Commentary on "Prognostic effect of carcinoma in situ in muscle-invasive urothelial carcinoma patients receiving neoadjuvant chemotherapy."

BACKGROUND

Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes.

MATERIALS AND METHODS

Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy.

RESULTS

A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio = 4.08; 95% CI: 1.19-13.98; P = 0.025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = 0.055) and OS (104.5 vs. 152.3 months; P = 0.091) outcomes similar to those for the pCR patients.

CONCLUSION

The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

δ-Opioid receptor activation modified microRNA expression in the rat kidney under prolonged hypoxia

Hypoxic/ischemic injury to kidney is a frequently encountered clinical problem with limited therapeutic options. Since microRNAs are differentially involved in hypoxic/ischemic events and δ-opioid receptor (DOR) activation is known to protect against hypoxic/ischemic injury, we speculated on the involvement of DOR activation in altering the microRNA (miRNA) expression in kidney under hypoxic condition. We selected 31 miRNAs based on microarray data for quantitative PCR analysis. Among them, 14 miRNAs were significantly altered after prolonged hypoxia, DOR activation or a combination of both. We found that 1) DOR activation alters miRNA expression profiles in normoxic conditions; 2) hypoxia differentially alters miRNA expression depending on the duration of hypoxia; and 3) DOR activation can modify hypoxia-induced changes in miRNA expression. For example, 10-day hypoxia reduced the level of miR-212 by over 70%, while DOR activation could mimic such reduction even in normoxic kidney. In contrast, the same stress increased miR-29a by >100%, which was reversed following DOR activation. These first data suggest that hypoxia comprehensively modifies the miRNA profile within the kidney, which can be mimicked or modified by DOR activation. Ascertaining the targeted pathways that regulate the diverse cellular and molecular functions of miRNA may provide new insights into potential therapies for hypoxic/ischemic injury of the kidney.

The dual cyclooxygenase/5-lipoxygenase inhibitor licofelone attenuates p-glycoprotein-mediated drug resistance in the injured spinal cord

There are currently no proven effective treatments that can improve recovery of function in spinal cord injury (SCI) patients. Many therapeutic compounds have shown promise in pre-clinical studies, but clinical trials have been largely unsuccessful. P-glycoprotein (Pgp, Abcb1b) is a drug efflux transporter of the blood-spinal cord barrier that limits spinal cord penetration of blood-borne xenobiotics. Pathological Pgp upregulation in diseases such as cancer causes heightened resistance to a broad variety of therapeutic drugs. Importantly, several drugs that have been evaluated for the treatment of SCI, such as riluzole, are known substrates of Pgp. We therefore examined whether Pgp-mediated pharmacoresistance diminishes delivery of riluzole to the injured spinal cord. Following moderate contusion injury at T10 in male Sprague-Dawley rats, we observed a progressive, spatial spread of increased Pgp expression from 3 days to 10 months post-SCI. Spinal cord uptake of i.p.-delivered riluzole was significantly reduced following SCI in wild type but not Abcb1a-knockout rats, highlighting a critical role for Pgp in mediating drug resistance following SCI. Because inflammation can drive Pgp upregulation, we evaluated the ability of the new generation dual anti-inflammatory drug licofelone to promote spinal cord delivery of riluzole following SCI. We found that licofelone both reduced Pgp expression and enhanced riluzole bioavailability within the lesion site at 72 h post-SCI. This work highlights Pgp-mediated drug resistance as an important obstacle to therapeutic drug delivery for SCI, and suggests licofelone as a novel combinatorial treatment strategy to enhance therapeutic drug delivery to the injured spinal cord.

Current research continues to support breastfeeding benefits

Lamaze International and Lamaze Certified Childbirth Educators are strong supporters of breastfeeding. This paper reviews eight recent studies that are related to breastfeeding and useful to clinicians and educators.

Abstract 329: δ-Opioid Receptor Mediated Regulation of Cortical MicroRNAs in the Rat Under Hypoxia

Cardiovascular disorders may reduce blood/oxygen supply to the brain, causing serious neurological disabilities. Activation of the delta-opioid receptor (DOR) induces cortical protection against hypoxic/ischemic insults. However, the mechanism underlying DOR protection is largely unclear yet. We have recently found that DOR activation modulates microRNA expression in the kidney exposed to hypoxic stress, suggesting that DOR protection may involve a microRNA mechanism. To determine if the microRNAs expressed in the cortex mediate DOR neuroprotection, we examined nineteen microRNAs, that are previously identified as hypoxia- and DOR-regulated microRNAs in the kidney, in the cortex treated with DOR activation in hypoxic condition. Total RNA for qPCR was isolated from the cortex of control or hypoxic rats as well as those animals treated with UFP-512, a potent and specific DOR agonist. Of the 19 microRNAs tested, 17 were significantly altered by hypoxia and/or DOR activation with the direction and amplitude dependent on hypoxic duration and times of DOR treatment. Several microRNAs such as miR-29b, 101b, -298, 324-3p, -347 and 466b were significantly depressed by hypoxia for 24 hours. The similar changes were seen in normoxic condition 24 hours after DOR activation with one time treatment of UFP-512. In contrast, some miRNAs were more tolerant to hypoxic stress and did not show any significant reduction until 5-days (e.g., miR-31 and -186) or 10-days (e.g., miR-29a, let-7f and -511), while DOR activation had differential effects on these miRNAs. Moreover, some miRNAs like miRs-363* and -370 were affected only by the combination of hypoxia and DOR treatment, with reductions greater than 70% in 5-day group. These data suggest that cortical microRNAs are significantly altered in response to hypoxia with differential hypoxia sensitivity among them and that DOR activation is able to modify, enhance or resolve the changes in microRNAs that are predicted to target ion transport, HIF, axonal guidance, free radical signaling, apoptosis and many other functions.

