Enhancing distress tolerance to uplift motivation in recovery: Results from an open development trial

Objective

This open pilot study examines the feasibility, acceptability, and qualitative outcomes of an interactive web- and text message-delivered personalized feedback intervention aimed at cultivating motivation and tolerance of distress for adults initiating outpatient buprenorphine treatment.

Methods

Patients (n = 10) initiating buprenorphine within the past 8 weeks first completed a web-based intervention focused on enhancing motivation and providing psychoeducation on distress tolerance skills. Participants then received 8 weeks of daily personalized text messages that provided reminders of salient motivational factors and recommended distress tolerance-oriented coping skills. Participants completed self-report measures to assess intervention satisfaction, perceived usability, and preliminary efficacy. Additional perspectives were captured via qualitative exit interviews.

Results

In total, 100% of retained participants (n = 9) engaged with the text messages throughout the entire 8-week period. Mean scores of 27 (SD = 5.05) on the Client Satisfaction Questionnaire at the end of 8-week period indicated a high degree of satisfaction with the text-based intervention. The average rating on the System Usability Scale was 65.3 at the end of the 8-week program, suggesting that the intervention was relatively easy to use. Participants also endorsed positive experiences with the intervention during qualitative interviews. Clinical improvements were observed across the intervention period.

Conclusions

Preliminary findings from this pilot suggest that the content and delivery method of this combined web- and text message-based personalized feedback intervention is perceived by patients as feasible and acceptable. Leveraging digital health platforms to augment buprenorphine has potential for high scalability and impact to reduce opioid use, increase adherence/retention to treatment, and prevent future incidence of overdose. Future work will evaluate the efficacy of the intervention in a randomized clinical trial design.

P06 The use of procalcitonin testing to improve antibiotic stewardship in all cause respiratory admissions: a retrospective analysis

Background

Improving antibiotic stewardship whilst simultaneously optimizing patient safety is a perpetually vexing clinical conundrum, which has been compounded by the current COVID-19 pandemic. Procalcitonin (PCT) measurement has previously demonstrated utility in this regard, when combined with routine clinical investigation, in certain patient populations.

Objectives

To assess whether the inclusion of PCT measurement as part of routine clinical care, instituted during a quality improvement project (QIP), increases the appropriateness of antibiotic administration.

Methods

A retrospective analysis was performed on 6 month interim data obtained from May to October 2021 during a QIP, which assessed the effect of PCT measurement on antimicrobial stewardship. All patients included had a primary diagnosis of respiratory illness and were analysed both together and as COVID-19 and non-COVID-19 subgroups to assess how often antibiotics were commenced on admission, duration of treatment and appropriateness of use. Finally, as sending microbiological samples made up part of the protocol, sample sending frequency was also studied.

Results

Thirty patients were included in both the COVID-19 and non-COVID-19 baseline subgroups who did not have PCT testing performed. Fifty-two patients were included in the PCT subgroup (27 COVID-19 positive and 25 COVID-19 negative). Following introduction of PCT testing, commencement of antibiotics on admission was reduced overall and in the COVID-19 positive subgroup (P = 0.0426 and P = 0.0446, respectively) with a significant decrease in inappropriate antibiotic prescribing in these two groups (P = 0.011 and P = 0.0157, respectively) and a trend towards reduced prescribing of AWaRe watch group antibiotics such as ceftriaxone. However, once prescribed, there was no difference in duration of antibiotic treatment or the frequency of microbiological sampling.

Conclusions

The data from this interim data analysis demonstrate that PCT measurement, when combined with routine clinical investigations in the acute respiratory setting, can be used to reduce inappropriate antibiotic prescribing. This was significantly reduced overall and in the COVID-19 positive subgroup but lost statistical significance in the COVID-19 negative subgroup, where it could be hypothesized that heterogeneity and inclusion of respiratory diseases where PCT has previously encountered difficulty in determining the presence of acute bacterial infection may be the cause. The significant effect demonstrated in the COVID-19 positive subgroup suggests particular utility in this patient population.

A qualitative examination of intentions and willingness for heavy drinking among young adult high-intensity drinkers

OBJECTIVE

Heavy episodic drinking (HED) and high-intensity drinking (HID) are common in young adulthood but pose unique risks. Quantitative studies have used the Theory of Planned Behavior (TPB) and the Prototype-Willingness Model (PWM) to understand decision-making processes underlying alcohol misuse. However, our understanding of intentions (plans) and willingness (openness) for HED/HID is in its nascent stages. This study represents the first qualitative examination of relationships between intentions and willingness to engage in HED/HID.

METHOD

We conducted individual interviews among 28 young adult high-intensity drinkers (12 male, 15 female, 1 trans male; M age = 23 years). Interviews focused on HED/HID events with open-ended questions examining: (a) variability in intentions/willingness by occasion and within a drinking event; (b) formation of intentions for consumption and/or intoxication; and (c) interplay of willingness and intentions on heavy drinking nights. Verbatim transcripts were coded within NVivo software and content was analyzed using applied thematic analysis.

RESULTS

Participants described intentions and willingness as varying by occasion and perceived their shifting across a drinking event. Intentions for heavy drinking reflected a desired level of intoxication, rather than a specific number of drinks. Willingness, rather than intentions, to engage in heavy drinking/HID was more evident.

CONCLUSIONS

Findings have significant implications for future measurement work in this area. There may be value in assessing intentions and willingness multiple times per day and during the drinking event itself. We also recommend that intentions for both consumption and intoxication levels be assessed, particularly in studies aiming to examine impaired control. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Influence of fibroids on cell-free DNA screening accuracy

OBJECTIVE

Cell-free DNA (cfDNA) screening assesses both maternal and placental cfDNA. Fibroids are common and release cfDNA into maternal serum. Genetic abnormality is seen in 50% of fibroids. We aimed to assess the impact of fibroids on the accuracy of genome-wide cfDNA screening.

METHODS

This was a prospective cohort study of singleton pregnancies examined at one of two centers in Melbourne and Sydney, Australia, between 1 November 2019 and 31 December 2020. All cases underwent pretest ultrasound examination to confirm an ongoing pregnancy of at least 10 weeks' gestation, and, at this stage, the number and volume of any uterine fibroid were documented. Genome-wide cfDNA screening was performed to detect all copy-number variants (CNV) > 7 megabases. The incidence of a false-positive result was compared between cases with and those without fibroids.

