Review: Interventions to prevent or manage self-harm among students in educational settings - a systematic review

BACKGROUND

At least half of all young people who die by suicide have previously self-harmed and most of those who self-harm will not seek help from health services for self-harming behaviours. By default, schools, colleges and universities necessarily play a key role in identifying those who self-harm and supporting them to access help.

METHODS

We conducted a systematic review (PROSPERO ID: CRD42021243692) of five databases (Medline, PsycINFO, ASSIA, ERIC and BEI) for quantitative studies evaluating interventions to reduce self-harm among students in schools, colleges and universities.

RESULTS

We identified six eligible studies that reported interventions. Two interventions used mindfulness-based approaches and the remaining four interventions focused on in-classroom education. Three interventions reported a significant reduction in self-harm, all three used in-classroom education. Of the six studies, one study was rated methodologically moderate, while the remaining five were weak.

CONCLUSION

In summary, the evidence base is limited in size and quality. Most current interventions to address self-harm in schools focus on training staff in awareness, with a significant gap in direct support for students.

Research Review: Integrated healthcare for children and young people in secondary/tertiary care - a systematic review

BACKGROUND

Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce.

AIM AND METHODS

This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index.

FINDINGS

A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used.

CONCLUSIONS

The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.

Leveraging Administrative Data to Better Understand and Address Child Maltreatment: A Scoping Review of Data Linkage Studies

BACKGROUND

This scoping review aimed to overview studies that used administrative data linkage in the context of child maltreatment to improve our understanding of the value that data linkage may confer for policy, practice, and research.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL, and ERIC electronic databases in June 2019 and May 2020 for studies that linked two or more datasets (at least one of which was administrative in nature) to study child maltreatment. We report findings with numerical and narrative summary.

RESULTS

We included 121 studies, mainly from the United States or Australia and published in the past decade. Data came primarily from social services and health sectors, and linkage processes and data quality were often not described in sufficient detail to align with current reporting guidelines. Most studies were descriptive in nature and research questions addressed fell under eight themes: descriptive epidemiology, risk factors, outcomes, intergenerational transmission, predictive modelling, intervention/service evaluation, multi-sector involvement, and methodological considerations/advancements.

CONCLUSIONS

Included studies demonstrated the wide variety of ways in which data linkage can contribute to the public health response to child maltreatment. However, how research using linked data can be translated into effective service development and monitoring, or targeting of interventions, is underexplored in terms of privacy protection, ethics and governance, data quality, and evidence of effectiveness.

Review: School-based mental health literacy interventions to promote help-seeking - a systematic review

BACKGROUND

School-based mental health literacy interventions aim to prevent mental disorders and promote mental wellbeing through improving the knowledge and understanding of mental health, mental disorders, and reducing stigma. Evidence suggests that good mental health literacy helps young people recognise mental health difficulties in themselves and in others, and seek help for mental health problems. Improved help-seeking can allow for early intervention, which prevents the progression of mental disorders and ultimately reduces the burden of mental disorders. The aim of this review is to identify and synthesise evidence on the effectiveness of school-based mental health literacy interventions in improving help-seeking outcomes.

METHODS

We searched MEDLINE, Embase, PsycINFO, ERIC, Child Development and Adolescent Studies, British Education Index and ASSIA (June 2020). Additional searches were conducted a year later to identify any new publications (June 2021). We included randomised controlled trials (RCTs) assessing the effectiveness or cost-effectiveness of school-based interventions to improve help-seeking outcomes for children and young people aged 4-18 years. Included studies were critically appraised.

RESULTS

We identified 11 studies investigating help-seeking outcomes of school-based mental health literacy interventions including a total of 7066 participants from 66 secondary schools. Overall, there is no strong evidence for the effectiveness of school-based mental health literacy interventions in improving help-seeking outcomes, including general attitudes towards help-seeking, personal intentions to seek help, knowledge of when and how to seek help for mental disorders, confidence to seek help, and actual help-seeking behaviours. None of the studies investigated the cost-effectiveness of the interventions.

CONCLUSION

The lack of standardised measures with established reliability and validity for help-seeking outcomes, and the incomprehensive consideration of the multi-faceted concepts of MH literacy and MH stigma have contributed to the scarcity of evidence for the effectiveness. Future research should focus on developing standardised measurement tools and including economic evaluations to understand pragmatic and financial aspects of school-based mental health literacy interventions.

Review: Education and training interventions, and support tools for school staff to adequately respond to young people who disclose self-harm - a systematic literature review of effectiveness, feasibility and acceptability

BACKGROUND

Self-harm among young people is a major public health concern, and whilst schools are well placed to identify and intervene with students who self-harm, the literature shows that school staff lack training and confidence in this area. This systematic review investigated the effectiveness, feasibility and acceptability of training interventions and support tools intended to equip school staff with skills and knowledge to adequately respond to students' disclosure of self-harm.

METHOD

References for this review were identified through systematic searches of Medline, Embase, PsycINFO, Child Development & Adolescent Studies, ERIC, ASSIA and British Education Index on with search terms 'self-harm', 'training', 'school staff' and 'young people'. Thematic synthesis was used to analyse qualitative data.

RESULTS

We found that all eight included studies evaluated interventions/tools that were highly effective in terms of an increase in knowledge, skills and confidence of staff in responding to self-harming youth. Acceptability was good with high levels of satisfaction and perceived benefit by staff, though data on feasibility of the interventions were lacking. Limitations of the studies included a paucity of follow-up data, and lack of data relating to student outcomes and actual changes in staff practice in schools.

CONCLUSIONS

The findings from this review indicate that more evidence is needed to determine the effectiveness, acceptability and feasibility of interventions/tools for school staff addressing self-harm. Further studies should focus on maintaining knowledge, confidence and comfort levels over time, and determine the feasibility of interventions/tools with different staff cohorts and across school settings, as well as address outcomes for students.

Annual Research Review: A systematic review of mental health services for emerging adults - moulding a precipice into a smooth passage

BACKGROUND

The transition between child and adult services should aim to support young people into the next stage of their life in a way that optimises their function. Yet financial, organisational and procedural barriers to continuity of care often hamper smooth transition between child and adult services.

AIM AND METHOD

We reviewed studies of transition from child to adult mental health services, focusing on: (a) rates of referrals and referral acceptance; (b) barriers and facilitators of successful transition; (c) continuity of care during and post-transition and (d) service users' experience of transition. Studies were identified through systematic searches of electronic databases: PsycINFO, Medline, Embase and Child Development and Adolescent Studies.

