CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings

BACKGROUND

Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU.

METHODS AND DESIGN

This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old).

AIM AND OBJECTIVES

The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks.

DISCUSSION

The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis.

TRIAL REGISTRATION

ISRCTN Number: 37176025, IRAS Number: 1004947.

TRIAL STATUS

In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.

Evaluation of risk factors for treatment failure in canine patients undergoing photoactivated chromophore for keratitis - corneal cross-linking (PACK-CXL): a retrospective study using additive bayesian network analysis

BACKGROUND

Infectious keratitis is a common ophthalmic condition in canine patients. Sequelae can include keratomalacia and corneal perforation, a vision threatening outcome. Photoactivated chromophore for keratitis - corneal cross-linking (PACK-CXL) is a non-surgical, adjunctive treatment method for infectious keratitis. The goal of this retrospective, multicenter study was to determine risk factors for treatment failure following PACK-CXL in canine patients suffering from suspected infectious keratitis. Medical records from four veterinary ophthalmology services were reviewed, and information related to patient demographics, ophthalmic findings, the PACK-CXL protocol used, and epithelialization time was collected and analyzed. Due to the potential for intervariable relationships, an additive Bayesian network (ABN) analysis was performed to evaluate these complex relationships.

RESULTS

Records for 671 eyes (668 dogs) were included in the analysis. Based on the ABN, in the population included here, patients who underwent an accelerated PACK-CXL protocol were less likely to experience treatment failure versus patients treated with a slow protocol. Mutual dependencies between exposure variables were identified by ABN, which would have been overlooked using classical regression. Corneal re-epithelialization time was shortened following PACK-CXL combined with topical medical therapy compared to PACK-CXL alone.

CONCLUSIONS

No risk factors associated with treatment failure were identified in the population included in the present study. Canine patients may benefit from the use of accelerated PACK-CXL protocols, especially when combined with topical antibiotics and anti-collagenolytic therapy. The reasons for this apparent positive impact on treatment outcome remain unclear.

A survey in the West Midlands of the United Kingdom of current practice in managing hypotension in lower segment caesarean section under spinal anaesthesia

BACKGROUND

Spinal anaesthesia, the most common form of anaesthesia for caesarean section, leads to sympathetic blockade and profound maternal hypotension resulting in adverse maternal and neonatal outcomes. Hypotension, nausea and vomiting remain common but until the publication of the National Institute of Health and Care Excellence (NICE) 2021 guidance, no national guideline existed on how best to manage maternal hypotension following spinal anaesthesia for caesarean section. A 2017 international consensus statement recommended prophylactic vasopressor administration to maintain a systolic blood pressure of >90% of an accurate pre-spinal value, and to avoid a drop to <80% of this value. This survey aimed to assess regional adherence to these recommendations, the presence of local guidelines for management of hypotension during caesarean section under spinal anaesthesia, and the individual clinician's treatment thresholds for maternal hypotension and tachycardia.

METHODS

The West Midlands Trainee-led Research in Anaesthesia and Intensive Care Network co-ordinated surveys of obstetric anaesthetic departments and consultant obstetric anaesthetists across 11 National Health Service Trusts in the Midlands, England.

RESULTS

One-hundred-and-two consultant obstetric anaesthetists returned the survey and 73% of sites had a policy for vasopressor use; 91% used phenylephrine as the first-line drug but a wide range of recommended delivery methods was noted and target blood pressure was only listed in 50% of policies. Significant variation existed in both vasopressor delivery methods and target blood pressures.

CONCLUSIONS

Although NICE has since recommended prophylactic phenylephrine infusion and a target blood pressure, the previous international consensus statement was not adhered to routinely.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Evaluating a multicomponent survivorship programme for men with prostate cancer in Australia: a single cohort study

OBJECTIVE

To evaluate the implementation of a multicomponent survivorship programme for men with prostate cancer and their carers.

DESIGN

A single cohort study, guided by the RE-AIM framework.

SETTING

Multiple health services in Australia.

PARTICIPANTS

Men with prostate cancer and their carers, and health professionals.

INTERVENTION

A 12-month telehealth programme that provided centralised and coordinated decision and information support, exercise and nutrition management, specialised clinical support and practical support to men and their carers.

DATA COLLECTION

Multiple sources of data including participant-reported health outcomes and experience of care, qualitative interviews, records of the programme were collected at different time points.

RESULTS

Reach: Of 394 eligible men at various stages of survivorship, 142 consented (36% consent rate) and 136 (96%) completed the programme. Adoption: All men participated in general care coordination and more than half participated in exercise and/or nutrition management interventions. Participation in the specialised support component (ie, psychosocial and sexual health support, continence management) was low despite the high level of need reported by men. Effectiveness: Overall, the men reported improvements in their experience of care. Implementation: Factors such as addressing service gaps, provision of specialised services, care coordination, adoption of needs-based and telehealth-based approaches were identified as enablers to the successful implementation of the programme. Issues such as insufficient integration with existing services, lack of resources and high caseload of the intervention team, men's reluctance to discuss needs and lack of confidence with technology were barriers in implementing the programme.

CONCLUSION

Survivorship interventions are relevant to men regardless of the stage of their disease and treatments undertaken. It is possible to provide access to a comprehensive model of survivorship care to promote the health and quality of life for men with prostate cancer.

TRIAL REGISTRATION NUMBER

This study was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12617000174381).

