Interprofessional education and practice guide: profiling readiness for practice-based IPE

Practice-based interprofessional education (IPE) is both a valuable and complex model of practice education. To support educators design, deliver, and implement high-quality practice-based IPE, this guideline was developed in conjunction with a placement profile. Underpinned by educational theory, this guideline and placement profile identifies key factors to consider before, during, and after practice-based IPE. Development of the profile has involved interprofessional collaboration as well as international feedback via conference workshops. The profile has been trialed in two clinical sites involved in practice-based IPE and refined following consultation with and feedback from educators. Educators can also use the profile to track site development over time and evidence resource and support requirements. Through use additional features may become relevant and users are encouraged to add or amend as is most beneficial to their site.

Inside-out: normalising practice-based IPE

Practice-based interprofessional education (IPE), a key feature in developing a collaboration-ready workforce, is poorly integrated in healthcare curriculums. This study aimed to synthesise educator perspectives on implementing practice-based IPE and develop recommendations to inform sustainable practice-based IPE. An ethnographic case study was carried out at a school of allied health. Data collection involved six observations, 11 interviews and a review of eight documents. Reflexive thematic analysis, informed by Normalisation Process Theory, established two key themes. First, we found that strategic planning is needed, with a coherent implementation agenda and planned reflection on activities. Second, building partnerships with placement partners was identified as essential. This can be achieved by supporting and championing practice-based IPE activities developed by placement sites and establishing how university and clinical educators can work collaboratively to deliver sustainable practice-based IPE. These conditions create a favourable environment for normalising practice-based IPE in healthcare curriculums, benefitting students, patients, and the overall healthcare service.

'It benefits patient care': the value of practice-based IPE in healthcare curriculums

BACKGROUND

Practice-based interprofessional education (IPE) is essential to prepare students for collaborative working. Pockets of practice-based IPE are integrated into healthcare curriculums in some regions. Yet practice-based IPE is not globally valued as a key element of healthcare curriculums. As students and clinical educators are key stakeholders, this study presents a case example of their experiences in a country where practice-based IPE is at an emergent stage. Their experiential knowledge generated important insights into how practice-based IPE is perceived. This learning can be applied, both locally and further afield, by those seeking to embed practice-based IPE in their placement curriculums.

METHODS

A qualitative case study was conducted at a school of allied health and partner placement sites in Ireland. Data collection comprised two participant observations, 13 interviews and 12 document analyses. Inductive thematic analysis and deductive framework analysis, underpinned by activity theory and Hofstede's cultural dimensions, informed data analysis and interpretations.

RESULTS

Participants are grappling to establish the value of practice-based IPE, illustrated in three themes: clarifying the concept of practice-based IPE, mapping IPE activities and diversifying interprofessionalism. First, ambiguous conceptualisation of why and how to implement practice-based IPE was identified. Highlighting how practice-based IPE improved patient care and safety created a clear rationale for implementation. It was also helpful to demonstrate how adaptations to existing practice education models, rather than entirely new models, could achieve high-quality practice-based IPE. Second, the positioning of practice-base IPE in the placement curriculum was unclear. Overt mapping of practice-based IPE activities onto learning outcomes within assessment tools enhanced its value within practice education. Third, varying levels of professional engagement were noted, perpetuating stereotypes. Creating diverse educator networks and embedding practice-based IPE in organisational strategy may incentivise engagement across a greater range of professions.

CONCLUSIONS

Implementing these recommendations could enhance the value of practice-based IPE and optimise student preparation for collaborative working. Practice-based IPE remains a complex model and the trajectory of embedding in healthcare curriculums will differ globally.

'Bumping along': a qualitative metasynthesis of challenges to interprofessional placements

CONTEXT

Interprofessional practice is required to manage complex health care needs globally. It is well established that interprofessional placements (IPP) prepare students to work collaboratively, yet IPP implementation remains limited and disjointed.

OBJECTIVES

This review synthesised student, educator and service user perspectives in order to better understand challenges of IPP and provide recommendations for sustainable IPP implementation.

