Australian primary health care nurses

Preconception care (PCC) entails counselling and interventions to optimise health before pregnancy. Barriers to this service delivery include access and time. Primary healthcare nurses (PHCNs) are uniquely placed to deliver PCC. The aim of this study was to understand PHCNs' knowledge, practice and attitudes to PCC. A cross-sectional study was performed of a convenience sample of PHCNs in Australia who were seeing people of reproductive age. Recruitment was via the Australian Primary Health Care Nurses Association (APNA) electronic communication platforms. The 18-item, online, anonymous survey captured demographics, as well as PCC knowledge, practices and attitudes. Descriptive statistics were used to describe our findings. In all, 152 completed surveys were received. Of all respondents, 74% stated they discuss PCC in their practice, although only 13% do so routinely. Of these, more preconception discussions are held with women than with men. In total, 95% of respondents identified at least one barrier to delivery of PCC, with lack of time and knowledge being the most common. The findings of this study can inform targeted strategies, including education programs and resources, and consideration of incentives to support PHCNs deliver PCC. This study identifies areas for improvement at the individual, organisational and health system levels to enhance the role of PHCNs in PCC.

Concordance between a neuroradiologist, a consultant radiologist and trained reporting radiographers interpreting MRI head examinations: An empirical study

INTRODUCTION

This study assessed agreement between MRI reporting radiographers and a consultant radiologist compared with an index neuroradiologist when reporting MRI head (brain/internal auditory meati [IAMs]) examinations. The effect on patient management of any discordant reports was also examined.

METHODS

Two trained MRI reporting radiographers (RRs), a consultant radiologist (CR) and an index neuroradiologist (INR) reported on a random sample of 210 MRI examinations. The radiographers reported during clinical practice and the radiologists in clinical practice conditions. Two independent consultant physicians (neuro-rehabilitation and neuropsychiatry) compared these reports with the index neuroradiologist report for agreement and the clinical importance of discrepant reports.

RESULTS

Overall observer agreement between the RRs and CR was comparable in relation to agreement with the INR: RR; 93/210 (44.3%); and the CR; 83/210 (39.4%) for all head MRI examinations (p = 0.32). For brain examinations the difference was similar: RR; 64/180 (35.6%); and CR; 54/190 (30.0%), p = 0.26. Agreement rates for the IAMs examinations were identical, 29/30 (97.7%). For all head MRI examinations (n = 210) there was a very small observed difference of <0.5% in mean agreement between the reporting radiographers and the consultant radiologist (p = 0.92) for examinations where a major disagreement would have been likely to have led to a change in patient management.

CONCLUSION

MRI reporting radiographers reported during clinical practice on MRI head examinations to a level of agreement comparable with a consultant radiologist.

IMPLICATIONS FOR PRACTICE

This is an area in which radiographers could provide additional reporting roles to the reporting service to increase capacity. Wider potential benefits include cost-effectiveness and role development/retention of radiographers.

Adjuvant treatment improves overall survival in women with high-intermediate risk early-stage endometrial cancer with lymphovascular space invasion

BACKGROUND

Adjuvant therapy in early-stage endometrial cancer has not shown a clear overall survival benefit, and hence, patient selection remains crucial.

OBJECTIVE

To determine whether women with high-intermediate risk, early-stage endometrial cancer with lymphovascular space invasion particularly benefit from adjuvant treatment in improving oncologic outcomes.

METHODS

A multi-center retrospective study was conducted in women with stage IA, IB, and II endometrial cancer with lymphovascular space invasion who met criteria for high-intermediate risk by Gynecologic Oncology Group (GOG) 99. Patients were stratified by the type of adjuvant treatment received. Clinical and pathologic features were abstracted. Progression-free and overall survival were evaluated using multivariable analysis.

RESULTS

405 patients were included with the median age of 67 years (range 27-92, IQR 59-73). 75.0% of the patients had full staging with lymphadenectomy, and 8.6% had sentinel lymph node biopsy (total 83.6%). After surgery, 24.9% of the patients underwent observation and 75.1% received adjuvant therapy, which included external beam radiation therapy (15.1%), vaginal brachytherapy (45.4%), and combined brachytherapy + chemotherapy (19.1%). Overall, adjuvant treatment resulted in improved oncologic outcomes for both 5-year progression-free survival (77.2% vs 69.6%, HR 0.55, p=0.01) and overall survival (81.5% vs 60.2%, HR 0.42, p<0.001). After adjusting for stage, grade 2/3, and age, improved progression-free survival and overall survival were observed for the following adjuvant subgroups compared with observation: external beam radiation (overall survival HR 0.47, p=0.047, progression-free survival not significant), vaginal brachytherapy (overall survival HR 0.35, p<0.001; progression-free survival HR 0.42, p=0.003), and brachytherapy + chemotherapy (overall survival HR 0.30 p=0.002; progression-free survival HR 0.35, p=0.006). Compared with vaginal brachytherapy alone, external beam radiation or the addition of chemotherapy did not further improve progression-free survival (p=0.80, p=0.65, respectively) or overall survival (p=0.47, p=0.74, respectively).

