Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

A domain-agnostic approach for characterization of lifelong learning systems

Despite the advancement of machine learning techniques in recent years, state-of-the-art systems lack robustness to "real world" events, where the input distributions and tasks encountered by the deployed systems will not be limited to the original training context, and systems will instead need to adapt to novel distributions and tasks while deployed. This critical gap may be addressed through the development of "Lifelong Learning" systems that are capable of (1) Continuous Learning, (2) Transfer and Adaptation, and (3) Scalability. Unfortunately, efforts to improve these capabilities are typically treated as distinct areas of research that are assessed independently, without regard to the impact of each separate capability on other aspects of the system. We instead propose a holistic approach, using a suite of metrics and an evaluation framework to assess Lifelong Learning in a principled way that is agnostic to specific domains or system techniques. Through five case studies, we show that this suite of metrics can inform the development of varied and complex Lifelong Learning systems. We highlight how the proposed suite of metrics quantifies performance trade-offs present during Lifelong Learning system development - both the widely discussed Stability-Plasticity dilemma and the newly proposed relationship between Sample Efficient and Robust Learning. Further, we make recommendations for the formulation and use of metrics to guide the continuing development of Lifelong Learning systems and assess their progress in the future.

Sociocultural influences on dietary behavior and meal timing among Native Hawaiian and Pacific Islander women at risk of endometrial cancer: a qualitative investigation

PURPOSE

Determine sociocultural influences on dietary behavior, body image, weight loss, and perceptions of the cultural appropriateness of a meal-timing intervention design and menu among Native Hawaiian and Pacific Islander (NHPI) women at risk of endometrial cancer.

METHODS

Six 90-min videoconference focus groups among NHPI women (n = 35) recruited by a community champion in Utah. Eligible women were aged ≥ 18 years at risk of endometrial cancer (i.e., BMI ≥ 25 kg/m², history of non-insulin-dependent diabetes or complex atypical endometrial hyperplasia) had a working cell phone capable of downloading a phone app, could use their cell phone during the day, and were not night-shift workers. Twelve semi-structured questions were posed during the focus groups. Using inductive qualitative methods based on Hatch's 9-step approach, de-identified transcript data were analyzed.

RESULTS

Overarching themes included economic factors, cultural influences, meal choice and timing, and perceptions of health. Subthemes included affordability, waste avoidance, inundated schedules, and cultural influences. Perceptions of body size and weight loss were influenced by family, community, and social media, whose messages could be conflicting. Important intervention components included satisfying, convenient pre-made meals, while barriers included the need to cook for family members.

CONCLUSIONS

Dietary interventions targeting metabolic health among NHPI women should consider the multitude of sociocultural and economic factors that influence food choices and meal timing in this population, including affordability, hectic schedules, and immigrant adjustment. Promoting the link between physical and mental well-being as opposed to weight loss is a key approach to reaching this population.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

A step towards truly independent access for everyone, everywhere

With good wayfinding, 72% of vision impaired people who normally use paratransit would prefer to use public transport services. However, good wayfindinfg services are hard to find. In the 30 years since the passing of the Americans with Disability Act (ADA) public policy has driven significant investment and advancements in accessibility in the United States. However, this has not yet led to a commensurate realization of freedom and independence for people with disabilities due to sustained psychosocial barriers. This paper describes the considerable progress being made in standards and technology for the delivery of wayfinding services to assist people in overcoming these barriers, whether their disabilities are visual, physical, or cognitive. Using an impact study of real-world trials of a novel infrastructure-free location technology for the provision of turn-by-turn instructions across indoor and wide-area environments, the authors will show how it is possible to deliver truly independent end-to-end access to public spaces and transport services. The Waymap technology uses wearable IoT devices and sensors within the smartphone to deliver an interactive audio-based augmented reality to guide and engage people as they explore the spaces around them. The paper focuses on how to scale wayfinding and travel services to be truly universal and the vital role played by nationally and internationally recognized standards with user involvement at their core.

How does better regulation shape EU health policy? A case study of unhealthy advertising regulation

Introduction

Better Regulation is a meta-regulatory tool designed to improve regulatory quality and reduce regulatory burden in the development of EU policy. Despite concerns by civil society that its operation may have a chilling effect on regulatory protections, its impact on health policy has not been researched systematically. Using provisions on high fat, sugar and salt (HFSS) food and alcohol advertising to children within the revision of the audiovisual media services directive (AVMSD) as a case study, we explore how the operation of Better Regulation affects EU health policy processes.

