Implementation fidelity of an Integrated Healthy Lifestyle Service: a process evaluation

Aims:

The current study aimed to evaluate implementation fidelity of an Integrated Healthy Lifestyle Service (IHLS).

Methods:

A pragmatic sample of 28 individual interviews and 11 focus groups were conducted. This resulted in a total of 81 (22 male) individuals comprising key stakeholders (n = 18), as well as intervention staff across senior management (n = 4), team lead (n = 14) and practitioner (n = 11) roles, and intervention clients (n = 34).

Results:

A mixed degree of implementation fidelity was demonstrated throughout the five a priori fidelity domains of study design, provider training, intervention delivery, intervention receipt, and enactment. Stakeholders, staff and clients alike noted a high degree of intervention receipt across all services offered. Contrastingly, practitioners noted that they received minimal formal operational, data systems, clinical, and curriculum training as well as a lack of personal development opportunities. Consequently, practitioners reported low confidence in delivering sessions and collecting and analysing any data. A top-down approach to information dissemination within the service was also noted among practitioners which affected motivation and overall team morale.

Conclusion:

Results can be used to conceptualise best practices as a process to further strengthen the design, delivery and recruitment strategies of the IHLS.

A master protocol to investigate a novel therapy acetyl-L-leucine for three ultra-rare neurodegenerative diseases: Niemann-Pick type C, the GM2 gangliosidoses, and ataxia telangiectasia

BACKGROUND

The lack of approved treatments for the majority of rare diseases is reflective of the unique challenges of orphan drug development. Novel methodologies, including new functionally relevant endpoints, are needed to render the development process more feasible and appropriate for these rare populations and thereby expedite the approval of promising treatments to address patients' high unmet medical need. Here, we describe the development of an innovative master protocol and primary outcome assessment to investigate the modified amino acid N-acetyl-L-leucine (Sponsor Code: IB1001) in three separate, multinational, phase II trials for three ultra-rare, autosomal-recessive, neurodegenerative disorders: Niemann-Pick disease type C (NPC), GM2 gangliosidoses (Tay-Sachs and Sandhoff disease; "GM2"), and ataxia telangiectasia (A-T).

METHODS/DESIGN

The innovative IB1001 master protocol and novel CI-CS primary endpoints were developed through a close collaboration between the Industry Sponsor, Key Opinion Leaders, representatives of the Patient Communities, and National Regulatory Authorities. As a result, the open-label, rater-blinded study design is considerate of the practical limitations of recruitment and retention of subjects in these ultra-orphan populations. The novel primary endpoint, the Clinical Impression of Change in Severity© (CI-CS), accommodates the heterogenous clinical presentation of NPC, GM2, and A-T: at screening, the principal investigator appoints for each patient a primary anchor test (either the 8-m walk test (8MWT) or 9-hole peg test of the dominant hand (9HPT-D)) based on his/her unique clinical symptoms. The anchor tests are videoed in a standardized manner at each visit to capture all aspects related to the patient's functional performance. The CI-CS assessment is ultimately performed by independent, blinded raters who compare videos of the primary anchor test from three periods: baseline, the end of treatment, and the end of a post-treatment washout. Blinded to the time point of each video, the raters make an objective comparison scored on a 7-point Likert scale of the change in the severity of the patient's neurological signs and symptoms from video A to video B. To investigate both the symptomatic and disease-modifying effects of treatment, N-acetyl-L-leucine is assessed during two treatment sequences: a 6-week parent study and 1-year extension phase.

DISCUSSION

The novel CI-CS assessment, developed through a collaboration of all stakeholders, is advantageous in that it better ensures the primary endpoint is functionally relevant for each patient, is able to capture small but meaningful clinical changes critical to the patients' quality of life (fine-motor skills; gait), and blinds the primary outcome assessment. The results of these three trials will inform whether N-acetyl-L-leucine is an effective treatment for NPC, GM2, and A-T and can also serve as a new therapeutic paradigm for the development of future treatments for other orphan diseases.

TRIAL REGISTRATION

The three trials (IB1001-201 for Niemann-Pick disease type C (NPC), IB1001-202 for GM2 gangliosidoses (Tay-Sachs and Sandhoff), IB1001-203 for ataxia telangiectasia (A-T)) have been registered at www.clinicaltrials.gov (NCT03759639; NCT03759665; NCT03759678), www.clinicaltrialsregister.eu (EudraCT: 2018-004331-71; 2018-004406-25; 2018-004407-39), and https://www.germanctr.de (DR KS-ID: DRKS00016567; DRKS00017539; DRKS00020511).

