A Novel Nephropsychology Clinic: Partnering With Patients in the Era of Value-Based Care in Nephrology

CKD and end-stage kidney disease are highly prevalent and complex chronic conditions with a high disease burden that corresponds to a high cost of care. Mental health conditions have a high prevalence in this population and add to the burden of disease, increase the cost of care, and are co-related with worse clinical outcomes. Despite these clear co-relations, mental health disorders remain underdiagnosed and undertreated in this population, secondary to multiple reasons, including patient-specific factors as well as systematic issues, including difficulty in accessing mental health experts. Here we describe a novel collaborative care model for patients with advanced CKD within the nephrology clinic space, in the form of a nephropsychology clinic. We present the details of our clinic, our preliminary findings, and propose that an integrated behavioral health model offers convenience for the patient and improves workflow for the physician, allowing a pathway to timely mental health interventions.

AB0434 EFFICACY AND SAFETY OF OBINUTUZUMAB IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITH SECONDARY NON-RESPONSE TO RITUXIMAB

Background

Secondary inefficacy characterized by infusion reactions and anti-drug antibodies occur in 14% of SLE patients treated with repeat rituximab courses(1). Obinutuzumab is a next-generation humanized type-2 anti-CD20 therapy licensed for hematological malignancies which may overcome this issue(2).

Objectives

We set out to evaluate the clinical efficacy and safety of obinutuzumab in a cohort of rituximab resistant SLE patients.

Methods

We collated data from SLE patients receiving obinutuzumab for secondary non-response to rituximab in BILAG centres. Disease activity was assessed using BILAG-2004, SLEDAI-2K and serology before, and 6 months after, obinutuzumab 2x1000mg infusions alongside methylprednisolone 100mg. Flow cytometry where possible was carried out using a multiple gating highly sensitive strategy.

Results

All 9 patients included in the study received obinutuzumab alongside concomitant oral immunosuppression. At 6 months post-obinutuzumab, there were significant reductions in median SLEDAI-2K from 12 to 6 (p=0.014) and total BILAG-2004 score from 21 to 2 (p=0.009). Complement C3 and dsDNA titres improved significantly (both p=0.04). Non statistically significant numerical improvements were seen in C4 levels.

Of 8/9 patients receiving concomitant oral prednisolone at baseline (all >10mg/day), 5/9 had their dose reduced at 6 months; 4/8 were on 5mg/day and were in Lupus Low Disease Activity State. After obinutuzumab, 6/9 patients with peripheral B-cell data achieved complete depletion including 4/4 assessed with highly sensitive assays. 1/9 obinutuzumab non-responder required cyclophosphamide therapy. 1 unvaccinated patient died from COVID-19.

Table 1.

Baseline characteristics, disease activity and steroid doses before and after last obinutuzumab/rituximab.

PatientEthnicityDisease duration (Years)Age (Years)Total BILAG-2004 before ObiTotal BILAG-2004 after ObiSLEDAI-2K before ObiSLEDAI-2K after ObiPrednisolone before Obi (mg)Prednisolone after Obi (mg)1South Asian10.836.41821481052South Asian6.324.424212430103South Asian11.934.829110410104South Asian8.241.92116015155South Asian6.829.43221181450606White European17.537.0128881557White European16.930.01211281058Caribbean6.244.225213010159Caribbean2.621.092166105Median (Q1, Q3)NA8.2 (6, 12)34.8 (29,37)21 (12, 25)2 (1, 2)12 (10, 14)6 (4, 8)10 (10, 15)10 (5, 15)

Conclusion

Obinutuzumab appears to be effective and steroid-sparing in renal and non-renal SLE patients with secondary non-response to rituximab. Obinutuzumab was shown to be effective in patients with severe renal and non-renal disease. Therefore, in those with previous responsiveness to B-cell depletion, switching to humanised type-2 anti-CD20 therapy is a logical approach following loss off efficacy.

