Virtual urgent care is here to stay: driving toward safe, equitable, and sustainable integration within emergency medicine

BACKGROUND

Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine.

METHODS

We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement.

RESULTS

The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada.

CONCLUSION

Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada.

Topologically associating domains are disrupted by evolutionary genome rearrangements forming species-specific enhancer connections in mice and humans

Distinguishing between conserved and divergent regulatory mechanisms is essential for translating preclinical research from mice to humans, yet there is a lack of information about how evolutionary genome rearrangements affect the regulation of the immune response, a rapidly evolving system. The current model is topologically associating domains (TADs) are conserved between species, buffering evolutionary rearrangements and conserving long-range interactions within a TAD. However, we find that TADs frequently span evolutionary translocation and inversion breakpoints near genes with species-specific expression in immune cells, creating unique enhancer-promoter interactions exclusive to the mouse or human genomes. This includes TADs encompassing immune-related transcription factors, cytokines, and receptors. For example, we uncover an evolutionary rearrangement that created a shared LPS-inducible regulatory module between OASL and P2RX7 in human macrophages that is absent in mice. Therefore, evolutionary genome rearrangements disrupt TAD boundaries, enabling sequence-conserved enhancer elements from divergent genomic locations between species to create unique regulatory modules.

It is currently unclear how evolutionary genome rearrangements affecting the mouse and human genomes influence the expression of genes important in immunity. Gilbertson et al. report that evolutionary genome rearrangements disrupt topologically associating domain boundaries, enabling sequence-conserved enhancer elements from divergent locations between species to create unique regulatory modules.

Using co-design to develop an online intervention for families after a sudden cardiac death in the young

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of Australia / NHMRC Co-funded Post Graduate Scholarship

Introduction

Sudden cardiac death (SCD) is a devastating complication of many genetic heart diseases. The psychological impact on surviving family members is significant and lifelong. Previous needs analysis found medical and psychological needs are of high importance but remain unmet in some cases. Co-design is an increasingly popular research method for the development of interventions and services that include users as contributing members of the research team. Previous research has shown co-design leads to innovative ideas that better address user needs.

Purpose

To use co-design to develop an online support intervention for families after SCD.

Methods

Semi-structured moderated online focus groups were held with key stakeholders, including family members who had experienced young SCD, healthcare professionals and researchers. Guided discussions were used to co-design an online support intervention. Thematic analysis of discussions and iterative feedback on draft materials guided content development.

Results

Four focus groups were held (average 11 participants per group). Stakeholder involvement facilitated development of high-level ideas and priority issues. Key benefits included creative content and materials developed based on user preference for stories, narratives and information reflecting everyday experience of families navigating the legal and medical processes surrounding SCD, normalising and supporting grief responses in the context of family relationships, and fostering hope.

Conclusion

Co-design supported creative presentation, tailoring of information and development of psychosocial interventions to meet the needs of SCD families. Further work is needed to pilot and trial the intervention, prior to it becoming a key resource in the care of these families.

Prevalence of cardiac abnormalities in sickle cell disease identified using cardiac magnetic resonance imaging

Background

Sickle cell disease (SCD) affects thousands of individuals in the United Kingdom causing significant morbidity and mortality. Modern therapies have been successful in increasing life expectancy, however these patients have an increased risk of cardiovascular complications and the extent to which sickle cell disease affects cardiac function is not well understood. Cardiac magnetic resonance imaging (MRI) is the gold standard imaging modality for evaluating myocardial function. It is known that sickle cell patients can present with pulmonary hypertension, left ventricular diastolic dysfunction, and atrial enlargement however the prevalence of other cardiac abnormalities has not been sufficiently investigated with cardiac MRI. In addition, the European Society of Cardiology (ESC) updated their definition of Heart Failure in 2016 and therefore will need to be re-assessed in this population.

Purpose

To evaluate the prevalence of cardiac abnormalities in the sickle cell population using cardiac MRI and based on the recently updated diagnostic criteria.

Methods

We conducted a retrospective review including all patients with sickle cell disease at a large tertiary hospital in London, United Kingdom who had been referred for cardiac MRI between 2011 and 2019. Data was collected data on various measures of cardiac function including: left ventricular ejection fraction (LVEF), left ventricular hypertrophy, left and right atrial enlargement, regional wall motion abnormalities, valvular disease, myocardial scarring, and cardiac iron load.