METHODS

A systematic metasynthesis of qualitative literature sourced from databases including CINAHL, Embase and PsycINFO was completed. Studies that incorporated student, educator and/or service user perspectives on IPP experiences were included. We focused specifically on factors limiting implementation of IPP. The presage-process-product (3P) theory provided the theoretical framework for inductive synthesis of 41 empirical studies. A confidence rating for findings was formulated using CERQual (confidence in evidence from reviews of qualitative research).

RESULTS

We developed three themes, which represent key challenges to IPP becoming embedded in placement culture: (i) thin theoretical foundations underpinned IPP, limiting understanding of the learning processes involved; (ii) implementation relied heavily on individual champions, which curtails investment and sustainability when personnel change, and (iii) students, educators and service users were unsure of the function of IPP and their respective roles, leading to uncertainty along with some negative perceptions of this placement approach.

CONCLUSIONS

In line with the 3P theoretical framework, IPP would benefit from explicit connections with educational and change management theories during presage stage IPP requires coordinated leadership and resource investment, and during product stage clear integration of interprofessional learning outcomes in curricula is advised. Addressing the identified challenges across the stages of IPP will support further development of IPP, firmly establishing this approach within placement culture. IPP can them make a significant contribution to the development of a collaborative practice-ready workforce. This in turn will enhance service user outcomes and safety.

Interventions to improve adherence to exercise therapy for falls prevention in community-dwelling older adults: systematic review and meta-analysis

BACKGROUND

exercise therapy is highly recommended for falls prevention in older adults; however, poor exercise adherence may limit treatment effectiveness.

OBJECTIVE

to assess the effectiveness of interventions to improve exercise adherence for community-dwelling adults (aged over 65 years), at risk of falling.

METHODS

eight databases were searched to identify randomised/quasi-randomised trials. The Capability, Opportunity, Motivation model of behaviour (COM-B) was used to categorise the identified adherence interventions. Studies with similar interventions that provided adherence outcome data per group were analysed to establish pooled intervention effect. Protocol registration with Propsero: (CRD42016033677).

RESULTS

of the 20 trials included (n = 4419), five provided data per group for adherence outcome. Meta-analysis of four studies (n = 482), containing interventions exploring the way exercise is delivered, demonstrated significantly better adherence in the intervention group (n = 166 experimental, n = 161 control Fixed effects model (FEM), SMD = 0.48 95% CI [0.26-0.70] P < 0.0001 I2 = 0%, very low GRADE evidence). Within this limited evidence base, interventions using telecommunication and the integration of exercise into activities of daily living appear most promising when delivering exercise at home. Meta-analysis to explore the effect that these interventions to improve adherence had on balance (n = 166 experimental, n = 161 control Random-effects model (REM), SMD = 0.82, 95% CI [-1.20-2.84] P = 0.43 I2 = 52%) and gait (n = 59 experimental, n = 56 control REM, SMD = 0.29, 95% CI [-1.62-2.20] P = 0.77 I2 = 48%), found no statistically significant effect.

CONCLUSIONS

adherence to exercise can be positively influenced; however, insufficient data exists to support any single intervention that also achieves effective outcomes for balance and gait.

How Beliefs About Bladder Dysfunction Among Health-Care Professionals Influence Clinical Practice Development: Perspectives of Allied Health Professionals, Nurses, and Managers

BACKGROUND

Bladder dysfunction can affect up to 75% of people with multiple sclerosis (MS) on several important life domains. It is a multifaceted problem that remains underdiagnosed by health-care professionals. The aims of this study were to understand the perceptions of Irish health-care professionals regarding bladder dysfunction and to explore current service provision for people with MS.

METHODS

Two focus groups, three dyadic interviews, and one semistructured interview with 14 health-care professionals lasting up to 90 minutes were audio-recorded. Participants included eight physiotherapists, two occupational therapists, three nurses, and one clinical case manager from acute and community settings.

