Immunogenicity and safety of a bivalent (omicron BA.5 plus ancestral) SARS-CoV-2 recombinant spike protein vaccine as a heterologous booster dose: interim analysis of a phase 3, non-inferiority, randomised, clinical trial

BACKGROUND

SARS-CoV-2 variants evade immunity despite vaccination with prototype COVID-19 vaccines or previous infection. The 2019nCoV-311 (part 2) study is evaluating immune responses after two booster doses of a vaccine containing the omicron BA.5 subvariant spike protein in adults previously vaccinated with a prototype mRNA vaccine. This interim analysis reports on day 28 immunogenicity and safety outcomes after one booster dose.

METHODS

In this phase 3, randomised, observer-blinded study conducted at 35 sites in Australia, medically stable, previously COVID-19-vaccinated (mRNA-based; ≥three doses) adults aged 18 years or older were enrolled and randomly allocated (1:1:1; via an interactive web response system) to receive two doses of bivalent (NVX-CoV2373 + NVX-CoV2540; bivalent group), authorised prototype (NVX-CoV2373; prototype group), or BA.5 (NVX-CoV2540; BA.5 group) vaccine. Only blinded personnel performed study assessments or had participant contact to collect data after study vaccination. Participants received vaccines containing 5 μg SARS-CoV-2 recombinant spike protein and 50 μg Matrix-M adjuvant, administered via a 0·5 mL intramuscular injection (2·5 μg of NVX-CoV2373 plus 2·5 μg of NVX-CoV2540 for the bivalent vaccine, prepared on-site as a 1:1 mixture). The coprimary endpoints include day 28 neutralising antibody geometric mean titre (GMT) ratios (GMTRs) to omicron BA.5 and the ancestral strain, and seroresponse rates to BA.5, in the bivalent and prototype groups. These endpoints were calculated in the per-protocol analysis set, which was defined as participants who had received a vaccine dose, had baseline and day 28 immunogenicity data, and were PCR-negative for SARS-CoV-2, with no major protocol deviations. The primary objective was to determine the primary outcome (antibody responses), which consisted of three comparisons: superiority of the bivalent versus prototype vaccine for neutralising antibody GMT to BA.5 (ie, lower bound of the GMTR 95% CI >1·0); non-inferiority of neutralising antibody seroresponse rate to BA.5 (ie, lower bound of the seroresponse rate 95% CI >-5%); and non-inferiority of neutralising antibody GMT to the ancestral strain (ie, lower bound of GMTR 95% CI >0·67). This trial was registered at ClinicalTrials.gov, number NCT05372588.

FINDINGS

Between March 22, 2023 and May 2, 2023, 837 participants were screened for eligibility and 766 were randomly allocated to receive the BA.5 (n=255), prototype (n=252), or bivalent (n=259) vaccine. After accounting for exclusions due to participants being baseline SARS-CoV-2-positive, having previous infection, or protocol deviations, the per-protocol analysis set included 694 participants (236 in BA.5 group, 227 in prototype group, and 231 in bivalent group). In this interim analysis (maximum follow-up 35 days after the first dose), the bivalent group, compared with the prototype group, had superior neutralising antibody responses to BA.5 (GMT 1017·8 [95% CI 891·0-1162·6] vs 515·1 [450·4-589·0]; GMTR 2·0 [1·69-2·33]) and a non-inferior seroresponse rate to BA.5 at day 28 (39·8% [33·5-46·5] vs 12·3% [8·4-17·3]; difference 27·5% [19·8-35·0]). The bivalent group also had non-inferior neutralising antibody responses to the ancestral strain (GMTR 1·0 [0·84-1·20]), compared with the prototype group. All vaccines were similarly well tolerated.

INTERPRETATION

All three coprimary endpoints were met in part 2 of the ongoing 2019nCoV-311 study. These data support the development of monovalent and/or bivalent vaccines for the most currently circulating variants, to optimise protection. With no new safety findings, further investigation of omicron-based subvariant vaccines is supported by the evidence.

FUNDING

Novavax.

Immunogenicity and safety of heterologous Omicron BA.1 and bivalent SARS-CoV-2 recombinant spike protein booster vaccines: a phase 3, randomized, clinical trial

BACKGROUND

Mutations present in emerging SARS-CoV-2 variants permit evasion of neutralization with prototype vaccines. A novel Omicron BA.1 subvariant-specific vaccine (NVX-CoV2515) was tested alone, or as a bivalent preparation in combination with the prototype vaccine (NVX-CoV2373), to assess antibody responses to SARS-CoV-2.

METHODS

Participants aged 18 to 64 years immunized with 3 doses of prototype mRNA vaccines were randomized 1:1:1 to receive a single dose of NVX-CoV2515, NVX-CoV2373, or bivalent mixture in a phase 3 study investigating heterologous boosting with SARS-CoV-2 recombinant spike protein vaccines. Immunogenicity was measured 14 and 28 days after vaccination for the SARS-CoV-2 Omicron BA.1 sublineage and ancestral strain. Safety profiles of vaccines were assessed.