Inactivation of the gene encoding the cationic antimicrobial peptide resistance factor MprF increases biofilm formation but reduces invasiveness of Listeria monocytogenes

AIMS

To understand the genetics involved in surface attachment and biofilm formation of Listeria monocytogenes.

METHODS AND RESULTS

An in vitro screen of a Himar1 transposon library of L. monocytogenes strain 15G01 identified three transposants that produced significantly different biofilm levels when compared to the wild-type strain; two mutants exhibited enhanced biofilm formation and one produced less biofilm biomass than the wild-type. The mutant 15G01 mprF::Himar1, which had a transposon insertion in the mprF gene, was selected for further analysis. The mutant produced a more densely populated biofilm on solid surfaces such as stainless steel and polystyrene, as determined using scanning electron and light microscopy. The 15G01 mprF::Himar1 mutant remained viable in biofilms, but showed an increase in sensitivity to the cationic antimicrobial gallidermin. The mutant also displayed reduced invasiveness in CaCo-2 intestinal cells, suggesting virulence properties are compromised by the inactivation of mprF.

CONCLUSIONS

Biofilm formation and gallidermin resistance of L. monocytogenes is influenced by mprF, but this trait is associated with a compromise in invasiveness.

SIGNIFICANCE AND IMPACT OF THE STUDY

The presence of pathogenic microorganisms in the food processing environment can cause a significant problem, especially when these microorganisms are established as biofilms. This study shows that the inactivation of the mprF gene results in enhanced biofilm formation and abiotic surface attachment of L. monocytogenes.

Effect of bismuth subnitrate on in vitro growth of major mastitis pathogens

The mode of action of bismuth subnitrate in teat sealant formulations as a preventative for intramammary infections during the dry period is unknown. Although previous studies proposed an action mechanism-creating a physical barrier in the teat canal to prevent bacterial invasion-it has not been proven experimentally. We hypothesized that bismuth subnitrate has an inhibitory effect on bacterial growth, in addition to its barrier effect. The objective of this study was to assess the effect of bismuth subnitrate on bacterial growth of major mastitis-causing agents. A strain of Streptococcus uberis (SR115), 2 strains of Staphylococcus aureus (SA3971/59 and SA1), and a strain of Escherichia coli (P17.14291) were tested in vitro for their ability to grow in the presence or absence of bismuth subnitrate. Disk diffusion testing, impedance measurement, and evaluation of bacterial growth in shaking conditions were the methods used to test this hypothesis. A reduction of growth in the presence of bismuth subnitrate occurred for all the strains tested. However, we observed strain and species variations in the extent of growth inhibition. These results suggest that an inhibitory effect on bacterial growth by bismuth subnitrate could partially explain the efficacy of bismuth-based formulations for preventing intramammary infections over the dry period. Further research is required to test the effect of teat sealant formulations on bacterial growth.

An extension of the Coconut Cream Agar method to screen Penicillium citrinum isolates for citrinin production

A simple and rapid screening method was developed for the detection of citrinin in fungal cultures using Coconut Cream Agar (CCA) described previously for detecting aflatoxin and ochratoxin A. Fifteen isolates of Penicillium citrinum were inoculated onto CCA and incubated at 25 and 30°C for 10 days. All isolates produced a distinct yellow green fluorescence on CCA when the reverse side of the agar plates were viewed under long wavelength UV light. Detection was optimal at 25°C after four to 5 days of incubation. Isolates positive by the CCA method also tested positive for citrinin production by the TLC agar plug method after growth on CCA, Czapek yeast extract agar and yeast extract sucrose agar. Control cultures were negative by both methods, indicating that the CCA Petri dish method was suitable for screening cultures for citrinin production.

