What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients

BACKGROUND

Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care.

METHODS

At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified.

RESULTS

A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only."

CONCLUSIONS

Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Burnout and depression: A cross sectional study among health care workers providing HIV care during the COVID-19 pandemic in Malawi

Health care workers (HCWs) in eastern Africa experience high levels of burnout and depression, and this may be exacerbated during the COVID-19 pandemic due to anxiety and increased work pressure. We assessed the prevalence of burnout, depression and associated factors among Malawian HCWs who provided HIV care during the COVID-19 pandemic. From April-May 2021, between the second and third COVID-19 waves in Malawi, we randomly selected HCWs from 32 purposively selected PEPFAR/USAID-supported health facilities for a cross-sectional survey. We screened for depression using the World Health Organization Self Report Questionnaire (positive screen: score≥8) and for burnout using the Maslach Burnout Inventory tool, (positive screen: moderate-high Emotional Exhaustion and/or moderate-high Depersonalization, and/or low-moderate Personal Accomplishment scores). Logistic regression models were used to evaluate factors associated with depression and burnout. We enrolled 435 HCWs, median age 32 years (IQR 28-38), 54% male, 34% were clinical cadres and 66% lay cadres. Of those surveyed, 28% screened positive for depression, 29% for burnout and 13% for both. In analyses that controlled for age, district, and residence (rural/urban), we found that screening positive for depression was associated with expecting to be infected with COVID-19 in the next 12 months (aOR 2.7, 95%CI 1.3-5.5), and previously having a COVID-19 infection (aOR 2.58, 95CI 1.4-5.0). Screening positive for burnout was associated with being in the clinical cadre (aOR 1.86; 95% CI: 1.2-3.0) and having a positive depression screen (aOR 3.2; 95% CI: 1.9-5.4). Reports of symptoms consistent with burnout and depression were common among Malawian HCWs providing HIV care but prevalence was not higher than in surveys before the COVID-19 pandemic. Regular screening for burnout and depression should be encouraged, given the potential for adverse HCW health outcomes and reduced work performance. Feasible interventions for burnout and depression among HCWs in our setting need to be introduced urgently.

When familiarity not novelty motivates information-seeking behaviour

Research has established that novelty motivates information-seeking behaviour in many situations. While novelty preferences have been well-studied, an understanding of conditions under which familiarity trumps novelty remains limited. Recent work has revealed that when a metacognitive experience indicates that unsuccessfully recalled information may still be available, a subsequent tendency to seek out unrecalled familiar information can emerge. We conducted three experiments to identify critical factors that determine when familiarity preferences can be observed. Experiment 1 demonstrated the critical role of a recent unsuccessful recall attempt in inducing such a preference. Experiment 2 revealed that the impact of recall attempts is not limited to situations that follow unsuccessful recall, as a familiarity preference was observed even when information was successfully generated. Experiment 3 showed that the level of confidence in the accuracy of any recalled information is a key factor, with moderate levels of confidence leading to the strongest subsequent familiarity preference. Together, our results suggest that novelty preferences in information-seeking are not ubiquitous, as specific situational demands including recent attempted memory retrieval, as well as metacognitive retrieval experiences, can induce familiarity preferences. Our findings can be interpreted within theoretical frameworks that emphasize the role of knowledge gaps as driving factors of information-seeking.

