An ethical approach to resolving value conflicts in child protection

Child protection professionals working in diverse societies are regularly faced with value conflicts. Recognising these, and resolving them in the best interests of children, is a task that requires child protection specialists to make complex judgements and decisions. In this paper the philosophical concepts of absolutism and relativism to child abuse are applied, and it explores how this approach has practical relevance to solving ethical dilemmas in child protection. Children's interests are best served by erring towards an absolutist approach to the diagnosis and recognition of maltreatment and towards a relativistic approach in determining how services respond to a harmful incident or situation. Absolutism and relativism are not alternatives, but part of a continuous process of recognising and negotiating ever-changing community, national and global norms. At the service level the dichotomy transpires into the need to be culturally competent in handling the conflicting needs, rights and values of children, families, communities and professionals, whilst retaining the skill of child advocacy.

Comprehensive analysis of common mitochondrial DNA variants and colorectal cancer risk

Several lines of evidence implicate mitochondrial dysfunction in the development of cancer. To test the hypothesis that common mtDNA variation influences the risk of colorectal cancer (CRC), we genotyped 132 tagging mtDNA variants in a sample of 2854 CRC cases and 2822 controls. The variants examined capture approximately 80% of mtDNA common variation (excluding the hypervariable D-loop). We first tested for single marker associations; the strongest association detected was with A5657G (P=0.06). Overall the distribution of association P-values was consistent with a null distribution. Next, we classified individuals into the nine common European haplogroups and compared their distribution in cases and controls. This analysis also provided no evidence of an association between mitochondrial variation and CRC risk. In conclusion, our results provide little evidence that mitochondrial genetic background plays a role in modifying an individual's risk of developing CRC.

Childhood socioeconomic circumstances and adult height and leg length in central and eastern Europe

BACKGROUND

Adult height and leg length have been shown to be positively associated with childhood socioeconomic circumstances in several studies in western populations. This study will determine whether similar associations are observable in settings with different social histories, and will assess whether adult leg length is more strongly associated than adult height.

METHODS

Random samples of men and women aged 45-69 years were taken from population registers in Novosibirsk (Russia), Krakow (Poland) and six towns of the Czech Republic, recruiting nearly 29,000 people. Participants completed a questionnaire that included questions regarding their mother's and father's education (not available in the Czech Republic) and ownership of several household items when they were 10 years old. Participants' standing and sitting heights were measured and from these an estimate of leg length was derived. Associations between indicators of childhood socioeconomic circumstances and anthropometric measures were analysed using linear regression.

RESULTS

Russian individuals were shorter and reported fewer household assets at the age of 10 years than Czech and Polish individuals. Parental education and household assets were strongly associated with each other and both were independently associated with height, leg length and trunk length. Height was associated with childhood circumstances more strongly than leg length. The associations of childhood circumstances with the leg/trunk ratio were weak and inconsistent.

CONCLUSION

In these urban populations in eastern Europe, adult height is associated with childhood conditions at least as strongly as leg length.

CASP8 variants D302H and -652 6N ins/del do not influence the risk of colorectal cancer in the United Kingdom population

Polymorphisms in CASP8 at 2q33.1 have been associated with the risk of developing cancer, specifically, the D302H variant (rs1045485) with breast cancer in the European population and the −652 6N ins/del promoter variant (rs3834129) with multiple tumours including colorectal cancer (CRC) in the Chinese population. We evaluated the relationship between −652 6N ins/del and D302H variants and risk of developing CRC in the UK population by genotyping 4016 cases and 3749 controls. Both variants showed no evidence of an association with risk of developing CRC (P=0.42 and 0.22, respectively). In contrast, the recently identified CRC susceptibility allele rs6983267 mapping to 8q24 was significantly associated with disease risk (P=8.94 × 10⁻⁸). It is thus very unlikely that variation in CASP8 defined by −652 6N ins/del or D302H influences the risk of CRC in European populations. The implications of our findings both in terms of population-specific effects and publication bias are discussed.

Characteristics of the m2000 automated sample preparation and multiplex real-time PCR system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae

We evaluated a new real-time PCR-based prototype assay for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae developed by Abbott Molecular Inc. This assay is designed to be performed on an Abbott m2000 real-time instrument system, which consists of an m2000sp instrument for sample preparation and an m2000rt instrument for real-time PCR amplification and detection. The limit of detection of this prototype assay was determined to be 20 copies of target DNA for both C. trachomatis and N. gonorrhoeae, using serially diluted linearized plasmids. No cross-reactivity could be detected when 55 nongonococcal Neisseria isolates and 3 non-C. trachomatis Chlamydia isolates were tested at 1 million genome equivalents per reaction. Concordance with the Roche Amplicor, BDProbeTec ET, and Gen-Probe APTIMA Combo 2 tests was assessed using unlinked/deidentified surplus clinical specimens previously analyzed with these tests. For C. trachomatis, concordance for positive results ranged from 93.7% to 100%, while concordance for negative results ranged from 98.2% to 100%. For N. gonorrhoeae, concordance for positive and negative results ranged from 91.4% to 100% and 99.3% to 100%, respectively. A workflow analysis of the prototype assay was conducted to obtain information on throughput under laboratory conditions. At 48 samples/run, the time to first result for both C. trachomatis and N. gonorrhoeae was 4.5 h. A total of 135 patient specimens could be analyzed in 8.9 h, with 75 min of hands-on time. This study demonstrated the technical and clinical feasibility of the new Abbott real-time PCR C. trachomatis/N. gonorrhoeae assay.