Getting the MOST out of follow-up: a randomized controlled trial comparing 3 monthly nurse led follow-up via telehealth, including monitoring CA125 and patient reported outcomes using the MOST (Measure of Ovarian Symptoms and Treatment concerns) with routine clinic based or telehealth follow-up, after completion of first line chemotherapy in patients with epithelial ovarian cancer

BACKGROUND

Physical symptoms, anxiety, depression, fear of recurrence, sexual dysfunction, and social withdrawal are common in women after treatment for ovarian cancer. Most patients would like and need help dealing with these symptoms. The traditional model of follow-up care is unstructured and largely focused on diagnosing recurrent disease, and most oncologists lack skills to identify and manage psychosocial issues. No high quality prospective clinical trials have been conducted to determine the optimal follow-up regimen or the cost effectiveness of ovarian cancer surveillance strategies.

PRIMARY OBJECTIVES

To assess emotional wellbeing, acceptability, safety, and cost effectiveness of nurse led follow-up via telehealth for women with ovarian cancer following completion of primary treatment.

STUDY HYPOTHESIS

We hypothesize that compared with routine clinic based follow-up, nurse led follow-up via telehealth, including serum CA125 monitoring and completion of a patient reported outcome instrument, the Measure of Ovarian Symptoms and Treatment concerns-Surveillance (MOST-S26), will improve emotional wellbeing in women with ovarian cancer; be feasible, safe, acceptable, and not delay the time to diagnosis of recurrent disease; will result in greater patient satisfaction; will identify more patients with psychological distress, lead to better care, and improved psychological outcomes; and be cost-effective.

TRIAL DESIGN

Phase II multicenter randomized trial comparing 3 monthly nurse led telehealth consultations that include serum CA125 monitoring and completion of the MOST-S26, with routine clinic based follow-up. The allocation ratio will be 1:1.

MAJOR INCLUSION/EXCLUSION CRITERIA

Eligible patients will be women with high grade epithelial ovarian cancer who have normalized serum CA125 (to <35 kU/L) at completion of first line chemotherapy.

PRIMARY ENDPOINTS

Emotional wellbeing at 12 months.

SAMPLE SIZE

150 patients.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

July 2023. Results expected in 2025, 24 months after the last participant is enrolled.

TRIAL REGISTRATION

ACTRN12620000332921.

An integrated multicomponent care model for men affected by prostate cancer: A feasibility study of TrueNTH Australia

OBJECTIVE

To evaluate the feasibility of implementing an integrated multicomponent survivorship care model for men affected by prostate cancer.

METHODS

Using a single arm prospective cohort study design, men with prostate cancer were recruited from two regional public hospitals in Australia for a 6-months program that provided information and decision support, exercise and nutrition management, specialised clinical support, and practical support through localised and central care coordination. Carers of the men were also invited to the program. Data were collected from multiple sources to evaluate: (1) recruitment capability and participant characteristics; (2) appropriateness and feasibility of delivering the specific intervention components using an electronic care management tool; and (3) suitability of data collection procedures and proposed outcome measures.

RESULTS

Of the 105 eligible men, 51 (consent rate 49%) participated in the program. Of the 31 carers nominated by the men, 13 consented (consent rate 42%). All carers and 50 (98%) men completed the program. Most (92%) men were newly diagnosed with localised prostate cancer. All men attended initial screening and assessment for supportive care needs; a total of 838 episodes of contact/consultation were made by the intervention team either in person (9%) or remotely (91%). The intervention was implemented as proposed with no adverse events. The proposed outcome measures and evaluation procedures were found to be appropriate.

CONCLUSIONS

Our results support the feasibility of implementing this integrated multicomponent care model for men affected by prostate cancer.

A role for cardiopulmonary exercise testing in detecting physiological changes underlying health status in Idiopathic pulmonary fibrosis: a feasibility study

Introduction

There is limited data available on the use of CPET as a predictive tool for disease outcomes in the setting of IPF. We investigated the feasibility of undertaking CPET and the relationship between CPET and quality of life measurements in a well-defined population of mild and moderate IPF patients.

Methods

A prospective, single-centre observational study.

Results

Thirty-two IPF patients (mild n = 23, moderate n = 9) participated in the study, n = 13 mild patients attended for repeat CPET testing at 12 months. At baseline, total K-BILD scores and total IPF-PROM scores significantly correlated with 6MWT distance, but not with baseline FVC % predicted, TLco % predicted, baseline or minimum SpO₂. VO₂ peak/kg at AT positively correlated with total scores, breathlessness/activity and chest domains of the K-BILD questionnaire (p < 0.05). VO₂ peak significantly correlated with total IPF PROM scores and wellbeing domains (p < 0.05), with a trend towards statistical significance for total IPF-PROM and VO₂ peak/kg at anaerobic threshold (p = 0.06).

There was a statistically significant reduction in FVC% predicted at 12 months follow up, although the mean absolute decline was < 10% (p < 0.05). During this period VO₂ peak significantly reduced (21.6 ml/kg/min ± 2.9 vs 19.1 ± 2.8; p = 0.017), with corresponding reductions in total K-BILD and breathlessness/activity domains that exceeded the MCID for responsiveness. Lower baseline VO₂ peak/kg at anaerobic threshold correlated with greater declines in total K-BILD scores (r =  − 0.62, 0.024) at 12 months. Whilst baseline FVC% predicted or TLco % predicted did not predict change in health status,

Conclusion

We have shown that it is feasible to undertake CPET in patients with mild to moderate IPF.

CPET measures of VO₂ peak correlated with both baseline and change in K-BILD measurements at 1 year, despite relatively stable standard lung function (declines of < 10% in FVC), suggesting its potential sensitivity to detect physiological changes underlying health status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01520-8.

