Implementation and dissemination of an African American popular opinion model to improve lupus awareness: an academic-community partnership

OBJECTIVE

Lupus is a chronic, autoimmune disease that disproportionately affects African Americans. We adapted the Centers for Disease Control and Prevention's Popular Opinion Leader model to implement an intervention tailored for African American individuals that leverages an academic-community partnership and community-based social networks to disseminate culturally appropriate lupus education.

METHODS

Academic rheumatologists, social scientists, and researchers in Boston, MA and Chicago, IL partnered with local lupus support groups, community organizations, and churches in neighborhoods with higher proportions of African Americans to develop curriculum and recruit community leaders with and without lupus (Popular Opinion Leaders; POLs). POLs attended four training sessions focused on lupus education, strategies to educate others, and a review of research methods. POLs disseminated information through their social networks and recorded their impact, which was mapped using a geographic information system framework.

RESULTS

We trained 18 POLs in greater Boston and 19 in greater Chicago: 97% were African American, 97% were female; and the mean age was 57 years. Fifty-nine percent of Boston POLs and 68% of Chicago POLs had lupus. POLs at both sites engaged members of their social networks and communities in conversations about lupus, health disparities, and the importance of care. Boston POLs documented 97 encounters with 547 community members reached. Chicago POLs documented 124 encounters with 4083 community members reached.

CONCLUSIONS

An adapted, community-based POL model can be used to disseminate lupus education and increase awareness in African American communities. Further research is needed to determine the degree to which this may begin to reduce disparities in access to care and outcomes.

"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life

BACKGROUND

Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL.

METHODS

Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently.

RESULTS

Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers.

CONCLUSIONS

Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

Developmentally appropriate care for adolescents and young adults with cancer: how well is Australia doing?

PURPOSE

Developmentally appropriate care underpins quality cancer treatment. This study aimed to describe how well Australian cancer services deliver patient-focussed, developmentally appropriate care to adolescents and young adults (AYAs) with cancer.

METHODS

In a national, cross sectional study, 196 AYAs with cancer aged between 15 and 25 years at diagnosis reported their general experiences of the cancer care team (Cancer Needs Questionnaire), access to age-appropriate treatment environments (Cancer Needs Questionnaire) and frequency of psychosocial assessment (Adolescent Friendly Hospital Survey).

RESULTS

Very positive responses were reported around engagement and communication with staff who were reported as approachable, friendly and trustworthy; 11 of the 14 items were positively rated by over 90% of respondents. In contrast, over 70% of AYAs expressed unmet need around their physical and social environments, whether in relation to the opportunity to be nursed in wards designed for AYAs, spend time with other young people with cancer, or talk to young people their own age; less than a third reported their needs had been met on the majority of these items. The frequency that specific psychosocial assessment domains were discussed was highly variable; responses suggested that AYAs were less commonly questioned about overtly sensitive topics. AYAs who experienced private consultations with health care providers (41%) were significantly more likely to experience thorough psychosocial assessment.

CONCLUSION

Australian cancer services are generally communicating well with AYAs. There is room for improvement around more developmentally specific aspects of healthcare quality, such as psychosocial assessment, and around treatment environments that promote greater social interaction between AYAs.

Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration

BACKGROUND

With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA).

AIMS

To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes.

METHODS

In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver.

RESULTS

Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis (NASH) without fibrosis (n = 68), NAFLD/NASH stage 1-3 fibrosis (n = 82), and NAFLD/NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma (HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese (BMI>35 kg/m² ). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes (OR 11.8, P < .001) and BMI (OR 1.4, P < .001) were the most significant predictors of advanced fibrosis.

CONCLUSIONS

In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity.

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.

Two birds with one stone: experiences of combining clinical and research training in addiction medicine

BACKGROUND

Despite a large evidence-base upon which to base clinical practice, most health systems have not combined the training of healthcare providers in addiction medicine and research. As such, addiction care is often lacking, or not based on evidence or best practices. We undertook a qualitative study to assess the experiences of physicians who completed a clinician-scientist training programme in addiction medicine within a hospital setting.