Subcutaneous immunoglobulin therapy in pediatric primary antibody deficiency

Subcutaneous immunoglobulin (SCIG) therapy is recognized as a standard treatment for primary antibody deficiency. SCIG is efficacious for the prevention of infections and is associated with a lower risk of systemic side effects, improved quality of life for patients and families and is preferred by children when compared with intravenous immunoglobulin replacement. For pediatric patients, SCIG is an ideal treatment modality that affords children and families more freedom and less disruption of important childhood activities. This article reviews the characteristics of SCIG to provide the pediatric practitioner with an understanding of the experiences their patients receiveing SCIG may encounter.

Disturbed sleep and preterm birth: a potential relationship?

PURPOSE

Many women report disturbed sleep during pregnancy, but its impact on clinical outcomes remains unknown. This study examined subjective sleep quality and daytime sleepiness in relation to preterm birth.

METHODS

A convenience sample of 220 pregnant women completed the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Perceived Stress Scale (PSS) during the second trimester. Women who had preterm and full-term births were compared on these measures.

RESULTS

The preterm birth rate of the sample was 14.6%. Sleep latency, the period from lights out to sleep onset, was significantly longer in the preterm group, which also reported a tendency to use more sleep medications, but had lower PSQI daytime dysfunction scores. Perceived stress did not differentiate preterm and full-term groups.

CONCLUSION

Disturbed sleep in pregnancy may be associated with preterm birth. Future studies should examine specific physiological factors that underlie this increased vulnerability.

Subcutaneous immunoglobulin replacement therapy for primary antibody deficiency: advancements into the 21st century

OBJECTIVES

To provide a review of the world literature and discuss the clinical role of subcutaneous immunoglobulin (SCIG) therapy for primary antibody deficiency.

DATA SOURCES

English-language publications on SCIG therapy were identified through MEDLINE and through the reference list of the initially identified publications.

STUDY SELECTION

Articles pertaining to SCIG for the treatment of immunodeficiency, particularly primary antibody deficiency, were selected.

RESULTS

SCIG therapy has been shown to be effective and safe for the treatment of primary immunodeficiency. The risk of systemic reactions during infusion is generally reported to be less than 1%. Many patients prefer SCIG over conventional intravenous immunoglobulin therapy because of increased convenience and independence associated with SCIG therapy. Publications show SCIG therapy to be advantageous in selected patient populations, such as children, pregnant women, and patients with poor intravenous access.

CONCLUSION

SCIG therapy has been widely used in some European countries for a number of years, but a Food and Drug Administration-approved product was only recently introduced into the United States in 2006. SCIG therapy offers unique advantages that are applicable to many patients receiving immunoglobulin therapy for primary immunodeficiency.

A molecular pathway including Id2, Tbx5, and Nkx2-5 required for cardiac conduction system development

The cardiac conduction system is an anatomically discrete segment of specialized myocardium that initiates and propagates electrical impulses to coordinate myocardial contraction. To define the molecular composition of the mouse ventricular conduction system we used microdissection and transcriptional profiling by serial analysis of gene expression (SAGE). Conduction-system-specific expression for Id2, a member of the Id gene family of transcriptional repressors, was identified. Analyses of Id2-deficient mice demonstrated structural and functional conduction system abnormalities, including left bundle branch block. A 1.2 kb fragment of the Id2 promoter proved sufficient for cooperative regulation by Nkx2-5 and Tbx5 in vitro and for conduction-system-specific gene expression in vivo. Furthermore, compound haploinsufficiency of Tbx5 and Nkx2-5 or Tbx5 and Id2 prevented embryonic specification of the ventricular conduction system. We conclude that a molecular pathway including Tbx5, Nkx2-5, and Id2 coordinates specification of ventricular myocytes into the ventricular conduction system lineage.

Upstream stimulatory factor represses the induction of carnitine palmitoyltransferase-Ibeta expression by PGC-1

Transcriptional regulation of carnitine palmitoyltransferase-1beta (CPT-1beta) is coordinated with contractile gene expression through cardiac-enriched transcription factors, GATA4 and SRF. Metabolic modulation of CPT-1beta promoter activity has been described with the stimulation of gene expression by oleate that is mediated through the peroxisome proliferator-activated receptor (PPAR) pathway. The coactivator, peroxisomal proliferator-activated receptor gamma coactivator (PGC-1), enhances gene expression through interactions with nuclear hormone receptors and the myocyte enhancer factor 2 (MEF2) family. PGC-1 and MEF2A synergistically activate CPT-1beta promoter activity. This stimulation is enhanced by mutation of the E-box sequences that flank the MEF2A binding site. These elements bind the upstream stimulatory factors (USF1 and USF2), which activate transcription in CV-1 fibroblasts. However, overexpression of the USF proteins in myocytes depresses CPT-1beta activity and significantly reduces MEF2A and PGC-1 synergy. Co-immunoprecipitation studies demonstrate that PGC-1 and USF2 proteins can physically interact. Our studies demonstrate that PGC-1 stimulates CPT-1beta gene expression through MEF2A. USF proteins have a novel role in repressing the expression of the CPT-1beta gene and modulating the induction by the coactivator, PGC-1.

