Data for diagnosis, monitoring and treatment in indigenous health: the case of cervical cancer

Deficiencies in the availability and quality of data on the health status of indigenous Australians have long been recognised. For cervical cancer, data demonstrate a 2-5 fold greater incidence rate and an 8-10 fold greater mortality rate for Indigenous women compared to non-Indigenous Australians. However, incidence and mortality data are only available for some states and there is little or no information available on the geographic or social distribution of risk, or the reasons for risk differentials. There are also little or no data on the utilisation of, or preferences for, screening services. Thus, while there is clearly a need for a cervical cancer control program specifically to target Indigenous women, current data are inadequate to inform planning and implementation, and current systems are inadequate to monitor effectiveness. This situation is the result of insufficient research and inadequate attention to recording of Indigenous status in routine data systems and applies to a greater or lesser extent across the spectrum of health of Indigenous Australians. Health workers across the spectrum in mainstream and Indigenous medical services have a shared responsibility for improving the availability and quality of data and ensuring the appropriate use of information necessary to achieve and monitor improvements in service delivery and health status of Indigenous people.

Nursing assessment and intervention for adult hemodialysis patients: application of Roy's Adaptation Model

A comprehensive assessment tool and intervention typology for adult hemodialysis patients, based on the Roy Adaptation Model, is presented. The Roy model is reviewed, and examples from the assessment tool and intervention typology are presented. A case study illustrates application of the tool and typology to nephrology nursing. Comparison of the tool and typology with the ANNA Standards of Clinical Practice revealed that the Roy Adaptation Model includes additional important aspects of nephrology nursing practice.

Duplication of ATR inhibits MyoD, induces aneuploidy and eliminates radiation-induced G1 arrest

Chromosome 3q alterations occur frequently in many types of tumours. In a genetic screen for loci present in rhabdomyosarcomas, we identified an isochromosome 3q [i(3q)], which inhibits muscle differentiation when transferred into myoblasts. The i(3q) inhibits MyoD function, resulting in a non-differentiating phenotype. Furthermore, the i(3q) induces a 'cut' phenotype, abnormal centrosome amplification, aneuploidy and loss of G1 arrest following gamma-irradiation. Testing candidate genes within this region reveals that forced expression of ataxia-telangiectasia and rad3-related (ATR) results in a phenocopy of the i(3q). Thus, genetic alteration of ATR leads to loss of differentiation as well as cell-cycle abnormalities.

Predicting communicative competence at 2 and 3 years from pragmatic skills at 10 months

It is proposed that children play an important part in determining the kinds of linguistic experience they receive, influencing their language environment by means of early pragmatic communication. These early behaviours may also be predictive of later communicative competence. As a preliminary investigation into the wider implications of children's potential influence over their linguistic environment, a study was undertaken which looked at infant pragmatic signalling systems and joint engagement skills, to establish whether these early interactive behaviours might be related to children's subsequent communicative development. During the course of the study, the frequency and distribution of early pragmatic behaviours in a random sample of 145 10-month-old infants were investigated, and their subsequent language development followed up at ages 24 and 36 months. The study examined (a) the predictive validity of specific pragmatic behaviours at age 10 months for language development at age 24 months and (b) the specificity and stability of profiles of communicative disability at 2 and 3 years. A subset of behaviours was identified which would have correctly predicted 82.4% of children found to have communicative difficulties at 24 months and 85.4% of those who did not. Predictive language profiles drawn up at age 24 months were substantially confirmed when the children were reassessed at age 36 months. It is proposed that specific early communicative behaviours may be predictive of a child's subsequent linguistic development. Additionally, 2-year-old children will be exhibiting certain patterns of language acquisition which may be significant for subsequent linguistic development. Implications for intervention are discussed.

Work shift duration: a review comparing eight hour and 12 hour shift systems

OBJECTIVES

Shiftwork is now a major feature of working life across a broad range of industries. The features of the shift systems operated can impact on the wellbeing, performance, and sleep of shiftworkers. This paper reviews the current state of knowledge on one major characteristic of shift rotas-namely, shift duration. Evidence comparing the relative effects of eight hour and 12 hour shifts on fatigue and job performance, safety, sleep, and physical and psychological health are considered. At the organisational level, factors such as the mode of system implementation, attitudes towards shift rotas, sickness absence and turnover, overtime, and moonlighting are discussed.

METHODS

Manual and electronic searches of the shiftwork research literature were conducted to obtain information on comparisons between eight hour and 12 hour shifts.

