Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol

INTRODUCTION

Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives.

METHODS AND ANALYSIS

Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives.

PROTOCOL REGISTRATION

https://osf.io/beqjr.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Applying an equity lens to hospital safety monitoring: a critical interpretive synthesis protocol

INTRODUCTION

Hospital safety monitoring systems are foundational to how adverse events are identified and addressed. They are well positioned to bring equity-related safety issues to the forefront for action. However, there is uncertainty about how they have been, and can be, used to achieve this goal. We will undertake a critical interpretive synthesis (CIS) to examine how equity is integrated into hospital safety monitoring systems.

METHODS AND ANALYSIS

This review will follow CIS principles. Our initial compass question is: How is equity integrated into safety monitoring systems? We will begin with a structured search strategy of hospital safety monitoring systems in CINAHL, EMBASE, MEDLINE and PsycINFO for up to May 2023 to identify papers on safety monitoring systems generally and those linked to equity (eg, racism, social determinants of health). We will also review reference lists of selected papers, contact experts and draw on team expertise. For subsequent literature searching stages, we will use team expertise and expert contacts to purposively search the social science, humanities and health services research literature to support the development of a theoretical understanding of our topic. Following data extraction, we will use interpretive processes to develop themes and a critique of the literature. The above processes of question formulation, article search and selection, data extraction, and critique and synthesis will be iterative and interactive with the goal to develop a theoretical understanding of equity in hospital monitoring systems that will have practice-based implications.

ETHICS AND DISSEMINATION

This review does not require ethical approval because we are reviewing published literature. We aim to publish findings in a peer-reviewed journal and present at conferences.

Quality Indicators for Youth Transitioning to Adult Care: A Systematic Review

BACKGROUND AND OBJECTIVE

Transition from pediatric to adult care is associated with adverse health outcomes for many adolescents with chronic illness. We identified quality indicators for transition to adult care that are broadly applicable across chronic illnesses and health systems.

METHODS

Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature were searched, covering earliest available date to July 2021. The Gray Matters framework was used to search gray literature. Two independent reviewers screened articles by title and abstract, followed by full-text review. Disagreements were resolved by a third reviewer. Studies were included that identified quality indicators developed via consensus-building methods. Indicators were organized into a framework categorized by illness specificity, level of care, Donabedian model, and Institute of Medicine quality domain. Appraisal of Guidelines for Research and Evaluation tool was used for critical appraisal.

RESULTS

The search identified 4581 articles, of which 321 underwent full-text review. Eight peer-reviewed studies and 1 clinical guideline were included, identifying 169 quality indicators for transition. Of these, 56% were illness specific, 43% were at the patient level of care, 44% related to transition processes, and 51% were patient centered and 0% equity focused. Common indicator themes included education (12%), continuity of care (8%), satisfaction (8%), and self-management/self-efficacy (7%). The study was limited by quality indicators developed through consensus-building methodology.

CONCLUSIONS

Although most quality indicators for transition were patient-centered outcomes, few were informed by youth and parents/caregivers, and none focused on equity. Further work is needed to prioritize quality indicators across chronic illness populations while engaging youth and parents/caregivers in the process.

Influence of patient-related factors on intraoperative blood loss during double opposing Z-plasty Furlow palatoplasty and buccal fat pad coverage: A prospective study

Background

Surgical procedures including palatoplasty have a risk for complications. The aim of this study was to investigate the intraoperative and early postoperative blood loss using the buccal fat pad (BFP) during cleft lip and/or cleft palate (CL/P) surgery.

Material and Methods

This prospective study included a total of 109 patients with cleft palate (CP) during a three-month period of treatment at Hasanuddin University Dental Hospital (permanent center) and charity trips in rural parts of Eastern Indonesia. All patients were treated with DOZ Furlow technique combined with BFP graft. Before and after surgery, the total amount of intraoperative blood loss was calculated by measuring the weight differences of the gauze swabs that were used to control the surgical bleeding followed by a complete blood count at three days postoperatively.

Results

The difference in the amount of blood loss based on age categories in charity groups was found to be significant (P<0.05). Overall, we found that high body weight and operation time significantly contributed to increased blood loss (P<0.05).

Conclusions

Weight and operative time can contribute to more blood loss during palatoplasty.

Key words:Buccal fat pad, complication, cleft lip, cleft palate, palatoplasty.

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review

OBJECTIVE

To characterise the extent to which health professionals perform SBAR (situation, background, assessment, recommendation) as intended (ie, with high fidelity) and the extent to which its use improves communication clarity or other quality measures.

DATA SOURCES

Medline, Healthstar, PsycINFO, Embase and CINAHL to October 2020 and handsearching selected journals.

STUDY SELECTION AND OUTCOME MEASURES

Eligible studies consisted of controlled trials and time series, including simple before-after design, assessing SBAR implementation fidelity or the effects of SBAR on communication clarity or other quality measures (eg, safety climate, patient outcomes).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently abstracted data according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses on study features, intervention details and study outcomes. We characterised the magnitude of improvement in outcomes as small (<20% relative increase), moderate (20%-40%) or large (>40%).

