Current Trends and Future Directions in Urban Social Prescribing

PURPOSE OF REVIEW

Social prescribing (SP) is defined as a non-medical community referral program to support well-being and health. This review explores the current evidence about the effectiveness of SP.

RECENT FINDINGS

This review examined existing SP models that have been or are being tested to connect people to these opportunities through direct and indirect referral schemes. The review identified a fifth model that facilitates a group-based approach used to mental well-being and resilience. While the development of SP largely originates from the UK, the global interest in SP has increased, with over 31 nations reporting elements of SP. The main goal of SP is to better integrate care between the traditional medical setting and resources available in the community and voluntary sectors. Although this review found widespread optimism around SP, there remain concerns about its effectiveness and demands for high-quality evaluations to strengthen the evidence base for SP.

SMG1, a nonsense-mediated mRNA decay (NMD) regulator, as a candidate therapeutic target in multiple myeloma

Early data suggested that CC-115, a clinical molecule, already known to inhibit the mammalian target of rapamycin kinase (TORK) and DNA-dependent protein kinase (DNA-PK) may have additional targets beyond TORK and DNA-PK. Therefore, we aimed to identify such target(s) and investigate a potential therapeutic applicability. Functional profiling of 141 cancer cell lines revealed inhibition of kinase suppressor of morphogenesis in genitalia 1 (SMG1), a key regulator of the RNA degradation mechanism nonsense-mediated mRNA decay (NMD), as an additional target of CC-115. CC-115 treatment showed a dose-dependent increase of SMG1-mediated NMD transcripts. A subset of cell lines, including multiple myeloma (MM) cell lines sensitive to the endoplasmic reticulum stress-inducing compound thapsigargin, were highly susceptible to SMG1 inhibition. CC-115 caused the induction of UPR transcripts and cell death by mitochondrial apoptosis, requiring the presence of BAX/BAK and caspase activity. Superior antitumor activity of CC-115 over TORK inhibitors in primary human MM cells and three xenograft mouse models appeared to be via inhibition of SMG1. Our data support further development of SMG1 inhibitors as possible therapeutics in MM.

Spatial Analysis and Lead-Risk Assessment of Philadelphia, USA

Childhood lead poisoning is an issue that continues to plague major U.S. cities. Despite efforts by the Philadelphia Department of Public Health to curtail systemic childhood lead poisoning, children continue to be identified with elevated blood lead levels. The persistence of elevated blood lead levels in children is concerning because lead poisoning has been linked to decreases in academic achievement and IQ, with associated repercussions for entire communities. This paper reports the results of an analysis of the spatial distribution of houses with lead paint (i.e., pre-1978), demolitions, and occurrence of historic smelters, in West and North Philadelphia, relative to elevated blood lead level data, to determine which lead sources act as primary lead-risk factors. The presence of lead paint in homes and the number of demolitions of older properties were found to have the highest correlations to elevated blood lead levels for children in Philadelphia. Using lead-risk factors including lead paint, housing code violations, demolitions, and owner-occupied housing units, a lead-risk assessment was performed at the census tract level to identify future soil sampling sites and high-risk neighborhoods in Philadelphia. These sites of high risk for lead exposure, and in particular the census tracts 175 and 172, should be prioritized for lead poisoning prevention initiatives.

Ethical considerations referred to in child health research published in leading nursing journals: 2015-2019

BACKGROUND

Child health research comprises complex ethical considerations. Understanding the extent to which the ethical process is reported in child health research is needed to improve reporting.

AIMS

To identify reportage of ethical considerations in child health research in leading nursing and paediatric journals.

METHODS

All child health research published between 2015 and 2019 in 10 leading nursing journals and two paediatric journals were retrieved and critically appraised for the reportage of informed consent and ethical approval.

RESULTS

Eight hundred and fifty-one child health research papers were included. Although 544 (79.9%) of the prospective studies mentioned informed consent, only 300 (55.2%) reported that written informed consent was obtained from the participants. Overall, 748 (87.9%) of child health research papers noted obtaining research ethics committee approval. Articles that mentioned financial support were significantly more likely to report informed consent and ethical approval than unfunded studies (all P < 0.001). Prospective studies showed higher rates of reportage of ethical approval compared to retrospective studies (P = 0.027). Rates of child consent (assent) obtained in different age groups of children ranged from 29.6% to 66.3%.

