Informed consent in episiotomy: Co-analysis with midwives and distillation of best practice

BACKGROUND

Performing an episiotomy where clinically indicated is a key intervention in the Obstetric Anal Sphincter Injury Care Bundle (OASI-CB) implemented across England and Wales to reduce the risk and increase the detection of severe perineal trauma after birth. Standards of consent provided to people in maternity care generally and for episiotomy specifically have been reported as suboptimal. Compromising birthing people's personal autonomy or sense of control has been linked to a dissatisfying birth experience, negative psychological sequelae, and litigation.

METHODS

This study explored experienced midwives' practice of informed consent for episiotomy during a midwife-led birth. We sampled 43 midwives across eight NHS Trusts in England and Wales using online focus groups and telephone interviews about their experience of consent in episiotomy. Using qualitative content analysis and art-based co-analysis methods with eight midwives from across the research sites, we co-analyzed and co-constructed three themes and four practice recommendations from the data.

RESULTS

Three themes were constructed from the data: Assent rather than consent, Change in culture to support best practice, and Standardized information. These themes informed the shaping of four recommendations for best practice in episiotomy informed consent.

CONCLUSION

This study has shown how variations in midwifery practice and culture may impact birthing people's experience of informed consent in episiotomy. Midwives may not have the knowledge or skills to conduct a detailed consent conversation, leading to variation in practice and messages for birthing people. The use of antenatal discussion aids can offer women the opportunity to become informed and fully participate in the decision-making process.

Red flags for episiotomy in a midwife-led birth: Using co-production with midwives to capture clinical experience

BACKGROUND

One of four key points in the Obstetric Anal Sphincter Injury Care Bundle, first piloted in the UK in 2016, was the directive to perform episiotomy when clinically indicated. Midwives are the primary health care professional for straightforward births in the UK and there is very little published literature that relates to their practice in this area.

AIM

The aim of the study was to explore experienced midwives' decision-making processes in their assessments for episiotomy during birth.

METHODS

43 midwives self-identifying as confident in performing episiotomy were sampled across 8 NHS Trusts in England and Wales. Data collection was via online focus groups and 1:1 interviews. Primary thematic analysis was undertaken by the research team. Preliminary themes were used to structure a co-production analysis workshop where eight experienced midwives undertook a secondary analysis of the data resulting in four overall themes.

FINDINGS

Four themes were identified, 'Optimising Perineal Function', 'Red Flags to Stimulate Decision-Making', 'The Midwives' Episiotomy' and 'Infiltration as a Catalyst for Birth'.

DISCUSSION

Midwives use a number of visual, auditory and touch cues to inform their assessments for episiotomy during birth.

CONCLUSION

This study provides valuable insight into the cues that guide experienced midwives' decision-making in relation to episiotomy and contributes evidence related to performing episiotomy when clinically indicated in spontaneous vaginal birth.

A 12-Month Randomized Clinical Trial of 38% SDF vs. Restorative Treatment

PURPOSE

The aim of this 2-arm, parallel-group, 12-mo randomized clinical trial was to compare the effectiveness of semiannual application of 38% silver diamine fluoride (SDF) versus restorative treatment (RT) to manage cavitated caries lesions in primary teeth in a diverse population of children in Michigan.

METHODS

Children aged 2 to 10 y with at least 1 soft cavitated lesion (International Caries Detection and Assessment System 5 or 6) with no pain or signs/symptoms of irreversible pulpitis were recruited and randomly assigned to 2 intervention groups. One random lesion per child received 38% SDF (twice, at a 6-mo interval) or RT. All interventions and assessments were done by calibrated dentists. Primary outcome measures were clinical failure rates: minor (e.g., reversible pulpitis, active/soft lesion or progression, restoration loss or need for replacement/repair, secondary caries) and major (e.g., irreversible pulpitis, abscess, extraction). Parent, child, and provider acceptability was also assessed.

RESULTS

Ninety-eight children were enrolled and randomized, with a mean (SD) age of 4.8 y (1.8); 46% were female and their mean dmft + DMFT was 6.3 (3.9). Sixty-nine children were assessed at 12 mo (sample was within the planned 30% attrition rate). There were significantly more teeth with minor failures (SDF = 65%, RT = 23%, P ≤ 0.001) and major failures (SDF = 13%, RT = 3%, P ≤ 0.001) in the SDF group than the RT group; 74% of SDF-treated lesions were hard at 12 mo vs. 57% at 6 mo. Providers stated that SDF was easier, faster, and more preferable than RT (P ≤ 0.001). No significant differences were found in parental satisfaction and acceptability. At 12 mo, children in the RT arm felt significantly (P < 0.05) happier with their tooth appearance and stated that their visit to the dentist hurt less.

