Characterizing the Palliative Care Physician Workforce: A Retrospective Cross-Sectional Study With Population-Based Data in Ontario, Canada

OBJECTIVES

Because of an increasing need to build capacity for end-of-life care, improving access to palliative care is a priority. Where a physician practices (eg, hospital, outpatient clinic, home) directly relates to the type of service and the stage of illness at which care is provided. In this study, we describe the physician palliative care specialist workforce and the settings of care within which they practice.

DESIGN

A retrospective cohort.

SETTING AND PARTICIPANTS

All physicians with palliative care billing codes who were practicing between April 1, 2018, and March 31, 2019, in Ontario, Canada.

METHODS

Descriptive statistics of physician billing location and frequency using linked population-based health administrative data.

RESULTS

We identified 8883 physicians who provided palliative care during the study period. Of those, 723 (8.1%) were classified as palliative care specialists (>10% of their billings encounters were palliative care). The majority (57.4%) of palliative care specialists worked in 1 setting more than 90% of their time, across home visits (27.1%), indirect care (22.4%), and office (7.9%). There were 61 palliative care specialists practicing in mixed locations who provided home visits, meaning 310 (42.9%) of the palliative care specialists delivered some home-based care.

CONCLUSIONS AND IMPLICATIONS

This research provides a comprehensive description of the current palliative care specialist physician workforce that can support efforts to build capacity for high-quality end-of-life care.

Respiratory syncytial virus in children: epidemiology and clinical impact post-COVID-19

PURPOSE OF REVIEW

Respiratory syncytial virus (RSV) remains a leading cause of mortality and morbidity worldwide. RSV seasonality was disrupted by COVID-19-associated nonpharmaceutical interventions (NPIs). We review RSV seasonality, molecular epidemiology, clinical manifestations, and community awareness to inform future prevention strategies.

RECENT FINDINGS

An initial reduction of RSV disease observed with NPIs, and subsequent global resurgence was associated with a collapse in genetic diversity. A lack of immunity is suggested to have contributed to the resurgence of RSV cases experienced post COVID-19. The median age of children admitted with RSV increased during the resurgence, likely secondary to the expanded cohort of RSV-immune naive children. The pandemic also played a role in increased community awareness, which can be utilized as part of a coordinated public health effort to introduce prevention strategies. Further education on signs and symptoms of RSV is still required.

SUMMARY

mAbs and maternal vaccines targeting RSV have the potential to reduce paediatric morbidity, however this new era of RSV prevention will require ongoing research to facilitate community awareness and engagement, and better respiratory surveillance. Tackling the global burden of RSV will require a coordinated effort and measures to ensure access and affordability of new prevention strategies.

An examination of housing interventions among youth experiencing homelessness: an investigation into racial/ethnic and sexual minority status

OBJECTIVES

The purpose of this study is to explore main and interaction effects of minority and multiple minority statuses on exits from homelessness and the stability of homelessness exits overtime.

METHODS

This study utilized the Homeless Management Information System administrative data of 10 922 youth experiencing homelessness collected from a convenience sample of 16 geographically diverse communities across the USA between 2015-17. Using multinomial logistic regression analyses and logistic regression, main effects and interaction effects of racial/ethnic minority identity and sexual/gender minority identity were examined on various homelessness exits (n = 9957) and housing sustainability (n = 5836).

RESULTS

Black youth, relative to White youth, were disproportionately exiting homelessness through incarceration (P < 0.001). Black and Latinx youth were less likely to successfully self-resolve their homelessness (both P < 0.05). Black heterosexual and Black and Latinx non-heterosexual youth were most frequently lost to the homeless system (all P < 0.01). Black youth, relative to White youth, were approximately half as likely to remain stably housed after returning to family (P < 0.01).

CONCLUSIONS

With respect to housing exits and exit stability, Black and Latinx heterosexual youth are consistently at a disadvantage. Homelessness/housing systems and programs need to conduct a deeper investigation into how they implement and develop equitable outreach and engagement practices.

