Needs Assessment for Pharmacy Program Creation Designed to Serve Minority Francophone Populations in Canada

OBJECTIVES

Current literature provides little insight into the need for French-language pharmaceutical services in Francophone minority settings in Canada. This study aims to understand the pharmaceutical care and services offered in French in Canada. It also aims to conduct a needs assessment in the context of curriculum development, by validating whether pharmaceutical needs are being met in Francophone minority settings in Canada.

METHODS

An online survey was sent to community members and health care professionals. Respondents were asked to identify the perceived importance of pharmaceutical needs and the degree to which they perceive these to be fulfilled in French and English in their communities.

RESULTS

A total of 113 community members and 109 health care professionals completed the survey. Most respondents were from Ontario (64.84%), Quebec (10.50%), or Atlantic Provinces (10.05%). In total, > 95% of survey respondents identified that pharmaceutical needs assessed were of very high importance. The rate of pharmaceutical need fulfillment was lower in French than English across all pharmaceutical needs assessed. The greatest difference in rate of pharmaceutical need fulfillment was seen with "Having safe access to required medication". The perception of pharmaceutical needs being met was congruent between community members and health care professionals.

CONCLUSION

These results confirm a lack of pharmaceutical needs being met in French in Canadian Francophone minority communities. There is a lack of French-language services that limit the ability to receive care in one's own language. Pharmacy education in French may be an effective approach to improve pharmaceutical care services received in French in Francophone minority communities.

Emotional Impact of Medication-Related Patient Safety Incidents on Canadian Hospital Pharmacists: A Mixed-Methods Study

Background

Patient safety incidents are the third leading cause of death in Canada. These occurrences have negative effects on patients and on the well-being of health care professionals. They also lead to financial burdens on the health care system. Several organizations focus on minimizing patient safety incidents; however, an area requiring additional research is evaluating the emotional impact of medication-related patient safety incidents (MRPSIs) on Canadian hospital pharmacists. An MRPSI is a preventable, unintended outcome resulting from medication management rather than an underlying disease. The consequences may be no harm, temporary harm, prolonged hospital stay, disability, or death.

Objectives

To describe the psychological burden on pharmacists after occurrence of an MRPSI and to identify supportive strategies.

Methods

This mixed-methods study involved a voluntary survey of hospital pharmacists and structured individual interviews. Survey respondents scored their emotional distress on the Impact of Event Scale (IES), a validated self-reporting tool used to assess the impact of traumatic life events. Interviewees' responses were analyzed qualitatively.

Results

Of the 128 pharmacists who had experienced an MRPSI and submitted a complete survey response, 105 (82%) had a score above 8 on the IES, indicating that the MRPSI had an important impact. Commonly reported factors contributing to MRPSIs were heavy workload, interruptions, and inexperience. The most desired support strategies included talking to a colleague, compassionate notification of the event through management, and involvement in team debriefs.

Conclusions

The emotional impact of MRPSIs as reported by Canadian hospital pharmacists is significant. Most participants felt that increased support is needed to overcome emotional burdens related to MRPSIs.

Biological markers to establish a relationship between the health status of the St. Lawrence River yellow perch (Perca flavescens) with a gradient of anthropogenic disturbances

Since the mid-1990s, the decline of the yellow perch population of Lake Saint-Pierre (hereinafter LSP) in Quebec, Canada has been the subject of several research programs. The combined effect of habitat deterioration, the presence of invasive species, and poor water quality negatively affected the yellow perch population in this lake. In 2013, we sampled yellow perch (larvae, juveniles and adults) at six sites along the St. Lawrence River representing a gradient of increasing human influences from upstream to downstream and measured several biomarkers including retinoid compounds (vitamin A). In the most contaminated sites (LSP, north and south shores), we found that retinoid stores were decreased in all three stages of development. To corroborate these results and to test other biomarkers, we once again sampled yellow perch (adults only) from the same sites. Results from our 2014 and 2015 samplings confirmed that LSP yellow perch appeared to be at a disadvantage compared to fish from upstream populations. Individuals from LSP have lower acetylcholinesterase (AChE) activity as well as lower retinoid levels in liver and plasma. These fish were also marked by lower levels of antioxidants such as lycopene and vitamin E. A discriminant analysis of this set of results confirmed that the yellow perch of the LSP could be easily discriminated from those of the other sites (2014 and 2015) on the basis of liver retinoid and, to a lesser extent, of the liver tocopherol and protein concentration of the muscle, as well as AChE activity and DROH (all-trans-3,4-dehydroretinol) measured in plasma.

