AB0099 METHOTREXATE REDUCES THE INVASIVE ACTIVITIES OF PRIMARY RA SYNOVIAL FIBROBLASTS

Background:

Rheumatoid Arthritis synovial fibroblasts (RASFs) are key player in tissue destruction via the production of a wide range of chemical reactions in the joint with high growth rate and resistance to mortality [1]. Methotrexate (MTX) is a dihydrofolate reductase inhibitor that attenuates inflammation within joints resulting in reduced cartilage and bone damage and is the anchor therapy for RA. Its mechanisms of action are thought to differ from its anti-proliferative effects and are known to include increased adenosine release (2), but may also involve alterations in intracellular methyl donor status resulting in alteration in DNA methylation and gene expression.

Objectives:

To investigate the effects of MTX on RASFs auto-aggressive activities, including invasion, migration, proliferation and apoptosis.

Methods:

RASF were derived from knee biopsies of RA patients taken at arthroscopy (n=9). Matrigel chambers were used to measure invasive activities. The cells were incubated with DMSO (control), 1μM or 10μM MTX for 96 hours. Wound healing (scratch assays) were used to measure migration. Proliferation and apoptosis was determined using BrdU and caspase-3/7 assays respectively. Significance was determined via repeated measures ANOVA using SPSS software.

Results:

Incubation with MTX resulted in significantly reduced invasive activity compared with DMSO control; 1μM (35%, p=0.006) and 10μM (58%, p=0.002) in paired samples. However MTX did not have significant effects on RASF migration, apoptosis or proliferation at either concentration.

Conclusion:

Our data reveals that MTX reduces the invasive potential of RASFs in vitro, this effect may contribute to the clinical efficacy of this agent. Further investigation will involve epigenome-wide methylation to determine if the DNA methylome of RASFs is altered by MTX.

References:

[1]Huber LC, et al. (2006) Rheumatol. 45(6):669-675.

[2]Chan ES & Cronstein BN (2010) Nat Rev Rheumatol 6(3):175-178.

Acknowledgments:

This abstract arose from work funded by the National Children’s Research Centre, Our Lady’s Children’s Hospital, Crumlin

Disclosure of Interests:

None declared

What do health visitors do? A national survey of activities and service organisation

BACKGROUND

Early interventions targeting health inequalities, and changing policies for mothers and pre-school children, have focused attention on existing interventions.

OBJECTIVES

To collect baseline data about current roles and activities undertaken by health visitors; and to understand the relationship between existing services and recommended practice shown in research about preventive programmes.

METHODS

A national postal survey was used to collect data about current roles and activities undertaken by health visitors across the UK (n=1459, 46% response rate).

RESULTS

A description is provided of activities undertaken and the types of needs addressed by health-visiting services. The established health-visiting purpose of using a caseload of infants and pre-school children as a base from which to reach out to a wider community seems to be still in place, with difficulty. The major focus of their work was on primary and secondary prevention, but included provision for identified problems. Two main patterns of service provision were identified; one 'comprehensive' and one that was more restricted. The 'restricted service,' available in most places, was mainly reactive, with child protection and social factors predominant. Even the 'comprehensive services' were far lower in intensity than programmes shown, through research, to improve family wellness. In addition, less than half of respondents thought that it was always feasible to deliver services as planned.

CONCLUSIONS

The results question the premise, upon which universal provision rests, that all families receive a service offering proactive health promotion and the timely identification of additional health needs.

Injuries in the Victorian thoroughbred racing industry

There is increasing concern in Australia about safety in the thoroughbred racing industry, but there has been no reported analysis of injury data. This review analyses injury and workers' compensation data recorded in Victoria. On the basis of the results, it is recommended that the injury and incident data collection systems are improved such that they are not only more complete but also accumulate more detailed information about the location of an incident or injury event, the activity at the time of the incident or injury event, and factors that may have influenced the occurrence.

An analysis of the forces required to drag sheep over various surfaces

Some occupational health and safety hazards associated with sheep shearing are related to shearing shed design. One aspect is the floor of the catching pen, from which sheep are caught and dragged to the shearing workstation. Floors can be constructed from various materials, and may be level or gently sloping. An experiment was conducted using eight experienced shearers as participants to measure the force exerted by a shearer when dragging a sheep. Results showed that significant changes in mean dragging force occurred with changes in both surface texture and slope. The mean dragging forces for different floor textures and slopes ranged from 359 N (36.6 kg) to 423N (43.2 kg), and were close to the maximum acceptable limits for pulling forces for the most capable of males. The best floor tested was a floor sloped at 1:10 constructed of timber battens oriented parallel to the path of the drag, which resulted in a mean dragging force 63.6N (15%) lower than the worst combination.

