Impact of disability-based discrimination in healthcare on parents of children with medical complexity

AIM

To qualitatively assess the impact of disability-based discrimination in healthcare on the parents of children with medical complexity (CMC).

METHOD

In this qualitative study, we conducted in-depth, semi-structured interviews with the parents of CMC. Data collection and analysis occurred iteratively; constant comparison methods were used to identify themes describing the impact of disability-based discrimination in pediatric healthcare on the parents of CMC.

RESULTS

Thirty participants from 15 US states were interviewed. Four themes were developed regarding the impact of disability-based discrimination in healthcare on parents. The themes were: (1) discrimination leads to a loss of trust in healthcare providers; (2) discrimination increases the burden of caregiving; (3) discrimination impacts parental well-being; and (4) racism and poverty-based discrimination amplifies disability-based discrimination.

INTERPRETATION

The experience of discrimination toward their child results in loss of trust and therapeutic relationship between provider and parent, causes increased burden to the family, and contributes to decreased parental well-being. These experiences are magnified in minoritized families and in families perceived to have a lower socioeconomic status based on insurance type.

Parents' Psychological and Decision-Making Outcomes following Prenatal Diagnosis with Complex Congenital Heart Defect: An Exploratory Study

Background. Parents with a fetus diagnosed with a complex congenital heart defect (CHD) are at high risk of negative psychological outcomes. Purpose. To explore whether parents' psychological and decision-making outcomes differed based on their treatment decision and fetus/neonate survival status. Methods. We prospectively enrolled parents with a fetus diagnosed with a complex, life-threatening CHD from September 2018 to December 2020. We tested whether parents' psychological and decision-making outcomes 3 months posttreatment differed by treatment choice and survival status. Results. Our sample included 23 parents (average Age[years]: 27 ± 4, range = 21-37). Most were women (n = 18), non-Hispanic White (n = 20), and married (n = 21). Most parents chose surgery (n = 16), with 11 children surviving to the time of the survey; remaining parents (n = 7) chose comfort-directed care. Parents who chose comfort-directed care reported higher distress (x ¯  = 1.51, s = 0.75 v. x ¯  = 0.74, s = 0.55; Mdifference = 0.77, 95% confidence interval [CI], 0.05-1.48) and perinatal grief (x ¯  = 91.86, s = 22.96 v. x ¯  = 63.38, s = 20.15; Mdifference = 27.18, 95% CI, 6.20-48.16) than parents who chose surgery, regardless of survival status. Parents who chose comfort-directed care reported higher depression (x ¯  = 1.64, s = 0.95 v. x ¯  = 0.65, s = 0.49; Mdifference = 0.99, 95% CI, 0.10-1.88) than parents whose child survived following surgery. Parents choosing comfort-directed care reported higher regret (x ¯  = 26.43, s = 8.02 v. x ¯  = 5.00, s = 7.07; Mdifference = 21.43, 95% CI, 11.59-31.27) and decisional conflict (x ¯  = 20.98, s = 10.00 v. x ¯  = 3.44, s = 4.74; Mdifference = 17.54, 95% CI; 7.75-27.34) than parents whose child had not survived following surgery. Parents whose child survived following surgery reported lower grief (Mdifference = -19.71; 95% CI, -39.41 to -0.01) than parents whose child had not. Conclusions. The results highlight the potential for interventions and care tailored to parents' treatment decisions and outcomes to support parental coping and well-being.

Highlights

Question: Do the psychological and decision-making outcomes of parents differ based on their treatment decision and survival outcome following prenatal diagnosis with complex CHD?Findings: In this exploratory study, parents who decided to pursue comfort-directed care after a prenatal diagnosis reported higher levels of psychological distress and grief as well as higher decisional conflict and regret than parents who decided to pursue surgery.Meaning: The findings from this exploratory study highlight potential differences in parents' psychological and decision-making outcomes following a diagnosis of complex CHD for their fetus, which appear to relate to the treatment approach and the treatment outcome and may require tailoring of psychological and decision support.

