Advanced practice in maternal/child nursing: history, current status, and thoughts about the future

Advanced practice nursing has undergone dramatic growth and change in during the past quarter century. Specialization in maternal/child health started with hospital-developed postlicensure programs which evolved into formal master's level programs. The first nurse-practitioner program in pediatrics was begun in 1965 at the University of Colorado. The last 25 years has seen an increase in clinical specialization and in advanced practice roles within the specialties. The growth of credentials and types of certification available have provided opportunities for nurses, but have also created confusion for consumers and other health care professionals. Current challenges facing advanced practice nurses include issues related to legal authority for scope of practice, direct reimbursement for services, and prescriptive authority. The current health care climate provides challenges and opportunities for nurses in advanced practice.

Species-specific elements in the large T-antigen J domain are required for cellular transformation and DNA replication by simian virus 40

The J domain of simian virus 40 (SV40) large T antigen is required for efficient DNA replication and transformation. Despite previous reports demonstrating the promiscuity of J domains in heterologous systems, results presented here show the requirement for specific J-domain sequences in SV40 large-T-antigen-mediated activities. In particular, chimeric-T-antigen constructs in which the SV40 T-antigen J domain was replaced with that from the yeast Ydj1p or Escherichia coli DnaJ proteins failed to replicate in BSC40 cells and did not transform REF52 cells. However, T antigen containing the JC virus J domain was functional in these assays, although it was less efficient than the wild type. The inability of some large-T-antigen chimeras to promote DNA replication and elicit cellular transformation was not due to a failure to interact with hsc70, since a nonfunctional chimera, containing the DnaJ J domain, bound hsc70. However, this nonfunctional chimeric T antigen was reduced in its ability to stimulate hsc70 ATPase activity and unable to liberate E2F from p130, indicating that transcriptional activation of factors required for cell growth and DNA replication may be compromised. Our data suggest that the T-antigen J domain harbors species-specific elements required for viral activities in vivo.

Ethnomedicinally selected plants as sources of potential analgesic compounds: indication of in vitro biological activity in receptor binding assays

A number of plant species used in traditional medicine for the relief of pain have been selected from the medicinal and scientific literature of China, South America, Asia and West Africa. Extracts were prepared and tested in three in vitro receptor radioligand binding assays to determine whether there was an indication of biological activity, in particular their selectivity to a single receptor implicated in the mediation of pain. The three neuropeptide receptors chosen were Bradykinin (BK II), expressed in Chinese hamster ovary cells (CHO), neurokinin 1 (NK 1) expressed in astrocytoma cells, and calcitonin gene related peptide (CGRP) which were all implicated in the mediation of acute pain in the mammaliancentral nervous system. The plant species chosen to investigate were Ageratum conyzoides, Barringtonia edulis, Croton tiglium, Ipomea pes-caprae, Panax ginseng, Physostigma venenosum, Sinomenium acutum, Solidago virgaurea, Symplocos leptophylla and Typhonium giganteum. The results showed that there was a strong indication of biological activity for some of the plants which are used ethnomedicinally to treat pain, in the three in vitro receptor binding assays used, and particular plant extracts exhibited selective action to a single receptor.

Identification and characterization of mycobacteriophage L5 excisionase

The well-characterized mycobacteriophage L5 forms stable lysogens in Mycobacterium smegmatis. Establishment of lysogeny involves integration of the phage genome into the chromosome of its mycobacterial hosts through an integrase-mediated site-specific recombination event. As L5 lysogens spontaneously generate free phage particles, prophage excision must also occur, although an L5 excisionase gene had not been identified. We show here that L5 gene 36 encodes the phage excisionase and is a small, heat-stable 56-amino-acid protein that strongly stimulates excisive recombination both in vivo and in vitro. The ability to manipulate the highly directional phage integration and excision reactions will provide powerful tools for the introduction, curing and recovery of foreign genes in recombinant mycobacterial strains.

Evaluation of the purity of a purified, inactivated hepatitis A vaccine (VAQTA)

Manufacture of VAQTA, an inactivated hepatitis A virus vaccine, includes extensive purification of the intact virus particle to remove endogenous components from the host cell culture lysate as well as compounds introduced in the upstream purification process. Analysis of the final purified hepatitis A virus product by SDS-PAGE prior to inactivation shows that greater than 95% of the protein in the preparation is found in four protein bands, which have been confirmed to be hepatitis A virus capsid proteins VP0, VP1, VP2 and VP3 based on Western blot and mass spectrometry analyses. Validation of the manufacturing process and direct analysis of the final product were used to demonstrate that no other specific host cell-derived components are detected and that process residuals are all below the limits of detection of the assays used. Establishment of a rigorous standard of high purity for this product was pursued to minimize the impact of impurities during clinical development of this product and will facilitate the incorporation of this product into combination vaccines.