RESULTS

Thematic analysis of transcripts yielded two key themes. The first theme involves the underlying beliefs of health-care professionals, their clinical practice, and experiential knowledge in the model of clinical practice development in relation to bladder management. The second theme addresses the pivotal points in this model where change can be implemented to optimize bladder management. The first element of change encompasses the interaction between clinical practice and experiential knowledge of health-care professionals. The second element of change incorporates how acknowledgment of individual beliefs of health-care professionals can further inform clinical practice and experiential knowledge.

CONCLUSIONS

These findings suggest that health-care professionals need to be aware of their beliefs in relation to bladder dysfunction. Examining these beliefs may influence how people with MS access health service provision for this disabling symptom. This type of reflexive practice may facilitate changes to existing perceptions and reduce the reluctance to discuss bladder symptoms.

Experiences of university students disclosing epilepsy to peers: ‘It's a shared thing now’

Introduction

While disclosure of concealable conditions like epilepsy can create social support, it may cause relationships to disintegrate. Friendship in young adulthood is pivotal in the transition to emotional autonomy, yet little is known about peer disclosure by university students with epilepsy. This qualitative study aimed to map key features in the process of epilepsy disclosure.

Method

Semi-structured interviews were completed with eight young adults (aged 18–25 years) with epilepsy enrolled in or recently graduated from Irish universities.

Findings

Thematic analysis yielded four main themes: (1) Assessing the disclosure recipient; (2) Managing the presentation of epilepsy; (3) Forging alliances; and (4) Feeling more positive. The process of disclosure centred on enlisting the support of allies deemed trustworthy by participants. Disclosure messages presented epilepsy neutrally to bolster allies' commitment to the role. Although participants viewed disclosure as beneficial to wellbeing, concern was expressed about acquiring a stigmatised social identity.

Conclusion

Occupational therapists are well placed to support young adults through the process of disclosure. Promoting a positive collective identity through peer mentorship promises to disrupt stigma. More broadly, partnerships between occupational therapists and epilepsy organisations or disability support services in third level education could establish an academic culture where supports are readily available to people with concealable illnesses.

The genomic architecture of resistance to Campylobacter jejuni intestinal colonisation in chickens

BACKGROUND

Campylobacter is the leading cause of foodborne diarrhoeal illness in humans and is mostly acquired from consumption or handling of contaminated poultry meat. In the absence of effective licensed vaccines and inhibitors, selection for chickens with increased resistance to Campylobacter could potentially reduce its subsequent entry into the food chain. Campylobacter intestinal colonisation levels are influenced by the host genetics of the chicken. In the present study, two chicken populations were used to investigate the genetic architecture of avian resistance to colonisation: (i) a back-cross of two White Leghorn derived inbred lines [(61 x N) x N] known to differ in resistance to Campylobacter colonisation and (ii) a 9(th) generation advanced intercross (61 x N) line.

RESULTS

The level of colonisation with Campylobacter jejuni following experimental infection was found to be a quantitative trait. A back-cross experiment using 1,243 fully informative single nucleotide polymorphism (SNP) markers revealed quantitative trait loci (QTL) on chromosomes 7, 11 and 14. In the advanced intercross line study, the location of the QTL on chromosome 14 was confirmed and refined and two new QTLs were identified located on chromosomes 4 and 16. Pathway and re-sequencing data analysis of the genes located in the QTL candidate regions identified potential pathways, networks and candidate resistance genes. Finally, gene expression analyses were performed for some of the candidate resistance genes to support the results.

CONCLUSION

Campylobacter resistance in chickens is a complex trait, possibly involving the Major Histocompatibility Complex, innate and adaptive immune responses, cadherins and other factors. Two of the QTLs for Campylobacter resistance are co-located with Salmonella resistance loci, indicating that it may be possible to breed simultaneously for enhanced resistance to both zoonoses.

