Clinician Perceptions of Barriers and Facilitators for Delivering Early Integrated Palliative Care via Telehealth

Early integrated palliative care (EIPC) significantly improves clinical outcomes for patients with advanced cancer. Telehealth may be a useful tool to deliver EIPC sustainably and equitably. Palliative care clinicians completed a survey regarding their perceptions of the barriers, facilitators, and benefits of using telehealth video visits for delivering EIPC for patients with advanced lung cancer. Forty-eight clinicians across 22 cancer centers completed the survey between May and July 2022. Most (91.7%) agreed that telehealth increases access to EIPC and simplifies the process for patients to receive EIPC (79.2%). Clinicians noted that the elderly, those in rural areas, and those with less-resourced backgrounds have greater difficulty using telehealth. Perceived barriers were largely patient-based factors, including technological literacy, internet and device availability, and patient preferences. Clinicians agreed that several organizational factors facilitated telehealth EIPC delivery, including technological infrastructure (85.4%), training (83.3%), and support from study coordinators (81.3%). Other barriers included systems-based factors, such as insurance reimbursement and out-of-state coverage restrictions. Patient-, organization-, and systems-based factors are all important to providing and improving access to telehealth EIPC services. Further research is needed to investigate the efficacy of telehealth EIPC and how policies and interventions may improve access to and dissemination of this care modality.

Improved separation and quantification method for microplastic analysis in sediment: A fine-grained matrix from Arctic Greenland

Microplastic analysis requires effective separation and purification methods, which greatly depend on the matrix and target particle size. Microplastics-sediment extraction usually involves intermediate steps, increasing processing time and particle loss, particularly for particles <100 μm. Here, we propose an improved separation and quantification method for fine-grained sediment that minimizes microplastic loss by reducing intermediate steps. First, the sample is treated with CH3COOH, KOH and NaClO, and only transferred for the density separation (ZnCl2). The extraction efficiency, visually evaluated on spiked samples, was higher than 90% for particles >100 μm and 83% for 63-75 μm particles. This indicates that a sequential extraction method reduces the risk of particle loss, particularly of the small size fraction. Comparatively, the extraction of ABS particles (20-100 μm) was low (30%) but the recovery, assessed via μFTIR, was higher (55%). Additionally, the proposed method can be adapted to other sediment types and environmental matrices.

Prazosin for nightmares in serious illness

Nightmares can be a distressing symptom in patients living with serious illness. Prazosin, a selective alpha-1 adrenergic antagonist, has been suggested to treat nightmares, with most data supporting its use in post-traumatic stress disorder (PTSD). We present the case of a 60-year-old woman with metastatic breast cancer who experienced healthcare-associated nightmares following hospitalisation. She did not meet diagnostic criteria for PTSD. Atypical antipsychotics and benzodiazepines were ineffective in controlling her nightmares, resulting in referral to our outpatient palliative medicine clinic. Prazosin was initiated alongside interdisciplinary psychosocial support, resulting in rapid resolution of her nightmares. To our knowledge, this is the first case to report on use of prazosin to manage nightmares in the outpatient palliative medicine setting.

Effect of an Artificial Intelligence Decision Support Tool on Palliative Care Referral in Hospitalized Patients: A Randomized Clinical Trial

CONTEXT

Palliative care services are commonly provided to hospitalized patients, but accurately predicting who needs them remains a challenge.

OBJECTIVES

To assess the effectiveness on clinical outcomes of an artificial intelligence (AI)/machine learning (ML) decision support tool for predicting patient need for palliative care services in the hospital.

METHODS

The study design was a pragmatic, cluster-randomized, stepped-wedge clinical trial in 12 nursing units at two hospitals over a 15-month period between August 19, 2019, and November 17, 2020. Eligible patients were randomly assigned to either a medical service consultation recommendation triggered by an AI/ML tool predicting the need for palliative care services or usual care. The primary outcome was palliative care consultation note. Secondary outcomes included: hospital readmissions, length of stay, transfer to intensive care and palliative care consultation note by unit.

RESULTS

A total of 3183 patient hospitalizations were enrolled. Of eligible patients, A total of 2544 patients were randomized to the decision support tool (1212; 48%) and usual care (1332; 52%). Of these, 1717 patients (67%) were retained for analyses. Patients randomized to the intervention had a statistically significant higher incidence rate of palliative care consultation compared to the control group (IRR, 1.44 [95% CI, 1.11-1.92]). Exploratory evidence suggested that the decision support tool group reduced 60-day and 90-day hospital readmissions (OR, 0.75 [95% CI, 0.57, 0.97]) and (OR, 0.72 [95% CI, 0.55-0.93]) respectively.

CONCLUSION

A decision support tool integrated into palliative care practice and leveraging AI/ML demonstrated an increased palliative care consultation rate among hospitalized patients and reductions in hospitalizations.

Improving time to palliative care review with predictive modeling in an inpatient adult population: study protocol for a stepped-wedge, pragmatic randomized controlled trial

Background

Palliative care is a medical specialty centered on improving the quality of life (QOL) of patients with complex or life-threatening illnesses. The need for palliative care is increasing and with that the rigorous testing of triage tools that can be used quickly and reliably to identify patients that may benefit from palliative care.

