Participant Engagement in Translational Genomics Research: Respect for Persons-and Then Some

The expansion of both formal and informal frameworks of "engaged" research in translational research settings raises emerging and substantial normative concerns. In this article, we draw on findings from a focus group study with members of a national consortium of translational genomic research sites. The goals were to catalog informal participant engagement practices, to explore the perceived roots of these practices and the motivations of research staff members for adopting them, and to reflect on their ethical implications. We learned that participant engagement is a deliberate strategy by research staff members both to achieve instrumental research goals and to "do research differently" in response to past research injustices. While many of the participant engagement practices used in translational genomic research are not new, important insights can be gained through a closer examination of the specific contours of participant engagement in this context. These practices appear to have been shaped by the professional training of genetic counselors and by the interests and needs of participants who enroll in clinical genomics studies. The contours of this contemporary application of engaged research principles have relevance not only to clinical genomics research but also to translational research broadly, particularly for how communities of clinical researchers are interpreting the principle of respect for persons. Our findings invite normative questions about the governance of these practices and sociological questions about whether and how clinical researchers in other professions are also engaging participants in translational research settings.

Development of consensus-based international antimicrobial stewardship competencies for undergraduate nurse education

BACKGROUND

There is growing recognition by national and international policymakers of the contribution nurses make towards antimicrobial stewardship. Although undergraduate education provides an ideal opportunity to prepare nurses for antimicrobial stewardship roles and activities, only two-thirds of undergraduate nursing programmes incorporate any antimicrobial stewardship teaching and only 12% cover all the recommended antimicrobial stewardship principles. Nurses also report that they do not have a good knowledge of antibiotics, and many have not heard of the term antimicrobial stewardship.

AIM

To provide international consensus on the antimicrobial stewardship competency descriptors appropriate for undergraduate nurse education.

METHODS

A modified Delphi approach comprising two online surveys delivered to an international panel of 15 individuals reflecting expertise in prescribing and medicines management in the education and practice of nurses; and antimicrobial stewardship. Data collection took place between February and March 2019.

FINDINGS

A total of 15 participants agreed to become members of the expert panel, of whom 13 (86%) completed round 1 questionnaire, and 13 (100%) completed round 2. Consensus was achieved, with consistently high levels of agreement across panel members, on six overarching competency domains and 63 descriptors, essential for antimicrobial stewardship practice.

CONCLUSION

The competency descriptors should be used to direct undergraduate nurse education and the antimicrobial stewardship practices of qualified nurses (including those working in new roles such as Nursing Associates) due to the high levels of agreement reached on competency descriptors.

Prioritizing research areas for antibiotic stewardship programmes in hospitals: a behavioural perspective consensus paper

SCOPE

Antibiotic stewardship programmes (ASPs) are necessary in hospitals to improve the judicious use of antibiotics. While ASPs require complex change of key behaviours on individual, team organization and policy levels, evidence from the behavioural sciences is underutilized in antibiotic stewardship studies across the world, including high-income countries (HICs). A consensus procedure was performed to propose research priority areas for optimizing effective implementation of ASPs in hospital settings using a behavioural perspective.

METHODS

A workgroup for behavioural approaches to ASPs was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). Eighteen clinical and academic specialists in antibiotic stewardship, implementation science and behaviour change from four HICs with publicly funded healthcare systems (e.g. Canada, Germany, Norway and the UK) met face-to-face to agree on broad research priority areas using a structured consensus method. Question addressed and recommendations: The consensus process assessing the ten identified research priority areas resulted in recommendations that need urgent scientific interest and funding to optimize effective implementation of ASPs for hospital inpatients in HICs with publicly funded healthcare systems. We suggest and detail behavioural science evidence-guided research efforts in the following areas: (a) comprehensively identifying barriers and facilitators to implementing ASPs and clinical recommendations intended to optimize antibiotic prescribing; (b) identifying actors ('who') and actions ('what needs to be done') of ASPs and clinical teams; (c) synthesizing available evidence to support future research and planning for ASPs; (d) specifying the activities in current ASPs with the purpose of defining a control group for comparison with new initiatives; (e) defining a balanced set of outcomes and measures to evaluate the effects of interventions focused on reducing unnecessary exposure to antibiotics; (f) conducting robust evaluations of ASPs with built-in process evaluations and fidelity assessments; (g) defining and designing ASPs; (h) establishing the evidence base for impact of ASPs on resistance; (i) investigating the role and impact of government and policy contexts on ASPs; and (j) understanding what matters to patients in ASPs in hospitals.

CONCLUSIONS

Assessment, revisions and updates of our priority-setting exercise should be considered at intervals of 2 years. To propose research priority areas in low- and middle-income countries, the methodology reported here could be applied.

