Why Competency Frameworks Are Insufficiently Nuanced for Health Equity Teaching and Assessment

This article suggests how competency-based medical education should robustly integrate health equity by focusing on physicians' responsibilities to (1) know why and how underlying structural mechanisms contribute to health equity and then (2) take action to achieve health equity in their practice. This article first canvasses currently available frameworks for helping trainees cultivate these 2 specific skills of discernment and action. This article then offers strategies for teaching and assessing these skills in specific learning activities.

"A Look Under the Hood": Reflections on the Inaugural RIME Mentorship Program

In 2021, Research in Medical Education (RIME) celebrated 60 years of advancing scholarship in health professions education (HPE). At that time, the nation's educational institutions faced a public reckoning on the long-standing pandemic of racism that sweltered in their practices and policies, laid bare by COVID-19 and the Black Lives Matters movement. RIME responded with a mentorship program for minoritized early career HPE faculty, which aims to amplify their voices in settings where their experiences and contributions are frequently dampened. The program fosters professional development through structured activities, participation as RIME committee interns, and formal mentorship channels to support career growth and offer experiences with scholarly publishing. This commentary was written by the first cohort of RIME mentees who are HPE scholars from various professions and diverse backgrounds with struggles traversing professional landscapes as immigrants and as individuals with minoritized identities and hopes for belonging in medical and educational institutions. In this commentary, the mentees describe the merits of the RIME mentorship program and what it meant to them and their unique marginalities. They also examine opportunities for improvements within the program to further reduce barriers faced by minoritized early career HPE faculty who often face limited support with scholarly activities.

Collaboration between the military and a charity: delivering care to patients, training to defence medical staff and defence engagement overseas

The Royal College of Anaesthetists Military Anaesthesia higher training module was approved in 2008. The opportunities for trainee deployments to operational environments are limited, and while the need to ensure training and demonstrate the unique military skill set remains, these may not be consistently attainable within NHS posts. This paper proposes a template for the successful integration of military training with a charity mission by describing experiences in Addis Ababa over the two weeks of Project Harar's 2020 Complex Surgery Mission. This model not only benefits patients and military trainees by providing opportunities to gain the skills and attributes required by the Armed Services Consultant Appointment Board, but also by projecting the Defence Medical Services on the global stage.

A Rare Post-infectious Rash: Pityriasis Rubra Pilaris After COVID-19 Infection

Pityriasis rubra pilaris (PRP) is a rare papulosquamous skin disorder that often presents with erythematous follicular-based hyperkeratotic papules that can become confluent and lead to erythroderma and electrolyte and thermoregulatory imbalances resulting from increased tissue perfusion and skin barrier breakdown. Due to this condition being uncommon, many specialties outside of dermatology are unfamiliar with this entity which poses unique diagnostic and management challenges. This case report involves a 55-year-old woman who presented to the emergency room with erythroderma secondary to PRP. It highlights the relevance of PRP in the context of in-hospital management by presenting the patient's clinical profile, diagnostic workup, and treatment plan. By emphasizing the distinctive clinical features and natural course of the disease, this report aims to enhance the understanding of this uncommon inflammatory skin condition.

Treatment burden and associated factors: a population-based survey in Central Denmark Region 2017

Background

Exploring treatment burden at a population level can provide evidence of the types of patients who need special attention and support. We aimed to determine factors associated with high perceived treatment burden in a population-based survey of adults living in the Central Denmark Region (23% of the Danish population).

Methods

The Danish Multimorbidity Treatment Burden Questionnaire (MTBQ) was included in the 2017 Danish population health survey. 28,627 individuals aged 25 years or over participated (64% response rate). Individuals who reported having one or more medical conditions or attending regular health check-ups were asked to complete the MTBQ. A global MTBQ score was calculated (range 0-100) and both the continuous scores and a four-category grouping of the scores into no, low, medium and high burden were used to statistically assess the association between treatment burden and sociodemographic and health-related factors.