RESULTS

Of participants who received trial vaccine (N = 829), those administered NVX-CoV2515 (n = 286) demonstrated superior neutralizing antibody response to BA.1 versus NVX-CoV2373 (n = 274) at Day 14 (geometric mean titer ratio [95% CI]: 1.6 [1.33, 2.03]). Seroresponse rates [n/N; 95% CI] were 73.4% [91/124; 64.7, 80.9] for NVX-CoV2515 versus 50.9% [59/116; 41.4, 60.3] for NVX-CoV2373. All formulations were similarly well-tolerated.

CONCLUSIONS

NVX-CoV2515 elicited a superior neutralizing antibody response against the Omicron BA.1 subvariant compared with NVX-CoV2373 when administered as a fourth dose. Safety data were consistent with the established safety profile of NVX-CoV2373.

Top Ten Research Priorities for Psoriasis, Atopic Dermatitis and Hidradenitis Suppurativa: The SkIN Canada Priority Setting Initiative

Background

The Skin Investigation Network of Canada (SkIN Canada) is a new national skin research network. To shape the research landscape and ensure its value to patient care, research priorities that are important to patients, caregivers, and health care providers must be identified.

Objectives

To identify the Top Ten research priorities for 9 key skin conditions.

Methods

We first surveyed health care providers and researchers to select the top skin conditions for future research within the categories of inflammatory skin disease, skin cancers (other than melanoma), and wound healing. For those selected skin conditions, we conducted scoping reviews to identify previous priority setting exercises. We combined the results of those scoping reviews with a survey of patients, health care providers, and researchers to generate lists of knowledge gaps for each condition. We then surveyed patients and health care providers to create preliminary rankings to prioritize those knowledge gaps. Finally, we conducted workshops of patients and health care providers to create the final Top Ten lists of research priorities for each condition.

Results

Overall, 538 patients, health care providers, and researchers participated in at least one survey or workshop. Psoriasis, atopic dermatitis and hidradenitis suppurativa (inflammatory skin disease); chronic wounds, burns and scars (wound healing); and basal cell, squamous cell and Merkel cell carcinoma (skin cancer) were selected as priority skin conditions. Top Ten lists of knowledge gaps for inflammatory skin conditions encompassed a range of issues relevant to patient care, including questions on pathogenesis, prevention, non-pharmacologic and pharmacologic management.

Conclusions

Research priorities derived from patients and health care providers should be used to guide multidisciplinary research networks, funders, and policymakers in Canada and internationally.

No significant clinical and radiological differences between fixed versus mobile bearing total knee replacement using the same semi-constrained implant type: a randomized controlled trial with mean 10 years follow-up

PURPOSE

The aim of this study was to compare the long-term clinical and radiological results between fixed (FB) and mobile bearing (MB) implants with identical design from the same manufacturer.

METHODS

From March 2007 to May 2009, we recruited 160 patients in a prospective, single centered, randomized controlled trial. The authors compared 81 FB total knee arthroplasty (TKA) versus 79 MB with medial compartment osteoarthritis. The same posterior stabilized HLS Noetos knee prosthesis (CORIN) was used in all patients. The two groups only differed by the tibial insert (fixed or mobile). The authors compared the postoperative Knee Society Score (KSS), the passive clinical and active radiological knee flexion, the implant survivorship, the complications, and the presence of radiolucent lines.

RESULTS

At mean 10.5 years' follow-up (range 8-12.1 years) no significant differences were found in clinical scores (KSS (p = 0.54), pain score (p = 0.77), stair climbing (p = 0.44), passive maximum flexion (p = 0.5)) or for radiological analyses (maximum active radiological flexion (p = 0.06), presence of progressive radiolucent lines (5 (MB group) versus 6 (FB group); p = 0.75)) between groups. No significant difference was found in overall implant survivorship (82% (MB group) versus 78% (FB group) p = 0.58) or complication rate (p = 0.32) at the last follow-up.

CONCLUSION

No significant clinical and radiological differences were found between fixed and mobile bearing TKA using the same semi-constrained implant type with comparable overall survivorship. The choice between a fixed or mobile bearing implant should be based on surgeon preference and experience with the selected implant.

LEVEL OF EVIDENCE

Prospective randomized controlled trial, Level II.

BIM mediates synergistic killing of B-cell acute lymphoblastic leukemia cells by BCL-2 and MEK inhibitors

B-cell acute lymphoblastic leukemia (B-ALL) is an aggressive hematological disease that kills ~50% of adult patients. With the exception of some BCR-ABL1(+) patients who benefit from tyrosine kinase inhibitors, there are no effective targeted therapies for adult B-ALL patients and chemotherapy remains first-line therapy despite adverse side effects and poor efficacy. We show that, although the MEK/ERK pathway is activated in B-ALL cells driven by different oncogenes, MEK inhibition does not suppress B-ALL cell growth. However, MEK inhibition synergized with BCL-2/BCL-XL family inhibitors to suppress proliferation and induce apoptosis in B-ALL cells. We show that this synergism is mediated by the pro-apoptotic factor BIM, which is dephosphorylated as a result of MEK inhibition, allowing it to bind to and neutralize MCL-1, thereby enhancing BCL-2/BCL-XL inhibitor-induced cell death. This cooperative effect is observed in B-ALL cells driven by a range of genetic abnormalities and therefore has significant therapeutic potential.