FINDINGS

Forty-seven papers describing 43 unique studies met inclusion criteria. Service provision is influenced by previous history and funding processes, and the presence or absence of strong primary care, specialist centres of excellence and coordination between specialist and primary care. Provision varies between and within countries, particularly whether services are restricted to 'core' mental health or broader needs. Unsupportive organisational culture, fragmentation of resources, skills and knowledge base undermine the collaborative working essential to optimise transition. Stigma and young people's concerns about peers' evaluation often prompt disengagement and discontinuation of care during transition, leading to worsening of symptoms and later, to service re-entry. Qualitative studies reveal that young people and families find the transition process frustrating and difficult, mainly because of lack of advanced planning and inadequate preparation.

CONCLUSIONS

Despite increasing research interest over the last decade, transition remains 'poorly planned, executed and experienced'. Closer collaboration between child and adult services is needed to improve the quality of provision for this vulnerable group at this sensitive period of development.

Determining stakeholder priorities and core components for school-based identification of mental health difficulties: A Delphi study

Only approximately half of children and young people (CYP) with mental health difficulties access mental health services in England, with under-identification of need as a contributing factor. Schools may be an ideal setting for identifying mental health difficulties in CYP, but uncertainty remains about the processes by which these needs can best be identified and addressed. In this study, we conducted a two-round, three-panel Delphi study with parents, school staff, mental health practitioners, and researchers to inform the development of a program to identify mental health difficulties in primary schools. We aimed to assess and build consensus regarding (a) the aims of such a program, (b) identification model preferences, (c) key features of the identification model, and (d) key features of the implementation model. A total of 54 and 42 participants completed the Round 1 and 2 questionnaires, respectively. In general, responses indicated that all three panels supported the idea of school-based identification of mental health difficulties. Overall, 53 of a possible 99 items met the criteria for inclusion as program core components. Five main priorities emerged, including that (a) the program should identify children experiencing mental health difficulties across the continuum of severity, as well as children exposed to adversity, who are at greater risk of mental health difficulties; (b) the program should train staff and educate pupils about mental health in parallel; (c) parental consent should be obtained on an opt-out basis; (d) the program must include clear mechanisms for connecting identified pupils to care and support; and (e) to maximize implementation success, the program needs to lie within a school culture that values mental health and wellbeing. In highlighting these priorities, our study provides needed stakeholder consensus to guide further development and evaluation of mental health interventions within schools.

Review: School-based interventions to improve mental health literacy and reduce mental health stigma - a systematic review

BACKGROUND

The steadily increasing prevalence of mental disorders in children and adolescents presents itself as a public health challenge, especially given the health, social and economic burden of mental disorders. School-based interventions aimed at improving mental health literacy and reducing mental health stigma have the potential to prevent mental disorders and promote mental well-being, thus reducing the burden of mental disorders. This review identified and synthesised evidence on the effectiveness of school-based interventions designed to improve mental health literacy and reduce mental health stigma.

METHODS

Electronic bibliographic databases including MEDLINE, Embase, PsycINFO, Education Resources Information Center (ERIC), Child Development and Adolescent Studies, British Education Index and Applied Social Sciences Index and Abstracts (ASSIA) were searched. Randomised controlled trials (RCTs) were included if they assessed the effectiveness or cost-effectiveness of school-based intervention aimed at improving mental health literacy and reducing mental health stigma for children and young people aged 4-18 years. Quality of studies was appraised using the EPHPP tool. A numerical summary and a narrative description of the findings in relation to the research questions were synthesised. This systematic review was registered with PROSPERO (CRD42020191265).

RESULTS

We identified 21 studies describing 20 unique school-based mental health interventions. Overall, there is moderate evidence suggesting that school-based mental health interventions can be effective in improving mental health literacy and reducing mental health stigma defined as attitudes and beliefs regarding mental disorders. However, there is less evidence for their long-term effectiveness, as most studies did not include follow-ups.

CONCLUSIONS

Despite exclusively including studies with randomised designs, intervention and methodological heterogeneity poses uncertainties to any conclusions made. Future research should focus on resolving methodological issues concerning how outcomes are assessed and include process evaluations to better inform the design of an intervention in term of its delivery and implementation.

Developing a Web-Based App to Assess Mental Health Difficulties in Secondary School Pupils: Qualitative User-Centered Design Study

BACKGROUND

Secondary schools are an ideal setting to identify young people experiencing mental health difficulties such as anxiety or depression. However, current methods of identification rely on cumbersome paper-based assessments, which are lengthy and time-consuming to complete and resource-intensive for schools to manage. Artemis-A is a prototype web app that uses computerized adaptive testing technology to shorten the length of the assessment and provides schools with a simple and feasible solution for mental health assessment.

OBJECTIVE

The objectives of this study are to coproduce the main components of the Artemis-A app with stakeholders to enhance the user interface, to carry out usability testing and finalize the interface design and functionality, and to explore the acceptability and feasibility of using Artemis-A in schools.

METHODS

This study involved 2 iterative design feedback cycles-an initial stakeholder consultation to inform the app design and user testing. Using a user-centered design approach, qualitative data were collected through focus groups and interviews with secondary school pupils, parents, school staff, and mental health professionals (N=48). All transcripts were thematically analyzed.

RESULTS

Initial stakeholder consultations provided feedback on preferences for the user interface design, school administration of the assessment, and outcome reporting. The findings informed the second iteration of the app design and development. The unmoderated usability assessment indicated that young people found the app easy to use and visually appealing. However, school staff suggested that additional features should be added to the school administration panel, which would provide them with more flexibility for data visualization. The analysis identified four themes relating to the implementation of the Artemis-A in schools, including the anticipated benefits and drawbacks of the app. Actionable suggestions for designing mental health assessment apps are also provided.

CONCLUSIONS

Artemis-A is a potentially useful tool for secondary schools to assess the mental health of their pupils that requires minimal staff input and training. Future research will evaluate the feasibility and effectiveness of Artemis-A in a range of UK secondary schools.

Feasibility of School-Based Identification of Children and Adolescents Experiencing, or At-risk of Developing, Mental Health Difficulties: a Systematic Review

Under-identification of mental health difficulties (MHD) in children and young people contributes to the significant unmet need for mental health care. School-based programmes have the potential to improve identification rates. This systematic review aimed to determine the feasibility of various models of school-based identification of MHD. We conducted systematic searches in Medline, Embase, PsycINFO, ERIC, British Education Index, and ASSIA using terms for mental health combined with terms for school-based identification. We included studies that assessed feasibility of school-based identification of students in formal education aged 3-18 with MHD, symptomatology of MHD, or exposed to risks for MHD. Feasibility was defined in terms of (1) intervention fit, (2) cost and resource implications, (3) intervention complexity, flexibility, manualisation, and time concerns, and (4) adverse events. Thirty-three studies met inclusion criteria. The majority focused on behavioural and socioemotional problems or suicide risk, examined universal screening models, and used cross-sectional designs. In general, school-based programmes for identifying MHD aligned with schools' priorities, but their appropriateness for students varied by condition. Time, resource, and cost concerns were the most common barriers to feasibility across models and conditions. The evidence base regarding feasibility is limited, and study heterogeneity prohibits definitive conclusions about the feasibility of different identification models. Education, health, and government agencies must determine how to allocate available resources to make the widespread adoption of school-based identification programmes more feasible. Furthermore, the definition and measurement of feasibility must be standardised to promote any future comparison between models and conditions.

