Methodology and development of a high-protein plant-based cheese alternative

Animal-based food products, such as meat and dairy, contribute the most to greenhouse gas emissions in the food sector. This, coupled with the demonstrably worsening climate crisis, means that there needs to be a shift to more sustainable alternatives in the form of plant-based foods. In particular, the plant-based cheese alternative industry is relevant, as the products lack critical functionalities and nutrition compared to their dairy-based counterparts. Waxy starch, plant-protein isolate, and coconut oil were combined to create a novel high-protein (18% w/w) plant-based cheese alternative. We determined that when using native waxy starch, we can enhance its existing viscoelastic properties by modulating gelatinization through adding plant protein and fat. Texture profile analysis indicated that the cheese analogues could reach hardness levels of 15-90N, which allowed samples to be tailored to a broader range of dairy products. We determined that plant proteins and fat can behave as particulate fillers, enhance network strength, and create strategic junction points during starch retrogradation. The degree of melt and stretch of the high-protein plant-based analogues were 2-3 times greater than those observed for commercial plant-based cheese alternatives and significantly more similar to dairy cheese. The rheological melting kinetics saw that the high-protein plant-based cheese alternative displayed more viscous properties with increasing temperature. Tan δ (G"/G') at 80 °C was used as an indicator for sample meltability where, values ≥ 1 indicate better melt and more viscous systems. The high-protein plant-based cheese alternative reached Tan δ values upwards to 0.7, whereas commercial plant-based cheese alternatives only reached tan δ values around 0.1. Ultimately, the novel high-protein plant-based cheese alternative demonstrates the use of simple ingredients to form complex food systems.

Quantifying neutralising antibody responses against SARS-CoV-2 in dried blood spots (DBS) and paired sera

The ongoing SARS-CoV-2 pandemic was initially managed by non-pharmaceutical interventions such as diagnostic testing, isolation of positive cases, physical distancing and lockdowns. The advent of vaccines has provided crucial protection against SARS-CoV-2. Neutralising antibody (nAb) responses are a key correlate of protection, and therefore measuring nAb responses is essential for monitoring vaccine efficacy. Fingerstick dried blood spots (DBS) are ideal for use in large-scale sero-surveillance because they are inexpensive, offer the option of self-collection and can be transported and stored at ambient temperatures. Such advantages also make DBS appealing to use in resource-limited settings and in potential future pandemics. In this study, nAb responses in sera, venous blood and fingerstick blood stored on filter paper were measured. Samples were collected from SARS-CoV-2 acutely infected individuals, SARS-CoV-2 convalescent individuals and SARS-CoV-2 vaccinated individuals. Good agreement was observed between the nAb responses measured in eluted DBS and paired sera. Stability of nAb responses was also observed in sera stored on filter paper at room temperature for 28 days. Overall, this study provides support for the use of filter paper as a viable sample collection method to study nAb responses.

Protocol for a definitive randomised controlled trial and economic evaluation of a community-based rehabilitation programme following hip fracture: fracture in the elderly multidisciplinary rehabilitation-phase III (FEMuR III)

INTRODUCTION

Proximal femoral (hip) fracture is common, serious and costly. Rehabilitation may improve functional recovery but evidence of effectiveness and cost-effectiveness are lacking. An enhanced rehabilitation intervention was previously developed and a feasibility study tested the methods used for this randomised controlled trial (RCT). The objectives are to compare the effectiveness and cost-effectiveness of the enhanced rehabilitation programme following surgical repair of proximal femoral fracture in older people compared with usual care.

METHODS AND ANALYSIS

Protocol for phase III, parallel-group, two-armed, superiority, pragmatic RCT with 1:1 allocation ratio; allocation sequence by minimisation programme with a built-in random element; secure web-based allocation concealment. The two treatments will be usual care (control) and usual care plus an enhanced rehabilitation programme (intervention). The enhanced rehabilitation will consist of a patient-held information workbook, goal setting diary and up to six additional therapy sessions. Outcome assessment and statistical analysis will be performed blind; patient and carer participants will be unblinded. Outcomes will be measured at baseline, 17 and 52 weeks' follow-up. Primary outcome at 52 weeks will be the Nottingham Extended Activities of Daily Living scale. Secondary outcomes will measure anxiety and depression, health utility, cognitive status, hip pain intensity, falls self-efficacy, fear of falling, grip strength and physical function. Carer strain, anxiety and depression will be measured in carers. All safety events will be recorded, and serious adverse events will be assessed to determine whether they are related to the intervention and expected. Concurrent economic evaluation will be a cost-utility analysis from a health service and personal social care perspective. An embedded process evaluation will determine the mechanisms and processes that explain the implementation and impacts of the enhanced rehabilitation programme.

ETHICS AND DISSEMINATION

National Health Service research ethics approval reference 18/NE/0300. Results will be disseminated by peer-reviewed publication.

TRIAL REGISTRATION NUMBER

ISRCTN28376407; Pre-results registered on 23 November 2018.

Accuracy of first-trimester ultrasound in diagnosis of tubal ectopic pregnancy in the absence of an obvious extrauterine embryo: systematic review and meta-analysis

OBJECTIVES

To determine the accuracy of ultrasound in the diagnosis of a tubal ectopic pregnancy in the absence of an obvious extrauterine embryo.

METHODS

This was a systematic review conducted in accordance with the PRISMA statement and registered with PROSPERO. We searched MEDLINE, EMBASE and The Cochrane Library for relevant citations from database inception to July 2014. Studies were selected in a two-stage process and their data extracted by two reviewers. Accuracy measures were calculated for each ultrasound sign, i.e. empty uterus, pseudosac, adnexal mass and free fluid in the pouch of Douglas, alone and in various combinations. Individual study estimates were plotted in summary receiver-operating characteristics curves and forest plots for examination of heterogeneity. The quality of included studies was assessed.

RESULTS

Thirty-one studies including 5858 women were selected from 19,959 citations. Following meta-analysis, an empty uterus on ultrasound was found to predict an ectopic pregnancy with a sensitivity of 81.1% (95% CI, 42.1-96.2%) and specificity of 79.5% (95% CI, 68.9-87.1%). The corresponding performance of the pseudosac, adnexal mass and free fluid were: 5.5% (95% CI, 3.3-9.0%) and 94.2% (95% CI, 75.9-98.8%); 63.5% (95% CI, 48.5-76.3%) and 91.4% (95% CI, 83.6-95.7%); and 47.2% (95% CI, 33.2-61.7%) and 92.3% (95% CI, 85.6-96.0%), respectively.

