Structural stigma within inpatient care for people who inject drugs: implications for harm reduction

BACKGROUND

 Individuals suffering with addiction have historically experienced disproportionally high levels of stigma. The process of inpatient care for those with substance abuse disorder (SUD) is multifaceted, shaped by the interplay of human interactions within the healthcare team and overarching structural factors like policy. While existing literature predominantly addresses personal and interpersonal stigma, the influence of structural stigma on care delivery practices remains understudied. Our research aims to investigate the impact of structural stigma on care processes for individuals with SUD admitted to acute medicine units.

METHODS

 We conducted a secondary analysis of observation notes and interview transcripts utilizing an analytic framework related to structural stigma adapted from previous research. Data was collected from June 2019 to January 2020 in 2 hospitals. 81 participants consented to observation and 25 to interviews. Interviews were conducted with patients (n = 8), healthcare staff (n = 16), and caregivers (n = 1).

RESULTS

 Each aspect of care for people with SUD is adversely influenced by structural forms of stigma. There was evidence of a gap in accessing care and time pressures which deteriorated care processes. Structural stigma also manifested in the physical spaces designed for care and the lack of adequate resources available for mental health and addictions care. We found that structural stigma perpetuated other forms of implicit and explicit stigma.

CONCLUSIONS

 Structural stigma and other forms of stigma are interconnected. Improving care for people with SUD in hospital settings may require addressing structural forms of stigma such as how physical spaces are designed and how mental healthcare is integrated with physical healthcare within inpatient settings.

216 IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM

Background

Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination¹. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.

Methods

The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.

We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1^st 2020 to January 12^th 2021.

A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.

Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.

Results

Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.

The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).

Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).

Conclusion

Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

Chlorhexidine Gluconate Bathing Program to Reduce Health Care-Associated Infections in Both Critically Ill and Non-Critically Ill Patients

BACKGROUND

Critical care nurses take care of patients with complicated, comorbid, and compromised conditions. These patients are at risk for health care-associated infections, which affect patients' lives and health care systems in various ways.

OBJECTIVE

To gauge the impact of routinely bathing patients with 4% chlorhexidine gluconate solution on the incidence of health care-associated infections in a medical-surgical intensive care unit and a postoperative telemetry unit; to outline the framework for a hospital-wide presurgical chlorhexidine gluconate bathing program and share the results.

METHODS

A standard bathing protocol using a 4% chlorhexidine gluconate solution was developed. The protocol included time studies, training, monitoring, and surveillance of health care-associated infections.

RESULTS

Consistent patient bathing with 4% chlorhexidine gluconate was associated with a 52% reduction in health care-associated infections in a medical-surgical intensive care unit. The same program in a postoperative telemetry unit yielded a 45% reduction in health care-associated infections.

CONCLUSION

A comprehensive daily 4% chlorhexidine gluconate bathing program can be implemented with standardized protocols and detailed instructions and can significantly reduce the incidence of health care-associated infections in intensive care unit and non-intensive care unit hospital settings.

Corrigendum to "Mixed methods feasibility study for the surviving opioid overdose with naloxone education and resuscitation (SOONER) trial" [Resuscitation Plus 6 (2021) 100131]

[This corrects the article DOI: 10.1016/j.resplu.2021.100131.].

Mixed methods feasibility study for the surviving opioid overdose with naloxone education and resuscitation (SOONER) trial

Aim

We plan to conduct a randomised clinical trial among people likely to witness opioid overdose to compare the educational effectiveness of point-of-care naloxone distribution with best-available care, by observing participants’ resuscitation skills in a simulated overdose. This mixed methods feasibility study aims to assess the effectiveness of recruitment and retention strategies and acceptability of study procedures.

Methods

We implemented candidate-driven recruitment strategies with verbal consent and destigmatizing study materials in a family practice, emergency department, and addictions service. People ≥16 years of age who are likely to witness overdose were randomized to point-of-care naloxone distribution or referral to an existing program. We evaluated participant skills as a responder to a simulated overdose 3–14 days post-recruitment. Retention strategies included flexible scheduling, reminders, cash compensation and refreshments. The primary outcome was recruitment and retention feasibility, defined as the ability to recruit 28 eligible participants in 28 days, with <50% attrition at the outcome simulation. Acceptability of study procedures and motivations for participation were assessed in a semi-structured interview.