A region in the first exon/intron of rat carnitine palmitoyltransferase Ibeta is involved in enhancement of basal transcription

Carnitine palmitoyltransferase-Ibeta (CPT-Ibeta) catalyses the transfer of long-chain fatty acids to the enzymes of beta-oxidation of muscle and heart. Transcriptional control of this regulatory protein is relevant to disorders of fatty acid oxidation and the switch to glucose metabolism that occurs in cardiac pathology. The presence of a transcriptional enhancer sequence in the first untranslated exon and first intron of the CPT-Ibeta gene was identified using deletional and mutational analysis, and by ligation of an oleate responsive element (fatty acid response element) to a minimal promoter. The enhancer sequences are contained in the first 40 bases downstream of the transcription start site and increase CPT-Ibeta reporter gene expression independent of any 5' cis-acting elements. Deletion of the first 40 bases of the 3'-untranslated region does not affect the up-regulation of transcription by 10 microM phenylephrine. However, mutation and/or deletion of bases between +11 and +30 dramatically decreases reporter gene expression. Electrophoretic mobility-shift assays reveal two DNA (+11 to +36)-protein complexes that appear cardiac specific. The exon/intron element enhances activation of the heterologous thymidine kinase promoter in a position- and orientation-dependent manner. Therefore we have identified a novel region in the first exon/intron of the CPT-Ibeta gene that acts as a non-classical transcriptional enhancer downstream of regulatory elements characterized previously in the 5'-flanking region of the minimal promoter.

SJL/J mice are highly susceptible to infection by mouse adenovirus type 1

Mouse adenovirus type 1 (MAV-1) targets endothelial and monocyte/macrophage cells throughout the mouse. Depending on the strain of mouse and dose or strain of virus, infected mice may survive, become persistently infected, or die. We surveyed inbred mouse strains and found that for the majority tested the 50% lethal doses (LD(50)s) were >10(4.4) PFU. However, SJL/J mice were highly susceptible to MAV-1, with a mean LD(50) of 10(-0.32) PFU. Infected C3H/HeJ (resistant) and SJL/J (susceptible) mice showed only modest differences in histopathology. Susceptible mice had significantly higher viral loads in the brain and spleen at 8 days postinfection than resistant mice. Infection of primary macrophages or mouse embryo fibroblasts from SJL/J and C3H/HeJ mice gave equivalent yields of virus, suggesting that a receptor difference between strains is not responsible for the susceptibility difference. When C3H/HeJ mice were subjected to sublethal doses of gamma irradiation, they became susceptible to MAV-1, with an LD(50) like that of SJL/J mice. Antiviral immunoglobulin G (IgG) levels were measured in susceptible and resistant mice infected by an early region 1A null mutant virus that is less virulent that wild-type virus. The antiviral IgG levels were high and similar in the two strains of mice. Taken together, these results suggest that immune response differences may in part account for differences in susceptibility to MAV-1 infection.

Dexter: a tool to facilitate impairment ratings

Calculating impairment in burn patients is crucial to understanding outcome. However, it is rarely reported after burns, presumably because the process of calculating impairment ratings is complicated and tedious. Computerized systems have been developed that facilitate the process, but it has not been established in burn patients that these systems reduce the time required to calculate impairment. We evaluated the Dexter Evaluation and Therapy System by Cedaron Medical Inc (Davis, CA). A sample of 10 manually recorded ratings was compared with 10 performed on the Dexter. Mean time for the manual technique was 65 +/- 35 minutes versus 37 +/- 13 minutes for the Dexter (P < .05, Mann-Whitney). The time taken to perform impairment ratings in burn survivors is significantly reduced by the use of the Dexter system. Time saving occurs primarily at three points: (1) electronic data entry directly from the measuring instruments, (2) compilation of data, and (3) rapid generation of reports.

Disseminated Bipolaris spicifera in a neonate

We report a premature infant with disseminated fungal infection identified as Bipolaris spicifera. The infant was born at 23 4/7 weeks' gestation, weighing 780 g. At day of life (DOL) 7 erythematous areas on the back were noticed that progressed to black, necrotic skin lesions. A shave biopsy showed invasive fungal organisms that were identified by culture as B. spicifera. The lesions progressed despite aggressive surgical debridement and antifungal therapy. On autopsy, fungal organisms found throughout the internal organs confirmed disseminated disease with B. spicifera. This organism is now more often recognized as a human pathogen; however, this is the first reported case in a neonate.

Diagnostic and operative transvaginal hydrolaparoscopy for infertility and pelvic pain

STUDY OBJECTIVE

To review our experience with diagnostic and operative transvaginal hydrolaparoscopy (THL), a procedure that is less invasive than operative laparoscopy.

DESIGN

Prospective, observational cohort study (Canadian Task Force classification II-2).

SETTING

Private institute and university-affiliated hospital.

PATIENTS

Twenty-nine women with infertility and 11 with pelvic pain.

INTERVENTIONS

Diagnostic and operative THL.

MEASUREMENTS AND MAIN RESULTS

Thirty-five (88%) diagnostic THLs were performed in the office and the other five were done in hospital for insurance reasons; all six operative THLs were performed in the office under conscious sedation. The procedure was conclusive (all organs seen) in 37 patients (93%). Based on THL, no further surgical intervention was recommended in 18 (62%) infertile women and 5 (45%) of those with pain. Further surgical intervention was required in 5 (56%) of 9 infertility patients with a previous normal hysterosalpingogram (HSG) and 6 (32%) of 19 infertility patients with no previous HSG.

CONCLUSION

Transvaginal hydrolaparoscopy can be performed in the office with minimal pain, with a conclusive examination anticipated in 93% of cases. The procedure is more accurate than HSG and similar to laparoscopy.

Research Update: Adopting Birth Philosophies to Guide Successful Birth Practicesand Outcomes

Research studies conducted recently in hospitals located in Switzerland and Canada reveal the importance of birth philosophies in attaining successful birth practices and outcomes.