Advancing methodology for scoping reviews: recommendations arising from a scoping literature review (SLR) to inform transformation of Children and Adolescent Mental Health Services

BACKGROUND

There is consensus that health services commissioning and clinical practice should be driven by scientific evidence. However, workload pressures, accessibility of peer reviewed publications and skills to find, appraise, and synthesise relevant evidence are often cited as barriers to uptake of research evidence by practitioners and commissioners alike. In recent years a growing requirement for rapid evidence synthesis to inform commissioning decisions about healthcare service delivery and provision of care contributed to an increasing popularity of scoping literature reviews (SLRs). Yet, comprehensive guidelines for conducting and reporting SLRs are still relatively scarce.

METHODS

The exemplar review used as a worked example aimed to provide a readily available, comprehensive, and user-friendly repository of research evidence for local commissioners to help them make evidence-informed decisions about redesigning East of England Children and Adolescent Mental Health Services. In conducting the review, we were broadly guided by Arksey and O'Malley's framework, however some modifications were made at different stages to better reflect the largely pragmatic objective of this review. This paper compares the methodology used with existing methodological frameworks for scoping studies, to add to the existing knowledge base.

RESULTS

We proposed the following advancements to the existing SLR frameworks: (i) Assemble a research team with complementary skills and expertise; (ii); Draw on expertise of external partners, particularly practitioners, decision-makers and commissioners who will be translating findings into practice; (iii) Pre-register the review protocol. Keep a detailed record of all steps and decisions and consider how they would impact on generalisability and utility of review findings; (iv) Use systematic procedures for literature searchers, selection of studies, data extraction and analysis; (v) If feasible, appraise the quality of included evidence; (vi) Be transparent about limitations of findings.

CONCLUSIONS

Despite some methodological limitations, scoping literature reviews are a useful method of rapidly synthesising a large body of evidence to inform commissioning and transformation of CAMHS. SLRs allow researchers to start with a broader questions, to explore the issue from different perspectives and perhaps find more comprehensive solutions that are not only effective, but also accounted for their feasibility and acceptability to key stakeholders.

Fast Ion Transport in the Three-Dimensional Reversed-Field Pinch

We report on the first comprehensive experimental and numerical study of fast ion transport in the helical reversed-field pinch (RFP). Classical orbit effects dominate the macroscopic confinement properties. The strongest effect arises from growth in the dominant fast ion guiding-center island, but substantial influence from remnant subdominant tearing modes also plays a critical role. At the formation of the helical RFP, neutron flux measurements indicate a drastic loss of fast ions at sufficient subdominant mode amplitudes. Simulations corroborate these measurements and suggest that subdominant tearing modes strongly limit fast ion behavior. Previous work details a sharp thermal transport barrier and suggests the helical RFP as an Ohmically heated fusion reactor candidate; the enhanced transport of fast ions reported here identifies a key challenge for this scheme, but a workable scenario is conceivable with low subdominant tearing mode amplitudes.

Delphi study to identify key features of community-based child and adolescent mental health services in the East of England

OBJECTIVE

To identify priorities for the delivery of community-based Child and Adolescent Mental health Services (CAMHS).

DESIGN

(1) Qualitative methods to gather public and professional opinions regarding the key principles and components of effective service delivery. (2) Two-round, two-panel adapted Delphi study. The Delphi method was adapted so professionals received additional feedback about the public panel scores. Descriptive statistics were computed. Items rated 8-10 on a scale of importance by ≥80% of both panels were identified as shared priorities.

SETTING

Eastern region of England.

PARTICIPANTS

(1) 53 members of the public; 95 professionals from the children's workforce. (2) Two panels. Public panel: round 1,n=23; round 2,n=16. Professional panel: round 1,n=44; round 2,n=33.

RESULTS

51 items met the criterion for between group consensus. Thematic grouping of these items revealed three key findings: the perceived importance of schools in mental health promotion and prevention of mental illness; an emphasis on how specialist mental health services are delivered rather than what is delivered (ie, specific treatments/programmes), and the need to monitor and evaluate service impact against shared outcomes that reflect well-being and function, in addition to the mere absence of mental health symptoms or disorders.

CONCLUSIONS

Areas of consensus represent shared priorities for service provision in the East of England. These findings help to operationalise high level plans for service transformation in line with the goals and needs of those using and working in the local system and may be particularly useful for identifying gaps in ongoing transformation efforts. More broadly, the method used here offers a blueprint that could be replicated by other areas to support the ongoing transformation of CAMHS.

Direct Measurement of a Toroidally Directed Zonal Flow in a Toroidal Plasma

Zonal flow appears in toroidal, magnetically confined plasmas as part of the self-regulated interaction of turbulence and transport processes. For toroidal plasmas having a strong toroidal magnetic field, the zonal flow is predominately poloidally directed. This Letter reports the first observation of a zonal flow that is toroidally directed. The measurements are made just inside the last closed flux surface of reversed field pinch plasmas that have a dominant poloidal magnetic field. A limit cycle oscillation between the strength of the zonal flow and the amplitude of plasma potential fluctuations is observed, which provides evidence for the self-regulation characteristic of drift-wave-type plasma turbulence. The measurements help advance understanding and gyrokinetic modeling of toroidal plasmas in the pursuit of fusion energy.

A systematic review of effectiveness and cost-effectiveness of school-based identification of children and young people at risk of, or currently experiencing mental health difficulties

BACKGROUND

Although school-based programmes for the identification of children and young people (CYP) with mental health difficulties (MHD) have the potential to improve short- and long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness of these programmes is underdeveloped. In this systematic review, we sought to identify and synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to identify students experiencing MHD, as measured by accurate identification, referral rates, and service uptake.

METHOD

Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British Education Index and ASSIA were searched. Comparative studies were included if they assessed the effectiveness or cost-effectiveness of strategies to identify students in formal education aged 3-18 years with MHD, presenting symptoms of mental ill health, or exposed to psychosocial risks that increase the likelihood of developing a MHD.

RESULTS

We identified 27 studies describing 44 unique identification programmes. Only one study was a randomised controlled trial. Most studies evaluated the utility of universal screening programmes; where comparison of identification rates was made, the comparator test varied across studies. The heterogeneity of studies, the absence of randomised studies and poor outcome reporting make for a weak evidence-base that only generate tentative conclusions about the effectiveness of school-based identification programmes.