Results

13,407 individuals completed the Danish MTBQ (mean age 59 years). Treatment burden was negatively associated with self-related health (rs = -0.45, P < 0.0001), health-related quality of life (rs = -0.46/-0.51, P < 0.0001) and positively associated with the number of long-term conditions (rs = 0.26, P < 0.0001) and perceived stress (rs = 0.44, P < 0.0001). Higher treatment burden was associated with young age, male sex, high educational level, unemployment, not living with a spouse/cohabitant, living with child(ren) and specific long-term conditions, including heart disease, stroke, diabetes and mental illness.

Conclusions

This is the first known population-based study of treatment burden. The findings provide important evidence to policy makers and clinicians about sociodemographic groups at risk of higher treatment burden. We recommend that patient-perceived treatment burden is included when evaluating interventions targeting patients with long-term conditions and multimorbidity and health-care system reorganisations.

Key messages

• Treatment burden is associated with poor health and health-related quality of life and, among others, young age, male sex, unemployment, not living with a spouse, and specific long-term conditions.

• We recommend that patient-perceived treatment burden is included when evaluating interventions targeting patients with long-term conditions and multimorbidity and health-care system reorganisations.

Development of a model of medication review for use in clinical practice: Bristol medication review model

BACKGROUND

Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model.

METHODS

A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material.

RESULTS

We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice.

CONCLUSIONS

The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.

Adventitious Agent Risk Assessment Case Study: Evaluation of RotaTeq(R) for the Presence of Porcine Circovirus

CONFERENCE PROCEEDING Proceedings of the PDA/FDA Adventitious Viruses in Biologics: Detection and Mitigation Strategies Workshop in Bethesda, MD, USA; December 1-3, 2010 Guest Editors: Arifa Khan (Bethesda, MD), Patricia Hughes (Bethesda, MD) and Michael Wiebe (San Francisco, CA) In June of 2010, results of metagenomic and panmicrobial microarray analysis of a number of commercially available vaccine products were published, identifying the unexpected presence of porcine circovirus (PCV) in of one of the vaccine products tested. This testing did not detect any sequences of contaminating viruses in RotaTeq® (rotavirus vaccine, live, oral, pentavalent, RV5, Merck & Co., Inc., Whitehouse Station, NJ). To confirm this finding, Merck developed and applied a number of polymerase chain reaction-based analytical methods and a test algorithm to systematically demonstrate the absence of infectious PCV in RotaTeq®. This paper will describe the methodology and rationale developed to thoroughly assess key starting materials, product intermediates, and final product to demonstrate the absence of infectious PCV, and the continued quality of this product. This approach could be applied to assess the validity of other adventitious agent risks encountered in biological processes and products.

Habitat use by female western roe deer (Capreolus capreolus): influence of resource availability on habitat selection in two contrasting years

In most previous studies of habitat selection, the use of a given habitat type is assumed to be directly proportional to its availability. However, the use and (or) the selection of a given habitat may be conditional on the availability of that habitat. We aim here to (i) identify the environmental variables involved in habitat selection, (ii) identify classes of individuals with similar patterns of habitat selection, and (iii) assess whether habitat use changes with changing availability of habitat types, within monthly home ranges of female western roe deer ( Capreolus capreolus (L., 1758)). We found that some females adjust their habitat use according to the distribution of resources within habitats. Females with similar home ranges in terms of resource quantity and quality showed similar patterns of habitat selection. Differences in habitat use between 2 years with contrasting resource availability showed that temporal changes of environmental conditions influenced the pattern of habitat selection by female roe deer. Habitat selection also differed between periods of the life cycle likely because of contrasted energy requirements. This study shows that the relationship between habitat use by herbivores and habitat availability is nonproportional, and that the availability of resources influences use mostly at intermediate values.