METHODS

We interviewed physicians from the St. Paul's Hospital Goldcorp Addiction Medicine Fellowship and learners from the hospital's academic Addiction Medicine Consult Team in Vancouver, Canada (N = 26). They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick's model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software (Nvivo 10).

RESULTS

We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training. Competing priorities, including clinical and family responsibilities, hindered training.

CONCLUSIONS

Combined training in addiction medicine and research is feasible and acceptable for current doctors and physicians in training. However, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required to improve curricula and research productivity.

An integrated approach to care attracts people living with HIV who use illicit drugs in an urban centre with a concentrated HIV epidemic

Background

People living with HIV (PLHIV) who are also marginalized by social and structural inequities often face barriers to accessing and adhering to HIV treatment and care. The Dr. Peter Centre (DPC) is a non-profit integrated care facility with a supervised injection room that serves PLHIV experiencing multiple barriers to social and health services in Vancouver, Canada. This study examines whether the DPC is successful in drawing in PLHIV with complex health issues, including addiction.

Methods

Using data collected by the Longitudinal Investigations into Supportive and Ancillary health services (LISA) study from July 2007 to January 2010, linked with clinical variables available through the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program, we identified DPC and non-DPC clients with a history of injection drug use. Bivariable and multivariable logistic regression analyses compared socio-demographic and clinical characteristics of DPC clients (n = 76) and non-DPC clients (n = 482) with a history of injection drug use.

Results

Of the 917 LISA participants included within this analysis, 100 (10.9%) reported being a DPC client, of which 76 reported a history of injection drug use. Adjusted results found that compared to non-DPC clients with a history of injection drug use, DPC-clients were more likely to be male (AOR: 4.18, 95% CI = 2.09–8.37); use supportive services daily vs. less than daily (AOR: 3.16, 95% CI = 1.79–5.61); to have been diagnosed with a mental health disorder (AOR: 2.11; 95% CI: 1.12–3.99); to have a history of interpersonal violence (AOR: 2.76; 95% CI: 1.23–6.19); and to have ever experienced ART interruption longer than 1 year (AOR: 2.39; 95% CI: 1.38–4.15).

Conclusions

Our analyses suggest that the DPC operating care model engages PLHIV with complex care needs, highlighting that integrated care facilities are needed to support the multiple intersecting vulnerabilities faced by PLHIV with a history of injection drug use living within urban centres in North America and beyond.

Meaningful engagement of people living with HIV who use drugs: methodology for the design of a Peer Research Associate (PRA) hiring model

Background

Community-based HIV, harm reduction, and addiction research increasingly involve members of affected communities as Peer Research Associates (PRAs)—individuals with common experiences to the participant population (e.g. people who use drugs, people living with HIV [PLHIV]). However, there is a paucity of literature detailing the operationalization of PRA hiring and thus limited understanding regarding how affected communities can be meaningfully involved through low-barrier engagement in paid positions within community-based participatory research (CBPR) projects. We aim to address this gap by describing a low-threshold PRA hiring process.

Results

In 2012, the BC Centre for Excellence in HIV/AIDS and the Dr. Peter AIDS Foundation collaborated to develop a mixed-method CBPR project evaluating the effectiveness of the Dr. Peter Centre (DPC)—an integrative HIV care facility in Vancouver, Canada. A primary objective of the study was to assess the impact of DPC services among clients who have a history of illicit drug use. In keeping with CBPR principles, affected populations, community-based organizations, and key stakeholders guided the development and dissemination of a low-barrier PRA hiring process to meaningfully engage affected communities (e.g. PLHIV who have a history of illicit drug use) in all aspects of the research project.

The hiring model was implemented in a number of stages, including (1) the establishment of a hiring team; (2) the development and dissemination of the job posting; (3) interviewing applicants; and (4) the selection of participants. The hiring model presented in this paper demonstrates the benefits of hiring vulnerable PLHIV who use drugs as PRAs in community-based research.