Sunflower-Associated Reductions in Varroa Mite Infestation of Honey Bee Colonies

Landscapes can affect parasite epidemiology in wild and agricultural animals. Honey bees are threatened by loss of floral resources and by parasites, principally the mite Varroa destructor and the viruses it vectors. Existing mite control relies heavily on chemical treatments that can adversely affect bees. Alternative, pesticide-free control methods are needed to mitigate infestation with these ectoparasites. Many flowering plants provide nectar and pollen that confer resistance to parasites. Enrichment of landscapes with antiparasitic floral resources could therefore provide a sustainable means of parasite control in pollinators. Floral rewards of Asteraceae plants can reduce parasitic infection in diverse bee species, including honey and bumble bees. Here, we tested the effects of sunflower (Helianthus annuus) cropland and pollen supplementation on honey bee resistance to macro- and microparasites. Although sunflower had nonsignificant effects on microparasites, We found that increased sunflower pollen availability correlated with reduced Varroa mite infestation in landscapes and pollen-supplemented colonies. At the landscape level, each doubling of sunflower crop area was associated with a 28% reduction in mite infestation. In field trials, late-summer supplementation of colonies with sunflower pollen reduced mite infestation by 2.75-fold relative to artificial pollen. United States sunflower crop acreage has declined by 2% per year since 1980, however, suggesting reduced availability of this floral resource. Although further research is needed to determine whether the observed effects represent direct inhibition of mite fecundity or mite-limiting reductions in honey bee brood-rearing, our findings suggest the potential for sunflower plantings or pollen supplements to counteract a major driver of honey bee losses worldwide.

I-DO GOC: Improving documentation in oncology with goals of care

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Background: Goals of Care (GOC) discussions are part of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early GOC discussions are associated with better quality of life, reduced use of futile medical care, and enhanced goal-concordant care. In order to increase GOC documentation within the electronic medical record (EMR), the Kaiser Permanente San Francisco medical oncology practice began an ASCO Quality Training Program initiative in January 2022 to increase oncologist discussion and documentation of GOC in advanced cancer patients. Methods: Baseline data on the frequency of GOC discussions was obtained through a structured chart review with a historical cohort of stage IV or recurrent cancer patients > 18 years old between 1/1/2020-6/1/2020. The project aimed to improve accessible GOC documentation from a baseline of 0% to a goal of 25% among stage IV or recurrent cancer patients seen by an oncologist between 1/2022 and 5/14/2022. Patients with hematologic malignancies were excluded. Oncologists were instructed to use a templated GOC automated phrase (Smartphrase) that consolidated content into a visible, centralized EMR location. The frequency of GOC Smartphrase usage among oncologists was tracked monthly through a customized dashboard. Plan-Do-Study-Act cycles included education on GOC documentation and monthly feedback for oncologists on performance. Results: Review of the 2020 historical cohort revealed no structured or accessible GOC documentation by oncologists. During the intervention period, 300 Stage IV and recurrent cancer patients were eligible for GOC documentation. The median age of the intervention group was 70 years, with the most common types of cancers represented: Prostate (21%), Breast (19%), and Lung (17%). Our study cohort included a diverse population: White (45%), Asian (36%), Black/African American (11%), and Hispanic (7%). Between 1/1/2022 to 5/14/22, 142 (47%) patients had at least one documented GOC conversation, exceeding the target of 25%. 100% of these structured conversations were viewable in the designated area in the EMR. Conclusions: Our ASCO Quality Training Program initiative successfully increased oncologists' overall number of GOC conversations and made those conversations more easily accessible to the entire care team. Our process for standardizing the documentation of GOC conversations was based on the use of a Smartphrase that helped organize the collected information within the EMR. During the study period, we increased the documented GOC rate from 0% to 47%. This can improve patient and physician satisfaction, as well as improve goal concordant care for patients with advanced cancer. Further efforts will be focused on sustaining these initial gains in GOC documentation and on promoting their broader use across our organization.

What matters most: Qualitative investigation of goals and values in a diverse sample of patients with advanced cancer

