Racial and Ethnic Disparities in Health-Related Quality of Life for Patients with Colorectal Cancer: Analysis of the SEER-MHOS Linked Data Set

PURPOSE/OBJECTIVE(S)

We hypothesized that racial and ethnic disparities exist in health-related quality of life (HRQOL) among older adults with colorectal cancer, both before and after diagnosis.

MATERIALS/METHODS

The Surveillance, Epidemiology, and End Results and Medicare Health Outcomes Survey (SEER-MHOS) linked data set was used to identify patients 65 years old and above who were diagnosed with colorectal cancer between 1996 and 2015. Self-reported race/ethnicity, the predictor of interest, was categorized as White (W), Asian/Pacific Islander (API), Black/African American (B), or Hispanic (H). HRQOL data from the 36-Item Short Form Survey and Veterans RAND 12-Item Health Survey were extracted within 24 months pre- and post-diagnosis. HRQOL was measured using the Physical Component Summary (PCS), Mental Component Summary (MCS), and Total Component Summary (TCS, a summation of PCS and MCS), which were the response variables. Associations were assessed via univariable (UVA) and multivariable (MVA) linear regression analysis, adjusting for age, sex, region, marital status, education, income, number of comorbidities, limitations in activities of daily living, stage, and histology. Pairwise comparisons were performed between all racial and ethnic groups.

RESULTS

We identified a total of 1,204 evaluable patients, with 815 in the pre-diagnosis cohort and 562 in the post-diagnosis cohort, including 173 patients in both. With unadjusted p-values, pre-diagnosis UVA revealed a higher mean PCS in API patients compared to W, B, and H patients (p<0.001, p<0.001, p = 0.02) as well as in W compared to H patients (p = 0.002); a higher mean MCS in W and API patients compared to B (p<0.001, p = 0.002) and H patients (p<0.001, p = 0.002); and a higher mean TCS in API compared to W, B, and H patients (p = 0.027, p<0.001, p<0.001) as well as in W compared to B and H patients (p<0.001, p = 0.012). Pre-diagnosis MVA revealed a higher mean PCS in API compared to B patients (p = 0.028) and a higher mean MCS in W and B compared to H patients (p = 0.022, p = 0.021). Post-diagnosis UVA showed a higher mean MCS in W compared to B and H patients (p<0.001 for both) as well as in API compared to H patients (p = 0.002), and a higher mean TCS in W and API patients compared to B (p<0.001, p = 0.045) and H patients (p<0.001, p = 0.007). Post-diagnosis MVA showed a higher mean MCS in API compared to H patients (p = 0.035). Compared to pre-diagnosis, post-diagnosis mean TCS was numerically lower for all groups.

CONCLUSION

Among older adults with colorectal cancer, there appear to be racial and ethnic disparities in HRQOL. Before the cancer diagnosis, API patients had better physical HRQOL than B patients, while W and B patients had better mental HRQOL than H patients. After diagnosis, API patients had better mental HRQOL than H patients. For all groups, the cancer diagnosis seemed to have a negative impact on overall HRQOL.

Trends in Racial and Ethnicity Disparities in the Health-Related Quality of Life in Older Adults with Breast Cancer: A SEER-MHOS National Database Study

PURPOSE/OBJECTIVE(S)

To examine racial and ethnic disparities in Health-Related Quality of Life (HRQOL) in older adults with breast cancer, both pre- and post-diagnosis.

MATERIALS/METHODS

Using the Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey (SEER-MHOS) database, we included patients > 65 years old with breast cancer diagnosed from 1998-2019, who had completed the Health Outcomes Survey within 24 months pre- and post-diagnosis, and who had a reported ethnicity of non-Hispanic White (W), non-Hispanic Asian or Pacific Islander (API), non-Hispanic Black or African American (B), or Hispanic (H). HRQOL data was measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the Medical Outcomes Study Short Form-36 and the Veterans RAND 12-Item Health Survey instruments. Univariable (UVA) and multivariable (MVA) linear regression models were fitted for MCS, PCS, and TCS (composite MCS and PCS) as response variables to assess for potential disparities between races and ethnicities. MVA models were adjusted for sex, age, marital status, education, income, number of comorbidities, limitations in activities of daily living, national region, histology, and treatment type (in post-diagnosis cohort only).

RESULTS

We identified 1,008 in the pre-diagnosis cohort (56.6% stage I, 29.8% stage II, 9.3% stage III, and 4.3% stage IV) and 991 patients in the post-diagnosis cohort (58.3% stage I, 28.6% stage II, 9.3% stage III, 3.8% stage IV). On UVA, differences in mean scores of TCS, PCS, and MCS, respectively, were found among W, API, B, and H patients in both pre-diagnosis and post-diagnosis cohorts (pre-diagnosis - TCS: 93.4, 93.0, 87.0, 86.3; PCS: 40.3, 40.0, 37.0, 37.5; MCS: 53.1, 52.9, 50.0, 48.7; post-diagnosis - TCS: 90.8, 90.3, 84.3, 83.5; PCS: 38.5, 39.2, 36.8, 34.5; MCS: 52.3, 51.1, 49.8, 46.8; all p < .001). A drop in PCS, MCS, and TCS scores numerically was observed for all groups. Among patients in the pre-diagnosis cohort who would be diagnosed with stage IV breast cancer, race was found to be a predictor of PCS with overall significance (p = 0.04) within MVA linear regression. Specifically, on the local test, compared to B, W had higher pre-diagnosis PCS scores (+13.32, p = 0.03). Race was not found to be a predictor in PCS, MCS, or TCS scores otherwise.

