Expansion of the Fertility Preservation Program to All Newly Diagnosed Prepubertal Patients with Cancer at a Pediatric Hospital

Background: As the majority of pediatric patients with cancer survive their disease, generating a population of over 500,000 childhood cancer survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which include temporary or permanent infertility caused by certain cancer treatments. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding the likelihood of gonadal dysfunction and to consider fertility preservation. Method: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal patients with cancer who met the criteria for fertility tissue preservation were correctly identified and offered an educational consultation and preservation. Results: Between July 15, 2022 and October 30, 2022, 54 patients' treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network's Risk Assessment tool. Fifteen patients were at a high level of significantly increased risk and 13 were eligible for consultation. Seven (46%) patients and their families received a consultation. Initiation of treatment before referral was the primary reason for lack of consultation. Six of seven patients receiving consultation (86%) elected to undergo preservation. Preservation procedures did not cause a delay in starting treatment for those patients. Discussion: A fertility preservation program with established policies and processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

Improved Screening for Depression in Patients Initiating Fertility Treatment

OBJECTIVE

To improve screening for depression in patients who are initiating fertility treatment at a reproductive endocrinology and infertility (REI) center by screening all patients at their initial visit using the Patient Health Questionnaire-9 (PHQ-9).

DESIGN

This quality improvement project was conducted using a plan-do-study-act cycle implemented with a postintervention study design.

SETTING/LOCAL PROBLEM

A medium-size REI center in a mid-Atlantic U.S. metropolitan area where screening for mental health status in patients initiating fertility treatments was not occurring.

PARTICIPANTS

Patients who were scheduled in person with REI providers for a new patient consult regarding fertility were declared eligible.

INTERVENTION/MEASUREMENTS

The PHQ-9 was administered by providers at initial consults for patients seeking fertility treatments from October 2022 to February 2023. Three cycles of the plan-do-study-act model were used to execute change. For all patients who scored 5 to 9 (mild depression), conversations regarding counseling referrals occurred. For all patients who scored ≥10 (moderate to severe depression), a referral for counseling and medication management was generated. Data were analyzed via descriptive statistics.

RESULTS

A total of 115 participants were included. A screening rate of 84.3% (n = 97) was achieved for patients initiating treatment. Of the 97 screened, 21 patients had a score of ≥5; 19 were given a referral for counseling. However, none of the patients attended a counseling session or started medication prescribed by their primary care provider during the 2-month follow-up period. Barriers identified included costs, personal preferences, and access to services.

CONCLUSION

The PHQ-9 screening tool was implemented at an REI clinic to improve the frequency of mental health screenings and provide necessary referrals. However, additional follow-up is needed to ensure patients are receiving appropriate mental health care.

Implementation of the Caprini risk assessment model (RAM) in surgical patients to decrease postsurgical venous thromboembolism and enoxaparin prescription at hospital discharge

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), has been an increasingly common post-surgical complication for surgical patients. In the United States, VTE has become a leading cause of preventable hospital death with more than half occurring after discharge and are directly linked to a recent (within 30 days) hospitalization or surgery [1]. In large, hospital-associated/acquired VTE (HA-VTE) are preventable through measures such as the use of risk stratification tools and chemoprophylaxis. The project institution, a community, academic, medical center, for multiple years has consistently remained a high outlier for postoperative VTE. Also, the choice of VTE chemoprophylaxis in surgical patients at the time of discharge depended on, and varied between, the individual prescribing physician. The goal was to implement and determine the efficacy of a standardized intervention tool, the Caprini risk assessment model (RAM), for reducing postoperative VTE complications and its influence on the physician's prescription of enoxaparin at discharge. Results: Risk assessment scoring pre-operatively increased from 0% baseline to 26.3% at Plan-Do-Study-Act (PDSA) cycle 1 and demonstrated a statistically significant change (p-value = 0.006). Risk assessment scoring pre-operatively was 42.9% by PDSA cycle 2 but was not statistically significantly different from PDSA cycle 1. Risk assessment scoring post-operatively (for eligible patients) remained the same throughout all three cycles at 0%. Appropriate prescription of anticoagulation declined from baseline (12.5%) to PDSA cycle 1 (0%), and improved at PDSA cycle 2 (33.3%), however no differences were significant (p-value 0.302). The National Surgical Quality Improvement Project (NSQIP) database showed a decline in VTE occurrences at the projects institution from baseline (1.02%, 6 occurrences, 2021) to PDSA cycle 2 (0.92%, 4 occurrences, 2022) when compared to the national benchmark (1.0%) for the first time since 2018. Given the significant national problem HA-VTE pose to the public, and the rise in occurrences, this quality improvement (QI) project is clinically relevant.

Reproductive endocrinology and infertility nurse online orientation program evaluation: a quality improvement initiative

Objective

To evaluate the effectiveness of a novel online orientation program (Nurses in REI Communication, Knowledge, and Skills [NRCKS]) among new and early-career reproductive endocrinology nurses to make recommendations for program quality improvement.

Design

Quality improvement.