Results

We enrolled 30 participants over 24 days, and retained 21 participants (70%, 95%CI 56.7–100). The most common motivation for participation was a desire to serve the community or loved ones in distress. Participants reported that study procedures were acceptable and that the outcome simulation provided a supportive and affirming environment.

Conclusion

The planned trial is ready for implementation. Recruitment and retention is feasible and study processes are acceptable for people who are likely to witness overdose. (Registration: NCT03821649).

Metabolomics and a breath sensor identify acetone as a biomarker for heart failure

Introduction

Metabolomics delivers more biological and clinical insight than targeted investigations. We applied metabolomics to patients with heart failure (HF) with reduced ejection fraction (HFrEF).

Methods

46 patients with HFrEF and 20 controls underwent metabolomic profiling, including liquid/gas chromatography mass spectrometry (LC-MS/GC-MS), nuclear magnetic resonance (NMR) metabolomics and solid-phase microextraction (SPME) volatilomics in plasma and urine. HFrEF was defined using left ventricular global longitudal strain (GLS) &lt;18%, ejection fraction &lt;50% and NTproBNP ≥35 pmol/L. A low cost consumer breath acetone (BrACE) sensor validated SPME results in 69 patients.

Results

34 metabolites were identified by GCMS, 33 by LCMS and 2 volatiles by SPME (acetone, 2-pentanone in plasma and urine). Alanine, aspartate and glutamate, citric acid cycle, arginine biosynthesis, glyoxylate and dicarboxylate metabolism were altered in HFrEF. Plasma acetone correlated with NT-proBNP (r=0.59, 95% CI 0.4 to 0.7), triacylglycerol (55:9), 2-oxovaleric and cis-aconitic acid, involved with ketone metabolism and mitochondrial energetics. BrACE &gt;1.5 ppm discriminated HF from other cardiac pathology (AUC 0.88, 95% CI 0.77 to 0.99, P&lt;0.0001).

Conclusion

Breath acetone was detectable in HFrEF patients using a consumer sensor ($1/test) and although not cardiac specific, discriminated HF from other cardiac pathology.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Health Research Council of New Zealand

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada

BACKGROUND

There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender.

METHODS

Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender.

RESULTS

Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men.

CONCLUSION

Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

Expression of BrpA in Streptococcus mutans is regulated by FNR-box mediated repression

Our previous studies showed that brpA in Streptococcus mutans, which encodes a member of the LytR-CpsA-Psr family of proteins, can be co-transcribed with brpB upstream as a bicistronic operon, and the intergenic region also has strong promoter activity. To elucidate how brpA expression is regulated, the promoter regions were analyzed using polymerase chain reaction-based deletions and site-directed mutagenesis and a promoterless luciferase gene as a reporter. Allelic exchange mutagenesis was also used to examine genes encoding putative trans-acting factors, and the impact of such mutations on brpA expression was analyzed by reporter assays. Multiple elements in the short brpA promoter (nucleotide -1 to -344 relative to start cordon ATG) were shown to have a major impact on brpA expression, including an FNR-box, for a putative binding site of an FNR-type of transcriptional regulator. When compared with the intact brpA promoter, mutations of the highly conserved nucleotides in FNR-box from TTGATgtttAcCtt to TTACAgaaaGtTac resulted in 1362-fold increases of luciferase activity (P < .001), indicative of the FNR-box-mediated repression as a major mechanism in regulation of brpA expression. When luciferase reporter was fused to the upstream brpBA promoter (nucleotides -784 to -1144), luciferase activity was decreased by 4.5-fold (P < .001) in the brpA mutant, TW14D, and by 67.7-fold (P < .001) in the brpB mutant, JB409, compared with the wild-type, UA159. However, no such effects were observed when the reporter gene was fused to the short brpA promoter and its derivatives. These results also suggest that brpA expression in S. mutans is auto-regulated through the upstream brpBA promoter.