CONCLUSION

Among older patients who would be diagnosed with stage IV breast cancer, W had better physical HRQOL as compared to B patients' pre-diagnosis. The decrease in numerical HRQOL scores of the physical domain in all groups post-diagnosis highlights the potential negative physical impact breast cancer has on patients, demonstrating the need for determining the proper resources and support to improve physical HRQOL following diagnosis.

The Inpatient Consultation Experience in Radiation Oncology: A Contemporary Evaluation of a Single Academic Institution

PURPOSE/OBJECTIVE(S)

Participating in an inpatient consultation service is an essential aspect of radiation oncology residency training. However, there are no reports in the literature describing the inpatient on-call experience. To better describe the clinical burden and define the learning opportunities associated with inpatient consultation service participation, inpatient on-call data were tracked and assessed.

MATERIALS/METHODS

From July 1, 2022, through Dec. 31, 2022, radiation oncology residents covering the on-call pager for the inpatient consultation service spanning two hospitals at a single academic institution prospectively self-reported the total number of pages, new consultations, inpatient treatment starts, and treatment indications. Patient billing records and paging logs were reviewed to confirm self-reported cases and track the number of business days between simulation and the first fraction of treatment. A new inpatient consultation was defined as a novel encounter requiring independent evaluation; as such, patients admitted during an ongoing course of radiotherapy who continued the planned course while inpatient were not included.

RESULTS

During the initial six months of tracking, on-call residents received a total of 607 pages with an average of 23.1 pages per week (range: 14-38). Of these pages, 212 were for new inpatient consultations with an average of 8.1 consultations per week (range: 2-15). Out of these 212 new consultations, 75 patients (35%) were treated on an inpatient basis. Nine patients (12%) received their first fraction of treatment on the same day as simulation, 13 (17%) on the next day, 11 (15%) two days after, 22 (29%) three days after, and 20 (27%) four or more days after simulation. The most common indications for urgent treatment were malignant spinal cord compression (27%), brain metastases (24%), tumor-related bleeding (8%), malignant obstruction of the airway or vasculature (8%), painful bone metastases (7%), and heterotopic ossification prophylaxis (7%). The most common primary sites of disease were leukemia/lymphoma (16%), gastrointestinal (13%), breast (11%), lung (9%), gynecologic (9%), sarcoma (9%), and benign (9%). Each individual resident's caseload differed greatly in quantity, indication, treatment site, and primary site over this six-month time period.

CONCLUSION

In this longitudinal analysis at a single academic institution, the radiation oncology inpatient consultation service experience was highly variable and diverse in clinical volume and treatment indication on a week-to-week and resident-to-resident basis. Exposure to radiation oncology emergencies is a vital component of residency training. However, the unpredictable nature of inpatient on-call scenarios can lead to variable educational experiences. Tracking inpatient on-call cases during residency may help identify areas needing improvement to enhance both patient care and residency training.

Racial and Ethnic Disparities in Health-Related Quality of Life in Older Adults with Non-Hodgkin Lymphoma

PURPOSE/OBJECTIVE(S)

To investigate whether health-related quality of life (HRQOL) disparities exist among different racial and ethnic groups in older patients with Non-Hodgkin Lymphoma (NHL), pre- and post-diagnosis.

MATERIALS/METHODS

Using the Surveillance, Epidemiology, and Ends Results-Medicare Health Outcomes Survey (SEER-MHOS) linked database, we included individuals 65 years and older with NHL and reported ethnicities of Whites, Asian, Black, and Hispanic, diagnosed from 1998-2019. HRQOL data within 24 months before and after diagnosis were measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36® and VR-12 instruments. The total combined score (TCS) is reflected by both the PCS and MCS. Multivariate analyses (MVA) adjusted for sex, age, marital status, education, income, year of diagnosis, number of comorbidities, limitations in activities of daily living (ADLs), national region, treatment type (post-diagnosis cohort only), stage, and histology.

