246 IMPROVING LUMBAR PUNCTURE TECHNIQUE AMONG INTERN TRAINEES TO ENHANCE QUALITY OF CARE FOR PATIENTS

Background

Lumbar puncture (LP) is a common procedure performed on older adults in acute medical settings. A higher peri-procedural risk has been shown in older patients. Non-consultant doctors (NCHDs) often lack confidence and competence in performing LP. Simulation based training using task trainers has been shown to improve confidence, preplanning skills and technique.

Methods

A simulation based teaching session was developed in a university teaching hospital (training structure was adapted from the LP training guide published in MedEdPortal). Small group teaching (with 6–8 learners) was delivered to 25 NCHDs with no prior exposure or experience with lumbar puncture completion. Trainees completed one LP simulation without practice to mastery level. On-demand and post-performance feedback was delivered to learners. An assessment checklist was completed by the supervisor. Learners completed an anonymised quantitative and qualitative questionnaire using Qualtrics XM software at a later date to evaluate self-perceived teaching outcomes.

Results

16 doctors completed the questionnaire (64% response rate). 55% rated the LP workshop as a ‘strongly positive’ impact on their learning, while 18% indicated a ‘positive’ impact on a 5-point Likert scale. 19% of trainees reported they were ‘very comfortable’ at performing the procedure post training, with 56.5% ‘comfortable’ to perform an LP in their clinical practice. Qualitative learner feedback included ‘more hands on practice’ on the mannequin, ‘smaller groups for the workshops’ and ‘more practice tips’ during the simulation workshop.

Conclusion

This pilot study demonstrated interest and positive feedback for the LP simulation training from novice doctors with improved self-assessed confidence. Formal development of an LP simulation training curriculum is underway. The impact of this training on patient care should be assessed in practice.

Global CO2 emissions from dry inland waters share common drivers across ecosystems

Many inland waters exhibit complete or partial desiccation, or have vanished due to global change, exposing sediments to the atmosphere. Yet, data on carbon dioxide (CO2) emissions from these sediments are too scarce to upscale emissions for global estimates or to understand their fundamental drivers. Here, we present the results of a global survey covering 196 dry inland waters across diverse ecosystem types and climate zones. We show that their CO2 emissions share fundamental drivers and constitute a substantial fraction of the carbon cycled by inland waters. CO2 emissions were consistent across ecosystem types and climate zones, with local characteristics explaining much of the variability. Accounting for such emissions increases global estimates of carbon emissions from inland waters by 6% (~0.12 Pg C y-1). Our results indicate that emissions from dry inland waters represent a significant and likely increasing component of the inland waters carbon cycle.

Nursing-led ultrasound to aid in trans-radial access in cardiac catheterisation: a feasibility study

Background

Trans-radial access is increasingly common for cardiac catheterisation. Benefits include reduced bleeding complications, length of hospital stay and costs.

Aims

To determine the feasibility of implementing a nurse-led ultrasound programme to measure radial artery diameter before and after cardiac catheterisation; to determine radial artery occlusion (RAO) rates, risk factors for RAO and predictors of radial artery (RA) diameter.

Method

A prospective observational cohort study design for 100 consecutive patients undergoing cardiac catheterisation, using RA access. Pre- and post-procedural RA diameter were measured using ultrasound, by specialist nurses trained to do so. Logistic regression analyses were performed to determine risk factors for RAO and predictors of RA diameter with results reported as odds ratios (OR) and 95% confidence intervals (CI).

Results

There were no adverse events, supporting the feasibility of nurse led ultrasound programmes. A 4% (n = 4) rate of occlusion was observed. Haemostasis device application time of greater than 190 min was a predictor of RAO (OR 3.12, 95% CI 0.31-31). Male gender and height were predictors for a RA diameter of >2.2 mm.

Conclusions

Nurses can lead the assessment of RA occlusion using ultrasound to enhance planning and care, including monitoring compression times to reduce RAO.

Common themes in patients requiring urgent cardiothoracic surgery after percutaneous coronary interventions: Case series and review of the literature

Urgent cardiothoracic surgical intervention for the management of complications of percutaneous coronary intervention is uncommon in the stent era. Nonetheless, given increasing procedural complexity, in part reflecting an aging population, an ongoing hazard for urgent surgery remains. We sought to review the incidence and outcome of urgent cardiothoracic surgery in patients undergoing PCI in a contemporary cohort at a tertiary referral centre. The incidence of cardiothoracic intervention for PCI related complications was low at 0.1% over a ten-year period, with iatrogenic coronary artery and aortic root dissection unable to successfully managed percutaneously recurrent precipitants for surgical involvement. Procedural features associated with the need for urgent surgery are noted and methods to overcome such complications discussed.

Randomized trial of a dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sensor-augmented pump therapy

AIMS

To test whether adjusting insulin and glucagon in response to exercise within a dual-hormone artificial pancreas (AP) reduces exercise-related hypoglycaemia.

MATERIALS AND METHODS

In random order, 21 adults with type 1 diabetes (T1D) underwent three 22-hour experimental sessions: AP with exercise dosing adjustment (APX); AP with no exercise dosing adjustment (APN); and sensor-augmented pump (SAP) therapy. After an overnight stay and 2 hours after breakfast, participants exercised for 45 minutes at 60% of their maximum heart rate, with no snack given before exercise. During APX, insulin was decreased and glucagon was increased at exercise onset, while during SAP therapy, subjects could adjust dosing before exercise. The two primary outcomes were percentage of time spent in hypoglycaemia (<3.9 mmol/L) and percentage of time spent in euglycaemia (3.9-10 mmol/L) from the start of exercise to the end of the study.

