Embedding interpersonal stigma resistance into the medical curriculum: a focus group study of medical students

BACKGROUND

Mental-health-related stigma among physicians towards people with mental illnesses remains a barrier to quality care, yet few curricula provide training with a proactive focus to reduce the potential negative impacts of stigma. The aim of our study was to explore medical students' perspectives on what areas of learning should be targeted (where stigma presents) and how they could be supported to prevent the formation of negative attitudes.

METHODS

Six focus group discussions were conducted with second, third, and fourth-year postgraduate medical students (n = 34) enrolled at The University of Melbourne Medical School in September - October 2021. Transcripts were analysed using inductive thematic analysis.

RESULTS

In terms of where stigma presents, three main themes emerged - (1) through unpreparedness in dealing with patients with mental health conditions, (2) noticing mentors expressing stigma and (3) through the culture of medicine. The primary theme related to 'how best to support students to prevent negative attitudes from forming' was building stigma resistance to reduce the likelihood of perpetuating stigma towards patients with mental health conditions and therefore enhance patient care. The participants suggest six primary techniques to build stigma resistance, including (1) reflection, (2) skills building, (3) patient experiences, (4) examples and exemplars, (5) clinical application and (6) transforming structural barriers. We suggest these techniques combine to form the ReSPECT model for stigma resistance in the curriculum.

CONCLUSIONS

The ReSPECT model derived from our research could provide a blueprint for medical educators to integrate stigma resistance throughout the curriculum from year one to better equip medical students with the potential to reduce interpersonal stigma and perhaps self-stigma. Ultimately, building stigma resistance could enhance care towards patients with mental health conditions and hopefully improve patient outcomes.

Effective communication of COVID-19 vaccine information to recently-arrived culturally and linguistically diverse communities from the perspective of community engagement and partnership organisations: a qualitative study

BACKGROUND

In many high-income countries, COVID-19 has disproportionately impacted Culturally and Linguistically Diverse (CALD) communities. Barriers to engaging with essential health messaging has contributed to difficulties in following public health advice and exacerbated existing inequity in Australia. Research suggests that recently-arrived CALD populations are particularly vulnerable to misinformation and are more likely to experience vaccine hesitancy. The aim of this study was to explore the barriers and enablers to COVID-19 vaccination among recently-arrived CALD communities in Melbourne's outer north and identify strategies to reduce hesitancy in this population.

METHODS

Semi-structured interviews were conducted with representatives from community organisations working with recently-arrived CALD communities in Melbourne's north. This included a mix of peer (from the community) and health care workers.

RESULTS

Fifteen participants from community organisations participated in interviews. Thematic analysis identified four themes; (1) trusted sources, (2) accurate and culturally sensitive information, (3) supported pathways and (4) enablers to vaccination.

CONCLUSIONS

Participants reported a perceived lack of accurate, culturally sensitive health information and service provision as key barriers to vaccination in recently-arrived CALD communities. Participants identified a range of perceived enablers to increasing vaccination uptake in the communities they work with, including utilising established channels of communication and harnessing the communities' strong sense of collective responsibility. Specific strategies to reduce vaccine hesitancy included identifying and utilising trusted sources (e.g. faith leaders) to disseminate information, tailoring health messages to address cultural differences, providing opportunities to contextualise information, and modifying service delivery to enhance cultural sensitivity. There is an urgent need for increased efforts from health and government agencies to build sustainable, collaborative relationships with CALD communities.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a UK oncology and reconstructive surgery service - benchmarking the data

The British Association of Oral and Maxillofacial Surgery is soon to implement the Quality Outcomes in Oral in Maxillofacial Surgery (QOMS) to provide a platform for quality management across the specialty in the UK. The initial oncology and reconstruction audits for QOMS involves data collection on specific procedures and metrics. The aim of this report is to determine their appropriateness using extant audit datasets in our institution that overlap substantially with the QOMS audits. Pre-existing datasets comprising information on patients treated for oral cavity SCC with curative intent were analysed. Data on surgical margins, lymphadenectomy lymph node yield, delay between surgery and adjuvant radiotherapy, duration of hospital stay, and complications including flap failures were analysed. All statistical analyses were performed with SPSS 25. Run charts describing longitudinal data were generated using SPC for Excel version 6. Twenty three patients (3.1%) of 701 resections had a positive surgical margin reported. Seventeen (4.3%) of patients had less than 18 LNs in the ND specimen analysed. Mean time to start date of adjuvant therapy was 62 days. Only 9% of patients commenced adjuvant therapy within 6 weeks. The median duration of stay was 18 days. In 1153 free flaps a failure rate of 4.3% was identified. A total of 1349 complications (CD I-V) were recorded in the 1111 patients undergoing major surgery with free flap reconstruction. The QOMS selected metrics for oncology and reconstruction are clinically relevant, readily measurable, and likely to be actionable by the surgical team.