CONCLUSIONS

Well-designed pragmatic trials that include the evaluation of cost-effectiveness and detailed process evaluations are necessary to establish the accuracy of different identification models, as well as their effectiveness in connecting students to appropriate support in real-world settings.

Acceptability of screening for mental health difficulties in primary schools: a survey of UK parents

BACKGROUND

Many children and young people experiencing mental health difficulties (MHD) do not access care, often due to inadequate identification. Schools have a unique potential to improve early identification; however, evidence is limited regarding the acceptability of school-based identification programmes. This study aimed to examine parents' beliefs about the acceptability of school-wide MHD screening in primary schools.

METHODS

We collaborated with experts in school-based mental health to develop a questionnaire to measure parental attitudes toward school-wide MHD screening. The questionnaire contained 13 items relating to acceptability; three open-text boxes for comments on harms, benefits, and screening in general; and four questions that captured demographic information. Parents of children attending four primary schools in Cambridgeshire and Norfolk completed the questionnaire. We calculated counts, percentages, and means for each statement, and analysed responses to open-ended questions using content analysis.

RESULTS

Two hundred ninety parents returned the questionnaire across the four schools (61% response rate). In the 260 questionnaires analysed, a total of 254 parents (98%) believed that it is important to identify MHD early in life, and 251 (97%) believed that schools have an important role in promoting pupils' emotional health. The majority of parents (N = 213; 82%) thought that screening would be helpful, although 34 parents (13%) thought that screening would be harmful. Perceived harms of screening included inaccurate identification, stigmatisation, and low availability of follow-up care. There was no clear consensus regarding how to obtain consent or provide feedback of screening results. There were no significant differences in responses according to ethnicity, gender, age, or school.

CONCLUSIONS

Results suggest that most parents within the socio-demographic context of our study will accept MHD screening within primary schools, and that school-based screening is viable from the perspective of parents. The comments provided about potential harms as well as suggestions for programme delivery are relevant to inform the development and evaluation of acceptable and sustainable school-based identification models. Implementation and scale-up of such programmes will require further understanding of the perspectives of mental health professionals, school staff, and the general public as well as further evaluation against the established standards for identification programmes.

Measuring dynamic fast ion spatial profiles with fusion protons in the Madison Symmetric Torus

Neutral beam injected fast ions play a dominant role in both the field reversed configuration (FRC) at TAE Technologies and the Madison Symmetric Torus (MST) reversed field pinch (RFP), making fast ion diagnosis a major pillar of both research programs. And as strongly self-organized plasmas, the FRC and RFP similarly exhibit dynamic relaxation events which can redistribute fast ions. Recently, a collaboration between TAE Technologies and the University of Wisconsin was conducted to develop a method for measuring a fast changing fast ion spatial profile with a fusion proton detector and to investigate commonalities between the two plasmas. The steerable detector was designed and built at TAE and installed on MST. The fusion proton emission profile resulting from injection of a 25 kV deuterium neutral beam is measured with better than 5 cm spatial resolution and 100 μs temporal resolution over the course of several 10s of shots. The fast ion density profile, forward modeled by tracing the orbits of the 3 MeV protons through a reconstructed magnetic equilibrium, is observed to flatten during global magnetic tearing mode activity, dropping by 30% in the core and increasing by a similar amount at the edge. The equilibrium profile is observed to be consistent with measurements made with a collimated neutron detector.

Evaluation of uptake and effect on patient-reported outcomes of a clinician and patient co-led chronic musculoskeletal pain self-management programme provided by the UK National Health Service

In the United Kingdom, chronic pain affects approximately 28 million adults, creating significant healthcare and socio-economic costs. The aim was to establish whether a programme designed to use best evidence of content and delivery will be used by patients with significant musculoskeletal pain problems. Of 528 patients recruited, 376 participated in a 7-week-long group-based self-management programme (SMP) co-delivered by clinical and lay tutors. Of these, 308 patients (mean age, 53 years; 69% females, 94% White) completed at least five SMP sessions. Six months after pre-course assessment, participants reported significantly improved patient activation and health status, lower depression and anxiety scores, decreased pain severity and interference, and improved self-management skills. There were no improvements in health state and pain self-efficacy. Uptake rate was 71% and completion 82%. The results should be of value to commissioners of pathways of care for the large numbers of patients attending the English NHS for chronic musculoskeletal pain.

Observation of Electron Bernstein Wave Heating in a Reversed Field Pinch

The first observation of rf heating in a reversed field pinch (RFP) using the electron Bernstein wave (EBW) is demonstrated on the Madison Symmetric Torus. Propagation across and heating in a stochastic magnetic field is observed. Novel techniques are required to measure the suprathermal electron tail generated by EBW heating in the presence of intense Ohmic heating. rf-heated electrons directly probe the edge transport properties in the RFP; measured loss rates imply a large noncollisional radial diffusivity.

Analysis techniques for diagnosing runaway ion distributions in the reversed field pinch

An advanced neutral particle analyzer (ANPA) on the Madison Symmetric Torus measures deuterium ions of energy ranges 8-45 keV with an energy resolution of 2-4 keV and time resolution of 10 μs. Three different experimental configurations measure distinct portions of the naturally occurring fast ion distributions: fast ions moving parallel, anti-parallel, or perpendicular to the plasma current. On a radial-facing port, fast ions moving perpendicular to the current have the necessary pitch to be measured by the ANPA. With the diagnostic positioned on a tangent line through the plasma core, a chord integration over fast ion density, background neutral density, and local appropriate pitch defines the measured sample. The plasma current can be reversed to measure anti-parallel fast ions in the same configuration. Comparisons of energy distributions for the three configurations show an anisotropic fast ion distribution favoring high pitch ions.

X-ray analysis of electron Bernstein wave heating in MST

A pulse height analyzing x-ray tomography system has been developed to detect x-rays from electron Bernstein wave heated electrons in the Madison symmetric torus reversed field pinch (RFP). Cadmium zinc telluride detectors are arranged in a parallel beam array with two orthogonal multi-chord detectors that may be used for tomography. In addition a repositionable 16 channel fan beam camera with a 55° field of view is used to augment data collected with the Hard X-ray array. The chord integrated signals identify target emission from RF heated electrons striking a limiter located 12° toroidally away from the RF injection port. This provides information on heated electron spectrum, transport, and diffusion. RF induced x-ray emission from absorption on harmonic electron cyclotron resonances in low current (<250 kA) RFP discharges has been observed.