Subjects

Reproductive endocrinology nurses.

Exposure

Online orientation program featuring 8 micromodules.

Main Outcome Measures

Knowledge acquisition, confidence, user experience, skills, and abilities.

Results

Nurses demonstrated a statistically significant increase in reproductive knowledge after completion of NRCKS. Most nurse users felt confident applying knowledge in the clinical settings after program completion. Nurse users had an overall positive experience with interactive components and quality of visuals. Most nurse users gained skills and abilities that they will implement into professional practice. Nurses suggested improving navigation, adding more visuals in content expert presentations, and teaching soft skills necessary for the role of reproductive endocrinology nurses.

Conclusions

Nurses in REI Communication, Knowledge, and Skills was well received by nurse participants and emphasized the receptivity and desire for reproductive health and fertility training among novice reproductive endocrinology nurses. Nurses in REI Communication, Knowledge, and Skills increased nursing knowledge, and nurses felt confident applying newly gained knowledge in the clinical setting on completion. Nurse participants provided invaluable feedback for quality improvement to inform the hard launch. The results emphasize the online orientation's strong potential to close the theory-practice gap.

Infertility and treatment-seeking practices among females and males with sickle cell disease in the Sickle Cell Disease Implementation Consortium registry

OBJECTIVE

To describe the prevalence of infertility and infertility treatment seeking among people enrolled in the Sickle Cell Disease Implementation Consortium (SCDIC) registry and identify sociodemographic and clinical correlates of infertility.

DESIGN

Cross-sectional.

PARTICIPANTS

The study population included 2108 women and men (≥18 years of age) enrolled in the SCDIC registry who completed the fertility questionnaire.

RESULTS

All participants who completed the infertility-specific questions were included in the analysis (1224 females; 884 males). Of these, 16.9% of males and 23.7% of females reported infertility, in contrast to rates in the general population (12% of males; 11% of females). Only 22.8% of this subgroup had sought a fertility consultation; of these, 41% received infertility testing and 58% received advice, yet only a few received specific treatment: ovulation medication (19.1%), fallopian tubal surgery (4.8%), other female treatment (17.5%), varicocelectomy (8.1%), or other male treatment (10.8%). Increasing age, employment status, and interaction between gender and single marital status are associated with reported infertility. We did not observe differences between groups relative to sickle cell disease (SCD) genotype, a broad category of self-reported hydroxyurea use any time during life, type of medical insurance, income, or education.

CONCLUSION

To our knowledge, this is the first study to examine self-reported identification of and treatment for infertility among a large sample of people with SCD. These findings suggest that (a) infertility occurs at a higher rate, but fertility care treatment seeking is less frequent than in the general public; and (b) sociodemographic and clinical differences between individuals who report experiencing infertility and those who do not did not emerge in this study.

Sex-based differences in the manifestations and complications of sickle cell disease: Report from the Sickle Cell Disease Implementation Consortium

INTRODUCTION

Sex-based clinical outcome differences in sickle cell disease (SCD) remain largely unknown despite evidence that female sex is associated with an increased lifespan. To better characterize sex-based differences in SCD, we assessed pain, treatment characteristics, laboratory measures and complications among males and females currently enrolled in the Sickle Cell Disease Implementation Consortium (SCDIC) registry.

METHODS

The SCDIC consists of eight comprehensive SCD centers and one data coordinating center that received funding from the National Heart Lung and Blood Institute to improve outcomes for individuals with SCD. Eligibility criteria included: 15 to 45 years of age and a confirmed diagnosis of SCD. Self-report surveys were completed and data were also abstracted from the participants' medical records.

RESULTS

A total of 2,124 participants were included (mean age: 27.8 years; 56% female). The majority had hemoglobin SS SCD genotype. Females had worse reports of pain severity (mean (SD) T-score 51.6 (9.6) vs 49.3 (10), p<0.001), more vaso-occlusive episodes (p = 0.01) and a higher occurrence of 3 or more hospital admissions in the past year (30.9% vs. 25.5, p = 0.03). On multivariable analysis, males had higher odds of acute chest syndrome (odds ratio (OR) 1.4, p = 0.002), cardiovascular (OR 1.70, p<0.001) and musculoskeletal (OR 1.33, p = 0.0034) complications and lower odds of depression (OR 0.77, p = 0.0381). Females had higher fetal hemoglobin levels with and without hydroxyurea use (9.6% vs 8.5%, p = 0.03 and 3% vs 2.2%, p = 0.0005, respectively).

CONCLUSION

Our data suggests that sex differences in clinical outcomes do occur among individuals with SCD. Future research needs to explore the mechanisms underlying these differences.

Systematic Screening for Perinatal Mood and Anxiety Disorders to Promote Onsite Mental Health Consultations: A Quality Improvement Report

INTRODUCTION

Perinatal mood and anxiety disorders are the most common complication during pregnancy and postpartum. Screening, diagnosis, and treatment for these disorders are inhibited by limited mental health resources for patients and health care providers, lack of provider training, and time constraints. Systematic screening combined with onsite mental health consultation is an evidence-based method to increase timely diagnosis and treatment. The purpose of this quality improvement project was to promote and improve onsite mental health consultations through the implementation of a systematic screening guideline.

