Did aid to the Ebola crisis divert aid for reproductive, maternal, and newborn health? An analysis of donor-reported data in Sierra Leone

BACKGROUND

Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014-16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response.

METHODS

We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)'s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014-16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes.

RESULTS

We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased.

CONCLUSIONS

Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.

An adaptable research platform for ex vivo normothermic machine perfusion of the liver

PURPOSE

This paper presents an assessment of a low-cost organ perfusion machine designed for use in research settings. The machine is modular and versatile in nature, built on a robotic operating system (ROS2) pipeline allowing for the addition of specific sensors for different research applications. Here we present the system and the development stages to achieve viability of the perfused organ.

METHODS

The machine's perfusion efficacy was assessed by monitoring the distribution of perfusate in livers using methylene blue dye. Functionality was evaluated by measuring bile production after 90 min of normothermic perfusion, while viability was examined using aspartate transaminase assays to monitor cell damage throughout the perfusion. Additionally, the output of the pressure, flow, temperature, and oxygen sensors was monitored and recorded to track the health of the organ during perfusion and assess the system's capability of maintaining the quality of data over time.

RESULTS

The results show the system is capable of successfully perfusing porcine livers for up to three hours. Functionality and viability assessments show no deterioration of liver cells once normothermic perfusion had occurred and bile production was within normal limits of approximately 26 ml in 90 min showing viability.

CONCLUSION

The developed low-cost perfusion system presented here has been shown to keep porcine livers viable and functional ex vivo. Additionally, the system is capable of easily incorporating several sensors into its framework and simultaneously monitor and record them during perfusion. The work promotes further exploration of the system in different research domains.

82 THE IMPACT OF THE COVID-19 PANDEMIC ON THE ACTIVITY OF A RAPID-ACCESS GERIATRIC DAY HOSPITAL SERVICE

Background

In the 1970s, Jack Flanagan developed the first Geriatric Day Hospital (GDH) in Ireland. Since, the GDH model of care has evolved to accommodate for the growing demands of our ageing population. Before the COVID-19 pandemic, the operational scope of our GDH was extended to allow for the rapid medical and multidisciplinary assessment and follow-up of older patients. During the pandemic, the GDH did not suspend operations and remained open as a COVID-negative ambulatory pathway. We evaluated the activity of this GDH service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office (Reference: 7419). Pseudonymised data corresponding to all GDH attendances between January 2017 and December 2021 were retrieved from the hospital electronic records. Yearly trends in proportions were tested with the Chi-square for trend statistic. Trends in monthly attendances were assessed via Statistical Process Control (SPC) charts with three-sigma limits. Statistical significance was set at p<0.05.

Results

There were 27,278 attendances of patients aged 65 and over to the GDH over the 5-year period (6,362, 5,978, 6,115, 4,306, and 4,517, respectively). Mean age was 82 every year. Of the 7,813 new episodes, yearly proportions referred directly by primary care teams were 10.4%, 29.5%, 38.6%, 24.5%, and 16.3% (p<0.001). SPC charts showed that Apr-May 2020 and Jan-Feb 2021 had significantly lower numbers of review attendances (50-59 and 146-142, respectively, average 324 p/m). However, new appointments did not significantly decline (average 130 p/m). Of the 7,813 new episodes, 2,595 (33.2%) were seen by Physiotherapy, and 1,860 (23.8%) by Occupational Therapy.

Conclusion

Our GDH saw a sustained number of new attendances and demonstrated increased community availability during the unprecedented COVID-19 crisis, especially during the first wave of the pandemic when hospital access was most affected. A rapid access GDH model can facilitate integrated care at times of crisis to promote ageing in place.

131 USE OF FDG-PET BRAIN IMAGING IN THE DIAGNOSIS AND MANAGEMENT OF DEMENTIA IN A UNIVERSITY HOSPITAL

Background

Neuroimaging is an increasingly important tool dementia work-up. Subtype diagnosis helps predict the course of the disease, aiding prognostication and management. Amyloid-beta peptide is intrinsic to the pathogenesis of Alzheimer’s disease (AD), forming characteristic neuritic plaques which can be imaged in vivo on positron emission tomography (PET) scans. NICE recommendations advise use of PET imaging if dementia sub-type diagnosis is unclear and AD is suspected. We sought to establish the referral patterns for FDG-PET brain scans for patients aged 60 and over in a university hospital and to establish whether this imaging modality contributed to a change in diagnosis or treatment.

