Remote delivery of cardiac rehabilitation can achieve equivalent health-related quality of life outcomes to in-person methods in patients with coronary heart disease: a multi-site study

Funding Acknowledgements

Type of funding sources: None.

Background In-person exercise-based cardiac rehabilitation (CR) has well-established benefits for health-related quality of life (HRQL) for patients with coronary heart disease (CHD). During COVID-19 pandemic restrictions, remote delivery replaced in-person CR, but the impact on HRQL is unclear. This study addresses this gap.

Methods Consecutive patients commencing CR at four sites in one Local Health District in Sydney were recruited (n = 194), recruited from December 2019 to October 2020. Remote delivery from March 2020 created a natural comparison group to in-person CR. HRQL was measured at CR entry and completion using the SF-12v2 and linear regression was used for analyses.

Results Participants were aged mean 65.94 (SD 10.45) years, were 80.9% male and diagnoses included elective PCI (37.9%), CABG (26.7%), and MI (34.9%) either with PCI (23.6%) or alone (11.3%). Participants received remote (n = 103, 53.1%) or in-person (n = 91, 46.9%; ≥ assessment + 2 sessions) CR, with more completions for in-person (75.8% vs 63.1%, p=.03). Remote participants were more likely to be white than ethnic minority (35.2% vs 13.6% p<.001), however, there were no differences in baseline HRQL for delivery group after adjustment.

HRQL improved from CR entry to completion regardless of delivery mode (adjusted). Most improvements occurred in physical function (SMD 6.37, 95% CI 4.81,7.92), role physical (SMD 5.72, 95% CI 4.29. 7.16) and physical component (SMD 5.77 95% CI 4.43, 7.12) scores. Least improvement occurred in mental component scores (SMD 1.65, 95%CI .53, 2.78).

Conclusion Remotely delivered CR provides comparable HRQL outcomes to in-person delivery, thus providing a promising alternative. Data are needed on cost-effectiveness, as well as staff and patient preferences.

Human connection: a valuable element for health-related quality of life outcomes in cardiac rehabilitation during COVID-19

Funding Acknowledgements

Type of funding sources: None.

Background The COVID-19 pandemic restrictions have pivoted in-person cardiac rehabilitation (CR) to remote delivery via telehealth. Patient perceptions on their CR participation in these models can guide CR coordinators improve program elements.

Purpose To qualitatively explore patient perceptions and experiences on how CR influenced their health-related quality of life (HRQL).

Methods A purposive sample of 16 patients were recruited, ensuring representation from four participating CR sites, gender, age, and mode of CR delivery. Semi-structured telephone or video interviews were conducted at six months following CR completion. Interviews were audio-recorded, transcribed verbatim and analysed using Braun and Clarke’s six-step thematic analysis.

Results Perceptions and experiences of patients were positive overall and similar between the two models. Three main themes were identified: value of human connection, benefits of exercise and need for more individualised approaches, and importance of telehealth as an adjunct to in-person CR. Patients have expressed the value of interacting with health care professionals and socialising with peers in similar circumstances; and the absence of these interactions was palpable to those who attended telehealth. Exercises were beneficial but needed to be tailored to individual capabilities and preferences. Telehealth offered convenience and was generally accepted. However, telehealth should be complementary and not a replacement to in-person CR. 

Conclusions Meaningful personal interactions with health care providers and other CR participants are most appreciated by patients in both in-person and telehealth models. Exercises are perceived to be more beneficial when individualised. Long-term outcomes from alternative CR delivery models should be evaluated.

A Privacy Attack on Multiple Dynamic Match-key based Privacy-Preserving Record Linkage

Introduction

Over the last decade, the demand for linking records about people across databases has increased in various domains. Privacy challenges associated with linking sensitive information led to the development of privacy-preserving record linkage techniques. The multiple dynamic match-key encoding approach recently proposed by Randall et al. (IJPDS, 2019) is such a technique aimed at providing enough privacy for linkage applications while obtaining high linkage quality. However, the use of this encoding in large databases can reveal frequency information that can allow the re-identification of encoded values.

Objectives

We propose a frequency-based attack to evaluate the privacy guarantees of multiple dynamic match-key encoding. We then present two recommendations that can be used in this match-key encoding approach to prevent such a privacy attack.

Methods

The proposed attack analyses the frequency distributions of individual match-keys in order to identify the attributes used for each match-key, where we assume the adversary has access to a plain-text database with similar characteristics as the encoded database. We employ a set of statistical correlation tests to compare the frequency distributions of match-key values between the encoded and plain-text databases. Once the attribute combinations used for match-keys are discovered, we then re-identify encoded sensitive values by utilising a frequency alignment method. Next, we propose two recommendations; one to alter the original frequency distributions and another to make the frequency distributions uniform. Both will help to prevent frequency-based attacks.

Results

We evaluate our privacy attack using two large real-world databases. The results show that in certain situations the attack can successfully re-identify a set of sensitive values encoded using the multiple dynamic match-key encoding approach. On the databases used in our experiments, the attack can re-identify plain-text values with a precision and recall of both up to 98%. Furthermore, we show that our proposed recommendations are able to make this attack harder to perform with only a small reduction in linkage quality.