PROCESS

The systematic screening guidelines included administration of the Patient Health Questionnaire-9 at the perinatal intake visit, the Edinburgh Perinatal Depression Scale between 28 and 32 weeks' gestation and again between 2 and 8 weeks postpartum. The guidelines included onsite mental health consultations for eligible women. Screening rates, attended onsite mental health consultations, and health care provider satisfaction and feedback surveys were collected over a 3-month period, before and after guideline implementation.

OUTCOMES

Perinatal mood and anxiety disorder screening rates were significantly increased from 24.9% to 64.2% (P < .001) at the perinatal intake visit and in the third trimester from 0.3% to 32.8% (P < .001) with the implementation of a systematic screening guideline. Onsite mental health consultations significantly increased from 7.2% to 15.2% (P < .001). Perinatal care providers (n = 9, 100%) were satisfied with the screening guideline and reported that it added 5 minutes or less to their office visits.

DISCUSSION

The implementation of a systematic perinatal mood and anxiety disorder screening guideline increased completed screenings in the perinatal period and increased the number of attended onsite mental health consultations. Systematic screening combined with onsite mental health consultation is a successful way to identify at-risk women and offer critical and convenient maternal mental health care without increasing the burden on perinatal care providers.

Impact of nurse practitioner navigation on access to care for patients with refractory gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common digestive complaint that can negatively affect patients' quality of life and have serious complications if inadequately treated.

LOCAL PROBLEM

Facilitating prompt and efficient access to digestive care is imperative especially given the current burden of gastrointestinal diseases such as GERD.

METHODS

A clinical team conducted a quality improvement study in which a nurse practitioner (NP) navigator performed a preconsultation chart review for patients with refractory GERD referred to an Esophagus Center between August and December 2018.

INTERVENTIONS

Based on preconsultation chart review, the NP navigator arranged for diagnostic testing and follow-up. Days from consultation to testing completion and establishment of plan were tracked and compared with historic controls. The NP navigator documented time spent for chart review and care coordination.

RESULTS

The median number of days from consultation to testing completion for patients who underwent NP navigation and required diagnostic testing (n = 26) was 33.5 as compared with 64.5 for historic controls who required testing but received usual care (n = 28) (p = .005). The median number of days from consultation to establishment of a management plan was 52 for patients who underwent NP navigation as compared with 97 for historic controls who did not (p = .005). The mean amount of time spent by the NP navigator for chart review and care coordination was 17.5 min (n = 30).

CONCLUSIONS

Incorporation of NP navigators into gastroenterology practices offers a potential solution for timelier patient care delivery.

Grade Incentive to Boost Course Evaluation Response Rates

Abstract In most schools of nursing, students rate their satisfaction with courses and teachers at the end of the semester. Low response rates on these evaluations make it difficult to interpret the results. Students were incentivized to complete their course evaluations by adding 1-2 points to one test score in the course in exchange for 85 % or higher participation by the total cohort. Ongoing monitoring and communication to students by faculty during the process was critical to motivating students to complete course evaluations. When the incentive was employed, student participation ranged from a low of 90 % to a high of 100 % response rate. The added points did not change any of the students' grades. Incentivizing students to complete course evaluations is an effective strategy to boost response rates without changing final course grades.

Implementation of a Hydrotherapy Protocol to Improve Postpartum Pain Management

INTRODUCTION

A growing number of women are seeking alternatives to traditional pharmacologic pain management during birth. While there has been an extensive array of nonpharmacologic options developed for labor, there are limited offerings in the postpartum period. The purpose of this quality improvement project was to implement a hydrotherapy protocol in the early postpartum period to improve pain management for women choosing a nonmedicated birth.

PROCESS

The postpartum hydrotherapy protocol was initiated in a certified nurse-midwife (CNM) practice in an urban academic medical center. All women who met criteria were offered a 30-minute warm water immersion bath at one hour postpartum. Pain scores were assessed prior to the bath, at 15 minutes after onset, and again at the conclusion (30 minutes). Women who completed the bath were also asked to complete a brief survey on their experience with postpartum hydrotherapy.

OUTCOMES

In women who used the bath (N = 45), there was a significant reduction in pain scores (P < .001) between the onset of the bath and scores at both 15 minutes and 30 minutes. There was no significant difference between pain scores at 15 minutes and 30 minutes (P = .97). Of those women who completed a survey (n = 43), 97.7% reported both that the bath reduced their pain and improved their birth experience. One hundred percent reported they would use it again in another birth.

DISCUSSION

This project demonstrated successful implementation of a hydrotherapy protocol as an alternative or adjunct to medication for early postpartum pain management that significantly reduced pain and improved the birth experience for those who used it. It offers a nonpharmacologic alternative where there have traditionally been limited options.

How We Engage Graduating Professional Students in Interprofessional Patient Safety

PROBLEM

Interprofessional curricula on patient safety do not acknowledge the culture and vulnerabilities of the student experience and often do not engage students.

