Access to and quality of care for sexual and gender minority women living with HIV in Metro Vancouver, Canada: Results from a longitudinal cohort study

BACKGROUND

While scarce, literature suggests that women at the intersection of HIV status and gender and/or sexual minority identities experience heightened social and health disparities within health care systems.

OBJECTIVES

This study examines the association between sexual and/or gender minority identities and: (1) experiences of poor treatment by health professionals and (2) being unable to access health services among a cohort of women living with HIV in Metro Vancouver, Canada.

DESIGN

Data were drawn from a longitudinal community-based cohort of women living with HIV (Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment).

METHODS

We examined associations between sexual and/or gender minority identities and the two outcomes. We drew on explanatory variables to measure sexual minority and gender minority identities independently and a combined variable measuring sexual and/or gender minority identities. The associations between each of these three variables and each outcome were analysed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios and 95% confidence intervals are reported.

RESULTS

The study sample included 1460 observations on 315 participants over 4.5 years (September 2014 to February 2019). Overall, 125 (39.7%) reported poor treatment by health professionals and 102 (32.4%) reported being unable to access health care services when needed at least once over the study period. A total of 110 (34.9%) of participants reported sexual and/or gender minority identities, 106 (33.7%) reporting sexual minority identities, with 29 (9.2%) reporting gender minority identities. In multivariable analysis, adjusting for confounders, sexual minority identities, and combined sexual and/or gender minority identities were significantly associated with increased odds of experiencing poor treatment by health professionals (sexual minority adjusted odds ratio = 1.39 (0.94-2.05); sexual and/or gender minority adjusted odds ratio = 1.48 (1.00-2.18)) and being unable to access health services (sexual minority adjusted odds ratio = 1.89 (1.20-2.97); sexual and/or gender minority adjusted odds ratio = 1.91 (1.23-2.98)). In multivariable analysis, gender minority identities were not significantly associated with increased odds of experiencing poor treatment by health professionals (gender minority adjusted odds ratio = 1.38; 95% CI = 0.76-2.52) and being unable to access health services (gender minority adjusted odds ratio = 1.72; 95% CI = 0.89-3.31) possibly due to low sample size among women with gender minority identities.

CONCLUSION

Our findings suggest the need for access to inclusive, affirming, trauma-informed health care services tailored specifically for and by women living with HIV with sexual and/or gender minority identities.

Use of upper-limb compression garments in the management of lipoedema

Compression hosiery is commonly used for the management of lymphoedema as well as lipoedema, but it is more commonly indicated for the lower limbs than for the upper limbs. The effects of compression hosiery on upper-limb lipoedema are poorly understood and researched. It is known that compression hosiery works in conjunction with activity or movement when standing or walking, which produces anti-inflammatory and oxygenating effects in the tissues. This effect is naturally difficult to realise in the upper limbs. Lymphoedema practitioners who treat those with lipoedema should bear in mind that compression treatment might not produce the same effects in upper-limb lipoedema as it does in lower-limb lipoedema. In these times of an overstretched health service, pragmatic resource use is essential.

A Space to Speak: Therapeutic Theater to Address Gender-Based Violence

This article examines the experience of eight graduate students in the drama therapy program at Lesley University when creating and performing a theater piece centered around gender-based violence. The performance piece, A Space to Speak, used the performers' real-life stories to highlight their vastly different, yet strikingly similar, experiences and invited the audience to examine their own relationship to those stories. A description of the process used to create and perform the piece is followed by a discussion of the impact the process had on the performers and audience members.

Emissions of VOCs From Polymer-Based Consumer Products: From Emission Data of Real Samples to the Assessment of Inhalation Exposure

The development of consumerism led to an increase in toy production. Such consumer products may contain non-intentionally added toxic substances that can emit from the product and may be inhaled by the consumer. Little data is available on the inhalation exposure of humans to volatile organic compounds (VOCs) from consumer products, so a reliable exposure assessment is needed. Only the emission chamber technique developed for building material emissions can provide solid estimations as it allows the products to be studied under real room conditions. This paper proposes a strategy to interpret emission experiment results from consumer products and assess the corresponding potential risk. It focuses on 14 common VOCs. The identification of the polymer type of 41 plastic articles was first performed by pyrolysis coupled online to gas chromatography with mass spectrometric detection (pyr-GC/MS). Their VOC profile was also determined by Dynamic Headspace-GC/MS (DHS-GC/MS). Softer polymers caused higher and broader emission profiles. Four specific toy samples were selected to be studied in a 203 l emission chamber and their emissions were compared to a reference material. A rapid decrease in the emissions was observed for each product and VOC. Based on these emission curves over time, the corresponding indoor air concentration could be calculated for the target VOCs for short-term or long-term exposures. The indoor air levels obtained were at least 35 times lower than the levels according to conventional indoor air guidelines. Guideline values were only exceeded using very conservative exposure scenarios.