CONCLUSION

Despite improvements in the reportage of ethical review and approval processes in child health research, consistent and transparent reports are still lacking.

What is the evidence for the impact of gardens and gardening on health and well-being: a scoping review and evidence-based logic model to guide healthcare strategy decision making on the use of gardening approaches as a social prescription

OBJECTIVE

To systematically identify and describe studies that have evaluated the impact of gardens and gardening on health and well-being. A secondary objective was to use this evidence to build evidence-based logic models to guide health strategy decision making about gardens and gardening as a non-medical, social prescription.

DESIGN

Scoping review of the impact of gardens and gardening on health and well-being. Gardens include private spaces and those open to the public or part of hospitals, care homes, hospices or third sector organisations.

DATA SOURCES

A range of biomedical and health management journals was searched including Medline, CINAHL, Psychinfo, Web of Knowledge, ASSIA, Cochrane, Joanna Briggs, Greenfile, Environment Complete and a number of indicative websites were searched to locate context-specific data and grey literature. We searched from 1990 to November 2019.

ELIGIBILITY CRITERIA

We included research studies (including systematic reviews) that assessed the effect, value or impact of any garden that met the gardening definition.

DATA EXTRACTION AND SYNTHESIS

Three reviewers jointly screened 50 records by titles and abstracts to ensure calibration. Each record title was screened independently by 2 out of 3 members of the project team and each abstract was screened by 1 member of a team of 3. Random checks on abstract and full-text screening were conducted by a fourth member of the team and any discrepancies were resolved through double-checking and discussion.

RESULTS

From the 8896 papers located, a total of 77* studies was included. Over 35 validated health, well-being and functional biometric outcome measures were reported. Interventions ranged from viewing gardens, taking part in gardening or undertaking therapeutic activities. The findings demonstrated links between gardens and improved mental well-being, increased physical activity and a reduction in social isolation enabling the development of 2 logic models.

CONCLUSIONS

Gardens and gardening can improve the health and well-being for people with a range of health and social needs. The benefits of gardens and gardening could be used as a 'social prescription' globally, for people with long-term conditions (LTCs). Our logic models provide an evidence-based illustration that can guide health strategy decision making about the referral of people with LTCs to socially prescribed, non-medical interventions involving gardens and gardening.

Social prescribing: a 'natural' community-based solution

This paper discusses social prescribing as part of the wider NHS England universal personalised care model, and it describes how community nurses can engage with social prescribing systems to support community resilience. A case study based on the example of gardening, as a nature-based social prescription provided by the RHS Bridgewater Wellbeing Garden, is provided to illustrate the scope, reach and impact of non-medical, salutogenic approaches for community practitioners. The authors argue that social prescribing and, in particular, nature-based solutions, such as gardening, can be used as a non-medical asset-based approach by all health professionals working in the community as a way to promote health and wellbeing. They consider how the negative impact of social distancing resulting from COVID-19 restrictions could be diluted through collaboration between a holistic, social prescribing system and community staff. The paper presents a unique perspective on how community nurses can collaborate with link workers through social prescribing to help combat social isolation and anxiety and support resilience.

Reporting of ethical approval and informed consent in clinical research published in leading nursing journals: a retrospective observational study

Background

Ethical considerations play a prominent role in the protection of human subjects in clinical research. To date the disclosure of ethical protection in clinical research published in the international nursing journals has not been explored. Our research objective was to investigate the reporting of ethical approval and informed consent in clinical research published in leading international nursing journals.

Methods

This is a retrospective observational study. All clinical research published in the five leading international nursing journals from the SCI Journal Citation Reports between 2015 and 2017 were retrieved to evaluate for evidence of ethical review.

