The Diamond Project: A Quality Improvement Model for Adopting Shared Service Delivery in the Washington Vaccines for Children Program

Context: Increasing federal requirements with no change in the Centers for Disease Control and Prevention budget creates an unsustainable delivery model between states and their local counterparts for programs like Vaccines for Children (VFC). Project: The Washington State Department of Health collaborated with the Washington Association of Local Public Health Officials to identify how best to improve the quality of the VFC program. Approach: Utilizing Quality improvement and Lean Six Sigma methods, the project team was able to adopt a new shared-service delivery model to improve the quality of the VFC program in Washington State. Discussion: Through utilization of quality improvement methods and Lean methodology Washington State Department of Health identified recommendations to adopt a shared-service delivery and implemented those changes.

Supporting the improvement of air quality management practices: The "FAIRMODE pilot" activity

This paper presents the first outcomes of the "FAIRMODE pilot" activity, aiming at improving the way in which air quality models are used in the frame of the European "Air Quality Directive". Member States may use modelling, combined with measurements, to "assess" current levels of air quality and estimate future air quality under different scenarios. In case of current and potential exceedances of the Directive limit values, it is also requested that they "plan" and implement emission reductions measures to avoid future exceedances. In both "assessment" and "planning", air quality models can and should be used; but to do so, the used modelling chain has to be fit-for-purpose and properly checked and verified. FAIRMODE has developed in the recent years a suite of methodologies and tools to check if emission inventories, model performance, source apportionment techniques and planning activities are fit-for-purpose. Within the "FAIRMODE pilot", these tools are used and tested by regional/local authorities, with the two-fold objective of improving management practices at regional/local scale, and providing valuable feedback to the FAIRMODE community. Results and lessons learnt from this activity are presented in this paper, as a showcase that can potentially benefit other authorities in charge of air quality assessment and planning.

The Neurobehavioral Phenotype in Mucopolysaccharidosis Type IIIB: an Exploratory Study

OBJECTIVES

Our goal was to describe the neurobehavioral phenotype in mucopolysaccharidosis Type IIIB (MPS IIIB). Parents report that behavioral abnormalities are a major problem in MPS III posing serious challenges to parenting and quality-of-life for both patient and parent. Our previous research on MPS IIIA identified autistic symptoms, and a Klüver-Bucy-type syndrome as indicated by reduced startle and loss of fear associated with amygdala atrophy. We hypothesized that MPS IIIB would manifest similar attributes when assessed with the same neurobehavioral protocol.

METHODS

Ten patients with MPS IIIB were compared with 9 MPS IIIA patients, all older than 6. 8 younger children with Hurler syndrome (1H) were chosen as a comparison group for the Risk Room procedure; MPS IH does not directly affect social/emotional function and these younger children were closer to the developmental level of the MPS IIIB group. To examine disease severity, cognitive ability was assessed. Four evaluations were used: the Risk Room procedure (to measure social-emotional characteristics, especially fear and startle responses), the Autism Diagnostic Observation Schedule (ADOS), the Sanfilippo Behavior Rating Scale (SBRS), and amygdala brain volumes calculated from manually-traced MRI images.

RESULTS

The two groups are equivalent in severity and show severe cognitive impairment. On the ADOS, the MPS IIIB patients exhibited the same autistic features as IIIA. The IIIB means differed from MPS IH means on most measures. However, the IIIB group did not approach the Risk Room stranger, like the MPS IH group who kept their distance, but unlike the IIIA group who showed no fear of the stranger. On the SBRS, the MPS IIIB patients were described as more inattentive and more fearful, especially of new people than the MPS IIIA. Onsets of some disease characteristics appeared more closely spaced and slightly earlier in MPS IIIB than IIIA.

CONCLUSIONS

On most behavioral measures, MPS IIIB patients did not differ substantially from MPS IIIA patients over age six, demonstrating autistic features and a Klüver Bucy-like syndrome including lack of fear and poor attention. Delay in onset of behavioral symptoms was associated with later diagnosis in two patients. Lack of fear, poor attention, and autistic-like symptomatology are as characteristic of MPS IIIB as they are of MPS IIIA. A possible difference is that the some behavioral abnormalities develop more quickly in MPS IIIB, If this is so, these patients may become at risk for harm and present a challenge for parenting even earlier than do those with MPS IIIA. .In future clinical trials of new treatments, especially with respect to quality of life and patient management, improvement of these behaviors will be an essential goal. Because very young patients were not studied, prospective natural history documentation of the early development of abnormal behaviors in MPS IIIB is needed.