Overcoming the problem of residual microbial contamination in dental suction units left by conventional disinfection using novel single component suction handpieces in combination with automated flood disinfection

OBJECTIVES

Decontaminating dental chair unit (DCU) suction systems in a convenient, safe and effective manner is problematic. This study aimed to identify and quantify the extent of the problems using 25 DCUs, methodically eliminate these problems and develop an efficient approach for reliable, effective, automated disinfection.

METHODS

DCU suction system residual contamination by environmental and human-derived bacteria was evaluated by microbiological culture following standard aspiration disinfection with a quaternary ammonium disinfectant or alternatively, a novel flooding approach to disinfection. Disinfection of multicomponent suction handpieces, assembled and disassembled, was also studied. A prototype manual and a novel automated Suction Tube Cleaning System (STCS) were developed and tested, as were novel single component suction handpieces.

RESULTS

Standard aspiration disinfection consistently failed to decontaminate DCU suction systems effectively. Semi-confluent bacterial growth (101-500 colony forming units (CFU) per culture plate) was recovered from up to 60% of suction filter housings and from up to 19% of high and 37% of low volume suction hoses. Manual and automated flood disinfection of DCU suction systems reduced this dramatically (ranges for filter cage and high and low volume hoses of 0-22, 0-16 and 0-14CFU/plate, respectively) (P<0.0001). Multicomponent suction handpieces could not be adequately disinfected without prior removal and disassembly. Novel single component handpieces, allowed their effective disinfection in situ using the STCS, which virtually eliminated contamination from the entire suction system.

CONCLUSION

Flood disinfection of DCU suction systems and single component handpieces radically improves disinfection efficacy and considerably reduces potential cross-infection and cross-contamination risks.

CLINICAL SIGNIFICANCE

DCU suction systems become heavily contaminated during use. Conventional disinfection does not adequately control this. Furthermore, multicomponent suction handpieces cannot be adequately disinfected without disassembly, which is costly in time, staff and resources. The automated STCS DCU suction disinfection system used with single component handpieces provides an effective solution.

Use of Cryopreserved, Particulate Human Amniotic Membrane and Umbilical Cord (AM/UC) Tissue: A Case Series Study for Application in the Healing of Chronic Wounds

Human amniotic membrane and umbilical cord tissues (AM/UC) are fetal tissues that contain proteins, cytokines, and growth factors that, when transplanted, can modulate inflammation and promote healing. Lyophilized, particulate AM/UC tissues can be used as wound coverings for chronic dermal ulcers or defects to promote granulation tissue formation and rapid re-epithelialization. This study reviews a case series of 5 patients presenting with chronic nonhealing wounds that received particulate AM/UC tissues (NEOX® FLO, Amniox Medical, Atlanta, GA). For all cases, wounds were debrided in the office setting and a single application of lyophilized particulate was used with minimal additional dressings. The lyophilized AM/UC tissue was placed within the wound bed and a dressing consisting of Adaptic®, 2x2 or 4x4 (Systagenix, Quincy, MA), Kling® (Johnson & Johnson, New Brunswick, NJ), and ACE™ (3M, St. Paul, MN) wrap were applied. Dressings were kept in place until weekly follow-up appointments in which a new Adaptic, 2x2 and Kling were applied. Overall, healing of wounds was noted to have a mean of 5 weeks to complete epithelialization. Upon complete healing patients were able to return to planned postoperative care and rehabilitation. Wound complications occur despite the best standard of care. Chronic wounds that remain weeks after surgery inhibit patients from progressing to physical rehabilitation and significantly affect patients both physically and mentally. These case presentations demonstrate how use of human AM/UC tissue may help wounds heal quickly and help patients return to normal function.

Antiretroviral therapy in pregnancy: local practice in East London, UK

A review of antiretroviral prescribing, mode of delivery and pregnancy outcome was performed to assess local practice against the new British HIV Association guidelines. HIV status prior to pregnancy, antiretroviral medication, viral load, mode of delivery and pregnancy outcome were determined in 95 pregnancies recorded between 2004 and 2006 via retrospective case-note review. In total, 75% (n=71) of pregnancies resulted in live births; 56% (n=53) of pregnancies occurred in women who knew they were HIV positive prior to the current pregnancy; 49% (n=26) of them conceived on antiretroviral therapy (ART). Use of protease-inhibitor-based ART and number of normalvaginal delivery increased and the use of zidovudine (AZT) monotherapy and emergency caesarean section (CS) fell during the study period. In conclusion, there was an increase in vaginal deliveries and a reduction in the number of emergency CSs between 2004 and 2006.

The role of manufacturers in reducing biofilms in dental chair waterlines

OBJECTIVES

This paper reviews how dental chair unit (DCU) manufacturers can contribute practically to resolving the problem of biofilm formation in dental unit waterlines (DUWs).