Methods

Requests for FDG-PET CT brain from 2019 – 2022 were retrospectively reviewed. Information was obtained from clinical notes and patient information software. Patient demographics, indication for scan, source of referral and whether imaging results led to a change in diagnosis or treatment was recorded.

Results

A total of 32 patients were reviewed, with a mean age of 65 years (13 females; 41%). We further analysed the 25 who were aged over 60; this subgroup had a mean age of 70 (9 females; 36%). All 25 patients were appropriately referred to assess for dementia subtype. A revision in diagnosis based on PET imaging was made in 17 (68%) cases. In 9 (30%) cases, results prompted change in dementia-specific pharmacological treatment, including donepezil and memantine. A further 6 (24%) had pharmacological treatment for non-cognitive symptoms of dementia adjusted, such as anti-depressants or anti-psychotics. The majority of referrals had come from neurologists (n = 15; 60%) rather than geriatricians (n = 10; 40%). The final diagnosis was AD in 12 cases (48%) and fronto-temporal dementia in 3 cases (12%).

Conclusion

PET scans are a useful functional imaging modality which can help to differentiate dementia subtypes and influence management.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Evaluation of A Novel Organ Perfusion Research Platform

This paper presents a novel, low cost, organ perfusion machine designed for use in research. The modular and versatile nature of the system allows for additional sensing equipment to be added or adapted for specific use. Here we introduce the system and present its preliminary evaluation by assessing its ability to maintain a predetermined input pressure. A proportional-integral-derivative (PID) controller was implemented and tested on a porcine liver to maintain input pressure to the hepatic artery and compared to bench tests. The results confirmed the effectiveness of the controller for maintaining input through the hepatic artery (HA) in a timely manner. Clinical Relevance-Machine Perfusion (MP) is proving to be an invaluable adjunct in clinical practice. With its ongoing success in the transplant arena, we propose MP for use in research. A cost-effective, versatile system that can be modified for specific research use to test new pharmacological therapies, imaging techniques or develop simulation training would be beneficial.

99 ASSESSMENT AND MANAGEMENT OF PAIN IN OLDER ADULTS WITH ACUTE FRACTURE ADMITTED UNDER AN ORTHOPAEDIC SERVICE

Background

Older adults with acute fractures often have suboptimal pain control, in particular those with cognitive impairment. Effective pain management improves rehabilitation engagement and earlier discharge from acute care. Our study aimed to evaluate pain management of older adults with acute fracture admitted under an orthopaedic service in a tertiary hospital.

Methods

Prospective review of patients over 65 years with an acute fracture admitted under an orthopaedic service. Review of chart, medication prescription and pain status. Data included type of fracture, comorbidities, cognitive status and analgesia prescribed. Data analysed using Excel.

Results

40 inpatients included. Median age 82 years (range 65-93 years), 70% female. 53% had cognitive impairment, ranging from mild to severe dementia. 75% had &gt;5 regular medications pre-admission. 80% had &gt;5 comorbidities.

Two-thirds (73%) had an acute hip fracture. Most (80%) inpatients had a surgical intervention, the remaining were managed conservatively.

Analgesia prescriptions included paracetamol for almost all patients (95%), non-steroidal anti-inflammatory drugs for 3 (8%) and regular opioids in only 3 (8%).

43% of patients reported pain at time of data collection. 13% had analgesia changed in the 24 hours beforehand. Pain adversely affected function in 205 and mobility in 28%.

2 patients were unable to verbalise pain however no pain scales or visual assessments were used.

Documentation of pain assessment was best by nurses (100%) followed by doctors (60%) and allied health professionals (40%).

Conclusion

Older adults with acute fracture are often multimorbid with cognitive impairment. This patient population are often untreated for pain with suboptimal pain assessment and analgesia review or prescriptions. Consequently we developed a pain policy for use on our orthopaedic service as a guide for effective pain assessment and management for older adults with acute fracture.

141 USING A TEMPLATE TO IMPROVE COMMUNICATION ON DISCHARGE LETTERS REGARDING BONE PROTECTION THERAPY AFTER HIP FRACTURE

Background

Hip fractures are a significant cause of morbidity and mortality amongst older adults. The Irish Hip Fracture Database Standard 5 requires that all patients with hip fracture have a bone health assessment completed; most are commenced on bone protection therapy (BPT) to reduce future fractures. Communication to general practitioners (GPs) regarding long-term BPT is often incomplete and challenging to improve. We aimed to upgrade this communication process at discharge.