Genome-wide SNP analysis identifies major QTL for Salmonella colonization in the chicken

Salmonella-infected poultry products are a major source of human Salmonella infection. The prophylactic use of antimicrobials in poultry production was recently banned in the EU, increasing the need for alternative methods to control Salmonella infections in poultry flocks. Genetic selection of chickens more resistant to Salmonella colonization provides an attractive means of sustainably controlling the pathogen in commercial poultry flocks and its subsequent entry into the food chain. Analysis of different inbred chickens has shown that individual lines are consistently either susceptible or resistant to the many serovars of Salmonella that have been tested. In this study, two inbred chicken lines with differential susceptibility to Salmonella colonization (61 ((R)) and N((S)) ) were used in a backcross experimental design. Unlike previous studies that used a candidate gene approach or low-density genome-wide screens, we have exploited a high-density marker set of 1255 SNPs covering the whole genome to identify quantitative trait loci (QTL). Analysis of log-transformed caecal bacterial levels between the parental lines revealed a significant difference at 1, 2, 3 and 4 days post-infection (P < 0.05). Analysis of the genotypes of the backcross (F1  × N) population (n = 288) revealed four QTL on chromosomes 2, 3, 12 and 25 for the two traits examined in this study: log-transformed bacterial counts in the caeca and presence of a hardened caseous caecal core. These included one genome-wide significant QTL on chromosome 2 at 20 Mb and three additional QTL, on chromosomes 3, 12 and 25 at 96, 15 and 1 Mb, respectively, which were significant at the chromosome-wide level (P < 0.05). The results generated in this study will inform future breeding strategies to control these pathogens in commercial poultry flocks.

Bladder dysfunction and quality of life for people with multiple sclerosis

PURPOSE

Bladder dysfunction affects 75% of people with multiple sclerosis (MS). People with MS are reluctant to seek treatment for this distressing symptom. This is the first-known study to explore in depth how bladder dysfunction interferes with quality of life for people with MS.

METHODS

Nineteen individual semi-structured interviews were conducted (M = 8, F = 11). Participants had a definite diagnosis of MS, aged between 37 and 64 years and had at least one bladder dysfunction symptom. The audio-recorded interviews lasted up to 90 min and were transcribed verbatim.

RESULTS

Thematic analysis within NVivo10 yielded two key themes: (1) Disruptions and loss and (2) ways of knowing. "Disruptions and Loss" explores how bladder dysfunction interrupted daily living activities and how this contributed to experiencing loss. "Ways of knowing" portrays the types of knowledge that existed around bladder dysfunction. Participants described using their experiential knowledge to self-manage bladder symptoms without advice from healthcare providers.

CONCLUSIONS

Bladder dysfunction imposes major disruptions on daily life. People with MS attempt to self-manage their bladder symptoms, despite current barriers to navigating existing healthcare infrastructure. Understanding these barriers and the individual strategies employed by people with MS are the first steps in facilitating independent management of bladder dysfunction. Implications for Rehabilitation Each individual's experience of bladder dysfunction is unique. Healthcare professionals must be prepared to discuss all disruptions and losses associated with bladder dysfunction for people with MS. People with MS have a vast range of knowledge in relation to their own bladder symptoms and healthcare professionals need to explore their existing self-management strategies during assessment. People with MS and healthcare professionals need to be educated on the wider health implications relating to bladder dysfunction.

Phenytoin loading doses in adult critical care patients: does current practice achieve adequate drug levels?

Phenytoin is regularly employed in the critically ill for prophylaxis against or treatment of seizure disorders. No prior studies have examined current dosing practices in an Australasian intensive care unit (ICU) setting. The aims of this study were to: a) describe the adequacy of contemporary dosing in respect to free and total serum phenytoin concentrations; b) identify factors associated with therapeutic drug concentrations; and c) examine the accuracy of predictive equations that estimate free concentrations in this setting. All patients receiving a loading dose of phenytoin in a tertiary-level ICU were eligible for enrolment; 53 patients were enrolled in the study. Serum samples to determine free and total phenytoin concentrations (measured by high performance liquid chromatography) were then drawn prior to the following dose. Free concentrations below the recommended target (<1 mg/l) were considered as suboptimal. The most common indication for phenytoin loading was traumatic brain injury (49%) and the mean administered dose was 14.5 (3.66) mg/kg. Twenty-six patients (49%) had suboptimal trough free concentrations, although this subgroup was significantly heavier and therefore received a lower per kilogram dose (12.8 [3.1] vs 16.3 [3.4] mg/kg, P=0.001). In multivariate analysis, larger weight adjusted doses (P=0.018), higher albumin concentration (P=0.034) and receiving phenytoin for an indication other than seizure (P=0.035), were associated with a greater likelihood of adequate concentrations. In conclusion, phenytoin dosing remains complex in critically ill patients, although lower per kilogram loading doses are strongly associated with free concentrations below the desired target.

