Evaluation of cardiovascular disease in the turner syndrome population in Northern Ireland

Background

There is higher frequency of both congenital heart disease and acquired cardiovascular conditions in patients with Turner syndrome. It is associated with increased early morbidity and mortality compared with the general population related mainly to cardiovascular complications.

Purpose

We sought to ascertain the prevalence and outcomes of cardiac abnormalities in patients with Turner syndrome in Northern Ireland.

Methods

Patients with Turner Syndrome who attended cardiology or gynaecology clinics in the Belfast Health and Social Care Trust were identified and demographic and clinical data were obtained.

Results

165 patients who had undergone cardiovascular assessment and imaging were identified. The mean age was 38±13 years. Hypercholesterolaemia was present in 49.7%, hypertension in 21% and diabetes mellitus in 15.2%. Patients with these cardiovascular risk factors were older compared to those without (Table 1). Ischaemic heart disease was present in 2.4%. Cardiac structural abnormalities were present in 52 patients (31.5%) and bicuspid aortic valve was the most common abnormality (23.6%). 9.1% of patients had a history of cardiothoracic surgery or catheter intervention and 1 patient had a previous Type A aortic dissection surgically repaired. The variety and frequency of cardiac structural abnormalities are listed in Table 2.

Conclusion

The prevalence of structural cardiac abnormalities and cardiovascular risk factors in Turner patients greatly exceeds that of the general population. This highlights the need for screening with cross sectional cardiac imaging plus early identification and management of cardiovascular risk factors.

Funding Acknowledgement

Type of funding sources: None.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Background

Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital.

Methods

Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy.

Results

419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%.

Conclusion

International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (> ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (>10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

505 INTERLEUKIN-6, C-REACTIVE PROTEIN, FIBRINOGEN, AND RISK OF RECURRENCE AFTER ISCHEMIC STROKE: SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Interleukin-6, C-reactive protein, fibrinogen, and risk of recurrence after ischaemic stroke: Systematic review and meta-analysis

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in log_e-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset

BACKGROUND AND OBJECTIVES

Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution.

METHODS

Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared.

RESULTS

A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h.

CONCLUSIONS

In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.

Abstract P3-04-05: Identification of SAR439859, an orally bioavailable selective estrogen receptor degrader (SERD) that has strong antitumor activity in wild-type and mutant ER+ breast cancer models

Estrogen receptor positive (ER+) breast cancer accounts for 70% of all breast cancers and is primarily treated with endocrine therapy. Approximately 40% of patients on endocrine therapy will become resistant via a number of mechanisms. There is evidence that in many cases ER continues to play a central role, including mutations in ER leading to a constitutively active receptor. Estrogen receptor degraders like fulvestrant are effective in shutting down ER signaling; however, poor pharmaceutical properties limit fulvestrant clinical activity and prevent it from achieving maximum receptor blockade.

We describe the discovery of SAR439859, a novel, orally bioavailable SERD that is a potent antagonist and degrader of ER both in vitro and in vivo. SAR439859 has robust activity in multiple ER+ breast cancer cell lines including cells that are resistant to tamoxifen as well as cell lines harboring ER mutants. Across a large panel of ER+ cells, SAR439859 demonstrated broad and superior ER degradation activity than most SERDs undergoing clinical testing. This leads to a profound inhibition of ER signaling, better inhibition of cell growth and results in improved in vivo efficacy. SAR439859 demonstrated tumor regression in all ER+ BC models including MCF7-ESR1 mutant-Y537S model, as well as patient-derived xenograft model that is resistant to endocrine therapies. Furthermore, SAR439859 displays limited cross-resistance with other class of SERDs.

Taken together, these results suggest that SAR439859 would be of therapeutic benefit in metastatic BC setting for patients harboring wild type or mutant ER. SAR439859 is being advanced toward the clinic.

Citation Format: Shomali M, Cheng J, Koundinya M, Weinstein M, Malkova N, Sun F, Hebert A, Cindachao M, Hoffman D, McManus J, Levit M, Pollard J, Vincent S, Besret L, Adrian F, Winter C, El-Ahmad Y, Halley F, Hsu K, Lager J, Garcia-Echeverria C, Bouaboula M. Identification of SAR439859, an orally bioavailable selective estrogen receptor degrader (SERD) that has strong antitumor activity in wild-type and mutant ER+ breast cancer models [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-04-05.