Effect of extended postmortem aging on beef muscles of differing quality grade during retail display

Aging of beef subprimals is a common industry practice to improve tenderness. However, the effect of extended aging (up to 63 days) on retail shelf life, tenderness, and eating quality of beef strip loin and sirloin of differing quality grades is not clearly understood. Therefore, in the current study, longissimus dorsi (strip loin) and gluteus medius muscles (sirloin) were collected from UDA Choice or Select carcasses and fabricated into six portions. Each of these portions were designated to an assigned time of wet aging (14, 21, 28, 35, 45, or 63 d) in vacuum bags. After aging, samples were fabricated into steaks and placed into a multi-deck retail display case for 72 h. Steaks were evaluated for color (instrumental and color panelists) every 8 h during retail display, and Warner Bratzler Shear Force (WBSF) and sensory analysis were conducted after retail display. The results were analyzed using the PROC MIXED procedure of SAS with repeated measures for the color data. Among the effects evaluated (aging, quality grade, and aging × quality grade), quality grade was not significant (P &gt; 0.05) for either strip loin or sirloin steaks. An aging x display hour interaction was identified (P &lt; 0.05) for the color measurements. In general, as aging time increased over the display period, color was negatively impacted. Although tenderness improved (P &lt; 0.05) with aging, the incidence of off flavors also increased, especially in sirloin steaks,&nbsp; suggesting that beef processors need to consider flavor changes during extended aging.&nbsp;

Prenatal Cadmium Exposure Alters Proliferation in Mouse CD4+ T Cells via LncRNA Snhg7

Objective

Prenatal cadmium (Cd) exposure leads to immunotoxic phenotypes in the offspring affecting coding and non-coding genes. Recent studies have shown that long non-coding RNAs (lncRNAs) are integral to T cell regulation. Here, we investigated the role of long non-coding RNA small nucleolar RNA host gene 7 (lncSnhg7) in T cell proliferation.

Methods

RNA sequencing was used to analyze the expression of lncRNAs in splenic CD4+ T cells with and without CD3/CD28 stimulation. Next, T cells isolated from offspring exposed to control or Cd water throughout mating and gestation were analyzed with and without stimulation with anti-CD3/CD28 beads. Quantitative qPCR and western blotting were used to detect RNA and protein levels of specific genes. Overexpression of a miR-34a mimic was achieved using nucleofection. Apoptosis was measured using flow cytometry and luminescence assays. Flow cytometry was also used to measure T cell proliferation in culture. Finally, lncSnhg7 was knocked down in splenic CD4+ T cells with lentivirus to assess its effect on proliferation.

Results

We identified 23 lncRNAs that were differentially expressed in stimulated versus unstimulated T cells, including lncSnhg7. LncSnhg7 and a downstream protein, GALNT7, are upregulated in T cells from offspring exposed to Cd during gestation. Overexpression of miR-34a, a regulator of lncSnhg7 and GALNT7, suppresses GALNT7 protein levels in primary T cells, but not in a mouse T lymphocyte cell line. The T cells isolated from Cd-exposed offspring exhibit increased proliferation after activation in vitro, but Treg suppression and CD4+ T cell apoptosis are not affected by prenatal Cd exposure. Knockdown on lncSnhg7 inhibits proliferation of CD4+ T cells.

Conclusion

Prenatal Cd exposure alters the expression of lncRNAs during T cell activation. The induction of lncSnhg7 is enhanced in splenic T cells from Cd offspring resulting in the upregulation of GALNT7 protein and increased proliferation following activation. miR-34a overexpression decreased GALNT7 expression and knockdown of lncSnhg7 inhibited proliferation suggesting that the lncSnhg7/miR-34a/GALNT7 is an important pathway in primary CD4+ T cells. These data highlight the need to understand the consequences of environmental exposures on lncRNA functions in non-cancerous cells as well as the effects in utero.

Variations in Low Electrical Stimulator Voltage Settings Minimally Influence Beef Longissimus Muscle Slice Shear Force Values

The objective of the current study was to evaluate the effect of differing electrical stimulation (ES) voltage levels on beef longissimus muscle tenderness, postmortem temperature, pH decline, and carcass quality. Beef carcasses from 3 commercial beef processing plants (A, B, C) were exposed to 3 varying voltage levels: (1) control (no ES), (2) ES level 1 (ES1; 60 Hz for 17 s each at 16, 20, 24, and 28 V), and (3) ES level 2 (ES2; 60 Hz for 17 s each at 25, 35, 45, and 55 V) prior to chilling. Ninety beef carcasses were selected from each of the 3 plants, and within a carcass, paired sides were randomly assigned to one of 3 ES treatments (n = 60 sides/treatment/plant). The results indicated that ES affected (P &lt; 0.05) muscle pH at 3 h postmortem in 2 of the 3 plants. However, ES did not affect (P &gt; 0.05) pH at the time of grading (postrigor). Although the slice shear force (SSF) values were lower (P &lt; 0.05) for ES steaks compared with controls, voltage did not affect (P &gt; 0.05) SSF values. Variation in SSF was observed among the plants (P &lt; 0.05), with steaks from Plant C having greater (P &lt; 0.05) SSF values compared with steaks from Plants A and B, which exhibited similar (P &gt; 0.05) SSF values. Overall, although ES steaks had lower SSF values compared with control steaks, the lack of difference in postmortem tenderness between ES1 and ES2 voltage settings indicated that the low ES voltages minimally influenced SSF values.

