Postpartum care: Discussions and counseling for the peripartum period

BACKGROUND

Traditionally, postpartum care is confined to inpatient care immediately post birth and one appointment approximately six weeks postpartum. Data supports a continuum of care model as best for the health of mother and baby. Despite most women having significant concerns about the postpartum period, these concerns are frequently incompletely addressed by providers. We surveyed prenatal and postpartum patients to understand their concerns and experiences discussing postpartum care with providers.

METHODS

Cross sectional surveys were administered between June 2019 and May 2021. Principal component analysis was used to show higher than average (positive) or lower than average (negative) conversations with providers about postpartum care examined by race, education, and parity. Chi squared tests were conducted to examine the significance of specific postpartum concerns.

RESULTS

421/450 patient surveys were analyzed, based on completion. Most patients were White (193), had post graduate degrees (188), privately insured (236), married (248), first time pregnant (152), and used doctors as their primary provider (267). Patients with lower education, higher parity and Black patients without postgraduate degrees reported higher than average postpartum counseling. Additionally, most patients expressed significant concerns about postpartum exhaustion (65.8%), breastfeeding (62.3%), pain (61.2%), physical activity (54.9%) and the baby blues (50.4%).

CONCLUSIONS

Postpartum concerns are incompletely and inconsistently addressed amongst patients based on race, parity, and education. A continuum of care approach, beginning in the third trimester, through the postpartum period, may provide better counseling to address all patients' concerns.

Procedural adverse events in pediatric patients with sickle cell disease undergoing chronic automated red cell exchange

BACKGROUND

Chronic automated red cell exchange (RCE) is increasingly employed for sickle cell disease (SCD). There is a paucity of data on the incidence of RCE adverse events (AEs) and potential patient and procedural risk factors for AEs.

METHODS

A retrospective review of pediatric SCD patients receiving chronic RCE over 3 years was performed to determine the frequency of AEs and identify procedural and patient AE risk factors. AE incidence, AE rate, incidence rate ratios (IRRs), and relative risks (RRs) were calculated based on various procedural and patient characteristics by univariable (UV) and multivariable (MV) analyses.

RESULTS

In 38 patients receiving 760 procedures, there were 150 (19.7%) AEs, 36 (4.7%) were symptomatic AEs. AE rates were 20.2 [95% CI 17.2, 23.6] and 4.8 [95% CI 3.49, 6.70] per 100 person months for AEs and symptomatic AEs, respectively. AE incidences were: hypocalcemia (117; 15.4%), dizziness (22; 3.0%), hypotension (15; 2.0%), and nausea (14; 1.8%). Patients with baseline Hct ≥30% experienced more total AEs and symptomatic AEs. Patients with pre-procedure systolic BP <50th percentile, severe CNS vasculopathy, and non-SCA genotype (HbSC or Sβ⁺ thalassemia) exhibited more total AEs. IHD depletion was not associated with an increased incidence of AEs or symptomatic AEs.

CONCLUSION

SCD patients with Hct ≥30%, systolic BP <50th percentile, severe CNS vasculopathy, and possibly non-SCA genotype may be at higher risk for RCE-related AEs. The effect of IHD on AE risk is likely minimal. Individualized AE risk assessment should be performed in all SCD patients undergoing chronic automated RCE.

Practices of sickle cell disease genetic screening and testing in the prenatal population

BACKGROUND

Genetic screening and testing are technologies historically underutilized in Black populations despite predicting diseases like sickle cell disease (SCD), which is predominantly found in Blacks. We surveyed prenatal patients to understand choices, beliefs and experiences surrounding genetic screening and testing, specifically for SCD.

METHODS

In this cross-sectional study, we surveyed 322 women during prenatal visits. Responses were analyzed to identify barriers to care and education about testing and screening for SCD. Patients rated whether they agreed or disagreed with statements regarding sickle cell health behaviors. We used χ2 tests to compare categorical variables by self-reported race. Binary logistic regression was used to determine the odds ratios and confidence intervals for each outcome.

RESULTS

Women were a mean (SD) age of 33.3 (6.1). 42.9% of patients self-identified as White while 41.3% of patients self- identified as Black. Screening questions were adjusted for differences in race, insurance, and education levels to show significant differences in responses between Blacks and Whites for screening for SCD (p = 0.047, OR 95% CI = 0.455 [0.210-0.989]) and plans to meet with genetic counselors (p = 0.049, OR 95% CI = 0.299 [0.090-0.993]). The statements "if sickle cell is not in their family, then it is likely not in themselves or their children," was significantly different between Black and White populations (p = 0.011, OR 95% CI = 0.207 [0.081-0.526]).

