualifications of public health nursing in Canada. The survey questionnaire was completed by 1,849 PHNs in all 42 public health units (response rate = 85%). About one tenth of the PHNs reported no activity as a caregiver/service provider. Most PHNs reported being active in the roles of educator/consultant, social marketer, and facilitator/communicator/collaborator. The community developer, policy formulator, research/evaluator, and resource manager/planner/coordinator roles were less frequently performed, however, increased activities in such roles were expected in the future. Nurses said that they needed further preparation to perform the latter roles. These results have implications for deployment of PHNs as Ontario's health system shifts to community health and health promotion.

Undulator radiation for at-wavelength interferometry of optics for extreme-ultraviolet lithography

Techniques are described for at-wavelength interferometry of multilayer coated optics designed for use in extreme-ultraviolet lithography. Broadly tunable undulator radiation, which covers the spectral region from 45 to 400 A, is described. The coherent power available at these wavelengths is described, and several types of interferometer that might be suitable at these short wavelengths are also described.

Comparison of liaison and staff nurses in discharge referrals of postpartum patients for public health nursing follow-up

The purpose of this study was to compare hospital staff nurses to public health liaison nurses in the accuracy and cost of postpartum referrals for public health nursing follow-up in the community. In the before phase of the study, public health liaison nurses assessed 304 mothers to determine the need for a follow-up visit by the public health nurse. In the after phase, staff nurses assessed 326 mothers. Public health nurses, unaware of the identity of the referring nurse and the referral decision, judged whether their visit had been required. Staff nurses correctly identified a higher proportion of referrals requiring public health nurse follow-up than liaison nurses. Although they referred more clients who did not require a public health nurse visit, costs of referrals by staff nurses remained lower.