Acceptability of intravenous propofol sedation for adolescent dental care

PURPOSE

Propofol is an intravenous anaesthetic agent commonly utilised in general anaesthesia, however in sub-anaesthetic concentrations can be utilised to provide sedation through automated dosing of target-controlled infusion (TCI). TCI has been shown to provide accurate and stable predicted plasma and effect-site concentrations of propofol. A four-part mixed-method prospective study was undertaken to evaluate the safety and patient acceptability of intravenous propofol sedation in adolescent patients requiring dental care. There is a paucity in the literature on patient-reported outcomes and patient safety in the management of adolescent patients for dental treatment.

METHODS

Demographics were recorded including age, gender, ASA Classification and Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) completed pre-operatively. Behaviour ratings of the Frankl and Houpt scales were recorded followed by post-operative questionnaire and telephone consultation. Consultation was completed following the procedure to determine patient satisfaction, memory of the procedure and any reported side effects of treatment. Qualitative thematic analysis was utilised.

RESULTS

55 patients were recruited for the study, of which 49 (mean age 14.67 years) completed the sedation study and were treated safely with no post-operative complications. The mean lowest oxygen saturation was 98.12% SpO₂ (SD 2.6). Thematic analysis demonstrated positive patient-reported outcomes to IV sedation.

CONCLUSION

Propofol TCI sedation is an effective treatment modality for the management of dentally anxious adolescents as a safe alternative to general anaesthesia, allowing the opportunity for increased provision of treatment per visit on those patients with a high dental need. Further randomised controlled trials comparing propofol TCI to other pharmacological managements are required.

Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review

Purpose

To determine in which clinical situations it is indicated or contra-indicated to prescribe cone beam computed tomography (CBCT) for paediatric patients.

Methods

Systematic review of in vivo paediatric research studies of diagnostic efficacy using CBCT, with supplementary searches for guideline documents on CBCT and for systematic reviews permitting inclusion of ex vivo and adult studies.

Results

After screening, 190 publications were included, mostly case studies. No systematic reviews were found of in vivo paediatric research. Fourteen studies of diagnostic efficacy were identified. The supplementary searches found 18 guideline documents relevant to the review and 26 systematic reviews. The diagnostic efficacy evidence on CBCT was diverse and often of limited quality. There was ex vivo evidence for diagnostic accuracy being greater using CBCT than radiographs for root fractures. The multiplanar capabilities of CBCT are advantageous when localising dental structures for surgical planning. Patient movement during scanning is more common in children which could reduce diagnostic efficacy.

Conclusions

No strong recommendations on CBCT are possible, except that it should not be used as a primary diagnostic tool for caries. Guidelines on use of CBCT in the paediatric age group should be developed cautiously, taking into account the greater radiation risk and the higher economic costs compared with radiography. CBCT should only be used when adequate conventional radiographic examination has not answered the question for which imaging was required. Clinical research in paediatric patients is required at the higher levels of diagnostic efficacy of CBCT.

Electronic supplementary material

The online version of this article (10.1007/s40368-019-00504-x) contains supplementary material, which is available to authorized users.

TAKING ACTION TO IMPROVE OUTCOMES FOR MEN LIVING WITH AND BEYOND PROSTATE CANCER

In Australia prostate cancer is the most commonly diagnosed cancer in men, with around 20,000 diagnosed each year (AIHW 2013, 2014). The many who survive it often battle with significant side-effects from treatment such as incontinence, loss of sexual function, fatigue and psychology issues.

An international, population-level initiative to promote healthy lifestyle practices among prostate cancer survivors

e287

Background: Growing evidence suggests that specific lifestyle practices (e.g., diet and exercise) may delay cancer progression among prostate cancer survivors (PCS) and restore post-treatment quality of life. However, there are limited efforts to translate this knowledge to sustainable behavior change among PCS at a population level. Methods: TrueNTH is an international partnership to develop innovative evidence-based interventions and care models to improve the physical and mental wellbeing of PCS. Within TrueNTH, four countries (U.S.A., Australia, Canada, U.K.) are developing solutions to improve lifestyle practices among PCS. Australia is implementing face-to-face and telehealth delivery of exercise and dietary programs facilitated by a web-based portal. Canada is implementing group-based exercise and yoga programs combined with a web-based portal to deliver exercise, nutrition and stress-reduction resources for PCS and caregivers. The U.K. is implementing a healthy living pharmacy approach to deliver tailored diet and exercise advice and support to men. The U.S. will implement a scalable web-based portal that reaches PCS, providers and partners and provides personalized exercise prescriptions and dietary advice, interactive guidance, and behavioral support via social media, tele-exercise, and face-to-face communities. Results: TrueNTH initiatives are in various phases of a three-year project. Australia has enrolled 30 of 80 men across 2 sites and via telehealth, and demonstrated acceptance of the portal. Canada has enrolled 30+ men in exercise programs and will soon add 4 sites and launch their portal. The UK has evaluated assessment protocols in 2 sites and will soon add a 3rd site and implement the pharmacy-based program. The U.S. is building the portal and supportive tools and will begin a trial in Fall 2016. Conclusions: Each TrueNTH program shares common goals to improve lifestyle practices among PCS. Common metrics across initiatives will allow for a global comparison of implementation approaches and assessment of impact at a population level. TrueNTH will utilize this initiative to create a lifestyle survivorship program that improves the lives of PCS worldwide.

Summary of the US FDA approval of belatacept

Elements of the Food and Drug Administration (FDA) review of the clinical data that supported the approval of the Biologics License Application (BLA) for belatacept for prophylaxis of organ rejection in adult patients receiving a kidney transplant are summarized. The article is not intended as a comprehensive summary of the entire belatacept data submission. Rather, the discussion is meant to illustrate aspects of the FDA's process for evaluating efficacy and safety, using belatacept as an example.

