School-wide implementation of positive behavioral interventions and supports in an alternative school setting: A case study

AIMS

The purpose of this 1-year case study was to identify how School-Wide Positive Behavioral Interventions and Supports (SW-PBIS) can be adapted to meet the needs of students in alternative schools and to evaluate the early impact of SW-PBIS on discipline outcomes.

METHODS

Suggestions for adaptations are provided at each stage of the intervention process with a focus on buy-in, training, data collection, and resource allocation.

RESULTS

Data from this case study included information about key components of the implementation process as well as initial outcomes. Process data revealed the importance of stakeholder buy-in, training opportunities, and potential adaptations to the framework. Outcome data from the first year of implementation indicated that the number of incident reports did not significantly differ from the baseline; however, there was a reduction in defiance-related behaviors and an increase in on-task behaviors.

CONCLUSION

This study contributes to the determination of the efficacy of SW-PBIS in a historically more punitive environment. Given the initial positive response and lessons learned, it is believed that, with the support of additional Tier 2 and Tier 3 interventions, SW-PBIS may be an appropriate framework to support students in alternative schools.

Evolutionary and Comparative Genomics to Drive Rational Drug Design, with Particular Focus on Neuropeptide Seven-Transmembrane Receptors

Seven transmembrane receptors (7TMRs), also known as G protein-coupled receptors, are popular targets of drug development, particularly 7TMR systems that are activated by peptide ligands. Although many pharmaceutical drugs have been discovered via conventional bulk analysis techniques the increasing availability of structural and evolutionary data are facilitating change to rational, targeted drug design. This article discusses the appeal of neuropeptide-7TMR systems as drug targets and provides an overview of concepts in the evolution of vertebrate genomes and gene families. Subsequently, methods that use evolutionary concepts and comparative analysis techniques to aid in gene discovery, gene function identification, and novel drug design are provided along with case study examples.

Robust Translation of γ-Secretase Modulator Pharmacology across Preclinical Species and Human Subjects

The amyloid-β peptide (Aβ)—in particular, the 42–amino acid form, Aβ1-42—is thought to play a key role in the pathogenesis of Alzheimer’s disease (AD). Thus, several therapeutic modalities aiming to inhibit Aβ synthesis or increase the clearance of Aβ have entered clinical trials, including γ-secretase inhibitors, anti-Aβ antibodies, and amyloid-β precursor protein cleaving enzyme inhibitors. A unique class of small molecules, γ-secretase modulators (GSMs), selectively reduce Aβ1-42 production, and may also decrease Aβ1-40 while simultaneously increasing one or more shorter Aβ peptides, such as Aβ1-38 and Aβ1-37. GSMs are particularly attractive because they do not alter the total amount of Aβ peptides produced by γ-secretase activity; they spare the processing of other γ-secretase substrates, such as Notch; and they do not cause accumulation of the potentially toxic processing intermediate, β-C-terminal fragment. This report describes the translation of pharmacological activity across species for two novel GSMs, (S)-7-(4-fluorophenyl)-N2-(3-methoxy-4-(3-methyl-1H-1,2,4-triazol-1-yl)phenyl)-N4-methyl-6,7-dihydro-5H-cyclopenta[d]pyrimidine-2,4-diamine (BMS-932481) and (S,Z)-17-(4-chloro-2-fluorophenyl)-34-(3-methyl-1H-1,2,4-triazol-1-yl)-16,17-dihydro-15H-4-oxa-2,9-diaza-1(2,4)-cyclopenta[d]pyrimidina-3(1,3)-benzenacyclononaphan-6-ene (BMS-986133). These GSMs are highly potent in vitro, exhibit dose- and time-dependent activity in vivo, and have consistent levels of pharmacological effect across rats, dogs, monkeys, and human subjects. In rats, the two GSMs exhibit similar pharmacokinetics/pharmacodynamics between the brain and cerebrospinal fluid. In all species, GSM treatment decreased Aβ1-42 and Aβ1-40 levels while increasing Aβ1-38 and Aβ1-37 by a corresponding amount. Thus, the GSM mechanism and central activity translate across preclinical species and humans, thereby validating this therapeutic modality for potential utility in AD.