Results

A total of 2041 citations have been identified from the contents of all the five leading nursing journals that were published between 2015 and 2017. Out of these, 1284 clinical studies have been included and text relating to ethical review has been extracted. From these, most of prospective clinical studies (87.5%) discussed informed consent. Only half of those (52.9%) reported that written informed consent had been obtained; few (3.6%) reported oral consent, and few (6.8%) used other methods such as online consent or completion and return of data collection (such as surveys) to denote assent. Notably, 36.2% of those did not describe the method used to obtain informed consent and merely described that “consent was obtained from participants or participants agreed to join in the research”. Furthermore, whilst most of clinical studies (93.7%) mentioned ethical approval; 92.5% of those stated the name of ethical committee and interestingly, only 37.1% of those mentioned the ethical approval reference. The rates of reporting ethical approval were different between different study type, country, and whether financial support was received (all P < 0.05).

Conclusion

The reporting of ethics in leading international nursing journals demonstrates progress, but improvement of the transparency and the standard of ethical reporting in nursing clinical research is required.

Social prescribing in cardiology: rediscovering the nature within us

Personalised care is integral to the delivery of the NHS England Long Term Plan. Enabling choice and supporting patients to make decisions predicated on ‘what matters to them’, rather than ‘what is the matter with them’ is a fundamental part of the NHS vision. Social prescribing uses non-medical, asset-based, salutogenic approaches to promote this personalised paradigm, and places the patient central to decision making. This article discusses how personalised care can be used to help people with cardiovascular disease using socially prescribed ‘nature-based’ interventions to support the pre-habilitation and rehabilitation of patients with cardiovascular disease. The concept of personalised care outlined and the significance of salutogenic principles as a complementary approach to the pathogenic model is discussed. The authors argue that this seemingly novel approach to using nature-based interventions can help promote wellbeing for people with cardiovascular disease as part of the wider personalised agenda.

Commissural communication allows mouse intergeniculate leaflet and ventral lateral geniculate neurons to encode interocular differences in irradiance

Key points

Unlike other visual thalamic regions, the intergeniculate leaflet and ventral lateral geniculate nucleus (IGL/vLGN) possess extensive reciprocal commissural connections, the functions of which are unknown.

Using electrophysiological approaches, it is shown that commissural projecting IGL/vLGN cells are primarily activated by light increments to the contralateral eye while cells receiving commissural input typically exhibit antagonistic binocular responses.

Across antagonistic cells, the nature of the commissural input (excitatory or inhibitory) corresponds to the presence of ipsilateral ON or OFF visual responses and in both cases antagonistic responses disappear following inactivation of the contralateral thalamus.

The steady state firing rates of antagonistic cells uniquely encode interocular differences in irradiance.

There is a pivotal role for IGL/vLGN commissural signalling in generating new sensory properties that are potentially useful for the proposed contributions of these nuclei to visuomotor/vestibular and circadian control.

Abstract

The intergeniculate leaflet and ventral lateral geniculate nucleus (IGL/vLGN) are portions of the visual thalamus implicated in circadian and visuomotor/vestibular control. A defining feature of IGL/vLGN organisation is the presence of extensive reciprocal commissural connections, the functions of which are at present unknown. Here we use a combination of multielectrode recording, electrical microstimulation, thalamic inactivation and a range of visual stimuli in mice to address this deficit. Our data indicate that, like most IGL/vLGN cells, those that project commissurally primarily convey contralateral ON visual signals while most IGL/vLGN neurons that receive this input exhibit antagonistic binocular responses (i.e. excitatory responses driven by one eye and inhibitory responses driven by the other), enabling them to encode interocular differences in irradiance. We also confirm that this property derives from commissural input since, following inactivation of the contralateral visual thalamus, these cells instead display monocular contralateral‐driven ON responses. Our data thereby reveal a fundamental role for commissural signalling in generating new visual response properties at the level of the visual thalamus.

Unlike other visual thalamic regions, the intergeniculate leaflet and ventral lateral geniculate nucleus (IGL/vLGN) possess extensive reciprocal commissural connections, the functions of which are unknown.

Using electrophysiological approaches, it is shown that commissural projecting IGL/vLGN cells are primarily activated by light increments to the contralateral eye while cells receiving commissural input typically exhibit antagonistic binocular responses.

Across antagonistic cells, the nature of the commissural input (excitatory or inhibitory) corresponds to the presence of ipsilateral ON or OFF visual responses and in both cases antagonistic responses disappear following inactivation of the contralateral thalamus.