CONCLUSION

At 12 mo, SDF-treated lesions had significantly more minor and major failures than RT, suggesting that SDF-treated teeth need to be closely monitored in a population at high caries risk (ClinicalTrials.gov NCT02601833).

KNOWLEDGE OF TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding whether to restore or apply silver diamine fluoride to cavitated lesions in primary teeth. Information on treatment outcomes and parent, child, and provider acceptability can help guide appropriate treatment decisions and need for monitoring.

Diagnosis of rotavirus infection in a vaccinated population: Is a less sensitive immunochromatographic method more suitable for detecting wild-type rotavirus than real-time RT-PCR?

BACKGROUND

Diagnosis of wild-type rotavirus disease may be complicated by the detection of vaccine-derived virus which can be detected in stool samples following immunisation. We evaluate an immunochromatographic assay and real-time RT-PCR to determine which is more suitable for the detection of wild-type rotavirus.

OBJECTIVES

To compare the Ct values of wild-type rotavirus and Rotarix determined by real-time RT-PCR. To establish the Ct value corresponding to the limit of detection of the immunochromatographic Combi-Strip method (Coris, BioConcept).

STUDY DESIGN

Retrospective review of real-time RT-PCR Ct values was performed on 100 samples tested by a pan-rotavirus assay (n = 50 wild-type, n = 50 Rotarix). Secondly the limit of detection of the Combi-Strip assay was determined by testing; wild-type rotavirus (n = 33, Ct range 6.85-34.26) samples, Rotarix (n = 9, Ct range 20.86-34.26) samples and rotavirus negative (n = 21) samples.

RESULTS

The median Ct of 50 wild-type rotavirus was Ct 12.43; range 6.11-32.66 compared with the median of 50 Rotarix, Ct 29.09; range 18.91-35.28, p=<0.0001. The limit of detection of the Combi-Strip method was approximately Ct 18. The 21 rotavirus negative samples were negative by real-time RT-PCR and Combi-Strip.

CONCLUSIONS

We found the Ct value was significantly lower, and therefore the viral load higher, for wild-type rotavirus compared to detectable Rotarix. The Combi-Strip assay detects most wild-type infections; however, it lacks sensitivity to detect low-level wild-type rotavirus and, beneficially, is unlikely to detect Rotarix. It is not a more suitable method than real-time RT-PCR when a definitive rotavirus result is required.

The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East: introduction and methodology

Opioid analgesics are critical to the effective relief of cancer pain. Effective treatment is predicated on sound assessments, individually tailored analgesic therapy, and the availability and accessibility of the required medications. In some countries, pain relief is hampered by the lack of availability or barriers to the accessibility of opioid analgesics. As the follow-up to a successful project to evaluate the availability and accessibility of opioids and regulatory barriers in Europe, the European Society for Medical Oncology (ESMO) and the European Association for Palliative Care (EAPC) undertook to expand their research to those parts of the world where data were lacking regarding these aspects of care, in particular Africa, Asia, the Middle East, Latin America and the Caribbean, and the states of India. This project has been undertaken in collaboration with the Union for International Cancer Control (UICC), the Pain and Policy Studies Group (PPSG) of the University of Wisconsin, and the World Health Organization (WHO), together with a consortium of 17 international oncology and palliative care societies. This article describes the study methodology.

Next steps in access and availability of opioids for the treatment of cancer pain: reaching the tipping point?

The reports of the Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East, together with the previous 2010 European Society for Medical Oncology (ESMO)/European Association for Palliative Care (EAPC) report from Europe, have provided critical data in demonstrating the deficiencies in many countries throughout the world. Formulary deficiencies and over-regulation are pandemic and must be addressed. This process is challenging and will require concerted and sustained efforts by clinical leaders and advocacy groups partnering with international and regional organizations and, of course, with national governments and their competent authorities. There is a growing international expertise and infrastructure to coordinate advocacy and strategic planning based on the World Health Organization (WHO) Model of Education, Policy Reform and Medication Availability.

Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI)

With nearly 1.1 billion inhabitants living in more than 50 countries, Africa is the world's poorest and most socioeconomically underdeveloped continent. Despite some advances for individual states, many African countries have very low opioid consumption and, overall, the continent has the lowest consumption per capita of any in the world. This article presents the findings of the first systematic study of the availability and accessibility of opioids for the management of cancer pain across the continent. Data are reported on the availability and accessibility of opioids for the management of cancer pain in 25 of 52 countries, with 744 million of the region's 1127 million people (66%) covered by the survey. Many countries had severely restricted formularies of opioids and only 15 of 25 had morphine available in oral IR, CR and injectable formulations. Even when opioids are on formulary they are often unavailable, and access is significantly impaired by widespread over-regulation that is pervasive across the region.