The longer term experiences of parent training: a qualitative analysis

BACKGROUND

Child conduct problems are a major public health priority. Group-based parenting programmes are popular in addressing such problems, but evidence for their longer-term effectiveness is limited. Moreover, process evaluations are rare and little is understood about the key facilitative and inhibitive factors associated with maintaining outcomes in the longer term.

METHOD

This study involved the use of qualitative methods as part of a larger process evaluation to explore the longer-term experiences of parents who participated in a randomized controlled trial (RCT) of the Incredible Years Parenting Programme (IYPP) in disadvantaged settings in Ireland. A series of one-to-one in-depth interviews was conducted with parents at 12- (n = 20) and 18-month follow-up (n = 8) and analysed using constructivist grounded theory.

RESULTS

Most parents reported positive child behaviour despite several challenges, but a substantial subset reported periods of relapse in positive outcomes. A relapse in child behaviour was linked to relinquishing skills in stressful times, the negative influence of an unsupportive environment, and the perceived ineffectiveness of parenting skills. Resilience in implementing skills despite adversity, and the utilization of available social supports, were associated with the maintenance of positive outcomes.

CONCLUSIONS

Strengthening resilience and social support capacities may be important factors in maintaining positive longer-term outcomes. Those who design, research and deliver parenting programmes might consider the possibility of including a relapse-prevention module and/or the provision of post-intervention supports for more vulnerable families.

Dimer of arfaptin 2 regulates NF-κB signaling by interacting with IKKβ/NEMO and inhibiting IKKβ kinase activity

IκB kinases (IKKs) are a therapeutic target due to their crucial roles in various biological processes, including the immune response, the stress response, and tumor development. IKKs integrate various upstream signals that activate NF-κB by phosphorylating IκB and also regulate many proteins related to cell growth and metabolism. Although they function as a heteromeric complex comprised of kinase subunits and an adaptor, these kinases produce distinct cellular responses by phosphorylating different target molecules, suggesting that they may also be regulated in a subtype-specific manner. In this study, arfaptin 2 was identified as an IKKβ-specific binding partner. Interestingly, arfaptin 2 also interacted with NEMO. Domain mapping studies revealed that the C-terminal region, including the IKKβ HLH domain and the first coiled-coil NEMO region were respectively required for interactions with the arfaptin 2 N-terminal flexible region. Overexpression of arfaptin 2 inhibited tumor necrosis factor (TNF)-α-stimulated nuclear factor-κB (NF-κB) signaling, whereas downregulation of arfaptin 2 by small interfering RNA enhanced NF-κB activity. Dimerization of arfaptin 2 through the Bin-Amphiphysin-Rvs domain may be essential to inhibit activation of NF-κB through multimodal interactions with IKKβs or IKKβ/NEMO, as ectopic expression of the arfaptin 2 fragment responsible for IKK interactions did not change TNFα-stimulated NF-κB activation. These data indicate that arfaptin 2 is the first molecule to regulate NF-κB signaling by interacting with the functional IKK complex but not by direct inhibiting IKKβ phosphorylation.