Benefits of interprofessional learning: an interprofessional MSc in child health

This article addresses interprofessional education (IPE) using a case study evaluating a multidisciplinary MSc course in child health. The participants felt that the nature of the course increased their interprofessional working skills and professional confidence. They described benefits, including new insights, a balanced variety of views, development of respect and equality between professionals, improved communication and a holistic approach to child health.

Clinical correlates of early medication adherence: West London first episode schizophrenia study

OBJECTIVE

Little is known about factors that mediate adherence with medication during the early stages of antipsychotic treatment in schizophrenia. This study sought to identify factors that may be associated with medication adherence in first-episode schizophrenia.

METHOD

In 101 patients, adherence was assessed along with potentially relevant variables, including attitudes toward medication, insight, substance misuse, side effects and psychopathology.

RESULTS

In a linear regression analysis, negative attitudes toward medication and a relative lack of insight contributed significantly towards poor adherence. Although poorly adherent patients had significantly higher scores on negative and disorganization syndromes, these did not contribute significantly towards adherence. Adverse medication side effects, subjective well-being and substance misuse showed no significant association with adherence.

CONCLUSION

At the initiation of drug treatment, attitudes toward medication and insight appear more relevant to medication adherence than side effects. Adherence appears to reflect a complex interaction of influences, which may change over time.

Prevalence of autistic spectrum disorder in children attending mainstream schools in a Welsh education authority

All mainstream primary schools in Cardiff were invited in July 1998 to participate in a prevalence survey of autistic spectrum disorder. Teachers of each class filled in a questionnaire based on ICD-10 criteria for autistic disorders. The Autism Spectrum Screening Questionnaire (ASSQ) was completed on children identified with problems identified by the questionnaire. A total of 11692 children born between 1 September 1986 and 31 August 1990 were screened: 234 (2%) children were identified as requiring an ASSQ; 151 of 234 (65%) ASSQs were returned. Of the 151, 60 children (52 male, 8 female; 40%) scored 22 or more. Their notes and the involved professionals were consulted. Thirty-five children, unknown to specialist services or with complex features, required additional assessment. Seventeen children (all male) were found to be on the autistic spectrum. When the overall rubric was disentangled we found a diverse population of affected children including a handful who did not fit easily into ICD-10 classification. Correcting for incomplete ascertainment we found a minimum prevalence of 20.2 out of every 10 000 (SE = 4.5) for autistic spectrum disorder in this population.

Evaluation of cultural competence and antiracism training in child health services

AIMS

To evaluate the acceptability and effectiveness of cultural competence and antiracism training to professionals providing services to ill or disabled children.

METHODS

Immediate post-training and retrospective questionnaire survey of trainees. Main outcome measures were acceptability; perceived relevance to practice; previous training in this area; perceived impact on professionals' confidence in providing care to diverse communities; and reported changes in behaviour and practice.

RESULTS

Cultural competence and antiracism training has been neglected in the health sector but is well received by professionals. It is a positive experience for trainees and perceived to be relevant to their practice. Appropriate and non-threatening training in cultural competence changes attitudes, behaviours, and practice, including promoting good practice in communication across linguistic and cultural differences.

CONCLUSIONS

Appropriate cultural competence and antiracism training is both effective and acceptable in child health services.

Heart defects and ocular anomalies in children with Down's syndrome

AIMS

To investigate whether ocular anomalies are associated with congenital heart defects in children with Down's syndrome.

METHODS

58 children with Down's syndrome were entered into a retrospective observational study. Children were assigned to heart defect groups based on medical records. Optometric tests had previously been carried out at the homes of the children.

RESULTS

A relation between congenital cardiac defects, myopia, and nystagmus was observed. Heart problems were not related to accommodative insufficiency, hyperopia, or strabismus.

CONCLUSION

In children with Down's syndrome heart defects were associated with both myopia and nystagmus.

Rapid determination of substrate specificity of Clostridium histolyticum beta-collagenase using an immobilized peptide library

The molecular basis of the substrate specificity of Clostridium histolyticum beta-collagenase was investigated using a combinatorial method. An immobilized positional peptide library, which contains 24,000 sequences, was constructed with a 7-hydroxycoumarin-4-propanoyl (Cop) fluorescent group attached at the N terminus of each sequence. This immobilized peptide library was incubated with C. histolyticum beta-collagenase, releasing fluorogenic fragments in the solution phase. The relative substrate specificity (k(cat)/K(m)) for each member of the library was determined by measuring fluorescence intensity in the solution phase. Edman sequencing was used to assign structure to subsites of active substrate mixtures. Collectively, the substrate preference for subsites (P(3)-P(4)') of C. histolyticum beta-collagenase was determined. The last position on the C-terminal side in which the identity of the amino acids affects the activity of the enzyme is P(4)', and an aromatic side chain is preferred in this position. The optimal P(1)'-P(3)' extended substrate sequence is P(1)'-Gly/Ala, P(2)'-Pro/Xaa, and P(3)'-Lys/Arg/Pro/Thr/Ser. The Cop group in either the P(2) or P(3) position is required for a high substrate activity with C. histolyticum beta-collagenase. S(2) and S(3) sites of the protease play a dominant role in fixing the substrate specificity. The immobilized peptide library proved to be a powerful approach for assessing the substrate specificity of C. histolyticum beta-collagenase, so it may be applied to the study of other proteases of interest.