RESULTS

The mean (95% confidence interval) times spent in hypoglycaemia (<3.9 mmol/L) after the start of exercise were 0.3% (-0.1, 0.7) for APX, 3.1% (0.8, 5.3) for APN, and 0.8% (0.1, 1.4) for SAP therapy. There was an absolute difference of 2.8% less time spent in hypoglycaemia for APX versus APN (p = .001) and 0.5% less time spent in hypoglycaemia for APX versus SAP therapy (p = .16). Mean time spent in euglycaemia was similar across the different sessions.

CONCLUSIONS

Adjusting insulin and glucagon delivery at exercise onset within a dual-hormone AP significantly reduces hypoglycaemia compared with no adjustment and performs similarly to SAP therapy when insulin is adjusted before exercise.

Serious statin-associated myotoxicity and rhabdomyolysis in Aboriginal and Torres Strait Islanders: a case series

BACKGROUND

Statins are associated with skeletal muscle adverse effects. These are generally considered mild and reversible, with more severe toxicity occurring rarely. There is little known regarding statin myotoxicity in Aboriginal and Torres Strait Islander Australians who are at high cardiovascular risk and likely to receive statins.

AIMS

To describe features of serious statin-associated myotoxicity (SSAM) occurring in Indigenous Australians and increase awareness of this condition.

METHODS

Observational case series of SSAM in Aboriginal or Torres Strait Islanders. Cases were identified from personal clinical experience, referrals, reports to the Therapeutic Goods Administration, medical literature, an Internet search and reports from a histopathology laboratory. Information was collected onto a standardised data collection form.

RESULTS

Fifteen cases of serious myotoxicity in Aboriginal or Torres Strait Islanders exposed to statins were identified from 2006 to 2012. The mean age was 55 (range 35-69). Painless weakness was the most common presentation. Interacting drugs were involved in seven cases. Biopsies were done in eight cases, three showed inflammatory polymyositis and five necrotising myositis. Three patients died and two had permanent severe disability. Resolution of symptoms after statin cessation was variable.

CONCLUSIONS

SSAM has occurred in the Indigenous Australian population with some fatalities. Awareness of the potential for SSAM is essential for early recognition and effective management to reduce probability of avoidable catastrophic harm. Safe, as well as effective use of medication, is essential for optimum health outcomes. Effective pharmacovigilance and therapeutic risk management are important for Aboriginal and Torres Strait Islander Australians.

Persistent complement-dependent anti-AnWj in a lymphoproliferative disorder: a case study and review

AnWj is a high-incidence antigen present on the red blood cells (RBCs) of greater than 99 percent of the general population. A 58-year-old man underwent autologous hematopoietic stem cell transplantation (HSCT) for stage IVa mantle cell lymphoma. This procedure was complicated by failure to engraft, necessitating ongoing support with blood components. After a 2-month period of uneventful transfusion support, the patient experienced increasingly severe reactions with fever and evidence of intravascular hemolysis, including hemoglobinuria. Testing revealed a complement-dependent anti-AnWj. Phenotyping confirmed the AnWj- phenotype. Anti-AnWj was persistent despite immunosuppression, including treatment with allogeneic HSCT. Of interest, the pathogenesis of the downregulation of the graft AnWj in this patient is unclear.

Impact of education on women with perinatal depression

OBJECTIVE

To assess the impact that education through participation in a depression screening program has on mental health literacy and help seeking behavior in perinatal women.

METHODS

Responses to a hypothetical case of depression, help seeking behavior, and screening levels for risk of depression using the Edinburgh Postnatal Depression Scale were compared between two groups of postnatal women; one group who had participated in a screening program and the other who had not. Those who participated in the screening program were also asked to evaluate the educational material they had received.

RESULTS

A total of 1309 women, broadly representative of postnatal women, answered one or more questionnaires. Those who had participated in the screening program were better able to recognize depression in a hypothetical case, and also assess their own mental state more appropriately. Those women who had been part of the program and did not score high on the EPDS were less likely to seek help, were more satisfied when they did and tended to benefit more from the educational booklet.

CONCLUSIONS

Participation in a screening program with educational material had significant benefits for mental health literacy and the health service use for perinatal women at risk for depression.

Estimation of infection prevalence from correlated binomial samples

Infection prevalence in a population often is estimated from grouped binary data expressed as proportions. The groups can be families, herds, flocks, farms, etc. The observed number of cases generally is assumed to have a Binomial distribution and the estimate of prevalence is then the sample proportion of cases. However, the individual binary observations might not be independent--leading to overdispersion. The goal of this paper was to demonstrate random-effects models for the estimation of infection prevalence from data which are correlated and in particular, to illustrate a nonparametric random-effects model for this purpose. The nonparametric approach is a relatively recent addition to the random-effects class of models and does not appear to have been discussed previously in the veterinary epidemiology literature. The assumptions for a logistic-regression model with a nonparametric random effect were outlined. In a demonstration of the method on data relating to Salmonella infection in Irish pig herds, the nonparametric method resulted in the classification of herds into a small number of distinct prevalence groups (i.e. low, medium and high prevalence) and also estimated the relative frequency of each prevalence category in the population. We compared the estimates from a logistic model with a nonparametric distribution for the random effects with four alternative models: a logistic-regression model with no random effects, a marginal model using a generalised estimating equation (GEE) and two methods of fitting a Normally distributed random effect (the GLIMMIX macro and the NLMIXED procedure both in SAS). Parameter estimates from random-effects models are not readily interpretable in terms of prevalences. Therefore, we outlined two methods for calculating population-averaged estimates of prevalence from random-effects models: one using numerical integration and the other using Monte Carlo simulation.