A collimated neutron detector for RFP plasmas in MST

The neutron emissivity profile in the Madison Symmetric Torus is being reconstructed through the use of a collimated neutron detector. A scintillator-photomultiplier tube (PMT) system is employed to detect the fusion neutrons with the plasma viewing volume defined by a 55 cm deep, 5 cm diameter aperture. Effective detection of neutrons from the viewing volume is achieved through neutron moderation using 1300 lbs of high density polyethylene shielding, which modeling predicts attenuates the penetrating flux by a factor of 10⁴ or more. A broad spectrum of gamma radiation is also present due to the unconfined fusion proton bombardment of the thick aluminum vacuum vessel. A 15 cm cylindrical liquid scintillator of 3.8 cm diameter is used to further increase directional sensitivity. A fast (5 ns rise time) preamplifier and digitization at 500 MHz prevent pulse pile-up even at high count rates (∼10⁴/s). The entire neutron camera system is situated on an adjustable inclining base which provides the differing plasma viewing volumes necessary for reconstruction of the neutron emissivity profile. This profile, directly related to the fast-ion population, allows for an investigation of the critical fast-ion pressure gradient required to destabilize a neutral beam driven Alfvénic mode which has been shown to transport fast ions.

Development towards a fast ion loss detector for the reversed field pinch

A fast ion loss detector has been constructed and implemented on the Madison Symmetric Torus (MST) to investigate energetic ion losses and transport due to energetic particle and MHD instabilities. The detector discriminates particle orbits solely on pitch and consists of two thin-foil, particle collecting plates that are symmetric with respect to the device aperture. One plate collects fast ion signal, while the second aids in the minimization of background and noise effects. Initial measurements are reported along with suggestions for the next design phase of the detector.

Development and feasibility of the Help to Overcome Problems Effectively (HOPE) self-management intervention for people living with multiple sclerosis

PURPOSE

To describe the development and feasibility of a self-management intervention called the Help to Overcome Problems Effectively (HOPE: MS), aimed at improving the physical and psychological wellbeing of people living with Multiple Sclerosis (MS).

METHOD

HOPE: MS is an innovative, 6-week group-based, manualised self-management intervention combining positive psychology theory and practice, and cognitive behavioural therapy (CBT). Participants (N = 21) recruited via a local East Midlands branch of the MS Society attended one of three HOPE: MS interventions and completed self-reported outcome measures in week 1 and week 6. The following outcome measures were used: The Multiple Sclerosis Impact Scale; Multiple Sclerosis Fatigue Severity Scale; The Multiple Sclerosis Self-Efficacy Scale; The Adult State Hope Scale; The Hospital Anxiety and Depression Scale; The Positive and Negative Affect Scale.

RESULTS

Post-intervention (6 weeks) mean scores decreased in the physical impact (baseline M = 65.6, SD = 17.4; 6 weeks M = 55.1, SD = 17.9, 95% CI [-4.39, -16.47] and the psychological impact of MS (baseline M = 24.0, SD = 7.3; 6 weeks M = 18.9; SD = 6.3, 95% CI [-2.54, -7.66]). There was also a decrease mean fatigue severity scores (baseline 49.4, SD = 13.3, 6 weeks M = 41.1, SD = 14.4, 95% CI [-2.65, -13.44]). There was a mean decrease in depression scores (baseline M = 6.9, SD = 3.5; 6 weeks M = 4.2, SD = 2.8, 95% CI [-1.43, -4.00]). There were smaller mean decreases in anxiety (baseline M = 7.6, SD = 3.4; 6 weeks M = 6.7 (4.0), 95% CI [0.69, -2.50]) and negative affect (baseline M = 22.9, SD = 6.8; 6 weeks M = 20.8 (8.1), 95% CI [0.69, -2.50]) refer Table 3 ). Mean MS self-efficacy scores (baseline 21.7, SD = 4.2; 6 weeks M = 24.1, SD = 4.7, 95% CI [0.23, 4.53]), mean total hope scores (baseline M = 23.3, SD = 10.7; 6 weeks M = 32.2 (10.6), 95% CI [4.91, 12.9]), hope agency scores (baseline M = 10.5, SD = 5.7; 6 weeks M = 15.7 (6.2), 95% CI [2.37, 8.01]), hope pathways (baseline M = 12.9, SD = 6.0; 6 weeks M = 16.6 (4.9), 95% CI [2.00, 5.43]) and positive affect scores increased (baseline M = 27.3, SD = 7.1; 6 months M = 32.2, SD = 8.4, 95% CI [0.42, 9.39]). Participants positively rated the intervention quality and delivery.

CONCLUSIONS

This feasibility study showed that the HOPE: MS was acceptable and useful to people living with MS. Further robust evaluations using a randomised controlled trial design with longer follow ups are needed to confirm early promising results of the HOPE: MS. Implications for rehabilitation Living with MS requires constant adjustments to cope with unpredictable symptoms. Self-management interventions have the potential to help people living with MS to improve their quality of life. A feasibility study of the HOPE: MS self-management group-based intervention showed that it was acceptable and useful to people living with MS.

An evaluation of a self-management program for patients with long-term conditions

OBJECTIVE

To evaluate a group-based self-management program (SMP) delivered as part of a quality improvement program, Co-Creating Health, for patients living with one of four long-term conditions (LTCs): chronic obstructive pulmonary disease, depression, diabetes, and musculoskeletal pain.

METHODS

The 7 week SMP was co-delivered by lay and health professional tutors. Patients completed self-reported outcome measures at pre-course and 6 months follow-up.

RESULTS

486 patients completed (attended ≥5 sessions) the SMP and returned pre-course and 6 months follow up data. Patients reported significant improvements in patient activation (ES 0.65, p<0.001), with 53.9% of all patients reporting a meaningful ≥4 point improvement. Health-related quality of life (ES 0.06, p=0.04), and health status (ES 0.33, p<0.001) were also significantly improved. Patients' anxiety (ES 0.37, p<0.001) and depression (ES 0.31, p<0.001) significantly improved. Patients also reported significant improvements in their self-management skills (p values from p<0.001 to p=0.028).

CONCLUSION

Attending the SMP led to improvements in a range of outcomes. Improvement in patient activation is important, as activated patients are more likely to perform self-care activities.

PRACTICE IMPLICATIONS

Co-delivered SMPs provide meaningful improvements in activation for >50% of those who complete and are a useful addition to self-management support provision.

Design of a retarding potential grid system for a neutral particle analyzer

The ion energy distribution in a magnetically confined plasma can be inferred from charge exchange neutral particles. On the Madison Symmetric Torus (MST), deuterium neutrals are measured by the Florida A&M University compact neutral particle analyzer (CNPA) and the advanced neutral particle analyzer (ANPA). The CNPA energy range covers the bulk deuterium ions to the beginning of the fast ion tail (0.34-5.2 keV) with high-energy resolution (25 channels) while the ANPA covers the vast majority of the fast ion tail distribution (∼10-45 keV) with low energy resolution (10 channels). Though the ANPA has provided insight into fast ion energization in MST plasma, more can be gained by increasing the energy resolution in that energy range. To utilize the energy resolution of the CNPA, fast ions can be retarded by an electric potential well, enabling their detection by the diagnostic. The ion energy distribution can be measured with arbitrary resolution by combining data from many similar MST discharges with different energy ranges on the CNPA, providing further insight into ion energization and fast ion dynamics on MST.