GATA-4 and serum response factor regulate transcription of the muscle-specific carnitine palmitoyltransferase I beta in rat heart

Transcriptional regulation of nuclear encoded mitochondrial proteins is dependent on nuclear transcription factors that act on genes encoding key components of mitochondrial transcription, replication, and heme biosynthetic machinery. Cellular factors that target expression of proteins to the heart have been well characterized with respect to excitation-contraction coupling. No information currently exists that examines whether parallel transcriptional mechanisms regulate nuclear encoded expression of heart-specific mitochondrial isoforms. The muscle CPT-Ibeta isoform in heart is a TATA-less gene that uses Sp-1 proteins to support basal expression. The rat cardiac fatty acid response element (-301/-289), previously characterized in the human gene, is responsive to oleic acid following serum deprivation. Deletion and mutational analysis of the 5'-flanking sequence of the carnitine palmitoyltransferase Ibeta (CPT-Ibeta) gene defines regulatory regions in the -391/+80 promoter luciferase construct. When deleted or mutated constructs were individually transfected into cardiac myocytes, CPT-I/luciferase reporter gene expression was significantly depressed at sites involving a putative MEF2 sequence downstream from the fatty acid response element and a cluster of heart-specific regulatory regions flanked by two Sp1 elements. Each site demonstrated binding to cardiac nuclear proteins and competition specificity (or supershifts) with oligonucleotides and antibodies. Individual expression vectors for Nkx2.5, serum response factor (SRF), and GATA4 enhanced CPT-I reporter gene expression 4-36-fold in CV-1 cells. Although cotransfection of Nkx and SRF produced additive luciferase expression, the combination of SRF and GATA-4 cotransfection resulted in synergistic activation of CPT-Ibeta. The results demonstrate that SRF and the tissue-restricted isoform, GATA-4, drive robust gene transcription of a mitochondrial protein highly expressed in heart.

Papers presented at the 8th international conference of maternity care researchers

This column provides a brief overview of some of the papers and presentations offered at the 8th International Conference of Maternity Care Researchers, held September 2000 at the University of Glasgow in Scotland.

Perinatal nursing research: a 25-year review--1976-2000

Parent-infant nursing research from 1976-2000 is reviewed through four groups of studies: development of research instruments, studies of mothers and fathers through the childbearing years, studies of newborns (both healthy and at risk), and studies of special populations. Potential directions for maternal/parent/newborn nursing research in the 21st century are suggested.

Ethical issues for nurses providing perinatal care in community settings

Ethical issues in perinatal nursing are complex in that two patients--mother and fetus--are considered. This work considers six areas of potential ethical conflict: conflict between the mother and fetus, informed consent, confidentiality, cultural conflicts, conflicts associated with managed care, and conflicts in childbirth education. Ethical principles of autonomy, beneficence, and justice are included. Strategies for resolving ethical conflicts in community practice settings are suggested.

Adolescent pregnancy rates in three European countries: lessons to be learned?

Adolescent pregnancy and abortion rates in the Netherlands, France, and Germany are lower than rates in the United States and the mean age of sexual debut is later. Contributing factors include philosophical differences about the rights and responsibilities of adolescents, access to contraceptives, sexuality education, and mass media campaigns. The data used in this article were gathered from meetings with health care providers in the three European countries studied and from published reports. While it is not possible to impose practices from one society upon another, nurses in North America may want to consider implementing some of these ideas in their practices.

Increased repair and cell survival in cells treated with DIR1 antisense oligonucleotides: implications for induced radioresistance

PURPOSE

To determine whether repression of a recently isolated, X-ray-responsive gene, DIR1, using antisense oligonucleotides could affect clonogenic cell survival and repair of DNA strand breaks and have a possible role in the mechanism underlying the phenomenon of 'induced radioresistance' (IRR).

MATERIALS AND METHODS

Three cell lines, V79, RT112 and UM-UC-3, which are known to exhibit low-dose hypersensitivity (HRS) and induced radioresistance (IRR), and the radiosensitive cell line ATBIVA, were transfected with antisense oligonucleotides directed towards the DIR1 gene. Scrambled oligonucleotides were used as controls. DNA single-strand break (ssb) repair, using the alkaline comet assay, and cell survival using a standard clonogenic assay was measured after exposure to X-rays.

RESULTS

Following treatment with 4Gy X-rays, the V79, RT112 and UM-UC-3 cell lines all exhibited significantly increased rates of ssb repair after transfection with DIR1 antisense oligonucleotides compared with cells transfected with scrambled oligonucleotides. They also demonstrated significantly enhanced survival after exposure to 2 Gy X-rays; the radiosensitive ATBIVA cells did not show these effects.

CONCLUSIONS

Repression of the DIR1 gene product leads to an increase in the rate of repair and cell survival in three radioresistant cells lines but not in the radiosensitive ATBIVA cell line. Because DIR1 is repressed by X-rays in the dose range where IRR is observed, it may represent a candidate gene involved in the IRR phenomenon.

Cost-benefit of a nursing telephone intervention to reduce preterm and low-birthweight births in an African American clinic population

BACKGROUND

A cost-benefit analysis was performed to estimate the cost-savings obtained from a nursing telephone intervention delivered to pregnant women identified as being at risk for preterm or low-birthweight births.

METHODS

After being screened for eligibility, a total of 1,554 women receiving prenatal care in a clinic located in Winston-Salem, North Carolina were randomized to intervention and control groups. Women in the intervention group received telephone calls from a registered nurse one or two times each week from the 24th through the 37th week of gestation.

RESULTS

No clinical benefits were realized by Caucasian participants. The intervention reduced preterm and low-birthweight births, and resulted in cost savings, for African-American mothers ages 19 and over. No significant differences were seen in the rates of low-birthweight or preterm births and no cost savings were realized from intervention with women ages 18 and younger.

CONCLUSIONS

A prenatal nursing support intervention in a clinic population of pregnant African American women was cost-beneficial for these adults (< or =19 years of age).

Cigarette smoking, low birth weight, and preterm births in low-income African American women

OBJECTIVE

To examine effects of light and heavy cigarette smoking on the incidence of low birth weight (LBW) and preterm births in African American women.

DESIGN

A total of 1146 low-income African American women participated in a randomized trial to test the effectiveness of nursing intervention in the reduction of preterm and LBW births. This secondary analysis focused on the effects of cigarette smoking on LBW (< 2500 gm) and preterm (< 37 weeks' gestation) births.