Back kinematics at take-off in elite showjumping horses over an upright and parallel-spread fence forming part of a three-fence combination

The objective of this study was to evaluate head, neck and back kinematics during take-off in elite level horses jumping, and to compare these over an upright and parallel spread fence. Ten mixed-breed elite-level showjumping horses were opportunistically evaluated jumping the same 15-fence course (1.35 m) during a British Equestrian Federation World Class Performance three-day training session. Two fences were evaluated using high-speed motion-capture (250 Hz). Head, neck and back kinematics of the horse were determined at take-off, at vertical orientation of leading and trailing third metacarpus/tarsus and as the trailing hindlimb left the floor. Very consistent patterns between all horses over both upright and spread fences were observed in neck-trunk (NT) angle, lumbosacral (LS) angle, the angle of the thoracolumbar (TL) to horizontal and of LS to horizontal. Head-neck (HN), TL angle and distance to fence showed moderate variation between horses. There were no significant differences between fence-type in HN, NT, TL, LS angle or distance to the fence, but TL to the horizontal angle was greater over the spread for all stride phases. LS to the horizontal angle was greater over the upright when the leading forelimb was vertical at take-off and when the trailing hindlimb was vertical at take-off. These findings suggest that elite horses may use some similar strategies to achieve a successful jump. Further understanding regions which are most influenced by velocity, rider, and horse stability could enable us to modify jumping patterns for the performance and welfare of jumping horses.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

BACKGROUND

Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities.

AIM

To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education.

METHODS

A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017.

FINDINGS

A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals.

CONCLUSION

Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Quantification of warm-up patterns in elite showjumping horses over three consecutive days: a descriptive study

There is very little reported information on warm-up practices in showjumping horses. The objective was to quantify warm-up jumping patterns/duration in a competition (field) environment in showjumping horses. Ten mixed-breed elite showjumping horses were assessed at a three-day training session. Riders warmed-up as they would normally for an elite competition and jumped at least one round of a 15-fence (135-145 cm) course on each day. Fence type/height, number of jumping efforts and lead take-off/landing limbs during warm-up were recorded. Rider global-positioning-system and inertial-motion-sensors recorded speed, time spent in each pace/rein plus stride length and stride duration during warm-up and course. Heart rate (HR) was recorded when the horse was resting in its stable and for the duration of the ridden exercise. Appropriate paired statistical tests were used to compare variables between days, and between warm-up and the round(s). Mean warm-up duration, time in each pace and on each rein did not differ within rider between days, however, there were inter-rider differences (mean warm-up duration = 18 min; range = 12-27 min). Number of jumping efforts and fence type/height did not differ between days. During warm-up, there was no preference in canter lead when approaching fences. However, on departure there was a preferred canter lead, plus jump landing and leaving lead limb asymmetry (left canter lead predominating in all cases). Horses cantered slower, with a shorter stride length and a longer stride duration during warm-up compared to when jumping the round (speed – warm-up: 4.21±0.09 m/s; round: 5.53±0.15 m/s; stride length – warm-up: 2.59±0.06 m; round: 3.16±0.08 m; stride duration – warm-up: 0.62±0.02 s; round: 0.58±0.03 s). Mean resting HR significantly decreased on consecutive study days. Mean, peak and final HR during warm-up did not significantly change between days. Results provide novel information on warm-up patterns in a competition (field) environment for elite horses, and suggest that showjumping horses may be warmed-up asymmetrically.

Clinical Sequencing Exploratory Research Consortium: Accelerating Evidence-Based Practice of Genomic Medicine

Despite rapid technical progress and demonstrable effectiveness for some types of diagnosis and therapy, much remains to be learned about clinical genome and exome sequencing (CGES) and its role within the practice of medicine. The Clinical Sequencing Exploratory Research (CSER) consortium includes 18 extramural research projects, one National Human Genome Research Institute (NHGRI) intramural project, and a coordinating center funded by the NHGRI and National Cancer Institute. The consortium is exploring analytic and clinical validity and utility, as well as the ethical, legal, and social implications of sequencing via multidisciplinary approaches; it has thus far recruited 5,577 participants across a spectrum of symptomatic and healthy children and adults by utilizing both germline and cancer sequencing. The CSER consortium is analyzing data and creating publically available procedures and tools related to participant preferences and consent, variant classification, disclosure and management of primary and secondary findings, health outcomes, and integration with electronic health records. Future research directions will refine measures of clinical utility of CGES in both germline and somatic testing, evaluate the use of CGES for screening in healthy individuals, explore the penetrance of pathogenic variants through extensive phenotyping, reduce discordances in public databases of genes and variants, examine social and ethnic disparities in the provision of genomics services, explore regulatory issues, and estimate the value and downstream costs of sequencing. The CSER consortium has established a shared community of research sites by using diverse approaches to pursue the evidence-based development of best practices in genomic medicine.

Community engagement and informed consent in the International HapMap project

The International HapMap Consortium has developed the HapMap, a resource that describes the common patterns of human genetic variation (haplotypes). Processes of community/public consultation and individual informed consent were implemented in each locality where samples were collected to understand and attempt to address both individual and group concerns. Perceptions about the research varied, but we detected no critical opposition to the research. Incorporating community input and responding to concerns raised was challenging. However, the experience suggests that approaching genetic variation research in a spirit of openness can help investigators better appreciate the views of the communities whose samples they seek to study and help communities become more engaged in the science.

Unexpected relationship between plasma protein binding and the pharmacodynamics of 2-NAP, a CCK1-receptor antagonist

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT?: * Two chemically diverse CCK1 receptor antagonists have been shown clinically to inhibit CCK-evoked contraction of human gallbladder [2, 3]. These studies have not examined the relationship between plasma concentration and effect, the latter usually considered to be predictive from the free drug concentration [8]. * We wanted to examine our novel CCK1 receptor antagonist in this validated model and also to explore its PK-PD relationship.