RESULTS

Twenty-eight studies (3 randomised controlled trials, 6 controlled before-after studies, and 19 uncontrolled before-after studies) met inclusion criteria. Of the nine studies assessing fidelity of SBAR use, four occurred in classroom settings and three of these studies reported large improvements. The five studies assessing fidelity in clinical settings reported small to moderate effects. Among eight studies measuring communication clarity, only three reported large improvements and two of these occurred in classroom settings. Among the 17 studies reporting impacts on quality measures beyond communication, over half reported moderate to large improvements. These improvements tended to involve measures of teamwork and culture. Improvements in patient outcomes occurred only with intensive multifaceted interventions (eg, early warning scores and rapid response systems).

CONCLUSIONS

High fidelity uptake of SBAR and improvements in communication clarity occurred predominantly in classroom studies. Studies in clinical settings achieving impacts beyond communication typically involved broader, multifaceted interventions. Future efforts to improve communication using SBAR should first confirm high fidelity uptake in clinical settings rather than assuming this has occurred.

PROSPERO REGISTRATION NUMBER

CRD42018111377.

Theory in quality improvement and patient safety education: A scoping review

INTRODUCTION

Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully characterized. The authors undertook a scoping review to examine the use of theory in quality improvement and patient safety education.

METHODS

Eligible articles used theory to inform the design or study of a quality improvement or patient safety curriculum. The authors followed scoping review methodology and searched articles referenced in 20 systematic reviews of quality improvement and patient safety education, or articles citing one of these reviews, and hand searched eligible article references. Data analysis involved descriptive and interpretive summaries of theories used and the perspectives the theories offered.

RESULTS

Eligibility criteria were met by 28 articles, and 102 articles made superficial mention of theory. Eligible articles varied in professional group, learning stage and journal type. Theories fell into two broad categories: learning theories (n = 20) and social science theories (n = 11). Theory was used in the design (n = 12) or study (n = 17) of quality improvement and patient safety education. The range of theories shows the opportunity afforded by using more than one type of theory.

DISCUSSION

Theory can guide decisions regarding quality improvement and patient safety education practices or play a role in selecting a methodology or lens through which to study educational processes and outcomes. Educators and researchers should make deliberate choices around the use of theory that relates to aspects of an educational program that they seek to illuminate.

Quality indicators for transition from paediatric to adult care for adolescents with chronic physical and mental illness: protocol for a systematic review

INTRODUCTION

Transition from paediatric to adult care is a complex process, which poses significant challenges for adolescents with chronic physical and mental illnesses. For many, transfer to adult care is associated with poor health and psychosocial outcomes. Quality indicators to evaluate transition to adult care are needed to benchmark and compare performance across conditions and health systems. This systematic review aims to identify quality indicators for successful transition to adult care which can be applied across chronic physical and/or mental illnesses.

METHODS

Published literature will be searched using MEDLINE, Embase and CINHAL from earliest available date to July 2021. Grey literature will be searched using the Grey Matters tool. Using a set of inclusion/exclusion criteria, two independent reviewers will screen titles and abstracts, followed by full-text review. Disagreements will be resolved by a third reviewer. Study selection and data extraction will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Study appraisal will be completed using the Appraisal of Guidelines for Research and Evaluation for Quality Indicators instrument. Extracted quality indicators will be categorised into a conceptual framework.

ETHICS AND DISSEMINATION

Results from this review will offer novel insights into quality indicators that may be used to measure and evaluate transition success across conditions, which will be disseminated via a Canadian transition collaborative, workshops and peer-reviewed publication. Extracted quality indicators will be further prioritised in a Delphi study with patients, caregivers and providers. This is a critical step in developing a core set of metrics to evaluate transitions to adult care. Ethics approval is not required as this review will identify and synthesise findings from published literature.

PROSPERO REGISTRATION NUMBER

CRD42020198030.

Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials

OBJECTIVE

To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline up to August 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS

Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured.

RESULTS

In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I²=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity.

CONCLUSIONS

Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.

A Matter of Urgency: Reducing Clinical Text Message Interruptions During Educational Sessions

BACKGROUND

Text messaging is increasingly replacing paging as a tool to reach physicians on medical wards. However, this phenomenon has resulted in high volumes of nonurgent messages that can disrupt the learning climate.

OBJECTIVE

Our objective was to reduce nonurgent educational interruptions to residents on general internal medicine.

DESIGN, SETTING, PATIENTS

This was a quality improvement project conducted at an academic hospital network. Measurements and interventions took place on 8 general internal medicine inpatient teaching teams.

INTERVENTION

Interventions included (1) refining the clinical communication process in collaboration with nursing leadership; (2) disseminating guidelines with posters at nursing stations; (3) introducing a noninterrupting option for message senders; (4) audit and feedback of messages; (5) adding an alert for message senders advising if a message would interrupt educational sessions; and (6) training and support to nurses and residents.

MEASUREMENTS

Interruptions (text messages, phone calls, emails) received by institution-supplied team smartphones were tracked during educational hours using statistical process control charts. A 1-month record of text message content was analyzed for urgency at baseline and following the interventions.

RESULTS

The interruption frequency decreased from a mean of 0.92 (95% CI, 0.88 to 0.97) to 0.59 (95% CI, 0.51 to0.67) messages per team per educational hour from January 2014 to December 2016. The proportion of nonurgent educational interruptions decreased from 223/273 (82%) messages over one month to 123/182 (68%; P < .01).

CONCLUSIONS

Creation of communication guidelines and modification of text message interface with feedback from end-users were associated with a reduction in nonurgent educational interruptions. Continuous audit and feedback may be necessary to minimize nonurgent messages that disrupt educational sessions.