Reasons of repeat dental treatment under general anaesthesia: A retrospective study

AIM

The purpose of this chart review study was to investigate the common factors that exist in paediatric patients requiring a repeat dental treatment under general anaesthesia (GA2) within four years after the initial dental treatment under general anaesthesia (GA1).

MATERIALS AND METHODS

The Electronic Health Records of one to 12 year-old children who received dental treatment under general anaesthesia (GA) between April 2004 and October 2009 were identified and analysed by a single examiner. Children who had GA2, within a four year period following GA1 were categorised as cases. Children who had only one dental treatment under GA were considered the control pool. Each case was matched to three controls based on sex and age range at GA1 of ± 6 months. Other recorded variables included: date of birth, date of GAs (GA1 and GA2 for cases; GA1 for controls), type of payment, dmfs before GA1, dental treatments provided under GA, return of 1-week post-GA1 follow-up, frequency of recare/recall visits following one-year post-GA1 visit and the type and frequency of post GA1 emergency visits.

RESULTS

Out of 581 subjects, 29 (4.99%) cases were matched to 87 controls. Medically compromised patients had four times the risk of GA2. At GA1, cases received statistically significant less sealants (p=0.026), less extractions (p<0.0001), and more composite restorations (p=0.0002) compared to controls.

CONCLUSION

Medically compromised children and children treated with more composites and fewer sealants and extractions at their initial dental treatment under general anaesthesia were more likely to have a repeat dental treatment under general anaesthesia within 4 years.

Achieving Thoracic Oncology data collection in Europe: a precursor study in 35 Countries

BACKGROUND

A minority of European countries have participated in international comparisons with high level data on lung cancer. However, the nature and extent of data collection across the continent is simply unknown, and without accurate data collection it is not possible to compare practice and set benchmarks to which lung cancer services can aspire.

METHODS

Using an established network of lung cancer specialists in 37 European countries, a survey was distributed in December 2014. The results relate to current practice in each country at the time, early 2015. The results were compiled and then verified with co-authors over the following months.

RESULTS

Thirty-five completed surveys were received which describe a range of current practice for lung cancer data collection. Thirty countries have data collection at the national level, but this is not so in Albania, Bosnia-Herzegovina, Italy, Spain and Switzerland. Data collection varied from paper records with no survival analysis, to well-established electronic databases with links to census data and survival analyses.

CONCLUSION

Using a network of committed clinicians, we have gathered validated comparative data reporting an observed difference in data collection mechanisms across Europe. We have identified the need to develop a well-designed dataset, whilst acknowledging what is feasible within each country, and aspiring to collect high quality data for clinical research.

Human papillomavirus and oral and oropharyngeal carcinoma: the essentials

There is a global increase in the prevalence of human papillomavirus (HPV)-driven oropharyngeal squamous cell carcinoma (OPSCC) in Australia and New Zealand. Risk factors for HPV-positive OPSCC are male gender, white race, age older than 40 but younger than 59 years old, having multiple lifetime sex partners, having oro-genital and oro-anal sex. High-risk HPV subtypes play a major role in the pathogenesis of OPSCC, however, they play a much lesser role in oral squamous cell carcinoma (OSCC). Among the laboratory tests used to detect oncogenic HPV infection, polymerase chain reaction is a sensitive method but does not reflect the role of HPV in oncogenesis. While widely used, p16 immunohistochemistry is both a sensitive and a specific surrogate marker for oncogenic HPV infection in OPSCC, but not in OSCC. However, it is a useful prognostic marker in OPSCC. The current gold standard to accurately detect oncogenic HPV infection is E6/E7 mRNAin situ hybridization. Because both HPV-positive and p16-positive OPSCC have better short-term prognoses there is current debate and trials on treatment de-escalation in HPV-positive OPSCC. Dental practitioners can play an important role in early diagnosis of HPV-positive OPSCC.