Methods

We employ a qualitative process tracing approach based on policy documents, Freedom of Information requests, media reporting, and expert interview data.

Results

After an evaluation in 2016, the revised AVMSD maintained a reliance on self- and co-regulation of alcohol and HFSS food advertising to children, despite significant evidence supportive of statutory measures and pressure from the public health community to strengthen provisions. This result aligns with calls from commercial actors to retain the status quo. Preliminary results indicate that pathways via which Better Regulation guidelines may have contributed to this outcome include, for instance, the structure and approach used in the impact assessment and the related scrutiny process, the design of the consultation strategy, and the evaluation criteria of the AVMSD proposal.

Conclusions

Considering how policymaking infrastructure - as a key political determinant of health - may shape the processes and dynamics underlying decision-making can support those working towards a policy environment which protects human and environmental health. In examining EU alcohol and HFSS food advertising provisions within the AVMSD revision through a focus on Better Regulation processes, we contribute a novel perspective towards explaining how measures to improve regulatory quality interact with actors’ agency to shape policy outputs.

Key messages

• The Better Regulation agenda should be understood as a key political determinant of health at the EU level.

• Understanding the ways in which governance tools such as Better Regulation can shape health policy is important for those engaged in promoting effective and evidence-informed public health action.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

The European Union Confronts COVID-19

Issue

The politics of European Union (EU) health policy are also the politics of European integration. Debate about EU policies always entails debate about the appropriate role and powers granted to the EU.

Description

From some angles, the EU looks more like a federation (ex EUA), deeply entrenched in its citizens' lives. It has a powerful shared culture among leaders and strong, entrepreneurial, and statelike political institutions. Its legal system is entwined with member state law to such an extent that member state courts have driven legal integration and change as much as EU institutions, both in general and in health. From another angle, it still looks like an international organization (ex WHO) or a regional trade block (ex Mercosur). We ask what policy a member state might make, but, in the case of the EU, many ask if the EU should have a policy at all. Should it respond, and, if so, how and to whose benefit?

Results

Like international organizations or confederations, though, the EU responds primarily to and is shaped by the demands of its member states. They have actively maintained this dichotomous structure so as to prevent transfer of power and loss of sovereignty. Member states ultimately determine the direction of the EU, and they have supported EU expansion only when they require a “European rescue of the nation state”.

Lessons

The EU's weak public health and social policy responses to the crisis reflect this effort on the part of member states to limit its role over the decades, whereas the major expansion in its role over the summer of 2020 reflects the perceived interests of member states, which now seek another European rescue of the nation state.

Main messages

This crisis of COVID-19 leave behind a different EU. Between the redefinition in salience, resource, and law of public health, shared European actions and the development of EU debt for member states, it is likely that a step forward promoted integration in health and beyond.

The microbiome mediates epiphyseal bone loss and metabolomic changes after acute joint trauma in mice

OBJECTIVE

To compare the early responses to joint injury in conventional and germ-free mice.

DESIGN

Post-traumatic osteoarthritis (PTOA) was induced using a non-invasive anterior cruciate ligament rupture model in 20-week old germ-free (GF) and conventional C57BL/6 mice. Injury was induced in the left knees of n = 8 GF and n = 10 conventional mice. To examine the effects of injury, n = 5 GF and n = 9 conventional naïve control mice were used. Mice were euthanized 7 days post-injury, followed by synovial fluid recovery for global metabolomic profiling and analysis of epiphyseal trabecular bone by micro-computed tomography (μCT). Global metabolomic profiling assessed metabolic differences in the joint response to injury between GF and conventional mice. Magnitude of trabecular bone volume loss measured using μCT assessed early OA progression in GF and conventional mice.

RESULTS

μCT found that GF mice had significantly less trabecular bone loss compared to conventional mice, indicating that the GF status was protective against early OA changes in bone structure. Global metabolomic profiling showed that conventional mice had greater variability in their metabolic response to injury, and a more distinct joint metabolome compared to their corresponding controls. Furthermore, differences in the response to injury in GF compared to conventional mice were linked to mouse metabolic pathways that regulate inflammation associated with the innate immune system.

CONCLUSIONS

These results suggest that the gut microbiota promote the development of PTOA during the acute phase following joint trauma possibly through the regulation of the innate immune system.

Helping the healer: population-informed workplace wellness recommendations for physician well-being

Background

The need to keep physicians healthy and in practice is critical as demand for doctors grows faster than the supply. Workplace wellness programmes can improve employee health and retain skilled workers.

