Cannabis for Healing in a Native Community Clinic: Development and Results from an Informatics Research Tool

This paper describes how the Puyallup Tribe created a clinic specializing in cannabis-based treatments and partnered with a university research team to assess the impacts of cannabis on patient outcomes. Clinic leaders and research team co-developed an informatics research tool that included survey questions about patient demographics, cannabis use, and measures of pain, depression, anxiety, other substance use, and trauma. Over the first 2.5 years of operations, 69 patients completed a survey. Participants were an average age of 50 years old (SD = 16.7), female (77.6%) and American Indian/Alaska Native (61.5%) with more than 12 years of education (66.7%). Over 77% of the participants used either cannabidiol-dominant (CBD) alone or both CBD and Tetrahydrocannabinol-dominant (THC) products, nearly 23% used neither CBD nor THC products. Most came to the clinic for a pain relief appointment (70.3%). Compared to the general population, participants experienced more pain-related comorbidities, such as anxiety, fatigue, sleep, and pain, and fewer physical functioning capabilities. Over half reported symptoms consistent with depressive or post-traumatic stress disorder. The informatics research tool was successfully integrated into a unique Tribally owned medical clinic.

Increasing the Self-Confidence of School Nurses to Respond to Emergency Situations

BACKGROUND

School nurses have various degrees of experience responding to respiratory or cardiac emergencies, and most only receive Basic Life Support training every 2 years as required. The goal of the study was to assess school nurses' confidence and competence in emergency situations before and after engaging in emergency preparedness high-fidelity simulations.

METHOD

This mixed methods study used a pre-/postsimulation survey design for a group of school nurses (N = 40) in the State of Hawaii. The pre- and postsimulation survey assessed professional demographics and measured confidence. After the presimulation survey, nurses participated in a 1-day training that included two separate emergency simulations using high-fidelity equipment. In addition, education was provided on the program's standardized emergency supply bags with equipment and their use during an emergency. The postsimulation survey was distributed 5 days after the educational intervention.

RESULTS

All confidence items significantly improved after the simulation session. Nurses noted the value of the training and hands-on simulation experience.

CONCLUSION

Simulation is a useful tool for increasing school nurses' confidence in responding to emergencies occurring on school campuses. [J Contin Educ Nurs. 2023;54(2):71-77.].

Addressing Health Disparities in LGBTQ Youth Through Professional Development of Middle School Staff

BACKGROUND

Significant health disparities exist for sexual minority youth (SMY). While supportive adults in schools have been shown to improve mental wellbeing and academic outcomes for students, most teachers do not receive training specific to lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) students.

METHODS

The project aimed at providing staff from a Hawaii middle school with "Safe Space" professional training to increase knowledge and comfort in supporting SMY. Pre- and post-training surveys were used to measure knowledge of LGBTQ issues and comfort in supporting LGBTQ students and a 2-week and 3-month survey assessed staff's application of newly learned material.

RESULTS

Sixty-four staff participated in the first of 2 training sessions with 59 completing both sessions. Results from the pre- and post-survey showed a 34.9% increase in knowledge of LGBTQ issues (effect size = 1.22) and a 5.5% increase in self-rated comfort level in supporting LGBTQ students (effect size = 0.22). A 3-month follow-up indicated that 52.9% of the respondents were actively applying knowledge learned within their school setting.

CONCLUSIONS

The project results demonstrate the value of the training not only in the short term but also staff's ability to apply the knowledge they learned. Given the success of implementation, expansion to other schools could facilitate ally-building attitudes and behaviors as a protective factor for SMY throughout the state.