Crustal fluid and ash alteration impacts on the biosphere of Shikoku Basin sediments, Nankai Trough, Japan

We present data from sediment cores collected from IODP Site C0012 in the Shikoku Basin. Our site lies at the Nankai Trough, just prior to subduction of the 19 Ma Philippine Sea plate. Our data indicate that the sedimentary package is undergoing multiple routes of electron transport and that these differing pathways for oxidant supply generate a complex array of metabolic routes and microbial communities involved in carbon cycling. Numerical simulations matched to pore water data document that Ca(2+) and Cl(1-) are largely supplied via diffusion from a high-salinity (44.5 psu) basement fluid, which supports the presence of halophile Archean communities within the deep sedimentary package that are not observed in shallow sediments. Sulfate supply from basement supports anaerobic oxidation of methane (AOM) at a rate of ~0.2 pmol cm(-3) day(-1) at ~400 mbsf. We also note the disappearance of δ-Proteobacteria at 434 mbsf, coincident with the maximum in methane concentration, and their reappearance at 463 mbsf, coinciding with the observed deeper increase in sulfate concentration toward the basement. We did not, however, find ANME representatives in any of the samples analyzed (from 340 to 463 mbsf). The lack of ANME may be due to an overshadowing effect from the more dominant archaeal phylotypes or may indicate involvement of unknown groups of archaea in AOM (i.e., unclassified Euryarchaeota). In addition to the supply of sulfate from a basement aquifer, the deep biosphere at this site is also influenced by an elevated supply of reactive iron (up to 143 μmol g(-1)) and manganese (up to 20 μmol g(-1)). The effect of these metal oxides on the sulfur cycle is inferred from an accompanying sulfur isotope fractionation much smaller than expected from traditional sulfate-reducing pathways. The detection of the manganese- and iron-reducer γ-Proteobacteria Alteromonas at 367 mbsf is consistent with these geochemical inferences.

Abstract P1-05-21: The role of epsin in promoting Epithelial-Mesenchymal Transition and metastasis by activating NF-kB signaling in breast cancer

Background: Breast Cancer progression and metastasis are multi-step processes that involve local tumor growth and invasion followed by tumor dissemination to and re-establishment at distant sites. The ability of a tumor to metastasize is the major determinant of the mortality of cancer patients. Thus, elucidating the molecular pathways essential for tumor metastasis is of high priority in cancer biology. We have previously demonstrated that deficiency of epsins, a family of endocytic clathrin adaptor proteins, decreases tumor growth by enhancing VEGF signaling in vascular endothelial cells and subsequently promoting dysfunctional tumor angiogenesis.

Research Objective: Our immediate aim in the current research is to determine the role of epsin in regulating breast cancer growth and metastasis by activating NF-κB signaling. Our ultimate goal is to seek better treatment for breast cancer patients.

Rationale: Our preliminary data demonstrate that epsins are overexpressed in human cancers, including breast cancer. Knockdown of epsins in human breast cancer cell line MDA-MB-231 inhibits in vitro cell proliferation and migration. Xenograft or tail-vein injection of epsin-deficient breast cancer cells reveals marked reduction in in vivo tumorigenesis and lung metastasis. Moreover, E-cadherin is increased and vimentin decreased in epsin-deficient MDA-MB-231 and in tumors derived from epsin-deficient MDA-MB-231 tumor models. Conversely, overexpression of epsin in breast epithelial cell line MCF10A and MDA-MB-231 results in decreased E-cadherin and increased vimentin expression.

Hypothesis: We hypothesize that epsin regulates EMT through modulating NF-κB signaling.

Methods: we use combined techniques of western blot, confocal immunofluorescence and RT-PCR to examine NF-κB activation.

Results: NF-κB phosphorylation, nuclear translocation and NF-κB target gene snail/slug expression is downregulated in epsin-deficient MDA-MB-231. Epsin overexpression in MDA-MB-231 increases NF-κB phosphorylation. Mechanistically, we show that epsin co-immunoprecipitates with components of TNF Receptor Signaling Complex (TNFR-SC) including TNFR1, TRADD, RIP, TRAF2 and NEMO in MDA-MB-231, which can be enhanced by TNFα stimulation. Conversely, recruitment of NEMO and TRAF2 to TNFR1 is impaired in epsin-deficient MDA-MB-231 compared to control upon TNFα treatment. Given that ubiquitin-interacting motifs (UIM) of epsin is important for its interaction with ubiquitinated proteins, we show that wild type (WT) but not a UIM-deficient mutant epsin (epsin ΔUIM) coprecipitates with TNFR1 in 293T cells. Overexpression of epsin ΔUIM inhibits NF-κB activation in MDA-MB-231 and 293T cells compared to WT. In addition, UIM of epsin and polyubquitination of RIP are required for the interaction of epsin with RIP in 293T cells response to TNFα.