CONCLUSION

Visualization of an empty uterus, adnexal mass, free fluid or a pseudosac has poor sensitivity for the diagnosis of a tubal pregnancy when an obvious extrauterine embryo is absent, but it has good specificity. We can therefore infer that ultrasound is more useful for 'ruling in' a tubal pregnancy than 'ruling out' one. However, the findings were limited by the poor quality of some included studies and heterogeneity in the index test and reference standard.

Accuracy of first-trimester ultrasound in diagnosis of intrauterine pregnancy prior to visualization of the yolk sac: a systematic review and meta-analysis

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound in predicting the location of an intrauterine pregnancy before visualization of the yolk sac is possible.

METHODS

This was a systematic review conducted in accordance with the PRISMA statement and registered with PROSPERO. We searched MEDLINE, EMBASE and The Cochrane Library for relevant citations. Studies were selected in a two-stage process and their data extracted by two reviewers. Accuracy measures were calculated for each ultrasound sign, i.e. gestational sac, double decidual sac sign, intradecidual sign, chorionic rim sign and yolk sac. Individual study estimates were plotted in summary receiver-operating characteristics curves and forest plots for examination of heterogeneity. The quality of included studies was assessed.

RESULTS

Seventeen studies including 2564 women were selected from 19 959 potential papers. Following meta-analysis, the presence of a gestational sac on ultrasound examination was found to predict an intrauterine pregnancy with a sensitivity of 52.8% (95% CI, 38.2-66.9%) and specificity of 97.6% (95% CI, 94.3-99.0%). The corresponding performance of the double decidual sac sign, intradecidual sign, chorionic rim sign and yolk sac were: 81.8% (95% CI, 68.1-90.4%) and 97.3% (95% CI, 76.1-99.8%); 66.1% (95% CI, 58.9-72.8%) and 100% (95% CI, 91.0-100%); 79.9% (95% CI, 73.0-85.7%) and 97.1% (95% CI, 89.9-99.6%); and 42.2% (95% CI, 27.7-57.9%) and 100% (95% CI, 54.1-100%), respectively.

CONCLUSION

Visualization of a gestational sac, double decidual sac sign, intradecidual sign or chorionic rim sign increases the probability of an intrauterine pregnancy but is not as accurate for diagnosis as the detection of the yolk sac. However, the findings were limited by the small number and poor quality of the studies included and heterogeneity in the index test and reference standard.

Coupled adaptive complex networks

Adaptive networks, which combine topological evolution of the network with dynamics on the network, are ubiquitous across disciplines. Examples include technical distribution networks such as road networks and the internet, natural and biological networks, and social science networks. These networks often interact with or depend upon other networks, resulting in coupled adaptive networks. In this paper we study susceptible-infected-susceptible (SIS) epidemic dynamics on coupled adaptive networks, where susceptible nodes are able to avoid contact with infected nodes by rewiring their intranetwork connections. However, infected nodes can pass the disease through internetwork connections, which do not change with time: The dependencies between the coupled networks remain constant. We develop an analytical formalism for these systems and validate it using extensive numerical simulation. We find that stability is increased by increasing the number of internetwork links, in the sense that the range of parameters over which both endemic and healthy states coexist (both states are reachable depending on the initial conditions) becomes smaller. Finally, we find a new stable state that does not appear in the case of a single adaptive network but only in the case of weakly coupled networks, in which the infection is endemic in one network but neither becomes endemic nor dies out in the other. Instead, it persists only at the nodes that are coupled to nodes in the other network through internetwork links. We speculate on the implications of these findings.

Effect of resource constraints on intersimilar coupled networks

Most real-world networks do not live in isolation but are often coupled together within a larger system. Recent studies have shown that intersimilarity between coupled networks increases the connectivity of the overall system. However, unlike connected nodes in a single network, coupled nodes often share resources, like time, energy, and memory, which can impede flow processes through contention when intersimilarly coupled. We study a model of a constrained susceptible-infected-recovered (SIR) process on a system consisting of two random networks sharing the same set of nodes, where nodes are limited to interact with (and therefore infect) a maximum number of neighbors at each epidemic time step. We obtain that, in agreement with previous studies, when no limit exists (regular SIR model), positively correlated (intersimilar) coupling results in a lower epidemic threshold than negatively correlated (interdissimilar) coupling. However, in the case of the constrained SIR model, the obtained epidemic threshold is lower with negatively correlated coupling. The latter finding differentiates our work from previous studies and provides another step towards revealing the qualitative differences between single and coupled networks.

Intention of parents to have male children vaccinated with the human papillomavirus vaccine

BACKGROUND

Although already approved for use in males in some jurisdictions, there is little information about parental attitudes toward having their sons receive the human papillomavirus (HPV) vaccine. The goal of this study was to ascertain parental intentions to vaccinate their sons with an HPV vaccine and to determine factors that predict this intention.

METHODS

Parents of children aged 8-18 years were recruited from across Canada through random digit dialling. Participants were asked to respond to a series of questions in the context of a Grade 6 (age 11/12 years old), publicly funded school-based HPV vaccine programme, including their intention to vaccinate their sons with the HPV vaccine. Parents were also asked about a series of characteristics thought to predict intention to vaccinate as well as demographic characteristics. Backwards logistic regression was conducted to calculate adjusted odds ratios (AOR) to identify the factors that are predictive of parents' intention to vaccinate their son(s) against HPV.

RESULTS

Of the 1381 respondents with male children, 67.8% (95% CI 65.3 to 70.3) intend to vaccinate their son(s) against HPV. Parents who had positive attitudes toward vaccines and the HPV vaccine in particular (AOR 41.5, 95% CI 9.5 to 181.7), parents who were influenced by subjective norms (AOR 7.8, 95% CI 5.8 to 10.5), parents who felt that the vaccine had limited influence on sexual behaviour (AOR 2.3, 95% CI 1.6 to 3.3) and parents who were aware of HPV (AOR 1.4, 95% CI 1.1 to 2.0) were significantly more likely to report an intention to vaccinate boys against HPV. In contrast, residence in British Columbia compared to Atlantic Canada (AOR 0.4, 95% CI 0.2 to 0.8) and higher education (AOR 0.7, 95% CI 0.5 to 0.9) were negatively associated with intention to vaccinate. Parents who reported an intention to vaccinate their daughters were also highly likely to report an intention to vaccinate their sons (kappa = 0.9, p<0.001).