CONCLUSION

Our findings suggest gaps in screening, testing, education, and pregnancy management choices between Black and White patients. Research should focus on decreasing these healthcare gaps and improving education that address concerns about SCD for relevant populations.

Men's experiences of radiotherapy treatment for localized prostate cancer and its long-term treatment side effects: a longitudinal qualitative study

Purpose

To investigate men’s experiences of receiving external-beam radiotherapy (EBRT) with neoadjuvant Androgen Deprivation Therapy (ADT) for localized prostate cancer (LPCa) in the ProtecT trial.

Methods

A longitudinal qualitative interview study was embedded in the ProtecT RCT. Sixteen men with clinically LPCa who underwent EBRT in ProtecT were purposively sampled to include a range of socio-demographic and clinical characteristics. They participated in serial in-depth qualitative interviews for up to 8 years post-treatment, exploring experiences of treatment and its side effects over time.

Results

Men experienced bowel, sexual, and urinary side effects, mostly in the short term but some persisted and were bothersome. Most men downplayed the impacts, voicing expectations of age-related decline, and normalizing these changes. There was some reticence to seek help, with men prioritizing their relationships and overall health and well-being over returning to pretreatment levels of function. Some unmet needs with regard to information about treatment schedules and side effects were reported, particularly among men with continuing functional symptoms.

Conclusions

These findings reinforce the importance of providing universal clear, concise, and timely information and supportive resources in the short term, and more targeted and detailed information and care in the longer term to maintain and improve treatment experiences for men undergoing EBRT.

Supplementary Information

The online version of this article (10.1007/s10552-020-01380-3) contains supplementary material, which is available to authorized users.

How do I … implement diagnostic management teams in transfusion medicine?

Diagnostic management teams (DMTs) were conceptualized approximately twenty years ago in response to increasing subspecialization in medicine. DMTs are a collaboration between diagnostic experts and clinicians that aim to improve accurate and timely diagnosis and treatment of disease. Diagnostic experts provide their expertise in the increasingly complex realm of laboratory testing and interpretation of those test results to guide appropriate test utilization for individual patients. Not only can this approach improve patient care and safety, but DMTs also decrease healthcare costs by reducing unnecessary testing and potential diagnostic errors. Following the DMT construct and principles along with the 2015 National Academy of Medicine recommendations, our transfusion medicine (TM) service streamlined the workup and management of platelet refractory (PR) patients by developing and implementing a formal PR laboratory consult. The goals of this DMT and consult are to improve diagnostic management of PR patients and to decrease delays in providing these patients with appropriate and compatible platelet units. A comprehensive interpretation of test results is directly uploaded to the patient's electronic medical record (EMR), which is associated with a CPT code allowing for compensation for the PR evaluation. Herein we describe the development of and experience with the DMT since its implementation.

Diagnostic Management Team: Platelet Refractory Algorithm and Consult

Platelet refractoriness occurs when a patient fails to achieve appropriate platelet count increment following platelet (plt) transfusion. Approximately 30% to 40% of cases are due to human leukocyte antigen (HLA) alloantibodies and 2% to 10% are due to human platelet antigen (HPA) alloantibodies, which can be detected by various assays. The results of these tests are then used to guide selection of appropriate units, such as crossmatch-compatible (XM) and HLA-matched (HLAm) plts. Given the various steps and tests involved in diagnosing and managing plt refractoriness, clinicians may order unnecessary tests resulting in delays in patient care. In April 2018, our institution formed a diagnostic management team (DMT) to establish an algorithmic approach to testing, diagnosing, and transfusing plt refractory patients.

We performed a retrospective review of clinician requests for XM or HLAm plts over a 9-month period prior to the launch of the DMT and compared that to requests placed during the initial 9-month period following the launch of the DMT. We collected the date transfusion medicine (TM) service was notified and the time to complete the following: 1-hour corrected count increment (CCI), ELISA indirect antibody screen, HLA flow cytometry PRA screen, HLA single antigen bead (SAB), and obtain the first XM or HLAm plt unit for the patient. There were 12 and 20 patients evaluated for plt refractoriness pre- and post-DMT, respectively. The median time to complete the ELISA indirect antibody screen was 2 days pre- and post-DMT, respectively. Eight percent of patients never had an ELISA screen performed pre-DMT. All patients meeting plt refractory criteria had ELISA screens performed post-DMT. Median time to complete HLA testing decreased from 4 days to 2 days and all patients who had positive FlowPRAs had subsequent SABs performed post-DMT compared to only 40% of patients pre-DMT. The median times to obtain the first XM unit were 6 and 5 days and the first HLAm unit was 5 and 6 days pre- and post-DMT, respectively. One patient had a CCI above 7,500 and four patients had negative screening ELISA and FlowPRA tests after the launch of the DMT. No further testing was performed and they continued to receive ABO-compatible (ABOc) plt units. Since the launch of the DMT, there is improved consistency regarding what tests are performed and standardization of the sequence in which the appropriate tests are ordered. We have reduced unnecessary testing by identifying patients with nonimmune-mediated etiologies of plt refractoriness. Divergence from the algorithm is the main issue encountered during the initial 9-month period following implementation of the DMT. This divergence stemmed from lack of consistent education about plt refractoriness and the DMT. We believe better adherence to the algorithm will lead to decreased product acquisition time and further improve efficiency.