Conclusions

The provision of low-barrier access to meaningful research employment described herein attempts to engage affected communities beyond tokenistic involvement in research. Our hiring model was successful at engaging five PRAs over a 2-year period and fostered opportunities for future paid employment or volunteer opportunities through ongoing collaboration between PRAs and a diverse range of stakeholders working in HIV/AIDS and addictions. Additionally, this model has the potential to be used across a range of studies and community-based settings interested in meaningfully engaging communities in all stages of the research process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12954-016-0116-z) contains supplementary material, which is available to authorized users.

Comparing the retinal structures and functions in two species of gulls (Larus delawarensis and Larus modestus) with significant nocturnal behaviours

Ring-billed gulls (Larus delawarensis) and gray gulls (Larus modestus) are two species active both by day and night. We have investigated the retinal adaptations that allow the diurnal and nocturnal behaviours of these two species. Electroretinograms and histological analyses show that both species have a duplex retina in which cones outnumber rods, but the number of rods appears sufficient to provide vision at night. Their retinas respond over the same scotopic dynamic range of 3.4logcdm(-2), which encompasses all of the light levels occurring at night in their photic environment. The amplitudes of the scotopic saturated a- and b-wave responses as well as the photopic saturated b-wave response and the photopic sensitivity parameter S are however higher in ring-billed gulls than in gray gulls. Moreover, the process of dark adaptation is about 30min faster in gray gulls than in ring-billed gulls. Our results suggest that both species have acquired in the course of their evolution functional adaptations that can be related to their specific photic environment.

Soil Disturbance and Hill-Slope Sediment Transport After Logging of a Severely Burned Site in Northeastern Oregon

Despite considerable public debate in recent years on the practice of postfire logging, few studies have directly evaluated its effects. Soil disturbance and hill-slope sediment transport were measured after a postfire logging operation conducted two years after the 1996 Summit Wildfire (Malheur National Forest), in northeastern Oregon. The wildfire was relatively severe, killing an average of 86% of the trees in experimental units, and leaving an average of 34% mineral soil exposed one year after the fire. Soil disturbance was measured both pre- and postharvest in four replicate units in each of three postfire harvest treatments (unlogged control, commercial harvest [most dead merchantable trees removed], fuel reduction harvest [most dead merchantable trees removed plus most dead trees >10-cm diameter]). There was a significant difference among treatments in the percentage of mechanically disturbed soil area, with an average of 19.4% disturbed in fuel reduction units and 15.2% in commercial units. Displacement (13.7% of soil area), apparent compaction (3.1%), and erosion (0.4%) were the most common types of machine-caused soil disturbance. Controls had significantly less change in mean displacement from pre- to posttreatment compared to fuel reduction units, and significantly less change in erosion compared to commercial units. At the experimental unit level, there was a significant correlation between the number of stems removed and the total amount of mechanical soil disturbance observed. Multiple regressions indicated that logging activity, reflected by the number of stems removed, explained more variation in soil disturbance than relative fire severity, reflected by tree mortality, forest floor mass, or the percentage of mineral soil exposed. There was no correspondence between disturbance within units and hill-slope sediment collected in silt fences below units. Visual inspections and sediment collected in silt fences indicated that little sediment exited the experimental units in the short term, and that the existing road system caused most of the observed hill-slope sediment transport. Low observed levels of sediment transport were likely due to a combination of low-to-moderate slopes, low-to-moderate—risk soils, logging over snow or dry ground, hand felling, no new roads, two years recovery of ground cover between the fire and the logging, problems with measuring hill-slope sediment, and the absence of severe weather events in the two years after postfire logging. Given these mitigating factors, hill-slope sediment transport measured in this study should be considered as representative of the low end of the range that would be expected in a postfire tractor logging operation on similar soils and under similar burn severity conditions. West. J. Appl. For. 21(3):123–133.