Evaluation of Beef Top Sirloin Steaks of Four Quality Grades Cooked to Three Degrees of Doneness

ObjectivesThe objective of this study was to evaluate the impact of quality grade on beef eating quality of top sirloin steaks when cooked to multiple degrees of doneness (DOD).Materials and MethodsBeef top sirloin butts (IMPS #184; N = 60; 15/quality grade) were collected to equally represent 4 quality grades [Prime, Top Choice (Modest and Moderate marbling), Low Choice, and Select]. Top butts were cut into six consecutive steaks, and then divided laterally to get a total of twelve steaks per top butt. Steaks were assigned to one of three DOD: rare (60°C), medium (71°C), and well-done (77°C). Steaks within each DOD were assigned to consumer sensory analysis, trained sensory analysis, fat and moisture analysis, and Warner-Bratzler shear force (WBSF). Consumers (N = 236) were fed samples under red lighting and evaluated steaks for juiciness, tenderness, flavor, and overall liking on continuous line scales. Trained sensory panelists evaluated samples for initial and sustained juiciness, myofibrillar and overall tenderness, connective tissue amount, beef flavor intensity, and off flavor intensity on similar continuous line scales. Data were analyzed as a split-plot, with a whole plot factor of quality grade, and sub-plot factor of DOD.ResultsThere were no interactions (P > 0.05) for all consumer ratings of palatability traits. For quality grade, no differences (P > 0.05) were observed for consumer ratings of tenderness, flavor, and overall liking; however, there was a significant effect (P = 0.01) on juiciness. Prime top sirloin steaks had higher (P < 0.05) juiciness ratings than all other quality grades, except for Top Choice. Additionally, as DOD increased, consumer ratings and the percentage of steaks rated acceptable for all palatability traits decreased (P < 0.05; rare > medium > well-done). There was a quality grade × DOD interaction (P < 0.05) for trained sensory ratings of myofibrillar tenderness, initial juiciness, and sustained juiciness. When steaks were cooked to medium, Prime and Top Choice steaks had higher (P < 0.05) panelist ratings for initial and sustained juiciness than Low Choice and Select steaks. Similar to trained panelist ratings of juiciness, Prime and Top Choice steaks had higher (P < 0.05) ratings of myofibrillar tenderness than Select steaks. Prime and Top Choice steaks had similar (P > 0.05) and higher (P < 0.05) ratings for myofibrillar tenderness when compared to Low Choice steaks. Within DOD, each successive increase in DOD resulted in a concurrent decrease (P < 0.05; rare > medium > well) in trained panelist ratings of myofibrillar tenderness, initial juiciness, and sustained juiciness. There was no quality grade by DOD interactions (P > 0.05) for Warner-Bratzler shear force. Prime steaks were more (P < 0.05) tender than Low Choice and Select steaks but were similar (P > 0.05) to Top Choice. Moreover, as DOD increased, WBSF concurrently increased (P < 0.05; well-done > medium > rare), with well-done steaks having WBSF values 0.8 kg tougher than rare steaks.ConclusionThese results indicate that regardless of DOD, quality grade had minimal impact on the palatability of beef top sirloin steaks. Therefore, unless cooked to a medium DOD, it is unnecessary for consumers, retailers, and foodservice to pay premium prices for higher quality top sirloin steaks, as the same eating experience will be provided.

Sensory and Visual Evaluation of Six Different Beef Shank Cuts from Asian Consumers