Prediction of the amount and rate of histamine degradation by diamine oxidase (DAO)

Histamine is a biogenic amine that forms in a variety of foods and can cause food poisoning at high concentrations (>500 ppm). In situations where the formation of histamine in food cannot be prevented through refrigeration, diamine oxidase (DAO) enzyme may be used to degrade histamine to safe levels. The aims of this work were to apply DAO in model (buffer) and real (cooked tuna soup used in the manufacture of a fish paste product, Rihaakuru) systems, in order to obtain predictions for the rates and amounts of histamine degradation. The two systems were set up with a constant concentration of histamine (500 mg/L) and the DAO enzyme (2534 units/L) at a temperature of 37°C, agitation at 100 rpm and an incubation time of 10h with variable pH (5-7) and salt concentrations (1-5%). A total of 15 experiments were designed for each system using central composite design (CCD). The data from these experiments were fitted into regression models; initially the data were used to generate an exponential decline model and then the data from this were fitted into a secondary response surface model (RSM) to predict the rate and amount of histamine degradation by DAO. The model system results indicated that DAO activity was not significantly affected by salt (p>0.05), and that activity reached a maximum within the pH range of 6-6.5 with an optimum at pH 6.3. However, the results obtained with the tuna soup model showed that the optimum oxidation of histamine using DAO occurred between pH 6-7 and salt 1-3%. This study defined the conditions for the use of DAO to degrade 500 mg/L of histamine in tuna soup used to manufacture Rihaakuru. The models generated could also be used to predict the rate and amount of histamine degradation in other foods that have similar characteristics to tuna soup.

Description and validation of a rapid (1 h) flow cytometry test for enumerating thermophilic bacteria in milk powders

AIMS

The aim of this study was to develop a rapid assay for enumerating thermophilic bacteria in milk powder.

METHODS AND RESULTS

The BactiFlow flow cytometer was used to count bacteria based on esterase activity in viable bacterial cells. A protocol for total viable bacteria was modified by heat-treating the sample to selectively label thermophilic bacteria. Samples of milk powder dissolved in 0.1% peptone were treated with 0.8% ethylenediaminetetraacetic acid to reduce background interference because of denatured milk proteins. Either thermophilic bacteria were added to the dissolved milk powder or milk powder solutions were incubated at 55 degrees C for 2-3 h to enrich the natural thermophile population for testing. Results from the BactiFlow were compared with traditional plate count results.

CONCLUSIONS

Thermophilic bacteria in milk powder can be enumerated within 1 h using the BactiFlow flow cytometer.

SIGNIFICANCE AND IMPACT OF THE STUDY

Microbiological test results obtained within 1 h can potentially be used to monitor manufacturing processes, effectively trace problems and provide confidence in the manufacture of product.

The Effect of the Manipulation of Follicle-Stimulating Hormone (FSH)-Peak Characteristics on Follicular Wave Dynamics in Sheep: Does an Ovarian-Independent Endogenous Rhythm in FSH Secretion Exist?1

We designed three experiments to investigate the relationship between FSH peaks and ovarian follicular waves and to examine whether an endogenous rhythm of FSH peaks exists in sheep. In experiment 1, anestrous ewes were treated with ovine FSH (oFSH) or vehicle (6 ewes per group) at the expected time of an endogenous FSH peak, to double the FSH-peak amplitude in treated ewes. In experiment 2, anestrous ewes were treated with either oFSH or vehicle (6 ewes per group) at the expected time of two consecutive interpeak nadirs, such that the treated ewes had 5 FSH peaks in the time frame of 3 FSH peaks in control ewes. In experiment 3, to measure FSH concentrations, daily blood samples were collected from 5 cyclic ewes for a control period during the estrous cycle and then for three 17-day periods after ovariectomy. Daily blood samples were collected from another group of 8 ovariectomized ewes that were treated with estradiol-releasing implants and intravaginal progestogen sponges. Doubling the FSH-peak amplitude did not alter the characteristics of the following follicular wave. Increasing the frequency of FSH peaks stimulated the emergence of additional follicular waves, but did not alter the rhythmic occurrence of FSH peaks and follicular wave emergence. Endogenous follicular waves in oFSH-treated ewes emerged and grew in the presence of the growing largest follicle of the induced follicular waves. Finally, based on the observation of serum FSH concentrations in ovariectomized ewes, it appears that there exists an endogenous rhythm for peaks in daily serum FSH concentrations, which is, at least in part, independent of regulation by ovarian follicular growth patterns.

Necrotizing sialometaplasia: An unusual bilateral presentation associated with antecedent anaesthesia and lack of response to intralesional steroids. Case report and review of the literature

Necrotizing sialometaplasia is a self-limiting, variably ulcerated benign process affecting minor salivary glands. Accurate histological diagnosis is paramount, as it has been mistaken for malignancy, which has resulted in excessively aggressive and unnecessary radical surgery. A unique case of bilateral necrotizing sialometaplasia, presenting with anaesthesia of the greater palatine nerves, is described. An attempt at active therapy with intralesional steroids had no effect on the course of the condition.

