The feasibility and effectiveness of a novel online mental health literacy course in supporting university student mental health: a pilot study

BACKGROUND

There is a need for effective universal approaches to promote and support university student mental health that are scalable and sustainable. In this pilot study we assess the feasibility and acceptability of a fully-digitalized, comprehensive mental health literacy course co-created with and tailored to the needs of undergraduate students. We also explore preliminary associations with mental health and positive behaviour change.

METHODS

An accredited online mental health literacy course was developed using state-of-the-art pedagogical principles and a reverse mentorship approach. The course was offered as an interdisciplinary undergraduate elective. Students completed an online survey before and after the 12-week course that collected demographic information and assessed mental health knowledge, emotional self-awareness, mental health, stigma, and health-related behaviors using validated measures. Dependent group t-tests were used to compare pre- and post-course levels of knowledge, mental health, sleep quality and substance use. Mental health outcomes of students who completed the course were compared to an age and sex-matched sample of students not enrolled in the course and who completed the same survey measures over the same academic year. Multivariable linear regression was used to examine the effect of course participation on outcomes at follow-up.

RESULTS

The course had good uptake and was positively reviewed by participants. Specifically, students found the course engaging, relevant, and applicable, and agreed they would recommend it to their peers. Among course participants there was improvement in mental health knowledge (p < 0.001) and emotional self-awareness (p = 0.02) at course completion. Compared to the matched comparison group, taking the course was associated with reduced alcohol (β = - 0.41, p = 0.01) and cannabis use (β = - 0.35, p = 0.03), and improved sleep quality (β = 1.56, p = 0.09) at the end of the term.

CONCLUSIONS

Findings suggest that delivering mental health literacy as an online accredited course may be an acceptable and effective way of promoting university student mental health through improved knowledge, emotional self-awareness, and healthy lifestyle choices. As the course is expanded to larger and more diverse student cohorts we will be able to further examine the short and long-term effectiveness of the course in supporting student mental health and the underlying mechanisms.

Speech production accuracy in children with Down syndrome: relationships with hearing, language, and reading ability and change in speech production accuracy over time

BACKGROUND

This study examines speech production accuracy in children with Down syndrome and concurrent relationships with hearing, language and reading ability. It also examines change in speech production accuracy over a 21-month period.

METHODS

A group of 50 children with Down syndrome (aged 5-10 years) completed measures of speech accuracy, non-verbal IQ, reading (single-word reading, letter-sound knowledge and phoneme blending) and language (expressive and receptive vocabulary and receptive grammar). Hearing was assessed by parental report. Speech accuracy was reassessed 21 months later.

RESULTS

Although there was considerable variability in the sample, speech was characterised by high levels of errors. There were no effects of gender, hearing status or non-verbal IQ on speech production accuracy. In contrast, speech production accuracy was significantly related to age and to measures of receptive vocabulary, phoneme blending and word reading. There was no significant improvement in speech production accuracy over time.

CONCLUSIONS

Children with Down syndrome experience difficulties producing accurate sounds in speech. These difficulties are related to age and to vocabulary and reading skills and persist over time, highlighting the need for intensive targeted speech intervention in this group of children.

Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study

OBJECTIVES

The aim of this study was to examine a large cohort of adults who received the zoster vaccine for evidence of an increased risk of prespecified adverse events requiring medical attention.

DESIGN

Two self-comparison approaches, including a case-centred approach and a self-controlled case series (SCCS) analysis were used.

SETTING

Eight managed-care organizations participating in the Vaccine Safety Datalink project in the United States.

SUBJECTS

A total of 193 083 adults aged 50 and older receiving a zoster vaccine from 1 January 2007 to 31 December 2008 were included.

MAIN OUTCOME MEASURES

Prespecified adverse events were identified by aggregated International Classification of Diseases, Ninth Revision (ICD-9) codes in automated health plan datasets.

RESULTS

The risk of allergic reaction was significantly increased within 1-7 days of vaccination [relative risk = 2.13, 95% confidence interval (CI): 1.87-2.40 by case-centred method and relative rate = 2.32, 95% CI: 1.85-2.91 by SCCS]. No increased risk was found for the following adverse event groupings: cerebrovascular events; cardiovascular events; meningitis; encephalitis; and encephalopathy; and Ramsay-Hunt syndrome and Bell's palsy.

CONCLUSIONS

The results of this study support the findings from the prelicensure clinical trials, providing reassurance that the zoster vaccine is generally safe and well-tolerated with a small increased risk of allergic reactions in 1-7 days after vaccination.

