Choosing Wisely Canada: Canadian fertility and andrology society’s list of top items physicians and patients should question in fertility medicine

Purpose

To create a Choosing Wisely Canada list of the top 5 diagnostic and therapeutic interventions that should be questioned in Reproductive Endocrinology and Infertility in Canada.

Methods

The Canadian Fertility and Andrology Society (CFAS) National Working Group developed an initial list of recommendations of diagnostic and therapeutic interventions that are commonly used, but are not supported by evidence, and could expose patients to unnecessary harm. These were chosen based on their prevalence, cost, potential for harm, and quality of supporting evidence. A modified Delphi consensus was used over 5 rounds to generate ideas, review supporting evidence, assess clinical relevance, estimate recommendation impact and narrow the recommendations list to 5 items.

Results

Fifty unique ideas were first proposed by the working group, and after 5 rounds including a survey of Canadian Fertility and Andrology Society (CFAS) members, the final list of recommendations was created, including topics related to unnecessary investigations and interventions for patients with infertility and recurrent pregnancy loss, and those undergoing IVF. In this article, we describe not only the Delphi process used to determine the list, but also provide a summary of the evidence behind each of the final recommendations.

Conclusions

The list of five recommendations highlights opportunities to initiate conversations between clinicians and patients about the risks, benefits, harms and costs of unnecessary fertility treatments and procedures in a Canadian context.

Effect of the UK Psychoactive Substances Act 2016 on episodes of toxicity related to new psychoactive substances as reported to the National Poisons Information Service. A time series analysis

BACKGROUND

There have been recent increases in use of new psychoactive substances (NPS) associated with acute health harms including hospital presentations due to toxicity and increasing numbers of deaths. In response, the UK Government enacted generic legislation on 26th May 2016 (the Psychoactive Substances Act) making it an offence to produce, possess with intent to supply, supply, import or export, or possess within a custodial setting a psychoactive substance. We studied the impact of this Act on monthly frequency of enquiries made by health professionals to the UK National Poisons Information Service (NPIS) about NPS. We also studied five commonly used 'conventional' drugs of misuse that had been controlled prior to January 2009.

METHOD

Anonymised clinical enquiries to the NPIS and accesses to the poisons information database TOXBASE were reviewed retrospectively from January 2009 to December 2018 to ascertain the trends in reported toxicity for NPS, cocaine, heroin, cannabis, amphetamines and MDMA. Data were analysed using interrupted time series analysis with the date of the PSA used as an independent predictor.

RESULTS

Over the period of study there were 3,866 NPIS telephone enquiries and 79,271 TOXBASE user accesses made by UK health professionals concerning NPS. There were increases in monthly TOXBASE accesses (t = 7.408, P < 0.0001) and telephone enquiries (t = 4.74, P < 0.001) over the pre-specified period January 2009 to May 2016. Comparing the period after the PSA with that before, there were significant reductions in TOXBASE accesses (t = -3.327, P < 0.001) and telephone enquiries (t = -6.97, P < 0.001), although reductions started before May 2016. There were no significant changes for the five conventional drugs. There were significant reductions in telephone enquiries (t = -3.418, P < 0.001) and non-significant reductions in TOXBASE accesses (t = -1.713, P = 0.089) for NPS between June 2016 and December 2018. Increases in telephone enquiries for cocaine and reductions TOXBASE accesses for MDMA were also observed over that period.

CONCLUSIONS

There have been significant recent reductions in NPIS enquiry activity relating to NPS; although these began before enactment of the PSA in May 2016.

Production of the 14 kDa trypsin inhibitor protein is important for maize resistance against Aspergillus flavus infection/aflatoxin accumulation

Maize (Zea mays L.) is one of the major crops susceptible to Aspergillus flavus Link ex. Fries infection and subsequent aflatoxin contamination. Previous studies found the production of an antifungal 14 kDa trypsin inhibitor (TI) was associated with maize aflatoxin resistance. To further investigate whether the TI plays any direct role in resistance, a TI gene silencing vector was constructed and transformed into maize. Mature kernels were produced from 66 transgenic lines representing 18 independent events. A final total of twelve lines representing four independent events were confirmed positive for transformation, five of which showed significant reduction (63 to 88%) in TI transcript abundance in seedling leaf tissue and seven of which showed significant TI protein reduction (39-85%) in mature kernels. Six of the seven silenced transgenic lines supported higher levels of aflatoxin production compared to negative controls. To further confirm the role of TI in field resistance to aflatoxin accumulation, DNA sequence polymorphisms from within the gene or linked simple sequence repeats were tested in four quantitative trait loci (QTL) mapping populations for QTL effect, and three QTL with log of the odds scores of 11, 4.5, and 3.0 and possibly caused by the TI protein encoding gene were found. Sequence polymorphisms were also tested for association to aflatoxin levels in an association mapping panel, and three single nucleotide polymorphisms were found associated with aflatoxin accumulation (P<0.01). The data from both RNAi and genetic mapping studies demonstrated that production of the TI in maize is important for its resistance to A. flavus infection and/or aflatoxin production.