References

[1]Vital EM, Dass S, Buch MH, Henshaw K, Pease CT, Martin MF, et al. B cell biomarkers of rituximab responses in systemic lupus erythematosus. Arthritis Rheum [Internet]. 2011 Oct [cited 2020 Oct 12];63(10):3038–47. Available from: https://pubmed.ncbi.nlm.nih.gov/21618204/

[2]Hassan SU, Md Yusof MY, Emery P, Dass S, Vital EM. Biologic Sequencing in Systemic Lupus Erythematosus: After Secondary Non-response to Rituximab, Switching to Humanised Anti-CD20 Agent Is More Effective Than Belimumab. Front Med [Internet]. 2020 Aug 27 [cited 2020 Sep 2];7:498. Available from: https://www.frontiersin.org/article/10.3389/fmed.2020.00498/full

Disclosure of Interests

Jack Arnold: None declared, Shouvik Dass Consultant of: Roche, Abbvie, UCB & Chugai, Employee of: Honoraria from Roche, Abbvie, UCB & Chugai, Sarah Twigg: None declared, Colin Jones: None declared, Benjamin Rhodes: None declared, Peter Hewins: None declared, Mithun Chakravorty: None declared, Philip Courtney: None declared, Michael Ehrenstein Grant/research support from: GSK, Employee of: Has received honoraria from GSK, Md Yuzaiful Md Yusof: None declared, Edward Vital Employee of: Has received honoraria from Roche

Adverse effects and duration of treatment of TB in Canterbury, New Zealand

BACKGROUND Treatment of TB is often extended beyond the recommended duration. The aim of this study was to assess prevalence of extended treatment and to identify associated risk factors. We also aimed to determine the frequency and type of adverse drug reactions (ADR) experienced by this study population.METHODS We performed a retrospective cohort study of all patients treated for active TB at Christchurch Hospital, Christchurch, New Zealand, between 1 March 2012 and 31 December 2018. Data for 192 patients were collected on patient demographics, disease characteristics and treatment characteristics, including planned and actual duration of treatment and ADRs.RESULTS Of 192 patients, 35 (18.2%) had treatment extended, and 85 (46.5%) of 183 with fully drug-susceptible TB received ≥9 months treatment. The most common reasons for extension were persistent or extensive disease and ADR. Extended treatment duration was not associated with any patient or disease characteristics. We found 35 (18.2%) patients experienced at least one ADR. The most common ADRs were hepatitis, rash and peripheral neuropathy.CONCLUSION TB treatment extension beyond WHO guidelines is common. Further research is needed to guide management of those with slow response to treatment. Methods for early detection of ADR, systems to improve adherence and therapeutic drug monitoring are potentially useful strategies.

The complement receptor 3 (CD11b/CD18) agonist Leukadherin-1 suppresses human innate inflammatory signalling

Complement receptor 3 (CR3, CD11b/CD18) is a multi‐functional receptor expressed predominantly on myeloid and natural killer (NK) cells. The R77H variant of CD11b, encoded by the ITGAM rs1143679 polymorphism, is associated robustly with development of the autoimmune disease systemic lupus erythematosus (SLE) and impairs CR3 function, including its regulatory role on monocyte immune signalling. The role of CR3 in NK cell function is unknown. Leukadherin‐1 is a specific small‐molecule CR3 agonist that has shown therapeutic promise in animal models of vascular injury and inflammation. We show that Leukadherin‐1 pretreatment reduces secretion of interferon (IFN)‐γ, tumour necrosis factor (TNF) and macrophage inflammatory protein (MIP)‐1β by monokine‐stimulated NK cells. It was associated with a reduction in phosphorylated signal transducer and activator of transcription (pSTAT)‐5 following interleukin (IL)‐12 + IL‐15 stimulation (P < 0·02) and increased IL‐10 secretion following IL‐12 + IL‐18 stimulation (P < 0·001). Leukadherin‐1 pretreatment also reduces secretion of IL‐1β, IL‐6 and TNF by Toll‐like receptor (TLR)‐2 and TLR‐7/8‐stimulated monocytes (P < 0·01 for all). The R77H variant did not affect NK cell response to Leukadherin‐1 using ex‐vivo cells from homozygous donors; nor did the variant influence CR3 expression by these cell types, in contrast to a recent report. These data extend our understanding of CR3 biology by demonstrating that activation potently modifies innate immune inflammatory signalling, including a previously undocumented role in NK cell function. We discuss the potential relevance of this to the pathogenesis of SLE. Leukadherin‐1 appears to mediate its anti‐inflammatory effect irrespective of the SLE‐risk genotype of CR3, providing further evidence to support its evaluation of Leukadherin‐1 as a potential therapeutic for autoimmune disease.