Methods

To that aim, we will conduct a two-armed stepped-wedge cluster randomized trial rolled out to two inpatient hospitals to evaluate whether a machine learning algorithm accurately identifies patients who may benefit from a comprehensive review by a palliative care specialist and decreases time to receiving a palliative care consult in hospital. This is a single-center study which will be conducted from August 2019 to November 2020 at Saint Mary’s Hospital & Methodist Hospital both within Mayo Clinic Rochester in Minnesota. Clusters will be nursing units which will be chosen to be a mix of complex patients from Cardiology, Critical Care, and Oncology and had previously established relationships with palliative medicine. The stepped wedge design will have 12 units allocated to a design matrix of 5 treatment wedges. Each wedge will last 75 days resulting in a study period of 12 months of recruitment unless otherwise specified. Data will be analyzed with Bayesian hierarchical models with credible intervals denoting statistical significance.

Discussion

This intervention offers a pragmatic approach to delivering specialty palliative care to hospital patients in need using machine learning, thereby leading to high value care and improved outcomes. It is not enough for AI to be utilized by simply publishing research showing predictive performance; clinical trials demonstrating better outcomes are critically needed. Furthermore, the deployment of an AI algorithm is a complex process that requires multiple teams with varying skill sets. To evaluate a deployed AI, a pragmatic clinical trial can accommodate the difficulties of clinical practice while retaining scientific rigor.

Trial registration

ClinicalTrials.gov NCT03976297. Registered on 6 June 2019, prior to trial start.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05546-5.

Extrarenal expression of α-klotho, the kidney related longevity gene, in Heterocephalus glaber, the long living Naked Mole Rat

The Naked Mole Rat (NMR), Heterocephalus glaber, provides an interesting model for studying biomarkers of longevity due to its long lifespan of more than 30 years, almost ten times longer than that of mice and rats. α-Klotho (klotho) is an aging-suppressor gene, and overexpression of klotho is associated with extended lifespan in mice. Klotho is predominantly expressed in the kidney. The expression profile of klotho in the NMR has not previously been reported. The present investigation studied the expression of klotho in the kidney of NMR with that of Rattus Norvegicus (RN) and demonstrated that klotho was expressed in the kidney of NMR at the same level as found in RN. Besides, a significant expression of Kl mRNA was found in the liver of NMR, in contrast to RN, where no hepatic expression was detected. The Klotho expression was further confirmed at the protein level. Thus, the results of the present comparative study indicate a differential tissue expression of klotho between different species. Besides its important function in the kidney, Klotho might also be of significance in the liver of NMR. It is suggested that the hepatic extrarenal expression of klotho may function as a further longevity-related factor in supplement to the Klotho in the kidney.

Multisite, Randomized Trial of Early Integrated Palliative and Oncology Care in Patients with Advanced Lung and Gastrointestinal Cancer: Alliance A221303

Background: We conducted a multicenter, randomized trial of early integrated palliative and oncology care in patients with advanced cancer to confirm the benefits of early palliative care (PC) seen in prior single-center studies. Methods: We randomly assigned patients with newly diagnosed incurable cancer to early integrated palliative and oncology care (n = 195) or usual oncology care (n = 196) at sites through the Alliance for Clinical Trials in Oncology. Patients assigned to the intervention were expected to meet with a PC clinician at least monthly until death, whereas usual care patients consulted PC on request. The primary endpoint was the change in quality of life from baseline to week 12 per the Functional Assessment of Cancer Therapy-General (FACT-G). Secondary outcomes included anxiety, depression, and communication about prognosis and end-of-life care. Results: Due to significant morbidity and a high proportion of measures that were not completed within the protocol window or for unknown reasons, the rate of missing data was high. We anticipated that 70% of patients (n = 280) would complete the FACT-G at baseline and week 12, but only 49.3% (n = 193/391) completed the measure. Delivery of the intervention was also suboptimal, as 14.9% (n = 29/195) of intervention patients had no PC visits by week 12. Intervention patients reported a mean 3.35 (standard deviation [SD] = 14.7) increase in FACT-G scores from baseline to week 12 compared with usual care patients who reported a 0.12 (SD = 12.7) increase from baseline (p = 0.10). Conclusion: This study highlights the difficulties of conducting multicenter trials of supportive care interventions in patients with advanced cancer. Clinical Trials Registration: NCT02349412.

Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation

CONTEXT

Differences among patient populations that present to consultative palliative care are not known. Such an appreciation would inform health-care delivery tailored to unique populations.

OBJECTIVES

We aimed to compare characteristics and palliative care needs of African Americans (AAs) and whites during initial palliative care consultation.

METHODS

We analyzed patient-reported, clinician-entered clinical encounter data from a large, multisite community-based, nonhospice palliative care collaborative. We included first specialty palliative care consultations from January 1, 2014, to July 2, 2015, across 15 sites within the Global Palliative Care Quality Alliance registry. Demographics, disease, performance status, advance care planning, and symptom prevalence/severity were compared.