RESULTS

Cigarette smoking had a significant effect on both LBW and preterm births. When light smokers were compared with nonsmokers, odds ratios were 1.89 (confidence interval (CI) 1.15, 3.13; p = 0.0127) for LBW births and 1.74 (CI 1.00; 3.02; p = 0.0499) for preterm births. When heavy smokers were compared with nonsmokers, odds ratios were 3.03 (CI 1.90, 4.86; p = 0.001) for LBW births and 2.60 (CI 1.55, 4.35; p = 0.0003) for preterm births.

CONCLUSION

Cigarette smoking was associated with significantly higher rates of both LBW and preterm births in this sample of African American women.

From randomized trial to community-focused practice

PURPOSE

To describe the use of findings from a randomized trial--a nursing intervention using telephone contacts to reduce the incidence of low-birth-weight and preterm births--in four community settings in North Carolina, to show that implementing research into practice is important. Low-birth-weight and preterm births are the major cause of high infant mortality in the United States. Rates are highest among African-American women. Telephone intervention as a strategy for preventive health care can be cost effective, reduce low-birth-weight and preterm births in African-American women, and provide a means of health consultation for parents of children age five and under.

ORGANIZING FRAMEWORK

Four community programs are discussed in relation to five phases of implementing and sustaining research in communities: research, transfer, transition, regeneration, and empowerment. Modification from the original research, bonuses, and barriers are described for each program.

METHODS

The randomized trial was conducted from 1990-1995. Randomized trial data and data for subsequent projects were collected from telephone interviews and health care records from 1994-1998. A successful adaptation was made from the original randomized trial to the four programs by (a) educating the staff for each program about the methods and findings in the original research, and (b) working with program staff to make appropriate modifications for each site.

CONCLUSIONS

Findings from a randomized trial can be used in a variety of settings. By working together, researchers and community-health nurses can integrate research findings into community-health nursing practice.

Trauma registry databases: a comparison of data abstraction, interpretation, and entry at two level I trauma centers

BACKGROUND

A key part of a viable trauma system is the Trauma Registry (TR), used for research, education, and performance improvement. This study sought to assess the consistency of data abstraction, interpretation, and entry by two hospitals with an identical TR database program.

METHODS

In phase I, trauma service personnel were queried as to how data were abstracted and entered into the TR. In phase II, a 1-year retrospective review was conducted of TR data for two trauma centers in San Antonio, Texas.

RESULTS

The phase I review revealed substantial variances in the coding and abstracting of TR data in 30 of the 500 elements (6%). Phase II demonstrated that, because of these variances, considerable differences resulted in coded types and causes of injury.

CONCLUSION

This study illustrates that these variances can impact attempts to combine databases, establish norms, or assess institutional outcomes. To ensure the standardization and accuracy of this valuable information, changes may be required. Recommendations include standardization and education. A uniform trauma registry or national certification may be necessary.

Biochemical markers for preterm labor and birth: what is their role in the care of pregnant women?

Two biochemical tests, one for oncofetal fibronectin (fFN) and the other for estriol found in maternal saliva (SalEst) have been developed to improve the ability to predict preterm labor and birth. Fetal fibronectin is a protein secreted by the trophoblast and not normally present in vaginal and cervical secretions late in pregnancy. The presence of fFN between 22 and 37 weeks gestation may be a marker for preterm labor. Salivary estriol is a form of estrogen produced in the placenta from fetal precursors. Normally, estriol rises during pregnancy--the rise being accelerated 3 to 5 weeks prior to both term and preterm births. Both tests have high negative predictive values. This may serve to prevent unnecessary treatment of women with uterine contractions who are not truly in preterm labor. The fFN specimen is collected during vaginal examination. Sexual intercourse or vaginal examination within the prior 24 hours, vaginal bleeding, and uterine contractions may lead to a false positive test. Salivary estriol may be collected by the woman in her own home; however, specific instructions about eating, drinking, smoking, and the timing of saliva collection must be followed. Further study of both tests is required to determine their potential for reducing rates of preterm birth.

Analytic performance of two automated nonpretreatment digoxin immunoassays

The analytic performance of two automated nonpretreatment digoxin methods, AxSYM Digoxin II and Vitros digoxin immunoassays, was assessed. Both assays had analytic sensitivities of less than 0.2 microg/L, were linear from digoxin concentrations of 0.5 to 4.0 microg/L, and showed acceptable precision, with a maximum total coefficient of variation (CV) of 8.9% and 6.4% for the AxSYM and Vitros, respectively. Comparison of the two methods using samples from patients receiving digoxin gave the following relationship: Vitros = 0.91 x AxSYM + 0.23 (r = 0.97, Sy,x = 0.12). Digoxinlike immunoreactive factor (DLIF) crossreactivity was examined in specimens from patients who had hepatic disease, renal insufficiency, had undergone cardiac surgery, and in neonatal cord blood samples. Minimal crossreactivity was observed for most samples and the average crossreactivity for each group of samples was comparable for the two methods. The recovery of digoxin added to samples from each group of DLIF was similar, except for that from cord blood samples, for which recovery was significantly lower with the AxSYM method. Titration of a digoxin-spiked serum pool with digoxin-immune Fab showed a similar decrease in the measured digoxin concentration for both methods. Overall, the analytic performance characteristics of these two methods were comparable.

Unloaded heart in vivo replicates fetal gene expression of cardiac hypertrophy

The cardiac response to increased work includes a reactivation of fetal genes. The response to a decrease in cardiac work is not known. Such information is of clinical interest, because mechanical unloading can improve the functional capacity of the failing heart. We compared here the patterns of gene expression in unloaded rat heart with those in hypertrophied rat heart. Both conditions induced a re-expression of growth factors and proto-oncogenes, and a downregulation of the 'adult' isoforms, but not of the 'fetal' isoforms, of proteins regulating myocardial energetics. Therefore, opposite changes in cardiac workload in vivo induce similar patterns of gene response. Reactivation of fetal genes may underlie the functional improvement of an unloaded failing heart.