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Background: Goals of care conversations (GOCC) are a complex part of patient-focused care. Current understanding of GOCC content is limited to post-hoc patient satisfaction surveys and focus groups evaluating end-of-life advance care planning physician-patient interactions, and documentation. We investigated patient goals and values through standardized GOCC documentation by oncologists in patients with advanced cancer. Methods: This pilot qualitative analysis of patient goals and values included all adult patients > 18 years with advanced recurrent or stage IV cancer seen at Kaiser Permanente San Francisco with an oncologist documented GOCC between 1/1/2022 to 5/14/22. Our team developed a templated GOCC automated phrase (Smartphrase) within our electronic medical record (EMR), with a selection tab that included a listing of common patient goals and values and an option to add free text. Team members reviewed each patient’s initial GOCC content was reviewed for frequently occurring themes consistent with goals and values. Results: A total of 178 patients had EMR documented GOCC, with a mean of 1.8 GOCC per patient. These patients were 51% (n = 94) female, with a median age of 68.5 years old. The population was racially diverse with 46% identifying as White, 32% Asian/Pacific Islander, 13% Black, 8% Hispanic/Latino, and 1% Other. The most common cancer types included breast (19%, n = 34), lower GI (16%, n = 29), and thoracic (14%, n = 25). Family members were present in 35% (n = 63) of GOCC. Table summarizes thematically grouped goals and values. Conclusions: Our findings highlight the importance of GOCC in routine oncology visits. Our standardized documentation tool for GOCC prompted medical oncologists to identify what matters most to patients with advanced or recurrent cancer regarding their values and goals related to care and quality of life. Among the wide range of responses, we identified that the most important goals and values to our patients include avoiding pain and suffering, physical independence, and living as long as possible. In contrast, patients rarely identified comfort-only treatment as a priority. This tool can guide goal-concordant care at initial onset of the cancer journey and be revisited as these conversations evolve over time. Future investigation is needed to understand how GOCC goals and values identified early impact patient satisfaction, change over time, influence treatment decisions, and potentially lead to an evolution in standard for goal-concordant care.[Table: see text]

Women's experiences using drugs to induce abortion acquired in the informal sector in Colombia: qualitative interviews with users in Bogotá and the Coffee Axis

In 2006, abortion in Colombia was decriminalised under certain circumstances. Yet some women continue to avail themselves of ways to terminate pregnancies outside of the formal health system. In-depth interviews (IDIs) with women who acquired drugs outside of health facilities to terminate their pregnancies (n = 47) were conducted in Bogotá and the Coffee Axis in 2018. Respondents were recruited when they sought postabortion care at a health facility. This analysis examines women's experiences with medication acquired outside of the health system for a termination: how they obtained the medication, what they received, how they were instructed to use the pills, the symptoms they were told to expect, and their abortion experiences. Respondents purchased the drugs in drug stores, online, from street vendors, or through contacts in their social networks. Women who used online vendors more commonly received the minimum dose of misoprostol according to WHO guidelines to complete the abortion (800 mcg) and received more detailed instructions and information about what to expect than women who bought the drug elsewhere. Common instructions were to take the pills orally and vaginally; most women received incomplete information about what to expect. Most women seeking care did not have a complete abortion before coming to the health facility (they never started bleeding or had an incomplete abortion). Women still face multiple barriers to safe abortion in Colombia; policymakers should promote better awareness about legal abortion availability, access to quality medication and complete information about misoprostol use for women to terminate unwanted pregnancies safely.

What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis

INTRODUCTION

In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them.

METHODS

A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews.

RESULTS

Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications.

CONCLUSIONS

As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.

The sexual and reproductive health of foreign-born women in the United States

Objective

To explore the sexual and reproductive health (SRH) behaviors, health insurance coverage and use of SRH services of women in the United States (U.S.) by nativity, disaggregated by race and ethnicity.

Study design

We analyzed publicly available and restricted data from the National Survey of Family Growth to assess differences and similarities between foreign-born and U.S.-born women, both overall and within Hispanic, non-Hispanic (NH) white, NH black and NH Asian groups.

Results

A larger proportion of foreign-born women than U.S.-born women lacked health insurance coverage. Foreign-born women utilized SRH services at lower rates than U.S.-born women; this effect diminished at the multivariate level, although race and ethnicity differences remained. Overall, foreign-born women were less likely to pay for SRH services with private insurance than U.S.-born women. Foreign-born women were less likely to use the most effective contraceptive methods than U.S.-born women, with some variation across race and ethnicity: NH white and NH black foreign-born women were less likely to use highly effective contraceptive methods than their U.S.-born counterparts, but among Hispanic women, the reverse was true.