RESULTS

Of 775 patients, 12.9% (N = 100) were AA. African Americans were younger (63 vs 75.4 years, P < .0001). A larger proportion of AAs had a diagnosis of cancer (45.0% vs 36.3%, P = .09) and in the hospital (71% vs 61.8%, P = .07). African Americans were more likely to have a Palliative Performance Score of 0 to 30 (35.6% vs 23.7%, P = .049). Around 50% in both racial groups were full code; slightly more than 40% had an advance directive. Nearly two-thirds in both racial groups reported 3 or more symptoms of any severity; one-third reported 3 or more moderate or severe symptoms. A larger proportion of Africans than whites reported pain of any severity (66.0% vs 56.1%, P = .06).

CONCLUSION

All patients present to palliative care consultations with significant symptom and advance care planning needs. Further research is needed to identify how to deliver palliative care: earlier, in noncancer conditions, and improve pain management in AA populations.

Evaluating Residents' Readiness to Elicit Advance Care Plans

BACKGROUND

Trainees are responsible for conducting advance care discussions but are often stressed by this role.

OBJECTIVE

We developed an instrument to determine whether residents could identify a clinical scenario that necessitated an examination of a patient's goals and preferences as they pertain to clinical care, and subsequently measured their readiness to engage in such discussions.

METHODS

Participants responded verbally to open-ended case presentations and completed survey items. We scored responses according to proximity to idealized answers.

RESULTS

The sample consisted of 44 internal medicine residents, 12 students, 5 hospitalists, and 3 palliative care attendings, all of whom volunteered for the study and participated in standard interviews. Residents had widely varying scores (range 0-12, maximum score of 15) on the scored open response items. For eliciting values, mean score increased with training, and students, trainees, and attending physicians had mean scores of 3.7, 5.7, and 8.7, respectively (P = .01). For recommending care, mean scores were 3.0, 6.5, and 9.3, respectively (P < .001). Scores were correlated closely with increasing clinical experience and inversely with self-reported stress when conducting a goals-of-care discussion. The Kuder-Richardson Formula 20 reliability for the instrument was 0.52. Interrater reliability for sections about eliciting and recommending care were 0.64 (P < .001) and 0.50 (P < .001), respectively. The 1-week test-retest reliability was 0.91 for open response items and 0.76 for Likert responses.

CONCLUSIONS

A verbally administered instrument can readily and rapidly characterize a trainee's readiness to participate in advance care planning with patients.

A new capitation payment system in dentistry: the patients' perspective

OBJECTIVE

To investigate patients' experiences of a new payment system for dental care in Sweden.

METHODS

Twenty interviews, with 12 women and 8 men, were analysed by thematic content analysis. The interviewees were all regularly attending patients, strategically selected from five general Public Dental Service clinics in urban Gothenburg, Sweden, who had chosen a new payment system based on capitation rather than the traditional fee-for-service system. Conducted by two clinical psychologists/researchers independent of dental profession, the interviews were guided by a semi-structured schedule, which included questions about the new payment system and about dental care and oral health. All interviews were audio-recorded and transcribed verbatim.

RESULTS

Two themes emerged from the analysis: "Choice" and "Commitment". The sub-themes defined patients as having chosen the new capitation scheme on their own initiative or after being influenced by relatives or by their dentist, and that the change of payment system was occasioned by previous bad (dental) experiences or in the hope of future (dental health) gain. The commitment was perceived as affording economic security and, through the contractual relationship with the provider, regular calls to attend the clinic.

CONCLUSIONS

Patients were generally in favour of the new payment system for dentistry in Sweden; however, important arguments were raised to improve the system, such as better communication concerning the contract and risk assessment.

Formation of an international quality improvement collaborative for palliative care: The Global Palliative Care Quality Alliance (GPCQA)

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Background: Formal mechanisms to share data on quality remain immature in specialty palliative care. As the field grows, infrastructure that promotes collaboration among academic and community-based practice will be required to foster comparisons and benchmarking of data to inform areas for quality improvement. Further, such relationships will create a palliative care “quality improvement laboratory”, where proposed guidelines and best practices can be developed, implemented, and tested. Methods: We set out to bring together specialty palliative care practices with a shared vision for collaborative quality improvement. We modeled our approach after the Institute for Healthcare Improvement Breakthrough Series alongside our Rapid Learning Quality Improvement paradigm. We use a set of common data collection procedures, across an electronic point-of-care platform called Quality Data Collection Tool (QDACT), alongside a centralized data registry. Further, we meet and discuss challenges and issues, compare best practices, and brainstorm new projects through biweekly conference calls. Results: We have created a multi-institutional collaboration for quality assessment and improvement in specialty palliative care. Termed the Global Palliative Care Quality Alliance, we have brought together 11 academic and community organizations, both general and oncology-specific, across six states to study various areas of quality practice. Short-term, we will conduct rapid-cycling quality improvement projects addressing National Quality Forum domains for quality palliative care, including documentation of spiritual assessment and timely advance care planning. Long-term, we aim to study the link between quality measure adherence and outcomes and further align our initiatives with those of other large consortia, like the Palliative Care Research Cooperative and Palliative Care Quality Network. Conclusions: Collaborative quality improvement is needed in specialty palliative care across a national platform. Developing the infrastructure to perform standardized quality improvement is achievable across multiple palliative care settings.