Aging and physical fitness are more important than obesity in determining exercise-induced generation of GH

Exercise is a potent stimulus for GH secretion. Aging and obesity are associated with a diminution of GH secretion. We wanted to determine whether age or fat mass is more important in regulating the GH response to exercise. Four groups of healthy men were studied: seven lean young men [age, <40 yr; body mass index (BMI), <25 kg/m(2)], six overweight young men (age, <40 yr; BMI, >27.5), seven lean older men (age, >60 yr; BMI, <25), and 6 overweight older men (age, 60 yr; BMI, >27.5). The men performed a maximal exercise test. GH secretion was higher in the younger men than in the older men. Peak GH was higher in the older lean men than in the older overweight men. There was no difference between the young groups. Fitness correlated negatively with age and positively with peak GH. In young men, there was no relation between BMI, bioimpedance, or leptin and GH secretion. In contrast, in older men there was an inverse correlation between measures of fat mass and GH secretion. Age and physical fitness are more important than body fat in regulating exercise-induced GH secretion. These findings have important clinical implications if we are to prevent the frailty and morbidity associated with aging.

The health of children in refuges for women victims of domestic violence: cross sectional descriptive survey

OBJECTIVES

To describe the health and developmental status of children living in refugees for women victims of domestic violence and to investigate their access to primary healthcare services.

DESIGN

Cross sectional survey.

SETTING

Women's refugees in Cardiff.

PARTICIPANTS

148 resident children aged under 16 years and their mothers.

MAIN OUTCOME MEASURES

Completeness of records on the child health system (register of all children that includes data on the child's health) for named health visitor, named general practitioner, and immunisation uptake; satisfactory completion of child health surveillance; Denver test results for developmental status; Rutter test scores for behavioural and emotional problems; reports of maternal concerns.

RESULTS

148/257 (58%) children living in refugee between April 1999 and January 2000 were assessed. Child health system data were incorrect (general practitioner and/or address) or unavailable for 85/148 (57%) children. Uptake of all assessments and immunisations was low. 13/68 (19%) children aged <5 years had delayed or questionable development on the Denver test, and 49/101 (49%) children aged 3-15 years had a Rutter score of >10 (indicating probable mental health problems). Concerns were expressed by mothers of 113/148 (76%) children. After leaving the refuge, 22 children were untraceable and 36 returned home to the perpetrator from whom the families had fled.

CONCLUSIONS

The children had a high level of need, as well as poor access to services. Time spent in a refuge provides a window of opportunity to review health and developmental status. Specialist health visitors could facilitate and provide support, liaison, and follow up.

Identification of vaccine candidate antigens from a genomic analysis of Porphyromonas gingivalis

Porphyromonas gingivalis is a key periodontal pathogen which has been implicated in the etiology of chronic adult periodontitis. Our aim was to develop a protein based vaccine for the prevention and or treatment of this disease. We used a whole genome sequencing approach to identify potential vaccine candidates. From a genomic sequence, we selected 120 genes using a series of bioinformatics methods. The selected genes were cloned for expression in Escherichia coli and screened with P. gingivalis antisera before purification and testing in an animal model. Two of these recombinant proteins (PG32 and PG33) demonstrated significant protection in the animal model, while a number were reactive with various antisera. This process allows the rapid identification of vaccine candidates from genomic data.

Lesions in gshA (Encoding gamma-L-glutamyl-L-cysteine synthetase) prevent aerobic synthesis of thiamine in Salmonella enterica serovar typhimurium LT2

Thiamine pyrophosphate is an essential cofactor that is synthesized de novo in Salmonella enterica serovar Typhimurium and other bacteria. In addition to genes encoding enzymes in the biosynthetic pathway, mutations in other metabolic loci have been shown to prevent thiamine synthesis. The latter loci identify the integration of the thiamine biosynthetic pathway with other metabolic processes and can be uncovered when thiamine biosynthesis is challenged. Mutations in gshA, encoding gamma-L-glutamyl-L-cysteine synthetase, prevent the synthesis of glutathione, the major free thiol in the cell, and are shown here to result in a thiamine auxotrophy in some of the strains tested, including S. enterica LT2. Phenotypic characterization of the gshA mutants indicated they were similar enough to apbC and apbE mutants to warrant the definition of a class of mutants unified by (i) a requirement for both the hydroxymethyl pyrimidine (HMP) and thiazole (THZ) moiety of thiamine, (ii) the ability of L-tryosine to satisfy the THZ requirement, (iii) suppression of the thiamine requirement by anaerobic growth, and (iv) suppression by a second-site mutation at a single locus. Genetic data indicated that a defective ThiH generates the THZ requirement in these strains, and we suggest this defect is due to a reduced ability to repair a critical [Fe-S] cluster.

Determination of up-to-date vaccination status for preschool-aged children: how accurate is manual assessment conducted by paraprofessional staff?

BACKGROUND

Accurate identification of underimmunized children is needed to determine which children need vaccination. Previous studies have found the accuracy of manually determining the immunization status from a personal vaccination record to be low (<50%).

OBJECTIVE

To determine the accuracy of manual immunization status assessment for preschool-aged children.

SUBJECTS AND SETTING

Children </=32 months old (n = 21 263) seen over 1 year at 12 women, infants, and children (WIC) sites in San Diego, California. Age at evaluation was between 0 and 24 months.

METHODS

Paraprofessional immunization specialists conducted manual immunization status assessment using the WIC client's personal vaccination record. Immunization status as recorded in the WIC record was compared with computerized assessment (the gold standard).

MEASURES AND RESULTS

For all patient encounters, 29 078 (80%) of 36 368 were assessed correctly; manual assessment outcome was not recorded in the WIC record for 2171 (6%) of encounters. Accuracy varied by WIC site (range: 70%-90%). The sensitivity at correctly identifying an underimmunized child per encounter was 53.6%; the specificity at correctly identifying a fully vaccinated child per encounter was 89. 4%. The 3 most common vaccines that were incorrectly assessed in identifying an underimmunized child were Haemophilus influenzae type b (43%), hepatitis B (37%), and diphtheria-tetanus toxoids and (cellular or acellular) pertussis vaccine (24%). Children with no outcome as recorded in the WIC record were 5 times as likely to be up-to-date.