The multiple arrhythmia dataset evaluation database (M.A.D.A.E.)

The convergence between wearable and medical device technologies is a natural progression. Miniaturization has allowed the design of small, compact monitoring systems that can record physiological signals over longer periods of time. Thus, the potential for these devices to expand the understanding of disease progression and patients' clinical status is very high. The accuracy of these devices, however, is dependent upon the computer algorithms utilized in the analysis of the large volume of physiological data monitored and/or recorded by the devices. Automated interpretation of the data by these new technologies, therefore, necessitates closer examination by regulatory organizations. The current requirements for the validation of novel Ambulatory ECG (A-ECG) annotation algorithms are based on the AAMI/ANSI-EC57 and IEC60601-2-47 Standard. These standards are being updated, but they rely on a very limited set of digitized ECG recordings from a couple of ECG databases built in the first half of the 70's. These reference signals are obsolete. We are developing a validation tool for computerized methods designed to detect and monitor cardiac activities based on body-surface ECGs. We will rely on a set of existing digital high-resolution 12‑lead A-ECG recordings acquired in cardiac patients and healthy individuals. These ECG signals include a large and unique set of electrocardiographic events. This tool is being qualified by the Center for Devices and Radiological Health of the United States Food and Drug Administration (FDA) as a Medical Device Development Tool (MDDT). This document provides insights into the design of the M.A.D.A.E. database, its functionalities, and its ultimate role in enabling the next generations of automatic interpretation of ECG signals.

Comparative Toxicity of Two Chemical Dispersants and Dispersed Oil in Estuarine Organisms

Chemical dispersants can be a useful tool to mitigate oil spills. This study examined potential risks to sensitive estuarine species by comparing the toxicity of two dispersants (Corexit^® EC9500A and Finasol^® OSR 52) individually and in chemically enhanced water-accommodated fractions (CEWAFs) of Louisiana Sweet Crude oil. Acute toxicity thresholds and sublethal biomarker responses were determined in seven species (sheepshead minnow, grass shrimp, mysid, amphipod, polychaete, hard clam, mud snail). Comparing median lethal (LC₅₀) values for the dispersants, Finasol was generally more toxic than Corexit and had greater sublethal toxicity (impaired embryonic hatching, increased lipid peroxidation, decreased acetylcholinesterase activity). The nominal concentration-based mean LC₅₀ for all species tested with Corexit was 150.31 mg/L compared with 43.27 mg/L with Finasol. Comparing the toxicity of the CEWAFs using the nominal concentrations (% CEWAF), Corexit-CEWAFs appeared more toxic than Finasol-CEWAFs; however, when LC₅₀ values were calculated using measured hydrocarbon concentrations, the Finasol-CEWAFs were more toxic. There was greater dispersion efficiency leading to greater hydrocarbon concentrations measured in the Corexit-CEWAF solutions than in equivalent Finasol-CEWAF solutions. The measured concentration-based mean LC₅₀ values for all species tested with Corexit-CEWAF were 261.96 mg/L total extractable hydrocarbons (TEH) and 2.95 mg/L total polycyclic aromatic hydrocarbons (PAH), whereas the mean LC₅₀ values for all species tested with Finasol-CEWAF were 23.19 mg/L TEH and 0.49 mg/L total PAH. Larval life stages were generally more sensitive to dispersants and dispersed oil than adult life stages within a species. These results will help to inform management decisions regarding the use of oil-spill dispersants.

Ovarian clear cell carcinoma recurrence presenting as subcutaneous nodules

Skin metastasis is a rare form of ovarian carcinoma spread and is associated with widespread disease and a poor prognosis. The authors present a case of a patient, with a past history of ovarian clear cell carcinoma, who presented with subcutaneous nodules as the first sign of recurrent metastatic disease.

What proportion of adult allergy referrals to secondary care could be dealt with in primary care by a GP with special interest?