Pharmacokinetic interactions between BMS-626529, the active moiety of the HIV-1 attachment inhibitor prodrug BMS-663068, and ritonavir or ritonavir-boosted atazanavir in healthy subjects

BMS-663068 is a prodrug of BMS-626529, a first-in-class attachment inhibitor that binds directly to HIV-1 gp120, preventing initial viral attachment and entry into host CD4(+) T cells. This open-label, multiple-dose, four-sequence, crossover study addressed potential two-way drug-drug interactions following coadministration of BMS-663068 (BMS-626529 is a CYP3A4 substrate), atazanavir (ATV), and ritonavir (RTV) (ATV and RTV are CYP3A4 inhibitors). Thirty-six healthy subjects were randomized 1:1:1:1 to receive one of four treatment sequences with three consecutive treatments: BMS-663068 at 600 mg twice daily (BID), BMS-663068 at 600 mg BID plus RTV at 100 mg once daily (QD), ATV at 300 mg QD plus RTV at 100 mg QD (RTV-boosted ATV [ATV/r]), or BMS-663068 at 600 mg BID plus ATV at 300 mg QD plus RTV at 100 mg QD. Compared with the results obtained by administration of BMS-663068 alone, coadministration of BMS-663068 with ATV/r increased the BMS-626529 maximum concentration in plasma (Cmax) and the area under the concentration-time curve in one dosing interval (AUCtau) by 68% and 54%, respectively. Similarly, coadministration of BMS-663068 with RTV increased the BMS-626529 Cmax and AUCtau by 53% and 45%, respectively. Compared with the results obtained by administration of ATV/r alone, ATV and RTV systemic exposures remained similar following coadministration of BMS-663068 with ATV/r. BMS-663068 was generally well tolerated, and there were no adverse events (AEs) leading to discontinuation, serious AEs, or deaths. Moderate increases in BMS-626529 systemic exposure were observed following coadministration of BMS-663068 with ATV/r or RTV. However, the addition of ATV to BMS-663068 plus RTV did not further increase BMS-626529 systemic exposure. ATV and RTV exposures remained similar following coadministration of BMS-663068 with either ATV/r or RTV. BMS-663068 was generally well tolerated alone or in combination with either RTV or ATV/r.

Science Autonomy for Rover Subsurface Exploration of the Atacama Desert

As planetary rovers expand their capabilities, traveling longer distances, deploying complex tools, and collecting voluminous scientific data, the requirements for intelligent guidance and control also grow. This, coupled with limited bandwidth and latencies, motivates onboard autonomy that ensures the quality of the science data return. Increasing quality of the data involves better sample selection, data validation, and data reduction. Robotic studies in Mars-like desert terrain have advanced autonomy for long distance exploration and seeded technologies for planetary rover missions. In these field experiments the remote science team uses a novel control strategy that intersperses preplanned activities with autonomous decision making. The robot performs automatic data collection, interpretation, and response at multiple spatial scales. Specific capabilities include instrument calibration, visual targeting of selected features, an onboard database of collected data, and a long range path planner that guides the robot using analysis of current surface and prior satellite data. Field experiments in the Atacama Desert of Chile over the past decade demonstrate these capabilities and illustrate current challenges and future directions.

Does Kisspeptin Belong to the Proposed RF-Amide Peptide Family?

Kisspeptin (KISS) plays a key role in regulating reproduction by binding to its receptor, GPR54. Because of the Arg-Phe (RF) sequence at its carboxyl terminus, KISS has been proposed to be a member of the RF-amide peptide family consisting of neuropeptide FF (NPFF), neuropeptide VF (NPVF), pyroglutamylated RF-amide peptide (QRFP), and prolactin-releasing hormone (PRLH). Evolutionary relationships of protein families can be determined through phylogenetic analysis. However, phylogenetic analysis among related peptide families often fails to provide sufficient information because only short mature peptide sequences from full preprohormone sequences are conserved. Considering the concept of the coevolution of peptide ligands and their cognate receptors, evolutionary relationships among related receptor families provide clues to explore relationships between their peptides. Although receptors for NPFF, NPVF, and QRFP are phylogenetically clustered together, receptors for PRLH and KISS are on different branches of the phylogenetic tree. In particular, KISS has been proposed to be a member of the KISS/galanin/spexin family based on synteny analysis and the phylogenetic relationship between their receptors. This article discusses the evolutionary history of the receptors for the proposed RF-amide peptide family and proposes that, from an evolutionary aspect, KISS has emerged from an ancestor, which is distinct from those of the other RF-amide peptides, and so should be classed separately.