Micro-computed X-ray tomography: a new non-destructive method of assessing sectional, fly-through and 3D imaging of a soft-bodied marine worm

The detailed examination of the internal and functional anatomy of soft-bodied marine worms has, until now, only been possible using the time consuming and destructive techniques of dissection, histology and electron microscopy. This is the first description of soft body morphology in polychaetes (Nephtys hombergii) derived by means of a bench-top X-ray micro-CT scanner. The data are augmented, for comparison, by dissections, microscopy and scanning electron microscopy of the same species to show how this non-destructive technique can rapidly and reliably produce high-quality morphological data. It can also be applied to rare or unique invertebrate soft tissue material from museum collections and also to large-scale invertebrate comparative anatomical studies possibly leading to greater evolutionary and taxonomic understanding. High-definition images were obtained without the use of special tissue enhancing stains or radio-opaque fluids and it is believed that this is the first time the technique has been successfully applied to this group of invertebrates. Extrapolation of the sectional imaging of regions of the gut and the production of three-dimensional rotating and 'fly-through' imaging can assist in assessment of aspects of functional anatomy.

Aflatoxin accumulation and kernel infection of maize hybrids inoculated with Aspergillus flavus and Aspergillus parasiticus

Over a three year period, we compared aflatoxin accumulation and kernel infection in maize hybrids inoculated with Aspergillus flavus isolate NRRL 3357, A. flavus isolate NRRL 19772, Aspergillus parasiticus isolate NRRL 6111, and all combinations of these isolates. Maize hybrids were inoculated with the Aspergillus strains using the side-needle technique at 7 days after midsilk (50% of the plants had silks emerged). Aspergillus kernel infection and aflatoxin contamination were determined at ca. 63 days after midsilk. A. flavus isolate 3357 induced high levels of aflatoxin contamination in the maize grain which was similar to levels found when this isolate was combined with the other two Aspergillus isolates. Kernel infection levels were higher in one hybrid when a combination of isolates including isolate 3357 was used. A. flavus isolate 3357 has been used to evaluate maize germplasm for aflatoxin resistance in the south-eastern USA for over 30 years. Our studies determined that inoculating plants with A. flavus isolate 3357 alone was sufficient for inducing aflatoxin contamination in grain at our location. A combination of A. flavus isolates which include isolate 3357 might be more effective in increasing levels of kernel infection and could also induce higher levels of aflatoxin at locations that do not favour disease development.

Field evaluations of concentrated spray applications of microencapsulated sex pheromone for codling moth (Lepidoptera: Tortricidae)

The application of a microencapsulated (MEC) sex pheromone formulation (Checkmate CM-F) for codling moth, Cydia pomonella (L.), in low volume, concentrated sprays was evaluated in a series of small plot and grower trials in apple, Malus domestica Borkhausen, and pear, Pyrus communis L. Preliminary tests found that MEC sprays applied at 172-207 kilopascals in 12-23 liters/ha deposited the highest density of microcapsules per leaf. The addition of a latex sicker did not increase the deposition of microcapsules. Small plot tests in 2004 compared the effectiveness of two low-volume sprayers against a standard high-volume spray (926 liters/ha) applied at 1,379 kilopascals. Moth catches and fruit injury were significantly lower in plots treated with the low-volume sprays compared with plots treated with the standard sprayer. These results suggest that concentrating the MEC formulation increases the deposition of microcapsules and improves its effectiveness. Larger trials were conducted with a low-volume sprayer in 4-ha plots within commercial apple (2005-2006) and pear orchards (2005) paired with similar plots treated with hand-applied pheromone dispensers. Levels of fruit injury were not significantly different between pheromone treatments in any of the three tests. Moth catches, however, were significantly higher in the MEC- versus the dispenser-treated apple plots in 2005. No difference was found in the fruit injury levels in MEC-treated apple orchards in 2005 caused by irrigation method, but moth catches were significantly higher in overhead versus undertree orchards. The advantages and current limitations of using MEC sex pheromone sprays to supplement current grower's management strategies for codling moth is discussed.

Paracetamol (acetaminophen) pack size restrictions and poisoning severity: time trends in enquiries to a UK poisons centre

BACKGROUND AND OBJECTIVE

In September 1998, legislation was introduced in the United Kingdom to limit paracetamol pack sizes to 16 tablets of 500 mg at general sales outlets and 32 tablets of 500 mg at pharmacies. The effect of the regulations on severity of paracetamol poisoning is unclear. The aim of this study was to describe trends in the severity of paracetamol poisoning and to assess the impact of the 1998 Regulations on the enquiries to a UK poisons centre.

METHODS

We extracted data about the age, sex and number of tablets or capsules of paracetamol ingested by patients notified to Guy's and St Thomas' Poisons Unit (London, UK) between 1996 and 2004.

RESULTS AND DISCUSSION

During the study period, there were approximately 140 000 patients with suspected paracetamol poisoning, accounting for around 11% of all patients reported to the poisons unit. The median number of tablets fell from 25 to 20 for males and 20 to 16 for females after 1998. There was also a reduction in the proportion of patients who ingested 17-32 tablets (from 36% to 30%) and 33-100 tablets (from 25% to 19%).

CONCLUSION

Following the 1998 Regulations there was a decline in the severity, but not frequency, of paracetamol poisoning cases reported to Guy's and St Thomas' Poisons Unit. It is unclear whether the decline in severity was a direct consequence of the regulations.