Lifetime reproductive success and composition of the home range in a large herbivore

The relationship between individual performance and nonrandom use of habitat is fundamental to ecology; however, empirical tests of this relationship remain limited, especially for higher orders of selection like that of the home range. We quantified the association between lifetime reproductive success (LRS) and variables describing lifetime home ranges during the period of maternal care (spring to autumn) for 77 female roe deer (Capreolus capreolus) at Trois-Fontaines, Champagne-Ardenne, France (1976-2000). We maintained population growth rate (adjusted to account for removals of non-focal animals) near rmax, which enabled us to define the fitness-habitat relationship in the absence of density effects. Using a negative binomial model, we showed that a roe deer's incorporation into its home range of habitat components important to food, cover, and edge (meadows, thickets, and increased density of road allowances) was significantly related to LRS. Further, LRS decreased with increasing age of naturally reclaimed meadows at the time of a deer's birth, which may have reflected a cohort effect related to, but not entirely explained by, a decline in quality of meadows through time. Predictive capacity of the selected model, estimated as the median correlation (rs) between predicted and observed LRS among deer of cross-validation samples, was 0.55. The strength of this relationship suggests that processes like selection of the site of a home range during dispersal may play a more important role in determining fitness of individuals than previously thought. Individual fitness of highly sedentary income breeders with high reproductive output such as roe deer should be more dependent on home range quality during the period of maternal care compared to capital breeders with low reproductive output. Identification of the most important habitat attributes to survival and reproduction at low density (low levels of intraspecific competition) may prove useful for defining habitat value ("intrinsic habitat value").

Use and misuse of aspirin in rural Ethiopia

OBJECTIVES

To investigate ability to distinguish simple analgesics, to document misconceptions about aspirin use, and to identify strategies to diminish potentially harmful aspirin use in Ethiopia.

DESIGN

Qualitative study (eight focus group discussions) used to inform cross-sectional survey.

SETTING

Butajira, a small town in southern Ethiopia, and surrounding rural areas.

PARTICIPANTS

Purposively selected informants for focus groups; random sample of urban and rural residents for cross-sectional survey.

MAIN OUTCOME MEASURES

Ability to distinguish aspirin from paracetamol; proportion using aspirin; proportion aware of common risks of aspirin.

RESULTS

Questionnaires were completed by 204 of the 250 residents sampled (82% response). Three-quarters of survey participants knew the difference between aspirin and paracetamol. Aspirin was used by 7.3% of respondents, and was mainly taken for headache and fever. In focus group discussions there was a suggestion that aspirin was considered particularly useful for children. There was very low awareness of the risks of using aspirin in children (2.5% unprompted, 18.6% prompted) or in people with asthma (1% unprompted, 5.9% prompted). Aspirin is cheap and widely available in urban and rural areas.

CONCLUSION

Awareness of the risks of aspirin use by children and in asthma is extremely low in this rural Ethiopian setting. Medications are purchased with minimal packaging by a population with low literacy. Drug dispensers and vendors must be trained to convey simple verbal warnings about aspirin use.

Detection breadth and limits for potential adventitious/endogenous contaminants in biopharmaceutical processes: a reality check for innovative methods

In this presentation we address the "gold standards" among diagnostic tests used to detect some potential adventitious and endogenous contaminants in human biologics and vaccines, reflecting on the breadth as well as limits of detection of these assays. This perspective may help developers of innovative diagnostics to address the unique needs of this highly regulated industry.