Conclusion: epsin promotes breast cancer growth and metastasis by upregulating NF-kB signaling and EMT. Epsin serves as scaffolding protein through UIM-polyubiquitin chain interaction to stabilize TNFR1 signaling complex (TNFR-SC) and subsequently enhance NF-kB signaling in breast cancer cells. Our study provides a basis for novel therapeutic targets for the development of anti-metastatic cancer treatments.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-05-21.

Elevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure: a marker of diastolic dysfunction and clinical risk

BACKGROUND

B-type natriuretic peptide (BNP) is widely accepted in the evaluation of left ventricular systolic dysfunction and heart failure. However, little is known of the implications of elevated BNP levels in individuals with preserved systolic function (PSF).

AIMS

To investigate the drivers and clinical implications of elevated BNP levels in asymptomatic individuals with established PSF.

METHODS

We enrolled 154 individuals who all underwent physical examination, BNP evaluation and Doppler-echocardiographic studies. They were divided into those above and below the median BNP level (50 pg/ml).

RESULTS

Independent predictors of higher BNP were older age, more severe left ventricular hypertrophy (LVH), reduced E/A ratio and ischaemic heart disease. Survival and multivariable analysis demonstrated more death and/or admission in those above the median BNP (HR: 4.79, p=0.007).

CONCLUSIONS

Elevated BNP is the strongest, independent predictor of serious adverse cardiovascular outcomes in this population and requires closer clinical follow-up.

Cytocompatibility of novel tin oxide thin films

The capacity of tin oxide films to support cell growth was investigated. Three substrates were used for the test: glass coverslips, glass coverslips spin coated with tin oxide and commercially available 316 stainless steel. The wettabilities and surface roughness of the three surfaces were measured before seeding 3T3 fibroblasts onto the samples. The behaviour of the cells grown on the tin oxide was compared to the uncoated glass and the steel and results showed that the cell growth on tin oxide compared favourably with the other substrates. The surface wettability appeared to have the strongest effect on cell adhesion to tin oxide.

Multiple-quantum MAS NMR of quadrupolar nuclei. Do five-, seven- and nine-quantum experiments yield higher resolution than the three-quantum experiment?

The question of whether or not higher-order (five-, seven- and nine-quantum) multiple-quantum magic angle spinning (MQMAS) experiments yield isotropic NMR spectra of half-integer quadrupolar nuclei with higher resolution than the basic three-quantum MAS experiment is examined. The frequency dispersion is shown theoretically to be greatly increased in higher-order MQMAS spectra, but it is argued that whether or not this translates into an increase in resolution depends upon the ratio of the homogeneous to inhomogeneous contributions to the isotropic linewidth. Experimentally, it is demonstrated using three-, five- and seven-quantum 45Sc MAS NMR and three- and five-quantum 27Al MAS NMR of crystalline samples that higher-order MQMAS experiments can yield a real and useful increase in resolution but that, owing to the presence of inhomogeneous broadening in the isotropic spectra, this increase is less than the theoretically predicted value. A number of practical issues relating to resolution in MQMAS NMR are also pointed out.

Plasma and vessel wall lipoprotein lipase have different roles in atherosclerosis