Aims

To broaden our understanding about ways to help doctors coping with mental health problems and to develop population-informed workplace wellness recommendations for physician populations.

Methods

Researchers surveyed physicians to document potential warning signs and prevention strategies. A survey was issued to doctors who presented to a physician health programme with mental health complaints. The survey captured respondents' feedback about how to identify and prevent mental health problems. Data were analyzed using simple descriptive statistics.

Results

There were 185 participants. Half of respondents believed their problems could have been recognized sooner and 60% said they exhibited signs that could aid in earlier detection. Potential warnings included fluctuations in mood (67%), increased comments about stress/burnout (49%) and behavioural changes (32%). To improve detection, prevention and care-seeking for mental health problems, doctors endorsed multiple items related to the use of interpersonal supports, personal factors and organizational dynamics throughout the survey.

Conclusions

The findings confirmed earlier work demonstrating the value of social and organizational support in maintaining physician health. It further indicated that earlier identification and/or prevention of mental health problems is not only possible, but that medical organizations are uniquely situated to carry out this work.

Abstract P2-11-13: Meta-analysis of local recurrence of invasive breast cancer after electron intraoperative radiotherapy

Background: Electron intraoperative radiotherapy (IORT) can be used during breast conservation surgery to treat early-stage invasive breast cancer. While IORT may be an attractive alternative to traditional post-operative radiotherapy for many patients, its effectiveness in preventing local recurrence is still being evaluated. Using data from current clinical and observational studies, we aimed to assess the impact of single-fraction electron IORT on local recurrence rates.

Methods: Studies on single-fraction electron IORT during breast conservation surgery were identified through a search of PubMed and Google Scholar, as well as secondary referencing. Local recurrence rate was the main outcome of interest. Protocols from each publication were assessed for potential sources of heterogeneity. A meta-analysis of proportions, using binomial distribution to model the within-study variability and a random effects model, was conducted to estimate a pooled local recurrence rate. In order to estimate a 5-year recurrence rate, we applied a single-sample Poisson-normal model to model the probability of events occurring during a fixed period of time (60 months).

Results: A total of 13 independent publications were identified for abstraction. The analysis demonstrated a pooled monthly local recurrence rate of 0.02% per person-month (95% CI: 0.00 – 0.06%) for the studies with &lt; 5 years of follow-up, 0.03% per person-month (0.02 – 0.06%) for studies with ≥ 5 years of follow-up, and 0.02% per person-month (0.01 – 0.04%) overall. Based on this model, the predicted 5-year recurrence rate is 2.7%, with a 95% confidence interval of 1.9% - 3.7%.

Conclusions: According to the published literature, the rate of breast cancer local recurrence after electron IORT was 0.02% per person-month; with an adjusted 5-year recurrence rate of 2.7%. These findings support the recent guidelines from the American Society for Radiation Oncology (ASTRO) supporting the use of electron IORT in low-risk patients.

Citation Format: Harness J, Shah C, Brooks E, Via C, Vicini F. Meta-analysis of local recurrence of invasive breast cancer after electron intraoperative radiotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-13.

Web Science in Medicine and Healthcare

Objectives: Medical social-media provide a new source of information within information gaining contexts. Facts, experiences, opinions or information on behaviour can be found in the medical web and could support a broad range of applications. The intention of this Focus Theme is to bring the existing research together and to show the possi -bilities, challenges and technologies for Web Science in medicine and healthcare.

Methods: This editorial provides an overview on the landscape of medical social-media and their possibilities in supporting healthcare. Further, it summarizes the three papers included in this Focus Theme.

Results and Conclusions: The three papers of this Focus Theme consider different aspects of Web Science in medicine which are 1) detection of drug interactions from social media, 2) inferring community structures from online forums and 3) improving access to online videos through assignment of SNOMED CT terms. All three papers show the potential of medical social-media in support -ing health information gathering processes from the web. However, several issues still need to be addressed in future: Methods are necessary for identifying high quality information from the medical web as well as for processing the language that is used by social media users to report about their symptoms, diseases and other health issues.

Prescribing patterns for psychotic and behavioural symptoms in dementia: a national survey

Aims and Method

To compare current prescribing practice for psychotic and behavioural symptoms in dementia with the available research. An anonymous questionnaire was sent to all members of the Faculty of Old Age Psychiatry, enquiring about preferred drug treatments.