CONCLUSIONS

Manual immunization assessment was specific but only moderately sensitive at identifying underimmunized children. Thus, many underimmunized children will by missed but only 10% of children will be referred inappropriately.

HIV-1-Specific CD4 helper function in persons with chronic HIV-1 infection on antiviral drug therapy as measured by ELISPOT after treatment with an inactivated, gp120-depleted HIV-1 in incomplete Freund's adjuvant

OBJECTIVE

We hypothesized that treatment of HIV-1-seropositive study subjects receiving potent antiviral therapy with an HIV-specific immune-based therapy would increase HIV-1-specific T-helper immune function.

DESIGN

10 HIV-1-seropositive study subjects receiving antiretroviral therapy were treated with an inactivated, gp120-depleted immunogen in IFA (HIV-1 immunogen, Remune) at baseline, week 12, and week 24.

METHODS

The frequency of HIV-1 antigen-stimulated interferon-gamma (IFN-gamma)-producing cells was determined by the ELISPOT assay.

RESULTS

Study subjects significantly increased their frequency of HIV-1-stimulated (p <. 001) or p24 antigen-stimulated (p <.01) IFN-gamma-producing cells after one, two, and three treatments of HIV-1 immunogen. Depletion of CD4 cells resulted in the strongest abrogation of the IFN-gamma response. The frequency of HIV-1 (r = 0.64; p =.0002) and p24 (r = 0. 72; p <.001) antigen-stimulated IFN-gamma-producing cells in the CD8-depleted population before and after treatment was associated with the lymphocyte-proliferative response.

CONCLUSIONS

Treatment with HIV-1 immunogen significantly enhanced the frequency of HIV-1-specific IFN-gamma-producing cells. Studies are ongoing to determine the relationship between this reversal of HIV-specific anergy and virologic outcomes.

A randomized controlled trial of Moderation-Oriented Cue Exposure

OBJECTIVE

A randomized controlled trial was conducted to examine the effectiveness of Moderation-Oriented Cue Exposure (MOCE) in comparison to Behavioral Self-Control Training (BSCT). The main hypothesis was that MOCE would be more effective than BSCT among a sample of problem drinkers aiming at moderate drinking. A subsidiary hypothesis was that MOCE would be relatively more effective than BSCT among problem drinkers with higher levels of alcohol dependence.

METHOD

Clients (N = 91; 75% men) were randomly allocated to either MOCE or BSCT. Treatment was delivered in weekly sessions by two trained therapists, in a nested design in which therapists switched to the alternative treatment modality approximately halfway through the trial. Follow-up was carried out 6 months following posttreatment assessment, with 85% successful contact.

RESULTS

There was no evidence for the general superiority of MOCE over BSCT. The subsidiary hypothesis was not confirmed. A subsample of clients (n = 14) showing levels of dependence at baseline above the commonly accepted cut-point for a moderation goal (Severity of Alcohol Dependence Questionnaire [SADQ] > 29) showed outcomes at least as favorable as those below the cut-point. The validity of self-reports of alcohol consumption and problems was supported by significant relationships with liver function tests (gamma-glutamyl transferase and alanine transferase).

CONCLUSIONS

These results provide no grounds for the replacement of BSCT by MOCE in routine, moderation-oriented treatment practice. Assuming they prefer it to abstinence and that it is not contra-indicated on other grounds, there seems no reason why clients showing a higher level of dependence (SADQ = 30-45) should not be offered a moderation goal.

A survey of postgraduate education programmes and research interests of GPs in community trusts in an inner city area

Following discussions with medical lecturers in a postgraduate centre, a questionnaire was sent to all the general practitioners (GPs) in three selected Community Trusts in an inner city area. Besides their qualifications and research interests, the GPs were asked for their views on continuing education. The results showed that opportunities for collaborative education with other members of the primary care groups (PCGs) would be possible if it focused on research methods and 'Health of the Nation' targets. The results showed that up to 61% of the GPs who responded had carried out research and had collaborated with nurses on the research projects. There was considerable variation across the Community Trusts in relation to the experience and interests of the GPs. The formation of the PCGs and joint commissioning offered an excellent opportunity for both collaborative educational opportunities and research. As the interests of the GPs is so diverse, some thought about consolidating and harnessing their interests and expertise in order to influence local and national research agendas may be of value.

Disease-modifying activity of SB 242235, a selective inhibitor of p38 mitogen-activated protein kinase, in rat adjuvant-induced arthritis

OBJECTIVE

To evaluate the effects of SB 242235, a potent and selective inhibitor of p38 mitogen-activated protein (MAP) kinase, on joint integrity in rats with adjuvant-induced arthritis (AIA).

METHODS

Male Lewis rats with AIA were orally treated either prophylactically (days 0-20) or therapeutically (days 10-20) with SB 242235. Efficacy was determined by measurements of paw inflammation, dual-energy x-ray absorptiometry for bone-mineral density (BMD), magnetic resonance imaging (MRI), microcomputed tomography (CT), and histologic evaluation. Serum tumor necrosis factor alpha (TNFalpha) in normal (non-AIA) rats and serum interleukin-6 (IL-6) levels in rats with AIA were measured as markers of the antiinflammatory effects of the compound.