Transcultural considerations in obstetrics and gynaecology: what the clinician needs to know

Healthcare professionals working in the field of obstetrics and gynaecology may encounter patients from a variety of cultural backgrounds, particularly in our inner cities. These women may have similar cultural beliefs and values about aspects of care they experience compared with native women, but they may also have differing beliefs and may present with preconceptions about the care they expect to receive. In our experience, traditional medical training has limited core teaching on the existence of such cultural variations, and professionals often only experience them through working in the clinical setting. This review was, therefore, undertaken with the aim of increasing awareness of such variations, in order to promote more holistic management, and ultimately to enhance patient care.

Engineering a stable and selective peptide blocker of the Kv1.3 channel in T lymphocytes

Kv1.3 potassium channels maintain the membrane potential of effector memory (T(EM)) T cells that are important mediators of multiple sclerosis, type 1 diabetes mellitus, and rheumatoid arthritis. The polypeptide ShK-170 (ShK-L5), containing an N-terminal phosphotyrosine extension of the Stichodactyla helianthus ShK toxin, is a potent and selective blocker of these channels. However, a stability study of ShK-170 showed minor pH-related hydrolysis and oxidation byproducts that were exacerbated by increasing temperatures. We therefore engineered a series of analogs to minimize the formation of these byproducts. The analog with the greatest stability, ShK-192, contains a nonhydrolyzable phosphotyrosine surrogate, a methionine isostere, and a C-terminal amide. ShK-192 shows the same overall fold as ShK, and there is no evidence of any interaction between the N-terminal adduct and the rest of the peptide. The docking configuration of ShK-192 in Kv1.3 shows the N-terminal para-phosphonophenylalanine group lying at the junction of two channel monomers to form a salt bridge with Lys(411) of the channel. ShK-192 blocks Kv1.3 with an IC(50) of 140 pM and exhibits greater than 100-fold selectivity over closely related channels. After a single subcutaneous injection of 100 microg/kg, approximately 100 to 200 pM concentrations of active peptide is detectable in the blood of Lewis rats 24, 48, and 72 h after the injection. ShK-192 effectively inhibits the proliferation of T(EM) cells and suppresses delayed type hypersensitivity when administered at 10 or 100 microg/kg by subcutaneous injection once daily. ShK-192 has potential as a therapeutic for autoimmune diseases mediated by T(EM) cells.

Influence of testing sequence on a child's ability to achieve maximal anaerobic and aerobic power

The aim of the study was to examine the order of testing sequence on a child's ability to achieve maximal anaerobic and aerobic power. Thirty-two children (20 females, 12 males) between 7 - 11 years of age participated in this study. All subjects were tested on three separate occasions as follows: anaerobic power session - Wingate Anaerobic Test (WAnT) only; aerobic power session - maximal oxygen consumption (V.O (2max)) test only; and experimental session - WAnT followed by a V.O (2max) test (WAnT/V.O (2max)) or a V.O (2max) test followed by a WAnT (V.O (2max)/WAnT), each with 20 minutes of rest between the assessments. No significant differences were observed between the baseline WAnT or V.O (2max) between the two groups. No significant differences were observed for WAnT power values in either group regardless of testing sequence. Children in the WAnT/V.O (2max) group had significantly lower experimental V.O (2max) (38.6 +/- 7.6 vs. 40.6 +/- 7.4 mL . kg (-1) . min (-1); p < 0.05), RER (1.10 +/- 0.08 vs. 1.13 +/- 0.07; p < 0.05), and exercise time (472 +/- 87 vs. 511 +/- 79 s; p < 0.01) values when compared to the baseline V.O (2max) test. The results of this study indicate that when assessing a child's anaerobic and aerobic power during the same testing session, the testing sequence is of importance. However, it appears that a V.O (2max) test can be performed 20 minutes prior to the WAnT without affecting anaerobic power in children.

Element levels in snakes in South Carolina: differences between a control site and exposed site on the Savannah River site

Levels of 18 elements, including lead, mercury, selenium, and uranium, were examined in three species of snakes from an exposed and reference site on the Department of Energy's Savannah River Site in South Carolina. We tested the hypotheses that there were no differences as a function of species, and there were no difference between the exposed and control site for blood and muscle (tail) samples for banded water snake (Nerodia fasciata), brown water snake (N. taxispilota) and cotton mouth (Akistrodon piscivorous). The banded water snakes collected were significantly smaller than the other two species. For blood, there were significant species differences only for barium, copper, selenium, uranium and zinc, while for muscle tissue there were significant interspecific differences in aluminum, arsenic, barium, cobalt, cesium, copper, iron, lead, mercury, manganese, strontium, vanadium and zinc, suggesting that muscle tissue in the tail is a better indicator of potential interspecific differences. It is also easier logistically to collect tail tissue than blood. Where one species had significantly higher levels than the other species in muscle tissue levels, cottonmouth had higher levels of five elements (aluminum, cobalt, lead, mercury, vanadium), brown water snake had two (lead, strontium), and banded water snake had only barium. There were few significant differences between the control and reference site for levels of blood, but several for muscle tissue. All three species had significantly higher levels of arsenic and manganese at Tim's Branch than the reference site, and nickel and uranium were significantly higher for banded water snake and cotton mouth, the larger species. Individuals with high exposure of one element were exposed to high levels of other elements.