Loss of heterozygosity on chromosomes 11 and 17 are markers of recurrence in TCC of the bladder

Approximately 2/3 of patients diagnosed with superficial transitional cell carcinoma of the urinary bladder (TCC) will recur within 2 years. Loss of chromosome 9 and loss of heterozygosity (LOH) at 9q34 in index TCCs identify a subset of patients at high risk of recurrence. This study explores genetic alterations on chromosomes 4, 8, 11 and 17 as predictors of recurrence. A total of 109 carcinomas were investigated at 26 loci. DNA was extracted from microdissected archival normal/tumour tissue and was analysed for loss of heterozygosity (LOH). Fluorescent PCR was performed and genotyping carried out on a Perkin Elmer ABI377 sequencer. LOH of D11S490 or D17S928 was significantly more frequent in index carcinomas of patients who experienced recurrence compared to those with no recurrence (P = 0.004 and 0.019 respectively). These results suggest that loss of these regions is associated with recurrence of TCC. Further investigation is required to identify genes in these regions, which might be responsible for driving recurrence in TCC of the urinary bladder.

Does the organization of postacute stroke care really matter?

BACKGROUND AND PURPOSE

Postacute rehabilitation stroke services represent a large component of stroke care. In the United States and elsewhere, major changes in the organization and funding of these services are limiting patient access to organized inpatient multidisciplinary care. We conducted a systematic review to evaluate the effectiveness of such services.

SUMMARY OF REVIEW

We defined our intervention as organized inpatient multidisciplinary rehabilitation commencing at least 1 week after stroke and sought randomized trials that compared this model of care with an alternative. The analysis was stratified by the particular service characteristics. We identified a heterogeneous group of 9 trials (6 of stroke rehabilitation units; 3 of general rehabilitation wards) recruiting 1437 patients. Organized inpatient multidisciplinary rehabilitation was associated with a reduced odds of death (odds ratio, 0.66; 95% CI, 0.49 to 0.88; P:<0.01), death or institutionalization (odds ratio, 0.70; 95% CI, 0.56 to 0.88; P:<0.001), and death or dependency (odds ratio, 0.65; 95% CI, 0.50 to 0.85; P:<0.001), which was consistent across a variety of trial subgroups. For every 100 patients receiving organized inpatient multidisciplinary rehabilitation, an extra 5 returned home in an independent state.

CONCLUSIONS

The results indicate that there can be substantial benefit from organized inpatient multidisciplinary rehabilitation in the postacute period, which is both statistically significant and clinically important.

Patient and tumor characteristics of colon cancers with microsatellite instability: a population-based study

Molecular screening for microsatellite instability (MSI) in colon cancers has been proposed to identify individuals with hereditary nonpolyposis colorectal cancer. To date, most reports of MSI in colorectal cancer have been based on studies of clinical case series or high-risk families. We examined the proportion of incident colon cancers in the general population that exhibit MSI by patient and tumor characteristics. We interviewed 201 colon cancer cases ascertained by the New Mexico Tumor Registry in the metropolitan Albuquerque area for demographic information, lifestyle factors, medical history, and family cancer history. Paired normal and tumor tissue specimens were obtained for each case. Three microsatellite markers were used; instability was defined as observed alteration at two or more loci. Overall, 37 of 201 (18%) colon cancers exhibited instability. MSI was more common among cases >70 years (26%) and most common among cases >80 years (38%). MSI was significantly associated with tumors in the proximal colon and with later stage and poor differentiation among cases >70 years. MSI was not associated with a history of polyps. Family history of colorectal cancer was associated with MSI only among cases <50 years. When all factors were analyzed jointly in a regression model, proximal subsite and poor differentiation remained significantly associated with MSI. One patient, whose tumor exhibited MSI, fulfilled the Amsterdam Criteria for hereditary nonpolyposis colorectal cancer. Our study provides a population-based estimate of MSI in colon tumors and a representative estimate of the proportion of colorectal cancer patients in the general population who consent to be interviewed for family cancer history and to have biological samples analyzed.

Pediatricians' response to the demand for school health programming

OBJECTIVE

Because of the broad and increasing interest in school health, the American Academy of Pediatrics (AAP) surveyed its members to determine their awareness of school health education/programs, their level of participation, their desire to participate, and their resource needs to participate more effectively.