Factors contributing to unintentional parathyroidectomy during thyroid surgery

Unintentional parathyroidectomy during thyroid surgery has an incidence ranging between 1% and 31% across institutions. Many studies have identified malignancy and central neck dissection as risk factors for losing parathyroid glands, but few studies have evaluated the impact of other factors such as lymphocytic thyroiditis, hyperthyroidism, or concomitant primary hyperparathyroidism. The purpose of this study was to investigate which factors contribute to parathyroid loss during thyroid surgery. Charts of 269 patients undergoing thyroid surgery at a tertiary care medical center from 2010 to 2013 were retrospectively reviewed. Sixty-six patients (24.5%) experienced unintentional parathyroidectomy. Bivariate analysis showed no significant differences in patient characteristics. Patients with unintentional parathyroid removal had a significantly smaller largest thyroid nodule size (P = 0.002), higher rate of central neck dissection (30.3% vs 7.9%, P < 0.0001), and higher rate of malignancy (50% vs 36.0%, P = 0.04). Multivariable analysis showed that the strongest risk factor for unintentional parathyroidectomy was central neck dissection (P = 0.0008; odds ratio 4.72, confidence interval 1.91-11.71). In conclusion, central neck dissection for thyroid malignancy is the strongest risk factor for unintentional thyroidectomy. The presence of concomitant primary hyperparathyroidism, lymphocytic thyroiditis, or hyperthyroidism did not appear to increase the risk of unintentional parathyroidectomy.

Production of recycled manure solids for bedding in Canadian dairy farms: I. Solid-liquid separation

Canadian dairy producers have an increasing interest in recycled manure solids (RMS) as bedding material because of reduced availability of traditional bedding resources. Information regarding methods to obtain RMS and composition of RMS is very limited. Hence, a 2-part investigation was developed to compare the performances of 3 mechanical solid-liquid manure separators (part I) and 4 composting methods (part II; companion paper in this issue) for the production of high quality RMS. In this first study, a roller press, a screw press, and a decanter centrifuge were tested for the separation of slurry manure from a commercial dairy farm. During the experiment, the quantity of slurry manure processed and the volume and mass of the liquid and solid fractions were measured. The energy consumption of each separator was recorded, and samples of the slurry, liquid, and solid effluents were collected for analysis. The type of separator did not significantly influence the chemical and bacteriological composition of RMS produced. The choice of a separator for Canadian dairy producers should thus be based on the equipment cost and its capacity, targeted solids dry matter (DM) content and structure, and fertilizing quality of the separated liquid. The decanter centrifuge produced the solid phase with the highest DM and best separation efficiencies for DM, N, and P. However, its low production capacity (1.5 m³/h vs. 9.1-20.3 m³/h) combined with its high acquisition cost (Can$145,000 vs. Can$75,000) and energy consumption (4.99 kWh/m³ vs. 0.10-0.35 kWh/m³) reduce its technical and profitability values. Besides, the centrifuge produced fine structured RMS and a low-quality liquid fraction, not suitable as dairy cow bedding and fertilizer, respectively. Both presses reached acceptable production capacity at a minimal operation cost. However, the poor performance in terms of DM (25%) of the model of screw press used in this study produced RMS unsuitable for immediate use without further processing. The model of roller press used in this study had the advantages of almost reaching the recommended DM content in RMS (>34%), being flexible in terms of inputs, and producing fluffy RMS. Nevertheless, its compression process seemed to allow greater passage of solids into the liquid fraction compared with the screw press. Part II of this work explores different composting methods to reduce the health risks associated with screw-pressed RMS before their use as bedding.

Canadian cancer screening disparities: a recent historical perspective

Across Canada, introduction of the Pap test for cervical cancer screening, followed by mammography for breast cancer screening and, more recently, the fecal occult blood test for colorectal cancer screening, has contributed to a reduction in cancer mortality. However, another contribution of screening has been disparities in cancer mortality between certain populations. Here, we explore the disparities associated with breast and cervical cancer screening and preliminary data concerning disparities in colorectal cancer screening. Although some disparities in screening utilization have been successfully reduced over time (for example, mammography and Pap test screening in rural and remote populations), screening utilization data for other populations (for example, low-income groups) clearly indicate that disparities have existed and continue to exist across Canada. Organized screening programs in Canada have been able to successfully engage 80% of women for regular cervical cancer screening and 70% of women for regular mammography screening, but of the women who remain to be reached or engaged in regular screening, those with the least resources, those who are the most isolated, and those who are least culturally integrated into Canadian society as a whole are over-represented. Population differences are also observed for utilization of colorectal cancer screening services. The research literature on interventions to promote screening utilization provides some evidence about what can be done to increase participation in organized screening by vulnerable populations. Adaption and adoption of evidence-based screening promotion interventions can increase the utilization of available screening services by populations that have experienced the greatest burden of disease with the least access to screening services.

Pharmacokinetic variability of extended interval tobramycin in burn patients

BACKGROUND

Aminoglycosides are mandatory in the treatment of severe infections in burns. However, their pharmacokinetics are difficult to predict in critically ill patients. Our objective was to describe the pharmacokinetic parameters of high doses of tobramycin administered at extended intervals in severely burned patients.

METHODS

We prospectively enrolled 23 burned patients receiving tobramycin in combination therapy for Pseudomonas species infections in a burn ICU over 2 years in a therapeutic drug monitoring program. Trough and post peak tobramycin levels were measured to adjust drug dosage. Pharmacokinetic parameters were derived from two points first order kinetics.