STUDY SELECTION

The review concentrates on how novel developments and changes in a range of specific areas have, and might contribute to DUW biofilm control. These include (i) DCU engineering and design changes; (ii) improvements to DCU supply water quality; (iii) development of automated DUW treatment procedures that are effective at controlling biofilm in the long-term, safe for patients and dental staff, environmentally friendly and which do not exhibit adverse effects on DCU components after prolonged use.

SOURCES

The majority of the material contained in this review is based on, or supported by the peer-reviewed literature.

DATA

The current consensus from the literature reveals that the emphasis on DUW biofilm and its control has focused on describing the problem and its control using a range of periodic and residual DUW treatment agents. Unfortunately, until recently, DCU manufacturers have provided very little specific guidance in this regard. Indeed, ensuring that DCUs provide good quality output water has generally been regarded to be the responsibility of dental practitioners. Some recent studies have shown that novel DCUs with integral semi-automated or automated DUW cleaning systems can effectively control DUW biofilm in the long-term. However, there are other potential DCU engineering and design changes that DCU manufacturers could undertake to further improve DUW biofilm control.

CONCLUSIONS

DCU manufacturers can significantly contribute to controlling the problem of DUW biofilm.

Development of polymorphic expressed sequence tag-derived microsatellites for the extension of the genetic linkage map of the black tiger shrimp (Penaeus monodon)

In this study, microsatellite markers were developed for the genetic linkage mapping and breeding program of the black tiger shrimp Penaeus monodon. A total of 997 unique microsatellite-containing expressed sequence tags (ESTs) were identified from 10 100 EST sequences in the P. monodon EST database. AT-rich microsatellite types were predominant in the EST sequences. Homology searching by the blastn and blastx programs revealed that these 997 ESTs represented 8.6% known gene products, 27.8% hypothetical proteins and 63.6% unknown gene products. Characterization of 50 markers on a panel of 35-48 unrelated shrimp indicated an average number of alleles of 12.6 and an average polymorphic information content of 0.723. These EST microsatellite markers along with 208 other markers (185 amplified fragment length polymorphisms, one exon-primed intron-crossing, six single strand conformation polymorphisms, one single nucleotide polymorphism, 13 non-EST-associated microsatellites and two EST-associated microsatellites) were analysed across the international P. monodon mapping family. A total of 144 new markers were added to the P. monodon maps, including 36 of the microsatellite-containing ESTs. The current P. monodon male and female linkage maps have 47 and 36 linkage groups respectively with coverage across half the P. monodon genome.

Single-cell RT-PCR gene expression profiling of acutely dissociated and immunocytochemically identified central neurons

Identification of neurons for single-cell mRNA profiling is difficult when cells of interest are located in heterogeneous brain regions. We developed a protocol in which acutely dissociated neurons are immunocytochemically labeled prior to single-cell reverse transcription-polymerase chain reaction (RT-PCR). We tested the protocol on hypothalamic melanin-concentrating hormone (MCH) and prepro-orexin (PPO) neurons, which are similarly distributed but functionally different. Cells dissociated from the perifornical region of the posterior hypothalamus of juvenile or adult rats were incubated with anti-MCH or anti-PPO primary antibodies, followed by washout and incubation with fluorescein-tagged secondary antibodies. Individual labeled cells were subjected to RT-PCR with primers for PPO and MCH. MCH mRNA was detected in 26 out of the 38 successfully reverse-transcribed cells identified as MCH-containing, and 28 cells out of the 42 identified as PPO-containing expressed PPO mRNA. No cell expressed both mRNAs. Most MCH neurons tested (five out of six) expressed the adrenergic alpha2A receptor mRNA, whereas it was absent from all seven PPO neurons tested. Neither PPO (n = 11) nor MCH (n = 6) cells expressed the type 2 orexin receptor mRNA. Thus, the method allows, with at least 66% confidence, immunocytochemical cell identification prior to mRNA studies of single neurons located in heterogeneous brain regions.

Audit of surgeon awareness of readmissions with venous thrombo-embolism

AIM

An audit was undertaken to assess whether surgeons were informed of the readmission of their patients with postoperative deep venous thrombosis (DVT), or pulmonary embolus (PE).

METHODS

A retrospective medical record review was conducted to detect patients who had an unplanned readmission in which DVT or PE formed part of the diagnosis and the first admission included a surgical procedure. The readmission was to John Hunter Hospital, Newcastle, Australia, a major tertiary referral teaching hospital, and the first admission was to any acute care hospital. The main outcome measures were: (i) hospital and specialty of the admitting doctor, (ii) the type of surgery performed, (iii) the length of time between admissions and (iv) the patient's previous medical history. The medical record was reviewed for documented evidence that the surgeon who performed the procedure was aware of the readmission.

RESULTS

Of the 215 patient reviewed, 34 were classified as unplanned readmissions following a surgical procedure. Twenty-four patients (70.6%) were readmitted under a different specialty, three (8.8%) patients were readmitted under the same specialty but under a different surgeon, and seven (20.6%) patients were readmitted under the same surgeon. Of the 27 patients admitted under a different consultant, only 12 (44.4%) had documented evidence that the previous surgeon was aware of the readmission.