RESULTS

SB 242235 inhibited lipopolysaccharide-stimulated serum levels of TNFalpha in normal rats, with a median effective dose of 3.99 mg/kg. When SB 242235 was administered to AIA rats prophylactically on days 0-20, it inhibited paw edema at 30 mg/kg and 10 mg/kg per day by 56% and 33%, respectively. Therapeutic administration on days 10-20 was also effective, and inhibition of paw edema was observed at 60, 30, and 10 mg/kg (73%, 51%, and 19%, respectively). Significant improvement in joint integrity was demonstrated by showing normalization of BMD and also by MRI and micro-CT analysis. Protection of bone, cartilage, and soft tissues was also shown histologically. Serum IL-6 levels were decreased in AIA rats treated with the 60 mg/kg dose of compound.

CONCLUSION

Symptoms of AIA in rats were significantly reduced by both prophylactic and therapeutic treatment with the p38 MAP kinase inhibitor, SB 242235. Results from measurements of paw inflammation, assessment of BMD, MRI, and micro-CT indicate that this compound exerts a protective effect on joint integrity, and thus appears to have disease-modifying properties.

Phenotypic analysis of human immunodeficiency virus (HIV) type 1 cell-mediated immune responses after treatment with an HIV-1 immunogen

It was hypothesized that immune recognition could be stimulated with combined immune-based and potent antiviral drug therapies. This study examined human immunodeficiency virus type 1 (HIV-1)-specific lymphocyte proliferation before and after treatment with an inactivated HIV-1 immunogen in 15 chronically infected HIV-1 seropositive subjects. Lymphocyte proliferation to the immunizing antigen (gp120-depleted HIV-1; P<.001), purified native p24 (P<.001), and recombinant p24 (P<.05) increased after treatment with the HIV-specific immune-based therapy. By HIV-1 antigen-specific flow cytometry, T helper CD4 lymphocytes, CD8 lymphocytes, and NK cells (all P<.001) were the predominant cell types proliferating in vitro after treatment. Additional phenotyping of proliferating cells revealed predominantly CD4 and CD8 memory (both P<.001) phenotypes. This study supports the concept that in vitro lymphocyte proliferation to HIV-1 antigens, augmented after treatment with an inactivated HIV-1 immunogen, involves primarily CD4 and CD8 cell memory immune responses.

Isolation of recombinant protective Helicobacter pylori antigens

A total of seven clones producing both new and previously described Helicobacter pylori proteins were isolated from a library of H. pylori genomic DNA. The screening approach by which these proteins were detected relied on the use of antisera raised in mice vaccinated with Helicobacter felis sonicate plus cholera toxin, a regimen which protects mice from H. pylori challenge. This strategy was designed to maximize the possibility of obtaining antigens which might be capable of conferring protection from H. pylori infection. Two of the clones were shown to encode the urease enzyme and the heat shock protein HspB, which have already been identified as protective antigens. The other five clones were sequenced, protein coding regions were deduced, and these sequences were amplified by PCR for incorporation into Escherichia coli expression vectors. The proteins produced from these expression systems were purified to allow testing for protective efficacy in an H. pylori mouse model. All five proteins were able to facilitate the clearance of a challenge with H. pylori, as judged by an assay of gastric urease activity and light microscopy on stomach sections. These results clearly indicate that the screening strategy has successfully identified candidate vaccine antigens.

CSF monoamine metabolite and beta endorphin levels in recently detoxified alcoholics and healthy controls: prediction of alcohol cue-induced craving?

BACKGROUND

Abnormalities in central neurotransmitter systems have been described in alcohol-dependent individuals and may contribute to alcohol craving. This study compared cerebrospinal fluid (CSF) levels of monoamine metabolites and beta endorphin levels in samples from early-onset alcohol-dependent patients (n = 20), late-onset alcohol-dependent patients (n = 14), and healthy controls (n = 23). It also evaluated whether these CSF measures levels predicted the degree of craving experienced in response to an alcohol cue.

METHODS

Individuals meeting DSM-III and -IV R-criteria for alcohol dependence, 1 to 3 months postdetoxification, and healthy controls underwent a lumbar puncture. Patients also completed a cue exposure test day between 3 and 15 days later.

RESULTS

Alcohol-dependent patients had lower CSF levels of the norepinephrine metabolite MHPG compared with the healthy subjects, but this difference disappeared when differences in age between the groups were accounted for. No other group comparisons between patients and healthy subjects reached significance. CSF levels of the dopamine metabolite HVA were significantly higher in the early-onset patients compared with the late-onset patients and controls. The CSF measures did not predict the precue levels of craving, or the increase in craving after alcohol cue exposure.

CONCLUSIONS

These results are inconclusive about the role of monoaminergic dysregulation in recovering alcoholics. They also question the utility of these CSF measures to predict alcohol cue reactivity in patients who have been sober at least 1 month.

Against women: are we looking after our general practitioners? GPs' views of the 1990 part-time contract

A postal survey was conducted looking at the roles and experiences of General Practitioners on part-time contracts. This involved their perception of the attitudes of their colleagues and patients to their part-time status, and the consequences of these for their professional development. Of the 130 General Practitioners with part-time contracts in the one Regional Health Authority that was being surveyed 77.7% responded; 74.3% of the respondents were women. Of the women General Practitioners who responded to this particular question, the predominant age-bands were 31-40 years [41.4% (41)] and 41-50 [19.2% (19)], whilst male General Practitioners were more evenly spread across the age bands. The results showed that the majority of General Practitioners took up part-time contracts to enable them to look after their dependants, though a sizeable minority wished for free time or to relieve stress from a full-time contract. Forty percent said that they felt excluded from decision making about continuity of patient care and practice policy. Just under forty percent also stated that their workload was excessive in comparison with their full-time counterparts. Further, many expressed the opinion that they were financially penalised. The cost effective correlation between the increased availability of General Practitioners (particularly women) for patient care, and the costly medical education and training of such General Practitioners not being 'wasted' for several years was also noted together for the need for ongoing (or continual) medical education and training. The findings of this survey suggest there are many unresolved issues involved in satisfactory part-time contracting arrangements for General Practitioners. This particularly affects women General Practitioners. Whilst the RCP policy statement addresses education and training for general practice, the question of not losing out in relation to training opportunities and promotion is not addressed. The unresolved effects of the intra-professional differences in opportunities may affect the inter-professional functioning of the primary health care team and ultimately continuity and quality of care for patients.