Comparison of the E3 and L3 regions for arming oncolytic adenoviruses to achieve a high level of tumor-specific transgene expression

Arming oncolytic adenoviral vectors with anticancer transgenes that can be expressed in a tumor-selective manner may enable the engineering of vectors with increased potency, while retaining their safety profile. Armed oncolytic adenoviral vectors were constructed in which transgene expression has been linked via modified splice acceptor sequences that did not necessitate the deletion of any part of the adenoviral genome. Several oncolytic adenoviral vectors were compared in which the transgene was inserted in place of either the E3 or the L3 region. While all vectors had similar viral growth and cytotoxicity characteristics, the highest level of transgene expression was observed from a vector in which the transgene had been inserted downstream of the L3 23K protease gene, the Ad-23K-GM vector. Notably, no transgene expression occurred with this vector in the absence of DNA replication either in vitro or in vivo. In contrast, viruses in which the transgene was inserted into E3 locations exhibited a low level of transgene expression even in the absence of DNA replication. In summary, by utilizing the L3 region for arming oncolytic viruses, higher levels of tumor-specific transgene expression can be obtained without the need to delete any parts of the viral genome.

Spatial and non-spatial risk factors associated with cage-level distribution of infectious salmon anaemia at three Atlantic salmon, Salmo salar L., farms in Maine, USA

The distribution of infectious salmon anaemia (ISA) was examined among 80 cages from three Atlantic salmon grow-out farms in Maine, USA that were stocked with smolts from a single hatchery. Cage-level disease was broadly defined as one or more moribund fish testing positive for infectious salmon anaemia virus (ISAV) by RT-PCR and a second confirmatory test (IFAT, culture or genotype sequence). Spatio-temporal and cage-level risks were explored using logistic regression and survival analysis. Non-spatial risk factors associated with ISA, or shortened survival time to disease, included increased predation, trucking company choice for smolt transfers, a finely-sedimented benthic substrate, and smaller average size of smolts at stocking. Univariable analysis identified the time-dependent spatial factor 'adjacency to newly infected cages' to be predictive of new infection in neighbouring cages 11-12 weeks later. However, none of the spatial factors, or their lags retained relevance in multiple-variable models. The results suggest a diffuse distribution of virus exposure throughout infected sites, with host-susceptibility factors probably influencing disease manifestation in individual cages. The narrow focus of the current study may limit application of the findings to other sites and year-classes. However, these data support the relevance of husbandry efforts to optimize fish health in regions affected by ISAV.

Tackling corruption in the pharmaceutical systems worldwide with courage and conviction

Poor drug access continues to be one of the main global health problems. Global inequalities in access to pharmaceuticals are caused by a number of variables including poverty, high drug prices, poor health infrastructure, and fraud and corruption--the latter being the subject of this article. There is growing recognition among policy makers that corruption in the pharmaceutical system can waste valuable resources allocated to pharmaceutical products and services. This, in turn, denies those most in need from life-saving or life-enhancing medicines. As a result, international organizations, including the World Health Organization and the World Bank are beginning to address the issue of corruption in the health sector broadly and the pharmaceutical system specifically. This is encouraging news for improving drug access for the global poor who are most harmed by corruption as they tend to purchase less expensive drugs from unqualified or illegal drug sellers selling counterfeit or sub-standard drugs. In our paper, we illuminate what are the core issues that relate to corruption in the pharmaceutical sector. We argue that corruption in the pharmaceutical system can be detrimental to a country's ability to improve the health of its population. Moreover, unless policy makers deal with the issue of corruption, funding allocated to the pharmaceutical system to treat health conditions may simply be wasted and the inequality between rich and poor in access to health and pharmaceutical products will be aggravated.

Structural polymorphism and endotoxic activity of synthetic phospholipid-like amphiphiles

The physicochemical characteristics and in vitro biological activity of various synthetic hexaacyl phospholipid dimers were compared with the respective behavior of bacterial endotoxins (lipopolysaccharide, LPS). The structural variations of the synthetic amphiphiles include different stereochemical (R,S) configurations about their ester- and amide-linkages for the acyl chains and differences in the length of the serine backbone spacer. The temperature of the gel to liquid crystalline phase transition of the acyl chains (T(c)) lies between 10 and 15 degrees C for the compounds with the shortest backbone and decreases rapidly for the compounds with longer backbones. The phase transition enthalpies (8-16 kJ x mol(-1)) are considerably lower than those of lipid A from hexaacyl endotoxins (28-35 kJ x mol(-1)). In contrast, the dependence of T(c) on Mg(2+) and water content shows a behavior typical for endotoxins: a significant increase with increasing Mg(2+) and decreasing water concentrations. The aggregate structure is sensitively dependent not only on the length of the backbone spacer but also on the different stereochemical variations. It can be directly correlated with the biological activity of the compounds. Thus, as with natural lipid A, the capacity to induce cytokine production in mononuclear cells is directly related to the affinity to form nonlamellar cubic or inverted hexagonal H(II) aggregate structures. Together with the data on the transport and intercalation of the dimers into phospholipid liposomes mediated by the lipopolysaccharide-binding protein (LBP), our conformational concept of endotoxicity and cell activation can be applied to these non-LPS structures: endotoxically active compounds incorporate into membranes of immune cells and cause conformational changes at the site of signaling proteins such as Toll-like receptors or K(+)-channels due to their conical molecular shape.

CT guided percutaneous fixation of sacroiliac fractures in trauma patients

BACKGROUND

Open reduction and internal fixation of unstable pelvic fractures has been advocated to minimize complications and avoid further injury. We have recently performed CT guided percutaneous fixation of sacroiliac joints as an alternative to open repair.

METHODS

From May 1, 1998 to April 30, 1999, our Level II trauma center admitted 76 patients with pelvic fractures, all due to blunt trauma. Twenty patients with unstable sacroiliac fracture-distractions underwent 22 percutaneous fixation procedures under general anesthesia in the radiology department by the third hospital day. Procedure times averaged 82 minutes. Localization with CT guidance was performed by the radiologist using 3-D images followed by percutaneous screw placement by the orthopaedic surgeon.