'We just stick together': how disabled teens negotiate stigma to create lasting friendship

BACKGROUND

Friendship is a crucial relationship offering practical support, enjoyment and improved health. When disability is added into the mix, the permutations of friendship shift. Despite the presence of inclusive social policies many disabled teens continue to experience stigma and social isolation, yet some teens are able to establish long-term friendships.

METHODS

A nuanced understanding about how disabled teens navigate stigma to create lasting friendships was constructed through this qualitative study. Seven boys and seven girls between the ages 15 to 20 years who experienced disability engaged in research interviews and participant observation sessions. Nine adults were also interviewed. A critical approach to data analysis was complimented by coding in Atlas.ti.

RESULTS

This article describes the strategies used by these disabled teens to make and keep friends: disrupting norms about friendship, coming out as disabled, connecting through stigma and choosing self-exclusion.

CONCLUSION

Disabled teens in this study felt a greater sense of belonging when with peers who shared the disability experience, thus self-exclusion was a viable strategy for creating sustainable friendships in the context of oppression. Social policy informed by the experiences of disabled youth in the current study will more effectively promote social inclusion by first acknowledging and then disrupting ableism.

Identification, cloning and characterisation of interleukin-1F5 (IL-36RN) in the chicken

The human IL-1 family contains eleven genes encoded at three separate loci. Nine, including IL-36 receptor antagonist (IL-36RN), also known as IL-1F5, are present at a single locus on chromosome 2, whereas IL-18 and IL-33 lie on chromosomes 11 and 9 respectively. There are currently only three known orthologues in the chicken - IL-1β, IL-18 and IL-1RN - which are encoded on chromosomes 22, 24 and unplaced, respectively. A novel chicken IL-1 family sequence representing IL-36RN (IL-1F5) was initially identified from an expressed sequence tag (EST) library by its similarity to both chicken IL-1RN and chicken IL-1β. Following isolation of the cDNA from the liver of an uninfected bird, a number of unique sequence features were identified. The predicted protein has a longer NH(2)-terminus than the human protein; however, as in mammals, this region contains neither a prodomain nor a signal peptide. A putative nuclear export sequence is also apparent, yet a similar motif is absent in mammalian IL-36RN. Although chIL-36RN exhibits low homology with its mammalian orthologues, it encodes a predicted β-trefoil structure whose β-strands are conserved with those of the mouse sequence. Unlike in mammals, chIL-36RN expression was constitutive in all tissues and cell subsets examined. In response to viral infection, expression was significantly downregulated in a line of birds which are susceptible to the virus. Chicken IL-36RN, like chIL-1RN, is not encoded at the chIL-1β locus, further emphasising the genomic fragmentation of the large IL-1 gene cluster found in mammals. This suggests differential evolution of this cytokine family since the divergence of birds and mammals from a common ancestor, and underlines the difficulty of determining the full repertoire of chIL-1 family members.