Conclusions

Our proposed privacy attack demonstrates the weaknesses of multiple match-key encoding that should be taken into consideration when linking databases that contain sensitive personal information. Our proposed recommendations ensure that the multiple dynamic match-key encoding approach can be used securely while retaining high linkage quality.

A quality improvement project to increase self-administration of medicines in an acute hospital

Quality problem or issue

A patient survey found significantly fewer patients reported they had self-administered their medicines while in hospital (20% of 100 patients) than reported that they would like to (44% of 100). We aimed to make self-administration more easily available to patients who wanted it.

Initial assessment

We conducted a failure, modes and effects analysis, collected baseline data on four wards and carried out observations.

Choice of solution

Our initial assessment suggested that the main areas we should focus on were raising patient awareness of self-administration, changing the patient assessment process and creating a storage solution for medicines being self-administered. We developed new patient information leaflets and posters and a doctor’s assessment form using Plan–Do–Study–Act cycles. We developed initial designs for a storage solution.

Implementation

We piloted the new materials on three wards; the fourth withdrew due to staff shortages.

Evaluation

Following collection of baseline data, we continued to collect weekly data. We found that the proportion of patients who wished to self-administer who reported that they were able to do so, significantly increased from 41% (of 155 patients) to 66% (of 118 patients) during the study, despite a period when the hospital was over capacity.

Lessons learned

Raising and maintaining healthcare professionals’ awareness of self-administration can greatly increase the proportion of patients who wish to self-administer who actually do so. Healthcare professionals prefer multi-disciplinary input into the assessment process.

The importance of physical function to people with osteoporosis

There is increasing need to understand patient outcomes in osteoporosis. This article discusses that fracture in osteoporosis can lead to a cycle of impairment, driven by complex psychosocial factors, having a profound impact on physical function/activity which accumulates over time. More information is required on how treatments impact physical function.

INTRODUCTION

There is increasing need to understand patient-centred outcomes in osteoporosis (OP) clinical research and management. This multi-method paper provides insight on the effect of OP on patients' physical function and everyday activity.

METHODS

Data were collected from three sources: (1) targeted literature review on OP and physical function, conducted in MEDLINE, Embase and PsycINFO; (2) secondary thematic analysis of transcripts from patient interviews, conducted to develop a patient-reported outcome instrument. Transcripts were re-coded to focus on OP impact on daily activities and physical function for those with and without fracture history; and (3) discussions of the literature review and secondary qualitative analysis results with three clinical experts to review and interpret the importance and implications of the findings.

RESULTS

Results suggest that OP, particularly with fracture, can have profound impacts on physical function/activity. These impacts accumulate over time through a cycle of impairment, as fracture leads to longer term detriments in physical function, including loss of muscle, activity avoidance and reduced physical capacity, which in turn leads to greater risk of fracture and potential for further physical restrictions. The cycle of impairment is complex, as other physical, psychosocial and treatment-related factors, such as comorbidities, fears and beliefs about physical activity and fracture risk influence physical function and everyday activity.

CONCLUSION

More information on how treatments impact physical function would benefit healthcare professionals and persons with OP in making treatment decisions and improving treatment compliance/persistence, as these impacts may be more salient to patients than fracture incidence.

Using chlamydia positivity to estimate prevalence: evidence from the Chlamydia Screening Pilot in England

Studies have suggested that positivity can be used to estimate the prevalence of Chlamydia trachomatis in large-scale chlamydia screening programmes. A recent pilot of opportunistic screening in England estimated that the prevalence among 16–24-year-old women in Portsmouth and Wirral was 9.8% and 11.2%, respectively. This study assessed the continued validity of positivity as an approximate for prevalence. We re-analysed data from the Chlamydia Screening Pilot to estimate positivity, calculated as total positive tests divided by total tests, and compared these estimates with the previously reported prevalence, measured as the number of women testing positive divided by the total number of women screened. Overall positivity was 9.4% in Portsmouth and 11.0% in the Wirral; these estimates were not statistically different from prevalence, regardless of health-care setting, age group or symptoms. We conclude that positivity can be used as a proxy for prevalence.

Clinician's Guide to Prevention and Treatment of Osteoporosis

The Clinician's Guide to Prevention and Treatment of Osteoporosis was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device, or procedure discussed in this publication.

Pharmacokinetic and Pharmacodynamic Analysis of Amprenavir-Containing Combination Therapy in HIV-1-Infected Children

Several factors influence the antiviral response to antiretroviral therapy. In this pharmacokinetic and pharmacodynamic analysis, the relationship of drug exposure, demographics, and cotherapy measures to antiviral response in a cohort of largely treatment-experienced children treated with amprenavir and nucleoside reverse transcriptase inhibitors was examined. Multiple pharmacodynamic and demographic factors were examined, but only the minimum plasma concentration (C(min))/protein-binding-adjusted 50% inhibitory drug concentration (IC(50)) ratio and whether individuals received 2 versus fewer than 2 nucleosides to which their viral isolates were susceptible were associated with the magnitude of the time-weighted average change in HIV-1 RNA log(10) copies/mL from baseline (AAUCMB). In multivariate logistic regression analysis, only the C(min)/IC(50) ratio was independently associated with having a >or=1 log(10) AAUCMB decline. The probability in the study population of having a >or=1log(10) AAUCMB was 50% and 85% at C(min)/IC(50) ratios of approximately 1 and 4, respectively. Of the multiple factors examined, only the C(min)/IC(50) ratio was a significant predictor of antiviral response in the first 8 weeks on amprenavir-containing combination antiretroviral therapy.