RESULTS

The research findings are largely equivocal. The bulk of the evidence suggests few differences between eight and 12 hour shifts in the way they affect people. There may even be advantages to 12 hour shifts in terms of lower stress levels, better physical and psychological wellbeing, improved durations and quality of off duty sleep as well as improvements in family relations. On the negative side, the main concerns are fatigue and safety. It is noted that a 12 hour shift does not equate with being active for only 12 hours.

CONCLUSIONS

There can be considerable extension of the person's time awake either side of the shift. However, the effects of longer term exposure to extended work days have been relatively uncharted in any systematic way. Longitudinal comparative research into the chronic impact of the compressed working week is needed.

Proliferation signaling and activation of Shc, p21Ras, and Myc via tyrosine 764 of human granulocyte colony-stimulating factor receptor

The membrane-distal region of the cytoplasmic domain of human granulocyte colony-stimulating factor receptor (G-CSF-R) contains four conserved tyrosine residues: Y704, Y729, Y744, and Y764. Three of these (Y729, Y744, and Y764) are located in the C-terminal part of G-CSF-R, previously shown to be essential for induction of neutrophilic differentiation. To determine the role of the tyrosines in G-CSF-mediated responses, we constructed tyrosine-to-phenylalanine (Y-to-F) substitution mutants and expressed these in a differentiation competent subclone of 32D cells that lacks endogenous G-CSF-R. We show that all tyrosines can be substituted essentially without affecting the differentiation signaling properties of G-CSF-R. However, substitution of one specific tyrosine, ie, Y764, markedly influenced proliferation signaling as well as the timing of differentiation. 32D cells expressing wild-type (WT) G-CSF-R (or mutants Y704F, Y729F, or Y744F) proliferated in G-CSF-containing cultures until day 8 and then developed into mature neutrophils. In contrast, 32D/Y764F cells arrested in the G1 phase of the cell cycle within 24 hours and showed complete neutrophilic differentiation after 3 days of culture. This resulted in an average 30-fold reduction of neutrophil production as compared with the 32D/WT controls. Importantly, G-CSF-mediated activation of Shc, p21Ras and the induction of c-myc were severely reduced by substitution of Y764. These findings indicate that Y764 of G-CSF-R is crucial for maintaining the proliferation/differentiation balance during G-CSF-driven neutrophil development and suggest a role for multiple signaling mechanisms in maintaining this balance.

Phase I and pharmacokinetic study of GI147211, a water-soluble camptothecin analogue, administered for five consecutive days every three weeks

GI1147211 is a 7-substituted 10,11-ethylenedioxy-20(S)-camptothecin analogue that inhibits the nuclear enzyme topoisomerase I. In this Phase I and pharmacological study, 24 patients with advanced solid malignancies received a total of 72 courses of GI147211 as a 30-min infusion daily for 5 consecutive days, at doses ranging from 0.3 to 1.75 mg/m2/day. Severe neutropenia precluded dose escalation above 1.5 mg/m2/day in minimally pretreated patients, and both severe neutropenia and thrombocytopenia were dose limiting in heavily pretreated patients at doses above 1.0 mg/m2/day. These doses are, therefore, recommended for subsequent Phase II evaluations of GI147211 in patients with comparable prior therapy. Nonhematological toxicities, including nausea, vomiting, fatigue, and anorexia, were mild to moderate. The disposition of GI147211 in blood was described by a linear three-compartment model, with renal elimination accounting for only 11% of drug distribution. No relationship was observed between the pharmacological exposure to GI147211 and effects on neutrophils; however, patients who developed dose-limiting myelosuppression did experience greater exposure to both the lactone and total forms of the drug. The hydrolysis kinetics of GI147211 revealed not only a shift of the drug to the inactive carboxylate form in human serum albumin but also stabilization of the lactone in erythrocytes, perhaps accounting for the observed lactone:total area under the concentration-time curve ratio of 0.27. These results indicate that GI147211 exhibits predictable toxicities and that further studies are warranted to determine the distinct role of this compound among currently available camptothecin analogues.