Effects of various pollutant mixtures on immune responses of the blue mussel (Mytilus edulis) collected at a salinity gradient in Danish coastal waters

The Baltic Sea is a semi-enclosed sea with a steady salinity gradient (3‰-30‰). Organisms have adapted to such low salinities, but are suspected to be more susceptible to stress. Within the frame of the integrated environmental monitoring BONUS + project "BEAST" the applicability of immune responses of the blue mussel was investigated in Danish coastal waters. The sampling sites were characterised by a salinity range (11-19‰) and different mixtures of contaminants (metals, PAHs and POPs), according to chemical analysis of mussel tissues. Variation partitioning (redundancy analysis) was applied to decompose salinity and contamination effects. The results indicated that cellular immune responses (total and differential haemocyte count, phagocytic activity and apoptosis) were mainly influenced by contaminants, whereas humoral factors (haemolytic activity) were mainly impacted by salinity. Hence, cellular immune functions may be suitable as biomarkers in monitoring programmes for the Baltic Sea and other geographic regions with salinity variances of the studied range.

Liraglutide, a once-daily human GLP-1 analogue, added to a sulphonylurea over 26 weeks produces greater improvements in glycaemic and weight control compared with adding rosiglitazone or placebo in subjects with Type 2 diabetes (LEAD-1 SU)

AIM

To compare the effects of combining liraglutide (0.6, 1.2 or 1.8 mg/day) or rosiglitazone 4 mg/day (all n >or= 228) or placebo (n = 114) with glimepiride (2-4 mg/day) on glycaemic control, body weight and safety in Type 2 diabetes.

METHODS

In total, 1041 adults (mean +/- sd), age 56 +/- 10 years, weight 82 +/- 17 kg and glycated haemoglobin (HbA(1c)) 8.4 +/- 1.0% at 116 sites in 21 countries were stratified based on previous oral glucose-lowering mono : combination therapies (30 : 70%) to participate in a five-arm, 26-week, double-dummy, randomized study.

RESULTS

Liraglutide (1.2 or 1.8 mg) produced greater reductions in HbA(1c) from baseline, (-1.1%, baseline 8.5%) compared with placebo (+0.2%, P < 0.0001, baseline 8.4%) or rosiglitazone (-0.4%, P < 0.0001, baseline 8.4%) when added to glimepiride. Liraglutide 0.6 mg was less effective (-0.6%, baseline 8.4%). Fasting plasma glucose decreased by week 2, with a 1.6 mmol/l decrease from baseline at week 26 with liraglutide 1.2 mg (baseline 9.8 mmol/l) or 1.8 mg (baseline 9.7 mmol/l) compared with a 0.9 mmol/l increase (placebo, P < 0.0001, baseline 9.5 mmol/l) or 1.0 mmol/l decrease (rosiglitazone, P < 0.006, baseline 9.9 mmol/l). Decreases in postprandial plasma glucose from baseline were greater with liraglutide 1.2 or 1.8 mg [-2.5 to -2.7 mmol/l (baseline 12.9 mmol/l for both)] compared with placebo (-0.4 mmol/l, P < 0.0001, baseline 12.7 mmol/l) or rosiglitazone (-1.8 mmol/l, P < 0.05, baseline 13.0 mmol/l). Changes in body weight with liraglutide 1.8 mg (-0.2 kg, baseline 83.0 kg), 1.2 mg (+0.3 kg, baseline 80.0 kg) or placebo (-0.1 kg, baseline 81.9 kg) were less than with rosiglitazone (+2.1 kg, P < 0.0001, baseline 80.6 kg). Main adverse events for all treatments were minor hypoglycaemia (< 10%), nausea (< 11%), vomiting (< 5%) and diarrhoea (< 8%).

CONCLUSIONS

Liraglutide added to glimepiride was well tolerated and provided improved glycaemic control and favourable weight profile.

Perfluoroalkyl compounds in Danish wastewater treatment plants and aquatic environments

This study reports the results of a screening survey of perfluoroalkyl compounds (PFCs) in the Danish environment. The study included point sources (municipal and industrial wastewater treatment plants and landfill sites) and the marine and freshwater environments. Effluent and influent water and sewage sludge were analysed for point sources. Sediment, blue mussels (Mytilus edulis) and liver from plaice (Pleuronectes platessa), flounder (Platichthys flesus) and eel (Anguilla anguilla) were analysed for the freshwater and marine environments. The results obtained show a diffuse PFCs contamination of the Danish environment with concentrations similar to those measured in other countries with the absence of primary contamination sources such as fluorochemical production. PFOS and PFOA were generally the most dominating PFCs measured in both point sources and the aquatic environments. PFCs were found in both inflow and outflow water and sewage sludge from municipal and industrial wastewater treatment plants (WWTPs), indicating that WWTPs can be significant sources to PFCs in the environment. This is also reflected in the locally elevated PFCs concentrations found in fish like eels from shallow freshwater and marine areas. However, the highest PFCs concentrations found in fish in this study was in plaice from the Skagerrak (156 ng/g wet weight PFOS), but it is unknown if this can be related to significant sources in the North Sea region or to differences between species. The concentrations of PFCs were below the detection limit in all analysed freshwater and marine samples of sediment and mussels. Despite the relatively low PFCs concentrations measured in marine fish, the high bioaccumulation potential of PFCs, particularly PFOS, may lead to high concentrations of PFCs in marine mammals as shown by previous investigations.