CONCLUSION

Adjuvant therapy improves both progression-free survival and overall survival in women with early-stage endometrial cancer meeting high-intermediate risk criteria with lymphovascular space invasion. External beam radiation or adding chemotherapy did not confer additional survival advantage compared with vaginal brachytherapy alone.

0280 Change in Sleep Depth Across the Night as a Measure of Sleep Adequacy

Introduction

It is well known that sleep becomes lighter towards the end of the night reflecting the reduction in homeostatic sleep pressure. We hypothesized that more adequate nocturnal sleep (i.e. sufficient quantity and quality for the individual) would result in a greater reduction in sleep depth across the night and would be reflected in decreased next-day sleep tendency.

Methods

In a secondary analysis of data from a study in which sleep depth was altered by sleep restriction combined with either placebo or gaboxadol (a delta-promoting drug) we correlated change across the night in two measures of sleep depth with next-day Multiple Sleep Latency Test (MSLT) latencies. Forty-one healthy subjects underwent 8 consecutive sleep studies; two baseline, four sleep restriction (5 hours) and two recovery nights. MSLT was performed following each baseline night and the last two restriction nights. Sleep depth in the first and last hours of NREM sleep was determined by two

methods

1) Log delta spectral power; 2) The odds-ratio-product (ORP), a recently introduced continuous measure of sleep depth. The difference between initial and final values was calculated (ΔDelta, ΔORP). Post-restriction MSLT latency was correlated with baseline MSLT latency, ΔDelta, ΔORP, log delta power and ORP in the last hour, lost total sleep time and lost REM time.

Results

ΔDelta was -0.27 ±0.13 and ΔORP was 0.17 ±0.13, both changes reflecting lightening of sleep across the night. In both univariate and multivariate analysis only baseline MSLT latency (p &lt 0.001) and ΔORP (p &lt 0.01) were significantly and positively correlated with post-restriction MSLT latency.

Conclusion

The reduction in sleep depth across the night as measured by ORP, but not by delta power, is significantly correlated with reduced objective sleepiness following sleep restriction. ΔORP may be a useful index that reflects sleep adequacy during the night.

Support

None

0150 Comparing Two Measures of Sleep Depth/ Intensity

Introduction

There is currently no well-validated method for evaluating objective sleep depth/intensity. Delta power is thought to reflect sleep depth based upon limited evidence. Odds-ratio-product (ORP) is a recently introduced continuous measure of sleep depth. We compared delta spectral power (delta) and ORP as measures of sleep depth/intensity during manipulations that altered sleep depth (sleep restriction with placebo or with a delta-promoting drug). We hypothesized that ORP will provide a more robust measure of sleep depth.

Methods

This is a secondary analysis of data from a study in which forty-one healthy subjects were sleep restricted and randomized to receive placebo or gaboxadol 15mg. Participants underwent consecutive in-laboratory sleep studies on two baseline, four sleep restriction (5 hours) and two recovery nights. The relation between delta or ORP during any given 30s epoch and sleep depth, operationally defined as the probability of arousal / awakening occurring during the next 30 seconds (arousability), was assessed.

Results

Mean ORP values differed significantly among the four sleep / wake stages, but delta power did not differentiate wake, N1 and N2. The relation between ORP and arousability was linear across the entire range of ORP whereas delta power detected differences in arousability only with delta values &lt 300 μV2. Correlations with arousability in individual subjects were stronger with ORP (p &lt 0.0001). Receiver operating characteristic analysis found the ability to predict imminent arousal to be significantly greater with ORP than with delta power for all experimental conditions (p &lt 0.0001). The increase in sleep depth with restriction alone was detected on the second day of restriction by ORP (p &lt 0.01) but not by delta.

Conclusion

As compared to delta power, ORP is more discriminating among sleep stages, more sensitive to sleep restriction, and more closely associated with arousability. These observations indicate ORP better reflects sleep depth/intensity.

Support

None

Adjuvant therapy for early stage, endometrial cancer with lymphovascular space invasion: Is there a role for chemotherapy?

OBJECTIVES

Lymphovascular space invasion (LVSI) is an independent risk factor for recurrence and poor survival in early-stage endometrioid endometrial cancer (EEC), but optimal adjuvant treatment is unknown. We aimed to compare the survival of women with early-stage EEC with LVSI treated postoperatively with observation (OBS), radiation (RAD, external beam and/or vaginal brachytherapy), or chemotherapy (CHEMO)+/-RAD.