Exploring the Dimensionality of a Brief School Readiness Screener for Use With Latino/a Children

This study contributed to the school readiness literature by examining the factor structure and reliability of a revised version of the Kindergarten Student Entrance Profile (KSEP). Teachers rated 579 Latino/a children during the first month of kindergarten using the KSEP. Factor analysis procedures (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]) supported a two-factor solution, social-emotional (SE; α = .88), cognitive (COG; α = .81), factor loadings > .51. These results provide evidence supporting the interpretation of KSEP ratings as distinct measures of Latino/a children’s SE and COG readiness at the time of kindergarten entry. Additional implications of the findings are also discussed.

Mcl1 regulates the terminal mitosis of neural precursor cells in the mammalian brain through p27Kip1

Cortical development requires the precise timing of neural precursor cell (NPC) terminal mitosis. Although cell cycle proteins regulate terminal mitosis, the factors that influence the cell cycle machinery are incompletely understood. Here we show in mice that myeloid cell leukemia 1 (Mcl1), an anti-apoptotic Bcl-2 protein required for the survival of NPCs, also regulates their terminal differentiation through the cell cycle regulator p27(Kip1). A BrdU-Ki67 cell profiling assay revealed that in utero electroporation of Mcl1 into NPCs in the embryonic neocortex increased NPC cell cycle exit (the leaving fraction). This was further supported by a decrease in proliferating NPCs (Pax6(+) radial glial cells and Tbr2(+) neural progenitors) and an increase in differentiating cells (Dcx(+) neuroblasts and Tbr1(+) neurons). Similarly, BrdU birth dating demonstrated that Mcl1 promotes premature NPC terminal mitosis giving rise to neurons of the deeper cortical layers, confirming their earlier birthdate. Changes in Mcl1 expression within NPCs caused concomitant changes in the levels of p27(Kip1) protein, a key regulator of NPC differentiation. Furthermore, in the absence of p27(Kip1), Mcl1 failed to induce NPC cell cycle exit, demonstrating that p27(Kip1) is required for Mcl1-mediated NPC terminal mitosis. In summary, we have identified a novel physiological role for anti-apoptotic Mcl1 in regulating NPC terminal differentiation.

Adjuvant whole brain radiation following resection of brain metastases

Brain metastasis is a common complication of systemic cancer and significant cause of suffering in oncology patients. Despite a plethora of available treatment modalities, the prognosis is poor with a median survival time of approximately one year. For patients with controlled systemic disease, good performance status, and a limited number of metastases, treatment typically entails surgical resection or radiosurgery, followed by whole brain radiotherapy (WBRT) to control microscopic disease. WBRT is known to control the progression of cancer in the brain, but it can also have toxic effects, particularly with regard to neurocognition. There is no consensus as to whether the benefit of WBRT outweighs the potential harm. We review the evidence related to the question of whether patients undergoing surgical resection of brain metastases should receive adjuvant WBRT.

Mcl-1 regulates the survival of adult neural precursor cells

Since the discovery of neural precursor cells (NPCs) in the adult mammalian brain, there has been a lot of excitement surrounding the potential for regeneration in the adult brain. For instance, many studies have shown that a significant number of NPCs will migrate to a site of injury and differentiate into all of the neural lineages. However, one of the main challenges affecting endogenous neural regeneration is that many of the NPCs that migrate to the injury site ultimately undergo apoptosis. Therefore, we sought to determine whether myeloid cell leukemia-1 (Mcl-1), an anti-apoptotic Bcl-2 protein, would promote the survival of adult NPCs by impeding apoptosis. To do this, we first confirmed that Mcl-1 is endogenously expressed within the adult NPC population using BrdU labeling assays. Next, we conditionally deleted Mcl-1 in adult NPCs using cre/lox technology and expressed Cre from the NPC-specific promoter Nestin. In vitro, cells that had Mcl-1 conditionally deleted had a 2-fold increase in apoptosis when compared to controls. In vivo, we used electroporation to conditionally delete Mcl-1 in adult NPCs and assessed apoptosis at 72h. after electroporation. As in our in vitro results, there was a 2-fold increase in apoptosis when Mcl-1 was conditionally deleted. Finally, we found that Mcl-1 over-expression reduced the endogenous rate of adult NPC apoptosis 2-fold in vitro. Collectively, these results demonstrate that Mcl-1 is crucial for the survival of adult NPCs and may be a promising target for future neural regeneration therapies.