Pertussis in young infants: clinical presentation, course and prevention

Pertussis is a highly contagious disease caused by the Gram negative aerobic coccobacillus, Bordetella pertussis. It may present with severe symptoms and complications in infants and can pose a diagnostic challenge. This is a vaccine preventable illness covered by the Irish Childhood Immunisation Schedule. In 2011, a retrospective review was conducted of the records of infants, under six months, with a confirmed diagnosis of pertussis, presenting to Temple Street Children's University Hospital (TSCUH). A summery of notifications of pertussis nationally, from 2001 to 2012, was also examined as part of the study. This found that the rate of reported cases of pertussis has been increasing in Ireland. This national increase corresponds with a rising number of cases identified at TSCUH. Patients commonly presented severely ill with cyanosis and apnoea, on a background of prolonged cough. We found that pertussis was diagnosed rapidly in most cases however in all cases there was a delay to commencement of appropriate macrolide therapy.

Does a low glycaemic index (GI) diet cost more during pregnancy?

&#160;The aim of this study was to examine the monetary cost of dietary change among pregnant women before and after receiving low glycaemic index (GI) dietary advice. The pregnant women in this study were a subgroup of participants in the Pregnancy and Glycaemic Index Outcomes (PREGGIO) study. Twenty women from the low GI dietary advice group, who had completed their pregnancies, were randomly chosen. All these women had completed three day food records at 12&#8211;16 weeks and again around 36 weeks of gestation. Consumer food prices were applied to recorded dietary intake data. The mean &#177; SD GI of the diet reduced from 55.1 &#177; 4.3 to 51.6 &#177; 3.9 (p = 0.003). The daily cost of the diet (AUD) was 9.1 &#177; 2.7 at enrolment and 9.5 &#177; 2.1 prior to delivery was not significantly different (p = 0.52). There were also no significant differences in the daily energy intake (p = 0.2) or the daily cost per MJ (p = 0.16). Women were able to follow low GI dietary advice during pregnancy with no significant increase in the daily costs.

Burying by rats in response to aversive and nonaversive stimuli

Previous investigations have shown that rats bury a variety of conditioned and unconditioned aversive stimuli. Such burying has been considered as a species-typical defensive reaction. In the present studies, rats buried spouts filled with Tabasco sauce, or condensed milk to which a taste aversion was conditioned, but did not bury water-filled spouts or spouts filled with a palatable novel food (apple juice) to which a taste aversion was not conditioned. However, in other experiments rats consistently and repeatedly buried Purina Rat Chow, Purina Rat Chow coated with quinine, and glass marbles. This indicates that a variety of stimuli, not all aversive or novel, evoke burying by rats. Whereas the behavior may reasonably be considered as a species-typical defensive behavior in some situations, the wide range of conditions that occasion burying suggests that the behavior has no single biological function.

Conditional relations by monkeys: Reflexivity, symmetry, and transitivity

Two cynomolgous macaques categorized six colors into two groups of three after conditional discrimination training (zero-delay symbolic match-to-sample). The procedures resulted in the establishment of relations among the elements of each set-relations that were not specifically trained and that can be characterized by the properties of reflexivity, symmetry, and transitivity. Each set of colors was related to a characteristic pattern of responding: One response pattern involved temporal duration (press and hold the response keys); the second response pattern entailed repeated pressing and releasing of the response keys (fixed ratio 8). Six combinations of two colors were trained, three combinations from each set. After discriminative performance stabilized for each monkey, they were tested with 10 additional color combinations, all of which differed from the training combinations. The conditional relations established between test combinations can be characterized as stimulus equivalence. The training procedures were analogous to the procedure of using category names, and have implications for understanding the function of language in the formation of equivalence classes.

Validation of a fully autonomous phosphate analyser based on a microfluidic lab-on-a-chip

This work describes the design of a phosphate analyser that utilises a microfluidic lab-on-a-chip. The analyser contains all the required chemical storage, pumping and electronic components to carry out a complete phosphate assay. The system is self-calibrating and self-cleaning, thus capable of long-term operation. This was proven by a bench top calibration of the analyser using standard solutions and also by comparing the analyser's performance to a commercially available phosphate monitor installed at a waste water treatment plant. The output of the microfluidic lab-on-a-chip analyser was shown to have sensitivity and linear range equivalent to the commercially available monitor and also the ability to operate over an extended period of time.