METHODS

We describe a patient safety collaboration between graduating nursing and medical students during their Capstone courses that fostered conversations about the similarities and differences in professional school experiences around patient safety. Students wrote reflections about an unanticipated patient outcome. Qualitative content analysis was used to characterize themes within student reflections, and to create audience response system questions to highlight differences in each profession's reflections and to facilitate discussion about those differences during the collaboration.

FINDINGS

Medical students identified events in which perceived patient outcomes were worse than events identified by nursing students. Nursing students identified more near-miss events. Nursing students positively impacted the event and attributed action to the presence of a clinical instructor and personal responsibility for patient care. Medical students described themselves as "only a witness" and attributed inaction to hierarchy and concern about grades.

CONCLUSIONS

Students felt the session would change their future attitudes and behaviors. Stevenson Chudgar Molloy Phillips Engle Clay.

The effect of milk on the attenuation of exercise-induced muscle damage in males and females

PURPOSE

The consumption of 500 ml milk following muscle damaging exercise can attenuate decreases in muscle functional capacity and increases in markers of muscle damage and soreness in males. There has been no similar research in female participants. Therefore, the aim of this study was to investigate the effects of milk consumption on exercise-induced muscle damage (EIMD) in males and females.

METHODS

Thirty-two team sport players (male n = 16; female n = 16) were randomly, but equally divided into four groups: male milk, male carbohydrate, female milk, and female carbohydrate. Immediately following muscle damaging exercise, participants consumed either 500 ml of milk or 500 ml of an energy-matched carbohydrate solution. Skeletal troponin I (sTnI), creatine kinase (CK), peak torque, counter movement jump height, 20 m sprint performance and passive and active soreness were recorded prior to and 24, 48 and 72 h post-EIMD.

RESULTS

For females, milk had a likely/very likely beneficial effect on attenuating losses in peak torque at 60°/s from baseline to 24, 48 and 72 h, and a likely beneficial effect in minimising decrements in sprint performance and soreness over 72 h. Milk was unlikely to have a negative effect on serum markers of damage from baseline to 48 and 72 h. For males, milk had an unclear effect on muscle function variables. Milk had a most likely/likely beneficial effect on limiting muscle soreness from baseline to 72 h, and a possible beneficial effect on attenuating increases in CK. The effect on sTnI was unlikely to be negative from baseline-72 h. Overall gender comparisons provided many unclear outcomes. However, female participants demonstrated smaller increases in sprint time, passive soreness, active soreness (non-dominant leg) and sTnI values.

CONCLUSION

Consumption of 500 ml of milk post-EIMD can limit decrements in muscle function in females, and limit increases in soreness and serum markers of muscle damage in females and males.

Supplementary biotin decreases tibial bone weight, density and strength in riboflavin-deficient starter diets for turkey poults

1. Growth and skeletal responses to different dietary concentrations of riboflavin and biotin were compared in turkey poults from hatch to 21 d of age. The birds were fed on a turkey starter diet with different concentrations of supplementary riboflavin (0, 20 and 40 mg/kg) and biotin (0, 0.3 and 0.6 mg/kg) in a factorial design. 2. Poults fed on diets with no supplementary riboflavin had poor gait scores, decreased times to sit and higher rates of culling compared to poults fed on the control diet (20 mg riboflavin and 0.3 mg biotin/kg [corrected] diet). Histologically, riboflavin deficiency was associated with a peripheral neuropathy similar to that described previously in chicks and, unexpectedly, in growth plate abnormalities. 3. Tibiae of poults fed on the control diet were larger, more dense, stronger and stiffer than the diets with no supplementary riboflavin. 4. Increasing supplementary biotin in poults fed on diets with no supplementary riboflavin was associated with a decrease in tibia weight, density, strength and stiffness. 5. The results demonstrated that riboflavin deficiency in fast-growing turkey poults was associated with growth retardation, growth plate disturbance and peripheral nerve dysfunction leading to an inability to walk.

Agreement between paper and pen visual analogue scales and a wristwatch-based electronic appetite rating system (PRO-Diary©), for continuous monitoring of free-living subjective appetite sensations in 7-10 year old children

Electronic capture of free-living subjective appetite data can provide a more reliable alternative to traditional pen and paper visual analogue scales (P&P VAS), whilst reducing researcher workload. Consequently, the aim of this study was to explore the agreement between P&P VAS and a wristwatch-based electronic appetite rating system known as the PRO-Diary© technique, for monitoring free-living appetite sensations in 7-10 year old children. On one occasion, using a within-subject design, the 12 children (n=6 boys; n=6 girls) recorded their subjective appetite (hunger, prospective food consumption, and fullness), at two time points before lunch (11:30 and 12:00) and every 60 min thereafter until 21:00. The agreement between the P&P VAS and PRO-Diary© technique was explored using 95% limits of agreement and 95% confidence intervals (95% CI) calculated using the Bland and Altman (1986) technique. For hunger, prospective food consumption and fullness, the 95% limits of agreement were -1±25 mm (95% CI: lower limit -8mm; upper limit +6mm), 0±21 mm (95% CI: lower limit -6mm; upper limit +6mm) and -6±24 mm (95% CI: lower limit -14 mm; upper limit +1mm), respectively. Given the advantages associated with electronic data capture (inexpensive; integrated alarm; data easily downloaded), we conclude that the PRO-Diary© technique is an equivalent method to employ when continuously monitoring free-living appetite sensations in 7-10 year old children, but should not be used interchangeably with P&P VAS.