Isolation of translactone-containing triterpenes with thrombin inhibitory activities from the leaves of Lantana camara

Methanolic extracts prepared from the leaves of Lantana camara have been found to inhibit human thrombin. An assay, in which thrombin activity is measured as a function of clot formation from fibrinogen, was used to guide the fractionation and purification of five principal active constituents (1-5), which were all characterized as 5,5-trans-fused cyclic lactone-containing euphane triterpenes.

Statistical shortcomings in licensing applications

This paper concerns the statistical work carried out with respect to clinical trials conducted for regulatory purposes. Although the general quality of such work has improved markedly over recent years and is now generally high, a number of shortcomings remain. A few of these arise from failure to follow well established statistical practice. Rather more arise from a poor understanding of areas of known statistical disagreement and from the unsatisfactory use of newer and more advanced techniques. Inadequacies in reporting statistical work are commonplace. Examples of all these shortcomings are provided and emphasis is placed on the value of a statistical contribution to overall summaries such as the clinical expert report.

The management of interim analyses in drug development

The ethical need for interim analyses in long-term trials of life-threatening conditions is well established, but recently there has been increased enthusiasm for the use of interim analyses in other areas of clinical research. Interim analysis is seen as a powerful tool in drug development to help reduce 'time to market' by allowing key decisions to be made earlier on the basis of one or more ongoing clinical trials. However, this goal can only be achieved without serious penalties if interim analyses are properly designed and executed, so that the integrity of the whole drug development programme is maintained. The purpose of this paper is to define procedures for the design and management of clinical trials which involve interim analyses. These procedures are intended to incorporate good clinical and statistical practice, hence maintaining high scientific standards not only of individual trials but also of the overall development programme. Aspects of design, conduct, analysis and dissemination of results are considered, with particular focus on the effective use of data monitoring committees in confirmatory efficacy trials.

A comparison of various estimators of a treatment difference for a multi-centre clinical trial

When a clinical trial is conducted at more than one centre it is likely that the true treatment effect will not be identical at each centre. In other words there will be some degree of treatment-by-centre interaction. A number of alternative approaches for dealing with this have been suggested in the literature. These include frequentist approaches with a fixed or random effects model for the observed data and Bayesian approaches. In the fixed effects model, there are two common competing estimators of the treatment difference, based on weighted or unweighted estimates from individual centres. Which one of these should be used is the subject of some controversy and we do not intend to take a particular methodological position in this paper. Our intention is to provide some insight into the relative merits of the indicated range of possible estimators of the treatment effect. For the fixed effects model, we also look at the merits of using a preliminary test for interaction assuming a 10 per cent significance level for the test. In order to make comparisons we have simulated a 'typical' trial which compares an active drug with a placebo in the treatment of hypertension, using systolic blood pressure as the primary variable. As well as allowing the treatment effect to vary between centres, we have concentrated on the particular case where one centre is out of line with the others in terms of its true treatment difference. The various estimators that result from the different approaches are compared in terms of mean squared error and power to reject the null hypothesis of no treatment difference. Overall, the approach that uses the fixed effects weighted estimator of overall treatment difference is recommended as one that has much to offer.

A Formulation of Trichoderma and Gliocladium to Reduce Damping-off Caused by Rhizoctonia solani and Saprophytic Growth of the Pathogen in Soilless Mix

Commercially manufactured cellulose granules (Biodac) were mixed with a sticker and fermentor-produced biomass of isolates of Trichoderma spp. and Gliocladium virens to produce a formulation in which chlamydospores in the biomass were "activated" with dilute acid. Activation resulted in the formation of young, actively growing hyphae of the biocontrol fungi within a 2- to 3-day period under no special aseptic conditions. Activated Biodac with biomass of isolates Gl-3, Gl-21, and Gl-32 of G. virens and isolate TRI-4 of T. hamatum applied to soilless mix at a rate of 1.5% (wt/wt) reduced damping-off of eggplant caused by Rhizoctonia solani (R-23) and resulted in stands comparable to that (88%) in noninfested soilless mix. Saprophytic growth of the pathogen was also reduced. The application of either of two activated Biodac formulations to provide the same amount (1.5% with 9.4 mg of biomass per g of Biodac or 0.2% with 75.0 mg of biomass per g of Biodac) reduced preemergence damping-off as well as saprophytic growth of R-23. Also, there was about a 10³-fold population increase of Gl-3 and TRI-4 in the soilless mix at the time of plant harvest compared with that provided to the soilless mix at the time of formulation addition. Activated Biodac of Gl-3 also reduced the spread of R-23 in soilless mix when the pathogen was applied at specific foci rather than evenly distributed. The inhibition of pathogen spread significantly reduced the postemergence damping-off of cucumber, eggplant, and pepper seedlings.