CONCLUSION

The rate of DVT/PE complications following surgery is underestimated. This may lead to a reduced emphasis in DVT/PE prophylaxis in the mistaken belief that DVT/PE frequency is rarer than it is. Improved communication between teams is necessary to improve care.

Prevention of orthopaedic wound infections: a quality improvement project

Using clinical practice improvement methodology, a project was undertaken to reduce the incidence of surgical wound infections following elective hip and knee replacement surgery. A team was established, key measures for improvement were identified, strategies for change were developed and an action plan was implemented. Outcomes for this project included a reduction in the rate of clean surgical wound infection for joint replacement surgery from 28% to zero. Average length of stay for total hip replacement surgery was reduced from 13.9 to 9.3 days and from 14.6 to 10.4 days for total knee replacement surgery. Guidelines for patient selection were developed along with a protocol for the management of preparation to prevent urinary tract infections. Post-discharge surveillance and a preoperative rehabilitation and exercise programme have been implemented. There is potential for wider uptake and implementation of the quality principles described herein.

State Medicaid nursing home reimbursement rates: adjusting for ancillaries

PURPOSE

State variation in inclusion of ancillary services in daily Medicaid nursing home reimbursement rates, versus covering ancillary costs outside of such rates, makes rate comparisons difficult. The purpose of this study is to adjust for inclusion of ancillaries when comparing Medicaid rates across states.

DESIGN AND METHODS

Data for 1987-1998 were drawn from a national survey of Medicaid reimbursement. Employing a random-effects model, the PANEL option in the LIMDEP software was used to estimate effects on state average Medicaid nursing facility constant-dollar rates of the inclusion in those rates of a set of ancillaries: physical therapy, occupational therapy, prescription drugs, nonprescription drugs, durable medical equipment (DME), medical supplies, and physician services.

RESULTS

Rates averaged higher when they included occupational therapy, physician services, nonprescription drugs, and both DME and medical supplies. Adjusting for the inclusion of ancillaries leads to a much different ranking of states than for unadjusted rates.

IMPLICATIONS

Public and industry policy makers should consider the inclusion of ancillaries in rates when considering the relative adequacy of rates across states.

Residential care supply and cognitive and physical problem case mix in nursing homes

OBJECTIVES

A rapid evolution has occurred in state policy and industry practices relative to assisted living and expanded use of residential care facilities for people with physical and cognitive frailty, yet relatively little is known about the interrelationship between this housing supply and nursing-home case mix.

METHODS

The association between residential care supply and the proportion of cognitively and physically impaired nursing facility residents was examined in more than 1,500 facilities in five states.

RESULTS

The proportion of nursing-home cases with only physical and cognitive impairment likely to be affected by emerging long-term care policy appears to be well under 10%. This effect is more persistent among admissions than continuing cases.

DISCUSSION

The findings raise caution about the optimistic assumptions of the interplay between residential care/assisted living policy and nursing-home use.

A review of 165 cases of transvaginal sacrospinous colpopexy performed by the Endo Stitch technique

The Endo Stitch technique has been in use in Geelong since 1994 as the method of performing transvaginal sacrospinous colpopexy (TSC). This article looks at the outcome of 165 of these procedures as assessed by a questionnaire. As the operation is technically easy, has a low complication rate and a high level of patient satisfaction we suggest that the Endo Stitch technique may be the method of choice for TSC.

Modulation of corneal endothelial hydration control mechanisms by Rolipram

Corneal stromal hydration is maintained by an active HCO3- transport mechanism located in the corneal endothelium. Whilst modulation of transport activity by changes in intracellular cAMP concentration have been noted, the site of effect is undefined. To resolve this question, the effects of Rolipram, a cAMP phosphodiesterase inhibitor, on endothelial physiology were determined. Addition of 0.1 mM Rolipram caused a threefold increase in intracellular cAMP with no change in cGMP. Associated with the increase in cAMP was a transient whole corneal thinning and a similarly transient increase in trans-endothelial potential difference, short-circuit current and resistance. The membrane potential hyperpolarized and the intracellular Na+ concentration decreased. The decreased intracellular Na+ was associated with an increased rate of Na+ extrusion between the endothelial cell and extracellular space. It is concluded that Rolipram increases the concentration of cAMP which activates the basolateral membrane Na+/K+-ATPase activity and increases net HCO3- transport. In addition there is a reduction in endothelial permeability which combined with the increase in pump activity may jointly explain the observed stromal thinning. The duplicity of responses indicates that if cAMP has a physiological role in regulating corneal hydration then it may operate on both the endothelial pump and the endothelial permeability.

Residential care supply, nursing home licensing, and case mix in four states

Simulation analyses quantify admission and continuing physical and cognitive impairment patient case-mix changes under two scenarios: with increases in residential care supply and with all nursing homes licensed only as skilled care facilities. Findings raise caution about the assumed interplay between residential care supply and nursing home use. The proportion of nursing home patients with only physical and cognitive impairment likely to be affected by current and emerging long-term care (LTC) policy was well under 25 percent of the nursing home population in each of the four study States. States varied in LTC supply and utilization controls.