Lessons Learned After Losing my Brother to an Overdose: A Call to Action for Nurse Leaders

The current overdose epidemic we are facing in Canada and internationally calls on nursing leaders to prioritize holistic and compassionate care for people who use drugs (PWUD) and their families. Nurses are well positioned to provide person-centred care and advocate with and for this population. To do so requires an examination of one's personal values and beliefs surrounding drugs and the people who use them. As a nurse leader, I was forced to confront my views about illicit drug use following the untimely death of my brother Brad from overdose. This paper chronicles my personal experience with his death and subsequent journey into advocacy for drug policy reform amidst an emerging overdose crisis. This short paper is written from my personal perspective, and informed by both personal and professional experiences in drug policy reform. It addresses strategies for challenging stigma and opportunities for partnering with PWUD through engagement in harm reduction.

A systematic quality assessment of Environmental Impact Statements in the oil and gas industry

The global economy relies heavily on oil and gas resources. However, hydrocarbon exploitation projects can cause significant impacts on the environment. But despite the production of numerous Environmental Impact Statements (EISs) to identify/mitigate such impacts, no study has specifically assessed the quality of EISs for both onshore and offshore oil and gas projects, with tested hypotheses. To address this research gap, our paper, for the first time, develops a modified Lee and Colley evaluation model to assess the quality of 19 sampled oil and gas project EISs produced from 1998 to 2008 in Nigeria. Our findings show that Project Description and Communication of Results are the main areas of strength. However, Environmental Impact Prediction, and Project Decommissioning, were among the key areas requiring attention. A key finding, though, is that Mann-Whitney tests suggest that there is no evidence that the quality of EISs for the latter period (2004-2008) is higher than that of the earlier period (1998-2004). We suggest that periodic systematic review of the quality of submitted/approved EISs (c. every 3-5years) should be established to monitor trends in EIS quality and identify strong and weak areas. This would help to drive continual improvement in both the EIA processes and the resultant EISs of technical engineering projects. Such reviews have the potential to illuminate some of the underlying problems of, and solutions to, oil and gas exploration, production and transportation, and their related environmental impacts. This suggested change would also be useful internationally, including for the burgeoning exploration and production of unconventional hydrocarbon resources.

Debunking health IT usability myths

Poor usability is a threat to patient safety and linked to productivity loss, workflow disruption, user frustration, sub-optimal product use and system de-installations. Although usability is receiving more attention nationally and internationally, myths about usability persist. This editorial debunks five common myths about usability (1) usability only concerns the look and feel of a product and is, therefore, only a minor concern, (2) usability is not measurable, (3) usability stifles innovation, (4) vendors are solely responsible for product usability, and (5) usability methods are not practical for use in healthcare.

Periodic paralysis: an unusual presentation of thyrotoxicosis

Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis and is up to 20 times more common in males. Cases usually present with painless muscle weakness precipitated by heavy exercise, fasting, an alcohol binge or large carbohydrate meal. Serum potassium is low in the majority, but normokalaemic (or even hyperkalaemic) TPP is recognised. Acute treatment of any electrolyte disorder, administration of a beta-blocker and treatment of the thyrotoxicosis leads to complete resolution. This rare diagnosis should be considered by the Acute Physician when confronted with any case of muscle weakness.

Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital

OBJECTIVE

To review the effect of interventions, including a complete restriction in the use of fluoroquinolones (FQs), used to control an outbreak of hospital-onset Clostridium difficile infection (HO-CDI) caused primarily by the epidemic North American pulsed-field gel electrophoresis type 1 strain.

DESIGN

Retrospective cohort and case-control study of all episodes of HO-CDI both before and after 2 interventions.

SETTING

Community hospital; January 1, 2005, through March 31, 2007. Interventions. Complete, 5-month, facility-wide restriction of fluoroquinolone use, during which a change in the environmental-services contractor occurred.

RESULTS

During a 27-month period, 319 episodes of HO-CDI occurred. The hospital-wide mean defined daily doses of antimicrobials decreased 22% after restricting FQ use, primarily because of a 66% decrease in the use of FQs. The interventions were also associated with a significant change in the HO-CDI incidence trends and with an absolute decrease of 22% in HO-CDI cases caused by the epidemic strain (from 66% before the intervention period to 44% during and after the intervention period; P=.02). Univariate analysis revealed that case patients with HO-CDI due to the epidemic strain were more likely than control patients, who did not have diarrhea, to receive a FQ, whereas case patients with HO-CDI due to a nonepidemic strain were not. However, FQ use was not significantly associated with HO-CDI in multivariable analysis.

