The Unspeakable Nature of Death & Dying During Childhood: A Silenced Phenomenon in Pediatric Care

In pediatric settings, the concept of hope is frequently positioned as a fundamental aspect of care and at odds with the possibility and proximity of death. This arguably fosters silence about death and dying in childhood despite evidence indicating the benefits of open communication at the end of life. In this paper, we describe the unspeakable nature of death and dying in childhood, including its conceptual and clinical causes and dimensions, its persistence, and the associated challenges for children and youth facing critical illnesses, their families, and society. We explore how the tension between hope and death can be reframed and apply our analysis to the context of medical assistance in dying for mature minors in Canada. Considering the lack of related literature, this paper offers initial reflections to form a framework for the unspeakable nature of death and dying in childhood and to advance the crucial need for research.

Perspectives of Canadian health leaders on the relationship between medical assistance in dying and palliative and end-of-life care services: a qualitative study

BACKGROUND

Medical assistance in dying (MAiD) was legalized in Canada in 2016, but coordination of MAiD and palliative and end-of-life care (PEOLC) services remains underdeveloped. We sought to understand the perspectives of health leaders across Canada on the relationship between MAiD and PEOLC services and to identify opportunities for improved coordination.

METHODS

In this quantitative study, we purposively sampled health leaders across Canada with expertise in MAiD, PEOLC, or both. We conducted semi-structured interviews between April 2021 and January 2022. Interview transcripts were coded independently by 2 researchers and reconciled to identify key themes using content analysis. We applied the PATH framework for Integrated Health Services to guide data collection and analysis.

RESULTS

We conducted 36 interviews. Participants expressed diverse views about the optimal relationship between MAiD and PEOLC, and the desirability of integration, separation, or coordination of these services. We identified 11 themes to improve the relationship between the services across 4 PATH levels: client-centred services (e.g., educate public); health operations (e.g., cultivate compassionate and proactive leadership); health systems (e.g., conduct broad and inclusive consultation and planning); and intersectoral initiatives (e.g., provide standard practice guidelines across health care systems).

INTERPRETATION

Health leaders recognized that cooperation between MAiD and PEOLC services is required for appropriate referrals, care coordination, and patient care. They identified the need for public and provider education, standardized practice guidelines, relationship-building, and leadership. Our findings have implications for MAiD and PEOLC policy development and clinical practice in Canada and other jurisdictions.

Envisioning Indigenous and biomedical healthcare collaboration at Stanton Territorial Hospital, Northwest Territories

Background: To improve the quality of care for Indigenous patients, local Indigenous leaders in the Northwest Territories, Canada have called for more culturally responsive models for Indigenous and biomedical healthcare collaboration at Stanton Territorial Hospital.Objective: This study examined how Indigenous patients and biomedical healthcare providers envision Indigenous healing practices working successfully with biomedical hospital care at Stanton Territorial Hospital.Methods: We carried out a qualitative study from May 2018 - June 2022. The study was overseen by an Indigenous Community Advisory Committee and was made up of two methods: (1) interviews (n = 41) with Indigenous Elders, patient advocates, and healthcare providers, and (2) sharing circles with four Indigenous Elders.Results: Participants' responses revealed three conceptual models for Indigenous and biomedical healthcare collaboration: the (1) integration; (2) independence; and (2) revisioning relationship models. In this article, we describe participants' proposed models and examine the extent to which each model is likely to improve care for Indigenous patients at Stanton Territorial Hospital. By surfacing new models for Indigenous and biomedical healthcare collaboration, the study findings deepen and extend understandings of hospital-based Indigenous wellness services and illuminate directions for future research.

Successional dynamics of a 35 year old freshwater mitigation wetland in southeastern New Hampshire

The long-term ecological success of compensatory freshwater wetland projects has come into question based on follow-up monitoring studies over the past few decades. Given that wetland restoration may require many years to decades to converge to desired outcomes, long-term monitoring of successional patterns may increase our ability to fully evaluate success of wetland mitigation projects or guide adaptive management when needed. In Portsmouth, New Hampshire a 4 ha wetland was constructed in an abandoned gravel quarry as off-site compensatory mitigation for impacts to a scrub-shrub swamp associated with property expansion. Building upon prior evaluations from 1992 and 2002, we conducted a floral survey in 2020 to compare results with prior surveys to document vegetation successional trends over time. In addition, we monitored the avian community throughout the growing season as a measure of habitat quality. The plant community mirrored documented successional trends of freshwater wetland restoration projects as native hydrophytes dominated species composition. Plant species composition stabilized as the rate of turnover, the measurement of succession, declined by nearly half after 17 years. Researchers should consider long-term monitoring of specific sites to better understand successional patterns of created wetlands as we documented long time frames required for the development of scrub-shrub swamps, red maple swamps, and sedge meadows. High species richness was attributed to beaver activity, topographic heterogeneity from Carex stricta tussocks, and the seed bank from the application of peat from the original wetland. Habitat heterogeneity of open water, herbaceous cover, and woody vegetation supports a diverse avian community including 11 wetland dependent species. Although the mitigation project has not created the full area of lost scrub-shrub swamp after 35 years, it has developed a structurally complex habitat and diverse avian community that effectively provides the functions and values of the impacted system.

Early experience with medical assistance in dying in Ontario, Canada: a cohort study

BACKGROUND

Medical assistance in dying (MAiD) was legalized across Canada in June 2016. Some have expressed concern that patient requests for MAiD might be driven by poor access to palliative care and that social and economic vulnerability of patients may influence access to or receipt of MAiD. To examine these concerns, we describe Ontario's early experience with MAiD and compare MAiD decedents with the general population of decedents in Ontario.

METHODS

We conducted a retrospective cohort study comparing all MAiD-related deaths with all deaths in Ontario, Canada, between June 7, 2016, and Oct. 31, 2018. Clinical and demographic characteristics were collected for all MAiD decedents and compared with those of all Ontario decedents when possible. We used logistic regression analyses to describe the association of demographic and clinical factors with receipt of MAiD.