RESULTS

Over the 14-month study period, 13 184 patients underwent cfDNA screening, of whom 1017 (7.7%) had fibroids. Fibroids were not identified in any of the 17 participants who had a false-positive result for chromosomes 13, 18, 21, X or Y. Ninety-five (0.7%) cases were screen-positive for subchromosomal aberration (SA), rare autosomal trisomy (RAT) or multiple abnormalities (MA), with 10 of these cases having a fetal genetic abnormality. The incidence of a false-positive RAT, MA or SA result was significantly higher in participants with fibroids (20/1017 (2.0%)) than in those without fibroids (64/12 167 (0.5%)). Women with fibroids were approximately six times as likely to have a false-positive result for SA, and this was associated positively with both fibroid number and volume.

CONCLUSIONS

Most women with fibroids do not have an abnormal result on genome-wide cfDNA screening. However, CNVs due to fibroids are associated with false-positive SA findings, although fibroids do not appear to influence cfDNA screening accuracy for the common autosomal trisomies or sex-chromosomal abnormalities. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Feasibility and acceptability of a digital health intervention to promote engagement in and adherence to medication for opioid use disorder

BACKGROUND

Buprenorphine-naloxone is an evidence-based treatment for opioid use disorder (OUD). Despite its efficacy, nearly half of patients discontinue treatment prematurely. Novel intervention strategies that may be delivered outside of traditional treatment settings are needed to support buprenorphine uptake and maintenance. The goal of this study was to elucidate key elements surrounding the acceptability/feasibility and structure of an interactive computer- and text message-delivered personalized feedback intervention for adults initiating outpatient buprenorphine treatment.

METHODS

Twenty-four adults engaged in treatment at two outpatient addiction treatment centers completed semistructured interviews exploring preferences around digital health interventions. Trained interviewers conducted interviews, the study audio-recorded them, and a professional agency transcribed them verbatim. The research team iteratively developed a coding structure using thematic and content analysis and entered it into a framework matrix. The team double coded each transcript.

RESULTS

The sample was balanced by gender, primary type of opioid use (prescription pills; heroin/fentanyl), and phase of recovery [early (≤8 weeks of treatment) vs. late (>8 weeks of treatment)]. The study reached saturation after 24 interviews (mean age = 38.9; 70.8% white; 8.3% Hispanic/Latino). (1) Acceptability/feasibility themes: A computer- and text message-based intervention that incorporates a motivational- and distress tolerance-based framework is highly acceptable. Presentation of material, including the length of the intervention, is effective in facilitating learning. The center should offer the intervention to individuals entering treatment and they should have the flexibility to complete the intervention at the center or in private from their own home. The use of technology for intervention delivery helps to overcome fears of judgment stemming from stigmatizing experiences. (2) Structural themes: The text message intervention should deliver both predetermined (automatic) and on demand messages. Two to three messages per day (morning and early evening), with the option to elicit additional messages as needed, would be ideal. The messages must be personalized. Incorporating multimedia such as emojis, gifs, and links to videos will increase interactivity.

CONCLUSIONS

Overall, adults engaged in outpatient buprenorphine treatment were receptive to an interactive computer- and text messaged-delivered personalized feedback intervention to support recovery. Incorporating thematic results on suggested structural changes may increase the usability of this intervention to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use.

Axonal excitability changes in children with spinal muscular atrophy treated with nusinersen

Spinal muscular atrophy (SMA) is associated with developmental disruption of motor axons in ventral roots of the spinal cord alongside motor axon degeneration. The pathogenesis of peripheral axonal change during development is pertinent to understand treatment response. Nerve excitability techniques, stimulating the median motor nerve at the wrist, were utilised to investigate axonal change during neurodevelopment in 24 children with SMA, compared with 71 age-matched controls. Longitudinal axonal response to nusinersen treatment in 18 children was also investigated. Significant differences in axonal development were noted in the youngest children with SMA, signified by reduced compound muscle action potential (CMAP) (P = 0.030), higher axonal threshold (P = 0.016), rheobase (minimal current amplitude of infinite duration, required to generate an action potential) (P = 0.012) and greater changes in depolarising and hyperpolarising threshold electrotonus. Subexcitability increased in all children with SMA, compared to controls. With treatment, nerve excitability changes were observed prominently in young children, with increases in CMAP, reduction in axonal threshold, fanning-in of threshold electrotonus, increase in resting current-threshold slope and reduction in subexcitability. Whilst motor axons continue to mature in SMA, developmental delays in passive and active membrane properties occur especially in early childhood. Concurrently, motor axons actively undergo degeneration. Nusinersen restores the developmental trajectory of motor axons reducing degeneration, especially in children with early treatment initiation. Our findings move the field forward in understanding the developmental aspect of childhood-onset motor neurone diseases and changes in axonal function associated with disease modification. KEY POINTS: Pathomechanisms in spinal muscular atrophy involve concurrent neurodevelopmental and neurodegenerative processes. The greatest delays in maturation of the passive and active properties of the peripheral motor axon are seen in early childhood. Nusinersen facilitates developmental recovery of the motor axon whilst also reducing neurodegeneration. Axonal dysfunction is reversed with SMN repletion particularly when intervention occurs early in development.

Using motivational interviewing to enhance emerging adults' engagement in weight loss: The Live Well RVA pilot randomized clinical trial

Background

Emerging adults (ages 18–25) are at high risk for overweight/obesity, yet traditional adult behavioural weight loss (BWL) interventions do not meet the needs of individuals at this developmental stage. Motivational interviewing (MI) is an evidence‐based approach to promote behaviour change but has not been tested for weight loss in this population. The study aimed to test the feasibility and preliminary efficacy of an MI‐enhanced weight loss programme to promote engagement, retention and weight loss in emerging adults.

Methods

Emerging adults with overweight/obesity (N = 47, 81% female, 47% racial/ethnic minority, body mass index [BMI] = 33.2 ± 4.6 kg/m²) were randomized to either standard BWL or MI‐enhanced BWL (MIBWL). Weight was assessed objectively at baseline and posttreatment (3 months). Engagement (in‐person session attendance [weeks 1 and 2], online self‐monitoring [weeks 3–12] and online content viewing [weeks 3–12]) was tracked throughout the program.

Results

Though results did not reach the level of statistical significance, participants in MIBWL demonstrated greater programme engagement (77% vs. 61.0%, p = .11; Cohen d = .48), retention (71% vs. 48.0%, p = .10; Cohen h = .47) and intent‐to‐treat weight loss (−3.3% vs. −2.2%, p = .37; Cohen d = .26) compared with those in BWL.

Conclusions

Effect sizes suggest that MI might be a viable approach to enhance engagement and retention in weight loss programmes targeting emerging adults. This finding is meaningful, given the documented challenges with engagement and retention in this vulnerable population and the relationship between engagement and better weight loss outcomes. The results of this small pilot study support efforts to replicate these findings within the context of a fully powered trial.