National Bone Health Alliance Bone Turnover Marker Project: current practices and the need for US harmonization, standardization, and common reference ranges

This position paper reviews how the National Bone Health Alliance (NBHA) will execute a project to help assure health professionals of the clinical utility of bone turnover markers; the current clinical approaches concerning osteoporosis and the status and use of bone turnover markers in the USA; the rationale for focusing this effort around two specific bone turnover markers; the need to standardize bone marker sample collection procedures, reference ranges, and bone turnover marker assays in clinical laboratories; and the importance of harmonization for future research of bone turnover markers.

INTRODUCTION

Osteoporosis is a major global health problem, with the prevalence and incidence of osteoporosis for at-risk populations estimated to be 44 million Americans. The potential of bone markers as an additional tool for health care professionals to improve patient outcomes and impact morbidity and mortality is crucial in providing better health care and addressing rising health care costs. This need to advance the field of bone turnover markers has been recognized by a number of organizations, including the International Osteoporosis Foundation (IOF), National Osteoporosis Foundation, International Federation of Clinical Chemistry, and Laboratory Medicine (IFCC), and the NBHA.

METHODS

This position paper elucidates how this project will standardize bone turnover marker sample collection procedures in the USA, establish a USA reference range for one bone formation (serum procollagen type I N propeptide, s-PINP) and one bone resorption (serum C-terminal telopeptide of type I collagen, s-CTX) marker, and standardize bone turnover marker assays used in clinical laboratories. This effort will allow clinicians from the USA to have confidence in their use of bone turnover markers to help monitor osteoporosis treatment and assess future fracture risk. This project builds on the recommendations of the IOF/IFCC Bone Marker Standards Working Group by developing USA reference standards for s-PINP and s-CTX, the markers identified as most promising for use as reference markers.

RESULTS

The goals of this project will be realized through the NBHA and will include its governmental, academic, for-profit, and non-profit sector stakeholders as well as major academic and commercial laboratories. Upon completion, a parallel effort will be pursued to make bone turnover marker measurements reliable and accepted by all health care professionals for facilitating treatment decisions and ultimately be reimbursed by all health insurance payers.

CONCLUSIONS

Successful completion of this project will help assure health professionals from the USA of the clinical utility of bone turnover markers and ties in with the parallel effort of the IOF/IFCC to develop worldwide bone turnover reference ranges.

Twelve months of nightly zolpidem does not lead to rebound insomnia or withdrawal symptoms: a prospective placebo-controlled study

Rebound insomnia, worsened sleep when discontinuing use of a hypnotic, is reported in some short-term studies. No study has prospectively assessed, using patient reports or nocturnal polysomnography (NPSG), the likelihood of rebound insomnia with chronic hypnotic use. The objectives of this study was to assess in primary insomniacs the likelihood of experiencing rebound insomnia and a withdrawal syndrome on repeated placebo substitutions over 12 months of nightly zolpidem use. A group of 33 primary insomniacs, without psychiatric disorders or drug and alcohol abuse, 32-65 years old, 15 men and 18 women, were randomized to take zolpidem 10 mg (n = 17) or placebo (n = 16) nightly for 12 months. In probes during months 1, 4, and 12, placebo was substituted for 7 consecutive nights in both the zolpidem and placebo groups. NPSGs were collected and Tyrer Bezodiazepine Withdrawal Symptom Questionnaires were completed on the first two discontinuation nights. Rebound insomnia was not observed on the first two and the seventh discontinuation nights and its likelihood did not increase over the 12 months of nightly zolpidem use. Some individuals did show rebound insomnia, approximately 30-40% of participants, but the percentage of 'rebounders' did not differ between the placebo and zolpidem groups and did not increase across 12 months. No clinically significant withdrawal symptoms on the Tyrer were observed on the discontinuation nights over the 12 months of nightly use. Chronic nightly hypnotic use at therapeutic doses by primary insomniacs does not lead to rebound insomnia or withdrawal symptoms.

Targeted plasma proteome profiling for early prediction of chemotherapy response and toxicity in colorectal cancer (CRC)