WHAT THIS STUDY ADDS

* 2-NAP inhibited CCK-evoked human gallbladder contraction in vivo but at a plasma free concentration that was, in theory, too low to have achieved adequate CCK1 receptor occupancy. * The study serves as a caveat to the assumption that free plasma concentration can be used to predict pharmacological effect.

AIMS

To study the pharmacokinetics and pharmacodynamics of 2-NAP (2-naphthalenesulfonyl-L-aspartyl-(2-phenethyl)amide), a selective CCK1 receptor antagonist in healthy volunteers.

METHODS

2-NAP was given to 12 healthy male volunteers in an ascending dose, safety and PK phase 1a study by 1 h i.v. infusion (0.6-9.6 mg kg(-1) h(-1)). A further 12 healthy male volunteers received i.v. CCK-8S (6.25 pmol kg(-1) h(-1)) to produce gallbladder contraction, measured by ultrasound recordings of gallbladder volume, and the effect of concurrent i.v. 2-NAP administration was studied. Plasma protein binding in vitro and ex vivo was measured by ultrafiltration and by equilibrium dialysis.

RESULTS

2-NAP was generally well tolerated, displayed linear pharmacokinetics and a very high degree of plasma protein binding (99.9%). A 105 min i.v. CCK-8S infusion induced a reduction in gallbladder volume of 14.9 (+/-7.0) ml during placebo co-infusion and this was reduced to 2.4 (+/-5.9) ml when 2-NAP was co-infused with CCK-8S (P = 0.00024, paired t-test, mean change 12.5 ml; 95% CI For mean 7.4, 18.3 ml). This extent of inhibition was consistent with a 2-NAP total plasma concentration of 36 microm, but when protein binding corrections were made, the 'free concentration' of 2-NAP was only 0.04 microm, a value much less than the average equilibrium dissociation constant of 2-NAP for human CCK1 receptors ( approximately 0.7 microm).

CONCLUSIONS

The pharmacological effect of a drug is usually considered to be determined by its free concentration. However, the complete inhibition of CCK-8S-evoked gallbladder contraction by a free plasma concentration of 0.04 microm 2-NAP was much greater than would have been predicted from simple drug-receptor occupancy theory and cautions against the general use of free concentration of drug for predicting pharmacological effect.

Pharmacokinetics and safety of oral almotriptan in healthy male volunteers

Almotriptan (LAS 31416) is a new, oral, specific 5-hydroxytryptamine(1B/1D) receptor agonist for the treatment of migraine. The pharmacokinetics and safety of a range of oral doses were assessed in 23 healthy male volunteers. Peak plasma concentrations were reached between 1.5 and 4 h after dosing. The maximum plasma concentration and area under the curve showed dose proportionality over the dose range 5-200 mg. The elimination half-life was constant at approximately 3 h across all dose levels. A substantial proportion of the initial dose was excreted in urine (27%-39%) during 12 h post-dose and the main excretory product was unchanged drug. Three major urinary metabolites were detected, all of which were pharmacologically inactive. The most common events following almotriptan administration were headache, tiredness and mild nausea. Nine events (18%) were classed as probably related to almotriptan and these were all at the highest dose level of 200 mg. The maximum tolerated dose of almotriptan was, therefore, determined as 150 mg. In conclusion, almotriptan is well tolerated following single, oral doses up to 150 mg and has predictable pharmacokinetics.

Body mass index in early and mid-adulthood, and subsequent mortality: a historical cohort study

BACKGROUND

The aim of this study was to investigate the associations between body mass index (BMI) in early and mid-adulthood, and BMI change between these ages, and mortality.

METHODS

Historical cohort study of 629 men, who had height and weight measured at the Student Health Service of the University of Glasgow in 1948-1949 (median age 22 y) and who reported their weight in a postal questionnaire in 1963-1966 (median age 38 y). The participants were followed up until April 2002 (mean follow-up: 35 y). During this time, 124 men died, 68 of cardiovascular disease (CVD) and 33 of cancer.

FINDINGS

Mean BMI increased from 21.4 kg/m(2) (standard deviation (s.d.): 2.2 kg/m(2)) in early adulthood to 24.2 kg/m(2) (s.d.: 3.0 kg/m(2)) in mid-adulthood. All-cause mortality was associated with being overweight (BMI> or =25 kg/m(2)) at age 22 but not at age 38, adjusted hazard ratio (HR): 1.85 (95% confidence interval (CI) 1.09-3.13) and 1.05 (95% CI: 0.73-1.52), respectively. BMI at age 22 y was more strongly associated with CVD mortality than was BMI at age 38 y, adjusted HR(22 y): 2.41 (95% CI: 1.26-4.60) and HR(38 y): 1.33 (95% CI: 0.82-2.16). There was no clear relationship between cancer mortality and BMI at either age: HR(22 y): 0.68 (95% CI: 0.16-2.91), HR(38 y): 0.90 (95% CI: 0.44-1.84), although relatively few men died of cancer in the follow-up period. Similar patterns were seen for obesity (BMI> or =30 kg/m(2)) as for being overweight. Analyses of weight patterns indicated particularly detrimental effects of overweight persisting from early to mid-adulthood.

CONCLUSIONS

BMI in early adulthood is positively related to CVD mortality in later life in men. The risk associated with early adulthood adiposity appeared to be greater than that in mid-adulthood. We did not demonstrate an association between weight gain and later mortality. These results reinforce the need to stem the obesity epidemic in children and young adults.

Is maternal transmission of coronary heart disease risk stronger than paternal transmission?