Mucopolysaccharidosis (MPS) Physical Symptom Score: Development, Reliability, and Validity

OBJECTIVES

We quantified medical signs and symptoms to construct the Physical Symptom Score (PSS) for use in research to assess somatic disease burden in mucopolysaccharidoses (MPS) to track disease and monitor treatments. We examined scoring reliability, its concurrent validity with other measures, and relationship to age in MPS type I.

METHODS

Fifty-four patients with MPS I (36 with Hurler syndrome treated with hematopoietic cell transplant and 18 with attenuated MPS I treated with enzyme replacement therapy), ages 5 to 18 years, were seen longitudinally over 5 years. The summation of frequency and severity of signs of specific organ involvement, surgeries, and hydrocephalus drawn from medical histories comprise the PSS. We examined relationship to age and to daily living skills (DLS) from the Vineland Adaptive Behavior Scale and physical quality of life from the Child Health Questionnaire (CHQ) for each group.

RESULTS

The PSS was associated with age in both groups, indicating increase in disease burden over time. The PSS was significantly negatively associated with DLS (r = -0.48) and CHQ (r = -0.55) in the attenuated MPS I but not in the Hurler group.

CONCLUSIONS

The association of somatic disease burden with physical quality of life and ability to carry out daily living skills suggests that the PSS will be useful in the measurement of disease and treatment effects in the attenuated MPS I group. Earlier treatment with transplant and differing parental expectations are possible explanations for its lack of association with other outcomes necessitating an adaptation for Hurler syndrome in the future.

Anisotropic conductance at improper ferroelectric domain walls

Transition metal oxides hold great potential for the development of new device paradigms because of the field-tunable functionalities driven by their strong electronic correlations, combined with their earth abundance and environmental friendliness. Recently, the interfaces between transition-metal oxides have revealed striking phenomena, such as insulator-metal transitions, magnetism, magnetoresistance and superconductivity. Such oxide interfaces are usually produced by sophisticated layer-by-layer growth techniques, which can yield high-quality, epitaxial interfaces with almost monolayer control of atomic positions. The resulting interfaces, however, are fixed in space by the arrangement of the atoms. Here we demonstrate a route to overcoming this geometric limitation. We show that the electrical conductance at the interfacial ferroelectric domain walls in hexagonal ErMnO(3) is a continuous function of the domain wall orientation, with a range of an order of magnitude. We explain the observed behaviour using first-principles density functional and phenomenological theories, and relate it to the unexpected stability of head-to-head and tail-to-tail domain walls in ErMnO(3) and related hexagonal manganites. As the domain wall orientation in ferroelectrics is tunable using modest external electric fields, our finding opens a degree of freedom that is not accessible to spatially fixed interfaces.

Targeted mid-trimester ultrasound examination: how does fetal anatomic visualization depend upon the duration of the scan?

OBJECTIVE

To determine the relationship between visualization of key fetal anatomic structures during mid-trimester ultrasound examination with gestational age and duration of examination.

METHODS

One hundred ultrasound examinations at 16-22 weeks' gestation were reviewed to determine the times at which key fetal anatomic features were seen. Scans were terminated at 30 min or when a comprehensive anatomic survey was complete. Exclusion criteria included multiple gestation, maternal weight>77 kg, abdominal wall scarring, and suspected fetal anomalies.

RESULTS

Visualization of cranial anatomy including lips, face, midline, ventricles, choroid plexus, and cerebellum was achieved in 98% of patients within 30 min. The corresponding figures for spine, cardiac screening (four-chamber, aortic, and pulmonary outflow views) and for abdominal anatomy (stomach, kidneys, bladder, ventral wall, and three-vessel cord) were 91%, 91%, and 99%, respectively. A complete anatomic survey including each of the above elements was obtained by 10, 15, 20, 25, and 30 min in 8%, 31%, 53%, 72% and 81% of the subjects. Rates of complete anatomic surveys within 30 min improved by gestational age interval, from 20/30 (67%) at 16-18 weeks, to 36/44 (82%) at 18-20 weeks, and 25/26 (96%) at 20-22 weeks; this rise was primarily due to improvements in visualization of the spine and heart.