The role of cherries in exercise and health

Recently, cherries and cherry products have received growing attention within the literature with regard to their application in both exercise and clinical paradigms. Reported to be high in anti-inflammatory and anti-oxidative capacity, cherries and their constituents are proposed to provide a similar but natural alternative akin to over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) or analgesics. Within exercise paradigms, concern has been raised with regard to the use of products, which inhibit such inflammatory or oxidative actions, because of the possibility of the blunting of physiological training adaptations. Despite this, numerous scenarios exist both within exercise and clinical populations where a goal of optimal recovery time is more important than physiological adaptation. This review critically evaluates and discusses the use of cherries as a supplementation strategy to enhance recovery of muscle function, inhibit exercise-induced inflammation, oxidative stress, and pain primarily; furthermore, the potential application of cherries to clinical populations is discussed.

Agreement between two methods of dietary data collection in female adolescent netball players

The accuracy of a combined dietary data collection method (self-reported, weighed food diary and 24-h recall technique) in 13 female, adolescent netball players (14-16 years) was explored. The girls were observed for a 12 h period (08:00-20:00), during which food and drink items were available ad libitum throughout the day and for the period between 20:00 and 08:00 the following morning. All items were covertly weighed before and after consumption to calculate observed energy intake. To calculate participant reported energy intake, food and drink items were weighed and recorded in a food diary by the participants, which was then supplemented with information from the 24-h recall the following morning. Agreement between observed and participant reported energy intake was calculated using the Bland and Altman technique. The mean difference between observed and participant reported energy intake was 0.46 MJ d(-1) (change in mean of 4.2%) indicating a slight bias towards over-reporting using the combined dietary data collection method. There was good agreement at the group level with the confidence interval for bias ranging from 0.00 to 0.92 MJ d(-1). The combined dietary data collection method is an effective technique to employ in 14-16-year old, female adolescent netball players when quantifying energy intake.

Energy intake and appetite following netball exercise over 5 days in trained 13-15 year old girls

Free-living energy intake and subjective appetite were monitored in a group of eleven 13-15-year old trained adolescent netball players. During preliminary visits, a FLEX heart rate calibration and resting metabolic test were conducted. Heart rate data were collected during a netball exercise session and sedentary period and during the waking hours of all study days, to enable exercise-induced and 24-h energy expenditure to be quantified. The girls completed two 5-day treatment weeks, interspersed with a 2-week 'wash out' period. A 47-min bout of netball exercise or an equivalent sedentary period was carried out on day 3 of each treatment week. Energy intake was measured over each 5-day period using a combined self-reported, weighed, food diary and 24-h recall interview technique. Subjective appetite (hunger, prospective food consumption, fullness) and mood were rated by subjects immediately before and after meals each day, and before and after the netball exercise and the sedentary period. Forty eight hour energy intake was significantly higher following the netball exercise compared to the sedentary period. The girls felt significantly more hungry immediately following the netball exercise compared to immediately before. In conclusion, a single intermittent exercise bout alters subsequent appetite and energy intake in trained 13-15-year old girls.

Influence of the glycaemic index of an evening meal on substrate oxidation following breakfast and during exercise the next day in healthy women

OBJECTIVE

To investigate whether the 'overnight second-meal effect' results in altered substrate oxidation during the postprandial period following breakfast and subsequent sub-maximal exercise in women.

SUBJECTS/METHODS

Seven recreationally active women were recruited for the study. In each trial, participants were provided with their evening meal on day 1, which was composed of either high glycaemic index (HGI) or low glycaemic index (LGI) carbohydrates (CHO). On day 2, participants were provided with a standard HGI breakfast and then performed a 60 min run at 65% \[V.]O(2 max) 3 h later.

RESULTS

The incremental area under the curve (IAUC) for plasma glucose concentrations during the postprandial period following breakfast was greater in the HGI trial compared to the LGI trial (P<0.01). Similarly, the IAUC for serum insulin concentrations was greater in the HGI trial than the LGI trial (P<0.05). No differences in plasma free-fatty acids (FFA) or plasma glycerol concentrations were found between trials during the postprandial period. During subsequent exercise, there were no significant differences in substrate metabolism.

CONCLUSION

The glycaemic index of an evening meal does not alter substrate oxidation at rest following breakfast or during subsequent submaximal exercise in women. This study provides further evidence for the overnight second-meal effect on glycaemic responses following a LGI mixed evening meal.