RESULTS

A total of 2241 patients (50.2% women) were included in the MAiD cohort, and 186 814 in the general Ontario decedent cohort. Recipients of MAiD reported both physical (99.5%) and psychologic suffering (96.4%) before the procedure. In 74.4% of cases, palliative care providers were involved in the patient's care at the time of the MAiD request. The statutory 10-day reflection period was shortened for 26.6% of people. Compared with all Ontario decedents, MAiD recipients were younger (mean 74.4 v. 77.0 yr, standardized difference 0.18);, more likely to be from a higher income quintile (24.9% v. 15.6%, standardized difference across quintiles 0.31); less likely to reside in an institution (6.3% v. 28.0%, standardized difference 0.6); more likely to be married (48.5% v. 40.6%) and less likely to be widowed (25.7% v. 35.8%, standardized difference 0.34); and more likely to have a cancer diagnosis (64.4% v. 27.6%, standardized difference 0.88 for diagnoses comparisons).

INTERPRETATION

Recipients of MAiD were younger, had higher income, were substantially less likely to reside in an institution and were more likely to be married than decedents from the general population, suggesting that MAiD is unlikely to be driven by social or economic vulnerability. Given the high prevalence of physical and psychologic suffering, despite involvement of palliative care providers in caring for patients who request MAiD, future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to a MAiD request.

Falling perinatal mortality in twins in the UK: organisational success or chance?

In June 2018, Mothers and Babies Reducing Risks through Audits and Confidential Enquiries across the UK (MBRRACE-UK) published a Perinatal Surveillance report of an audit between 2013-2016. This noted that the stillbirth rate for twins nearly halved between 2014-2016; whereas the stillbirth rate for singletons remained static. There was a statistically significant reduction in the rate of stillbirth in twins over this period from 11.07 (95% CI, 9.78-12.47) to 6.16 (95% CI, 5.20-7.24) per 1000 total births. This commentary discusses these observations, the effects of twin chorionicity, and the potential obstetric and neonatal interventions, as well as public health improvements, that may have influenced these findings.

Adolescent Males' Understanding of Infertility as a Long-Term Effect of Cancer Therapy

Cancer therapy can result in infertility in childhood cancer survivors; however, little is known about how young adolescent males make sense of infertility and potential future parenthood. What's more, research shows that many healthcare professionals in Canada do not discuss fertility preservation (FP) with this vulnerable population. This study examines how male adolescent childhood cancer survivors understand infertility as a long-term effect of cancer treatments. We used a narrative analysis to examine 16 interviews with 14-18-year-old males. The findings from this research illustrate that FP discussions may raise meaningful questions for young men about how they see themselves and construct their identities. The findings also demonstrate that young men's beliefs about FP may be informed by family narratives, and it shows that biological parenthood may be important to adolescent males.

High performance in healthcare priority setting and resource allocation: A literature- and case study-based framework in the Canadian context

Priority setting and resource allocation, or PSRA, are key functions of executive teams in healthcare organizations. Yet decision-makers often base their choices on historical patterns of resource distribution or political pressures. Our aim was to provide leaders with guidance on how to improve PSRA practice, by creating organizational contexts which enable high performance. We carried out in-depth case studies of six Canadian healthcare organizations to obtain from healthcare leaders their understanding of the concept of high performance in PSRA and the factors which contribute to its achievement. Individual and group interviews were carried out (n = 62) with senior managers, middle managers and Board members. Site observations and document review were used to assist researchers in interpreting the interview data. Qualitative data were analyzed iteratively with the literature on empirical examples of PSRA practice, in order to develop a framework of high performance in PSRA. The framework consists of four domains - structures, processes, attitudes and behaviours, and outcomes - within which are 19 specific elements. The emergent themes derive from case studies in different kinds of health organizations (urban/rural, small/large) across Canada. The elements can serve as a checklist for 'high performance' in PSRA. This framework provides a means by which decision-makers in healthcare might assess their practice and identify key areas for improvement. The findings are likely generalizable, certainly within Canada but also across countries. This work constitutes, to our knowledge, the first attempt to present a full package of elements comprising high performance in health care PSRA.

Olly Olly Oxen Free (or Ally Ally in Free): Playing Hide and Seek in Allocating Resources for Child and Youth Health

There are powerful arguments for increased investment in child and youth health. But the extent to which these benefits can be realized is shaped by health institutions' priority setting processes. We asked, "What are the unique features of a pediatric care setting that should influence choice and implementation of a formal priority setting and resource allocation process?" Based on multiple sources of data, we created a "made-for-child-health" lens containing three foci reflective of the distinct features of pediatric care settings: the diversity of child and youth populations, the challenges in measuring outcomes and the complexity of patient and public engagement.

Decision maker perceptions of resource allocation processes in Canadian health care organizations: a national survey

BACKGROUND

Resource allocation is a key challenge for healthcare decision makers. While several case studies of organizational practice exist, there have been few large-scale cross-organization comparisons.

METHODS

Between January and April 2011, we conducted an on-line survey of senior decision makers within regional health authorities (and closely equivalent organizations) across all Canadian provinces and territories. We received returns from 92 individual managers, from 60 out of 89 organizations in total. The survey inquired about structures, process features, and behaviours related to organization-wide resource allocation decisions. We focus here on three main aspects: type of process, perceived fairness, and overall rating.

RESULTS

About one-half of respondents indicated that their organization used a formal process for resource allocation, while the others reported that political or historical factors were predominant. Seventy percent (70%) of respondents self-reported that their resource allocation process was fair and just over one-half assessed their process as 'good' or 'very good'. This paper explores these findings in greater detail and assesses them in context of the larger literature.

CONCLUSION

Data from this large-scale cross-jurisdictional survey helps to illustrate common challenges and areas of positive performance among Canada's health system leadership teams.