OBJECTIVE

To test whether intergenerational transmission of coronary heart disease (CHD) to offspring is greater from the mother than from the father, the association between parental history of CHD and coronary mortality in male offspring was examined.

DESIGN

Prospective cohort study with 43 years of follow up.

SETTING

University of Glasgow.

PARTICIPANTS

Male students (n = 8402) aged 16-30 years when examined in 1948 to 1968.

MAIN OUTCOME MEASURE

Fatal CHD.

MAIN RESULTS

Of the 8402 men studied, 615 (7.3%) reported a history of CHD in at least one of the parents: 479 (5.8%) for fathers only, 124 (1.6%) for mothers only, and a further 12 (0.2%) for both their parents. During follow up, 373 (4.4%) men died of CHD. Parental history of disease was associated with fatal CHD and controlling for personal risk factors such as cigarette smoking, body mass index, systolic blood pressure, and father's social class did not attenuate this relation. The fully adjusted hazard ratios were 1.53 (95% confidence interval (CI) 1.08 to 2.18), 1.19 (95% CI 0.61 to 2.32), and 8.65 (95% CI 2.65 to 28.31) for father only, mother only, and both parents with CHD, respectively, compared with men whose parents did not have CHD. There was some evidence for interaction between parental histories (p = 0.049), with particularly high risk if both parents reported a history of CHD.

CONCLUSIONS

This study found no differential transmission of CHD. Paternal history of CHD was at least as important as maternal history. Data from other comparable cohorts provide no consistent evidence of differential transmission. Intergenerational transmission of CHD does not appear to have differential effects between mothers and fathers.

Body mass index in young adulthood and cancer mortality: a retrospective cohort study

STUDY OBJECTIVE

To examine the relation between body mass index (BMI) in young adulthood and subsequent mortality from cancer.

DESIGN

Cohort study.

SETTING

University of Glasgow student health service. Weight and height were measured by a physician, and used to calculate BMI.

PARTICIPANTS

8335 men and 2340 women who attended the student health service while at university between 1948 and 1968, and who were followed up with the NHS central register.

MAIN RESULTS

The main outcome measure was cancer mortality. Three hundred and thirty nine men and 82 women died of cancer during the follow up (mean 41 years). BMI was associated with mortality from all cancers in men and women, although it did not reach conventional statistical significance. The adjusted hazard ratio (HR) (95% CI) per 5 kg/m(2), was 1.22 (0.97 to 1.53) in men and 1.43 (0.95 to 2.16) in women. Two hundred men and 61 women died from cancers not related to smoking. The adjusted HR for mortality from these were 1.36 (1.02 to 1.82) and 1.80 (1.13 to 2.86) respectively. These results are adjusted for height, number of siblings, pulse rate, year of birth, age, smoking, birth order, number of siblings, and age at menarche in women. Site specific analyses, comparing the highest with the lowest quartile of the BMI distribution found increased risks of prostate cancer (n=28) and breast cancer among heavier subjects. No association between BMI and colorectal cancer was found.

CONCLUSIONS

BMI in adolescence has lasting implications for risk of cancer mortality in later life. Future research will include measures of BMI throughout the lifecourse, to determine the period of greatest risk of obesity, in terms of cancer mortality.

Conserved function of Caenorhabditis elegans UNC-30 and mouse Pitx2 in controlling GABAergic neuron differentiation

We are taking a cross-species approach to identify genes that are required for mammalian GABAergic neuron differentiation. On the basis of homeodomain similarity, the vertebrate Pitx genes appear to be orthologs of unc-30, a Caenorhabditis elegans gene necessary for differentiation of the GABAergic phenotype of type D neurons. One of the Pitx genes, Pitx2, is expressed in regions of GABAergic neurogenesis in the mammalian brain. These observations led us to test the functional conservation of the mouse Pitx2 and worm unc-30 genes using a rescue assay. Pitx2 rescues the GABAergic differentiation defect and partially rescues the axon guidance and behavioral phenotypes of unc-30 mutants, indicating a high degree of functional conservation between these evolutionarily related genes. Previous studies show that UNC-30 directly regulates the unc-25/glutamate decarboxylase gene that encodes the enzyme for GABA synthesis. We find that the promoter regions of the mouse and human genes coding for the 67 kDa glutamate decarboxylase (Gad1) also contain binding sites matching the UNC-30/Pitx2 consensus binding site sequence. We show that these sites specifically bind to Pitx2 protein in vitro and that in transfected neuroblastoma cells, the Pitx2 binding sites contribute to the basal activity of the Gad1 promoter. Furthermore, in cotransfection experiments, we find that Pitx2 strongly activates the Gad1 promoter. These results indicate that Pitx2 may regulate Gad1 expression in mammals, suggesting a new role for this key developmental transcription factor as a regulator of GABAergic differentiation during mammalian neural development. Our results suggest that some of the mechanisms regulating GABAergic differentiation are evolutionarily conserved.

Confidentiality and healthcare

This is the seventh in a series of articles on ethics, professional governance and the law that BJS will run through the remainder of 2001.