Consensus guidelines on quantifying HIV-related oral mucosal disease

The workshop agreed that the development of consensus quantification protocols was desirable, but that this whole field was underdeveloped, to date. The working goals were therefore redefined (vide infra). Three possible protocols were presented and discussed relating to oral hairy leukoplakia, oral ulceration (NOS) and oral candidiasis. There was agreement that different data-set protocols would have to be developed for specific HIV-related mucosal diseases. Furthermore, the data set should be consistent, standardized and disaggregated. In this way, with everyone working to the same standards of outcome, data from geographically, nationally, socially or culturally different areas could be readily compared. A future meeting to generate the disease-specific protocols would, most likely, be needed.

The resistance to heat of thermo-resistant streptococci attached to stainless steel in the presence of milk

Skim milk residues had a significant impact on the sensitivity to heat of a dairy isolate of the thermo-resistant, Streptococcus thermophilus. Cells of S. thermophilus (H) suspended in water or in milk had D values at 60 degrees C of 2.0 and 14 min, respectively. Cells of S. thermophilus (H) attached to stainless steel in the presence of water or milk had D values at 60 degrees C of 2.2 and 8.1 min, respectively. The attached cells in both experiments were heat-treated in the presence of water. The increase in heat resistance could not be fully attributed to individual components (caseinate or whey) in the milk. The potential for thermo-resistant streptococci to survive heat treatment in a dairy manufacturing plant is therefore greater than may be expected for the organism in less complex environments.

The oral cavity in Crohn's disease

We assessed the utility of expert oral examination as a part of the diagnostic evaluation of patients with suspected Crohn's disease. Of 45 patients with newly diagnosed CD, 25 had been examined by a dentist. Twelve (48%) of these had oral CD lesions. Mucosal tags constituted the most frequent form of oral lesion (8/12). Of 8 oral biopsy specimens, 6 (75%) contained non-caseating granulomas. Patients with oral CD had more oral symptoms, presented for diagnosis sooner, and were more likely to have other upper gastrointestinal inflammation than those without oral lesions. Oral manifestations of CD are common in children; therefore, expert oral examination may be useful during diagnostic evaluation of children with suspected inflammatory bowel disease.

The growth of Bacillus stearothermophilus on stainless steel

AIMS

To determine the potential for Bacillus stearothermophilus cells to form biofilms of significance in dairy manufacture.

METHODS AND RESULTS

The ability of isolates of B. stearothermophilus from dairy manufacturing plants to attach to stainless steel surfaces was demonstrated by exposing stainless steel samples to suspensions of spores or vegetative cells and determining the numbers attaching using impedance microbiology. Spores attached more readily than vegetative cells. The attachment of cells to stainless steel was increased 10-100-fold by the presence of milk fouling the stainless steel. The growth of B. stearothermophilus as a biofilm on stainless steel surfaces was determined using a continuously flowing experimental reactor. Vegetative cells were released in greater numbers than spores from biofilms of most strains studied. Biofilms of one strain (B11) were studied in detail. Biofilms of > 106 cells cm-2 formed in the reactor and released approximately 106 cells ml-1 into milk passing over the biofilm. A doubling time of 25 min was calculated for this organism grown as a biofilm.

CONCLUSION

The formation of biofilms of thermophilic Bacillus species within the plant appears to be a likely cause of contamination of manufactured dairy products. Methods to control the formation of biofilms in dairy manufacturing plants are required to reduce the contamination of dairy products with thermophilic bacilli.

SIGNIFICANCE AND IMPACT OF THE STUDY

Biofilms of B. stearothermophilus growing in dairy manufacturing plants can explain the contamination of dairy products with these bacteria.

Cervical length at 23 weeks in twins in predicting spontaneous preterm delivery

OBJECTIVE

To establish the relationship between cervical length at 23 weeks' gestation in twin pregnancies and risk of spontaneous preterm delivery.

METHODS

Cervical length was measured during routine antenatal care by transvaginal sonography at 23 (range 22-24) weeks' gestation in 215 twin pregnancies. Distribution of cervical length was determined, and sensitivity and false-positive rate for spontaneous preterm delivery at or before 28, 30, 32, and 34 weeks for cutoff cervical lengths of 15, 25, 35, and 45 mm were calculated.