CONCLUSIONS

An outbreak of epidemic-strain HO-CDI was controlled at a community hospital after an overall decrease in antimicrobial use, primarily because of a restriction of FQ use and a change in environmental-services contractors. The restriction of FQ use may be useful as an adjunct control measure in a healthcare facilities during outbreaks of epidemic-strain HO-CDI.

One stop fertility clinic

The objective of this study was to determine the feasibility and acceptability of out-patient based investigation of infertile couples using a prospective observational study based in a large undergraduate teaching hospital. We studied couples referred to secondary care for investigation of their infertility. Investigations involved pelvic ultrasound, diagnostic hysteroscopy and culdoscopy. The main outcome measures were feasibility of investigations, findings, patient views, and a management plan.

RESULTS

199 of 347 (57.3%) couples referred met our selection criteria, and 162 of this group have attended. Thirty-one (19.1%) were judged to be unsuitable for culdoscopy, and culdoscopy failed in a further 29 (17.9%). The average time for the three procedures was 41.2 (SD 17.2) minutes, and over 1/3 of patients were found to have pelvic pathology. The investigations were well tolerated and there was only one complication necessitating admission to hospital. Most patients appreciated the need for a single hospital visit and the availability of immediate results.

CONCLUSIONS

A One Stop approach to the investigation of infertility is attractive but not suitable for or desired by all infertile couples. Organisational issues were also identified.

Synergistic neurotoxicity of carbon tetrachloride/carbon disulfide (80/20 fumigants) and other pesticides in grain storage workers

Neurophysiologic, neurobehavioral, and neuropsychologic profiles in 17 grain storage workers, 1 grain inspector, and 4 malting laboratory workers are described. The effects of CS2 toxicity as seen in viscose rayon workers as well as in experimental animals is remarkably similar to the clinical profile of our grain storage workers. CS2 use explains the dysfunction of peripheral axons, auditory nerve, the optic nerve, and the extrapyramidal system, as well as altered behavior and cognition changes. The signs and symptoms in these workers seem to be dose-related and we note that workers separated out from the areas where fumigation took place reported improvement not seen by fellow workers who continued the fumigant treatment routine. Likewise, malting laboratory workers exposed only to the grain dust from 3 to 7 years showed only minimal symptoms. Though a number of mechanism have been suggested for the alteration of neuropsychological function, the chelating ability of DDC derived from CS2 and its ability to markedly increase copper and zinc within the central nervous system suggests a mechanism of toxicity analogous to copper intoxication as in Wilson's Disease and may explain the production of extrapyramidal symptoms in these patients. Chelation of copper might prove therapeutic in CS2 poisoning. It is obvious that both basic and clinical research will be necessary to sort out the questions raised. We applaud the EPA's decision to ban the use of 80/20 fumigants and also methyl bromide, and trust that similar toxic substances be carefully studied before their selection for replacing these previous toxic agents. We further decry the technique of re-introducing grain dust into the food chain rather than destroying it, since the dust contains very high residues of fumigant material. We speculate on the possible role of CS2 and other pesticides in the food chain and the incidence of Parkinsonian symptoms in these patients and the general public.

A critical analysis of the benefits and limitations of an applied degree in undergraduate nursing education

The purpose of this paper is to present a critical analysis of the applied degree in nursing as an alternative to collaborative models of undergraduate education delivery by different post-secondary institutions. The notion of having multiple levels of entry into nursing (Northrup et al. 2004) and the authority of colleges to award degrees in nursing (Skolnik 1994) have important practical implications for the profession. Since there is a paucity of Canadian literature about applied degrees in nursing, this paper will make an important contribution to the field of nursing education. Due to the collaborative partnerships that have emerged in many jurisdictions in order to meet the baccalaureate degree as the entry-to-practice requirement, an analysis of the Applied Degree in Nursing is relevant and timely. The paper provides a brief history of the baccalaureate degree as the entry-to-practice requirement for nursing, along with an overview of the rationale for the baccalaureate degree from regulatory, research, academic and practice perspectives. Through an analysis of the benefits, limitations and implications of the applied degree, we conclude that this new applied baccalaureate challenges nursing's status as an academic discipline.