Process Evaluation of the Hunter Illawarra Kids Challenge Using Parent Support Study: A Multisite Randomized Controlled Trial for the Management of Child Obesity

The purposes of this article are to (a) outline findings from secondary or process outcome data of the Hunter Illawarra Kids Challenge Using Parent Support (HIKCUPS) study and (b) inform the design and development of future research interventions and practice in the management of child obesity. Data were collected by means of facilitator evaluations, independent session observation, attendance records, and parent questionnaires. Internal validity and reliability of the program delivery were high. All parents reported positive changes in their children as a result of the physical activity program, the dietary modification program, or both. Most participants completed the home activities, but more than half reported that finding time to do them was problematic. Facilitator review indicated that future programs should specifically cater to children of similar age or same sex, allow adequate time for explanation of complex nutritional concepts, and use intrinsic motivators for participants. Recommendations for future interventions, specifically the implementation of subsequent HIKCUPS or other multisite effectiveness studies, are detailed.

The HIKCUPS trial: a multi-site randomized controlled trial of a combined physical activity skill-development and dietary modification program in overweight and obese children

Background

Childhood obesity is one of the most pressing health issues of our time. Key health organizations have recommended research be conducted on the effectiveness of well-designed interventions to combat childhood obesity that can be translated into a variety of settings. This paper describes the design and methods used in the Hunter Illawarra Kids Challenge Using Parent Support (HIKCUPS) trial, an ongoing multi-site randomized controlled trial, in overweight/obese children comparing the efficacy of three interventions: 1) a parent-centered dietary modification program; 2) a child-centered physical activity skill-development program; and 3) a program combining both 1 and 2 above.

Methods/Design

Each intervention consists of three components: i) 10-weekly face-to-face group sessions; ii) a weekly homework component, completed between each face-to-face session and iii) three telephone calls at monthly intervals following completion of the 10-week program. Details of the programs' methodological aspects of recruitment, randomization and statistical analyses are described here a priori.

Discussion

Importantly this paper describes how HIKCUPS addresses some of the short falls in the current literature pertaining to the efficacy of child obesity interventions.

The HIKCUPS trial is funded by the National Medical Research Council, Australia.

The HIKCUPS trial: a multi-site randomized controlled trial of a combined physical activity skill-development and dietary modification program in overweight and obese children

BACKGROUND

Childhood obesity is one of the most pressing health issues of our time. Key health organizations have recommended research be conducted on the effectiveness of well-designed interventions to combat childhood obesity that can be translated into a variety of settings. This paper describes the design and methods used in the Hunter Illawarra Kids Challenge Using Parent Support (HIKCUPS) trial, an ongoing multi-site randomized controlled trial, in overweight/obese children comparing the efficacy of three interventions: 1) a parent-centered dietary modification program; 2) a child-centered physical activity skill-development program; and 3) a program combining both 1 and 2 above.

METHODS/DESIGN

Each intervention consists of three components: i) 10-weekly face-to-face group sessions; ii) a weekly homework component, completed between each face-to-face session and iii) three telephone calls at monthly intervals following completion of the 10-week program. Details of the programs' methodological aspects of recruitment, randomization and statistical analyses are described here a priori.

DISCUSSION

Importantly this paper describes how HIKCUPS addresses some of the short falls in the current literature pertaining to the efficacy of child obesity interventions. The HIKCUPS trial is funded by the National Medical Research Council, Australia.

End-of-life care resource utilization: A single provider perspective

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Background: Most cancer physicians are aware that significant resources are spent in the last year of life but they are provided little feedback on cost or yield of care. Awareness of resource allocation for patients near the end of life may influence physician conversation with patients and families, treatment recommendations, and hospice referral. Methods: UWHealth cancer registry data were used to identify 90 patients who had died in a recent three year period and were cared for at least in part by the medical oncologist being evaluated. Health services utilization within UWHealth (hospital and hospital based clinic sites) was assessed for the last 6 months of life in 66 patients where a clear date of death could be identified. Data included in- and out-patient, pharmacy, laboratory, radiation and imaging services. Hospice charges are not included. Results: In the last 6 months of life, radiology, radiation therapy and pharmacy charges made up 52% of the total. Use of CT, MRI and palliative radiation increased near the end of life. In the last two months of life, 47% of the entire pharmacy charges were spent. In-patient services were greatly increased in the last month of life. Overall charges and more expensive services were highest in the last month of life. Conclusions: Care near the end of life is expensive. This review targeting patients affiliated with one medical oncologist at a large academic health center showed that radiology, radiotherapy, and pharmacy charges involved more than half the total accrued in the last 6 months of life. Feedback such as this if routinely provided to individual oncologists and disease oriented teams may generate strategies for improving end of life care. Even if expensive, some services may be helpful and necessary, others may not. Discussion regarding accountability for resource allocation within the multidisciplinary setting of cancer care may aid in developing improved end of life approaches for patients.