RESULTS

Cervical length distribution was skewed toward shorter length and the median value was 38 mm. In 11.2% and 4.2% of cases, length was up to 25 mm and up to 15 mm, respectively. The spontaneous delivery rates at or before 28, 30, 32, and 34 weeks were 3.8%, 4.7%, 8.0%, and 17.5%, respectively, and were not statistically significantly related to any demographic characteristics, obstetric history, or chorionicity. Sensitivity to predict spontaneous preterm delivery was 100%, 80%, 47%, and 35% for 28, 30, 32, and 34 weeks, respectively, for cervical length up to 25 mm. The corresponding sensitivity values for cervical lengths up to 15 mm were 50%, 40%, 24%, and 11%. The rate of spontaneous delivery at or before 32 weeks increased exponentially with decreasing cervical length at 23 weeks, from 2.9% at or greater than 46 mm, to 4.3% at 36-45 mm, 6.7% at 26-35 mm, 31% at 16-25 mm, and 66% at 15 mm or less.

CONCLUSION

Measurement of cervical length in twin pregnancies predicted risk of spontaneous early preterm delivery.

Susceptibility of pollen to UV-B radiation: an assay of 34 taxa

Much of the ultraviolet-B radiation (UV-B) research on plants has concentrated on vegetative plant parts, and only a small fraction has dealt with the reproductive system. The present study analyzed pollen grains of 34 taxa germinated and grown under two levels of UV-B radiation (187 and 460 mW/m2) or no UV-B (control group). Visible radiation at 260 mmol/m/s was present in all treatments. Taxa included those with binucleate and trinucleate pollen types. We detected differences among species. A significant reduction in pollen germination occurred in only five species. Pollen tubes of >50% of the species showed significant reduction in length. Trinucleate pollen types were more likely to exhibit tube length reduction than the binucleate types. Proportionately more monocotyledonous species were sensitive to UV-B treatment than dicotyledonous species, and proportionately more wild species were sensitive than cultivated species and pollen collected from plants growing in the field were somewhat more sensitive than pollen collected from plants grown in the greenhouse. Species in which pollination occurred earlier in the season were more likely to be susceptible to UV-B radiation than those for which anthesis took place later in the season, suggesting a possible adaptation to UV-B radiation.

p53 mutations and protein expression in primary cultures of normal oral mucosa in smokers and non-smokers

The normal oral mucosa from 77 individuals of known smoking and alcohol-intake history was cultured. After 14-21 days in culture, epithelial cells were stained for p53 expression using immunohistochemistry. PCR-SSCP analysis of the p53 gene was also performed on a random sub-set of these samples (20 non-smokers and 21 smokers). Expression of the stable, non-functional form of p53 protein as detected by the p53-240 antibody was found to be significantly elevated in the cultured oral mucosa of smokers. (P < 0.01). PCR-SSCP analyses indicated a higher level of base changes in smokers than in non-smokers. These observations are consistent with other findings of significantly increased p53 protein expression in the oral mucosa and other tissues of smokers and suggests that p53 mutations may be an early event in smoking-induced oral cancers.

Recurrent second trimester miscarriage

Understanding the aetiology of a second trimester miscarriage allows the obstetrician to assess the recurrence risk in the next pregnancy and guides future management. Causes include anatomical abnormalities, cervical incompetence, genital tract infection, multiple pregnancy, auto-immune factors, vaginal bleeding, and fetal abnormalities. Transvaginal ultrasound of the cervix in pregnancy may have a role in the diagnosis of cervical incompetence. There is an association between genital tract infection and second trimester miscarriage, but the value of antibiotics in the prevention of miscarriage is still to be defined.

Preterm labour and delivery

Preterm birth is a major cause of perinatal morbidity and mortality. It accounts for 5-10% of all births, and any treatment to prevent it could have a profound effect on neonatal outcome in both human and economic terms. The pathogenesis of both term and preterm birth remain poorly understood. Our ability to predict those at risk of preterm labour is also inaccurate, despite the creation of scoring systems, uterine activity monitoring, cervical ultrasound and several biochemical markers. Current drug therapies for preterm labour have not been shown in randomised controlled trials to significantly affect perinatal morbidity and mortality. Furthermore, most are associated with significant maternal or fetal side effects. Nitric oxide (NO) is a potent smooth muscle relaxant, produced when NO synthase acts on the amino acid L-arginine. Its presence has been demonstrated in human myometrium. We have conducted an observational study which has suggested that glyceryl trinitrate (GTN), and NO donor, may be effective in prolonging gestation. A randomised trial comparing GTN to intravenous ritodrine is currently recruiting patients; results will be available in the Spring of 1997. Few side effects have so far been encountered. Evidence suggests that GTN, an NO donor, should be a safe and effective tocolytic and early observations are encouraging; randomised trials currently underway should determine the significance of this breakthrough in the management of preterm labour.