Perceptions of general environmental problems, willingness to expend federal funds on these problems, and concerns regarding the Los Alamos National Laboratory: Hispanics are more concerned than Whites

Perceptions about general environmental problems, governmental spending for these problems, and major concerns about the US Department of Energy's Los Alamos National Laboratory (LANL) were examined by interviewing 356 people attending a gun show in Albuquerque, New Mexico. The hypothesis that there are differences in these three areas as a function of ethnicity was examined. We predicted that if differences existed, they would exist for all three evaluations (general environmental problems, government spending, and environmental concerns about LANL). However, this was not the case; there were fewer ethnic differences concerning LANL. Hispanics rated most general environmental problems higher than Whites and rated their willingness to expend federal funds higher than Whites, although all groups gave a lower score on willingness than on concern. Further, the congruence between these two types of ratings was higher for Hispanics than for others. In general, the concerns expressed by subjects about LANL showed few ethnic differences, and everyone was most concerned about contamination. These data indicate that Hispanics attending a gun show are equally or more concerned than others about environmental problems generally but are not more concerned about LANL. The data can be useful for developing future research and stewardship plans and for understanding general environmental problems and their relationship to concerns about LANL. More generally, they indicate that the attitudes and perceptions of Hispanics deserve increased study in a general population.

HIV evolution: CTL escape mutation and reversion after transmission

Within-patient HIV evolution reflects the strong selection pressure driving viral escape from cytotoxic T-lymphocyte (CTL) recognition. Whether this intrapatient accumulation of escape mutations translates into HIV evolution at the population level has not been evaluated. We studied over 300 patients drawn from the B- and C-clade epidemics, focusing on human leukocyte antigen (HLA) alleles HLA-B57 and HLA-B5801, which are associated with long-term HIV control and are therefore likely to exert strong selection pressure on the virus. The CTL response dominating acute infection in HLA-B57/5801-positive subjects drove positive selection of an escape mutation that reverted to wild-type after transmission to HLA-B57/5801-negative individuals. A second escape mutation within the epitope, by contrast, was maintained after transmission. These data show that the process of accumulation of escape mutations within HIV is not inevitable. Complex epitope- and residue-specific selection forces, including CTL-mediated positive selection pressure and virus-mediated purifying selection, operate in tandem to shape HIV evolution at the population level.

A pragmatic cluster randomized controlled trial of an educational intervention for GPs in the assessment and management of depression

BACKGROUND

General practitioners (GPs) can be provided with effective training in the skills to manage depression. However, it remains uncertain whether such training achieves health gain for their patients.

METHOD

The study aimed to measure the health gain from training GPs in skills for the assessment and management of depression. The study design was a cluster randomized controlled trial. GP participants were assessed for recognition of psychological disorders, attitudes to depression, prescribing patterns and experience of psychiatry and communication skills training. They were then randomized to receive training at baseline or the end of the study. Patients selected by GPs were assessed at baseline, 3 and 12 months. The primary outcome was depression status, measured by HAM-D. Secondary outcomes were psychiatric symptoms (GHQ-12) quality of life (SF-36), satisfaction with consultations, and health service use and costs.

RESULTS

Thirty-eight GPs were recruited and 36 (95%) completed the study. They selected 318 patients, of whom 189 (59%) were successfully recruited. At 3 months there were no significant differences between intervention and control patients on HAM-D, GHQ-12 or SF-36. At 12 months there was a positive training effect in two domains of the SF-36, but no differences in HAM-D, GHQ-12 or health care costs. Patients reported trained GPs as somewhat better at listening and understanding but not in the other aspects of satisfaction.

CONCLUSIONS

Although training programmes may improve GPs' skills in managing depression, this does not appear to translate into health gain for depressed patients or the health service.

Perceptual indicators of environmental health, future land use, and stewardship

There are important linkages between the health of humans and the environment, restoration of degraded lands, and long-term stewardship of public lands, yet most environmental indicators deal only with assessing the physical and biological aspects of ecosystems. In this article, we examine the ratings of perceptions of several environmental problems for their utility as indicators of environmental quality, and examine perceptions of future land use by people interviewed in Santa Fe, New Mexico, near the Department of Energy's (DOE) Los Alamos National Laboratory (LANL). Overall, people with lower incomes rated environmental problems as more severe than others, were more willing to spend federal funds to solve them, and were consistent in their ratings of severity of environmental problems and their willingness to spend federal funds. Cleaning up LANL and other Department of Energy sites, received the highest rating for expenditure of federal funds. The highest rated future uses for DOE sites were for recreation and for National Environmental Research Parks. People with less education generally gave higher ratings to most future land uses for DOE than did those with more education. However, those with higher education gave higher ratings to nuclear reprocessing, and nuclear material storage. Where there were differences, the people interviewed at Santa Fe rated all environmental problems (except pesticides) as more severe than did those previously interviewed in Albuquerque (located farther from the LANL site), and they were more willing to spend federal funds on these problems. Ratings for all future land uses did not differ between the Santa Fe and Albuquerque respondents. These perception-based indicators show general agreement among people living close and farther away from LANL with respect to cleaning up LANL and the future land uses for the site. These indicators should be considered by regulators, site personnel, and policy makers in future management and land use decisions.

Metals in horseshoe crabs from Delaware Bay

We examined the concentrations of arsenic, cadmium, chromium, lead, manganese, mercury, and selenium in the eggs, leg muscle, and apodeme (carapace musculature) in horseshoe crabs ( Limulus polyphemus) from eight places on the New Jersey and Delaware sides of Delaware Bay to determine whether there were locational differences. Although there were locational differences, the differences were not great. Further, contaminant levels were generally low. The levels of contaminants found in horseshoe crabs were well below those known to cause adverse effects in the crabs themselves or in organisms that consume them or their eggs. Contaminant levels have generally declined in the eggs of horseshoe crabs from 1993 to 2001, suggesting that contaminants are not likely to be a problem for secondary consumers or a cause of their decline.