Responses of susceptible and cyfluthrin-resistant broiler house populations of lesser mealworm (Coleoptera: Tenebrionidae) to gamma-cyhalothrin

Gamma-Cyhalothrin was proposed as an agent for management of lesser mealworm, Alphitobius diaperinus (Panzer) (Coleoptera: Tenebrionidae), in Australian broiler houses. From 2007 to 2009, baseline susceptibility of 20 Australian broiler farm beetle populations plus an insecticide-susceptible laboratory population was determined for gamma-cyhalothrin by using topical application. In addition, repeat testing and regression analyses of specific beetle populations to gamma-cyhalothrin showed that topical application was a very reliable and repeatable testing method. The 21 populations were tested with a cyfluthrin discriminating concentration (based on LC(99.9), 0.0007% [AI]) to identify possible cross-resistance. Across all populations, there was a significant linear relationship between the gamma-cyhalothrin LC50 value and mortality induced by the cyfluthrin LC(99.9). Full cyfluthrin baseline studies of seven populations indicated that gamma-cyhalothrin was twice as toxic as cyfluthrin, even against susceptible beetles and resistance ratios at the cyfluthrin LC50 and LC(99.9), varied considerably, with maxima of 56.6 and 83.6 respectively. Corresponding ratios for gamma-cyhalothrin for the same populations were 8.6 (LC50) and 7.9 (LC(99.9)). There were no significant correlations between beetle weights and gamma-cyhalothrin LC50 or LC(99.9), values. A discriminating concentration of 0.005% (AI) gamma-cyhalothrin was chosen to detect any future changes in susceptibility. Results of this study suggest that cyfluthrin can confer cross-resistance to gamma-cyhalothrin in A. diaperinus, but the magnitude of this resistance is unpredictable. Thus, widespread and frequent cyfluthrin use in broiler houses in eastern Australia, which has selected for cyfluthrin resistance, also has resulted in reduced susceptibility to gamma-cyhalothrin. Due to its higher relative toxicity, gamma-cyhalothrin is still potentially useful for management of lesser mealworm, but due to cross-resistance issues, adoption of gamma-cyhalothrin for broiler house use will require a cautious and judicious approach.

Use of high-resolution mass spectrometry to investigate a metabolite interference during liquid chromatography/tandem mass spectrometric quantification of a small molecule in toxicokinetic study samples

During routine liquid chromatography/tandem mass spectrometric (LC/MS/MS) bioanalysis of a small molecule analyte in rat serum samples from a toxicokinetic study, an unexpected interfering peak was observed in the extracted ion chromatogram of the internal standard. No interfering peaks were observed in the extracted ion chromatogram of the analyte. The dose-dependent peak area response and peak area response versus time profiles of the interfering peak suggested that it might have been related to a metabolite of the dosed compound. Further investigation using high-resolution mass spectrometry led to unequivocal identification of the interfering peak as an N-desmethyl metabolite of the parent analyte. High-resolution mass spectrometry (HRMS) was also used to demonstrate that the interfering response of the metabolite in the multiple reaction monitoring (MRM) channel of the internal standard was due to an isobaric relationship between the (13)C-isotope of the metabolite and the internal standard (i.e., common precursor ion mass), coupled with a metabolite product ion with identical mass to the product ion used in the MRM transition of the internal standard. These results emphasize (1) the need to carefully evaluate internal standard candidates with regard to potential interferences from metabolites during LC/MS/MS method development, validation and bioanalysis of small molecule analytes in biological matrices; (2) the value of HRMS as a tool to investigate unexpected interferences encountered during LC/MS/MS analysis of small molecules in biological matrices; and (3) the potential for interference regardless of choice of IS and therefore the importance of conducting assay robustness on incurred in vitro or in vivo study samples.