Chronic oedema: a prevalent health care problem for UK health services

Chronic oedema (CO) is a major clinical problem worldwide, which has many important secondary consequences for health, activity and participation. Effective treatment planning and organisation of services is dependent on an understanding of the condition and its epidemiology. This cross-sectional study was designed to estimate the point prevalence of CO within the health services of one UK urban population and to determine the proportions that have concurrent leg ulceration. Patients with CO in all anatomic sites were ascertained by health care professionals in one acute and one community hospital, all relevant outpatient and community nursing services, general practices and all nursing/residential homes in one urban catchment area (Derby City). The presence and distribution of oedema was confirmed through a brief clinical examination. A battery of demographic and clinical details was recorded for each case. Within the study population of Derby City residents, 971 patients were identified with CO [estimated crude prevalence 3·93 per 1000, 95% confidence interval (CI) 3·69-4·19]. The prevalence was the highest among those aged 85 or above (28·75 per 1000) and was higher among women (5·37 per 1000) than men (2·48 per 1000). The prevalence among hospital inpatients was 28·5%. Only five (3%) patients in the community population had oedema related to cancer or cancer treatment. Of the 304 patients identified with oedema from the Derby hospitals or community health services, 121 (40%) had a concurrent leg ulcer. Prevalence statistics and current demographic trends indicate that CO is a major and growing health care problem.

Does age matter? Sexual event-level analysis of age-disparate sexual partners among gay, bisexual and other men who have sex with men (GBM) in Vancouver, Canada

BACKGROUND

To determine factors associated with age-disparate sexual partners among Vancouver gay, bisexual and other men who have sex with men (GBM).

METHODS

Sexually active GBM aged ≥16 years were recruited from February 2012 to February 2014. Participants self-completed a questionnaire on demographics, attitudes and sexual behaviour and substance use at last sexual event with five most recent partners. Two generalised linear mixed models identified factors associated with: (1) 'same-age' (referent), 'younger' or 'much-younger' and (2) 'same-age' (referent), 'older' or 'much-older' partners. Statistical interactions between age and HIV status were tested.

RESULTS

Participants (n=719) were predominantly gay (85.1%), White (75.0%), HIV-negative/unknown status (72.9%) with median age of 33 years (Q1,Q3: 26,47). A minority of sexual events were reported with much-older/much-younger partners (13.7%). In the multivariable models, GBM reporting older partners were more likely to be Asian or Latino, have greater Escape Motivation scores, report their partner used erectile dysfunction drugs (EDDs) and have received something for sex; compared with condom-protected insertive anal sex, participants with older partners were more likely to report condomless insertive anal sex with a serodiscordant or unknown status partner or no insertive anal sex. GBM reporting older partners were less likely to be bisexual-identified, have given something for sex and report event-level alcohol and EDD use. GBM reporting younger partners were more likely to have annual incomes >$30 000 and have met their partner online. As per significant statistical interactions, age-disparate relations were more common for younger HIV-positive and older HIV-negative GBM.

CONCLUSIONS

Differences among age-disparate partners highlight important targets for health promotion and future research.

Awareness and use of nonoccupational post-exposure prophylaxis among men who have sex with men in Vancouver, Canada

OBJECTIVES

Nonoccupational post-exposure prophylaxis (nPEP) is a strategy to reduce the risk of HIV infection in those with high-risk exposure. This study characterized nPEP awareness among gay, bisexual and other men who have sex with men (MSM) in Metro Vancouver, British Columbia, Canada after a pilot nPEP programme established in 2012.

METHODS

Momentum Health Study participants were MSM aged ≥16 years recruited via respondent-driven sampling (RDS) who completed a computer-assisted self-interview. Stratifying patients by HIV status, we used multivariable logistic regression with backward selection to identify factors associated with nPEP awareness. All analyses were RDS-adjusted.

RESULTS

A total of 51.9% (112 of 173) of HIV-positive and 48.5% (272 of 500) of HIV-negative participants had heard of nPEP. Only 3% (five of 106) of HIV-negative participants who reported recent high-risk sex used nPEP. Generally, nPEP awareness was higher for participants who engaged in sexual activities with increased HIV transmission potential. Factors associated with greater awareness among HIV-negative participants included recent alcohol use, higher communal sexual altruism, previous sexually transmitted infection diagnosis, and greater perceived condom use self-efficacy. Other factors associated with greater awareness among HIV-negative participants included white race/ethnicity, gay sexual identity, more formal education, lower personal sexual altruism, and Vancouver residence. Greater nPEP awareness among HIV-positive participants was associated with greater perceived agency to ask sexual partners' HIV status and more frequently reporting doing so, a higher number of lifetime receptive sex partners, and greater access to condoms.