The practice of general internal medicine by subspecialists

To determine the proportion of specialists in internal medicine at a university medical center practicing general internal medicine in addition to their specialty, full-time and voluntary faculty were asked to complete a questionnaire concerning their practice patterns. In addition, the directories of two of the largest managed-care groups in the area were reviewed to identify physicians who were also faculty members, to determine whether faculty in these directories self-identified as general internists. Excluding those with primary research appointments, 303 faculty in the Department of Medicine were asked to participate. Of these, 187 (62%) responded, of whom 86 (46%) were full-time and 101 (54%) voluntary faculty. Of the respondents, 183 (98%) were either board certified (152; 81%) or board eligible (31; 17%) in a subspecialty. Both general internal medicine and specialty medicine were practiced by 116 (65%), with full-time faculty being more likely to have solely subspecialty practices (P < .001). The majority of faculty (150; 80%) participated in managed care. A review of directories of two managed-care groups revealed that 100 (87%) of the 115 faculty with appointments within subspecialty divisions of the Department of Medicine were listed as general internists. Subspecialists in internal medicine already spend considerable time practicing general medicine and are increasingly willing to identify themselves as generalists. Unless this is recognized, the future need for generalists may be overestimated considerably.

An empirical study of the psychodynamics of suicide

This paper presents results from an empirical study of four key psychodynamic concepts (self-directed aggression, object loss, ego functioning disturbance, pathological object relations) of suicidal behavior. The sample consists of hospitalized psychiatric patients following a suicide attempt (attempters: n = 52) and demographically similar hospitalized psychiatric patients with no history of suicidal behavior (controls: n = 47). The study was designed to ascertain whether attempters differed from matched psychiatric control patients on the four psychodynamic constructs hypothesized to be associated with suicide. It was predicted that attempters would manifest higher levels of depression and self-targeted anger, a more significant history of loss, less adaptive defenses, and more primitive object representations. Results strongly supported an object-relational view of suicidal behavior. In addition, support for the loss hypothesis was found in the identification of one specific constellation of losses. Namely, attempters were significantly more likely to report a history of childhood loss combined with a recent loss in adulthood than were their nonattempter counterparts. Limited support was provided for the other two hypotheses in differentiating suicidal from nonsuicidal severely ill psychiatric patients. This unexpected finding is examined and suggestions are made for the refinement and greater specification of psychodynamic theories regarding the etiology of suicidal behavior, with the aim of differentiating individuals prone to such action from those with similar psychopathology and dynamic issues who do not actually attempt suicide. Limitations of the study are discussed and implications of the findings for the theory and treatment of suicidal behavior are offered.

Can Oxford heal itself?

The fast-growing HMO was hammered on Wall Street after revealing its massive computer problems. Those foul-ups are being fixed, but now comes the hard part--reclaiming the trust of stunned shareholders and outraged doctors.

Signaling functions of the tyrosine residues in the betac chain of the granulocyte-macrophage colony-stimulating factor receptor

The granulocyte-macrophage colony-stimulating factor (GM-CSF) receptor (GMR) is a heterodimeric receptor expressed by myeloid lineage cells. Binding of GM-CSF activates at least one receptor-associated tyrosine kinase, JAK2, and rapidly induces tyrosine phosphorylation of the GMR betac-chain (GMRbeta), but not the GMR alpha-chain (GMRalpha). To examine the role of GMRbeta tyrosine phosphorylaiton, each of the 8 tyrosine residues in the cytoplasmic domain of the human GMRbeta was mutated to phenylalanine (GMRbeta-F8), and this mutant receptor was expressed with wild-type GMRalpha in the interleukin-3-dependent murine hematopoietic cell line, Ba/F3. GM-CSF induced tyrosine phosphorylation of multiple cellular proteins in cells expressing GMRbeta-F8 , including JAK2 and STAT5. However, GM-CSF-induced tyrosine phosphorylation of both SHP2 and SHC was reduced or absent compared with wild-type. Next, a series of 8 receptors were generated, each containing only a single, restored, tyrosine residue. Tyrosine 577 was found to be sufficient to regenerate GM-CSF-dependent phosphorylation of SHC, and any of Y577, Y612, or Y695 was sufficient to regenerate GM-CSF-inducible phosphorylation of SHP2. Despite the signaling defect to SHC and SHP2, Ba/F3 cells expressing GMRbeta-F8 were still able to proliferate in response to 10 ng/mL of human GM-CSF, although mitogenesis was impaired compared with wild-type GMRbeta, and this effect was even more prominent at lower concentrations of GM-CSF (1 ng/mL). Overall, these results indicate that GMRbeta tyrosine residues are not necessary for activation of the JAK/STAT pathway or for proliferation, viability, or adhesion signaling in Ba/F3 cells, although tyrosine residues significantly affect the magnitude of the response. However, specific tyrosine residues are needed for activation of SHC and SHP2.