e15063

Background: Accurate predictors of chemotherapy response and toxicity in CRC are required to improve the safety, efficacy and costs of treatment. Plasma proteomic profiling using multiple reaction monitoring mass spectrometry (MRM-MS) couples assay multiplexing with high specificity to determine levels of pre-selected biomarker proteins. Our aims were to investigate the utility of plasma proteomic profiling using MRM-MS for predicting: (1) early haematological toxicity, (2) response and (3) survival for patients receiving chemotherapy for CRC. Methods: Patients with locally advanced and metastatic CRC receiving chemotherapy were enrolled. Plasma collection was performed pre-chemotherapy, at day 3 and day 15 of treatment. Toxicity assessments (NCI Criteria v3.0) were prospectively collected for all patients and treatment response (RECIST) assessed for patients with metastatic disease. MRM-MS assays were designed for 39 peptides representing 31 liver derived plasma proteins with reported roles in inflammation and/or cancer. Statistical analysis was performed using the 2-sample t-test to assess statistically significant fold change differences (p<0.05) between sample days for: (1) patients with absence or presence of ≥ Grade 2 neutropenia after two cycles and (2) responders (CR and PR) versus non-responders (SD or PD). Results: Plasma proteomic profiling for 39 peptides was performed for 17 patients. The greatest change in protein levels was observed between Day 3 and 15 with 9% of proteins showing a 1.5 fold or greater change with some proteins showing a ≥ 200-fold change in level. Three proteins (clusterin, paraoxanse and apolipoprotein A1) were significantly different in the group analysed for neutropenia and four proteins (kininogen I, serum paraoxonase/ arylestease 1, apolipoprotein A-1 and complement C4a) were significantly different in the group analysed according to response. Survival analysis was not performed due to the short follow up. Discussion: Our results are encouraging for the use of a robust mass spectrometry technique for early prediction of neutropenia and chemotherapeutic response in CRC.

No significant financial relationships to disclose.

Strategies used to increase chlamydia screening in general practice: a qualitative study

OBJECTIVES

To explore strategies used by chlamydia screening co-ordinators and practice staff to implement genital chlamydia screening within general practices.

METHODS

Qualitative phenomenological study using individual semi-structured telephone interviews. Screening co-ordinators were selected purposively in Phase 1 and 2 areas of the Department of Health National Chlamydia Screening Programme in England, where there was significant screening in general practice. Open questions were asked about: the factors that determined high chlamydia screening rates; maintaining motivation for screening; and strategies to increase screening in general practices.

RESULTS

Co-ordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalized screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time-saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. Chlamydia screening was sustained through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the 'at-risk' population from the screening team. Co-ordinators' enthusiasm and project management skills were as important as sexual health experience. Co-ordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public.

CONCLUSIONS

All practice staff need to be encouraged to become champions of the chlamydia screening programme through education, especially aimed at older clinicians and receptionists. The National Health Service should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.

Establishing the National Chlamydia Screening Programme in England: results from the first full year of screening

BACKGROUND

The phased implementation of the National Chlamydia Screening Programme (NCSP) began in September 2002. The NCSP offers opportunistic screening for chlamydia to women and men under 25 years of age attending clinical and non-clinical screening venues using non-invasive urine or vulvo-vaginal swab samples tested via nucleic acid amplification. This review describes the implementation of the NCSP, reports positivity rates for the first year, and explores risk factors for genital chlamydial infection.

METHODS

Cross sectional study of the first year's screening data from the NCSP. A standardised core dataset for each screening test was collected from 302 screening venues, excluding genitourinary medicine (GUM) clinics, across 10 phase 1 programme areas. We estimated chlamydia positivity by demographic and behavioural characteristics, and investigated factors associated with infection through univariate and multivariate analyses.

RESULTS

Chlamydia positivity among people under 25 years of age screened in non-GUM settings was 10.1% (1538/15 241) in women and 13.3% (156/1172) in men. Risk factors varied by sex: for women-age 16-19, non-white ethnicity, and sexual behaviours were associated with infection; for men-only age 20-24 and non-white ethnicity were associated with infection.

DISCUSSION

In the first phase of the NCSP, 16 413 opportunistic screens among young adults under 25 years of age were performed at non-GUM settings and testing volume increased over time. Rates of disease were similar to those found during the English screening pilot and were comparable to the first year of widespread screening in Sweden and the United States. The screening programme in England will continue to expand as further phases are included, with national coverage anticipated by 2008.

Opportunistic screening for genital chlamydial infection. I: acceptability of urine testing in primary and secondary healthcare settings

OBJECTIVES

To determine the acceptability of opportunistic screening for Chlamydia trachomatis in young people in a range of healthcare settings.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples tested by ligase chain reaction (LCR). Data on uptake and testing were collected and in-depth interviews were used for programme evaluation.

SETTING

General practice, family planning, genitourinary medicine clinics, adolescent sexual health clinics, termination of pregnancy clinics, and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics) in two health authorities (Wirral and Portsmouth and South East Hampshire). Main participants: Sexually active women aged between 16 and 24 years attending healthcare settings for any reason.

MAIN OUTCOME MEASURES

Uptake data: proportion of women accepting a test by area, healthcare setting, and age; overall population coverage achieved in 1 year. Evaluation data: participants' attitudes and views towards opportunistic screening and urine testing.

RESULTS

Acceptance of testing by women (16-24 years) was 76% in Portsmouth and 84% in Wirral. Acceptance was lower in younger women (Portsmouth only) and varied by healthcare setting within each site. 50% of the target female population were screened in Portsmouth and 39% in Wirral. Both the opportunistic offer of screening and the method of screening were universally acceptable. Major factors influencing a decision to accept screening were the non-invasive nature of testing and treatment, desire to protect future fertility, and the experimental nature of the screening programme.

CONCLUSIONS

An opportunistic model of urine screening for chlamydial infection is a practical, universally acceptable method of screening.

Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases

OBJECTIVES

To determine the prevalence and treatment outcomes among young women screened opportunistically for genital Chlamydia trachomatis and to evaluate the impact of screening in those participating.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples, tested by ligase chain reaction (LCR). In-depth interviews were used for programme evaluation.