CONCLUSIONS

A comprehensive anatomical survey can be completed in 10 min or less in a minority of patients. For each 5-min time increment up to 30 min, the rate of complete surveys improves. Rates of completed anatomic surveys rise with gestational age.

Odour-evoked [Ca2+] transients in mitral cell dendrites of frog olfactory glomeruli

We measured Ca2+ concentration, [Ca2+], transients in mitral cell distal apical dendritic tufts produced by physiological odour stimulation of the olfactory epithelium and electrical stimulation of the olfactory nerve (ON) using two-photon scanning and conventional wide-field microscopy of Ca2+-Green-1 dextran in an in vitro frog nose-brain preparation. Weak or strong ON shock-evoked fluorescence transients always had short latency with an onset 0-10 ms after the onset of the bulb local field potential, rapidly increasing to a peak of up to 25% fractional fluorescence change (DeltaF/F) in 10-30 ms, were blocked by 10 microM CNQX, decaying with a time constant of about 1 s. With stronger ON shocks that activated many receptor axons, an additional, delayed, sustained AP5-sensitive component (peak at approximately 0.5 s, up to 40% DeltaF/F maximum) could usually be produced. Odour-evoked [Ca2+] transients sometimes displayed a rapid onset phase that peaked within 50 ms but always had a sustained phase that peaked 0.5-1.5 s after onset, regardless of the strength of the odour or the amplitude of the response. These were considerably larger (up to 150% DeltaF/F) than those evoked by ON shock. Odour-evoked [Ca2+] transients were also distinguished from ON shock-evoked transients by tufts in different glomeruli responding with different delays (time to onset differed by up to 1.5 s between different tufts for the same odour). Odour-evoked [Ca2+] transients were increased by AMPA-kainate receptor blockade, but substantially blocked by AP5. Electrical stimulation of the lateral olfactory tract (5-6 stimuli at 10 Hz) that evoked granule cell feedback inhibition, blocked 60-100% of the odour-evoked [Ca2+] transient in tufts when delivered within about 0.5 s of the odour. LOT-mediated inhibition was blocked by 10 microM bicuculline.

What factors account for hormone replacement therapy prescribing frequency?

OBJECTIVES

The purpose of this study was to compare hormone replacement therapy (HRT) prescribing frequency to provider characteristics, attitudes and beliefs about menopause and HRT.

METHODS

There was a mailed survey of providers at a large staff-model HMO in Washington state. Participants included 250 family practice physicians, 22 gynecologists, and 13 women's health care specialists and nurse midwives (83% response rate). The primary outcome, "HRT prescribing frequency" (derived from automated pharmacy and visit data) was defined as: the total number of estrogen prescriptions written by the provider and filled by women aged 50-80 years during the 12 months prior to the survey, divided by the number of visits made to the provider by women aged 50-80 years during that same 12-month period. Covariates included provider characteristics and beliefs about menopause and HRT. Logistic regression was used to distinguish providers in the upper 40% versus the lower 60% of HRT prescribing frequency.

RESULTS

Controlling for age and practice type, HRT prescribing frequency was lower among men than women providers (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.21-0.65), higher among providers who agreed (vs. disagreed or neutral) that a convincing scientific case has been made that HRT prevents heart disease (OR 2.66, 95% CI 1.53-4.61), and higher among those in the upper tertile vs. lower tertiles of an HRT encouragement scale (OR 2.50, 95% CI 1.29-4.85).

CONCLUSIONS

Female providers and providers with positive attitudes toward HRT are the most likely to prescribe it.