Investigation of retroviral involvement in chronic fatigue syndrome

Within the last few years significant efforts have been made to identify objective reliable diagnostic markers from individuals with chronic fatigue syndrome (CFS). We report the absence of a previously described retroviral marker (HTLV-II gag) in a blinded study of CFS cases. Even with excellent reproducible sensitivities, this marker failed in repeated attempts to distinguish cases from controls. In addition, four other retroviruses (simian T cell leukaemia virus, human spumavirus, bovine leukaemia virus and simian retrovirus) were examined for their presence in these CFS cases and found to be absent. Our findings suggest that these agents, at least as markers, are non-distinguishing for CFS and that other factors may be confounding the resolution of an aetiology to this syndrome.

Inter-Rater Reliability of the Diagnoses of Psychosis and Depression in Individuals with Intellectual Disabilities

BACKGROUND: There is a history of over-prescription of antipsychotics to individuals with intellectual disability (ID), while antidepressants may be under-prescribed. However, appropriate treatment is best supported when the diagnosis of psychosis or depression is valid and carries good predictive validity. The present authors report a study examining one aspect of validity, namely whether skilled clinicians can agree on whether an individual with an ID is psychotic or depressed. MATERIALS AND METHODS: Pairs of clinicians assessed 52 individuals. Agreement was assessed using Cohen's kappa statistic and agreement proportion. RESULTS: Overall agreement was high for both psychosis and depression. Whether the individual had mild ID or moderate/severe ID did not have a significant impact on agreement. CONCLUSIONS: Experienced clinicians achieved a high level of agreement as to whether a person with ID was psychotic or depressed similar to that found for those without ID. The findings provide some support for treatment interventions based on diagnosis.

DNA recognition by the oestrogen receptor: from solution to the crystal

BACKGROUND

The steroid/nuclear hormone receptors are a large family of conserved ligand-activated transcription factors that regulate gene expression through binding to response elements upstream of their target genes. Most members of this family bind to DNA as homodimers or heterodimers and recognize the sequence, spacing and orientation of the two half-sites of their response elements. The recognition and discrimination of the sequence and arrangements of these half-sites are mediated primarily by a highly conserved DNA-binding domain.

RESULTS

Here we describe the DNA-binding properties of the isolated DNA-binding domain of the oestrogen receptor, the ERDBD, and its refined NMR structure. This domain is monomeric in solution, but two molecules bind cooperatively to specific DNA sequences; this cooperativity determines the arrangement of half-sites that is recognized by the ERDBD. The 10 carboxy-terminal residues and a region of 15 residues within the domain are disordered in the solution structure, yet are important for DNA binding.

CONCLUSION

The cooperative nature of ERDBD binding to DNA is important. The previously-determined X-ray structure of the ERDBD dimer bound to DNA shows that the 15 internal residues disordered in solution make contact both with DNA and with the corresponding region of the other monomer. These results suggest that these residues become ordered during the process of binding to DNA, forming the dimer interface and thus contributing to the cooperative interaction between monomers.

Structure of the TRFH dimerization domain of the human telomeric proteins TRF1 and TRF2

TRF1 and TRF2 are key components of vertebrate telomeres. They bind to double-stranded telomeric DNA as homodimers. Dimerization involves the TRF homology (TRFH) domain, which also mediates interactions with other telomeric proteins. The crystal structures of the dimerization domains from human TRF1 and TRF2 were determined at 2.9 and 2.2 A resolution, respectively. Despite a modest sequence identity, the two TRFH domains have the same entirely alpha-helical architecture, resembling a twisted horseshoe. The dimerization interfaces feature unique interactions that prevent heterodimerization. Mutational analysis of TRF1 corroborates the structural data and underscores the importance of the TRFH domain in dimerization, DNA binding, and telomere localization. A possible structural homology between the TRFH domain of fission yeast telomeric protein Taz1 with those of the vertebrate TRFs is suggested.