Conclusion

Our findings demonstrate that the SRH behaviors, needs and outcomes of foreign-born women differ from those of U.S-born women within the same race/ethnic group.

Implications

This paper contributes to the emergent literature on immigrants in the U.S. by laying the foundation for further research on the SRH of the foreign-born population in the country, which is critical for developing public health policies and programs to understand better and serve this growing and diverse population.

Galápagos sperm whales (Physeter macrocephalus): waxing and waning over three decades

While population sizes and structures naturally fluctuate over time, rapid within-generation changes are usually driven by shifts in habitat quality and (or) abrupt mortality. We evaluate how sperm whales (Physeter macrocephalus L., 1758 = Physeter catodon L., 1758) responded to the dynamic habit off the Galápagos Islands over 30 years, relating it to variation in prey availability and whaling operations in the tropical Pacific. In the 1980s, males and females were commonly sighted foraging and socializing in the northwest of the archipelago. Sightings decreased during the 1990s; by the 2000s, they became very rare: occasional single foraging males were sighted and females abandoned the archipelago. In the 2010s, whales return to the southern waters, in large groups with apparently more breeding males and calves. The waxing and waning of Galápagos sperm whales are likely caused by environmental shifts together with ripple effects of whaling. Their patchy prey are influenced by variation in sea temperature and productivity, which drives movements of whales in and out of the archipelago. Whaling may have aggravated these movements by leaving an attractive surplus of prey in coastal waters depleted of whales. These findings highlight the magnitude of spatiotemporal scales used by sperm whales and the consequent challenges of assessing population dynamics of long-lived, mobile pelagic species.

Longitudinal Study of Caries Development from Childhood to Adolescence

The World Health Organization (WHO) stated that globally, dental caries is the most important oral condition. To develop effective prevention strategies requires an understanding of how this condition develops and progresses over time, but there are few longitudinal studies of caries onset and progression in children. The aim of the study was to establish the pattern of caries development from childhood into adolescence and to explore the role of potential risk factors (age, sex, ethnicity, and social deprivation). Of particular interest was the disease trajectory of dentinal caries in the permanent teeth in groups defined by the presence or absence of dentinal caries in the primary teeth. Intraoral examinations to assess oral health were performed at 4 time points by trained and calibrated dentist examiners using a standardized, national diagnostic protocol. Clinical data were available from 6,651 children. Mean caries prevalence (% D₃MFT > 0) was 16.7% at the first clinical examination (ages 7-9 y), increasing to 31.0%, 42.2%, and 45.7% at subsequent examinations. A population-averaged model (generalized estimating equations) was used to model the longitudinal data. Estimated mean values indicated a rising D₃MFT count as pupils aged (consistent with new teeth emerging), which was significantly higher (4.49 times; 95% confidence interval, 3.90-5.16) in those pupils with caries in their primary dentition than in those without. This study is one of the few large longitudinal studies to report the development of dental caries from childhood into adolescence. Children who developed caries in their primary dentition had a very different caries trajectory in their permanent dentition compared to their caries-free contemporaries. In light of these results, caries-free and caries-active children should be considered as 2 separate populations, suggesting different prevention strategies are required to address their different risk profiles.

Social structure of long-finned pilot whales (Globicephala melas) off northern Cape Breton Island, Nova Scotia

Cetacean social structures include fluid and stable elements. Long-finned pilot whales (Globicephala melas) live in units that interact forming labile groups. In this study conducted off Cape Breton Island, between 1998–2011, we confirm unit membership predicts associations between individuals. We determine how units are structured and interact. We delineated 21 nearly-stable social units, with an average 7 members. For units where multiple individuals are sexed, both sexes are present. Most units showed long-term stability, while one showed evidence of splitting. Three units shared individuals with the largest unit (K, average size = 29). Splitting is likely triggered by size and difficulties maintaining associations between all individuals. Pilot whales face many pressures driving sociality at a range of temporal and social scales producing a multilevel society. While we have produced a more detailed model of long-finned pilot whale social structure, there are still unanswered questions, particularly whether units are strict matrilines.