RESULTS

Tobramycin peak concentration was 7.4 (3.1-19.6)microg/ml and Cmax/MIC ratio 14.8 (2.8-39.2). Half-life was 6.9 (range 1.8-24.6)h with a distribution volume of 0.4 (0.2-1.0)l/kg. Clearance was 35 (14-121)ml/min and was weakly but significantly correlated with creatinine clearance.

CONCLUSION

Tobramycin had a normal clearance, but an increased volume of distribution and a prolonged half-life in burned patients. However, the pharmacokinetic parameters of tobramycin are highly variable in burned patients. These data support extended interval administration and strongly suggest that aminoglycosides should only be used within a structured pharmacokinetic monitoring program.

Stability and subjective taste acceptability of four glycopyrrolate solutions for oral administration

The oral tablet form of glycopryrrolate has been discontinued in Canada because of declining use. Alternatives include injectable glycopyrrolate, which is still on the market, and an oral solution compounded from the injectable form. The stabilities of different oral solutions of gycopyrrolate formulated from the injectable form were studied by using a high-performance liquid chromatographic technique. The 0.2 mg/mL injectable solution of glycopyrrolate was diluted 1:1 with water, simple syrup, a Hospital for Sick Children vehicle, or Ora-Plus/Ora-Sweet vehicle. After 35 days of storage, more than 90% of the original concentration of glycopyrrolate was still present in all solutions, regardless of whether the solution was kept at room temperature or refrigerated. A simple taste test indicated that Ora-Plus/Ora-Sweet solution and simple syrup were better choices as vehicles for the glycopyrrolate oral dosage form.

Transport screening of drug cocktails through an in vitro blood-brain barrier: is it a good strategy for increasing the throughput of the discovery pipeline?

PURPOSE

The objective of the current study was to investigate whether blood-brain barrier (BBB) permeability studies in vitro could be accelerated by running several compounds together in the same experiment.

METHODS

To address this question, we compared the transport of six compounds run separately with the results of the same compounds run together (cocktails).

RESULTS

The study clearly demonstrated that the outcome of the experiments were totally different depending on the strategy used. Furthermore, the study highlights the importance of having the resistance to drug transport offered by filters without cells under control, as the filter membrane itself can be the rate-limiting step for some compounds; in addition, there is always a potential risk of interactions between molecules in cocktails as well as drug-drug interaction at the level of BBB transporters. In this study, the presence of several P-glycoprotein substrates in the drug cocktail was found to cause breakdown of the BBB.

CONCLUSIONS

The results demonstrate that unless a strategy that involves running several compounds in the same experiment is properly validated, the results are of little predictive value.

Effects of γ- and Hydroxypropyl-γ-cyclodextrins on the Transport of Doxorubicin across an in Vitro Model of Blood-Brain Barrier

Association between doxorubicin (DOX) and gamma-cyclodextrin (gamma-CD) or hydroxypropyl-gamma-CD (HP-gamma-CD) has been examined to increase the delivery of this antitumoral agent to the brain. The stoichiometry and the stability constant of gamma-CD or HP-gamma-CD and DOX complexes were determined in physiological medium by UV-visible spectroscopy. By using an in vitro model of the blood-brain barrier (BBB), endothelial permeability and toxicity toward the brain capillary endothelial cells of DOX, gamma-CD, and HP-gamma-CD were performed. For each CD, endothelial permeability was relatively low and a disruption of the BBB occurred at 20 microM, 20 mM, and 50 mM DOX, gamma-CD, and HP-gamma-CD, respectively. Increasing amounts of CDs were added to a fixed DOX concentration. Addition of gamma-CD or HP-gamma-CD, up to 15 and 35 mM, respectively, decreased the DOX delivery, probably due to the low complex penetration across the BBB and the decrease in free DOX concentration. Higher CD concentrations increased the DOX delivery to the brain, but this effect is due to a loss of BBB integrity. In contrast to what was observed on Caco-2 cell model with various drugs, CDs are not able to increase the delivery of DOX across our in vitro model of BBB.

Recent speciation in the Indo-West Pacific: rapid evolution of gamete recognition and sperm morphology in cryptic species of sea urchin

The rich species diversity of the marine Indo-West Pacific (IWP) has been explained largely on the basis of historical observation of large-scale diversity gradients. Careful study of divergence among closely related species can reveal important new information about the pace and mechanisms of their formation, and can illuminate the genesis of biogeographic patterns. Young species inhabiting the IWP include urchins of the genus Echinometra, which diverged over the past 1-5 Myr. Here, we report the most recent divergence of two cryptic species of Echinometra inhabiting this region. Mitochondrial cytochrome oxidase 1 (CO1) sequence data show that in Echinometra oblonga, species-level divergence in sperm morphology, gamete recognition proteins and gamete compatibility arose between central and western Pacific populations in the past 250 000 years. Divergence in sperm attachment proteins suggests rapid evolution of the fertilization system. Divergence of sperm morphology may be a common feature of free-spawning animals, and offers opportunities to simultaneously understand genetic divergence, changes in protein expression patterns and morphological evolution in traits directly related to reproductive isolation.