Exposure of South Carolinians to commercial meats and fish within their meat and fish diet

There has been considerable interest in the public's exposure to a variety of contaminants through the consumption of wild fish and game, yet there is little information on consumption of commercial meats and fish, or the relationship between commercial and self-caught fish. We conducted a dietary survey in 1999 to estimate exposure levels of 464 individuals from people attending the Palmetto Sportsmen's Classic. Mean consumption was similar for beef, chicken/turkey, and wild-caught fish, and much lower for pork and store-bought fish, and still lower for restaurant fish. There were no ethnic differences in the consumption of most commercial fish and meats, although the differences for chicken approached significance. There were significant ethnic differences in consumption of wild-caught fish. Women ate significantly less of all meat types, except store-bought fish. People over 45 ate less beef than younger people, and people younger than 32 ate significantly more chicken than others. There were no significant differences in consumption patterns as a function of income, except for chicken and wild-caught fish; people with higher incomes ate more chicken than others, and people with lower incomes ate more wild-caught fish than others. When all wild-caught and commercial fish and meats are considered, there are significant differences only for ethnicity and gender. Blacks consume significantly more fish than Whites, and men consume significantly more than women.

Metals in feathers of sooty tern, white tern, gray-backed tern, and brown noddy from islands in the North Pacific

Levels of heavy metals are usually higher in adult than young birds because they eat larger, more contaminated prey, or because they have had longer to accumulate metals in their tissues. Further, levels of contaminants are usually less in birds nesting on remote, offshore islands than in birds breeding closer to mainland areas that are urbanized and industrialized. We examined the feather levels of arsenic, cadmium, chromium, lead, manganese, mercury, and selenium in adult sooty terns (Sterna fuscata), gray-backed terns (Sterna lunata), and brown noddy (Anous stolidus, and adult and young white terns (Gygis alba, from Midway Atoll, and in adult and young sooty terns and adult brown noddy from Manana Island, Hawaii (chicks of other terns were not available). We tested and rejected the null hypotheses that metal levels are not significantly different among species, ages, and locations. Despite their small size, adult white terns had the highest levels of lead, arsenic and tin. Brown noddies had the highest levels of cadmium, chromium, manganese, and selenium. Sooty and white terns had the highest levels of mercury. Sooty tern adults had significantly higher levels of cadmium, mercury, and selenium than young, while young had significantly higher levels of arsenic and manganese. White tern adults had significantly higher levels of selenium and tin than young, while young had higher levels of cadmium and mercury than adults. Except for mercury, there were significant inter-location differences within species in all heavy metals. Contrary to expectation, where the differences were great, metals generally were higher in the feathers of terns and noddies from Midway than from Manana.

Expression, candidate gene, and population studies of the melanocortin 5 receptor

In mouse the melanocortin 5 receptor is known to regulate sebaceous gland function. To clarify its role in man, we have studied melanocortin 5 receptor expression in skin, and allelic variation at the melanocortin 5 receptor locus in diverse human populations and candidate disease groups. Melanocortin 5 receptor protein and mRNA expression were studied by immunohistochemistry and reverse transcriptase polymerase chain reaction. Melanocortin 5 receptor mRNA was detected in normal skin and cultured keratinocytes but not in cultured fibroblasts or melanocytes. Immunohistochemistry revealed melanocortin 5 receptor immunoreactivity in the epithelium and appendages, including the sebaceous gland, eccrine glands, and apocrine glands, as well as low level expression in the interfollciular epidermis. In order to screen for genetic diversity in the melanocortin 5 receptor that might be useful for allelic association studies we sequenced the entire melanocortin 5 receptor coding region in a range of human populations. One nonsynonymous change (Phe209Leu) and four synonymous changes (Ala81Ala, Asp108Asp, Ser125Ser, and Thr248Thr) were identified. Similar results were found in each of the populations except for the Inuit in which only the Asp108Asp variant was seen. The apparent "global distribution" of melanocortin 5 receptor variants may indicate that they are old in evolutionary terms. Variation of melanocortin 5 receptor was examined in patients with acne (n = 21), hidradenitis supprativa (n = 4), and sebaceous gland lesions comprising sebaceous nevi, adenomas, and hyperplasia (n = 13). No additional mutations were found. In order to determine the functional status of the Phe209Leu change, increase in cAMP in response to stimulation with alpha-melanocyte-stimulating hormone was measured in HEK-293 cells transfected with either wild-type or the Phe209Leu variant. The variant melanocortin 5 receptor was shown to act in a concentration-dependent manner, which did not differ from that of wild type. We have therefore found no evidence of a causative role for melanocortin 5 receptor in sebaceous gland dysfunction, and in the absence of any association between variation at the locus and disease group, the pathophysiologic role of the melanocortin 5 receptor in man requires further study.