Mycobacterial diseases and antitumour necrosis factor therapy in USA

OBJECTIVE

In North America, tuberculosis and nontuberculous mycobacterial (NTM) disease rates associated with antitumour necrosis factor α (anti-TNFα) therapy are unknown.

METHODS

At Kaiser Permanente Northern California, the authors searched automated pharmacy records to identify inflammatory disease patients who received anti-TNF therapy during 2000-2008 and used validated electronic search algorithms to identify NTM and tuberculosis cases occurring during anti-TNF drug exposure.

RESULTS

Of 8418 anti-TNF users identified, 60% had rheumatoid arthritis (RA). Among anti-TNF users, 18 developed NTM and 16 tuberculosis after drug start. Anti-TNF associated rates of NTM and tuberculosis were 74 (95% CI: 37 to 111) and 49 (95% CI: 18 to 79) per 100 000 person-years, respectively. Rates (per 100, 000 person-years) for NTM and tuberculosis respectively for etanercept were 35 (95% CI: 1 to 69) and 17 (95% CI: 0 to 41); infliximab, 116 (95% CI: 30 to 203) and 83 (95% CI: 10 to 156); and adalimumab, 122 (95% CI: 3 to 241) and 91 (95% CI: 19 to 267). Background rates for NTM and tuberculosis in unexposed RA-patients were 19.2 (14.2 to 25.0) and 8.7 (5.3 to 13.2), and in the general population were 4.1 (95% CI 3.9 to 4.4) and 2.8 (95% CI 2.6 to 3.0) per 100, 000 person-years. Among anti-TNF users, compared with uninfected individuals, NTM case-patients were older (median age 68 vs 50 years, p<0.01) and more likely to have RA (100% vs 60%, p<0.01); whereas, tuberculosis case-patients were more likely to have diabetes (37% vs 16%, p=0.02) or chronic renal disease (25% vs 6%, p=0.02).

CONCLUSIONS

Among anti-TNF users in USA, mycobacterial disease rates are elevated, and NTM is associated with RA.

Evaluation of the safety, reactogenicity and immunogenicity of FluBlok® trivalent recombinant baculovirus-expressed hemagglutinin influenza vaccine administered intramuscularly to healthy adults 50-64 years of age

BACKGROUND

Alternative methods for influenza vaccine production are needed to ensure adequate supplies.

METHODS

Healthy adults 50-64 years were assigned randomly to receive one intramuscular injection of trivalent recombinant hemagglutinin (rHA) or U.S. licensed trivalent inactivated vaccine (TIV) containing H1, H3 and B antigens (Ag) derived from 2007 to 2008 influenza virus strains A/Solomon Islands/03/2006 (H1N1), A/Wisconsin/67/2005 (H3N2), and B/Malaysia/2506/2004. Each rHA dose contained 45 μg HA/strain of the 2007-2008 FDA-recommended Ag vs. 15 μg/strain for TIV. Antibody (Ab) responses were measured using a hemagglutination-inhibition (HAI) assay at baseline and 28 days post-vaccination. Respiratory samples for viral culture were collected from subjects with influenza-like illness (ILI) during the 2007-2008 season in the U.S.

RESULTS

601 subjects were enrolled. Vaccines were well tolerated. Seroconversion (the percentage of subjects with either (a) a pre-vaccination HAI titer ≤ 10 and a post-vaccination HAI titer ≥ 40 or (b) a pre-vaccination titer ≥ 10 and a minimum four-fold rise in post-vaccination HAI antibody titer) in the TIV and rHA groups, respectively, was obtained in 66% vs. 72% for H1; 44% vs. 61% for H3; and 41% vs. 41% for B. Proportions achieving titers ≥ 40 were 96% vs. 96% for H1, 75% vs. 85% for H3, and 94% vs. 93% vs. B. Geometric mean titer ratios at day 28 (TIV/rHA) were 0.77 for H1; 0.58 for H3; and 1.05 for B, respectively. ILI frequencies were low and similar in both groups.

CONCLUSIONS

Both vaccines were safe and immunogenic. Ab responses vs. H1 and H3 Ags were significantly higher in the rHA group, with similar responses to B. Furthermore, the FluBlok group had a statistically significantly higher seroconversion rate against influenza A/H3N2 compared to the TIV group.