Are women with polycystic ovary syndrome resistant to activated protein C?

OBJECTIVE

This study was performed to test the hypothesis that an increased prevalence of activated protein C (APC) resistance in women with polycystic ovary syndrome (PCOS) puts them at increased risk of miscarriage and thrombosis.

DESIGN

Case control study.

SETTING

A district general hospital in the United Kingdom.

PATIENT(S)

Forty-one women with PCOS and 25 controls.

INTERVENTION(S)

Clinical histories, ultrasound scans, and venepunctures.

MAIN OUTCOME MEASURE(S)

Diagnosis of PCOS or control, clinical histories, APC resistance according to an activated partial thromboplastin time-based assay.

RESULT(S)

There was no significant difference in the proportion of women with APC resistance in both groups (three women in the PCOS group [7%] vs. one woman in the control group [4%]). The prevalence of APC resistance in the entire study population was 6.5%. In the PCOS group, 29% (12/41) gave a positive family history of thrombosis compared with 8% (2/25) in the control group. None of the women with a positive family history of thrombosis had abnormal antithrombin 111, protein C, or protein S levels.

CONCLUSION(S)

This study suggests that women with PCOS may have the same prevalence of APC resistance as the background population and that APC resistance may not put them at a higher risk of thrombosis or miscarriage compared with the case of the general population.

Factors impacting on shared care working relationships between practice nurses and general practitioners: a literature review

Practice nurses have worked in general practice for many years yet little is known or published in Australia about their work. Recent health care reforms in Australia, particularly the establishment of the Divisions of General Practice and various best-practice innovations linked to the National GP Strategy have seen an increase in the role of practice nurses. Despite this GPs in Australia are cautious about the role of practice nurses. Much of this caution arises from reform in general practice in Britain particularly the establishment of fund-holding for general practice. This article reviews the literature on practice nurses in Britain and Australia within the framework of the health reforms in general practice in both countries.

Identification of a novel hybrid glycophorin gene encoding GP.Hop

BACKGROUND

The GP.Hop (Mi.IV) phenotype expresses the MNS low-incidence antigens Mur, Hop, TSEN, MINY, and MUT. Because serologically similar MNS phenotypes expressing some or all of these antigens were shown to be carried by hybrid GP(B-A-B) proteins, it was proposed that a similar protein would be found for GP.Hop. The identification of a second GP.Hop propositus (ES) initiated a study to determine the molecular basis of this phenotype.

STUDY DESIGN AND METHODS

Serologic tests and immunoblotting analysis with glycophorin-specific antibodies were performed. GYPB, the gene encoding the GPB protein, was cloned and sequenced after reverse transcription PCR amplification of total RNA isolated from ES. GYPB-specific primers encompassing GYPB pseudoexon 3, intron 3, and exon 4 were also used to clone and sequence genomic DNA from ES and MH, the original GP.Hop proband.

RESULTS

Serologic and immunochemical data confirmed that ES's RBCs carried antigens associated with the GP.Hop phenotype. Sequencing of ES's cDNA demonstrated the presence of genes predicted to encode s-specific GPB and an S-specific GP(B-A-B) hybrid in which the 3' end of GYPB pseudoexon 3 had been replaced by a short nucleotide sequence from exon 3 of the GPA gene (GYPA). The hybrid nucleotide sequence contained sequence motifs previously shown to be required for the expression of the Mur, Hop, TSEN, MINY, and MUT, which is consistent with their presence as detected serologically. Genomic DNA analysis found that the crossover point in GYPB pseudoexon 3 was identical in ES and MH.

CONCLUSIONS

The GP.Hop phenotype is produced by a hybrid GP(B-A-B) protein caused by a DNA insertion of GYPA into GYPB. The composition of the hybrid protein is GPB(1-26)-GPpsiB(27-50)-GPA(51-58)-GPB(S)(59-103).

The role of the practice nurse. An exploratory study

AIM

There is little research on the role of the practice nurse in Australia. However, there is some evidence that practice nurses are no longer primarily receptionists, but rather function as nurses. This article reports on a small qualitative study that set out to identify areas of effective shared care between general practitioners and practice nurses.

METHOD

Semistructured interviews were conducted with general practitioners and practice nurses in eight general practices. A general practitioner who did not employ a practice nurse and a general practitioner and two nurse practitioners at a Community Health Centre were also interviewed.

RESULTS

It was found that general practitioners and practice nurses have established effective working relationships that enhance patient care. Shared care was not found, except to some extent in the area of wound care.

CONCLUSION

Most GPs and practice nurses interviewed believed that the current funding model, requiring GPs to sight all patients before a fee can be claimed, restricts the potential use of practice nurses' expertise, for example with patients returning for routine blood tests or blood pressure monitoring, or wound dressing. A change to the current model would have implications for the education and accreditation of practice nurses.