The steady state firing rates of antagonistic cells uniquely encode interocular differences in irradiance.

There is a pivotal role for IGL/vLGN commissural signalling in generating new sensory properties that are potentially useful for the proposed contributions of these nuclei to visuomotor/vestibular and circadian control.

Growing spaces: an evaluation of the mental health recovery programme using mixed methods

BACKGROUND

Therapeutic horticulture is a nature-based method that includes a range of green activities, such as gardening, to promote wellbeing. It is believed that therapeutic horticulture provides a person-centred approach that can reduce social isolation for people with mental health problems.

AIMS

The aim of the project was to evaluate the impact of a mental health recovery programme that used therapeutic horticulture as an intervention to reduce social inclusion and improve engagement for people with mental health problems.

METHODS

A mixed-methods approach was used and data from four semi-structured focus group interviews, 11 exit interviews and 20 'recovery star' datasets were collected from September 2015 to October 2017. Qualitative data from the interviews were thematically analysed, and quantitative data based on a recovery star outcomes tool were analysed using descriptive statistics to demonstrate trends and progression. The findings were then triangulated to provide a rich picture of the impact of the mental health recovery programme.

RESULTS

The recovery star data indicated that participants were working towards self-reliance. Qualitative data from the exit interview and semi-structured focus groups found similar results. The triangulated findings highlight that the mental health recovery programme enabled participant integration into the community through providing a space to grow and build self-confidence while re-engaging with society. The results suggest that using therapeutic horticulture as an intervention within the mental health recovery programme can support people with mental health problems to re-engage socially. Nature-based activities could be used within the 'social prescribing' movement to encourage partnership working between the NHS and voluntary sector organisations which can complement existing mental health services.

CONCLUSION

The use of therapeutic horticulture as an intervention within a mental health recovery programme can support people with mental health problems to re-engage with the community and is integral to the rehabilitation process. The mental health recovery programme should be promoted within the social prescribing movement as an evidence-based opportunity to support people in the community.

Combined experience of six independent laboratories attempting to create an Ewing sarcoma mouse model

Ewing sarcoma (ES) involves a tumor-specific chromosomal translocation that produces the EWS-FLI1 protein, which is required for the growth of ES cells both in vitro and in vivo. However, an EWS-FLI1-driven transgenic mouse model is not currently available. Here, we present data from six independent laboratories seeking an alternative approach to express EWS-FLI1 in different murine tissues. We used the Runx2, Col1a2.3, Col1a3.6, Prx1, CAG, Nse, NEFL, Dermo1, P0, Sox9 and Osterix promoters to target EWS-FLI1 or Cre expression. Additional approaches included the induction of an endogenous chromosomal translocation, in utero knock-in, and the injection of Cre-expressing adenovirus to induce EWS-FLI1 expression locally in multiple lineages. Most models resulted in embryonic lethality or developmental defects. EWS-FLI1-induced apoptosis, promoter leakiness, the lack of potential cofactors, and the difficulty of expressing EWS-FLI1 in specific sites were considered the primary reasons for the failed attempts to create a transgenic mouse model of ES.

Reporting of ethical considerations in clinical trials in Chinese nursing journals

BACKGROUND

It is acknowledged that publishers now require all primary research papers to demonstrate that they have obtained ethical approval for their research.

OBJECTIVES

To assess the rate of reporting of ethical approval in clinical trials in core nursing journals in mainland China.

RESEARCH DESIGN

A retrospective observational study.

PARTICIPANTS

All clinical trials published in all of the 12 core nursing periodicals from 2016 edition China Science and Technology Journal Citation Report (core version) between 2013 and 2016 were retrieved by hand to explicate rate of reporting ethical approval and informed consent.

ETHICAL CONSIDERATIONS

The study did not require approval from the research ethics committee as it did not involve human subjects or records.