Time-resolved ion energy distribution measurements using an advanced neutral particle analyzer on the MST reversed-field pinch

An advanced neutral particle analyzer (ANPA) capable of simultaneously measuring hydrogen and deuterium ions of energies up to 45 keV has recently been developed for use on the Madison Symmetric Torus. The charge-to-mass separation allows for separate analysis of bulk deuterium ions and hydrogen ions injected with a 1 MW, 25 keV neutral beam. Orientation of the ANPA allows sampling of different regions of ion velocity space; a radial viewport favors collection of ions with high v(perpendicular)∕|v| while a recently installed tangential viewport favors ions with high v(||)∕|v|, such as those from the core-localized fast ion population created by the neutral beam. Signals are observed in the ANPA's highest energy channels during periodic magnetic reconnection events, which are drivers of anisotropic, non-Maxwellian ion energization in the reversed-field pinch. ANPA signal strength is dependent on the background neutral density, which also increases during magnetic reconnection events, so careful analysis must be performed to identify the true change in the ion distribution. A Monte Carlo neutral particle tracing code (NENE) is used to reconstruct neutral density profiles based on D(α) line emission, which is measured using a 16-chord filtered photodiode array.

Calibration of an advanced neutral particle analyzer for the Madison Symmetric Torus reversed-field pinch

A new E∥B neutral particle analyzer, which has recently been installed on Madison Symmetric Torus (MST) reversed-field pinch (RFP), has now been calibrated, allowing the measurement of the fast ion density and energy distribution. This diagnostic, dubbed the advanced neutral particle analyzer (ANPA), can simultaneously produce time resolved measurements of the efflux of both hydrogen and deuterium ions from the plasma over a 35 keV energy range with an energy resolution of 2-4 keV and a time resolution of 10 μs. These capabilities are needed to measure both majority ion heating that occurs during magnetic reconnection events in MST and the behavior of the fast ions from the 1 MW hydrogen neutral beam injector on MST. Calibration of the ANPA was performed using a custom ion source that resides in the flight tube between the MST and the ANPA. In this work, the ANPA will be described, the calibration procedure and results will be discussed, and initial measurements of the time evolution of 25 keV neutral beam injection-born fast ions will be presented.

Fast-particle-driven Alfvénic modes in a reversed field pinch

Alfvénic modes are observed due to neutral beam injection for the first time in a reversed field pinch plasma. Modeling of the beam deposition and slowing down shows that the velocity and radial localization are high. This allows instability drive from inverse Landau damping of a bump-on-tail in the parallel distribution function or from free energy in the fast ion density gradient. Mode switching from a lower frequency toroidal mode number n=5 mode that scales with beam injection velocity to a higher frequency n=4 mode with Alfvénic scaling is observed.

Experimental evidence for a reduction in electron thermal diffusion due to trapped particles

New high time resolution measurements of the electron thermal diffusion χ(e) throughout the sawtooth cycle of the Madison Symmetric Torus reversed-field pinch have been made by utilizing the enhanced capabilities of the upgraded multipoint, multipulse Thomson scattering system. These measurements are compared to the χ(e) due to magnetic diffusion predicted by using information from a new high spectral resolution zero-β nonlinear resistive magnetohydrodynamic simulation performed, for the first time, at the Lundquist number of high current Madison Symmetric Torus plasmas (S≈4×10(6)). Agreement between the measured and predicted values is found only if the reduction in thermal diffusion due to trapped particles is taken into account.

Electron heat transport measured in a stochastic magnetic field

New profile measurements have allowed the electron thermal diffusivity profile to be estimated from power balance in the Madison Symmetric Torus where magnetic islands overlap and field lines are stochastic. The measurements show that (1) the electron energy transport is conductive not convective, (2) the measured thermal diffusivities are in good agreement with numerical simulations of stochastic transport, and (3) transport is greatly reduced near the reversal surface where magnetic diffusion is small.

Observation of velocity-independent electron transport in the reversed field pinch

Confinement of runaway electrons has been observed for the first time in a reversed field pinch during improved-confinement plasmas in the Madison Symmetric Torus. Energy-resolved hard-x-ray flux measurements have been used to determine the velocity dependence of the electron diffusion coefficient, utilizing computational solutions of the Fokker-Planck transport equation. With improved-confinement, the fast electron diffusivity drops by 2 orders of magnitude and is independent of velocity. This suggests a change in the transport mechanism away from stochastic magnetic field diffusion.

Core electrostatic fluctuations and particle transport in a reversed-field pinch

Potential and electron-density fluctuation profiles, phi(r) and ñ(e)(r)/n(e), are measured for the first time in the core of a reversed-field pinch using a heavy ion beam probe. It is found that the fluctuations are broadband and correlated with the core resonant m/n=1/6 tearing mode. The electrostatic-fluctuation-induced particle transport in the core of standard RFP plasmas, estimated from measured <ñ(e)phi>, is small compared to the total particle flux. Measurements of fluctuations and estimates of fluctuation induced particle transport in improved confinement RFP discharges are also presented.

A prospective, randomized clinical trial of universal WBC reduction

BACKGROUND

Recipient exposure to allogeneic donor WBCs results in transfusion complications for selected populations of recipients. Whether or not WBC reduction should be universally applied is highly controversial.

STUDY DESIGN AND METHODS

In a general hospital, a randomized, controlled clinical trial of conversion to universal WBC reduction was conducted. Patients (11%) with established medical indications for WBC-reduced blood were not eligible. All other patients who required transfusion were assigned at random to receive either unmodified blood components or stored WBC-reduced RBCs and platelets. Analysis for each patient was restricted to the first hospitalization.

RESULTS

All eligible patients (n = 2780) were enrolled. Three specified primary outcome measures were not different between the two groups: 1) in-hospital mortality (8.5% control; 9.0% WBC-reduced; OR, 0.94 [95% CI, 0.72-1.22]; p = 0.64); 2) hospital length of stay (LOS) after transfusion (median number of days, 6.4 for control and 6.3 for WBC-reduced; p = 0.21); and 3) total hospital costs (median, $19,500 for control and $19,200 for WBC-reduced, p = 0.24). Secondary outcomes (intensive care LOS, postoperative LOS, antibiotic usage, and readmission rate) were not different between the two groups. Subgroup analysis based on patient age, sex, amount of blood transfused, or category of surgical procedure showed no effect of WBC reduction. Patients who received WBC-reduced blood had a lower incidence of febrile reactions (p = 0.06).