Canadian national surveys on pandemic influenza preparations: pre-pandemic and peri-pandemic findings

Background

Prior to the 2009 H1N1 Influenza pandemic, public health authorities in Canada and elsewhere prepared for the future outbreak, partly guided by an ethical framework developed within the Canadian Program of Research on Ethics in a Pandemic (CanPREP). We developed a telephone-based survey based on that framework, which was delivered across Canada in late 2008. In June, 2009, the WHO declared pandemic Phase 6 status and from the subsequent October (2009) until May 2010, the CanPREP team fielded a second (revised) survey, collecting another 1,000 opinions from Canadians during a period of pre-pandemic anticipation and peri-pandemic experience.

Methods

Surveys were administered by telephone with random sampling achieved via random digit dialing. Eligible participants were adults, 18 years or older, with per province stratification approximating provincial percentages of national population. Descriptive results were tabulated and logistic regression analyses used to assess whether demographic factors were significantly associated with outcomes, and to identify divergences (between the pre-pandemic and intra-pandemic surveys).

Results

N = 1,029 interviews were completed from 1,986 households, yielding a gross response rate of 52% (AAPOR Standard Definition 3). Over 90% of subjects indicated the most important goal of pandemic influenza preparations was saving lives, with 41% indicating that saving lives solely in Canada was the highest priority and 50% indicating saving lives globally was the highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with serious health conditions which that increased risks. Strong majorities favoured stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced.

Conclusions

Results suggest Canadians trust public health officials to make difficult decisions, providing emphasis is maintained on reciprocity and respect for individual rights. Canadians also support international obligations to help poorer countries and associated efforts to save lives outside the country, even if intra-national efforts are reduced.

Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public's perspectives

BACKGROUND

Pandemic influenza may exacerbate existing scarcity of life-saving medical resources. As a result, decision-makers may be faced with making tough choices about who will receive care and who will have to wait or go without. Although previous studies have explored ethical issues in priority setting from the perspective of clinicians and policymakers, there has been little investigation into how the public views priority setting during a pandemic influenza, in particular related to intensive care resources.

METHODS

To bridge this gap, we conducted three public town hall meetings across Canada to explore Canadian's perspectives on this ethical challenge. Town hall discussions group discussions were digitally recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Six interrelated themes emerged from the town hall discussions related to: ethical and empirical starting points for deliberation; criteria for setting priorities; pre-crisis planning; in-crisis decision-making; the need for public deliberation and input; and participants' deliberative struggle with the ethical issues.

CONCLUSIONS

Our findings underscore the importance of public consultation in pandemic planning for sustaining public trust in a public health emergency. Participants appreciated the empirical and ethical uncertainty of decision-making in an influenza pandemic and demonstrated nuanced ethical reasoning about priority setting of intensive care resources in an influenza pandemic. Policymakers may benefit from a better understanding the public's empirical and ethical 'starting points' in developing effective pandemic plans.

Ethical framework for resource allocation during a drug supply shortage

Drug supply shortages are common in health systems due to manufacturing and other delays. Frequently, shortages are successfully addressed through conservation and redistribution efforts, with limited impact on patient care. However, when Sandoz Canada Inc. announced in February 2012 that it was reducing production of a number of generic injectable drugs at its Quebec facility, the scope and magnitude of the drug supply shortage were unprecedented in Canada. The potential for an extreme scarcity of some drugs raised ethical concerns about patient care, including the need to limit access to some health services. In this article, the authors describe the development and implementation of an ethical framework to promote equitable access to drugs and healthcare services in the context of a drug supply shortage within and across health systems.

Canadian survey on pandemic flu preparations

Background

The management of pandemic influenza creates public health challenges.

An ethical framework, 'Stand on Guard for Thee: ethical considerations in pandemic influenza preparedness' that served as a template for the World Health Organization's global consultation on pandemic planning, was transformed into a survey administered to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning.

Methods

All framework authors and additional investigators created items that were pilot-tested with volunteers of both sexes and all socioeconomic strata. Surveys were telephone administered with random sampling achieved via random digit dialing (RDD). Eligible participants were adults, 18 years or older, with per province stratification equaling provincial percent of national population. Descriptive results were tabulated and logistic regression analyses were used to assess whether demographic factors were significantly associated with outcomes.

Results

5464 calls identified 559 eligible participants of whom 88.5% completed surveys. Over 90% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada and 50% endorsing saving lives globally as the highest priority. Older age (OR = 8.51, p < 0.05) and current employment (OR = 9.48, p < 0.05) were associated with an endorsement of saving lives globally as highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with a serious health condition that increased risks. Over 84% supported the government's provision of disability insurance and death benefits for health care workers facing elevated risk. Strong majorities favored stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. While 92% of this group, believed provision should be 7 to 10% of all resources generated, 43% believed the provision should be greater than 10%.

Conclusions

Results suggest trust in public health officials to make difficult decisions, providing emphasis on reciprocity and respect for individual rights.

Setting priorities in global child health research investments: guidelines for implementation of CHNRI method

This article provides detailed guidelines for the implementation of systematic method for setting priorities in health research investments that was recently developed by Child Health and Nutrition Research Initiative (CHNRI). The target audience for the proposed method are international agencies, large research funding donors, and national governments and policy-makers. The process has the following steps: (i) selecting the managers of the process; (ii) specifying the context and risk management preferences; (iii) discussing criteria for setting health research priorities; (iv) choosing a limited set of the most useful and important criteria; (v) developing means to assess the likelihood that proposed health research options will satisfy the selected criteria; (vi) systematic listing of a large number of proposed health research options; (vii) pre-scoring check of all competing health research options; (viii) scoring of health research options using the chosen set of criteria; (ix) calculating intermediate scores for each health research option; (x) obtaining further input from the stakeholders; (xi) adjusting intermediate scores taking into account the values of stakeholders; (xii) calculating overall priority scores and assigning ranks; (xiii) performing an analysis of agreement between the scorers; (xiv) linking computed research priority scores with investment decisions; (xv) feedback and revision. The CHNRI method is a flexible process that enables prioritizing health research investments at any level: institutional, regional, national, international, or global.