The palliative management of fungating malignant wounds--generalising from multiple-case study data using a system of reasoning

The project focused on individual experiences, from 45 participants, of living with a fungating wound and the performance of wound dressings in reducing the impact of the wounds on daily living. A case study design was adopted. This posed a key methodological challenge in the form of the contentious epistemological issue, characterised in the literature as the "nomothetic-idiographic dilemma". This issue concerns the nature of knowledge generated from an individual case and its generalisability. A system of reasoning was adopted as the analytic strategy, within a theory-driven evaluation, to abstract general issues from the case study data to construct explanations of symptom control and dressing performance. The latter were generalised beyond the individual cases with the use of theory. This paper focuses on the methodological issues that are inherent in the use of a case study design and the nature of the evidence generated. The system of reasoning is described and illustrated using data from a single participant with advanced uterine cancer and a fungating nodule in the groin.

Outcome of pseudoseizures in children and adolescents: a 6-year symptom survival analysis

Outcome was studied of all children and adolescents with pseudoseizures without epilepsy, who were referred and treated as in-patients and/or day patients in the tertiary psychiatric ward at Birmingham Children's Hospital, UK between 1988 and 1994. Information was derived from case-note data. Freedom from seizures for six months was defined as 'cure', as no recurrences after this period were noted. Kaplan-Meier survival analysis was used. Seventeen patients were identified: 15 females and two males; mean age at presentation to the tertiary psychiatric service was 12 years 9 months (SD 26 months; range 8 years 3 months to 15 years 9 months). Fourteen participants recovered and resumed regular school attendance. Three were lost to follow-up due to being referred on to other agencies before recovery because they became too old for the service. Recovery followed an exponential distribution, with a mean symptom survival time following treatment of 1.5 years. These results are consistent with a treatment effect. Younger age at presentation, female sex, having more types of seizures, and not receiving both in-patient and outpatient treatment were associated with better outcome. The deteriorating prognosis with age at treatment suggests prompt identification may be important in ensuring a good outcome.

The biology of HIV infection

This article reviews the cell and molecular biology of human immunodeficiency virus (HIV), emphasizing the features that lead to opportunistic infection by organisms such as mycobacteria. Mycobacteria, especially M. avium complex and M. tuberculosis infections, are closely associated with HIV disease. HIV is a very small retrovirus and its high mutation rate leads to extremely variable viral populations, both within and between individuals. It is coated with glycoprotein 120 (gp120), which it uses to bind to and infect a range of CD4+ leukocytes, depending on the co-receptor specificity. T cell-tropic HIV strains tend to use the CXCR-4 chemokine receptor, while macrophage-tropic strains tend to use the CCR-5 chemokine receptor. Immunosuppression is induced in a number of ways. As well as frank depletion of virus-infected T cells, antigen-specific T cell clones can be selectively deleted by mechanisms such as defective antigen presentation by HIV-infected macrophages (activation-induced cell death). Changes in cytokine production in HIV infection are also proposed. All this leads to falling T cell counts, B cell dysregulation and macrophage dysfunction. Opportunistic infections exploit this immunosuppressed environment. Certain infections are prevalent, reflecting factors such as environmental exposure to pathogens, poor mucosal defences and subcellular interactions between HIV and, e.g. viral or mycobacterial infections. Opportunistic infection exacerbates immune destruction by HIV, producing a vicious cycle that is ultimately fatal.

Generalising to theory: the use of a multiple case study design to investigate needs assessment and quality of care in community nursing

This paper outlines the detail of the case study method used in a project commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB) to investigate the changing educational needs of community nurses with regard to needs assessment and quality of care in the context of the NHS and Community Care Act, 1990. It explains the methodological procedures and analytic processes which led to integration of data across the whole study, focusing on the role of a prior theoretical framework in case study design. Recently qualified practitioners (health visitors and district nurses) were observed during a regular shift (N=134 visits), concentrating on their practice of assessing needs, and on liaison and collaboration within teams and across sectors. They were interviewed after the observation period (N=33 practitioners), to determine the extent of formality they attached to each assessment, and elicit information about aspects which may be embedded in everyday practice as well as those recorded for explicit requirements.The preliminary analysis resulted in the modification of a model for assessing service quality, and identified various points where a 'policy-practice gap' might arise between policies and practice in both the health service and education. The practicalities of operationalising a multiple case study design into research are highlighted, and the mechanism for 'generalising to theory' illustrated.

Purified lipopolysaccharide from Francisella tularensis live vaccine strain (LVS) induces protective immunity against LVS infection that requires B cells and gamma interferon

Previous results have demonstrated that nonspecific protective immunity against lethal Francisella tularensis live vaccine strain (LVS) or Listeria monocytogenes infection can be stimulated either by sublethal infection with bacteria or by treatment with bacterial DNA given 3 days before lethal challenge. Here we characterize the ability of purified lipopolysaccharide (LPS) from F. tularensis LVS to stimulate similar early protective immunity. Treatment of mice with surprisingly small amounts of LVS LPS resulted in very strong and long-lived protection against lethal LVS challenge within 2 to 3 days. Despite this strong protective response, LPS purified from F. tularensis LVS did not activate murine B cells for proliferation or polyclonal immunoglobulin secretion, nor did it activate murine splenocytes for secretion of interleukin-4 (IL-4), IL-6, IL-12, or gamma interferon (IFN-gamma). Immunization of mice with purified LVS LPS induced a weak specific anti-LPS immunoglobulin M (IgM) response and very little IgG; however, infection of mice with LVS bacteria resulted in vigorous IgM and IgG, particularly IgG2a, anti-LPS antibody responses. Studies using various immunodeficient mouse strains, including LPS-hyporesponsive C3H/HeJ mice, muMT(-) (B-cell-deficient) knockout mice, and IFN-gamma-deficient mice, demonstrated that the mechanism of protection does not involve recognition through the Lps(n) gene product; nonetheless, protection was dependent on B cells as well as IFN-gamma.