Abstract P4-11-02: Acceptability and usability of iPrevent, a web-based decision support tool for assessment and management of breast cancer risk

Background: iPrevent estimates an individual's personal BC risk, using either the IBIS or BOADICEA algorithms, and provides tailored risk management information on screening, lifestyle modifications, risk-reducing surgery and risk-reducing medication. It is designed to be used collaboratively by women and their clinicians. The purpose of this pre-implementation pilot study was to assess the clinical usability and acceptability of the iPrevent prototype, and to identify barriers to clinical implementation. Exploratory aims investigated patients' BC worry, anxiety, risk perception and knowledge before and after using iPrevent. Methods: Eligible clinicians worked in primary care (PC), breast surgical (BS) or genetics clinics (GC). Their female patients were eligible if aged 18-70 years with no personal cancer history. Clinicians were familiarized with iPrevent using hypothetical cases, then actor scenarios, and lastly iPrevent was trialed with patients. All participants completed the System Usability Scale (SUS) and an acceptability questionnaire 2 weeks after using iPrevent. Patients also completed the Lerman BC Worry Scale, Spielberger State-Trait Anxiety Inventory, and BC risk perception and prevention knowledge questionnaires before and 2 weeks after using the tool. Data were summarized using descriptive statistics. Results: 63 participants comprising 20 clinicians (median age 47 years, 8 PC, 6 BS, 6 GC) and 43 patients (median age 38 years, 16% high risk, 51% moderate risk, 33% average risk) were recruited. Usability was rated above average (SUS score &gt;68) by most clinicians (68%) and patients (76%). Most (79% of clinicians, 81% of patients) agreed iPrevent was 'easy to use', although 10 (53%) clinicians and 10 (27%) patients reported that it was too long. Most clinicians (84%) and patients (86%) found iPrevent 'very' or 'somewhat' helpful. 89% of participants reported that iPrevent provided the right amount of information. 5% reported to 'rarely' or 'not at all' worry about BC before iPrevent, and 29% after use. 25% of patients reported less impact of worrying about BC after iPrevent, 47% were unchanged and 28% reported more impact of worrying about BC after iPrevent use. State anxiety remained the same. 87% of patients correctly reported their risk category after using iPrevent® compared with 40% before. BC prevention knowledge improved for most questions. Conclusions: iPrevent has high usability and acceptability. Exploratory analyses suggest that iPrevent may also improve patients' BC risk perception and knowledge without adversely affecting anxiety or BC worry. Because concerns about length could be a barrier to implementation, data entry has been abbreviated in the modified version of iPrevent that will be publically available.

Citation Format: Phillips K-A, Lo L, Bressel M, Collins IM, Emery J, Weideman P, Keogh L, Steel E, Bickerstaffe A, Mann GB, Trainer A, Hopper JL, Antoniou AC, Cuzick J, Butow P. Acceptability and usability of iPrevent, a web-based decision support tool for assessment and management of breast cancer risk [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-11-02.

Parent Preferences for Medical Error Disclosure: A Qualitative Study

OBJECTIVE

According to disclosure guidelines, patients experiencing adverse events due to medical errors should be offered full disclosure, whereas disclosure of near misses is not traditionally expected. This may conflict with parental expectations; surveys reveal most parents expect full disclosure whether errors resulted in harm or not. Protocols regarding whether to include children in these discussions have not been established. This study explores parent preferences around disclosure and views on including children.

METHODS

Fifteen parents of hospitalized children participated in semistructured interviews. Three hypothetical scenarios of different severity were used to initiate discussion. Interviews were audiotaped, transcribed, and coded for emergent themes.

RESULTS

Parents uniformly wanted disclosure if harm occurred, although fewer wanted their child informed. For nonharmful errors, most parents wanted disclosure for themselves but few for their children.With respect to including children in disclosure, parents preferred to assess their children's cognitive and emotional readiness to cope with disclosure, wishing to act as a "buffer" between the health care team and their children. Generally, as event severity decreased, they felt that risks of informing children outweighed benefits. Parents strongly emphasized needing reassurance of a good final outcome and anticipated difficulty managing their emotions.

CONCLUSIONS

Parents have mixed expectations regarding disclosure. Although survey studies indicate a stronger desire for disclosure of nonharmful events than for adult patients, this qualitative study revealed a greater degree of hesitation and complexity. Parents have a great need for reassurance and consistently wish to act as a buffer between the health care team and their children.

Topically applied connective tissue growth factor/CCN2 improves diabetic preclinical cutaneous wound healing: potential role for CTGF in human diabetic foot ulcer healing

AIMS/HYPOTHESIS

Topical application of CTGF/CCN2 to rodent diabetic and control wounds was examined. In parallel research, correlation of CTGF wound fluid levels with healing rate in human diabetic foot ulcers was undertaken.

METHODS

Full thickness cutaneous wounds in diabetic and nondiabetic control rats were treated topically with 1 μg rhCTGF or vehicle alone, on 2 consecutive days. Wound healing rate was observed on day 14 and wound sites were examined for breaking strength and granulation tissue. In the human study across 32 subjects, serial CTGF regulation was analyzed longitudinally in postdebridement diabetic wound fluid.