MHC studies in nonmodel vertebrates: what have we learned about natural selection in 15 years?

Elucidating how natural selection promotes local adaptation in interaction with migration, genetic drift and mutation is a central aim of evolutionary biology. While several conceptual and practical limitations are still restraining our ability to study these processes at the DNA level, genes of the major histocompatibility complex (MHC) offer several assets that make them unique candidates for this purpose. Yet, it is unclear what general conclusions can be drawn after 15 years of empirical research that documented MHC diversity in the wild. The general objective of this review is to complement earlier literature syntheses on this topic by focusing on MHC studies other than humans and mice. This review first revealed a strong taxonomic bias, whereby many more studies of MHC diversity in natural populations have dealt with mammals than all other vertebrate classes combined. Secondly, it confirmed that positive selection has a determinant role in shaping patterns of nucleotide diversity in MHC genes in all vertebrates studied. Yet, future tests of positive selection would greatly benefit from making better use of the increasing number of models potentially offering more statistical rigour and higher resolution in detecting the effect and form of selection. Thirdly, studies that compared patterns of MHC diversity within and among natural populations with neutral expectations have reported higher population differentiation at MHC than expected either under neutrality or simple models of balancing selection. Fourthly, several studies showed that MHC-dependent mate preference and kin recognition may provide selective factors maintaining polymorphism in wild outbred populations. However, they also showed that such reproductive mechanisms are complex and context-based. Fifthly, several studies provided evidence that MHC may significantly influence fitness, either by affecting reproductive success or progeny survival to pathogens infections. Overall, the evidence is compelling that the MHC currently represents the best system available in vertebrates to investigate how natural selection can promote local adaptation at the gene level despite the counteracting actions of migration and genetic drift. We conclude this review by proposing several directions where future research is needed.

Influence of the embryonic preplate on the organization of the cerebral cortex: a targeted ablation model

Transgenic mice were generated to permit the targeted ablation of cortical preplate cells at the time they are born. In these mice, the 1.3 kb golli promoter of the myelin basic protein gene was used to drive the herpes simplex virus thymidine kinase (TK) transgene in cortical preplate cells. Heterozygous transgenic pairs were bred, and pregnant dams were treated with ganciclovir at embryonic days 11-12 to ablate preplate cells at the time the preplate was forming. This paradigm exposed control (TK-) and experimental (TK+) littermates to exactly the same conditions. Embryological ablation of preplate cells led to an early disruption of the radial glial framework and subplate structure in the developing cortex and dramatically altered the cellular lamination and connectivity of the cortical plate. The disturbed radial glial network contributed to an impaired radial migration of neurons into the cortical plate from the ventricular zone. The cortical plate became dyslaminated, and there was a substantial reduction in short- and long-range cortical projections within the cortex and to subcortical regions. Cell death within the cortical plate and the proliferative zones was substantially increased in the ablated animals. After birth, a cortical lesion developed, which became exacerbated with the secondary onset of hydrocephaly in the second postnatal week. The results underscore the critical importance of the preplate in cortex formation, mediated through its guidance of the formation of radial glial scaffolding, subsequent neuronal migration into the incipient cortical plate, and the final arrangement of its vertical organization and cellular connectivity.

Comparative analysis of population structure across environments and geographical scales at major histocompatibility complex and microsatellite loci in Atlantic salmon (Salmo salar)

Evidence of selection acting on major histocompatibility complex (MHC) genes has been illustrated with the analysis of their nucleotide sequences and allele frequency distribution. Comparing the patterns of population differentiation at neutral markers and MHC genes in the wild may provide further insights about the relative role of selection and neutrality in shaping their diversity. In this study, we combine both methods to assess the role of selection on a MHC gene in Atlantic salmon. We compare variation at a MHC class II B locus and microsatellites among 14 samples from seven different rivers and seven subpopulations within a single river system covering a variety of habitats and different geographical scales. We show that diversifying selection is acting on the sites involved in antigen presentation and that balancing selection maintains a high level of polymorphism within populations. Despite important differences in habitat type, the comparison of the population structure at MHC and microsatellites on large geographical scales reveals a correlation between patterns of differentiation, indicating that drift and migration have been more important than selection in shaping population differentiation at the MHC locus. In contrast, strong discrepancies between patterns of population differentiation at the two types of markers provides support for the role of selection in shaping population structure within rivers. Together, these results confirm that natural selection is influencing MHC gene diversity in wild Atlantic salmon although neutral forces may also be important in their evolution.