DISCUSSION

The majority of Canadian parents would intend to have their male children receive the HPV vaccine in the context of a publicly funded school-based immunisation programme. Overall attitudes toward vaccine, recommendations from health professionals and impact of the vaccine on sexual practices are important predictors of intention to have a male child receive the HPV vaccine.

Exercise in patients with advanced non-small cell lung cancer (NSCLC): Compliance and population characteristics of patients referred to the McGill Cancer Nutrition-Rehabilitation Program (CNRP)

8631

Background: Few studies focus on exercise in advanced NSCLC. We evaluated compliance with exercise prescription in stages 3/4 NSCLC. Methods: Patients (pts) referred to the CNRP, a multidisciplinary clinic, for weight/functional loss were evaluated for participation in a supervised exercise program. Compliance with exercise was scored as 0 (refused/home exercise), 1 (<6 sessions in 2 mo), and 2 (≥ 6 sessions in 2 mo). Gender, age, PS, stage, CRP, weight loss, and quality of life [Edmonton Syptom Assessment Scale (ESAS)] were assessed by univariate and multivariate analyses. Survival from the time of exercise prescription was calculated using the Kaplan-Meier method and compared using the log-rank test. Results: 168 pts were referred to the CNRP from April 2002 to September 2005. 92/168 (54%) were prescribed exercise. Of the 76 remaining pts, 3 (4%) refused, and 6 (8%) were on an exercise trial. Others were excluded due to bone metastasis/severe pain (50 pts, 66%), cardiovascular instability (13 pts, 17%) or poor PS (4 pts, 5%). Of the 92 who were prescribed exercise, the compliance score was 0 in 38 (41%), 1 in 37 (40%) and 2 in 17(19%). There were no significant differences in gender, age, PS, stage, ESAS, and weight loss at the time of referral among the three compliance groups. Most pts (15/17) with a compliance score of 2 were referred prior to or during initial treatment, whereas those with compliance scores of 0 and 1 were referred later in the course of treatment. Compliance with exercise correlated with survival (p<0.001). The median survival from time of exercise prescription for pts with a compliance score of 2 was 22 mo (95%CI 13.4,30.2); compared with 5 mo (95%CI 3.7,5.6) and 7 mo (95%CI 2.5,11.5) for those with compliance scores of 0 and 1 respectively. No serious adverse events occurred. Conclusion: A select group of advanced NSCLC pts can exercise safely at a moderate-high level. Those referred earlier tended to be more compliant, and their longer survival may reflect a lead time bias. Clinical trials are needed to evaluate efficacy of exercise in newly diagnosed NSCLC.

No significant financial relationships to disclose.

Prognostic value of baseline inflammatory markers in inoperable non-small cell lung cancer (NSCLC)

17035

Background: Markers of chronic inflammation are not commonly included in standard NSCLC staging, which remains anatomically based. Several studies have reported that an increased C-reactive protein (CRP), a marker of chronic inflammation, presages short survival for NSCLC patients (pts). A cohort of 68 pts with advanced NSCLC (stages 3A, 3B and 4) was studied in order to evaluate the prognostic value for survival of various pretreatment inflammatory parameters. Methods: The following factors were collected at the time of diagnosis prior to treatment: sex, age, stage, performance status, CRP, LDH, hemoglobin, platelets, albumin, and white blood cells (WBC). Statistical evaluation employed univariate and multivariate analyses. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. Results: Median survival for the entire cohort was ten months (mo) (95% CI 7, 15). Those with stages 3A, 3B (18 pts) had a survival of 11 mo (95% CI 6,15), whereas those with 3B (effusion)/4 (50 pts) had a survival of 8 mo (95% CI 3,13). Univariate analysis identified CRP and WBC as the only significant prognostic factors for survival (p < 0.01). Multivariate analysis also demonstrated that CRP (p = 0.005), and WBC (p=0.009) displayed independent correlation with prognosis. CRP and WBC were then combined into a prognostic index (PI) ranging from 0–2. The total score demonstrated a better stratification value for survival. Both parameters were normal [WBC ≤ 11, CRP ≤ 10] (PI 0) in 26 (38%) pts; one parameter was elevated (PI 1) in 27 (40%) pts; and both parameters were elevated (PI 2) in 15 (22%) others. Pts with PI 0 had a median survival of 14 mo (95% CI 12, 21); those with PI 1 had a median survival of 7 mo (95% CI 5, 10); and pts with PI 2 had a median survival of 5 mo (95% CI 3, 7). Conclusions: Systemic inflammatory markers predicted survival in our cohort with NSCLC. These data need to be confirmed in a larger validation study. Studies on staging systems that include inflammatory markers are indicated. Clinical trials linking anti-inflammatory therapies with chemotherapy should be prioritized.

No significant financial relationships to disclose.

Epidemiology and outcome of bacterial meningitis in Canadian children: 1998-1999

BACKGROUND

The introduction of Hemophilus influenzae type b (Hib) conjugate vaccine as part of the routine childhood vaccination schedule in Canada has resulted in a dramatic reduction in the cases of Hib meningitis. We describe the epidemiology and outcome of bacterial meningitis in Canadian children six years after the introduction of Hib conjugate vaccine and prior to the introduction of the conjugate Streptococcus pneumoniae vaccine.

METHODS

A retrospective chart review from January 1998 to December 1999 of children with meningitis identified at eight Canadian tertiary care children's hospitals belonging to the PICNIC network.

RESULTS

Bacterial meningitis was documented in 104 (11%) of 970 children presenting with meningitis. The most common isolated organisms were: Streptococcus pneumoniae (54%), group B streptococci (13%), and Neisseria meningitidis (11%). The mean age was 2.2 +/- 3.5 yr. Forty seven percent of the children required admission to Intensive Care Unit (ICU), and 19% required artificial ventilation. Sequelae were documented among 32 children (31%) prior to discharge and there were 6 (5.6%) deaths attributable to meningitis and sepsis.

CONCLUSIONS

Bacterial meningitis is an important cause of morbidity in Canadian children with S. pneumoniae replacing H. influenzae as the leading potentially vaccine preventable cause. Despite proper initiation of antimicrobial therapy, meningitis results in great morbidity and mortality in children in Canada.

Glaucoma electronic patient record--design, experience and study of high-risk patients

AIM

To set-up a glaucoma electronic patient record (GEPR) and study referral details to a new glaucoma service, concentrating on high-risk patients.

METHOD

A GEPR was designed using the pre-existing hospital information technology (IT) infrastructure. Referral details of all new patients to the glaucoma service were completely electronically entered and analysed.

