Context-specific synthetic T cell promoters from assembled transcriptional elements

Genetic engineering of human lymphocytes for therapeutic applications is constrained by a lack of transgene transcriptional control, resulting in a compromised therapeutic index. Incomplete understanding of transcriptional logic limits the rational design of contextually responsive genetic modules1. Here, we juxtaposed rationally curated transcriptional response element (TRE) oligonucleotides by random concatemerization to generate a library from which we selected context-specific inducible synthetic promoters (iSynPros). Through functional selection, we screened an iSynPro library for "IF-THEN" logic-gated transcriptional responses in human CD8+ T cells expressing a 4-1BB second generation chimeric antigen receptor (CAR). iSynPros exhibiting stringent off-states in quiescent T cells and CAR activation-dependent transcriptional responsiveness were cloned and subjected to TRE composition and pattern analysis, as well as performance in regulating candidate antitumor potency enhancement modules. These data reveal synthetic TRE grammar can mediate logic-gated transgene transcription in human T cells that, when applied to CAR T cell engineering, enhance potency and improve therapeutic indices.

Definitions, indications and practice of urotherapy in children and adolescents: - A standardization document of the International Children's Continence Society (ICCS)

BACKGROUND

Urotherapy is an umbrella term for all non-surgical, non-pharmacological interventions for lower urinary tract disorders (LUTD) in children and adolescents. Urotherapy is a specialized practice, which has become mainstay therapy not only for daytime urinary incontinence, but also for nocturnal enuresis, functional constipation and fecal incontinence. The aim of urotherapy is to achieve the normalization of the micturition and bowel pattern and to prevent further functional disturbances by repeated training. It is well known that in the treatment of adult and childhood incontinence a team approach is best, where there are shared areas of expertise and also discipline-specific expertise available.

AIM

We present a consensus view from a cross-professional team of experts affiliated with the International Children's Continence Society on definitions, indications and practice of urotherapy. This is a selective, non-systematic review with practical recommendations for the implementation and research on urotherapy.

METHODS

The document uses the globally accepted ICCS terminology. Evidence-based literature serves as the basis, but in areas lacking in primary evidence, expert consensus is used. Before submission, a full draft was made available to all ICCS members for additional comments.

RESULTS

Urotherapy uses non-pharmacological, non-surgical methods and focuses on behavioral interventions, largely based on cognitive-behavioral psychotherapy (CBT). Standard urotherapy comprises components such as provision of information, instructions, life-style advice, counselling and registration of symptoms. Specific urotherapy is tailored towards specific disorders and includes alarm treatment, biofeedback training, pelvic floor training, neurostimulation and other interventions. Fig. 1. Urotherapy is a treatment that addresses all aspects of incontinence, leading to the best clinical outcome. This includes somatic, psychosocial, and behavioral problems and quality of life. Therefore urotherapy is recommended by the ICCS as the first-line treatment for most types of LUTD. The document is intended to be clinically useful in primary, secondary and tertiary care.

Determining the effects of insulin Detemir on endogenous secretion of insulin

Type 2 diabetes (T2D) is a long-term metabolic disorder. A pilot trial was designed to investigate the effects of the long acting insulin Detemir on endogenous insulin secretion, to assess use in early T2D care. Provesn metabolic system models are used to identify patient-specific insulin sensitivity and endogenous insulin secretion from clinical data. Post-cardiac surgery patients with early T2D or pre-diabetes based on HbA1c were given a bolus of insulin Detemir on one day, and none on the second day in hospital. Blood glucose, insulin, C-Peptide, and all nutrition given are recorded. Early results from N=3 patients show 0.8-1.0U/hour insulin Detemir doses have no apparent suppression of endogenous insulin secretion, but does help lower glucose levels. The results show the model captures glucose-insulin dynamics in pre-diabetic post-surgical patients, and insulin Detemir may be useful to support individuals with pre-diabetes in reducing blood glucose levels. Tests with higher doses, need to be carried out to verify these results over a greater range of patients.

Author Correction: Reproducible, interactive, scalable and extensible microbiome data science using QIIME 2

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Structure/property comparisons of chemistries based on renewable 1,3-propanediol and petroleum-derived alkylene oxides

Structure/property comparisons were made of chemistries based on renewable 1,3-propanediol (PDO)- versus petroleum-based alkylene oxides as well as comparisons of the respective polyethers, emulsifiers, and cosmetic formulations based on these feedstocks. Green Chemistry Principles were applied in the manufacture of polyethylene glycol (PEG)-free renewable PDO-based oligomers and PDO-based fatty acid ester emulsifiers. Sustainable cosmetic products formulated with renewable PDO-based emulsifiers gave equivalent performance in sensory and moisturization evaluations compared to those formulated with the petroleum-derived PEG-based emulsifiers.