RESULTS

CTGF treated diabetic wounds had an accelerated closure rate compared with vehicle treated diabetic wounds. Healed skin withstood more strain before breaking in CTGF treated rat wounds. Granulation tissue from CTGF treatment in diabetic wounds showed collagen IV accumulation compared with nondiabetic animals. Wound α-smooth muscle actin was increased in CTGF treated diabetic wounds compared with untreated diabetic wounds, as was macrophage infiltration. Endogenous wound fluid CTGF protein rate of increase in human diabetic foot ulcers correlated positively with foot ulcer healing rate (r = 0.406; P < 0.001).

CONCLUSIONS/INTERPRETATION

These data collectively increasingly substantiate a functional role for CTGF in human diabetic foot ulcers.

Effects of seat structural dynamics on current ride comfort criteria

The ISO 2631-1 ( 1997 ) provides methodologies for assessment of the seated human body comfort in response to vibrations. The standard covers various conditions such as frequency content, direction and location of the transmission of the vibration to the human body. However, the effects of seat structural dynamics mode shapes and corresponding resonances have not been discussed. This study provides important knowledge about the effects of vehicle seat structural vibration modes on discomfort assessment. The occupied seat resonant frequencies and corresponding vibration modes were measured and comfort test was carried out based on the paired comparison test method. The results show that the ISO 2631-1 ( 1997 ) method significantly underestimates the vibration discomfort level around the occupied seat twisting resonant frequencies. This underestimation is mainly due to the ISO suggested location of the accelerometer pad on the seatback. The centre of the seatback is a nodal point at the seat twisting mode. Therefore, it underestimates the total vibration transferred to the occupant body from the seatback.

PRACTITIONER SUMMARY

The effects of the vehicle seat structural dynamics have not been discussed in the human body vibration ISO . The results of this research show that the current measurement method suggested by ISO 2631-1 (1997) can significantly underestimate the vibration discomfort level at around the seat structural vibration mode.

Medication reconciliation during transitions of care as a patient safety strategy: a systematic review

Medication reconciliation identifies and resolves unintentional discrepancies between patients' medication lists across transitions in care. The purpose of this review is to summarize evidence about the effectiveness of hospital-based medication reconciliation interventions. Searches encompassed MEDLINE through November 2012 and EMBASE and the Cochrane Central Register of Controlled Trials through July 2012. Eligible studies evaluated the effects of hospital-based medication reconciliation on unintentional discrepancies with nontrivial risks for harm to patients or 30-day postdischarge emergency department visits and readmission. Two reviewers evaluated study eligibility, abstracted data, and assessed study quality. Eighteen studies evaluating 20 interventions met the selection criteria. Pharmacists performed medication reconciliation in 17 of the 20 interventions. Most unintentional discrepancies identified had no clinical significance. Medication reconciliation alone probably does not reduce postdischarge hospital utilization but may do so when bundled with interventions aimed at improving care transitions.

Diffusion-weighted MR imaging in early diagnosis and prognosis of hypoglycemia

SUMMARY

We describe 2 cases of diffusion-weighted (DW) MR imaging in hypoglycemic coma. One patient, with diffuse cortical lesions, had a poor outcome, but the other, with transient white matter abnormalities, made a complete recovery. The distinctive patterns of DW MR imaging abnormalities in hypoglycemic patients should be recognized and may be a predictor of clinical outcome.

[Relationship of lipoprotein(a) to fibrinolytic activities in healthy subjects]

Plasma tissue-type plasminogen activator(tPA) and plasminogen activator inhibitor(PAI-1) and lipoprotein(a) [Lp(a)] in 133 healthy subjects were determined. The results demonstrated that PAI-1 activity was higher in Lp(a) > or = 0.3 g.L-1 group than Lp(a) < 0.3 g.L-1 group (P < 0.05). Univariate statistical analyses showed Lp(a) concentration was positively associated with PAI-1 activity (P < 0.01), but not with age, sex, body mass index, blood lipids or tPA activity.

Tubal ectopic pregnancy: an evaluation of laparoscopic surgery versus laparotomy in 614 patients

We performed a prospective nonrandomized multicentre study to compare laparoscopic surgery and laparotomy in the immediate surgical outcome of tubal ectopic pregnancy (TEP), at 9 teaching hospitals in Hong Kong with a laparoscopic surgical service, on all patients with the operative diagnosis of tubal ectopic pregnancy between July 1, 1996 and June 30, 1997. In the period studied, 630 patients were recruited of which 614 were suitable for analysis. In them, 382 (62.2%) had laparoscopic surgery while the rest had laparotomy with or without diagnostic laparoscopy. Significantly more cases of shock ended in laparotomy (86.1% versus 13.9%). After exclusion of patients with shock, laparoscopic surgery offered a significantly shorter postoperative hospital stay (mean 2.7 days versus 5.3 days), a slightly lower perioperative complication rate (8.1% versus 13.9%) and more conservative surgery (90.1% of all salpingotomies) than laparotomy. A longer operating time was needed for laparoscopic surgery (1.2 hours versus 1.01 hours).

A prospective randomized study comparing hysteroscopy and curettage (H & C) under local anaesthesia (LA) and general anaesthesia (GA) in Chinese population

OBJECTIVE

To compare the difference in patient's acceptance of local anaesthesia (LA) and general anaesthesia (GA) hysteroscopy and curettage in Chinese population.

DESIGN

A prospective randomized study.

SUBJECTS AND METHODS

In the period September 1994 to August 1995, all Chinese women with abnormal uterine bleeding or suspected uterine anomaly who warranted hysteroscopy and uterine curettage were invited to participate in this study with informed consent. They were randomly allocated to the control (i.e. GA) and study (i.e. LA) group.