RESULTS

In total, 40,278 papers were published in 12 nursing periodicals between 2013 and 2016. Out of these, 9488 (23.6%) focused on clinical trials. Informed consent obtained from patients or the legally authorized representative was reported in 51.8% of clinical trials. Notably, only 27.4% of clinical trials reported that they had obtained written consent. Furthermore, 25.9% of clinical trials described ethical approval; however, the rate of reporting informed consent and ethical approval in these 12 nursing journals in China during 4 years from 2013 to 2016 improved markedly, with 38.1%, 44.0%, 59.0% and 66.6%, respectively (p < 0.001), and 17.6%, 21.9%, 28.6% and 35.8%, respectively (p < 0.001). In addition, both reporting informed consent and reporting written informed consent had a positive significant correlation with the reporting ethical approval (p < 0.05 or < 0.01).

CONCLUSION

Chinese scientific nursing journals have improved the rate of reporting informed consent and ethical approval in clinical trials during the last 4 years. However, it should be noted that nearly half of clinical trials still did not report either ethical approval or whether informed consent was obtained. Efforts from editors, researchers, sponsors and authors are needed to ensure the transparency of ethical scrutiny and adherence to ethical guidelines in publishing clinical trials in Chinese nursing journals.

Person-centred discharge education following coronary artery bypass graft: A critical review

AIMS AND OBJECTIVES

To examine the extent that individualised education helps reduce depression and anxiety and improves self-care for people who have undergone coronary artery bypass graft surgery.

BACKGROUND

Individualised discharge planning is increasingly important following cardiac surgery due to recurrent admissions as well as the issue of anxiety and depression, often due to lack of preparation. The hospital to home transition is fundamental in the recovery process. Individualised education and person-centred care ensure that patients' educational needs are met. This empowers patients, increasing self-efficacy or confidence, resulting in autonomy, a smoother discharge process and avoiding postdischarge problems and rehospitalisation.

DESIGN

A critical review of published peer-reviewed literature was conducted.

METHODS

Electronic databases searched included MEDLINE, CINAHL, the Cochrane Library and PsychInfo 2009-2015.

RESULTS

Eight articles were identified for review, and a Critical Appraisal Skills Programme framework was used to determine the quality of the papers, all of the papers focussed on coronary artery bypass graft. The designs were typically experimental or quasi-experimental with two reviews.

CONCLUSION

A greater understanding of the patients' needs allows tailored education to be provided, which promotes self-care management. This level of patient empowerment increases confidence and ultimately minimise anxiety and depression. Despite the varying teaching and learning methods associated with individualised education, patient-centred education has the potential to assist cardiac nurses in adequately preparing patients for discharge following their coronary artery bypass graft.

RELEVANCE TO CLINICAL PRACTICE

Development of individualised education programmes is crucial in preparing patients for discharge. The reduction in readmission to hospital has a significant effect on already stretched resources, and the reduction in postoperative complications during the recovery period linked with depression and anxiety will have a positive effect on the individuals' ability to self-care, health and well-being.

Pain from the inside: understanding the theoretical underpinning of person-centered care delivered by pain teams

Chronic back pain is globally acknowledged as a common reason why people seek help from health professionals. The complexity of persistent chronic pain can undermine the person's self-esteem and present a number of challenges to an individual's ability to manage their pain. Multi-professional person-centered care is advocated as a key strategy to support people with chronic back pain. However, the impact of these approaches on restoring the person's independence is unclear, and little is known about whether and how person-centered approaches restore autonomy and influence the person's ability to manage their pain. The aim of this grounded theory study was to generate understanding about person-centered care from the perspectives of people with chronic back pain and the multi-professional teams who cared for them. Semi-structured interviews were used to collect data from 17 people with chronic back pain over one year. A constant comparative analytical approach identified five key categories: the skeptical professional, validation, becoming a person, regaining control, and restoring faith. These categories formed the "conditional partnership" as a theory to explain person-centered care, which related to the way in which the partnership developed between the patients and teams. The findings suggest that person-centered care was influenced by the participants' need to be believed and the relationship developed with health care providers. Crucially, these findings suggest that legitimizing the pain experience through person-centered approaches to care can empower people with chronic back pain to regain control of their lives and their pain.