Development of an integrated digital health intervention to promote engagement in and adherence to medication for opioid use disorder

BACKGROUND

Buprenorphine-naloxone is an evidence-based treatment for Opioid Use Disorder. However, despite its efficacy, nearly half of participants are unsuccessful in achieving stabilization (i.e., period of time following medication induction in which medication dose is adjusted to be effective in reducing cravings/withdrawal, minimize potential side effects, and eliminate illicit substance use). This paper presents the study design and protocol for a digital health intervention designed to promote engagement in and adherence to buprenorphine treatment, offered through an outpatient addiction treatment center, through motivational enhancement and distress tolerance skills training. Personalized feedback interventions represent a promising method to effectively motivate engagement in and adherence to buprenorphine treatment. These interventions are generally brief, individually tailored, and have the potential to be delivered via mobile platforms. Distress tolerance, a transdiagnostic vulnerability factor, has been implicated in the development and maintenance of substance use. Targeting distress tolerance may improve substance use treatment outcomes by promoting the ability to persist in goal-directed activity even when experiencing physical or emotional distress.

METHODS

The study aims are to: (1) develop and refine an interactive computer- and text message-delivered personalized feedback intervention that incorporates distress tolerance skills training for persons who have elected to initiate outpatient buprenorphine treatment (iCOPE); (2) examine the feasibility, acceptability, and preliminary efficacy of iCOPE for increasing abstinence, adherence, and retention in treatment compared to a treatment as usual comparison condition; and, (3) examine potential mechanisms that may underlie the efficacy of iCOPE in improving outcomes, including motivation, distress tolerance, self-regulation, and negative affect.

DISCUSSION

Results of this study will be used to determine whether to proceed with further testing through a large-scale trial. This work has the potential to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use. Trial Registration NCT03842384.

Chemotherapy-Induced Peripheral Neuropathy in Long-term Survivors of Childhood Cancer: Clinical, Neurophysiological, Functional, and Patient-Reported Outcomes

Importance

In light of the excellent long-term survival of childhood cancer patients, it is imperative to screen for factors affecting health, function, and quality of life in long-term survivors.

Objective

To comprehensively assess chemotherapy-induced peripheral neuropathy in childhood cancer survivors to define disease burden and functional effect and to inform screening recommendations.

Design, Setting, and Participants

In this cross-sectional observational study, cancer survivors who were treated with chemotherapy for extracranial malignancy before age 17 years were recruited consecutively between April 2015 and December 2016 from a single tertiary hospital-based comprehensive cancer survivorship clinic and compared with healthy age-matched controls. Investigators were blinded to the type of chemotherapy. A total of 169 patients met inclusion criteria, of whom 48 (28.4%) were unable to be contacted or declined participation.

Exposures

Chemotherapy agents known to be toxic to peripheral nerves.

Main Outcomes and Measures

The clinical peripheral neurological assessment using the Total Neuropathy Score was compared between recipients of different neurotoxic chemotherapy agents and control participants and was correlated with neurophysiological, functional, and patient-reported outcome measures.

Results

Of the 121 childhood cancer survivors included in this study, 65 (53.7%) were male, and the cohort underwent neurotoxicity assessments at a median (range) age of 16 (7-47) years, a median (range) 8.5 (1.5-29) years after treatment completion. Vinca alkaloids and platinum compounds were the main neurotoxic agents. Clinical abnormalities consistent with peripheral neuropathy were common, seen in 53 of 100 participants (53.0%) treated with neurotoxic chemotherapy (mean Total Neuropathy Score increase, 2.1; 95% CI, 1.4-2.9; P < .001), and were associated with lower limb predominant sensory axonal neuropathy (mean amplitude reduction, 5.8 μV; 95% CI, 2.8-8.8; P < .001). Functional deficits were seen in manual dexterity, distal sensation, and balance. Patient-reported outcomes demonstrating reduction in global quality of life and physical functioning were associated with the Total Neuropathy Score. Cisplatin produced long-term neurotoxicity more frequently than vinca alkaloids.

Conclusions and Relevance

Clinical abnormalities attributable to peripheral neuropathy were common in childhood cancer survivors and persisted long term, with concurrent deficits in patient-reported outcomes. Both the type of neurotoxic agent and a targeted clinical neurological assessment are important considerations when screening survivors for long-term neuropathy. Further development of peripheral neuropathy-specific pediatric assessment tools will aid research into neuroprotective and rehabilitative strategies.

009 Axonal excitability properties in dravet’s syndrome reflect effect of loss of sodium channels

Introduction

Mutations in SCN1A encoding the Nav1.1 subunit of the neuronal sodium channel underlie the devastating epilepsy of Dravet’s syndrome.1 The mechanism by which Nav1.1 dysfunction causes seizures is not clear. In vitro and in silico channel evaluation can support mutation pathogenicity but cannot define the in vivo impact of channel dysfunction. Axonal excitability studies can show the pattern of single-channel dysfunction in disorders where the channel is peripherally expressed.2 This study was undertaken to determine whether axonal excitability studies could detect changes in Dravet’s patients related to the condition or due to medication effect.

Methods

Patients with Dravet’s syndrome were recruited from clinics in Sydney and Melbourne and axonal excitability studies were performed. Excitability results were analysed in 3 age groups and compared to age-matched normal controls.

Results

Twenty six patients (ages 2–46) were studied. Findings were most pronounced in patients aged 20–46 (n=7) with 6.9% greater increase in threshold during hyperpolarization(p=0.1), 7.6% greater threshold decrease on depolarization(p=0.005) and, in the recovery cycle, 19.7% reduction in superexcitability(p=0.002) and 26% reduction in subexcitability(p=0.03). Axonal excitability studies resembled previously published changes seen in patients with sodium channel blockade caused by acute tetrodotoxin poisoning.3

Conclusions

Changes in excitability of axonal membrane in Dravet’s syndrome are consistent with a decrease in sodium channel function. As the affected channel in Dravet’s syndrome is not peripherally expressed, the effect seen is likely due to the heavy anticonvulsant regime required to control epilepsy, combined with a progressive loss of sodium channel function that occurs with age.

References

Meisler MH, O’Brien JE, Sharkey LM. Sodium channel gene family: epilepsy mutations, gene interactions and modifier effects. J Physiol 2010;588:1841–1848.

Tomlinson SE, Howells J, Burke D. In vivo assessment of neurological channelopathies: Application of peripheral nerve excitability studies. Neuropharmacology. 2018 Apr;132:98–107.

Kiernan MC, Isbister GK, Lin CS, Burke D, Bostock H. Acute tetrodotoxin-induced neurotoxicity after ingestion of puffer fish. Ann Neurol 2005;57:339–48.