Results

Classical antipsychotics were chosen by 50% for psychotic symptoms over atypical antipsychotics (43%) and were preferred for aggression (48%) and sexual disinhibition (55%). Antidepressants were favoured in treating anxiety (41%) and lability (45%).

Clinical Implications

Alternatives to classical antipsychotics, especially for behavioural symptoms, have yet to be researched satisfactorily. In view of the continued widespread use of classical antipsychotics and recent concerns about their safety, we call for this to be addressed.

Medico-legal implications of drug treatment in dementia: prescribing out of licence

AIMS AND METHOD

There is increasing evidence-based knowledge in the drug treatment of psychotic and behavioural symptoms in dementia, but drugs do not possess a formal licence for these indications. Drug companies, health authorities, NHS trusts and medical defence unions were asked for their advice on the medico-legal implications for the prescribing clinician.

RESULTS

Drug companies, health authorities, medical defence unions and NHS trusts are aware of out-of-licence prescribing and leave ultimate accountability with the clinician. A suggested best practice is that of obtaining the patient's consent.

CLINICAL IMPLICATIONS

Out-of-licence prescribing for psychotic and behavioural symptoms in dementia is widespread. This patient group may be unable to grant consent. The accountability of individual clinicians should be supported by more adequate medico-legal frameworks.

Challenging cognitive cases among physician populations: case vignettes and recommendations

BACKGROUND

Physicians are not immune to cognitive impairment. Because of the risks created by practising doctors with these issues, some have suggested developing objective, population-specific measures of evaluation and screening guidelines to assess dysfunction. However, there is very little published information from which to construct such resources.

AIMS

To highlight the presentation characteristics and provide evaluation recommendations specific to the needs of physicians with actual or presumed cognitive impairment.

METHODS

A retrospective database and chart review of cognitively impaired doctors who presented to a physician health programme (PHP). Complex cases were highlighted using simple descriptives and clinical vignettes.

RESULTS

A total of 124 cases were included. Clients presented with a variety of issues other than cognitive concerns. We identified four principal domains of impairment: (i) diseases of (or in) the brain (48%); (ii) mood/ anxiety disorders or treatment side effects (28%); (iii) substance use (9%) and (iv) traumatic brain injury (7%). Age was not a good predictor of impairment and brief screening using the Montreal Cognitive Assessment demonstrated a ceiling effect with this cohort. Although many clients underwent some type of professional or personal transition, impairment did not necessarily indicate worse functioning after care.

CONCLUSIONS

Physician cognitive evaluations should consider a variety of secondary sources of information, particularly vocational performance reports. It may take time before cognitive impairment can be diagnosed or ruled-out in this population. Prior assumptions, especially for non-cognitive referrals, can lead to inaccurate diagnosis and referrals. PHPs must manage cognitive cases carefully, not only in their clinical complexity but also in their psychosocial aspects.

Physician health programmes and malpractice claims: reducing risk through monitoring

BACKGROUND

Physician health programmes (PHPs) are peer-assistance organizations that provide support to physicians struggling with addiction or with physical or mental health challenges. While the services they offer are setting new standards for recovery and care, they are not immune to public debate and criticism since some have concerns about those who are enrolled in, or have completed, such programmes and their subsequent ability to practice medicine safely.

AIMS

To examine whether medical malpractice claims were associated with monitoring by a PHP using a retrospective examination of administrative data.

METHODS

Data on PHP clients who were insured by the largest malpractice carrier in the state were examined. First, a business-model analysis of malpractice risk examined relative risk ratings between programme clients and a matched physician cohort. Second, Wilcoxon analysis examined differences in annual rates of pre- and post-monitoring claims for PHP clients only.

RESULTS

Data on 818 clients was available for analysis. After monitoring, those enrolled in the programme showed a 20% lower malpractice risk than the matched cohort. Furthermore physicians' annual rate of claims were significantly lower after programme monitoring among PHP clients (P < 0.01).

CONCLUSIONS

This is the only study examining this issue to date. While there are a variety of reasons why physicians present to PHPs, this study demonstrates that treatment and monitoring is associated with a lowered risk of malpractice claims and suggests that patient care may be improved by PHP monitoring.

Web science in medicine and healthcare

OBJECTIVES

Medical social-media provide a new source of information within information gaining contexts. Facts, experiences, opinions or information on behaviour can be found in the medical web and could support a broad range of applications. The intention of this Focus Theme is to bring the existing research together and to show the possibilities, challenges and technologies for Web Science in medicine and healthcare.