Top tips for interprofessional education and collaborative practice research: a guide for students and early career researchers

Interprofessional research within the contexts of education and health and social care practice has grown exponentially within the past three decades. To maintain the momentum of high-quality research, it is important that early career researchers embarking on their first research journey and new to interprofessional education or interprofessional collaborative practice feel supported in making their contribution to the field. This guide, developed by the Center for the Advancement of Interprofessional Education (CAIPE) Research Group, has been written with these groups in mind who are embarking on their first research journey, and new to the interprofessional field. It aims to raise awareness of academic resources and share practical advice from those who have previously experienced problems when undertaking interprofessional research in education or health and social care practice.

Does oral care with chlorhexidine reduce ventilator-associated pneumonia in mechanically ventilated adults?

Oral colonisation by pathogens contributes to contracting ventilator-associated pneumonia (VAP). The aim of this review was to determine whether the use of the antiseptic chlorhexidine in the intra-oral cavity reduced its incidence in the critically ill, mechanically ventilated adult. The findings from this review led to the conclusion that chlorhexidine reduced the occurrence of VAP. Although a recommendation to implement the use of intra-oral chlorhexidine for mechanically-ventilated patients within critical care can be made, further exploration into required frequency and method of administration would be beneficial to reduce unnecessary exposure and hinder pathogenic resistance.

A Simple Disabilities Curriculum Improves Student Awareness of Disabilities

Learners sometimes struggle to communicate and empathize with patients with disabilities. Possible explanations for this include lack of access and exposure, emotional immaturity, and knowledge deficits. This often leads to a perception that disabilities lie outside the scope of primary care. We constructed a disabilities curriculum and embedded it within our existing third year curriculum. This curriculum is different from others because of the hands-on component in which the students are paired with a patient with a disability, the goal being to help patients transition successfully from pediatric to adult care. The disabilities curriculum also requires the students to listen to a lecture describing the healthcare challenges facing persons with disability. The curriculum also includes a video showing proper etiquette toward patients with disabilities in medical environments. Finally, the students together visit the home of a young person with disabilities. The students complete the validated “Medical Student Attitudes toward Persons with Disabilities” survey before and after the curriculum is completed. We compare those responses with another institution where the curriculum is not offered.

Food Insecurity Prevalence and Correlates in a Diverse Urban College Student Population (P04-054-19)

Objectives

To estimate the prevalence of food insecurity and to examine its correlates among students at an urban commuter-college.

Methods

Cross-sectional survey of 450 students enrolled at an urban commuter-college. Chi-square test was used to assess differences in socio-demographics characteristics, overweight/obesity status, fruit and vegetable consumption and perceived stress by food security level.

Results

Among students surveyed, 25.6% were food insecure with 12.2% having low food security and 13.3% having very low food security. The rate of food insecurity was significantly higher in black (55.6%) and Hispanic (52.7%) students compared to white (17.7%) and Asian (28.2%) students (P < 0.01). Older students (25–40 y) were also more likely to be food insecure than younger (≤ 25 y) students (42.5% vs. 28.1%; P = 0.02). There were no significant differences in fruit and vegetable consumption, overweight/obese status or perceived stress among food secure and food insecure students.

Conclusions

Food insecurity was found to be a prevalent problem in this sample, particularly in older, Black and Hispanic students. Colleges and universities must provide options and resources for low-income students to help increase access to and affordability of nutritious foods.

Funding Sources

“This material is based upon work that is supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under award number ____________. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the U.S. Department of Agriculture.”

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis

OBJECTIVE

Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy.

METHODS

CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention.

RESULTS

Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2  = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable).

CONCLUSION

In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Participatory action research into implementing open access in musculoskeletal X-ray: Management and staff perspectives

INTRODUCTION

Neighbouring Trusts have implemented open access (walk-in) services to shorten waiting times in x-ray. Despite this, staff perceptions of their effectiveness have not yet been studied. This study forms the initial baseline evaluation phase of wider participatory action research investigating the implementation of an open access service for general practitioner musculoskeletal x-ray referrals. Staff perceptions regarding effectiveness of the current service were gathered, including their opinions regarding the effectiveness of open access services.