Photorefractive keratectomy for treatment of flap complications in laser in situ keratomileusis

PURPOSE

To present the results of photorefractive keratectomy (PRK) for treatment of laser in situ keratomileusis (LASIK) flap complications.

METHODS

Compilation of case reports through solicitation on Kera-net, an Internet surgery discussion site.

RESULTS

PRK was performed on 13 patients from 2 weeks to 6 months after LASIK flap complications. The technique used for the PRK varied. Epithelial removal was performed using no-touch phototherapeutic keratectomy (PTK) in six of the 13 patients and manual debridement in the other seven patients. A dilute solution of 20% ethanol was used to facilitate manual debridement in five of the seven patients. In two of these five patients, the epithelium was replaced as in laser-assisted subepithelial keratomileusis (LASEK). A solution of 0.02% mitomycin C was used after laser ablation to prevent haze formation in three patients. After an average 7 months of follow-up, uncorrected visual acuity was 20/20 in six patients, 20/25 in four patients, and 20/30 in two patients. The visual acuity in one patient was 20/80, purposely left undercorrected for monovision. Best spectacle-corrected visual acuity was 20/20 in 10 of 13 patients. Three patients were 20/25, losing one line of best spectacle-corrected visual acuity. On slit-lamp examination, at last follow-up appointment, stromal haze was graded from trace to none in all patients.

CONCLUSIONS

Photorefractive keratectomy is a safe and effective technique for treatment of patients with LASIK flap complications.

Identification of Thiothrix unzii in two distinct ecosystems

AIMS

Molecular procedures were used to identify Thiothrix spp. in biofilms from sulphide-rich waters in two distinct ecosystems.

METHODS AND RESULTS

Biofilm samples were obtained from two groundwater-fed systems in central and northern Florida, including an artesian spring and municipal water tank. The 16S rDNA in each sample was directly amplified by polymerase chain reaction.

CONCLUSIONS

Clonal libraries of biofilm 16S rDNA from each site contained rDNA sequences that were 99-99.5% similar to Thiothrix unzii.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report of T. unzii in a natural system. Biofilm formation by Thiothrix spp. can cause fouling in groundwater processing equipment, including municipal water-processing facilities, agricultural irrigation systems and spring water bottling plant filters. Biofouling can have severe economic and human health impacts as it will influence flow rates and related water treatments. Characterization of specific fouling bacteria and their molecular ecology is essential for their regulation.

Gastrointestinal stromal tumors, intramural leiomyomas, and leiomyosarcomas in the rectum and anus: a clinicopathologic, immunohistochemical, and molecular genetic study of 144 cases