Abstract P3-10-13: Dual targeting of androgen receptor and IKK alpha is a potential therapeutic strategy for triple negative breast cancer

Background

There are limited treatments for triple negative breast cancer (TNBC) patients and an unmet need for targeted approaches in these patients. In the last 4-5 years, the prevalence of high androgen receptor (AR) expression in TNBCs has been noted in up to 50% of tumors suggesting it has clinical relevance. The non-canonical NF-kB pathway is also upregulated in this patient group and it has been reported that that there is crosstalk between these pathways. Therefore the aim of this study was to examine the expression of IKKα and AR in breast cancer tissue samples, to assess if combining these markers increased prognostic power.

Methods

Immunohistochemistry was performed on tissue microarray of 410 patients to assess proteins level of IKK alpha and AR. Protein expression levels were assessed using the weighted histoscore (WHS) method. The median was employed as the cut off for IKK alpha and 1% as cut off for AR. Expression was analyzed for associations with cancer-specific survival (CSS) and recurrence-free survival (RFS).

Results

In a cohort of 370 breast cancers nether AR nor IKK alpha alone or combined were associated with CSS or RFS. Stratifying patients by ER status did not impact CSS or RFS. However, in TNBC patients (n=82) high expression of AR was associated with shorter CSS (HR 2.55 95 CI 1.61-5.59, p=0.013). To assess if combining AR and IKK alpha increased prognostic power, AR and IKK alpha were combined into a single score: 0= low expression of both or high expression of one and 1= high expression of both. In the full cohort or when stratified by ER status the score was not associated with CSS or RFS, however in TNBC the combined score potentiated the effect observed with AR alone, (HR 1.68 95 CI 1.20-2.33, p=0.001). Patient CSS was stratified from 11.5 years to 4.6 years and was independently associated with CSS when compared with common clinicopathological factors (HR 1.56 95CI 1.11-2.21, p=0.011). In addition, the combined score was associated with decrease radiotherapy use (p=0.032), increased recurrence rate (p=0.014), decreased cytotoxic T cells (p=0.007), B cells (p=0.043) and macrophages (p=0.037).

Conclusions

A combined AR and IKK alpha score is an independent prognostic classification for patients with TNBC. Patients with high expression of both AR and IKK alpha a significantly reduced survival and were immune cell cold. This study suggests that this patient group will not benefit from immunotherapy but dual targeting with anti-androgens and IKK alpha selective inhibitors could offer a novel therapeutic strategy for this patient group.

Citation Format: Roseweir AK, Khongthong P, Dickson K, Bennett L, Edwards J. Dual targeting of androgen receptor and IKK alpha is a potential therapeutic strategy for triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-13.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Occupational health purchasing behaviour by SMEs--a new theoretical model

BACKGROUND

Factors influencing corporate decisions to purchase occupational health (OH) are unknown.

AIMS

To assist the marketing of OH services to small- and medium-sized enterprises (SMEs) by characterizing purchasing behaviour.

METHODS

We developed a 2×2 model, based on published studies, to describe OH purchasing behaviour by SMEs. We tested the model by analysis of responses to a cross-sectional market research survey carried out in November 2007. The companies surveyed were SMEs employing 30-250 employees, within the localities of five UK National Health Service OH services: West London, Buckinghamshire, Cambridge, Portsmouth and York. We chose a sample representative of all SMEs for each location. The survey explored knowledge of OH and the perceived importance of a variety of services.

RESULTS

We obtained responses from 387 companies (19%); 81% indicated that they knew about OH and 24% had purchased OH services. OH was rated 'very important' by 35%, and 65% rated it as 'quite' or 'very important'. Sickness absence and its business impact were monitored by 89%. Enterprises claiming OH understanding were significantly more likely to purchase OH services (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.6-8.0). Companies employing fewer than 90 employees were significantly less likely to purchase such services than larger ones (OR 0.17, 95% CI 0.09-0.3).

CONCLUSIONS

OH knowledge and company size are key determinants of SME purchasing behaviour. Our findings support our proposed theoretical model. However, more research could explore claimed knowledge of OH with respect to the proposed purchaser types and business benefits.