Reducing preterm and low birthweight births: still a nursing challenge

Preterm birth and low birthweight are correlated with much of the infant death seen in the United States. Despite 15 years of research, both preterm birth rates and low birthweight rates continue to increase. This article describes what is known about the prevention of preterm birth and low birthweight, and offers advice to nurses for nursing interventions that could prove effective in preventing such tragedies in the future.

The prevalence of domestic violence among women seeking abortion

OBJECTIVE

To determine the prevalence of self-reported abuse in a population of women aged 18 years or older seeking elective pregnancy termination, and to compare abused and nonabused women with respect to the primary reasons for pregnancy termination.

METHODS

A self-administered questionnaire was returned by 486 women seeking outpatient abortion. The survey included demographic information, abuse screening, and items regarding partner involvement/awareness of the pregnancy, and abuse as a determinant of the abortion decision. One open-ended item asking the primary reason for pregnancy termination was included.

RESULTS

The prevalence of self-reported abuse in this population was 39.5%. White women were significantly more likely to report any history of abuse than nonwhite women. Relationship issues were the only reason for pregnancy termination given more often by women with an abuse history than by nonabused women. Women with abuse histories were significantly less likely than nonabused women to inform the partner of the pregnancy or to have partner support for or involvement in the abortion decision.

CONCLUSION

The prevalence of abuse reported by women in this population suggests that many women seeking abortion services may have abuse histories. Abused women may have different reasons for pregnancy termination than nonabused women and may be more likely to make the abortion decision without partner involvement. When routine screening for abuse is included in abortion counseling, health providers have the opportunity for developing a safety plan and initiating appropriate referral.

Comparison of four commercial urinary albumin (microalbumin) methods: implications for detecting diabetic nephropathy using random urine specimens

The results of four urinary albumin methods used to identify patients with early diabetic renal disease were compared using random urine samples from healthy and diabetic patients. These methods were the Beckman Array and Behring BNAI immunonephelometric methods, the Dade aca particle-enhanced turbidimetric inhibition immunoassay method, and the INCSTAR SPQ immunoturbidimetric method. The albumin/creatinine ratio reference interval was found to be 2-20 mg albumin/g creatinine (mg/g) for the Array and 3.5-27.5 mg/g for the aca method. All four methods were compared using urines from a group of diabetic and nondiabetic patients. The BNAI, SPQ and Array methods compared well with one another while the aca demonstrated a positive bias of almost 60% at the 30 mg/g and 300 mg/g levels with certain lots of reagent and calibrator. Calibrator cross-over experiments demonstrated that some of the positive bias of the aca method could be accounted for by calibrator differences.

A randomized trial of nurse intervention to reduce preterm and low birth weight births

OBJECTIVE

To test the effect of telephone calls from registered nurses to low-income pregnant women on the rates of low birth weight (LBW) and preterm births.

METHODS

A total of 1554 women receiving prenatal care in a public clinic who met study criteria and who consented were assigned randomly to intervention and control groups. Women in the intervention group received telephone calls from a registered nurse, one or two times weekly from 24 weeks' through 37 weeks' gestation. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Low birth weight rates were 10.9% in the intervention group and 14.0% in the control group (RR 0.75; 95% CI 0.55, 1.03; P = .072). For gestational age less than 37 weeks, rates were 9.7 in the intervention group and 11.0 in the control group (RR .87; 95% CI 0.62, 1.22; P = .415). In the subgroup of low-income black women 19 years of age and older, a statistically significant difference was found in preterm birth rates before 37 weeks (8.7% in the intervention group versus 15.4% in the controls [RR 0.56; 95% CI 0.38, 0.84; P = .004]).

CONCLUSION

There was no difference in LBW or preterm births between intervention and control groups in the total sample. In a secondary analysis of black subjects 19 years of age and older, there was a significant difference in preterm birth rates.

Attitudes and practices of registered nurses toward women who have experienced abuse/domestic violence

OBJECTIVE

To compare the education, attitudes, and practices related to domestic violence of perinatal nurses from three types of practice sites.

DESIGN

A descriptive study of responses to a questionnaire administered to a convenience sample and through a mailing.

SETTING

Education conferences and responses to a mailing.

PARTICIPANTS

Two hundred seventy-five nurses in perinatal practice (87 public health, 71 hospital, 117 private office).

MAIN OUTCOME MEASURES

Primary outcomes were attitudes and beliefs about domestic violence and nursing behavior when domestic violence was identified. The effects of education about domestic violence on practice and the effect of a personal/family history of domestic violence on practice were examined.

RESULTS

Some differences were found in the attitudes and beliefs of nurses from different practice sites, but more differences were found in their behaviors. Only 54% of the total sample reported having education about domestic violence, received in formal or continuing education programs. Public health nurses were the most likely to have such education. Education affected both attitudes and behavior. In the total sample, 31% of nurses reported abuse of themselves or family members.

CONCLUSIONS

Nursing care for women who have experienced domestic violence includes assessment and appropriate counseling. Many nurses in this study lacked education about domestic violence. The provision of education about abuse and domestic violence is a first step toward a change in nursing practice.