RESULTS

A GEPR was successfully established. A total of 402 referrals were studied. In all, 43% (40) of high-risk clinic patients (IOP>29 mmHg, or C/D ratio >0.8 or moderate to advanced visual field defects) had to wait longer than 8 weeks from GP referral to be seen at the glaucoma service. Of these, nine patients lost more than one line of Snellen's visual acuity attributable to glaucoma. The optometrist failed to document IOP in 17%, fundoscopy in 30%, and visual fields in 45% of all referrals.

CONCLUSIONS

A GEPR can be introduced in an NHS setting without disruption of clinical care and ophthalmic training, and facilitates detailed, accurate and rapid audit. Study of high-risk glaucoma referrals showed inadequate optometric referral details and poor prioritisation of urgent cases. This information is being utilised with the cooperation of local optometrists to refine the pattern of glaucoma referrals.

Visual impairment in elderly patients with hip fracture: causes and associations

AIMS

To evaluate the current visual status and ophthalmic history of a sample of elderly patients with fractured neck of femur and to study the relationship between visual status and demographic factors.

METHODS

A four-centre study of all patients admitted to hospital with fractured neck of femur. The setting was two district (Ayr, Dunfermline) and two teaching (Glasgow, Dundee) hospitals in Scotland. The study examined 537 patients aged 65 years and over admitted with acute fractured neck of femur to hospital.

RESULTS

Bilateral visual impairment (binocular visual acuity worse than 6/12) was found in 239 of 518 patients (46%). Of this group, the principal causes for visual deficit were untreated cataract (49%), macular degeneration (21%), uncorrected refractive error (17%), and glaucoma (3%). The visually impaired group were more likely to have symptomatic visual complaints (58 vs 26%), however, were less likely to be under optometric care (71 vs 85%). A higher proportion of the group with visual impairment lived in areas of social deprivation (40 vs 26%).

CONCLUSIONS

Patients with fractured neck of femur represent a frail elderly group that have poorer vision than that documented in any other elderly population. The visual defect was potentially remediable in the majority of cases but this group of individuals are not generally in touch with the ophthalmic services. Social deprivation appears to be associated with this groups' inability to access ophthalmic care.

Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment*

AIM

To describe previous contact with optometry and ophthalmic services in a group of elderly patients with and without visual impairment (VI) who had fallen and sustained a fractured neck of femur.

METHOD

A cross sectional study of 537 patients aged 65 and over who had undergone hip fracture surgery in four Scottish centres (Glasgow, Ayr, Dundee and Fife). All patients had an in-depth optometric history, ophthalmic history and examination.

RESULTS

Three hundred and ninety-three (79%) patients reported optometric contact in the 3 years preceding surgery and 107 (21%) patients had not seen an optometrist for more than 3 years. In the latter group, 64 had VI, which was due to uncorrected refractive error in 17 (27%) and untreated cataract in 20 (31%). VI (best binocular visual acuity of 6/18 or less) was found in 239 (46%) patients. A past ophthalmic history was present in 257 (50%) patients. Only 39 (16%) patients with VI were under ophthalmic care at the time of the study.

CONCLUSIONS

There was significantly poor optometric and ophthalmic contact in patients who had VI and had fallen and sustained hip fracture. A proportion of the VI (66%) was due to uncorrected refractive error and untreated cataract. Public health providers should be made aware of the fact that current optometric and ophthalmic care pathways are not accessed by this group of elderly patients with VI and at risk of falling.

Using an interdisciplinary approach to training to develop the quality of communication with adults with profound learning disabilities by care staff

The study examines the effects of training on care staff's communication to service users with profound and severe learning disabilities. An interdisciplinary therapeutic training programme aimed to improve care staff's cognitions about disability, to alter their communicative practice and to provide them with practical solutions to the communication difficulties of the service users. Participants were each video recorded with a single service user before and during training. The recordings formed the basis of the communication workshops. Both baseline and final recordings were evaluated using criteria based on verbal and non-verbal interactions. The criteria assessed alterations in the care staff's language use, verbal responses, and interpretation and praise of service users' communication. The use of posture, position, eye contact and gaze monitoring during interactions was also evaluated. The pre- and post-training analysis demonstrated alterations and improvements in care staff's use of verbal communication as well as gaze monitoring and position during interactions. A follow-up study 6 months later showed many of the post-training positive changes had been maintained or had continued to develop. It is suggested that the success and implementation of the communication training in the workplace was due to the collaborative therapeutic nature of the training package. The interdisciplinary and integrated training programme had facilitated a willingness to change and led to the development of a positive view of each other's practice. The recommendations from each of the therapist's training programme formed an integral part of the care staff's new care plans for each service user. This contributed to the continuing development the care staff's therapeutic role.

Characterization of a novel serine/threonine protein phosphatase (PfPPJ) from the malaria parasite, Plasmodium falciparum

A novel protein phosphatase cDNA of the PPP superfamily was identified from the malaria parasite, Plasmodium falciparum (Pf), and tentatively named PfPPJ. The predicted primary structure of the phosphatase contained all the known conserved motifs of the PPP superfamily essential for catalytic activity. The enzyme was specific for dephosphorylation of phosphoserine and phosphothreonine residues with very little activity against phosphotyrosine residues. However, the sequence at its C-terminal end was unique, and was consistent with its resistance to the classical PP2A-specific inhibitors such as okadaic acid and microcystin-LR, and the PP1-specific inhibitor, mammalian heat-stable inhibitor-2 (I-2). Even the catalytic core of PfPPJ had a sequence substantially different from the other PPPs such that PfPPJ could be placed in an apparently separate phylogenetic branch. At 294 amino acids residues, PfPPJ was one of the smallest okadaic acid-resistant PPP phosphatases known. By Northern blot analysis, the expression of the PfPPJ mRNA showed the following pattern: schizont > ring > trophozoite, which closely paralleled the expression of the protein, as determined by immunofluorescence. Together, these results suggested a parasitic stage-specific transcriptional regulation of this novel and potentially unique protozoan phosphatase.

Developing an information pack for the Asian carers of people with autism spectrum disorders

An investigation is described which forms the basis for the development of an information package for the Asian carers of people with autism spectrum disorders (ASD) and learning disabilities. The results of semi-structured interviews and planning for questionnaires with three different linguistic Asian groups (Urdu, Gujarati and Bengali) are presented. The views, attitudes and awareness of autism, knowledge of support services and perceived priority of needs are analysed for the three different communities. The investigation concludes with recommendations as to whether separate information is needed by each culture or whether a single information pack can be used and presented in each language format. The possible presentation format in which the information can be produced is also discussed.