Resolution of pluripotential intermediates in murine hematopoietic differentiation by global complementary DNA amplification from single cells: confirmation of assignments by expression profiling of cytokine receptor transcripts

Although hematopoiesis is known to proceed from stem cells through a graded series of multipotent, oligopotent, and unipotent precursor cells, it has been difficult to resolve these cells physically one from another. There is, therefore, corresponding uncertainty about the exact distribution and timing of the expression of genes known to be important in hematopoietic differentiation. In earlier work, the generation of a set of amplified complementary DNAs (cDNAs) from single precursor cells was described, whose biologic potential was determined by the outcome of cultured sibling cells. In this study, the new acquisition of cDNA from multipotent myeloid precursor cells is described, as is the mapping of RNA-level expression of 17 distinct cytokine receptors (c-kit, Flk-1, Flk-2/Flt-3, c-fms, gp130, erythropoietin receptor, GM-CSFRalpha, G-CSFR, TNFR1, IL-1RI, IL-1RII, IL-2Rbeta, IL-3-specific beta receptor, IL-4R, IL-6Ralpha, IL-7Ralpha, and IL-11Ralpha) to the enlarged sample set, spanning stages from pentapotent precursors through oligopotent intermediates to committed and maturing cells in the myeloid and lymphoid lineages. Although the enhanced scope and resolving power of the analysis yielded previously unreported observations, there was overall agreement with known biologic responsiveness at individual stages, and major contradictions did not arise. Moreover, each precursor category displayed a unique overall pattern of hybridization to the matrix of 17 receptor probes, supporting the notion that each sample pool indeed reflected a unique precursor stage. Collectively, the results provide supportive evidence for the validity of the cDNA assignments to particular stages, the depth of the information captured, and the unique capacity of the sample matrix to resolve individual stages in the hematopoietic hierarchy.

Changes in blood pressure among students attending Glasgow University between 1948 and 1968: analyses of cross sectional surveys

OBJECTIVES

To examine the changes in blood pressure over time in a cohort of young adults attending university between 1948 and 1968.

DESIGN

Cross sectional study.

SETTING

Glasgow University.

PARTICIPANTS

12 414 students aged 16-25 years-9248 men (mean age 19.9 years) and 3164 women (19.2 years)-who participated in health screening on entering university between 1948 and 1968.

MAIN OUTCOME MEASURES

Systolic and diastolic blood pressure.

RESULTS

In male students mean systolic blood pressure adjusted for age decreased from 134.5 (95% confidence interval 133.8 to 135.2) mm Hg in those born before 1929 to 125.7 (125.0 to 126.3) mm Hg in those born after 1945, and diastolic blood pressure dropped from 80.3 (79.8 to 80.8) mm Hg to 74.7 (74.2 to 75.1) mm Hg. For female students the corresponding declines were from 129.0 (127.5 to 130.5) mm Hg to 120.6 (119.8 to 121.4) mm Hg and from 79.7 (78.7 to 80.6) mm Hg to 77.0 (76.5 to 77.5) mm Hg. Adjustment for potential confounding factors made little difference to these findings. The proportion of students with hypertension declined substantially in both sexes.

CONCLUSIONS

Substantial declines in systolic and diastolic blood pressure over time were occurring up to 50 years ago in young adults who were not taking antihypertensive medication. Since blood pressure tracks into adult life, the results of the cross sectional comparisons suggest that factors acting in early life may be important in determining population risk of cardiovascular disease. Changes in such factors may have made important contributions to the decline in rates of cardiovascular diseases, particularly stroke, seen in developed countries during the past century.

Quality of life in lung cancer patients: as an important prognostic factor

Given that lung cancer is one of the common cancers world-wide, the implications of focusing on quality of life as well as survival require to be understood. We have carried out a study of the relationship between survival and quality of life in patients with lung cancer comparing patients those who lived with those who died within 3 months. The design of the study allowed every patient in a defined geographical area with a potential diagnosis of lung cancer to be studied from first outpatient consultation till after a definitive treatment has been given. Quality of life was measured using three standard questionnaires: the Nottingham Health Profile (NHP), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer supplementary questionnaire (QLQ-LC13) in addition to a study specific questionnaire collecting data on demographic, social, clinical and performance status. The contribution of quality of life in relation to survival adjusted for known prognostic factors was determined using Cox's proportional hazard model. In all 129 lung cancer patients were interviewed, and 96 patients were alive at 3-months follow-up. Only 90 of 96 patients alive at 3-months follow-up were assessable. Descriptive analyses showed that those who were dead had more perceived health problems, greater level of symptoms and significant lower physical and role functioning and global quality of life at presentation. On the other hand, univariate analyses showed that patients' aggregate scores on the NHP, the functioning scores, and global quality of life scores alone were significant predictors of survival (P<0.03, P<0.04, P<0.04, respectively ). The multivariate analyses showed that pre-diagnosis global quality of life was the most significant predictor of the length of survival even after adjusting for known prognostic factors (age, P<0.04; extent of disease, P<0.03; global quality of life, P<0.02), while performance status, sex and weight loss were not. This study confirmed that pre-diagnosis quality of life was a significant predictor of survival. Indeed, pre-diagnosis quality of life should be considered as a clinical status which has to be established by physicians before treatment starts as it is such an important predictor of survival.

Age at menarche: secular trends and association with adult anthropometric measures

BACKGROUND

Age at menarche has been used as a marker of environmental conditions during childhood. Previous work has shown trends of decreasing age at menarche throughout the 19th century, but reported trends in the 20th century have been less consistent. The nature of the relationship between age at menarche and adult life anthropometric measures may be important in understanding the importance of this measure on disease in later life.