Expression of type 2 11beta-hydroxysteroid dehydrogenase and corticosteroid hormone receptors in early human fetal life

In adult life, the type 2 isozyme of 11beta-hydroxysteroid dehydrogenase (11betaHSD2) protects the mineralocorticoid receptor (MR) from glucocorticoid by inactivating cortisol to cortisone. 11betaHSD2 activity has been reported in human fetal tissues, where glucocorticoids may impair fetal growth yet are also required for normal fetal development. Using digoxigenin-labeled complementary ribonucleic acid (RNA) probes and an in-house 11betaHSD2 antiserum, we have analyzed the expression of 11betaHSD2, MR, and glucocorticoid receptor (GR) in human fetal tissues of gestational age 6-17 weeks (n=15). 11BetaHSD2 expression was absent at gestational age 6+ weeks, but was expressed in abundance in many fetal tissues between 8-12 weeks. At this time, 11betaHSD2 colocalized with GR messenger RNA (mRNA) expression in metanephros, gut, muscle, spinal cord and dorsal root ganglia, periderm, sex chords of testis, and adrenal. In particular within fetal kidney, intense expression of 11betaHSD2 and GR mRNA was observed over Bowman's capsule and the vascular tufts of developing glomeruli as they migrated from the surface of the kidney to the inner cortex. Only lung and adrenal medullary rests demonstrated high levels of GR mRNA but low levels of 11betaHSD2. 11BetaHSD2 mRNA and immunoreactivity staining patterns were similar, with the exception of the fetal adrenal, where mRNA was localized to the outer definitive zone but immunoreactivity was localized to the inner fetal zone. Colocalization of 11betaHSD2 (and GR mRNA) with MR mRNA was observed principally within epithelial cells of collecting ducts, particularly after 16 weeks gestation when the pattern of distribution of 11betaHSD2 became more adult in nature. High levels of MR mRNA were observed within developing bone. The data indicate that 11betaHSD2 in fetal life principally modulates ligand access to the GR in most fetal tissues, notably glomeruli and tubules in the developing kidney, testis, and periderm, and this may be have ramifications for fetal sodium homeostasis and differentiation. The development of tissues previously shown to have a critical requirement for glucocorticoids, such as lung and adrenal medulla, is facilitated by the expression of GR mRNA, but not 11betaHSD2. The expression of MR mRNA in high abundance in bone suggests a role for corticosteroids in human bone development, and the low/absent expression of 11betaHSD2 at this site suggests that it is functionally acting as a GR.

Detection of immunoglobulin G (IgG) and IgM antibodies to Toxoplasma gondii: evaluation of four commercial immunoassay systems

A comparative evaluation of the following commercial immunoassays for the determination of antibodies to Toxoplasma gondii was performed: Behring Diagnostics OPUS Toxo G and Toxo M, Abbott Diagnostics IMX Toxo-IgG 2.0 and Toxo-IgM, Sanofi Diagnostics Pasteur Platelia Toxo IgG and Toxo IgM, and bioMérieux Vitek VIDAS Toxo IgG and IgM. Of 676 specimens that were tested for Toxoplasma-specific immunoglobulin G (IgG) antibodies, 26% were reactive by all methods while 8% displayed some discrepancy. Of 718 specimens that were tested for Toxoplasma-specific IgM antibodies, 3% were reactive by all methods while 10% displayed some discrepancy. Analysis of discrepant specimens revealed performance shortcomings with all IgM-specific assays. The impact of such shortcomings is magnified in a population with a low prevalence of toxoplasmosis.

The development of the Louis MACRO (Mother and Child Risk Observation) forms: assessing parent-infant-child risk in the presence of maternal mental illness

OBJECTIVE

The theoretical framework and psychometric properties of the MACRO (Mother and Child Risk Observation) 1 and 2 forms (age 0 to 4 year) are presented. The MACRO forms provide ratings on five domains--three related to parenting, two on infant (or child) characteristics and maternal mental state. Case vignettes illustrate their clinical utility.

METHOD

Ratings on the MACRO of 110 mother-infant and 85 mother-toddler consecutive admissions to a South Australian psychiatric in-patient mother-infant unit provided data on internal consistency, interrater, and test-retest reliability.

RESULTS

Internal consistency was between .79 and .95 for all MACRO domains. Item-total correlations were between .39 and .90 with the exception of one item. Social Support. Distributions of item scores indicated acceptable discrimination. Interrater reliability was .79 or above for all domains. Test-retest reliability after 7 days was .71 or above.

CONCLUSIONS

Preliminary psychometric investigations of the MACRO was favorable. Should further validity investigations prove satisfactory, the MACRO will provide a valuable clinical and research tool. The MACRO offers a convenient framework for assessing risk and interpreting the impact of maternal mental illness upon children within a context that permits consideration of factors such as illness severity, parenting practices, and child contribution to outcome.