No significant financial relationships to disclose.

Parenteral antioxidant treatment preserves temporal discrimination following intrahippocampal aggregated Aβ(1–42) injections

There is evidence that oxidative stress may play a role in the neuropathology of Alzheimer's disease (AD). This study used an aggregated beta-amyloid (Abeta) injection model of AD in the rat, and a recycling conjunctive schedule of food reinforcement to examine the effects of bilateral intrahippocampal injections of aggregated Abeta(1-42) (5.0 microl/side) on temporal discrimination, and the efficacy of the antioxidant alpha-tocopherol (150 mg/kg daily p.o.) in alleviating these effects. The results indicated that bilateral intrahippocampal injections of aggregated Abeta(1-42) detrimentally affected temporal discrimination from five-day block 31-35 post-injections until the end of the study (90 days post-injections). Daily treatment with alpha-tocopherol improved temporal discrimination under the recycling conjunctive schedule following aggregated Abeta(1-42) injections from the five-day block 61-65 days until the end of the study.

Behavioural and histopathological analyses of ibuprofen treatment on the effect of aggregated Abeta(1-42) injections in the rat

It has been suggested that inflammatory processes may play a role in the development of Alzheimer's disease (AD), and that nonsteroidal anti-inflammatory drug treatments may provide protection against the onset of AD. In the current study male Wistar rats were trained in two-lever operant chambers under an alternating lever cyclic-ratio ratio (ALCR) schedule. When responding showed no trends, subjects were divided into groups. One group was bilaterally injected into the CA3 area of the hippocampus with 5 microl of aggregated beta-amyloid (Abeta) suspension, and one group was bilaterally injected into the CA3 area of the hippocampus with 5 microl of sterile saline. Subgroups were treated twice daily with 0.1 ml (40 mg/kg) ibuprofen administered orally. The results indicated that chronic administration of ibuprofen protected against detrimental behavioural effects following aggregated Abeta injections. Withdrawal of ibuprofen treatment from aggregated Abeta-injected subjects produced a decline in behavioural performance to the level of the non-treated aggregated Abeta-injected group. Ibuprofen treatment reduced the numbers of reactive astrocytes following aggregated Abeta injection, and withdrawal of ibuprofen resulted in an increase of reactive astrocytes. These results suggest that induced inflammatory processes may play a role in AD, and that ibuprofen treatment may protect against some of the symptoms seen in AD.

Tracing functionally identified neurones in a multisynaptic pathway in the hamster and rat using herpes simplex virus expressing green fluorescent protein

Using a genetically modified herpes simplex virus encoding green fluorescent protein we sought to establish if this viral modification could be used in transneuronal tracing studies of the sympathetic nervous system. The herpes simplex virus encoding green fluorescent protein was injected into the adrenal medulla of three hamsters and six rats. After a suitable survival period, neurones in the sympathetic intermediolateral cell column of the thoracolumbar spinal cord, rostral ventral medulla and paraventricular nucleus of the hypothalamus were clearly identified by the presence of a green fluorescence in the cytoplasm of the neurones of both species. Thus, herpes simplex virus encoding green fluorescent protein labelled chains of sympathetic neurones in the hamster and rat and therefore has the potential to be used in transneuronal tracing studies of autonomic pathways in these species.

RGS18 is a myeloerythroid lineage-specific regulator of G-protein-signalling molecule highly expressed in megakaryocytes