Hypothetical constructs, hypothetical questions, and the expert witness

Professor John Henry Wigmore in 1940 described the hypothetical question as an intolerable obstruction of truth. Since that time, the nature and application of the hypothetical question in the courtroom, as well as responses to this line of questioning during expert testimony, have been sources of controversy. Governed by legal philosophical foundations, the hypothetical construct addresses what there is, in a general sense, and what can or ought to be. Alexy (2004) has described the nature of legal philosophy as the epistemological question of what we can know. This article begins by examining the philosophical underpinnings, legal parameters, and teaching purposes of posing hypothetical queries. A social-psychological backdrop for the use of hypothetical questions is then discussed followed by a broader discussion of the hypothetical question's role in court procedures. This paper identifies hypothetical questions used in court as devices to elicit information, or as predictions that potentially change underlying factual interpretations of evidence. In particular, on cross examination hypothetical questions seek to make opposing experts assume facts that are incongruent with their conclusions or opinions. Sometimes in these situations, experts are led to re-evaluate opinions based on alternative understandings of events and behaviors. Thus, this paper's final aim is to explore a foundational understanding of hypothetical questions asked of expert witnesses with special reference to mental health issues. Options for responding to hypothetical questions on the stand are considered along the dimensions of assertiveness-passivity, compliance-resistance, and possible redefinitions of the hypothetical issues.

Ten year performance evaluation of a field-scale zero-valent iron permeable reactive barrier installed to remediate trichloroethene contaminated groundwater

The Monkstown zero-valent iron permeable reactive barrier (ZVI PRB), Europe's oldest commercially-installed ZVI PRB, had been treating trichloroethene (TCE) contaminated groundwater for about 10 years on the Nortel Network site in Northern Ireland when cores from the reactive zone were collected in December, 2006. Groundwater data from 2001-2006 indicated that TCE is still being remediated to below detection limits as the contaminated groundwater flows through the PRB. Ca and Fe carbonates, crystalline and amorphous Fe sulfides, and Fe (hydr)oxides have precipitated in the granular ZVI material in the PRB. The greatest variety of minerals is associated with a approximately 1-2 cm thick, slightly cemented crust on top (up-gradient influent entrance) of the ZVI section of the PRB and also with the discontinuous cemented ZVI material ( approximately 23 cm thick) directly below it. The greatest presence of microbial communities also occurred in the up-gradient influent portion of the PRB compared to its down-gradient effluent section, with the latter possibly due to less favorable conditions (i.e., high pH, low oxygen) for microbial growth. The ZVI filings in the down-gradient effluent section of the PRB have a projected life span of >10 years compared with ZVI filings from the continuous to discontinuous cemented up-gradient ZVI section (upper approximately 25 cm) of the PRB, which may have a life span of only approximately 2-5 more years. Supporting Information from applied, multi-tracer testing indicated that restricted groundwater flow is occurring in the upper approximately 25 cm of the ZVI section and preferential pathways have also formed in this PRB over its 10 years of operation.

Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomised factorial controlled equivalence trial

OBJECTIVE

To compare the efficacy of 100 mg and 200 mg of mifepristone and 24- and 48-hour intervals to administration of 800 microg vaginal misoprostol for termination of early pregnancy.

DESIGN

Placebo-controlled, randomized, equivalence trial, stratified by centre.

SETTING

13 departments of obstetrics and gynecology in nine countries.

POPULATION

2,181 women with 63 days or less gestation requesting medical abortion.

METHODS

Two-sided 95% CI for the risk differences of failure to complete abortion were calculated and compared with 5% equivalence margin between two doses of mifepristone and two intervals to misoprostol administration. Proportions of women with adverse effects were compared between the regimens using standard testes for proportions.

OUTCOME MEASURES

Rates of complete abortion without surgical intervention and adverse effects associated with the regimens.

RESULTS

Efficacy outcome was analysed for 2,126 women (97.5%) excluding 55 lost to follow up. Both mifepristone doses were found to be similar in efficacy. The rate of complete abortion was 92.0% for women assigned 100 mg of mifepristone and 93.2% for women assigned 200 mg of mifepristone (difference 1.2%, 95% CI: -1.0 to 3.5). Equivalence was also evident for the two intervals of administration: the rate of complete abortion was 93.5% for 24-hour interval and 91.7% for the 48-hour interval (difference -1.8%, 95% CI: -4.0 to 0.5). Interaction between doses and interval to misoprostol administration was not significant (P = 0.92). Adverse effects related to treatments did not differ between the groups.

CONCLUSIONS

Both the 100 and 200 mg doses of mifepristone and the 24- and 48-hour intervals have a similar efficacy to achieve complete abortion in early pregnancy when mifepristone is followed by 800 micrograms of vaginally administered misoprostol.

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa

OBJECTIVE

To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility.

DESIGN

Cross-sectional study.

SETTING

Public termination of pregnancy (TOP) services in three provinces.

SAMPLE

A total of 673 women attending the above services for TOP.

METHODS

Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (< or = 8 weeks gestation by woman or provider estimate and > 8 weeks by ultrasound).

MAIN OUTCOME MEASURES

Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'.

RESULTS

Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI = -27 to 63). Mean provider- and LMP-based estimates were two (95% CI = -30 to 35) and less than one day(s) (95% CI = -46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable.

CONCLUSIONS

Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.

Self-reported anti-social behaviour: prevalence and risk factors amongst adolescents with and without intellectual disability

BACKGROUND

Research has suggested increased risk of anti-social behaviour amongst individuals with intellectual disability (ID).