METHODS

Qualitative data were obtained via three semi-structured interviews with radiology management and two (cross-site) staff focus groups over a 2 month period. Template analysis was used to interpret the data with the aid of NVIVO 11 to facilitate analysis.

RESULTS

Template analysis uncovered several drivers for changing the current service including waiting times, external pressures, patient choice and administrative delays. 'Flexibility' was the key theme to arise during discussion regarding the effectiveness of the current service. Potential for improved access was highlighted as a major benefit to the implementation of open access, however 'workload', 'staffing' and 'communication' were all identified as potential barriers to its implementation.

CONCLUSION

Although several staff members were satisfied with current service several drivers for change were identified that need to be addressed in order to truly deliver a service that fulfils the patients' needs. Results will inform the wider participatory action research that will investigate the barriers to implementing an open access service and identify whether this is indeed a suitable method of addressing the drivers for change.

General distress, hopelessness-suicidal ideation and worrying in adolescence: concurrent and predictive validity of a symptom-level bifactor model for clinical diagnoses

BACKGROUND

Clinical disorders often share common symptoms and aetiological factors. Bifactor models acknowledge the role of an underlying general distress component and more specific sub-domains of psychopathology which specify the unique components of disorders over and above a general factor.

METHODS

A bifactor model jointly calibrated data on subjective distress from The Mood and Feelings Questionnaire and the Revised Children's Manifest Anxiety Scale. The bifactor model encompassed a general distress factor, and specific factors for (a) hopelessness-suicidal ideation, (b) generalised worrying and (c) restlessness-fatigue at age 14 which were related to lifetime clinical diagnoses established by interviews at ages 14 (concurrent validity) and current diagnoses at 17 years (predictive validity) in a British population sample of 1159 adolescents.

RESULTS

Diagnostic interviews confirmed the validity of a symptom-level bifactor model. The underlying general distress factor was a powerful but non-specific predictor of affective, anxiety and behaviour disorders. The specific factors for hopelessness-suicidal ideation and generalised worrying contributed to predictive specificity. Hopelessness-suicidal ideation predicted concurrent and future affective disorder; generalised worrying predicted concurrent and future anxiety, specifically concurrent generalised anxiety disorders. Generalised worrying was negatively associated with behaviour disorders.

LIMITATIONS

The analyses of gender differences and the prediction of specific disorders was limited due to a low frequency of disorders other than depression.

CONCLUSIONS

The bifactor model was able to differentiate concurrent and predict future clinical diagnoses. This can inform the development of targeted as well as non-specific interventions for prevention and treatment of different disorders.

Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography

BACKGROUND

In the event of failure to secure the airway by conventional means, it may be necessary to perform invasive airway access via the cricothyroid membrane. No studies have addressed anatomy of this structure in the obstetric population. We aimed to review the anatomical variation of this structure in a population of childbearing age.

METHODS

We searched the radiology database for computed tomography studies of the neck performed in a 13-month period in consecutive patients aged 15-55 years. Studies on 18 females and 22 males were reviewed. Male patients were included for comparison. Data were reconstructed using a high spatial frequency algorithm to optimise spatial resolution. Five parameters were measured: distance from the skin to the membrane, maximum midline height of the membrane in the vertical plane, maximum transverse diameter of the membrane, neck diameter and cartilaginous calcification.

RESULTS

The distance (mean range) from skin to the membrane was similar in females and males (16.2 [3-33] vs. 13.9 [3-37] mm, P = 0.42). The vertical height (9.9 [7-17] vs. 11.4 [8-15] mm, P = 0.04) and maximum width of the membrane (14.5 [10-17] mm vs. 12.5 [10-15] mm, P < 0.01) were greater in males. Cartilaginous calcification was low and did not differ between genders.

CONCLUSIONS

The cricothyroid membrane is not necessarily a superficial structure and consequently may be difficult to palpate. The smallest dimensions of the membrane indicate that smaller than recommended cricothyroidotomy devices may be required in some patients as the external diameter of commercial trocar devices and tracheal tubes may exceed 7 mm.