ObjectivesThe objective of this study was to evaluate factors affecting Asian consumers’ purchasing decisions and eating preferences of six different beef shank cuts.Materials and MethodsSix shank cuts, three from forequarter [biceps brachii (shank A); a combination of deep digital flexor and flexor digitorum superficialis (shank B); extensor carpi radialis (shank C)], and three from hindquarter [flexor digitorum superficialis (shank D); deep digital flexor (shank E), a combination of long digital extensor, medial digital extensor and peroneus tertius (shank F)] were collected from 12 USDA low choice beef carcasses (n = 72). Shanks from the left side of the carcasses were used for consumer panels and stewed in water for 90 min at 98°C. Asian consumers (n = 91) from Manhattan, KS, evaluated samples for connective tissue texture, amount of connective tissue, juiciness, flavor, overall texture (a combination of myofibrillar tenderness and connective tissue texture) and sensory overall liking. Consumers (n = 84) also visually evaluated the size, surface color and visual overall liking of shank samples from the right side of the carcasses. Finally, consumers rated each sample as either acceptable or unacceptable. All ratings were done on either a Just About Right (JAR) or a continuous line scale.ResultsShanks A, C, D and F received similar scores close to JAR (P > 0.05) for connective tissue texture. Connective tissue texture of shank E was harder than shanks A and D, and shank B was the hardest of all (P < 0.01). For connective tissue amount, shanks A, D, and E received ratings close to JAR (P > 0.05). Consumers rated shank B with too much and shank C and F with too little (P < 0.01) connective tissue. Shanks A, D, and F received similar ratings close to JAR for juiciness (P > 0.05), while shanks C and E were rated less juicy, and shank B was the least juicy among all (P < 0.01). For overall texture, shanks A, D, and F received similar ratings close to JAR (P > 0.05), and shanks C and E were tougher than those rated JAR (P < 0.01). Again, shank B was the toughest among all for overall texture (P < 0.01). Shanks A, D, and F received the highest sensory overall liking scores, followed by shanks C and E, and shank B received the lowest overall liking score among all the shank cuts (P < 0.01). All shank cuts received high sensory acceptability scores (> 85%) except for shank B (62%; P < 0.01). Shanks A and C both received scores that were close to JAR for shank size. Consumers indicated that shanks B, E, and F were too big in size, while shank D was too small (P < 0.01). However, shanks B, C, E, and F had the greatest and similar raw weight (P > 0.05), followed by shank A, while shank D was the lightest of all (P < 0.01). For visual overall liking, shanks A and C received the highest scores, followed by shanks B, E, and F, and shank D received the lowest score (P < 0.05). Shanks A and C were most visually acceptable (> 95%), while shanks B, D, E, and F were less acceptable than shanks A and C (> 70%; P < 0.01). Finally, consumers indicated that there was no difference in flavor and surface color among different shank cuts (P > 0.05).ConclusionConnective tissue texture and amount directly affected Asian consumers’ eating preference for different beef shank cuts, while shank size was the main factor affecting their purchasing decision.

PSINET: Assisting HIV Prevention Amongst Homeless Youth by Planning Ahead

Homeless youth are prone to Human Immunodeficiency Virus (HIV) due to their engagement in high risk behavior such as unprotected sex, sex under influence of drugs, etc. Many non-profit agencies conduct interventions to educate and train a select group of homeless youth about HIV prevention and treatment practices and rely on word-of-mouth spread of information through their social network. Previous work in strategic selection of intervention participants does not handle uncertainties in the social network's structure and evolving network state, potentially causing significant shortcomings in spread of information. Thus, we developed PSINET, a decision support system to aid the agencies in this task. PSINET includes the following key novelties: (i) it handles uncertainties in network structure and evolving network state; (ii) it addresses these uncertainties by using POMDPs in influence maximization; and (iii) it provides algorithmic advances to allow high quality approximate solutions for such POMDPs. Simulations show that PSINET achieves ~60% more information spread over the current state-of-the-art. PSINET was developed in collaboration with My Friend's Place (a drop-in agency serving homeless youth in Los Angeles) and is currently being reviewed by their officials.

Pseudoexon activation increases phenotype severity in a Becker muscular dystrophy patient

We report a dystrophinopathy patient with an in-frame deletion of DMD exons 45-47, and therefore a genetic diagnosis of Becker muscular dystrophy, who presented with a more severe than expected phenotype. Analysis of the patient DMD mRNA revealed an 82 bp pseudoexon, derived from intron 44, that disrupts the reading frame and is expected to yield a nonfunctional dystrophin. Since the sequence of the pseudoexon and canonical splice sites does not differ from the reference sequence, we concluded that the genomic rearrangement promoted recognition of the pseudoexon, causing a severe dystrophic phenotype. We characterized the deletion breakpoints and identified motifs that might influence selection of the pseudoexon. We concluded that the donor splice site was strengthened by juxtaposition of intron 47, and loss of intron 44 silencer elements, normally located downstream of the pseudoexon donor splice site, further enhanced pseudoexon selection and inclusion in the DMD transcript in this patient.