METHODS

This was a multi-institutional, retrospective cohort study of women with stage I or II EEC with LVSI who underwent hysterectomy+/-lymphadenectomy from 2005 to 2015 and received OBS, RAD, or CHEMO+/-RAD postoperatively. Progression-free survival and overall survival were evaluated using Kaplan-Meier estimates and Cox proportional hazards models.

RESULTS

In total, 478 women were included; median age was 64 years, median follow-up was 50.3 months. After surgery, 143 (30%) underwent OBS, 232 (48.5%) received RAD, and 103(21.5%) received CHEMO+/-RAD (95% of whom received RAD). Demographics were similar among groups, but those undergoing OBS had lower stage and grade. A total of 101 (21%) women recurred. Progression-free survival (PFS) was improved in both CHEMO+/-RAD (HR = 0.18, 95% CI: 0.09-0.39) and RAD (HR = 0.31, 95% CI: 0.18-0.54) groups compared to OBS, though neither adjuvant therapy was superior to the other. However, in grade 3 tumors, the CHEMO+/-RAD group had superior PFS compared to both RAD (HR 0.25; 95% CI: 0.12-0.52) and OBS cohorts (HR = 0.10, 95% CI: 0.03-0.32). Overall survival did not differ by treatment.

CONCLUSIONS

In early-stage EEC with LVSI, adjuvant therapy improved PFS compared to observation alone. In those with grade 3 EEC, adjuvant chemotherapy with or without radiation improved PFS compared to observation or radiation alone.

Identifying physiological measures of lifetime welfare status in pigs: exploring the usefulness of haptoglobin, C- reactive protein and hair cortisol sampled at the time of slaughter

BACKGROUND

Physiological measures indicative of the welfare status of animals during rearing could form part of an abattoir-based animal health and welfare assessment tool. A total of 66 pigs were used in this study, the aim of which was to assess how serum concentrations of haptoglobin (Hp) and C-reactive protein (CRP) (assessed in 51 pigs), and hair concentrations of cortisol (assessed in 65 pigs), measured at or close to slaughter, reflected welfare-related indicators recorded from the animal during its lifetime. These indicators were recorded at intervals between 7 and 21 weeks of age and included assigning scores for levels of tail and skin lesions, recording the presence or absence of certain health issues, and conducting qualitative behavioural assessments (QBA).

RESULTS

Pigs recorded as having tail lesions during their lifetime had higher hair cortisol levels than those with no tail lesions (tail lesions: 47.87 ± 3.34 pg/mg, no tail lesions: 42.20 ± 3.29 pg/mg, P = 0.023), and pigs recorded as having moderate or severe tail lesions had higher Hp levels than those with no or mild tail lesions (moderate/severe: 1.711 mg/ml ± 0.74, none/mild: 0.731 mg/ml ±0.10, P = 0.010). Pigs recorded as being lame during their lifetime tended to have higher hair cortisol levels than non-lame pigs (lame: 52.72 pg/mg ± 3.83, not lame: 43.07 pg/mg ± 2.69, P = 0.062). QBA scores were not associated with any of the physiological measures (P > 0.05). Receiver Operator Curve (ROC) analysis was also carried out to get a better understanding of the usefulness of the physiological measures in discriminating animals that had had welfare-related issues recorded during their lifetime from those that had not. Hair cortisol was determined as having 'moderate' accuracy in discriminating pigs that were tail bitten on-farm from unbitten pigs (AUC: 0.748) while Hp and CRP were determined to have no meaningful discriminatory ability (AUC < 0.600).

CONCLUSION

This research should be repeated on a larger scale, but the results suggest that hair cortisol measured at slaughter could provide insight into the welfare status of pigs during their lifetime. Hp may be a useful indicator of tail lesions in pigs. However, further research utilising a greater proportion of severely bitten pigs is required before conclusions can be drawn.

Cardiovascular risk in patients with small and medium abdominal aortic aneurysms, and no history of cardiovascular disease

Background

Cardiovascular disease (CVD) is the main cause of death in people with abdominal aortic aneurysm (AAA). There is little evidence that screening for AAA reduces all-cause or cardiovascular mortality. The aim of the study was to assess whether subjects with a small or medium AAA (3·0–5·4 cm), without previous history of clinical CVD, had raised levels of CVD biomarkers or increased total mortality.

Methods

This prospective study included subjects with a small or medium AAA and controls, all without a history of clinical CVD. CVD biomarkers (high-sensitivity C-reactive protein, hs-CRP; heart-type fatty acid-binding protein, H-FABP) were measured, and survival was recorded.