Methods

Initial audit was conducted assessing documentation of BPT after hip fracture in discharge letters to GPs. Subsequently we created a detailed BPT template for discharge letters containing clear information for GPs regarding medication initiation and advice for ongoing management. The template was introduced and doctors were educated on its use. We then re-audited discharge letters following this intervention. Patients included were over 60 years old with hip fracture. Patients deemed clinically unsuitable for BPT were excluded.

Results

Ninety discharge letters were reviewed, 45 at initial audit and another 45 after introducing the BPT template. Mean age was 80 years old, 66 (73%) were female. In the first audit cycle, 28/45 discharge letters (62%) briefly specified BPT. On repeating the audit cycle (following introduction of the discharge letter template) all 45/45 discharge letters (100%) clearly specified BPT. Most letters (41/45; 91%) included the detailed BPT template. Following this intervention all doctors reported increased awareness and understanding of BPT, and satisfaction with template use in discharge letters.

Conclusion

Effective implementation of a discharge letter template significantly improved communication to GPs regarding BPT following hip fracture.

138 DELAYED BLOOD PRESSURE RECOVERY AFTER STANDING INDEPENDENTLY PREDICTS FRACTURE IN COMMUNITY-DWELLING OLDER PEOPLE

Background

Orthostatic hypotension, characterized by delayed blood pressure recovery (DBPR) after standing, is a risk factor for falls but the longitudinal relationship with fracture is not yet known. The aim of this study was to examine the prospective risk of fracture associated with DBPR.

Methods

This study, embedded within the Irish Longitudinal Study on Ageing (TILDA), examined prospective risk of fracture (hip, wrist or vertebral) associated with DBPR at 8-year follow-up in a population-representative sample of more than 3,000 (54% female) community-dwelling older people. Orthostatic blood pressure (BP) was measured using a finometer during active stand at TILDA Wave 1. DBPR was defined as systolic BP ≤ 20 mmHg lower and/or diastolic BP ≤ 10 mmHg from baseline value at 30, 60 and 90 seconds after standing. Participants with a fracture reported at any of Waves 2–5 were defined as having ‘Incident Fracture’. Logistic regression models were used to estimate odds ratios (ORs) for the association between DBPR and incident fracture.

Results

Seven percent (212/3117) of participants sustained a fracture during follow-up. DBPR at 30 seconds was a significant predictor of any fracture [OR 1.80, 95% confidence interval (CI) 1.28–2.53] and hip fracture (OR 4.44, 95% CI 2.03–9.71) in fully adjusted models. DBPR at 30 seconds did not predict wrist or vertebral fracture. DBPR at 60 seconds also predicted any fracture (OR 1.74, 95% CI 1.19–2.54) and hip fracture (OR 4.66, 95% CI 2.12–10.26) whereas DBPR at 90 seconds predicted any (OR 1.99, 95% CI 1.38–2.87), wrist (OR 1.87, 95% CI 1.19–2.95), and hip fracture (OR 3.39, 95% CI 1.45–7.93) in fully adjusted models.

Conclusion

Delayed BP recovery independently predicts fracture in community-dwelling older people, is potentially modifiable, and can be measured in an ambulatory setting. Given the morbidity and mortality associated with fractures, identification of such risk factors is crucial in order to inform preventative strategies.

"Watch Me Grow- Electronic (WMG-E)" surveillance approach to identify and address child development, parental mental health, and psychosocial needs: study protocol

Background

The COVID-19 pandemic and the associated economic recession has increased parental psychosocial stress and mental health challenges. This has adversely impacted child development and wellbeing, particularly for children from priority populations (culturally and linguistically diverse (CALD) and rural/regional communities) who are at an already increased risk of health inequality. The increased mental health and psychosocial needs were compounded by the closure of in-person preventive and health promotion programs resulting in health organisations embracing technology and online services. Watch Me Grow- Electronic (WMG-E) – developmental surveillance platform- exemplifies one such service.

WMG-E was developed to monitor child development and guide parents towards more detailed assessments when risk is identified. This Randomised Controlled Trial (RCT) aims to expand WMG-E as a digital navigation tool by also incorporating parents’ mental health and psychosocial needs. Children and families needing additional assessments and supports will be electronically directed to relevant resources in the ‘care-as-usual’ group. In contrast, the intervention group will receive continuity of care, with additional in-person assessment and ‘warm hand over’ by a ‘service navigator’ to ensure their needs are met.