Perceived Disability-Based Discrimination in Health Care for Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Disability-based discrimination in health care can lead to low quality of care, limited access to care, and negative health consequences. Yet, little is known regarding the experiences of disability-based discrimination in health care for children with medical complexity and disability. An understanding of disability-based discrimination in pediatrics is needed to drive change and improve care.

METHODS

We conducted in-depth, semistructured interviews with caregivers of children with medical complexity and disability. Participants were purposefully recruited through national advocacy and research networks. Interviews were conducted via video conferencing, recorded, and transcribed. Data collection and analysis occurred iteratively. An inductive thematic analysis approach with constant comparison methods was used to identify themes that form a conceptual framework of disability-based discrimination in health care.

RESULTS

Thirty participants from diverse backgrounds were interviewed. Six themes emerged, forming a conceptual framework of disability-based discrimination in health care. Three themes described drivers of discrimination: lack of clinician knowledge, clinician apathy, and clinician assumptions. Three themes described manifestations of discrimination: limited accessibility to care, substandard care, and dehumanization.

CONCLUSIONS

Children with medical complexity may face disability-based discrimination in health care. Themes describing the drivers and manifestations of discrimination offer a conceptual framework of disability-based discrimination. Understanding the drivers and acknowledging perceived manifestations can provide insight into improving patient care for children with disabilities.

Parents' quality of life and health after treatment decision for a fetus with severe congenital heart defect

PURPOSE

This exploratory study examines differences in parents' quality of life by treatment decision and the child's survival outcome in the context of life-threatening congenital heart disease (CHD).

DESIGN AND METHODS

Parents of a fetus or neonate diagnosed with severe CHD enrolled in the observational control group of a clinical trial (NCT04437069) and completed quality of life (i.e., contact with clinicians, social support, partner relationship, state of mind), mental and physical health survey measures. Comparisons were made between parents who chose comfort-directed care or surgery and between those whose child did and did not survive.

RESULTS

Parents who chose surgery and their child did not survive reported the most contact with their clinicians. Parents who chose comfort-directed care reported lower social support than parents who chose surgery and their child did not survive as well as poorer state of mind compared to parents who chose surgery.

CONCLUSIONS

Some aspects of parents' quality of life differed based on their treatment decision. Parents who choose comfort-directed care are vulnerable to some negative outcomes.

PRACTICE IMPLICATIONS

Decision support tools and bereavement resources to assist parents with making and coping with a complex treatment decision is important for clinical care.

Are people with diabetes getting the support they need? Deficits between support desired and received from family and friends relates to poorer health

OBJECTIVE

To determine the mismatch of desired support versus support received and to evaluate the impact of these mismatches on health outcomes of people with diabetes.

METHODS

This cross-sectional study is a secondary data analysis of medical record and survey data of participants with Type 1 and Type 2 diabetes from a diabetes care and education program. Biophysical metrics included HbA1c, body mass index, systolic blood pressure, diastolic blood pressure, triglycerides, and high- and low-density lipoproteins. Psychosocial and self-care survey outcomes included diabetes distress, diabetes self-care, and diabetes self-efficacy. Support mismatch was a difference score (support desired-support received). Descriptive statistics were computed for demographics, clinical characteristics, and primary outcomes. Multiple linear regressions were computed.

RESULTS

The percentage of participants experiencing support mismatch (surplus/deficits) across six domains was: 15%/27% (foot care), 22%/24% (take medicine), 24%/23% (test blood sugar), 21%/29% (physical activity), and 18%/34% (follow meal plan). Greater support deficits were associated with higher triglyceride levels, increased diabetes distress, and lower diabetes self-efficacy.

CONCLUSIONS

Findings indicate that greater support deficits can be a risk factor for some poorer physical and psychosocial health outcomes.

PRACTICE IMPLICATIONS

Interventions to facilitate functional supportive behaviors are an avenue for future research and clinical practice.