Leucocytosis in polycythaemia vera predicts both inferior survival and leukaemic transformation

Leucocytosis (leucocyte count >15 x 10(9)/l) was recently associated with thrombosis in polycythaemia vera (PV). This study sought the prognostic relevance of leucocytosis for survival and leukaemic or fibrotic transformation. Amongst 459 patients with PV seen at our institution in recent years (median age, 60 years; 56% males), 146 deaths and 88 leukaemic (n = 34) or fibrotic (n = 54) transformations were documented. Arterial or venous thrombosis occurred in 14% and 9% of patients at diagnosis and in 25% and 15% during follow-up, respectively. Multivariate analysis identified the advanced age (P < 0.0001), leucocytosis (leucocyte count >/=15 x 10(9)/l; P = 0.0006) and arterial thrombosis at diagnosis (P = 0.01) as independent predictors of inferior survival. In the absence of the first two risk factors, median survival was projected at 272 months as opposed to 108 months in the presence of both risk factors (P < 0.0001). Leucocytosis was also identified as an independent predictor of both leukaemic transformation and venous thrombosis during follow-up. Time-to-event analysis did not disclose a significant association between single or multiple cytotoxic drug exposure and either leukaemic or fibrotic transformation. The current study highlighted the prognostic relevance of leucocytosis on various aspects of the disease in PV.

The impact of leukocytosis on survival, leukemic transformation, and thrombosis in polycythemia vera

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Background: A leukocyte count of > 15 ×109/L has recently been associated with myocardial infarction in polycythemia vera (PV). In the current study, we examine the impact of such degree of leukocytosis on survival, leukemic transformation (LT), and thrombosis in a large cohort of PV patients from a single institution Methods: Data was abstracted from the medical records of a consecutive cohort of patients with PV defined by the World Health Organization criteria. Results: i. Patient characteristics The study cohort included 459 patients (median age, 60 years). Median follow-up was 64 months. ii. Survival In a multivariable analysis, advanced age, leukocyte count of = 15 × 109/L, and arterial thrombosis at diagnosis were significantly associated with inferior survival. A prognostic model based on age = 60 years and leukocyte count = 15 × 109/L separated low-risk, intermediate-risk, and high-risk patient groups with respective median survivals of 272, 162, and 108 months (p<0.0001). iii. Leukemic transformation In a multivariable analysis, only leukocyte count was significantly associated with LT; median leukemia-free survival for patients with leukocyte count = 15 × 109/L was 273 months vs. not reached for those with lower leukocyte count (p<0.0001). iv. Thrombosis at diagnosis In multivariable analysis, arterial thrombosis at diagnosis was significantly associated with previous history of arterial thrombosis, hypertension, and tobacco use; venous thrombosis at diagnosis was significantly associated with previous venous event and splenomegaly. v. Thrombosis during follow- up In multivariable analysis, arterial thrombosis during follow-up was significantly associated with previous arterial event, hypertension, and tobacco use; venous thrombosis during follow-up was significantly associated with previous venous event, diabetes mellitus, advanced age, and leukocyte count = 1,500 × 109/L. Conclusions: The current study for the first time identifies leukocytosis as a risk factor for inferior survival, LT risk, and venous thrombosis in PV.

No significant financial relationships to disclose.

Transfer of mercury in the marine food web of West Greenland

Total mercury (THg), methylmercury (MeHg) and stable isotopes of nitrogen (delta(15)N) and carbon (delta(13)C) were measured in three invertebrate, five fish, three seabird and three marine mammal species of central West Greenland to investigate trophic transfer of mercury in this Arctic marine food web. The food web magnification factor (FWMF) estimated as the slope of the regression between the natural logarithm of THg or MeHg concentrations (mg kg(-1) dw) and tissue delta(15)N ( per thousand) was estimated to 0.183 (SE = 0.052) for THg and 0.339 (SE = 0.075) for MeHg. The FWMFs were not only comparable with those reported for other Arctic marine food webs but also with quite different food webs such as freshwater lakes in the sub-Arctic, East Africa and Papua New Guinea. This suggests similar mechanisms of mercury assimilation and isotopic (delta(15)N) discrimination among a broad range of aquatic taxa and underlines the possibility of broad ecosystem comparisons using the combined contaminant and stable isotope approach.

Health status of Mya arenaria bivalves collected from contaminated sites in Canada (Saguenay Fjord) and Denmark (Odense Fjord) during their reproductive period