Methods

Using an RCT we will determine: (1) parental engagement with developmental surveillance; (2) access to services for those with mental health and social care needs; and (3) uptake of service recommendations. Three hundred parents/carers of children aged 6 months to 3 years (recruited from a culturally diverse, or rural/regional site) will be randomly allocated to the ‘care-as-usual’ or ‘intervention’ group. A mixed methods implementation evaluation will be completed, with semi-structured interviews to ascertain the acceptability, feasibility and impact of the WMG-E platform and service navigator.

Conclusions

Using WMG-E is expected to: normalise and de-stigmatise mental health and psychosocial screening; increase parental engagement and service use; and result in the early identification and management of child developmental needs, parental mental health, and family psychosocial needs. If effective, digital solutions such as WMG-E to engage and empower parents alongside a service navigator for vulnerable families needing additional support, will have significant practice and policy implications in the pandemic/post pandemic period.

Trial registration

The trial (Protocol No. 1.0, Version 3.1) was registered with ANZCTR (registration number: ACTRN12621000766819) on July 21st, 2021 and reporting of the trial results will be according to recommendations in the CONSORT Statement.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse

Aims

The perinatal period is a time of high risk of relapse for women with a history of bipolar affective disorder (BPAD). We describe the pregnancy management of women with BPAD and identify risk factors for postpartum relapse.

Methods

The case records of 78 women with BPAD referred to perinatal mental health services before conception, during pregnancy or the postpartum period, between 1998 and 2009 in Birmingham UK, were screened. In women who were managed during pregnancy, those who relapsed in the postpartum were compared with those who remained well.

Results

Forty-seven percent of women with BPAD referred in pregnancy suffered postpartum relapse. Women who were unwell at referral, younger, with unplanned pregnancy, previous perinatal episodes or a family history of BPAD were more likely to suffer postpartum illness.

Conclusion

Identifying risk factors for postpartum relapse enables us to individualise the estimation of a woman's risk and modify care plans accordingly. Duration of wellness prior to pregnancy is not associated with a lower risk of postpartum illness and so it is imperative that all women with BPAD receive referral in pregnancy.

The New Beginnings Program for Divorcing and Separating Families: Moving from Efficacy to Effectiveness

This article describes a program of research on effectively transporting the New Beginnings Program (NBP), a university-tested prevention program for divorced families, to community settings. The status of four steps in this research are described: (1) Selecting a community partner; (2) Developing effective methods of engaging parents; (3) Redesigning the NBP to be easily delivered with high quality and fidelity in community agencies, and (4) Adapting the NBP to meet the needs of the full population of divorcing families. The article concludes with a discussion of plans for an effectiveness trial to evaluate the NBP when delivered in community settings.

Synthesis of halogenated trimetoquinol derivatives and evaluation of their .beta.-agonist and thromboxane A2 (TXA2) antagonist activities

The 5,8-difluoro (4), 5-iodo (5), 8-iodo (6), and 5-trifluoromethyl (7) derivatives of trimetoquinol (TMQ, 1) have been synthesized and evaluated for their ability to stimulate beta 1 (guinea pig atria) and beta 2 (guinea pig trachea) adrenoceptors as well as for their inhibitory activity against U46619 [a thromboxane A2 (TXA2) mimetic]-mediated contraction of rat thoracic aorta and human platelet aggregation. Both 5 and 6 were considerably less active than TMQ on both beta-adrenergic systems and gave a rank order of stimulatory potency of 1 much greater than 6 greater than or equal to 5. Similarly, iodine substitution at either position also caused a reduction in TXA2 antagonist activity with a rank order potency of 1 greater than 6 much greater than 5. Compared to 1, however, 5-iodo-TMQ (5) showed a marked selectivity for blockade of U46619 responses in rat aorta over human platelets. On beta-systems, 4 had reduced potency compared to TMQ and was similarly nonselective. Introduction of a trifluoromethyl group at the 5-position of TMQ completely abolished both beta 1- and beta 2-adrenergic agonist activities while imparting weak antagonist activity on beta 1 receptors. On TXA2 systems, both 4 and 7 possessed significantly decreased inhibitory activity compared to TMQ. The synthetic approaches to the synthesis of 8-(trifluoromethyl)-TMQ (8) are also described. The enantiomers of the 8-fluoro derivative (3) of TMQ were separated on a preparative Chiralcel OD column and evaluated on beta-adrenergic systems and TXA2 systems. On beta-adrenergic systems, (S)-(+)-8-fluoro-TMQ was at least 10-fold more potent than (R)-(-)-8-fluoro-TMQ. Conversely, (R)-(-)-8-fluoro-TMQ was approximately 14-fold more potent as an antagonist of TXA2-mediated aggregation in human platelets than (S)-(+)-8-fluoro-TMQ. In contrast to platelets, (S)-(+)-8-fluoro-TMQ was an agonist in rat aorta whereas (R)-(-)-8-fluoro-TMQ was an antagonist.