Effects of the glycemic index of breakfast on metabolic responses to brisk walking in females

OBJECTIVE

The aim of this study was to examine the metabolic responses during 1 h of brisk walking, 3 h after ingesting high glycemic index (HGI) and moderate glycemic index (MGI) breakfasts.

DESIGN AND SUBJECTS

Six females completed three treadmill walking trials (approximately 50% VO2 max), separated by at least 1 month. Three hours before walking, they ingested either water or a HGI or MGI breakfast. The MGI breakfast consisted of a mixture of an HGI breakfast cereal and low GI carbohydrate (CHO) foods. The GI values of the HGI and MGI meals were 77 and 51, respectively.

SETTING

The study took place in the School of Sport and Exercise Sciences at Loughborough University, Loughborough, UK.

RESULTS

In the HGI and MGI trials, plasma glucose and serum insulin concentrations peaked 15 min into the postprandial period. At the onset of exercise, plasma insulin concentrations were twofold higher in the HGI (31.5+/-7.7 microl U l(-1)) than in the MGI trial (15.2+/-1.9 microl U l(-1)) (P<0.05). However, there were no differences in substrate utilization between the two CHO trials.

CONCLUSION

These results suggest that although the addition of LGI CHO foods to an HGI breakfast cereal reduces the overall GI of the meal, the metabolic response to exercise is similar to that following a breakfast comprised entirely of HGI foods.

Derivation of a scrapie-free sheep flock from the progeny of a flock affected by scrapie

The Cheviot flock at the Institute for Animal Health's Neuropathogenesis Unit (npu) has endemic scrapie, which affects primarily vrq/vrq sheep and at high frequency. A new flock with a full range of PrP genotypes, including the highly susceptible vrq/vrq, has been produced on a separate site, from animals in the npu breeding flock, and it remains scrapie-free after eight years. In contrast, in a parallel flock at the npu farm, scrapie has reappeared after five years, although the animals were kept in separate accommodation from the scrapie-affected sheep. During this time the npu breeding flock continued to have scrapie cases. Although it is known that highly susceptible sheep can remain free of infection in a clean environment, this is the first report of the infection being removed successfully from the bloodlines of scrapie-affected sheep. The results confirm that scrapie is not a genetic disease dependent only on the PrP gene sequence, but requires both genetic susceptibility and an infectious agent.

Frequencies ofPrPgene haplotypes in British sheep flocks and the implications for breeding programmes

AIMS

To analyse the frequencies of prion (PrP) gene haplotypes in UK sheep flocks and evaluate their relevance to transmissible spongiform encephalopathies (TSEs) and TSE resistance breeding programmes in sheep.

METHODS AND RESULTS

Genomic DNA isolated from sheep blood was PCR amplified for the coding region of the PrP gene and then sequenced. This study has analysed the sequence of PrP between codons 110 and 245 in 6287 ARQ haplotypes revealing a total of eight variant sequences, which represent a higher than expected 41% of all ARQ haplotypes. The additional PrP gene dimorphisms were M112T, L141F, M137T, H143R, H151C, P168L, Q175E and P241S.

CONCLUSION

The results do not suggest a correlation between the occurrence of a specific ARQ haplotype and the scrapie disease status of a flock. The ARQ haplotype variability appears to be different in the UK sheep flocks compared with sheep flocks from outside the UK.

SIGNIFICANCE AND IMPACT OF THE STUDY

Additional PrP dimorphisms may impact on the methodologies used for standard PrP genotyping in sheep breeding programmes. Some of these polymorphisms were found with significant frequencies in the UK sheep flocks and should therefore be considered in breeding programmes.

Risk of scrapie in British sheep of different prion protein genotype

There is a well-established association between sheep prion protein (PrP) genotype and the risk of death from scrapie. Certain genotypes are clearly associated with susceptibility to the disease and others to resistance. However, there have been no attempts to quantify the disease risk for all 15 PrP genotypes. Here, datasets of the PrP genotypes of nearly 14 000 British sheep and of more than 1500 confirmed scrapie cases were combined to yield an estimate of scrapie risk (reported cases per annum per million sheep of the genotype, or RCAM) for British sheep. The greatest scrapie risk by far, ranging from 225 to 545 RCAM, was for the VRQ-encoding genotypes ARQ/VRQ, ARH/VRQ and VRQ/VRQ. The next greatest risk (37 RCAM) was for the ARQ/ARQ genotype. The ARR/ARR genotype was the only numerically significant genotype for which no scrapie cases have been reported. The AHQ allele conferred resistance and the risk of scrapie in AHQ/VRQ sheep was very low (0·7 RCAM), although there was a higher and moderate risk for the AHQ homozygote (5 RCAM). The ARH allele appeared to confer susceptibility when encoded with VRQ, but possible resistance when encoded with other alleles. Scrapie risk varied with age: for VRQ/VRQ and ARH/VRQ the risk peaked at 2 years of age; that for ARQ/VRQ peaked at 3 years. There was some evidence that, following the lower risk at 4 and 5 years, a second rise occurred from about 6 years. Comparison with other published data indicated that the scrapie risk of certain PrP genotypes may differ between Great Britain and other countries.