Who Engages and Why It Matters?

While the use and benefits of serious games in health care are increasingly recognized, the impact of individuals' game engagement remains understudied, limiting the potential for impact. This pilot study aims to describe game engagement and its associations with learning outcomes, sociodemographics, and health factors in women with advanced cancer receiving a 12-week self-advocacy serious game intervention. Game engagement was collected from study tablets and weekly self-reported surveys. Participants' game engagement was overall high but with large amounts of variation and did not differ by their sociodemographics and health factors. Participants with lower baseline symptom severity were more likely to repeat game scenarios, and those who engaged in all scenarios had higher connected strength post-intervention. Knowing what prevents patients with advanced cancer from engaging in the serious game enlightens ways to refine the gamified interventions. Future research is suggested to evaluate patients' engagement to deepen understanding of its impacts on learning outcomes.

Two Specialists, Two Recommendations: Discordance Between Urologists' & Radiation Oncologists' Prostate Cancer Treatment Recommendations

OBJECTIVE

To examine the treatment recommendation patterns among urologists and radiation oncologists, the level of concordance or discordance between physician recommendations, and the association between physician recommendations and the treatment that patients received.

METHOD

The study was a secondary analysis of data from a randomized clinical trial conducted November 2010 to April 2014 (NCT02053389). Eligible participants were patients from the trial who saw both specialists. The primary outcome was physician recommendations that were scored using an adapted version of the validated PhyReCS coding system. Secondary outcomes included concordance between physician recommendations and the treatment patients received.

RESULTS

Participants were 108 patients (Mean age 61.9 years; range 43-82; 87% non-Hispanic White). Urologists were more likely to recommend surgery (79% of recommendations) and radiation oncologists were more likely to recommend radiation (68% of recommendations). Recommendations from the urologists and radiation oncologists were concordant for only 33 patients (30.6%). Most patients received a treatment that both physicians recommended (59%); however, 35% received a treatment that only one of their physicians recommended. When discordant, urologists more often recommended surgery and radiation oncologists recommended radiation and surgery as equally appropriate options.

CONCLUSION

Urologists and radiation oncologists are more likely to differ than agree in their treatment recommendations for the same patients with clinically localized prostate cancer and more likely to favor treatment aligned with their specialty. Additional studies are needed to better understand how patients make decisions after meeting with two different specialists to inform the development of best practices within oncology clinics.

Study protocol for a randomised clinical trial of a decision aid and values clarification method for parents of a fetus or neonate diagnosed with a life-threatening congenital heart defect

INTRODUCTION

Parents who receive the diagnosis of a life-threatening, complex heart defect in their fetus or neonate face a difficult choice between pursuing termination (for fetal diagnoses), palliative care or complex surgical interventions. Shared decision making (SDM) is recommended in clinical contexts where there is clinical equipoise. SDM can be facilitated by decision aids. The International Patient Decision Aids Standards collaboration recommends the inclusion of values clarification methods (VCMs), yet little evidence exists concerning the incremental impact of VCMs on patient or surrogate decision making. This protocol describes a randomised clinical trial to evaluate the effect of a decision aid (with and without a VCM) on parental mental health and decision making within a clinical encounter.

METHODS AND ANALYSIS

Parents who have a fetus or neonate diagnosed with one of six complex congenital heart defects at a single tertiary centre will be recruited. Data collection for the prospective observational control group was conducted September 2018 to December 2020 (N=35) and data collection for two intervention groups is ongoing (began October 2020). At least 100 participants will be randomised 1:1 to two intervention groups (decision aid only vs decision aid with VCM). For the intervention groups, data will be collected at four time points: (1) at diagnosis, (2) postreceipt of decision aid, (3) postdecision and (4) 3 months postdecision. Data collection for the control group was the same, except they did not receive a survey at time 2. Linear mixed effects models will assess differences between study arms in distress (primary outcome), grief and decision quality (secondary outcomes) at 3-month post-treatment decision.