A monoclonal cytolytic T-lymphocyte response observed in a melanoma patient vaccinated with a tumor-specific antigenic peptide encoded by gene MAGE-3

Vaccination of melanoma patients with tumor-specific antigens recognized by cytolytic T lymphocytes (CTL) produces significant tumor regressions in a minority of patients. These regressions appear to occur in the absence of massive CTL responses. To detect low-level responses, we resorted to antigenic stimulation of blood lymphocyte cultures in limiting dilution conditions, followed by tetramer analysis, cloning of the tetramer-positive cells, and T-cell receptor (TCR) sequence analysis of the CTL clones that showed strict specificity for the tumor antigen. A monoclonal CTL response against a MAGE-3 antigen was observed in a melanoma patient, who showed partial rejection of a large metastasis after treatment with a vaccine containing only the tumor-specific antigenic peptide. Tetramer analysis after in vitro restimulation indicated that about 1/40,000 postimmunization CD8(+) blood lymphocytes were directed against the antigen. The same TCR was present in all of the positive microcultures. TCR evaluation carried out directly on blood lymphocytes by PCR amplification led to a similar frequency estimate after immunization, whereas the TCR was not found among 2.5 x 10(6) CD8(+) lymphocytes collected before immunization. Our results prove unambiguously that vaccines containing only a tumor-specific antigenic peptide can elicit a CTL response. Even though they provide no information about the effector mechanisms responsible for the observed reduction in tumor mass in this patient, they would suggest that low-level CTL responses can initiate tumor rejection.

'Good genes as heterozygosity': the major histocompatibility complex and mate choice in Atlantic salmon (Salmo salar)

According to the theory of mate choice based on heterozygosity, mates should choose each other in order to increase the heterozygosity of their offspring. In this study, we tested the 'good genes as heterozygosity' hypothesis of mate choice by documenting the mating patterns of wild Atlantic salmon (Salmo salar) using both major histocompatibility complex (MHC) and microsatellite loci. Specifically, we tested the null hypotheses that mate choice in Atlantic salmon is not dependent on the relatedness between potential partners or on the MHC similarity between mates. Three parameters were assessed: (i) the number of shared alleles between partners (x and y) at the MHC (M(xy)), (ii) the MHC amino-acid genotypic distance between mates' genotypes (AA(xy)), and (iii) genetic relatedness between mates (r(xy)). We found that Atlantic salmon choose their mates in order to increase the heterozygosity of their offspring at the MHC and, more specifically, at the peptide-binding region, presumably in order to provide them with better defence against parasites and pathogens. This was supported by a significant difference between the observed and expected AA(xy) (p = 0.0486). Furthermore, mate choice was not a mechanism of overall inbreeding avoidance as genetic relatedness supported a random mating scheme (p = 0.445). This study provides the first evidence that MHC genes influence mate choice in fish.

Factors affecting the sterility of work areas in barrier isolators and a biological safety cabinet

Factors affecting the sterility of the work area in barrier isolators and a biological safety cabinet (BSC) were studied. A study in a mother-and-child tertiary care teaching hospital in Canada examined the effects of a range of variables on the sterility of work areas in four barrier isolators and a standard BSC. The variables consisted of type of equipment (barrier isolator or BSC), day of the week (Monday through Thursday), time of day (0800-1000, 1000-1200, 1200-1400, and 1400-1600), sampling site (16 surfaces and 5 air sedimentation zones), type of product prepared (antimicrobial, total parenteral nutrient solution, etc.), cleaning procedure (before or after primary cleaning), and level of product preparation activity (none to intense). A total of 657 surface and air sedimentation samples, 327 plated onto Trypticase soy agar (TSA) and 330 onto Sabouraud dextrose agar (SAB-D), were taken during a 20-day period. Thirty-three (5%) of the samples yielded microbial growth when cultured (24 on TSA and 9 on SAB-D). A total of 74 isolates were identified, including Bacillus, Staphylococcus, Penicillium, Micrococcus, Corynebacterium, and Mucor species. Single-variable analysis showed that sampling site, sample type, the time of day samples were taken, and the types of equipment contributed significantly to microbial growth in the samples taken. Several variables were associated with microbial growth in samples from the work areas of barrier isolators and a BSC. More study is needed to compare BSCs and barrier isolators with respect to sterility.

Monoclonal antibody 57B stains tumor tissues that express gene MAGE-A4

Monoclonal antibody (Mab) 57B, which was raised against a recombinant MAGE-A3 protein, was tested for its ability to stain cells expressing various members of the MAGE-A gene family. COS-7 cells transfected with cDNAs encoding MAGE-A1, A2, A3, A4, A6, or A12 were stained, whereas those transfected with MAGE-A8, A9, A10, or A11 cDNAs were not. However, in tissue sections, we observed a different pattern of staining: the antibody effectively stained the tumors that expressed MAGE-A4 and only these tumors, regardless of the expression of the other MAGE-A genes. It seems, therefore, that at the level of MAGE gene expression found in tumors, a level clearly lower than that observed in transfected COS cells, only the MAGE-A4 protein can be reliably detected. We conclude that the 57B Mab should be useful for tumor diagnosis related to therapeutic vaccination involving MAGE-A4.