Safety restraint injuries in fatal motor vehicle collisions

The presence of an apparent seat belt mark (SBM) on a car crash occupant is often used as evidence for use of a seat belt at the time of the crash and, conversely, the lack of a SBM is used as an indication that no seat belt was used. This study examined whether there are clear indications of seat belt use to be found at autopsy and evaluated the sensitivity and specificity of apparent SBM and whether the use of a seat belt and seating location affects the type and severity of injuries sustained. Information on the type of injuries sustained and seatbelt use was retrieved from autopsy reports and police reports, respectively, for cases of fatal motor vehicle collisions occurring in Sydney, Australia over a 5-year period. In this study, a SBM was only found on restrained occupants. The proportion of restrained occupants with evidence of a SBM was 36% (sensitivity), whilst unrestrained occupants showed no evidence of a SBM (100% specificity). A SBM was also found to reliably reflect the seating position of the occupant. We conclude that restrained occupants can be expected to show evidence of the seat belt in just over one third of cases and that the absence of a SBM is not necessarily an indication that no seat belt was used. Spurious SBM is very unlikely to be present if the occupant was unrestrained.

Ghost-tree: creating hybrid-gene phylogenetic trees for diversity analyses

BACKGROUND

Fungi play critical roles in many ecosystems, cause serious diseases in plants and animals, and pose significant threats to human health and structural integrity problems in built environments. While most fungal diversity remains unknown, the development of PCR primers for the internal transcribed spacer (ITS) combined with next-generation sequencing has substantially improved our ability to profile fungal microbial diversity. Although the high sequence variability in the ITS region facilitates more accurate species identification, it also makes multiple sequence alignment and phylogenetic analysis unreliable across evolutionarily distant fungi because the sequences are hard to align accurately. To address this issue, we created ghost-tree, a bioinformatics tool that integrates sequence data from two genetic markers into a single phylogenetic tree that can be used for diversity analyses. Our approach starts with a "foundation" phylogeny based on one genetic marker whose sequences can be aligned across organisms spanning divergent taxonomic groups (e.g., fungal families). Then, "extension" phylogenies are built for more closely related organisms (e.g., fungal species or strains) using a second more rapidly evolving genetic marker. These smaller phylogenies are then grafted onto the foundation tree by mapping taxonomic names such that each corresponding foundation-tree tip would branch into its new "extension tree" child.

RESULTS

We applied ghost-tree to graft fungal extension phylogenies derived from ITS sequences onto a foundation phylogeny derived from fungal 18S sequences. Our analysis of simulated and real fungal ITS data sets found that phylogenetic distances between fungal communities computed using ghost-tree phylogenies explained significantly more variance than non-phylogenetic distances. The phylogenetic metrics also improved our ability to distinguish small differences (effect sizes) between microbial communities, though results were similar to non-phylogenetic methods for larger effect sizes.

CONCLUSIONS

The Silva/UNITE-based ghost tree presented here can be easily integrated into existing fungal analysis pipelines to enhance the resolution of fungal community differences and improve understanding of these communities in built environments. The ghost-tree software package can also be used to develop phylogenetic trees for other marker gene sets that afford different taxonomic resolution, or for bridging genome trees with amplicon trees.

AVAILABILITY

ghost-tree is pip-installable. All source code, documentation, and test code are available under the BSD license at https://github.com/JTFouquier/ghost-tree .

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

BACKGROUND

Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI).

OBJECTIVE

To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.

RECOMMENDATIONS

Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

Temporal variability is a personalized feature of the human microbiome

BACKGROUND

It is now apparent that the complex microbial communities found on and in the human body vary across individuals. What has largely been missing from previous studies is an understanding of how these communities vary over time within individuals. To the extent to which it has been considered, it is often assumed that temporal variability is negligible for healthy adults. Here we address this gap in understanding by profiling the forehead, gut (fecal), palm, and tongue microbial communities in 85 adults, weekly over 3 months.

RESULTS

We found that skin (forehead and palm) varied most in the number of taxa present, whereas gut and tongue communities varied more in the relative abundances of taxa. Within each body habitat, there was a wide range of temporal variability across the study population, with some individuals harboring more variable communities than others. The best predictor of these differences in variability across individuals was microbial diversity; individuals with more diverse gut or tongue communities were more stable in composition than individuals with less diverse communities.