METHODS

Self-administered questionnaires were mailed to a randomized representative sample of AAP members (N = 1602). Overall response rate was 64.5%. Some responses were stratified for analysis by gender; age (>45 years or </=45 years); practice area (urban, suburban, or rural); practice setting (solo, group, or hospital); and type of practice (general versus specialty). chi2 Tests were used to compare responses.

RESULTS

Greater than half of the pediatricians who responded to the questionnaire were aware of school health education curriculum on risky adolescent behaviors in their community, counseling services (58%), school nursing services (63%), and screening services (71%); however, more than half were not aware of curriculum on injury/violence prevention, fitness, or whether a school health advisory council was available. Most pediatricians supported comprehensive school health education (pregnancy prevention, 82%; violence prevention, 77%; mental health, 56%). Also, respondents supported services (counseling, 76%; nutrition, 65%; screening/referral, 58%; school-based primary care, 58%). Although 22% of AAP pediatricians are currently working with local school programs, >70% wanted to become involved or more involved and needed information on how they may be able to participate. Only 25% believed they were adequately prepared. Two thirds believed school-based clinics were one of the best ways to reach underserved children and adolescents and should include preteens.

CONCLUSION

AAP pediatricians want to become more involved with comprehensive school health programs. The ways in which they want to participate vary substantially. Most pediatricians thought they needed additional education. The AAP has developed recommendations for graduate medical education and continuing medical education for pediatricians to participate in integrated school health services.

A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke

BACKGROUND AND PURPOSE

Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems; all of these are potentially modifiable with exercise. The purposes of this randomized, controlled pilot study were (1) to develop a home-based balance, strength, and endurance program; (2) to evaluate the ability to recruit and retain stroke subjects; and (3) to assess the effects of the interventions used.

METHODS

Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were randomized to a control group or to an experimental group that received a therapist-supervised, 8-week, 3-times-per-week, home-based exercise program. The control group received usual care as prescribed by the patients' physicians. Baseline and postintervention assessments included the Fugl-Meyer Motor Assessment, the Barthel Index of Activities of Daily Living (ADL), the Lawton Scale of Instrumental ADL, and the Medical Outcomes Study-36 Health Status Measurement. Functional assessments of balance and gait included a 10-m walk, 6-Minute Walk, and the Berg Balance Scale. Upper extremity function was evaluated by the Jebsen Test of Hand Function.

RESULTS

Of 22 patients who met study criteria, 20 completed the study and 2 refused to participate. The experimental group tended to improve more than the control group in motor function (Fugl-Meyer Upper Extremity: mean change in score, 8. 4 versus 2.2; Fugl-Meyer Lower Extremity: 4.7 versus -0.9; gait velocity: median change, 0.25 versus .09 m/s; 6-Minute Walk: 195 versus 114 ft; Berg Balance Score: 7.8 versus 5; and Medical Outcomes Study-36 Health Status Measurement of Physical Function: 15. 5 versus 9). There were no trends in differences in change scores by the Jebsen Test of Hand Function, Barthel Index, and Lawton Instrumental ADL Scale.

CONCLUSIONS

This study demonstrated that a randomized, controlled clinical trial of a poststroke exercise program is feasible. Measures of neurological impairments and lower extremity function showed the most benefit. Effects of the intervention on upper extremity dexterity and functional health status were equivocal. The lasting effects of the intervention were not assessed.

Delivery of newly synthesized Na(+)-K(+)-ATPase to the plasma membrane of A6 epithelia