NON-CELIAC SPRUE: A CASE OF OLMESARTAN-INDUCED ENTEROPATHY

Diarrhea, weight loss and villous atrophy is usually associated with the autoimmune disease celiac sprue, which is generally diagnosed by testing for tissue transglutaminase (tTG) or endomysial antibodies. In patients with negative serologies, however, other causes of villous atrophy must be investigated, including infection, irritable bowel disease, intestinal neoplasms and drug-induced enteropathy.

The genetics of SLE: an update in the light of genome-wide association studies

Understanding the pathogenesis of SLE remains a considerable challenge. Multiple abnormalities of both the innate and adaptive immune system have been described and, furthermore, immunological dysfunction precedes clinical presentation by many years. There is a strong genetic basis to SLE, which means that genetic studies can play a key role in furthering our understanding of this disease. Since susceptibility variants are present from birth and are unaffected by the course of the disease, or by its treatment, genetic analysis is, perhaps uniquely, capable of identifying fundamental, causative, disease mechanisms. Over the last 12 months, there has been a staggering increase in our understanding of SLE genetics. We have seen the identification of new and important SLE susceptibility genes through candidate gene studies, and we have seen the publication of two whole-genome association analyses. The 'hypothesis free' whole-genome studies have provided additional evidence in support of a number of existing susceptibility genes and have identified novel gene candidates. In this article, we review the current SLE genetics literature in the light of these recent advances and we discuss our current understanding of the functional role of the key susceptibility genes. By considering how these genes fall into clusters with shared function we can begin to understand how dysregulation at a number of key immunological steps may predispose to the development of SLE.

Quantification of the genetic component of basal C-reactive protein expression in SLE nuclear families

C-reactive protein (CRP) is a heritable acute-phase plasma protein also expressed at low, basal, levels in healthy individuals. Elevated basal CRP has been associated with increased cardiovascular risk, while CRP dysregulation may be a feature of systemic lupus erythematosus (SLE). In this cohort of 496 Caucasian SLE families we estimated basal CRP heritability, h(2)= 27.7%. We typed a dense map of CRP single nucleotide polymorphisms (SNPs) and found that seven were associated with basal CRP using both a regression approach and an orthogonal family-based test (P = 0.001-0.011), as were haplotypes carrying the minor allele of these SNPs. SNPs in the interleukin-1beta and interleukin-6 genes were associated with basal CRP. No association was seen between CRP genotype and SLE. Using a variance components approach we estimated that the CRP genotype accounted for only 15% of the total genetic component of basal CRP variation, perhaps explaining the limited evidence of association between CRP and disease. Most of the genetic determinants of basal CRP variation therefore remain unknown. Multiple genes may be involved and identifying them will provide an insight into pathways regulating CRP expression, highlight potential cardiovascular disease and SLE candidates and improve the ability of basal CRP to predict cardiovascular risk.

General aspects of the genetics of SLE

The application of genetic techniques to the study of systemic lupus erythematosus (SLE) has identified candidate genes with diverse immunological function. There is a growing understanding that susceptibility to SLE is due to a complex interaction of multiple genes and environmental factors, and that many of these may be shared with other autoimmune diseases. In this first of a series of review articles we outline our current understanding of SLE genetics, in particular summarising the results of recent association studies.