ETHICS AND DISSEMINATION

This study was approved by the University of Utah Institutional Review Board. Study findings have and will continue to be presented at national conferences and within scientific research journals.

TRIAL REGISTRATION NUMBER

NCT04437069 (Pre-results).

Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

Provider insights on shared decision-making with families affected by CHD

BACKGROUND AND OBJECTIVES

Little data exist on provider perspectives about counselling and shared decision-making for complex CHD, ways to support and improve the process, and barriers to effective communication. The goal of this qualitative study was to determine providers' perspectives regarding factors that are integral to shared decision-making with parents faced with complex CHD in their fetus or newborn; and barriers and facilitators to engaging in effective shared decision-making.

METHODS

We conducted semi-structured interviews with providers from different areas of practice who care for fetuses and/or children with CHD. Providers were recruited from four geographically diverse centres. Interviews were recorded, transcribed, and analysed for key themes using an open coding process with a grounded theory approach.

RESULTS

Interviews were conducted with 31 providers; paediatric cardiologists (n = 7) were the largest group represented, followed by nurses (n = 6) and palliative care providers (n = 5). Key barriers to communication with parents that providers identified included variability among providers themselves, factors that influenced parental comprehension or understanding, discrepant expectations, circumstantial barriers, and trust/relationship with providers. When discussing informational needs of parents, providers focused on comprehensive short- and long-term outcomes, quality of life, and breadth and depth that aligned with parental goals and needs. In discussing resources to support shared decision-making, providers emphasised the need for comprehensive, up-to-date information that was accessible to parents of varying situations and backgrounds.

CONCLUSIONS

Provider perspectives on decision-making with families with CHD highlighted key communication issues, informational priorities, and components of decision support that can enhance shared decision-making.

Preparing Patients with Early Stage Prostate Cancer to Participate in Clinical Appointments Using a Shared Decision Making Training Video

Background

Rates of shared decision making (SDM) are relatively low in early stage prostate cancer decisions, as patients’ values are not well integrated into a preference-sensitive treatment decision. The study objectives were to develop a SDM training video, measure usability and satisfaction, and determine the effect of the intervention on preparing patients to participate in clinical appointments.

Methods

A randomized controlled trial was conducted to compare a plain-language decision aid (DA) to the DA plus a patient SDM training video. Patients with early stage prostate cancer completed survey measures at baseline and after reviewing the intervention materials. Survey items assessed patients’ knowledge, beliefs related to SDM, and perceived readiness/intention to participate in their upcoming clinical appointment.

Results

Of those randomized to the DA + SDM video group, most participants (91%) watched the video and 93% would recommend the video to others. Participants in the DA + SDM video group, compared to the DA-only group, reported an increased desire to participate in the decision (mean = 3.65 v. 3.39, P < 0.001), less decision urgency (mean = 2.82 v. 3.39, P < 0.001), and improved self-efficacy for communicating with physicians (mean = 4.69 v. 4.50, P = 0.05). These participants also reported increased intentions to seek a referral from a radiation oncologist (73% v. 51%, P = 0.004), to take notes (mean = 3.23 v. 2.86, P = 0.004), and to record their upcoming appointments (mean = 1.79 v. 1.43, P = 0.008).

Conclusions

A novel SDM training video was accepted by patients and changed several measures associated with SDM. This may be a scalable, cost-effective way to prepare patients with early stage prostate cancer to participate in their clinical appointments.

Experiences of a Health System's Faculty, Staff, and Trainees' Career Development, Work Culture, and Childcare Needs During the COVID-19 Pandemic

IMPORTANCE

In March 2020, US public buildings (including schools) were shut down because of the COVID-19 pandemic, and 42% of US workers resumed their employment duties from home. Some shutdowns remain in place, yet the extent of the needs of US working parents is largely unknown.

OBJECTIVE

To identify and address the career development, work culture, and childcare needs of faculty, staff, and trainees at an academic medical center during a pandemic.