A taxonomy of needs assessment, elicited from a multiple case study of community nursing education and practice

The role and expectations of community nurses in carrying out needs assessments changed when an internal quasi-market was introduced to the British health service under the National Health Service (NHS) & Community Care Act 1990. This paper reports on a study commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB) to investigate the changing educational needs of community nurses with regard to needs assessment in the context of this legislation. A multiple case study design was utilized and four cases identified, incorporating the geographical variation in England. Recently qualified practitioners (health visitors and district nurses) were observed during a regular shift (n=134 visits), concentrating on their practice of assessing needs, and on liaison and collaboration within teams and across sectors. Participants were interviewed after the observation period (n=33 practitioners), to determine the extent of formality they attached to each assessment, and to elicit information about aspects which may be embedded in everyday practice. Single and multiple case analyses across the four cases used an iterative process of pattern-matching, replication logic and explanation building. The preliminary analysis yielded a descriptive 'taxonomy' which could serve as a basis for classifying the variants of needs assessment and help to clarify the whole phenomenon. When applied further to the data, this revealed the complex interactions between the different ideals (relating to policy, nursing and ascribed worth), the various types (purpose, formality/specificity and complexity) and timing (in relation to client, service and practice issues) within needs assessment.

Implementing new health visiting services through action research: an analysis of process

An action research project based in a single fundholding practice on the South Coast of England aimed to identify needs relevant to families with resident children, then to use the contracting system to redirect health visiting practice to meet those needs. The naïvety of this plan was well recognised, so the processes that occurred during implementation of the proposed changes were recorded throughout. An analysis of these participant observation data revealed various organisational constraints and facilitators that arose during contract negotiations. Two new full time health visiting posts were established, each with an innovative and somewhat controversial focus. One health visitor was employed to establish a community development project in an underserved area of the town, while the other was to provide a home visiting service for the families of school aged children. The processes involved in structuring decisions about 'health needs' and how these are best met are analysed for each of the two new posts. The analysis reveals powerful influences that affect the implementation of new health visiting services.

Identifying approaches to meet assessed needs in health visiting

An action research project, based in a single fundholding practice on the south coast of England, aimed to identify the health needs of families with resident children, then use the contracting system to redirect health visiting services to meet those needs. After assessing the health needs, it was necessary to assess the potential of a range of health visiting approaches that might be proposed to meet those needs. This paper explains how the approaches were assessed for use in the local area and why funding for two additional, innovative posts was deemed necessary. Despite the unsophisticated evidence base for health visiting interventions, a case can be made for commissioning particular service approaches by using a combination of survey data and results from controlled and uncontrolled service evaluations. The supportive focus of health visitor home visiting remains an appropriate use of existing resources, but the usual intensity of visiting may be insufficient for full effectiveness. To rationalize such services by targeting them only at individuals with established needs risks an exacerbation of deteriorating health trends across an area. Alternatively, augmenting home visiting with a community development approach to improve the adverse social environments in which families live may help to change the underlying factors that contribute to ill-health and prove more widely cost-effective.

Resources revisited: salutogenesis from a lay perspective

Health visitors are being pressured to move away from their traditional role in health promotion and public health to focus more closely on people with established clinical disorders. This is partly because of a paucity of theoretical explanations against which to assess interventions directed explicitly at promoting health rather than only preventing disease. However, there are growing public health concerns about increasing inequalities and rising numbers of disadvantaged groups in the UK as well. This paper revisits a grounded theory study that revealed how, in the absence of a need for clinical intervention, health visitors appear to assess needs by treating health as a process fuelled by the accumulation and use of 'resources for health'. Wider theories about salutogenesis ('health creation') and research showing the importance of health and social capital demonstrate the potential of this idea, and were combined with the health visiting study to create a theoretical framework for analytical purposes. Semi-structured interviews with the main carer in 50 families with resident children were analysed using this framework, to provide a lay perspective on how people consider they maintain their health. The analysis demonstrated the usefulness of treating health as a process and of focusing on the development of health-related resources rather than only on presenting problems. The processes of developing capacity were shown to be more important than the presence or absence of specific resources. Links with personal empowerment were apparent; cultural patterns that evolved across generations and neighbourhoods revealed possible pathways to social cohesion. Practice approaches that enhance or inhibit the development of these health-creating resources were identified, and considered in the light of emerging public health needs.