Myelopoiesis and lymphopoiesis are controlled by haematopoietic growth factors, including cytokines, and chemokines that bind to G-protein-coupled receptors (GPCRs). Regulators of G-protein signalling (RGSs) are a protein family that can act as GTPase-activating proteins for G(alphai)- and G(alphaq)-class proteins. We have identified a new member of the R4 subfamily of RGS proteins, RGS18. RGS18 contains clusters of hydrophobic and basic residues, which are characteristic of an amphipathic helix within its first 33 amino acids. RGS18 mRNA was most highly abundant in megakaryocytes, and was also detected specifically in haematopoietic progenitor and myeloerythroid lineage cells. RGS18 mRNA was not detected in cells of the lymphoid lineage. RGS18 was also highly expressed in mouse embryonic 15-day livers, livers being the principal organ for haematopoiesis at this stage of fetal development. RGS1, RGS2 and RGS16, other members of the R4 subfamily, were expressed in distinct progenitor and mature myeloerythroid and lymphoid lineage blood cells. RGS18 was shown to interact specifically with the G(alphai-3) subunit in membranes from K562 cells. Furthermore, overexpression of RGS18 inhibited mitogen-activated-protein kinase activation in HEK-293/chemokine receptor 2 cells treated with monocyte chemotactic protein-1. In yeast cells, RGS18 overexpression complemented a pheromone-sensitive phenotype caused by mutations in the endogeneous yeast RGS gene, SST2. These data demonstrated that RGS18 was expressed most highly in megakaryocytes, and can modulate GPCR pathways in both mammalian and yeast cells in vitro. Hence RGS18 might have an important role in the regulation of megakaryocyte differentiation and chemotaxis.

Retinal development of West Australian dhufish, Glaucosoma hebraicum

An investigation of retinal specializations was carried out in larval and juvenile dhufish, Glaucosoma hebraicum (Glaucosomidae, Teleostei). The development of photoreceptors and formation of the retinal mosaic was followed by light and electron microscopy. At hatching the eye was undifferentiated. Cone photoreceptors were present by day 3 posthatch (dph), when exogenous feeding began. Single and multiple cones were present in a row arrangement from 3 dph to 20 dph, when the first rod nuclei were observed. Between 20 dph and approximately 3 months posthatch (mph), the row arrangement was replaced by a square mosaic of four double cones surrounding a single cone, and the cones increased in size, with the outer segments reaching up to 30 microm in length. During the period of spatial rearrangement, triple cones were often observed. From their first appearance, rod photoreceptors were added rapidly. Investigation of ganglion cell topography in 3-mph fish that had attained the adult-like square photoreceptor mosaic was carried out using retinal wholemounts. The highest densities of neurones in the ganglion cell layer were in temporal retina but no well-defined area centralis was observed. Microspectrophotometric measurements of the visual pigments within the outer segments of the photoreceptors of 3-mph fish revealed double cones with identical absorption spectra in each member of the outer segment, and the wavelength of maximum absorption (lambda(max)) located at 522 nm. Single cones were found to possess a visual pigment with lambda(max) at 460 nm and rods with a lambda(max) of 498 nm. The results imply that the larvae and juveniles are adapted for survival in coastal waters and may be active in relatively low light levels from early stages of development.

Thermodynamic basis for sequence-specific recognition of ssDNA by an autoantibody

11F8 is a sequence-specific DNA binding monoclonal autoantibody previously isolated from an autoimmune lupus-prone mouse [Stevens, S. Y., and Glick, G. D. (1999) Biochemistry 38, 560-568]. This antibody, like many other lupus anti-DNAs, localizes to kidney tissue and eventually leads to renal damage through a process that first involves the binding of DNA antigens. A series of experiments were conducted to investigate the thermodynamic and structural basis by which this antibody discriminates between specific, noncognate, and nonspecific sequences. Sequence-specific binding occurs with a minimal dependence on the polyelectrolyte effect along with a favorable binding enthalpy reflecting the presence of base stacking and contacts to DNA bases. This favorable binding enthalpy apparently is derived from desolvation at the binding interface and is consistent with recent models of the nonclassical hydrophobic effect. Noncognate recognition is also driven by the nonclassical hydrophobic effect, but is accompanied by highly unfavorable entropies that are responsible for reduced affinity relative to the high-affinity consensus sequence. Nonspecific recognition is driven completely by the polyelectrolyte effect involving extensive electrostatic interactions with the phosphate backbone. Collectively, the data demonstrate the ability of 11F8 to adapt its mode of binding to the available DNA surface and provide a thermodynamic model for sequence-specific recognition of single-stranded DNA. The salient features of this model employ the paradigms invoked to explain protein.dsDNA, protein.RNA, and antibody.antigen binding.

Responding to SUPPORT: an academic medical center examines its end-of-life care practices. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

The purpose of this exploratory study was to examine the end-of-life (EOL) care rendered to patients and families within a large midwestern academic medical center during a recent one-year period. An investigator-developed audit tool was used to review the final hospitalization records of 100 patients. Data were collected regarding demographic variables, final hospitalization, medical diagnoses and histories, and documented end-of-life care. Major findings included a majority of deaths occurring within medical services on critical care units, a frequent short length of stay, a majority of Do Not Resuscitate or Withdrawal of Support orders being written 1-3 days prior to death, an unstable health status prior to admission, and presence of at least one significant chronic illness in the past medical history. Findings are being used to address EOL care related issues within the institution.