Health insurance coverage and healthcare utilization among homeless young adults in Venice, CA

BACKGROUND

Homeless young adults are a vulnerable population with great healthcare needs. Under the Affordable Care Act, homeless young adults are eligible for Medicaid, in some states, including California. This study assesses homeless young adults' health insurance coverage and healthcare utilization prior to Medicaid expansion.

METHODS

All homeless young adults accessing services at a drop-in center in Venice, CA, were invited to complete a self-administered questionnaire; 70% of eligible clients participated (n = 125).

RESULTS

Within this majority White, heterosexual, male sample, 70% of homeless young adults did not have health insurance in the prior year, and 39% reported their last healthcare visit was at an emergency room. Past year unmet healthcare needs were reported by 31%, and financial cost was the main reported barrier to receiving care. Multivariable logistic regression found that homeless young adults with health insurance were almost 11 times more likely to report past year healthcare utilization.

CONCLUSIONS

Health insurance coverage is the sole variable significantly associated with healthcare utilization among homeless young adults, underlining the importance of insurance coverage within this vulnerable population. Service providers can play an important role by assisting homeless young adults with insurance applications and facilitating connections with regular sources of health care.

Identifying Future High Cost Individuals within an Intermediate Cost Population

BACKGROUND

Improving health and controlling healthcare costs requires better tools for predicting future health needs across populations. We sought to identify factors associated with transitioning of enrollees in an indigent care program from an intermediate cost segment to a high cost segment of this population.

METHODS

We analyzed data from 9,624 enrollees of the Virginia Coordinated Care program between 2010 and 2013. Each fiscal year included all enrollees who were classified in intermediate cost segment in the preceding year and also enrolled in the program in the following year. Using information from the preceding year, we built logistic regression models to identify the individuals in the top 10% of expenditures in the following year. The effect of demographics, count of chronic conditions, presence of the prevalent chronic conditions, and utilization indicators were evaluated and compared. Models were compared via the Bayesian information criterion and c-statistic.

RESULTS

The count of chronic conditions, diagnosis of congestive heart failure, and numbers of total hospital visits and prescriptions were significantly and independently associated with being in the future high cost segment. Overall, the model that included demographics and utilization indicators had a reasonable discrimination (c=0.67).

CONCLUSIONS

A simple model including demographics and health utilization indicators predicted high future costs. The count of chronic conditions and certain medical diagnoses added additional predictive value. With further validation, the approach could be used to identify high-risk individuals and target interventions that decrease utilization and improve health.

Pregnancy attitudes, contraceptive service utilization, and other factors associated with Los Angeles homeless youths' use of effective contraception and withdrawal

STUDY OBJECTIVE

This study aims to understand the associations of contraceptive service utilization (ie, accessing condoms or birth control), pregnancy attitudes, and lifetime pregnancy history among male and female homeless youth in relation to use of effective contraception and withdrawal.

DESIGN, SETTING, AND PARTICIPANTS

Between October 2011 and February 2012, homeless youth (14-27 years old) from 2 drop-in centers in Los Angeles (N = 380) were recruited and completed a questionnaire. The data in this paper are restricted to those who reported vaginal sex at last sex (N = 283).

MAIN OUTCOME MEASURES

Analyses examined history of foster care, sexual abuse, exchange sex, pregnancy, lifetime homelessness duration, current living situation, contraceptive service utilization, and pregnancy attitudes in predicting use of effective contraception and withdrawal at last sex.

RESULTS

Over 62% of females and 43% of males report having ever been pregnant or impregnating someone. There are no gender-based differences in pregnancy attitudes; 21% agree they would like to become pregnant within the year. Additionally, there are no gender-based differences in reported contraceptive use at last vaginal sex. In the multivariable model, high school education, contraceptive service utilization (Relative Risk Ratio [RRR]: 4.0), and anti-pregnancy attitudes (RRR: 1.3) are significant positive predictors of using effective contraception; anti-pregnancy attitudes (RRR: 1.2) and gender (RRR: 0.3) are significantly associated with using withdrawal.

CONCLUSIONS

Health professionals should acknowledge that some homeless youth desire pregnancy; for those that do not, access to effective contraception is important. Programs must continue to promote pregnancy prevention, and include discussions of healthy pregnancy habits for pregnancy-desiring youth.