44 Misregulation of ten-eleven translocation 3 CXXC domain leads to abnormal formation of 5-hydroxymethylcytosine and expression of pluripotency genes in pig embryos

Ten-eleven translocation (TET) methylcytosine dioxygenases are considered to play an important role in regulation of DNA methylation patterns by converting 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC). TET3 protein, a member of TET family, is enriched in mature oocytes and early stage embryos and contributes to DNA demethylation of the paternal genome in zygotes. N-terminal CXXC domain of TET3 is thought to be important in catalysing 5mC oxidation through its DNA binding potential. However, it is not clear whether specific DNA binding of CXXC domain is required for 5hmC conversion in mammalian embryos. Here, we investigated the role of TET3 CXXC domain in controlling 5hmC formation in fertilized pig embryos by injecting TET3 CXXC domain into mature pig oocytes as a dominant negative to inhibit the direct binding of TET3 to the genome through the CXXC domain. The CXXC domain of pig TET3 was identified through bioinformatics comparison of TET3 sequences among different species and cloned from mature pig oocyte-derived cDNA. To construct the green fluorescent protein (GFP)-CXXC fusion protein, CXXC sequence was subcloned into N-terminal GFP fusion vector, and then mRNA was synthesised by in vitro transcription. The GFP-CXXC mRNA (100 ng/µL) was injected into oocytes matured in vitro for 36 to 37h. Then, the oocytes were fertilized at 42h post-maturation. Water-injected oocytes served as a control. At 17h post-fertilization, zygotes were collected to analyse 5hmC level by immunocytochemistry. The level of 5hmC was analysed using ImageJ (https://imagej.nih.gov/ij/). Expression of pluripotency-related genes at Day 7 blastocysts was examined through quantitative RT-PCR; ΔΔCt method was used to analyse the quantitative RT-PCR data and Student’s t-test was used for statistical analysis. All experiments were conducted at least three times and P-values of less than 0.05 were considered significant. The GFP-CXXC was exclusively localised in pronuclei, indicating that the CXXC domain may lead to nuclear localization of TET3. The level of 5hmC in zygotes was not altered by the overexpression of GFP-CXXC. Interestingly, in 2-cell stage embryos, the 5hmC level was reduced in GFP-CXXC injected embryos compared with the control group, suggesting that CXXC domain is important for 5hmC formation post-DNA replication. There was an increase in transcript abundance of NANOG and ESRRB in blastocysts developed from GFP-CXXC injected oocytes compared with control blastocysts (P&lt;0.05). There was no difference in the expression of POU5F1 and SOX2. In this study, we found that CXXC domain of TET3 is critical in maintaining the level of 5hmC formation at 2-cell stage and proper level of pluripotency-related genes (NANOG and ESRRB) in blastocysts. Future studies will focus on elucidating mechanisms behind the changes after overexpression of GFP-CXXC in pig embryos.

209 Overexpression of WAVE1 activates pluripotency-related genes in porcine somatic cells

Despite extensive efforts, cellular reprogramming in livestock species has had limited success. Induced pluripotent stem cells (iPSC) have been established; however, these cells often show incomplete reprogramming status, and constitutive expression of exogenous reprogramming factors is required due to inactivation of endogenous pluripotency-related genes. A previous study reported that overexpression of the Xenopus egg-derived WAVE1 gene assists reprogramming of murine somatic cells into the pluripotent state. The WAVE1 gene is also required for oocyte-mediated reprogramming by transcriptional activation of embryonic genes. In this study, we investigated the role of porcine WAVE1 in cellular reprogramming by inducing overexpression of WAVE1 in porcine fetal fibroblasts (PFF). Previously, we cloned the coding sequences (CDS) of porcine WAVE1 using porcine expressed sequence tags (EST) and predicted porcine WAVE1 sequences. The WAVE1 CDS, derived from porcine mature oocytes, was overexpressed in PFF by transfection using the Neon system. Then, G418-based antibiotic selection was performed to enrich cells constitutively overexpressing WAVE1. After cell culture for 4 weeks, RNA was extracted from the WAVE1 transfected and control PFF, and cDNA was synthesised from the RNA using random hexamers. The cDNAs were used for quantitative reverse transcription PCR to analyse the expression pattern of pluripotency- and reprogramming-related genes: POU5F1, NANOG, KLF2, SOX2, DPPA3, ZFP42, ESRRB, TET1, TET2, and TET3. The expression of target genes were normalized to GAPDH level and the ΔΔCt algorithm was used for analysis. Three technical replications and 4 biological replications were performed. Student’s t-test was used for the comparison and P-values&lt;0.05 were considered significant. On average, a 20-fold increase of WAVE1 was observed in the transfected cells compared with control cells. Interestingly, overexpression of WAVE1 activated some of the pluripotency-related genes in porcine PFF. Specifically, transcript levels of NANOG, KLF2, and SOX2 were increased compared with those in the control cells (P&lt;0.05). In addition, levels of POU5F1 and DPPA3 tended to be higher in WAVE1-overexpressing cells compared with those in the control cells (P&lt;0.1). However, transcript levels of other pluripotency-related genes (ZFP42, DPPA3, and ESRRB) did not change in WAVE1-overexpressing cells. The expression level of TET family (TET1, TET2, and TET3), which is enriched in pluripotent stem cells and a key regulator of DNA methylation, was not changed in WAVE1-overexpressing cells. These results indicate that WAVE1 can be a novel factor in porcine cellular reprogramming. Considering that a key defect of current porcine iPSC generation is insufficient expression of endogenous pluripotency genes, application of WAVE1 may enhance quality of porcine iPSC. We intend to evaluate expression of pluripotency markers at the protein level in WAVE1-overexpressing cells and investigate mechanisms underpinning WAVE1-mediated reprogramming process in future studies.

Assessing the Appearance and Fluorescence of Resin-Infiltrated White Spot Lesions With Caries Detection Devices

OBJECTIVE

This in vitro study examined the effectiveness of caries detector devices in assessing the ability of resin infiltration (RI) (Icon, DMG-Hamburg, Hamburg, Germany) to improve the optical properties of enamel white spot lesions (WSLs).

METHODS AND MATERIALS

Ten caries-free third molars were used. Photographs, a subjective visual assessment of the photographs, fluorescent camera (FC) images using the Spectra (Air Techniques, Melville, NY, USA), and laser fluorescent (LF) readings using the DIAGNOdent (KaVo, Biberach, Germany) were obtained from each tooth's buccal surface. Specimens were coated with nail polish leaving a rectangular window on the buccal surface and placed in pH 4.5 lactic acid gel for two weeks to create a WSL. The WSLs were analyzed by the same methods. RI was applied to half of each WSL; final photographs were then taken, and caries detector assessments were conducted. FC images were converted to grayscale, and the fluorescent image's brightness intensity was measured using ImageJ. Data were analyzed with analysis of variance and Tukey-Kramer honestly significant difference test. Significance was set at α=0.05.