RESULTS

There was minimal procedural blood loss and no post-procedural wound complications. There was one operative delay due to respiratory difficulties and one postoperative death unrelated to the pelvic fracture. All patients were mobilized on the first post-procedural day.

CONCLUSION

CT guided fixation of unstable pelvic fractures minimizes blood loss during a short procedure with few subsequent complications and allows early mobilization of the patients.

Behavioral characteristics of children with daytime wetting

PURPOSE

We hypothesized in this descriptive investigation that children with daytime wetting demonstrate unique emotional/behavioral patterns, independent of gender and age, compared to children with nocturnal wetting.

MATERIALS AND METHODS

Two groups of children 5 to 17 years old with day wetting and urinary tract infections in the absence of organic etiology were recruited for study. There were 488 children in group 1 and 418 in group 2. Group 1 was given a short set of behavioral questions and group 2 was evaluated for behavioral characteristics with a revised and longer set of questions. Also in group 2 children with nocturnal wetting only were recruited as a comparison group. A subgroup of 58 children was randomly selected from group 2 and administered 2 standardized questionnaires.

RESULTS

Children with day wetting and urinary tract infection had a significantly higher rate of constipation (35%) than those with day wetting and no infection (25%, p <0.02). Parents of group 1 children reported the level of frustration and anger to be similar whether the children had urinary tract infection or not. Parents also reported that only 3.8% of children had significant learning or school problems. Parents of group 2 did not report any differences between nighttime and daytime wetting with respect to positive outlook, organizational skills or willingness to talk. Differences were noted, with daytime wetters perceived as more stubborn (p <0.0001), secretive (p <0.0001), refusing to follow parental requests (p <0.002) and constipation (p <0.0003). Of the subsample group the incidence of verified attention deficit/hyperactivity disorder was highest in children with daytime wetting and no infection (21%), and nighttime wetting (22%) compared to 0% in daytime wetting and infection. The Child Behavioral Checklist results on this sample suggested that 35% of the children with daytime wetting and no infection earned significant T scores of mixed or externalizing symptoms, while the nocturnal enuresis group demonstrated 16% significant T scores, primarily externalizing. All females with the daytime wetting and infection showed significant T scores within the internalizing domain. The Child Behavioral Checklist defines externalizing behaviors as aggressive and acting out behaviors, while internalizing behaviors include withdrawn and anxious/depressed behaviors. Mixed behaviors on this questionnaire include social, attention and thought problems.

CONCLUSIONS

These data suggest that a minority of children with daytime wetting and infection tend to show an internalizing style of problems (11%) and constipation, while those with daytime wetting and no infection show a more mixed style of psychological problem (35%). In contrast, the nighttime wetting group tends to show externalizing problems (16%). Based on a subsample of the data children with daytime wetting and no infection, and nighttime wetting showed a significantly incidence of verified attention deficit/hyperactivity disorder compared to the general population. According to parent perceptions, stubbornness and secretiveness seem to describe a style that the children with daytime wetting exhibit that is not present in those with nighttime wetting. There is a possible role of uncontrol and over control psychological styles to the development and treatment of daytime wetting as well as the relationship of these styles to treatment outcome. Further research is needed to clarify the psychological style of children with daytime wetting to customized treatment protocols.

The potential toxicity of Ilex myrtifolia in beef cattle

Spatial and temporal patterns of death loss in a beef cowherd indicated a possible relationship between the loss of 11 cows and the consumption of Ilex myrtifolia (myrtle leaf holly). To investigate this relationship, plant material from Ilex myrtifolia was harvested and 2 feeding trials were performed. The 1st trial involved intermittent feeding of plant material to 4-mo-o calves for 2 w, and the 2nd trial was continuous plant feeding to 2-mo-o calves for 35 d. No significant clinical pathology, histological or gross lesions resulted and no clinical signs consistent with the original herd problem were observed, suggesting that berries, leaves and stems from Ilex myrtifolia were not sufficiently toxic to induce clinical effects under these experimental conditions.

An adenovirus E1A mutant that demonstrates potent and selective systemic anti-tumoral efficacy

Replication-selective oncolytic viruses constitute a rapidly evolving and new treatment platform for cancer. Gene-deleted viruses have been engineered for tumor selectivity, but these gene deletions also reduce the anti-cancer potency of the viruses. We have identified an E1A mutant adenovirus, dl922-947, that replicates in and lyses a broad range of cancer cells with abnormalities in cell-cycle checkpoints. This mutant demonstrated reduced S-phase induction and replication in non-proliferating normal cells, and superior in vivo potency relative to other gene-deleted adenoviruses. In some cancers, its potency was superior to even wild-type adenovirus. Intravenous administration reduced the incidence of metastases in a breast tumor xenograft model. dl922-947 holds promise as a potent, replication-selective virus for the local and systemic treatment of cancer.

Allergy prevalence and causal factors in the domestic environment: results of a random population survey in the United Kingdom

BACKGROUND

Surveys of the prevalence of allergic diseases associated with domestic allergens (eg, asthma, rhinitis, hay fever, eczema, and dermatitis) are usually undertaken in restricted geographic areas. They are often based on specific demographic subgroups (eg, children) or are derived from treatment data (eg, GP consultations). Causal factors are seldom quantified in these reports.