Developmental themes in women's emotional experiences of motherhood

In this study, women's levels of ego development and their psychological difficulties were examined in relation to feelings in the maternal role. The sample consisted of 91 mothers from diverse socioeconomic backgrounds. Ego development was assessed by the Washington University Sentence Completion Test, and psychological difficulties were operationalized by self-reported global symptomatology, maternal substance abuse, and expressed anger. Outcome variables included feelings of satisfaction, distress, and support in the maternal role, as well as the degree to which negative and positive emotions were integrated in response to hypothetical vignettes of challenging everyday child-rearing experiences. Hypotheses were that women at high levels of ego development would show greater deterioration in the presence versus absence of self-reported adjustment problems than would those at lower levels. A series of interaction effects each indicated trends consistent with the hypotheses. These results add to accumulating evidence that tendencies toward self-examination, characteristic of high developmental levels, do not inevitably serve protective functions but may be linked with heightened reactivity to negative intrapsychic forces.

Effect of alpha-difluoromethylornithine on rectal mucosal levels of polyamines in a randomized, double-blinded trial for colon cancer prevention

BACKGROUND

Polyamines (e.g., putrescine, spermidine, and spermine) are required for optimal cell growth. Inhibition of polyamine synthesis suppresses carcinogen-induced epithelial cancers, including colon cancer, in animal models. In a short-term phase IIa trial, we determined that low doses of alpha-difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase (an enzyme involved in polyamine synthesis), reduced the polyamine content of normal-appearing rectal mucosa of subjects with a prior history of resected colon polyps. In a follow-up study, we have attempted to determine the lowest dose of DFMO that can suppress the polyamine content of rectal mucosa over a course of 1 year with no or minimal side effects.

METHODS

Participants were randomly assigned to daily oral treatment with a placebo or one of three doses (0.075, 0.20, or 0.40 g/m2) of DFMO. Baseline and serial determinations of polyamine levels in rectal mucosa and extensive symptom monitoring (including audiometric measurements, since DFMO causes some reversible hearing loss at higher doses) were performed over a 15-month period.

RESULTS

DFMO treatment reduced putrescine levels in a dose-dependent manner. Following 6 months of treatment, doses of 0.20 and 0.40 g/m2 per day reduced putrescine levels to approximately 34% and 10%, respectively, of those observed in the placebo group. Smaller decreases were seen in spermidine levels and spermidine:spermine ratios. Polyamine levels increased toward baseline values after discontinuation of DFMO. Although there were no statistically significant differences among the dose groups with respect to clinically important shifts in audiometric thresholds and nonaudiologic side effects, statistically significant higher dropout and discontinuation rates were observed in the highest dose group.

CONCLUSIONS

Polyamine levels in rectal mucosa can be continuously suppressed by daily oral doses of DFMO that produce few or no side effects. A dose of 0.20 g/m2 can be used safely in combination phase IIb or single-agent phase III chemoprevention trials.

Preferential association of membrane phospholipids with the human erythrocyte hexose transporter

This study reports the results of an investigation to determine to what extent the influence of membrane lipids on the human erythrocyte sugar transporter protein activity (Caruthers, A. and Melchior, D.L. (1988) Annu. Rev. Physiol. 50, 257-271) is related to lipid/protein associations in the membrane bilayer. Differential scanning calorimetry was carried out on the human erythrocyte transport protein reconstituted into artificial bilayers formed from preselected lipids. it was found that the transport protein displays a preferential and in some cases strongly preferential affinity for specific lipid types. This association is a function of lipid head group, backbone and hydrocarbon chain length. It appears that the affinity of the transport protein for various lipids can correlate with the lipid's ability to influence transporter activity. This study further suggests that certain lipids (in this case sphingomyelin) can induce an oligomeric association of HEST monomers in the bilayer.