Results

82 patients and 123 cardiac MRI scans were reviewed in this study. 68% of patients were female and the average age at time of scan was 37 years. The average left ventricular ejection fraction was 57% (n=82). Cardiac abnormalities were identified in 60% of patients. The most common cardiac abnormalities reported were: valvular regurgitation (46%; n=28), left atrial enlargement (28%; n=19), right atrial enlargement (16%; n=11), left ventricular hypertrophy (11%; n=8), regional wall motion abnormalities (10%; n=7), and myocardial scar with late gadolinium enhancement (9%; n=7). 28% of the patients were diagnosed with Heart Failure; 11% of the patients satisfied the diagnostic criteria for HFpEF (Heart failure with preserved ejection fraction, n=9), 10% with HFrEF (Heart Failure with reduced ejection fraction, n=8), and 7% with HFmrEF (Heart Failure with mid-range ejection fraction, n=6).

Conclusion

Sickle cell disease affects cardiac function in the majority of patients resulting in numerous cardiac abnormalities. We have described the overall extent of these effects using data from cardiac MRI scans, which has not been commonly used thus far. This has implications for both the diagnosis and subsequent management of cardiac abnormalities in this population, and it can be used to further investigate and guide the development of targeted treatments for these patients.

Funding Acknowledgement

Type of funding source: None

The association between sympatho-vagal balance and central blood pressures

Purpose

High central blood pressure is more predictive of cardiovascular disease (CVD) versus high peripheral blood pressure. Measures of central pressures (CPs) include, central systolic blood pressure (CSBP) and central diastolic blood pressure. Measures of central pressures augmentation (CPsA) include augmentation pressure (AP) and the augmentation index @ 75 beats·min-1 (AIx@75). Increased sympathetic tone (ST) is also associated with CVD. The low to high frequency ratio (LF/HF) is often used to determine sympatho-vagal balance. Given the association between ST, CPs, CPsA and CVD there is a need to understand the association between these predictors of CVD. The aims of this study were to examine the association between the LF/HF ratio, CPs, and CPsA in men and women collectively and based on gender.

Methods

We measured the LF/HF ratio, CSBP, AP, and AIx@75 in 102 participants (41F/61M). The LF/HF ratio was determined via power spectral density analysis. CSBP, AP, and AIx@75 were determined via applanation tonometry.

Results

The LF/HF ratio was inversely associated with AP (r = -0.26) and AIx @75 (r = -0.29) in the combined group of men and women. The LF/HF ratio was inversely associated with CSBP (r = -0.27), AP (r = -0.28), and AIx@75 (r = -0.32) in men, but not in women.

Conclusion

There is an inverse association between the LF/HF ratio, AP, and AIx@75 in men and women combined. The association between the LF/HF ratio, CSBP, AP, and AIx@75, differs based on gender.

Functional lasing microcapillaries for surface-specific sensing

Lasing-based sensors have several advantages over fluorescent devices, specifically related to the high light intensity and narrow mode linewidth that can improve the speed and accuracy of the sensor performance. In this work, a microcapillary-based lasing sensor is demonstrated, in which the lasing wavelengths are sensitive to the surface binding of specific materials. In order to achieve this, we utilized lasing into the "star" and "triangle" modes of a conventional microcapillary and tracked the mode positions after the deposition of a polyelectrolyte tri-layer and the subsequent amide binding of carboxy-functionalized polystyrene microspheres. While the lasing mode spectrum becomes increasingly complicated by the addition of the surface layers, careful mode selection can be used to monitor the layer-by-layer surface binding in a mechanically and optically robust device. For polystyrene microspheres, the detection limits were 9.75 nM based upon the lasing mode shift, which compares favorably with fluorescence-based devices. The methods presented in this work could readily be extended to other surface binding schemes and lasing wavelengths, showing that capillary microlasers could be used for many potential applications that capitalize on stable lasing-based detection methods.