HIV disclosure among adults living with HIV

Research on disclosure among heterosexual adult person(s) living with HIV (PLH) was reviewed, omitting disclosure of parental HIV to children. Disclosure has been studied within five additional relational contexts: with partners, family members, friends, healthcare professionals and in work settings. Disclosure is higher among women than men, among Latino and white compared to African-American families, and among younger compared to older HIV-positive adults. Most PLH disclose to their sexual partners and family members, yet there is a significant minority who do not disclose. Similarly, rates of disclosure to employers range from 27-68%, suggesting broad variability in perceived consequences of employment disclosures. Of concern, 40% of PLH do not consistently disclose to their healthcare professionals. Rather than examine HIV disclosures in the context of relationships, it is possible to understand disclosures around personal identity. Disclosure decisions are often made to tell everyone (making HIV status a central attribute of one's identity), no one (requiring strategies for securing social support while remaining anonymous) or some people (requiring strategic decisions based on context). Given that disclosure decisions are central to personal identity, future data on disclosure and interventions designed to increase disclosure or comfort with disclosure must focus on communication strategies adopted by PLH to present a coherent identity.

Pro-social and problematic social network influences on HIV/AIDS risk behaviours among newly homeless youth in Los Angeles

We examined the social network composition among newly homeless youth over time and assessed how pro-social and problematic peers affected sexual and drug-using HIV/AIDS risk-behaviours among 183 youth in Los Angeles County, California. The percentage of newly homeless youth who reported that 'most' or 'all' of their friends were attending school, had jobs, and got along with their families was 73%, 24%, and 50% respectively. Logistic regression models indicated that presence of these pro-social peers reduced HIV risk behaviours at two years; odds of HIV-risk were lower with a greater number of peers who attend school, have a job, or have positive family relationships or if networks change over time to include more of these peers. Presence of problematic peers increased the likelihood of HIV risk-taking; odds of HIV risk behaviours increased with a greater number of peers at baseline who steal, have overdosed, have been arrested, or are in a gang, or if networks change to include more of these peers. Interventions should target newly homeless youth in networks that contain problematic peers, but should strive to harness the naturally occurring pro-social peer influences present in these networks.

Families living with HIV

Given the historical emergence of the AIDS epidemic first among gay men in the developed world, HIV interventions have primarily focused on individuals rather than families. Typically not part of traditional family structures, HIV-positive gay men in Europe and the US lived primarily in societies providing essential infrastructure for survival needs that highly value individual justice and freedom. Interventions were thus designed to focus on at-risk individuals with programmes that were age and gender segregated. As the epidemic has unfolded, the early focus on individuals has become inadequate: families live with HIV, not just individuals. Families' structure, economy, migration patterns, and developmental life cycles are affected by HIV, and these changes radiate throughout the community creating parallel stresses. Family-based, intergenerational models of detection, prevention and treatment services offer enhanced opportunities for effective interventions and suggest very different intervention settings and strategies. However, these models also require addressing the family's basic needs for survival and security in order to be successfully implemented and sustained over time. As HIV was an opportunity for marginalized persons in the developed world to 'turn their life around', the strengths of families in the developing world may be mobilized to contribute to the community's long-term health, survival and security needs.

Molecular fingerprinting on the SIMD parallel processor Kestrel

In combinatorial library design and use, the conformation space of molecules can be represented using three-dimensional (3-D) pharmacophores. For large libraries of flexible molecules, the calculation of these 3-D pharmacophoric fingerprints can require examination of trillions of pharmacophores, presenting a significant practical challenge. Here we describe the mapping of this problem to the UCSC Kestrel parallel processor, a single-instruction multiple-data (SIMD) processor. Data parallelism is achieved by simultaneous processing of multiple conformations and by careful representation of the fingerprint structure in the array. The resulting application achieved a 35+ speedup over an SGI 2000 processor on the prototype Kestrel board.

The Human Genome Project and gene therapy: a genetic counselor's perspective

The Human Genome Project (HGP) and clinical trials of gene therapy create an expanded role for genetic counselors, nurses, and other health care practitioners. Translating fundamental advances in genetics into a benefit of clinical practice can be challenging. In addition to patients, the public and other professionals, including judges and lawyers, need to be educated about genetics and genetic testing and the potential for genetic intervention. The article provides an overview of the HGP, explains the concept of gene transfer, provides examples of clinical trials for specific diseases, and addresses practical issues related to the role of the coordinator in clinical trials of gene transfer.