RESULTS

Overall 90% of the controls and 91% of the study group were satisfied with the procedure. The hysteroscopic diagnostic accuracy was 83%. Significantly higher percentage of patients in the study group opted for the same form of admission arrangement if given the choice.

CONCLUSION

Hysteroscopy and curettage under LA and GA are equally acceptable in the Chinese population in Hong Kong. The patient satisfaction rate is high in both groups. Hysteroscopic diagnosis is highly accurate in malignant condition (100% sensitivity and 83% specificity).

Specification of neurotransmitter identity by Phox2 proteins in neural crest stem cells

We have investigated the specification of noradrenergic neurotransmitter identity in neural crest stem cells (NCSCs). Retroviral expression of both wild-type and dominant-negative forms of the paired homeodomain transcription factor Phox2a indicates a crucial and direct role for this protein (and/or the closely related Phox2b) in the regulation of endogenous tyrosine hydroxylase (TH) and dopamine-beta hydroxylase (DBH) gene expression in these cells. In collaboration with cAMP, Phox2a can induce expression of TH but not of DBH or of panneuronal genes. Phox2 proteins are, moreover, necessary for the induction of both TH and DBH by bone morphogenetic protein 2 (BMP2) (which induces Phox2a/b) and forskolin. They are also necessary for neuronal differentiation. These data suggest that Phox2a/b coordinates the specification of neurotransmitter identity and neuronal fate by cooperating environmental signals in sympathetic neuroblasts.

Cell lineage determination and the control of neuronal identity in the neural crest

The molecular mechanisms underlying the determination of neuronal identity in the vertebrate peripheral nervous system are only just beginning to come into focus. Many of these mechanisms, such as the involvement of cascades of bHLH transcription factors and lateral inhibition via the Notch-Delta system, appear to have been conserved from Drosophila (Ghysen et al. 1993; Jan and Jan 1993). The way in which these genetic circuits are controlled by instructive growth factors, and the manner in which they lead to expression of a particular neuronal identity, is far from clear. This process is being elucidated by studies of neurogenesis in the peripheral autonomic lineage, which is arguably the best-understood neurogenic lineage in vertebrates. Emerging evidence is beginning to suggest that neuronal diversity within the autonomic and sensory lineages may be generated by related, but distinct, mechanisms. All autonomic progenitors express a common bHLH protein, MASH1, which appears to be induced by members of the BMP2 subfamily secreted by the tissues to which these progenitors migrate. Additional signals may then act on these progenitors in different locations to induce the expression of other transcription factors, which act in conjunction with MASH1 to specify the final phenotypes of the different autonomic neuron subtypes (sympathetic, parasympathetic, and enteric). Although different classes of autonomic neurons develop in very different locations within the body, different classes of sensory neurons are located together in dorsal root ganglia. The finding that distinct but related subtypes of bHLH proteins, the neurogenins, are expressed by different classes of sensory neuron precursors early in development suggests that sensory neuron diversity, in contrast to autonomic neuron diversity, may be pre-specified at or before the time neural crest cells begin their emigration from the neural tube.

Efficacy of transabdominal ultrasound examination in the diagnosis of early pregnancy complications in an emergency department

OBJECTIVE

To assess the value of ultrasound in an emergency department in the diagnosis of early pregnancy complications, the efficacy of a study protocol in identifying ectopic pregnancies, and the agreement on ultrasound findings among emergency department staff and gynaecologists.

METHODS

All women presenting with early pregnancy complications had a transabdominal ultrasound scan performed by the attending doctor and checked by a senior doctor. The ultrasound findings were classified as normal intrauterine pregnancy (IUP), probable abnormal pregnancy, definite ectopic pregnancy, no definite IUP, and other. Women with clinical and ultrasound findings compatible with threatened abortion were referred to a gynaecologist, or were admitted if findings suggested abnormal or ectopic pregnancy, or if a definite IUP could not be confirmed on ultrasound scan. For patients who were admitted or referred, a transvaginal ultrasound scan was performed by the attending gynaecologist. The findings of the gynaecologist were used as the gold standard.

RESULTS

151 cases were enrolled during a four month study period. Ultrasound findings in the emergency department included definite IUP in 95 (63%), probable abnormal IUP in 20 (13%), no definite IUP in 23 (21%), and other findings in four (3%). For evaluating the presence or absence of IUP, sensitivity of the initial scan was 82% (95% confidence interval 76% to 88%) and specificity 92% (88% to 96%). Agreement between junior and senior emergency department doctors on their ultrasound findings was 81% (75% to 87%) and between emergency department senior staff and gynecologists 85% (79% to 91%). The diagnoses made in the emergency department were thought to be compatible with the final assessments by gynaecologist in 72% (65% to 79%). Using either no definite IUP or other findings as a positive screening test for ectopic pregnancy, the sensitivity, specificity, positive predictive value, and negative predictive value were 80% (74% to 86%), 78% (71% to 85%), 12% (7% to 17%), and 99% (97% to 100%), respectively.

CONCLUSIONS

Transabdominal ultrasound performed in the emergency department is useful in screening for early pregnancy complications. Ectopic pregnancy should be suspected when no IUP is found on preliminary scanning.