An Australasian test of the recent African origin theory using the WLH-50 calvarium

This analysis investigates the ancestry of a single modern human specimen from Australia, WLH-50 (Thorne et al., in preparation; Webb, 1989). Evaluating its ancestry is important to our understanding of modern human origins in Australasia because the prevailing models of human origins make different predictions for the ancestry of this specimen, and others like it. Some authors believe in the validity of a complete replacement theory and propose that modern humans in Australasia descended solely from earlier modern human populations found in Late Pleistocene Africa and the Levant. These ancestral modern populations are believed to have completely replaced other archaic human populations, including the Ngandong hominids of Indonesia. According to this recent African origin theory, the archaic humans from Indonesia are classified as Homo erectus, a different evolutionary species that could not have contributed to the ancestry of modern Australasians. Therefore this theory of complete replacement makes clear predictions concerning the ancestry of the specimen WLH-50. We tested these predictions using two methods: a discriminant analysis of metric data for three samples that are potential ancestors of WLH-50 (Ngandong, Late Pleistocene Africans, Levant hominids from Skhul and Qafzeh) and a pairwise difference analysis of nonmetric data for individuals within these samples. The results of these procedures provide an unambiguous refutation of a model of complete replacement within this region, and indicate that the Ngandong hominids or a population like them may have contributed significantly to the ancestry of WLH-50. We therefore contend that Ngandong hominids should be classified within the evolutionary species, Homo sapiens. The Multiregional model of human evolution has the expectation that Australasian ancestry is in all three of the potentially ancestral groups and best explains modern Australasian origins.

Casein kinase 2-mediated phosphorylation of respiratory syncytial virus phosphoprotein P is essential for the transcription elongation activity of the viral polymerase; phosphorylation by casein kinase 1 occurs mainly at Ser(215) and is without effect

The major site of in vitro phosphorylation by casein kinase 2 (CK2) was the conserved Ser(232) in the P proteins of human, bovine, and ovine strains of respiratory syncytial virus (RSV). Enzymatic removal of this phosphate group from the P protein instantly halted transcription elongation in vitro. Transcription reconstituted in the absence of P protein or in the presence of phosphate-free P protein produced abortive initiation products but no full-length transcripts. A recombinant P protein in which Ser(232) was mutated to Asp exhibited about half of the transcriptional activity of the wild-type phosphorylated protein, suggesting that the negative charge of the phosphate groups is an important contributor to P protein function. Use of a temperature-sensitive CK2 mutant yeast revealed that in yeast, phosphorylation of recombinant P by non-CK2 kinase(s) occurs mainly at Ser(215). In vitro, P protein could be phosphorylated by purified CK1 at Ser(215) but this phosphorylation did not result in transcriptionally active P protein. A triple mutant P protein in which Ser(215), Ser(232), and Ser(237) were all mutated to Ala was completely defective in phosphorylation in vitro as well as ex vivo. The xanthate compound D609 inhibited CK2 but not CK1 in vitro and had a very modest effect on P protein phosphorylation and RSV yield ex vivo. Together, these results suggest a role for CK2-mediated phosphorylation of the P protein in the promoter clearance and elongation properties of the viral RNA-dependent RNA polymerase.

Variable morbidity of respiratory syncytial virus infection in patients with underlying lung disease: a review of the PICNIC RSV database. Pediatric Investigators Collaborative Network on Infections in Canada

OBJECTIVE

We wished to compare outcomes of respiratory syncytial virus (RSV) infection in children with bronchopulmonary dysplasia (BPD) with those with other pulmonary disorders: cystic fibrosis, recurrent aspiration pneumonitis, pulmonary malformation, neurogenic disorders interfering with pulmonary toilet, and tracheoesophageal fistula.

METHODS

Children with RSV infection hospitalized at seven Canadian pediatric tertiary care hospitals in 1993 through 1994 and 9 hospitals in 1994 through 1995 were enrolled and prospectively followed. This study is a secondary analysis of data from this prospective cohort.

RESULTS

Of the 1516 patients enrolled the outcomes of 159 with preexisting lung disorders before RSV lower respiratory tract infection constitute this report. There were no significant differences among the 7 groups (BPD, cystic fibrosis, recurrent aspiration pneumonitis, pulmonary malformation, neurogenic disorders interfering with pulmonary toilet, tracheoesophageal fistula, other) for the morbidity measures: duration of hospitalization, intensive care unit (ICU) admission, duration of ICU stay, mechanical ventilation and duration of mechanical ventilation. Patients using home oxygen were more likely to be admitted to the ICU than those who had never or previously used home oxygen (current 57.1%, past 23.8%, never 33.3%, P = 0.03).

CONCLUSIONS

Children with other underlying diseases have morbidity similar to those with BPD. Prophylactic interventions against RSV should also be studied in these groups.

Treatment of severe pertussis: a study of the safety and pharmacology of intravenous pertussis immunoglobulin

BACKGROUND

Pertussis in infants is often severe, resulting in complications and prolonged hospitalization. Treatment is limited to supportive care. Antibiotics do not significantly alter the course of the disease. Therapies directed at pertussis toxin, a major virulence factor of Bordetella pertussis, might be beneficial. This study examines the safety and pharmacology of intravenous pertussis immunoglobulin (P-IGIV), which has high levels of pertussis toxin antibodies.

METHODS

P-IGIV was prepared as a 4% IgG solution from the pooled plasma from donors immunized with inactivated pertussis toxoid. The IgG pertussis toxin antibody concentration of 733 microg/ml is >7-fold higher than contained in conventional intravenous immunoglobulin products. Children with presumptive pertussis were allocated to one of three treatment doses of P-IGIV.

RESULTS

Twenty-six of 30 enrolled children had confirmed pertussis. There were no adverse events associated with P-IGIV except one patient who had transient hypotension that responded to an infusion rate decrease. P-IGIV doses of 1500, 750 and 250 mg/kg achieved > or =4-fold, 3-fold and >2-fold rises in peak geometric mean titers of pertussis toxin IgG antibodies, respectively. P-IGIV exhibited a half-life of 38.4 days and a volume of distribution of 87.8 ml/kg. All three treatment groups showed declines in lymphocytosis (P < 0.05) and paroxysmal coughing by the third day after P-IGIV infusion compared with preinfusion values.

CONCLUSION

P-IGIV is safe and achieves high pertussis toxin antibody titers in infants. This study provides data for a prospective, controlled trial of P-IGIV.