BACKGROUND

The concept of a General Practitioner with Special Interest (GPwSI) was first proposed in the 2000 National Health Service Plan, as a way of providing specialised treatment closer to the patient's home and reducing hospital waiting times. Given the patchy and inadequate provision of allergy services in the UK the introduction of GPwSIs might reduce the pressure on existing specialist services.

OBJECTIVES

This study assessed what proportion of referrals to a specialist allergy clinic could be managed in a GPwSI allergy service with a predefined range of facilities and expertise (accurate diagnosis and management of allergy; skin prick testing; provision of advice on allergen avoidance; ability to assess suitability for desensitisation).

METHODS

100 consecutive GP referrals to a hospital allergy clinic were reviewed to determine whether patients could be seen in a community-based clinic led by a general practitioner with special interest (GPwSI) allergy. The documentation relating to each referral was independently assessed by three allergy specialists. The referrals were judged initially on the referral letter alone and then re-assessed with the benefit of information summarised in the clinic letter, to determine whether appropriate triage decisions could be made prospectively. The proportion of referrals suitable for a GPwSI was calculated and their referral characteristics identified.

RESULTS

29 % referrals were judged unanimously appropriate for management by a GPwSI and an additional 30 % by 2 of the 3 reviewers. 18 % referrals were unsuitable for a GPwSI service because of the complexity of the presenting problem, patient co-morbidity or the need for specialist knowledge or facilities.

CONCLUSIONS AND CLINICAL RELEVANCE

At least a quarter, and possibly half, of allergy referrals to our hospital-based service could be dealt with in a GPwSI clinic, thereby diversifying the patient pathway, allowing specialist services to focus on more complex cases and reducing the waiting time for first appointments.

Masculinisation of the zebra finch song system: roles of oestradiol and the Z-chromosome gene tubulin-specific chaperone protein A

Robust sex differences in brain and behaviour exist in zebra finches. Only males sing, and forebrain song control regions are more developed in males. The factors driving these differences are not clear, although numerous experiments have shown that oestradiol (E2 ) administered to female hatchlings partially masculinises brain and behaviour. Recent studies suggest that an increased expression of Z-chromosome genes in males (ZZ; females: ZW) might also play a role. The Z-gene tubulin-specific chaperone A (TBCA) exhibits increased expression in the lateral magnocellular nucleus of the anterior nidopallium (LMAN) of juvenile males compared to females; TBCA+ cells project to the robust nucleus of the arcopallium (RA). In the present study, we investigated the role of TBCA and tested hypotheses with respect to the interactive or additive effects of E2 and TBCA. We first examined whether E2 in hatchling zebra finches modulates TBCA expression in the LMAN. It affected neither the mRNA, nor protein in either sex. We then unilaterally delivered TBCA small interfering (si)RNA to the LMAN of developing females treated with E2 or vehicle and males treated with the aromatase inhibitor, fadrozole, or its control. In both sexes, decreasing TBCA in LMAN reduced RA cell number, cell size and volume. It also decreased LMAN volume in females. Fadrozole in males increased LMAN volume and RA cell size. TBCA siRNA delivered to the LMAN also decreased the projection from this brain region to the RA, as indicated by anterograde tract tracing. The results suggest that TBCA is involved in masculinising the song system. However, because no interactions between the siRNA and hormone manipulations were detected, TBCA does not appear to modulate effects of E2 in the zebra finch song circuit.

Hormonal regulation of steroid receptor coactivator-1 mRNA in the male and female green anole brain

Green anole lizards are seasonal breeders, with male sexual behaviour primarily regulated by an annual increase in testosterone. Morphological, biochemical and behavioural changes associated with reproduction are activated by testosterone, generally with a greater effect in the breeding season (BS) than in the nonbreeding season (NBS). The present study investigates the possibility that differences in a steroid receptor coactivator may regulate this seasonal difference in responsiveness to testosterone. In situ hybridisation was used to examine the expression of steroid receptor coactivator-1 (SRC-1) in the brains of gonadally intact male and female green anoles across breeding states. A second experiment examined gonadectomised animals with and without testosterone treatment. Gonadally intact males had more SRC-1 expressing cells in the preoptic area and larger volumes of this region as defined by these cells than females. Main effects of both sex and season (males > females and BS > NBS) were present in cell number and volume of the ventromedial hypothalamus. An interaction between sex and season suggested that high expression in BS males was driving these effects. In hormone-manipulated animals, testosterone treatment increased both the number of SRC-1 expressing cells in and volumes of the preoptic area and amygdala. These results suggest that testosterone selectively regulates SRC-1, and that this coactivator may play a role in facilitating reproductive behaviours across both sexes. However, changes in SRC-1 expression are not likely responsible for the seasonal change in responsiveness to testosterone.