Seed Treatment Using Pre-infiltration and Biocontrol Agents to Reduce Damping-off of Corn Caused by Species of Pythium and Fusarium

Bioassays were conducted in a greenhouse at 18°C to determine the effectiveness of a seed treatment used in combination with biocontrol agents for the reduction of corn damping-off caused by species of Pythium and Fusarium. Corn seeds were infiltrated with tap water, drained, air-dried, and then coated with biomass of an antagonistic fungus, Gliocladium virens isolate Gl-3, or an antagonistic bacterium, Burkholderia cepacia isolates Bc-B or Bc-1, or a combination of Gl-3 with each of the bacterial isolates. A nonsterile field soil was infested with a combination of pathogens: Pythium ultimum, P. arrhenomanes, and Fusarium graminearum at 2 inoculum rates (1× and 4×). Pre-infiltration enhanced (P ≤ 0.05) disease control with most treatments at both inoculum rates. Treatments with biocontrol agents alone or in combination, as well as the fungicide captan, effectively reduced the disease at a pathogen inoculum rate of 1×, resulting in greater (P ≤ 0.05) seedling stands, plant height, and fresh weight, and lower (P ≤ 0.05) root rot severity compared with untreated seeds in infested soil. At a pathogen inoculum rate of 4×, stands were lower (P ≤ 0.01) and root-rot severity was higher (P ≤ 0.01) compared to those at 1× for all treatments. Nevertheless, coating seeds with all biocontrol agents (alone or in combination), except with Bc-1 alone, reduced disease (P ≤ 0.05) compared to untreated seeds in infested soil. At both inoculum rates of 1× and 4×, coating seeds with Gl-3 + Bc-B was more effective (P ≤ 0.05) in disease control than any other treatment, resulting in stands, growth rate (plant height and fresh weight), and root rot severity similar to plants from untreated seeds in noninfested soil. In addition, when the exudate from a 2-h infiltration of corn seed was added to the seeds during seed coating, seedling stand was often lower and root rot severity was often higher than those from infiltrated seeds (P ≤ 0.05). These results indicated that the infiltration process removed certain exudates, including nutrients and/or stimulants (not detected in this study) that might be utilized by pathogens to initiate seed infection. A thin-layer chromatography (TLC) profile of the exudates showed the presence of eight amino acids and three major carbohydrates.

New active substances authorized in the United Kingdom between 1972 and 1994

AIMS

The study was undertaken to assemble a list of all new active medicinal substances authorised in the United Kingdom between 1972 and 1994; to assess whether the pattern of introductions had changed; and to examine withdrawal rates and the reasons for withdrawal.

METHODS

The identities of those new active substances whose manufacturers had obtained Product Licences between 1972 and 1994 were sought from the Medicines Control Agency's product data-base. For each substance relevant information was retrieved including the year of granting the Product Licence, its therapeutic class, whether currently authorised (and, if not, reason for withdrawal), and its nature (chemical, biological etc.).

RESULTS

The Medicines Control Agency's data-base was cross-checked against two other data-bases for completeness. A total of 583 new active substances (in 579 products) were found to have been authorised over the study period. The annual rates of authorisation varied widely (9 to 40 per year). Whilst there was no evidence for any overall change in the annual rates of authorising new chemical entities, there has been a trend for increasing numbers of new products of biological origin to be authorised in recent years. Fifty-nine of the 583 new active substances have been withdrawn (1 each for quality and efficacy, 22 for safety, and 35 for commercial reasons).

CONCLUSIONS

For reasons that are unclear there is marked heterogeneity in the annual rates of authorisation of new active substances. Their 10 year survival is approximately 88% with withdrawals being, predominantly, for commercial or safety reasons. This confirms the provisional nature of assessments about safety at the time when a new active substance is introduced into routine clinical practice, and emphasises the importance of pharmacovigilance.