Na(+)-K(+)-ATPase is localized to the basolateral cell surface of most epithelial cells. Conflicting results regarding the intracellular trafficking of Na(+)-K(+)-ATPase in Madin-Darby canine kidney cells have been reported, with delivery to both apical and basolateral membranes or exclusively to the basolateral cell surface. We examined the delivery and steady-state distribution of Na(+)-K(+)-ATPase in the amphibian epithelial cell line A6 using an antibody raised against Na(+)-K(+)-ATPase alpha-subunit and sulfo-N-hydroxysuccinimidobiotin to tag cell surface proteins. The steady-state distribution of the Na(+)-K(+)-ATPase was basolateral, as confirmed by immunocytochemistry. Delivery of newly synthesized Na(+)-K(+)-ATPase to the cell surface was examined using [35S]methionine and [35S]cysteine in a pulse-chase protocol. After a 20-min pulse, the alpha-subunit and core glycosylated beta-subunit were present at both apical and basolateral cell surfaces. The alpha-subunit and core glycosylated beta-subunit delivered to the apical cell surface were degraded within 2 h. Mature alpha/beta-heterodimer was found almost exclusively at the basolateral surface after a 1- to 24-h chase. These data suggest that immature Na(+)-K(+)-ATPase alpha-subunit and core glycosylated beta-subunits are not retained in the endoplasmic reticulum of A6 cells and apparently lack sorting signals. Mature Na(+)-K(+)-ATPase is targeted to the basolateral surface, suggesting that basolateral targeting of the protein is conformation dependent.

Multiple mechanisms of N-phosphonacetyl-L-aspartate resistance in human cell lines: carbamyl-P synthetase/aspartate transcarbamylase/dihydro-orotase gene amplification is frequent only when chromosome 2 is rearranged

Rodent cells resistant to N-phosphonacetyl-L-aspartate (PALA) invariably contain amplified carbamyl-P synthetase/aspartate transcarbamylase/dihydro-orotase (CAD) genes, usually in widely spaced tandem arrays present as extensions of the same chromosome arm that carries a single copy of CAD in normal cells. In contrast, amplification of CAD is very infrequent in several human tumor cell lines. Cell lines with minimal chromosomal rearrangement and with unrearranged copies of chromosome 2 rarely develop intrachromosomal amplifications of CAD. These cells frequently become resistant to PALA through a mechanism that increases the aspartate transcarbamylase activity with no increase in CAD copy number, or they obtain one extra copy of CAD by forming an isochromosome 2p or by retaining an extra copy of chromosome 2. In cells with multiple chromosomal aberrations and rearranged copies of chromosome 2, amplification of CAD as tandem arrays from rearranged chromosomes is the most frequent mechanism of PALA resistance. All of these different mechanisms of PALA resistance are blocked in normal human fibroblasts.

Biosynthesis and cell surface delivery of the NHE1 isoform of Na+/H+ exchanger in A6 cells

The Na+/H+ exchanger isoform NHE1 is localized to the basolateral membrane of renal and intestinal epithelia. We examined the plasma membrane distribution, biosynthesis, and cell surface delivery of NHE1 in A6 epithelia. NHE1 was localized to the basolateral membrane. Studies of NHE1 biosynthesis with a pulse-chase protocol demonstrated that a core glycosylated, endoglycosidase H-sensitive, 90-kDa NHE1 was present 0-5 h into the chase period and that mature 110-kDa NHE1 was present 1-24 h into the chase period. Studies of plasma membrane delivery of newly synthesized NHE1 demonstrated that the 90-kDa NHE1 was detected at both apical and basolateral membranes 2-5 h into the chase period. The 110-kDa NHE1 was observed at the basolateral membrane 5-24 h into the chase period. These results suggest that NHE1 is expressed primarily at the basolateral membrane of A6 cells, that core glycosylated NHE1 is delivered to the plasma membrane in a nonpolarized manner, and that nature 110-kDa NHE1 is delivered to the basolateral membrane.

Perioperative on-site haemoglobin determination: as accurate as laboratory values?

PURPOSE

This study assessed the accuracy of photometer based haemoglobin (Hb) determination technology (HemoCue) when used by different anaesthetists in situations of rapidly changing Hb values during anaesthesia.