OBJECTIVE

This study was designed to quantify the prevalence of allergic disease among a representative cross-section of population in the United Kingdom. It was also designed to quantify the reported causal factors in terms of domestic allergen and irritant sources and activities leading to exposure.

METHODS

Two thousand respondents were selected from across the UK. These respondents were interviewed using a short series of questions that formed part of a larger, more general omnibus questionnaire. The questions required respondents to report on diagnosed allergic disease and causal factors within their household, giving a total sample base of 5,609 people.

RESULTS

Asthma and hay fever account for the majority of reported cases of allergic disease in the UK (12% and 10% of total household, respectively). Pollen, house dust mite excreta (HDM allergen), and pet dander are the three most common allergic triggers (42%, 27%, and 17% respectively). Dusting and being near pets each account for about 20% of the reported domestic activities triggering an allergic response.

CONCLUSION

The feedback from the general population indicates asthma and hay fever to be the predominant allergic conditions, with dust and pet dander the most common sources of allergen/irritant. Key tasks such as changing bed linen and vacuuming were not perceived as being as important as dusting in terms of activities leading to reaction.

Primary antiphospholipid syndrome: a cause of catastrophic shunt thrombosis in the newborn

This is a unique report of systemic-to-pulmonary artery shunt thromboses secondary to primary antiphospholipid syndrome and antithrombin III deficiency in a neonate with cyanotic congenital heart disease. This infant with tricuspid atresia experienced thromboses of two modified Blalock-Taussig shunts en route to a bidirectional cavo-pulmonary shunt and potential future Fontan operation. Chronic warfarin anticoagulation has prevented additional thrombo-embolic events.

Kluyveromyces lactis SEF1 and its Saccharomyces cerevisiae homologue bypass the unknown essential function, but not the mitochondrial RNase P function, of the S. cerevisiae RPM2 gene

RPM2 is a Saccharomyces cerevisiae nuclear gene required for normal cell growth yet the only known function of Rpm2p is as a protein subunit of yeast mitochondrial RNase P, an enzyme responsible for the 5' maturation of mitochondrial tRNAs. Since mitochondrial protein synthesis in S. cerevisiae is not essential for viability, RPM2 must provide another function in addition to its known role as a mitochondrial tRNA processing enzyme. During a search for RPM2 homologues from Kluyveromyces lactis, we recovered a K. lactis gene that compensates for the essential function but not the RNase P function of RPM2. We have named this gene SEF1 (Suppressor of the Essential Function), DNA sequence analysis of SEF1 reveals it contains a Zn(2)-Cys(6) binuclear cluster motif found in a growing number of yeast transcription factors. The SEF1 homologue of S. cerevisiae also compensates for the essential function of RPM2. The two proteins share 49% identity and 72% amino acid sequence similarity.

Cognitive models that predict physician judgments of capacity to consent in mild Alzheimer's disease

OBJECTIVE

To identify cognitive measures that predict consent capacity of normal and demented older adults as judged by experienced physicians. This study is a companion to the physician competency judgment research reported in this issue.

DESIGN

Predictor models for competency judgments of individual physicians were developed using independent patient neuropsychological test measures and discriminant function analyses (DFA).

SETTING

University medical center.

PARTICIPANTS

Subjects were 16 normal older controls and 29 patients with mild AD (MMSE > or = 20). Five experienced medical center physicians were recruited as competency decision-makers.

MEASUREMENTS

Subjects were videotaped responding to a standardized consent capacity interview (SCCI) designed to evaluate capacity to consent to treatment. Interview subjects were also independently administered (off videotape) a battery of neuropsychological measures theoretically and empirically linked to competency function. Study physicians blinded to subject diagnosis and neuropsychological test performance individually viewed each SCCI videotape and made a judgment of competent or incompetent to consent to treatment. Stepwise DFA identified neuropsychological predictors of each physician's competency judgments for the full sample (N = 45). Classification DFAs determined how accurately these predictor models classified competency outcomes assigned by the individual physician.

RESULTS

Cognitive models differed across individual physicians and were related to stringency of judgments for AD patients. Under stepwise DFA, delayed verbal recall (R2 = .57, P < .0001) predicted judgments of Physician 1 (incompetency rate of 90% for AD patients), short term verbal recall (R2 = .43, P < .0001) predicted judgments of Physician 2 (incompetency rate of 52%), phonemic word fluency (R2 = .27, P < .001) predicted judgments of Physician 3 (incompetency rate of 24%), and visuomotor tracking/sequencing (R2 = .31, P < .001) predicted judgments of Physician 4 (incompetency rate of 14%). (No predictor model was available for Physician 5 as this physician found all subjects to be competent). These single predictor solutions correctly classified 93%, 87%, 87%, and 96% of cases for Physicians 1-4, respectively. Use of two predictor solutions achieved successful classification rates between 98% and 100%.

CONCLUSIONS

We identified two cognitive models of consent capacity as judged by physicians: (1) verbal recall and (2) simple executive function. The verbal recall model predicted judgments of physicians likely to find mild AD patients incompetent, whereas the executive function model predicted judgments of physicians likely to find mild AD patients competent. Assessment of verbal recall and simple executive functions may provide important information in the clinical evaluation of capacity to consent to treatment.

Consistency of physician judgments of capacity to consent in mild Alzheimer's disease

OBJECTIVE

To investigate the agreement of physician judgments of capacity to consent to treatment for normal and demented older adults.