MASH1 activates expression of the paired homeodomain transcription factor Phox2a, and couples pan-neuronal and subtype-specific components of autonomic neuronal identity

We have investigated the genetic circuitry underlying the determination of neuronal identity, using mammalian peripheral autonomic neurons as a model system. Previously, we showed that treatment of neural crest stem cells (NCSCs) with bone morphogenetic protein-2 (BMP-2) leads to an induction of MASH1 expression and consequent autonomic neuronal differentiation. We now show that BMP2 also induces expression of the paired homeodomain transcription factor Phox2a, and the GDNF/NTN signalling receptor tyrosine kinase c-RET. Constitutive expression of MASH1 in NCSCs from a retroviral vector, in the absence of exogenous BMP2, induces expression of both Phox2a and c-RET in a large fraction of infected colonies, and also promotes morphological neuronal differentiation and expression of pan-neuronal markers. In vivo, expression of Phox2a in autonomic ganglia is strongly reduced in Mash1 −/− embryos. These loss- and gain-of-function data suggest that MASH1 positively regulates expression of Phox2a, either directly or indirectly. Constitutive expression of Phox2a, by contrast to MASH1, fails to induce expression of neuronal markers or a neuronal morphology, but does induce expression of c-RET. These data suggest that MASH1 couples expression of pan-neuronal and subtype-specific components of autonomic neuronal identity, and support the general idea that identity is established by combining subprograms involving cascades of transcription factors, which specify distinct components of neuronal phenotype.

MASH1 maintains competence for BMP2-induced neuronal differentiation in post-migratory neural crest cells

BACKGROUND

The interplay between growth factors and transcription factors in vertebrate neurogenesis is poorly understood. MASH1 is a basic helix-loop-helix (bHLH) transcription factor that is essential for autonomic neurogenesis. Bone morphogenetic protein (BMP) 2, and its relative BMP4, have been shown to induce expression of MASH1 and to promote autonomic neuronal differentiation in neural crest stem cells. The relationship between expression of MASH1 and the neurogenic competence of neural crest cells has not been investigated, however.

RESULTS

We have examined the function of MASH1 in neurogenic competence using a population of immuno-isolated neural-crest-derived progenitor cells. Post-migratory neural crest cells isolated from fetal rat gut expressed Mash1, yet comprised a mixture of committed neuronal precursors and non-neuronal cells. The non-neuronal cells remained competent to differentiate to neurons, however, if challenged with BMP2. Such competence declines with time and is paralleled by a decline in Mash1 expression in the cells. Expression of endogenous Mash1 can be maintained by BMP2; in turn, constitutive expression of Mash1 from a retroviral vector maintains competence for neuronal differentiation in response to late addition of BMP2.

CONCLUSIONS

These data suggest that MASH1 promotes competence for neurogenesis, in a manner similar to its homologs, the proneural genes achaete-scute in Drosophila. They also reveal an unexpected feedback interaction between BMP2 and MASH1 during neuronal differentiation. MASH1 may play multiple roles at successive stages of development within a neurogenic lineage, only one of which is revealed by a loss-of-function mutation.

Identification of novel paired homeodomain protein related to C. elegans unc-4 as a potential downstream target of MASH1

A novel paired homeodomain protein, PHD1, that is most closely related to C. elegans unc-4 has been identified by a differential RT-PCR method. PHD1 is expressed in a narrow layer adjacent to the ventricular zone of the dorsal spinal cord, immediately following expression of MASH1 but preceding overt neuronal differentiation. Some cells coexpressing MASH1 and PHD1 can be seen, suggesting that these two genes are sequentially activated within the same lineage. In the olfactory sensory epithelium, PHD1 expression not only follows but is dependent upon MASH1 function, suggesting that PHD1 acts downstream of MASH1. A sequential action of bHLH and paired homeodomain proteins is apparent in other neurogenic lineages and may be a general feature of both vertebrate and invertebate neurogenesis.

Distinct subpopulations of enteric neuronal progenitors defined by time of development, sympathoadrenal lineage markers and Mash-1-dependence

Enteric and sympathetic neurons have previously been proposed to be lineally related. We present independent lines of evidence that suggest that enteric neurons arise from at least two lineages, only one of which expresses markers in common with sympathoadrenal cells. In the rat, sympathoadrenal markers are expressed, in the same order as in sympathetic neurons, by a subset of enteric neuronal precursors, which also transiently express tyrosine hydroxylase. If this precursor pool is eliminated in vitro by complement-mediated lysis, enteric neurons continue to develop; however, none of these are serotonergic. In the mouse, the Mash-1−/− mutation, which eliminates sympathetic neurons, also prevents the development of enteric serotonergic neurons. Other enteric neuronal populations, however, including those that contain calcitonin gene related peptide are present. Enteric tyrosine hydroxylase-containing cells co-express Mash-1 and are eliminated by the Mash-1−/− mutation, consistent with the idea that in the mouse, as in the rat, these precursors generate serotonergic neurons. Serotonergic neurons are generated early in development, while calcitonin gene related peptide-containing enteric neurons are generated much later. These data suggest that enteric neurons are derived from at least two progenitor lineages. One transiently expresses sympathoadrenal markers, is Mash-1-dependent, and generates early-born enteric neurons, some of which are serotonergic. The other is Mash-1-independent, does not express sympathoadrenal markers, and generates late-born enteric neurons, some of which contain calcitonin gene related peptide.