Results

Of a total of 815 people, 476 with an AAA and 339 controls, a cohort of 86 with small or medium AAA (3–5·4 cm) and 158 controls, all with no clinical history of CVD, were identified. The groups were matched for age and sex. The AAA group had higher median (i.q.r.) levels of hs-CRP (2·8 (1·2–6·0) versus 1·3 (0·5–3·5) mg/l; P &lt; 0·001) and H-FABP (4·6 (3·5–6·0) versus 4·0 (3·3–5·1) µg/l; P = 0·011) than controls. Smoking was more common in the AAA group; however, hs-CRP and H-FABP levels were not related to smoking. Mean survival was lower in the AAA group: 6·3 (95 per cent confidence interval (c·i.) 5·6 to 6·9) years versus 8·0 (7·6 to 8·1) years in controls (P &lt; 0·001). Adjusted mortality was higher in the AAA group (hazard ratio 3·41, 95 per cent c·i. 2·11 to 9·19; P &lt; 0·001).

Conclusion

People with small or medium AAA and no clinical symptoms of CVD have higher levels of hs-CRP and H-FABP, and higher mortality compared with controls. They should continue to receive secondary prevention against CVD.

An RGD sequence in the P2Y(2) receptor interacts with alpha(V)beta(3) integrins and is required for G(o)-mediated signal transduction

The P2Y(2) nucleotide receptor (P2Y(2)R) contains the integrin-binding domain arginine-glycine-aspartic acid (RGD) in its first extracellular loop, raising the possibility that this G protein-coupled receptor interacts directly with an integrin. Binding of a peptide corresponding to the first extracellular loop of the P2Y(2)R to K562 erythroleukemia cells was inhibited by antibodies against alpha(V)beta(3)/beta(5) integrins and the integrin-associated thrombospondin receptor, CD47. Immunofluorescence of cells transfected with epitope-tagged P2Y(2)Rs indicated that alpha(V) integrins colocalized 10-fold better with the wild-type P2Y(2)R than with a mutant P2Y(2)R in which the RGD sequence was replaced with RGE. Compared with the wild-type P2Y(2)R, the RGE mutant required 1,000-fold higher agonist concentrations to phosphorylate focal adhesion kinase, activate extracellular signal-regulated kinases, and initiate the PLC-dependent mobilization of intracellular Ca(2+). Furthermore, an anti-alpha(V) integrin antibody partially inhibited these signaling events mediated by the wild-type P2Y(2)R. Pertussis toxin, an inhibitor of G(i/o) proteins, partially inhibited Ca(2+) mobilization mediated by the wild-type P2Y(2)R, but not by the RGE mutant, suggesting that the RGD sequence is required for P2Y(2)R-mediated activation of G(o), but not G(q). Since CD47 has been shown to associate directly with G(i/o) family proteins, these results suggest that interactions between P2Y(2)Rs, integrins, and CD47 may be important for coupling the P2Y(2)R to G(o).

Foot problems in patients with systemic sclerosis

OBJECTIVES

To assess the nature of the foot problems experienced in patients with systemic sclerosis (SSc) and patient awareness of such problems.

METHODS

Fifty unselected patients (42 females, eight males) with SSc were assessed by means of examination by a senior podiatrist, completion of a questionnaire detailing past and present foot problems, determination of random plasma glucose, plain X-rays of the feet, and measurement of the ankle/brachial index and of digital pulses by Doppler ultrasound.

RESULTS

Eighty-six per cent of patients reported colour changes in their feet in response to temperature changes, 82% reported pain usually related to cold, 26% had suffered foot ulceration and 8% had a history of foot surgery. Podiatry assessment confirmed the presence of significant abnormalities, including ulcerations in 10%, pre-ulcerative lesions in 34%, toenail changes in 62%, callus formation in 80% and calcinosis in 18%. Forty per cent of the patients had problems with the fitting of shoes, and 19% had been provided with footwear from the hospital. Plain films of the feet demonstrated the presence of erosions in 6%, soft-tissue calcification in 17%, osteopenia in 26% and degenerative changes in 60% of cases. Ten per cent of the patients had an abnormal ankle brachial index (less than 1.0). Only 21% of the 47 patients in whom digital pulses were examined had normal pulses in all toes, and in 26% all toe pulses were absent.

CONCLUSION

Although problems with the hands are well recognized in SSc, foot problems also occur in the majority of patients, and can be a cause of major disability. Care of the feet is therefore an important part of the management of SSC.