DESIGN

Subjects were individually administered a standardized consent capacity interview. Physicians viewed videotapes of these interviews and made judgments of capacity to consent to treatment.

SETTING

University medical center.

PARTICIPANTS

Subjects assessed for competency (N = 45) were 16 normal older controls and 29 patients with mild Alzheimer's disease (AD). Five medical center physicians with experience assessing the competency of dementia patients were recruited from the specialties of geriatric psychiatry, geriatric medicine, and neurology.

MEASUREMENTS

Subjects were videotaped responding to a standardized consent capacity interview (SCCI) designed to evaluate capacity to consent to treatment. Study physicians blinded to subject diagnosis individually viewed each SCCI videotape and made a judgment of competent or incompetent to consent. Agreement of physician judgments was evaluated using percentage agreement, kappa, and logistic regression.

RESULTS

Competency judgements of physicians showed high agreement for controls but low agreement for AD patients. Physicians as a group achieved 98% judgment agreement for the controls but only 56% judgment agreement for the mild AD patients. The physician group kappa for controls was 1.00 (P < .0001) and differed significantly (P < .0001) from the physician group kappa of .14 (P = .44) for AD patients, indicative of a real difference in the ability of the study physicians to judge consistently competency across the two groups. Similarly, logistic regression analysis showed significant variability in physician judgements for the AD group (chi 2 = 63.8, P < .0001) but not for the control group (chi 2 = 4.1, P = 1.00). Within the Ad group, pairwise analyses revealed significant judgment disagreement (P < .01) for seven of the 10 physician pairs.

Check bite impressions using irreversible alginate/reversible hydrocolloid combination

A restoration that the patient reports as "high" is a common problem for the restorative dentist. Check bite, dual bite, or closed mouth impressions address this problem effectively by eliminating the opposing arch impression and articulating the opposing cast accurately. In this article a procedure that combines irreversible hydrocolloid and reversible hydrocolloid results in a rapid, clean, and effective solution.

Spinal cord infarct after arterial switch associated with an umbilical artery catheter

Paraplegia after an open heart operation in a neonate is a rare complication. We report a case of a infant in whom paraplegia developed after a successful arterial switch operation for transposition of the great arteries. The infant was monitored and resuscitated in the preoperative period with umbilical arterial and venous catheter tips located in the midthoracic region. He likely suffered a clinically silent thromboembolic event predisposing him to a localized hemorrhagic infarction during the repair.

Treatment of malignant phaeochromocytoma, paraganglioma and carcinoid tumours with 131I-metaiodobenzylguanidine

131I-metaiodobenzylguanidine (MIBG) has been used for the therapy of neural crest tumours. We report our experience with this agent in nine patients (malignant phaeochromocytoma 2; malignant paragangliomas 3; malignant carcinoid tumours 4). Six patients had soft tissue metastases alone while three had both soft tissue and bone metastases. The follow-up period ranged from 8 to 110 months, the number of doses ranged from one to seven with 3.1 to 11.1 GBq per administration and a cumulative activity from 4.8 to 40.1 GBq, while the tumour response was assessed according to World Health Organization (WHO) criteria. None of the patients showed complete tumour regression. Five patients showed complete symptomatic and three showed complete hormonal responses. Three patients with carcinoid tumours died. 131I-MIBG is thus a useful therapeutic modality which provides temporary palliation of these difficult tumours, but is rarely curative.

Brine shrimp development in space: ground-based data to shuttle flight results

The brine shrimp, Artemia salina, has been used as a model system to assess microgravity effects on developing organisms. Following fertilization and early development, the egg can arrest in early gastrula as a dehydrated cyst stage that is stable to harsh environments over long time periods. When salt water is added, the cysts can reactivate, with embryonic development and egg hatching occurring in about 24 h. A series of larval molts or instars, over about a 2 week period, results in the adult crustacean. We have assessed these developmental events in a closed syringe system, a bioprocessing module, in ground-based studies, and have conducted preliminary in-orbit experiments aboard the Space Shuttle Atlantis during the flights of STS-37 and STS-43. Although the in-flight data are limited, spectacular degrees of development have been achieved.

Clinical and angiographic characteristics and outcome of patients with rest-unstable angina occurring during regular aspirin use

Today many patients admitted with an acute coronary syndrome are already taking aspirin. Because they have symptoms despite antithrombotic therapy, these patients are presumed to be at higher risk for subsequent clinical events. In a pilot trial of antithrombotic therapy in patients with unstable angina at rest or non-Q wave infarction, 93 patients admitted within 48 h of pain were prospectively followed up for 12 weeks. On admission, 29 patients (31%) were already taking daily aspirin; 64 (68%) were receiving no antiplatelet agent. After enrollment all patients received antithrombotic therapy with either aspirin or heparin according to protocol regardless of prior aspirin use. The two groups (prior users versus nonusers of aspirin) were similar with regard to age, gender, coronary risk factors, prior antianginal medication, duration of symptomatic coronary disease, presentation with non-Q wave infarction and extent of electrocardiographic changes on admission. Quantitative analysis of coronary arteriograms (on a 0 to 10 scale) showed similar myocardium-in-jeopardy scores (JS). Follow-up events (recurrent ischemia [Isch], infarction [MI] and revascularization [Revasc]) were: (formula: see text) Aspirin users experiencing rest angina are similar to other patients with ischemic rest pain. The "resistant to aspirin" group does not constitute a subgroup that is at higher risk for cardiac events or revascularization.