A serine residue in ClC-3 links phosphorylation-dephosphorylation to chloride channel regulation by cell volume

In many mammalian cells, ClC-3 volume-regulated chloride channels maintain a variety of normal cellular functions during osmotic perturbation. The molecular mechanisms of channel regulation by cell volume, however, are unknown. Since a number of recent studies point to the involvement of protein phosphorylation/dephosphorylation in the control of volume-regulated ionic transport systems, we studied the relationship between channel phosphorylation and volume regulation of ClC-3 channels using site-directed mutagenesis and patch-clamp techniques. In native cardiac cells and when overexpressed in NIH/3T3 cells, ClC-3 channels were opened by cell swelling or inhibition of endogenous PKC, but closed by PKC activation, phosphatase inhibition, or elevation of intracellular Ca2+. Site-specific mutational studies indicate that a serine residue (serine51) within a consensus PKC-phosphorylation site in the intracellular amino terminus of the ClC-3 channel protein represents an important volume sensor of the channel. These results provide direct molecular and pharmacological evidence indicating that channel phosphorylation/dephosphorylation plays a crucial role in the regulation of volume sensitivity of recombinant ClC-3 channels and their native counterpart, ICl.vol.

An exploratory study of demand for the health visiting service within a marketing framework

A small exploratory study was carried out to consider the concept of demand for the health visiting service from the clients' perspective. Because of the internal market introduced to the British health system under the National Health Service and Community Care Act, the idea of 'marketing' was used as a conceptual framework to underpin the study. Guided interviews were carried out with a sample of nine mothers of pre-school children to elicit the reasons why clients access the service, what they value about it and how they think it could be improved. A detailed qualitative analysis of these data indicates that demand for health visiting relates, in the first instance, to clients' knowledge of the service. This knowledge, and the extent to which the service meets their expectations, appear to influence the value the women place on health visiting and their subsequent use of it. A cycle is described, which illustrates critical points at which health visiting responses affect demand and use of service. The implications of the study for health visiting and for marketing the service are discussed.

Molecular identification of a volume-regulated chloride channel

A volume-regulated chloride current (ICl.vol) is ubiquitously present in mammalian cells, and is required for the regulation of electrical activity, cell volume, intracellular pH, immunological responses, cell proliferation and differentiation. However, the molecule responsible for ICl.vol has yet to be determined. Although three putative chloride channel proteins expressed from cloned genes (P-glycoprotein, pICln and ClC-2 ) have been proposed to be the molecular equivalent of ICl.vol, neither P-glycoprotein nor pICln is thought to be a chloride channel or part thereof, and the properties of expressed ClC-2 channels differ from native ICl.vol. Here we report that functional expression in NIH/3T3 cells of a cardiac clone of another member of the ClC family, ClC-3, results in a large basally active chloride conductance, which is strongly modulated by cell volume and exhibits many properties identical to those of ICl.vol in native cells. A mutation of asparagine to lysine at position 579 at the end of the transmembrane domains of ClC-3 abolishes the outward rectification and changes the anion selectivity from I- > Cl- to Cl- > I- but leaves swelling activation intact. Because ClC-3 is a channel protein belonging to a large gene family of chloride channels, these results indicate that ClC-3 encodes ICl.vol in many native mammalian cells.

Analysing clinical practice guidelines. A method of documentary analysis

This paper will describe a method of documentary analysis used in a study examining the validity of clinical guidelines issued to health visitors to assist them in identifying families requiring increased health visitor support. This forms the preliminary work for a wider study examining how health visitors decide to increase support to vulnerable families. Although a number of published research texts discuss the value of records and documents as important data sources for health service researchers, there is relatively little information available about the processes of documentary analysis. This paper offers one method for analysing clinical practice guidelines, it describes the development of a critique and analysis tool and explores the strengths and weaknesses of this particular analysis instrument.

Salmonella serogroups identified from adult diarrhoeal out-patients in Addis Ababa, Ethiopia: antibiotic resistance and plasmid profile analysis

Forty five Salmonella strains were isolated from 700 diarrhoeal samples collected from adult diarrhoeal out-patients in Addis Ababa. Among the isolates, serogroup C comprised 31.1%, B 24.4%, S.typhi 15.6%, D 13.3%, A 8.9% and E 6.7%. Among the isolates, 71.1% were resistant to tetracycline, 68.9% to ampicillin, 66.7% to cephalothin, 57.8% to trimethoprim-sulphamethoxazole, 53.9% to kanamycin, 46.7% to chloramphenicol and less than 31.8% of the isolates were resistant to other drugs. Among S.typhi isolates, 28.6% were resistant to chloramphenicol and this shows the emergence of chloramphenicol resistant S.typhi strains in Ethiopia. Gentamicin and polymyxin B were found to be the drugs of choice for cases of salmonellosis including S.typhi. All drug resistant isolates analysed for plasmids contained multiple plasmids ranging in sizes from 1.8 to greater than 21 Kilobases.