Differential expression of nuclear 11beta-hydroxysteroid dehydrogenase type 2 in mineralocorticoid receptor positive and negative tissues

Corticosteroid hormone action is controlled at a pre-receptor level by the activity of two isoforms of 11beta-hydroxysteroid dehydrogenase (11beta-HSD), catalyzing the interconversion of hormonally active cortisol to inactive cortisone. In particular 11beta-HSD2 protects the mineralocorticoid receptor (MR) from glucocorticoid excess, enabling aldosterone to interact with the MR. We have analyzed the subcellular localization of 11beta-HSD2 in relation to the expression of the MR in human colon and placenta. 3H-aldosterone binding studies confirmed expression of the MR in human colon but not term placental trophoblast. Enzyme activity studies and Western blot analyses carried out on subcellular fractions confirmed the presence of 11beta-HSD2 in microsomes. In colon, but not placenta, 11beta-HSD2 was also localized to the microsome-free, nuclear fraction. Protection upon the MR by 11beta-HSD2 in "classical" mineralocorticoid target tissues such as colon can be subserved at both a nuclear and extra-nuclear level. Tissue specific factors are responsible for the subcellular localization of 11beta-HSD2 and we postulate that one such factor may be the MR itself.

Ontogeny and sexual dimorphic expression of mouse type 2 11beta-hydroxysteroid dehydrogenase

11beta-hydroxysteroid dehydrogenase (11beta-HSD) catalyzes the interconversion of cortisol to hormonally inactive cortisone (corticosterone (B) to 11-dehydrocorticosterone (A) in rodents), and as such is established as a pre-receptor signalling pathway for corticosteroid hormone action. To further evaluate the role of this enzyme in adult and fetal life we have characterized two isoforms of 11beta-HSD in mouse tissues. Mouse 'liver' or type 1 11beta-HSD is a bi-directional dehydrogenase/oxo-reductase (K(m) for B 1.9 microM, K(m) for A 0.73 microM). Oxo-reductase activity utilized only NADPH as a co-factor, whilst dehydrogenase activity increased with both NAD or NADP. Mouse 'kidney' or 11beta-HS3D2 activity was NAD-dependent with a K(m) for B of 0.11 microM. Dexamethasone was not a substrate. Using an in-house mouse 11beta-HSD2 cDNA and NAD-dependent activity studies, 11 beta-HSD2 was expressed in epithelial cells of colon, renal collecting ducts, ovary, and adrenal, but was absent in liver, spleen, testis and heart. With the exception of gonadal tissues, activity and mRNA levels were consistently higher in adult male versus female tissues. In fetal kidney and colon there was absent/low levels of 11beta-HSD2 expression from fetal day 15 to term (day 19/20). Placental 11beta-HSD2 mRNA and activity were highest on fetal day 13/14 and fell progressively to undetectable levels by term. Two isoforms of 11beta-HSD are present in mouse tissues in accordance with other mammalian species. The sexual-dimorphic expression 11 beta-HSD2 in kidney and colon may reflect male-female differences in sodium homeostasis, and the absent expression of 11 beta-HSD2 in late gestation may facilitate glucocorticoid-dependent maturation of mouse fetal tissues.

Adrenal 11 beta-hydroxysteroid dehydrogenase

11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) catalyzes the interconversion of cortisol (F) to inactive cortisone (E) in man (corticosterone (B) to 11-dehydrocorticosterone (A) in rodents) and plays a crucial role in regulating corticosteroid hormone action. Two isoforms of this enzyme have been characterized; a low affinity NADP(H)-dependent enzyme (11 beta-HSD1) and a high affinity NAD-dependent dehydrogenase (11 beta-HSD2). We have analysed the expression of 11 beta-HSD in the rodent and human adrenal gland and have investigated its role with respect to glucocorticoid-mediated catecholamine biosynthesis. Our studies indicated higher expression of 11 beta-HSD2 mRNA in male versus female intact mouse adrenal. Both 11 beta-HSD isoforms were detected in intact male rat adrenal homogenates. For the 11 beta-HSD1 isoform, NADPH-dependent oxo-reductase activity exceeded that of NADP-dependent dehydrogenase activity (188 versus 98 pmol/mg.protein.hr). In situ hybridisation studies indicated specific localisation of 11 beta-HSD1 mRNA to cells at the corticomedullary junction. 11 beta-HSD2 mRNA was uniformly distributed across the cortex and was low/absent in the medulla. Administration of glycyrrhizic acid in vivo (> 100 mg/kg for 4 days) resulted in inhibition of 11 beta-HSD1 mRNA and activity and a decrease in mRNA levels for the glucocorticoid-dependent enzyme, phenylethanolamine N-methyltransferase, whilst levels of the glucocorticoid-independent enzyme, tyrosine hydroxylase were unchanged. No 11 beta-HSD expression was observed in the rat phaeochromocytoma cell line, PC12 cells, nor in human normal adrenal gland or phaeochromocytoma specimens. There are marked species and sex differences in the expression of 11 beta-HSD isoforms within the adrenal. The role of 11 beta-HSD within the adrenal gland remains obscure, but at least in the rat, the expression of the reductase enzyme, 11 beta-HSD1, to the corticomedullary junction may serve to maintain high medullary glucocorticoid concentrations required for catecholamine biosynthesis.

Evaluation of monoclonal anti-D reagents using D variant cells

Monoclonal anti-D antibodies submitted to the Third Monoclonal International Workshop were evaluated against a number of D variant cells using standard serological techniques. The monoclonal antibodies were able to discriminate between the cells of Categories Va, VI and DFR but not Category III cells. Cells within each category did not give any aberrant results. The Rh:33 cells behaved as normal Rh(D) positive cells.