CONCLUSIONS

Following implementation of an nPEP pilot programme, nPEP awareness among HIV-negative MSM was 51% and use was 3%. These data support the need to expand access to and actively promote nPEP services.

Blow fly Lucilia sericata nuclease digests DNA associated with wound slough/eschar and with Pseudomonas aeruginosa biofilm

In chronic wounds, it may be clinically important to remove extracellular bacterial and patient DNA as its presence may impede wound healing and promote bacterial survival in biofilm, in which extracellular DNA forms part of the biofilm architecture. As medicinal maggots, larvae of Lucilia sericata Meigen (Diptera: Calliphoridae) have been shown to efficiently debride wounds it became of interest to investigate their excretions/secretions (ES) for the presence of a deoxyribonuclease (DNAse) activity. Excretions/secretions products were shown to contain a DNAse, with magnesium, sodium and calcium metal ion dependency, and a native molecular mass following affinity purification of approximately 45 kDa. The affinity purified DNAse degraded genomic bacterial DNA per se, DNA from the slough/eschar of a venous leg ulcer, and extracellular bacterial DNA in biofilms pre-formed from a clinical isolate of Pseudomonas aeruginosa. The latter finding highlights an important attribute of the DNAse, given the frequency of P. aeruginosa infection in non-healing wounds and the fact that P. aeruginosa virulence factors can be toxic to maggots. Maggot DNAse is thus a competent enzyme derived from a rational source, with the potential to assist in clinical wound debridement by removing extracellular DNA from tissue and biofilm, and promoting tissue viability, while liberating proteinaceous slough/eschar for debridement by the suite of proteinases secreted by L. sericata.

Wound debridement potential of glycosidases of the wound-healing maggot, Lucilia sericata

The wound-healing maggot, Lucilia sericata Meigen (Diptera: Calliphoridae), degrades extracellular matrix components by releasing enzymes. The purpose of this study was to investigate the glycosylation profiles of wound slough/eschar from chronic venous leg ulcers and the complementary presence of glycosidase activities in first-instar excretions/secretions (ES1) and to define their specificities. The predominant carbohydrate moieties present in wound slough/eschar were determined by probing one-dimensional Western blots with conjugated lectins of known specificities. The presence of specific glycosidase activities in ES1 was determined using chromogenic and fluorogenic substrates. The removal of carbohydrate moieties from slough/eschar proteins by glycosidases in ES1 was determined by two-dimensional electrophoresis and Emerald 300 glycoprotein staining. α-D-glucosyl, α-D-mannosyl and N-acetylglucosamine residues were detected on slough/eschar-derived proteins. Furthermore, it was demonstrated that the treatment of slough/eschar with ES1 significantly reduced uptake of the carbohydrate-specific stain. Subsequently, α-D-glucosidase, α-D-mannosidase and N-acetylglucosaminidase activities were identified in ES1. Specific chromogenic and fluorogenic substrates and gel filtration chromatography showed that these activities result from distinct enzymes. These activities were mirrored in the removal of α-D-glucosyl, α-D-mannosyl and N-acetylglucosamine residues from proteins of slough/eschar from maggot-treated wounds. These data suggest that maggot glycosidases remove sugars from slough/eschar proteins. This may contribute to debridement, which is ultimately accomplished by a suite of biochemically distinct enzymes present in ES1.

P4-15-02: Clinical and Epidemiological Correlates of Elevated Distress Thermometer Scores in Breast Cancer Patients

Objectives: Distress is prevalent in breast cancer patients and can be detrimental to quality of life, performance status, treatment adherence, and satisfaction with medical care. The National Comprehensive Cancer Network (NCCN) developed the Distress Thermometer (DT) as a quick and efficient self-assessment tool for screening distress in cancer patients. While surveys estimate that between 20–40% of patients with cancer have significant levels of distress, fewer than 10% are identified and treated. Given time and monetary constraints, it is important to refine screening criteria to identify patients with elevated risk for distress. In this study, we identify clinical and epidemiological factors that are associated with an increased likelihood of elevated DT scores (≥4 and ≥7) in breast cancer patients.