Clinical ethicists' perspectives on organisational ethics in healthcare organisations

BACKGROUND

Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature.

OBJECTIVE

To describe clinical ethicists' perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues.

DESIGN AND SETTING

Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada.

RESULTS

From the clinical ethicists' perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation's moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support.

CONCLUSION

Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education.

Pandemic influenza preparedness: an ethical framework to guide decision-making

Background

Planning for the next pandemic influenza outbreak is underway in hospitals across the world. The global SARS experience has taught us that ethical frameworks to guide decision-making may help to reduce collateral damage and increase trust and solidarity within and between health care organisations. Good pandemic planning requires reflection on values because science alone cannot tell us how to prepare for a public health crisis.

Discussion

In this paper, we present an ethical framework for pandemic influenza planning. The ethical framework was developed with expertise from clinical, organisational and public health ethics and validated through a stakeholder engagement process. The ethical framework includes both substantive and procedural elements for ethical pandemic influenza planning. The incorporation of ethics into pandemic planning can be helped by senior hospital administrators sponsoring its use, by having stakeholders vet the framework, and by designing or identifying decision review processes. We discuss the merits and limits of an applied ethical framework for hospital decision-making, as well as the robustness of the framework.

Summary

The need for reflection on the ethical issues raised by the spectre of a pandemic influenza outbreak is great. Our efforts to address the normative aspects of pandemic planning in hospitals have generated interest from other hospitals and from the governmental sector. The framework will require re-evaluation and refinement and we hope that this paper will generate feedback on how to make it even more robust.

Priority setting in hospitals: Fairness, inclusiveness, and the problem of institutional power differences

Priority setting tends to take place in health care settings that are hierarchical and politically complex. Fair processes, as defined for example by Daniels' and Sabin's accountability for reasonableness framework, have been identified as essential for securing socially acceptable priority setting decisions. However, power differences in the decision-making context can pose a serious impediment to fair priority setting in health care organizations. Comparatively little attention has been paid to examining the institutional conditions within which priority setting decisions are made. We review a case study of priority setting in hospital operational planning in Toronto, which had been designed by executive leaders to be broadly inclusive of senior and middle-level clinical and administrative leaders. We report three power differences that arose as limiting factors on the inclusiveness of the priority setting process. We argue that these findings have significant theoretical implications for the accountability for reasonableness framework and propose a fifth condition, the "empowerment condition", which states that there should be efforts to minimise power differences in the decision-making context and to optimise effective opportunities for participation in priority setting.

Evidence, economics and ethics: resource allocation in health services organizations

Priority setting is a challenge for health services organizations across health systems. Because demand for health services exceeds available resources, health services priorities must be set to ensure resources are used appropriately to meet the community's health needs. Various approaches have been developed to assist decision-makers to set priorities in their organizations. The dominant approaches come from evidence-based medicine, economics and ethics.

Setting priorities in health care organizations: criteria, processes, and parameters of success

BACKGROUND

Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly.

DISCUSSION

We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.

SUMMARY

Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.

Prediction of preterm delivery in twin pregnancy: a prospective, observational study of cervical length and fetal fibronectin testing

OBJECTIVE

To evaluate prospectively cervical length measurements and fetal fibronectin detection as predictors of spontaneous preterm delivery in an unselected population of twin pregnancies.

METHODS

Transvaginal ultrasound assessments of cervical length were performed serially at 18, 24, 28 and 32 weeks' gestation. Receiver-operating characteristic curves were generated at each time point to determine the optimal cut-off for cervical length and rate of change in cervical length in the prediction of preterm delivery (< 35 weeks). A bedside assay for the detection of fetal fibronectin in the maternal vaginal secretions was performed prior to cervical length measurements from 24 weeks. Likelihood ratios (LRs) were used to assess the performance of each test.

RESULTS

The spontaneous preterm delivery rate was 16.5% in 91 studied twin pregnancies. A cervical length </= 25 mm at 18 weeks (LR+ 9.7, sensitivity 14.3%) and </= 22 mm at 24 weeks (LR+ 9.6, sensitivity 28.6%) were the best predictors of preterm delivery. A shortening of cervical length >/= 2.5 mm per week between 18 and 28 weeks' gestation also predicted preterm delivery (LR+ 10.8, sensitivity 16.7%). There was no relationship between the detection of fetal fibronectin and preterm delivery.

CONCLUSIONS

This study confirms the value of transvaginal ultrasound assessment of cervical length as a predictor of preterm delivery in twin pregnancies. However, the poor sensitivity of this test makes it unsuitable as a single predictor of preterm delivery. Fetal fibronectin testing does not identify twin pregnancies destined to deliver prematurely.

Analysis of diversity among 3-chlorobenzoate-degrading strains of Rhodopseudomonas palustris

The phenotypic and genetic characteristics of 14 strains of the purple nonsulfur bacterium Rhodopseudomonas palustris were studied to assess diversity within this species. While all strains had certain phenotypic characteristics in common, including the ability to metabolize benzoate and degrade 2- and 3-chlorobenzoate, there were also significant differences among the strains such as the rate of growth in media containing benzoate as a carbon source. Genetic characterization of the strains revealed there were three divergent lineages in the species. Based on 16S rRNA gene sequences, the 14 strains could be grouped into three distinct clusters (A, B, and C), and this clustering was congruent with that based on gene sequences of form II ribulose-1,5-bisphosphate carboxylase/oxygenase (RubisCO). Although BOX-PCR genomic DNA fingerprints of all 14 strains exhibited differences, analysis of the fingerprint images and UPGMA/product-moment analysis of similarities showed there were three groupings that were entirely consistent with clusters based on other characteristics of the strains. Thus, regardless of the method of analysis used, strains in groups A and B consistently clustered together and were separate from those of group C. These results suggest that strains in groups A-B and C represent phylogenetically related clones that have diverged from one another. This indicates that at least three lineages of Rhodopseudomonas palustris exist among the strains included in this study, and that each may be particularly well adapted to a distinct ecological niche.