CONCLUSIONS

Longitudinal sampling of a relatively large number of individuals allowed us to observe high levels of temporal variability in both diversity and community structure in all body habitats studied. These findings suggest that temporal dynamics may need to be considered when attempting to link changes in microbiome structure to changes in health status. Furthermore, our findings show that, not only is the composition of an individual's microbiome highly personalized, but their degree of temporal variability is also a personalized feature.

Subsampled open-reference clustering creates consistent, comprehensive OTU definitions and scales to billions of sequences

We present a performance-optimized algorithm, subsampled open-reference OTU picking, for assigning marker gene (e.g., 16S rRNA) sequences generated on next-generation sequencing platforms to operational taxonomic units (OTUs) for microbial community analysis. This algorithm provides benefits over de novo OTU picking (clustering can be performed largely in parallel, reducing runtime) and closed-reference OTU picking (all reads are clustered, not only those that match a reference database sequence with high similarity). Because more of our algorithm can be run in parallel relative to “classic” open-reference OTU picking, it makes open-reference OTU picking tractable on massive amplicon sequence data sets (though on smaller data sets, “classic” open-reference OTU clustering is often faster). We illustrate that here by applying it to the first 15,000 samples sequenced for the Earth Microbiome Project (1.3 billion V4 16S rRNA amplicons). To the best of our knowledge, this is the largest OTU picking run ever performed, and we estimate that our new algorithm runs in less than 1/5 the time than would be required of “classic” open reference OTU picking. We show that subsampled open-reference OTU picking yields results that are highly correlated with those generated by “classic” open-reference OTU picking through comparisons on three well-studied datasets. An implementation of this algorithm is provided in the popular QIIME software package, which uses uclust for read clustering. All analyses were performed using QIIME’s uclust wrappers, though we provide details (aided by the open-source code in our GitHub repository) that will allow implementation of subsampled open-reference OTU picking independently of QIIME (e.g., in a compiled programming language, where runtimes should be further reduced). Our analyses should generalize to other implementations of these OTU picking algorithms. Finally, we present a comparison of parameter settings in QIIME’s OTU picking workflows and make recommendations on settings for these free parameters to optimize runtime without reducing the quality of the results. These optimized parameters can vastly decrease the runtime of uclust-based OTU picking in QIIME.

Effects of racing on reticulocyte concentrations in Greyhounds

BACKGROUND

Greyhounds have several hematologic variables that are outside of the respective reference intervals of other dog breeds. In addition, increases in HCT, total protein and HGB concentration, and RBC and WBC counts occur immediately after exercise; these values return to resting values within a few hour after racing.

OBJECTIVE

This study evaluated the effects of exercise on the concentration of reticulocytes in circulating blood in racing Greyhounds. We hypothesized that reticulocyte numbers are significantly increased immediately after a race, and return to baseline within one to 2 h postrace.

METHODS

Fifty actively racing Greyhounds at the Wheeling Island Racetrack and Casino were included in the study. Samples were collected by jugular venipuncture one day prior to racing at the kennel (resting), immediately after racing, and one to 2 h after the race (recovery). Reticulocyte counts were determined with an IDEXX ProCyte Dx Hematology Analyzer (IDEXX Laboratories, Inc., Westbrook, ME, USA). Due to a nonparametric distribution, the results were statistically compared using the Friedman test.

RESULTS

Reticulocyte concentrations were significantly different among the 3 sample collection times (P < .0001). There was a significant increase in reticulocyte concentration immediately after racing (P < .001); one to 2 h after racing, the reticulocyte numbers decreased significantly (P < .001) to counts comparable to resting samples.

CONCLUSION

The increase in reticulocyte concentration is probably related to splenic contraction secondary to the release of catecholamines, although premature bone marrow release could also account for these changes. Thus, it is important to consider a Greyhound's activity and degree of excitement when interpreting selected hematologic data in a clinical setting.

Structural correlation between cuticular hydrocarbons and female contact sex pheromone of German cockroachBlattella germanica (L.)

The structural relationships between the cuticular hydrocarbons and the contact sex pheromone of the female German cockroach,Blattella germanica, were investigated. Cuticular hexane extracts were separated into hydrocarbon and ketone fractions by TLC or silicic acid column chromatography. The ketone fraction (which contains the major contact sex pheromone component) was analyzed by GC-MS before and after reduction to ydrocarbon. In addition to 3,11-dimethyl-2-nonacosanone, 3,11-dimethyl-2-heptacosanone was also identified. Females have the 3,11- and 3,9-dimethyl C27 and C29 alkanes, but only the 3,11- isomer of the dimethylketones. Inddition to the hydrocarbon components previously reported, a number of new components were characterized. Although the ratios of cuticular hydrocarbons differ among nymphs, adult males, and adult females, they have qualitatively identical hydrocarbon profiles, suggesting that the production of the contact sex pheromone results from the sex-specific oxidation of 3,11-imethylalkanes to pheromone components by the female.