The purpose of this study was to examine the health status and gametogenetic activity in Mya arenaria clams collected at various sites in the St. Lawrence Estuary (Quebec, Canada) and in the Odense Fjord (Denmark). Clam soft tissues were analyzed for metals/metalloids and organotin compounds to confirm their exposure to these contaminants. Their health status was assessed by a test battery of biomarkers designed to measure the early biological effects of contaminants, which include expression of defence mechanisms such as xenobiotic conjugation (glutathione S-transferase), expression of stress proteins (i.e., heme oxygenase and metallothioneins), changes in gametogenetic activity, and individual morphometric characteristics. Clam tissues were also examined for the presence of oxidative damage to lipids, formation of DNA strand breaks, and alterations in heme metabolism. The results showed that clams sampled from sites with either ferry activity or intensive boat traffic in marinas were contaminated by metals/metalloids such as Ag, Al, As, Co, Cr, Cu, Fe, Hg, Mn, Mo, Ni, Pb, Sn, V, and Zn. The clams also contained relatively high amounts of tributyltin (TBT) in their tissues (in the ng TBT/g range for both areas), with digestive glands containing more organotins than did gonadal tissues. Moreover, clams collected from TBT-contaminated sites had higher amounts of tin-heme adducts and lower total heme in their digestive glands. Condition factor, age distribution, and sex ratio were significantly altered in clams from impacted sites in the Saguenay Fjord and accompanied by an increased male/female sex ratio. Gametogenetic activity was also negatively affected, as revealed by reductions in gonadosomatic index, maturation index, aspartate transcarbamylase activity, and vitellogenin-like proteins. The Saguenay Fjord clams displayed a complex pattern of stress responses and damage such as increased heme oxygenase activity, phase 2 conjugation enzyme activity, lipid peroxidation, and altered DNA strand breaks. The integration of biomarker response data into a biomarker index at the whole-individual level (morphometric characteristics) and for various organs (gill, digestive gland, and gonad) revealed that, relative to the control site, morphological characteristics and gonadal activity were most affected at the most contaminated site, while the effects were more pronounced in the digestive gland and gill at moderately impacted sites. We conclude that the health status of M. arenaria clams at these contaminated sites is compromised, with obvious disruption of reproductive activity.

Sustained effects of pioglitazone vs. glibenclamide on insulin sensitivity, glycaemic control, and lipid profiles in patients with Type 2 diabetes

AIMS

This study compared the effects of 52 weeks' treatment with pioglitazone, a thiazolidinedione that reduces insulin resistance, and glibenclamide, on insulin sensitivity, glycaemic control, and lipids in patients with Type 2 diabetes.

METHODS

Patients with Type 2 diabetes were randomized to receive either pioglitazone (initially 30 mg QD, n = 91) or micronized glibenclamide (initially 1.75 mg QD, n = 109) as monotherapy. Doses were titrated (to 45 mg for pioglitazone and 10.5 mg for glibenclamide) to achieve glycaemic targets during the next 12 weeks: fasting blood glucose of < or = 7 mmol/l and 1-h postprandial blood glucose of < or = 10 mmol/l. Patients were maintained on the titrated dose for 40 weeks.

RESULTS

Pioglitazone significantly increased insulin sensitivity compared with glibenclamide, as assessed by homeostasis model assessment (17.0% vs. -13.0%; P < 0.001), quantitative insulin sensitivity check index (0.011 vs. -0.007; P < 0.001) and fasting serum insulin (-1.3 pmol/l vs. 23.8 pmol/l; P = 0.007). The glibenclamide group had significantly lower HbA1c than the pioglitazone group after 12 weeks of therapy (7.8% vs. 8.3%, P = 0.015), but significantly higher HbA1c after 52 weeks of therapy (7.8% vs. 7.2%, P = 0.001). Pioglitazone significantly (vs. glibenclamide) increased mean HDL-C (P < 0.001), decreased mean triglycerides (P = 0.019), and decreased mean atherogenic index of plasma (AIP; P = 0.001) and mean total cholesterol/HDL-C (P = 0.004), without significantly elevating mean total cholesterol or mean LDL-C compared with glibenclamide. CONCLUSIONS These data suggest that the effects of pioglitazone are more sustained than those of glibenclamide for improving insulin sensitivity in patients with Type 2 diabetes, and that 52 weeks' treatment with pioglitazone has favourable effects on glycaemic control and lipoprotein profile.

Dynamic nuclear polarization by electrical spin injection in ferromagnet-semiconductor heterostructures

Electrical spin injection from Fe into AlxGa1-xAs quantum well heterostructures is demonstrated in small (<500 Oe) in-plane magnetic fields. The measurement is sensitive only to the component of the spin that precesses about the internal magnetic field in the semiconductor. This field is much larger than the applied field and depends strongly on the injection current density. Details of the observed hysteresis in the spin injection signal are reproduced in a model that incorporates the magnetocrystalline anisotropy of the epitaxial Fe film, spin relaxation in the semiconductor, and the dynamic polarization of nuclei by the injected spins.

Modulation of myosin function by isoform-specific properties of Saccharomyces cerevisiae and muscle tropomyosins

Tropomyosin is an extended coiled-coil protein that influences actin function by binding longitudinally along thin filaments. The present work compares cardiac tropomyosin and the two tropomyosins from Saccharomyces cerevisiae, TPM1 and TPM2, that are much shorter than vertebrate tropomyosins. Unlike cardiac tropomyosin, the phase of the coiled-coil-forming heptad repeat of TPM2 is discontinuous; it is interrupted by a 4-residue deletion. TPM1 has two such deletions, which flank the 38-residue partial gene duplication that causes TPM1 to span five actins instead of the four of TPM2. Each of the three tropomyosin isoforms modulates actin-myosin interactions, with isoform-specific effects on cooperativity and strength of myosin binding. These different properties can be explained by a model that combines opposite effects, steric hindrance between myosin and tropomyosin when the latter is bound to a subset of its sites on actin, and also indirect, favorable interactions between tropomyosin and myosin, mediated by mutually promoted changes in actin. Both of these effects are influenced by which tropomyosin isoform is present. Finally, the tropomyosins have isoform-specific effects on in vitro sliding speed and on the myosin concentration dependence of this movement, suggesting that non-muscle tropomyosin isoforms exist, at least in part, to modulate myosin function.