Priority setting for new technologies in medicine: a transdisciplinary study

BACKGROUND

Decision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers.

DISCUSSION

Daniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based.

SUMMARY

We have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution.

Effect of ketorolac and low-molecular-weight heparin individually and in combination on haemostasis

Low-molecular-weight heparins, when used in surgical patients for thromboprophylaxis, may be used concurrently with ketorolac, a non-steroidal anti-inflammatory drug that is used for analgesia. Because these two agents can influence the haemostatic system, it is important to identify any such effect. The haemostatic interaction between dalteparin and ketorolac was assessed in a double-blind, placebo-controlled, randomized, crossover study of healthy male volunteers each given all four combinations of ketorolac/placebo and dalteparin/placebo. The effect of ketorolac and dalteparin on haemostasis was assessed by measuring in-vitro platelet aggregation, anti-factor-Xa, activated partial thromboplastin times and skin bleeding time. The results were analysed for evidence of an interaction between ketorolac and dalteparin. Ketorolac inhibited platelet aggregation in whole blood and platelet-rich plasma. The administration of dalteparin led to a significant increase in levels of anti-factor-Xa and a significant prolongation in the activated partial thromboplastin time, although it remained within the range of the normal population. There was no evidence of any interaction between ketorolac and dalteparin with regard to platelet aggregation, anti-factor-Xa activity or activated partial thromboplastin time. The administration of ketorolac significantly prolonged the skin bleeding time. There was a significant interaction between ketorolac and dalteparin to prolong the bleeding time, although dalteparin alone had no effect on bleeding time. There was an interaction between ketorolac and dalteparin, which affected bleeding times. Such an interaction raises the possibility of haemorrhagic complications developing perioperatively when these agents are used concomitantly. Further studies are required to examine the clinical importance of this interaction.

Increased nitrotyrosine in the diabetic placenta: evidence for oxidative stress

OBJECTIVE

To evaluate the presence of nitrotyrosine (NT) residues in placental villous tissue of diabetic pregnancies as an index of vascular damage linked to oxidative stress.

RESEARCH DESIGN AND METHODS

Villous tissue was collected and flash frozen after delivery from 10 class C and D IDDM patients (37.9+/-3.2 weeks) and 10 normotensive pregnant individuals (37.5+/-3.8 weeks). Serial sections of tissue were immunostained with specific antibodies to NT, endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), and manganese superoxide dismutase (MnSOD). Sections were scored for intensity of immunostaining (0-3) by three observers blinded to the identity of tissue.

RESULTS

All tissues demonstrated immunostaining for eNOS in both syncytiotrophoblast and stem villous vascular endothelium with no apparent differences between groups. Immunostaining for iNOS was seen in the villous stroma, but again was not different between the two groups. Significantly more intense NT staining was apparent in vascular endothelium and villous stroma (both P < 0.02) of diabetic placentas. The endothelium of large villous vessels of diabetic tissues also showed more intense immunostaining for MnSOD (P < 0.01).

CONCLUSIONS

In these diabetic pregnancies, we were unable to show increased eNOS, unlike previous findings in preeclamptic pregnancies. The presence of NT may indicate vascular damage in the diabetic placenta due to peroxynitrite action formed from increased synthesis/interaction of nitric oxide and superoxide. The apparently paradoxical increase in MnSOD expression may be an adaptive response to increased superoxide generation.

Puerperal thromboprophylaxis: comparison of the anti-Xa activity of enoxaparin and unfractionated heparin

Low molecular weight heparins are used extensively for thromboprophylaxis. The aim of this study was to compare the activity of the low molecular weight heparin, enoxaparin, 20 mg and 40 mg, given once per day with unfractionated heparin, 7500iu given twice per day, in terms of their anti-Xa activity in puerperal women following caesarean section and with an additional risk factor for venous thromboembolism. Seventeen women were randomised to receive one of the three treatments. The anti-Xa activity associated with each treatment was measured prior to treatment and at 2, 4, 6, 12 and 24 hours. The mean anti-Xa values of the groups receiving enoxaparin, 20 mg and 40 mg, were significantly higher than those of the group receiving unfractionated heparin. There was no difference between the two enoxaparin groups in terms of the anti-Xa activity profiles. This study suggests that the use of enoxaparin is superior to unfractionated heparin in terms of anti-Xa activity.

Circulating cell adhesion molecule concentrations in diabetic women during pregnancy

OBJECTIVE

To determine whether circulating concentrations of defined cell adhesion molecules, which are thought to reflect endothelial expression, are increased in insulin-dependent diabetic women during pregnancy.

METHODS

Pregnant diabetic women demonstrating good glycemic control and without major complications before pregnancy were studied at 8-12 (n = 15), 18 (n = 15), 28 (n = 16), 32 (n = 16), and 36 (n = 16) weeks' gestation. A subgroup of ten diabetic women was sampled longitudinally through all five gestational ages. The diabetic women were compared with healthy nondiabetic women sampled cross sectionally at 12 (n = 20), 28 (n = 19), and 36 (n = 19) weeks' gestation. Nonpregnant diabetic (n = 22) and nonpregnant nondiabetic women (n = 28) also were studied. Plasma concentrations of the cell adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular endothelial cell adhesion molecule-1 (VCAM-1) were measured by enzyme-linked immunosorbent assay.