Gastrointestinal stromal tumors (GISTs), the specific KIT-positive mesenchymal tumors of the gastrointestinal tract, have been sporadically reported in the rectum, but there are few clinicopathologic series. In this study we analyzed the clinicopathologic features of 133 anorectal GISTs, 3 intramural leiomyomas (LMs), and 8 leiomyosarcomas (LMSs) from the files of the Armed Forces Institute of Pathology and the Haartman Institute of the University of Helsinki. Ninety-six GISTs were documented as KIT-positive and three additional ones as CD34-positive. Thirty-four tumors were included by their histologic similarity to KIT- or CD34-positive cases. GIST-specific c-kit gene mutations, mostly in exon 11, were documented in 18 of 29 cases (62%). The GISTs occurred in adults with the age range of 17-90 years (median 60 years) with a significant male predominance (71%). The tumors ranged from small asymptomatic intramural nodules to large masses that bulged into pelvis causing pain, rectal bleeding, or obstruction. They were mostly highly cellular spindle cell tumors; four tumors had an epithelioid morphology. The tumors coexpressed CD34 and KIT and were rarely positive for smooth muscle actin or desmin and never for S-100 protein. Seventy percent of patients with tumors >5 cm with more than 5 mitoses/50 high power fields (HPF) (n = 31) died of disease, whereas only one tumor <2 cm with <5 mitoses/50 HPF (n = 21) recurred and none caused death. Long latency was common between primary operation and recurrences and metastases; either one occurred in 60 of 111 patients with follow-up (54%). Distant metastases were in the liver, bones, and lungs. Three benign actin- and desmin-positive and KIT-negative intramural LMs, similar to those seen in the esophagus, were identified. There were eight LMSs, six of which formed a polypoid intraluminal mass and were actin-positive and KIT-negative. Despite high mitotic counts, only one LMS patient died of disease. A great majority of rectal smooth muscle and stromal tumors are GISTs, which have a spectrum from minimal indolent tumors to overt sarcomas. Intramural LMs are exceptional, and true LMSs are rare, and similar to colonic ones, often present as intraluminal polypoid masses that appear to have a better prognosis than GISTs with similar mitotic rates.

Management development for mid-level managers: results of a demonstration project

This article examines a demonstration program to develop skills and experience for middle managers at a mid-sized urban hospital. Many of the middle managers selected for the program lacked formal management training or management experience prior to their present position. Elements of the program are summarized and first year accomplishments examined. Issues associated with continuation and replication of the program are discussed so that other hospitals may benefit from the lessons learned during development and implementation.

Reconciling the patient's right to confidentiality and the family's need to know

OBJECTIVE

Persistent difficulties have been identified in relation to confidentiality in mental health settings. The objective of the current investigation was to develop practical options enabling clinicians to negotiate this issue in a manner that in sensitive to families.

METHOD

A review of the international literature, the current legal and policy settings, and the needs of clients and their families was undertaken. Additional material was drawn from the authors' own practice and advocacy experience.

RESULTS

The literature and policies reviewed emphasised the importance of meaningful collaboration between clinicians and families. A close reading of the relevant legislation revealed possibilities for an interpretation of confidentiality that facilitates such collaboration. Options for negotiating the engagement phase which are consistent with meaningful collaboration were then developed.

CONCLUSION

Rather than assuming that confidentiality is an intransient problem, the authors conclude that dealing with the question of confidentiality sensitively presents clinicians with an opportunity to develop quality relationships with both clients and their families.

Clostridium difficile: epidemiology and clinical features

To determine the epidemiologic features of Clostridium difficile in Halifax, Nova Scotia, the authors studied two groups of hospitalized patients, one group of outpatients and a fourth group of 54 healthy subjects. The first group consisted of 29 patients with diarrhea, whose stool was found to contain C. difficile or its cytotoxin, or both. Twenty-two underwent sigmoidoscopic examinations; of these, 18 had abnormal colonic mucosa and 6 of the 18 had pseudomembranous colitis. In the second group of 127 patients on general medical wards, 22 (17%) carried C. difficile. Thirteen of the 22 had diarrhea, and 3 had pseudomembranous colitis. Clustering of patients with C. difficile was evident. In vitro production of toxin by isolates of C. difficile from these patients was more likely if antibiotics had been given. Only 1 (4.5%) of the 22 outpatients with various gastrointestinal disorders (group 3) and none of the 54 healthy subjects (group 4) carried C. difficile. The clinical spectrum of infection with C. difficile extended from asymptomatic patients to those with nonspecific colitis and pseudomembranous colitis.