Protein kinase C and receptor kinase gene expression in olfactory receptor neurons

Recent biochemical evidence indicates that protein kinase C (PKC) and G-protein-coupled receptor kinases (GRKs) are involved in olfactory signal termination and desensitization. The polymerase chain reaction (PCR) was used to investigate the expression of PKC and GRK genes in olfactory tissue and in isolated olfactory receptor neurons from channel catfish (Ictalurus punctatus). Sequence analysis of cloned PKC PCR products showed that the alpha, beta, delta, epsilon, and theta isotypes were expressed in olfactory tissue. Sequence analysis of PCR products obtained from isolated olfactory receptor neurons showed that PKC beta and PKC delta were expressed in the receptor cells. A 600-bp GRK PCR product was obtained from isolated olfactory neurons that shared 86% and 92% amino acid sequence identity to the mammalian beta-adrenergic receptor kinase gene products beta ARK1 and beta ARK2, respectively. Go6976, a specific inhibitor of calcium-regulated PKC activity, completely inhibited odorant-stimulated PKC activity in isolated olfactory cilia. This result suggested that odorant-stimulated PKC activity is mediated by the calcium-sensitive PKC beta isotype. Taken together, these results are consistent with the conclusion that PKC beta and beta ARK mediate odorant receptor phosphorylation and olfactory signal termination.

Protein kinase C and receptor kinase gene expression in olfactory receptor neurons

Recent biochemical evidence indicates that protein kinase C (PKC) and G-protein-coupled receptor kinases (GRKs) are involved in olfactory signal termination and desensitization. The polymerase chain reaction (PCR) was used to investigate the expression of PKC and GRK genes in olfactory tissue and in isolated olfactory receptor neurons from channel catfish (Ictalurus punctatus). Sequence analysis of cloned PKC PCR products showed that the alpha, beta, delta, epsilon, and theta isotypes were expressed in olfactory tissue. Sequence analysis of PCR products obtained from isolated olfactory receptor neurons showed that PKC beta and PKC delta were expressed in the receptor cells. A 600-bp GRK PCR product was obtained from isolated olfactory neurons that shared 86% and 92% amino acid sequence identity to the mammalian beta-adrenergic receptor kinase gene products beta ARK1 and beta ARK2, respectively. Go6976, a specific inhibitor of calcium-regulated PKC activity, completely inhibited odorant-stimulated PKC activity in isolated olfactory cilia. This result suggested that odorant-stimulated PKC activity is mediated by the calcium-sensitive PKC beta isotype. Taken together, these results are consistent with the conclusion that PKC beta and beta ARK mediate odorant receptor phosphorylation and olfactory signal termination.

Parent Line: nurse telephone intervention for parents and caregivers of children from birth through age 5

PURPOSE

To describe the development and implementation of Parent Line, a program to improve the health and development status of children through periodic telephone contact by nurses.

POPULATION

Low-income parents of children from birth through age 5.

CONCLUSION

Telephone contact with a nurse, combined with peer counselor contact when no telephone is available, is welcomed by parents and can address needs in a timely way that might be unmet otherwise. Telephone intervention can provide social and emotional support, education, and advocacy for families.

PRACTICE IMPLICATIONS

The telephone can be of value to pediatric nurses in providing anticipatory guidance and health teaching, and be a support to parents throughout the preschool years.

Family violence issues in obstetrics and gynecology, primary care, and nursing texts

OBJECTIVE

To evaluate major texts in obstetrics and gynecology, primary care, and nursing for their content in the area of family violence.

METHODS

The study included 48 medical texts and 19 nursing texts published between 1990 and 1996. Key words and phrases were identified and indices searched. Minimum requirements for content on domestic violence included 12 issues identified as important. If the text contained any information on an issue, it received one point. A domestic violence content score was calculated, and a maximum score of 12 was possible. Textbooks were evaluated for content related to domestic violence as well as rape, child sexual abuse, abuse in pregnancy, and elder abuse.

RESULTS

Thirty-seven percent of physician texts and 63% of nursing texts included some content on domestic violence. On our domestic violence content scale, 16% of medicine texts and 10% of nursing texts scored 9-12.

CONCLUSION

The availability of information on family violence is limited in both medical and nursing texts.

A new tool to measure pressure under burn garments

This article introduces a new tool to measure the pressure that is under pressure garments. The Iscan (Tekscan, Inc.) system uses a patented ultra-thin (0.007 inch) sensor with multiple sensing locations that sample continuously at 100 times per second. It is noninvasive, convenient, and quick. The study had two parts. First, we established the validity and reliability of the device. Next, garment/scar interface pressures were measured on new garments with use of the Iscan system. Four garment types were studied, with 10 measurements made in each group: Isotoner gloves (Smith & Nephew Roylan, Inc.); custom-fit pressure gloves; Tubigrip forearm sleeves (Seton Health Care Group); and custom-fit pressure forearm sleeves. Mean garment/scar interface pressures were 18 +/- 2 mm Hg for the Isotoner glove, 34 +/- 5 mm Hg for the custom-fit pressure glove, 20 +/- 7 mm Hg for the Tubigrip sleeve, and 35 +/- 6 mm Hg for the custom-fit sleeve. We concluded that the Iscan system can be used to measure pressure under pressure garments accurately and reliably, and that custom-fit hand and forearm garments provide more pressure than Isotoner gloves or Tubigrip sleeves.

A check on rational drug design: crystal structure of a complex of human immunodeficiency virus type 1 protease with a novel gamma-turn mimetic inhibitor

We have previously reported (Newlander et al., J. Med. Chem. 1993, 36, 2321-2331) the design of human immunodeficiency virus type 1 (HIV-1) protease inhibitors incorporating C7 mimetics that lock three amino acid residues of a peptide sequence into a gamma-turn. The design of one such compound, SB203238, was based on X-ray structures of reduced amide aspartyl protease inhibitors. It incorporates a gamma-turn mimetic in the P2-P1' position, where the carbonyl of the C7 ring is replaced with an sp3 methylene group yielding a constrained reduced amide. It shows competitive inhibition with Ki = 430 nM at pH 6.0. The three-dimensional structure of SB203238 bound to the active site of HIV-1 protease has been determined at 2.3 A resolution by X-ray diffraction and refined to a crystallographic R-factor (R = sigma magnitude of Fo magnitude of - magnitude of Fc magnitude of /sigma magnitude of Fo magnitude of, where Fo and Fc are the observed and calculated structure factor amplitudes, respectively) of 0.177. The inhibitor lies in an extended conformation in the active site; however, because of the constrained geometry of the C7 ring, it maintains fewer hydrogen bonds with the protein than in most other HIV-1 protease-inhibitor complexes. More importantly, the inhibitor binds to the enzyme differently than predicted in its design, by binding with the P2-P1' alpha-carbon atoms shifted by approximately one-half a residue toward the N-terminus from their presumed positions. This study illustrates the importance of structural information in an approach to rational drug design.