RESULTS

Significantly higher median (range) concentrations of E-selectin (63.0 [20.2-107.0] ng/mL) and ICAM-1 (281.5 [171.6-778.4] ng/mL) but not VCAM-1 (459.7 [301.0-909.7] ng/mL) were found in nonpregnant diabetic women compared with nonpregnant nondiabetic women (43.5 [18.1-93.2], 243.6 [174.4-329.2], and 476.0 [253.8-929.4] ng/mL, respectively). During pregnancy these significant differences between diabetic and control groups were lost. The median (range) concentration of E-selectin (50.0 [21.2-96.3] ng/mL) was significantly lower in pregnant compared with nonpregnant diabetic women. The plasma concentrations of E-selectin and ICAM-1 did not change significantly with gestation in either diabetic or nondiabetic pregnant groups. Vascular endothelial cell adhesion molecule-1 concentration changed significantly with gestation in the diabetic pregnant group only.

CONCLUSION

Circulating concentrations of defined vascular cell adhesion molecules are not increased abnormally in diabetic women with good glycemic control during otherwise uncomplicated pregnancy.

Recognition of a Nocardia transvalensis complex by resistance to aminoglycosides, including amikacin, and PCR-restriction fragment length polymorphism analysis

Amikacin resistance, rare among nocardiae, was observed in 58 clinical isolates of nocardiae. All of these isolates hydrolyzed hypoxanthine, and 75 to 100% utilized citrate, D-galactose, and D-trehalose as sole carbon sources. Based on utilization of I-erythritol, D-glucitol, i-myo-inositol, D-mannitol, and ribitol and susceptibility to amoxicillin-clavulanic acid, the 58 isolates were separable into four groups. One group was negative for I-erythritol and ribitol and included all the isolates belonging to Nocardia asteroides complex antibiogram type IV. The remaining three groups were positive for I-erythritol and ribitol and were grouped within Nocardia transvalensis. The group that included the type strain was designated N. transvalensis sensu stricto, and the other two groups were designated new taxons 1 and 2. PCR-restriction fragment length polymorphism (RFLP) analysis of a 439-bp segment of the 65-kDa heat shock protein gene with XhoI and HinfI produced identical patterns for 53 (91%) and 58 (100%) isolates, respectively, and differentiated them from all other Nocardia taxa. NarI- and HaeIII-derived RFLP patterns clearly differentiated each of the four biochemically defined taxa. These four groups were also distinguishable by using the chromogenic substrates in Dade MicroScan test panels. By high-performance liquid chromatography, these isolates exhibited the same unique mycolic acid-ester elution patterns that differed from those of all other clinically significant nocardiae. Gas-liquid chromatographic analysis of fatty acids also produced similar patterns for all isolates that distinguished them from all other Nocardia taxa, but did not differentiate the four taxa within the complex. We propose the designation N. transvalensis complex for these four groups of nocardiae, pending further genetic evaluation.

Rapid identification of clinically significant species and taxa of aerobic actinomycetes, including Actinomadura, Gordona, Nocardia, Rhodococcus, Streptomyces, and Tsukamurella isolates, by DNA amplification and restriction endonuclease analysis

A previously described PCR-restriction fragment length polymorphism (RFLP) identification schema for Nocardia that used an amplified 439-bp segment (amplicon) of the 65-kDa heat shock protein gene was evaluated for potential use with isolates of all clinically significant aerobic actinomycetes. The study included 28 reference (American Type Culture Collection) strains and 198 clinical isolates belonging to 20 taxonomic groups. Of these 198 isolates, 188 could be differentiated by this PCR-RFLP method. Amplicons from all aerobic actinomycete isolates lacked BstEII recognition sites, thereby distinguishing them from those of mycobacteria that contain one or more such sites. Of 29 restriction endonucleases, MspI plus HinfI produced RFLP patterns that differentiated 16 of the 20 taxa. A single RFLP pattern was observed for 15 of 20 taxa that included 65% of phenotypically clustered isolates. Multiple patterns were seen with Gordona bronchialis, Nocardia asteroides complex type VI, Nocardia otitidiscaviarum, Nocardia transvalensis, and Streptomyces spp. Streptomyces RFLP patterns were the most heterogeneous (five patterns among 19 isolates), but exhibited a unique HinfI fragment of > 320 bp. RFLP patterns that matched those from type strains of Streptomyces albus, Streptomyces griseus, or Streptomyces somaliensis were obtained from 14 of 19 Streptomyces isolates. Only 10 of 28 isolates of N. otitidiscaviarum failed to yield satisfactory amplicons, while only 6 of 188 (3.2%) clinical isolates exhibited patterns that failed to match one of the 21 defined RFLP patterns. These studies extended the feasibility of using PCR-RFLP analysis as a rapid method for the identification of all clinically significant species and taxa of aerobic actinomycetes.

Analysis of the cbbXYZ operon in Rhodobacter sphaeroides

Three genes, cbbX, cbbY, and cbbZ were found downstream from the form I ribulose 1,5-bisphosphate carboxylase/oxygenase (RubisCO) genes of Rhodobacter sphaeroides. As in chemoautotrophic bacteria, cbbZ was shown to encode phosphoglycolate phosphatase (PGP), whereas the identities of cbbX and cbbY are not known. To determine the physiological function of the cbbXYZ gene products, we constructed R. sphaeroides strains in which the genes were inactivated and characterized the resultant mutant strains according to growth phenotype and levels of RubisCO and PGP. Only a mutation in cbbX resulted in a discernible phenotype, namely, impaired photoautotrophic growth. No PGP activity was observed in any of the mutants, suggesting that the three genes are transcriptionally linked. Studies with a spontaneous chemoautotrophic competent derivative of the CBBX mutant suggested that the cbbXYZ gene products are not essential for chemoautotrophic growth. PGP activity determined in the wild-type strain grown under a variety of growth conditions, and in various strains containing mutations in Calvin-Benson-Bassham cycle structural and regulatory genes, indicated that transcription of the cbb(I) operon influenced expression of the downstream cbbXYZ operon.