A cluster-randomized controlled trial: fluoride varnish in school children

We conducted a school-based parallel cluster randomized controlled trial with 36-month follow-up of children aged 7 to 8 years. Primary schools were randomly assigned to 2 groups: 3 applications of fluoride varnish (22,600 ppm) each year or no intervention. The primary outcome was DFS increment in the first permanent molars, with the hypothesis that 9 applications of varnish over 3 years would result in a lower increment in the test group. Follow-up measurements were recorded by examiners blind to the allocation. Ninety-five schools were randomized to the test and 95 to the reference groups; 1473 (test) and 1494 (reference) children participated in the trial. An intention-to-treat analysis was carried out with random effects models. The DFS increment was 0.65 (SD 2.15) in the test and 0.67 (SD 2.10) in the reference groups, respectively. There was no statistically significant difference between the groups. We were unable to demonstrate an effect for fluoride varnish when it was used as a public health intervention to prevent caries in the first permanent molar teeth (Inter-national Standard Randomized Controlled Trial Registration: ISRCTN: #72589426).

Behaviourally specific preferred associations in bottlenose dolphins, Tursiops spp

We investigated association patterns of 52 photographically identified, free-ranging bottlenose dolphins (Tursiops spp. Gervais, 1855) across four behavioural states (rest, travel, social, and foraging/feeding) to investigate how behavioural state influences patterns of association. Group composition and behavioural data were extracted from 2178 encounter surveys collected over 3 years. Analyses revealed three general types of association: (1) affiliates, which consistently demonstrate preferred associations across all behavioural states; (2) acquaintances, which never form preferred associations but still associate in at least one behavioural state; and (3) behavioural associates, which form preferred associations in at least one, but not all behavioural states. The majority of associations in Shark Bay, Australia, are acquaintance type (38.2%), with affiliates (5.7%, principally between adult males) and behavioural associates (28.9%, principally between juveniles) being relatively rarer. Permutation tests identified behaviourally specific preferred associations during all behavioural states. Although behaviourally specific preferred associations appear to exist within the Shark Bay social structure, it seems that the social organization and mating system constrain the social relationships for the majority of males and females in differing ways which prevent them from having behavioural associates, leaving juveniles free to associate based on short-term expediency and behavioural specific needs.

Vocal clans in sperm whales (Physeter macrocephalus)

Cultural transmission may be a significant source of variation in the behaviour of whales and dolphins, especially as regards their vocal signals. We studied variation in the vocal output of 'codas' by sperm whale social groups. Codas are patterns of clicks used by female sperm whales in social circumstances. The coda repertoires of all known social units (n = 18, each consisting of about 11 females and immatures with long-term relationships) and 61 out of 64 groups (about two social units moving together for periods of days) that were recorded in the South Pacific and Caribbean between 1985 and 2000 can be reliably allocated into six acoustic 'clans', five in the Pacific and one in the Caribbean. Clans have ranges that span thousands of kilometres, are sympatric, contain many thousands of whales and most probably result from cultural transmission of vocal patterns. Units seem to form groups preferentially with other units of their own clan. We suggest that this is a rare example of sympatric cultural variation on an oceanic scale. Culture may thus be a more important determinant of sperm whale population structure than genes or geography, a finding that has major implications for our understanding of the species' behavioural and population biology.