Overlapping expression of zebrafish T-brain-1 and eomesodermin during forebrain development

T-box transcription factors are important determinants of embryonic cell fate and behaviour. Two T-box genes are expressed in the developing telencephalon of several vertebrate species, including amphibia, birds and mammals. Here we report the cloning of zebrafish T-brain-1 (tbr1) and eomesodermin (eom). As a prelude to genetic studies of neuro-ectodermal fate determination we studied their expression pattern during embryogenesis and early larval development. Eom is expressed in the presumptive telencephalon from around the 4-5 somite stage in bilaterally symmetric groups of cells; the number of positive cells increases dramatically with time and encompasses the entire dorsal telencephalon by the 22 somite stage. Tbr1 is expressed from the 18 somite stage in a subset of eom-expressing cells. By 24 hpf eom and tbr1 are expressed in largely overlapping domains in the dorsal telencephalon, tbr1 is expressed in postmitotic cells whereas eomes is also expressed in proliferative ventricular zone cells. Both genes are also found in a small domain of the diencephalon bordering the telencephalon. A detailed analysis of the expression of tbr1 and eom in the brain of 4 day old larvae shows that the two T-box genes are differentially expressed in various cell populations of the developing brain.

Stabilisation of Salmonella vaccine vectors by the induction of trehalose biosynthesis

The growth of an aroA mutant of Salmonella typhimurium (SL3261) in minimal medium containing 0.5 M NaCl resulted in the intracellular accumulation of 2.2 micromol trehalose/mg total protein. The vacuum drying of these bacteria in the presence of trehalose allowed the recovery of 35% of the viable cells that were present before drying. In contrast, bacteria cultured in control medium accumulated 0.4 micromol trehalose/mg total protein and only 5% of the viable cells were recovered after vacuum drying with trehalose. Similar results were obtained when S. typhimurium SL3261, expressing the vaccine antigen (F1-antigen) of Yersinia pestis, was cultured in minimal medium with or without 0.5 M NaCl and dried in the presence of trehalose. Although these results indicate the potential for trehalose stabilisation of vaccine strains of S. typhimiurium, growth in minimal medium containing 0.5 M NaCl resulted in the loss of invasion competence of the bacteria.

Ace/Fgf8 is required for forebrain commissure formation and patterning of the telencephalon

Fibroblast growth factors (Fgfs) form a large family of secreted signalling proteins that have a wide variety of roles during embryonic development. Within the central nervous system (CNS) Fgf8 is implicated in patterning neural tissue adjacent to the midbrain-hindbrain boundary. However, the roles of Fgfs in CNS tissue rostral to the midbrain are less clear. Here we examine the patterning of the forebrain in zebrafish embryos that lack functional Fgf8/Ace. We find that Ace is required for the development of midline structures in the forebrain. In the absence of Ace activity, midline cells fail to adopt their normal morphology and exhibit altered patterns of gene expression. This disruption to midline tissue leads to severe commissural axon pathway defects, including misprojections from the eye to ectopic ipsilateral and contralateral targets. Ace is also required for the differentiation of the basal telencephalon and several populations of putative telencephalic neurons but not for overall regional patterning of forebrain derivatives. Finally, we show that ace expression co-localises with anterior neural plate cells that have previously been shown to have forebrain patterning activity. Removal of these cells leads to a failure in induction of ace expression indicating that loss of Ace activity may contribute to the phenotypes observed when anterior neural plate cells are ablated. However, as ace mutant neural plate cells still retain at least some inductive activity, then other signals must also be produced by the anterior margin of the neural plate.

A double-blind placebo-controlled trial of antioxidant therapy in limited cutaneous systemic sclerosis

OBJECTIVE

To evaluate the effects of a combination of micronutrient antioxidants (selenium, beta-carotene, vitamin C, vitamin E and methionine) with allopurinol in patients with limited cutaneous systemic sclerosis (SSc).

METHODS

The study was designed as a placebo-controlled double-blind crossover study. A carryover effect was detected retrospectively for some of the prescribed antioxidants, and so the data were analysed as: (a) a between group comparison of the first 10 week treatment period; and (b) a within group comparison of the first and second 10-week periods in those who received placebo treatment first. Study end-points were plasma von Willebrand factor (vWF), thermographic response to a standard cold challenge, frequency and duration of Raynaud's attacks, patient opinion, and specialised biochemical parameters (fatty acid profiles, antioxidants and markers of free radical injury).

RESULTS

Thirty-three patients were recruited. The median duration of Raynaud's phenomenon was 10 years (range 2 to 50 years) in the active-first group and 10 years (range 4 to 53 years) in the placebo-first group. In the 10-week study, there were no differences between the active and placebo groups in the change from baseline for vWF, for the parameters of the rewarming curve, or for patients' symptoms. Despite a rise in circulating antioxidant levels, there was no fall in markers of free radical mediated injury. In the 20-week cross-over study, patients did not experience any clinical benefit from active treatment compared to placebo.