The molecular regulation of the reductive pentose phosphate pathway in Proteobacteria and Cyanobacteria

In phototrophic and chemoautotrophic proteobacteria, genes encoding enzymes of the Calvin-Benson-Bassham pathway of CO2 fixation are often found in clusters that are transcribed from a single promoter under control of the LysR-type transcriptional activator, CbbR. Mutations affecting CbbR prevent induction of cbb genes. Gel-retardation assays have demonstrated CbbR binding to putative regulatory regions of cbb operons, and in two cases, footprinting experiments have delimited the nucleotide sequence protected by CbbR. Fusion of cbb control sequences to reporter genes has allowed the regions required for promoter activity to be defined, and recent experiments indicate that the cbb regulon in Rhodobacter is controlled by a global two-component signal transduction system that also regulates other metabolic processes in this organism. Different ways of regulating CBB cycle enzymes that also have roles in heterotrophic metabolism have recently been discovered. In cyanobacteria, the genes of the CBB pathway are organized and regulated differently, and these oxygen-evolving phototrophic bacteria have evolved different strategies to control the assimilation of CO2.

DNA amplification and restriction endonuclease analysis for differentiation of 12 species and taxa of Nocardia, including recognition of four new taxa within the Nocardia asteroides complex

Nineteen reference and 156 clinical strains of the genus Nocardia belonging to 12 taxonomic groups were studied for restriction fragment length polymorphism (RFLP) by using an amplified 439-bp segment of the 65-kDa heat shock protein gene. Of 30 restriction endonucleases, digestion with MspI and then digestion with BsaHI produced RFLP band patterns which separated all 12 groups except N. asteroides type IV from 6 of 12 N. transvalensis isolates and N. carnea from the N. asteroides type VI isolates. Commonly encountered species such as N. nova, N. farcinica, N. brasiliensis sensu stricto, and N. otitidiscaviarum were easily separated. Each taxon resulted in a single RFLP band pattern that included > or = 96% of all biochemically grouped isolates for 9 of 12 taxa with MspI and for 8 of 12 taxa with BsaHI. With the use of both patterns, only 6 of 175 (3.4%) isolates failed to fit the biochemically defined group patterns. These studies provide the first evidence for the separate identities of four antibiogram-defined (but currently unnamed) groups within the N. asteroides complex (types I, II, IV, and VI) and the presence of two subgroups within N. transvalensis. They also provide genotypic evidence for the separate identities of N. nova and N. farcinica. The lack of BstEII recognition sites in amplicons obtained from nocardiae provides a simple and rapid method for the differentiation of nocardiae from mycobacteria. DNA amplification with RFLP analysis is the first rapid method that distinguishes all clinically significant taxa and recognized species within the genus Nocardia.

PCR amplification and restriction endonuclease analysis of a 65-kilodalton heat shock protein gene sequence for taxonomic separation of rapidly growing mycobacteria

A total of 129 reference and clinical strains of rapidly growing mycobacteria (RGM) belonging to 10 taxonomic groups were studied for restriction fragment length polymorphism patterns from a PCR-amplified 439-bp segment of the 65-kDa heat shock protein (HSP) gene. Of 24 endonucleases evaluated, restriction fragment length polymorphism patterns produced by HaeIII and BstEII and then by AciI and CfoI gave the best separation. Sixty percent of all RGM taxa studied were differentiated by HaeIII digests alone. Single unique patterns were observed with HaeIII and/or BstEII for Mycobacterium fortuitum (100%), M. chelonae (94%), M. abscessus (96%), M. smegmatis (100%), M. mucogenicum (formerly the M. chelonae-like organism) (100%), and the sorbitol-negative third biovariant of M. fortuitum (100%). Evidence is presented in support of two subgroups within M. peregrinum, M. smegmatis, and the unnamed third biovariant of M. fortuitum (sorbitol positive and sorbitol negative). PCR-based technology provides a rapid, accurate system for the identification of clinically important species of RGM which should be particularly useful for reference laboratories.

A case of recurrent typhoid fever in the United States: importance of the grandmother connection and the use of large restriction fragment pattern analysis of genomic DNA for strain comparison

An 8-year old girl was infected for a second time with Salmonella typhi by contact with her grandmother, a known typhoid carrier. The S. typhi from both patient and grandmother had closely related genomic pulsed field gel electrophoresis patterns that differed from epidemiologically unrelated strains. The girl responded well to a 14-day course of oral trimethoprimsulfamethoxazole. The grandmother was treated successfully with a 28-day regimen of oral ciprofloxacin. Typhoid fever remains an endemic disease in the United States, largely because of recognized chronic stool carriers. Most of these carriers had typhoid in the preantibiotic era and remain potential sources of disease when they provide meals for others, not uncommonly grandchildren. The importance of this "grandmother" connection to endemic typhoid fever is reviewed, as is the potential use of pulsed field gel electrophoresis pattern analysis for comparison of strains of S. typhi.

Identification of epitopes and affinity purification of thyroid stimulating auto-antibodies using synthetic human TSH receptor peptides

We prepared a series of overlapping peptides (29 in total, 20 amino acids each) containing the sequence of the entire extracellular domain of the human TSH receptor. Three peptides (181-200, 376-394, and EC3 (629-639)) bound IgG from patients with Graves' disease in an enzyme linked immunoassay. Peptide 181-200 bound IgG from 9 of 10, EC3 from 8 of 10, and 376-394 from 6 of 10 patients respectively, compared to 0 of 9 controls. We affinity purified TSHr auto-antibodies from four Graves' patients using the three above noted peptides bound to epoxy-activated sepharose. Thyroid stimulating activity was enriched in the bound fraction from at least two of the three peptide affinity columns in each of the four patients, although the pattern of affinity enrichment differed between patients. One patient was found to possess a combination of stimulatory and inhibitory TSHr antibodies and, after affinity purification, the anti-376-394 and anti-EC3 fractions were enriched in stimulatory activity, suggesting that those regions of the receptor were epitopes for stimulatory antibodies. However, affinity purification against peptide 181-200 produced an IgG preparation that was not stimulatory, but was a potent thyroid inhibitor. Thus, we have not only partially purified TSHr auto-antibodies, but also successfully separated stimulatory and inhibitory antibodies from a single patient using combination TSHr peptide affinity.