METHODS

This editorial provides an overview on the landscape of medical social-media and their possibilities in supporting healthcare. Further, it summarizes the three papers included in this Focus Theme.

RESULTS AND CONCLUSIONS

The three papers of this Focus Theme consider different aspects of Web Science in medicine which are 1) detection of drug interactions from social media, 2) inferring community structures from online forums and 3) improving access to online videos through assignment of SNOMED CT terms. All three papers show the potential of medical social-media in supporting health information gathering processes from the web. However, several issues still need to be addressed in future: Methods are necessary for identifying high quality information from the medical web as well as for processing the language that is used by social media users to report about their symptoms, diseases and other health issues.

Pathways for the hydrolysis of phorate: product studies by (31)P NMR and GC-MS

A new intramolecular mechanism is proposed for the hydrolysis of phorate. (31)P NMR was used to study the formation of P-containing products of phorate hydrolysis in situ. When hydrolysis was followed by (31)P NMR, a dominant P-containing product was found and was identified to be diethyl dithiophosphate using methylation and GC-MS. Combining the data from phorate hydrolysis at three different temperatures, thermodynamic parameters were calculated. The contributions of various possible pathways to phorate hydrolysis are discussed.

Evidence for altered synthesis of type II collagen in patients with osteoarthritis

There is evidence to suggest that the synthesis of type II collagen is increased in osteoarthritis (OA). Using an immunoassay, we show that the content of the C-propeptide of type II procollagen (CPII), released extracellularly from the newly synthesized molecule, is directly related to the synthesis of this molecule in healthy and osteoarthritic articular cartilages. In OA cartilage, CPII content is often markedly elevated (mean 7.6-fold), particularly in the mid and deep zones, reaching 29.6% of the content in newborn. Synthesis is also directly related to total collagen II content in OA, suggesting its importance in maintaining collagen content and cartilage structure. The release of CPII from cartilage is correlated directly with cartilage content. However, the increase in CPII in OA cartilage is not reflected in serum, where a significant reduction is observed. Together these studies provide evidence for alterations in procollagen II synthesis in vivo in patients with OA.

Effect of standard and high dose ranitidine on [13C]urea breath test results

OBJECTIVE

It has been suggested that standard dose H2 blockers will affect the [14-C]urea breath test. The aim of this study was to evaluate the effect of standard and high dose ranitidine on the [13C]urea breath test in a prospective cross-over study.

METHODS

Volunteers found to be positive for H. pylori by IgG serology and [13C]urea breath test were given either ranitidine 150 mg b.i.d. or 300 mg b.i.d. for 14 days. Repeat breath tests were completed on the last day of antisecretory dosing and study patients were immediately crossed over to the other ranitidine dose. The third breath test was performed at 14 days after initiation of the new dose.

RESULTS

A total of 20 volunteers were enrolled. Using the established cut-off of 2.4% for the commercial breath test, only one patient developed negative results on H2 blockers. This patient had negative breath tests on both ranitidine doses and remained test-negative off all medications 6 wk after study completion, suggesting either a false positive baseline test or an unexpected bacterial eradication. No specific trend in breath test results was observed for the group (p=NS). On ranitidine 300 mg, six of 19 patients elevated their breath results from 23% to 112% (mean 76%) above baseline.

CONCLUSION

Ranitidine at standard or high doses did not generate a reproducible decline in breath test results. Histamine 2 blockers do not need to be discontinued before urea breath testing.

Synthesis and oral efficacy of a 4-(butylethylamino)pyrrolo[2,3-d]pyrimidine: a centrally active corticotropin-releasing factor1 receptor antagonist

The syntheses of a centrally active nonpeptide CRF1 receptor antagonist 2, butylethyl[2,5-dimethyl-7-(2,4,6-trimethylphenyl)-7H-pyrrolo [2,3-d]pyrimidin-4-yl]amine (CP-154,526), and its analogs 11-14 and [3H]-2 are reported. The in vitro CRF1 receptor binding affinity in the series 2, the pharmacokinetic properties of 2 in rats, and the anxiolytic-like effects of orally administered 2 are presented.

Identification of C31 and C32 sterols in Pneumocystis carinii hominis-infected human lungs

Two sterols in autopsied whole lung specimens obtained from Pneumocystis carinii pneumonia patients were detected by gas-liquid chromatography and their structures were elucidated by mass spectrometry and nuclear magnetic resonance spectrometry. Both were in the lanosterol series; the C31 sterol, with a methyl group at C-24, was identified as euphorbol, and the more abundant C32 sterol, with an ethyl group at C-24, is given the trivial name pneumocysterol.