Patient knowledge of peripheral vascular disease in an outpatient setting: an Achilles heel?

Peripheral vascular disease (PVD) has numerous modifiable risk factors. This study aimed to establish patients' awareness of risk factors and causes of PVD and their understanding of mechanisms of secondary prevention. A prospective survey of awareness of PVD among patients attending a tertiary vascular clinic for management of peripheral vascular disease was undertaken. Institutional review board approval was granted. Statistical analysis was performed using SPSS version 18.0 software. There was a 100% response rate, with 97 participants (53 male). Seventeen patients (19%) reported an interval of greater than six months from the onset of symptoms to first seeking medical attention with their General Practitioner. Only 19 (20%) could correctly identify 3 or more risk factors for peripheral vascular disease. Patients have limited awareness of PVD and its consequences. Educational initiatives are needed to encourage patients to seek early medical attention and raise awareness of modifiable risk factors in the community.

A systematic review of laparoscopic port site hernias in gastrointestinal surgery

INTRODUCTION

Port site hernia is an important yet under-recognised complication of laparoscopic surgery, which carries a high risk of strangulation due to the small size of the defect involved. The purpose of this study was to examine the incidence, classification, and pathogenesis of this complication, and to evaluate strategies to prevent and treat it.

METHODS

Medline was searched using the words "port site hernia", "laparoscopic port hernia" "laparoscopic complications" and "trocar site hernias". The search was limited to articles on cholecystectomy, colorectal, bariatric or anti-reflux surgery published in English. A total of 42 articles were analysed and of these 35 were deemed eligible for review. Inclusion criteria were laparoscopic gastrointestinal surgery in English only with reported incidence of port site herniation. Studies were excluded if insufficient data was provided. Eligible studies were also cross-referenced.

RESULTS

Analysis of 11,699 patients undergoing laparoscopic gastrointestinal procedures demonstrated an incidence of port site hernias of 0.74% with a mean follow-up of 23.9 months. The lowest incidence of port site herniation was for bariatric surgery with 0.57% in 2644 patients with a mean follow-up of 67.4 months while the highest incidence was for laparoscopic colorectal surgery with an incidence of 1.47% in 477 patients with a mean follow-up of 71.5 months.

CONCLUSION

All fascial defects larger than or equal to 10mm should be closed with peritoneum, while smaller defects may require closure in certain circumstances to prevent herniation. Laparoscopic port site herniation is a completely preventable cause of morbidity that requires a second surgical procedure to repair.

An analysis of the utilisation and expenditure of medicines dispensed for the management of severe asthma

There are approximately 6,300 people in Ireland with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and with a fast growing elderly population the incidence of COPD is likely to increase. This study examines the prescribing patterns of medicines dispensed for the management Asthma/COPD in patients over the age of 35 years using the HSE-Primary Care Reimbursement Services (PCRS) prescribing databases. The HSE-PCRS pharmacy claims data, which covers all those over 70 years of age and means tested for those less than 70 years, was analysed for the years 2005/2006. Approximately 26,548 (17.9%) of patients who were prescribed a respiratory drug received inhaled short-acting beta2 agonists in combination with a regular standard-dose inhaled corticosteroid. A further 5,044 (3.4%) were also prescribed a regular inhaled long-acting beta2 agonist (salmeterol or formoterol). A total of 2506 patients (6.2%) on combination therapy were co-prescribed four different anti-asthmatic treatments inclusive of oral prednisolone. A small proportion of the patients prescribed a respiratory drug were co-prescribed nicotine replacement therapy (n = 5177, 3.5%). In total there were 9,728 (6.2%) patients prescribed a mucolytic drug in combination with a respiratory drug and the rate of co-prescribing with antibiotics was 22%. COPD is a debilitating disease that is primarily caused by smoking and is therefore largely preventable. The HSE-PCRS pharmacy claims data is a valuable tool for helping to assess the burden of this disease in the Irish context.