Shigella serogroups identified from adult diarrhoeal out-patients in Addis Ababa, Ethiopia: antibiotic resistance and plasmid profile analysis

Fifty shigella strains were isolated from 700 diarrhoeal samples collected from adult diarrhoeal out-patients in Addis Ababa. Among the isolates, serogroup A comprised 28%, B 44%, C 18% and D 10%. Among all shigella serogroups, highest resistance was encountered to tetracycline (74%), ampicillin (70%), cephalothin (64%), trimethoprim-sulfamethoxazole (52%) and chloramphenicol (50%) while least resistance was observed to gentamicin (0%), polymyxin B (10%) and nalidixic acid (14%). Gentamicin, polymyxin B and nalidixic acid were found to be the drugs of choice for cases of shigellosis. All drug resistant isolates analysed for plasmids contained multiple plasmids ranging from 1.8 to greater than 21 Kilobases.

Care of the abused woman. A hospital's educational program assesses values and beliefs

To answer questions about staff's ability to identify, assess, and support victims of woman abuse, St. Joseph's Hospital, Hamilton, Ontario, Canada, organized a task group that included a cross section of staff and representatives of a local women's shelter. A comprehensive literature review strongly confirmed the need for a program that would provide staff with relevant information about abused women and challenge them to examine their values and beliefs. The task group constructed a questionnaire that included six different scales measuring various aspects of respondents' beliefs and attitudes about woman assault. The educational program for the pilot units included a training video, in-service workshops, a resource training manual, and an assessment tool to assist staff in screening female patients. The survey identified some key areas of concern, including some widely held misconceptions about the causes of abuse. After the educational program, test scores showed significant changes, particularly on scales that measured belief in popular myths and the degree to which respondents held perpetrators responsible for their actions. Overall, the project demonstrated that values and beliefs related to woman assault can be significantly affected by an educational approach that combines information sharing with the opportunity for dialogue and questions.

Establishing a framework for research: the example of needs assessment

This paper explains the early planning stage of a study commissioned by the English National Board which will investigate the changing educational needs of community nurses with regard to needs assessment and quality of care in the context of the NHS and Community Care Act 1990. Two focus groups, comprising 22 participants altogether, generated data which were used to augment and clarify issues explored in an initial literature review. Some of the methodological issues are explained. Traditional community nursing approaches to needs assessment appeared to value process and integration, while the new legislation emphasizes the separateness of assessment; there is a danger that it may be seen as a single event. The consumer views were both supportive and critical about each of the approaches; some important insights were gained, and a confident basis from which to launch the study identified. The approach offers one possible way to clarify the starting point of a project when carrying out a standard literature review seems insufficient. This may occur with under-researched or rapidly changing phenomena, or if a field of interest is the subject of multiple interpretations or lack of consensus.

The mitogen-activated protein kinase kinase MEK1 stimulates a pattern of gene expression typical of the hypertrophic phenotype in rat ventricular cardiomyocytes

Adult mammalian ventricular cardiomyocytes are terminally differentiated cells that enlarge adaptively by hypertrophy. In this situation, genes normally expressed in the fetal ventricular cardiomyocyte (e.g. atrial natriuretic factor (ANF), beta-myosin heavy chain (beta-MHC), and skeletal muscle (SkM) alpha-actin) are re-expressed, and there is transient expression of immediate early genes (e.g. c-fos). Using appropriate reporter plasmids, we studied the effects of transfection of the constitutively active or dominant negative mitogen-activated protein kinase kinase MEK1 on ANF, beta-MHC, and SkM alpha-actin promoter activities in cultured ventricular cardiomyocytes. ANF expression was stimulated (maximally 75-fold) by the hypertrophic agonist phenylephrine in a dose-dependent manner (EC50, 10 microM), and this stimulation was inhibited by dominant negative MEK1. Cotransfection of dominant negative MEK1 with a dominant negative mitogen-activated protein kinase (extracellular signal-regulated protein kinase (ERK2)) increased this inhibition. Transfection with constitutively active MEK1 constructs doubled ANF promoter activity. The additional cotransfection of wild-type ERK2 stimulated ANF promoter activity by about 5-fold. Expression of beta-MHC and SkM alpha-actin was also stimulated. Promoter activity regulated by activator protein-1 or c-fos serum response element consensus sequences was also increased. We conclude that the MEK1/ERK2 cascade may play a role in regulating gene expression during hypertrophy.

Approaches to community needs assessment: a literature review

In the light of the growing awareness of professionals in the community of the need to undertake health needs assessments of the population, this literature review sets out to explore, delineate and critically analyse the various approaches to community needs assessment, to facilitate a greater understanding of their strengths and weaknesses. The review commences by highlighting its complex nature, and attempting to define what is meant by 'needs assessment' from the differing perspectives of three dominant approaches, namely sociology, epidemiology and health economics. It continues by putting forward an argument for the use of the community health profile, being a multi-focal approach to needs assessment, combining quantitative with qualitative data, and proceeds with a discussion of strengths and weaknesses related to its compilation, in particular factors relating to reliability and validity of data sources. The consumer perspective is also reviewed, as are issues surrounding the ethics of data collection and problems concerning aggregation of the numerous data sources into meaningful policy. Throughout the review, issues are discussed with reference to the current political context in the United Kingdom. Equally important is the community nurse perspective, which is integrated into the arguments where appropriate.