Interaction of protein kinase C and cAMP-dependent pathways in the phosphorylation of the Na,K-ATPase

To test the hypothesis that there is cross-talk between the protein kinase C (PKC) and protein kinase A (PKA) pathways in the regulation of the Na,K-ATPase, we measured its phosphorylation in mammalian cell cultures. Phosphorylation of the PKC site, Ser-18, appeared to be due to the activation of the alpha isoform of the kinase. In NRK-52E and L6 cells, this phosphorylation was reduced by prior activation of a cAMP-dependent signaling pathway with forskolin. In principle this would be consistent with direct interaction between the two phosphorylation sites, but further investigation suggested a more indirect mechanism. First, phosphorylation of Ser-938, the PKA site, could not be detected despite the presence of active PKA. Second, there was a major reduction in the phosphorylation of unrelated phosphoproteins as a consequence of elevation of cAMP, suggesting generalized reduction of kinase activity or activation of phosphatase activity. In NRK-52E and L6, phosphorylation of the Na, K-ATPase at Ser-18 paralleled this global change. In C6 cells, in contrast, there was no cAMP effect on Na,K-ATPase phosphorylation at Ser-18 and no global cAMP effect on other phosphoproteins. The cross-talk is evidently mediated by events occurring at the cellular level.

Internal energies of analyte ions generated from different matrix-assisted laser desorption/ionization matrices

A transfer of energy into the internal modes of the matrix and analyte is expected to occur during matrix-assisted laser desorption/ioniziation (MALDI) processes. Both the physical and thermochemical properties of the MALDI matrix used can influence the ion internal energy and analyte ion fragmentation. Here we report the effect of several MALDI matrices on the relative internal energy of the 2'-deoxyadenylyl-(3',5')-2'-deoxyguanosine (AG) anion. Relative internal energies were probed by low-energy collision-induced dissociation in a Fourier transform ion cyclotron resonance mass spectrometer. Sublimation temperatures of the matrices under study were also determined and found to lie between 409 and 455 K. Analyte ion internal and initial kinetic energies did not correlate with matrix sublimation temperatures. In contrast, a strong correlation between the relative internal energy of the analyte anions and the gas-phase basicity of the matrix anions was found. These results suggest that gas-phase proton transfer reactions play an important role in MALDI analyte ion formation and influence their internal energy and fragmentation behavior. Copyright 2000 John Wiley & Sons, Ltd.

Methadone maintenance and hepatitis C virus infection among injecting drug users

Harm reduction strategies for the prevention of transmission of human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs) have been widely implemented in Australia and are seen to have been effective in preventing the spread of HIV. A major strategy has been increasing the availability of and accessibility to methadone maintenance therapy (MMT) programmes. We have reviewed the experience of a major MMT general practice with hepatitis C virus (HCV) infection from 1991 to 1995. Of 1741 individuals tested for HCV antibodies at least once 66.7% were positive. Of 73 IDUs who were initially seronegative and were retested at least once, 19 were subsequently seropositive. Seroconverters to HCV were younger than non-seroconverters, and were more likely to have evidence of previous hepatitis B infection. The overall HCV incidence rate was 22 cases per 100 person-years, and this did not differ between those on MMT programs (continuous or interrupted) between HCV tests and those not on MMT. These findings suggest that the role of MMT in the control of the spread of HCV infection among IDUs needs further assessment, and that control of the current epidemic of HCV infection among IDUs in Australia will be very difficult.

Impact of improved laboratory compliance on notification of genital Chlamydia trachomatis infection in Victoria

BACKGROUND AND OBJECTIVES

Although regulations in Victoria require notification of chlamydia infection by both clinician and laboratory, review found many reports that were notified only by one source (i.e., were unmatched).

GOALS

To identify problems with the notification system and to improve the quality of surveillance for this disease.

STUDY DESIGN

All notified cases of chlamydia diagnosed in January or February 1995 were followed up by contacting diagnosing doctors. Identified noncompliant laboratories were asked to provide a list of all diagnoses for the period and institute ongoing reporting. Notification data were reviewed for timeliness and completeness.

RESULTS

Clinicians never notified without laboratory confirmation. Soliciting laboratory reports increased total notifications by 30%, and there was a highly significant improvement in reporting by both clinicians and laboratories. Reasons for failure to notify by clinicians included an assumption by some clinicians that laboratories would notify and ignorance that notification was required.

CONCLUSIONS

Notified cases generally are now accompanied by a laboratory report, and although nonnotification by clinicians continues, notification has improved. Further improvements in clinician notification may depend on doctors knowing that public health action results from reporting. An alternative to requiring doctors' time to be spent in duplicate notification would be to strengthen laboratory reporting and then check that adequate treatment and partner notification has occurred through contact with the diagnosing doctor.