A double-blind, placebo-controlled crossover study investigating the effect of porcine secretin in children with autism

A recent patient series reported the incidental findings of improved social and language skills in 3 children with autistic spectrum disorders after the administration of secretin, a peptide hormone. However, a subsequent study did not find evidence for a drug effect. Parents are seeking treatment with secretin despite the absence of empirical investigations demonstrating amelioration in autism symptomology. In order to more precisely measure the effects of secretin, this study investigated the effect of a single intravenous dose of porcine secretin on 12 autistic children through a randomized, double-blind, placebo-controlled, crossover study. Children were assessed on objective language and on social, neuropsychological, and gastrointestinal measures to evaluate drug effects. The study was conducted over a 16-week trial. The results indicated that significant differences were not observed on the majority of the dependent variables. Statistically significant differences were observed on measures of positive affect and activity level following secretin infusion. In general, the autistic children did not demonstrate the improvements described in the initial retrospective report.

Odor-evoked calcium signals in dendrites of rat mitral cells

Mitral cell dendrites do more than passively integrate and convey synaptic potentials to the soma, they release transmitter onto local interneurones to mediate recurrent and lateral inhibition. Several mechanisms may control the level of dendritic intracellular calcium ([Ca(2+)]) and define timing for dendritic release. Here we investigated in vivo, how odor controls calcium dynamics in mitral cell dendrites by combining intracellular recording and two-photon microscopy imaging of [Ca(2+)]. During odor stimulation, two types of [Ca(2+)] changes accompany membrane potential oscillations that are phase-locked with the respiratory cycle: (i) one is graded and parallels the membrane potential, even below the threshold for action potential firing; (ii) a second is transient, triggered by sodium action potentials that invade the entire dendritic tree. These results indicate that mitral cell dendritic compartments are synchronized by action potentials and suggest that the efficacy of dendritic synapses is finely tuned by odor-evoked graded changes in [Ca(2+)].

Pulmonary macrophage counts in deceased infants: baseline data for further study of infant mortality

Infant lung samples were obtained prospectively at autopsy by medical examiner pathologists in five areas of the United States and regardless of the cause of death. Four sections were examined for each case and were taken from the anterior and posterior aspects of the right and left upper lung lobes. Lung sections were stained with HAM-56 immunostain, which is specific for macrophages. Sixty-one cases were evaluated for the study. Three pathologists independently counted the number of macrophages per 40x field (10x ocular) in 10 contiguous fields near the center of each lung section examined. There was good agreement between pathologists on the average number of macrophages observed in each case. The mean macrophage count for all fields counted was 16.5 per 40x field (range 0-136), and the mean for individual cases was 16 (range 6.6-39.4). There was no observed difference between right, left, anterior, and posterior lung sections. There was a tendency for cases certified as sudden infant death syndrome to show lower macrophage counts than those with other causes of death, but the difference was of only marginal statistical significance. Seven of 10 cases in which infants died after a survival period in the hospital had a mean macrophage count greater than the overall mean of 16 per 40x field. These data suggest that mean pulmonary macrophage counts > 16 per 40x field may be a marker for causes of death other than sudden infant death syndrome or that there was a survival interval. These data may be useful as baseline data for further studies of infant mortality possibly involving pathologic changes in the lungs.

Pulmonary hemosiderin in deceased infants: baseline data for further study of infant mortality

Infant lung samples were obtained prospectively at autopsy by medical examiner pathologists in five areas of the United States. Tissues were submitted regardless of the cause of death. Lung sections were stained with Prussian blue to detect deposits of hemosiderin. Fifty-nine cases were evaluated for the study. The four sections examined for each case were taken from the anterior and posterior aspects of the right and left upper lung. Three pathologists independently scanned the lung sections microscopically using a 10x objective lens (with 10x ocular lens) and indicated an "iron score" by indicating for each section if it showed no staining for iron-hemosiderin (Score 0), occasional staining with most fields negative (Score 1), focally abundant staining with most fields having no staining (Score 2), focally abundant staining with most fields showing positive staining (Score 3), or prominent staining throughout the section (Score 4). There was good agreement between pathologists on the iron score for each case. A total iron score was calculated by adding the scores based on each pathologist's observations. The mean total iron score was 6 (range, 1-44), with the range of possible total iron scores being 0 to 48. There was no significant difference between the four lung sections in a given case. Six cases had total iron scores that were at least twice the mean (i.e., total iron score > 12); in five of these cases death was caused by conditions other than sudden infant death syndrome, including one case in which asphyxia was the cause of death. These data are consistent with other reports that pulmonary hemosiderin in deceased infants is suggestive of a cause of death other than sudden infant death syndrome. The data may be useful as baseline data for further studies of infant mortality involving possible pathologic changes in the lungs.