Culture in whales and dolphins

Studies of animal culture have not normally included a consideration of cetaceans. However, with several long-term field studies now maturing, this situation should change. Animal culture is generally studied by either investigating transmission mechanisms experimentally, or observing patterns of behavioural variation in wild populations that cannot be explained by either genetic or environmental factors. Taking this second, ethnographic, approach, there is good evidence for cultural transmission in several cetacean species. However, only the bottlenose dolphin (Tursiops) has been shown experimentally to possess sophisticated social learning abilities, including vocal and motor imitation; other species have not been studied. There is observational evidence for imitation and teaching in killer whales. For cetaceans and other large, wide-ranging animals, excessive reliance on experimental data for evidence of culture is not productive; we favour the ethnographic approach. The complex and stable vocal and behavioural cultures of sympatric groups of killer whales (Orcinus orca) appear to have no parallel outside humans, and represent an independent evolution of cultural faculties. The wide movements of cetaceans, the greater variability of the marine environment over large temporal scales relative to that on land, and the stable matrilineal social groups of some species are potentially important factors in the evolution of cetacean culture. There have been suggestions of gene-culture coevolution in cetaceans, and culture may be implicated in some unusual behavioural and life-history traits of whales and dolphins. We hope to stimulate discussion and research on culture in these animals.

Reliability of photographic and molecular techniques for sexing northern bottlenose whales (Hyperoodon ampullatus)

Identifying the sex of living cetaceans can be difficult, even when species are sexually dimorphic. We compare two methods of molecular sexing (ZFY (zinc finger protein gene) and SRY (sex-determining region Y gene)) and evaluate the effectiveness of photographic techniques for identifying sex in northern bottlenose whales, Hyperoodon ampullatus, in the Gully, off Nova Scotia, Canada. Samples from individuals of known sex from historic Norwegian whaling (n = 19) and from recent strandings (n = 3) were used to test the reliability of the molecular techniques. Although both methods gave accurate results, the ZFY method was found to be unsuitable for degraded (historic) samples, owing to the large size of the target DNA fragment. Results from the two molecular-sexing methods were in agreement for biopsy samples taken from bottlenose whales in the Gully (7 males and 13 females). Photographs of the melon profile were used to assign free-swimming animals to the categories female - immature male, subadult male, and mature male. Melon photographs of adult-sized animals taken up to 7 years apart were consistently assigned to the same category. Overall, sex identification from melon photographs was in agreement with results from molecular sexing. However, animals in the category female - immature male were difficult to assign on the basis of morphological features alone.

Cultural selection and genetic diversity in matrilineal whales

Low diversities of mitochondrial DNA (mtDNA) have recently been found in four species of matrilineal whale. No satisfactory explanation for this apparent anomaly has been previously suggested. Culture seems to be an important part of the lives of matrilineal whales. The selection of matrilineally transmitted cultural traits, upon which neutral mtDNA alleles "hitchhike," has the potential to strongly reduce genetic variation. Thus, in contrast to other nonhuman mammals, culture may be an important evolutionary force for the matrilineal whales.

The presentation of newly-diagnosed diabetic patients in Uganda

We assessed the clinical characteristics of newly-diagnosed diabetic patients presenting to the Mulago Hospital Diabetic Clinic for the first time between 1 January 1993 and 10 August 1994. There were 252 patients: 117 men and 135 women. Mean age at onset of diabetes was 45 years (range 2-87 years) and peak incidence was at 40-49 years. Body mass index (BMI) was available in only 71 patients, of whom 53.5% (33.8% female, 19.7% male) were overweight (BMI > 25 in women, in > 27 men) and 11.3% (8.5% men, 2.8% women) were underweight (BMI < 20). Obesity was more marked in young women. Almost all patients presented with the classical symptoms of diabetes, and the majority were severely hyperglycaemic. A family history of diabetes was identified in 16%. Concurrent illnesses at diagnosis of diabetes were unusual. Sepsis was commonest (11.9%), followed by malaria (7.8%), tuberculosis (1.2%), AIDS (1.2%) and pancreatitis (0.8%). Peripheral neuropathy was present in 46.4% of patients, hypertension (BP > 150/100) in 27.3%, impotence in 22.2% of the men, proteinuria in 17.1%, ischaemic heart disease in 4.8%, foot ulcers in 4.0% and cataracts in 3.2%. Insulin was the most commonly prescribed treatment (52.8%); 31% of patients received oral hypoglycaemic agents, only 15.1% were managed on diet only, and 1.2% opted for herbal medicine.