RESULTS

Subjective assessment of the photographs showed that RI improved the appearance of the WSLs so that they resembled intact enamel. Mean FC-brightness intensities for intact, demineralized, and demineralized RI-treated areas were 159.6 ± 9.2, 123.4 ± 7.2, and 160.9 ± 11.5, respectively. There were no significant differences in fluorescent intensity between the intact and RI areas ( p=0.58). The demineralized areas had significantly lower fluorescent intensity than both the RI-treated and intact areas ( p<0.001). LF values did not differ significantly between intact, demineralized, or RI-treated areas.

CONCLUSIONS

This study demonstrates the ability of RI to restore artificial WSLs to the esthetics and fluorescence of intact enamel. The FC can be used to assess the optical properties of WSLs and the impact of RI on these properties.

The impact of social support and partner relationship dynamics on engagement in HIV care and antiretroviral treatment adherence among MSM in Latin America

In Latin America (LA), HIV prevalence among MSM is estimated at thirty times greater than in the general male population. Little is known about the role of social support or disclosure status in relation to the HIV care continuum among LA MSM. Using multivariable logistic generalized estimation equations, we assessed the impact of social support satisfaction and disclosure status on engagement in HIV care, ART initiation, and ART adherence with data from an online, multinational sample of HIV infected MSM in Latin America (N = 2,350). 80.0% were engaged in HIV care, 71% initiated ART, and among those, 37% reported missing at least one dose in the past month. In multivariable models, compared to being very satisfied with social support, being somewhat satisfied (aOR = 0.73, 95% CI 0.56, 0.95) or somewhat dissatisfied (aOR = 0.83, 95% CI 0.70, 0.98) were associated with reduced odds of reporting 100% ART adherence. Disclosure of status was associated with a greater odds of HIV care engagement (OR = 1.63, 95% CI 1.28, 2.07) and ART initiation (OR = 1.55, 95% CI 1.30, 1.84). Greater satisfaction with social support and comfort disclosing HIV status to these sources were associated with improved engagement in HIV care and greater initiation of ART among MSM in LA.

Radiographic and clinical changes of the patellar tendon after tibial plateau leveling osteotomy

Patellar tendon thickening (PTT) and patellar tendinosis (PTS) have been discussed in the veterinary literature as a post-operative complication of tibial plateau leveling osteotomy (TPLO). The purpose of this study was to define radiographic PTT, determine the frequency of and risk factors for PTT and PTS, and describe the clinical and histopathological findings of PTS after TPLO. We hypothesized that the location of the osteotomy alters forces placed on the patellar tendon resulting in PTT or PTS. Radiographs and medical records from 83 dogs undergoing 94 TPLO procedures were retrospectively evaluated. Two months post-operatively, 19 dogs (20.2%) had a normal patellar tendon or mild PTT, 51 (54.3%) had moderate PTT, and 24 (25.5%) had severe PTT. Seven of the 24 dogs (7.4%) with severe PTT had clinical signs consistent with PTS. Only dogs with severe PTT developed PTS (p < 0.0001). The risk factors for the development of PTT include: a cranial osteotomy, a partially intact cranial cruciate ligament (CCL) in conjunction with a cranial osteotomy, and post-operative tibial tuberosity fracture. The only risk factor identified for the development of PTS was a partially intact CCL. Four dogs with PTS improved with conservative therapy and one improved with surgical treatment. Two dogs had tendon biopsies with histopathological review that showed tendon degeneration with lack of inflammation. As only the dogs with severe PTT develop PTS, a caudal osteotomy for the prevention of PTT and subsequent PTS is recommended.

Non-contrast CT at comparable dose to an abdominal radiograph in patients with acute renal colic; impact of iterative reconstruction on image quality and diagnostic performance

OBJECTIVES

The aim was to assess the performance of low-dose non-contrast CT of the urinary tract (LD-CT) acquired at radiation exposures close to that of abdominal radiography using adaptive statistical iterative reconstruction (ASiR).

METHODS

Thirty-three patients with clinically suspected renal colic were prospectively included. Conventional dose (CD-CT) and LD-CT data sets were contemporaneously acquired. LD-CT images were reconstructed with 40 %, 70 % and 90 % ASiR. Image quality was subjectively and objectively measured. Images were also clinically interpreted.

RESULTS

Mean ED was 0.48 ± 0.07 mSv for LD-CT compared with 4.43 ± 3.14 mSv for CD-CT. Increasing the percentage ASiR resulted in a step-wise reduction in mean objective noise (p < 0.001 for all comparisons). Seventy % ASiR LD-CT images had higher diagnostic acceptability and spatial resolution than 90 % ASiR LD-CT images (p < 0.001). Twenty-seven calculi (diameter = 5.5 ± 1.7 mm), including all ureteric stones, were correctly identified using 70 % ASiR LD-CT with two false positives and 16 false negatives (diameter = 2.3 ± 0.7 mm) equating to a sensitivity and specificity of 72 % and 94 %. Seventy % ASiR LD-CT had a sensitivity and specificity of 87 % and 100 % for detection of calculi >3 mm.

CONCLUSION

Reconstruction of LD-CT images with 70 % ASiR resulted in superior image quality than FBP, 40 % ASIR and 90 % ASIR. LD-CT with ASIR demonstrates high sensitivity and specificity for detection of calculi >3 mm.

TEACHING POINTS

• Low-dose CT studies for urinary calculus detection were performed with a mean dose of 0.48 ± 0.07 mSv • Low-dose CT with 70 % ASiR detected calculi >3 mm with a sensitivity and specificity of 87 % and 100 % • Reconstruction with 70 % ASiR was superior to filtered back projection, 40 % ASiR and 90 % ASiR images.

Patient and provider attitudes towards monitored naltrexone treatment of alcohol dependence in schizophrenia

OBJECTIVE

To describe the attitudes of patients and their mental health providers regarding participation in a controlled trial of directly monitored naltrexone (NTX) treatment for alcohol dependence in schizophrenia.

METHOD

Ninety participants with schizophrenia and their providers were asked to report opinions of treatment with oral NTX or placebo 3 times per week for 12 weeks, motivational counseling (MI), and voucher-based incentives (VBI) for attendance.