SETTING

Screening was offered in two health authorities at general practice, family planning, genitourinary medicine (GUM), adolescent sexual health, termination of pregnancy clinics and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics). Main participants: Sexually active women (16-24 years) attending for any reason.

MAIN OUTCOME MEASURES

Screening data: prevalence of infection by age and healthcare setting; proportion of positive patients attending for treatment. Evaluation data: participants' attitudes and views towards screening and follow up.

RESULTS

In total, 16 930 women (16-24 years) were screened. Prevalence was higher in younger women (16-20) than those aged 21-24 years and was highly variable at different healthcare settings (range 3.4%-17.6%). Prevalence was approximately 9% in general practice. The role of the project health advisers in managing results and coordinating treatment of positive individuals was essential; the vast majority of all positives were known to be treated. Women felt that screening was beneficial. Improving awareness and education about sexually transmitted infections is required to alleviate negative reactions associated with testing positive for infection.

CONCLUSIONS

Prevalence of infection outside GUM clinics is substantial and opportunistic screening using urine samples is an acceptable method of reaching individuals with infection who do not normally present at specialist clinics.

Issues in the demography of Mongolian nomadic pastoralism

"Taking a historical perspective this paper examines the ecological and political influences on Mongolian demography. Changes in political policy, domestic economy, health services, venereal diseases and shortages of men are considered in examining the unusual pattern of very low fertility, followed by a rise in the 1950s and 1960s and a gradual fertility decline, even in the absence of modern contraception. It is concluded that the lack of simultaneity between major political and demographic changes suggest that there are no direct responses to policy, despite the strong pronatalist stance, but that health services, particularly in the realms of venereal disease treatment, have had a major influence on Mongolian demographic patterns. The indirect consequences of government policy--education, health services in rural areas, rapid urbanisation--appear to have a stronger influence than the pronatalism, and ironically have led to rapid fertility decline."

GyneFix: a UK experience

OBJECTIVES

To present the experience of family planning providers and clients in the UK with the GyneFix intrauterine implant device.

METHOD

Audit of 138 GyneFix insertions at the Ella Gordon Family Planning Unit in Portsmouth, from 1997 to 1999.

RESULTS

Of 138 attempts at GyneFix insertion, 134 were successful. Forty per cent were inserted in nulliparous women. The removal rate was 15%, half of which were due to unacceptable side-effects. The expulsion rate was 8% ranging over a period of a few days to 12 months after insertion. There were no reported perforations or accidental pregnancies with GyneFix in situ in this series. There were no reported pregnancies as a result of unnoticed expulsion.

CONCLUSIONS

The results obtained in this study are minimal estimates obtained from a retrospective analysis. The numbers are small but they are comparable to results reported from other family planning centers in the UK. Although GyneFix clearly has a useful role, there is a need for a large-scale prospective randomized study to establish the benefits and potential disadvantages of the GyneFix device.

Emergence of resistance to protease inhibitor amprenavir in human immunodeficiency virus type 1-infected patients: selection of four alternative viral protease genotypes and influence of viral susceptibility to coadministered reverse transcriptase nucleoside inhibitors

Previous data have indicated that the development of resistance to amprenavir, an inhibitor of the human immunodeficiency virus type 1 protease, is associated with the substitution of valine for isoleucine at residue 50 (I50V) in the viral protease. We present further findings from retrospective genotypic and phenotypic analyses of plasma samples from protease inhibitor-naïve and nucleoside reverse transcriptase inhibitor (NRTI)-experienced patients who experienced virological failure while participating in a clinical trial where they had been randomized to receive either amprenavir or indinavir in combination with NRTIs. Paired baseline and on-therapy isolates from 31 of 48 (65%) amprenavir-treated patients analyzed demonstrated the selection of protease mutations. These mutations fell into four distinct categories, characterized by the presence of either I50V, I54L/I54M, I84V, or V32I+I47V and often included accessory mutations, commonly M46I/L. The I50V and I84V genotypes displayed the greatest reductions in susceptibility to amprenavir, although each of the amprenavir-selected genotypes conferred little or no cross-resistance to other protease inhibitors. There was a significant association, for both amprenavir and indinavir, between preexisting baseline resistance to NRTIs subsequently received during the study and development of protease mutations (P = 0.014 and P = 0.031, respectively). Our data provide a comprehensive analysis of the mechanisms by which amprenavir resistance develops during clinical use and present evidence that resistance to concomitant agents in the treatment regimen predisposes to the development of mutations associated with protease inhibitor resistance and treatment failure.