A comparison of fatal with non-fatal knife injuries in Edinburgh

Assault using a knife is a common problem in the United Kingdom. Between February 1992 and December 1996, 120 individuals died or received hospital treatment in Edinburgh after being assaulted with a knife. Twenty individuals (17%) died as a result of their injuries. Comparison of the survivors with non-survivors revealed both groups to have similar age and sex distributions, but those who died had significantly more severe injuries when scored according to the Abbreviated Injury Scale. Eight individuals died of unsurvivable chest injuries at the scene of the attack and of the remainder, only five reached hospital with signs of life. Analysis of hospital treatment using TRISS methodology revealed there to be two unexpected survivors and no unexpected deaths. The risk of death appears to depend mostly upon injuries sustained and also to a lesser extent upon other factors such as alcohol consumption and the presence of a bystander capable and willing to request emergency medical assistance. There does not appear to be much potential to save lives by improving hospital treatment for those assaulted with a knife in Edinburgh. Instead, greater focus needs to be placed upon rapid transfer to hospital and upon restricting the possession and use of knives.

An update on British medical students' lifestyles

Information about medical students' lifestyles was obtained from 785 second-year students from seven medical schools in Great Britain by a personally administered questionnaire. Fifteen per cent of the students were non-drinkers. Among those who drank, 48% of the men and 38% of the women exceeded sensible weekly limits of alcohol consumption, and high-risk levels of consumption were reported by 12% of men and 7% of women. Cannabis had been used at least once or twice by more than half the men and 40% of the women, and 10% reported regular use (weekly or more often). Experience with other illicit drugs was also reported: amphetamines (8% of students), LSD (7%), ecstasy (4%), amyl/butyl nitrate (10%) and magic mushrooms (7%). Nineteen per cent of the students had used two or more different drugs. Experience with illicit drugs started before entering university in more than a third of those who used them. Comparison of the results with other student surveys suggests that the lifestyles of medical students differ little from those of other student groups, but that alcohol and illicit drug consumption is increasing in university students generally. Prospective studies are under way to establish whether medical students change their lifestyles at later stages of their course and after qualification.

thiBPQ encodes an ABC transporter required for transport of thiamine and thiamine pyrophosphate in Salmonella typhimurium

In Salmonella typhimurium, thiamine pyrophosphate (TPP) is a required cofactor for several enzymes in central metabolism. Herein we identify a new thi operon, thiBPQ (designated sfuABC in Escherichia coli), required for the transport of thiamine and TPP into the cell. Insertions in the operon result in strains that are phenotypically and biochemically defective in thiamine and TPP transport. Data presented herein show that this operon is transcriptionally repressed in the presence of exogenous thiamine, with TPP the likely regulatory molecule. This work represents the first identification of thiamine transport genes in bacteria and demonstrates the function of a proposed ABC transporter in E. coli.

Dose-related ethanol-like effects of the NMDA antagonist, ketamine, in recently detoxified alcoholics

BACKGROUND

This study evaluated the dose-related ethanol-like subjective effects of the N-methyl-D-aspartate (NMDA) glutamate receptor antagonist ketamine hydrochloride in recently detoxified alcoholics.

METHODS

Twenty male inpatients meeting DSM-III-R criteria for alcohol dependence and who had not consumed alcohol for 10 to 27 days prior to the study completed 3 test days that involved the intravenous infusion of ketamine hydrochloride (0.1 mg/kg or 0.5 mg/kg) or saline solution under randomized double-blind conditions. Ethanol-like subjective effects were assessed using the Sensation Scale; the Biphasic Alcohol Effects Scale; visual analog scales to measure "high" and degree of similarity to ethanol, cocaine, and marijuana; a scale assessing the number of standard alcohol drinks producing similar subjective effects; and visual analog scales measuring ethanol craving.

RESULTS

Ketamine produced dose-related ethanol-like effects on each scale measuring its similarity to ethanol. Its effects were more similar to the sedative or descending limb effects of ethanol than to the stimulant or ascending limb effects. Ketamine effects also were more like ethanol than marijuana or cocaine. Ethanol-like effects were more prominent at the higher ketamine dose, a dose rated as similar to greater levels of ethanol intoxication. However, ketamine did not increase craving for ethanol.

CONCLUSION

The production of ethanol-like subjective effects by ketamine supports the potential clinical importance of NMDA receptor antagonism among the mechanisms underlying the subjective effects of ethanol in humans.

Novel technetium (III)-Q complexes for functional imaging of multidrug resistance (MDR1) P-glycoprotein

Overexpression of the multidrug resistance (MDR1) P-glycoprotein (Pgp) correlates with cancer chemotherapeutic failure. Lipophilic cationic radiopharmaceuticals such as 99mTc-sestamibi, 99mTc-tetrofosmin and 99Tc-furifosmin (Tc-Q12) have been validated as transport substrates for the MDR1 Pgp and may enable functional imaging of the MDR phenotype in cancer by observing enhanced washout rates of the tracers in those tumor areas expressing Pgp. To further explore and optimize the Pgp recognition properties of Schiff base phosphine mixed-ligand complexes of the Tc-Q series of nonreducible (Tc(III) cations, a variety of Tc-Q complexes were synthesized and tested in vitro for recognition as transport substrates by the human MDR1 Pgp.