Lipoprotein lipase (LPL) is a key enzyme in lipoprotein metabolism, and has been hypothesized to exert either pro- or anti-atherogenic effects, depending on its localization. Decreased plasma LPL activity is associated with the high triglyceride (TG);-low HDL phenotype that is often observed in patients with premature vascular disease. In contrast, in the vessel wall, decreased LPL may be associated with less lipoprotein retention due to many potential mechanisms and, therefore, decreased foam cell formation. To directly assess this hypothesis, we have distinguished between the effects of variations in plasma and/or vessel wall LPL on atherosclerosis susceptibility in apoE-deficient mice. Reduced LPL in both plasma and vessel wall (LPL(+/-)E(-/-)) was associated with increased TG and increased total cholesterol (TC) compared with LPL(+/+)E(-/-) sibs. However despite their dyslipidemia, LPL(+/-)E(-/-) mice had significantly reduced lesion areas compared to the LPL(+/+)E(-/-) mice. Thus, decreased vessel wall LPL was associated with decreased lesion formation even in the presence of reduced plasma LPL activity. In contrast, transgenic mice with increased plasma LPL but with no increase in LPL expression in macrophages, and thus the vessel wall, had decreased TG and TC and significantly decreased lesion areas compared with LPL(+/+)E(-/-) mice. This demonstrates that increased plasma LPL activity alone, in the absence of an increase in vessel wall LPL, is associated with reduced susceptibility to atherosclerosis. Taken together, these results provide in vivo evidence that the contribution of LPL to atherogenesis is significantly influenced by the balance between vessel wall protein (pro-atherogenic) and plasma activity (anti-atherogenic).

The influence of hospital-based prescribers on prescribing in general practice

OBJECTIVE

To document the influence of hospital prescribers on prescribing in general practice.

DESIGN AND PARTICIPANTS

Five percent of members of the Irish College of General Practitioners (n = 92) prospectively recorded 40 consecutive prescriptions.

INTERVENTIONS

The name, dose and amount of medicine prescribed as well as the indication for therapy, details of their practice, distribution of private/GMS patients, and the number of years since qualification were recorded. The cost of individual prescriptions was calculated based on the ingredient cost and the number of days of treatment. This was subsequently correlated with the origin of the prescription. Each prescription was classified as either new or repeat.

MAIN OUTCOME MEASURES AND RESULTS

Of 3286 prescriptions, 69% were for the state-supported General Medical Services (GMS) patients and 31% for private patients. Repeat prescriptions constituted 51%; 49% were new prescriptions. While hospital doctors initiated only 8% of private prescriptions, they initiated 38% of GMS prescriptions, particularly repeat prescriptions and those for cardiovascular, hormonal and centrally-acting agents. Prescriptions for anti-infectives, oral contraceptives, dermatological preparations and musculoskeletal drugs were mostly initiated in general practice. The median cost for hospital-initiated GMS prescriptions (5.93 Pounds) was greater than the cost of general practitioner (GP)-initiated prescriptions (3.49 Pounds; p < 0.01). Prescriptions from GPs who were qualified for less than 10 years and those with a mixed urban and rural practice were less costly (p < 0.05) than those issued by doctors qualified for over 10 years or working predominantly in an urban or rural area. These findings may also reflect differences in patient population, morbidity and demography.

CONCLUSIONS

Our study indicates that hospital-initiated prescriptions are responsible for a significant proportion, both in volume and cost of GP prescribing.

Accessible dental care for children

The development of a school-based comprehensive and cost-efficient oral health care program requires careful planning centered on the needs expressed by the community. Gaining the support and the cooperation of school officials and parents creates an environment that has a significantly greater opportunity for success. Location, appropriate design of the facility and support from a local charitable organization further insure excellent access and expeditious care.

Prosocial self-schemas, self-awareness, and children's prosocial behavior

Three studies examined the hypothesis that a child's prosocial self-schema predicts prosocial behavior. In Study 1, only self-aware boys showed a self-schema-behavior relation. Study 2 altered both salience of donating opportunity and relationship of recipient to donor. The hypothesized Self-Awareness x Self-Schema interaction was significant, and there were no gender differences. Study 3 systematically manipulated the salience of the donating opportunity. All participants were self-aware. For boys in high and low salience conditions, prosocial self-schema predicted donating behavior. For girls, prosocial self-schema predicted behavior only in the high salience condition. The findings demonstrate that self-schemas can regulate behavior when participants are self-aware. Girls, however, may require higher salience of the donating opportunity for the self-schema to affect their behavior.

Low rate of generic prescribing in the Republic of Ireland compared to England and Northern Ireland: prescribers' concerns

We compared the level of generic prescribing in the Republic of Ireland, Northern Ireland and England and surveyed the views of Irish College of General Practitioners members. In 1993, generic drugs (pure generics and branded generics together) comprised 17.4% of total dispensing in the General Medical Services Scheme, significantly less than Northern Ireland or England where pure generics alone comprised 25% and 38% respectively of total dispensing in the National Health Services. General practitioners accurately self-estimated their level of generic prescribing but are concerned about the reliability/quality of generic products on the market, possible legal liabilities associated with their use and the fact that pharmacists may legally dispense more expensive proprietary preparations in the case of private prescriptions written generically. Prescribers need reassurance regarding legal and quality assurance aspects of generic prescribing if the level of generic drug use is to increase.