RESULTS

We identified 2506 patients in the pre-diagnosis and 1903 patients in the post-diagnosis cohorts. In the pre-diagnosis cohort, univariate analysis (UVA) revealed that Whites had higher MCS scores than Asians (53.4 vs 50.2, p = 0.001), Blacks (53.4 vs 48.3, p<0.001), and Hispanics (53.4 vs 49.9, p<0.001). It was also revealed that Whites had higher PCS scores than Blacks (40.5 vs 37.4, p = 0.005), Whites had higher TCS scores than Blacks (93.4 vs 85.1, p<0.0001) and Hispanics (93.4 vs 87.3, p<0.0001), and Asians had higher TCS scores than Blacks (90.5 vs 85.1, p = 0.012). MVA revealed the following: Whites had higher MCS scores than Asians (52.3 vs 50.0, p = 0.038), Blacks (52.3 vs 49.1, p = 0.002), and Hispanics (52.3 vs 49.8, p = 0.005); Whites had higher TCS scores than Blacks (92.5 vs 87.9, p<0.006) and Hispanics (92.5 vs 88.6, p = 0.006); and Asians had higher TCS scores than Blacks (92.6 vs 87.9, p = 0.045). In the post-diagnosis cohort, UVA revealed that Whites had higher PCS scores than Hispanics (36.2 vs 34.1, p = 0.046); Whites had higher MCS scores than Asians (51.3 vs 48.8, p = 0.035), Blacks (51.3 vs 48.7, p = 0.033), and Hispanics (51.3 vs 46.7, p<0.0001); Whites had higher TCS scores than Blacks (87.0 vs 82.3, p = 0.021) and Hispanics (87.0 vs 78.5, p<0.0001); and Asians had higher TCS scores than Hispanics (86.5 vs 78.5, p = 0.001). MVA revealed that Whites had higher MCS scores than Hispanics (47.6 vs 44.0, p = 0.002); Whites had higher TCS scores than Hispanics (83.5 vs 76.5, p<0.0001), and Asians had higher TCS scores than Hispanics (83.7 vs 76.5, p = 0.006).

CONCLUSION

HRQOL disparities exist among different racial and ethnic groups in older patients with NHL. Pre-diagnosis, Whites had better mental HRQOL compared to Asians, Blacks, and Hispanics. Whites also had better overall HRQOL as compared to Blacks and Hispanics, and Asians had better overall HRQOL than Blacks. Post-diagnosis, Whites had better mental and overall HRQOL than Hispanics, and Asians had overall better HRQOL than Hispanics.

Characterizing the phylogenetic specialism-generalism spectrum of mammal parasites

The distribution of parasites across mammalian hosts is complex and represents a differential ability or opportunity to infect different host species. Here, we take a macroecological approach to investigate factors influencing why some parasites show a tendency to infect species widely distributed in the host phylogeny (phylogenetic generalism) while others infect only closely related hosts. Using a database on over 1400 parasite species that have been documented to infect up to 69 terrestrial mammal host species, we characterize the phylogenetic generalism of parasites using standard effect sizes for three metrics: mean pairwise phylogenetic distance (PD), maximum PD and phylogenetic aggregation. We identify a trend towards phylogenetic specialism, though statistically host relatedness is most often equivalent to that expected from a random sample of host species. Bacteria and arthropod parasites are typically the most generalist, viruses and helminths exhibit intermediate generalism, and protozoa are on average the most specialist. While viruses and helminths have similar mean pairwise PD on average, the viruses exhibit higher variation as a group. Close-contact transmission is the transmission mode most associated with specialism. Most parasites exhibiting phylogenetic aggregation (associating with discrete groups of species dispersed across the host phylogeny) are helminths and viruses.

Mesenchymal stem cells produce functional cartilage matrix in three-dimensional culture in regions of optimal nutrient supply

Mesenchymal stem cells (MSCs) are a promising cell source for the treatment of musculoskeletal disease. However, MSC chondrogenesis in 3D culture generates constructs whose macroscopic (bulk) mechanical properties are inferior to constructs formed with chondrocytes. To investigate where and why these deficits in functionality arise, we assessed the local (microscopic) properties of cell-laden hydrogel constructs. Both chondrocyte- and MSC-laden constructs showed pronounced depth dependency, with ~3.5 and ~11.5 fold decreases in modulus from the surface to central regions, respectively. Importantly, in the surface region, properties were similar, suggesting that MSCs can produce matrix of mechanical equivalence to chondrocytes, but only in conditions of maximal nutrient support. Dynamic culture on an orbital shaker (which enhances diffusion) attenuated depth-dependent disparities in mechanics and improved the bulk properties compared to free swelling conditions (225 to 438 kPa for chondrocytes, 122 to 362 kPa for MSCs). However, properties in MSC-based constructs remained significantly lower due to persistent mechanical deficits in central regions. MSC viability in these central regions decreased markedly, with these changes apparent as early as day 21, while chondrocyte viability remained high. These findings suggest that, under optimal nutrient conditions, MSCs can undergo chondrogenesis and form functional tissue on par with that of the native tissue cell type. However, the lack of viability and matrix production in central regions suggests that chondrogenic MSCs do not yet fully recapitulate the advanced phenotype of the chondrocyte, a cell that is optimized to survive (and thrive) in a mechanically challenging and nutrient-poor environment.