METHODS

Tracer assays with human drug-sensitive KB-3-1 epidermal carcinoma and MDR KB-8-5 cells expressing nonimmunodetectable and modest levels of MDR1 Pgp, respectively, were used to screen and pharmacologically characterize 37 novel 99mTc-Q analogs.

RESULTS

The ideal agent should have low nonspecific binding, high distinction in net uptake between drug-sensitive cells and MDR tumor cells, and high enhancement of uptake in resistant cells after treatment with an MDR modulator, indicating selective blockade of Pgp-mediated efflux of the radiotracer. Three analogs, trans-[5,5'-(1,2-ethanediyldiimino)bis(2-OEt-2-Me-4-penten-3 -one)]bis[dimethyl(3-OMe-1-propyl)phosphine]99mTc(III) (99mTc-Q63) and two trans-[bis(methyl-bis(3-OMe-1-propyl)phosphine)] analogs (99mTc-Q57 and 99mTc-Q58) displayed transport distinctions between drug-sensitive and MDR cell lines that were equal to or greater than all previously available agents. Cyclosporin A, an MDR modulator, had no significant effect in KB-3-1 cells for these 99mTc-complexes but enhanced tracer accumulations in KB-8-5 cells with IC50 values of approximately 1 microM. In contrast, the non-MDR agents methotrexate and cisplatin had no effect on accumulation of 99mTc-Q complexes and 99mTc-sestamibi in KB-8-5 cells.

CONCLUSION

Technetium-99m-Q57, 99mTc-Q58 and 99mTc-Q63 are avid transport substrates recognized by the human MDR1 Pgp, and have enhanced in vitro properties that may enable functional imaging of Pgp in vivo with improved signal-to-noise ratios and tissue contrast compared to currently available agents.

Patterns of alcohol consumption, smoking and illicit drug use in British university students: interfaculty comparisons

The use of tobacco, alcohol and illicit drugs was investigated by questionnaire in 3699 second year students in ten UK universities. Patterns of use varied considerably between different faculty groups. Tobacco use was most prevalent in arts, social science and biological science students, among whom 36-39% of men and nearly one third of women were regular smokers, and least in female veterinary students (5%). Alcohol consumption was greatest in biological science students: 23% of those who drank exceeded 'hazardous' levels compared with 10-16% in all other faculties. Prevalence of cannabis use was highest in arts and social science students of whom 27% reported regular weekly use compared with 9-22% in other faculties. Experience with other illicit drugs was greatest among arts, social science and physical science students, of whom 64-71% reported experience at least once or twice, and least among veterinary students (42%). Identification of different lifestyles may help to direct appropriate health information to particular student groups.

Characterization of thiI, a new gene involved in thiazole biosynthesis in Salmonella typhimurium

Thiamine pyrophosphate (TPP) is a required cofactor in Salmonella typhimurium that is generated de novo by the condensation of 4-amino-5-hydroxymethyl pyrimidine (HMP) pyrophosphate and 4-methyl-5-(beta-hydroxyethyl)-thiazole (THZ) monophosphate. The THZ and HMP moieties are independently synthesized, and labeling studies have demonstrated probable metabolic precursors to both. We present herein the initial characterization of thiI, a gene required for THZ synthesis. We show that thiI is a 1,449-bp open reading frame located at minute 9.65 on the S. typhimurium chromosome and that it encodes a 483-amino-acid protein with a predicted molecular mass of 55 kDa. Unlike genes in the thiamine biosynthetic operon at minute 90, thiI is not transcriptionally regulated by TPP.

Characterization of thiL, encoding thiamin-monophosphate kinase, in Salmonella typhimurium

Thiamin pyrophosphate is an essential cofactor that is synthesized de novo by Salmonella typhimurium. In bacteria, the end product of the de novo biosynthetic pathway is thiamin monophosphate, which is then phosphorylated by thiamin-monophosphate kinase (EC 2.7.4.16) to form thiamin pyrophosphate. We have isolated and characterized the thiL gene of S. typhimurium and showed that thiL is a 978-base pair open reading frame encoding a 35-kDa protein with thiamin-monophosphate kinase activity. thiL was located in the 10-centisome region of the S. typhimurium chromosome. We demonstrated that altered thiamin-monophosphate kinase activity resulted in decreased repression of transcription of thiamin pyrophosphate-regulated thiamin biosynthetic genes. In contrast to other thi loci, thiL is not transcriptionally regulated by thiamin pyrophosphate. This result is consistent with a dual role for ThiL in de novo biosynthesis and in salvage of exogenous thiamin.

Evidence of acoustic startle hyperreflexia in recently detoxified early onset male alcoholics: modulation by yohimbine and m-chlorophenylpiperazine (mCPP)