Caenorhabditis elegans levamisole resistance genes lev-1, unc-29, and unc-38 encode functional nicotinic acetylcholine receptor subunits

We show that three of the eleven genes of the nematode Caenorhabditis elegans that mediate resistance to the nematocide levamisole and to other cholinergic agonists encode nicotinic acetylcholine receptor (nAChR) subunits. unc-38 encodes an alpha subunit while lev-1 and unc-29 encode non-alpha subunits. The nematode nAChR subunits show conservation of many mammalian nAChR sequence features, implying an ancient evolutionary origin of nAChR proteins. Expression in Xenopus oocytes of combinations of these subunits that include the unc-38 alpha subunit results in levamisole-induced currents that are suppressed by the nAChR antagonists mecamylamine, neosurugatoxin, and d-tubocurarine but not alpha-bungarotoxin. The mutant phenotypes reveal that unc-38 and unc-29 subunits are necessary for nAChR function, whereas the lev-1 subunit is not. An UNC-29-GFP fusion shows that UNC-29 is expressed in body and head muscles. Two dominant mutations of lev-1 result in a single amino acid substitution or addition in or near transmembrane domain 2, a region important to ion channel conductance and desensitization. The identification of viable nAChR mutants in C. elegans provides an advantageous system in which receptor expression and synaptic targeting can be manipulated and studied in vivo.

Immunoprecipitation and virus neutralization assays demonstrate qualitative differences between protective antibody responses to inactivated hepatitis A vaccine and passive immunization with immune globulin

Antibodies to hepatitis A virus (anti-HAV) were measured in children from two separate vaccine trials (n = 70) 4 weeks after a dose of inactivated hepatitis A vaccine (VAQTA). The geometric mean titers (GMTs) of anti-HAV were 49.3 and 45.2 mIU/mL by immunoassay, while reciprocal GMTs of neutralizing anti-HAV were 6.5 and 15.0 by an 80% radioimmunofocus inhibition test (RIFIT) and 55.6 and 92.0 by antigen reduction assay (HAVARNA). The GMT of antibody detected by radioimmunoprecipitation (RIPA) was > or =401. These data establish serologic correlates of protection against disease and show that RIPA is most sensitive for detection of early vaccine-induced antibody. Sera collected from adults (n = 20) 7 days after administration of immune globulin contained similar antibody levels by immunoassay (45.1 mIU/mL) and slightly higher GMTs of neutralizing antibody (27.5 by RIFIT and 146 by HAVARNA) but negligible precipitating antibody (GMT, 5.6). These results are best explained by differences in the affinity of antibodies for virus following active versus passive immunization.

Seed Treatment with a Fungal or a Bacterial Antagonist for Reducing Corn Damping-off Caused by Species of Pythium and Fusarium

Bioassays were conducted under greenhouse conditions to test the efficacy of antagonists applied to corn (Zea mays) seed for protection against seed rot and seedling damping-off at 18 and 25°C in a field soil artificially infested with a combination of Pythium ultimum, P. arrhenomanes, and Fusarium graminearum. Biomass of Gliocladium virens isolates Gl-3 or Gl-21, Trichoderma viride isolate Tv-1, or peat-based slurry of Burkholderia cepacia isolates Bc-B, Bc-T, or Bc-1 was coated individually onto corn seeds in one test, and Gl-3 or Bc-B at four inoculum levels was used in another test. Seed treatments with most of the biocontrol agents, as well as with the fungicide captan, significantly (P ≤ 0.05) increased seedling stand, plant height and fresh weight, and decreased root rot severity compared with untreated seeds in pathogen-infested soil. Coating seeds with the biocontrol fungus G. virens isolate Gl-3 was the most effective treatment, resulting in greater (P ≤ 0.05) seedling stand, plant height, and fresh weight, and lower (P ≤ 0.05) severity of root rot than those parameters from seeds treated with captan or other antagonists at both temperatures. The results from the seeds treated with Gl-3 were similar to those of untreated seeds in noninfested soil. In treatments with Bc-1, Bc-T, Bc-B, or Tv-1, incubation temperature affected plant emergence, root rot severity, plant height, and fresh weight (P ≤ 0.01). Conversely, in seeds coated with Gl-3 or Gl-21, these parameters were similar at both temperatures. The minimum number of propagules needed per corn seed to obtain plant emergence comparable to that from captan-treated seeds was between 10⁴ and 10⁵ CFU for Gl-3 and >10⁸ for Bc-B. When propagules of Gl-3 were applied at a rate >10⁶ CFU per seed, seedling emergence was greater (P ≤ 0.05) than that from captan-treated seeds.