15-epi-lipoxin A4 reduces the mortality of prematurely born pups in a mouse model of infection-induced preterm birth

Preterm birth remains the leading cause of neonatal mortality and morbidity worldwide. There are currently few effective therapies and therefore an urgent need for novel treatments. Although there is much focus on trying to alter gestation of delivery, the primary aim of preterm birth prevention therapies should be to reduce prematurity related mortality and morbidity. Given the link between intrauterine infection and inflammation and preterm labour (PTL), we hypothesized that administration of lipoxins, key anti-inflammatory and pro-resolution mediators, could be a useful novel treatment for PTL. Using a mouse model of infection-induced PTL, we investigated whether 15-epi-lipoxin A₄ could delay lipopolysaccharide (LPS)-induced PTL and reduce pup mortality. On D17 of gestation mice (n = 9–12) were pretreated with vehicle or 15-epi-lipoxin A₄ prior to intrauterine administration of LPS or PBS. Although pretreatment with 15-epi-lipoxin A₄ did not delay LPS-induced PTL, there was a significant reduction in the mortality amongst prematurely delivered pups (defined as delivery within 36 h of surgery) in mice treated with 15-epi-lipoxin A₄ prior to LPS treatment, compared with those receiving LPS alone (P < 0.05). Quantitative real-time (QRT)-PCR analysis of utero-placental tissues harvested 6 h post-treatment demonstrated that 15-epi-lipoxin A₄ treatment increased Ptgs2 expression in the uterus, placenta and fetal membranes (P < 0.05) and decreased 15-Hpgd expression (P < 0.05) in the placenta and uterus, suggesting that 15-epi-lipoxin A₄ may regulate the local production and activity of prostaglandins. These data suggest that augmenting lipoxin levels could be a useful novel therapeutic option in the treatment of PTL, protecting the fetus from the adverse effects of infection-induced preterm birth.

Developmental changes in BDNF protein in the song control nuclei of zebra finches

The zebra finch song system provides an excellent model to study the mechanisms underlying the development of sex difference in brain structure and function. Only male zebra finches sing and the brain nuclei controlling song learning and production are considerably larger than in females. Sexual differentiation may in part be regulated by estrogen, but other molecules including neurotrophic factors likely also affect masculinization. Brain derived neurotrophic factor (BDNF) plays a crucial role in numerous aspects of vertebrate brain development and function, including neurogenesis, cell survival, growth of axonal projections, synaptogenesis and processes linked to learning and memory. The current study investigated the expression of BDNF protein in juvenile males and females at four ages, as well as in adults, to begin to evaluate the potential roles of endogenous BDNF in particular stages of structural and functional development of the song system. In both HVC and the robust nucleus of the arcopallium (RA), males had more BDNF+ cells than females. The number of immunopositive cells increased in males and decreased in females as they matured, in a pattern generally consistent with a role for BDNF in sensorimotor integration of song learning. In addition, in HVC (but not RA) the ratio of mature BDNF compared to its precursor proBDNF was greater in adult males than those at post-hatching day 25, indicating a region-specific shift in the relative availability of the two forms. Collectively, the data suggest that changes in BDNF protein expression across development may be associated with song system maturation, particularly during the sensorimotor integration of masculine vocalizations.

Volcanism on Mars controlled by early oxidation of the upper mantle

Detailed information about the chemical composition and evolution of Mars has been derived principally from the SNC (shergottite-nakhlite-chassignite) meteorites, which are genetically related igneous rocks of Martian origin. They are chemically and texturally similar to terrestrial basalts and cumulates, except that they have higher concentrations of iron and volatile elements such as phosphorus and chlorine and lower concentrations of nickel and other chalcophile (sulphur-loving) elements. Most Martian meteorites have relatively young crystallization ages (1.4 billion years to 180 million years ago) and are considered to be derived from young, lightly cratered volcanic regions, such as the Tharsis plateau. Surface rocks from the Gusev crater analysed by the Spirit rover are much older (about 3.7 billion years old) and exhibit marked compositional differences from the meteorites. Although also basaltic in composition, the surface rocks are richer in nickel and sulphur and have lower manganese/iron ratios than the meteorites. This has led to doubts that Mars can be described adequately using the 'SNC model'. Here we show, however, that the differences between the compositions of meteorites and surface rocks can be explained by differences in the oxygen fugacity during melting of the same sulphur-rich mantle. This ties the sources of Martian meteorites to those of the surface rocks through an early (>3.7 billion years ago) oxidation of the uppermost mantle that had less influence on the deeper regions, which produce the more recent volcanic rocks.

The association of waiting times from diagnosis to surgery with survival in women with localised breast cancer in England

BACKGROUND

Survival from breast cancer in the United Kingdom is lower than in other developed countries. It is unclear to what extent waiting times for curative surgery affect survival.