Anion dependence of bumetanide binding and ion transport by the rabbit parotid Na(+)-K(+)-2Cl- co-transporter: evidence for an intracellular anion modifier site

The anion dependence of [3H]bumetanide binding and 22Na+ transport by the rabbit parotid Na(+)-K(+)-2Cl- co-transporter was studied in acinar basolateral membrane vesicles (BLMVs). Cl-, Br- and NO3- have a biphasic effect on binding consistent with the presence of two anion sites associated with the bumetanide binding event, a high-affinity stimulatory site and a lower-affinity inhibitory site. We show that formate shares only the stimulatory site and SO4(2-) only the inhibitory site. The initial rate of [3H]bumetanide binding was stimulated by formate or low [Cl-] and inhibited by SO4(2-) or high [Cl-], but the rate of [3H]bumetanide dissociation was not affected by the presence of these anions in the dissociation medium. However, when [3H]bumetanide was bound to BLMVs in the presence of formate its rate of dissociation was more than four times faster than when binding took place in the presence of Cl-. These observations indicate that the binding of bumetanide and the stimulatory anion are ordered such that the anion must necessarily bind first and subsequently cannot dissociate until after bumetanide dissociates. In zero-trans-flux experiments, extravesicular SO4(2-) and formate had no effect on 22Na+ transport via the co-transporter [Turner and George (1988) J. Membr. Biol. 102, 71-77]. Thus neither of the anion sites associated with bumetanide binding is a Cl- transport site. However, we show here that SO4(2-) inhibits transport when present in the intravesicular space. Since the BLMV preparation is predominantly oriented cytosolic-side-in, this observation indicates the existence of an inhibitory cytosolic anion modifier site. Our data suggest that this site is identical to the inhibitory anion site associated with bumetanide binding.

Status report on maternal and child health indicators

The health of pregnant women and children has improved substantially since the 1960s. In the past decade, however, progress in preventing infant deaths, reducing the incidence of low-birth-weight infants, and ensuring first trimester prenatal care has slowed. African-American infants suffer a significantly higher risk of poor pregnancy outcome. Immunization rates for preschoolers remain low. Changing social conditions including a rising child poverty rate, a high teenage birth rate, an increased rate of births to unmarried women, and higher levels of unintended pregnancy may be contributing to stalled progress.

Voices from different places: but why a medical school faculty?

Interdisciplinary collaboration between nursing and medicine is a valued goal, but one which is difficult to achieve. Two nurses who are faculty members in medical schools reflect on their unique roles and how these encompass interdisciplinary research, teaching, and practice.

Etiology of low-birthweight birth: a population-based study

BACKGROUND

Preterm and low-birthweight births remain the major correlates of infant mortality in the United States. The recognition that these births result from varying proximal etiologies is essential to the development of preventive strategies specific to each etiologic group.

METHODS

Using vital statistics data tapes provided by the North Carolina Center for Health and Environmental Statistics, mothers in 20 counties who delivered infants with birthweights between 1 pound and 5 pounds, 8 ounces were identified. Maternal hospital records of 4,754 women were reviewed for data about prenatal and intrapartal events. Two perinatologists classified births into four proximal etiology groups: term-lowbirthweight, medically indicated preterm birth, preterm premature rupture of membranes, and idiopathic preterm birth. Information from birth certificate and hospital records was merged to provide an expanded data set.

RESULTS

Race, age, education, and marital status are associated with different patterns of proximal etiology. Rates were higher for all etiologies in black women and in young women; however, the absolute number of LBW births was highest among white women. Idiopathic preterm birth was highest in black women and decreased as age increased; medical indications for preterm birth increased with increasing age.

CONCLUSIONS

Classification of LBW births by etiologic group provides insights of value to both clinicians and researchers. Studies in which LBW and/or preterm birth are the outcome variables will be enhanced by identifying etiology. Multiple preventive strategies should address varying etiologic groups.

Analogues of the thrombin receptor tethered-ligand enhance mesangial cell proliferation

Thrombin stimulates cytosolic calcium mobilization and tritiated thymidine incorporation in rat glomerular mesangial cells. This effect may be mediated by a thrombin receptor similar to the receptor found in human platelets. In order to test this possibility, a series of analogues of the thrombin receptor peptide, SFLL-RNPNDKYEPF, was evaluated for their effects on mesangial cells. Analogues of the thrombin receptor peptide containing five, six, seven and 14 amino acids were as efficacious as thrombin with respect to calcium mobilization and thymidine incorporation, although they were significantly less potent. The dissimilarity in potency between thrombin and the thrombin receptor peptides is consistent with the kinetics of the proposed mechanism of action of the enzyme, since the cleavage by thrombin of its receptor results in a tethered ligand which is at a relatively high concentration compared to the free peptides in solution. Those thrombin receptor peptide analogues which showed decreased activity in platelets were tested in mesangial cells. Removal of serine at position one, N-acetylation, or replacement of the phenylalanine at position two with alanine resulted in analogues which were inactive in stimulating mesangial cell proliferation or calcium mobilization. In addition, those analogues which had no stimulatory effects in mesangial cells were not antagonists of SFLLRN-mediated calcium mobilization and thymidine incorporation in mesangial cells.