The Mental Adjustment to HIV scale: measurement and dimensions of response to AIDS/HIV disease

Attitudes of people with HIV disease towards HIV have seldom been measured. However, a well-established scale to measure attitudes toward cancer in those with the disease, the 38-item Mental Adjustment to Cancer (MAC) scale was modified to assess adjustment to HIV disease. We administered the scale to 107 Australian men with HIV infection, of whom 36 had an AIDS-defining condition, who were patients at an ambulatory care facility and in a research study. The data were factor analyzed using a method identical to that used in the development of the MAC scale to determine the latent dimensions of attitudes toward HIV/AIDS. The Mental Adjustment to HIV scale (MAH) factor analysis revealed five factors: Helplessness-Hopelessness, Fighting Spirit, and Denial-Avoidance as in the original MAC scale, plus a Fatalism subscale which also measured Preoccupation, and a new subscale, which measured Belief in Influencing the Course of the Disease. Together, these five factors accounted for half of the variance. These data suggest that while there are similarities between mental attitude to cancer and mental attitude to HIV in the latent dimensions of the questionnaire items, there are also some differences. Most significant is the belief in people with HIV disease in being able to personally influence the course of the illness, and the combination of Preoccupation with Fatalism. The five subscales of the MAH scale had Cronbach's alpha reliabilities between 0.80 and 0.55. The MAH appears to be a useful way to measure total attitudes and subscale scores of people with HIV infection, including AIDS, to their disease.

The association between spouse-reported Type A behaviour pattern and coronary heart disease

This paper describes further validation of the Spouse-Report Type A Behaviour Pattern Questionnaire. In a case controlled study of 61 cardiac patients versus 61 community controls, the questionnaire was found to discriminate statistically between a group of patients with proven coronary heart disease and a group of matched healthy controls on the anger/hostility subscale and total Type A score. No relationship between Type A score and coronary heart disease severity was found. Possible explanations for these findings are examined.

Outcome prediction in childhood acute lymphoblastic leukaemia by molecular quantification of residual disease at the end of induction

Methods to detect and quantify minimal residual disease (MRD) after chemotherapy for acute lymphoblastic leukaemia (ALL) could improve treatment by identifying patients who need more or less intensive therapy. We have used a clone-specific polymerase chain reaction to detect rearranged immunoglobulin heavy-chain gene from the leukaemic clone, and quantified the clone by limiting dilution analysis. MRD was successfully quantified, by extracting DNA from marrow slides, from 88 of 181 children with ALL, who had total leucocyte counts below 100 x 10(9)/L at presentation and were enrolled in two clinical trials, in 1980-84 and 1985-89. Leukaemia was detected in the first remission marrow of 38 patients, in amounts between 6.7 x 10(-2) and 9.9 x 10(-7) cells; 26 of these patients relapsed. Of 50 patients with no MRD detected, despite study of 522-496,000 genomes, only 6 relapsed. The association between MRD detection and outcome was significant for patients in each trial. In the first trial, patients relapsed at all levels of detected MRD, whereas in the later trial, in which treatment was more intensive and results were better, the extent of MRD was closely related to the probability of relapse (5 of 5 patients with > 10(-3) MRD, 4 of 10 with 10(-3) to 2 x 10(-5), 0 of 3 with levels below 2 x 10(-5), and 2 of 26 with no MRD detected). Early quantification of leukaemic cells after chemotherapy may be a successful strategy for predicting outcome and hence individualizing treatment in childhood ALL, because the results indicate both in-vivo drug sensitivity of the leukaemia and the number of leukaemic cells that remain to be killed by post-induction therapy.

Prognostic significance of detection of monoclonality in remission marrow in acute lymphoblastic leukemia in childhood. Australian and New Zealand Children's Cancer Study Group

Techniques based on the polymerase chain reaction (PCR) to detect rearrangement of the immunoglobulin or T-cell receptor genes can detect residual disease in leukemia and hence have the potential to improve prognosis and treatment. Such techniques may involve either detection of monoclonality, which is simple and quick but has limited sensitivity, or specific detection of the leukaemic clone, which is complex and time-consuming but has high sensitivity. The PCR was used to detect monoclonal rearrangements of the immunoglobulin heavy chain and/or T-cell receptor gamma chain genes in archival marrow specimens from 185 children with acute lymphoblastic leukemia who achieved remission during two consecutive Australasian trials of treatment. A monoclonal rearrangement was detected at diagnosis in 152 (84%) patients and in these patients detection of the same rearrangement in the remission marrow at the end of induction therapy was highly significantly correlated with outcome. There were nine patients in whom polymerase chain reaction showed only the monoclonal rearrangement and eight (89%) relapsed; there were 26 patients in whom PCR showed the leukemic monoclonal rearrangement as well as polyclonal rearrangements from normal lymphocytes and 12 (46%) relapsed; and there were 117 patients in whom only polyclonal rearrangements could be detected and only 29 (25%) relapsed. In patients who relapsed, remissions were shorter in those patients in whom the leukemic rearrangements had been detected in the remission marrow. Treatment in the later trial was more intensive than in the earlier trial, the results were better and the PCR detected the leukemic rearrangement in the remission marrow in significantly fewer patients. We conclude that detection by PCR of the monoclonal gene rearrangement of the leukemic clone in remission marrow indicates that numerous leukemic cells have survived induction therapy and is a good predictor of relapse. However, due to limited sensitivity of the test, failure to detect the leukemic clone by PCR is not a sufficiently good predictor of ultimate cure.