METHODS

This study reports the results of a secondary analysis of data relating to self-reported anti-social behaviour, obtained from the 1999 Office for National Statistics (ONS) study of the mental health of children and adolescents in Great Britain. Self-report data from 4174 adolescents was available. Within this group, a sub-group of 98 adolescents with ID was identified. Data covered a variety of sub-types of anti-social behaviour.

RESULTS

Comparisons of individuals with ID and those without ID indicated a significantly higher prevalence of a number of types of self-reported anti-social behaviour in the ID sample. Further analyses indicated however, that these between group differences were accounted for by the higher rates of social deprivation and child mental health problems among the ID sample.

CONCLUSIONS

Rather than ID per se being associated with increased rates of anti-social behaviour, adolescents with ID may be more likely to experience risk factors (lower socio-economic status and mental health problems) known to be associated with anti-social behaviour. The clinical implications of this and possible future directions for research are discussed.

Comparative studies of high performance swimming in sharks II. Metabolic biochemistry of locomotor and myocardial muscle in endothermic and ectothermic sharks

Metabolic enzyme activities in red (RM) and white (WM) myotomal muscle and in the heart ventricle (HV) were compared in two lamnid sharks (shortfin mako and salmon shark), the common thresher shark and several other actively swimming shark species. The metabolic enzymes measured were citrate synthase (CS), an index of aerobic capacity, and lactate dehydrogenase (LDH), an index of anaerobic capacity. WM creatine phosphokinase (CPK) activity, an index of rapid ATP production during burst swimming, was also quantified. Enzyme activities in RM, WM and HV were similar in the two lamnid species. Interspecific comparisons of enzyme activities at a common reference temperature (20 degrees C) show no significant differences in RM CS activity but higher CS activity in the WM and HV of the lamnid sharks compared with the other species. For the other enzymes, activities in lamnids overlapped with those of other shark species. Comparison of the HV spongy and compact myocardial layers in mako, salmon and thresher sharks reveals a significantly greater spongy CS activity in all three species but no differences in LDH activity. Adjustment of enzyme activities to in vivo RM and WM temperatures in the endothermic lamnids elevates CS and LDH in both tissues relative to the ectothermic sharks. Thus, through its enhancement of both RM and WM enzyme activity, endothermy may be an important determinant of energy supply for sustained and burst swimming in the lamnids. Although lamnid WM is differentially warmed as a result of RM endothermy, regional differences in WM CS and LDH activities and thermal sensitivities (Q(10) values) were not found. The general pattern of the endothermic myotomal and ectothermic HV muscle metabolic enzyme activities in the endothermic lamnids relative to other active, ectothermic sharks parallels the general pattern demonstrated for the endothermic tunas relative to their ectothermic sister species. However, the activities of all enzymes measured are lower in lamnids than in tunas. Relative to lamnids, the presence of lower WM enzyme activities in the thresher shark (which is in the same order as the lamnids, has an RM morphology similar to that of the mako and salmon sharks and may be endothermic) suggests that other factors, such as behavior and swimming pattern, also affect shark myotomal organization and metabolic function.

Outpatient management of low-velocity gunshot-induced fractures

This prospective study evaluated the efficacy of an outpatient management protocol for patients with a gunshot-induced fracture with a stable, nonoperative configuration. Forty-one patients (44 fractures) with a grade I or II open, nonoperative fracture secondary to a low-velocity missile comprised the study population. Patients were treated by a standard protocol, which included 1 g of cefazolin administered in the emergency room and a 7-day course of oral cephalexin. Follow-up visits were performed until complete wound and fracture healing were achieved. Thirty-two (78%) of 41 patients underwent full follow-up. Average follow-up was 5.2 months. One (2.8%) fracture (distal fibula) developed a superficial infection, which responded to an additional week of oral antibiotics, and no patient developed a deep infection. There was 1 delayed union and 2 patients with painful retained shrapnel. These results demonstrate that patients with stable, low-velocity, gunshot-induced fractures can be managed effectively and safely on an outpatient basis using this protocol.