Transneuronal tracing of airways-related sensory circuitry using herpes simplex virus 1, strain H129

Sensory input from the airways to suprapontine brain regions contributes to respiratory sensations and the regulation of respiratory function. However, relatively little is known about the central organization of this higher brain circuitry. We exploited the properties of the H129 strain of herpes simplex virus 1 (HSV-1) to perform anterograde transneuronal tracing of the central projections of airway afferent nerve pathways. The extrathoracic trachea in Sprague-Dawley rats was inoculated with HSV-1 H129, and tissues along the neuraxis were processed for HSV-1 immunoreactivity. H129 infection appeared in the vagal sensory ganglia within 24 h and the number of infected cells peaked at 72 h. Brainstem nuclei, including the nucleus of the solitary tract and trigeminal sensory nuclei were infected within 48 h, and within 96 h infected cells were evident within the pons (lateral and medial parabrachial nuclei), thalamus (ventral posteromedial, ventral posterolateral, submedius, and reticular nuclei), hypothalamus (paraventricular and lateral nuclei), subthalamus (zona incerta), and amygdala (central and anterior amygdala area). At later times H129 was detected in cortical forebrain regions including the insular, orbital, cingulate, and somatosensory cortices. Vagotomy significantly reduced the number of infected cells within vagal sensory nuclei in the brainstem, confirming the main pathway of viral transport is through the vagus nerves. Sympathetic postganglionic neurons in the stellate and superior cervical ganglia were infected by 72 h, however, there was no evidence for retrograde transynaptic movement of the virus in sympathetic pathways in the central nervous system (CNS). These data demonstrate the organization of key structures within the CNS that receive afferent projections from the extrathoracic airways that likely play a role in the perception of airway sensations.

Cortical activation and lamina terminalis functional connectivity during thirst and drinking in humans

The pattern of regional brain activation in humans during thirst associated with dehydration, increased blood osmolality, and decreased blood volume is not known. Furthermore, there is little information available about associations between activation in osmoreceptive brain regions such as the organum vasculosum of the lamina terminalis and the brain regions implicated in thirst and its satiation in humans. With the objective of investigating the neuroanatomical correlates of dehydration and activation in the ventral lamina terminalis, this study involved exercise-induced sweating in 15 people and measures of regional cerebral blood flow (rCBF) using a functional magnetic resonance imaging technique called pulsed arterial spin labeling. Regional brain activations during dehydration, thirst, and postdrinking were consistent with the network previously identified during systemic hypertonic infusions, thus providing further evidence that the network is involved in monitoring body fluid and the experience of thirst. rCBF measurements in the ventral lamina terminalis were correlated with whole brain rCBF measures to identify regions that correlated with the osmoreceptive region. Regions implicated in the experience of thirst were identified including cingulate cortex, prefrontal cortex, striatum, parahippocampus, and cerebellum. Furthermore, the correlation of rCBF between the ventral lamina terminalis and the cingulate cortex and insula was different for the states of thirst and recent drinking, suggesting that functional connectivity of the ventral lamina terminalis is a dynamic process influenced by hydration status and ingestive behavior.

Effect of aging on regional cerebral blood flow responses associated with osmotic thirst and its satiation by water drinking: a PET study

Levels of thirst and ad libitum drinking decrease with advancing age, making older people vulnerable to dehydration. This study investigated age-related changes in brain responses to thirst and drinking in healthy men. Thirst was induced with hypertonic infusions (3.1 ml/kg 0.51M NaCl) in young (Y) and older (O) subjects. Regional cerebral blood flow (rCBF) was measured with positron emission tomography (PET). Thirst activations were identified by correlating rCBF with thirst ratings. Average rCBF was measured from regions of interest (ROI) corresponding to activation clusters in each group. The effects of drinking were examined by correlating volume of water drunk with changes in ROI rCBF from maximum thirst to postdrinking. There were increases in blood osmolality (Y, 2.8 +/- 1.8%; O, 2.2 +/- 1.4%) and thirst ratings (Y, 3.1 +/- 2.1; O, 3.7 +/- 2.8) from baseline to the end of the hypertonic infusion. Older subjects drank less water (1.9 +/- 1.6 ml/kg) than younger subjects (3.9 +/- 1.9 ml/kg). Thirst-related activation was evident in S1/M1, prefrontal cortex, anterior midcingulate cortex (aMCC), premotor cortex, and superior temporal gyrus in both groups. Postdrinking changes of rCBF in the aMCC correlated with drinking volumes in both groups. There was a greater reduction in aMCC rCBF relative to water drunk in the older group. Aging is associated with changes in satiation that militate against adequate hydration in response to hyperosmolarity, although it is unclear whether these alterations are due to changes in primary afferent inflow or higher cortical functioning.

Increased movement pain in osteoarthritis of the hands is associated with A beta-mediated cutaneous mechanical sensitivity

The relationship between joint pain and hyperalgesia has been explored in animal models of articular inflammation, but is yet to be shown in the most common rheumatologic condition: osteoarthritis. In this study, cutaneous thermal and mechanical pain thresholds were measured over the thumb of patients with osteoarthritis of the hands. In symptomatic patients, pain was manipulated through resisted active movement of the thumb. Provocation of movement pain (MP) was associated with a sustained fall in mechanical pain thresholds. Thermal pain thresholds remained stable during increases in joint pain. Increased mechanical sensitivity after exacerbation of MP was alleviated by A beta fiber blockade. It appears that superficial tenderness over the osteoarthritic thumb fluctuates with pain arising from movement of the joint. It is concluded that dorsal horn mechanisms contribute to MP-related hyperalgesia in osteoarthritis of the hands.