The impact of a supplementary medication review and counselling service within the oncology outpatient setting

The impact on the care of breast cancer patients, of a pharmacy technician-led medication review and counselling clinic, provided in an outpatient setting, was investigated using a controlled randomised study. Compared to the controls, clinic patients showed a significantly improved level of understanding of their chemotherapy support medication (95% CI for difference in mean knowledge rating scores=2.165-2.826, P<0.001) and a significant reduction in the median number of support items required (two compared to five in the control, P<0.001). This resulted in a significant reduction in mean medication expenditure per patient (26.70 vs 10.20 British Pound, 95% CI for the mean difference in cost 6.72 - 26.26 British Pound, P<0.001). The clinic was also associated with significant reductions in chemotherapy delays (P<0.001) and dose reductions due to side effects (P=0.003). Other benefits from the clinic were a reduction in pharmacy dispensing time and a highly significant reduction in pharmacy time spent resolving post-clinic prescription queries (P<0.001). Taking into account the initial technician training cost, the scheme represented an annual saving to the Trust of over 15,000 British Pound. The clinic serves as a model for those wishing to improve outpatient services to breast cancer patients.

Microleakage of high-strength glass ionomer: resin composite restorations in minimally invasive treatment

Atraumatic Restorative Treatment (ART) has been investigated as an alternative caries treatment. The technique involves removal of loose tooth structure with a spoon excavator, followed by placement of an adhesive restorative material, often a high-strength glass ionomer. This study compares the microleakage of a high-strength glass ionomer/resin composite and two occlusal resin composite restoration techniques.

The effect of double adhesive application on the shear bond strength to dentin of compomers using three one-bottle adhesive systems

The development of one-bottle dentin adhesive systems resulted in much optimism about providing simplified predictable esthetic dentistry. However, laboratory testing of these systems continues to provide significant variations between facilities. A potential effect of the number of applications was noted in this author's laboratory. This study evaluated the effect of doubling the manufacturer's recommended number of applications on shear bond strength to dentin. Ninety human molars were divided into groups of 15. The occlusal surfaces were finished to 600 grit SiC to provide a flat dentin bonding surface. Prime & Bond NT-Dyract, Optibond Solo-Elan and One Step-Dyract were evaluated. Each material was tested using: (1) the recommended number of adhesive applications and (2) twice the number of applications recommended. All adhesive applications were accomplished before light curing the adhesive. The specimens were thermocycled after one week of storage and tested in shear after two weeks. Specimens were also fabricated after adding Rhodamine D to the adhesive to allow for visualization using confocal microscopy. These teeth were sectioned and viewed 24 hours after fabrication. A t-test was used to compare differences within product groups. The results showed a significant effect (p < 0.001) when a double application of Prime & Bond NT was used. No difference was seen with Optibond Solo or One Step. All specimens appeared to have a uniform, glossy appearance of adhesive during fabrication. Therefore, the appearance of the adhesive after application may not be a reliable predictor of acceptable bonding. Confocal microscopy showed that single application Prime & Bond NT specimens did not exhibit a uniform thickness of adhesive across the entire interface. Tubule penetration and hybridization was apparent for all specimens.

Changing patterns of sedation use for routine out-patient diagnostic gastroscopy between 1989 and 1998

BACKGROUND

Knowledge of sedation trends for upper gastrointestinal endoscopy is important for health service planning, particularly in view of rapidly increasing demands on endoscopy services. However, no data are available on sedation trends in Britain over the past 10 years.

AIM

To determine sedation use for routine gastroscopy in a single endoscopy unit between 1989 and 1998.

METHODS

This was a retrospective study of 9795 consecutive adults (mean age 56 years, range 18-100 years; 4512 females) who had undergone a gastroscopy between 1989 and 1998. Clinical, pharmacological and endoscopic data were retrieved from a computerized database.

RESULTS

Over the 10-year study period, the sedation rate remained constant for patients undergoing therapeutic endoscopy (P=0.99) and those undergoing in-patient diagnostic examinations (P=0.63). In contrast, the sedation rate for out-patient diagnostic endoscopy decreased by 54%, from a high of 70% in 1990 to 32% in 1998 (P < 0.0001). Logistic regression analysis showed that the decline in sedation use was greater in females (P < 0.0001) than males and in procedures performed by non-consultant compared to consultant staff (P=0.01).

CONCLUSIONS

If our results form part of a national trend, they will have important implications for cardiopulmonary monitoring strategies, recovery room practices and for complication rates due to the use of sedation for upper gastrointestinal endoscopy.