CONCLUSION

No clinical benefit could be demonstrated from active treatment. There are several possible explanations for this negative result, including the short duration of therapy. It is possible that antioxidant therapy, to be effective, needs to be given early in the SSc disease process, before the onset of irreversible tissue damage.

Renal injury and salt-sensitive hypertension after exposure to catecholamines

We investigated whether chronic infusion of phenylephrine could induce structural and functional changes in the kidney of rats with the subsequent development of salt-sensitive hypertension. Rats were infused with phenylephrine (0.15 mmol/kg per day) by minipump, resulting in a moderate increase in systolic blood pressure (BP) (17 to 25 mm Hg) and a marked increase in BP variability as measured by an internal telemetry device. After 8 weeks, the phenylephrine infusion was stopped with the return of BP to normal, and a nephrectomy was performed for histological studies. Glomeruli were largely spared, but focal tubulointerstitial fibrosis was present, with the de novo expression of osteopontin by injured tubules, macrophage and "myofibroblast" accumulation, and focal increases in mRNA for transforming growth factor beta by in situ hybridization. Peritubular capillaries at sites of injury had distorted morphology with shrinkage, rounding, and focal rarefaction, and endothelial cell proliferation was also identified. Rats were randomized to a high (8% NaCl or 1.36 mol/kg) or low (0.1% NaCl or 17 mmol/kg) salt diet. After 4 to 8 weeks, phenylephrine-treated rats on a high salt diet developed marked hypertension, which was in contrast with phenylephrine-treated rats placed on a low salt diet or vehicle-treated rats given a high salt diet. Hypertension after phenylephrine exposure correlated with the initial mean systolic BP (r(2)=0.99) and the degree of BP lability (r(2)=0.99) during the phenylephrine infusion, the amount of osteopontin expressed in the initial biopsy/nephrectomy (r(2)=0.74), and the final glomerular filtration rate (r(2)=0.58). These studies provide a mechanism by which a markedly elevated sympathetic nervous system can induce salt-dependent hypertension even when the hyperactive sympathetic state is no longer engaged.

"Nothing about me, without me": participatory action research with self-help/mutual aid organizations for psychiatric consumer/survivors

Participatory action research with self-help/mutual aid organizations for psychiatric consumer/survivors is reviewed. We begin by tracing the origins of and defining both participatory action research and self-help/mutual aid. In so doing, the degree of correspondence between the assumptions/values of participatory action research and those of self-help/mutual aid for psychiatric consumer/survivors is examined. We argue that participatory action research and self-help/mutual aid share four values in common: (a) empowerment, (b) supportive relationships, (c) social change, and (d) learning as an ongoing process. Next, selected examples of participatory action research with psychiatric consumer/survivor-controlled self-help/mutual aid organizations which illustrate these shared values are provided. We conclude with recommendations of how the key values can be promoted in both the methodological and substantive aspects of future participatory action research with self-help/mutual aid organizations for psychiatric consumer/survivors.

Goal-directed transesophageal echocardiography performed by intensivists to assess left ventricular function: comparison with pulmonary artery catheterization

OBJECTIVES

Transesophageal echocardiography (TEE) is a valuable procedure for assessing left ventricular (LV) function, but it has not been widely applied in critical care because of the limited number of intensivists who are trained in echocardiography. This prospective study was designed to evaluate the feasibility of training intensivists to perform a goal-directed, limited-scope TEE to assess LV function in critically ill patients using a pediatric monoplane TEE probe. A secondary goal was to compare the usefulness of the TEE data with that of data obtained by a simultaneous pulmonary artery catheter (PAC).

DESIGN

Prospective, blinded.

SETTING

University teaching hospital.

PARTICIPANTS

One hundred consecutive, intubated, intensive care unit patients.

INTERVENTIONS

Five surgical intensivists with no previous background in echocardiography were trained under the supervision of two cardiologists to perform limited-scope TEE using a monoplane pediatric probe. One intensivist (A) reviewed the PAC data and recorded a diagnostic impression and therapeutic plan. A second intensivist (B), blinded to the PAC data, then performed TEE to determine cardiac volume, LV wall thickness, and LV global and regional wall motion. Intensivists A and B reviewed the data from both PAC and TEE, and intensivist A then formulated a new diagnosis and therapeutic plan.