Side reactions in the pyroglutamic acid-7-amino-4-methylcoumarin synthesis

N-Formylpyroglutamic acid-7-amido-4-methylcoumarine and pyroglutamyl-pyroglutamic acid-7-amido-4-methylcoumarin are the major products in the synthesis of pyroglutamic acid-7-amido-4-methylcoumarin by phosphorus pentachloride in dimethylformamide and dicyclohexylcarbodiimide under pyridine activation.

D-arabitol metabolism in Candida albicans: construction and analysis of mutants lacking D-arabitol dehydrogenase

Candida albicans produces large amounts of the acyclic pentitol D-arabitol in culture and in infected animals and humans, and most strains also grow on minimal D-arabitol medium. An earlier study showed that the major metabolic precursor of D-arabitol in C. albicans was D-ribulose-5-PO4 from the pentose pathway, that C. albicans contained an NAD-dependent D-arabitol dehydrogenase (ArDH), and that the ArDH structural gene (ARD) encoded a 31-kDa short-chain dehydrogenase that catalyzed the reaction D-arabitol + NAD <=> D-ribulose + NADH. In the present study, we disrupted both ARD chromosomal alleles in C. albicans and analyzed the resulting mutants. The ard null mutation was verified by Southern hybridization, and the null mutant's inability to produce ArDH was verified by Western immunoblotting. The ard null mutant grew well on minimal glucose medium, but it was unable to grow on minimal D-arabitol or D-arabinose medium. Thus, ArDH catalyzes the first step in D-arabitol utilization and a necessary intermediate step in D-arabinose utilization. Unexpectedly, the ard null mutant synthesized D-arabitol from glucose. Moreover, 13C nuclear magnetic resonance studies showed that the ard null mutant and its wild-type parent synthesized D-arabitol via the same pathway. These results imply that C. albicans synthesizes and utilizes D-arabitol via separate metabolic pathways, which was not previously suspected for fungi.

Successful negotiations. Develop your personal strategy for negotiating

Successful managers are successful negotiators. This article addresses how to develop a negotiation strategy that fits an individual manager's personality and objectives. The authors provide 12 rules aimed at developing that personal strategy and also define the elements of power, skill, and timing, and their relevance to the negotiating process.

Factors Associated With Perceived Competency Levels of Graduating Seniors in a Baccalaureate Nursing Program

Factors hypothesized to affect perceived competency levels of graduating seniors were examined in three classes from a BSN program in a large southeastern university (N = 204). Although externship participation was unrelated to perceived competency, employment in a health care setting during the nursing program was positively related. Trait anxiety and social support were also significantly related to competency. A pervasive theme in both quantitative and qualitative data was students' desire for more practice of technical skills. Students also expressed the desire for more positive feedback from faculty. There are a number of implications of these findings, including curricular modifications, identification and intervention with highly anxious students, and increased faculty caring and support. Given the rigor of the professional nursing role, we owe it to our graduates to send them into the work arena with a healthy sense of self-confidence.

Promoting situational support for nurses in practice

Situational support entails promoting autonomy, control over practice, group cohesion, manager consideration, and substantive exchange. Support can reinforce nurses' coping mechanisms, preserve their integrity, and thereby promote quality patient care. Using concept clarification and case examples the authors identify support mechanisms and coping styles for nurses at work and discuss how situational support can be used to cope with stress.

Characterization of recombinant RI beta and evaluation of the presence of RI beta protein in rat brain and testicular extracts