Methods: We assessed 229 consecutive female patients with the DT at their initial consultation for breast cancer at the Huntsman Cancer Hospital between September 2007 and December 2008. The DT screening tool measures a global level of distress using a visual analogue scale from 0–10 in the shape of a thermometer, with zero identified as “No Distress” and ten labeled as “Extreme Distress.” The DT screening tool also includes a checklist of common emotional, family, physical, practical, and spiritual concerns with instructions for the paitent to indicate which of those concerns contributed to the distress they experienced within the past week. We chose a score ≥4 as our cutoff for a positive screen for “distress” and a score ≥7 as our cutoff for a positive screen for “extreme distress/depression” based on previous studies. Variables included in the analyses were: age, employment status, race/ethnicity, personal history of depression, family history of breast cancer, marital status, estrogen and progesterone receptor status, stage of cancer, time since diagnosis, and recurrence. Descriptive statistics and logistic regression models were used to determine associations between DT and patient data. Results: Emotional and physical concerns were associated with scores ≥4 and scores ≥7. Spiritual concerns were significantly associated with patients reporting scores ≥7. Patients who were non-Caucasian, unemployed, had a prior history of depression, who presented for recurrent disease, or who had been recently diagnosed had a higher likelihood of scores ≥4 and scores ≥7.

Conclusions: The likelihood of scoring ≥4 and ≥7 on the DT screening tool is highest during the first 30 days after receiving a breast cancer diagnosis. Four groups of patients should be targeted for aggressive screening: patients with a prior diagnosis of depression, patients presenting with recurrent disease, unemployed patients, and non-Caucasian patients. Interventions should address physical, emotional and spiritual concerns.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-02.

Confirming nasal airway dimensions observed on panoramic and posterior-anterior cephalometric radiographs using an acoustic rhinometer

AIM

This study aimed to confirm the nasal airway dimensions observed in standard dental radiographs through analysis of the anterior nasal cross-sectional area and nasal volume with acoustic rhinometry.

METHOD

Participants were chosen from the patient population under consideration for interceptive orthodontic treatment at Tufts University's Pediatric Dentistry Clinic. A total of 55 Caucasian subjects, of both sexes (males=28, females =27), and ranging from age 6-9 years (mean= 7.33) were enrolled. Utilizing the ImageJ program, the subjects' panoramic and PA cephalometric radiographs were analyzed for radiolucent anterior nasal cross-sectional area. Subjects were then examined with the Eccovision Acoustic Rhinometer, which measured anterior nasal cross-sectional area and nasal volume. Data were grouped together, and areas and volume gathered from the radiographs and rhinometer analyzed for any correlation. Statistical analysis was performed using the SPSS program. Data was further divided into right and left nasal side, and a Pearson Correlation Matrix was created for 8 predictor variables (right and left panoramic area, right and left cephalometric area, right and left rhinometer area, and right and left rhinometer volume).

RESULTS

Values in this correlation matrix ranged from 0.712 to 0.988; all were statistically significant at the <0.01 level (2-tailed test).

CONCLUSION

A very strong correlation was found between the anterior nasal cross-sectional area calculated from the radiographs, and the anterior nasal cross-sectional area and nasal volume from the rhinometer.

Degradation of eschar from venous leg ulcers using a recombinant chymotrypsin from Lucilia sericata

BACKGROUND

Larvae of the greenbottle Lucilia sericata are used to debride nonhealing wounds and stimulate the production of fresh granulation tissue. Previous publications have shown that secretions from L. sericata contain a number of proteolytic activities including a chymotrypsin that degrades a number of extracellular matrix components such as fibronectin, laminin and collagen.

OBJECTIVES

To produce a recombinant L. sericata chymotrypsin (chymotrypsin I) and determine its effects on the degradation of patient wound eschar.

METHODS

An active recombinant chymotrypsin I from L. sericata was cloned and expressed in Sf9 cells and its subsequent effects ex vivo on eschar from venous leg ulcers were determined by two-dimensional electrophoresis.