Partial and whole gene deletion mutations of the GCK and HNF1A genes in maturity-onset diabetes of the young

AIMS/HYPOTHESIS

Heterozygous mutations of glucokinase (GCK) and hepatocyte nuclear factor-1 alpha (HNF1A; also known as hepatic transcription factor 1 [TCF1]) genes are the most common cause of MODY. Genomic deletions of the HNF1B (also known as TCF2) gene have recently been shown to account for one third of mutations causing renal cysts and diabetes syndrome. We investigated the prevalence of partial and whole gene deletions in UK patients meeting clinical criteria for GCK or HNF-1alpha/-4alpha MODY and in whom no mutation had been identified by sequence analysis.

METHODS

A multiplex ligation-dependent probe amplification (MLPA) assay was developed using synthetic oligonucleotide probes for 30 exons of the GCK, HNF1A and HNF4A genes.

RESULTS

Partial or whole gene deletions were identified in 1/29 (3.5%) probands using the GCK MLPA assay and 4/60 (6.7%) of probands using the HNF1A/-4A MLPA assay. Four different deletions were detected: GCK exon 2, HNF1A exon 1, HNF1A exons 2 to 10 and HNF1A exons 1 to 10. An additional Danish pedigree with evidence of linkage to HNF1A had a deletion of exons 2 to 10. Testing other family members confirmed co-segregation of the deletion mutations with diabetes in the pedigrees.

CONCLUSIONS/INTERPRETATION

Large deletions encompassing whole exons can cause GCK or HNF-1alpha MODY and will not be detected by sequencing. Gene dosage assays, such as MLPA, are a useful adjunct to sequence analysis when a diagnosis of MODY is strongly suspected.

The PACT trial: Interim results of a randomized trial of TNFerade biologic plus chemoradiation (CRT) compared to CRT alone in locally advanced pancreatic cancer (LAPC)

4102

Background: TNFerade is a second-generation replication-deficient adenovector, carrying the transgene encoding human TNF-α, regulated by the stress-inducible promoter Egr-1. In a phase I trial of TNFerade + radiation in 36 patients with advanced or refractory solid tumors, a 47% objective tumor response rate was observed, including 100% complete responses in 3 stage 4 melanoma patients, with 2/3 disease-free at >3.5 years. Methods: This controlled phase II trial randomizes 74 patients with newly diagnosed unresectable LAPC to 5-wks of TNFerade (4 × 1011 pu via weekly intratumoral injection) + CRT (5-FU [200 mg/m2/day CIV × 5 days/wk] and 50.4 Gy radiation) or CRT alone. All patients receive maintenance gemcitabine. Endpoints: Progression-free survival, safety, radiographic tumor response, CA 19–9 and survival. Results: In dose escalation (n=50) dose-limiting toxicities occurred in 3 patients at 1 × 1012 pu (pancreatitis in 2 and biliary obstruction), setting the MTD at 4 × 1011 pu. Compared with the first two cohorts (n=30), the MTD (n = 11) was associated with greater locoregional control and progression-free survival, a higher rate of stable or decreasing CA 19–9, improved overall survival (median = 11.2), and a high (45%) resection rate. Accrual continues in the randomized phase of the study at 20+ centers. The most frequent adverse events in the first 16 enrolled patients have been nausea (75%), abdominal pain (63%), constipation (50%), anemia (38%), diarrhea (38%), vomiting (38%), and weight loss (38%), with no significant difference in severity or frequency between the TNFerade + CRT and CRT groups. No thromboembolic events have been reported. Serum TNF-alpha levels have remained low (peak = 45.3 pg/mL, in a CRT patient). CA 19–9 has been stable (no change > 100 U/mL) or decreased in all but one CRT patient. Conclusions: These initial data indicate that TNFerade plus CRT, given as weekly intratumoral injections to patients with LAPC, is feasible and tolerable compared to CRT alone. With continued accrual, comparative tumor response and toxicity data will be available and updated.