A cyclopentenone prostaglandin activates mesangial MAP kinase independently of PPARgamma

The mitogen-activated protein (MAP) kinases mediate the response of renal glomerular mesangial cells to a variety of physiologic and pathologic stimuli. This investigation examines the effect of the cyclopentenone prostaglandin 15-deoxy-delta(12,14)-prostaglandin J2 (15d-PGJ2) on MAP kinases in human mesangial cells. We show that 15d-PGJ2 dose-dependently increases the extracellular signal-regulated kinase (ERK) activity of human mesangial cells, but has no effect on Jun-NH2-terminal kinase or p38 MAP kinase. Despite the fact that 15d-PGJ2 is a peroxisome proliferator-activated receptor (PPAR) ligand, and PPARgamma is shown to be expressed by mesangial cells, the thiazolidinedione PPARgamma agonist ciglitazone does not activate ERK. Additionally, a synthetic PPARgamma antagonist does not attenuate the activation of ERK by 15d-PGJ2. 15d-PGJ2-mediated ERK activation is however blocked by the MEK inhibitor PD 098059, appears to require phosphatidylinositol-3 kinase, but is independent of protein kinase C activation. These results demonstrate a novel effect of 15d-PGJ2 to induce ERK in human mesangial cells independently of PPARgamma.

The abundance of Met30p limits SCF(Met30p) complex activity and is regulated by methionine availability

Ubiquitin-mediated degradation plays a crucial role in many fundamental biological pathways, including the mediation of cellular responses to changes in environmental conditions. A family of ubiquitin ligase complexes, called SCF complexes, found throughout eukaryotes, is involved in a variety of biological pathways. In Saccharomyces cerevisiae, an SCF complex contains a common set of components, namely, Cdc53p, Skp1p, and Hrt1p. Substrate specificity is defined by a variable component called an F-box protein. The F- box is a approximately 40-amino-acid motif that allows the F-box protein to bind Skp1p. Each SCF complex recognizes different substrates according to which F-box protein is associated with the complex. In yeasts, three SCF complexes have been demonstrated to associate with the ubiquitin-conjugating enzyme Cdc34p and have ubiquitin ligase activity. F-box proteins are not abundant and are unstable. As part of the SCF(Met30p) complex, the F-box protein Met30p represses methionine biosynthetic gene expression when availability of L-methionine is high. Here we demonstrate that in vivo SCF(Met30p) complex activity can be regulated by the abundance of Met30p. Furthermore, we provide evidence that Met30p abundance is regulated by the availability of L-methionine. We propose that the cellular responses mediated by an SCF complex are directly regulated by environmental conditions through the control of F-box protein stability.

Do general practitioners' attitudes towards depression predict their clinical behaviour?

BACKGROUND

GPs' attitudes towards depression vary, as do their abilities to detect and manage it effectively. Associations between attitudes and clinical behaviour have not yet been demonstrated directly. We tested two hypotheses: (1) that questionnaire measures of GPs' confidence in identifying depression predict their ability to identify depression in their patients; and (2) that GPs who prefer antidepressants prescribe more than those who prefer psychotherapy.

METHODS

Forty GPs in Liverpool and Manchester completed the Depression Attitude Questionnaire (DAQ) and were asked for prescribing (PACT) information. Attender surveys using the General Health Questionnaire (GHQ-12), in combination with GP ratings of patients' psychological status, generated indices for GPs' case identification, bias and accuracy. We tested associations between these indices and the four DAQ components, in particular GPs' confidence in diagnosis, across a total of 1436 patients. We also compared the DAQ component on attitudes to treatment with relevant PACT data.

RESULTS

The DAQ assessment of GPs' ability to identify cases of depression bore no relationship to their observed ability, as measured by accuracy, bias, or identification indices. However, there were significant associations between observed diagnostic ability and: preference for psychotherapy; ease in managing depression; and, belief in successful treatment. PACT data were available for 26 (65%) GPs. There was an association between preference for antidepressants and prescription of SSRIs (rs 0.3981, P < 0.044), but not for overall antidepressant or tricyclic prescribing, or for dose of dothiepin.

CONCLUSIONS

The DAQ measure of ease of identification is not valid when compared to actual clinical practice. The ability of GPs to identify depression may not be an independent variable, but may rather reflect other beliefs, attitudes and skills. This has considerable implications for educational interventions in primary care.

Detection of circulating uroplakin-positive cells in patients with transitional cell carcinoma of the bladder

PURPOSE

Although transitional cell carcinoma of the bladder (TCC) metastasizes frequently with devastating consequences, no marker has been available to monitor this process. Uroplakins are a group of specific markers for normal urothelium and are continuously expressed by the majority of TCCs. Detection of uroplakin-positive cells in the circulation would be a strong indication of hematogenous dissemination of tumor cells in patients with TCC.

MATERIALS AND METHODS

Total RNAs were extracted from peripheral blood of 60 patients with TCC (50 non-metastatic and 10 metastatic) and 10 healthy controls, reverse-transcribed and subjected to polymerase chain reaction amplification (RT-PCR) using oligonucleotide primers of human uroplakin II gene. A uroplakin-expressing human bladder cancer cell line (RT4) was used as a positive control to establish the sensitivity of the RT-PCR assay.

RESULTS

We showed that the PCR-amplification of the mRNA encoding uroplakin II (UPII), a 15-kDa urothelium-specific marker, constitutes a highly sensitive and specific assay for detecting 100% of transitional cell carcinoma tissue, and that this assay can detect a single bladder cancer cell in a 5-ml. blood sample. UPII mRNA was detected in the blood samples of 2 patients with metastatic bladder cancer without chemotherapy and 1 out of 8 such patients with chemotherapy, but not in those of 50 non-metastatic patients or normal controls.

CONCLUSIONS

Uroplakin II is a highly specific marker for human TCC and the detection of uroplakin II in the peripheral blood is associated with metastatic spread of bladder cancer cells. The specific and sensitive detection of uroplakin II provides a useful adjunct for detecting bladder cancer metastasis, staging, and monitoring chemotherapeutic response.