Enhancement of cardiac function by cyclocreatine in models of cardiopulmonary bypass

This study tests the hypothesis that the administration of cyclocreatine prior to global ischemia enhances recovery of cardiac function during reperfusion. Two models were used. First, in a Langendorff-working heart model of normothermic cardioplegic arrest, rats (n = 6 per group) were injected intravenously with saline or cyclocreatine (600, 300, or 150 mg/kg). After 30 min or 2 h, hearts were excised and perfused in the Langendorff mode for 5 min and then in the working heart mode for 20 min. Normothermic arrest was induced by infusing warm St. Thomas solution once; then hearts were kept at 37 degrees C for 40 min. Following arrest, hearts were reperfused in the Langendorff mode for 15 min and then in the working mode for 30 min. Cyclocreatine consistently produced significantly better recovery of aortic flow and cardiac output compared to that of saline hearts. Second, in an intact canine model of cold cardioplegic arrest, adult mongrel dogs (n = 3 to 6 per group) underwent aortic cross-clamping for 1 h, followed by reperfusion on bypass for 45 min and off bypass for 4 h. Dogs were injected intravenously with saline or cyclocreatine (500 mg/kg) for 1 h before experiment. Post-bypass segmental contractility and cardiac output were significantly better in cyclocreatine hearts compared to that of controls. In a limited study, after a 3 h aortic cross-clamp time, cyclocreatine hearts achieved 91% baseline function while control hearts failed after 2 h. Results of this study suggest that cyclocreatine, without inotropic or chronotropic effect, protects the heart from global ischemic injury.

Distinguishable patterns of protein-DNA interactions involving complexes of basic helix-loop-helix proteins

Myogenic factors and TAL1 possess distinguishable DNA binding characteristics when they form a complex with basic helix-loop-helix (bHLH) proteins of class A. These characteristics were evident in electrophoretic mobility shift assays showing that complexes of myogenic factors and HTF4 displayed a relatively high affinity for the enhancer in the muscle creatine kinase gene, whereas TAL1 appeared to greatly attenuate the interaction of HTF4 with this enhancer. In addition, by forming a complex with HTF4 in solution, TAL1 could exert a negative effect on the interactions of HTF4 with elements that include E box motifs of microE2 (CAGCTG) and kappa E2/microE5 (CACCTG) type. Similarly, heterodimers containing TAL1 and the DNA binding domain of E47 exhibited a relatively weak affinity for microE2 and kappa E2/microE5 core motifs. The results of both studies invoked the hypothesis that in vivo TAL1 might act as a negative regulator of microE2 and kappa E2/microE5 sequence motifs by forming a complex with the products of the E2A and HTF4 genes. Support for this hypothesis was obtained by transient expression analyses where TAL1 was found to inhibit the activation effects produced by E2-5 and HTF4a on a reporter gene construct containing repeated microE2 and microE5 motifs, derived from the immunoglobulin gene enhancer.

Evidence of cardiac inflammation after open heart operations

In this study, 6 anesthetized dogs underwent global cardiac arrest for 1 hour, followed by reperfusion on bypass for 45 minutes. The hearts were then weaned off cardiopulmonary bypass and monitored for an additional 2 hours. Using modified Boyden chambers, high levels of neutrophil chemotactic activity were detected (using a checkerboard analysis) in the coronary sinus effluents obtained during cardiac arrest. The activity tended to decline during reperfusion. Assay of myeloperoxidase (a marker for neutrophils) revealed an accumulation of large numbers of neutrophils in the right (14 +/- 1.1 x 10(4) cells/g wet weight) and left (16 +/- 1 x 10(4) cells/g wet weight) ventricles after 2 hours of reperfusion. Light microscopy evaluation confirmed the presence of neutrophils, not only in the ventricles, but also in a greater number in the right and left atria. Electron microscopy study of these hearts revealed the presence of mild reversible changes, indicating good preservation of the hearts during arrest. Results of this study provide evidence for an acute inflammatory reaction that takes place after cardiac operations and suggest a role for myocardial tissues in the initiation of such a response through their release of neutrophil chemotactic factors.