Outbreak of vancomycin-resistant Enterococcus faecium in a neonatal intensive care unit

An outbreak of vancomycin-resistant Enterococcus faecium involving 28 infants in a neonatal intensive care unit was observed. Successful control of the outbreak was achieved following use of patient and staff cohorting, contact isolation precautions, patient and environmental surveillance cultures, environmental decontamination, molecular typing, introduction of an alcohol-based hand disinfectant, and decreased use of vancomycin.

Specific interactions of the telomeric protein Rap1p with nucleosomal binding sites

The telomeres of Saccharomyces cerevisiae are structurally and functionally well characterized. Their telomeric DNA is packaged by the protein Rap1p (repressor activator protein 1). Rap1p is a multifunctional, sequence-specific, DNA-binding protein which, besides participating in the regulation of telomeres structure and length, is also involved in transcriptional regulation of genes essential for cell growth and in silencing. Whereas the long tracts of telomeric DNA repeats of higher eukaryotes are mostly organized in closely spaced canonical nucleosomal arrays, it has been proposed that the 300 base-pairs of S. cerevisiae telomeric DNA are organized in a large non-nucleosomal structure that has been called the telosome. Recently, nucleosomes have been found also in Tetrahymena thermophila telomeres, suggesting that, in general, telomere structural differences between lower and higher eukaryotes could be quantitative, rather than qualitative. Using an in vitro model system, we have addressed the question of whether Rap1p can form a stable ternary complex with nucleosomes containing telomeric binding sites, or competes with nucleosome core formation. The approach we have taken is to place a single Rap1p-binding site at different positions within a nucleosome core and then test the binding of Rap1p and its DNA-binding domain (Rap1p-DBD). We show here that both proteins are able to specifically recognize their nucleosomal binding site, but that binding is dependent on the location of the site within the nucleosome core structure. These results show that a ternary complex between a nucleosome and Rap1p is stable and could be a possible intermediate between telomeric nucleosomes and telosomes in the dynamics of S. cerevisiae telomere organization.

Neural correlates of recovery from aphasia after damage to left inferior frontal cortex

OBJECTIVE

To determine neural correlates of recovery from aphasia after left frontal injury.

METHODS

The authors studied the verbal performance of patients with infarcts centered in the left inferior frontal gyrus (IFG), using a battery of attention-demanding lexical tasks that normally activate the left IFG and a simpler reading task that does not normally recruit the left IFG. The authors used positron emission tomography (PET) and functional MRI (fMRI) to record neural activity in the same group of patients during word-stem completion, one of the attention-demanding lexical tasks. To identify potential neural correlates of compensation/recovery, they analyzed the resulting data for the group as a whole (PET, fMRI) and also for each participant (fMRI).

RESULTS

Patients with damage to the left IFG were impaired on all attention-demanding lexical tasks, but they completed the word-reading tasks normally. The imaging studies demonstrated a stronger-than-normal response in the right IFG, a region homologous to the damaged left IFG. The level of activation in the right IFG did not correlate with verbal performance, however. In addition, a perilesional response within the damaged left IFG was localized in the two patients who gave the best performance in the word-stem completion task and showed the most complete recovery from aphasia.

CONCLUSIONS

Right-IFG activity may represent either the recruitment of a preexisting neural pathway through alternative behavioral strategies or an anomalous response caused by removal of the left IFG. Perilesional activity in the left IFG may represent sparing or restoration of normal function in peri-infarctual tissue that was inactive early on after injury. This activity may be of greater functional significance than right IFG activity because it was associated with more normal verbal performance.

The influence of nutrition on methyl mercury intoxication

This article reviews progress in the research of methyl mercury (MeHg) and nutrient interactions during the past two decades. Special emphasis is placed on the following three major areas: a) effects on kinetics, b) effects on toxicity, and c) possible mechanisms. Dietary information is not usually collected in most epidemiologic studies examining of the effects of MeHg exposure. However, inconsistency of the MeHg toxicity observed in different populations is commonly attributed to possible effects of dietary modulation. Even though the mechanisms of interaction have not been totally elucidated, research in nutritional toxicology has provided insights into the understanding of the effects of nutrients on MeHg toxicity. Some of this information can be readily incorporated into the risk assessment of MeHg in the diets of fish-eating populations. It is also clear that there is a need for more studies designed specifically to address the role of nutrition in the metabolism and detoxification of MeHg. It is also important to collect more detailed dietary information in future epidemiologic studies of MeHg exposure.