High frequency of autologous anti-melanoma CTL directed against an antigen generated by a point mutation in a new helicase gene

We have identified an Ag recognized by autologous CTL on the melanoma cells of a patient who enjoyed an unusually favorable clinical evolution. The antigenic peptide, which is presented by HLA-A28 molecules, is encoded by a mutated sequence in a new gene. This gene, which was named MUM-3, is expressed ubiquitously and shows homology with the RNA helicase gene family. Limiting dilution analysis indicated that at least 0.15% of the blood CD8 T cells were tumor-specific CTL precursors. The MUM-3 Ag was recognized by 90% of these CTL, indicating that it is the dominant target Ag of the tumor-specific CTL response. The high frequency of anti-MUM-3 CTL was confirmed with tetramers of soluble HLA-A28 molecules loaded with the antigenic peptide. MUM-3 tetramers stained 1.2% of blood CD8 cells, a frequency that has never been reported for T cells directed against a strictly tumor-specific Ag. To confirm these results, the CD8 T cells that were clearly labeled with tetramers were restimulated in clonal conditions. About 90% of these cells proliferated, and all the resulting clones proved lytic and MUM-3 specific. By improving the conditions used for the in vitro restimulation of CTL precursors by the tumor cells, the same frequency could be obtained in limiting dilution analysis. These results show that some cancer patients have a high frequency of circulating CTL that are directed against a strictly tumor-specific Ag. These CTL are responsive to restimulation in vitro and are easily detected with tetramers. Such responses may therefore be an achievable goal for therapeutic vaccination with tumor-specific Ags.

3D reconstruction method from biplanar radiography using non-stereocorresponding points and elastic deformable meshes

Standard 3D reconstruction of bones using stereoradiography is limited by the number of anatomical landmarks visible in more than one projection. The proposed technique enables the 3D reconstruction of additional landmarks that can be identified in only one of the radiographs. The principle of this method is the deformation of an elastic object that respects stereocorresponding and non-stereocorresponding observations available in different projections. This technique is based on the principle that any non-stereocorresponding point belongs to a line joining the X-ray source and the projection of the point in one view. The aim is to determine the 3D position of these points on their line of projection when submitted to geometrical and topological constraints. This technique is used to obtain the 3D geometry of 18 cadaveric upper cervical vertebrae. The reconstructed geometry obtained is compared with direct measurements using a magnetic digitiser. The order of precision determined with the point-to-surface distance between the reconstruction obtained with that technique and reference measurements is about 1 mm, depending on the vertebrae studied. Comparison results indicate that the obtained reconstruction is close to the actual vertebral geometry. This method can therefore be proposed to obtain the 3D geometry of vertebrae.

APH-1, a POU homeobox gene expressed in the salt gland of the crustacean Artemia franciscana

We characterized the first POU-homeoprotein in a crustacean (designated APH-1 for Artemia POU-Homeoprotein, EMBL Y15070). The amino acid sequence of the APH-1 POU-domain is identical, except for two residues, to that of the two class III POU proteins Cf1-a (Drosophila) and POU-M1 (Bombyx mori). Southern blot analysis suggests that crustaceans have only one class III POU gene. RT-PCR and whole-mount in situ hybridization show that APH-1 mRNA is present in larvae specifically in the salt gland, an organ which is involved in osmoregulation, and disappears in the adult.

Comparison between a short and a conventional blade periodontal curet: an in vitro study

This in vitro study was done to compare a short-blade, long-shank (test) curet designed for deeper pockets of incisors and a conventional Gracey 1/2 curet regarding (a) their ability to remove root surface material at different pocket depths, and (b) their effect on root surface roughness. 2 groups of 12 senior dental hygiene students used either the randomly assigned test or conventional curet for a defined period on maxillary and mandibular incisors in a cross-over experimental design. Extent of root debridement was determined by assessing the removal of black enamel paint on root surfaces within pockets using a computerized video routine and root surface roughness measured using a profilometer. When each surface of the root was analyzed separately at 2-mm increments, the test instrument exhibited superior material removal on all surfaces at the 4-6 mm CAL (p-values<0.001). However, the test curet caused a rougher surface than the conventional curet on all surfaces (p<0.001), with a mean difference of 0.27 microm. While it is assumed that the ability of the test instrument to debride the root surface of deeper pockets more thoroughly is clinically more important than the rougher root surfaces it produces, this can only be assessed by further studies in vivo.

[Overuse of psychotropic drugs in seniors]

Seniors take three times as many drugs as the general population and are the group most vulnerable to the adverse effects of drug therapy. For this reason, it is extremely important that they receive support to help them understand and manage their medications. To highlight the major problems in managing medication, determine the risk factors and prevent overdosing of psychotropic drugs in seniors, the authors carried out a study of 549 senior rural residents living at home. The study findings indicate that 19 per cent of people aged 65 or over take no drugs at all, while 24 per cent have five prescriptions or more. Two thirds of respondents (65.7%) who had only one prescription were well informed about their medication, compared with just 14 per cent of those taking five drugs or more. One quarter (27%) said they never received information about their prescription, while 17.3 per cent reported that the labels on their prescription bottles were useless because the print was too small, too pale or because they could not read them. Close to half the respondents (42.6%) reported occasionally forgetting whether they had taken their medication. The findings also indicate that the respondents' sex, their perception of their personal state of health, the population density, and the depression index are all major variables that significantly relate to use of psychotropic drugs. All of the findings identify the specific needs of seniors and suggest a focus for nursing intervention.