Perioperative GMCSF limits the proangiogenic plasma protein changes associated with colorectal cancer resection

AIMS

Colorectal resection (CR) increases plasma VEGF levels which may promote residual tumor growth. This study assessed the effect of perioperative GMCSF on plasma levels of sVEGFR1, Ang-1 and Ang-2 and also the impact of post-GMCSF plasma on in vitro endothelial cell (EC) growth and invasion. Ang-2 increases while sVEGFR1 and Ang-1 impede angiogenesis.

METHODS

Fifty-nine CR cancer patients were randomized to 7 perioperative doses of GMCSF or saline for 3days prior and 4days after CR. Blood samples were taken pre-drug (PreRx) and on several postoperative days (POD). Protein levels were assessed and PreRx and POD 5 plasma added to EC cultures after which branch point formation (ECBPF) and invasion (ECI) were measured.

RESULTS

sVEGFR1 levels were significantly higher on POD 1 and POD 5 in both groups but the GMCSF POD 5 level was twice the control value (p=0.002). Ang-2 levels were higher on PODs 1 and 5 in both groups (p<0.05) but the control POD 5 value (vs. GMCSF) was greater (p=0.03). Ang-1 decreases were noted in all (p=not significant, ns). The control group POD 5 ECBPF was 35.8% greater than Pre Rx (p=0.001) while the GMCSF result was 18.0% lower (p=ns); the control POD 5 median percent change from baseline was greater than the GMCSF result(p=0.008). The POD 5 ECI was +12.2% for the control group vs. baseline (p=ns) and -17.2% for the GMCSF group (p=ns): the control median percent change was greater than in the GMCSF group(p=0.045).

CONCLUSION

CR-related plasma changes are proangiogenic (>Ang-2) and anti-angiogenic (>sVEGFR1); the net effect is promotion of in vitro ECBPF. GMCSF limits the proangiogenic changes (higher POD 5 sVEGFR1 levels and lower Ang-2 elevations, lower POD 5 ECBPF and ECI). The clinical import of these effects is unclear; perioperative GMCSF has anti-angiogenic plasma effects that may limit tumor growth. Further investigation is warranted.

Indications and practical applications for high-profile saline breast implants

BACKGROUND

High-profile round saline breast implants that permit a better match of implant diameter to the base diameter of the breast are now available.

OBJECTIVE

The advantages and disadvantages of high-profile breast implants are defined from the point of view of the author's initial experience.

METHODS

The maximal optimal breast implant was determined on the basis of preoperative measurements, with emphasis on breast base diameter. Patients selected implant size using trial implants in a bra of the desired cup size. The implant profile with the best match to breast base diameter at the selected size range was used.

RESULTS

Sixty-seven patients, of a total of 164 patients who received saline breast implants during a 14-month period, received high-profile breast implants.

CONCLUSIONS

High-profile saline implants provide a useful option for the patient who desires an implant size that exceeds the natural breast base diameter in standard profiles. Rippling may be diminished in these cases. A more conical shape may be achieved in cases of periareolar mastopexy with augmentation. Disadvantages of the high-profile design include less mobility of the implant and a less obtuse transition from the chest to the upper breast compared with results achieved with standard round implants.

Nitrogen and phosphorus in soil solutions and drainage streams in Upper Teesdale, northern England: implications of organic compounds for biological nutrient limitation

The availability of nitrogen (N) and phosphorus (P) to organisms is a fundamental control on the ecology of uplands in the British Isles, yet there has been relatively little consideration of the role of organic forms of these nutrients. N and P fractions in soil solutions and drainage streams were determined at monthly intervals over 1 year from Widdybank Fell, Upper Teesdale National Nature Reserve, an upland area of northern England. Nitrogen was present in inorganic and organic forms at relatively high concentrations, whereas P was mainly organic, with inorganic P concentrations near the detection limit (1 microg Pl(-1)). The highest concentrations of organic P occurred in 'pulses' during the spring. These pulses may have originated in the soil following drying and rewetting cycles, and appear to demonstrate hydrochemical connectivity between soils and streams. Seasonal changes in N:P ratio were estimated in various ways to assess when the availability of these elements was likely to influence organisms. Based on inorganic nutrients alone, marked P limitation would be expected throughout the year, but inclusion of organic nutrients suggests that some communities may become N-limited during the spring. This agrees with known seasonal changes in the biology of the cyanobacterium Rivularia, which dominates the main drainage streams. Our data highlight the importance of including organic nutrients when assessing biological nutrient limitation.