RESULTS

The recombinant enzyme had the attributes of a chymotrypsin, possessing sequence homology with other chymotrypsins and demonstrating attributes of the native enzyme including cleavage of the chymotrypsin substrate succinyl-alanyl-alanyl-prolyl-phenylalanyl-7-amino-4-methyl coumarin, inhibition by phenylmethylsulphonyl fluoride and lack of inhibition by amidinophenylmethylsulphonyl fluoride. Importantly, the recombinant chymotrypsin cleaved the majority of proteins from slough/eschar from venous leg ulcers in a superior manner to chymotrypsins from human and bovine sources.

CONCLUSIONS

The ex vivo degradation of eschar from venous leg ulcers indicates the potential value of recombinant chymotrypsin I as a novel, stand-alone debridement agent.

Maize chloroplast DNA fragment encoding the large subunit of ribulosebisphosphate carboxylase

In vitro linked transcription-translation of chloroplast DNA has been used to show that the large subunit of ribulose-1,5-bisphosphate carboxylase [3-phospho-D-glycerate carboxy-lyase (dimerizing), EC 4.1.1.39] is encoded by Zea mays chloroplast DNA. A BamHI-generated chloroplast DNA sequence cloned in Escherichia coli is shown to direct the in vitro synthesis of this protein identified as large subunit by its size, serological properties, and limited proteolytic digestion products.

The effects of single dose anxiolytic medication on the CO2 models of anxiety: differentiation of subjective and objective measures

This was a double blind, placebo-controlled, 4-way cross-over study in 12 healthy volunteer subjects of the acute effects of three drugs each of which are used in the clinic to treat some forms of anxiety: propranolol 40 mg, hydroxyzine 25 mg, flupentixol 0.5 mg and placebo. Each test session consisted of inhalation of air for 20 min, 10-min rest, inhalation of CO2 7.5% for 20 min, 10-min rest, followed by a single vital capacity inhalation of 35% CO2. The CO2 7.5% was administered at peak drug effect. Subjective effects were measured using Visual Analogue Scales (VAS), the Panic Symptom Inventory and the Generalised Anxiety Disorder Assessment inventory. Twelve subjects participated (eight men), with a mean age of 25.9 years. The expected subjective effects of CO2 were seen and these were significantly different from effects of peak air. However, there were no statistically significant differences between the drugs or between drugs and placebo, indeed there was a trend for some VAS anxiety scores to be higher than placebo in the drug groups. There were some significant differences in cardiovascular responses to CO2, with propranolol significantly decreasing heart rate and flupentixol increasing blood pressure when compared with placebo. The lack of subjective anxiolytic actions of the three drugs contrasts with our previous findings with acute benzodiazepines and chronic selective serotonin reuptake inhibitor administration. It may be that prolonged treatment with these agents would be required to show anxiolytic effects, although it may also be that their efficacy is insufficient to be demonstrated in this model. The lack of anxiolytic actions of propranolol, despite a significant reduction in heart rate, is a further support for a central action of CO2 to produce anxiety.

End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year

The objectives of this study are to ascertain how many patients who died in a district general hospital in England might have been able to be cared for at home, to obtain the cost of each inpatient stay, to make an estimate of the maximum resource implications of care packages for these patients, and to calculate the savings in hospital admissions that could be used for the development of community services. These objectives are dependant on full implementation of the End of Life Strategy. A descriptive study of all inpatient deaths in one year in a district general hospital in the south west of England was conducted. Data collection - case notes of all patients who died at the hospital from the beginning of June 2006 to end of May 2007. A total of 599 case notes of 627 patients who died in the study period were reviewed. A total of 331 patients (56%) were not assessed as being in the last year of life. Of the remaining 44%, 152 (26%) were clearly in the last year of life and 110 (18%) had significant co-morbidities and could probably have been recognised as being in the last year of life. A total of 399 (67%) of patients were appropriately admitted to hospital for their final illness, 194 (33%) could have been looked after at home. At least 119 (20%) clearly and 75 (13%) probably could have stayed at home. The mean cost of admission was 3173 pound per patient. A total of 77 (13%) of patients were admitted from nursing homes and 53 (69%) of these could have stayed in the nursing home to die. A total of 44% of all patients who died within the district general hospital had chronic life threatening illnesses. A maximum of one third of all hospital deaths could have been looked after at home if excellent end of life services were in place. When commissioning end of life care services, it is possible to calculate how many extra patients may need community care packages and the cost that could be redistributed from hospital to community for these services.