The Queen Scallop Aequipecten opercularis: a new source of information on late Cenozoic marine environments in Europe

Few data exist on seasonal variation in the temperature (or other aspects of the environment) of late Cenozoic shelf seas in Europe. Ontogenetic records in the shell of Aequipecten opercularis, a widespread, fast-growing and typically well-preserved bivalve, are a potential source. Study of modern forms has shown that oxygen stable isotopes are incorporated in equilibrium with surrounding seawater (hence providing a faithful record of temperature) and data from late Holocene A. opercularis of the southern North Sea Basin (SNSB) indicate that extreme winter (as well as summer) temperatures are registered. Oxygen isotope data from apparently well-preserved, mid-Pliocene shells of the SNSB indicate seasonal temperatures similar to present, whereas microgrowth increment data suggest substantially warmer conditions, in accordance with other evidence. The balance of evidence thus implies cryptic diagenetic corruption of the isotopic temperature signature in mid-Pliocene shells. However, it would be premature to discount the possibility of cooler mid-Pliocene conditions than currently recognized. Ontogenetic variation in carbon isotopic composition within shells is minor and apparently unrelated to environment, but differences between mid-Pliocene, late Holocene and modern shells probably relate to changes in atmospheric CO2 concentration. Unlike certain taxa, seasonal variation is not evident in the strontium or magnesium contents of the A. opercularis shell, but may be displayed by other trace elements, hence affording (together with seasonal increment width variation) a means of independent temporal calibration of isotope profiles. Ontogenetic records of environment from A. opercularis can be complete (and, in the case of increment data, easily recovered) but are of short duration. They must be complemented by (less complete) records from longer lived taxa to obtain the fullest possible environmental history. Seasonal cycles in ontogenetic records afford a means of establishing age and growth rate, and can therefore provide information of value for evolutionary studies and management of living populations.

Infertility in female rabbits (Oryctolagus cuniculus) alloimmunized with the rabbit zona pellucida protein ZPB either as a purified recombinant protein or expressed by recombinant myxoma virus

Development of immunocontraceptives for wild rabbit populations requires selection of both effective antigens and effective delivery systems. Recombinant rabbit zona pellucida glycoprotein B (ZPB) produced in eukaryotic cells in vitro was an effective antigen and induced sustained infertility in 70% of female rabbits. This required two boosts and serum antibody titers of 12 800 or greater. Antibody titers in females were low after the initial immunization, as might be expected with a self-antigen; however, male rabbits had a strong antibody response, indicating that the protein was immunologically foreign. To develop a delivery system, ZPB was delivered by infection with a recombinant myxoma virus. In contrast to the results with ZPB protein, infection of rabbits induced a similar serum antibody response to ZPB in both sexes. This indicated that presentation of ZPB in the context of a virus infection was able to overcome tolerance in females. However, the antibody titers were lower than 12 800, and only 25% of female rabbits were infertile. This antibody response was boosted by injections of recombinant ZPB protein, after which 80% of female rabbits were infertile. Infertility was associated with antibody binding to zonae and varying degrees of ovarian pathology characterized by follicular degeneration and substantial depletion of primordial follicles. Oocyte and follicular degeneration appeared to be the principal mechanism of infertility and may be primarily induced by antibodies to ZPB.

Wearing Two Hats: Consumer & Provider

To change public attitudes toward people with mental illness, consumers need positive visibility and a strong community voice. We are making progress, although slowly, to eliminate the stigma surrounding mental illness. Progress can be attributed to the fact that the mentally ill are now living in our communities among us, and people are beginning to understand them more.

Parenting stress and mothers of young children with chronic illness: a cross-cultural study

This study examined the sources of parenting stress among mothers from Israel, Japan, Jordan, and the United States who had a young child with a chronic illness. The results indicated mothers from all four countries experienced high levels of child-focused and parent-focused stress that indicated a need for nursing intervention.

Cancer surveillance in the U.S.: can we have a national system?

Cancer-related services are consuming ever-increasing health resources; along with this trend, health care costs are rising. As health care planners, researchers, and policymakers formulate strategies to meet this challenge, they are looking to cancer registries and the health information system built around them as collectors of the most extensive information regarding cancer treatment in the U.S. Currently, there are multiple programs collecting and reporting data regarding cancer incidence, morbidity, mortality, and survival. This report profiles cancer surveillance efforts in the U.S. and describes the National Coordinating Council for Cancer Surveillance, which was organized in 1995 to facilitate a collaborative approach among the organizations involved.