Clinical governance. 1: Evidence-based practice

Practitioners have a responsibility to ensure their practice is based on sound clinical evidence and that the care delivered is of a high quality. What are the best ways of achieving this in the reality of the modern NHS?

Synthesis of N-alkyl substituted indolocarbazoles as potent inhibitors of human cytomegalovirus replication

The synthesis and antiviral evaluation of unsymmetrical indolocarbazole derivatives of Arcyriaflavin A, substituted with a range of alkyl groups at the indole nitrogen, is described. Structure-activity relationships in this series against human cytomegalovirus (HCMV) replication in cell culture are reported. Compound 4b was identified as potent inhibitor of HCMV (IC(50)=19 nM), which retained activity against a range of HCMV strains including ganciclovir resistant isolates.

Feature selection for examining behavior by pathology laboratories

Australia has a universal health insurance scheme called Medicare, which is managed by Australia's Health Insurance Commission. Medicare payments for pathology services generate voluminous transaction data on patients, doctors and pathology laboratories. The Health Insurance Commission (HIC) currently uses predictive models to monitor compliance with regulatory requirements. The HIC commissioned a project to investigate the generation of new features from the data. Feature generation has not appeared as an important step in the knowledge discovery in databases (KDD) literature. New interesting features for use in predictive modeling are generated. These features were summarized, visualized and used as inputs for clustering and outlier detection methods. Data organization and data transformation methods are described for the efficient access and manipulation of these new features.

Functionalism and holism: community nurses' perceptions of health

This paper reports the results of a study that was designed to explore and examine the perceptions of two groups of newly qualified community nurses about the factors they considered to be embedded within the concepts of health, health-enhancing behaviours at individual, family and community levels and their 'innermost self'. The research was exploratory in nature, and included two sample groups: group 1 comprised 16 newly qualified health visitors; group 2 comprised 16 newly qualified community mental health nurses. Purposive sampling was used and data were collected using semi-structured interviews. The group of health visitors perceived health in terms of physical fitness and functional states. At a global level they perceived the need to provide education on health matters. They gave generously to 'charities' and perceived the 'inner self' as 'that part that matters'. The group of community mental health nurses perceived health in terms of holism and being states. Their concept of health was related to listening to each individual's perception of what is 'right' and 'health-enhancing' for them. At a global level they considered the protection of the ozone layer and the promotion of a just and equitable society which focused on the reduction of poverty, to be key health-enhancing activities. They perceived their 'innermost self' to be 'that part of me that makes life worth living', and the soul. The findings have implications for developing new and creative approaches for teaching the holistic concept of health and healing. Educational activities could be designed which strive to ensure that nurses themselves have safe and health embracing opportunities for exploring all the elements that are embedded within the topic of health. Their role in facilitating holistic health promoting activities for all clients also needs to be addressed.

Standardisation of temperature observed by automatic weather stations

Daily mean, maximum and minimum surface air temperature data were gathered from a network of automatic weather stations (AWS) within the Moor House National Nature Reserve in northern England. Five AWS were installed next to the official Environmental Change Network weather station at Moor House. Data were compared graphically and correction constants were calculated to adjust data from each AWS to the standard of the official station by optimising the concordance correlation coefficient. Each corrected station was re-located next to one of five in-situ stations in and around the reserve, allowing correction of all temperature sensors to a common standard. The mean error associated with measured daily mean, maximum and minimum temperature for each sensor does not exceed +/- 0.2 K. The procedure quantifies a source of systematic measurement error, improving the identification of spatial temperature differences between stations.

Architectural and physiological heterogeneity within the synflorescence of the pseudoviviparous grass Poa alpina var. vivipara L

Many biotypes of the northern-hemisphere Arctic-Alpine grass Poa alpina L. reproduce asexually via prolification of the spikelet axis to produce dehiscing shoots. Although capable of photosynthesis, the source-sink characteristics of these synflorescence systems are unknown, including the degree to which plantlets from different regions of the synflorescence are capable of providing for their own carbon requirements, or contributing to other sinks. Photosynthetic rates within the paracladial zone, as determined by infrared gas analysis (IRGA), exceeded respiratory rates by 3-4-fold. (14)CO(2) tracer studies determined that the paracladial zone was not only as efficient at fixing carbon as the youngest fully expanded leaf (per unit dry weight), but that both organs exported carbon mainly basipetally (cf. extensive acropetal export from this leaf in seminiferous grasses). Distal plantlets of the paracladial zone fixed approximately 20% more (14)CO(2) than did proximal plantlets. This was by virtue of their greater dry weight. At dehiscence, 'distal' plantlets were more likely to become established, and possessed relative growth rates more than 10 times those of 'proximal' plantlets. Paracladial heterogeneity was also apparent as an increased proportion of aborted spikelets on proximal paracladia. The possible causes of this heterogeneity are discussed.