Usefulness of ST-segment changes in greater than or equal to 2 leads on the emergency room electrocardiogram in either unstable angina pectoris or non-Q-wave myocardial infarction in predicting outcome

To determine the reliability of the admission electrocardiogram in predicting outcome in patients hospitalized for chest pain at rest, 90 patients were randomized into a trial of aspirin versus heparin in unstable angina or non-Q-wave myocardial infarction, and prospectively followed for 3 months. The emergency room admission electrocardiogram was analyzed for ST-segment deviation greater than or equal to 1 mm/lead and T-wave changes. Unfavorable outcomes were recurrent ischemic pain, myocardial infarction and coronary revascularization with angioplasty or surgery. In patients who underwent coronary arteriography, a myocardium in jeopardy score ranging from 0 to 10 was assigned, based on the number of vessels with a diameter stenosis greater than or equal to 70% and the location of the stenoses. Considering all 90 patients, an admission electrocardiogram with ST-segment deviation in greater than or equal to 2 leads had a positive predictive value for adverse clinical events of 79% and a negative predictive value of 64%. In the subset of patients without left ventricular hypertrophy and whose admission electrocardiograms were recorded during chest pain (62 of 90), the positive predictive value of ST deviation in greater than or equal to 2 leads improved to 89% and the negative value to 72%. Of the 62 patients, 53 underwent coronary arteriography. There was a positive linear correlation between the total number of leads with ST-segment deviation and the myocardium in jeopardy score (r = 0.80, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral uptake of MIBG: adrenoceptors visualized?

Radiolabelled metaiodobenzylguanidine (MIBG) localizes in adrenergic neurons. A study was carried out to evaluate the uptake of this radiopharmaceutical in cerebral tissues. Twenty-three patients with neural crest tumours, who had no evidence of central nervous system disease, were evaluated. Each patient underwent a diagnostic MIBG study, followed by a therapy dose with 131I-MIBG and subsequent scintigraphy. Focal uptake was seen in the cerebellum (CB), basal nuclei and thalamic region (BNTr), 24 and 48 h postinjection on the diagnostic images. The BNTr to cerebral cortex ratio ranged from 1.05 to 1.79. Uptake was also seen on the days 2, 3, 4 and 6 post-therapy images. Single photon emission computed tomography (SPECT) clearly outlined the uptake in the CB and BNTr. The BNTr to cerebral cortex ratio ranged from 1.10 to 1.85 and CB to cerebral cortex ratio from 1.18 to 2.01. It is hypothesized that the focal uptake observed in the CB and BNTr is due to adrenergic receptor binding. It is felt that SPECT with radiolabelled MIBG may prove to be a useful tracer for mapping the adrenergic receptors in the human brain.

Usefulness of antithrombotic therapy in resting angina pectoris or non-Q-wave myocardial infarction in preventing death and myocardial infarction (a pilot study from the Antithrombotic Therapy in Acute Coronary Syndromes Study Group)

In a prospective pilot trial of antithrombotic therapy in the acute coronary syndromes (ATACS) of resting and unstable angina pectoris or non-Q-wave myocardial infarction, 3 different antithrombotic regimens in the prevention of recurrent ischemic events were compared for efficacy. Ninety-three patients were randomized to receive aspirin (325 mg/day), or full-dose heparin followed by warfarin, or the combination of aspirin (80 mg/day) plus heparin and then warfarin. Trial antithrombotic therapy was added to standardized antianginal medication and continued for 3 months or until an end point was reached. Analysis, by intention-to-treat, of the 3-month end points, revealed the following: recurrent ischemia occurred in 7 patients (22%) after aspirin, in 6 patients (25%) after heparin and warfarin, and in 16 patients (43%) after aspirin combined with heparin and then warfarin; coronary revascularization occurred in 12 patients (38%) after aspirin, in 12 patients (50%) after heparin and warfarin, and in 22 patients (60%) after aspirin combined with heparin and then warfarin; myocardial infarction occurred in 1 patient (3%) after aspirin, in 3 patients (13%) after heparin and warfarin, and in no patient after aspirin combined with heparin and then warfarin; no deaths occurred after aspirin or after aspirin combined with heparin and then warfarin, but 1 patient (4%) died after warfarin alone; major bleeding occurred in 3 patients (9%) after aspirin, in 2 patients (8%) after heparin and warfarin, and in 3 patients (8%) after aspirin combined with heparin and then warfarin. Recurrent myocardial ischemia occurred at 3 +/- 3 days after randomization.(ABSTRACT TRUNCATED AT 250 WORDS)

The treatment of intraperitoneal malignant disease with monoclonal antibody guided 131I radiotherapy

Seven patients with small volume ovarian carcinoma, remaining after conventional therapy with surgery and a platinum containing chemotherapy regimen, were treated with intraperitoneal monoclonal antibody guided radiotherapy. 100 mCi131I conjugated to 10 mg of monoclonal antibody were injected i.p. in 2,000 ml peritoneal dialysis fluid. Patients were evaluated 3 months later; 3 had clinical progressive disease while third look laparotomy demonstrated progressive disease in 3 of the remaining 4 patients. The seventh patient did not have a third look laparotomy and is currently inevaluable for response. Five patients with recurrent malignant ascites not controlled by diuretics or repeated paracentesis were similarly treated with 75-170 mCi131I conjugated to 10 mg monoclonal antibody. In three patients the ascites was controlled for a mean of 4 months. One patient died too early to assess the control of his ascites but tumour cells disappeared from the ascitic fluid after therapy. In the patient whose ascites were not controlled, a subpopulation of antigen-negative tumour cells was demonstrated. This study was unable to demonstrate a therapeutic benefit for i.p. injected monoclonal antibody guided radiotherapy for solid intraperitoneal tumour but suggests that it may be capable of controlling the accumulation of antigen positive malignant ascites.