Student ePortfolios to develop reflective skills and demonstrate competency development: Evaluation of a curriculum pilot project

INTRODUCTION

The University of British Columbia Faculty of Dentistry developed a longitudinal curriculum pilot project to assess the usefulness of portfolios for dental students to develop reflective skills and demonstrate competency development, and to examine relationships between portfolio grades and clinical success.

MATERIALS AND METHODS

Students in one dental class created portfolios with reflections on examples relevant to eight selected competency statements each year of the program. As part of our program evaluation, we set out to look at trends in portfolio grades, meta-reflection skills, student and faculty views of the project, and relationships among portfolio grades, 4th year clinical grades and faculty rankings.

RESULTS

Portfolio grades improved from years 1 to 3, dropping off slightly in year 4. The highest level of internal consistency for grades within and between years occurred with Competency 42, while the lowest level occurred with Competency 4. Most students were able to demonstrate meta-reflection by 4th year. Students generally agreed with portfolios and reflection in concept, but suggested a looser structure, and they shared concerns with faculty about the workload involved. Portfolio grades did not correlate with clinical course grades (P = 0.092), but they did correlate significantly with faculty rankings except for year 1.

CONCLUSION

While portfolio grades for reflections were not consistent, and they did not quite correlate with clinical course grades, they correlated strongly with faculty rankings. Future use of portfolios at UBC Dentistry will be enhanced by increasing curricular support regarding both competency development and the importance of reflection for professionals, decreasing workload by focusing on five Key Competencies, incorporating more formative and face-to-face feedback, and providing greater opportunities for peer sharing.

Blended learning in situated contexts: 3-year evaluation of an online peer review project

BACKGROUND

Situated and sociocultural perspectives on learning indicate that the design of complex tasks supported by educational technologies holds potential for dental education in moving novices towards closer approximation of the clinical outcomes of their expert mentors. A cross-faculty-, student-centred, web-based project in operative dentistry was established within the Universitas 21 (U21) network of higher education institutions to support university goals for internationalisation in clinical learning by enabling distributed interactions across sites and institutions. This paper aims to present evaluation of one dental faculty's project experience of curriculum redesign for deeper student learning.

METHODS

A mixed-method case study approach was utilised. Three cohorts of second-year students from a 5-year bachelor of dental surgery (BDS) programme were invited to participate in annual surveys and focus group interviews on project completion. Survey data were analysed for differences between years using multivariate logistical regression analysis. Thematic analysis of questionnaire open responses and interview transcripts was conducted.

RESULTS

Multivariate logistic regression analysis noted significant differences across items over time indicating learning improvements, attainment of university aims and the positive influence of redesign. Students perceived the enquiry-based project as stimulating and motivating, and building confidence in operative techniques. Institutional goals for greater understanding of others and lifelong learning showed improvement over time. Despite positive scores, students indicated global citizenship and intercultural understanding were conceptually challenging.

CONCLUSIONS

Establishment of online student learning communities through a blended approach to learning stimulated motivation and intellectual engagement, thereby supporting a situated approach to cognition. Sociocultural perspectives indicate that novice-expert interactions supported student development of professional identities.

Reducing the carbon footprint of the operating theatre: a multicentre quality improvement report

Currently, there are very few provisions for recycling in theatres. We measured the weight of clinical waste for several orthopaedic operations. This waste was then examined and sorted into domestic waste and clinical waste. With staff education it is possible to reduce the amount of clinical waste generated by the operating theatre by roughly 50%. A greater awareness of disposal options leads to a reduction in waste disposed of by incineration.

International peer review in undergraduate dentistry: enhancing reflective practice in an online community of practice

To stimulate and enhance student learning in the areas of global citizenship, critical reflection and e-learning, an online international peer review using a purpose-built web platform, has been developed between international dental schools. Since its inception in 2007, n = 6 dental schools from six different countries have participated with n = 384 dental students engaged in online peer review. Project development was conceptually analysed utilising Lave and Wenger's notion of a community of practice (CoP). Analysis drew on the three core components within the CoP organising framework: domain, community and practice. All three components were evident in building project identity. The domain focused on both curriculum and institutional co-operation. The community was evident for both educators and students. Finally, analysis of practice was found to be significant in terms of sustained interaction and collaboration. Empirical evaluation is recommended as the next phase of project design.