RESULTS

Seventy-nine percent of participants "liked the study a lot," and 94% reported that it was helpful. Study components rated as helpful by participants were: VBI (95% of participants), meeting with staff 3 times per week (84%), reporting alcohol use (82%), MI (82%), reporting psychiatric symptoms (73%), breath alcohol testing (72%), and study medication (57%). Benefits reported by patients were: feeling better mentally (67%), drinking less (52%), feeling better physically (49%), and stopping drinking (27%). Seventy percent of providers reported that the study was helpful. Benefits noted by providers included: reduced drinking (33%), better treatment adherence (32%), stopping drinking (23%), and reduced psychiatric symptoms (22%). Patient/provider responses agreed on helpfulness with stopping or reducing drinking.

CONCLUSIONS

Most participants with schizophrenia liked participating in a clinical trial of directly observed naltrexone treatment for alcohol dependence, and found incentives for attendance, frequent staff contact and monitoring of drinking, and motivational counseling to be the most helpful. Most participants reported improvement in mental health and reduced drinking. Mental health providers also reported that the study was helpful, but they did not describe the same degree of benefit as did patients.

NDRG2, a novel regulator of myoblast proliferation, is regulated by anabolic and catabolic factors

Skeletal muscle tissue undergoes adaptive changes in response to stress and the genes that control these processes are incompletely characterised. NDRG2 (N-myc downstream-regulated gene 2), a stress- and growth-related gene, was investigated in skeletal muscle growth and adaption. While NDRG2 expression levels were found to be up-regulated in both differentiated human and mouse myotubes compared with undifferentiated myoblasts, the suppression of NDRG2 in C2C12 myoblasts resulted in slowed myoblast proliferation. The increased expression levels of the cell cycle inhibitors, p21 Waf1/Cip1 and p27 Kip1, and of various muscle differentiation markers in NDRG2-deficient myoblasts indicate that a lack of NDRG2 promoted cell cycle exiting and the onset of myogenesis. Furthermore, the analysis of NDRG2 regulation in C2C12 myotubes treated with catabolic and anabolic agents and in skeletal muscle from human subjects following resistance exercise training revealed NDRG2 gene expression to be down-regulated during hypertrophic conditions, and conversely, up-regulated during muscle atrophy. Together, these data demonstrate that NDRG2 expression is highly responsive to different stress conditions in skeletal muscle and suggest that the level of NDRG2 expression may be critical to myoblast growth and differentiation.

Radiographic and clinical changes of the patellar tendon after tibial plateau leveling osteotomy 94 cases (2000-2003)

Patellar tendon thickening (PTT) and patellar tendinosis (PTS) have been discussed in the veterinary literature as a post-operative complication of tibial plateau leveling osteotomy (TPLO). The purpose of this study was to define radiographic PTT, determine the frequency of and risk factors for PTT and PTS, and describe the clinical and histopathological findings of PTS after TPLO. We hypothesized that the location of the osteotomy alters forces placed on the patelloar tendon resulting in PTT or PTS. Radiographs and medical records from 83 dogs undergoing 94 TPLO procedures were retrospectively evaluated. Two months post-operatively, 19 dogs (20.2%) had a normal patellar tendon or mild PTT, 51 (54.3%) had moderate PTT, and 24 (25.5%) had severe PTT. Seven of the 24 dogs (7.4%) with severe PTT had clinical signs consistent with PTS. Only dogs with severe PTT developed PTS (p < 0.0001). The risk factors for the development of PTT include: a cranial osteotomy, a partially intact cranial cruciate ligament (CCL) in conjunction with a cranial osteotomy, and post-operative tibial tuberosity fracture. The only risk factor identified for the development of PTS was a partially intact CCL. Four dogs with PTS improved with conservative therapy and one improved with surgical treatment. Two dogs had tendon biopsies with histopothological review that showed tendon degeneration with lack of inflammation. As only the dogs with severe PTT develop PTS, a caudal osteotomy for the prevention of PTT and subsequent PTS is recommended.

Real-time RT-PCR analysis of housekeeping genes in human skeletal muscle following acute exercise

Studies examining gene expression with RT-PCR typically normalize their mRNA data to a constitutively expressed housekeeping gene. The validity of a particular housekeeping gene must be determined for each experimental intervention. We examined the expression of various housekeeping genes following an acute bout of endurance (END) or resistance (RES) exercise. Twenty-four healthy subjects performed either a interval-type cycle ergometry workout to exhaustion (∼75 min; END) or 300 single-leg eccentric contractions (RES). Muscle biopsies were taken before exercise and 3 h and 48 h following exercise. Real-time RT-PCR was performed on β-actin, cyclophilin (CYC), glyceraldehyde-3-phosphate dehydrogenase (GAPDH), and β2-microglobulin (β2M). In a second study, 10 healthy subjects performed 90 min of cycle ergometry at ∼65% of V̇o2 max, and we examined a fifth housekeeping gene, 28S rRNA, and reexamined β2M, from muscle biopsy samples taken immediately postexercise. We showed that CYC increased 48 h following both END and RES exercise (3- and 5-fold, respectively; P < 0.01), and 28S rRNA increased immediately following END exercise (2-fold; P = 0.02). β-Actin trended toward an increase following END exercise (1.85-fold collapsed across time; P = 0.13), and GAPDH trended toward a small yet robust increase at 3 h following RES exercise (1.4-fold; P = 0.067). In contrast, β2M was not altered at any time point postexercise. We conclude that β2M and β-actin are the most stably expressed housekeeping genes in skeletal muscle following RES exercise, whereas β2M and GAPDH are the most stably expressed following END exercise.

A multilevel modelling approach to analysis of patient costs under managed care

The growth of the managed care model of health care delivery in the USA has led to broadened interest in the performance of health care providers. This paper uses multilevel modelling to analyse the effects of managed care penetration on patient level costs for a sample of 24 medical centres operated by the Veterans Health Administration (VHA). The appropriateness of a two level approach to this problem over ordinary least squares (OLS) is demonstrated. Results indicate a modicum of difference in institutions' performance after controlling for patient effects. Facilities more heavily penetrated by the managed care model may be more effective at controlling costs of their sicker patients.

On measuring the hospital cost/quality trade-off

This paper explores the relationship between cost and quality of hospital care. A total operating cost function is estimated for 137 US Department of Veterans Affairs hospitals for 1988-1993 using three rate-based measures of quality as regressors. The high likelihood of the existence of measurement error in quality in the cross section leads to the application of novel instrumental variable techniques. Results suggest that mortality and readmission indices are adjusted inadequately for illness severity. The measure on the failure to follow up inpatient discharges with outpatient care, however, appears to increase cost. The results of this paper underscore a number of practical difficulties and challenges facing government or other systems in evaluating the relative performance of their hospitals.