Skin moisturization by hydrogenated polyisobutene--quantitative and visual evaluation

Hydrogenated polyisobutene (HP) is used in topically applied cosmetic/personal care formulations as an emollient that leaves a pleasing skin feel when applied, and rubbed in after application. This effect, although distinguishable to the user, is difficult to define and quantify. Recognizing that some of the physical properties of HP such as film formation and wear resistance may contribute, in certain mechanisms, to skin moisturization, we designed a short-term pilot study to follow changes in skin moisturization. HP's incorporation into an o/w emulsion at 8% yielded increased viscosity and reduced emulsion droplet size as compared to the emollient ester CCT (capric/caprylic triglyceride) or a control formulation. Quantitative data indicate that application of the o/w emulsion formulation containing either HP or CCT significantly elevated skin moisture content and thus reduced transepidermal water loss (TEWL) by a maximal approximately 33% against the control formulation within 3 h and maintained this up to 6 h. Visual observation of skin treated with the HP-containing formulation showed fine texture and clear contrast as compared to the control or the CCT formulation, confirming this effect. As a result of increased hydration, skin conductivity, as measured in terms of corneometer values, was also elevated significantly by about tenfold as early as 20 min after HP or CCT application and was maintained throughout the test period. Throughout the test period the HP formulation was 5-10% more effective than the CCT formulation both in reduction of TEWL as well as in increased skin conductivity. Thus, compared to the emollient ester (CCT), HP showed a unique capability for long-lasting effect in retaining moisture and improving skin texture.

Study of ventricular interaction during pulmonary embolism using clinical identification in a minimum cardiovascular system model

Cardiovascular disturbances are difficult to diagnose and treat because of the large range of possible underlying dysfunctions combined with regulatory reflex mechanisms that can result in conflicting clinical data. Thus, medical professionals often rely on experience and intuition to optimize hemodynamics in the critically ill. This paper combines an existing minimal cardiovascular system model with an extended integral based parameter identification method to track the evolution of induced pulmonary embolism in porcine data. The model accounts for ventricular interaction dynamics and is shown to predict an increase in the right ventricle expansion index and a decrease in septum volume consistent with known physiological response to pulmonary embolism. The full range of hemodynamic responses was captured with mean prediction errors of 4.1% in the pressures and 3.1% in the volumes for 6 sets of clinical data. Pulmonary resistance increased significantly with the onset of embolism in all cases, as expected, with the percentage increase ranging from 89.98% to 261.44% of the initial state. These results are an important first step towards model-based cardiac diagnosis in the Intensive Care Unit.

Assessing the influence of payment on motivations of women participating as oocyte donors

We report on the motivations of potential ovum donors entering an assisted reproduction program and discuss the potential ramifications of escalating payments to donors. From July 1995 to July 1998, recruitment of ovum donors was directed at healthy women between 21 and 34 years of age. Financial remuneration for services rendered was USD 2,500 from July 1995 through March 1998 and increased to USD 5,000 after that. Donors were screened and consented according to established SART guidelines. The demographic background of the women was similar for women paid USD 2,500 to those receiving USD 5,000. The financial motivation was greater in those receiving USD 5,000 (68%) than USD 2,500 (39%). Some form of expressed altruism was similarly present in both groups (USD 5,000 90%, and USD 2,500 91%). However, altruism expressed as the sole motivation occurred more in those receiving USD 2,500 (61%) compared to USD 5,000 (32%). Financial reimbursement has escalated for the services of ovum donors in order to maintain the increasing demand. While money has become a dominant factor motivating ovum donors, its seductive nature requires even greater attention to adequate informed consent. Young donors may be unable to adequately weigh the risks of ovarian hyperstimulation and oocyte retrieval against the monetary reward.

Surgery after downstaging of unresectable hepatic tumors with intra-arterial chemotherapy

BACKGROUND

This retrospective study was performed to assess the outcome among patients who underwent hepatic resection or tumor ablation after hepatic artery infusion (HAI) therapy down-staged previously unresectable hepatocellular carcinoma (HCC) or liver metastases from colorectal cancer (CRC).

METHODS

Between 1983 and 1998, 25 patients with HCC and 383 patients with hepatic CRC metastases were treated with HAI therapy for unresectable liver disease. We retrospectively reviewed the records of 26 (6%) of these patients who underwent subsequent surgical exploration for tumor resection or ablation.