MEASUREMENTS AND MAIN RESULTS

Intensivists performed 48 TEE examinations under direct supervision of a cardiologist, and 52 without supervision, but reviewed poststudy. The average duration of TEE was 12 +/- 7 minutes. The intensivists' interpretations of TEE data were deemed correct in 93% of cases for LV wall thickness, 87% for intracardiac volume status, 81% for regional LV wall motion abnormalities, and 77% for global LV function. When the TEE and PAC technologies were compared, it was found that the TEE data disagreed with the PAC evaluation of intracardiac volume in 55% of cases and with the PAC assessment of myocardial function in 39% of cases. The post-PAC therapeutic recommendations were different from the post-TEE therapeutic recommendations in 58% of patients.

CONCLUSIONS

Training intensivists in limited-scope, goal-directed TEE, using a pediatric monoplane probe to evaluate LV function, can be done rapidly and safely, and yield data pertinent to management of critically ill patients even in the early stages of skill acquisition.

Getting kids and keeping them: lesbian motherhood in europe

Summary This article looks at two major issues faced by lesbian mothers in Europe: getting kids and keeping them. The first part focuses on the ways lesbians have children, and in particular the different levels of access to formal insemination services for lesbians in European countries. The second part examines custody issues faced by lesbians with children from previous heterosexual relationships, and those faced by lesbians who have children within a lesbian relationship; and legal recognition of the bond between non-biological parents and their children. The article is based on original research and interviews carried out by the author for the book Lesbian Motherhood in Europe.

Medical planning--casualty treatment times at first and second line

OBJECTIVE

To establish the average time taken to treat a seriously wounded battle casualty at First and Second Line (Role 1 and Role 2) according to the British Army Casualty Treatment Regimes under simulated conditions, and, in doing so, to assess whether British medical facilities are capable of meeting the medical planning directives of the Allied Command Europe Rapid Reaction Corps (ARRC).

DESIGN

A casualty evacuation exercise, using standard ARRC medical planning data, deploying the war establishment of personnel and equipment of an armoured Battle Group Regimental Aid Post (RAP) and an armoured Field Ambulance.

SUBJECTS

200 simulated casualties, using 120 healthy soldiers dressed in expendable clothing and carrying a description of their injuries and clinical status.

MAIN OUTCOME MEASURED

The time taken to treat simulated seriously wounded casualties at Role 1, the RAP and at Role 2, the Field Ambulance Dressing Station (DS).

RESULTS

The mean treatment time at Role 1 was 28 minutes and at Role 2 was 17 minutes.

CONCLUSION

Within the (large) caveat of simulation, as presently configured, the Field Ambulance (DS) is well able to cope with the casualty load expected of it by ARRC medical planners but the RAP of the armoured Battle Group is not.

Thermodilution cardiac output measurement during simultaneous volume infusion through the venous infusion port of the pulmonary artery catheter

OBJECTIVE

To determine the effect on thermodilution cardiac output (TDCO) measurements of continuous volume infusion through the right atrial venous infusion port of the pulmonary artery catheter.

DESIGN

Prospective, blinded, randomly allocated crossover.

SETTING

Surgical intensive care unit in a university hospital.

PARTICIPANTS

Forty-nine hemodynamically stable patients between the ages of 43 and 84 in the intensive care unit and with a pulmonary artery catheter in place.

INTERVENTIONS

Each patient received two room-temperature infusions (250 or 500 mL/hr) of 5% dextrose. Consecutive TDCO measurements were taken during each infusion and during a control period (no infusion). The sequence of infusion rates and control period was randomly determined. At both infusion rates, most patients exhibited a decrease in TDCO measurement of between 0.1 and 3.0 L/min. Although some patients exhibited an increase in measured TDCO, this increase was primarily between 0.1 and 0.5 L/min.

MEASUREMENTS AND MAIN RESULTS

The mean TDCO measurements at infusion rates of 0, 250, and 500 mL/hr were 6.77, 6.49, and 6.47 L/min, respectively. Measured TDCO decreased on volume infusion by 0.3 +/- 0.13 L/min (mean +/- SD, p < 0.02).

CONCLUSION

Rapid continuous infusion of fluid through the venous infusion port of the pulmonary artery catheter significantly limits the accuracy of simultaneous TDCO measurements. Optimally, TDCO measurements should be avoided during rapid volume infusion.