Apolipoprotein E is upregulated in olfactory bulb glia following peripheral receptor lesion in mice

Apolipoprotein E (apoE), a lipid transporting protein, has been postulated to participate in nerve regeneration. To better clarify apoE function in the olfactory system, we evaluated the amount and distribution of apoE in the olfactory bulb following olfactory nerve lesion in mice. Olfactory nerve was lesioned in 2- to 4-month-old mice by intranasal irrigation with Triton X-100. Olfactory bulbs were collected at 0, 3, 7, 21, 42, and 56 days postlesion, and both apoE concentrations and apoE distribution were determined. ApoE levels, as determined by immunoblot analysis, were twofold greater than normal during nerve degeneration at 3 days. ApoE levels remained elevated by approximately 1.5 times normal levels at 7 through 21 days after injury and returned to baseline by 56 days. Immunocytochemical studies supported these observations. ApoE immunoreactivity was prominent on the olfactory nerve at 3 days after lesion and decreased to baseline levels at later time periods. Double-labeling immunocytochemical studies confirmed that both reactive astroglia and microglia produced detectable amounts of apoE following the lesion. Return of apoE expression to baseline paralleled measures of olfactory nerve maturation as measured by olfactory marker protein. These data suggest that apoE increases concurrent with nerve degeneration. ApoE may facilitate efficient regeneration perhaps by recycling lipids from degenerating fibers for use by growing axons. The association of apoE genotype with dementing illnesses may represent a diminished ability to support a lifetime of nerve regeneration.

Clinical governance: learning and changing practice

CONTEXT

This paper describes a very simple, non-threatening method for improving communication and sharing learning points.

OBJECTIVE

To test whether sharing anonymised reporting of problems and helpful hints is acceptable and useful to staff.

DESIGN

A pink slip (pinkie) was designed and made available in every clinic venue. All staff were asked to write about any episodes where practice was less than optimum or to share good clinical experiences. The forms could be completed anonymously if preferred. A senior nurse collated the reports monthly and fed them back to all staff as a report. In May 2000 all staff were surveyed for their opinion of the scheme.

RESULT

Over 22 months, 139 'pinkies' were returned. Fifty-six of the 100 'less than optimum' events were classified as 'system failures'. The response to the staff survey was very positive, with 62% of staff replying. Fifty-four of the 55 staff found the scheme helpful. A third of those who responded had contributed and all but two individuals felt able to contribute if the situation arose again.

CONCLUSION

This simple system of self completed pink slips has allowed examples of less than optimum practice and helpful suggestions to be shared across a large service that has a predominantly part time work force providing services from over 15 venues. The system is seen as non-threatening and was acceptable to over 95% of the staff who responded to the survey. Fifty percent of doctors and nurses had made a submission. Changes in practice have resulted since its introduction.

Valrubicin: an alternative to radical cystectomy for carcinoma in situ of the bladder

Treatment options for patients who fail BCG therapy are limited. While cystectomy may be curative, not all patients can withstand the medical and/or psychologic stresses associated with surgery or resection. Valrubicin represents a safe and effective second-line intravesical therapy.

NKIATRE is a novel conserved cdc2-related kinase

The mitogen-activated protein kinases (MAPKs) and the cyclin-dependent kinases (CDKs) are key mediators of cell proliferation in response to extracellular signals. Recent additions to each of these families and the identification of kinases with structural features of both have provided insights into fundamental processes, such as cell division and differentiation. To identify novel serine kinases with features of MAPKs or CDKs, a degenerate PCR-based amplification approach was undertaken. The 57- and 52-kDa isoforms of a novel protein kinase, termed NKIATRE, were molecularly cloned from rat brain and jejunum cDNA libraries. Like the MAPKs, NKIATRE has a Thr-Xaa-Tyr motif in kinase subdomain VIII. NKIATRE also shows close homology to the cyclin-dependent kinase class of protein kinases and the cdc2-related kinases NKIAMRE, KKIALRE, and KKIAMRE, containing both conserved inhibitory phosphorylation sites and a putative cyclin-binding domain. Two isoforms of NKIATRE that differ in their carboxy-terminal ends have been identified. A functional nuclear localization signal is specific to the longer 57-kDa alpha isoform. Sequence similarity to the putative human tumor suppressor gene NKIAMRE, which is lost in leukemic patients with chromosome 5q deletions, suggests that NKIATRE may have a role in restricting cell growth or maintaining differentiation.

Pastoralists, agropastoralists and migrants: interactions between fertility and mobility in northern Burkina Faso

Seasonal rural to urban migration of young men is becoming an increasingly important part of the rural economy of the West African Sahel, yet little is known about how the short-term contact of men with urban centres might affect reproductive decisions and outcomes in sending areas. In northern Burkina Faso, substantial variation in short-term migration rates of young Fulani men to cities provides an opportunity to explore interactions between migration and fertility in this area. The groups most involved in seasonal labour migration experience substantially lower fertility than non-migrating groups. Fertility differentials arise largely from higher rates of secondary sterility among migrating groups, probably caused by an increased incidence of sexually transmitted diseases. Such mechanisms as changes in attitudes and knowledge regarding birth control, and the undermining of traditional practices of marriage, breastfeeding, and sexual abstinence are far less important.