A standardised breakfast tolerance test in pregnancy: comparison with the 75 g oral glucose tolerance test in unselected mothers and in those with impaired glucose tolerance

There is still disagreement concerning the optimal procedure for the diagnosis of milder degrees of hyperglycaemia in pregnancy. We have compared the results of a 75 g oral glucose tolerance test (OGTT) and a standardised breakfast test performed one week apart in 102 non-diabetic women with a singleton pregnancy. There was poor correlation between the two tests (r = 0.15) at two hours, and neither test was predictive of adverse maternal or fetal outcome. One hundred and four patients with impaired glucose tolerance, diagnosed at 30 weeks' gestation by 75 g OGTT, subsequently had a breakfast and lunch meal profile. There was no significant correlation between the two-hour OGTT value and either the two hour post-breakfast value (r = 0.35) or the maximum profile value (r = 0.33). Using the WHO diagnostic criterion of > 8 mmol/l for the OGTT and a maximum glucose concentration > 6.8 mmol/l for the meal profile, there was no relationship between an abnormal result in either test and pregnancy outcome. In our obstetric environment, the 75 g OGTT, a standardised breakfast test, and a structured meal profile, all failed to provide a useful indication of pregnancy outcome in mothers not already known to have diabetes.

The topology of transcription by immobilized polymerases

Current models for RNA synthesis involve an RNA polymerase that tracks along a static template. However, research on chromatin loops suggests that the template slides past a polymerase immobilized in a large transcription factory. The evidence for immobilized polymerases is reviewed, and a model for transcription by such fixed enzymes is presented. According to the model, gene activation would involve reducing gene-factory distance and increasing the affinity of a promoter for a factory. Locus controlling regions and enhancers would attach to a factory and increase the chances that a promoter could bind to a polymerase; after transcriptional termination, the gene would detach from the factory. As some RNA processing occurs cotranscriptionally, processing sites are also likely to be associated with the factory.

The effect of various oestrogens and progestogens on the susceptibility of low density lipoproteins to oxidation in vitro

OBJECTIVE

To investigate the effect of different oestrogens and progestogens, at various concentrations, on the oxidation of low density lipoproteins (LDL) in vitro.

METHODS

Oestradiol, oestrone, oestriol and equilin, as well as medroxyprogesterone acetate, norgestrel and norethisterone, were added to isolated male LDL, before it was oxidised in the presence of copper ions at 37 degrees C. The oxidation process was monitored spectrophotometrically by the production of conjugated dienes. The lag time to oxidation and the maximum rate of propagation of the reaction were used as measures of the resistance and susceptibility of the LDL to oxidation respectively.

RESULTS

The lag time was increased from 43.7 +/- 1.5 min (mean +/- SEM) for LDL without any added hormone, to 81.2 +/- 1.0 min by 1 microM oestradiol (P < 0.01), 77.9 +/- 4.6 min by 1 microM oestrone (P < 0.01), 67.6 +/- 6.2 min by 1 microM equilin (P < 0.01), and 51.8 +/- 2.8 min by 1 microM oestriol (P < 0.05). The maximum rate of propagation of the reaction was decreased from 0.23 +/- 0.01 nmol conjugated dienes/mg LDL-protein/min (mean +/- SEM) (control LDL) to 0.14 +/- 0.006 nmol/mg/min by oestradiol (P < 0.01), 0.15 +/- 0.009nmol/mg/min by oestrone (P < 0.01), 0.17 +/- 0.012 nmol/mg/min by equilin (P < 0.01) and 0.19 +/- 0.014 nmol/mg/min (P < 0.05) by oestriol. The progestogens alone had no antioxidant effect, nor did their addition to the oestrogens influence their antioxidant activity.

CONCLUSIONS

These results demonstrate that all oestrogens investigated have an inhibitory effect on LDL oxidation in vitro. The magnitude of this effect varied, being of the order oestradiol > oestrone > equilin > oestriol.

On the structure of replication and transcription factories

Recent experiments suggest that active polymerases are concentrated in large structures, 'factories', within eukaryotic nuclei. Data concerning the structure of these factories is reviewed.