A new high-content model system for studies of gastrointestinal transit: the zebrafish

The zebrafish gastrointestinal (GI) tract displays an anatomy and cellular architecture that is similar to the human GI tract, with concentric layers of inner epithelia, connective tissue, circular muscle and outer longitudinal muscle layers. Propulsion of luminal content results from the integrated activity of smooth muscle cells, enteric neurons and the interstitial cells of Cajal (ICC). Zebrafish larvae are transparent and propagating contractions in the entire GI tract are easily visualized. A new moderate-throughput zebrafish-based GI transit assay is described in this issue of Neurogastroenterology and Motility. This assay utilizes intact zebrafish larvae which contain essential regulatory elements (ICC and enteric neurons). Forward genetic analysis, which identifies genes underlying specific phenotypes, is possible using the zebrafish system. The zebrafish model system compliments existing models for studies of GI motility and will contribute to the understanding of the regulation of GI motility, and to identification of novel drug targets.

Kit-like immunoreactivity in the zebrafish gastrointestinal tract reveals putative ICC

Gastrointestinal (GI) motility results from the coordinated actions of enteric neurons, interstitial cells of Cajal (ICC), and smooth muscle cells. The GI tract of the zebrafish has a cellular anatomy that is essentially similar to humans. Although enteric nerves and smooth muscle cells have been described, it is unknown if ICC are present in the zebrafish. Immunohistochemistry and PCR were used determine expression for the zebrafish Kit orthologue in the zebrafish gastrointestinal tract. Cells displaying Kit-like immunoreactivity were identified in the muscular layers of the adult zebrafish gastrointestinal tract. Two layers of Kit-positive cells were identified, one with multipolar cells located between the longitudinal and circular smooth muscle layers and one with simple bipolar cells located deep in the circular muscle layer. Primers specifically designed to amplify mRNA coding for two zebrafish kit genes, kita and kitb, and two kit ligands, kitla and kitlb, amplified the expected transcript from total RNA isolated from zebrafish GI tissues. The Sparse mutant, a kita null mutant, showed reduced contraction frequency and increased size of the GI tract indicating a functional role for kita. These data establish the presence of a cellular network with Kit-like immunoreactivity in the myenteric plexus region of the zebrafish GI tract, adjacent to enteric neurons. Expression of kita and kitb, and the ligands kitla and kitlb, were verified in the adult GI tract. The anatomical arrangement of the Kit-positive cells strongly suggests that they are ICC.

How to care for uncomplicated skin and keep it free of complications

Many of the skin problems associated with lymphoedema and other chronic oedemas can be reduced or even prevented with appropriate and effective skin care. In particular, the use of emollients to maintain skin condition and integrity can reduce the frequency and severity of cellulitic episodes. This article describes best practice in the care of the skin in cases of uncomplicated lymphoedema.

Why RNA and DNA have different structures

In the early years of molecular biology--over 50 years ago--we were faced with many unknowns. A significant one at the time was the relationship between DNA and RNA, both in terms of structure and function. Function is often a reflection of structure. Here I outline some of the early research in this area, especially for RNA structure, which was completely unknown when we started.

Kit/stem cell factor receptor-induced phosphatidylinositol 3'-kinase signalling is not required for normal development and function of interstitial cells of Cajal in mouse gastrointestinal tract

Signalling mediated by the receptor tyrosine kinase c-Kit is required for normal development of interstitial cells of Cajal (ICC). c-Kit activates several signalling pathways, including the phosphatidylinositol 3'-kinase (PI3'-kinase) pathway. The signals required for ICC development and maintenance are not well understood. Studies indicate a role for PI3'-kinase. We studied ICC function and morphology in mice homozygous for the tyrosine 719 to phenylalanine c-Kit mutation, which disrupts all PI3'-kinase binding to c-Kit. Functionally, the electrical slow waves in the jejunum and inhibitory junction potentials were normal in adult mutants. Morphologically, the distribution of ICC was not altered in mutants. There was no difference in the density of ICC in the jejunum of adults or newborns from quantitative analysis of c-Kit immunoreactivity. The number of ICC obtained in culture was the same using mutants or wild-type littermates. The density and organization of nerves in the jejunum of mutants was not affected. Deletion of c-Kit-induced PI3'-kinase signalling does not affect the function or development of ICC in the mouse. This is an important and counterintuitive result, given the role of PI3'-kinase signalling downstream of c-Kit and the role of both c-Kit and PI3'-kinase individually in ICC development.