AIM

To establish whether mean age at menarche changed during the first half of the 20th century, and to determine the nature of associations between age at menarche and anthropometric measures in young adulthood.

SUBJECTS AND METHODS

3433 female students, who were born between 1919 and 1952 and who attended health checks at the student health service of the University of Glasgow between 1948 and 1968.

RESULTS

Mean age at menarche decreased from 13.2 years in the earliest born to 12.5 years in the latest born students. These results were not explained by changes in socio-demographic factors. Menarcheal age was positively associated with height and negatively associated with weight and BMI, results independent of socio-demographic and behavioural factors.

CONCLUSIONS

The falling age at menarche described here may be related to nutritional influences in the first half of the 20th century. The influence of menarche on BMI in early adulthood may have important health consequences.

Height and cancer mortality: results from the Glasgow University student cohort

The aim of the study was to examine the association between height and cancer mortality in a socially homogeneous group of subjects. The study was based on a cohort of students, 8397 men and 2329 women, aged 16-30 y, who attended the University of Glasgow between 1948 and 1968. Mean follow-up time was 40 y. Height was measured at a medical examination performed at the student health service. The outcome measures used in the study were all-cause mortality and mortality from: all cancers, smoking and non-smoking related cancers and cancers related to sex hormones. No substantial or statistically significant associations were seen between height and all-cause or all-cancer mortality in either sex. Neither were any significant associations found between height and any of the sub-types of cancer studied (ie those related to smoking, those not related to smoking, and those related to sex hormones). Previous observations which have shown positive associations between height and cancer mortality have generally been based on populations with diverse social origins, among whom the variation in height will reflect variation in health and nutrition in childhood. The relatively low level of such variation in the present study may account for the negative findings. Public Health (2000) 114, 451-455

A double-blind comparison of terazosin and tamsulosin on their differential effects on ambulatory blood pressure and nocturnal orthostatic stress testing

OBJECTIVES

This single-centre, double-blind, randomized parallel-group study compared ambulatory blood pressure (AMBP) and heart rate (HR) profiles and responses to orthostatic testing (OT) for recommended regimens of tamsulosin (TAM, modified release formulation) and terazosin (TER), two alpha1-adrenoceptor antagonists that differ in their selectivity for alpha1-adrenoceptor subtypes, pharmacokinetic properties and recommended posology for the treatment of lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO).

METHODS

50 elderly normotensive male volunteers (mean age 68 years, range 61-78; 27 had LUTS) entered a single-blind 24-hour placebo run-in followed by a 15-day double-blind treatment in which the TER group received a 1-week treatment with 1 mg, then 1 week with 2 mg and finally a last dose of 5 mg, each dose administered once daily in the evening, while TAM subjects received 0.4 mg once daily after breakfast throughout. Subjects had AMBPs and OT while hospitalized on four occasions: during the placebo run-in and subsequent to the first dose of 1, 2 and 5 mg TER or at corresponding times under TAM. Regular OT (blood pressure after 5 min supine and after 2 min standing) was carried out between 6:00 and 6:30 a.m.; 'nocturial' OT took place whenever the subject had to leave the bed at night to void.

RESULTS

The baseline blood pressure values were slightly higher in the TAM group, but under treatment there was little difference between the treatments with regard to circadian changes in AMBP and HR. Under TER, there were 10 incidents of symptomatic hypotensive OT in 9 subjects (2 with syncope); furthermore, there were 24 events of asymptomatic exaggerated (> or = 20 mm Hg) decrease in systolic blood pressure in 12 subjects. With TAM in contrast, there was only 1 subject who experienced symptomatic hypotensive OT on 3 occasions (this subject had a previous history of vertigo and ought not to have been included); 7 subjects on TAM showed 16 incidents of asymptomatic hypotensive OT. The difference between TER and TAM was statistically significant for the number of subjects with positive symptomatic OT (p = 0.011).

CONCLUSION

Once-daily dosing of TAM after breakfast at a fixed dose level (0.4 mg) offers a more efficient protection against undesired cardiovascular extension effects in the normotensive elderly treated for LUTS suggestive of BPO than the usually recommended treatment schedule of TER with step-up doses (1-5 mg) administered at night.

Disability in young people and adults one year after head injury: prospective cohort study

OBJECTIVE

To determine the frequency of disability in young people and adults admitted to hospital with a head injury and to estimate the annual incidence in the community.

DESIGN

Prospective, hospital based cohort study, with one year follow up of sample stratified by coma score.

SETTING

Five acute hospitals in Glasgow.

SUBJECTS

2962 patients (aged 14 years or more) with head injury; 549 (71%) of the 769 patients selected for follow up participated.

MAIN OUTCOME MEASURES

Glasgow outcome scale and problem orientated questionnaire.

RESULTS

Survival with moderate or severe disability was common after mild head injury (47%, 95% confidence interval 42% to 52%) and similar to that after moderate (45%, 35% to 56%) or severe injury (48%, 36% to 60%). By extrapolation from the population identified (90% of whom had mild injuries), it was estimated that annually in Glasgow (population 909 498) 1400 young people and adults are still disabled one year after head injury.

CONCLUSION

The incidence of disability in young people and adults admitted with a head injury is higher than expected. This reflects the high rate of sequelae previously unrecognised in the large number of patients admitted to hospital with an apparently mild head injury.