Patterns of kinship in groups of free-living sperm whales (Physeter macrocephalus) revealed by multiple molecular genetic analyses

Mature female sperm whales (Physeter macrocephalus) live in socially cohesive groups of 10-30, which include immature animals of both sexes, and within which there is communal care of the young. We examined kinship in such groups using analyses of microsatellite DNA, mitochondrial DNA sequence, and sex-linked markers on samples of sloughed skin collected noninvasively from animals in three groups off the coast of Ecuador. Social groups were defined through photographic identification of individuals. Each group contained about 26 members, mostly female (79%). Relatedness was greater within groups, as compared to between groups. Particular mitochondrial haplotypes were characteristic of groups, but all groups contained more than one haplotype. The data are generally consistent with each group being comprised of several matrillines from which males disperse at about the age of 6 years. There are indications of paternal relatedness among grouped individuals with different mitochondrial haplotypes, suggesting long-term associations between different matrilines.

Blood pressure responses to phenylephrine infusions in subjects with Cushing's syndrome

The pathogenesis of the hypertension associated with Cushing's syndrome is not completely understood. Sensitivity to pressor agents may play a role. We have investigated this possibility by measuring blood pressure (BP) during incrementally increasing infusions of the alpha-adrenergic agonist phenylephrine. Ten subjects (8 women: 2 men), aged 40 +/- 5 years (mean +/- s.e.m.) with Cushing's syndrome were studied. All had raised BP but none had received any anti-hypertensive treatment for at least 16 days before study. Ten age- (40 +/- 5 years) and sex-matched control subjects were also studied. At 13.30, 30 min after a light meal, subjects had an intravenous cannula inserted, ECG leads and a sphygomanometer cuff attached, and then rested supine in a quiet room for 30 min. Phenylephrine was then infused incrementally at intervals of 5 min. The doses used were 0.3, 0.6, 0.9, 1.35 and 2 micrograms/kg/min. Basal mean blood pressure (MAP) was 108 +/- 2 mm Hg (mean +/- s.e.m.) in patients and 74 +/- 3 mm Hg in controls (P < 0.05) and pulse rate was 75 +/- 5 and 68 +/- 3 beats/min (NS), respectively). MAP increased and pulse rate decreased linearly with time. The rate of rise of MAP was 1.7 +/- 0.4 mm Hg/min in subjects and 1.1 +/- 0.2 mm Hg/min in controls (NS). The rate of decrease of pulse was significantly more rapid in Cushing's subjects than in controls (1.4 +/- 0.2; 0.6 +/- 0.1 beats/min2; P < 0.05). The lack of any increased BP response to alpha-adrenergic stimulation suggests that altered sensitivity is not a major cause of the increased BP seen in patients with Cushing's syndrome.

Uptake and Continued Metabolic Activity of Azotobacter Within Fungal Protoplasts

Uptake of vegetative cells of Azotobacter vinelandii into protoplasts of the mycorrhizal fungus Rhizopogon sp. can be induced by treatment with polyethylene glycol (molecular weight, 6000). An L-form of the bacteria has been selected for within the differentiated fungal mycelium which is capable of acetylene reduction and nitrogen fixation, as confirmed by nitrogen-15 assays; this allows the fungus to grow on media lacking any combined nitrogen. The fungus grows and reduces acetylene on concentrations of antibiotics that prevent the growth and activity of free-living Azotobacter. Electron microscopy has revealed modified mitochondrial forms or included bacterial L-forms surrounded by an extra fungal membrane within the hyphae of the modified strains. Poly-beta-hydroxybutyric acid, a storage product of Azotobacter cysts, has also been identified in the hyphae. This would appear to be the first report of the transgenosis for acetylene reduction activity and nitrogen fixation into a eukaryote cell.