[Morphometric characteristics of the scoliotic spine]

GOAL

Results from a morphometric investigation performed on a rare complete scoliotic specimen are presented. The aim of the study is to describe the vertebral body wedging.

MATERIALS

The specimen used in the study presented a thoracic curve of 150 degrees Cobb angle with the apex at T8. The measures were made using 3D-computer graphics models. The wedging in the frontal and sagittal planes as well as the 3D wedging were measured. The height variation of the vertebral bodies was also measured.

RESULTS

The wedging measures show that it increases progressively with the vertebral level to reach a maximum of 27 degrees at the apex. Perdriolle has found a linear relation between the vertebral body wedging and the Cobb angle. The relation predicts a wedging of 24 degrees for 150 degrees of Cobb angle. An inflection point was identified on the vertebral end plate on the convex side. These inflection points were described by Perdriolle as being on the concave side of the vertebra.

CONCLUSION

Our measures follow the relation between the Cobb angle and the wedging of the vertebral body, even for very large Cobb angles. Furthermore, inflection points on the vertebral body were identified on the convex side as opposed to the concave side in the literature. This leads us to believe that the vertebral body wedging progressively affects the vertebral endplates.

Mutations of the beta2-microglobulin gene result in a lack of HLA class I molecules on melanoma cells of two patients immunized with MAGE peptides

Mutations have been identified in the beta2-microglobulin gene of tumor cells of two metastatic melanoma patients who received immunizations with MAGE peptides. One mutation abolishes the start codon whereas the other introduces a premature stop codon. The second beta2-microglobulin allele of both tumors appears to be lost on the basis of sequence data and loss of microsatellite heterozygosity. The lack of beta2-microglobulin gene product results in the absence of HLA class I antigens on the surface of the tumor cells. This may explain why the tumors of both patients progressed despite the immunization treatment and shows the necessity of analyzing in depth the antigen presentation capability of the tumor cells for the interpretation of clinical trials involving anti-tumor vaccination.

[Computer graphic analysis of the three dimensional deformities of scoliotic vertebrae]

GOAL

A computer graphics method that permits the reconstruction, visualization and measure of the vertebral deformities of the scoliotic spine is presented.

MATERIALS

Medical imaging techniques utilizing computerized tomography is at the foundation of the reconstruction technique. The studied morphometric parameters are: 1) vertebral body wedging, 2) transverse and spinous process orientation and dimensions and 3) bilateral variation of pedicular dimensions.

RESULTS

The reconstructed specimen showed the usefulness of this technique for visualizing and measuring vertebral deformities. Preliminary results seem to be in agreement with the literature concerning the deformities of scoliotic vertebrae.

CONCLUSION

This tool will be useful in morphometric investigations for the evaluation of the deformations of scoliotic vertebrae.

Functional analysis of the Numb phosphotyrosine-binding domain using site-directed mutagenesis

The Numb protein is involved in cell fate determination during Drosophila neural development. Numb has a protein domain homologous to the phosphotyrosine-binding domain (PTB) in the adaptor protein Shc. In Shc, this domain interacts with specific phosphotyrosine containing motifs on receptor tyrosine kinases and other signaling molecules. Residues N-terminal to the phosphotyrosine are also crucial for phosphopeptide binding to the Shc PTB domain. Several amino acid residues in Shc have been implicated by site-directed mutagenesis to be critical for Shc binding to receptor tyrosine kinases. We have generated homologous mutations in Numb to test whether, in vivo, these changes affect Numb function during Drosophila sensory organ development. Two independent amino acid changes that interfere with Shc binding to phosphotyrosine residues do not affect Numb activity in vivo. In contrast, a mutation shown to abrogate the ability of the Shc PTB domain to bind residues upstream of the phosphotyrosine virtually eliminates Numb function. Similar results were observed in vitro by examining the binding of the Numb PTB domain to proteins from Schneider S2 cells. Our data confirm the importance of the PTB domain for Numb function but strongly suggest that the Numb PTB domain is not involved in phosphotyrosine-dependent interactions.