METHODS

Using national databases for England (cancer registries, Hospital Episode Statistics and Office of National Statistics), we identified 53 689 women with localised breast cancer, aged ≥ 15 years, diagnosed between 1996 and 2009, who had surgical resection with curative intent within 62 days of diagnosis. We used relative survival and excess risk modelling to determine associations between waiting times and 5-year survival.

RESULTS

The median diagnosis to curative surgery waiting time among breast cancer patients was 22 days (interquartile range (IQR): 15-30). Relative survival was similar among women waiting between 25 and 38 days (RS: 93.5%; 95% CI: 92.8-94.2%), <25 days (RS: 93.0%; 95% CI: 92.5-93.4%) and between 39 and 62 days (RS: 92.1%; 95% CI: 90.8-93.4%). There was little evidence of an increase in excess mortality with longer waiting times (excess hazard ratio (EHR): 1.06; 95% CI: 0.88-1.27 comparing waiting times 39-62 with 25-38 days). Excess mortality was associated with age (EHR 65-74 vs 15-44 year olds: 1.23; 95% CI: 1.07-1.41) and deprivation (EHR most vs least deprived: 1.28; 95% CI: 1.09-1.49), but waiting times did not explain these differences.

CONCLUSION

Within 62 days of diagnosis, decreasing waiting times from diagnosis to surgery had little impact on survival from localised breast cancer.

Sexually dimorphic and developmentally regulated expression of tubulin-specific chaperone protein A in the LMAN of zebra finches

Sex differences in brain and behavior exist across vertebrates, but the molecular factors regulating their development are largely unknown. Songbirds exhibit substantial sexual dimorphisms. In zebra finches, only males sing, and the brain areas regulating song learning and production are much larger in males. Recent data suggest that sex chromosome genes (males ZZ; females ZW) may play roles in sexual differentiation. The present studies tested the hypothesis that a Z-gene, tubulin-specific chaperone protein A (TBCA), contributes to sexual differentiation of the song system. This taxonomically conserved gene is integral to microtubule synthesis, and within the song system, its mRNA is specifically increased in males compared to females in the lateral magnocellular nucleus of the anterior nidopallium (LMAN), a region critical for song learning and plasticity. Using in situ hybridization, Western blot analysis, and immunohistochemistry, we observed effects of both age and sex on TBCA mRNA and protein expression. The transcript is increased in males compared to females at three juvenile ages, but not in adults. TBCA protein, both the number of immunoreactive cells and relative concentration in LMAN, is diminished in adults compared to juveniles. The latter was also increased in males compared to females at post-hatching day 25. With double-label immunofluorescence and retrograde tract tracing, we also document that the majority of TBCA+ cells in LMAN are neurons, and that they include robust nucleus of the arcopallium-projecting cells. These results indicate that TBCA is both temporally and spatially primed to facilitate the development of a sexually dimorphic neural pathway critical for song.

Expression of aromatase and two isozymes of 5α-reductase in the developing green anole forebrain

Neural steroids, as well as the enzymes that produce these hormones, are important for sexual differentiation of the brain during development. Aromatase converts testosterone into oestradiol. 5α-reductase converts testosterone to 5α-dihydrotestosterone and occurs in two isozymes: type 1 (5αR1) and type 2 (5αR2). Each of these enzymes is present in the developing brain in many species, although no work has been carried out examining the expression of all three enzymes in non-avian reptiles with genetic sex determination. In the present study, we evaluated mRNA expression of neural aromatase, 5αR1 and 5αR2, on the day of hatching and at day 50 in one such lizard, the green anole. We describe the distribution of these enzymes throughout the brain and the quantification of mRNA expression in three regions that control adult sexual behaviours: the preoptic area (POA) and ventromedial amygdala (AMY), which are involved in male displays, as well as the ventromedial hypothalamus, which regulates female receptivity. Younger animals had a greater number (POA) and density (AMY) of 5αR1 mRNA expressing cells. We detected no effects of sex or age on aromatase or 5αR2. In comparison with data from adults, the present results support the idea that the green anole forebrain has not completely differentiated by 50 days after hatching and that 5αR1 may play a role in the early development of regions important for masculine function.