Characterization of protein Ser/Thr phosphatases of the malaria parasite, Plasmodium falciparum: inhibition of the parasitic calcineurin by cyclophilin-cyclosporin complex

Two major protein phosphatase (PP) activities were purified from cytosolic extracts of the erythrocytic stage of the malaria parasite, Plasmodium falciparum. Both enzymes were specific for phosphoserine and phosphothreonine residues with very little activity against phosphotyrosine residues. The biochemical properties of the enzymes suggested their strong similarity with eukaryotic PP2A and PP2B protein phosphatases. Both enzymes preferentially dephosphorylated the alpha subunit of phosphorylase kinase, and were resistant to inhibitor-1. The PP2A-like enzyme required Mn2+ for activity and was inhibited by nanomolar concentrations of okadaic acid (OA). The cDNA sequence of the PP2A-like enzyme was identified through a match of its predicted amino acid sequence with the N-terminal sequence of the catalytic subunit. The PP2B-like (calcineurin) enzyme was stimulated by calmodulin and Ca2+ or Ni2+, but was resistant to OA. Malarial calcineurin was strongly and specifically inhibited by cyclosporin A (CsA) only in the presence of wild type P. falciparum cyclophilin but not a mutant cyclophilin. The inhibition was noncompetitive, and provides a potential explanation for the cyclosporin-sensitivity of the parasite. There was no significant quantitative difference in the total protein Ser/Thr phosphatase activity among the ring, trophozoite, and schizont stages.

Comparative safety of tetanus-diphtheria toxoids booster immunization in students in Grades 6 and 9

BACKGROUND

Tetanus-diphtheria toxoids (Td) booster immunization is generally recommended for Grade 9 students (14- to 16-year-olds) but targeting younger students may enhance vaccine uptake or facilitate simultaneous vaccinations. However, earlier vaccination might cause greater side effects. This study was undertaken to compare the safety of Td vaccinations in students in Grade 6 (11 to 12 years old) and Grade 9.

METHODS

A controlled, sequential assessment of Td vaccine, adsorbed, was conducted in one urban school district, starting with Grade 9 students. Grade 6 students were given Td concurrently with Dose 3 of hepatitis B vaccine. Adverse effects were assessed during visits 2 days after vaccination. Participation criteria, immunization technique and assessment procedures were standardized.

RESULTS

Of 410 students vaccinated, 204 in Grade 9 and 206 in Grade 6, 391 (95.4%) were assessed in person. Nineteen missed follow-up visits but telephone interviewers established that none missed school because of vaccine side effects. At follow-up Grade 6 students more often reported deltoid pain with arm movement (35.2% vs. 10.8%, P < 0.001). Injection site redness > or = 50 mm in diameter was present in 12.2% of Grade 6 and 3.6% of Grade 9 students (P < 0.001) whereas swelling > or = 50 mm diameter was present in 22.4 and 10.8%, respectively (P < 0.01). Fewer than 10% of subjects took analgesics for injection site pain. Only 5 students (1.3%) rated Td site morbidity as severe/unacceptable. Hepatitis B site morbidity was minimal in comparison.

CONCLUSION

Td boosters were moderately reactogenic in adolescents. Younger students more often experienced injection site morbidity but considered it bearable. Booster immunizations can reasonably be offered within the age range of 11 to 16 years.

Evaluation of an approach for adults with profound learning difficulties

A local day care unit for adults with profound learning disabilities is a popular community project. It receives many visits from students and volunteers and is also visited by a variety of support staff. The presence of these visitors makes an impact on the Unit's communication environment. A nursing and speech and language therapy project used photography to address the visitors' perceptions of the clients' communication and identify the visitors' information needs about the clients' communication skills. As a result of this evaluation the induction policy was changed and the leaflets were introduced. The time commitment to the initial project for therapy and nursing staff is discussed in relation to the effective and alternative use of therapeutic time for this client group.

A comparison of training approaches for support assistants using the Hanen philosophy

The introduction of the Hanen Programme (Watson, 1993) for parents of children who will in the future attend special schools can have training implications for their school's staff. These factors have led to a speech and language therapy service working in collaboration with its local schools to offer courses for special needs support assistants. The design, planning and delivery of the courses were based on Hanen philosophy. Some courses were exclusively for support assistants and others offered the opportunities for them to work in differing degrees of partnership with children's parents. The successes and the limitations of support assistants attending parents Hanen courses were evaluated.

Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada Study

OBJECTIVE

To determine nosocomial transmission of respiratory syncytial virus (RSV) in Canadian pediatric hospitals, outcomes associated with nosocomial disease, and infection control practices.

DESIGN

A prospective cohort study in the 1992 to 1994 winter respiratory seasons.

SETTING

Nine Canadian pediatric university-affiliated hospitals.

PARTICIPANTS

Hospitalized children with symptoms of lower respiratory tract infection (at least one of cough, wheezing, dyspnea, tachypnea, and apnea) and RSV antigen identified in a nasopharyngeal aspirate.

RESULTS

Of 1516 children, 91 (6%) had nosocomial RSV (NRSV), defined as symptoms of lower respiratory tract infection and RSV antigen beginning >72 hours after admission. The nosocomial ratio (NRSV/[com-munity-acquired RSV {CARSV})] + NRSV) varied by site from 2.8% to 13%. The median length of stay attributable to RSV for community-acquired illness was 5 days, but 10 days for nosocomial illness. Four children with NRSV (4. 4%) died within 2 weeks of infection, compared with 6 (0.42%) with CARSV (relative risk = 10.4, 95% confidence interval: 3.0, 36.4). All sites isolated RSV-positive patients in single rooms or cohorted them. In a multivariate model, no particular isolation policy was associated with decreased nosocomial ratio, but gowning to enter the room was associated with increased risk of RSV transmission (incidence rate ratio 2.81; confidence interval: 1.65, 4.77).

CONCLUSIONS

RSV transmission risk in Canadian pediatric hospitals is generally low. Although use of barrier methods varies, all sites cohort or isolate RSV-positive patients in single rooms. Children with risk factors for severe disease who acquire infection nosocomially have prolonged stays and excess mortality.

Economic evaluation of respiratory syncytial virus infection in Canadian children: a Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study

OBJECTIVES

To quantify the cost and distribution of health care resources consumed annually in management of Canadian children from birth to 4 years of age with respiratory syncytial virus (RSV) infection.

STUDY DESIGN

Estimates of direct medical expenditures (in 1993 U.S. dollars) were collected from a prospective cohort study of hospitalized children with RSV and from national and provincial databases.