Health-as-process: a health visiting perspective

Health visitors are community nurses who define their role specifically in terms of health promotion, although they have often found difficulty in explaining how their seemingly diffuse and unfocused practice achieves this. The grounded theory study reported here set out to uncover some of the hidden processes and features embedded within health visiting, so the practice might be more clearly articulated. This paper reports one aspect of that study, which suggests that health visitors treat health as a lifelong process, involving the accumulation and use of 'resources for health'. The relevance of approaches which appeared both caring and educational will be set in the context of therapeutic nursing and adult education theories. Historically, health visitors have links with both nursing and health education; the analysis presented here helps to clarify the relationships between these different areas of work. The paper will explain how treating health as a process allows multiple competing views and ideas about health and health promotion to be integrated into a manageable form, thus allowing positive health to be promoted within a broad, acceptable socio-cultural context. However, the analysis also highlighted various points at which treating health as a process contradicts the firmly measurable requirements of the market-orientated health service. Nevertheless, where health visitors are sufficiently skilled, and are permitted by their employing authorities to use this approach, it may serve to protect clients from intrusive and accusing interventions, made in the name of health promotion.

In health visiting, a routine visit is one that has passed

Pressure on British health workers to be more explicit in articulating the function, purpose and outcome of their role has increased with the introduction of general management and shift to a market-place orientation, since implementation of the NHS and Community Care Act (1990). However, a recurring theme in the history of health visiting has been the difficulty which practitioners experience in trying to explain exactly what it is that they do. This has often been portrayed as a major failing, and possibly even a reason to discontinue the service. This paper will offer a potential explanation for this difficulty, and suggest that the management of uncertainty and ambiguity are central to the role. It will draw on a grounded theory study which explored how health visitors choose which approach to use in any particular situation encountered in their work. The analysis suggested that health visiting's central focus is on situations which are unpredictable, ambiguous or anomalous. The study revealed an approach to health promotion which requires a highly developed ability to cope in a safe and therapeutic way with shifting, uncertain and ill-defined health needs, and to recognize and respond to complex, potentially risk-filled situations. Drawing on examples which illustrate the implications of these concepts in practice, the paper suggests that, much as midwives have long claimed that a 'normal delivery is one that is over', so in health visiting a 'routine visit' can only be recognized as such once it has taken place.(ABSTRACT TRUNCATED AT 250 WORDS)

Professional development and change in a learning organization

There is a growing tendency for learning in the workplace to be seen as a managerial function rather than as the responsibility of educationalists. As managers prepare to take a more active role in facilitating professional education, they need to consider the extent to which their organizational arrangements help or hinder the learning of professional skills. There is a potential risk that the development of important clinical practice skills may be inadvertently overlooked, because of the kind of organizational arrangements in force. This paper outlines alternative approaches to organizational development, explaining the basis for implementing 'holographic principles' when planning a system. A situational analysis carried out in an inner-city community provider unit revealed an alternative, more directive and fragmented arrangement. The analysis is used to illustrate how a focus on developing the organization as a learning environment during periods of rapid and multiple change can also help to promote clinical nursing skills.

Health promotion in the general practice setting

Two major studies of health promotion interventions in the general practice setting appear to show that nurses are less effective than doctors in influencing people to make necessary lifestyle changes. But, as this briefing argues, both studies were heavily dominated by the medical model. Such an approach, focusing on ill-health, not health, fails to take into account the wider social and economic factors influencing individuals' behaviours. Far from indicating the need for greater input from doctors, the studies serve to reinforce arguments against the medical model in health. promotion, and underline the need for the health-oriented approach which now underpins all nursing education and training.

Regulation of GATA-2 phosphorylation by mitogen-activated protein kinase and interleukin-3

GATA-2 is a member of a family of transcription factors which bind a common DNA sequence motif (WGA-TAR) through an evolutionarily conserved zinc finger domain. An essential role for GATA-2 in the development of hematopoietic stem cells has recently been shown in gene targeting experiments in mice. Here we show that GATA-2 exists in hematopoietic progenitor cells as a phosphoprotein. Stimulation of progenitors with interleukin-3 (IL-3) results in enhanced phosphorylation of GATA-2 which occurs within 5 min. IL-3 is known to signal in part through mitogen-activated protein (MAP) kinase, and evidence for MAP kinase signaling in the control of GATA-2 phosphorylation was obtained by genetically manipulating the MAP kinase pathway in COS cells using either constitutively activating or interfering mutants of MAP kinase kinase. Furthermore, using an interfering mutant of MAP kinase kinase, we directly demonstrated a critical role for the MAP kinase pathway in the IL-3-dependent phosphorylation of GATA-2 in hematopoietic progenitor cells. Finally, in vitro phosphorylation experiments using recombinant GATA-2 raise the possibility that MAP kinase itself may phosphorylate GATA-2. Our results provide evidence for phosphorylation via the MAP kinase pathway constituting a cytoplasmic link between GATA-2 and growth factor receptors and are consistent with the hypothesis that GATA-2 is involved in the growth factor responsiveness and proliferation control of hematopoietic progenitor cells.