Investigation of an adhesive system used with direct and indirect applications

A laboratory investigation was performed that examined the adhesive properties of a new adhesive system. Contrasts were made with other commercially established systems, and indirect and direct bonding procedures were investigated. For the indirect evaluation, simulated restorations were bonded with an experimental resin cement. Sealing was assessed through microleakage analysis. Adhesive strength value was measured by shear bond strength methods. Further, the marginal quality of the restorations was assessed using scanning electron microscopy. Finally, the adhesive shear bond strengths were established using direct bonding.

Retentive strength of an amalgam bonding agent: chemical vs light vs dual curing

Dentin bonding agents have been shown to enhance retention of amalgam restorations by mechanical means. Little research is available on which mode of curing may optimize amalgam bonding. This in vitro study compared the bond strengths exhibited by three variations of a bonding agent, each using a different curing mode, with two earlier versions of amalgam resin liners and cavity varnish. The six test groups of lining agents for amalgam restorations included [C] chemical-cured, [L] light-cured and [D] dual-cured versions of one filled adhesive resin (Clearfil Liner Bond 2V), [LF] Light-cured, Filled resin (Clearfil Liner Bond 2, Kuraray Co.); [LCF] Light- and Chemical-cured, Filled resin Clearfil Liner Bond + Protect Liner, Kuraray Co) and [V] Varnish (Copalite, Cooley & Cooley, Ltd). For each group, 20 Class V cavity preparations were cut in human molars. The preparations were 2.5 mm deep and 3 mm wide at the pulpal floor, with a slightly divergent taper. After treating the preparation with the bonding agent, a 3/4 inch, 18 gauge flat-headed wire nail was seated in the cavity with its head at the pulpal floor of the preparation, and Tytin amalgam (Kerr Corp, Romulus, MI) was condensed into the preparation around the nail. All restorations were stored for 24 hours in distilled water at 37 degrees C, then subjected to 2500 thermal cycles (8 degrees C to 58 degrees C). After one week the samples were tested to failure in tension using an Instron Universal Testing Machine (crosshead speed = 2 mm/min) and peak load (kg) was recorded. Significant differences in retention were found using ANOVA and the Games & Howell post hoc test (p = 0.05). The mean loads at failure (+/- SD) were C 13.1 (+/- 2.4), L 21.8 (+/- 6.1), D 26.8 (+/- 7.4), LCF 23.8 (+/- 7.4), LF 21.4 (+/- 3.3) and V 2.0 (+/- 1.8). All dentin-bonding agents exhibited significantly greater retention than the varnish. While the bond strengths of the dual cured (D) and the light-cured (L) liners were not significantly different from one another, both were significantly higher than the chemically-cured (C) resin liner in terms of retention.

Microleakage and retention of bonded amalgam restorations

PURPOSE

To compare the microleakage and bond strength exhibited by two light-cured, filled dentin bonding agents, a resin cement, and cavity varnish.

MATERIALS AND METHODS

The four test groups of lining agents for amalgam restorations included (LF) Light-cured, Filled resin (Clearfil Liner Bond 2); (LCF) light- and chemical-cured, Filled resin (Clearfil Liner Bond + Protect Liner); (RC) Resin Cement (Panavia 21); and (V) Varnish (Copalite). For each group, 20 Class V cavity preparations were cut in human extracted molars. Tytin amalgam was condensed into the preparation. After storage for at least 24 hrs in distilled water at 37 degrees C, all restorations were subjected to 2500 thermal cycles (8 degrees C to 48 degrees C). After 1 wk, specimens were tested. For the leakage tests, teeth were immersed in 45Ca, sectioned, and radiographs of sections were evaluated and then evaluated by Ridit analysis. Retention samples were tested to failure in tension using an Instron machine and peak load (kg) was recorded.

RESULTS

Compared to varnish, the two dentin bonding agents (LF and LCF) significantly decreased microleakage at the cementum margin but not at the enamel margin. The two dentin bonding agents also exhibited significantly greater retentive strength than either the resin cement or the varnish.