Mucosal lesions due to oral cocaine use

Cocaine abuse is a major public health problem worldwide and is increasingly common in Europe. Oral use of cocaine in two patients resulted in unusual white lesions on their anterior maxillary gingivae/vestibule. GDPs should be alert to this newly described lesion.

Detection of cytomegalovirus and Epstein-Barr virus in labial salivary glands in Sjogren's syndrome and non-specific sialadenitis

To investigate the role of herpes viruses in Sjogren's syndrome, minor (labial) salivary gland tissues from Sjogren's syndrome and from non-specific sialadenitis were examined for Epstein-Barr virus (EBV) and human cytomegalovirus (HCMV) DNA by the polymerase chain reaction. Almost half of all salivary glands studied contained EBV and/or HCMV. There was, however, no significant difference between the detection of EBV or HCMV in salivary glands from patients with Sjogren's syndrome or non-specific sialadenitis. The findings are consistent with the persistence of EBV and HCMV in minor salivary glands following primary infection, but do not indicate a direct role for either virus in the aetiology of Sjogren's syndrome, and do not exclude reactivation of the viruses in this disease.

Intravenous antiplatelet efficacy and safety of the platelet GPIIb/IIIa antagonist, DMP 728 in anesthetized dogs

DMP 728, cyclo (D-2-aminobutyrate-N-Methyl-L-Arginyl-Glycyl-L-Aspartyl- 3-amino-methyl-benzoic acid) methanesulfonate salt, is a novel antiplatelet agent with high affinity and specificity for human and canine platelet GPIIb/IIIa (alpha 2/beta 3) receptors. DMP 728 demonstrated a potent antiplatelet efficacy in inhibiting ADP-induced platelet aggregation in either human or canine PRP with an IC50 of 0.046 and 0.015 microM, respectively. The IC50 of DMP 728 in inhibiting human platelet aggregation in PRP ranged from 0.02-0.05 microM regardless of the agonist used or even their combinations. Additionally, DMP 728 displayed a much greater affinity in inhibiting 125I-fibrinogen binding to stimulated human platelets as compared to the linear peptide RGDS or fibrinogen. The present study was undertaken to examine the i.v. antiplatelet efficacy and safety of DMP 728 in anesthetized dogs. In anesthetized mongrel dogs, DMP 728 (0.001-1.0 mg/kg, i.v. bolus) produced a dose-dependent inhibition of ex vivo platelet aggregation induced by ADP. The onset of inhibition was immediate, and the duration of antiplatelet effects was dose-dependent. A maximal inhibition of platelet aggregation and a reversible prolongation of bleeding time at 0.01 mg/kg were shown. Additionally, the antiplatelet efficacy/safety of DMP 728 was examined after i.v. administration at different infusion rates ranging from 0.008 to 0.833 micrograms/kg/min for 2 hours. A minimal antiplatelet effect was observed at the 0.008 micrograms/kg/min for 2 hours, while a maximal inhibition of platelet aggregation along with a reversible prolongation of bleeding time was achieved at 45-60 min post-infusion of 0.08 micrograms/kg/min x 2 hours. Prolongation of bleeding time was significantly reduced upon the cessation of the infusion while maximal inhibition of platelet aggregation was maintained longer. At all of the above regimens, DMP 728 did not result in any significant effects on platelet counts. Furthermore, DMP 728 did not elicit any other platelet unrelated adverse effects over wide range of doses. These data suggest that DMP 728, a low molecular weight platelet GPIIb/IIIa receptor antagonist, is a potent and systemically active antiplatelet agent with reversible effects on bleeding time.