Surveillance for sexually transmissible diseases in Victoria, 1983 to 1992

Surveillance systems have been developed in Victoria to determine trends in sexually transmissible diseases (STDs). Notifications to the Health Department (including laboratory notification since May 1990) have been supplemented by data about strains of Neisseria gonorrhoeae and cultures for Chlamydia trachomatis processed by the Microbiological Diagnostic Unit, enhanced laboratory surveillance of syphilis, and data on genital herpes and genital warts from the Melbourne Sexual Health Centre. During the period under review the incidence of gonorrhoea declined, rapidly at first, and then more slowly. For women, this trend has continued, while gonorrhoea acquired abroad by men has become relatively more important. Since 1988, gonorrhoea in homosexual men has increased, and rectal isolates have increased concurrently, raising concerns about HIV risk behaviour. Cases of syphilis are likely to be ascertained through STD, antenatal and refugee screening, rather than because of symptoms or contact tracing. Chlamydia is a the most common notifiable STD, despite underreporting and underdiagnosis. In 1991, 832 cases were notified, increasing to 1377 in 1992. In 1992, of the 73 cases (65 per cent of notifications) where the doctor identified a risk, 15 per cent was attributed to homosexual contact, and 27.4 per cent to heterosexual exposure. Limitations in the data include inadequate standard case definitions for many STDs, changes in the statutory requirement for notifications in 1990, underreporting, changes in diagnostic and screening patterns, and lack of detailed demographic data. Education of general practitioners is needed to improve diagnosis and notification of chlamydia.

Milk composition and lactation of beta-casein-deficient mice

beta-Casein is a major protein component of milk and, in conjunction with the other caseins, it is assembled into micelles. The casein micelles determine many of the physical characteristics of milk, which are important for stability during storage and for milk-processing properties. There is evidence that suggests that beta-casein may also possess other, nonnutritional functions. To address the function of beta-casein, the mouse beta-casein gene was disrupted by gene targeting in embryonic stem cells. Homozygous beta-casein mutant mice are viable and fertile; females can lactate and successfully rear young. beta-Casein was expressed at a reduced level in heterozygotes and was completely absent from the milk of homozygous mutant mice. Despite the deficiency of beta-casein, casein micelles were assembled in heterozygous and homozygous mutants, albeit with reduced diameters. The absence of beta-casein expression was reflected in a reduced total protein concentration in milk, although this was partially compensated for by an increased concentration of other proteins. The growth of pups feeding on the milk of homozygous mutants was reduced relative to those feeding on the milk of wild-type mice. Various genetic manipulations of caseins have been proposed for the qualitative improvement of cow's milk composition. The results presented here demonstrate that beta-casein has no essential function and that the casein micelle is remarkably tolerant of changes in composition.

The epidemiology of HIV-1 infection in Victoria. The Victorian Collaborative Group on HIV and AIDS Surveillance (VCGHAS)

OBJECTIVE

To describe the epidemiology of infection with the human immunodeficiency virus type 1 (HIV-1) in Victoria from 1980 to 1991.

DESIGN

Data on HIV-1 infection in Victoria, obtained through routine laboratory-based surveillance, were entered in a database. Missing information was sought by contacting the referring doctor where possible.

SETTING

In Victoria, the acquired immunodeficiency syndrome (AIDS) is notifiable to Health Department Victoria by diagnosing doctors, and laboratories are required to notify new diagnoses of HIV-1 infection, without identifiers. All confirmatory testing for HIV-1 has taken place at the State HIV Reference Laboratory at Fairfield Hospital.

MAIN OUTCOME MEASURES

Diagnoses of HIV-1 infection, as confirmed at the State HIV Reference Laboratory by western blot immunoassay, and notifications of AIDS to Health Department Victoria.

RESULTS

Over six years the annual number of diagnoses of HIV-1 infection in Victoria remained constant despite a substantial increase in the number of tests performed. To the end of 1991, 2679 people had been diagnosed with HIV-1 infection, 686 of whom had developed AIDS. Information on exposure was available for 2379 (88.8%). Homosexual and bisexual men made up 75.5% (85.0% of those for whom exposure had been ascertained); 3.4% were female or heterosexual male injecting drug users; and 3.7% were heterosexuals with no history of injecting drug use. The latter two groups contributed 2.0% in 1985 to the proportion of all new diagnoses for which exposure was known, and 14.3% in 1991; for recipients of contaminated blood or blood products before 1985 this proportion fell from 12.4% to 1.0%. The cumulative incidence of HIV-1 diagnoses was highest in the age group 25-29 years, and 20% of all HIV-1 infected people were under 25 at the time of diagnosis. In 1991, 81 of the 311 people who had been diagnosed with HIV-1 infection had had previous negative or indeterminate results of tests; half of these had acquired infection in the previous year.

CONCLUSION

Most HIV-1 infections in Victoria have been acquired through male homosexual contact, with a small but increasing proportion of diagnoses occurring in heterosexuals. Laboratory-based surveillance of voluntary testing, despite its limitations, has provided valuable information on the extent of the HIV-1 epidemic in Victoria. Surveillance of all HIV-1 test results and of seroconverters now supplements routine surveillance of HIV diagnoses and will ensure a more accurate picture of the epidemic in coming years.