Comparative yield of endocervical and metaplastic cells. Two sampling techniques: wooden spatula and cytology brush

OBJECTIVE

To compare two sampling techniques in their ability to obtain endocervical and metaplastic cells from the Papanicolaou smear.

DESIGN

Prospective clinical trial comparing the criterion standard of a wooden spatula to a cytology brush.

SETTING

Community-based family medicine clinic in London, Ont.

PATIENTS

Consecutive sample of 102 women aged 15 to 58 years requiring a Pap smear between October 1992 and October 1993 who presented to the office of their family physician and were assessed by one resident or one faculty physician.

INTERVENTIONS

A Pap smear was obtained from each participant using first the wooden spatula and then the cytology brush.

MAIN OUTCOME MEASURES

The number of Pap smears done in the study population that contained endocervical or metaplastic cells.

RESULTS

Endocervical cell yield was significantly greater using the cytology brush (93.1%) than using the spatula (61.8%) (P < 0.001). There was no significant difference in metaplastic cell yield between the cytology brush (71.6%) and the spatula (63.7%). At least one of these cell types was identified on 95.1% of cytology brush samples and on 79.4% of spatula samples (P < 0.001). The resident and faculty physician were not significantly different in their rate of detecting endocervical or metaplastic cells.

CONCLUSIONS

Adding a cytology brush sample to the Pap smear resulted in a significant increase in the rate of Pap smears that detected cells. The cytology brush was significantly better than the spatula for detecting endocervical cells (P < 0.001), but not significantly better for detecting metaplastic cells.

Postmigratory neural crest cells expressing c-RET display restricted developmental and proliferative capacities

c-RET is an orphan receptor tyrosine kinase essential for enteric neurogenesis in mice and is involved in several human genetic disorders. RET is also one of the earliest surface markers expressed by postmigratory neural crest cells in the gut. We generated anti-RET monoclonal antibodies to isolate such cells. We find that RET+ cells are antigenically and functionally distinct from neural crest stem cells (NCSCs) characterized previously. Unlike NCSCs, which are RET- and MASH1-, most RET+ cells express MASH1. Moreover, unlike NCSCs, which are multipotent and have high proliferative capacity, many RET+ cells generate only neurons following a limited number of divisions. This behavior is observed even in the presence of glial growth factor, a polypeptide that suppresses neuronal and promotes glial differentiation by NCSCs. These data provide direct evidence for the existence of committed neuronal progenitor cells and support a model of neural crest lineage diversification by progressive restriction of developmental potential.

Transvaginal endoscopic oophorectomy

Four women underwent transvaginal endoscopic oophorectomy during vaginal hysterectomy. The adnexa were visualized with a laparoscope inserted into the upper vagina. Bilateral salpingo-oophorectomy or oophorectomy was carried out with standard laparoscopic instruments introduced through the vagina without a pneumoperitoneum; Endoloop sutures and bipolar electrocoagulation were used for hemostasis.

Comparison of prostaglandin E2 vaginal tablet with amniotomy and intravenous oxytocin for induction of labour

Prostaglandins have been increasingly used in obstetrical practice for cervical ripening and induction of labour. We set out to investigate the effectiveness of prostaglandin E2 (PGE2) vaginal pessaries in inducing labour in the Chinese population in Hong Kong. In the period August, 1991 to August, 1992, we recruited 206 pregnant Chinese women who required induction of labour for various obstetrical indications into the trial. The study group had induction of labour by PGE2 vaginal pessaries and the control group underwent amniotomy plus oxytocin infusion. These patients were alternately assigned either method of induction. They were further divided into primiparous and multiparous (parity 1 and 2 only) groups. Only 101 primiparas and 99 multiparas were available in the final analysis of the trial. Various aspects of labour, delivery, maternal and fetal outcome were compared. For primiparas, the traditional combined induction was the preferred method. For multiparas, both induction methods were quite satisfactory and there was a trend toward lesser blood loss and pethidine requirement in the PGE2 users.

Sympathetic neuroblasts undergo a developmental switch in trophic dependence

Sympathetic neurons require NGF for survival, but it is not known when these cells first become dependent on neurotrophic factors. We have examined in vitro mitotically active sympathetic neuroblasts immuno-isolated from different embryonic stages, and have correlated this functional data with the expression of neurotrophin receptor mRNAs in vivo. Cells from E14.5 ganglia are supported by neurotrophin-3 (NT-3) in a serum-free medium, but not by NGF; NT-3 acts as a bona fide survival factor for these cells and not simply as a mitogen. By birth, sympathetic neurons are well-supported by NGF, whereas NT-3 supports survival only weakly and at very high doses. This change in neurotrophin-responsiveness is correlated with a reciprocal switch in the expression of trkC and trkA mRNAs by sympathetic neuroblasts in vivo. These data suggest that neurotrophic factors may control neuronal number at earlier stages of development than previously anticipated. They also suggest that the acquisition of NGF-dependence may occur, at least in part, through the loss of receptors for these interim survival factors.