Delivery of recombinant product from subcutaneous implants of encapsulated recombinant cells in canines

Delivering recombinant therapeutic proteins from a universal microencapsulated cell line is an alternate method for gene therapy. It has proved effective in the treatment of several murine models of human genetic diseases. However, in scaling up to large animal models, intraperitoneal Implantations of these microcapsules in canines were associated with excessive Inflammatory response and rapid degradation. We now show that subcutaneous implantation of microencapsulated cells in canines is effective in delivering recombinant product systemically for extended periods, provides a surgically benign site, leads to less inflammatory response, and permits longer-term survival of microcapsules. Allogeneic MDCK cells engineered to secrete human growth hormone (hGH) were microencapsulated in alginate-poly-L-lysine-alginate and implanted subcutaneously. Systemic delivery of hGH was evident within 4 hours and peaked by day 1 after implantation in all dogs. The gradual decline of hGH in the circulation in the first 2 weeks coincided with the development of anti-hGH antibodies by day 11. The high titer persisted for more than 1 month, demonstrating indirectly the persistent delivery of hGH. Microcapsules retrieved from the subcutaneous implant maintained their structure throughout the experiment and were free of host cellular adhesions. The mechanical integrity of the subcutaneously implanted microcapsules also appeared superior to that of the intraperitoneal implant. Hence the subcutaneously implanted microcapsules required minimal surgical intervention and led to a low level of inflammatory response, and the implant survived for at least 1 month, thus demonstrating the feasibility of systemic delivery of recombinant products via subcutaneous implantation in large animals.

Discipline across generations

The objective of this qualitative research was to understand how parents decide which discipline practices they will repeat from their childhoods. Participants chose not to repeat punishment practices when a strong, negative effect was remembered. However, some parents repeated physical punishment practices even when a strong, negative effect was remembered if they believed the practices were effective or culturally valued, if they were under stress, or if the parents lacked alternative strategies.

Planning ahead: goal-directed problem solving by 2-year-olds

On tasks that require overcoming an obstacle along an existing path to a physically present goal, infants and very young children evince planning. In each of 3 experiments, the authors tested 21- and 27-month-olds' ability to construct a path to a mentally re-presented goal. Across experiments, the authors varied the number and type of cues to the solution provided. After exposure to the goal-state configuration of problems, both age groups showed evidence of planning (Experiment 1). Demonstration of the initial step in the solution path in Experiment 2 was not as effective as exposure to the goal state in Experiment 1. Even with specification of a greater proportion of the goal path, goal-state configuration information was particularly effective in facilitating performance (Experiment 3). The results suggest productive generation of solutions to novel problems by young children; planning is facilitated by goal-state configuration information.

Planning ahead: goal-directed problem solving by 2-year-olds

On tasks that require overcoming an obstacle along an existing path to a physically present goal, infants and very young children evince planning. In each of 3 experiments, the authors tested 21- and 27-month-olds' ability to construct a path to a mentally re-presented goal. Across experiments, the authors varied the number and type of cues to the solution provided. After exposure to the goal-state configuration of problems, both age groups showed evidence of planning (Experiment 1). Demonstration of the initial step in the solution path in Experiment 2 was not as effective as exposure to the goal state in Experiment 1. Even with specification of a greater proportion of the goal path, goal-state configuration information was particularly effective in facilitating performance (Experiment 3). The results suggest productive generation of solutions to novel problems by young children; planning is facilitated by goal-state configuration information.

Time-out: an overused and misused milieu intervention

TOPIC

The basic logic of the time-out, its conceptual underpinnings, its misuse in inpatient psychiatry, and suggestions for appropriate application.

PURPOSE

In the inpatient treatment setting, time-outs can become an automatic response to any behavioral infraction. When this happens, time-outs begin to lose their effectiveness because the intervention does not necessarily address the child's needs or the underlying mechanisms of the inappropriate behavior. They also can be misused when time-outs escalate into a lengthy stay in a seclusion room. The author examines the dynamic underlying the misuse and overuse of the time-out.