Simian foamy virus infection among zoo keepers

We investigated 322 North American zoo workers in an anonymous serosurvey for antibodies to simian foamy viruses to establish the potential risk of zoonotic transmission by these retroviruses. 4 of 133 (3%) individuals who worked specifically with mammals including primates were seropositive, primarily with chimp-like viruses, indicating the importance of work practices to reduce exposure to these agents.

Distance learning for post-registered nursing: the facts

AIM

To explore nurses' perceptions and evaluate the potential of distance learning as a method of teaching for post-registered nurses working in the community.

METHOD

The study used open-ended questions in focus groups. Each group consisted of nine students each with an interest in post-registration learning. The interviews were taped and transcribed (n = 18).

RESULTS

The respondents saw distance learning as a necessary way of updating their knowledge, as long as the education provided was relevant to their practice. They also saw this method of learning as an opportunity to take responsibility for their own learning. There was a conflict of opinion, however, as some respondents felt the courses to be a flexible way to teach and learn, while others found the courses to be too focussed and not necessarily relevant.

CONCLUSION

The study provides an insight into distance learning and what some post-registered nurses perceive to be important factors associated with it as a method of teaching. It suggests that post-registered nurses working in the community will benefit from distance learning as a method of teaching.

Localization of a putative transcriptional regulator (ATRX) at pericentromeric heterochromatin and the short arms of acrocentric chromosomes

ATRX is a member of the SNF2 family of helicase/ATPases that is thought to regulate gene expression via an effect on chromatin structure and/or function. Mutations in the hATRX gene cause severe syndromal mental retardation associated with alpha-thalassemia. Using indirect immunofluorescence and confocal microscopy we have shown that ATRX protein is associated with pericentromeric heterochromatin during interphase and mitosis. By coimmunofluorescence, ATRX localizes with a mouse homologue of the Drosophila heterochromatic protein HP1 in vivo, consistent with a previous two-hybrid screen identifying this interaction. From the analysis of a trap assay for nuclear proteins, we have shown that the localization of ATRX to heterochromatin is encoded by its N-terminal region, which contains a conserved plant homeodomain-like finger and a coiled-coil domain. In addition to its association with heterochromatin, at metaphase ATRX clearly binds to the short arms of human acrocentric chromosomes, where the arrays of ribosomal DNA are located. The unexpected association of a putative transcriptional regulator with highly repetitive DNA provides a potential explanation for the variability in phenotype of patients with identical mutations in the ATRX gene.

Marked improvement in asthma after Lap-Band surgery for morbid obesity

BACKGROUND

Asthma and morbid obesity are common chronic conditions that may be related. Laparoscopic banding provides effective weight control of morbid obesity. The aim of this study was to evaluate the prevalence of asthma in the morbidly obese and the changes in asthma after laparoscopic adjustable gastric banding (LAGB) (Lap-Band) surgery for morbid obesity.

METHODS

Asthma was assessed preoperatively in all patients presenting for LAGB. 32 consecutive asthmatic patients were followed up clinically and by a standard questionnaire at least 12 months after surgery, and any change in asthma impact was recorded.

RESULTS

The prevalence of the doctors' diagnosis of asthma was 24.6% (73 of 296 consecutive patients). This was significantly higher than the prevalence in the Australian community of 12% to 13% (P < 0.001). The 32 patients who were followed up had a mean body weight of 125.2 kg and a body mass index (BMI) of 45.7 kg/m2 prior to operation, and a weight of 89.3 kg (BMI 32.9 kg/m2) at follow-up. All 32 patients recorded a lower asthma score postoperatively. There were significant improvements in all aspects of asthma assessed. These included severity, daily impact, medications needed, hospitalization, sleep, and exercise. The mean preoperative scaled asthma score was 44.5 +/- 16. There was a highly significant reduction at follow-up to a mean value of 14.3 +/- 11 (P < 0.001).