Oligonucleotide fingerprinting of isolates of Candida species other than C. albicans and of atypical Candida species from human immunodeficiency virus-positive and AIDS patients

Oligonucleotide fingerprinting of genomic DNA from oral isolates of four different Candida species other than C. albicans and atypical chlamydospore-positive isolates from human immunodeficiency virus (HIV)-positive individuals and AIDS patients was investigated as a means for differentiating between isolates within individual species. Oligonucleotides composed of simple repetitive sequence motifs, including (GACA)4, (GATA)4, (GGAT)4, (GTG)5, and (GT)8, all yielded fingerprints suitable for strain segregation of 8 C. tropicalis isolates, 12 Torulopsis (Candida) glabrata isolates, 8 atypical Candida isolates, and, except for (GATA)4, 2 C. krusei probe in turn and so generate several distinct DNA fingerprints of the same DNA sample. However, none of the probes yielded fingerprints suitable for strain segregation with three C. parapsilosis isolates. The (GATA)4 probe was also used to detect restriction fragment length polymorphisms among a genetically closely related group of atypical Candida isolates on primary isolation from an additional HIV-infected patient. These chlamydospore-positive atypical Candida isolates were sucrose positive, were of C. albicans serotype A, hybridized weakly with the C. albicans-specific mid-repeat sequence probe 27A, and yielded fingerprint profiles by random polymorphic DNA analysis that were distinct from those derived from C. albicans isolates. The C. stellatoidea ex-type strain NCPF 3108 was indistinguishable from the atypical Candida isolates in all these tests and also yielded an identical carbohydrate and nitrogen source assimilation profile by using the ID 32C yeast identification system.

A trial to control the tsetse fly, Glossina morsitans centralis, with low densities of odour-baited targets in west Zambia

A large-scale trial investigated the possibility of eradicating G.m.centralis from a traditional cattle rearing area using odour-baited targets at a reduced overall target density from 4 to 0.5-2.3 per km2, thus cutting down initial material costs by about 50%. Only the periphery of what was thought to be prime tsetse habitat (dense woodland) was treated with targets. These were all black or blue/black cloth (1.8 x 1 m), sprayed with deltamethrin suspension concentrate and baited with butanone and/or acetone (40-130 mg/h) and 1-octen-3-ol (0.5 mg/h). Although fly catches from traps and flyrounds initially dropped by approximately 3% per day and trypanosomiasis cases declined by 99% within a year, eradication was not achieved, so that more targets were deployed at a later stage. Although initially cheaper, the option of using reduced target densities proved financially unattractive because of prolonged periods of target maintenance prior to eradication. Revised strategies for tsetse control with odour-baited, insecticide-impregnated targets in west Zambia are presented.

The adequacy of physician reimbursement for pediatric care under Medicaid

This article examines 1989 Medicaid physician reimbursement for pediatric care in 47 states and the District of Columbia. To assess the adequacy of payment, several state reimbursement policies were analyzed, including physician payment methods, frequency of payment updates, and fee data for five common evaluation and management codes and two Early and Periodic Screening, Diagnosis, and Treatment visit categories. Physician payment rates were evaluated to determine overall state and regional patterns of Medicaid reimbursement. They were also compared with regional private market fee data and average national Medicare fees to assess their adequacy. The majority of state Medicaid programs used fixed fee schedules as their physician reimbursement method. Nearly one fourth of states that update their fees overall by physician specialty have not adjusted their rates since 1985 or before. Medicaid reimbursement rates for five commonly used evaluation and management Physicians' Current Procedural Terminology (4th ed) office visit codes and Early and Periodic Screening, Diagnosis, and Treatment screening and follow-up examinations varied substantially across states and among regions. States in the West paid the highest rates for most office visits, while Northeastern states generally paid the least. A comparison of Medicaid payment rates with private market fee data revealed that Medicaid payments for established patients averaged less than two thirds of market rates for pediatricians, family physicians, and general practitioners. New patient care is reimbursed somewhat better. Regional variations are substantial. In addition, a comparison of Medicaid payment rates with 1988 Medicare fee data showed that average Medicaid reimbursement rates were less than four fifths of average allowed Medicare charges. Policy implications include the need to increase Medicaid rates so that they are much closer to private insurance and Medicare rates, particularly in the Northeast and in selected states, in order to increase participation by pediatric providers in Medicaid. In addition, efforts to re-evaluate reimbursement relative to level of service, as used in Medicare's resource-based relative value scales, deserve further research. Finally, comparable access to comprehensive pediatric care especially in underserved urban areas will require not only improvements in physician reimbursement but also more deliberate efforts to affect the maldistribution of mainstream medical care. Approaches to measure the impact of enhanced reimbursement on access to care by Medicaid-eligible children are discussed.