Comparison of methods for retroviral mediated transfer of glucocerebrosidase gene to CD34+ hematopoietic progenitor cells

Gaucher disease is an excellent candidate for gene therapy by transduction of hematopoitic stem cells. In this study, we compared methods which allow an increase in transfer of the glucocerebrosidase gene to human hematopoietic progenitor cells. Several techniques were employed, including the use of cytokines, bone marrow stroma, fibronectin, centrifugal enhancement and in vitro long-term culture. The effect of prestimulation with cytokines interleukin-3 (IL-3), interleukin-6 (IL-6) and stem cell factor (SCF) on transduction of cord blood CD34+ cells was examined. The results suggest that 16-h prestimulation was sufficient for efficient transduction. We examined the effect of bone marrow stroma and fibronectin, both of which increased transduction efficiency up to 36% and 44%, respectively, as measured by PCR for the integrated GC-cDNA in clonogenic cells (9% without any support). Transduction efficiency of 83% was obtained using 2-h centrifugation. Combining centrifugation and in vitro culture in long-term bone marrow culture media containing cytokines (IL-3/IL-6/SCF), CD34+ cells from cord blood and peripheral blood of 3 Gaucher patients were transduced weekly for 21 d. The results of 6 separate experiments consistently demonstrated transduction efficiency of 100% after 7-d in vitro culture. This transduction protocol combining centrifugation and in vitro long-term culture is an attractive method and can be applied to clinical trials.

A novel complementary deoxyribonucleic acid is abundantly and specifically expressed in the uterus during pregnancy

OBJECTIVE

Our purpose was to identify novel genes expressed by the uterus during late pregnancy.

STUDY DESIGN

A complementary deoxyribonucleic acid library constructed from late pregnancy mouse uterus was screened by differential hybridization with complementary deoxyribonucleic acid probes constructed from late pregnancy mouse uterus and nonpregnant mouse uterus. Radiolabeled complementary deoxyribonucleic acid probes derived from one of the complementary deoxyribonucleic acids isolated were used in northern hybridizations against ribonucleic acid collected from pregnant and nonpregnant uterus and a variety of other mouse tissues.

RESULTS

A total of 40 positive clones were isolated; half were identified as cytotoxic T-lymphocyte antigen-2 alpha (a putative inhibitor of the protease cathepsin L) and the other half represented a novel complementary deoxyribonucleic acid. Conceptual translation of the complementary deoxyribonucleic acid predicted a novel protein of 154 amino acids that is proline rich and acidic (pregnancy-specific uterine protein). Northern hybridizations demonstrated that message is abundant in the uterus during late pregnancy. After birth expression rapidly decreased and message was no longer found in the uterus by the third day. A minimal amount of message is present in placental ribonucleic acid, but expression is otherwise not detected in a variety of adult and fetal tissues surveyed, suggesting that expression of this gene is limited to the pregnant uterus.

CONCLUSIONS

The abundance of message and expression apparently limited to the pregnant uterus suggests that the protein represented by this complementary deoxyribonucleic acid may play an important role in pregnancy.

Molecular diagnosis of cystic fibrosis

The clinical and pathologic features of patients with cystic fibrosis are summarized, and generalized genotype or phenotype correlations are discussed in this article. Incorporation of modern molecular biologic techniques into a rapid, cost-efficient, and specific diagnostic laboratory test is outlined. The protocol for the multiplex polymerase chain reaction detection of five common cystic fibrosis transmembrane conductance regulator (CFTR) mutations by ASO hybridization is detailed. Neonatal screening and issues involved in the genetic counseling of families at risk for cystic fibrosis are presented. Recommendations for molecular diagnostic testing in cystic fibrosis are made.

Enzymatic and molecular diagnosis of Gaucher disease

Advances in the knowledge of the molecular genetics of Gaucher disease has made diagnosis more certain. Carrier detection in kindreds in which the responsible mutation has been defined is completely reliable now. Coupled with enzymatic assays, the diagnostic capabilities are greater than before. Use of these methods provides important information to individuals at risk and allows them to make critical decisions. The new, simplified methods reviewed in this article permit the molecular diagnosis of the disease and carrier stage of large numbers of samples within 1 week.