SOURCES

Personal observations and published literature.

CONCLUSIONS

The time-out is a useful tool, but only when employed with minded intent and understanding of how it is supposed to help the child.

Effects of the NSAIDs meloxicam and indomethacin on cartilage proteoglycan synthesis and joint responses to calcium pyrophosphate crystals in dogs

NSAIDs are a major cause for concern for their propensity to cause joint deterioration in canine, as in human, patients receiving these drugs for treatment of pain in osteoarthritis and other acute and chronic painful conditions. To determine the potential effects of the new NSAID meloxicam on cartilage integrity, the effects of this drug on proteoglycan biosynthesis in vitro and ex vivo were compared with those of indomethacin, a known inhibitor of sulphated proteoglycans that accelerates joint injury in human osteoarthritis. In vitro cartilage proteoglycan synthesis from a radiosulphate precursor was unaffected by 0.5-10.0 micromol/L meloxicam but was significantly inhibited by 50 micromol/L indomethacin after 6 or 24 h incubation of femoral or tibial cartilage explants in organ culture. This is in accord with previous observations in human or porcine articular cartilage under the same culture conditions. Studies were performed in vivo to establish the effects of the NSAIDs on joint integrity. This involved determining cartilage proteoglycan synthesis ex vivo, leukocyte, fluid and protein accumulation, as well as pain relief. Thus, meloxicam (0.2 mg/kg i.v. x 3 doses) or indomethacin (0.5 mg/kg i.v. x 3 doses) was given for 26 h and the effects were compared with a control (1.0 ml saline i.v. x 3 doses) in dogs in which acute inflammation had been induced by intra-articular (i.a.) injection of calcium pyrophosphate dihydrate (CPPD) crystals into the right stifle joint, an equivalent volume of saline being injected into the left stifle joint as a control. No effects were observed of the treatment with the NSAIDs on ex vivo sulphated proteoglycan synthesis. The lack of the expected inhibitory effects of indomethacin may be related to the relatively low plasma concentrations of this drug obtained during the 26 h period of treatment. The pain response, which was elicited up to 6 h following i.a. injection of CPPD crystals, was totally prevented by the treatment with meloxicam and to a lesser extent with indomethacin. There were no effects from the drug treatment on synovial inflammatory reactions (fluid and cell accumulation), although the protein concentration of the exudate was reduced by meloxicam. This indicates that, at the doses given, it was possible to discriminate the analgesic action from the anti-inflammatory action of the two NSAIDs, this being achieved at relatively low plasma concentrations of these drugs. In conclusion, while relatively high therapeutic concentrations of indomethacin inhibit cartilage proteoglycan synthesis, this is not an effect seen even at high concentrations of meloxicam. Furthermore, the lack of effects on proteoglycan synthesis was evident when these two drugs were given in vivo to dogs. However, the signs of pain, but not the inflammation in the joint, were relieved by low plasma concentrations of the drugs. Meloxicam may thus be safely employed for acute analgesia without the potential risks of joint cartilage damage that occurs with indomethacin given at antiinflammatory doses for long periods of time.

The long-term efficacy of a behavioral parent training intervention for families with 2-year-olds

The effectiveness of a behavioral parent training (BPT) intervention for improving maternal self-efficacy, maternal stress, and the quality of mother-toddler interactions has been demonstrated (Gross, Fogg, & Tucker, 1995). The 1-year follow-up of the 46 parents of toddlers (assigned to an intervention or comparison group) who participated in that study is reported. It was hypothesized that (a) BPT would lead to enduring positive changes in parenting self-efficacy, parenting stress, and parent-toddler interactions; and (b) the amount of parent participation in the intervention would be correlated with greater gains in parent-child outcomes at 1 year. All the families were retained and significant gains in maternal self-efficacy, maternal stress, and mother-child interactions were maintained. Minimal BPT effects were found for fathers. BPT dosage was related to reductions in mother critical statements and negative physical behaviors at 1-year postintervention. The findings are consistent with self-efficacy theory and support parenting self-efficacy as a target for BPT in families of young children.