METHODS

(Part 1) In the laboratory, repeated measurements were done on 16 split samples of blood using both the Hematology Analyzer (CELL-DYN 3500 System, Abbot Laboratories, San Jose, California) and the photometer. (Part 2) Twelve patients had blood samples drawn from an arterial line for simultaneous Hb determination in the hospital laboratory and by the photometer. At the same time, capillary samples were taken from the patient's earlobe for Hb determination by the photometer. All sample collection and photometer measurements were done by the same operator. (Part 3) The Part 2 protocol was then repeated with different anaesthetists performing both the sampling and the photometer measurements. Statistical comparison was by ANOVA and a two-tailed paired t-test.

RESULTS

(Part 1) Samples determined by the photometer and the laboratory were highly correlated (r2 = 1.0, P < 0.001). The average error of each method was similar ( < 4%). (Part 2) Using a 2-tailed paired t-test, the photometer arterial measurements were not different from the laboratory measurements, however the photometer capillary measurements were consistently approximately 8% higher (P = 0.003). (Part 3) When multiple operators performed the sampling there were no differences on arterial or capillary samples (r2 = 0.942, r2 = 0.851 respectively), although the variance was greater.

CONCLUSIONS

The HemoCue haemoglobinometer has sufficient accuracy to support treatment decisions regarding blood transfusions.

On the carrying capacity for large ungulates of African savanna ecosystems

The effect of pastoral management on the standing crop biomass of large ungulates, an index of carrying capacity, is analysed at a regional level by using data compiled from published sources covering east and south Africa. The effect of primary production is controlled for by using two environmental factors, rainfall and soil nutrient availability, and the effect of species richness of the ungulate community is evaluated. The results confirm the dominant effect of rainfall, and demonstrate that soil nutrient levels also strongly affect the biomass of large ungulate communities. For a given level of rainfall, on rich soils (high nutrient availability) the biomass of large ungulates is about 20 times as great as on poor soils with low nutrient availability. The model based on rainfall and soil nutrient classes accounts for 87% of the variance in large ungulate biomass. Pastoral and natural ecosystems do not differ significantly in large ungulate biomass; there is therefore currently no evidence that extensive pastoral management increases carrying capacity for large ungulates above the levels observed in natural communities. Species richness, a measure of biodiversity, had a significant but very small effect on the biomass-rainfall relation in the complete data set. When analysed by pastoral management, the effect of this factor was significant for the set of natural ecosystems only. Pastoral management and species richness may therefore have compensatory effects. These results suggest that the carrying capacity is limited at the community, rather than the species, level.

Dual specificity kinases--a new family of signal transducers

Phosphorylation/dephosphorylation reactions are one of the dynamic mechanisms through which cells modulate protein activity in response to environmental stimuli. The eukaryotic molecules which are responsible for the phosphorylation of serine, threonine and tyrosine residues appear to have co-ordinately evolved from simple prokaryotic enzymes which primarily respond to nutritional cues. In multicellular eukaryotes the complexity of data transfer greatly exceeds that of simple bacteria. The eukaryotic cell needs to exchange information with neighbouring and distant sister cells. Positional, nutritional and hormonal data are transmitted from the extracellular milieu across the plasma membrane and into the cytoplasm. In certain cases the signal must pass into the nucleus or other subcellular organelles where it is decoded and the proper cellular response initiated. All of these events have been shown to have a protein kinase component and it seems likely that in mammalian cells over 1,000 different kinase molecules have evolved to form the requisite signal transducing networks. In this review we describe a previously unappreciated family of protein kinases, the dual specificity or DSK kinases, which play important roles in the regulation of normal cellular growth and differentiation.

When I'm calling you

Discussion groups among sectors of the population often excluded from consultation homed in on healthcare needs, say Paul Duncan and Liz Higgins, looking at findings from Waltham Forest HA.