Axonal sprouting following lesions of the rat substantia nigra

Parkinson's disease is characterized by the progressive loss of dopaminergic neurons in the substantia nigra pars compacta. Symptoms do not appear until most nigral neurons are lost, implying that compensatory mechanisms are present. Sprouting has been proposed as one of these mechanisms. This study quantified the extent of compensatory axonal sprouting following injury of dopaminergic neurons within the substantia nigra pars compacta. Specifically, the extent of the axonal arbour and axonal varicosity morphology was measured after partial destruction (with 6-hydroxydopamine) of the substantia nigra of the adult male rat. Four months later, the substantia nigra was injected with the anterograde neuronal tracer dextran-biotin to trace the full extent of individual axons. An unbiased estimate of neuron number was performed in each animal. This demonstrated nigral neuronal loss ranging from 10 to 90% on the side that received the injection whilst a 7% reduction was observed in the side contralateral to the lesion. Coincident with this loss, some nigral neurons lose tyrosine hydroxylase expression. Vigorous axonal sprouting was observed in the terminal arbours of lesioned animals and was associated with an increased axonal varicosity size. Axonal varicosities and branching points were primarily confined to the dorsal 1.5mm of the caudate-putamen, an area predominantly innervated by nigral neurons. It appears that dopaminergic neurons were responsible for this sprouting because the density of dopamine transporter immunoreactive varicosities in the caudate-putamen was maintained until about a 70% loss of neurons. It was concluded that substantial compensation in the form of sprouting and new dopaminergic synapse formation occurs following lesions of the substantia nigra pars compacta.

The anatomy and cell biology of peripheral myelin protein-22

The gain of function phenotypes exhibited by the heterozygous Tr, Tr-J, and CMT1A mutations indicate that these mutations interfere with more than the function of a single PMP22 allele. The identification of proteins that interact with PMP22 and that are sensitive both to stoichiometry and the effects of the mutations could provide important leads to a unified hypothesis to explain the riddle of the PMP22-related neuropathies.

Biological hazards

This article outlines the biological hazards that nurses may face in their workplace. It hopes to inform nurses how they can reduce such hazards at work and contribute to a safer working environment.

Physiological evidence for arteriovenous anastomoses in the uterine circulation of late-pregnant ewes

1. The objective of the present study was to determine whether arteriovenous anastomoses (AVA) are present in the uterine circulation of conscious, late-pregnant ewes. 2. Twenty late-pregnant ewes were assigned to two groups. In group 1, 15 microm coloured microspheres were injected into the uterine artery of the pregnant horn and the relative proportion of microspheres trapped in the uterus and lungs was determined. The percentage shunting of blood measured by this method was 17+/-3%, representing a blood flow of 164+/-39 mL/min (n = 12). Any contribution of ovarian, cervical, rectal and other vascular beds was specifically excluded in this group. 3. In group 2, total uterine capillary flow was measured using the reference blood flow method, by injecting 15 microm microspheres into the heart. Calibrated flow probes, placed on both main uterine arteries, concurrently measured total uterine blood flow. Total blood flow to the uterus (flow probe) was significantly greater (t = 3.415; P = 0.027) than uterine capillary flow (microspheres), indicating AVA shunting in the uterine circulation. Mean total blood flow to the uterus was 1749+/-160 mL/min, of which an average 25+/-5% (n = 5 sheep) was shunted. 4. The percentage AVA shunting for groups 1 and 2 was not significantly different (t = 1.219; P = 0.24) and, when combined, the mean percentage of uterine blood flow passing through AVA in the late-pregnant sheep was determined to be 19+/-3%. 5. The present study shows that AVA are present and patent in the uterine circulation of late-pregnant ewes and that they account for the shunting of approximately 20% of the uterine blood flow into the maternal venous circulation.

Unrecognized pregnancy in the overdosed or poisoned patient

A 22-year-old woman was found in bed unresponsive and hypotensive after an apparent overdose. Subsequent workup in the emergency department identified a ruptured ectopic pregnancy and extensive hemoperitoneum. A significant delay occurred when emergency physicians excluded the possibility of pregnancy because of the patient's normal menstrual history. A qualitative serum or urine pregnancy test is recommended in all women of child-bearing age who present with poisoning or drug overdose.

[Collaboration between non-governmental organizations and governments for health sector reform]

One of the most prominent current trends is the vital and increasingly visible role played by nongovernmental organizations (NGOs) in the world in general and in the activities and conferences sponsored by the United Nations (UN). Given these circumstances, part of the mission of PAHO is to strengthen the ties between governments and NGOs through provision of technical cooperation and support in priority program areas, such as health care, and facilitation of the exchange of information and experiences. This report examines different lines of action designed to improve collaboration between NGOs and governments in the area of health sector reform.

[The United Nations confronts the challenges of a changing world: the 49th Annual DPI/NGO Conference]

The United Nations (UN), previously considered a forum exclusively for sovereign governments, has changed over time in tune with various political, economic, social, and cultural phenomena. One of these is the growing presence of nongovernmental organizations (NGOs) in international agencies and activities. The 49th Annual Conference of the Department of Public Information and NGOs, held at UN headquarters on 10 September 1996, analyzed the extent to which the UN is allowing NGOs to participate in its discussions of policy, institutional reform, and field operations. The issues discussed at the Conference and the challenges that face the UN in a changing world from the subject of this report.