Hostility and anger measures in coronary heart disease

Recent research addressing the link between psychological factors and risk of coronary heart disease (CHD) has focused on the areas of hostility and anger and produced sometimes contradictory results. This study makes use of four questionnaire measures of hostility and anger, which were administered to matched groups with and without CHD. Quicker experiences of anger with greater verbal expression best predicted CHD. The difficulties in teasing out the relative contributions of emotional expression, experience and personality using available questionnaires are discussed.

Quantitation of targets for PCR by use of limiting dilution

We describe a general method to quantitate the total number of initial targets present in a sample using limiting dilution, PCR and Poisson statistics. The DNA target for the PCR was the rearranged immunoglobulin heavy chain (IgH) gene derived from a leukemic clone that was quantitated against a background of excess rearranged IgH genes from normal lymphocytes. The PCR was optimized to provide an all-or-none end point at very low DNA target numbers. PCR amplification of the N-ras gene was used as an internal control to quantitate the number of potentially amplifiable genomes present in a sample and hence to measure the extent of DNA degradation. A two-stage PCR was necessary owing to competition between leukemic and non-leukemic templates. Study of eight leukemic samples showed that approximately two potentially amplifiable leukemic IgH targets could be detected in the presence of 160,000 competing non-leukemic genomes. The method presented quantitates the total number of initial DNA targets present in a sample, unlike most other quantitation methods that quantitate PCR products. It has wide application, because it is technically simple, does not require radioactivity, addresses the problem of excess competing targets and estimates the extent of DNA degradation in a sample.

Detection and quantitation of neoplastic cells in acute lymphoblastic leukaemia, by use of the polymerase chain reaction

We report a simple and robust method for sensitive quantitation of leukaemic cells in acute lymphocytic leukaemia. Chain determining region 3 (CDR3) of the immunoglobulin heavy chain gene is a precise genetic marker for a patient's leukaemic clone. Quantitation of the leukaemic lymphocytes was achieved by use of the polymerase chain reaction to detect CDR3 at limiting dilution of DNA samples. Five patients were studied and high levels (1 in 1 to 1 in 10) of leukaemic cells were detected at diagnosis or relapse. Leukaemic cells were detected in remission marrows from three patients, at levels of 1 in 1000 to 1 in 100,000. All five patients showed a 1000 to 100,000-fold reduction in the levels of leukaemic cells after induction therapy. This technique should prove useful for monitoring therapy and may help predict outcome.

The RANZCP membership examination: a review of the relevant literature

The design of any assessment system, as well as the way it is scored, must be intimately linked to the purpose it is to serve. Previous literature on the RANZCP membership examination has tended to focus exclusively on issues of reliability and validity at the expense of broader concerns. The present paper selectively reviews the literature on assessment in education highlighting the differences between normative and criterion referencing and their implications for the profession. Published studies of the reliability of post-graduate written and oral examinations are reviewed focussing particularly on those conducted in psychiatric settings. Finally, the arguments for and against continuous assessment are summarised. Greater familiarity with the literature may result in more informed and constructive debate about the assessment process than has hitherto been evident.

Abnormal beta and gamma sialoglycoprotein associated with the low-frequency antigen Lsa

This paper describes the association of the low-frequency antigen Lsa with high-molecular-weight variants of beta- and gamma-sialoglycoproteins (beta-SGP, gamma-SGP). The variant beta-SGP, designated beta Lsa, carries the Ge3 epitope and the epitopes recognised by 3 murine monoclonal anti-beta-SGP antibodies. The variant gamma-SGP, designated gamma Lsa, carries the Ge2 and Ge3 epitopes. Both beta Lsa and gamma Lsa showed enhanced reactions in immunoblotting with anti-Ge3 sera--which may indicate the presence of 2 Ge3 epitopes on beta Lsa and gamma Lsa. These findings would be consistent with the proposed structure of the Lsa glycophorin C gene.

Application of the avidin-biotin immunohistochemical method for the diagnosis of alveolar hydatid disease from tissue sections

The avidin-biotin immunohistochemical (ABC) method was applied to the diagnosis of alveolar hydatid disease in patients from the hyperendemic region of western Alaska. The test was specific for larval cestodes of the genus Echinococcus, and exhibited high sensitivity. A negative reaction was obtained in all cases in which spontaneous death of the larval cestode had occurred. Results were inconsistent in sections of lesions from patients who had received long-term therapy with mebendazole, because of the persistence of antigens for a considerable time following the death of the parasite.

Immunocytochemical localization of a kallikrein-like serine protease (esterase A) in rat salivary glands

Light and electron microscopic (EM) immunocytochemical methods have been used to localize arginine esterase A, a kinin-generating enzyme immunologically similar to tissue kallikrein, in rat salivary glands. Both polyclonal and monoclonal antibodies to arginine esterase A were used in these studies. By means of a polyclonal antiserum, esterase A was found in granular tubules of submandibular glands and in striated ducts of all three major salivary glands, in a distribution similar to that of tissue kallikrein. With recently developed specific monoclonal antibodies to esterase A, this enzyme was localized in the granules of some (but not all) granular convoluted tubule cells (GCT) and along the basal membranes (but not in apical granules) of striated ducts. By an EM immunoperoxidase method, esterase A was localized subcellularly in granules of some GCT cells and along the basal cell membranes of the tubule and duct system. Thus, this enzyme is found in some sites (GCT granules) shared with tissue kallikrein, but in some unique sites, i.e., basal membranes of striated ducts. The polyclonal antibody used in the present study cross-reacted with tissue kallikrein, but when absorbed with kallikrein, it gave the staining pattern characteristic of monoclonal antibody to esterase A.