Delivery of recombinant gene product to canines with nonautologous microencapsulated cells

An alternative and potentially cost-effective approach to somatic gene therapy is to engineer a universal cell line secreting the desired product suitable for implantation into different patients without immune rejection. Encapsulating these cells in immunoprotective alginate microcapsules showed that this approach was effective in treating murine models of human diseases. We now report that this approach is also effective in delivering recombinant gene products to large animals. Canine MDCK cells encapsulated in alginate microcapsules were able to deliver recombinant human growth hormone to nonautologous dogs in vivo. However, the same microcapsules capable of prolonged delivery in mice soon disappeared after implantation in dogs. In contrast, when these microcapsules were modified by using a higher concentration of alginate cross-linked with barium instead of calcium, and by fabricating the alginate as a gelled bead without solubilizing the core, more prolonged and higher levels of recombinant product were obtained. Laminating the surface of the beads with poly-L-lysine and alginate provided an even more mechanically stable device that lasted for >2 months instead of <14 days in vivo and delivered >20 ng of human growth hormone/ml of plasma within the first week. The apparent disappearance of the growth hormone from the circulation after day 14 was due to rapid clearance by anti-human growth hormone antibodies and not due to loss of cell viability. However, all microcapsules provoked an inflammatory reaction, causing mild omentitis, and eventually disappeared from the intraperitoneal cavity. In conclusion, systemic delivery of recombinant gene products with nonautologous cells protected in alginate microcapsules has been shown to be feasible in canine recipients. While improved level and duration of delivery have been achieved by increasing the mechanical stability of the microcapsules, further improvements in biocompatibility and stability will be required for human application.

Respiratory infection in lipid-fed rabbits enhances sudanophilia and the expression of VCAM-1

The pathogenesis of atherosclerosis has been related to infection of the arterial wall, but it is not clear whether this occurs before or after the development of lipid-containing lesions. Respiratory bacterial infection increases the expression of vascular cell adhesion molecule-1 (VCAM-1). We therefore examined whether a similar infection would enhance atherosclerosis in New Zealand White rabbits fed chow supplemented by 15% (w/w) egg yolk for 50 days. Rabbits with naturally acquired respiratory infection by Pasteurella multocida, pathogen-free (SPF) animals infected by P. multocida in the laboratory, and age-matched SPF rabbits maintained in a disease-free environment were used. Endothelial cells expressing VCAM-1 in the aorta between intercostal arteries 3 and 5 were identified using anti-VCAM-1 (Rb1/9) and an alkaline-phosphatase-linked secondary antibody and quantified in Häutchen preparations. The remainder of the aorta was stained with Sudan IV to show lipid deposition. The expression of VCAM-1 (mean +/- SEM per 10,000 cells) was 22 +/- 8 (n = 5) in the lipid-fed SPF rabbits, significantly different from that in the lipid-fed rabbits with naturally occurring infection (190 +/- 51 (n = 5)) or from rabbits infected in the laboratory (106 +/- 25 (n = 5)). The extent of Sudanophilia was significantly greater in the naturally infected rabbits (8.3 +/- 1.2%) or infected SPF rabbits (10.3 +/- 1.8%) than in the SPF rabbits (2.7 +/- 0.8%; P < 0.05). Antibiotic treatment in naturally infected rabbits reduced the number of cells expressing VCAM-1 and the extent of the Sudanophilia to baseline levels. Thus, Sudanophilia is enhanced by bacterial infection in rabbits fed egg yolk and is associated with a significant increase in VCAM-1.

Increased expression of vascular cell adhesion molecule-1 by the aortic endothelium of rabbits with Pasteurella multocida pneumonia