Infectious feline herpesvirus detected in distant bone and tendon following mucosal inoculation of specific pathogen-free cats

Emerging evidence suggests that cats infected with feline herpesvirus-1 (FHV-1) may experience a brief viremic phase. The objective of this study was to determine whether natural routes of FHV-1 inoculation could result in viremic transmission of infectious virus to connective tissues (cortical bone, tendon). Three specific pathogen-free cats were experimentally inoculated with FHV-1 via a combined mucosal (oronasal, ocular) route. Cats were euthanized at the peak of clinical signs to aseptically harvest tissues (cortical bone, tendon, trachea/tongue) for co-culture with a susceptible cell line to promote spread of infectious virus. Viral infection of Crandall-Rees feline kidney cells was microscopically visualized by cytopathic effect (CPE). Additionally, co-culture DNA was extracted either at the point of CPE or 16 days of culture without evidence of CPE, to amplify FHV-1 glycoprotein B gene using real-time PCR. Infectious virus was detected in distant cortical bone (two cats, moderate to severe clinical signs) and tendon (one cat, severe clinical signs). Direct infection of mucosal (trachea, tongue) tissues also was confirmed in these two cats. In contrast, all co-cultured tissues from the third cat (mild clinical signs) were negative for FHV-1 by CPE and PCR. Results of this study demonstrated that early primary FHV-1 viremia may be distributed to distant connective tissues.

Prevalence of overweight, obesity and underweight among 5-year-old children in Saint Lucia by three methods of classification and a comparison with historical rates

BACKGROUND

The study aimed to determine if child obesity rates have risen in the Caribbean nation of Saint Lucia, as found globally, and whether under-nutrition coexists, as in other developing nations. The average adult in Saint Lucia is overweight, thus considerable child obesity might be expected, but there are no current data.

METHODS

Heights and weights were obtained from a sample (n= 425) of the 2001 birth cohort of Saint Lucian children measured during the nation-wide 2006/2007 Prior to School Entry Five-Year Assessment. Prevalence of overweight, obesity and underweight were estimated by Centers for Disease Control (CDC), Cole et al. and new World Health Organization (WHO) methods. Previously reported 1976 estimates, including children ≤60 months of age only, based on National Centre for Health Statistics curves, were adjusted to new WHO equivalents using an algorithm developed by Yang and de Onis, and compared with rates in our subsample of children ≤60 months of age (n= 99).

RESULTS

Regardless of classification method, overweight and obesity rates were high: 14.4% and 9.2% (WHO); 11.3% and 12.0% (CDC); and 9.9% and 7.1% (Cole et al.), respectively. Underweight estimates also varied: 4.7% (WHO); 11.3% (CDC) and 6.6% (Cole et al.). Obesity in our young subsample (15.2%; WHO) was more than 3 times the adjusted 1976 rate (4.3%).

CONCLUSIONS

Obesity among Saint Lucian pre-schoolers has tripled in 30 years. Our findings also suggest that this country, like many undergoing a 'nutrition transition', faces the dual challenge of over-nutrition and under-nutrition. Routine monitoring of overweight and underweight is needed in Saint Lucia, as is the implementation and evaluation of programmes to address these problems.

Activity of cediranib, a highly potent and selective VEGF signaling inhibitor, in alveolar soft part sarcoma