Identification of Gas6 as a ligand for Mer, a neural cell adhesion molecule related receptor tyrosine kinase implicated in cellular transformation

Mer/Nyk/Eyk is an orphan receptor tyrosine kinase expressed at high levels in monocytes and cells derived from epithelial and reproductive tissues. Overexpression of Mer has been associated with lymphoid malignancies. Here we identify Gas6, the product of a growth arrest specific gene, as a ligand for Mer. Gas6 has previously been shown to activate both Axl and Rse/Tyro3, two other receptor tyrosine kinases in the same family as Mer. The apparent relative association and dissociation rate constants of Gas6 for soluble Axl, Rse/Tyro3 and Mer were compared using surface plasmon resonance. Gas6 was shown to induce rapid phosphorylation of Mer expressed in several different types of cells. We also observed a transient activation of p42 MAP kinase following activation of Mer by Gas6. Thus, Gas6 exerts its biological effects through multiple receptor tyrosine kinases.

Pharmacokinetics, tissue distribution, and expression efficiency of plasmid [33P]DNA following intravenous administration of DNA/cationic lipid complexes in mice: use of a novel radionuclide approach

The pharmacokinetics, tissue distribution, and efficacy of a systemic gene transfer method were examined in male BALB/c mice (6-8 weeks old) using 33P-labeled plasmid DNA for luciferase. The DNA was delivered via tail vein injection in saline ([33P]DNA) or in a cationic lipid formulation ([33P]DNA/lipid). One group of mice received approximately equal to 1-3 microCi (45 micrograms of DNA) of either formulation, and mice were euthanized at 2 and 20 min, and 1 and 24 h postdose (2 mice/time point). Blood and plasma radioactivity were quantified, and whole body autoradiographic (WBAR) images were obtained from 20-microns whole body sections. A tissue distribution (TD) study was conducted in a second group of mice, which received approximately equal to 4-6 microCi (45-60 micrograms of DNA) of [33P]DNA/lipid. Mice were euthanized at 1.5 h (1 mouse; [33P]DNA/lipid) or 24 h (2 mice/ group), and organ radioactivity and luciferase expression were measured in lung, liver, kidney, spleen thymus, and parotid salivary gland by direct quantitation methods. Microautoradiography (MAR) was performed on a third group of mice (n = 2), which received 3 microCi (45 micrograms of DNA) of [33P]DNA/lipid and were euthanized at 24 h postdose. For WBAR, the [33P]DNA/lipid tissue distribution (% dose equiv/g) at 2 min was lung >> liver > spleen (red pulp) > kidney (cortex); at 24 h the ranking was spleen (red pulp) > liver > lung, kidney (cortex). The [33P]DNA organ distribution observed at 2 min was liver >> spleen (red pulp) > lung, blood > kidney (cortex); at 24 h the ranking was liver, spleen (red pulp) > kidney (cortex) > lung, blood. High levels of radioactivity in bone (cortical, marrow, growth plate) in both groups may represent uptake of the 33P-labeled test articles by the cellular component of the bone marrow, particularly macrophages, as well as deposition of [33P]phosphate in the bone matrix following metabolism of the [33P]DNA. In the luciferase component of the study, no expression was observed in the [33P]DNA group at 24 h. The [33P]- DNA/lip group exhibited expression as early as 1.5 h in the lung; at 24 h, expression was seen in all the organs examined. Microautoradiography of 24-h tissue samples revealed radioactivity in hepatic Kupffer cells, reticuloendothelial system cells in the marginal zone of the spleen, and diffusely along alveolar septae with scattered accumulations in alveolar macrophages. The results of the WBAR, TD, MAR, and luciferase assay show that the use of cationic lipids significantly altered the biodistribution and resulting expression of the DNA plasmid. Further, 33P (0.25 MeV beta, half-life = 25 days) was shown to be an excellent radionuclide for quantitative WBA and MAR, providing sharp images with less personal hazard and greater ease of handling than 32P (1.71 MeV beta, half-life = 14.3 days).

A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control

This study was conducted to evaluate the effect of automated telephone patient monitoring and counseling on patient adherence to antihypertensive medications and on blood pressure control. A randomized controlled trial was conducted in 29 greater Boston communities. The study subjects were 267 patients recruited from community sites who were >or= 60 years of age, on antihypertensive medication, with a systolic blood pressure (SBP) of >or= 160 mm Hg and/or a diastolic blood pressure (DBP) of >or= 90 mm Hg. The study compared subjects who received usual medical care with those who used a computer-controlled telephone system in addition to their usual medical care during a period of 6 months. Weekly, subjects in the telephone group reported self-measured blood pressures, knowledge and adherence to antihypertensive medication regimens, and medication side-effects. This information was sent to their physicians regularly. The main study outcome measures were change in antihypertensive medication adherence, SBP and DBP during 6 months, satisfaction of patient users, perceived utility for physicians, and cost-effectiveness. The mean age of the study population was 76.0 years; 77% were women; 11% were black. Mean antihypertensive medication adherence improved 17.7% for telephone system users and 11.7% for controls (P = .03). Mean DBP decreased 5.2 mm Hg in users compared to 0.8 mm Hg in controls (P = .02). Among nonadherent subjects, mean DBP decreased 6.0 mm Hg for telephone users, but increased 2.8 mm Hg for controls (P = .01). For telephone system users, mean DBP decreased more if their medication adherence improved (P = .03). The majority of telephone system users were satisfied with the system. Most physicians integrated it into their practices. The system was cost-effective, especially for nonadherent patient users. Therefore, weekly use of an automated telephone system improved medication adherence and blood pressure control in hypertension patients. This system can be used to monitor patients with hypertension or with other chronic diseases, and is likely to improve health outcomes and reduce health services utilization and costs.

Cost allocation patterns between hospital inpatient and outpatient departments

OBJECTIVE

This study examines changes in hospitals' cost allocation patterns between inpatient and outpatient departments in response to the implementation of the prospective payment system. DATA SOURCES AND STUDY SETTINGS: The analysis was carried out using data for 3,961 hospitals obtained from the Medicare Cost Reports and from the American Hospital Association for the years 1984 through 1988.

STUDY DESIGN

A total operating cost function was estimated on the two outputs of discharges and outpatient visits. The estimation results were instrumental in disaggregating costs into inpatient and outpatient components. This was done cross-sectionally for each of the five years.

PRINCIPAL FINDINGS

Comparison of this cost breakdown with that of hospital revenue provides evidence of distinct patterns in which nonteaching, rural, and small hospitals increasingly allocated greater costs to outpatient departments than did large, urban, and teaching hospitals.

CONCLUSIONS

The results suggest that small rural hospitals turned to the outpatient side in the face of tough economic challenges over the period of study. Because differences in cost allocation patterns occur by particular hospital category, analyses that rely on accounting cost or revenue data in order to identify cost differences among those same categories may come to erroneous conclusions. In particular, because teaching hospitals apportion costs more heavily on the inpatient side, cost allocation differences cause upward bias in the PPS medical education adjustment.