Protein and cell engineering of components of the human immunoglobulin E receptor/effector system: applications for therapy and diagnosis

Adaptive immune responses characterised by the synthesis of antibodies of the immunoglobulin E (IgE) isotype play an important role in type I hypersensitivity disorders and parasitic infestations, diseases which have an significant socioeconomic impact world-wide. This paper considers potential applications of recent advances in our understanding of the origin of isotype specific immune responses which emerged as a result of cell and protein engineering studies on components of the human IgE/receptor/effector system. Furthermore, the identification of the receptor binding regions in IgE as a result of the development of a stable assay system has important applications for the design of rational therapeutic interventions in allergy and asthma, the treatment of mast cell tumours, and the establishment of procedures for the selective isolation of cells expressing the high-affinity receptor for IgE for functional studies.

Volume-controlled ventilation is made possible in infants by using compliant breathing circuits with large compression volume

We studied the weight dependency of set tidal volume (VTset) during volume-controlled ventilation of 80 infants (ASA physical status I-IV, 0.7-20 kg), including prematures, neonates, and exprematures, who were anesthetized for major and minor surgery, including abdominal, thoracic, and neurosurgical procedures. After neuromuscular blockade and endotracheal intubation, infant's lungs were ventilated with an Ohmeda 7800 volume-limited ventilator and either a pediatric or adult circle breathing system (PC or AC) or a Bain circuit (Ba) and a pediatric- or adult-sized bellows (PB or AB). Except for larger and older infants in the ACAB group, body weight, age, peak inspiratory pressure (PIP), ETCO2, and SPO2 did not differ among groups. Compression volume loss was large in the five circuits tested. We found that VTset/kg varied with weight in a curvilinear relationship where y represents volume added and x represents PIP (y = 175.02x-0.87; r2 - 0.87), whereby VTset is approximately 150-200 mL/kg for a 1-kg infant and approximately 25 mL/kg for infants > or = 10 kg. Ventilation was adequate in each infant, except for one with extremely poor pulmonary compliance. We conclude that large compression volumes associated with compliant breathing systems make possible the use of volume-controlled ventilators in small infants.

Internal calvarial bone distraction in rabbits with experimental coronal suture immobilization

Correction of craniosynostosis involves removal of the coronal suture to allow for expansion of the developing brain and normal craniofacial growth. Frequently, however, the site reossifies, restricts growth, and requires additional surgery. The present study was designed to assess the effects of an internal, subperiosteal calvarial distractor on suturectomy site patency and compensatory craniofacial growth changes in an experimental rabbit model of coronal suture synostosis. In the present study, 43 1 1/2-week-old rabbits were used. Amalgam markers were placed across the frontonasal, coronal, and anterior lambdoidal sutures in all animals. Twenty-nine rabbits underwent bilateral coronal suture immobilization using methyl methacrylate. Fourteen rabbits were left untreated and served as sham controls. At 6 weeks of age, the immobilized rabbits were divided into three groups: (1) immobilized (controls), (2) suturectomy, and (3) suturectomy and distraction. The distractors were activated percutaneously at an average of 0.6 mm/week for 5 weeks (3 mm total). Lateral head radiographs were taken at 1 1/2, 6, 12, and 18 weeks of age. Results revealed that, by 6 weeks of age, animals with coronal suture immobilization exhibited significantly (p < 0.01) reduced growth across the coronal suture, resulting in shorter and inferiorly rotated cranial vaults compared with sham controls. By 12 weeks of age, rabbits with distraction returned to normal (sham control) coronal suture marker separation, whereas rabbits with immobilized sutures and suturectomy only showed significantly reduced marker distances. Rabbits with distraction also exhibited greater anterior cranial base lengths compared with the other experimental groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin resistance, lipoproteins, body fat and hemostasis in nonobese men with angina and a normal or abnormal coronary angiogram

OBJECTIVES

The aim of this study was to compare metabolic risk factors in men with anginal chest pain and a normal or abnormal coronary angiogram with those in healthy men.

BACKGROUND

Risk factors for coronary heart disease, including lipoprotein abnormalities, hypertension and adiposity, may be metabolically interlinked, with insulin resistance and hyperinsulinemia being pivotal to these disturbances.

METHODS

Glucose and insulin metabolism, lipids and lipoproteins, hemostasis, blood pressure and body fat distribution were measured in 77 nonobese middle-aged men who had anginal chest pain (39 with an abnormal coronary angiogram and 38 with no detectable angiographic abnormality) and were compared with those of 40 healthy men of similar age and body mass index.

RESULTS

Patients with chest pain had higher insulin responses to an intravenous glucose challenge, lower insulin sensitivity, lower high density lipoprotein (HDL) and subfraction 2 cholesterol, lower apolipoprotein AI, higher triglycerides, greater android fat and higher systolic blood pressure at rest compared with levels in healthy control subjects (p < 0.05). Those with an abnormal coronary angiogram had lower tissue plasminogen activator levels, higher plasminogen activator inhibitor 1 levels and more android fat than did those with a normal angiogram (p < 0.05). Insulin sensitivity correlated positively with HDL (p < 0.05) and subfraction 2 (p < 0.001) cholesterol and negatively with triglycerides (p < 0.01), android fat proportion (p < 0.01) and systolic blood pressure (p < 0.05), whereas insulin response showed converse correlations.