Job Satisfaction Among Hospital Nurses: Facility Size and Location Comparisons

Despite recent declines in turnover and vacancy rates, maintaining a stable nursing staff continues to be critical to the effective operation of American hospitals. Job satisfaction is a pivotal element in nurse retention, and organizational theory suggests that some of the factors that influence job satisfaction vary by facility size. This is a study of job satisfaction among a sample of 731 nurses providing direct patient care in 22 hospitals. The sample includes approximately equal numbers of nurses employed in very small rural hospitals (1-49 beds), medium sized facilities located in small towns (50-99 beds), and larger metropolitan institutions (> 100 beds). Differences by hospital size were observed in overall job satisfaction and in five sub-dimensions of that concept (i.e., professional status, task requirements, pay, organizational policies, and autonomy). With the exception of pay, the results indicated that nurses employed in the very small rural hospitals were more satisfied with their jobs. Differences by hospital size were also observed in the personal characteristics of the nurses, several specific aspects of their job, and in their perceptions of job mobility. A set of four hierarchically nested ordinary least squares regression models indicated that job-specific characteristics were the most powerful predictors of job satisfaction.

Children's perceptions of AIDS

Knowledge and attitudes about AIDS were surveyed in 147 children between the ages of 6 and 12. Awareness of and accurate information about AIDS increased steadily through the early school years. From third grade on, over 90% of children had heard of AIDS, with the majority capable of providing additional accurate information. Significant misconceptions were also identified in all age groups. Television was found to be the major source of information about AIDS for most children.

Substituted cyclic imides as potential anti-gout agents

N-substituted cyclic imides of phthalimide, 2,3-dihydrohalazine-1,4-dione, and diphenimide were shown to reduce the serum uric acid levels in normal and hyperuric mice at 20 mg/kg/day I.P. for 14 days. The agents were potent inhibitors of commercial xanthine dehydrogenase and xanthine oxidase enzyme activities with IC50 values from 10(-7) to 10(-8) M concentrations of drug.

Granulocyte colony-stimulating factor stimulates recovery of granulocytes in patients receiving dose-intensive chemotherapy without bone marrow transplantation

Bone marrow colony-stimulating factors (CSF) ameliorate hematologic toxicity of standard chemotherapy regimens and may allow relatively safe use of intensive and more efficacious doses of anticancer drugs. Twenty-four patients with cancers for which no standard regimens were likely to be effective received repeated courses of a combination of cisplatin (150 mg/m2), etoposide (1,500 mg/m2), and cyclophosphamide (5,000 mg/m2) at doses for which bone marrow transplantation is usually used. A total of 10 patients received escalating doses of recombinant human granulocyte CSF (rhG-CSF); 11 patients receiving identical chemotherapy and supportive therapy without rhG-CSF served as controls for the first cycle of therapy. Five of these patients and 3 additional patients also served as their own controls, receiving rhG-CSF for all cycles after the first. No patient received bone marrow transplantation. rhG-CSF shortened the median duration of severe granulocytopenia (less than or equal to 100/mm3) in a dose-related fashion (P less than .03; Kruskal-Wallis test). Patients not receiving rhG-CSF had a median of 8.5 days of granulocytopenia. Those receiving 40 micrograms/kg of rhG-CSF for approximately 20 days from the third day after chemotherapy had a median of 7.0 days (P less than .23) and those receiving 60 micrograms/kg had a median of 5.5 days (P less than .007) of granulocytopenia. An rhG-CSF dose of 20 micrograms/kg had no effect. Recovery to a granulocyte count of at least 500/mm3 took a median of 12 days in the control group and 8 days (P less than .03) in patients receiving rhG-CSF at a dose of 60 mg/kg. The duration of antibiotic therapy (a median, 9.0 days v 5.0 days) was shortened with the two higher and effective doses of rhG-CSF compared with control patients. The duration of hospitalization (median of 20 days v 19 days) was not shortened. These findings that rhG-CSF decreases the risk of granulocytopenia associated with this particular dose-intensive chemotherapy regimen therapy administered without bone marrow transplantation.