"Occult" hepatitis B virus as source of infection in liver transplant recipients

Hepatitis B virus (HBV) infection almost always recurs after liver transplantation in patients who were surface antigen (HBsAg) positive before surgery but apparent de novo acquisition of infection in a transplant setting has not previously been reported. We have used sensitive techniques to elucidate the origin of such infections in patients in a California transplantation programme. We tested post-transplant serum from 207 patients who had been HBsAg negative and found 20 to be HBsAg positive. The origin of infection was identified in 7 patients, being occult pre-transplant infection in 5 and occult infection in the donor in 2. No pre-transplant patient nor donor with demonstrable HBV DNA had serological markers of hepatitis B. Post-transplant HBV DNA was present in serum from 19 patients. Analysis of the variable pre-S region of HBV demonstrated 100% sequence homology between recipient liver and post-transplant serum (2 patients) and between donor serum and recipient post-transplant serum (2). There was only 84% homology between the 2 different patients infected with subtype adw. 19 patients are alive, 9 without histological evidence of hepatitis (mean follow-up 33 months), and survival was significantly greater than that of a group with recurrent HBV infection. Apparent acquisition of HBV infection with liver transplantation is not rare, and may be due to occult pre-transplant infection or occult infection in the donor. The post-transplant outcome of this infection tends to be benign but our findings do underscore the clinical relevance of HBV infection in the absence of serological markers.

Measuring inpatient and outpatient costs: a cost-function approach

In this article, the authors estimate a multiple-output cost function for a sample of 2,235 hospitals during the period 1984-88 to disaggregate total costs into inpatient and outpatient components. The results suggest that outpatient cost growth is roughly proportional to that of inpatient cost, despite much higher relative growth in revenues and utilization on the outpatient side. The stability in the outpatient/inpatient cost ratio implies that the increase in the outpatient-to-inpatient utilization ratio was offset by a decline in their relative unit costs.

Characterization of a candidate bcl-1 gene

The t(11;14)(q13;q32) translocation has been associated with human B-lymphocytic malignancy. Several examples of this translocation have been cloned, documenting that this abnormality joins the immunoglobulin heavy-chain gene to the bcl-1 locus on chromosome 11. However, the identification of the bcl-1 gene, a putative dominant oncogene, has been elusive. In this work, we have isolated genomic clones covering 120 kb of the bcl-1 locus. Probes from the region of an HpaII-tiny-fragment island identified a candidate bcl-1 gene. cDNAs representing the bcl-1 mRNA were cloned from three cell lines, two with the translocation. The deduced amino acid sequence from these clones showed bcl-1 to be a member of the cyclin gene family. In addition, our analysis of expression of bcl-1 in an extensive panel of human cell lines showed it to be widely expressed except in lymphoid or myeloid lineages. This observation may provide a molecular basis for distinct modes of cell cycle control in different mammalian tissues. Activation of the bcl-1 gene may be oncogenic by directly altering progression through the cell cycle.

Cloning of the t(11;14)(q13;q32) translocation breakpoints from two human leukemia cell lines

The t(11;14)(q13;q32) translocation has been associated with several subtypes of human leukemia and lymphoma. It has been proposed that this translocation activates a proto-oncogene designated BCL1. In an effort to better understand the mechanism by which this translocation leads to malignancy, we have studied this translocation in two human cell lines. MO1094 and MO2058 were derived from patients with prolymphocytic variants of chronic lymphocytic leukemia. Southern blotting of the MO2058 cell line documented that the translocation linked the Jh region in the immunoglobulin heavy chain gene to the previously described BCL1 major translocation cluster (MTC). Using the polymerase chain reaction, we cloned this translocation and showed that the chromosome 11 breakpoint was within 7 bp of two other samples reported previously. Southern blotting of the MO1094 cell line suggested that the translocation in this cell line might link Jh sequences to a new region in the BCL1 locus on chromosome 11. Therefore, the MO1094 breakpoint was cloned from a genomic library. Comparison with normal cloned DNA from the BCL1 locus showed that the chromosome 11 breakpoint occurred 24 kb telomeric of the MTC. This work reinforces the concept that translocation breakpoints in the BCL1 locus are scattered over at least 63 kb.

Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures. A prospective evaluation

OBJECTIVES

To summarize the results of a 6-year, ongoing, prospective study of the risk for human immunodeficiency virus type 1 (HIV-1) transmission among health care workers, and to estimate the magnitude of the risk for HIV-1 infection associated with different types of occupational exposures.

DESIGN

Prospective cohort study; the median follow-up for employees sustaining parenteral exposures was 30.2 months (range, 6 to 69 months).

SUBJECTS

Health care workers at the Clinical Center, National Institutes of Health, including those reporting parenteral and nonparenteral occupational exposures to HIV-1.

MEASUREMENTS AND MAIN RESULTS

One thousand three hundred and forty-four clinical health care workers reported 179 percutaneous and 346 mucous membrane exposures to fluids from HIV-1-infected patients during a 6-year period. Responding to a supplementary questionnaire, 559 of these workers reported 2712 cutaneous exposures to blood from HIV-1-infected patients and more than 10,000 cutaneous exposures to blood from all patients during a 12-month period. Occupational transmission of HIV-1 occurred in a single worker after a parenteral exposure to blood from an HIV-1-infected patient. No infections occurred after either mucous membrane or cutaneous exposures to blood from HIV-1-infected patients. Use of newer diagnostic technologies (for example, antigen detection, gene amplification) has not resulted in the identification of occupationally transmitted seronegative infections.

CONCLUSIONS

Combining our results with those of other prospective studies, the risk for HIV-1 transmission associated with a percutaneous exposure to blood from an HIV-1-infected patient is approximately 0.3% per exposure (95% CI, 0.13% to 0.70%); the risks associated with occupational mucous membrane and cutaneous exposures are likely to be substantially smaller. These data support the use of barrier precautions and suggest a need for strategies that change health care providers' attitudes and behaviors.

A survey of homeless adults in urban emergency shelters

Following a review of several studies of homeless populations, the authors describe a survey of 68 homeless adults in eight urban emergency shelters in Hennepin County, Minnesota. The results indicated impressive rates of mental illness, alcoholism, minor criminality, and chronic medical and dental problems. More significant, the authors believe, both for the homeless and for public policy planners, is that a majority of the interviewees were disconnected from supportive social networks and were underutilizing medical and welfare programs for which they were eligible. Almost 40 percent of those with chronic health problems were receiving no medical care, and only 6 percent were receiving mental health services, although more than 50 percent needed such care. The authors compare the findings with those of studies discussed in the literature review.