CONCLUSION

A beneficial effect of conversion from selective to universal WBC reduction was not demonstrated.

Measurement of the current-density profile and plasma dynamics in the reversed-field pinch

First measurements of the current-density profile in the core of a high-temperature reversed-field pinch are presented. The current-density profile is observed to peak during the sawtooth cycle and broaden promptly at the crash. This change in profile can be linked to magnetic relaxation and the dynamo which is predicted to drive antiparallel current in the plasma core. For high-confinement discharges, the dynamo is suppressed and the current-density profile is observed to strongly peak.

Reduced edge instability and improved confinement in the MST reversed-field pinch

Improved confinement has been achieved in the MST through control of the poloidal electric field, but it is now known that the improvement has been limited by bursts of an edge-resonant instability. Through refined poloidal electric field control, plus control of the toroidal electric field, we have suppressed these bursts. This has led to a total beta of 15% and a reversed-field-pinch-record estimated energy confinement time of 10 ms, a tenfold increase over the standard value which for the first time substantially exceeds the confinement scaling that has characterized most reversed-field-pinch plasmas.

Control of density fluctuations and electron transport in the reversed-field pinch

A recent study conducted on the Madison Symmetric Torus reversed-field pinch has shown that control of density fluctuations can be achieved through modification of the current density profile. Most of the power in the density fluctuations is directly associated with core-resonant resistive tearing modes. We report that, during auxiliary current drive experiments, these density fluctuations are reduced about an order of magnitude over the entire plasma cross section and the resulting electron confinement is increased eightfold.

Long-term follow-up of living kidney donors: quality of life after donation

The University of Minnesota has been a strong advocate of living donor kidney transplants. The benefits for living donor recipients have been well documented. The relative low risk of physical complications during donation has also been well documented. Less well understood is the psychosocial risk to donors. Most published reports have indicated an improved sense of well-being and a boost in self-esteem for living kidney donors. However, there have been some reports of depression and disrupted family relationships after donation, even suicide after a recipient's death. To determine the quality of life of our donors, we sent a questionnaire to 979 who had donated a kidney between August 1, 1984, and December 31, 1996. Of the 60% who responded, the vast majority had an excellent quality of life. As a group, they scored higher than the national norm on the SF-36, a standardized quality of life health questionnaire. However, 4% were dissatisfied and regretted the decision to donate. Further, 4% found the experience extremely stressful and 8% very stressful. We used multivariate analysis to identify risk factors for this poor psychosocial outcome and found that relatives other than first degree (odds ratio=3.5, P=0.06) and donors whose recipient died within 1 year of transplant (odds ratio=3.3, P=0.014) were more likely to say they would not donate again if it were possible. Further, donors who had perioperative complications (odds ratio=3.5, P=0.007) and female donors (odds ratio=1.8, P=0.1) were more likely to find the overall experience more stressful. Overall, the results of this study are overwhelmingly positive and have encouraged us to continue living donor kidney transplants.

Orientation with style. Matching teaching/learning style

Satisfaction with orientation and the link to overall job satisfaction are important because of the cost of providing new employees with orientation. Matching the teaching style of preceptors with the learning style of orientees is one way to maximize satisfaction. In this article, the author reports the results of a study conducted to determine whether there was a difference in an orientee's perceived satisfaction with orientation, based on whether the teaching style of the preceptor and the learning style of the orientee were matched or not matched. Personality type identified by the Meyers-Briggs Type Indicator (1962) was used as a measurement of teaching/learning style. The study also evaluated which of the four dimensions of personality type had the strongest relationship between matching or not matching and satisfaction. Those orientees who matched their primary preceptors on the personality preferences of introversion or extraversion reported statistically significant higher levels of satisfaction than those who did not match. Matching/not matching of the introversion/extraversion preference also showed the strongest correlation to overall satisfaction. An exploratory analysis revealed aspects of orientation having the strongest relationship to overall satisfaction. These included creativity, original thinking, experimentation, sensitivity, and flexibility.

Plateletpheresis in 90- to 110-pound donors using the CS-3000 blood cell separator

BACKGROUND

Increases in the use of single-donor apheresis components have increased the need for platelet donors. In the United States, persons must weigh 110 pounds or more to qualify as blood donors, and the same weight limitation has been placed on apheresis donors. Because automated plateletpheresis with some instruments differs considerably from whole-blood donation with respect to the volume of blood removed from the donor, the feasibility of using persons weighing between 90 and 110 pounds as platelet donors was evaluated by the use of the CS-3000 blood cell separator.

STUDY DESIGN AND METHODS

The study was performed using female subjects who met all usual donor requirements except for minimum weight. The standard platelet collection procedure of the instrument was used, except that the blood processing rate was manually selected so as to optimize the blood withdrawal and return rate in individuals. Vital signs were recorded before and after donation as were signs or symptoms of any type of donor reaction.

RESULTS

Twenty-six of 28 women completed the donation procedure; in two instances, collection was terminated prematurely because of an inability to maintain adequate venous access. An average of 4.5 x 10(11) platelets were collected during a mean donation time of 110 minutes. All donors tolerated the procedure well, and no serious adverse reactions were seen. Because of the administration of priming solution and anticoagulant during apheresis, there was a net positive fluid balance following the procedure, in spite of the removal of approximately 220 mL of platelet concentrate.

CONCLUSION

These preliminary studies suggest that 90- to 110-pound persons may serve as plateletpheresis donors. Additional studies are needed to more fully document the safety and efficacy of this approach. The use of lower-weight donors may significantly increase the number of persons available to provide single-donor platelet components.

A prospective, randomized study of the use of platelet concentrates irradiated with ultraviolet-B light in patients with hematologic malignancy

BACKGROUND

Irradiation of platelet concentrates (PCs) with ultraviolet-B (UVB) light inactivates the contaminating white cells and might be an alternative to filtration for the prevention of alloimmunization to HLA antigens and subsequent refractoriness to further platelet transfusions in multiply transfused patients with bone marrow failure.

STUDY DESIGN AND METHODS

Patients with hematologic malignancy, mainly acute myeloid leukemia, were prospectively assigned in a random manner to receive either UVB-irradiated or control, nonirradiated PCs. All patients were given red cells that were white cell reduced by filtration. Transfusion efficacy and alloimmunization were assessed by means of corrected count increments, requirement for red cells and PCs, and measurement of lymphocyte-reactive antibodies.

RESULTS

UVB-irradiated PCs had a clinical efficacy similar to controls as judged by corrected count increments at 1 to 6 and 12 to 24 hours and by the median requirement for red cell and platelet transfusions. Alloimmunization determined by measurements of lymphocyte-reactive antibodies using both conventional and antiglobulin-augmented lymphocytotoxicity techniques was not abolished in recipients of UVB-irradiated PCs (4/30, 13%) but was less than that in controls (5/20, 25%; p = NS). The mean number of platelet transfusion episodes prior to the occurrence of alloimmunization was greater in the control group (27 vs. 10; p = 0.017).