Comparison of the Retinal Structure and Function in Four Bird Species as a Function of the Time They Start Singing in the Morning

We postulated that the retinas of bird species that are the earlier singers are more sensitive to low light conditions than species that sing closer to sunrise. The selected species were the American Robin (Turdus migratorius) and the Hermit Thrush (Catharus guttatus) as early singers, the Common Grackle (Quiscalus quiscula) and the Mourning Dove (Zenaida macroura) which join the dawn chorus near sunrise. Scotopic electroretinogram (ERGs) intensity-response functions were obtained from anesthetized birds, following which the animals were euthanized and their retinas processed for histological analysis. Based on k values, generally considered an adequate measurement of the scotopic (rod) retinal sensitivity, all species yielded comparable night vision capabilities. However, based on the maximal (mixed rod-cone response) amplitude of the scotopic b-wave, our results indicate that robins and thrushes yield larger scotopic ERGs compared with doves and grackles, but unexpectedly do not have higher rod:cone ratios. Increased thickness of the retinal inner nuclear layer and higher numbers of ganglion cells in robins and thrushes compared with doves and grackles suggest a greater number of synaptic connections maximizing vision under low light conditions, and might support their higher retinal responses under scotopic conditions. The higher ERG V(max) of robins and thrushes might also be explained, at least in part, by the optics (i.e., their lower minimum F-numbers), resulting in brighter retinal images, rather than from higher sensitivity of their retina. Our results suggest that an early onset of dawn singing might be correlated with the retinal ability to detect the first dim crepuscular lights.

Retinal Morphology and Electrophysiology of Two Caprimulgiformes Birds: The Cave-Living and Nocturnal Oilbird (Steatornis caripensis), and the Crepuscularly and Nocturnally Foraging Common Pauraque (Nyctidromus albicollis)

Oilbirds (Steatornis caripensis) breed in the total darkness of caves and forage at night on fruits. Common pauraques (Nyctidromus albicollis) are crepuscular and nocturnal foragers on flying insects. We examined if their retinal structure and function can be correlated with their types and periods of activity. Electroretinograms (ERGs) were obtained from anesthetized birds in photopic and scotopic conditions to a wide range of light intensities, following which the retinas were processed for histological analysis. Retinal sensitivity is higher in oilbirds than in common pauraques. Under scotopic conditions with maximum flash luminance, the average (+/- 95% CI) b-wave amplitude of oilbirds is double that of common pauraques (500.4 +/- 49.8 and 245.4 +/- 40.9 microV, respectively) but, under photopic conditions, the results are the reverse (common pauraque: 69.4 +/- 18.1; oilbird: 23.0 +/- 4.4 microV). On the other hand, the retina of both species is highly rod-dominated, but rods are highly more numerous in oilbirds than in common pauraques (rods:cones ratio: 123:1 and 5:1, respectively). In oilbirds, rods are largely thinner and their outer segments are 1.0 microm in diameter and 18.6 microm in length. They are distributed over various levels in the photoreceptor layers, an arrangement known for deep-sea fishes, but so far unknown for birds. In common pauraques, rods are patchily distributed and their outer segments are 4.0 microm in diameter and 53 microm in length. The oilbirds rod thinness allows more rods per area unit, and thus to catch more photons per area unit under darkness, while the low cone number suggests that the species has poor daytime vision, which concurs with the species cavernicolous daytime habits. The lower rod number of common pauraques, compared to oilbirds, appears counterbalanced by their patchiness and longer and thicker outer segments to provide high retinal sensitivity. In addition, common pauraques also have a tapetum. These features, combined with a higher proportion of cones, show that common pauraques are well equipped for crepuscular and nocturnal foraging on flying insects in an open environment.

Diurnal and nocturnal visual capabilities in shorebirds as a function of their feeding strategies