Neutrophil-specific 99mTc-labeled anti-CD15 monoclonal antibody imaging for diagnosis of equivocal appendicitis

We evaluated 99mTc-labeled anti-CD15 immunoglobulin M monoclonal antibody (LeuTech) for diagnosing acute appendicitis in patients with an equivocal clinical presentation. LeuTech avidly binds to circulating and sequestered human polymorphonuclear neutrophils in vivo, eliminating in vitro cell labeling and blood handling.

METHODS

We studied 49 patients to evaluate the safety and efficacy of LeuTech imaging. 99mTc-labeled LeuTech was prepared on site using a lyophilized kit, 99mTc-labeled pertechnetate, and 2 different incubation techniques, 1 at room temperature and the other at 37 degrees C. The abdomen was serially imaged for up to 3 h after the intravenous administration of 370-740 MBq 99mTc-labeled LeuTech. Scans were read as positive or negative for acute appendicitis or other intraabdominal infection. The institutional diagnosis was established by surgery, other diagnostic studies, or 1-mo clinical follow-up.

RESULTS

Scans were positive for appendicitis in all 26 patients with appendicitis, for a sensitivity of 100%, and negative for appendicitis in 19 of 23 patients without appendicitis, for a specificity of 83%. Accuracy, positive predictive value, and negative predictive value were 92%, 87%, and 100%, respectively. Results were not different between the LeuTech preparations. The rate of laparotomies with negative findings in patients who underwent surgery was 10%. The average time from injection to LeuTech visualization in the appendix for cases positive for appendicitis was 9 min. No serious adverse reactions occurred.

CONCLUSION

LeuTech imaging is safe, rapid, and sensitive for diagnosis of appendicitis in equivocal cases. The potential advantages of LeuTech over currently available radiopharmaceuticals for infection imaging are ease of preparation, absence of blood handling, excellent image quality, no requirement for SPECT, and rapid diagnostic uptake.

Intraindividual comparison of 99mTc-labelled anti-SSEA-1 antigranulocyte antibody and 99mTc-HMPAO labelled white blood cells for the imaging of infection

Technetium-99m labelled antigranulocyte antibodies are ready to use and are sensitive and specific in the diagnosis of infectious diseases. 99mTc-SSEA antigranulocyte antibodies have a very high affinity constant (Kd 10(-12) M) for human neutrophils (PMNs), and excellent imaging qualities with high target/background ratios. The aim of this study was to compare the diagnostic accuracy of the 99mTc-anti-SSEA-1 monoclonal antibody (Mab) with that of 99mTc-hexamethylpropylene amine oxime (HMPAO)-labelled white blood cells (WBCs). To this end, 17 patients with 23 proven infectious foci were examined with 555 MBq 99mTc-anti-SSEA-1 MAb and with 370 MBq 99mTc-HMPAO labelled autologous leucocytes within a period of 7 days. All the infections were confirmed by culture, biopsy, surgery and follow-up. Whole-body images and planar spot views with the antibody were performed at 1-h, 4-h and 24-h post injection; the biodistribution of the antibody was quantified, absorbed radiation doses were calculated and the diagnostic results were compared with the 99mTc-HMPAO WBC images. Human anti-mouse antibody (HAMA) evaluation was performed in all patients before and 3 months after antibody injection. Blood was drawn at different times after 99mTc-anti-SSEA-1 MAb injection to determine the amount of granulocyte-associated radioactivity and to calculate recovery. 99mTc-anti-SSEA-1 MAb scintigraphy detected all 23 lesions, while 21 were detected with 99mTc-HMPAO WBC scan. In this small group of patients, the sensitivity and specificity of 99mTc-anti-SSEA-1 MAb scintigraphy were 95% and 96% respectively, as compared with 91% and 82% respectively for 99mTc-HMPAO WBC scan. An increasing uptake of the injected activity in the lesion at different time points was indicative of high affinity and of specific PMN binding. There was no HAMA formation. In four of five patients investigated, a transient mild leukopenia was found at 15 min p.i.. There was increased uptake of the antibody in liver and spleen and normal uptake in kidneys and bone marrow. The estimated radiation doses for the whole body and the red bone marrow were 1.1x10(-2) cGy/37 MBq and 5.3x10(-2) cGy/37 MBq, respectively. The activity associated to the PMNs in vivo was 33.5%, 30.6%, 21.3% and 9% at 5, 15, 30 and 45 min. post-injection, respectively. It is councluded that use of 99mTc-anti-SSEA-1 antigranulocyte antibodies demonstrates promising results comparable to those obtained with 99mTc-labelled autologous WBCs. The 99mTc-labelled MAb is ready to use, has excellent image qualities and a high target/background ratio.