FGF-8 in the ventral pharynx alters development of myocardial calcium transients after neural crest ablation

Cardiac neural crest ablation results in depressed myocardial calcium transients and elevated proliferation in myocardium at a stage when cardiac neural crest cells are not in contact with the myocardium. To test the hypothesis that cardiac neural crest-derived cells, which migrate into the caudal, ventral pharynx at stage 14, block a signal from the ventral pharynx, we cultured stage 12 chick heart tube or myocardial strips in the presence or absence of ventral pharynx. We found that myocardium cultured with ventral pharynx that had not yet contacted neural crest cells had significantly reduced calcium transients and an increased rate of proliferation. Ventral pharynx from intact embryos at a stage when neural crest-derived cells had reached the pharynx had no effect on myocardial calcium transients. Ventral pharynx from neural crest-ablated embryos continued to suppress myocardial calcium transients at this later stage. Myocardium cultured with FGF-2 also showed a significant reduction in calcium transients. An FGF-2-neutralizing Ab reversed the deleterious effect of the ventral pharynx on myocardial calcium transients and proliferation. We therefore examined the expression of FGF-2 and similar FGFs in the ventral pharynx. Only FGF-8 was expressed in a temporospatial pattern that made it a viable candidate for altering the myocardial calcium transient during stages 14-18. In explant cultures, neutralizing Ab for FGF-8 rescued development of the myocardial calcium transient in neural crest-ablated chick embryos.

Cell biology of cardiac development

Building a vertebrate heart is a complex task and involves several tissues, including the myocardium, endocardium, neural crest, and epicardium. Interactions between these tissues result in the changes in function and morphology (and also in the extracellular matrix, which serves as a substrate for morphological change) that are requisite for development of the heart. Some of the signaling pathways that mediate these changes have now been identified and several investigators are now filling in the missing pieces in these pathways in hopes of ultimately understanding the molecular mechanisms that govern healthy heart development. In addition, transcription factors that regulate various aspects of heart development have been identified. Transcription factors of the GATA and Nkx2 families are of particular importance for early specification of the heart field and for regulating expression of genes that encode proteins of the contractile apparatus. This chapter highlights some of the most significant discoveries made in the rapidly expanding field of heart development.

The automatic updating of egocentric spatial relationships and its impairment due to right posterior cortical lesions

The non-visual updating of body-centred spatial relationships was investigated in an experiment in which blindfolded patients had to point to previously seen targets after a body rotation in the absence of vision. Patients with lesions to the right dorsal (RD) area were impaired at updating their positions relative to non-RD patients and normal subjects: they tended to underestimate systematically the angle through which they had turned. The results are interpreted in terms of impoverished locomotor input and/or systematically biased processing or locomotor proprioception in the RD patients, which prevented accurate tracking of changes in egocentric spatial relationships.

Double-stranded RNA injection produces null phenotypes in zebrafish

Zebrafish is a simple vertebrate that has many attributes that make it ideal for the study of developmental genetics. One feature that has been lacking in this model system is the ability to disable specifically targeted genes. Recently, double-stranded RNA has been used to silence gene expression in the nematode Caenorhabditis elegans. We have found that expression of the green fluorescent protein (GFP) from a microinjected plasmid vector can be suppressed in zebrafish embryos by the coinjection of a double-stranded RNA that is specifically targeted to GFP. To determine that double-stranded RNA can attenuate endogenous gene expression, single-cell zebrafish embryos were injected with double-stranded RNA specifically targeted to Zf-T and Pax6.1. We found that microinjection of double-stranded Zf-T RNA resulted in a high incidence of a phenotype similar to that of ntl. Furthermore, Zf-T gene expression could not be detected by in situ hybridization and the message was decreased by 75% by semiquantitative RT-PCR in 12-h embryos that had been injected with the double-stranded RNA. Expression of the zebrafish genes sonic hedgehog and floating head was altered in the embryos microinjected with the Zf-T double-stranded RNA in a manner that is remarkably similar to the zebrafish no-tail mutant. Microinjection of double-stranded RNA targeted to Pax6.1 was associated with depressed expression of Pax6. 1 and resulted in absent or greatly reduced eye and forebrain development, similar to the phenotype seen in mouse mutants. Simultaneous injection of Pax6.1 and Zf-T resulted in embryos lacking notochords, eyes, and brain structures.