The acute effects of amisulpride (50 mg and 200 mg) and haloperidol (2 mg) on cognitive function in healthy elderly volunteers

In this double-blind, placebo controlled, four-way cross-over trial in 16 healthy elderly volunteers, the acute effects of haloperidol 2 mg, amisulpride 50 mg and 200 mg, were assessed on a range of tests of cognitive function. On each study day, cognitive performance was assessed prior to dosing and at 2, 4, 6, 9, 12 and 24 h after dosing with the following tests from the Cognitive Drug Research computerized assessment system: simple reaction time, digit vigilance task, choice reaction time, visual tracking, Critical Flicker Fusion, body sway, numeric working memory, immediate and delayed word recall, word recognition and self-ratings of mood and alertness. Haloperidol showed a general tendency to impair performance, and although this did not reach significance compared to placebo, for two tasks there were significant impairments with haloperidol compared to amisulpride. Amisulpride 50 mg and 200 mg, was not associated with impairment. In fact, there was some suggestion of improvement over placebo on three measures. The timings of assessment were appropriate for the study compounds. Furthermore, in a recent study in which a smaller number of elderly volunteers was tested on the same cognitive assessment system, a clear profile of acute impairments of haloperidol 3 mg, was identified. This indicates that haloperidol 2 mg, is not a sufficient dose to affect cognitive function in the elderly, supporting the general absence of effects with this dose in the young. Thus, the general absence of cognitive impairments with amisulpride at the doses used in this study suggests that this compound does not impair cognitive function in the elderly.

Blood pressure in young adulthood and mortality from cardiovascular disease

Blood pressure measured in young adult men is positively associated in later life with increased cardiovascular disease mortality. The implication of this finding is that risk of cardiovascular disease starts in early life.

A comparison of the photosensitizing potential of trovafloxacin with that of other quinolones in healthy subjects

Treatment with some quinolones is associated with an abnormal skin reaction following exposure to sunlight (photosensitivity). The objective of the current study was to compare the photosensitizing potential of a new quinolone, trovafloxacin, with that of ciprofloxacin, lomefloxacin and placebo. Forty-eight healthy males (age range 19-45 years) were randomized to receive a 7 day course of treatment with: (i) trovafloxacin 200 mg od; (ii) ciprofloxacin 500 mg bd; (iii) lomefloxacin 400 mg od; or (iv) placebo bd. Minimal erythema doses (MEDs) were assessed using a monochromator at baseline and on day 5 of treatment, for wavelengths of 305 +/- 5, 335 +/- 30, 365 +/- 30, 400 +/- 30 and 430 +/- 30 nm; 335 +/- 30 and 365 +/- 30 nm are within the UVA range. Immediate reaction MEDs were similar in all treatment groups. However, between baseline and day 5, the mean decreases in delayed-reaction MED (24 h) at 335 +/- 30 nm were only 18.99% for trovafloxacin versus placebo (P = 0.1267), compared with 53.77% (P 0.0001) and 64.13% (P 0.0001) for ciprofloxacin and lomefloxacin, respectively. Similarly, at 365 +/- 30 nm, trovafloxacin produced the smallest reduction in delayed MED versus placebo (43.66%), compared with ciprofloxacin (61.53%) and lomefloxacin (75.81%). These differences between trovafloxacin and ciprofloxacin and lomefloxacin were significant at both 335 +/- 30 and 365 +/- 30 nm (P 0.029). All MED values returned to baseline levels within 2 days of drug cessation. These results show that trovafloxacin has significantly less photosensitizing potential than either ciprofloxacin or lomefloxacin. This photosensitivity appears to be induced only by wavelengths in the UVA region, is maximal at 24 h and is a short-term effect.

Organisation of services for acute stroke in Scotland--report of the Scottish stroke services audit

An audit was undertaken of hospital service provision for acute strokes in Scotland, using as a template key recommendations in the four SIGN guidelines on management of stroke. A questionnaire and structured interview was undertaken of key personnel in the 43 Trusts and three directly managed units providing in-patient stroke care in Scotland, and the 15 Health Boards commissioning stroke care. All Trusts and Health Boards participated and a complete set of information for each was recorded on a data-base and analysed. This report gives an overview for 14 key components of an integrated stroke service with results presented in four bands according to Trust type determined by the number of strokes admitted. No Trust provided all key components and for a few components a lack of provision was widespread, e.g. fast-track assessment clinics for TIA and minor stroke, access to CT scanning within 48 hours. Variation occurred between Trusts of similar size, between Trusts of different sizes. Overall the Health Boards were at a preliminary stage in the development of stroke specific service specifications. The results of the audit are a view of stroke services around April 1998, and should enable commissioners and providers to consider how to progress implementation of the clinical guidelines on stroke care.

Determinants of adolescent blood pressure: findings from the Glasgow University student cohort

OBJECTIVE

To establish whether the blood pressure (BP) of young adults is related to their physical or behavioural attributes.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 11,284 males and 3491 females who attended the University of Glasgow between 1948 and 1968.

OUTCOME MEASURES

Systolic and diastolic BP.

RESULTS

Body mass index (BMI) and weight were positively associated with BP in males and females. Height had a small positive association with male systolic BP and female diastolic BP. Haemoglobin levels were associated with raised BP in females. Albuminuria was associated with raised BP in males but not females. Smoking and alcohol consumption were associated with small negative effects on BP, although the measurement of alcohol consumption in the study was crude, and these results may not be free of confounding. Insufficient outdoor exercise was associated with higher BP in females but not males. No social class gradients in BP levels were seen, although having a higher number of siblings was associated with slightly lower BP in males.