Based upon recent reports that the mRNA from the regulatory (R) RI beta subunit of cAMP-dependent protein kinase (PKA) was expressed in testicular extracts, we determined whether testicular extracts exhibited RI beta protein. To accomplish this goal, we initially determined the fundamental labeling and ionic characteristics of recombinant RI beta. Recombinant RI beta eluted from DEAE-cellulose with a salt concentration (of 0.075 M) equivalent to its elution position from soluble mouse brain extracts with catalytic subunit-free RI alpha. As predicted by its amino acid sequence homology to RI alpha, recombinant RI beta was not phosphorylated by PKA but was labeled specifically with 8-azido-adenosine 3':5'-[32P]monophosphate (8-N3[32P]cAMP). Additionally, RI antisera reacted equally with RI alpha (47 kDa) and recombinant RI beta (53 kDa). However, recombinant RI beta exhibited an unexpectedly basic pI of 6.65-6.85. By using a pH gradient for isoelectric focussing that allowed for clear focussing of 8-N3[32P]cAMP-labeled recombinant RI beta, 8-N3[32P]cAMP-labeled RI beta was readily detected by two-dimensional gel electrophoresis in rat brain particulate extracts and exhibited a pI equivalent to that of recombinant RI beta. The 53-kDa RI beta was undetectable either by its immunoreactivity or upon photoaffinity labeling with 8-N3[32P]cAMP by one or two-dimensional gel electrophoresis in soluble or particulate extracts of testes of 14-day-old, 45-day-old, or adult rats or in epididymal sperm. However, 8-N3[32P]cAMP-labeled RI beta was detected, albeit in very small levels, by two-dimensional electrophoresis upon separation of PKAs in testes of 14-day-old rats by DEAE-cellulose chromatography but was absent in equivalent extracts from adult rat testes. These results demonstrate that the unexpectedly basic pI of RI beta allows for its clear separation by two-dimensional electrophoresis from the RII proteins and therefore allows for its unambiguous identification. Further studies, however, are required to resolve the basis for the apparent disparity in testis RI beta mRNA and protein.

The use of N-(7-nitrobenz-2-oxa-1,3-diazole-4-yl)-labeled lipids in determining transmembrane lipid distribution

Transbilayer lipid distribution of small unilamellar vesicles (SUVs) and large unilamellar vesicles (LUVs) was measured using 31P-nuclear magnetic resonance (NMR) spectroscopy, chemical modification with 2,4,6-trinitrobenzene sulfonic acid (TNBS) and dithionite reduction of N-(7-nitrobenz-2-oxa-1,3-diazole-4-yl)-labeled lipid (NBD-lipid). The dithionite assay was the most reproducible of the three assays, with 1.2% error for SUVs and 3.9% error for LUVs. The dithionite assay also agreed best with theoretical inner:outer leaflet ratios, based on vesicle diameters determined by electron microscopy (Thomas et al. (1989) Biochem. Biophys. Acta 978, 85-90). Dithionite assay measurements were within 2.7% of theoretical ratios for SUVs and 2.3% for LUVs, while the NMR assay for SUVs was 14% lower than theoretical ratios and 23% lower for LUVs. The accuracy of NBD-lipids as markers for total transbilayer lipid was investigated. NBD-labeled phosphatidylserine, phosphatidylcholine and phosphatidylglycerol were accurate markers for total transbilayer lipid distribution, as their distributions were in close agreement with theoretical ratios. However, NBD-labeled phosphatidylethanolamine displayed a slight preference for the inner leaflet at low mole fractions of phosphatidylethanolamine, while native phosphatidylethanolamine showed a preference for the outer leaflet at the same concentration. NBD-labeled phosphatidic acid also showed a slight preference for the inner leaflet. We conclude that although dithionite-based assessment of NBD-labeled lipids across membrane bilayers can be a powerful analytical tool, caution must be used in the interpretation of results.

Effects of reduced O2 delivery with anemia, hypoxia, or ischemia on peak VO2 and force in skeletal muscle

This investigation was designed to describe alterations in O2 uptake (VO2) and tension development in a contracting in situ gastrocnemious-plantaris muscle preparation during three conditions of reduced O2 delivery [arterial O2 concentration X blood flow (Q)]. The three conditions, hypoxemia (H), ischemia (I), and anemia (A), were matched for O2 delivery. A normoxic normal flow condition was also utilized for comparison. H was produced by respiring the animals with 9% O2 in N2; I was produced by lowering Q, and A was produced by hemodilution with 6% dextran. The stimulation pattern for the isometric tetanic contractions used was 1 train/s, and each train was 200 ms, 70 Hz, and 6 V. The muscle was maximally contracted during each of the experimental conditions, and the conditions were administered in random order. In each bout the contractions continued for 5 min with 30 min of rest between bouts. Samples of arterial and muscle venous blood were obtained during the last 30 s of each bout. VO2 during I (125 ml.kg-1.min-1) was less than during N (145 ml.kg-1.min-1; P < 0.05) and greater than during H or A (104 and 101 ml.kg-1.min-1, respectively; P < 0.05). Venous PO2 (PVO2) was significantly lower during H (17.1 Torr) compared with the other conditions; no differences existed between N, I, and A (26.8, 26.0, and 28.1 Torr, respectively). Tension development was reduced by the reduction of O2 delivery during I, H, and A compared with N. Tension developed among the reduced O2 delivery groups was not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteoarthritis in the human knee: a dynamic process of cartilage matrix degradation, synthesis and reorganization