HIRA, a DiGeorge syndrome candidate gene, is required for cardiac outflow tract septation

DiGeorge syndrome (DGS) is a congenital disease characterized by defects in organs and tissues that depend on contributions by cell populations derived from neural crest for proper development. A number of candidate genes that lie within the q11 region of chromosome 22 commonly deleted in DGS patients have been identified. Orthologues of the DGS candidate gene HIRA are expressed in the neural crest and in neural crest-derived tissues in both chick and mouse embryos. By exposing a portion of the premigratory chick neural crest to phosphorothioate end-protected antisense oligonucleotides, ex ovo, followed by orthotopic backtransplantation to the untreated embryos, we have shown that the functional attenuation of cHIRA in the chick cardiac neural crest results in a significantly increased incidence of persistent truncus arteriosus, a phenotypic change characteristic of DGS, but does not affect the repatterning aortic arch arteries, the ventricular function, or the alignment of the outflow tract.

Automatic spatial updating during locomotion without vision

People can update their spatial relationships relative to the environment while walking without vision. The hypothesis that such updating is automatic was tested in a locomotor task in which the subjects were asked to refrain from updating their positions. Subjects walked without vision to one of four previously seen targets via a second location. In one condition--the updating condition--the subjects were asked to walk to the real position of the target relative to the second location; in another--the ignoring condition--they were asked to imagine that they had not moved from the starting point and to walk from the second location as if walking to the target from the initial location. When the subjects were asked to start walking to the target as soon as it was named by the experimenter, they performed better in the updating condition than in the ignoring condition. When the subjects were allowed more time to respond, the difference in performance between these two conditions disappeared. The results suggest that the subjects automatically updated their positions as they moved, but that, given enough time, they could override this updating retrospectively using more deliberate cognitive processing.

National palliative care education and training needs analysis

This purpose of this research study was to conduct a needs analysis for the education and training of palliative care providers. The research methodology was a descriptive survey of the education and training needs of palliative care providers. A total of 1848 questionnaires was distributed to the palliative care providers throughout Australia and a return rate of 34 per cent (627) was attained. The responses from Australia metropolitan areas totalled 51.7 per cent and those from Australian rural and remote areas totalled 48.3 per cent (302). The results showed that the specific education and training needs, as identified by the palliative care providers, included pain management, loss and grief, drug therapies, education updates and other needs. Deficiencies of current education and training programs in palliative care included cost as most postgraduate courses are not HECs funded but are offered as full fee-paying courses. Travel and distance were reported as the most prohibitive aspect to attending a palliative care course. The content in existing palliative care programs predominantly focused on providing care in a palliative care unit or a respite setting. More emphasis needs to be placed on caring for patients in their home; a shift from death in the hospital to death in the home.

GATA-1 expression pattern can be recapitulated in living transgenic zebrafish using GFP reporter gene

In this study, DNA constructs containing the putative zebrafish promoter sequences of GATA-1, an erythroid-specific transcription factor, and the green fluorescent protein reporter gene, were microinjected into single-cell zebrafish embryos. Erythroid-specific activity of the GATA-1 promoter was observed in living embryos during early development. Fluorescent circulating blood cells were detected in microinjected embryos 24 hours after fertilization and were still present in 2-month-old fish. Germline transgenic fish obtained from the injected founders continued to express green fluorescent protein in erythroid cells in the F1 and F2 generations. The green fluorescent protein expression patterns in transgenic fish were consistent with the pattern of GATA-1 mRNA expression detected by RNA in situ hybridization. These transgenic fish have allowed us to isolate, by fluorescence-activated cell sorting, the earliest erythroid progenitor cells from developing embryos for in vitro studies. By generating transgenic fish using constructs containing other zebrafish promoters and green fluorescent protein reporter gene, it should be possible to visualize the origin and migration of any lineage-specific progenitor cells in a living embryo.

The classification of patients with chronic pain: age as a contributing factor

OBJECTIVE

To explore the influence of age on the empirical classification of patients with chronic pain.

DESIGN

Cluster analyses of two cohorts defined by age.

SETTING

Two outpatient pain management clinics for young and older people.

SAMPLE

The sample consisted of 340 patients between the ages of 17 and 93 years, who were consecutively assessed on admission to the multidisciplinary pain clinics. The subjects were allocated to two groups according to age; either 17 to 65 years or 66 years and older.

MEASUREMENTS

Clustering was carried out using standardised scores from measures of pain (McGill Pain Questionnaire), depression (Zung or Geriatric Depression Scales), and impact of pain (Sickness Impact Profile adapted for pain).

RESULTS

Previous classifications of younger adults were replicated in the clusters of: "Good Pain Control," "Positive Adaption to Pain," and "Chronic Pain Syndrome." A fourth cluster, "High Impact," was identified in the older group and subsequently replicated in the combined sample. This group consisted of subjects with high levels of impact of pain and depression and low levels of pain.

CONCLUSION

Age differences are present in the clinical presentation of chronic pain patients. Some older patients with chronic pain present with a unique constellation of clinical symptoms, and the classic patient profile of high pain, high impact, and high mood disturbance (i.e., Chronic Pain Syndrome) identified in younger to middle-aged adults does not occur as frequently in older patients. A number of explanations are presented to account for these differences, including comorbidity as well as other medical, psychological, and social factors.