An ergonomic approach to stress

The relationships between psychology and ergonomics centre around the concept of stress. This paper outlines the concept that stress is a mismatch between the demands made on an individual and his ability to cope. The nature and theories of stress are reviewed and sources of stress in the nursing profession are analysed. Coping is recognized as a way of reducing the actual or perceived stresses. However, a common method of coping is to disguise the symptoms by taking therapeutic drugs, tobacco or alcohol. It is argued that these methods are a maladaptation since in themselves they can cause illness and death. Evidence of smoking habits in relation to perceived stress in the nursing profession is given. It is concluded that a direct action approach to reduce workplace (organizational) stressors can be achieved by an ergonomic approach to the problem, and that this, if successful, will obviate the need to resort to unhealthy coping mechanisms. Suggestions are put forward as to how some of the major recognised sources of stress in the nursing profession can be analysed and removed by applying ergonomic methods. Shift working is seen by many nurses as a particular stressor. The relationships between lighting quality and circadian rhythm control are discussed as a further example of how an ergonomic solution might be sought.

Radioimmunodiagnosis of ovarian cancer using 123I-labelled, tumor-associated monoclonal antibodies

Monoclonal antibodies to epithelial cells, antigenic determinants labelled with I123 and I125, were administered to 10 immunodeficient mice bearing subcutaneous xenografts of human ovarian cancer. Radio scans of the body taken with a gamma camera at various time intervals demonstrated the presence of the cancer in all the mice. The smallest detectable tumor was approximately 1 mm in diameter. In a subsequent clinical study using 123I-labelled monoclonal antibodies in 10 patients with ovarian cancer, tumor detection was achieved in 8 patients, with tumor uptake of labelled antibody ranging between 0.2-2.6%. As a complementary method to existing forms of diagnosis, the targeting of monoclonal antibodies to ovarian cancer cells in vivo raises the hope of achieving early diagnosis in otherwise undetectable ovarian cancer, and provides encouragement to the concept of selective therapy in oncology.

A rapid quantitative method for the preparation of 123I-iodo-hippuric acid

The labelling of o-iodo-hippuric acid (hippuran) with 123I by several methods was investigated with a view to producing a simple one-step kit preparation. The requirements for the final product are high labelling efficiency and high radiochemical purity. A method which incorporates CuSO4 . 5H2O as a catalyst was found which gave promising preliminary results. Such variables as pH, mass of CuSO4 . 5H2O, volume of 0.02 N NaOH containing the 123I, reaction temperature and time were investigated in detail and optimum values obtained. The results have led to the production of a kit which can be stored for up to 3 months in liquid form and up to 9 months if freeze-dried. The kit has been used in several thousand patients and has yielded consistently good clinical results.

Measuring chronic schizophrenic patients attitudes toward their illness and treatment

The right to refuse medication is a legal right now being extended by federal courts to many voluntary and involuntary mental patients. However, little is known of the insight that chronically ill mental patients bring to the decision of whether or not to accept prescribed medication. In this study, the authors interviewed 45 chronic schizophrenic inpatients to determine their understanding of their illness, need for admission, and need for medication and other treatment. Only 13 per cent understood they were mentally ill, and only 27 per cent of the patients understood that they needed medication. The findings suggest that many chronically mentally ill patients lack sufficient insight into their condition to make sound judgments about medication and treatment. Moreover, even those patients who improved with medication did not improve in their insight into their need for treatment.

A multiobserver comparison of 99mTcO4 and 123I thyroid imaging

The thyroids of forty patients were imaged using 2 mCi(74 MBq) 99mTc pertechnetate (99mTcO4) followed within one week by 2 mCi (74 MBq) 123I Iodide. The images obtained were evaluated by eight observers for 6 morphological criteria and assigned to 6 diagnostic categories with a confidence grading on a seven level scale (grade 1 being that for maximum confidence). Images were obtained with 123I for the same counts and the same times as those with 99mTcO4 and compared using an index in which the number of diagnostic categories and the mean confidence grading within each category were taken into account. The mean index obtained for 99mTcO4 images (9.2) was significantly greater (P less than 0.05, thus representing a lower observer confidence and less interobserver diagnostic agreement) than the mean indices for 123I equal count images (5.6) and 123I equal time images (6.8). The diagnoses made on the basis of 123I images were more frequently concordant with the final diagnosis after six months follow up (75% for equal counts and 77% for equal time) than those with 99mTcO4(63%). The radioisotope of iodine most suited to modern nuclear medicine instrumentation and with the most favourable radiation dosimetry is 123I which is recommended for those areas of thyroid imaging where iodine is superior.

Clinical applications of immunofixation: a more sensitive technique for the detection of Bence Jones protein

Immunofixation in agarose gel has been compared with agarose electrophoresis for the detection of Bence Jones protein in urine. The technique has a sensitivity between five and 10 times greater than electrophoresis and allows the identification of multiple Bence Jones proteins and Bence Jones proteins with fast mobility in the presence of other urinary proteins. In four out of 12 patients studied, Bence Jones protein was undetectable by electrophoresis of 300 times concentrated urine but was clearly identified by immunofixation.