Some shorebird species forage with the same feeding strategy at night and during daytime, e.g. visual pecking in the Wilson's Plover (Charadrius wilsonia) or tactile probing in the Short-billed Dowitcher (Limnodromus griseus). The American Woodcock (Scolopax minor) uses tactile probing, by day and by night, but sometimes pecks for insects during daytime. The Black-winged Stilt (Himantopus himantopus) is a visual pecker, both by day and by night, and sometimes forages tactilely on windy (agitated water surface) moonless nights. Territorial Willets (Catoptrophorus semipalmatus) are visual peckers during daylight and on moonlight conditions but switch to tactile feeding under lower light conditions. It could be postulated that some shorebird species would switch from visual feeding during daytime to tactile foraging at night because they have poor night vision compared to species that are always sight foragers irrespective of the time of the day. This issue was examined by comparing retinal structure and function in the above species. Electroretinograms (ERGs) were obtained at different light intensities from anesthetized birds, and the retinae were processed for histological observations. Based on ERGs, retinal sensitivity, and rod:cone ratios, both plovers and stilts are well adapted for nocturnal vision. Although they have low rod density compared to that of stilts and plovers, Willets and woodcocks have a scotopic retinal sensitivity similar to that of stilts and plovers but rank midway between plovers and dowitchers for the b-wave amplitude. Dowitchers have the lowest scotopic b-wave amplitude and retinal sensitivity and appear the least well adapted for night vision. Based on photopic ERGs and cone densities, although stilts, Willets and dowitchers appear as well adapted for daytime vision, plovers occupy the last rank of all species examined. Compared to the nighttime tactile feeders and those that switch from daytime visual pecking to tactile feeding at night, nighttime sight feeders have a superior rod function and, consequently, potentially superior nocturnal visual capabilities.

Behavioral, morphological and physiological correlates of diurnal and nocturnal vision in selected wading bird species

We examined in selected wading bird species if diurnal or nocturnal foraging and the use of visual or tactile feeding strategies could be correlated with retinal structure and function. The selected species were the Yellow-crowned Night Heron (Nycticorax violaceus), a crepuscular and nocturnal forager, the Great Blue Heron (Ardea herodias), a mainly crepuscular, but also diurnal and nocturnal feeder, the Roseate Spoonbill (Ajaia ajaja), a mainly crepuscular feeder which forages more at night than during the day, the Cattle (Bubulcus ibis) and Tricolored (Egretta tricolor) egrets and the American White Ibis (Eudocimus ruber) which forage only during daytime. Herons and egrets are visual foragers; ibises and spoonbills are tactile feeders. Electroretinograms were obtained from anesthetized birds in photopic and scotopic conditions to a wide range of light intensities, following which the retinae were processed for histological analysis. Based on rod densities and rods:cones ratios, nocturnal vision capability is greater in the Yellow-crowned Night Heron, followed by the Great Blue Heron and the spoonbill, then by the egrets and the ibis. Visual feeders that forage near dawn or dusk or at night have a higher rods:cones ratio, and consequently a greater night vision capability, than visual feeding species which forage only during daytime. Visual nocturnal feeders have a night vision capability greater than tactile diurnal as well as tactile nocturnal feeders. However, based on maximum scotopic b-wave amplitudes, all species studied have roughly comparable night vision capability. The factor that best discriminates between wading bird species appears to be the daytime visual capabilities. Indeed, the diurnal ibis and egrets have similar cone densities, cones:rods ratios, and photopic a-wave amplitudes, values which are greater than those measured in the two nocturnally active heron species.

Impacts of training of village health volunteers in reduction of morbidity from acute respiratory infections in childhood in southern Thailand

In 1990, the Ministry of Public Health of Thailand started a five-year education program on management of cases with acute respiratory infection (ARI). The objective of this-study was to test whether such a program could reduce the average number of sick days of the target children. 30 villages in the study district were randomly allocated into 15 study and 15 control villages. A 2-day training workshop for village health volunteers from the study villages was conducted. The cohort of children age below 5 years in the two areas were followed-up for 19 week in the peak season of the disease. Among the 664 and 649 target children with 67,083 and 67,984 child-days observed in the study and the control villages, 71 and 41 children, respectively, were free from any episode. The preventive odds ratio of treatment adjusted for age and village effects = 0.88, 95% (CI 0.4-1.95). The median of the average sick periods in the individuals were 27 and 34 days, respectively. After adjusting for age, episodes/month and locality, the ratio of average sick days between children in the study and control villages was 0.89 (95% CI 0.76-1.05) or 11% shorter duration without statistical significance. The adjusted odds ratios of visiting the health center, private clinics, the community hospital and provincial hospital were 0.95 (95% CI 0.69-1.25), 1.43 (95% CI 0.98-2.11), 2.01 (95% CI 1.06-3.82) and 4.71 (95% CI 1.50-14.8), respectively. The training program thus had rather little impact on morbidity of the disease but tended to promote utilization of higher level of health services by the affected children.