Vascular cell adhesion molecule-1 (VCAM-1) is expressed by endothelial cells in a variety of inflammatory conditions in experimental animals and humans. It is increased in rabbit endothelium after the intravenous administration of endotoxin, after cholesterol feeding, in regeneration after injury, and in alloxan-induced diabetes mellitus. The effect of a respiratory tract infection with Pasteurella multocida, a common laboratory pathogen in rabbits, on VCAM-1 expression by aortic endothelial cells and on the endothelial ultrastructure was examined in specific-pathogen-free (SPF) New Zealand White rabbits infected by the instillation of a suspension of live organisms into the nose and in conventionally raised rabbits with naturally acquired P. multocida infection. Age-matched SPF rabbits maintained in a disease-free environment were controls. Rabbits were euthanized 50 days after infection, the aorta was excised, and the endothelial cells expressing VCAM-1 were identified by immunohistochemistry. Perfusion-fixed aortas from infected and SPF rabbits were prepared for examination by electron microscopy. All infected animals had pneumonitis and leukocytosis. In SPF rabbits the total leukocyte count was highest at postinfection day 25. There was a significant (P < 0.05) increase in the number of VCAM-1-positive aortic endothelial cells in infected SPF rabbits (34 +/- 4/10(4) endothelial cells; n = 5) and rabbits with naturally acquired infection (57 +/- 14/10(4) endothelial cells; n = 5) compared with control animals (12 +/- 3 per 10(4) endothelial cells; n = 4). The endothelium of infected rabbits had morphologic alterations consistent with injury. Thus infection at remote sites can activate arterial endothelium and induce the expression of VCAM-1.

Seven Days and Counting: How Inpatient Nurses Might Adjust Their Practice to Brief Hospitalization

1. Inpatient nurses can help create a seamless health care system by designing groups and specific interventions that begin at the time of admission and continue after discharge. 2. Inpatient nurses must clearly articulate how they intervene for the benefit of patients and how they engineer the coordinated staff effort that maintains the basic safety and structure of the environment. 3. Nurses should learn how to organize and report observations so they formulate a concise assessment summary while also collecting data that are useful to the unit's outcome evaluation.

Dementia care creating a therapeutic milieu

1. In dementia care, the full spectrum of interventions in a therapeutic milieu provides for safety, structure, support, involvement, and validation. 2. A safe environment accommodates wandering and compensates for physical and cognitive impairments. A therapeutic milieu provides for both physical and psychologic safety. 3. Two components of structure include the design of the physical environment and the schedule of activities. 4. The central element that defines quality in a therapeutic milieu is the dimension of interpersonal relationships.

Presynaptic calcium and serotonin-mediated enhancement of transmitter release at crayfish neuromuscular junction

Fura-2 microfluorometric measurements of calcium concentrations in excitor motor nerve terminals of the first walking leg of crayfish Procambrus clarkii were made during application of serotonin (5-HT) to examine whether changes in residual calcium concentration or calcium influx are responsible for the 5-HT-induced increase in transmitter release at this synapse. Calcium concentrations and EPSPs were monitored simultaneously during 0.5-Hz and moderate-frequency (3-16 Hz) stimulation before, during, and after a 5-min application of 5-HT at concentrations between 5 and 100 microM. We did not observe a significant increase in resting calcium concentration [Ca2+]i in presynaptic terminals during or after application of 5-HT despite simultaneously recorded excitatory junction potential (EJP) enhancement. Injection of the calcium buffer EGTA to concentrations sufficient to reduce significantly the buildup of frequency-dependent facilitation during trains of action potentials did not reduce 5-HT-mediated EJP enhancement. We therefore conclude that 5-HT does not release calcium from intracellular stores to an extent sufficient to overcome calcium buffering and removal systems. Spontaneous release of transmitter quanta was increased by 5-HT to the same extent in normal and increased-osmolarity saline in the absence of measured changes in [Ca2+]i. Thus, changes in residual calcium cannot explain 5-HT-induced synaptic enhancement. Increasing the action-potential-mediated calcium influx by broadening the spike or by increasing extracellular calcium increased evoked transmitter release and increased the accumulation of calcium during trains of action potentials. However, though 5-HT produced a comparable synaptic enhancement, we found no evidence for increased calcium accumulation during trains of action potentials, suggesting that net calcium influx, buffering, and removal are not affected by 5-HT. Therefore, we conclude that 5-HT's action does not result from effects on calcium metabolism and suggest that it acts on the neurosecretory apparatus to increase the effectiveness of calcium for stimulating release. Furthermore, based on its relatively constant effects on facilitated and unfacilitated action-potential-evoked release and spontaneous transmitter release, we conclude that 5-HT actions are independent of the concentration of calcium that is driving release.