DESIGN, SETTING, AND PARTICIPANTS

For this survey study, between August 5 and August 20, 2020, a Qualtrics survey was emailed to all faculty, staff, and trainees at University of Utah Health, an academic health care system that includes multiple hospitals, community clinics, and specialty centers. Participants included 27 700 University of Utah Health faculty, staff, and trainees who received a survey invitation. Data analysis was performed from August to November 2020.

MAIN OUTCOMES AND MEASURES

Primary outcomes included experiences of COVID-19 and their associations with career development, work culture, and childcare needs.

RESULTS

A total of 5030 participants completed the entire survey (mean [SD] age, 40 [12] years); 3738 (75%) were women; 4306 (86%) were White or European American; 561 (11%) were Latino or Latina (of any race), Black or African American, American Indian, Alaska Native, and Native Hawaiian or Pacific Islander; and 301 (6%) were Asian or Asian American. Of the participants, 2545 (51%) reported having clinical responsibilities, 2412 (48%) had at least 1 child aged 18 years or younger, 3316 (66%) were staff, 791 (16%) were faculty, and 640 (13%) were trainees. Nearly one-half of parents reported that parenting (1148 participants [49%]) and managing virtual education for children (1171 participants [50%]) were stressors. Across all participants, 1061 (21%) considered leaving the workforce, and 1505 (30%) considered reducing hours. Four hundred forty-nine faculty (55%) and 397 trainees (60%) perceived decreased productivity, and 2334 participants (47%) were worried about COVID-19 impacting their career development, with 421 trainees (64%) being highly concerned.

CONCLUSIONS AND RELEVANCE

In this survey of 5030 faculty, staff, and trainees of a US health system, many participants with caregiving responsibilities, particularly women, faculty, trainees, and (in a subset of cases) those from racial/ethnic groups that underrepresented in medicine, considered leaving the workforce or reducing hours and were worried about their career development related to the pandemic. It is imperative that medical centers support their employees and trainees during this challenging time.

A systematic review of intensive outpatient care programs for high-need, high-cost patients

Five percent of the patient population accounts for 50% of U.S. healthcare expenditures. High-need, high-cost patients are medically complex for numerous reasons, often including behavioral health needs. Intensive outpatient care programs (IOCPs) are emerging, innovative clinics which provide patient-centered care leveraging multidisciplinary teams. The overarching goals of IOCPs are to reduce emergency department visits and hospitalizations (and related costs), and improve care continuity and patient outcomes. The purpose of this review was to examine the effectiveness of IOCPs on multiple outcomes to inform clinical care. A systematic search of the literature was conducted to identify articles. Six studies were included that varied in rigor of research design, analysis, and measurement of outcomes. Most studies reported results on healthcare utilization (n = 4) and costs (n = 3), with fewer reporting results on patient-reported and health-related outcomes (n = 2). Overall, there were decreasing trends in emergency department visits and hospitalizations. However, results on healthcare utilization varied based on time of follow-up, with shorter follow-up times yielding more significant results. Two of the three studies that evaluated costs found significant reductions associated with IOCPs, and the third was cost-neutral. Two studies reported improvements in patient-reported outcomes (e.g., satisfaction, depression, and anxiety). Overall, these programs reported positive impacts on healthcare utilization and costs; however, few studies evaluated patient characteristics and behaviors (e.g., engagement in care) which may serve as key mechanisms of program effectiveness. Future research should examine patient characteristics, behaviors, and clinic engagement metrics to inform clinical practice.

Don't Risk It. Older Adults Perceive Fewer Future Opportunities and Avoid Social Risk Taking

Drawing from life-span psychology, we conducted two studies to test perceptions of time left in the future as an underlying mechanism for age differences in self-reported social risk taking. Study 1 included 120 younger (25-35 years) and 119 older (60-91 years) community-dwelling adults. Study 2 included 439 participants (18-85 years) mostly recruited from Amazon Mechanical Turk. In both studies, older age was associated with rating a lower likelihood of social risk taking (e.g., speaking about an unpopular issue) and perceiving the future as holding fewer future opportunities and being more limited. Perceptions of fewer future opportunities with aging statistically mediated age-related declines in social risk taking. Findings highlight motivational factors as key for understanding age differences in social risk taking. Implications of age differences in social risk taking on factors related to well-being, such as social support and strain, are discussed.