Late-onset infections of infants in neonatal units

OBJECTIVE

To examine regional variations in the incidence of late-onset neonatal infections in Australian and New Zealand neonatal units.

METHODOLOGY

A longitudinal, prospective surveillance study of systemic sepsis (septicaemia or meningitis) in 11 neonatal units: 10 in the Australian States of the Northern Territory, New South Wales, Queensland, Victoria and Western Australia, and 1 in Christchurch, New Zealand. The results are reported of late-onset neonatal infection (defined as sepsis after 48 h) for the second year of prospective surveillance, data being collected from 1 October 1992 to 30 September 1993.

RESULTS

Data were available on 24535 live births in Australia, representing approximately 10% of all live births in the country. There were 320 episodes of sepsis in Australian units affecting 294 babies. One hundred of these episodes (31%) were early-onset; 3.0% of babies admitted to six tertiary care neonatal units attached to maternity hospitals developed late sepsis, and this rate did not differ between units. The proportion of babies infected was inversely related to birthweight: 22.6% of babies under 1OOOg, but 0.6% over 2000g. Coagulase negative staphylococci were the commonest cause of late-onset sepsis. There were 26 episodes of S. aureus septicaemia, of which only one was due to MRSA. Meningitis occurred in 13 babies (5.9%) with late-onset sepsis. The mortality from late-onset sepsis was 7.7%.

CONCLUSIONS

Coagulase-negative staphylococci are the commonest cause of late-onset sepsis of babies in neonatal units. There were no major regional differences in the incidence of, or the organisms causing, late sepsis.

Evaluation of interphase fluorescence in situ hybridization on direct hematological bone marrow smears

Traditional cytogenetic analysis from bone marrow aspirates is time consuming and frequently suboptimal due to poor viability of cells in culture. Fluorescence in situ hybridization (FISH) with appropriate DNA probes is a potential alternative to routine cytogenetics. Our study examined the reliability of uptake of specific alpha satellite centromere probes from chromosome 18 (D18Z1) and X (DXZ1) and the Yq heterochromatin (pHY3.4) directly from routine hematological bone marrow smears. Altogether 34 separate hybridizations, performed on slides from 20 patients, were scored for fluorescence signals. Cells in interphase were examined with each probe using unstained slides. In addition Giemsa stained slides were destained and then used for interphase FISH. Between 412 and 631 cells were scored for the expected number of signals; 2 for the 18 centromere, 2 for the X centromere in females, one signal for the Yqh in males. The results showed the expected number of signals in 87-97% of cells with the 18 and X probes and 95-97% of cells with the Y probe. Interphase FISH is a reliable, reproducible technique for use on direct bone marrow smears.

The use of Glasgow Coma Scale in poisoning

A 12-month prospective study was undertaken to observe current practice and to determine if a Glasgow Coma Scale (GCS) of 8 or less on admission is a useful parameter to predict the need for airway protection in poisoning. For the period of September 1988 to August 1989, there were 414 admissions for poisoning with 3 fatalities (0.7%). A total of 41 patients (10%) were assessed by attending physicians as requiring airway protection. An initial GCS of 8 or less had a sensitivity of 90% and specificity of 95% for predicting the need for intubation. Logistic regression analysis showed an odds ratio of 0.48 for the relationship between GCS and intubation, significant at P < 0.001. In addition, the absence of a gag reflex on admission gave a sensitivity of 70% and specificity of 100% for predicting the need for airway protection. Further analysis showed that the presence or absence of a gag reflex added nothing to the GCS for the prediction of probability for intubation. In conclusion, an initial GCS of 8 or less was found to be a useful guideline for intubation. However, it should be used in conjunction with the clinical context.

Priapism not associated with sickle cell disease in a Nigerian. Case report

A 25-year-old man presented with priapism that was successfully treated by a saphenocavernous shunt. The case is unusual in that most cases of priapism in Nigeria are associated with sickle cell disease and this one was not.