Engineered herpes simplex virus expressing IL-12 in the treatment of experimental murine brain tumors

Genetically engineered, neuroattenuated herpes simplex viruses (HSVs) expressing various cytokines can improve survival when used in the treatment of experimental brain tumors. These attenuated viruses have both copies of gamma(1)34.5 deleted. Recently, we demonstrated increased survival of C57BL/6 mice bearing syngeneic GL-261 gliomas when treated with an engineered HSV expressing IL-4, as compared with treatment with the parent construct (gamma(1)34. 5(-)) alone or with a virus expressing IL-10. Herein, we report construction of a conditionally replication-competent mutant expressing both subunits of mIL-12 (M002) and its evaluation in a syngeneic neuroblastoma murine model. IL-12 induces a helper T cell subset type 1 response, which may induce more durable antitumor effects. In vitro studies showed that, when infected with M002, both Vero cells and murine Neuro-2a neuroblastoma cells produced physiologically relevant levels of IL-12 heterodimers, as determined by ELISA. M002 was cytotoxic for Neuro-2a cells and human glioma cell lines U251MG and D54MG. Neurotoxicity studies, as defined by plaque-forming units/LD(50), performed in HSV-1-sensitive A/J strain mice found that M002 was not toxic even at high doses. When evaluated in an intracranial syngeneic neuroblastoma murine model, median survival of M002-treated animals was significantly longer than the median survival of animals treated with R3659, the parent gamma(1)34.5(-) mutant lacking any cytokine gene insert. Immunohistochemical analysis of M002-treated tumors identified a pronounced influx of CD4(+) T cells and macrophages as well as CD8(+) cells when compared with an analysis of R3659-treated tumors. We conclude that M002 produced a survival benefit via oncolytic effects combined with immunologic effects meditated by helper T cells of subset type 1.

Assays that measure selective killing of virus-infected cells

When evaluating potential antiviral compounds, determining the effect of the drug on virus replication is usually the prime concern. However, since virus replication is dependent on the host cell, in circumstances where virus infection is not rapidly lytic to cells, the effect of these compounds on cell growth and viability merits consideration. Differential host cell metabolism has been reported for cells infected with viruses, e.g., HIV, measles, and HSV, and therefore it is possible that cells infected with viruses have different susceptibilities to antiviral drugs, depending on the their mode of action. Experience with HIV and a potential anti-HIV drug, EF13, showed that HIV-chronically infected cells were markedly more susceptible to EF13 than their parent uninfected cells (1); however, acutely HIV-infected cells showed a similar susceptibility as uninfected cells to EF13 (2). In addition, cells containing actively replicating HIV-1 were more susceptible to EF13 than either uninfected cells or cells infected with but not producing HIV-1 (3).

In utero alcohol and postnatal methylphenidate: locomotion and dopamine receptors

Prenatal alcohol exposure can cause central nervous system abnormalities and dysfunction referred to as Alcohol-Related Neurodevelopmental Disorder (ARND). Repeated intermittent methylphenidate (Ritalin) was used as a psychopharmacological challenge to reveal functional alterations in dopamine binding sites in rats exposed prenatally to alcohol. Pregnant Long-Evans dams were intubated with 0, 3, or 5 g/kg/day of alcohol from gestational day (GD) 8 to GD20. Adult offspring received repeated intraperitoneal injections of 0, 4, or 8 mg/kg of methylphenidate (MET), and were tested periodically for locomotor activity. Autoradiographic assessment of dopamine D1 and D2 receptors binding were visualized using [3H]SCH 23390 and [3H]raclopride, respectively. Prenatal alcohol did not produce significant dose-dependent effects on adult locomotor activity. Repeated MET injections produced dose-dependent sensitization of locomotor activity in all groups. The 3-g/kg prenatal alcohol group had a significantly decreased number of dopamine D2 binding sites within the dorsal and ventral striatum. This effect was reversed by MET. The neural changes detected in the lower alcohol group may indicate persistent changes within the dopaminergic system due to prenatal alcohol exposure.

Antiviral efficacy of disinfectant solution MRI-1

Disinfectant MRI-1 was prepared by dissolution of non-ionic and ionic detergent in ethanol. The disinfectant inactivated extracellular and intracellular enveloped and non-enveloped viruses including herpes viruses, influenza A and human immunodeficiency disease virus in suspension or on surfaces by pre-exposure or post-exposure to the disinfectant; in addition, cells were disabled as potential hosts for viral infection using concentrations of MRI-1 which were 50-fold less than the operative concentration for disinfection. There was no evidence of in vitro mutagenicity using Salmonella typhimurium or sensitization or other adverse effect in a guinea pig model or in human subjects.

Metabolic and monetary costs of avoidable parenteral nutrition use

BACKGROUND

We prospectively collected data on in patients receiving parenteral nutrition to determine the magnitude of potentially preventable metabolic and monetary costs associated with parenteral nutrition.

METHODS

Parenteral nutrition was prescribed by the treating physicians with optional consultation from a multidisciplinary metabolic support service. Days on parenteral nutrition, appropriateness of parenteral nutrition, metabolic complications, and avoidable parenteral nutrition charges were determined. Parenteral nutrition use was considered "indicated" or "not indicated" based on the American Society for Parenteral and Enteral Nutrition guidelines and "preventable" if the gastrointestinal tract was functional but not accessed when possible.

RESULTS

Of the 209 parenteral nutrition starts, 62% were indicated, 23% were preventable, and 15% were not indicated. Parenteral nutrition starts were deemed indicated in 82% of instances in which a metabolic support service consult was obtained, compared with 56% in which a consultation was not obtained (p = .004). Hyperglycemia was the most common metabolic complication, with an overall incidence of 20%. Metabolic complications occurred less frequently in patients who received a metabolic support service consultation compared with patients who did not (34% vs 66% of parenteral nutrition days, respectively; p = .004). Parenteral nutrition use of < or =5 days duration was significantly less frequent among patients who received metabolic support service consultation (16% vs 35%; p = .002). Parenteral nutrition that was not indicated or preventable resulted in excess annualized patient charges of more than one half million dollars not accounting for charges related to treatment of potentially avoidable parenteral nutrition complications.