Astrocyte reactivity in neonatal mice: apparent dependence on the presence of reactive microglia/macrophages

In neonatal mice, an acute injury produced by a stab wound to the cortex results in minimal astrocyte reactivity, as has been observed by others. However, if the source of the stab wound, a piece of nitrocellulose (NC) membrane, were now implanted in the cortex for a period of time (chronic NC implant injury), then extensive astroglial reactivity in the neonatal brain ensues. The astrogliosis is manifested by increased mRNA, protein content, and immunoreactivity for GFAP, and by ultrastructural changes. Given the previous reports that inflammatory cytokines are possible mediators of astrocyte reactivity (e.g., Balasingam et al: J Neurosci 14:846, 1994), we examined the brain parenchyma of neonatal mice following an NC stab or implant injury, with minimal or extensive astrogliosis, respectively, for a possible differential representation of inflammatory cells. A significant correlation (r = 0.87, P < 0.05) was observed between the occurrence of astrogliosis and the presence of reactive microglia/macrophages; no other inflammatory cell type was detected in the brain parenchyma of neonatal mice following NC implant injury. We suggest that reactive microglia/macrophages are required for the evolution of cells into reactive astrocytes following insults to the neonatal brain.

Outcome of rotationally unstable pelvic ring injuries treated operatively

Twenty-nine patients with unstable rotational injuries treated operatively were observed for an average of 39 months. There were 24 associated orthopaedic injuries. Twenty-seven patients had symphysis disruption (4 with rami fractures) and 2 had rami fractures associated with an acetabular fracture. Followup evaluation of those who could be evaluated in each category revealed that 96% had no pain or pain only on strenuous activity, ambulated without assistance or limitations, and returned to work. Open reduction and internal fixation of rotationally unstable pelvic fractures results in a high functional success rate.

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.

Discriminative power of visual evoked potential characteristics in multiple sclerosis

To investigate the discriminative power of pattern-reversal visual evoked potential characteristics (peak latencies and amplitude) and to test whether the addition of visual evoked potential amplitude can increase the power of the visual evoked potential in the diagnosis of multiple sclerosis, we retrospectively studied visual evoked potentials in 59 patients with definite multiple sclerosis and 126 control subjects. Two check sizes (17' and 10') were used. Females had significantly higher amplitudes and shorter latencies than males. N80 latency showed a gradual increase and P100 amplitude a decrease with age. P100 latency was stable between the ages of 20 and 55 years but was increased in childhood and the elderly. The significance of visual evoked potential peak latencies and amplitude in separating the two groups was investigated by means of a (multivariate) discriminant analysis. The visual evoked potential with a pattern of 10' could be measured in 58% of patients with multiple sclerosis. The exclusive use of the P100 amplitude in the discriminant analysis resulted in a percentage of correctly classified cases of 84%, whereas for P100 and N80 latency it was 85% and 90%, respectively. With the 17' pattern, the N80 latency yielded also a higher correct percentage than did the P100 latency. Although N80 latency is, to a greater extent than P100 latency, influenced by age, sex and size of stimulus pattern, when these influences are accounted for, the N80 latency is a more sensitive measure than P100 latency in the classification of multiple sclerosis. Combined use of latency and amplitude for discriminant analysis yielded no significant improvement of the percentage of correctly classified cases.

Specific binding of endocrine transforming growth factor-beta 1 to vascular endothelium

The presentation of recombinant biologically active 125I-TGF-beta 1 via the bloodstream to potential target cells in mice and rats was evaluated by quantitative light and electron microscope radioautography. Specificity was evaluated by in vivo competition with excess unlabeled TGF-beta 1, and integrity of the ligand at the binding site was demonstrated by trichloroacetic acid precipitation after extraction from tissues. The distribution of radiolabel at 2.5, 15, 30, 45, and 60 min after 125I-TGF-beta 1 injection revealed radiolabel principally over microvasculature endothelium but at times > 2.5 min over endothelial endocytic components indicative of internalization. Nonspecific binding of 125I-TGF-beta 1 to the apex of the proximal convoluted tubule of the kidney indicated it as the likely site of rapid clearance of TGF-beta 1 from the circulation, while a comparison of the binding of 125I-TGF-beta 1 (endothelial) to that of 125I-TGF-beta 1 complexed with alpha 2-macroglobulin-methylamine (liver parenchyma) indicated that clearance of TGF-beta 1 complexed alpha 2-macroglobulin was likely via the hepatic alpha 2-macroglobulin receptor. The endothelial TGF-beta receptors uncovered here are likely involved in the local regulatory mechanism of leukocyte and monocyte adhesion and tissue infiltration regulated by endocrine TGF-beta 1.