RESULTS

At a median of 9 months (range 7-12 months) after HAI treatment, four patients (16%) with HCC underwent exploratory surgery; two underwent resection with negative margins, and the other two were given radiofrequency ablation (RFA) because of underlying cirrhosis. At a median postoperative follow-up of 16 months (range 6-48 months), all four patients were alive with no evidence of disease. At a median of 14.5 months (range 8-24 months) after HAI therapy, 22 patients with hepatic CRC metastases underwent exploratory surgery; 10 underwent resection, 6 underwent resection and RFA or cryotherapy, and 2 underwent RFA only. At a median follow-up of 17 months, 15 (83%) of the 18 patients with CRC who had received surgical treatment had developed recurrent disease; the other 3 died of other causes (1 of postoperative complications) within 7 months of the surgery. One patient in whom disease recurred underwent a second resection and was disease-free at 1 year follow-up.

CONCLUSIONS

Hepatic resection or ablation after tumor downstaging with HAI therapy is a viable option for patients with unresectable HCC. However, given the high rate of recurrence of metastases from CRC, hepatic resection or ablation after downstaging with HAI should be used with caution.

Intraoperative lower extremity compartment pressures in lithotomy-positioned patients

PURPOSE

Measurement of anterior leg compartment pressures in eight patients (16 limbs) who were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery.

METHODS

Anterior leg compartment pressures were measured in eight patients (16 limbs) by using a slit catheter, whereas subjects were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery.

RESULTS

Compartment pressures had minor elevations after initial lithotomy positioning, and gradually increased over time. Levels elevated to 30 mmHg at an average of five (range, 3.5 to 6) hours. The maximum recorded leg compartment pressure was 70 mmHg. The addition of Trendelenburg positioning was noted to consistently increase compartment pressures. All pressures returned to less than 10 mmHg shortly after removing the limb from the stirrups and placing the limb supine. No patients developed clinical evidence of compartment syndrome.

CONCLUSIONS

Leg anterior compartment pressures rise when limbs are placed in the lithotomy position for prolonged periods of time. The rise in pressure is increased with the addition of Trendelenburg positioning. Anterior compartment pressures reached a threshold of 30 mmHg at an average of five hours. The results of this study suggest that lithotomy positioning of the lower extremities has the potential to initiate leg compartment syndrome when the period of positioning approaches five hours. Removing the limbs from the stirrups and placing them in the supine position allows the pressure in the compartments to return to normal.

Adenovirus-mediated expression of a ribozyme to c-myb mRNA inhibits smooth muscle cell proliferation and neointima formation in vivo

Smooth muscle cell (SMC) proliferation is an important component of restenosis in response to injury after balloon angioplasty. Inhibition of proliferation in vivo can limit neointima hyperplasia in animal models of restenosis. Ribozymes against c-myb mRNA have been shown to be effective inhibitors of SMC proliferation in vitro. The effectiveness of adenovirus as a gene therapy vector in animal models of restenosis is well documented. In order to test the utility of ribozymes to inhibit SMC proliferation by a gene therapy approach, recombinant adenovirus expressing ribozymes against c-myb mRNA was generated and tested both in vitro and in vivo. This adenovirus ribozyme vector is shown to inhibit SMC proliferation in culture and neointima formation in a rat carotid artery balloon injury model of restenosis.

Flexion and traction effect on C5-C6 foraminal space

OBJECTIVE

To determine the effects of cervical flexion and traction on foraminal volume and isthmus area at the C5-C6 foraminal space in cadavers.

DESIGN

This study evaluated the foraminal space at C5-C6 in cadaver specimens during flexion and traction of the cervical spine.

SETTING

An orthopedic biomechanics laboratory and department of radiology of a university medical center.

PATIENTS OR OTHER PARTICIPANTS

Nine cadaver cervical spines, C1 through T3, were used in the study. Superficial tissues were dissected, preserving the ligaments.

INTERVENTIONS

Proximal and distal portions of the cadaver spines were potted using bone cement. Spines were mounted and imaged with computed tomography in neutral position, 15 degrees of flexion, and maximum flexion with and without 25lbs of axial traction.

MAIN OUTCOME MEASURES

The areas and volumes of the foramen were measured and calculated.

RESULTS

Flexion alone significantly increased the foraminal volume and isthmus area at C5-C6. Traction resulted in little additional change.

CONCLUSIONS

For cervical spines with mild to moderate degenerative changes at C5-C6, cervical flexion with or without traction produces significant increases in foraminal volume and area at the foraminal isthmus.

Value-based formulas for purchasing. Pursuing value in Medicaid managed care: access to care and enrollee information management

Medicaid and other publicly funded health coverage programs face special challenges in managed care purchasing. This article discusses two of those challenges based on the state of Minnesota's experience: how to develop, evaluate, and communicate access to care; and how to manage the transfer of enrollee eligibility and health status information.