CONCLUSIONS

This study illustrates that not-indicated and preventable parenteral nutrition initiation, short-term parenteral nutrition use, and metabolic complications are less likely when patients receive consultation by a multidisciplinary team with expertise in nutrition and metabolic support. Furthermore, the avoidance of inappropriate parenteral nutrition use translates into substantial cost savings.

Bone density in long term users of depot medroxyprogesterone acetate

OBJECTIVE

To identify any adverse effect on bone density in long term users of depot medroxyprogesterone acetate (DMPA) for contraception.

DESIGN

Cross-sectional measurement of bone density in users with amenorrhoea of more than one year or any woman using DMPA for more than five years.

SETTING

Community Family Planning Clinics in Portsmouth and Manchester.

POPULATION

One hundred and eighty-five women aged 17-52 years (mean 33.3 years) who had used DMPA for between 1 and 16 years and were attending the clinics for further injections, between August 1994 and August 1996.

METHODS

Dual energy X-ray measurement of bone density of femoral neck and lumbar spine, and venous blood sample taken just prior to the next injection of DMPA.

MAIN OUTCOME MEASURES

Bone density of femoral neck and lumbar spine and serum oestradiol in relationship to years of DMPA use and duration of amenorrhoea.

RESULTS

Most women (n=153) had serum oestradiol levels < 150 pmol/l. Despite this, the mean bone density of the lumbar spine compared with the population mean for women aged 20-59 years gave a Z score (95% CI) of -0.332 (-0.510 to -0.154). There was no significant difference in the mean density of the femoral neck from the normal population mean.

CONCLUSION

Despite amenorrhoea and low serum oestradiol, this sample of long term DMPA users had bone density only minimally below the normal population mean. We therefore found no clinically important adverse effect on bone density and therefore no reason to recommend bone conserving measures, such as add-back oestrogen.

The influence of the milieu on the rate of neutralisation of herpes simplex virus 1

The rate of neutralisation of herpes simplex virus 1 was increased by up to more than five hundred-fold when the virus suspension and antiserum were each diluted to one hundred-fold in water instead of phosphate buffered saline. This phenomenon, which was observed for two human positive sera and a rabbit purified polyclonal antibody, may represent an unrecognised homeostatic mechanism where neutralising antibody is 'dilution-fast' under physiological conditions of transudation or pathological conditions of inflammation.

A system for isolation, transport and storage of herpes simplex viruses

A major difficulty with diagnostic virus isolation concerns the relative thermolability of certain viruses, e.g. herpes simplex virus type 2, which may, therefore, lose infectivity during transport to the laboratory. This study describes a system of virus isolation and transport, which depends on direct inoculation at the bedside or clinic, to a monolayer or suspension of susceptible cells with subsequent incubation for 10 h at approximately 32 degrees C, whereupon the newly synthesised virus becomes very stable if the cells are subsequently maintained at room temperature. This system was found to increase the sensitivity of isolation of herpes simplex virus, particularly under conditions of asymptomatic virus excretion or if there was significant delay in transportation of clinical samples to the virus laboratory. It is envisaged that this system will allow clinical self-sampling by the patient with application to epidemiological surveys in both the developed and underdeveloped world.

Mammalian mitogen-activated protein kinase pathways are regulated through formation of specific kinase-activator complexes

Mammalian cells contain at least three signaling systems which are structurally related to the mitogen-activated protein kinase (MAPK) pathway. Growth factors acting through Ras primarily stimulate the Raf/MEK/MAPK cascade of protein kinases. In contrast, many stress-related signals such as heat shock, inflammatory cytokines, and hyperosmolarity induce the MEKK/SEK(MKK4)/SAPK(JNK) and/or the MKK3 or MKK6/p38(hog) pathways. Physiological agonists of these pathway types are either qualitatively or quantitatively distinct, suggesting few common proximal signaling elements, although past studies performed in vitro, or in cells using transient over-expression, reveal interaction between the components of all three pathways. These studies suggest a high degree of cross-talk apparently not seen in vivo. We have examined the possible molecular basis of the differing agonist profiles of these three MAPK pathways. We report preferential association between MAP kinases and their activators in eukaryotic cells. Furthermore, using the yeast 2-hybrid system, we show that association between these components can occur independent of additional eukaryotic proteins. We show that SAPK(JNK) or p38(hog) activation is specifically impaired by co-expression of cognate dominant negative MAP kinase kinase mutants, demonstrating functional specificity at this level. Further divergence and insulation of the stress pathways occurs proximal to the MAPK kinases since activation of the MAPK kinase kinase MEKK results in SAPK(JNK) activation but does not cause p38(hog) phosphorylation. Therefore, in intact cells, the three MAPK pathways may be independently regulated and their components show specificity in their interaction with cognate cascade members. The degree of intermolecular specificity suggests that mammalian MAPK signaling pathways may remain distinct without the need for specific scaffolding proteins to sequester components of individual pathways.