Preventing AIDS: knowledge, attitudes, and practices

1. Because health care providers are the key professionals in advising patients about prevention and treatment of HIV/AIDS, the degree to which spread can be prevented is at least partially a function of preventive and education measures taken by health care professionals. 2. Nurses surveyed believe that they do not have the right to refuse treatment to patients infected with HIV. 3. Twenty percent of health care professionals indicated they did not have adequate information concerning HIV, with the largest group being nurse executives in long-term care facilities. 4. The survey indicated that more efficient and effective educational methods should be used to increase health care practitioners' knowledge about AIDS.

Halogen-substituted trimetoquinol analogs as thromboxane A2 receptor antagonists in platelets and aorta

Trimetoquinol (TMQ) is a non-prostanoid compound that blocks prostaglandin H2/thromboxane A2 (TXA2) receptor-mediated responses initiated by a prostaglandin (PG) H2 analog, U46619, in human platelets and rat aorta. Ring fluorine-substituted TMQ analogs selectively antagonized PG-dependent human platelet activation induced by U46619, arachidonic acid, collagen, ADP or epinephrine; and were about 300-fold less potent as inhibitors of PG-independent responses mediated by thrombin or bacterial phospholipase C. For each inducer of the PG-dependent pathway, the rank order of inhibitory potency was identical (TMQ > 8-fluoro-TMQ > 5-fluoro- TMQ). Iodine substitution yielded a similar rank order of antagonism against U46619-induced platelet activation (TMQ > 8-iodo-TMQ > 5-iodo-TMQ), and all TMQ analogs inhibited platelet aggregation in whole blood as well as in platelet-rich plasma. Inhibition of specific [3H]SQ 29,548 binding by TMQ analogs was highly correlated with inhibition of functional responses to U46619. Radioligand binding experiments using TMQ analogs with rat platelets showed no interspecies difference in comparison with human platelets. The rank order of inhibitory potencies for the fluorinated (but not iodinated) TMQ analogs changed in rat thoracic aorta with 8-fluoro-TMQ > TMQ > or = 5-fluoro-TMQ as antagonists of U46619-induced vascular contraction. These findings demonstrate that the primary mechanism of antiplatelet action of TMQ analogs is related to a blockade of TXA2 receptor sites, and ring-halogenated TMQ analogs distinguish between TXA2-mediated functional responses in vascular smooth muscle and platelets.

A comprehensive assessment plan for professional preparation programs in health education at Eastern Illinois University

Federal- and state-mandated criteria for accountability have promoted an "assessment movement" in higher education. The federal focus caused higher education's regional accrediting bodies to place greater emphasis on assessment for institutional accountability. Numerous approaches have been identified for the assessment process including comprehensive examinations, evaluation by alumni and internship preceptors, and self-report data by students. The Role Delineation Project Curriculum Framework also has been useful in assessing curricula. Strategies used in a comprehensive assessment plan for the Health Studies Dept. at Eastern Illinois University include focus group interviews, Departmental Advisory Council review, and assessment by internship preceptors. Data indicate the professional preparation program adequately prepares students in Responsibilities I, II, III, IV, and VII. Further consideration will be given to revising the curriculum to include material to prepare students in competencies required for Responsibilities V and VI.

Interactions of HTF4 with E-box motifs in the long terminal repeat of human immunodeficiency virus type 1

We have identified three consensus E-box motifs in the long terminal repeat of human immunodeficiency virus type 1. One of these E boxes interacts selectively with representative members of the class A group of basic helix-loop-helix proteins, including HTF4, E47, and their heterodimers. Our analyses implicate the helix-loop-helix proteins in regulation of human immunodeficiency virus type 1 gene expression.

Handedness in childhood autism shows a dissociation of skill and preference

Hand preference and hand skill were assessed in 20 children with autism, 20 normal controls and 12 children with mental retardation. 90% of the normal controls and 92% of the children with mental retardation showed concordance for hand preference and hand skill (i.e. the preferred hand was also the more skillful), whereas only 50% of the children with autism showed concordance of preference and skill, the remaining 50% preferring to use the hand which was less skillful. Children with autism also showed a lesser degree of handedness and a lesser degree of consistency than the other groups, although this was unrelated to the discordance of skill and asymmetry. A developmental model of handedness is proposed in which the development of handedness as preference is ontogenetically prior to the development of handedness as skill asymmetry, such that in normal children the development of skill asymmetry occurs as a secondary consequence of the establishment of preference. The causal sequence is disrupted in autism, so that although preference is established, it does not subsequently result in concordant skill asymmetry.