Cytokine mobilization of peripheral blood stem cells in patients with Gaucher disease with a view to gene therapy

As clinical trials for gene therapy in Gaucher disease (GD) begin, questions regarding the biology of the hematopoietic stem cell in this disease remain unanswered. This study demonstrates the ability to mobilize and collect CD34+ cells in three patients with the disorder. Our RAC/FDA-approved clinical trial utilizes mobilized peripheral blood stem cells (PBSC) as the target cells for gene transfer. In this approach, a white blood cell fraction is collected by apheresis, enriched for CD34+ cells, and transduced with a retroviral vector carrying the glucocerebrosidase (GC) gene. Transduced cells from the patient with activity corrected to at least normal levels will be returned to the patient without myelosuppressive therapy. We report here the effect of cytokines in mobilizing PBSC in three patients with GD. Two (patients 1 and 2) were given granulocyte colony-stimulating factor (G-CSF) at a dose of 5 micrograms/kg/d and one (patient 3) was given 10 micrograms/kg/d for 10 days. Leukaphereses were done daily for 5 days and the products enriched for CD34+ cells using the clinical Ceprate (CellPro) column. The CD34+ cells in all fractions were monitored daily during mobilization and leukaphereses. Subset analysis for the expression of Thy-1, CD38, HLA-DR, and CD33 on the CD34+ cells was performed. An increase in CD34+ cells in the peripheral blood was noted from day 5 onward (up to a six-fold increase). Up to a 625-fold enrichment in CD34+ cells in the apheresis product was noted using the clinical Ceprate column. Totals of 1.2, 3.5, and 2.1 x 10(6) CD34+ cells/kg were collected in the three patients. A diminution in the percent of CD34+/Thy-1+ cells was noted with enrichment. In vitro retroviral transduction of the CD34-enriched cells using centrifugation promoted transduction protocol previously described (Bahnson AB et al., Centrifugal enhancement of retroviral-mediated gene transfer. Journal of Virology Methods 54:131, 1995) and modified for clinical use, demonstrated a mean transduction efficiency of 37% (range 8.3-87.1%) in clonogenic cells and up to 50% in long-term culture-initiating cells (LTC-IC) at week 6. Significantly, we have been able to achieve up to a 50-fold increase in the level of GC above deficient levels in the patients' CD34+ enriched cells when maintained in vitro in culture. The study demonstrates that up to a six-fold increase in CD34+ cells in the PB can be achieved with cytokines in patients with GD. CD34+ cells can be collected in numbers sufficient for conventional transplantation and transduced efficiently in vitro. In gene therapy trials for genetic disorders to date, myelosuppressive therapy is not advocated. The clinical trial will demonstrate whether this number of transduced CD34+ cells will be adequate for competitive engraftment of genetically corrected PBSC.

Computerized tomography in hereditary nonprogressive chorea

A 56-year-old woman had a 50-year history of childhood-onset chorea without progressive neurologic deficit. The patient's father had a lifelong extrapyramidal disorder characterized by a head-nodding tremor and involuntary movements especially evident with anxiety. The computerized tomographic scan was normal, without evidence of cortical or caudate atrophy. The computerized tomographic scan supports the notion of a functional rather than a structural lesion, and may aid in the discrimination of hereditary nonprogressive chorea from more devastating forms of hereditary chorea.

A computer system for clinical microbiology

The Department of Clinical Microbiology at St Thomas' Hospital has been producing bacteriological reports on a computer for more than three years and is now producing some 2300 reports per week. The system is operated entirely by laboratory staff without special training, and involves the use of optical mark reader (OMR) forms as worksheets, automatic validation and release of most reports, the use of local terminals, and scrutiny of reports by pathologists using a visual display unit. The OMR worksheet records not only the final result but also most of the tests and observations made on the samples; it is the only working document used by technicians. One specialist clinic submits its laboratory requests on an OMR form, which is subsequently used to record the results. The reports are printed and also filed in the computer to produce analyses for hospital, laboratory, and clinical management.

Fugue states in sleep and wakefulness: a psychophysiological study

A patient's refusal to participate in recommended treatment is a problem faced in all branches of medicine. However, psychiatry faces special problems because of its authority to impose hospitalization and treatment on unwilling patients. Nowhere is this more poignant than in the treatment of patients exhibiting suicidal behavior where the potential for imminent self-destruction exists. As part of a prospective study to develop utilization review standards for the hospitalization of suicide attempters, cases were identified where there was independent agreement between both the experts' standards and the treating resident psychiatrists that hospitalization was required. Despite this agreement, the patients were not hospitalized because the patients refused. By most criteria, these patients were a high risk group. They had made repeated suicide attempts, used lethal means which eventuated in serious medical consequences, and were still suicidal when referred for treatment. The emergency room psychiatrists reported feeling confused, anxious, and annoyed in dealing with these patients, and the patients signed out against medical advice. A review of these cases indicates that discussions of social control vs. medical responsibility and clear criteria for hospitalization should be incorporated into residency training programs since the emergency room resident faces these tension-producing issues frequently with several different types of patients. Moreover, utilization review criteria may help to set standards which will assist the psychiatrist in making these difficult decisions.