CONCLUSIONS

These findings provide new evidence of the central role of insulin resistance and hyperinsulinemia in the development of risk factors associated with coronary heart disease.

Chronically ill children in self-care: issues for pediatric nurses

The self-care (or latchkey) arrangement for children with a chronic illness is an important topic for pediatric nurses. This article reviews the impact of self-care for children's development, examines the effectiveness of teaching self-care skills to latchkey children, and provides assessment and intervention information to help pediatric nurses who are working with parents and children with chronic illness who are in self-care.

Implementation of the postdischarge follow-up call in the patient care units

The Telephone Call Back System was implemented from October 1989 in the Inpatient and Ambulatory Care Units as a postdischarge follow-up and as an evaluation of the patients' hospital experience. Nurses called patients discharged from the Ambulatory Care Unit within 24 hours postdischarge and within 24-48 hours from the Inpatient Unit. Questions asked included present physical status, ocular discomfort, availability of assistance at home, and if there were any questions and concerns. For the year 1990, 77 percent of the patients discharged from the Ambulatory Care Unit were called and 71 percent were contacted. From the Inpatient Unit, 89 percent were called and 68 percent were contacted. Patient response required the following nursing interventions: review of discharge instructions, referral to an ophthalmologist and/or an internist, referral to a patient representative/social worker, reassurance on ocular signs and symptoms consistent with a normal postsurgical period, and patient teaching other than ophthalmic care. Patients discharged from the Inpatient Unit required more nursing intervention than patients discharged from the Ambulatory Care Unit. More than 99% of the patients discharged in both patient care units were satisfied with their hospital care. These results indicate the importance of postdischarge follow-up in the continuity of health care and in the transition from the health care institution to the home setting.

Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic

OBJECTIVE

To evaluate a clinic set up specifically to assess patients with recent onset chest pain, particularly those presenting with a normal resting electrocardiogram.

DESIGN

Retrospective review of case notes.

SETTING

Cardiac department of a tertiary referral cardiothoracic centre.

PATIENTS

250 consecutive patients with recent onset chest pain seen within 24 hours of general practitioner referral.

OUTCOME MEASURES

Clinical diagnosis and management.

RESULTS

40% of patients were seen within seven days of the onset of symptoms. Twenty seven per cent had non-cardiac symptoms and could be discharged while 60% were considered to have cardiac pain. Sixty six patients (26%) were admitted directly from the clinic and 48 of these underwent coronary angiography within three weeks. Seventy patients (28%) have so far undergone intervention (angioplasty or coronary artery surgery), 22 within one month of presentation. One hundred and nine patients (44%) presented with a normal resting electrocardiogram, 21 of whom were considered to have unstable angina. Forty one of these patients were investigated of whom 37 were found to have significant coronary disease and 26 have undergone intervention.

CONCLUSIONS

This experience highlights the inadequacy of a routine electrocardiogram reporting service in patients with recent onset of chest pain. An alternative facility offering immediate and complete cardiac assessment produced patient benefit with early diagnosis and intervention. Investigation of these patients, however, accounted for 5% of cardiac catheterisation laboratory throughput; this was a significant additional and unscheduled workload.

Frontal bone advancement and compensatory craniofacial growth changes in rabbits with experimental coronal suture immobilization

Recent clinical advances in the surgical correction of coronal suture synostosis involve the overcorrection of a frontal bone segment to allow for unrestricted expansion of the developing neurocapsular matrix. However, the effects of such large-scale calvarial repositioning on subsequent brain mass growth trajectories and compensatory cranio-facial growth changes is unclear. This study was designed to investigate this relationship in an experimental rabbit model of bilateral coronal suture synostosis. Amalgam markers were placed across the frontonasal, coronal, and anterior lambdoid sutures in thirty-one 1.5-week-old rabbits. Twenty-one animals underwent bilateral coronal suture immobilization using methyl-methacrylate. Ten animals were left untreated and served as sham controls. At 6 weeks of age, the coronal suture was released by frontal bone craniotomy or frontal bone craniotomy with a 6-mm frontal bone advancement. Lateral head radiographs were taken at 1.5, 6, 7, 9, 12, and 18 weeks of age. Results revealed that by 6 weeks of age, animals with coronal suture immobilization exhibited growth disturbances across the various sutures resulting in altered craniofacial and cranial vault shape compared to control animals. Following coronal suture release, animals that underwent craniotomy showed rapid restenosis, which resulted in significantly altered cranial vault shape and cranial orthocephalization by 18 weeks of age. Animals that underwent frontal bone advancement exhibited normal overall craniofacial growth by 18 weeks of age compared with control animals but did exhibit regional compensatory growth disturbances at the frontonasal and anterior lambdoid sutures, possibly related to neural tissue distension.(ABSTRACT TRUNCATED AT 250 WORDS)

Stability of school-age children's survey responses

School-age children may have low levels of response stability on many questions asked in survey research. This article incorporates evidence from a three-wave panel study into a discussion of some possible causes of low stability. In general, children's responses to questions of fact were more stable than responses to questions of opinion. The findings suggest that when questionnaires are carefully developed, school-age children are reliable respondents.