Postnatal localization and morphogenesis of cells expressing the dopaminergic D2 receptor gene in rat brain: expression in non-neuronal cells

The cellular localization of the dopaminergic D2 receptor (D2R) mRNA and protein was determined during postnatal development, from birth to 35 days, in the rat neostriatum by in situ hybridization histochemistry and immunohistochemistry. To localize and identify more precisely the morphology of cells expressing the D2R mRNA, nonradioactive, digoxigenin in situ hybridization was performed. Throughout this period of development, D2R mRNA and protein were widely expressed by neostriatal cells, adjoining forebrain cells and small cellular processes. Within morphologically identifiable neurons, the expression of the D2 receptor appeared to occur after cell division ceased. D2R gene expression appeared during neuronal migration and followed the developmental pattern of neuronal settling within the neostriatum. Both D2R mRNA and protein appeared to colocalize in neostriatal cells and the labeling of both appeared to accumulate within the cells progressively with age. The structural phenotypes of neostriatal neurons bearing D2R mRNA and protein were diverse throughout postnatal development. The most frequently stained cells were a heterogeneous group of medium spiny and aspiny neurons. Large cells corresponding to aspiny neurons were less frequently stained. Both phenotypes exhibited considerable postnatal growth of their cell bodies. In addition to neurons, other cell types were also observed to express the D2R mRNA and protein over the developmental period studied. These other cells included patches of ciliated ependymal cells lining the lateral ventricles and many interfascicular oligodendroglia of forebrain fiber tracts. These results demonstrate the unexpected expression of the dopaminergic D2 receptor in non-neuronal cells within the brain. They provide a novel morphologic suggestion that the dopaminergic D2 receptor may support unrecognized, nonsynaptic functions in specific non-neuronal cell populations in the nervous system.

HNF-6 is expressed in endoderm derivatives and nervous system of the mouse embryo and participates to the cross-regulatory network of liver-enriched transcription factors

Hepatocyte nuclear factor-6 (HNF-6) is a liver-enriched transcription factor that contains a single cut domain and a novel type of homeodomain. Here we have studied the developmental expression pattern of HNF-6 in the mouse. In situ hybridization experiments showed that HNF-6 mRNA is detected in the liver at embryonic day (E) 9, at the onset of liver differentiation. HNF-6 mRNA disappeared transiently from the liver between E12.5 and E15. In transfection experiments HNF-6 stimulated the expression of HNF-4 and of HNF-3 beta, two transcription factors known to be involved in liver development and differentiation. HNF-6 was detected in the pancreas from E10.5 onward, where it was restricted to the exocrine cells. HNF-6 was also detected in the developing nervous system. Both the brain and the spinal cord started to express HNF-6 at E9-9.5 in postmitotic neuroblasts. Later on, HNF-6 was restricted to brain nuclei, to the retina, to the ventral horn of the spinal cord, and to dorsal root ganglia. Our observations that HNF-6 contributes to the control of the expression of transcription factors and is expressed at early stages of liver, pancreas, and neuronal differentiation suggest that HNF-6 regulates several developmental programs.

Could oral erythromycin optimize high energy continuous enteral nutrition?

BACKGROUND

Intravenous erythromycin has previously been reported to stimulate gastric emptying, to inhibit gastric acid secretion and to stimulate pancreatic secretion during continuous gastric infusion of a liquid diet in healthy volunteers.

AIM

The aim of this study was to evaluate the effects of oral erythromycin (160 mg/h) on gastrointestinal function under these conditions in seven healthy subjects.

METHOD

This randomized double-blind cross-over study measured the gastric emptying rate of nutrients, gastric acid secretion, gastric pH, jejunal flow rate as well as biliopancreatic secretion and duodeno-caecal transit time during a 19.9 kJ/min continuous infusion of a nutrient solution (4.18 kJ/mL) in the antrum over a 6-h period by a perfusion method.

RESULTS

The nutrition was well tolerated except by one subject with placebo perfusion. During the 6-period, total gastric volume and gastric volume of nutrient decreased during erythromycin administration by 22 +/- 8 and 22 +/- 6%, respectively. Gastric acid secretion was not modified by erythromycin. Lipase and bile salt outputs were significantly higher with erythromycin. The duodeno-caecal transit time was not statistically different with drug and placebo (169 +/- 15 and 146 +/- 19 min, respectively).

CONCLUSION

During continuous gastric infusion of a liquid diet, the effect of oral erythromycin on gastric emptying could be useful to optimize cyclic enteral nutrition or to enhance the tolerance of enteral nutrition.

Managed care fundamentals: implications for health care organizations and health care professionals

Managed care is changing our health care delivery system as radically as the computer chip has changed telecommunications. Health care professionals and organizations that do not understand managed care's implications will not be prepared for the future. For example, one implication of managed care is payment capitation, which is the transfer of financial risk from the insurer to the provider. As a result, health care providers, including occupational therapy professionals, need to be better managers of scarce resources by recognizing the cost implications among various alternative procedures while still delivering quality care. Under managed care with capitation, occupational therapists will need to learn to provide services within the parameters of a fixed budget, requiring reengineering of the therapies and processes of care and a considerable reduction in the procedures and modalities for any given treatment or therapy. As a result, patients will be required to do more for themselves, and occupational therapists will have to become better patient educators and motivators. Additionally, managed care will require changes in professional curriculums, emphasis through continuing education, and assimilation of better cost information to practitioners to facilitate decision making. Implications of managed care other than payment capitation are assigning to enrollees a gatekeeper who is responsible for limiting access to costly specialty services, practicing utilization review to audit usage patterns and provide constructive recommendations to reduce costs and improve service quality, and forming networks and associations among medical providers for developing economies of scale and providing an integrated continuum of health care services to enrollees.