Comparison of retentiveness of amalgam bonding agent types

Previous studies on amalgam bonded restorations indicated that amalgam bonding agents increased the bond strength of amalgam to tooth structure. This in vitro study was designed to compare how the mode of curing and the presence of filler in the resin would affect the bond strength of amalgam. The five test groups of lining agents for amalgam restorations included Chemical-cured, Unfilled resin (CU-Clearfil New Bond); Light-cured, Unfilled resin with a delayed chemical-cure property (LU*-Clearfil Photo Bond); Light-cured, Filled resin with a delayed chemical-cure property (LF*-Clearfil Photo Bond + Protect Liner); Dual-cured, Unfilled resin (DU-All-Bond 2); and Varnish (V-Copalite). For each group, 20 class 5 cavity preparations were cut on the facial, lingual, or proximal surfaces of human molars, which were embedded in acrylic resin. The preparations were 2.5 mm deep and 3 mm wide at the pulpal floor with a slightly divergent taper. After treating the preparation with the bonding agent, a 3/4-inch, 18-gauge flat-headed wire nail was placed into the cavity with the head at the pulpal floor of the preparation, and Tytin amalgam was then condensed into the preparation around the nail. The restorations were stored for 24 hours in distilled water at 37 degrees C and then subjected to 2500 thermal cycles (8 degrees C to 48 degrees C). After 1 week, specimens were tested to failure in tension using an Instron Universal Testing Machine (crosshead speed = 2 mm/min) and peak load (kg) was recorded. The mean loads at failure (+/- SD) were LF* 26.4 (+/- 7.0), DU 23.9 (+/- 6.4), LU* 16.0 (+/- 3.1), CU 14.3 (+/- 8.0), and V 9.5 (+/- 5.6). Significant differences were found using a one-way ANOVA and the Games and Howell post hoc test at a significance level of alpha = 0.05. The LF* and DU groups were not significantly different from each other, but they were significantly higher in peak load than all other groups. LU* was significantly higher than the varnish (V) but not significantly higher than CU. CU was not significantly higher than the varnish (V). The adhesives forming a thicker resin interface (the light-cured resin with filled resin liner and the dual-cured unfilled resin) demonstrated significantly greater retention than the light-cured unfilled resin, chemical-cured unfilled resin, and the varnish control.

Imaging inflammatory diseases with neutrophil-specific technetium-99m-labeled monoclonal antibody anti-SSEA-1

Imaging inflammatory diseases with a 99mTc-labeled neutrophil-specific agent that can be injected directly intravenously continues to be a challenge.

METHODS

The antibody, anti-SSEA-1, chosen from studies of 10 neutrophil-specific MAbs, recognizes CD-15 antigens (5.1 x 10(5)/human PMN) with a high association constant (kd = 10(-11) M). One hundred micrograms of MAb labeled with 10-20 mCi 99mTc either by a direct or DTPA conjugation method were injected intravenously into 12 patients (9 men, 3 women, aged 19-48 yr) with clinical evidence of ongoing inflammatory processes. Vital signs of all patients were recorded before and up to 3 hr following administration of the MAb. HAMA was determined in two patients. Anterior and posterior spot views and whole-body images were obtained. All patients except one underwent biopsy, US or CT examinations and/or surgical procedures. Blood samples collected from five patients were analyzed. In nine patients, quantitative organ distribution was determined and radiation dosimetry was calculated.