Chronicity of infection with Treponema paraluis-cuniculi in New Zealand white rabbits

Popliteal lymph nodes from eight New Zealand white rabbits with clinical or serological evidence of naturally acquired infection with Treponema paraluis-cuniculi were transferred to rabbits that had not been exposed to this infection. Lymph nodes from two rabbits successfully transmitted infection. The nodes from one of these rabbits transmitted infection during both the acute and chronic stages of infection. Recipients that were successfully infected showed concomitant antibody responses in the Venereal Disease Research Laboratory (VDRL), rapid plasma reagin (RPR), and fluorescent treponemal antibody-absorption (FTA-ABS) tests six to 10 weeks after inoculation; recipients of uninfected nodes showed no change in serological state. Antibody responses were followed by the development of dark field positive genital lesions 14 to 15 weeks after inoculation.

Clinical course and treatment of venereal spirochaetosis in New Zealand white rabbits

Ten sporadic cases of venereal spirochaetosis, caused by Treponema paraluis-cuniculi, were seen in New Zealand white rabbits in two years. An equal number of males and females were affected. Females tended to have milder clinical signs than males. Lesions were usually found on the prepuce in males and the vulva in females, although the anus and skin of the perineum were also affected. Facial lesions were rare. Lesions healed in seven to 28 days in rabbits treated with penicillin. Eight rabbits had antibodies reactive in the Venereal Disease Research Laboratory (VDRL), rapid plasma reagin (RPR), and fluorescent treponemal antibody absorbed (FTA-ABS) tests when the disease was first diagnosed. In several rabbits followed longitudinally, RPR test results became negative two to four months after antimicrobial treatment, VDRL antibody titres diminished but usually persisted at low levels, while FTA-ABS antibodies declined slowly and were still evident 12 months after treatment.

Treponema paraluis-cuniculi infection in a commercial rabbitry: epidemiology and serodiagnosis

The epidemiology of Treponema paraluis-cuniculi infection in a commercial rabbit breeding facility was described using several serologic tests. The Venereal Disease Research Laboratory, rapid plasma reagin, microhemagglutination and fluorescent treponemal antibody-absorption tests were used to detect antibodies to T paraluis-cuniculi. Young adult New Zealand white rabbits, tested prior to entry into the breeding program, were nearly always free of T paraluis-cuniculi infection. In adult females, the prevalence of T paraluis-cuniculi infection increased with parity; females para 6 or greater were usually seropositive. Most adult males seroconverted within 6 months of entering the breeding program; all males were seropositive after 12 months in the breeding program. This suggested that T paraluis-cuniculi spreads mainly by horizontal transmission during breeding in adult rabbits. Of the two nontreponemal antigen tests used, the Venereal Disease Research Laboratory test was more sensitive, whereas the rapid plasma reagin test was more specific in detecting T paraluis-cuniculi infection; the fluorescent treponemal antibody-absorption test was used as the confirmatory treponemal antigen test. However, neither nontreponemal antigen test was completely satisfactory. On the other hand, the sensitivity and specificity of the microhemagglutination test compared favorably with the fluorescent treponemal antibody-absorption test. Since the microhemagglutination test combines desirable features of both a screening and verification procedure, it should be the test of choice for detection of T paraluis-cuniculi infection.

Selective media for Pasteurella multocida and Bordetella bronchiseptica

Easily prepared and inexpensive culture medium for the isolation of Pasteurella multocida and Bordetella bronchiseptica from the nares of laboratory rabbits was prepared by incorporating 2 micrograms/ml clindamycin into standard blood agar. Using this medium, the time and materials required to identify and isolate Pasteurella multocida was substantially reduced with only a slight loss in sensitivity. The combination of 2 micrograms/ml clindamycin and 4 micrograms/ml neomycin was effective in isolating Bordetella bronchiseptica from rabbits.

Ventricular septal defect due to septal infarction after repair of tetralogy of fallot

A case is reported of ventricular septal defect resulting from septal infarction following repair of a tetralogy of Fallot. The infarct probably resulted from division of a septal coronary artery during resection of the hypertrophied infundibulum. The superficial position of the septal artery on the right side of the septum in tetralogy makes it surprising that this complication has not been previously reported.

Inappropriate antihypertensive therapy in the elderly

Six symptomless patients aged 64-84 (mean 72) years received antihypertensive therapy from their family doctors. Pretreatment systolic pressures ranged from 160 to 220 mm Hg and disastolic pressures from 80 to 120 mm Hg. Within one week of starting therapy all six patients were admitted as emergencies with epidoses of unconsciousness. Admission systolic pressures ranged from 80 to 150 mm Hg and diastolic pressures from 50 to 90 mm Hg. Before admission each patient had experiences symptoms of postural hypotension and had become housebound. After antihypertensive therapy was stopped, one patient had a residual left homonymous hemianopia but the others recovered completely. A raised systolic and distolic pressure is common in the elderly; potent antihypertensive treatment may seriously impair the quality of life and is often unecessary.