CONCLUSION

The results from the current study indicate that modifiable risk factors, such as weight and exercise affect the BP of young adults. The impact of these factors, coupled with the known tracking of BP from adolescence to adulthood, emphasise the importance of healthy behaviour patterns in young people.

Effects of exposure to heavy particles on a behavior mediated by the dopaminergic system

The effects of exposure to heavy particles on behaviors mediated by the central nervous system (CNS) are qualitatively different than the effects produced by exposure to other types of radiation. One behavior mediated by the CNS is the amphetamine-induced taste aversion, which is produced by pairing a novel tasting solution with injection of amphetamine. When the conditioning day is three days following irradiation, exposing rats to low doses of 56Fe particles (600 MeV/n or 1 GeV/n) eliminates the taste aversion produced by injection of amphetamine, which is dependent upon the integrity of the central dopaminergic system, but has no effect on the aversion produced by injection of lithium chloride which is mediated by the gastrointestinal system. In contrast to the effects obtained using heavy particles, exposing rats to 60CO gamma rays or to fission spectrum neutrons has no selective effect upon the acquisition of either amphetamine- or lithium chloride-induced taste aversions. When the conditioning day occurs four months following exposure to 1 GeV/n 56Fe particles, there is an enhancement of the amphetamine-induced taste aversion. The implications of these findings for approaches to risk assessment are considered.

CNS-induced deficits of heavy particle irradiation in space: the aging connection

Our research over the last several years has suggested that young (3 mo) rats exposed to whole-body 56Fe irradiation show neuronal signal transduction alterations and accompanying motor behavioral changes that are similar to those seen in aged (22-24 mo) rats. Since it has been postulated that 1-2% of the composition of cosmic rays contain 56Fe particles of heavy particle irradiation, there may be significant CNS effects on astronauts on long-term space flights which could produce behavioral changes that could be expressed during the mission or at some time after the return. These, when combined with other effects such as weightlessness and exposure to proton irradiations may even supercede mutagenic effects. It is suggested that by determining mechanistic relationships that might exist between aging and irradiation it may be possible to determine the common factor(s) involved in both perturbations and develop procedures to offset their deleterious effects. For example, one method that has been effective is nutritional modification.

Needs assessment in primary care: general practitioners' perceptions and implications for the future

BACKGROUND

Health needs assessment can guide the appropriate shift to primary care by identifying the most effective and efficient resource allocation to meet the needs of populations. Assessing health care needs will be a continuing challenge for primary care trusts in Scotland (or equivalent groups in other parts of the United Kingdom); however, lessons must be learned from the experience of needs assessment that followed the 'internal market' reforms of the 1990s.

AIM

To examine general practitioners' (GPs') awareness and experience of needs assessment, to identify barriers to needs assessment in primary care, and to ascertain how better progress might be made in the future.

METHOD

A postal questionnaire survey of 1777 Scottish GPs (a one-in-two sample) was combined with a semistructured interview survey of 'lead' GPs from a random sample of 64 mainland Scottish practices between May and August 1996.

RESULTS

Sixty-five per cent (1154) of GPs responded to the questionnaire, of which 54% (965) were completed. Over 73% (47) of interviews were completed. Most GPs were unfamiliar with the concept of needs assessment and there was no evidence that needs assessment had influenced commissioning decisions. Most GPs argued that it was not a 'core' activity and that they lacked training in the relevant skills. While the attitude of the majority was indifferent, cynical, and sometimes hostile, a minority, comprising mostly younger fundholders, was more enthusiastic about needs assessment.

CONCLUSION

The motivation and attitude of the majority of GPs present a barrier to needs assessment in primary care. GPs will require more resources and training if they are to undertake this responsibility. Most GPs believe than incentives (financial or organisational) will be necessary. Primary care trusts and equivalent structures should be aware of these attitudes as they seek to establish plans based on estimates of population needs in defined locations.

Magnesium activation of GTP hydrolysis or incubation in S-adenosyl-l-methionine reverses iron-56-particle-induced decrements in oxotremorine enhancement of K+-evoked striatal release of dopamine

Previous research has determined that the deficits in motor behavior seen in aged animals irradiated with (56)Fe particles involved alterations in muscarinic receptor sensitivity. In the present experiments, we determined whether increasing either membrane fluidity by exposure of striatal slices from irradiated ((56)Fe particles) animals to S-adenosyl-l-methionine (SAM) or GTP hydrolysis with Mg(2+) would reverse this (56)Fe-particle-induced loss of muscarinic receptor sensitivity, as has been observed in aged animals. Results indicated that, while increasing Mg(2+) concentrations in the incubation medium was effective in reducing the radiation effects, SAM was able to effect some reversal of the radiation effects only at the lower concentration (200 microM). These results suggest that similar mechanisms may be involved in the deficits in signal transduction seen after (56)Fe-particle irradiation to those seen in aging, and that these may include changes in the membrane structure or composition that could alter subsequent responsiveness of transduction pathways. The results further suggest that, as has been reported previously, (56)Fe-particle irradiation may accelerate brain aging, and that since these HZE particles contribute at least 1% of the dose that astronauts would receive from cosmic rays, long-term exposure on extended space flights (e.g. to Mars) may produce similar deficits that could have immediate or delayed effects on behavior.