RESULTS

The annual cost of RSV-associated illness was almost $18 million. The largest component of direct expenditures (62%) was for inpatient care for the estimated 0.7% of all infected children ill enough to require admission. Physician fees comprised only 4% of inpatient expenses. Expenditures for ambulatory patients accounted for 38% of direct costs.

CONCLUSIONS

The greatest reductions in the economic cost of RSV infections will be found in interventions that reduce duration of or prevent hospital stay. Costs for management of RSV infection in children in the Canadian health care system are considerably less than charges reported in the United States.

Recognising the smiles that cry for help

This article describes a small project set up by nurses and a speech and language therapist in a day unit for people with learning difficulties. The project looked at communication between clients and their visitors.

PICNIC (Pediatric Investigators Collaborative Network on Infections in Canada) study of the role of age and respiratory syncytial virus neutralizing antibody on respiratory syncytial virus illness in patients with underlying heart or lung disease

OBJECTIVE

To determine the effects of age and respiratory syncytial virus (RSV) antibody status on frequency and severity of RSV infections in children with underlying heart or lung disease.

DESIGN

Cohort study conducted during two consecutive RSV seasons.

SETTING

Ambulatory patients at eight Canadian pediatric tertiary care centers.

METHODS

Subjects under 3 years old with underlying heart disease who were digoxin-dependent or had not received corrective cardiac surgery or with underlying lung disease were enrolled. Demographic information and an acute sera for RSV neutralizing antibody was obtained on enrollment. Weekly telephone follow-up consisting of a respiratory illness questionnaire was followed with a home visit to obtain a nasopharyngeal aspirate when there was new onset of respiratory symptoms. The specimen was used to detect RSV antigen. RSV illnesses were grouped as upper or lower respiratory tract infection (LRI) based on clinical and radiographic findings. RSV hospitalizations were considered to be those RSV infections that resulted in hospitalization.

RESULTS

Of 427 enrolled subjects, 160 had underlying lung disease only, 253 had underlying heart disease only, and 14 had both. Eleven percent and 12% of lung and heart disease groups, respectively, had an RSV LRI. Three percent and 6% of lung and heart disease groups, respectively, were hospitalized with RSV infection. A significant decrease in frequency of RSV LRI and RSV hospitalization occurred with increasing age, with a major drop in those older than 1 year vs those younger than 1 year. Acute sera were available from 422 subjects. Geometric mean RSV antibody titers demonstrated a U-shaped distribution with increasing age. The trend to lower antibody concentrations in premature infants did not reach statistical significance. The frequency of RSV infection and RSV LRI was lower in patients with antibody at a titer more than 100, although the difference for RSV hospitalization was not statistically significant. These differences remained significant after age adjustment.

CONCLUSION

Both age and RSV antibody status impact on RSV illness and LRI. Reduction in illness frequency with increasing age may lead to more informed targeting of those children most likely to benefit from RSV immune globulin prophylaxis.

Does ribavirin impact on the hospital course of children with respiratory syncytial virus (RSV) infection? An analysis using the pediatric investigators collaborative network on infections in Canada (PICNIC) RSV database

OBJECTIVES

To determine the relationship between receipt of aerosolized ribavirin and the hospital course of high-risk infants and children with respiratory syncytial virus (RSV) lower respiratory infection (LRI).

METHODS

The 1993-1994 Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) RSV database consists of prospectively enrolled children with acute RSV LRI, admitted to nine Canadian pediatric tertiary care centers. After excluding cases with compromised immunity and/or nosocomial infection, subsets with any congenital heart disease (CHD), chronic lung disease (CLD), age </=6 weeks (INFANT), gestation </=36 weeks (PREM), or severe disease within 48 hours of admission as shown by an oxygen saturation </=90% or an FiO2 requirement of >.35 (EARLY HYPOXIA) were studied in two ways. First, each risk group subset was analyzed separately to assess the association between ribavirin receipt and measures of disease severity including duration of intensive care, mechanical ventilation, hypoxia and RSV-attributable hospital stay. Secondly, ribavirin was added as an independent variable to a previously described multiple regression model for RSV-attributable length of hospital stay and two mutually exclusive subsets were analyzed: 1) previously healthy patients with >/=1 of: INFANT, PREM, or EARLY HYPOXIA; 2) patients with CHD and/or CLD.

RESULTS

Between January 1993 and June 1994, 1425 community-acquired hospitalized cases of RSV LRI were entered into the RSV database. Among these 750 (52.6%) fit into one or more of the defined subsets including 97 CHD, 134 CLD, 213 INFANT, 211 PREM, and 463 EARLY HYPOXIA. The proportion ventilated in each group was 20.6%, 20.9%, 15.5%, 15.2%, and 13.3%, respectively. Across the subsets ribavirin use ranged from 36% to 57% of ventilated patients and 6% to 39% of nonventilated patients. For nonventilated patients in each subset the median RSV-attributable hospital length of stay (RSV-LOS) was 2 to 3 days longer for ribavirin recipients and the duration of hypoxia was significantly increased. Duration of intensive care unit (ICU) stay was also increased for all ribavirin-treated subgroups except those with CHD. In contrast, for ventilated patients, ribavirin therapy was not significantly associated with any of the outcome measures regardless of risk group. In the multiple regression model, ribavirin was significantly associated with a prolonged RSV-LOS both for children with CHD and/or CLD as well as for those whose only risk factors included INFANT, PREM, and/or EARLY HYPOXIA.

CONCLUSIONS

These data raise further doubts about the clinical effectiveness of ribavirin in infants and children with risk factors for severe disease. Selection bias, with ribavirin used for sicker children, may have influenced outcome. Nevertheless the long durations of hospitalization, ICU, ventilation, and oxygen supplementation in nonventilated ribavirin recipients stress the need for further randomized trials to assess its efficacy.

Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of admission and management variation in patients hospitalized with respiratory syncytial viral lower respiratory tract infection

OBJECTIVE

To describe differences in patients hospitalized with respiratory syncytial virus (RSV) lower respiratory tract infection (LRI) at nine Canadian tertiary care hospitals. In addition, this study describes the variation in use of drug and other interventions.

METHODS

Data on patients hospitalized with RSV LRI and their outcomes were prospectively collected. Demographic data were obtained on enrollment by center study nurses. Data recorded daily included clinical assessment, oxygen saturation determination, and interventions (bronchodilators, steroids, ribavirin, antibiotics, intensive care, and mechanical ventilation) received during the day. Patients were divided into those with underlying diseases including congenital heart disease, chronic lung disease, immunodeficiency, or multiple congenital anomalies and those who were previously healthy. Mean RSV-associated length of stay and the proportion of patients receiving each intervention in each group were determined by hospital.