Fine mapping of the chicken salmonellosis resistance locus (SAL1)

Salmonella enterica serovar Typhimurium is a Gram-negative bacterium that has a significant impact on both human and animal health. It is one of the most common food-borne pathogens responsible for a self-limiting gastroenteritis in humans and a similar disease in pigs, cattle and chickens. In contrast, intravenous challenge with S. Typhimurium provides a valuable model for systemic infection, often causing a typhoid-like infection, with bacterial replication resulting in the destruction of the spleen and liver of infected animals. Resistance to systemic salmonellosis in chickens is partly genetically determined, with bacterial numbers at systemic sites in resistant lines being up to 1000-fold fewer than in susceptible lines. Identification of genes contributing to disease resistance will enable genetic selection of resistant lines that will reduce Salmonella levels in poultry flocks. We previously identified a novel resistance locus on Chromosome 5, designated SAL1. Through the availability of high-density SNP panels in the chicken, combined with advanced back-crossing of the resistant and susceptible lines, we sought to refine the SAL1 locus and identify potential positional candidate genes. Using a 6(th) generation backcross mapping population, we have confirmed and refined the SAL1 locus as lying between 54.0 and 54.8 Mb on the long arm of Chromosome 5 (F = 8.72, P = 0.00475). This region spans 14 genes, including two very striking functional candidates; CD27-binding protein (Siva) and the RAC-alpha serine/threonine protein kinase homolog, AKT1 (protein kinase B, PKB).

Polyelectrolyte multilayer films promote human cord blood stem cells differentiation into mature endothelial cells exhibiting a stable phenotype

BACKGROUND

recent studies in bio-engineering have showed the influence of Polyelectrolyte Multilayer (PEM) films on endothelial cells (ECs), especially poly(sodium-4-styrene-sulfonate) (PSS) and poly(allylamine hydrochloride) (PAH). They were tested either with human mature ECs or rabbit immature endothelial progenitor cells (EPCs), but never on human EPCs. In view to obtain an EC covered surface, human cord blood (HCB) EPCs were cultivated on PSS/PAH films.

MATERIAL AND METHODS

PEMs were obtained by 7 alternate depositions of cationic PAH and anionic PSS layers. HCB mononuclear cells were isolated by centrifugation through density gradient. 7 days after seeding on PEM, unattached cells were removed and adherent EPCs were cultivated in endothelial specific medium until P6. Appearance of CD31 and vWF was evaluated by confocal microscopy.

RESULTS

EPCs not only successfully adhered on PEM, but also spread and proliferated. Moreover, cells differentiated into a typical endothelial cobblestone monolayer within 2 weeks. Immunostaining of CD31 and vWF confirmed the formation of an EC-like confluent monolayer. Furthermore, these cells showed after 6 passages a good phenotypic stability while reseeded on the PEM film.

CONCLUSION

these results show an easy way to obtain mature ECs from human stem cells, which may open new applications for a scaffold cellularization in tissue bio-engineering.

Towards the selection of chickens resistant to Salmonella and Campylobacter infections

Resistance to infection with enteric pathogens such as Salmonella and Campylobacter can be at many levels and include both non-immune and immune mechanisms. Immune resistance mechanisms can be specific, at the level of the adaptive immune response, or non-specific, at the level of the innate immune response. Whilst we can extrapolate to some degree in birds from what is known about immune responses to these pathogens in mammals, chickens are not "feathered mice", but have a different repertoire of genes, molecules, cells and organs involved in their immune response compared to mammals. Fundamental work on the chicken's immune response to enteric pathogens is therefore still required. Our studies focus particularly on the innate immune response, as responses of heterophils (the avian neutrophil equivalent) from commercial birds, and macrophages from inbred lines of chickens, correlate with resistance or susceptibility to Salmonella infection with a variety of Salmonella serovars and infection models. We work on two basic resistance mechanisms - resistance to colonization with Salmonella or Campylobacter, and resistance to systemic salmonellosis (or fowl typhoid). To map genes involved in resistance to colonization with Salmonella and Campylobacter, we are using a combination of expression quantitative trait loci (eQTLs) from microarray studies, allied with whole genome SNP arrays (WGA), a candidate gene approach and analysis of copy number variation across the genome. For resistance to systemic salmonellosis, we have refined the location ofa novel resistance locus on Chromosome 5, designated SAL1, using high density SNP panels, combined with advanced back-crossing of resistant and susceptible lines. Using a 6th generation backcross mapping population we have confirmed and refined the SAL1 locus to 8-00 kb of Chromosome 5. This region spans 14 genes, including two very striking functional candidates; CD27-binding protein (Siva) and the RAC-alpha serine/threonine protein kinase homologue, AKT1.