CONCLUSION

In this trial, UVB irradiation did not diminish the clinical efficacy of platelet transfusions. There was a small but nonsignificant reduction alloimmunization, but no difference in refractoriness of the two groups was observed. Larger prospective randomized studies are required to confirm these findings and to compare UVB irradiation with white cell reduction.

Human stomach class IV alcohol dehydrogenase: molecular genetic analysis

A partial human stomach alcohol dehydrogenase (ADH) encoding cDNA has been isolated, cloned, and sequenced, which contains 222 nucleotides encoding amino acid residues 227-299 of the ADH subunit. The amino acid sequence deduced from this cDNA was highly homologous with the rat stomach class IV ADH sequence recently reported (81.1% sequence identity). Homology with other human ADH classes was also observed: class I, 58.1% sequence identity; class II, 39.2% sequence identity; class III, 55.4% sequence identity; and class V, 50.0% sequence identity. These results support a proposal that the isolated cDNA encodes a partial sequence for human stomach class IV ADH. This sequence retains val294 for all other human ADH classes reported, as compared with an ala294 at this position reported for rat class IV ADH. This ala residue may contribute to the very high Km values with ethanol for the latter enzyme. In addition, three substitutions are reported for key residues in the coenzyme binding site: 251, gln/ser; 260, gly/asn; and 261, gly/asn, which may contribute to the weak coenzyme binding properties reported for human class IV ADH.

Cloning and molecular analysis of the Salmonella enterica ansP gene, encoding an L-asparagine permease

A gene (ansP), which encodes an L-asparagine permease, has been isolated from a cosmid library of Salmonella enterica during screening for recombinant clones which encode L-asparaginase. Nucleotide sequence analysis reveals that the gene product is a polypeptide of 497 amino acid residues, containing 12 putative transmembrane segments. The calculated molecular mass is 54 kDa, although maxicell analysis by SDS-PAGE gave an apparent molecular mass of 37 kDa. Comparison of the deduced amino acid sequence with sequence databases showed significant homology with a family of basic and aromatic amino acid permeases. Strains containing the cloned ansP gene demonstrated a many-fold increase in L-asparagine uptake in comparison with control strains.

Chlorpyrifos oxon binds directly to muscarinic receptors and inhibits cAMP accumulation in rat striatum

Although the acute effects of organophosphorus esters are generally ascribed to inhibition of acetylcholinesterase, work in this laboratory and others indicates that organophosphorus insecticides also interact directly with cholinergic receptors. The current study verifies that the insecticide O,O-diethyl O-3,5,6-trichloro-2-pyridinyl phosphorothionate (chlorpyrifos) and its oxon metabolite inhibits acetylcholinesterase (AChE). The metabolite inhibits rat brain AChE three orders of magnitude more rapidly than chlorpyrifos. In addition to their ability to inhibit AChE, these compounds were shown to interact directly with muscarinic receptors of rat striatum. The oxon metabolite bound at low concentrations to muscarinic receptors labeled by the muscarinic agonist [3H] cis-methyldioxolane; chlorpyrifos oxon bound with an IC50 value of 22.1 +/- 3.6 nM. The receptors bound by chlorpyrifos oxon account for approximately 30% of muscarinic receptors of the striatum and are of the m2 subtype. The binding of chlorpyrifos oxon to the m2 receptor results in a covalent modification of the receptor that does not interfere with the ability of the receptor to interact with the agonist carbachol. This receptor modification may be responsible for the inhibition of adenylate cyclase activity by chlorpyrifos oxon. The oxon inhibited adenylate cyclase with an IC50 of 155 +/- 78 nM. The inhibition of adenylate cyclase activity was not blocked by atropine and was additive to that produced by carbachol. The altering of postreceptor signal transduction by chlorpyrifos oxon may interfere with normal cellular signaling, thereby disturbing neurological function. Direct interaction of chlorpyrifos oxon with muscarinic receptors and associated signal transduction is a potential mechanism of neurotoxicity that is independent of AChE inhibition.

Role of N-terminal domain of histidine-rich glycoprotein in modulation of macrophage Fc gamma receptor-mediated phagocytosis

A brief exposure of murine peritoneal inflammatory macrophages to plasma histidine-rich glycoprotein (HRG; 77,000-81,000 MW) for 1-2 hr increased Fc gamma receptor (Fc gamma R) expression and phagocytic function in these cells. However, a continual culture of the cells without the presence of HRG for the next 18-48 hr resulted in down-regulation of Fc gamma R expression and phagocytic function. Similarly, HRG decreased Fc gamma RII expression in less differentiated human THP-1 monocytic cells during treatment for 18 hr, as determined by cellular ELISA and metabolic labelling. The molecular mechanism by which HRG regulates Fc gamma R expression is unknown. However, at a relatively high concentration (> 1 microgram/ml), HRG altered the cellular metabolism by increasing cellular protein synthesis but reducing protein secretion. These observations suggest a likely mechanism for the HRG-mediated reduction of Fc gamma R expression. A degraded HRG (40,000 MW) which possessed an identical N-terminal sequence as that of the native HRG was capable of decreasing macrophage Fc gamma R expression and phagocytosis. The results indicate that the functional domain of HRG responsible for binding to macrophages is localized to the N-terminal half.

Effects of a protective foam on scrubbing and gloving

OBJECTIVE

To test the effects of a skin protectant on surgical scrub and glove integrity.

DESIGN

Forty-nine healthy adult volunteers were assigned (12 subjects per group) to apply a protective foam (DermaMed; Benchmark Enterprises, Salt Lake City, Utah) in conjunction with surgical scrub in one of the following formulations: 70% isopropyl alcohol, a liquid detergent base containing 4% chlorhexidine gluconate, a liquid detergent base containing 7.5% povidone-iodine, or a nonantimicrobial liquid soap (control). According to a standard protocol, subjects performed a surgical scrub on 3 days (every other day). Foam was applied after surgical scrub on day 1 and before surgical scrub on day 3. No foam was applied on day 2. Subjects were gloved for 2 hours after surgical scrub.

SETTING

Laboratory setting.

RESULTS

On all test days, there were significant differences in bacterial reduction by products (chlorhexidine gluconate or alcohol > povidone-iodine > control). When controlling for baseline counts and products used, there were no significant differences in colony-forming unit counts on hands with or without foam immediately after scrubbing or at 2 hours after scrub on gloved or ungloved hands, nor were there differences in glove leakage rates when foam was on hands.

CONCLUSIONS

Such protectants can be used without detrimental effects to scrub effectiveness or glove integrity.