No significant financial relationships to disclose.

Genotypic, clinical, and demographic characteristics of children infected with Helicobacter pylori

Helicobacter pylori isolates vary between geographic regions. Certain H. pylori genotypes may be associated with disease outcome. Thirty-eight children underwent diagnostic upper endoscopy at four medical centers and were retrospectively analyzed to determine if H. pylori virulence genes were associated with endoscopic disease severity, histologic parameters, and host demographics. The H. pylori virulence genotype was analyzed by a reverse hybridization line probe assay and type-specific PCR. Endoscopic ulcers or erosions were found in 17 (45%) patients, with 13 (34%) of these patients having antral nodularity. Histological gastritis, of varying severity, was present in all children. Four patients harbored more than one H. pylori strain: one subject had both cagA(+) and cagA-negative strains, while three patients harbored either two different cagA-negative strains (two children) or two cagA(+) strains (one child). There were 28 (74%) cagA(+) isolates; 19 were associated with the vacA s1b genotype, 7 were associated with the vacA s1a genotype, 1 was associated with the vacA s1c genotype, and 1 was associated with the s2 genotype. Of 14 cagA-negative isolates, 6 were vacA s2 genotype, 4 were vacA s1b, 3 were vacA s1a, and 1 was vacA s1c. Nine of ten (90%) Hispanics had similar H. pylori strains (vacA s1b,m1), and all Asian-Canadian children were infected by strains with vacA s1c genotype. No correlation between H. pylori strain and endoscopic or histopathologic abnormalities was found. This study provides a baseline framework of North American children and their H. pylori strains, serving as a powerful epidemiological tool for prospective investigations to better understand the transmission and evolution of diverse disease outcomes.

Characteristics of Helicobacter pylori infection in Jamaican adults with gastrointestinal symptoms

Helicobacter pylori infection is common in Jamaica. Describing its epidemiology in a population-based study depends largely on serology, but serologic assays have not been validated in this population. To address this issue, we examined the presence of H. pylori infection in 30 sequential adult patients with gastroduodenal symptoms by three biopsy-based methods (rapid urease test, histology, and culture) as well as by one research and two commercial enzyme-linked immunosorbent assays (ELISAs). A patient was considered H. pylori positive if the organism was detected by at least one biopsy-based method. Eighteen (60%) of the 30 patients were H. pylori positive by these criteria, whereas 21 (70%) were seropositive for H. pylori immunoglobulin G by our research ELISA. The presence of H. pylori infection in patients with gastric cancer and those with chronic gastritis was missed by biopsy-based methods but was detected by serologic assays. This observation indicates that serologic assays may be better suited for the detection of this infection in a population in which H. pylori-associated pathology is prevalent. The performance of our research ELISA in detecting biopsy-based H. pylori-positive cases was excellent, with a sensitivity and specificity of 100% and 75%, respectively. Molecular genotyping of the isolates revealed that the predominant H. pylori genotypes in this cohort of Jamaicans were cagA(+) vacA slb-m1, and iceA2. The validated serologic assay enables us to interpret epidemiologic data from population-based studies in Jamaica by comparison to those from other populations.

Effect of food on the pharmacokinetics and bioavailability of oral imiquimod relative to a subcutaneous dose

OBJECTIVES

The present study, the first clinical pharmacokinetic report of the immune response modifier imiquimod, was conducted to assess the effect of food on the oral absorption of imiquimod, to characterize its pharmacokinetics, and to estimate its oral bioavailability.

SUBJECTS AND METHODS

Sixteen healthy male volunteers completed this open-label, randomized, three-period crossover study. Subjects received a 100 mg oral dose of imiquimod after fasting in one period, after a standarized, high fat meal in another, and a 30 mg subcutaneous dose in the third period.