The influence of secondary senescence processes within the culm of a pseudoviviparous grass (Poa alpina var. vivipara L.) on the supply of water to propagules

An anatomical investigation of the culm of pseudoviviparous alpine meadow grass (Poa alpina var. vivipara L.) revealed that transpiration flow, as delimited by Lucifer Yellow tracer dye, was maintained despite advanced senescence (as evidenced by loss of chlorophyll and chloroplasts), with leafy spikelets driving transpiration flow. Transpiration flow was not hindered by cavitation or tylosis in older culms, the low frequencies of these senescence processes being bypassed via nodal plexi. Despite this, water content of plantlets declined over time and water stress became apparent, suggesting that water supply via the determinate culm was not sufficient for the increasing transpirational demand of indeterminate plantlets. The implications of declining water content on the biomechanical properties of the culm, and concomitant limitations on the pseudoviviparous reproductive strategy, are discussed. Nomenclature of grass follows Hubbard.

The Community Tracking Study analyses of market change: introduction

OBJECTIVE

To introduce two articles and describe methods that are common to them.

DATA SOURCES/STUDY SETTING

Interviews conducted in person in 1996/1997 with leaders of organizations involved in the financing and delivery of healthcare.

STUDY DESIGN

As part of the Community Tracking Study, 12 metropolitan statistical areas (MSAs) were selected randomly from MSAs with populations over 200,000. Researchers made baseline site visits to these communities and conducted from 36 to 60 interviews, depending on the size of the site. The communities were compared to identify common patterns of change and differences across communities.

DATA COLLECTION/EXTRACTION METHODS

Researchers conducted interviews with a broad cross-section of leaders in each community. Interview modules were designed to obtain multiple perspectives on a question.

PRINCIPAL FINDINGS AND CONCLUSIONS

Fundamental changes in the way care is actually delivered is likely to lag behind the extensive changes in organizational relationships that are taking place.

Responses of the growth hormone (GH) and insulin-like growth factor axis to exercise, GH administration, and GH withdrawal in trained adult males: a potential test for GH abuse in sport

GH abuse by elite athletes is currently undetectable. To define suitable markers of GH doping, we assessed the effects of acute exercise, GH administration, and GH withdrawal on the GH/insulin-like growth factor (IGF) axis in athletic adult males. Acute endurance-type exercise increased serum GH, GH-binding protein (GHBP), total IGF-I, IGF-binding protein (IGFBP)-3, and acid-labile subunit (ALS), each peaking at the end of exercise. IGFBP-1 increased after exercise was completed. Free IGF-I did not change with exercise. Recombinant human GH treatment (0.15 IU/kg x day) for 1 week increased serum total IGF-I, IGFBP-3, and ALS, exaggerating the responses to exercise. IGFBP-2 and IGFBP-1 were trivially suppressed. After GH withdrawal, the GH response to identical exercise was suppressed. Total IGF-I, IGFBP-3, and ALS returned to baseline over 3-4 days. In summary, 1) acute exercise transiently increased all components of the IGF-I ternary complex, possibly due to mobilization of preformed intact complexes; 2) GH pretreatment augmented the exercise-induced changes in ternary complexes; 3) postexercise IGFBP-1 increments may protect against delayed onset hypoglycemia; 4) serum total IGF-I, IGFBP-3, and ALS may be suitable markers of GH abuse; and 5) differences in disappearance times altered the sensitivity of each marker for detecting GH abuse.

Indolocarbazoles: potent, selective inhibitors of human cytomegalovirus replication

In our search for new, safer anti-HCMV agents, we discovered that the natural product Arcyriaflavin A (la) was a potent inhibitor of HCMV replication in cell culture. A series of analogues (symmetrical indolocarbazoles) was synthesised to investigate structure activity relationships in this series against a range of herpes viruses (HCMV, VZV, HSV1, and 2). This identified a number of novel, selective and potent inhibitors of HCMV, 12,13-dihydro-2,10-difluoro-5H-indolo[2,3-a]pyrrolo[3,4-c]carbazol e-5,7-(6H)-dione (1d) being the best example (IC50=40 nM, therapeutic index > 1450). Compounds described in this series were generally poor inhibitors of protein kinase C betaII, and no correlation was found between the ability to inhibit HCMV and the enzyme PKC.