TUNAS AS SMALL AS 207 mm FORK LENGTH CAN ELEVATE MUSCLE TEMPERATURES SIGNIFICANTLY ABOVE AMBIENT WATER TEMPERATURE

Tunas (family Scombridae) maintain muscle temperatures (Tm) elevated significantly above ambient water temperature (Ta) by using vascular counter-current heat exchangers (retia mirabilia) to conserve metabolic heat generated by continuous contraction of red muscle fibers. Previous work has documented endothermy and both behavioral and physiological thermoregulation in tunas, but only individuals greater than approximately 1 kg body mass had been studied. The purpose of this study was to measure Tm and to examine heat exchanger morphology in smaller fish in order to determine the minimum size at which tunas can elevate Tm significantly above Ta. Measurements of Tm made immediately after capture in field-caught and laboratory-raised tunas (Euthynnus lineatus, Auxis thazard, A. rochei and Thunnus albacares) spanning a size range of 15.5&shy;667 mm fork length (FL) show that tunas 207 mm FL (162.3 g) and larger can elevate red muscle temperature by at least 3.0&deg;C above Ta. E. lineatus, A. thazard and A. rochei of this size possess blood vessels serving the red muscle that are arranged as both lateral and central heat exchangers; the smallest tuna with evidence of a rete was a 108.5 mm FL E. lineatus. In the ectothermic scombrid Scomberomorus sierra (108.7&shy;132.0 mm FL), Tm was elevated 0.2&shy;0.5&deg;C above Ta, and the greatest Tm elevation reported in any ectothermic species is only 2.7&deg;C. Taken together, these data provide evidence that tunas greater than 207 mm FL are endothermic.

Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results

To investigate the importance of arterial integrity in tibial fracture healing, the authors retrospectively assessed prognosis as a function of arterial injury in a large series of tibial fracture patients. The records of 114 patients who were treated for an open fracture of the tibia at a San Francisco hospital between 1981 and 1991 were selected for review; in each case, the injury had been caused by a blunt trauma, and arteriography had been performed to evaluate a suspected arterial injury in the ipsilateral extremity. Sixty-two patients had had a normal arteriogram and 52 had demonstrated occlusion of one or two of the three arteries that supply the foot. The group of patients who had demonstrated arterial occlusion had a significantly greater incidence of delayed union or nonunion (24 of 52 compared with ten of 62) and notably more cases of osteomyelitis (nine of 52 compared with four of 62); when the patients with osteomyelitis are excluded, the difference between the groups is still significant. This study is the first that indicates that patients with open fractures of the tibia who demonstrate arterial occlusion in their ipsilateral extremity may be more prone to delayed union or nonunion. More vigilant follow-up evaluation may therefore be warranted in such patients to better anticipate the need for exchange rodding or bone grafting.

Close encounters: an examination of UFO experiences

Ss who reported UFO experiences were divided into those whose experiences were nonintense (e.g., seeing lights and shapes in the sky) and those whose experiences were intense (e.g., seeing and communicating with aliens or missing time). On a battery of objective tests Ss in these 2 groups did not score as more psychopathological, less intelligent, or more fantasy prone and hypnotizable than a community comparison group or a student comparison group. However, Ss in the UFO groups believed more strongly in space alien visitation than did comparison Ss. The UFO experiences of Ss in the intense group were more frequently sleep-related than the experiences of Ss in the nonintense group. Among the combined UFO Ss, intensity of UFO experiences correlated significantly with inventories that assessed proneness toward fantasy and unusual sensory experiences. Implications are discussed.

Use of a Herbert screw for interphalangeal joint arthrodesis

Fifty-one Herbert-screw fixation procedures were performed for interphalangeal fusion in the hand. The preoperative diagnoses included rheumatoid arthritis, degenerative arthritis, posttraumatic arthritis, and chronic mallet finger. All patients were observed until there was clinical and radiographic evidence of union. Solid osseous union occurred in all patients. Herbert screw fixation for interphalangeal arthrodesis was a simple, effective technique permitting early mobilization; complications were minimal.

Close encounters: an examination of UFO experiences

Ss who reported UFO experiences were divided into those whose experiences were nonintense (e.g., seeing lights and shapes in the sky) and those whose experiences were intense (e.g., seeing and communicating with aliens or missing time). On a battery of objective tests Ss in these 2 groups did not score as more psychopathological, less intelligent, or more fantasy prone and hypnotizable than a community comparison group or a student comparison group. However, Ss in the UFO groups believed more strongly in space alien visitation than did comparison Ss. The UFO experiences of Ss in the intense group were more frequently sleep-related than the experiences of Ss in the nonintense group. Among the combined UFO Ss, intensity of UFO experiences correlated significantly with inventories that assessed proneness toward fantasy and unusual sensory experiences. Implications are discussed.