Evaluating Critical Thinking Skills of Baccalaureate Nursing Students

This study evaluates the critical thinking skills of students enrolled in a baccalaureate nursing program, using the WGCTA, for the classes of 1993 through 1996. Scores were obtained at entry and at end of junior and senior years. The mean entry WGCTA score was 56 for all four classes; however, the 1995 and 1996 classes had significantly higher scores than the class of 1994. Critical thinking scores were higher at entry for older students and students who had completed another education degree; however, critical thinking scores were lower for students who had previous nursing experience. After adapting for age, previous degree, and nursing experience, no significant differences in the WGCTA scores from entry to end of junior and senior years emerged for the classes of 1993, 1994, 1995. Critical thinking skills have become the hallmark of education. The National Education Goal Panel has advocated for an increase in the ability to think critically, communicate effectively and solve problems (Banta, 1993). In turn, the nursing profession has incorporated these goals of higher education into its educational programs. The National League for Nursing (NLN) includes the measurement of critical thinking as a required outcome in the evaluation and accreditation of baccalaureate and higher degree programs in nursing. This critical thinking outcome must reflect the student's skill in analysis, reasoning, research, or decision making as these skills relate to the nursing discipline (National League for Nursing, 1992). To meet the NLN's critical thinking outcome criterion, nursing programs must have a method of evaluating this skill. Many programs use the Watson-Glaser Critical Thinking Appraisal (WGCTA), which is a standardized instrument. The College of Nursing at the University of Arkansas for Medical Sciences (UAMS) adopted this instrument to evaluate the critical thinking skills of students in the baccalaureate nursing program.

Pathologic features of rhabdomyosarcoma before and after treatment: a clinicopathologic and immunohistochemical analysis

Few studies have analyzed the relationship among pathology, therapy-induced changes, proliferative activity, and outcome for rhabdomyosarcoma (RMS), despite the challenges of histopathologic interpretation of this tumor after treatment. Although cytodifferentiation and decreased mitotic activity after treatment were documented previously, the clinical consequences of these changes are uncertain because of the small number of cases analyzed. We analyzed 16 RMSs with pre- and post-treatment specimens for clinicopathologic features, outcome, and immunohistochemical data on formalin-fixed, paraffin-embedded tissue for vimentin, smooth muscle actin, muscle-specific actin, desmin, myoglobin, p53 protein, topoisomerase II-alpha, and MIB-1 proliferative activity. Four of eight alveolar (ARMS), five of five botryoid (BRMS), and two of three nonbotryoid embryonal (ERMS) RMSs displayed varying degrees of post-therapeutic histologic maturation and expressed one or more myoid markers. The remaining five RMSs had no cytodifferentiation. Myoid marker expression did not change significantly. In BRMS, MIB-1 and topoisomerase II-alpha proliferative activity decreased after therapy and correlated with cytodifferentiation and survival. This relationship was less clear for ERMS and ARMS. Five nonbotryoid RMSs without cytodifferentiation had either unchanged or increased proliferative activity, and four of these patients died of RMS. Six nonbotryoid RMSs with both cytodifferentiation and residual foci of undifferentiated cells had variable outcomes, including longer survival. We conclude that BRMS and ERMS exhibit therapy-induced cytodifferentiation more frequently than does ARMS. Cytodifferentiation and decreased proliferative activity are associated with favorable outcome in BRMS; unchanged or increased post-therapeutic proliferative activity suggests aggressive biologic potential in ERMS and ARMS. Combined patterns of cytodifferentiation and residual undifferentiated foci might be associated with increased, decreased, or unchanged proliferative activity and are difficult to interpret, but the presence of cytodifferentiation might presage an improved survival. Immunohistochemical analysis for proliferation markers might be useful for highlighting foci of less differentiated RMS or cytodifferentiated tumor cells in contrast to non-neoplastic, terminally differentiated muscle cells.

Protection against oral and gastrointestinal diseases: importance of dietary nitrate intake, oral nitrate reduction and enterosalivary nitrate circulation

Over the last 20 years, dietary nitrate has been implicated in the formation of methemoglobin and carcinogenic nitrosamines in humans. This has led to restrictions of nitrate and nitrite levels in food and drinking water. However, there is no epidemiological evidence for an increased risk of gastric and intestinal cancer in population groups with high dietary vegetable or nitrate intake. A reevaluation of our currently very negative perception of dietary nitrates comes from recent research into the metabolism and enterosalivary circulation of nitrate in mammals. These studies showed that nitrate is converted to nitrite in the oral cavity that then "fuels" an important mammalian resistance mechanism against infectious diseases. Moreover, there is now evidence that the conversion of nitrate into oxides of nitrogen prevents the formation carcinogenic nitrosamines.