An outbreak of Serratia marcescens infections related to contaminated chlorhexidine

An outbreak of Serratia marcescens infections occurred in a university tertiary-care hospital. Alcohol-free chlorhexidine solutions were contaminated with S marcescens. The majority of patient and chlorhexidine strains had similar pulsed field-gel electrophoresis banding patterns. Chlorhexidine was recalled, and the rate of S marcescens isolation returned to baseline. Chlorhexidine without alcohol should not be used as an antiseptic.

Intestinal trefoil factor controls the expression of the adenomatous polyposis coli-catenin and the E-cadherin-catenin complexes in human colon carcinoma cells

Intestinal trefoil factor 3 (TFF3) is a member of the trefoil family of peptides, small molecules constitutively expressed in epithelial tissues, including the gastrointestinal tract. TFF3 has been shown to promote migration of intestinal epithelial cells in vitro and to enhance mucosal healing and epithelial restitution in vivo. In this study, we evaluated the effect of recombinant TFF3 (rTFF3) stimulation on the expression and cellular localization of the epithelial (E)-cadherin-catenin complex, a prime mediator of Ca2+ dependent cell-cell adhesion, and the adenomatous polyposis coli (APC)-catenin complex in HT29, HCT116, and SW480 colorectal carcinoma cell lines. Stimulation by rTFF3 (10(-9) M and 10(-8) M) for 20-24 hr led to cell detachment and to a reduction in intercellular adhesion in HT29 and HCT116 cells. In both cell lines, E-cadherin expression was down-regulated. The expression of APC, alpha-catenin and beta-catenin also was decreased in HT29 cells, with a translocation of APC into the nucleus. No change in either cell adhesion or in the expression of E-cadherin, the catenins, and APC was detected in SW480 cells. In addition, TFF3 induced DNA fragmentation and morphological changes characteristic of apoptosis in HT29. Tyrphostin, a competitive inhibitor of protein tyrosine kinases, inhibited the effects of TFF3. Our results indicate that by perturbing the complexes between E-cadherin, beta-catenin, and associated proteins, TFF3 may modulate epithelial cell adhesion, migration, and survival.

Squamous cell carcinoma of the penis in a circumcised man: a case for dermatology and urology, and review of the literature

Squamous cell carcinoma of the penis is most frequent in uncircumcised men. Other contributing factors include human papillomavirus infection, phimosis, balanitis, and smoking. We present a patient, circumcised at birth, who showed penile squamous cell carcinoma in situ and was treated with carbon dioxide laser ablation. Squamous cell carcinoma rarely presents in patients circumcised as infants. Factors contributing to chronic inflammation may predispose to this disease. Carbon dioxide and neodymium:YAG lasers are two modalities that are successful in the treatment of in situ and probably early invasive penile carcinoma. Optimal treatment includes coordination with a urologist if urethral disease is present.

Total prostate and transition zone volumes, and transition zone index are poorly correlated with objective measures of clinical benign prostatic hyperplasia

PURPOSE

We determined if total prostate volume, transition zone volume or transition zone index is correlated with the severity of clinical benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A total of 93 men 52 to 85 years old, who were referred to a urology outpatient facility for treatment of clinical BPH, elevated serum prostate specific antigen or abnormal digital rectal examination, underwent measurement of total prostate and transition zone volume at transrectal ultrasonography. All men were requested to undergo uroflowmetry and complete the American Urological Association (AUA) symptom score.

RESULTS

The pairwise correlations between AUA symptom score, versus total prostate and transition zone volumes and transition zone index were not statistically or clinically significant. A weak pairwise relationship was observed between peak flow rate versus total prostate volume (r2 = 0.160), transition zone volume (r2 = 0.156) and transition zone index (r2 = 0.147). The pairwise relationships between AUA symptom scores versus all prostate volumes were not statistically significant for subjects with mild (score 8 or less) or moderate to severe (score more than 8) symptoms.

CONCLUSIONS

Total prostate and transition zone volumes, and transition zone index are not directly related to AUA symptom score and only weakly related to peak flow rate. These findings provide further evidence that the total prostate, total BPH and relative BPH volumes are not useful determinants of the severity of clinical BPH.

Effect of terazosin on prostatism in men with normal and abnormal peak urinary flow rates

OBJECTIVES

To determine if men with normal peak urinary flow rates (PFR) and prostatism respond to terazosin.

METHODS

Forty-one men over the age of 50 years with an American Urological Association (AUA) symptom score greater than 8, postvoid residual urine volume (PVR) less than 300 mL, and no clinical or biochemical evidence of prostate cancer were treated with terazosin independent of the baseline PFR. The effect of terazosin on the AUA symptom score and PFR were compared for subjects with a PFR of 15 mL/s or less (group I) and those with a PFR greater than 15 mL/s (group II).

RESULTS

The baseline age, AUA symptom score, prostate volume, and PVR were not significantly different between the two groups. The mean changes in AUA symptom score were -45.0% and -49.5% for groups I and II, respectively. The mean changes in PFR were 7.0% and -26.6% for groups I and II, respectively.

CONCLUSIONS

The effect of terazosin on AUA symptom score is independent of baseline PFR, indicating that the mechanism of action of terazosin is not exclusively mediated by reduction of bladder outlet obstruction. Randomized controlled studies are required to confirm this provocative observation.

Sustainable urbanization in Vietnam

"This paper examines the nature of [urban-based economic growth in Vietnam] and contends that the present size of Ho Chi Minh City and Hanoi are much greater than official figures suggest. It then goes on to review the situation with regard to urban poverty, basic needs and the environment to illustrate the extent to which this unacknowledged growth is not only threatening the sustained expansion of those cities, but also the sustainability of the economic growth on which the country is so reliant."