Two-dimensional noise-robust blind deconvolution of ultrasound images

This paper presents a new method for 2-D blind homomorphic deconvolution of medical B-scan ultrasound images. The method is based on noise-robust 2-D phase unwrapping and a noise-robust procedure to estimate the pulse in the complex cepstrum domain. Ordinary Wiener filtering is used in the subsequent deconvolution. The resulting images became much sharper with better defined tissue structures compared with the ordinary images. The deconvolved images had a resolution gain along the order of 3 to 7, and the signal-to-noise ratio (SNR) doubled for many of the images used in our experiments. The method gave stable results with respect to noise and grey levels through several image sequences.

Hypertrophic cardiomyopathy caused by a novel alpha-tropomyosin mutation (V95A) is associated with mild cardiac phenotype, abnormal calcium binding to troponin, abnormal myosin cycling, and poor prognosis

BACKGROUND

We report hypertrophic cardiomyopathy (HCM) in a Spanish-American family caused by a novel alpha-tropomyosin (TPM1) mutation and examine the pathogenesis of the clinical disease by characterizing functional defects in the purified mutant protein.

METHODS AND RESULTS

HCM was linked to the TPM1 gene (logarithm of the odds [LOD] score 3.17). Sequencing and restriction digestion analysis demonstrated a TPM1 mutation V95A that cosegregated with HCM. The mutation has been associated with 13 deaths in 26 affected members (11 sudden deaths and 2 related to heart failure), with a cumulative survival rate of 73+/-10% at the age of 40 years. Left ventricular wall thickness (mean 16+/-6 mm) and disease penetrance (53%) were similar to those for the ss-myosin mutations L908V and G256E previously associated with a benign prognosis. Left ventricular hypertrophy was milder than with the ss-myosin mutation R403Q, but the prognosis was similarly poor. With the use of recombinant tropomyosins, we identified several functional alterations at the protein level. The mutation caused a 40% to 50% increase in calcium affinity in regulated thin filament-myosin subfragment-1 (S1) MgATPase assays, a 20% decrease in MgATPase rates in the presence of saturating calcium, a 5% decrease in unloaded shortening velocity in in vitro motility assays, and no change in cooperative myosin S1 binding to regulated thin filaments.

CONCLUSIONS

In contrast to other reported TPM1 mutations, V95A-associated HCM exhibits unusual features of mild phenotype but poor prognosis. Both myosin cycling and calcium binding to troponin are abnormal in the presence of the mutant tropomyosin. The genetic diagnosis afforded by this mutation will be valuable in the management of HCM.

The effect of tailoring a model HIV prevention program for local adolescent target audiences

In five U.S. sites (Nashville, Tennessee; Newark, New Jersey; northern Virginia; Phoenix, Arizona; and Sacramento, California), HIV risk-reduction workshops were mounted as a part of the Prevention Marketing Initiative (PMI). In four of the five sites, the workshop curriculum was a version of Be Proud! Be Responsible! (Jemmott, Jemmott, & McCaffree, 1996) that had been tailored to fit the needs of local target audiences. This article describes the evaluation of the PMI workshops. Protective effects on several behavioral determinants and behavioral outcome measures were observed 1 month after the workshops. Based on the overall pattern of results, it was concluded that the PMI workshops reduced the likelihood of unprotected sex among participants. The intervention developed by Jemmott and colleagues appears to have retained its effectiveness after it was tailored to meet perceived local needs.

Performance evaluation of two-dimensional phase unwrapping algorithms

We present a performance evaluation of eight two-dimensional phase unwrapping methods with respect to correct phase unwrapping and execution times. The evaluated methods are block least squares (BLS), adaptive integration (AI), quality guided path following (QUAL), mask cut (MCUT), multigrid (MGRID), preconditioned conjugate gradient (PCG), Flynn's (FLYNN), and Liang's (LIANG). This set included integration- (path following), least-squares-, L(1)-, and model-based methods. The methods were tested on several synthetic images, on two magnetic resonance images, and on two interferometry images. The synthetic images were designed to demonstrate different aspects of the phase unwrapping problem. To test the noise robustness of the methods, independent noise was added to the synthetic images to yield different signal-to-noise ratios. Each experiment was performed 50 times with different noise realizations to test the stability of the methods. The results of the experiments showed that the congruent minimum L(1) norm FLYNN method was best overall and the most noise robust of the methods, but it was also one of the slowest methods. The integration-based QUAL method was the only method that correctly unwrapped the two interferometry images. The least-squares-based methods (MGRID, PCG) gave worse results on average than did the integration- (or path following) based methods (BLS, AI, QUAL, MCUT) and were also slower. The model-based LIANG method was sensitive to noise and resulted in large errors for the magnetic resonance images and the interferometry images. In conclusion, for a particular application there is a trade-off between the quality of the unwrapping and the execution time when we attempt to select the most appropriate method.