Biochemical analysis of mutant T7 primase/helicase proteins defective in DNA binding, nucleotide hydrolysis, and the coupling of hydrolysis with DNA unwinding

We characterized nine helicase-deficient mutants of bacteriophage T7 helicase-primase protein (4A') prepared by random mutagenesis as reported in the accompanying paper (Rosenberg, A. H., Griffin, K., Washington, M. T., Patel, S. S., and Studier, F. W. (1996) J. Biol. Chem. 271, 26819-26824). Mutants were selected from each of the helicase-conserved motifs for detailed analysis to understand better their function. In agreement with the in vivo results, the mutants were defective in helicase activity but were active in primase function. dTTP hydrolysis, DNA binding, and hexamer formation were examined. Three classes of defective mutants were observed. Group A mutants (E348K, D424N, and S496F), defective in dTTP hydrolysis, lie in motifs 1a, 2, and 4 and are possibly involved in NTP binding/hydrolysis. Group B mutants (R487C and G488D), defective in DNA binding, lie in motif 4 and are responsible directly or indirectly for DNA binding. Group C mutants (G116D, A257T, S345F, and G451E) were not defective in any of the activities except the helicase function. These mutants, scattered throughout the protein, appear defective in coupling dTTPase activity to helicase function. Secondary structural predictions of 4A' and DnaB helicases resemble the known structures of RecA and F1-ATPase enzymes. Alignment shows a striking correlation in the positions of the amino acids that interact with NTP and DNA.

Selection, identification, and genetic analysis of random mutants in the cloned primase/helicase gene of bacteriophage T7

T7 gene 4 specifies two overlapping proteins 4A, a 566-amino acid primase/helicase, and 4B, a 503-amino acid helicase whose initiation codon is the 64th codon of the 4A protein. The 4A' gene, which has a leucine codon replacing the 4B initiation codon, specifies a single 566-amino acid protein that can provide the primase and helicase functions required for normal T7 growth. We selected N-methyl-N'-nitro-N-nitrosoguanidine mutants in the cloned 4A' gene that no longer support the growth of a phage that completely lacks gene 4. Genetic mapping of the 76 mutations found them to be distributed throughout the protein, including both the N-terminal and C-terminal halves of the molecule thought to represent primase and helicase domains, respectively. Complementation tests with partially and completely defective phage showed that all but five of the mutants lacked helicase function but retained primase function. The other five, which lacked both functions, all made short proteins, including one missing only 60 amino acids. No mutations lacked only primase function, and none mapped within the first 105 amino acids, which includes the 63-amino acid region unique to 4A that contains elements required to recognize primase sites. Forty-six mutations were sequenced and included 27 missense mutations affecting 25 amino acids. Many mutations in the N-terminal half of the protein affected its solubility in cell extracts. Mutations in the C-terminal half clustered in or near five helicase consensus sequences. Biochemical analysis of nine of the mutant proteins is described in the accompanying paper (Washington, M. T., Rosenberg, A. H., Griffin, K., Studier, F. W., and Patel, S. S. (1996) J. Biol. Chem. 271, 26825-26834).

Analysis of FGF function in normal and no tail zebrafish embryos reveals separate mechanisms for formation of the trunk and the tail

To analyse the roles of FGF activity and brachyury during gastrulation we have directly compared the consequences of inhibition of FGF-receptor signalling with the phenotype of the zebrafish brachyury mutant, no tail (ntl). We show that expression of ntl is regulated by FGF and that inhibition of FGF receptor-signalling leads to complete loss of the trunk and tail. Since the ntl mutant lacks the tail and notochord but has an otherwise normal trunk, this demonstrates that trunk development is dependent upon an unidentified gene, or set of genes, referred to as no trunk (ntk) which is regulated by FGF. We propose a model to explain the FGF-dependent regulation of ntl and ntk that accounts for the above phenotypes. Consistent with this model, over-expression of eFGF led to suppression of anterior fates and development of trunk and tail derivatives only. In addition, widespread activation of convergence and extension movements resulted in the formation of multiple axis-like structures. Expression of eve1 and cad1 was also regulated by FGF activity, suggesting that during gastrulation FGF activity is normally restricted to the germ ring where these genes, and ntl, are expressed. Taken together these data suggest that the germ ring acts as a posteriorising centre during AP patterning, mediated by FGF activity in this tissue.

Adherence to very-low-fat diet by a group of cardiac rehabilitation patients in the rural southeastern United States

This 28-week observational study measured adherence to and acceptability of the diet and nutrition component of an Ornish-type program among patients in a rural southern setting. Ten volunteers followed a very-low-fat (10% of energy), total vegetarian diet and participated in a program of exercise, stress management, and group support. Patients made significant dietary changes and found the diet "acceptable." Three patients consumed less than 10% of energy from fat and two additional patients consumed less than 20% of energy from fat. Eighty-five percent of the patients' meals adhered to a near vegetarian diet. Weight loss ranged from 0.1 to 11.7 kg (0.25 to 26 lb). Lipid values were unchanged. At 12 months, without the benefit of the structured program, one patient reported 100%, six reported 85%, and two reported 50% adherence to the dietary principles. We conclude that motivated patients with coronary artery disease can follow a very-low-fat, near vegetarian diet but experience difficulty without a structured program.