Determining the prognosis for limb salvage in major vascular injuries with associated open tibial fractures

Nineteen patients with open tibial fractures and associated arterial injuries were reviewed. Vascular injuries were documented by either arteriography (74%) or clinical examination and direct visualization of injuries intraoperatively. Arterial injuries were divided into those proximal to and those distal to the trifurcation. Proximal injuries involved the popliteal artery in all cases, whereas distal injuries involved the anterior tibial artery, posterior tibial artery, peroneal artery, or combinations of these arteries. All patients' limbs were initially considered salvageable. The eventual amputation rate was 58%. The Mangle Extremity Severity Scores ranged from 4 to 9, and Gustilo's open fracture classification system included 21% Type IIIB and 79% Type IIIC injuries. An isolated anterior tibial artery or peroneal artery injury had a good prognosis. A poor outcome was correlated with posterior tibial artery and popliteal artery injuries and injuries involving all three major distal trifurcation arteries simultaneously. These findings were statistically significant (P less than .05). Traditional criteria for primary amputation are reviewed, and the relevance of a varied prognosis with specific vascular injuries is discussed.

Localization of epidermal growth factor receptors in cells of the enamel organ of the rat incisor

Epidermal growth factor (EGF) is a peptide shown to effect precocious incisor tooth eruption in rat pups. Binding sites for EGF were visualized in the continuously erupting adult rat incisor by light and electron microscope radioautography after in vivo injection of 125I-EGF. These binding sites represented EGF receptors because of (i) competition between 125I-EGF binding at 2 min after injection and a coinjected excess of unlabeled EGF; (ii) the receptor-mediated endocytosis of 125I-EGF at 15 and 30 min after injection; and (iii) the demonstration of EGF receptor kinase activation in vivo. The stem and the mitotic cells in the epithelial odontogenic organ at the growing end of the tooth develop into two nondividing layers of the enamel organ: (i) ameloblasts which secrete enamel and are subsequently involved in the enamel maturation process, and (ii) papillary layer cells situated between the blood supply and the ameloblasts. Although few EGF receptors were present at the mitotic end, receptor density was highest at the mature end of the enamel organ. High levels of 125I-EGF binding were found on papillary layer cells and ruffle-ended, but not smooth-ended, ameloblasts. This implies a cyclical exteriorization and internalization of receptors during modulations between the two cell types. These data suggest that the EGF receptor mediates a major function of the enamel organ in the formation of enamel.

Growth retardation and the development of the respiratory system in fetal sheep

In an experimental model of fetal growth retardation which involves the reduction of placental mass in ewes, we have investigated the effects of intrauterine deprivation on aspects of structural development of the trachea and lungs of fetal sheep (140 days gestation). We have also measured the volume of luminal liquid aspirated from the lungs and the phospholipid content of this liquid as an index of pulmonary surfactant production. The effects of growth retardation are evident in the trachea where the structural development of the mucosal and submucosal layers has been affected. Abnormal aspects of development include the frequent lack of a ciliated border on epithelial cells in the mucosal layer and the reduction in the extent of the folds usually characteristic of this layer in near term fetal sheep. Although the fetal lungs are smaller in growth retardation (P less than 0.01) they are appropriate for fetal weight and their structural development does not appear to have been retarded. In contrast, lung liquid volume is significantly reduced in relation to lung weight in growth retarded fetuses and the concentration of phospholipids in lung liquids is also reduced (P less than 0.01).

Induction of acrosome reactions by chondroitin sulfates in vitro corresponds to nonreturn rates of dairy bulls

This study was designed to relate nonreturn rates to induction of acrosome reactions by the glycosaminoglycan chondroitin sulfate. Semen samples were obtained from four bulls above and four bulls below 65% nonreturn. Washed sperm from four ejaculates from each bull were incubated for 9 h with 0, 1, 10, or 50 micrograms/ml chondroitin sulfate. Acrosome reactions were evaluated by microscopy with Nomarski optics. Sperm from the higher fertility bulls exhibited significantly higher percentages of acrosome reactions to 10 and 50 micrograms/ml of chondroitin sulfate, and the slope of their dose-response regression line was significantly greater.

The effect of blinding and pinealectomy in unilaterally ovariectomized rats

Bilateral optic enucleation was observed to block partially the hypertrophy of the remaining ovary in unilaterally ovariectomized rats of a Charles River, CD strain. The inhibitory effects of blinding on compensatory ovarian hypertrophy (COH) were reversed when pinealectomy was performed at the same time as bilateral optic enucleation, three weeks prior to unilateral ovariectomy. Sham pinealectomy was without effect. When only pinealectomy was performed, a slight increase in COH was observed.

Serum follicle stimulating hormone (FSH) levels were estimated by a modification of the Steelman-Pohley bioassay in control, blinded, blindedpinealectomized and pinealectomized rats following unilateral ovariectomy. The increase in serum FSH at four days was blocked by blinding, an effect which was abolished by coupling pinealectomy with optic enucleation. Pinealectomy alone was followed by an increase in serum FSH slightly above control values.

These experiments demonstrate the blockage of COH by blinding and the mediation of this effect of blinding by the pineal gland. They further suggest that the increased secretion of FSH into the blood following unilateral ovariectomy is reduced under pineal influence.