The genes encoding E-selectin (SELE) and lymphotactin (SCYC1) lie on separate chicken chromosomes although they are closely linked in human and mouse

Three differentially expressed selectin genes (SELE, SELP, and SELL), important in the initial stages of leukocyte extravasation, have been reported in mammals. All three genes map close to the chemokine SCYC1 (small inducible cytokine subfamily C, member 1) in a large conserved chromosomal segment that extends from RXRG (retinoic acid receptor, gamma) to TNNT2 (troponin T2) on Chromosome (Chr) 1 in both human and mouse. In the mouse, we demonstrate that Sele is flanked by Prrx1 (paired-related homeobox gene 1) and Scyc1 and define the order of, and distances between, loci as centromere-Prrx1-(0.7+/-0.7 cM)-Sele-(1.2+/-0.9 cM)-Scyc1-telomere. In the chicken, we isolated BAC clones containing PRRX1, SELE, and SCYC1 and positioned them by fluorescent in situ hybridization. SELE and PRRX1 mapped to the short arm of chicken Chr 8 and SCYC1 mapped to the region equivalent to 1q11-1q13 on the long arm of chicken Chr 1. The location of SELE on chicken Chr 8 was independently established by linkage analysis of COM0185, an (AT)16 microsatellite locus identified in a BAC clone that contained SELE. COM0185 was linked to several loci that mapped to one end of chicken Chr 8, with the order of loci, and genetic distances (in cM) between them defined as MSU0435, MSU0325-(7.8+/-3.7)-COM0185-(5.8+/-3.2)-ROS0338-(9.6+/-4.0)-ABR0322-(3.8+/-2.6)-GLUL. We have therefore positioned an evolutionary breakpoint in mammals and chickens between SELE and SCYC1. Furthermore, comparative mapping analysis of the RXRG-TNNT2 chromosomal segment that is conserved on human and mouse Chr 1 indicates that it is divided into four segments in the chicken, each of which maps to a different chromosome.

Extradural block. Confirmation of the injection site by X-ray monitoring

X-ray monitoring was used to confirm the accuracy of extradural block in 100 patients who attended the Pain Relief Clinic for treatment of a variety of different conditions. A Tuohy needle was introduced by the central or paramedian approach and conventional physical signs, notably loss of resistance, used to identify entry into the extradural space. A radio-opaque dye was introduced prior to the analgesic solution, to display the injection site. X-ray screening confirmed the accuracy of the block in 83 patients, but unexpectedly in 17 the point of the needle was either just outside the spinal canal or only partly in the extradural space. There was no difficulty in correcting the needle position with the X-ray facilities available. Imprecise needle siting is only partially explained by technical problems. Imprecise siting of the needle may be responsible for at least some cases of inadequate analgesia or unexpected complications. In our view X-ray confirmation of site is essential for difficult extradural blocks, or when neurolytic solutions are introduced into the spinal canal. It may also be useful in teaching and research.

Peptic ulceration in men. Epidemiology and medical care

Estimates of the population prevalence of peptic and duodenal ulceration in men aged between 25 and 64 years were made in the London borough of Lambeth. The sampling frame for these estimates was a 20% private census. The lifetime prevalence rate of proved peptic ulcer (haematemesis, gastric and duodenal ulcers as validated by operation or barium meal), adjusted for age and social class, was estimated to be 6-7%, while the similarly adjusted lifetime prevalence for duodenal ulcer was 4-4%. The lifetime prevalences increased with age but not significantly so. A social class gradient was demonstrated with the highest prevalence in social class I and II. Previously described associations with blood group, secretor status, and serum pepsinogen were confirmed. Reported use of medical services increased with increasing severity of symptoms. A large number of respondents, however, who reported symptoms reported no medical care. It seemed unlikely that those men who reported symptoms and no medical care had demonstrable peptic ulcers.