CONCLUSIONS

There is a high prevalence of asthma in morbidly obese adults, and major reductions in asthma severity occur after Lap-Band(r) surgery and weight loss. Mechanisms other than direct weight loss appear to play a part in this improvement. Prevention of gastroesophageal reflux may be an important factor.

Polymerase chain reaction assays for the diagnosis of infection with the porcine endogenous retrovirus and the detection of pig cells in human and nonhuman recipients of pig xenografts

BACKGROUND

Pigs offer an unlimited source of xenografts for humans. However, recipients of pig xenografts are inevitably exposed to the porcine endogenous retrovirus (PERV), which is carried in the pig germline. The ability of PERV to infect human cells in vitro has heightened safety concerns regarding the transmission of PERV to pig xenograft recipients.

METHODS

In response to the need to establish laboratory tests for the surveillance of PERV infection, we have developed polymerase chain reaction (PCR) assays to detect PERV pol and gag sequences by using conserved primers and probes. In addition, we have developed a PCR assay to detect pig-specific mitochondrial DNA (mtDNA) sequences as a marker of pig cells.

RESULTS

Analysis of assay sensitivities using cloned target copies in a background of human DNA demonstrated a detection threshold of 1, 5, and 1 copy for the PERV gag, pol, and pig mtDNA PCR assays, respectively. All three PCR assays gave negative results on peripheral blood lymphocyte samples from 69 humans, as well as 6 baboons and 6 macaques, demonstrating 100% specificity. The PERV and pig mtDNA assays were integrated into a simple testing algorithm that allows the differentiation between pig cell microchimerism and true xenogeneic infection. To allow for monitoring of PERV expression, a reverse transcriptase-PCR assay was also developed to detect cell-free PERV RNA.

CONCLUSION

The use of the diagnostic tests described here will help define the risks of PERV transmission associated with the use of pig xenografts in humans and nonhuman primates.

Saponins and phenolic content in plant dietary additives of a traditional subsistence community, the Batemi of Ngorongoro District, Tanzania

Reports of plants added to milk and meat-based soups by the Maasai and Batemi in East Africa support a role for phenolic antioxidants and hypocholesterolemic agents in the diet, and provide explanation of the low incidence of cardiovascular disease of populations that traditionally consume high levels of dietary fat and cholesterol. Plant food additives used by the Batemi of Ngorongoro District, Tanzania, were tabulated, based on interviews with 22 informants, while 17 specimens were collected in the field and analyzed for saponin and phenolic content. A total of 81% of the Batemi additives and 82% of those known to be used by the Maasai contain potentially hypocholesterolemic saponins and/or phenolics.

Effects of psycho-educational interventions on sexual health risks and psycho-social adaptation in young adults with genital herpes

The purpose of this study was to test the outcomes of group psycho-educational intervention (PEI) led by nurses on sexual health risks (knowledge, behaviour, disease burden) and psycho-social adaptation (depression, mood states, self-efficacy) in young adults with the chronic disease, genital herpes. Two hundred and fifty-two young adults with symptomatic genital herpes participated in a randomized controlled trial (RCT). The intervention was participation in a three-session group PEI facilitated by a nurse in the community. Participants completed questionnaires measuring sexual health risks (herpes knowledge, sexual risk behaviour, disease burden of patterns of recurrences of outbreaks of the disease), and psycho-social adaptation (depression using the Beck Depression Inventory [BDI], mood states using the Profile of Mood States [POMS], and feelings of self-efficacy for protection from sexually transmitted diseases [PSTD]) at induction into the study, and at 3 and 6 months. Participants were mainly employed, Caucasian, single women in their twenties (X = 27.1 years, SD = 4.3), with some college education; 23% of the sample were men. After controlling for baseline knowledge about genital herpes, the experimental group had significantly more knowledge than the control group at 3 and 6 months' post-intervention. They also reported using condoms and spermicides to prevent the spread of genital herpes more often than did the control group. The implications for nurses in the community include the following: (a) PEI is an intervention that can be used by nurses in the community with a high-risk population; (b) group intervention is a viable treatment for people with a highly stigmatized, chronic sexually transmitted disease (STD); and (c) further testing of the use of PEI by nurses in the community with other high-risk populations is needed.