RESULTS

The oral bioavailability of imiquimod was on average 47%, and independent of whether imiquimod was administered with or without food. Oral imiquimod was absorbed in both fasted and non-fasted states with an absorption half-life of approximately 1 hour. However, there seemed to be a delay in the initiation of the absorption process when food was administered, which translated in to a Tmax of approximately 2.6 hours while fasting and one hour later in the non-fasted state. Imiquimod was rapidly eliminated with a half-life of approximately 2.5 hours and a total body clearance of approximately 970 ml/hxkg. Although equivalence could not be established due to the large intersubject variability, no significant differences in rate (Cmax) and extent (AUC) of oral absorption were observed between the fasted and non-fasted states. In addition, the Cmax, AUC and bioavailability values for individual subjects were consistent between both oral treatments.

CONCLUSION

This study suggests that food does not have a major effect on the rate, extent of absorption or bioavailability of oral imiquimod, and thus, it is suitable to administer imiquimod orally in either the fasted or non-fasted states.

The hemodialysis access: preferences and concerns of patients, dialysis nurses and technicians, and physicians

One hundred twenty-eight hemodialysis patients and 64 medical personnel consisting of dialysis nurses and technicians, hemodialysis access surgeons and nephrologists were surveyed about their preferences and concerns in regard to the hemodialysis vascular access. The access preferred by physicians was the A-V fistula in the lower arm. In contrast, the access preferred by dialysis nurses and technicians was the polytetrafluoroethylene (PTFE) graft in the lower arm. Patients desired a superficial access in the forearm which was easy to cannulate, had minimal effect on their appearance, provided quick hemostasis after dialysis and enabled arm comfort during dialysis. Physicians felt the most significant concerns about the access were thrombosis and infection. Nurses and technicians ranked difficult cannulation and insufficient access blood flows that prohibited dialysis adequacy as their major problems. For patients the most common problem was pain during needle insertion. This survey concluded that the A-V fistula remains the access of choice. However, appropriate maturation of the fistula must occur before needle insertion is attempted. An immature fistula is difficult to cannulate, has fragile veins resulting in blood leakage around the needle infiltrating the subcutaneous tissues and has inadequate blood flows for successful dialysis. Patients who are introduced to dialysis with inadequate access function or access failure from either an A-V fistula or a PTFE graft have increased morbidity, inadequate dialysis and enhanced anxiety about dialysis treatments. To increase the success and acceptance of A-V fistulas in hemodialysis patients it is incumbent upon the nephrologist to protect the future access arm from damage to the vasculature and to allow for fistula maturation before cannulation. Surgical protocols must improve the appropriate selection of a fistula or PTFE graft for various age groups and disease categories. Better patient preparation and selection of the proper access type for each patient will enhance early access function and subsequent access survival.

Assessing attachment: convergent validity of the adult attachment interview and the parental bonding instrument

OBJECTIVE

The aim of this study was to determine whether or not the Parental Bonding Instrument (PBI) can provide information about parent-child attachment that is comparable to information obtained from the Adult Attachment Interview (AAI), a more complex measure of attachment.

METHOD

One hundred and thirty emotionally and/or behaviourally disturbed adolescents (73 male, 57 female; ages 13-19 years, x = 15.3 +/- 1.47 years) participating in a study of attachment and suicidality completed the PBI and the AAI. Data from these measures were compared within participants.

RESULTS

Maternal care and overprotection on the PBI differed significantly by AAI attachment classification (F3,122 = 2.79, p = 0.012), with autonomous participants showing the most optimal and unresolved participants the least optimal PBI results. Maternal love and maternal involvement/role reversal on the AAI were significant predictors of maternal care and maternal overprotection, respectively, on the PBI (R2 = 0.15; R2 = 0.16). These predictions improved when AAI scales measuring idealisation and involving anger towards the mother were included in the regression analyses (R2 = 0.35; R2 = 0.20). Autonomous participants on AAI showed the highest scale correlations across instruments.