10523

Background: Alveolar soft part sarcoma (ASPS) is a rare entity making up <1% of soft tissue sarcomas (STS). It is typically indolent but with a high incidence of metastatic disease, usually to lungs, but also to sites such as the brain. Response to conventional chemotherapy is poor (overall response rates are approximately 7% [Reichardt P et al,Eur J Cancer.2003;39:1511–1516]). This is a preliminary report of the activity of cediranib, a highly potent and selective VEGF signaling inhibitor, in this disease. Methods: Efficacy and tolerability data were collected for seven patients with ASPS. One patient was treated in a phase II randomized trial of cediranib ± prophylactic antihypertensive therapy and six were treated in a Phase II study in patients with imatinib-refractory gastrointestinal stromal tumors or other STS. Cediranib was administered orally, once daily at an initial dose of 45 mg. Response was assessed using RECIST (Response Evaluation Criteria in Solid Tumors). Results: Median age at diagnosis was 39 years (range: 26–49). All patients had pulmonary metastases and two had additional sites of disease (brain, bone, intra-abdominal) at study entry. Adverse events were generally CTC grade 1–2 and manageable. The most common adverse events were fatigue (n = 6), diarrhea (n = 5), stomatitis (n = 4), headache (n = 3), and hypertension (n = 3). Four patients had a best response of partial response, two patients had a confirmed reduction in maximum tumor diameter of ≥10% and <30% and one patient experienced stable disease. As of November 2008, three patients remain on treatment with a median (range) time on study of 61 weeks (49–74). Time to progression and progression-free survival will be calculated and available at the time of presentation. Conclusions: These data demonstrate the promising preliminary activity and safety of chronic administration of cediranib in this disease. Further investigation is warranted, particularly as there is no effective systemic treatment for patients with advanced ASPS.

[Table: see text]

RNA interference-mediated silencing of the polo-like kinase 1 gene enhances chemosensitivity to gemcitabine in pancreatic adenocarcinoma cells

Gemcitabine is the first-line chemotherapeutic agent for advanced adenocarcinoma of the pancreas; however, chemoresistance to gemcitabine remains a major cause of failure for the clinical treatment of this disease. Polo-like kinase 1 (Plk-1) is highly expressed in pancreatic cancer cell lines and pancreatic tumour tissues, and is involved in a wide variety of cell cycle processes. Nevertheless, its biological role and implication for gemcitabine resistance are not clearly defined. In this study, we used RNA-interference (RNAi)-mediated depletion of Plk-1 to determine its potential for sensitizing pancreatic tumour cells to gemcitabine. We showed that the level of Plk-1 protein was correlated significantly with gemcitabine resistance in human pancreatic adenocarcinoma cells and that overexpression of Plk-1 reduced sensitivity to gemcitabine in these cells. In addition, small interfering RNA (siRNA)-mediated knockdown of Plk-1 caused cell cycle arrest at G2/M and the reduction of cellular proliferation. More importantly, the treatment of pancreatic cancer cells with Plk-1 siRNA followed by exposure to gemcitabine dramatically decreased cell viability and increased cellular apoptosis, as compared with treatment with either agent alone. These observations indicate that down-regulation of Plk-1 expression by RNAi enhances gemcitabine sensitivity and increases gemcitabine cytotoxicity in pancreatic tumour cells. This is the first demonstration that the combination of Plk-1 gene therapy and gemcitabine chemotherapy has synergistic anti-tumour activity against pancreatic carcinoma in vitro. This combination treatment warrants further investigation as an effective therapeutic regimen for patients with resistant pancreatic cancer and other tumours.

Ecological and genetic evidence that low-order streams inhibit dispersal by red-backed salamanders (Plethodon cinereus)

While many studies have examined the barrier effects of large rivers on animal dispersal and gene flow, few studies have considered the barrier effects of small streams. We used displacement experiments and analyses of genetic population structure to examine the effects of first-order and second-order streams on the dispersal of terrestrial red-backed salamanders, Plethodon cinereus (Green, 1818). We marked red-backed salamanders from near the edges of one first-order stream and one second-order stream, and experimentally displaced them either across the stream or an equal distance farther into the forest. A comparison of return rates indicated that both streams were partial barriers to salamander movement, reducing return rates by approximately 50%. Analysis of six microsatellite loci from paired plots on the same side and on opposite sides of the second-order stream suggested that the stream did contribute to genetic differentiation of salamander populations. Collectively, our results imply that low-order streams do influence patterns of movement and gene flow in red-backed salamanders. We suggest that given the high density of first-order and second-order streams in most landscapes, these features may have important effects on species that, like red-backed salamanders, have limited dispersal and large geographic ranges.