Dorsal thoracic cord compression from a spinal angiolipoma: case report and brief comment

Angiolipomas are benign tumors usually found in the forearms of young adults. To the best of our knowledge only 63 cases of spinal angiolipomas have been reported in the literature up until 1999 (MEDLINE 1966-1999). We report a case of a spinal angiolipoma causing dorsal cord compression in a 44-year-old woman presenting with subacute lower limb paresthesias, in the absence of sensory or motor findings, which mimicked multiple sclerosis by history. Operative intervention was curative.

Varied duration of congenital hypothyroidism potentiates perseveration in a response alternation discrimination task

The behavior of five groups of rats (seven rats per group) made hypothyroid for varying lengths of time and one group of seven normal control rats was assessed under forced alternation fixed-ratio (FR1, FR3, FR5 and FR10), alternating lever cyclic-ratio (ALCR) and progressive-ratio (PR3) schedules of reinforcement. Hypothyroidism was produced by adding methimazole (MMI) to the drinking water of pregnant dams from embryonic day E16 to postnatal day P25. Four groups were given replacement thyroxine (T4) injections beginning at specific time points (P1, P7, P13, and P19). There were no differences in behavioral performance between control and experimental groups under the FR schedule, which indicates that the animals' sensorimotor abilities were intact. Under the forced ALCR schedule, all groups reached criteria similarly. However, under the choice lever ALCR schedule, control animals and those which received T4 replacement from early on (P1, P7, P13 groups) performed well and all had reached criteria by 11 sessions. In contrast, animals which did not receive any T4 replacement or received it late (P19 group) took longer to reach criteria and 5/14 animals had not reached criteria at all by 20 sessions. This deterioration in performance was paralleled by an increase in perseverative behavior as evidenced by an increased frequency of pressing the wrong lever when alternation of lever was required. This suggests that congenital hypothyroidism results in increased perseveration leading to a decrease in learning when a discrimination between correct and incorrect operanda is made available.

Congenital hypothyroidism impairs response alternation discrimination behavior

The behavior of six congenitally hypothyroid and six normal control rats was assessed under forced alternation fixed-ratio, alternating lever cyclic-ratio (ALCR) and progressive-ratio schedules of reinforcement. Hypothyroidism was produced by adding methimazole (MMI) to the drinking water of pregnant dams from embryonic day 16 to postnatal day 25. There were no differences in behavioral performance between MMI-treated and control animals under the fixed-ratio and progressive ratio schedules. There were also no differences in circulating triiodothyronine levels between groups at the end of the study. Under the ALCR schedule, when alternation of responding was forced during the first three cycles but both levers (choice) were presented during the last three cycles (correct lever active), the entire control group reached a competency criteria in nine sessions. In contrast, only two MMI-treated animals reached criteria after 17 sessions, and the remaining four MMI-treated animals did not reach criteria by 30 sessions of training. These results suggest that congenital hypothyroidism impairs learning when a discrimination between correct and incorrect operanda is made available.

Left atrial myxomas presenting with right hand weakness

A 63-year-old man with multiple left atrial myxomas presenting with right hand weakness is described. Two-dimensional echocardiography obtained during the evaluation for his stroke showed a large left atrial mass. At surgery, two separate left atrial myxomas were excised. Pathology confirmed the diagnosis. Although left atrial myxomas are uncommon, they should be included in the differential diagnosis of stroke, especially in patients who present without cardiovascular or cerebrovascular risk factors. The absence of cardiac symptoms and signs does not rule out a cardiac myxoma.

Delayed behavioral effects following intrahippocampal injection of aggregated A beta (1-42)

Beta amyloid protein (A beta) is the major extracellular component of Alzheimer's disease (AD) plaques. In the current study, A beta (1-42) was aggregated in vitro using a method which produces A beta aggregates similar to those found in the AD brain. Twelve male Sprague-Dawley rats were trained in two-lever operant chambers under an alternating lever cyclic-ratio (ALCR) schedule. When performance was stable on the ALCR schedule, six subjects were injected (bilaterally into the CA3 area of the dorsal hippocampus) with 5.0 microliters aggregated A beta in suspension, and the remaining six subjects were injected with 5.0 microliters sterile water. Behavioral testing resumed 5 days after surgery and continued for 90 days post-injection. Aggregated A beta injection did not affect the number of lever switching errors made in a daily session but did affect the number of incorrect lever response perseverations. After approximately 30 days post-injection, aggregated A beta injection detrimentally affected ability to track the changing parameters of the schedule, and decreased the efficiency by which subjects obtained reinforcers. From approximately day 50 post-injection onward, A beta-injected subjects demonstrated significantly higher numbers of incorrect lever response perseverations than did sterile water-injected subjects. These effects appeared to be central rather than peripheral, as A beta injection did not decrease running response rates under the ALCR schedule. The delayed onset of behavioral effects seen in this and other behavioral studies may be a result of a cascade of potentially harmful responses induced through glial activation following aggregated A beta injection.

Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients

BACKGROUND

Patients with cancer frequently experience episodes of acute pain, i.e., breakthrough pain, superimposed on their chronic pain. Breakthrough pain is usually treated with short-acting oral opioids, most of which provide some relief after 15-20 minutes, with peak effects after 30-45 minutes. Oral transmucosal fentanyl citrate (OTFC), a unique formulation of the opioid fentanyl, has been shown to provide meaningful pain relief within 5 minutes in patients following surgery. We conducted a multicenter, randomized, double-blinded, placebo-controlled trial of OTFC for cancer-related breakthrough pain.

METHODS

Patients who were 18 years of age or older, receiving the equivalent of at least 60 mg oral morphine or at least 50 microg transdermal fentanyl per day for chronic cancer-related pain, and experiencing at least one episode of breakthrough pain per day were studied. After titration to an effective OTFC dose, subjects were given 10 randomly ordered treatment units (seven OTFC units and three placebo units) in the form of identical lozenges. If acceptable pain relief was not achieved within 30 minutes, subjects were instructed to take their previous breakthrough pain medication (i.e., rescue medication). Pain intensity, pain relief, and use of rescue medication were evaluated at 15-minute intervals over a 60-minute period.

RESULTS

Eighty-nine of 92 patients who received the randomized treatment were assessable (i.e., treated with at least one unit of OTFC and one unit of placebo). OTFC produced significantly larger changes in pain intensity and better pain relief than placebo at all time points (two-sided P<.0001). Episodes treated with placebo required the use of rescue medication more often than episodes treated with OTFC (34% versus 15%; relative risk = 2.27; 95% confidence interval = 1.51-3.26; two-sided P<.0001).

CONCLUSIONS

OTFC appears effective in the treatment of cancer-related breakthrough pain.

Intrahypothalamic discriminative stimulus effects of neuropeptide Y

Neuropeptide Y (NPY) is one of the most ubiquitous neurotransmitters in the CNS and has been implicated in a variety of psychological and physiological functions. The current study investigated whether intrahypothalamic (I.H.) administrations of NPY were behaviorally discriminable from saline injections. Rats were trained to differentially respond based on whether they received I.H. injections of NPY (0.5 microg/0.5 microl) or saline (0.5 microl 0.9% NaCl). Subjects demonstrated discriminative control (85% correct in 8 out of 10 consecutive sessions) after a mean of 32 sessions. The ability of subjects to discriminate I.H. NPY from saline was dose dependent, with the lowest NPY dose tested (0.03 microg/0.5 microl) generalizing to saline. The opioid antagonist naloxone blocked the discrimination of NPY when administered I.P. (3.0 mg/kg) or I.H. (50 microg/0.5 microl).

Lung cancer: review of the ECOG experience. Eastern Cooperative Oncology Group

Lung cancer represents a major health epidemic worldwide. This article reviews some of the recent results of Eastern Cooperative Oncology Group (ECOG) trials in this disease.

Anticipation in schizophrenia: biology or bias?

Anticipation is a genetic phenomenon wherein age of disease onset decreases and/ or severity increases in successive generations. Anticipation has been demonstrated for several neuropsychiatric disorders with expanding trinucleotide repeats recently identified as the underlying molecular mechanism. We report here the results of an analysis of anticipation performed with multiplex families segregating schizophrenia. Thirty-three families were identified through the NIMH Genetics Initiative that met the following criteria: had at least two affected members in successive generations and were not bilineal. Affectation diagnoses included schizophrenia, schizoaffective disorder-depressed, and psychosis NOS. Additional analyses included the Cluster A personality disorders. Three indices of age of onset were used. Disease severity was measured by several different indices. Four sampling schemes as suggested by McInnis et al. were tested, as well as additional analysis using pairs ascertained through the parental generation. Anticipation was demonstrated for age of onset, regardless of the index or sampling scheme used (P<0.05). Anticipation was not supported for disease severity. Analyses that took into account drug use and diminished fecundity did not affect the results. While the data strongly support intergenerational differences in disease onset consistent with anticipation, they must be viewed cautiously given unavoidable biases attending these analyses.