Developmental changes in the sexually dimorphic expression of secretory carrier membrane protein 1 and its co-localisation with androgen receptor protein in the zebra finch song system

The song system of zebra finches differs dramatically between the sexes in terms of both structure and function. Only males sing and the brain regions regulating the learning and production of this behaviour are far more developed in males than females. Mechanisms regulating sexual differentiation likely include both direct genetic and hormonal processes. Expression of both mRNA and the protein product for secretory carrier membrane protein 1 (SCAMP1), a sex chromosome gene, are increased in the brains of juvenile males compared to females. Here we investigated developmental changes in SCAMP1 containing cells in song nuclei and co-localisation with androgen receptor (AR) protein from post-hatching day 25 through adulthood. Almost all SCAMP1 cells co-expressed AR and approximately half of the AR cells expressed SCAMP1 in the HVC and robust nucleus in the arcopallium (RA) of both sexes and in the Area X of males (which could not be clearly defined in females). In HVC and RA, more single and double-labelled cells were detected in males than females overall, and the sex differences increased as animals matured. The results suggest the potential for interaction of these two proteins in regulating development of brain and/or behaviour.

Aromatase mRNA in the brain of adult green anole lizards: effects of sex and season

Neural testosterone metabolism, particularly the synthesis of oestradiol (E(2)) via the aromatase enzyme, is important for sexual behaviours in many vertebrates. In green anole lizards, E(2) metabolised from testosterone facilitates female receptivity and increases sexual motivation in males. Testosterone treatment increases aromatase activity in the whole brain homogenates of gonadectomised male, but not female, anoles, which is an effect limited to the breeding season (BS). To investigate the potential for local effects of this enzyme in reproductive behaviour, we used in situ hybridisation for aromatase mRNA to examine expression during the BS and nonbreeding season (NBS) in areas of the brain that control male sexual behaviours [preoptic area (POA) and amygdala (AMY)], as well as one regulating female reproductive behaviours ventromedial hypothalamus (VMH). Males had a greater total number of aromatase-expressing cells in the POA than females, and the density of aromatase-expressing cells (number per unit volume) was greater in the VMH and AMY of females. This density was also higher during the BS than NBS in the POA. Expression of aromatase in the AMY appeared to be lateralised because trends were detected for the left side to have more total cells and more cells per unit volume than the right. These results suggest that, similar to other vertebrates, regional aromatisation of testosterone may be important for the control of sex-specific reproductive behaviours.

Sex- and age-related differences in ribosomal proteins L17 and L37, as well as androgen receptor protein, in the song control system of zebra finches

The zebra finch song system is sexually dimorphic--only males sing, and the morphology of forebrain regions controlling the learning and production of this song is greatly enhanced in males compared to females. Masculinization appears to involve effects of steroid hormones as well as other factors, perhaps including the expression of sex chromosome genes (males: ZZ, females: ZW). The present study investigated three proteins--two encoded by Z-linked genes, ribosomal proteins L17 and L37 (RPL17 and RPL37), including their co-localization with androgen receptor (AR), from post-hatching day 25 to adulthood. Extensive co-expression of AR with the ribosomal proteins was detected in the three song nuclei investigated (HVC, robust nucleus of the arcopallium (RA), and Area X) across these ages. In general, more cells expressed each of these proteins in males compared to females, and the sex differences increased as animals matured. Specific patterns differed across regions and between RPL17 and RPL37, which suggest potential roles of one or both of these proteins in the incorporation and/or differentiation of song system cells.

Conducting oral examinations for cancer in general practice: what are the barriers?

BACKGROUND

The incidence of oral (mouth) cancer in the UK is continuing to rise. Individuals who are at greatest risk rarely visit a dentist but do consult general medical practitioners (GMPs). Therefore, GMPs could have an important role in the early detection of oral cancer. Research has shown that GMPs do not opportunistically screen high-risk individuals; however, the barriers to screening are poorly understood.

OBJECTIVES

To understand the reasons why GMPs may not screen for oral cancer.

METHODS

A questionnaire was developed, using the Theory of Planned Behaviour (TPB), to measure GMPs attitudes to and screening for oral cancer. The questionnaire was designed using all the key theoretical constructs of the TPB and incorporating the themes identified in a qualitative elicitation study. The questionnaire was posted to 499 GPs in Surrey Primary Care trust.

RESULTS

Two hundred and twenty-eight completed questionnaires were returned (46%). Two TPB constructs [subjective norm (e.g. peer pressure) and perceived external control factors (e.g. adequate equipment, time constraints)] were identified as significant predictors of 'intention' to perform oral screening. Intention and perceived internal control factors (e.g. self-efficacy) were predictive of actually performing oral screening with patients.

CONCLUSIONS

The results of the study suggest that there is considerable potential for improving intention to perform oral cancer screening in general practice. Theory-based interventions could include further training to enhance confidence, expertise, knowledge and ease of examination, the provision of adequate equipment in the surgery and increasing the motivation to comply with significant others by introducing guidelines on opportunistic screening.