"Let's stick together"--a grounded theory exploration of interprofessional working used to provide person centered chronic back pain services

Chronic back pain is a global phenomenon and a common reason why patients seek help from health professionals. Person-centered interprofessional working is acknowledged as the main strategy for chronic back pain management; however, the complexity of chronic pain can present significant challenges for teams. Although methods used by interprofessional teams to collaborate have been previously explored, how they work together to deliver person-centered chronic back pain care has received limited attention. The aim of this study was to explore person-centered care from the perspectives of people with chronic back pain and the interprofessional teams who cared for them. A grounded theory methodology was used to capture the interprofessional team's perspectives of person-centered working. A purposive sample of four chronic back pain management teams participated in semi-structured face-to-face interviews and focus groups. Data were thematically analyzed using a constant comparative method. Three categories emerged, collective efficacy, negotiated space and team maturity, which illustrated the attributes of interprofessional teams that influenced person-centered working. The findings suggest that collective efficacy matures over time within a negotiated coalesced space and re-enforces the need for teams to stick together to ensure effective person-centered care.

Being an effective nurse consultant in the English National Health Service: what does it take? A study of consultants specializing in safeguarding

AIMS

This study established key attributes and perceived strengths, weaknesses, opportunities and threats (SWOT) of nurse consultants specializing in safeguarding children.

BACKGROUND

The nurse consultant role in England spans four domains--clinical, leadership, education and research--and was intended to enable senior nurses to remain in clinical practice.

METHOD

ata identifying the time spent by the nurse consultants in the four domains was collated and a thematic content analysis of the SWOT of the role was ascertained from semi-structured interviews with nurse consultants (n = 4) and stakeholders (n = 6).

RESULTS

Strengths and opportunities in clinical (consultancy), leadership and educational functions were identified but some weaknesses and threats in terms of nurse consultant's contributions to research were also identified. The role was neither wholly strategic nor clinical. Role ambiguity meant that they were not always valued by managers, making the role potentially expendable.

CONCLUSIONS

Nurse consultants are pivotal within health-care organizations because they span clinical practice and leadership enabling them to support managers in strategic planning, commissioning and implementation of policy.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse consultants can support strategic practice development and influence quality and effectiveness service-wide. To succeed they must be understood, supported and nurtured by managers.

Education needs for integrated care: a literature review

AIM

This paper reports a systematic review to identify the education needs of the workforce within primary care to promote the effective delivery of integrated health and social care services.

BACKGROUND

The need for different professionals to work more closely dominates global health policy. The drive to develop a workforce prepared for the future is crucial to the success of integrated services. However, some have argued that nurses are ill-equipped to meet the challenges of integrated service provision. The ability to work interprofessionally is an important skill which needs to be developed to support integrated working.

METHODS

Structured searches were undertaken on organizational websites and the Caredata, CINAHL, Cochrane Library, MEDLINE, Sociofile databases between December 2002 and April 2004 to identify policy documents and primary research studies. The robustness of identified research studies were appraised using recognized appraisal tools.

FINDINGS

Six themes were identified which indicate essential elements needed for integrated care. The need for effective communication between professional groups within teams and an emphasis on role awareness are central to the success of integrated services. In addition, education about the importance of partnership working and the need for professionals to develop skills in relation to practice development and leadership through professional and personal development is needed to support integrated working.

CONCLUSION

Education which embeds essential attributes to integrated working is needed to advance nursing practice for interprofessional working. Further research exploring this and its impact on integrated provision is essential to ensure that evidence-based services are provided. The reinforcement of partnerships between higher education institutions and health and social care organizations should ensure that the workforce is educated to manage continuous change in service delivery. Innovative ways of teaching and learning which promote inter-professional working need to be explored.

The quantity of naturally processed peptides stably bound by HLA-A*0201 is significantly reduced in the absence of tapasin