Unscheduled CDK1 activity in G1 phase of the cell cycle triggers apoptosis in X-irradiated lymphocytic leukemia cells

Cyclin-dependent kinase 1 (CDK1) is a major component of the cell cycle progression engine. Recently, several investigations provided evidence demonstrating that unscheduled CDK1 activation may also be involved in apoptosis in cancerous cells. In this article, we demonstrate that X-ray irradiation induced G1 arrest in MOLT-4 lymphocytic leukemia cells, the arrest being accompanied by reduction in the activity of CDK2, but increased CDK1 activity and cell apoptosis in the G1 phase. Interestingly, this increase in CDK1 and apoptosis by ionizing radiation was prevented by pretreatment with the CDK1 inhibitor, roscovitine, suggesting that CDK1 kinase activity is required for radiation-induced apoptotic cell death in this model system. Furthermore, cyclin B1 and CDK1 were detected co-localizing and associating in G1 phase MOLT-4 cells, with the cellular lysates from these cells revealing a genotoxic stress-induced increase in CDK1 phosphorylation (Thr-161) and dephosphorylation (Tyr-15), as analyzed by postsorting immunoprecipitation and immunoblotting. Finally, X-irradiation was found to increase Bcl-2 phosphorylation in G1 phase cells. Taken together, these novel findings suggest that CDK1 is activated by unscheduled accumulation of cyclin B1 in G1 phase cells exposed to X-ray, and that CDK1 activation, at the wrong time and in the wrong phase, may directly or indirectly trigger a Bcl-2-dependent signaling pathway leading to apoptotic cell death in MOLT-4 cells.

Pharmacologic profiling of transcriptional targets deciphers promoter logic

The blueprint for cellular diversity and response to environmental change is encoded in the cis-acting regulatory sequences of most genes. Deciphering this 'cis-regulatory code' requires multivariate data sets that examine how these regions coordinate transcription in response to diverse environmental stimuli and therapeutic treatments. We describe a transcriptional approach that profiles the activation of multiple transcriptional targets against combinatorial arrays of therapeutic and signal transducing agents. Application of this approach demonstrates how cis-element composition and promoter context combine to influence transcription downstream of mitogen-induced signaling networks. Computational dissection of these transcriptional profiles in activated T cells uncovers a novel regulatory synergy between IGF-1 and CD28 costimulation that modulates NF-kappaB and AP1 pathways through signaling cascades sensitive to cyclosporin A and wortmannin. This approach provides a broader view of the hierarchical signal integration governing gene expression and will facilitate a practical design of combinatorial therapeutic strategies for exploiting critical control points in transcriptional regulation.

234.Calcium involvement in glucose induced GLUT3 expression in preimplantation mouse embryos

Despite their inability to utilise glucose for energy prior to compaction (E3), mouse embryos have a requirement for at least a brief glucose exposure to permit normal development. In the absence of this glucose pulse in vitro, we and others have found that embryos cleave to form morulae but fail to form blastocysts and subsequently degenerate. These embryos do not develop the capacity to utilise glucose preferentially and are unable to adapt to their nutrient environment and utilise alternate substrates (1). This inability to utilise glucose is due to failure to express GLUT3 at compaction (2). Brief glucose exposure prior to the 8-cell stage is sufficient to permit the embryo to undergo compaction, express GLUT3 and ultimately form a blastocyst, suggesting that glucose induces metabolic differentiation of the developing embryo. In this study we have explored the role of intracellular calcium in response to glucose given its central role in pancreatic glucose induced signalling events. Zygotes were cultured in the presence and absence of glucose and treated with either calcium mobilising agents, ethanol or ionomycin at 54�h post hCG or with the intracellular calcium chelator BAPTA-AM. Embryos were fixed and assayed for GLUT3 expression individually at 96�h post hCG using confocal immunofluorescence. Release of intracellular calcium by either ethanol or ionomycin, activated GLUT3 expression in a glucose like manner (P�<�0.01) suggesting that calcium transients may be involved in glucose sensing. Moreover, buffering of calcium with the calcium chelator BAPTA-AM interfered with the ability of glucose to activate GLUT3 expression (P�<�0.05), suggesting that glucose exposure does result in calcium transients that affect GLUT3 expression. It is unclear whether these calcium transients occur as a result of influx of extracellular calcium via voltage-gated ion channels or the release of calcium from intracellular stores via inositol triphosphate-gated calcium release channels in the endoplasmic reticulum. (1) Martin and Leese (1995) Mol. Reprod. Dev. 40, 436–443. (2) Pantaleon et al. (2001) Proc 32nd Annual SRB Conference, Gold Coast, Qld. A42.