Multiple myeloma and bullous lichenoid lesions: an unusual association

Many associations of lichenoid reactions have been described but this case appears to be a previously unreported association--with multiple myeloma. This case also demonstrates the necessity of a mucosal biopsy with adequate hematologic and serologic investigations to obtain a definitive diagnosis.

1988 NAPNAP membership survey. Part II: characteristics of the members

In 1988, the 2560 members of NAPNAP were surveyed about their educational preparation, demographic characteristics, and professional employment status. Questions were included on members' opinions about issues that should be emphasized by NAPNAP in the future. Approximately 52% of the members returned usable questionnaires. In this second part of the survey results, we report the characteristics of members, how these characteristics have changed over time, and what the members believe NAPNAP's future priorities should be.

1988 NAPNAP membership survey: characteristics of members' practice

In 1988 the characteristics of the 2560 members of NAPNAP were determined by means of a mailed survey. Approximately 52% of the members returned usable questionnaires. Members were asked for information about their educational preparation, demographic characteristics, and professional employment status. Data about members' practice, how their practice has changed over time where possible, and implications for the future are reported.

Effects of the 65-mph speed limit on rural interstate fatalities in New Mexico

As a result of federal legislation passed in April 1987, New Mexico was the first state to resume a 65-mph speed limit on rural Interstate highways. We compared the rates of fatal crashes before and after the speed limit change. The rate of fatal crashes in the 1 year after the speed limit was increased was 2.9 per 100 million vehicle-miles traveled, compared with a predicted rate of 1.5 per 100 million vehicle-miles based on the trend of the 5 previous years. When fatal crashes that occurred after the speed limit change were compared with fatal crashes in the 5 previous years, there was no difference in the mean age and sex of the at-fault drivers, mean age and sex of the victims, seat belt use by the victims, or alcohol involvement of the crashes. The increase in fatal crashes can be attributed to an increase in fatal single-vehicle crashes. Vehicles on rural Interstates are traveling at greater rates of speed and a larger proportion of vehicles are exceeding the 65-mph speed limit. The benefits associated with the 65-mph speed limit should be weighed against the increased loss of lives.

Anionic salivary proteins associated with connective tissue disorders: sialated tissue kallikreins

Parotid saliva was collected from 32 patients with rheumatoid arthritis, 10 with systemic lupus erythematosus, three with mixed connective tissue disease, 12 with progressive systemic sclerosis, two with primary Sjögren's syndrome, and four with Raynaud's syndrome. Tissue kallikreins were measured by radioimmunoassay, and saliva samples were subjected to isoelectric focusing followed by immunoblotting or silver staining. The results showed that the saliva of patients with connective tissue diseases contained increased amounts of immunoreactive tissue kallikrein. In addition, there was an increase in the multiple forms of anionic tissue kallikreins, resulting mainly from a shift in their distribution towards that of higher sialic acid content and lower isoelectric point. These changes were most obvious in patients with systemic lupus erythematosus. Novel or unusual glycosylation may explain the occurrence of increased amounts of anionic salivary proteins in connective tissue diseases.

Lingual abscess in a patient with anorexia nervosa

A 30-year-old female patient suffering from anorexia nervosa, developed an acute submandibular cellulitis. She was found to have a lingual abscess, for which the only detectable source of infection was a grossly carious lower molar. The oral features of the more common eating disorders are described.

Hematologic status in recurrent aphthous stomatitis compared with other oral disease

The hematologic status of 144 consecutive patients in the United Kingdom with oral disease (69 with recurrent aphthous stomatitis; 75 with other disorders) was examined in an attempt to resolve the controversy as to whether levels of hemoglobin, blood cell numbers and indices, and blood film are adequate in the screening of patients with aphthae. Though hemoglobin levels and red blood cell indices were normal in patients with recurrent aphthous stomatitis, there was still a small minority of patients with deficiencies of iron (low serum ferritin), folate (low red blood cell levels), or vitamin B12 (low serum levels) that would have remained undetected. Full hematologic screening of patients with recurrent aphthous stomatitis thus reveals latent deficiency states, at least in some parts of the world, and there are good reasons for elucidating the underlying cause and correcting these deficiencies, particularly vitamin B12 deficiency. Therapeutic studies are now required to establish the frequency with which deficiencies actually predispose to recurrent aphthous stomatitis.