Promoter analysis in living zebrafish embryos identifies a cis-acting motif required for neuronal expression of GATA-2

We have used zebrafish embryos to dissect the promoter activity of a gene with a complex expression pattern during embryogenesis. GATA-2 is a transcription factor required for hematopoiesis and is dynamically expressed in hematopoietic tissues and in the central nervous system. Using constructs containing zebrafish GATA-2 genomic flanking sequences and the green fluorescent protein (GFP) reporter gene, we demonstrate that distinct regulatory domains are required for hematopoietic, enveloping layer (EVL), and neuronal expression of GATA-2. During gastrulation, GFP expression is confined to the ventral ectoderm and lateral mesoderm and is lacking in the dorsal shield. Cells derived from the regions expressing GFP give rise to hematopoietic progenitors, EVL cells, and neurons. Deletion analysis of the 7.3-kb GATA-2 promoter region revealed that a 1.1-kb DNA sequence is critical for expression of GATA-2 in neurons. Fine mapping revealed that a 31-bp region is required for neuron enhancer activity, and mutagenesis showed that the DNA motif CCCTCCT is essential for GATA-2 promoter activity in the central nervous system of zebrafish. Our use of zebrafish embryos can be exploited as a whole animal system for the dissection of any developmentally regulated vertebrate promoter.

Measuring the activity of older people with chronic pain

OBJECTIVE

A variety of instruments have been applied to the measurement of activity, yet few, if any, have been validated specifically for older people with chronic pain. This study has sought to examine the utility of the Human Activity Profile (HAP) for describing activity in a sample drawn from a pain clinic for older people.

DESIGN

The HAP was administered to 193 older pain clinic patients, 72 of whom completed the profile on a second occasion. A further 55 responses were collected from a group of community-dwelling volunteers. The factor structure of the HAP was tested using these 320 responses. The factors subsequently derived were compared with the Sickness Impact Profile (SIP) and the Barthel Index (BI). The discriminant validity of the HAP was examined by comparing factor scores for groups determined by gender, diagnosis, and status in the pain clinic.

RESULTS

The 94 items of the HAP loaded onto 10 factors, which explained 63.7% of the variance. These factors demonstrated moderate associations with the BI and the subscales of the SIP. The factors discriminated between men and women (F[12.180] = 9.85. p < 0.000). Differences were also present between subjects with a musculoskeletal pain problem, postherpetic neuralgia, and pain-free volunteers (F[24.340] = 4.7. p < 0.000). Factor scores increased between pre- and postclinic assessments (F[12.60] = 4.79. p < 0.000).

CONCLUSIONS

The HAP has demonstrated qualities which favor its adoption as an activity measure for older pain clinic patients.

The effect of medical status on the activity level of older pain clinic patients

OBJECTIVE

This project sought to assess the effect of disease status on the activity level of older people suffering from chronic pain.

DESIGN

A retrospective comparison of groups defined by disease attributes.

SETTING

Outpatient pain management clinic for older people.

SAMPLE

The sample consisted of 115 patients, of a possible 144, aged between 52 and 91 years, who were assessed upon admission to a multidisciplinary pain management clinic. Subjects were allocated to groups for comparison on the basis of the diagnosis of their pain problem and the extent of coexistent medical problems.

MEASUREMENTS

Groups were compared on scores of activity level using the Human Activity Profile, with and without pain (McGill Pain Questionnaire) and depressive symptom (Geriatric Depression Scale) scores as covariates.

MAIN RESULTS

Both pain diagnosis and number of additional medical problems characterized groups that were distinguishable by level of activity. A musculoskeletal disorder was associated with greater impact on activity than either postherpetic neuralgia or pain associated with a psychiatric diagnosis. Less activity was also evident among the subjects with several additional medical problems. However, this effect did not operate independently of depressive symptoms.

CONCLUSIONS

Disease status is a factor that rarely explains variations in the pain experience of young adult patients with chronic pain. The results from this study suggest that disease state does influence self-reported activity level in older people with chronic pain. The influence of medical status should be acknowledged as an important factor when assessing and managing the older patient with chronic pain.

Effect of the transcription start region of the herpes simplex virus type 1 latency-associated transcript promoter on expression of productively infected neurons in vivo