The health care experience and health behaviour of the Chinese: a survey based in Hull

Lack of knowledge about the health care experience and health behaviour of an important ethnic minority group prompted a study to inform the provision of health care and promote local action in Hull. Thirty Chinese 'takeaway' shops were randomly selected from the Yellow Pages of the Hull telephone directory, and all Chinese people working in them asked to complete a questionnaire. It contained questions on their knowledge, use and experience of primary health care and health promotion, together with aspects of their health behaviour. The same questionnaire in English was delivered to all workers in 30 fish and chip shops, to provide a White comparison group. Eighty (71 per cent) of the Chinese returned their questionnaire, and 73 (67 per cent) were returned from the chip-shop workers. The results indicate that the Chinese in Hull are not making optimal use of health services; they use some services inappropriately, whereas others, such as preventive health programmes, are under-used. One of the main reasons is identified as the language/communication difficulties faced by many Chinese. Other reasons are also highlighted and their implications discussed. The findings of this survey are in keeping with the mainly unpublished work undertaken elsewhere on this comparatively little researched ethnic minority group.

Differential interactions of indolealkylamines with 5-hydroxytryptamine receptor subtypes

Affinities of drugs for 21 indolealkylamine derivatives, some with putative hallucinogenic activity, were determined at 5-HT1A, 5-HT2A and 5-HT2B recognition sites, using radioligand competition studies. Nearly all of the derivatives displayed greatest potency for the 5-HT2A receptor, labelled by [125I]R-(-)DOI in the cortex of the rat. Most derivatives displayed 2-10 times lower affinity at the HT2B receptor labelled by [3H]ketanserin in bovine cortex. Derivatives lacking ring substituents displayed lower affinities for all of the recognition sites, compared to derivatives substituted in the 4- or 5-position of the indole ring. The 4-hydroxylated derivatives displayed 25-380-fold selectivity for the 5-HT2A site, vs the 5-HT1A site, while the 5-substituted derivatives displayed approximately equal potency at the 5-HT1A and 5-HT2A sites. Affinity of all the compounds at the 5-HT2B site was greater than 300 nM. The 6-substituted derivatives displayed greater than micromolar affinities for all of the 5-HT recognition sites examined. The size of the N,N-dialkyl substituent was a secondary determinant of affinity, with groups larger than N,N-diisopropyl resulting in a marked reduction in affinity at both the 5-HT2A and 5-HT1A recognition sites. This study demonstrated that hallucinogenic 4-hydroxy-indolealkylamines, like psychotomimetic phenylisopropylamines, bind potently and selectively to the 5-HT2A recognition site, labelled by [125I]R-(-)DOI. This provides further evidence indicating that this recently described subtype of the 5-HT2 receptor may partially mediate the action of hallucinogenic agents.

Traditional Chinese infant supplementary medical foods given by mothers in Hong Kong

Chinese mothers living in Hong Kong are used to giving their babies special medicinal food to strengthen the infant's internal defences and to restore the body's harmonious state. However since the majority of registered doctors are trained in the Western pharmacological tradition it is difficult for them to comprehend the concepts and idioms of this practice. This paper set out to investigate the frequency and varieties of medicinal foods given to 166 Chinese infants during the first 30 months after birth. One hundred and forty seven babies were given medicinal foods at some stage. The frequency of their administration varied from weekly to once or twice per month. The most popular medicinal food was "Job's tears" and the most widely administered compound herb preparations were milk preparation solution, flower teas and various cool teas. The potential pharmacological effects of these medicinal foods were searched from a Chinese medicines computerized database and found to be principally anti-inflammatory, bacteriostatic, diuretic and appetite stimulant. This study contributed a better appreciation of the popularity of infant supplementary medicinal foods in Hong Kong and the rationale for their use.

A better guideline on milk requirements for babies below 6 months

The volume of infant formula required for babies below the age of 6 months continues to pose problems both for parents and child health care workers. To investigate this, about 150 bottle-fed babies were studied every 2 months from birth for their milk intake and weight gain. They were fed on demand with full strength infant formula and weaning was started at about 4 months. Weight gain was normal, with growth patterns comparable to Cambridge babies. The mean (s.d.) daily milk volumes in millilitres consumed were: 582 (144), 847 (163), 851 (176), 812 (219) at 7 days, 2, 4 and 6 months, respectively. With such a wide range of milk intake at each age, it would be inappropriate and misleading to provide a single mean recommended volume. Thus, percentile values are suggested as a better guideline for recommended intake. Estimation was made for the volume of milk required if milk was the sole source of energy for the first 6 months.

The ratio of mid-arm circumference to occipital frontal circumference in Chinese babies: a marker of late gestation growth retardation

The ratio of mid-arm circumference to occipital frontal circumference (MAC/OFC), an index of late gestation growth retardation, was determined in 175 healthy newborn term Chinese babies. The ratio of 0.31 (S.D., 0.02) was significantly higher than in recent data published for Asian, White and Black neonates: whether this is due to differences in measuring techniques or better intra-uterine nutrition remains to be seen. As an initial test of its potential usefulness this ratio was determined in 12 term Chinese babies who showed clinical signs of undernutrition. All but one had a ratio 2S.D. or more below the mean. The MAC/OFC ratio, with its ease of measurement, simplicity and cheapness, is a useful addition to existing methods for assessing late gestation nutritional status.

Nutritional status in hospital inpatients: implications for nutritional support services

In a population of 473 inpatients, a profile of nutritional status from obesity to marasmic-kwashiokor was observed. Thirty-two per cent of the population were overweight or obese (n = 153), forty-five per cent were of normal weight (n = 211), 8% were at risk of protein-energy malnutrition (n = 39), and 15% (n = 70) had grades of protein-energy malnutrition from marasmus to marasmic-kwashiokor. The implications for improved nutritional support services for hospitalised patients are discussed.