Preclinical studies suggest that acoustic startle amplitude is increased during ethanol withdrawal. The current study evaluated the effects of intravenous infusion of the alpha 2-adrenergic antagonist, yohimbine (0.4 mg/kg), the serotonin partial agonist m-chlorophenylpiperazine (mCPP, 0.1 mg/kg), and placebo administered to 22 male patients meeting DSM-III-R criteria for alcohol dependence and 13 male healthy subjects. Patients and healthy subjects completed 3 test days under double-blind conditions in a randomized order. Patients were sober for 12-26 days prior to testing. On each test day, participants completed startle testing 80 min following drug infusion. Stimuli with varying intensities (90, 96, 102, 108, 114 dB) were presented in a randomized order balanced across four blocks. Stimuli consisted of 40-ms bursts of white noise administered every 45-60 s for 15-20 min through headphones. Analyses indicated that patients exhibited elevated acoustic startle magnitudes on the placebo day relative to healthy subjects. In patients, the magnitude of startle amplitudes elicited at 90 dB, but not 114 dB, correlated significantly with the number of previous alcohol detoxifications. Yohimbine increased startle magnitudes and reduced startle latencies relative to placebo and mCPP in both patients and healthy subjects. mCPP did not alter startle magnitude in either group. Yohimbine also increased the probability that a 90-dB stimulus produced a startle response in healthy subjects, but not in patients. Blunting of yohimbine effects on startle probability may reflect the baseline elevations in startle probability levels in patients, but may also be consistent with other evidence of reduced postsynaptic, but not presynaptic, noradrenergic function in these same patients. These data replicate and extend previous reports indicating that yohimbine facilitates the acoustic startle response in humans. They also further implicate the number of episodes of ethanol withdrawal as a factor influencing subsequent neurobiological responsivity in chronic alcoholic patients. Based on the current data, future research should explore whether measurement of the acoustic startle response provides an objective quantitative severity measure of ethanol withdrawal.

Alcohol and drug use in UK university students

BACKGROUND

Alcohol and illicit drug use are increasing among school children and young adults in the UK. Such increases have also been noted among university students and there is a need for a large survey across different universities and faculties. We report such a survey.

METHODS

Information about drinking, use of cannabis and other illicit drugs, other lifestyle variables, and subjective ratings of anxiety and depression was obtained by questionnaire in a cross-faculty sample of 3075 second-year university students (1610 men, 1447 women, 18 sex not stated) from ten UK universities. The questionnaire was personally administered during scheduled lecture hours and almost all the students participated. The sample reflected the interfaculty and sex distribution and the proportion of non-white students at UK universities.

FINDINGS

11% of the students were non-drinkers. Among drinkers, 61% of the men and 48% of the women exceeded "sensible" limits of 14 units per week for women and 21 for men. Hazardous drinking (> or = 36 units per week for women, > or = 51 for men) was reported by 15% of the drinkers. Binge drinking was declared by 28% of drinkers. 60% of the men and 55% of the women reported having used cannabis once or twice and 20% of the sample reported regular cannabis use (weekly or more often). Experience with other illicit drugs was reported by 33% of the sample, most commonly LSD (lysergic acid diethylamide), amphetamines, Ecstasy (methylenedioxymethamphetamine), and amyl/butyl nitrate which had each been used by 13-18% of students. 34% of these had used several drugs. Drug use had started at school in 46% of the sample; 13% began after entering university. The overwhelming reason given for taking alcohol or drugs was pleasure. Subjective ratings of anxiety on the hospital anxiety depression scale were high, and sleep difficulties were common, but neither related to alcohol or drug use.

INTERPRETATION

There is a need for better education about alcohol, drugs, and general health in universities. Such education should include all faculties. It remains unclear whether university students' lifestyles are carried over into later life.

Restricted integration into genomic DNA following transfection of Chinese-hamster ovary cells with N-acetylgalactosamine-4-sulphatase cDNA

The effect of using different conditions of electroporation for introducing the gene coding for human N-acetylgalactosamine-4-sulphatase into Chinese-hamster ovary (CHO) cells has been studied in an effort to increase the yield of recombinant protein. In each case the range of enzyme activities in the medium of transfected cells proved to be similar, with genetic analysis of a higher producer revealing only one gene copy integrated. Hence, allowing for position effects, the number of gene copies stably integrated into the CHO genome of all transfectants presumably was low, potentially a single copy in each. This inability to allow high-copy-number integration may suggest a constraint on the levels of this protein which can be tolerated by the cell.

Planning and commissioning of health services for children and young people

BACKGROUND

Local audits in England and Wales performed in 1994 showed that child health commissioning was not being given priority. We were concerned that child health commissioning was in addition not performed in a child-centred way, with the best interests of children to the fore.

METHOD

A survey of health authorities and boards was performed, to investigate child health commissioning in the United Kingdom. A questionnaire was sent to all directors of public health medicine in post in November 1994. The main outcome measures were child health experience within commissions and the context of children's services within the wider commissioning process.

RESULTS

A total of 120 (92%) of 129 authorities replied. Sixty-nine (58 per cent) had a named person with responsibility for child health services, of who 7 (5 per cent) worked exclusively within this area, 42 (32 per cent) had experience within clinical child health, and 19 (15 per cent) had postgraduate qualifications in child health. One hundred and five (81 per cent) authorities replied to a question on the comprehensiveness of the commissioning process; of these, 45 (34 per cent) planned and commissioned children's services in their entirety and 60 (46 per cent) planned and commissioned children's services in the context of other service areas. A majority did not plan and commission acute and community services together.

CONCLUSION

Many authorities had no named person with responsibility for a child health strategy. Of those that did, most named persons had inadequate experience and few had postgraduate qualifications in child health. Most authorities had no comprehensive planning mechanisms for children's services. In consequence, most commissions were failing to comply with the UN Convention on the Rights of the Child.

Enhanced secretory ability for the human factor VIII light chain produced in baculovirus-infected insect cells

The light and truncated heavy chains of human factor VIII, expressed separately in baculovirus-infected insect cells, exhibited different secretory behaviour when compared with each other and with a biologically active fusion molecule of the truncated heavy and light chains. The light chain was very efficiently secreted into culture medium, as judged by high extracellular protein levels and the absence of evidence for light chain retention within cells. Alternatively, proteins containing the heavy chain sequence were poorly secreted and appeared to be sequestered within cells, suggesting that regions within the heavy chain are responsible for the low levels of secreted protein which have generally been observed for recombinant factor VIII.