Living longer with help from others: Seeking advice lowers mortality risk

Associations between self-sufficiency and advice seeking with mortality risk were examined to assess the long-term implications of individualistic and interpersonally oriented strategies. Wave 1 participants from the National Survey of Midlife Development in the United States ( N = 6116, 25–75 years, Mage = 46.38 years) completed questionnaires assessing demographics, self-sufficiency, advice seeking, social support, and health. Cox proportional hazard models indicated that each standard deviation increase in seeking advice was associated with an 11 percent decreased hazard of dying 20 years later. Self-sufficiency was not significantly related. Future research should examine contexts in which interpersonal strategies are adaptive, as seeking advice from others promotes longevity.

Retinal ganglion cell response to axotomy and nerve growth factor antiserum treatment in the regenerating visual system of the goldfish (Carassius auratus): an in vivo and in vitro analysis

In vitro nerve growth factor (NGF) antiserum (anti-NGF) treatment was found to significantly depress retinal ganglion cell neurite outgrowth in goldfish explant culture. Goldfish retinas, conditioned by a 14-day prior optic nerve crush, demonstrated a significant dose response inhibition of neurite outgrowth if incubated with various concentrations of the antiserum (i.e. concentrations from full strength to 1:100) before explantation for tissue culture. NGF added to the incubation medium containing antiserum partially eliminated the inhibition of neurite outgrowth during the first 4 days of explant culture. Antiserum treatment at the higher concentrations (i.e. full strength and 1:1.5 dilution) caused a cessation of nerve growth from explants between culture days 3 and 4. However, controls at this time still exhibited vigorous neurite outgrowth. In vivo treatment with anti-NGF administered intraocularly at 7 days after optic nerve crush (i.e. 7 DPA) was found to significantly reduce the size and complexity of retinal ganglion cell nucleoli when analyzed morphometrically at 14 DPA. No other cell parameters measured (i.e. cell size, nuclear size, cell/nuclear ratios and mitochondrial, Golgi and RER densities) were found to be affected by the single antiserum treatment.

Retinal ganglion cell response to nerve growth factor in the regenerating and intact visual system of the goldfish (Carassius auratus)

Light and electron microscopic observations indicated that 1 microgram NGF injected into the goldfish eye at the time of optic nerve crush initiated significant retinal ganglion cell body, nuclear and nucleolar hypertrophy when compared to controls at 7 days post-axotomy (7 DPA). In addition, the ultrastructural morphometric values for NGF-treated retinal ganglion cells at 7 DPA were not significantly different from the normal hypertrophy found in 14 DPA controls. Therefore, it appears that NGF treatment caused an acceleration of the normal cell body response to axotomy by about a week. These responses were found to be specific for the NGF molecule and dose-dependent over a 100-1000 ng NGF concentration range. In contrast to the lesioned state, NGF treatment had no significant influence on intact, non-lesioned retinal ganglion cell morphology as measured by morphometric analysis. These results strongly indicate that the responsiveness of the goldfish retinal ganglion cells to NGF is initiated by the axotomy. Eyes treated with NGF in the same manner that elicited the dramatic retinal ganglion cell morphological changes at 7 DPA could also be shown to significantly increase neurite outgrowth from retinal explants cultured at the same post-operative period (i.e. 7 DPA).