CONCLUSIONS

Attachment information obtained from the PBI and the AAI is comparable in participants with optimal attachment histories, but not in participants showing idealisation or anger towards their mothers. Caution is, therefore, advisable when using the PBI to obtain attachment information in clinical samples where suboptimal attachment histories are likely.

Administration of imiquimod, an interferon inducer, in asymptomatic human immunodeficiency virus-infected persons to determine safety and biologic response modification

A phase I study to determine safety, maximum tolerated dose, and biologic response during multiple once-a-week administration of oral imiquimod, an immune response modifier, was conducted in 12 adults with early human immunodeficiency virus (HIV) infection. All completed the dose-escalation phase of weekly dosing at 100-mg increments and received at least one maintenance dose, 100 mg below the patient's toxic dose, for 12 weeks. Dose-limiting toxicity occurred in 3 patients at 200-mg, 5 at 300-mg, and 3 at 400-mg dose levels. One tolerated the 500-mg dose without dose-limiting toxicity. Dose-limiting toxicities included fatigue, fever, malaise, increased transaminases, hypotension, vomiting, and depression. Seven of 12 completed 12 weeks of maintenance. At > or = 200 mg of imiquimod, all patients had biologic responses, measured by elevations in serum interferon, beta2-microglobulin, and neopterin levels. Imiquimod induced pronounced levels of circulating interferon in asymptomatic HIV-infected persons, with variable effect on virus load.

A phase I clinical trial of imiquimod, an oral interferon inducer, administered daily

Imiquimod is an orally active interferon inducer with anti-tumour activity in experimental animals. In this study the tolerability, toxicity and biological effects of daily oral imiquimod administration were investigated in 21 patients with refractory cancer. Patients were treated with doses of 25 mg, 50 mg, 100 mg or 200 mg on a projected 112 day course. Only three patients completed the course, all at the 50 mg dose. Treatment toxicities were dose related and mainly comprised flu-like symptoms, nausea and lymphopenia. Of the 21 patients, five received dose reductions and in five treatment was discontinued because of treatment-related toxicity. The biological activity of imiquimod was confirmed by significant and sustained rises in peripheral blood mononuclear cell (PBMC) 2-5A synthetase (2-5AS) levels at all doses. At 100 mg and 200 mg these occurred within the first 24 h of administration. Levels of neopterin and beta 2-microglobulin (beta 2M) were also significantly elevated when assessed after three weeks' treatment. Interferon production was not demonstrated within the first 24 h of the initial dose but, following repeated doses, ten of the patients developed detectable serum interferon concentrations with a maximum value of 5600 IU ml-1 recorded. Administration of imiquimod did not have any significant effect on serum levels of tumour necrosis factor (TNF) or interleukin 1 (IL-1), nor did it lead to development of detectable levels of antibodies to interferon. One mixed clinical response was observed after 4 weeks' treatment at 100 mg in a patient with renal cell cancer. Daily administration of imiquimod causes activation of the interferon production system but at higher doses results in unacceptable toxicity. Further investigation of imiquimod as an interferon-inducing agent in cancer patients is suggested at either the lower dose levels or employing alternative dosing schedules.

Care of a woman with Down's syndrome using the Neuman Systems Model

Care study

Alice Bird is a 26-year-old women with Down's syndrome and a severe learning disability. Following a long illness, Alice's father passed away just before my involvement with the family. Alice now lives at home with her mother, aged 70, and an older sister, Janice, aged 34, who has a mild learning disability and is also being treated for mental health problems.

Two other brothers live nearby and are in regular contact with the family. My initial contact with this family followed a request for help in planning long-term care for Alice in the event of the mother's death. Mrs Bird, having recently lost her husband, realised that her daughter would almost certainly live longer than her and wanted to feel that appropriate plans had been made.