RESULTS

A total of 1516 patients were enrolled at nine hospitals during January 1 to June 30, 1993, and January 1 to April 30, 1994. Significant differences were observed among hospitals in the proportion of patients with underlying disease, postnatal age less than 6 weeks, hypoxia, and pulmonary infiltrate on chest radiograph. The mean length of stay varied among hospitals from 8.6 to 11.8 days and 4.6 to 6.7 days in compromised and previously healthy patients, respectively. Except for receipt of bronchodilators, compromised patients were significantly more likely to receive interventions than previously healthy patients. There was variation among hospitals in receipt of most interventions in compromised and previously healthy patients. This variation was statistically significant for previously healthy patients but not statistically significant in those with underlying disease, because the numbers of patients in the latter group were much smaller. The magnitude of the variation for each intervention, however, was not different between those with underlying disease compared with previously healthy patients.

CONCLUSION

Differences exist among tertiary pediatric hospitals in the nature of the patients admitted with RSV LRI. Variation occurred in the use of five interventions among the hospitals, regardless of whether the patient had underlying illness or was previously healthy. Given their current widespread use, high cost, and potential side effects, randomized clinical trials are needed to determine the efficacy of different drug treatments used to treat infants hospitalized with RSV.

Study of interobserver reliability in clinical assessment of RSV lower respiratory illness: a Pediatric Investigators Collaborative Network for Infections in Canada (PICNIC) study

Randomized trials of ribavirin therapy have used clinical scores to assess illness severity. Little information on agreement for these findings between observers has been published. We decided to determine interobserver agreement for (1) a history for apnea or respiratory failure; (2) assessment of cyanosis, respiratory rate, retractions, and oximetry; and (3) determination of reason for hospitalization (requirement for medications, supportive care, underlying illness, poor home environment). At eight centers 137 RSV-infected patients were assessed by two observers blinded to the assessments by others with no interventions made between assessments. Observations were categorized, and agreement was summarized as percentage of observed agreement, Pearson correlation, or as a kappa statistic. Observed agreement for a history of either apnea or a respiratory arrest was at least 90% at all centers, with seven of the eight centers in total agreement. At all centers except one, the agreement on the reason why the patient remained in hospital was at least 80%. The observed agreement for assessing cyanosis was at least 94% at all eight centers. The correlation coefficient for respiratory rate varied from 0.42 to 0.97 across centers. The kappa values for agreement beyond chance for retractions varied from 0.05 to 1.00. The kappa values for oxygen saturation measures varied from 0.31 to 0.70. Although not statistically significant, there appeared to be more variation as the time between assessments increased. In conclusion, agreement for historical findings and assessment of cyanosis was high. However, there was wide variation in agreement in the other assessments. Training to ensure consistent and reproducible assessment by different examiners will be necessary if these findings are to be used as outcome variables in clinical trials.

Assessment of a universal, school-based hepatitis B vaccination program

OBJECTIVE

To assess a hepatitis B vaccination program offered to all grade 6 students in British Columbia in 1992.

DESIGN

Cohort study.

SETTING

British Columbia, Canada.

PARTICIPANTS

All grade 6 students were offered vaccine. Subsets of 454 and 259 students participated in studies of minor adverse events and seroresponse, respectively.

INTERVENTION

The vaccine used was Engerix-B, 20 micrograms, given at intervals of 0, 1, and 6 months.

MAIN OUTCOME MEASURES

Province-wide acceptance and series completion rates and reports of severe adverse events. Minor adverse events and immunogenicity in subsamples.

RESULTS

A total of 127,922 vaccine doses were administered. Initial enrollment totaled 43,358 students or 95.4% of those eligible. The series was completed by 41,594 students (95.6%). Minor adverse events were infrequent in the cohort assessed: no absenteeism or physician visits resulted from vaccination. Sixty-nine reported severe adverse events met surveillance definitions, the major categories being injection site reactions (23% of reports), fainting (20%), and rashes (17%). There was one instance of anaphylaxis. Only 13 of these events resulted in recommendations to discontinue the series. Of students tested following the series, 98% had levels of antibody to hepatitis B surface antigen considered to be protective (> or = 10 IU/L), the geometric mean titer being 690 IU/L (95% confidence interval, 498 to 957 IU/L).

CONCLUSION

Our experience indicates that school-based programs for universal vaccination of preadolescents can be highly acceptable and efficient.

Three immediate early gene response elements in the proximal preprotachykinin-A promoter in two functionally distinct domains

The preprotachykinin-A promoter contains two blocks of DNA sequence, with a high degree of homology to one another, both containing activator protein 1/cAMP response element-like elements which constitute cis-acting regulatory domains. These two domains are differentially regulated in HeLa cells and primary cultures of dorsal root ganglion neurons when they are placed in the context of a reporter gene driven by the c-fos minimum promoter. One of the domains, corresponding to a region of the preprotachykinin promoter spanning nucleotides -345 to -308, contains two activator protein 1 elements adjacent to an E-box binding protein consensus sequence. Both of the activator protein 1 elements can bind a complex containing c-fos/c-fos related antigen proteins and the adjacent E-box element is specifically recognized by proteins present in HeLa nuclear extract. This domain requires the synergistic action of both activator protein 1 elements to drive expression of the reporter gene in both HeLa and dorsal root ganglion cells. The second or proximal domain spans nucleotides -198 to -155 and contains a previously characterized activator protein 1/cAMP response element/ATF enhancer element which, in contrast to the activator protein 1 elements in the distal domain, functions in both HeLa and dorsal root ganglion cells as one copy. This domain is differentially regulated in HeLa and dorsal root ganglia. The previously characterized enhancer activity is repressed in the context of the extended cis-acting domain in HeLa cells but remains active in dorsal root ganglion, although no further enhancement of activity supported by the single enhancer is observed when in the context of the extended sequence. This proximal domain, in addition to binding the enhancer complex, can be bound by at least two other complexes, one of which binds to an E-box consensus sequence. As the elements corresponding to the E-box consensus in both domains cross-compete for binding of specific complex(es) it would appear that repression of the activity of the proximal domain is correlated with a specific protein complex binding adjacent to the characterized enhancer in the region spanning nucleotides -198 to -155. The preprotachykinin-A proximal promoter is therefore bound by multiple activator protein I complexes, which in the context of the cis-acting domains in which they are present can be differentially regulated. In the proximal domain their function may also be regulated in a tissue-specific manner by other proteins which bind to adjacent regulatory elements.