Two-dimensional phase unwrapping using a block least-squares method

We present a block least-squares (BLS) method for two-dimensional (2-D) phase unwrapping. The method works by tessellating the input image into small square blocks with only one phase wrap. These blocks are unwrapped using a simple procedure, and the unwrapped blocks are merged together using one of two proposed block merging algorithms. By specifying a suitable mask, the method can easily handle objects of any shape. This approach is compared with the Ghiglia-Romero method and the Marroquin-Rivera method. On synthetic images with different noise levels, the BLS method is shown to be superior, both with respect to the resulting gray values in the unwrapped image as well as visual inspection. The method is also shown to successfully unwrap synthetic and real images with shears, fiber-optic interferometry images, and medical magnetic resonance images. We believe the new method has the potential to improve the present quality of phase unwrapped images of several different image modalities.

DSM-III-R Axis I and II disorders in agoraphobic patients with and without panic disorder

Patients attending an inpatient phobia treatment program were diagnosed for DSM-III-R Axis I and II disorders, using the Structured Clinical Interview for DSM-III-R Disorders, and completed a set of self-report instruments. They were divided into 3 groups: (a) those who met the criteria for panic disorder with agoraphobia (n = 57), (b) those who met the criteria for agoraphobia without a history of panic disorder (n = 21), and (c) those who met criteria for other anxiety disorders, but not for panic/agoraphobia (n = 14). On Axis I, more of the panic with agoraphobia than of the agoraphobia without panic patients had obsessive-compulsive disorder. On Axis II, no significant differences between the agoraphobic patients with and without panic occurred. However, the number of hysterical traits was related to the presence of panic disorder among the agoraphobic patients. Avoidant and dependent traits were related to symptom severity.

Strategies for improving patient compliance

Achieving patient compliance in taking prescribed medications is a formidable challenge for all clinicians. As PAs, we have daily opportunities to communicate with patients and improve their compliance. An office-based compliance program, combining patient education and behavior-modification components, can be beneficial in this regard. Strategies for improving compliance include giving clear, concise, and logical instructions in familiar language, adapting drug regimens to daily routines, eliciting patient participation through self-monitoring, and providing educational materials that promote overall good health in connection with medical treatment.

Use of resectoscope for colon cancer

Urologic endoscopic resectoscopes greatly simplify electrofulguration and resection of rectal tumors. The most important advantage is the enhanced visibility that allows determination of the depth of resection and good hemostasis. The indications for this procedure are otherwise-poor surgical candidates, palliation, excision of locally aggressive tumors such as villous adenomas, and bowel diversion prior to definitive therapy. Bleeding, peritoneal perforation requiring colostomy, and postoperative infection have all been reported, but the complication rate appears to be acceptable. Further clinical studies are necessary to determine if, indeed, this can be considered a curative procedure. Finally, because the practicing urologist is intimately aware of the technical aspects of the urologic resectoscope, he will probably be called on to perform, and should be aware of, this procedure.

Physical fitness level in patients with anxiety and depressive disorders

Physical work capacity (PWC) and pulmonary function were measured shortly after admission in 90 inpatients with anxiety and depressive disorders. PWC was dramatically reduced while pulmonary function was slightly increased compared with predicted normal values. This indicates that the low fitness levels were caused by physical inactivity, and it is a strong argument for integrating physical fitness training into psychiatric treatment programs. Values obtained by direct measurement and indirect calculations of PWC were highly correlated (R = 0.67). The mean differences between the two tests were 21% on an individual level and 5% on a group level.

Renin release selectively stimulated by prostaglandin I2 in isolated rat glomeruli

Renal glomeruli were isolated from rat kidneys using a passive mechanical sieving technique. Glomerular microsomal fraction, glomerular homogenate, or intact glomeruli were incubated with [1-14C]arachidonic acid, and the profile of prostaglandin (PG) synthesis was determined by thin-layer chromatography. The three incubation systems produced 15.3, 20.8, and 40.4% 6-keto-PGF1 alpha; 19.1, 23.5, and 15.3 PGF2 alpha; 5.7, 9.1, and 3.9% thromboxane (TX) B2; 36.0, 35.1, and 37.0% PGE2; and 23.9, 11.3, and 3.4% PGD2, respectively. Glomeruli were placed in suspension within glass chambers and superfused with Krebs solution. Superfusion with 1.6 x 10(-4) M arachidonic acid stimulated a significant release of renin from glomeruli, whereas 2.7 x 10(-6) M PGE1, PGE2, PGF2 alpha, TXB2, PGD2, or a stable analog of PGH2 had no effect on renin. When the rapid breakdown of PGI2 was counteracted by either increasing the concentration to 1.7 x 10(-4) M or stabilizing in Krebs at pH 9.4, it stimulated a significant increase in renin release. Reducing the arachidonic acid concentration to 1.6 x 10(-5) M eliminated both renin release and PGI2 synthesis, while increased PGE2 synthesis persisted. Finally, using an inhibitor of PGI2 synthesis, azo analog 1 (2.8 x 10(-6) M), 6-keto-PGF1 alpha produced in response to arachidonic acid was eliminated, as was the concurrent release of renin, but PGE2 synthesis was not affected. These results suggest that the mechanism of direct interaction between renal PG and renin in isolated glomeruli is selectively due to the action of PGI2.