Phase II trial of hepatic arterial infusion of fluorouracil and recombinant human interferon alfa-2b for liver metastases of colorectal cancer refractory to systemic fluorouracil and leucovorin

PURPOSE

To determine the toxicity, response rate, and survival in patients treated with hepatic arterial infusion (HAI) of fluorouracil (5-FU) plus recombinant human interferon alfa-2b (rIFN-alpha 2b) (Intron-A; Schering-Plough, Inc, Kenilworth, NJ) for colorectal carcinoma (CRC) liver metastases refractory to systemic 5-FU plus leucovorin (LCV).

PATIENTS AND METHODS

Forty-eight patients were given a 6-hour HAI of rIFN-alpha 2b 5 MU/m2 followed by an 18-hour HAI of 5-FU, 1,500 mg/m2 daily for 5 days. Twenty-nine patients were treated through percutaneously placed catheters and 19 through implantable infusion pumps (Shiley Infusaid Inc, Noorwood, MA). Treatment cycles were repeated every 28 to 35 days.

RESULTS

There were three (6.6%) complete remissions (CRs) and 12 (26.6%) partial remissions (PRs), for a CR plus PR rate of 33.3% among 45 assessable patients (95% confidence interval [CI], 20% to 49%). The median response duration was 7 months, while median survival duration was 15 months. Grade 3 to 4 treatment-related toxic effects included mucositis (40%), neutropenia (42%), and thrombocytopenia (12%). No hepatobiliary toxicity was encountered in any of the patients. Treatment was discontinued because of progressive liver disease in 23 patients and extrahepatic progression in 16, while six patients continue treatment through an infusaid pump.

CONCLUSION

HAI of 5-FU plus rIFN-alpha 2b is well tolerated, devoid of hepatobiliary toxicity, and can produce a response rate of 33.3% among patients refractory to bolus intravenous (IV) 5-FU plus LCV. The lack of hepatobiliary toxicity may permit salvage HAI with floxuridine (FUDR) in patients whose liver tumors fail to respond to HAI of 5-FU plus rIFN-alpha 2b. Because diarrhea was not a common side effect of HAI of 5-FU plus rIFN-alpha 2b, it would be of interest to investigate whether alternating HAI of 5-FU and rIFN-alpha 2b with systemic irinotecan (CPT-11) will decrease the incidence of both hepatic and extrahepatic disease progression.

Judgements and processes in care decisions in acute medical and surgical wards

The decisions which health care professionals make are the basis of treatment and care given. In order to evaluate effective care it seems logical to suggests that an awareness of the decisions which health care professionals make and how they make them is needed. This study examines the processes nurses use when making decisions about the health care needs of acutely ill patients. In stage one, 104 qualified nurses were interviewed to identify how they decide health care needs. In stage two, a 'think aloud' technique was used with patient simulations to obtain verbal protocols from a further 55 qualified nurses to identify the information strategies they used when making these decisions. The results suggest that nurses base their health care decisions mainly on their assessment of qualitative patient states or conditions. Initial indications are that the processes used differ from those characterized in the diagnostic reasoning model, with the context in which decisions are made being an important influence together with nurses' experience. It is suggested that, in order to develop effective predictive models and clinical guidelines which aid decision making, more research into the nature of health care professionals' decision making is carried out.

Overview and critique of judgement and decision making in health care: social and procedural dimensions

This paper presents an outline of the scope for the application of decision theory to health care. Firstly, the main approaches to and assumptions of decision theory are discussed. Secondly, health care decision making is reviewed. It is noted that decision theory can be applied to either the health care professional or to the lay person. Applications of decision theory to clinical practice, to the management of care and to resourcing are considered. Thirdly, some areas which would repay further research are identified. These include social processes in individual and group decision making, the temporal distribution of outcomes and the development of techniques capable of dealing with the complex and dynamic features of decisions. On the basis of the foregoing, some conclusions are drawn.

Comparison between the Health Belief Model and Subjective Expected Utility Theory: predicting incontinence prevention behaviour in post-partum women

A small-scale study was undertaken to test the relative predictive power of the Health Belief Model and Subjective Expected Utility Theory for the uptake of a behaviour (pelvic floor exercises) to reduce post-partum urinary incontinence in primigravida females. A structured questionnaire was used to gather data relevant to both models from a sample antenatal and postnatal primigravida women. Questions examined the perceived probability of becoming incontinent, the perceived (dis)utility of incontinence, the perceived probability of pelvic floor exercises preventing future urinary incontinence, the costs and benefits of performing pelvic floor exercises and sources of information and knowledge about incontinence. Multiple regression analysis focused on whether or not respondents intended to perform pelvic floor exercises and the factors influencing their decisions. Aggregated data were analysed to compare the Health Belief Model and Subjective Expected Utility Theory directly.