Retinal ganglion cell response to axotomy and nerve growth factor antiserum in the regenerating visual system of the newt (Notophthalmus viridescens): an ultrastructural morphometric analysis

One 3.0 mg dose of the nerve growth factor antiserum (anti-NGF) injected into the vitreous chamber of the eye at the time of optic nerve transection elicits significant changes in the normal newt (Notophthalmus viridescens) retinal ganglion cell body response to axotomy at 7 and 14 days postaxotomy (DPA). Light microscopic observations indicate that anti-NGF treatment significantly reduces the per cent of retinal ganglion cells demonstrating nuclear chromatin reactivity (ie., homogeneous to a more heterogeneous state) from 33.36 +/- 3.02 to 22.82 +/- 2.98%. In addition, the per cent of retinal ganglion cells demonstrating prominent nucleoli is dramatically decreased from 32.08 +/- 1.64 to 18.20 +/- 1.79% at 7 DPA. It is also important to note that the number of prominent nucleoli in the 7 DPA group is reduced to such an extent by anti-NGF treatment that the value is not significantly different from that of intact controls. Intact controls will routinely exhibit approximately half the number of prominent nucleoli that are normal for the untreated 7 DPA group. A definite dose-response relationship can be shown to exist between the per cent of nuclear reactive ganglion cells demonstrating prominent nucleoli and various anti-NGF concentrations at 14 DPA. There does not appear to be a dose-response relationship between various anti-NGF concentrations and the per cent of retinal ganglion cells demonstrating nuclear reactivity at 14 DPA. However, the degree of nuclear chromatin reactivity appears to be less at the higher anti-NGF concentrations (ie., greater than or equal to 3.0 mg/eye) at 14 DPA. Electron microscopic morphometric analysis reveals that anti-NGF treatment significantly reduces the cell perikaryal area at 7 and 14 DPA while the nuclear area remains unchanged. Therefore, there is a significant decrease in the cytoplasmic/nuclear ratios at both 7 and 14 DPA in response to anti-NGF treatment which appears more pronounced by 14 DPA. Anti-NGF treatment also significantly reduces the mitochondrial and nucleolar densities, as well as the nucleolar areas of cells at 7 and 14 DPA. There are no significant changes in Golgi field densities in response to anti-NGF treatment.

Retinal ganglion cell response to axotomy and nerve growth factor in the regenerating visual system of the newt (Notophthalmus viridescens): an ultrastructural morphometric analysis

Nerve growth factor (NGF) treatment, given as a single 200 BU intraocular injection at the time of optic nerve transection, was found to significantly accelerate the retinal ganglion cell response to axotomy in the newt (Notophthalmus viridescens). In the control series the per cent of neurons in the retinal ganglion layer demonstrating nuclear reactivity (i.e. chromatin changes) reaches a peak by 14 days post axotomy (14 DPA), plateaus through 21 DPA and falls thereafter, returning to control levels by 90 DPA. NGF treatment is shown to significantly accelerate the entrance of responding retinal ganglion cells into the reactive nuclear phase between 1 and 7 DPA, and by 7 DPA nuclear reactivity has reached a peak, in contrast to 14 DPA for control values. Consequently, NGF treatment causes retinal ganglion cells to be in the nuclear reactive state a week longer than controls but reactivity diminishes after 21 DPA as in controls. Electron microscopic morphometric analysis further substantiates these observations by demonstrating that NGF treatment can elicit certain cellular organelle changes a week earlier (i.e. at 7 DPA) than they would normally occur (i.e. at 14 DPA) in response to axotomy. In addition to eliciting cellular hypertrophy at 7 DPA, NGF treatment significantly increases Golgi field densities in the neuronal perikaryal cytoplasm as well as a doubling of the number of nucleoli per nucleus and stimulating a significant increase in nucleolar cross-sectional areas. A dose-response relationship exists between the per cent of retinal ganglion cells demonstrating nuclear reactivity at 7 DPA and various NGF concentrations which compares favorably with the dose response study involving the number of regenerating axons per nerve cross-section at 14 DPA. Studies to determine if the NGF mediated responses were a specific effect elicited by this protein molecule or whether they are also produced by other peptides which share some properties in common with NGF demonstrate that only NGF is capable of eliciting these responses.