It has been previously reported that the latency-associated transcript (LAT) promoter contains a DNA sequence at the LAT transcription start site which resembles the ICP4 consensus DNA binding site and that this site allows ICP4-mediated downregulation of the LAT promoter in transient assays (A. H. Batchelor and P. O'Hare, J. Virol. 64:3269-3279, 1990). We have confirmed these data by showing that an ICP4-expressing plasmid will downregulate lacZ expression from a plasmid containing the LAT promoter and transcription start site (pJA1) and does not downregulate lacZ expression from a plasmid in which the start site has been mutagenized (pWAG15). To determine the role of the LAT transcription start site in regulating LAT promoter activity in the context of the virus, two recombinant viruses, KOS-1 and KOS-15, were studied. KOS-1 contains an 863-bp portion of the LAT promoter, including the LAT cap site, fused to the lacZ gene and inserted into the gC locus (T.P. Margolis, F. Sedarati, A.T. Dobson, L.T. Feldman, and J.G. Stevens, Virology 189:150-160, 1992). The second virus (KOS-15) was constructed in identical fashion, using plasmid pWAG-15, which is not downregulated by ICP4. Vero cells productively infected with KOS-15 produce 10-fold more beta-galactosidase than do those infected with KOS-1. In murine dorsal root ganglia acutely infected with KOS-1, only 1.2% of dorsal root ganglion neurons that expressed viral antigen also expressed beta-galactosidase. In contrast, in KOS-15-infected mice, beta-galactosidase was detected in 18% of viral antigen-positive neurons. Similar findings were observed in trigeminal ganglia acutely infected with KOS-1 and KOS-15. Thus, the region encompassing the LAT transcription start site appears to play an important role in repression of the LAT promoter activity not only in vitro but also in acutely infected neurons in vivo. These results suggest that during productive infection with HSV-1, LAT expression is tightly regulated.

Pain in older persons

Chronic pain is more prevalent in older persons than in young adults. In this review the physiological, pathological, and psychological reasons for altered pain sensibility in older persons are explored and strategies for the management of pain in older persons described. The evidence suggests that altered physiology of peripheral and central pain mechanisms combine with psychological attitudes, such as stoicism and reluctance to confirm the presence of pain, to raise pain threshold. However, once pain is experienced, older persons describe the same severity, quality, and psychological disturbance as younger persons. There is some evidence to suggest that the complaint of pain in the presence of pathology is reported less often in older persons. On the other hand, the presence of persistent or recurrent clinical pain may have a greater impact on the psychological, social, and physical function of older adults. It is also clear, however, that further empirical studies are required in order to delineate the age-related differences and similarities in the chronic pain experience. Management of chronic pain in the elderly requires meticulous diagnosis of the causal pain mechanisms as well as a holistic approach which gives due regard to psychological and social consequences of pain.

The herpes simplex virus type 1 reactivation function lies outside the latency-associated transcript open reading frame ORF-2

The latency-associated transcription unit has been shown to be important for in vivo reactivation of herpes simplex virus from the latent state. A recombinant virus was constructed to alter the largest open reading frame in this region. This virus had a wild-type reactivation phenotype, suggesting that herpes simplex virus does not require a protein function from this reading frame for efficient reactivation from latency.

Herpes simplex virus latency-associated transcript is a stable intron

The latency-associated transcript (LAT) is the major viral transcript detected by in situ hybridization of mouse and human sensory ganglia latently infected with herpes simplex virus type 1. The last 750 bases of LAT are complementary to infected-cell polypeptide 0, a herpes simplex virus type 1 immediate-early gene that encodes a transactivating protein that may facilitate re-activation of the virus from the latent state. Several laboratories have shown that LAT accumulates in the nucleus and is not polyadenylylated. Recently, we showed that the promoter for LAT lies 688 bases upstream from its 5' end. We report here that LAT is actually a uniquely stable intron. Furthermore, LAT effectively inhibits transactivation of gene expression by infected-cell polypeptide 0 in transient transfection assays.

Identification of the latency-associated transcript promoter by expression of rabbit beta-globin mRNA in mouse sensory nerve ganglia latently infected with a recombinant herpes simplex virus

The herpes simplex virus type 1 latency-associated transcript (LAT) is expressed as a major species in latently infected mouse neurons. Previous sequence analysis revealed no obvious promoter elements near the 5' end of the LAT, but a TATA box and other potential promoter elements were found 700 base pairs upstream. A recombinant virus in which the rabbit beta-globin gene was inserted immediately downstream of the TATA box expressed globin mRNA and did not express the LAT. A second recombinant virus, in which this TATA box was removed, was negative for LAT expression in a latent infection. The location of the LAT promoter suggested that RNA upstream of the LAT was synthesized and degraded during latent-phase transcription. Low levels of this RNA were observed by in situ hybridization. In other experiments, RNA from a productive infection was used to detect a transcript extending from the LAT promoter to a polyadenylation signal approximately 8.5 kilobase downstream. These data suggest that the LAT may be processed from a larger transcription unit which begins distal to the TATA box 700 base pairs upstream of the LAT and extends to a polyadenylation signal almost 5 kilobases downstream of the 3' end of the LAT.

Total knee arthroplasty after septic arthritis

Total knee arthroplastie were performed as salvage procedures in 1- patients with irreversible knee destruction secondary to bacterial arthritis. All now have functioning knees that are pain-free and average 85 degrees of motion. None has evidence of clinical infection at present. These patients are not yet regarded as cured. They may remain at risk for the development of late reinfections. This procedure is not advocated as the operation of choice for patients with knee joint destruction secondary to bacterial arthritis. We emphasize the risk involved and the necessity for obtaining the informed consent of the patient before proceeding with total knee arthroplasty when there has been previous infection.