NMR studies of muscle glycogen synthesis in insulin-resistant offspring of parents with non-insulin-dependent diabetes mellitus immediately after glycogen-depleting exercise

To examine the impact of insulin resistance on the insulin-dependent and insulin-independent portions of muscle glycogen synthesis during recovery from exercise, we studied eight young, lean, normoglycemic insulin-resistant (IR) offspring of individuals with non-insulin-dependent diabetes mellitus and eight age-weight matched control (CON) subjects after plantar flexion exercise that lowered muscle glycogen to approximately 25% of resting concentration. After approximately 20 min of exercise, intramuscular glucose 6-phosphate and glycogen were simultaneously monitored with 31P and 13C NMR spectroscopies. The postexercise rate of glycogen resynthesis was nonlinear. Glycogen synthesis rates during the initial insulin independent portion (0-1 hr of recovery) were similar in the two groups (IR, 15.5 +/- 1.3 mM/hr and CON, 15.8 +/- 1.7 mM/hr); however, over the next 4 hr, insulin-dependent glycogen synthesis was significantly reduced in the IR group [IR, 0.1 +/- 0.5 mM/hr and CON, 2.9 +/- 0.2 mM/hr; (P < or = 0.001)]. After exercise there was an initial rise in glucose 6-phosphate concentrations that returned to baseline after the first hour of recovery in both groups. In summary, we found that following muscle glycogen-depleting exercise, IR offspring of parents with non-insulin-dependent diabetes mellitus had (i) normal rates of muscle glycogen synthesis during the insulin-independent phase of recovery from exercise and (ii) severely diminished rates of muscle glycogen synthesis during the subsequent recovery period (2-5 hr), which has previously been shown to be insulin-dependent in normal CON subjects. These data provide evidence that exercise and insulin stimulate muscle glycogen synthesis in humans by different mechanisms and that in the IR subjects the early response to stimulation by exercise is normal.

A phase I evaluation of chronotropic delivery of floxuridine by hepatic arterial infusion in patients with metastatic colorectal cancer

Hepatic arterial infusion (HAI) of floxuridine is often used for metastatic colorectal cancer, though this is associated with dose-limiting hepatobiliary toxicity. A phase I trial was initiated to determine if circadian-patterned HAI floxuridine would reduce toxicity. Twenty-one patients were enrolled, and they received a continuous 14-day HAI of floxuridine, with 90-95% of the drug delivered over the same six-hour period daily. The therapy was tolerable, but there was no reduction in hepatobiliary toxicity. The response rate of 33% (1 complete and 6 partial responses) was similar to that of regimens that do not utilize circadian timing. HAI floxuridine chronotherapy for metastatic colorectal cancer cannot be recommended.

Information sources used in decision making: considerations for simulation development

Simulation tasks, together with think aloud techniques are often used to research the cognitive processes individuals go through when making a decision or solving a problem. They have been utilised to a certain degree within nursing. A study was carried out to try and identify the sources of information nurses in acute medical and surgical wards used to make assessment judgements. A sample of 114 nurses were interviewed, and their responses analysed using content analysis. Four main sources of information were identified, with verbal interaction being the source of information most frequently mentioned by the subjects. The content of material presented in simulations is normally tested using techniques such as expert panels. However, this paper suggests that of equal importance may be the form of presentation or source of that information. It is suggested that in order to increase the validity of information obtained from simulation tasks, the form of presentation of information to the subject should also be considered.

Determinants of Pro-Environmental Behaviors

Research teams in five countries (France, Germany, Italy, Portugal, UK) developed in common a comparative study on individual attitudes and behaviors towards the environment, and on the importance of environmental issues in the media of these countries. The sample was composed of 742 subjects, teachers and engineers. Results presented here focus on a cross-countries comparison of the media analysis and the questionnaire data. Important differences are observed between the level of pro-environmental behaviors and the nature of their determinants.