Death masks and life masks at Edinburgh University

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Potency enhancement of a GnRH agonist: GnRH-receptor microaggregation stimulates gonadotropin release

Binding of gonadotropin releasing hormone (GnRH, pyro-Glu1-His2-Trp3-Ser4-Tyr5-Gly6-Leu7-Arg8-Pro9-Gly-NH210) to its plasma membrane receptor is the first step leading to pituitary luteinizing hormone (LH) release. In the present study, we have prepared the ethylene glycol bis(succinimidyl succinate) (EGS) dimer of a GnRH agonist, D-Lys6-GnRH; that is, (D-Lys6-GnRH)-EGS-(D-Lys6-GnRH). The bridge length of the EGS is about 15A. This dimer stimulates LH release from pituitary cultures with full efficacy but slightly less potency than D-Lys6-GnRH indicating that the dimerization merely restricts the action of each molecule of D-Lys6-GnRH with respect to the other. When a concentration of the dimer, which alone is too low to evoke substantial LH release, is incubated with pituitary cell cultures in the presence of antibody (AB) against D-Lys6-GnRH, considerable potency enhancement occurs. LH release in response to the AB-dimer conjugate requires extracellular Ca2+ and is blocked by Pimozide. The monovalent form (i.e. reduced pepsin fragment) of AB is ineffective in stimulating release. The addition of antibody to the dimer appears to confer the ability to cross-link receptors and indicates that receptor microaggregation as such is sufficient to activate the effector system in these cells and evoke release.

Interaction of lysophosphatidylcholine with phosphatidylcholine bilayers. A photo-physical and NMR study

Several photo-physical methods together with 31P-NMR have been used to investigate the effect of lysophosphatidylcholine on phosphatidylcholine bilayers. 31P-NMR shows that the permeability of the vesicle to Eu3+ increases sharply above approx. 40% lysophosphatidylcholine: fluorescence-quenching studies also show this type of behavior. Similar sharp changes in vesicle properties are observed via the photo-physical technique at this lysophosphatidylcholine/phosphatidylcholine composition. Fluorescence spectra of pyrene and pyrene carboxaldehyde show that increasing lysophosphatidylcholine composition increases the polarity of the environments of these probes up to 40% lysocompound. Above this composition the photo-physical properties of the probes slowly revert to those characteristic of the micellar lyso-compound. The pyrene fluorescence lifetime, the fine structure of the fluorescence, and the case of formation of pyrene excimer in these bilayer mixtures suggest that pyrene complexes weakly with the charged nitrogen of the choline group of the phosphatidylcholine and that the physical state of the system has a striking effect on this complexation process. Similar experiments with simple quaternary compounds lend strong support to this suggestion. The studies monitor in several ways the effect of bilayer composition on movement of molecules in these systems. The degree or site of solubilization of carcinogens is also uniquely affected by composition.

Decreased vasopressin content in brain stem of rats with spontaneous hypertension

The content of arginine vasopressin in the brain stem and neurohypophysis of adult spontaneously hypertensive rats was measured by radioimmunoassay and the values were compared to those measured in normotensive Wistar-Kyoto rats. In the brain stem of hypertensive rats, AVP content was decreased by 77% while neurohypophyseal AVP content was increased by 26%. The results demonstrate that brain stem AVP levels and neurohypophyseal AVP levels may change differentially and they are consistent with the possibility that brain stem AVP may be involved in altering cardiovascular reflex activity.

An assessment of the therapeutic potential of azapropazone in rheumatoid arthritis

A trial to compare the therapeutic potential of 1200 mg. azapropazone daily with 3.9 g. aspirin daily was carried out in 108 out-patients with rheumatoid arthritis over a 14-day period. Analysis of results from the 85 patients with completed assessment data (49 on azapropazone; 36 on aspirin) showed that azapropazone was better than aspirin from the point of view of pain relief, number of days patients were withdrawn prematurely from the trial, and patient satisfaction with treatment. The differences, however, were not statistically significant. The authors compare the results obtained in this trial with those obtained previously from trials with 13 other antirheumatic drugs using the same method.