Connecting values and program development. A Canadian hospital's experience with mission integration

Catholic values distinguish Catholic healthcare facilities, their staff members like to say. But those values can remain merely rhetorical unless they are integrated into the facility's actual programs. The staff of St. Joseph's Hospital, Hamilton, Ontario, has been encouraged to express the facility's values in everyday language. More important, the staff has had an opportunity to employ those values--a belief in the sacredness of life and the dignity of the person; a special obligation to the poor and vulnerable; and a commitment to treat the "whole person"--in two new programs. One is for women who have miscarriages. The hospital's Obstetrics Department, realizing that society often fails to recognize the deep grief involved, developed a program for women experiencing early pregnancy loss (EPL). The EPL protocol stresses the uniqueness of each patient and the importance of support, continuity, appropriateness of care, and postdischarge follow-up for her. The hospital has also emphasized Catholic values in developing a set of guidelines for the examination of patients. St. Joseph's found that publicity about sexual abuse was making both patients and medical practitioners wary of physical examinations. The guidelines, called "Culture and Sensitivity," remind care givers that patients feel vulnerable and should be treated with respect and care, on one hand. On the other hand, the guidelines say, appropriate reassuring touch remains part of the healing process.

Interleukin-1 activates a novel protein kinase cascade that results in the phosphorylation of Hsp27

An IL-1-stimulated protein kinase cascade resulting in phosphorylation of the small heat shock protein hsp27 has been identified in KB cells. It is distinct from the p42 MAP kinase cascade. An upstream activator kinase phosphorylated a 40 kDa kinase (p40) upon threonine and tyrosine residues, which in turn phosphorylated a 50 kDa kinase (p50) upon threonine (and some serine) residues. p50 phosphorylated hsp27 upon serine. p40 and p50 were purified to near homogeneity. All three components were inactivated by protein phosphatase 2A, and p40 was inactivated by protein tyrosine phosphatase 1B. The substrate specificity of p40 differed from that of p42 and p54 MAP kinases. The upstream activator was not a MAP kinase kinase. p50 resembled MAPKAPK-2 and may be identical.

Activation of MAP kinase kinase is necessary and sufficient for PC12 differentiation and for transformation of NIH 3T3 cells

The MAP kinase pathway is activated by a wide variety of external signals leading to cell proliferation or differentiation. However, it is not clear whether activation of this pathway is required for cellular responses or whether it is only one branch point in signal transduction. To investigate these questions, we generated constitutively activated and interfering mutants of MAP kinase kinase 1. The activated mutants stimulated PC12 cell neuronal differentiation and transformed NIH 3T3 cells. The interfering mutants inhibited growth factor-induced PC12 differentiation, growth factor stimulation of proliferation, and reverted v-src- and ras-transformed cells. These results therefore show that, depending on cellular context, activation of MAP kinase kinase is necessary and sufficient for cell differentiation or proliferation.

Identification of the sites in MAP kinase kinase-1 phosphorylated by p74raf-1

Many growth factors whose receptors are protein tyrosine kinases stimulate the MAP kinase pathway by activating first the GTP-binding protein Ras and then the protein kinase p74raf-1. p74raf-1 phosphorylates and activates MAP kinase kinase (MAPKK). To understand the mechanism of activation of MAPKK, we have identified Ser217 and Ser221 of MAPKK1 as the sites phosphorylated by p74raf-1. This represents the first characterization of sites phosphorylated by this proto-oncogene product. Ser217 and Ser221 lie in a region of the catalytic domain where the activating phosphorylation sites of several other protein kinases are located. Among MAPKK family members, this region is the most conserved, suggesting that all members of the family are activated by the phosphorylation of these sites. A 'kinase-dead' MAPKK1 mutant was phosphorylated at the same residues as the wild-type enzyme, establishing that both sites are phosphorylated directly by p74raf-1, and not by autophosphorylation. Only the diphosphorylated form of MAPKK1 (phosphorylated at both Ser217 and Ser221) was detected, even when the stoichiometry of phosphorylation by p74raf-1 was low, indicating that phosphorylation of one of these sites is rate limiting, phosphorylation of the second then occurring extremely rapidly. Ser217 and Ser221 were both phosphorylated in vivo within minutes when PC12 cells were stimulated with nerve growth factor. Analysis of MAPKK1 mutants in which either Ser217 or Ser221 were changed to glutamic acid, and the finding that inactivation of maximally activated MAPKK1 required the dephosphorylation of both serines, shows that phosphorylation of either residue is sufficient for maximal activation.