RESULTS

Labeling yields were 94.8% +/- 1.4% and 95.8% +/- 3.5%, respectively. All patients had unequivocally positive images within 3 hr of the MAb injection. Eleven of these were confirmed by other modalities. One patient recovered on antibiotics and was sent home without surgery or other procedures. The lack of radioactivity in the thyroid or gastrointestinal tract indicated that the in vivo stability of the agent was excellent. At 3 hr postinjection, bladder activity in six patients was 1.3% +/- 0.4% of the administered dose. At this time, splenic uptake (7.7% +/- 1.0% ad. dose) and red marrow uptake (14 +/- 1.8%) were lower than those of 111In-WBC. At 49.0% +/- 3.2% administrated dose, liver uptake was at the upper limit with 111In-WBC uptake. Renal uptake was only 2.4% +/- 0.03% administered dose. At 2 hr postinjection, 14% to 51% of the radioactivity was associated with PMN. Radioactivity with lymphocytes was 0.7% to 10.9%, 1.2% to 4.3% with platelets and 1.1% to 2.4% with RBC. No HAMA were detectable in either patient, and no adverse reaction was detectable in any patient.

CONCLUSION

Results are highly encouaging and have prompted us to prepare a kit for instant preparation and to initiate clinical trials.

Parental bonding and separation-individuation difficulties among late adolescent eating disordered women

This study is an exploration of both interpersonal and intrapsychic factors associated with eating disorders in late adolescent women. It examines perceived parental bonding characteristics and resolution of the second separation-individuation process for both eating and non-eating disordered subjects. Subjects were 20 late adolescent eating disordered women and 20 symptom-free late adolescent female university students. All subjects received the Eating Disorder Inventory, the Parental Bonding Inventory, and the Separation-Individuation Test of Adolescence. Late adolescent eating disordered women reported significantly higher levels of maternal overprotectiveness during childhood and had significantly higher levels of separation anxiety and lower healthy separation scores than non-eating disordered students.

Shared governance at Saint Joseph's Hospital of Atlanta: a mature professional practice model

Quality in work comes from people who care about what they do, are consistent, and have a desire to make a difference. This is not something that can be taught, but it can be nurtured. Patient care is the perfect place to start. Nurses participating in a shared practice situation can extend their working system to others. The rewards of quality care are felt by the patient, by the staff, and ultimately by the hospital. The desire to make a difference grows as more people become involved in a system. Developing systems that are positive, goal oriented, and rewarding is the first step toward shared practice. Shared governance then becomes a natural progression in determining the framework in which a nurse functions.

Occupational ideology and clinical decision-making in British nursing

As the first phase of a study to assess the usefulness of the nursing process model of nursing practice, a survey was carried out in one health district to ascertain the predominant occupational ideology of clinical nurses, their perception of decision-making about individual patient care in everyday work, and their view of whether they ought to exercise a decision-making role with respect to 23 aspects of patient care. Two hundred ideology scale questionnaires were processed, together with perceived and normative decisions inventories. Subjects were representative of six nursing fields, i.e. general nursing, geriatric nursing, psychiatric nursing, mental handicap nursing, health visiting and district nursing. The main findings were that nurses predominantly espouse a professional ideology, they perceive decision-making to be part of their everyday work and contend that they ought to be able to make decisions in 22 out of the 23 areas of patient care included in the inventories. Differences in ideology between the groups and between men and women are identified and discussed, and some areas of role conflict highlighted. The professional ideology was found to correlate significantly with decision-making and a significant correlation was established between paramedicine and bureaucracy.

Investigation into the microbial flora of healing and non-healing decubitus ulcers

Seventy-four pressure lesions in fifty-three geriatric patients were observed at weekly intervals to determine the bacterial flora and the healing index of each lesion, expressed as initial area of lesion (cm2) - final area of lesion (cm2) divided by time in days. The micro-organisms which caused infection included Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, Bacteroides fragilis and Bacteroides asaccharolyticus. Many lesions contained a mixed flora. P mirabilis and Ps aeruginosa were associated with necrotic (p less than 0.005) and enlarging (p less than 5 x 10(-7)) lesions. Bacteroides spp were associated with necrotic lesions (p less than 0.05). The presence of S aureus in a lesion was not associated with any particular trend in healing index. The implications of the microbiological findings are discussed.