The matrix of articular cartilage undergoes degenerative changes in osteoarthritis which involve a number of matrix molecules. The structural and mechanical integrity is organized around the composite collagen II, IX, XI fibrillar organization. The small proteoglycan decorin that binds to these fibrils may influence their structure and mechanical properties. Aggrecan interacts indirectly via hyaluronic acid and possibly directly through unknown mechanisms. When collagen is cleaved at the articular surface in early osteoarthritis, decorin and aggrecan are lost. Increases in decorin and aggrecan content occur deeper in the cartilage. This is accompanied by evidence for increased formation of collagen fibrils and increased degradation and synthesis of aggrecan and type II collagen. The net contents of these proteoglycan per tissue do not, however, change until advanced degeneration occurs. These degradative processes are likely catalyzed by metalloproteinases and cysteine proteases. Cartilage exhibits significant capacity for remodelling which may be enhanced by therapeutic management of this process.

Native but not denatured recombinant human immunodeficiency virus type 1 gp120 generates broad-spectrum neutralizing antibodies in baboons

The protection of individuals from human immunodeficiency virus type 1 (HIV-1) infection with an envelope subunit derived from a single isolate will require the presentation of conserved epitopes in gp120. The objective of the studies presented here was to test whether a native recombinant gp120 (rgp120) immunogen would elicit responses to conserved neutralization epitopes that are not present in a denatured recombinant gp120 antigen from the same virus isolate. In a large study of 51 baboons, we have generated heterologous neutralizing activity with native, glycosylated rgp120SF2 but not with denatured, nonglycosylated env 2-3SF2. After repeated exposure to rgp120SF2 formulated with one of several adjuvants, virus isolates from the United States, the Caribbean, and Africa were neutralized. The timing of the immunization regimen and the choice of adjuvant affected the virus neutralization titers both quantitatively and qualitatively. These results suggest that vaccination with native, glycosylated rgp120 from a single virus isolate, HIV-SF2, may elicit a protective immune response effective against geographically and sequentially distinct HIV-1 isolates.

The effects of caffeine on graded exercise performance in caffeine naive versus habituated subjects

The physiological effects of caffeine on subjects habituated to caffeine is relatively unstudied compared to those of caffeine naive subjects during graded exercise. Thus, the purpose of this investigation was to determine the effects of caffeine on maximal oxygen consumption (VO2max) and the anaerobic threshold in these two populations. Seventeen moderately trained males were classified according to caffeine usage: (1) caffeine consumption 25 mg.day-1 or less (CN) (n = 8) or (2) caffeine consumption above 300 mg.day-1 (CH) (n = 9). The subjects were tested post-absorptive on the same cycle ergometer on three occasions with 7 days separating the tests. One hour before each test the subject ingested either a gelatin capsule (C); 3 mg.kg-1 body weight of caffeine (C3); or 5 mg.kg-1 body weight of caffeine (C5). The subject then performed an incremental VO2max test beginning at 50 W and the work rate was increased 30 W every 2 min until the subject could not maintain the power output. Serial venous blood samples were drawn over 30 s at the end of each stage. The CN group significantly increased resting heart rate (fc) and expired ventilation volume (VE) after C3 and C5 and VO2 after C5. No significant differences were found for exercise VE, VO2, respiratory exchange ratio, fc or time to exhaustion. There were no significant differences (P less than 0.05) in the lactate threshold or the ventilatory threshold between treatment in either group. The CH subjects showed a significant increase (P less than 0.05) in resting plasma free fatty acid (FFA) concentration only during the C3 and C5 treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

A Strategy to Identify the Learning Needs of Staff Nurses

Rapidly changing technology and the trend toward specialization make continuing education (CE) vital for today's nurses. Various methods to assess CE needs of nurses are described in the literature. This article outlines an assessment strategy implemented to determine staff nurses' perceptions of their learning needs. In addition, head nurses and clinical directors were surveyed regarding their perceptions of the staff nurses' learning needs. The chosen strategy used limited resources to contact a large number of nurses within a short time frame. Results indicated that the three groups surveyed perceived similar learning needs for staff nurses.