Hepatitis B prevalence and risk factors for HBsAg carriage amongst Somali households in Liverpool

The prevalence of hepatitis B core antibody (anti-HBc) and surface antigen (HBsAg) in the Somali population in Liverpool is described and groups who may benefit from vaccination are identified. A cross-sectional descriptive study was undertaken. A total of 439 subjects, aged between 10 months and 80 years, from 151 households, were screened for anti-HBc and HBsAg. One hundred ninety-four (44.2%) were children aged less than 15 years. Three hundred and nine (69%) of enrolled subjects were born in Somalia, 122 (27.2%) were born in the UK and 8 were born elsewhere. Of the study population, 5.7% were carriers of HBsAg, with the highest prevalence in adults aged 20 to 44 years (9.4%). A history of circumcision (RR 95% CI; 1.2, 1.1-1.5) was the most significant risk factor for HBsAg carriage, but was not significant on multivariate analysis. Prevalence of anti-HBc was 27.5%, and increased with age over the first four decades. Univariate analysis showed that a history of living in a refugee camp (RR 95% CI; 3.1, 1.7-5.7), receiving an injection in Somalia (2.1, 1.7-2.5), a history of circumcision or other surgical procedure in Somalia (1.4, 1.3-1.6) and being born in Somalia (1.3, 1.2-1.4) were significant risk factors for anti-HBc positivity. On multivariate analysis, only circumcision (OR 95% CI; 4.3, 1.8-10.3) and receiving an injection in Somalia (2.5, 1.5-4.4) remained significant. Seven of 80 (8.7%) children born in the UK and aged five years or less had evidence of exposure to hepatitis B, of whom only one had a close family member identified to be HBsAg seropositive. Previous infection with hepatitis B is common in this population. Horizontal transmission may be continuing at an early age within the UK, suggesting a population of at risk individuals who would benefit from surveillance and immunisation. Community circumcision is a risk factor for hepatitis B transmission and best practice should be followed when this procedure is undertaken.

Why do GPs not implement evidence-based guidelines? A descriptive study

BACKGROUND

There is an acknowledged gap between research findings and their implementation in clinical practice despite the existence of effective educational interventions.

OBJECTIVES

Our aim was to identify what is impeding GPs from pursuing currently recognized good practice and implementing evidence-based guidelines in their management of hypertension in the elderly.

METHOD

We carried out a qualitative study using semi-structured interviews conducted during focus group outreach visits to 34 GPs from nine practices in Merseyside involved in an educational programme designed to improve the management of hypertension in the elderly.

RESULTS

Several barriers to the implementation of evidence-based guidelines in the management of hypertension in the elderly were identified. These included: doubts about the applicability of trial data to particular patients; the poor adherence of GPs to practice protocols; ageist attitudes of some GPs; the effect of time pressure and financial considerations making the subject a low priority; the absence of an effective computer system; and the absence of an educational mentor. All participants demonstrated a very positive attitude to practice-based education. They also welcomed external audit data, which compared their performance with that of other practices. Single-handed GPs were particularly enthusiastic about this approach as it provided them with the peer pressure they lacked.

CONCLUSIONS

In order to bridge the gap between research and practice, educators need to address the various 'barriers to change' amongst practitioners.

Targeting of p300 to the interleukin-2 promoter via CREB-Rel cross-talk during mitogen and oncogenic molecular signaling in activated T-cells

In this report, we explore the mechanisms of targeting of p300 to the interleukin-2 (IL-2) promoter in response to mitogenic and oncogenic molecular signals. Recruitment of p300 by cAMP-responsive element-binding protein-Rel cross-talk at the composite CD28 response element (CD28RE)-TRE element of the IL-2 promoter is essential for promoter inducibility during T-cell activation, and CD28RE-TRE is the exclusive target of the human T-cell lymphotropic virus type I oncoprotein Tax. The intrinsic histone acetyltransferase activity of p300 is dispensable for activation of the IL-2 promoter, and the N-terminal 743 residues contain the minimal structural requirements for synergistic transactivation of the CD28RE-TRE, the IL-2 promoter, and endogenous IL-2 gene expression. Mutational analysis of p300 reveals differential structural requirements for the N-terminal p300 module by individual cis-elements within the IL-2 promoter. These findings provide evidence that p300 assembles at the IL-2 promoter to form an enhanceosome-like signal transduction target that is centrally integrated at the CD28RE-TRE element of the IL-2 promoter through specific protein module-targeted associations in activated T-cells.