Nucleotide sequence and functional analysis of cbbR, a positive regulator of the Calvin cycle operons of Rhodobacter sphaeroides

Structural genes encoding Calvin cycle enzymes in Rhodobacter sphaeroides are duplicated and organized within two physically distinct transcriptional units, the form I and form II cbb operons. Nucleotide sequence determination of the region upstream of the form I operon revealed a divergently transcribed open reading frame, cbbR, that showed significant similarity to the LysR family of transcriptional regulatory proteins. Mutants containing an insertionally inactivated cbbR gene were impaired in photoheterotrophic growth and completely unable to grow photolithoautotrophically with CO2 as the sole carbon source. In the cbbR strain, expression of genes within the form I operon was completely abolished and that of the form II operon was reduced to about 30% of the wild-type level. The cloned cbbR gene complemented the mutant for wild-type growth characteristics, and normal levels of ribulose 1,5-bisphosphate carboxylase/oxygenase (RubisCO) were observed. However, rocket immunoelectrophoresis revealed that the wild-type level of RubisCO was due to overexpression of the form II enzyme, whereas expression of the form I RubisCO was 10% of that of the wild-type strain. The cbbR insertional inactivation did not appear to affect aerobic expression of either CO2 fixation operon, but preliminary evidence suggests that the constitutive expression of the form II operon observed in the cbbR strain may be subject to repression during aerobic growth.

The Rubisco activase (rca) gene is located downstream from rbcS in Anabaena sp. strain CA and is detected in other Anabaena/Nostoc strains

A gene encoding ribulose 1,5-bisphosphate carboxylase/oxygenase (Rubisco) activase (rca) was found downstream from the rbcLrbcS operon in the heterocystous cyanobacterium Anabaena sp. strain CA. Two unknown open reading frames were shown to be located between rbcS and rca in strain CA and all the genes, rbcLrbcS, ORF1, ORF2, and rca were in the same transcriptional orientation. The deduced amino acid sequence of the Anabaena Rubisco activase showed both similarities and differences to the plant enzyme with considerable differences at the carboxy and amino termini. Proposed ATP-binding sites were conserved in the cyanobacterial protein. Recombinant cyanobacterial Rubisco activase, however, reacted with antisera to spinach Rubisco activase. Hybridization studies, using the Anabaena sp. strain CA rca gene as a heterologous probe, detected homologous sequences in heterocystous Anabaena/Nostoc strains but not in unicellular or nonheterocystous filamentous cyanobacteria, suggestive of a close evolutionary relationship of chloroplasts and heterocystous cyanobacteria.

Uniform designation for genes of the Calvin-Benson-Bassham reductive pentose phosphate pathway of bacteria

Structural and regulatory genes encoding enzymes and proteins of the reductive pentose phosphate pathway have been isolated from a number of bacteria recently. In the phototroph Rhodobacter sphaeroides, and in two chemoautotrophic bacteria, Alcaligenes eutrophus and Xanthobacter flavus, these genes have been found in distinct operons. However, in these three organisms and in other bacteria where certain of these genes have been discovered, a uniform nomenclature to designate these genes has been lacking. This report represents an effort to provide uniformity to the designation of these genes from all bacteria.

Identification, expression, and deduced primary structure of transketolase and other enzymes encoded within the form II CO2 fixation operon of Rhodobacter sphaeroides

Previous studies had indicated that the form II or B cluster of CO2 fixation structural genes is part of a large operon in Rhodobacter sphaeroides (Gibson, J. L., Chen, J.-H., Tower, P. A., and Tabita, F. R. (1990) Biochemistry 29, 8085-8093). In this investigation, we have sequenced the DNA between the prkB and rbpL genes and provide evidence for three distinct open reading frames which encode additional structural genes of the Calvin reductive pentose phosphate pathway; these genes encode the enzymes transketolase, glyceraldehyde phosphate dehydrogenase, and aldolase. Noteworthy is transketolase, which may be expressed to high levels in Escherichia coli. This study thus represents the initial description of the primary structure of bacterial transketolase, a key enzyme of the reductive and the oxidative pentose phosphate pathways. Each of the genes are separated by short stretches of intergenic sequence, consistent with earlier evidence which suggested that these genes are cotranscribed and part of a large operon controlled by sequences upstream from fbpB.

Nucleotide sequence, transcriptional analysis, and expression of genes encoded within the form I CO2 fixation operon of Rhodobacter sphaeroides

In Rhodobacter sphaeroides, many of the structural genes encoding enzymes of the Calvin cycle are duplicated and grouped within two separate clusters. In this study, the nucleotide sequence of a 5627-base pair region of DNA that contains the form I Calvin cycle gene cluster has been determined. The five open reading frames are arranged in the order, fbpA prkA cfxA rbcL rbcS and are tightly linked and oriented in the same direction. The results of insertional mutagenesis studies suggest the genes are organized within an operon. Consistent with this proposal, the cfxA gene has been tentatively identified as a gene encoding the Calvin cycle enzyme, aldolase. Measurement of the activities of various Calvin cycle enzymes in the insertion mutants showed that inactivation of genes within one CO2 fixation cluster affected expression of genes within the second cluster, revealing a complex regulatory network.

Extreme ultraviolet transmission of a synthetic diamond thin film

The transmission of a thin film of synthetic diamond was measured at various wavelengths in the extreme ultraviolet. The measurements agree with a prediction based on published carbon attenuation coefficients assuming the density of natural diamond. A betterfit to the data results when an additional approximately 200-A layer of silicon is included in the model. It is believed that this silicon layer exists as silicon carbide.