Tapasin plays a critical role in promoting peptide binding by major histocompatibility complex (MHC) class I molecules in the endoplasmic reticulum. In its absence, cell surface expression of most allotypes is significantly reduced. Two exceptions are HLA-A*0201 and HLA-B*2705. In this study, the repertoire of peptides bound endogenously by these allotypes in the absence of tapasin was examined and stability of the HLA class I/peptide complexes assessed. Similar quantities of peptides were recovered from B*2705 complexes expressed in the absence and presence of tapasin and the composition of the peptide pools were not radically different. However, the stability of B*2705 molecules expressed at the surface of tapasin-deficient cells was found to be reduced which suggests there are subtle changes to the peptide repertoire. The impact of the absence of tapasin was more dramatic for A*0201. Although equivalent levels of cell surface A*0201 are expressed in the presence and absence of tapasin, very little A*0201 glycoprotein was recovered from tapasin-deficient cells suggesting the complexes readily dissociate. Consistent with reduced stability, A*0201 complexes were found to be rapidly lost from the surface of tapasin-deficient cells. Analysis of the small quantity of endogenously bound peptides recovered from A*0201 expressed in the absence of tapasin revealed a complex mixture typical of A*0201 molecules expressed in normal cells. Therefore these molecules are unable to exploit the alternative supply of TAP-independent A*0201-binding peptides present in the endoplasmic reticulum. Loading of A*0201 with peptides from both TAP-dependent and TAP-independent sources is significantly compromised without tapasin.

The quality of hospital discharge: a survey of discharge arrangements for the over-65s

A three-phase study comprising semi-structured interviews with patients and/or their carers, follow-up postal questionnaires, and a postal survey of the views of professionals involved in the discharge of participating patients was conducted to assess the quality of arrangements for patients over 65 years of age, discharged from hospitals in Chester and Ellesmere Port in the United Kingdom. A large majority of patients (80%) felt they had been adequately consulted about arrangements for their discharge, but less than 2% of health and social care professionals considered all discharges satisfactory. This apparent disparity between patient and professional views may be explained by low levels of expectation among patients in this aspect of their care and their reluctance to express views which they fear may compromise future care. Continuing difficulties with interprofessional communication and liaison suggest that further attention to discharge management is required if improvements are to be effected.

Evaluation of 201Tl SPET myocardial perfusion imaging in the detection of coronary artery disease after orthotopic heart transplantation

Accelerated coronary artery disease is a common complication following orthotopic cardiac transplantation. The relationship between acute rejection and accelerated coronary artery disease remains unclear. While thallium-201 (201Tl) imaging has been advocated in the diagnosis of post-transplant coronary arteriopathy, other investigators have found little role for this technique in the evaluation of such patients. We undertook a retrospective review of 13 stress/rest (10 exercise, 2 dobutamine, 1 dipyridamole) and 2 rest/rest 201Tl single photon emission tomographic (SPET) imaging studies performed in seven patients post-cardiac transplantation (mean duration post transplantation = 2.5 years). Four of these patients had serial studies with an average interval between studies of 8.3 months (range 3-14 months). Coronary angiography was performed within 12 months of each 201Tl study (mean = 4.2 months). Using the coronary angiographic diagnostic criterion of > or = 50% stenosis in one or more vessels, one or more fixed or reversible segmental defects were found on 201Tl imaging with a sensitivity of 78% and specificity of 33%. When the angiographic criterion of > 70% stenosis in one or more vessels was used the sensitivity increased to 100%, and where reversible segments were diagnostic the sensitivity was 67% and the specificity range from 42 to 58%. Although based on a small sample of patients, these results suggest that use of appropriate test methods and interpretive criteria may improve the utility of 201Tl SPET myocardial imaging in the diagnosis of coronary artery disease in cardiac transplant patients. Limited specificity may reflect associated pathological processes in these patients, including rejection, oedema and focal inflammation.

Substituent effects in the catalytic hydrogenation of steroidal Δ4- and Δ5-3,3-ethyleneketals

A number of isomeric Δ4- and Δ5-3,3-ethylenedioxy steroids were prepared to study the substituent effects on the relative amounts of 5α and 5β ketals formed during catalytic hydrogenation. Hydrogenation of Δ5-3,3-ethylenedioxy steroids with palladium on charcoal as catalyst yielded 5α steroids exclusively. The Δ4-3,3-ethylenedioxy compounds yielded mixtures of 5α and 5β ketals in which slightly more 5β product was formed than was obtained by catalytic hydrogenation of the equivalent Δ4-3-oxo steroid. Substituents in the C-11 position of the Δ4 ketals diminish the amount of 5β steroid formed during hydrogenation.