The genetic basis of migraine: how much do we know?

Migraine with and without aura is thought to be genetically complex with aggregation in families due to a combination of environmental and genetic tendencies. Twin studies are most important in establishing the multifactorial nature of migraine with heritability approaching 50%. Familial hemiplegic migraine (FHM) on the other hand is an autosomal dominant, highly penetrant, though rare form of migraine with strong genetic tendency. Fifty percent of families with FHM are linked to chromosome 19p13 and mutations demonstrated for some in a brain expressed calcium channel alpha 1A subunit, CACNL1A4. Other FHM loci have been identified on chromosome 1q and further genetic heterogeneity is likely. The exact role of the mutated calcium channel in the pathway leading to hemiplegic migraine is yet to be established. Changes in the electrophysiologic properties of the mutated forms of the CACNL1A4 calcium channel expressed in heterologous systems help establish the functional significance of the mutations and suggest that chromosome 19p-linked FHM, an episodic disorder, represents a CNS channelopathy. Additional candidate genes causative for migraine might include other calcium channel subunits and related proteins important for neuronal membrane stability. Delineating the cascade of biochemical events leading to hemiplegic migraine will serve as a model for understanding the pathophysiology of more common forms of migraine. The evidence suggesting that some families of migraine with and without aura might also be related to the chromosome 19p locus, chromosome Xq28 locus, or DRD2 receptor polymorphisms is reviewed.

Barriers to referral in patients with angina: qualitative study

OBJECTIVES

To explore barriers to patients being referred for possible revascularisation.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

16 patients aged under 75 years with stable angina and their doctors.

SETTING

General practice in Toxteth, Liverpool.

RESULTS

Fear of both hospitals and medical tests was common and largely hidden from the doctors. Patients felt they were old, had low expectations of treatment, viewed angina as a chronic illness, and knew little about new developments in angina treatment. Patients and doctors had difficulty in recognising angina symptoms that were not textbook definitions amid multiple comorbidity. Patients saw doctors as busy and did not want to bother them with their condition. Cultural gaps and communication difficulties existed despite all but one patient having English as their first language.

CONCLUSIONS

Listening to patients is vital to address inequitable access to health services: how patients are treated by doctors today affects acceptability of referral tomorrow. Primary care groups in deprived areas should work with communities to address local fears. This will involve collaboration between primary, secondary, and tertiary care. Cultural gaps exist between patients and doctors in deprived areas, and diagnostic confusion can occur particularly in the presence of other psychological and physical morbidity. Adequate time and resources-for example, education for doctors and patients and provision of interpreters-need to be provided if inequitable access to revascularisation procedures is to be addressed.

Hybrid zones and the genetic architecture of a barrier to gene flow between two sunflower species

Genetic analyses of reproductive barriers represent one of the few methods by which theories of speciation can be tested. However, genetic study is often restricted to model organisms that have short generation times and are easily propagated in the laboratory. Replicate hybrid zones with a diversity of recombinant genotypes of varying age offer increased resolution for genetic mapping experiments and expand the pool of organisms amenable to genetic study. Using 88 markers distributed across 17 chromosomes, we analyze the introgression of chromosomal segments of Helianthus petiolaris into H. annuus in three natural hybrid zones. Introgression was significantly reduced relative to neutral expectations for 26 chromosomal segments, suggesting that each segment contains one or more factors that contribute to isolation. Pollen sterility is significantly associated with 16 of these 26 segments, providing a straightforward explanation of why this subset of blocks is disadvantageous in hybrids. In addition, comparison of rates of introgression across colinear vs. rearranged chromosomes indicates that close to 50% of the barrier to introgression is due to chromosomal rearrangements. These results demonstrate the utility of hybrid zones for identifying factors contributing to isolation and verify the prediction of increased resolution relative to controlled crosses.