Identification and characterization of a novel tyrosine kinase from megakaryocytes

Protein-tyrosine kinases play pivotal roles in cell signal transduction. We have isolated a cDNA clone encoding a novel human intracytoplasmic tyrosine kinase, termed matk (megakaryocyte-associated tyrosine kinase). Expression of matk mRNA was predominantly found in cells of megakaryocytic lineage. The matk cDNA clone encodes a polypeptide of 527 amino acids and has closest sequence similarity to the csk tyrosine kinase. Sequence comparisons also indicate that matk contains src homology region 2 and 3 domains but lacks the NH2-terminal myristylation signal, the negative regulatory tyrosine (Tyr-527), and the autophosphorylation site (Tyr-416) corresponding to those found in src. Antibodies raised against the NH2 terminus of matk immunoprecipitated a 60-kDa protein from the CMK human megakaryocyte cell line. Expression of matk mRNA was up-regulated in megakaryocytic cells induced to differentiate by the phorbol ester. Based on its restriction in expression and its modulation during in vitro differentiation, it is likely that matk participates in signal transduction during megakaryocytopoiesis.

Collaboration in health care: the education link

Collaboration is high on the current policy agenda. It is often suggested that 'shared learning' within multi-disciplinary teams, across sectors and different service agencies, will help to improve collaboration. But education has a wider role than one of simply teaching different groups together, writes Sarah Cowley. Improved inter-disciplinary working can be achieved by ensuring that each professional feels valued for their particular role and skills.

Supporting dying people

A descriptive interview survey was carried out to identify and assess the needs of dying people and their families and to see how far those needs were met by services available in the district. The main carers were interviewed six months after the death, and the majority said they were satisfied with care offered. However, a detailed analysis of comments made in response to the open-ended questions that were asked sheds light on the difficulties faced by many people in gaining access to services.

Characterization of adhesive interactions between human endothelial cells and megakaryocytes

Cell-cell adhesion is essential for many immunological functions and is believed to be important in the regulation of hematopoiesis. Adhesive interactions between human endothelial cells and megakaryocytes were characterized in vitro using the CMK megakaryocytic cell line as well as marrow megakaryocytes. Although there was no adhesion between unactivated human umbilical vein endothelial cells (HUVEC) and megakaryocytes, treatment of HUVEC with inflammatory cytokines such as IL-1 beta, tumor necrosis factor alpha, INF-gamma, or the phorbol ester phorbol myristate acetate (PMA) resulted in a time- and dose-dependent increase in adhesion. Stimulation of marrow megakaryocytes or CMK cells with the cytokines IL-1 beta, GM-CSF, IL-6, IL-3, or PMA augmented their adhesion to endothelium. Monoclonal antibodies against the LFA-1 subunit of the leukocyte adherence complex CD18 inhibited the binding of marrow megakaryocytes or CMK cells to HUVEC. Adhesion blocking experiments also demonstrated that the VLA-4/VCAM-1 pathway was important for megakaryocyte attachment to HUVEC. Adhesion promoted maturation of megakaryocytic cells as measured by increased expression of glycoproteins GpIb and GpIIb/IIIa and by increased DNA content. These observations suggest that alterations in megakaryocyte adhesion may occur during inflammatory conditions, mediated by certain cytokines, resulting in augmented megakaryocyte maturation.

Effects of the stem cell factor, c-kit ligand, on human megakaryocytic cells

The kit ligand (KL), also termed stem cell factor (SCF), is a recently discovered hematopoietic growth factor that augments response of early progenitor cells to other growth factors and supports proliferation of continuous mast cell lines. Histological studies suggest that the receptor for SCF/KL, the c-kit proto-oncogene product, is present in bone marrow megakaryocytes. We studied the effects of SCF/KL on immortalized human megakaryocytic cell lines (CMK, CMK6, and CMK11-5) and on isolated human marrow megakaryocytes. Human SCF/KL alone or in combination with the hematopoietic growth factors, interleukin-3 (IL-3), granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-6, stimulated proliferation of these megakaryocytic cell lines. SCF/KL treatment did not alter expression of gpIb, gpIIb/IIIa, LFA-1, ICAM-1, or GMP-140 in CMK cells. No effect on ploidy was observed. Furthermore, human SCF/KL induced expression of IL-1 alpha, IL-1 beta, IL-2, and IL-6 in CMK cells. In a fibrin clot system, SCF/KL modestly potentiated megakaryocyte colony formation when added alone to cultures containing CD34+, DR+ bone marrow cells. Addition of SCF/KL with IL-3 or GM-CSF to these cultures resulted in a more marked marrow megakaryocytic cells. SCF/KL may directly affect megakaryocytopoiesis, as well as secondarily modulate hematopoiesis through induction of cytokines in target cells.

A symbolic awareness context identified through a grounded theory study of health visiting

The purpose of the study, which is not yet complete, was one of theory building or conceptualization. This was needed because of a lack of information about how health visitors identify which approach to use within any particular situation. An overview of the method of grounded theory explains how data were collected and analysed. Then, one major aspect of the emerging theory--a symbolic awareness context which seems to surround and influence interactions between health visitors and their clients--is outlined. The analysis suggests that, when the interaction is examined in context, any one question, purpose or topic selected by health visitor or client as a specific focus, forms only a relatively small component part of the whole. Strategies which enhance openness and consonance within the context are detailed. The awareness context has implications for health visiting practice and organization.