Pair bonding in the female zebra finch: a potential role for the nucleus taeniae

Male and female zebra finches are highly social and form pair bonds typically associated with reproduction. To determine how these bonds affect a female's behavioral response to future interactions, females were paired with a male for 2 weeks, separated for 48 h, and then exposed to the same or a novel male. Control females were left unpaired and introduced to a novel male. Behaviors, as well as neural ZENK expression, were quantified. Females displayed higher levels of behaviors associated with pair bonds (clumping and preening) toward their mates than novel males, and display of these behaviors was correlated with expression of the immediate early gene ZENK in the nucleus taeniae of one group of females, those interacting with their mates. Behaviors of the stimulus males were largely unaffected, but those interacting with an unpaired female attempted to mount more than those interacting with their mates. The results indicate that the nucleus taeniae may play some role in the maintenance of pair bonds in this species. Additionally, females may provide some signal to influence elements of the behavior of males.

Phase III study of irinotecan/5FU/LV (FOLFIRI) or oxaliplatin/5FU/LV (FOLFOX) ± cetuximab for patients (pts) with untreated metastatic adenocarcinoma of the colon or rectum (MCRC): CALGB 80203 preliminary results

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Background: FOLFIRI or FOLFOX are 1st-line treatments (Rx) for MCRC. Cetuximab is an IgG1 Mab that targets the epidermal growth factor receptor (EGFR) and is approved as monotherapy or in combination with irinotecan in irinotecan-refractory, EGFR + pts with MCRC. CALGB 80203 randomized untreated MCRC pts to FOLFOX or FOLFIRI ± cetuximab (independent of EGFR status.) Methods: Pts with performance status 0–1 with tumor blocks available for EGFR analysis received either irinotecan 180 mg/m2 over 1.5 hours (h) or oxaliplatin 85 mg/m2 over 2h combined with LV 400 mg/m2 over 2h and 5FU 400 mg/m2 bolus, then 46–48h CI 5FU 2400 mg/m2 q o w. Cetuximab dose: 400 mg/m2 loading dose, then 250 mg/m2 qw. Rx continued until progression or toxicity; subsequent Rx was not mandated although information was collected on such rx. Accrual goal was 2200 pts with intended 1° endpt of overall survival (OS). 80203 closed administratively in 1/05 (due to slow accrual) with 238 pts accrued. 2° endpts of response rate (RR), progression free survival (PFS), duration of R and toxicity are now able to be analyzed. Results: Accrual: FOLFIRI (A) - 61; FOLFIRI + cetuximab (B) - 59: FOLFOX (C) - 60; FOLFOX + cetuximab (D) - 58; approx median follow-up (f/u) is 12 months. RR (CR + PR, not all yet confirmed): A - 34%; B - 42%; C - 32%; D - 55%. RR was similar in the FOLFIRI or FOLFOX arms (A+B v. C+D; 38% v. 43%, p=0.44; chi-square) while C225 containing arms (B+D) v. non-C225 arms (A+C) had a superior RR (49% v. 33%; p=0.014, chi-square) It is too early to tell if there are differences in PFS, duration of response or OS. No significant differences in gr III diarrhea or any gr IV toxicities were seen. Conclusions: These results suggest that FOLFIRI and FOLFOX are similar in efficacy for pts with untreated MCRC and that adding cetuximab to either in1st-line Rx appears to increase response rates. PFS and duration of response do not appear different at this analysis. Further f/u and an analysis of prospective companion correlative studies may help to further clarify these results.

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Low oxygen exposure does not cause pulmonary injury in the newborn rat

BACKGROUND

Two recent studies have suggested that low levels of supplemental inspired oxygen may cause lung injury in preterm infants.

AIMS

To assess lung injury of newborn rats exposed to 14 days of low-level variation of oxygen.

STUDY DESIGN

Four groups were compared with 12 animals per group and 4 lung sections per animal. These were, a control group raised in room air and three groups raised in levels of inspired oxygen fluctuating around the following mean values: group Lo (mean FiO(2) 0.179), group N (mean FiO(2) 0.213), and group Hi (mean FiO(2) 0.247). The degree of oxygen variability was identical for each group. Lungs were inflated at 20 cm H(2)O, fixed and stained with H and E and Millers Elastin.

SUBJECTS

Sprague Dawley albino newborn rats.

OUTCOME MEASURES

Random alveolar areas were studied and analysed using imaging software to assess total amount of tissue and elastin, number of secondary septa, and mean linear intercept.

RESULTS

There were no significant differences between the three experimental oxygen groups and the control group in terms of lung/body weight ratio and the measured markers of lung development.

CONCLUSION

We conclude that low-level oxygen supplementation during early lung development does not affect alveolar development in the newborn rat.