The cognitive component of nursing assessment: an analysis

This paper presents an analysis of the cognitive component of nursing assessment, complimenting the growth in knowledge of other important aspects of assessment. The purpose of the paper is to provide a framework for understanding how nurses structure assessment problems and the types of judgements they make. The thrust of the analysis is based on a comparison between nursing assessment and medical diagnosis, since the cognitive component and judgements formed in medical diagnosis have been more fully articulated. The results suggest that there may be similarities between the cognitive strategies used in nursing assessment and those used in medical diagnosis, particularly in relation to the gathering and organization of information. But the purpose of the information search appears to be different. In medical diagnosis the aim is to establish an explanation for the patient's presenting problem. In nursing assessment, on the other hand, the aim appears to be to provide an accurate picture of the patient's current condition or situation. The assessments formulated fit the definition of a judgement and, in common with medical diagnoses, include some form of prediction. Unlike the medical diagnoses, however, which usually remain stable throughout treatment, the assessments need to change as the patient's condition changes. The cognitive component of assessment has significant implications for nurse education and clinical practice. Further understanding of how nurses structure assessment problems and formulate judgements is therefore needed. The findings may also help to clarify the meaning of nursing diagnosis.

Hepatic arterial infusion of floxuridine, leucovorin, doxorubicin, and cisplatin for hepatocellular carcinoma: effects of hepatitis B and C viral infection on drug toxicity and patient survival

PURPOSE

To conduct a pilot trial of hepatic arterial infusion (HAI) of floxuridine (FUDR), leucovorin, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and cisplatin (FLAP) in nonresectable hepatocellular cancer (HCC) confined to the liver and assess the effects of hepatitis B (HBV) and hepatitis C (HCV) viral markers on toxicity, response to treatment, and patient survival.

PATIENTS AND METHODS

Of 31 HCC patients, 13 were HBV- and HCV-nonreactive, and 18 had evidence of either current or prior HBV and/or HCV infection. Treatment was delivered through percutaneous hepatic arterial catheters, and Infusaid pumps (Shiley Infusaid, Norwood, MA) were placed in responding patients. Cisplatin (100 mg/m2) and Adriamycin (30 to 35 mg/m2) were administered on day 1, followed by a continuous 24-hour HAI of an admixture of floxuridine (60 mg/m2) and leucovorin (15 mg/m2) daily for 4 days. Treatment was repeated every 5 weeks.

RESULTS

Twelve (41%) of 29 assessable patients had a partial response (PR), with a median time to disease progression of 13 months. Six (50%) of 12 HBV-negative (HBV-)/HCV-negative (HCV-) and six of 17 (35%) HBV-positive (HCV+) and/or HCV-positive (HCV+) patients achieved a PR. Eight patients have been maintained in remission for a median duration greater than 15.5 months. The median survival duration of all 31 patients was 15 months, 7.5 months among HBV+ and/or HCV+ patients, and significantly longer among hepatitis-non-reactive patients (P = .007). (A median has not yet been reached.) Granulocylopenia (< 0.1 x 10(3)/microL), thrombocytopenia (< 25 x 10(3)/microL), and hospitalizations for infectious complications were significantly more common among HBV-HCV-reactive than -nonreactive patients: 56%, 50%, and 67% versus 15%, 15%, and 8%, respectively (P < .05 for all).

CONCLUSION

HAI of FLAP has induced long-term PR and has palliated extensive nonresectable HCC. Positive hepatitis serology appeared to increase bone marrow susceptibility to myelotoxic drugs. Conceivably, one or both viruses may have a direct inhibitory effect on bone marrow progenitors and thereby contribute to the observed myelotoxicity.

Reduction of systemic drug exposure after hepatic arterial infusion of doxorubicin with complete hepatic venous isolation and extracorporeal chemofiltration

BACKGROUND

Hepatic arterial infusion of doxorubicin has produced tumor response in hepatic malignancies; however, the limited success of these treatments is related in part to dose-limiting systemic toxicities. The purpose of this study was to determine whether a novel venous isolation-chemofiltration system could limit systemic exposure to doxorubicin after hepatic arterial infusion.

METHODS

Doxorubicin (1 or 3 mg/kg) was infused in the hepatic arteries of domestic pigs after complete hepatic venous isolation was achieved with a dual-balloon vena cava catheter. The hepatic vein effluent was pumped through an extracorporeal carbon chemofiltration circuit. Doxorubicin levels were measured in prefilter (hepatic vein), postfilter, and systemic serum at intervals up to 1 hour after drug infusion.

RESULTS

Complete hepatic venous isolation with extracorporeal chemofiltration significantly reduced (> 90%) the postfilter and systemic levels of doxorubicin compared with prefilter levels (p < 0.01). At the time animals were killed 7 days after infusion of doxorubicin (3 mg/kg), tissue levels of doxorubicin in the liver showed a 16-fold increase compared with levels in the heart (p < 0.01).

CONCLUSIONS

For chemotherapeutic drugs like doxorubicin with a low first-pass extraction by the liver, the novel system described herein achieved significant reduction in systemic drug exposure. This system will allow dose intensification of doxorubicin administered by hepatic arterial infusion to treat hepatic malignancies.