The conception of community children's nursing services in Northern Ireland

This report is an exploration of the implications of establishing a community children's nursing service in Northern Ireland. It provides a description of the backdrop to the development of the service in the United Kingdom, and the experiences of children's nurses in attempting to upgrade the quality of care offered to sick children in this province. The frustrations that have characterized this development are explored in detail within the context of broader changes in health care on the national scene. The article ends with recommendations for implementing an effective service, following our experiences in Northern Ireland.

Can non-prosecutory enforcement of public health legislation reduce smoking among high school students?

BACKGROUND

Smoking by adolescents has been identified as a major public health issue. Raising the legal age of cigarette purchase from 16 to 18 years has attempted to address the issue by restricting adolescents' access. METHODS/STRATEGY: A prospective study evaluating the impact of non-prosecutory enforcement of public health legislation involving 'beat police' was conducted in the Northern Sydney Health region. Secondary students, aged 12 to 17 years, from both intervention and control regions were surveyed about cigarette smoking habits by means of a self-completed questionnaire administered pre- and post-intervention.

RESULTS

12,502 anonymous questionnaires were completed. At baseline, 19.3% of male students and 21.2% of female students indicated they were current smokers. Age and sex stratified chi-squared analysis revealed significantly lower post-intervention smoking prevalence for year 8 and 10 females and year 7 males among the intervention group. Higher post-intervention smoking prevalences were demonstrated for year 7 and 9 females and year 8 males among the intervention group and in year 10 males and year 11 females among the control group. The analysis of combined baseline and follow-up data from coeducational schools with logistic regression techniques demonstrated that the intervention had a significant effect in reducing smoking prevalence among year 7 students only (OR = 0.54).

CONCLUSION

Our study demonstrates the difficulties in restricting high school students' access to cigarettes. Isolated non-prosecutory strategies are likely to only have a limited impact on reducing smoking prevalence among high school students.

The legal and ethical status of children in health care in the UK

Ethical issues about children's rights in respect of matters concerning resource allocation or treatment opportunities are now a matter for public consumption and concern. Alongside this exists a long-frustrated desire by children's nurses to promote children's health. Long-held assumptions about the legal and moral status of children within the health care system in this country are now rightly scrutinized and challenged. Those of us who claim to represent children now possess an opportunity to exploit public attention for the benefit of these children. This article will explore selected major relevant legal and moral concepts that relate to children with the aim of making transparent some of the important and often confusing information available. It is anticipated that debates about the legal and ethical status of children may be stimulated and fuelled from the following discussion. It is strongly recommended that entering into dialogue with families and children about their perceived needs will go a long way towards advancing thoughtful nursing care of individual children, their families and the general population.

The contribution of health promotion to community children's nursing

This article discusses the range of current thinking on health promotion with special reference to community children's nursing. The scene is set with the identification of a number of issues currently at the heart of the promotion of health in children and young people. Emphasis is placed on the unprecedented expansion of interest in the promotion of children's health in Northern Ireland. Current meanings attributed to health promotion are discussed and applied to the practice of community children's nursing. Some of the contentious elements of these definitions and meanings are debated. For example, the distinct meanings of health and well-being in children are discussed and the issue of whether health promotion should be aimed at individual children, their families, or their communities is pondered. Prevention, it is argued, is one particularly important component of the promotion of health in children in the community in Northern Ireland.

Insulin-like growth factors (IGFs) and IGF binding proteins-1, -2, and -3 in newborn serum: relationships to fetoplacental growth at term

Cord sera were obtained from term, Chilean newborns exhibiting various patterns of intrauterine growth and assayed for IGF-1, IGF-2, IGFBP-1, IGFBP-2, and IGFBP-3 by specific radioimmunoassays (RIA). Serum levels of each peptide were correlated with birth weight (BW), ponderal index (PI), and placental weight (PW). Total IGF-1 levels correlated with BW (r = 0.665, P = 0.0001). PI (r = 0.527, P = 0.004), and PW (r = 0.596, P = 0.0017). In contrast, IGF-2 failed to correlate with any growth parameter. Of the three binding proteins, IGFBP-3 exhibited the strongest relationship to each growth parameter. IGFBP-3 correlated significantly with BW (r = 0.71, P < 0.0001), PI (r = 0.782, P < 0.0001), and PW (r = 0.57, P = 0.0029). In addition IGFBP-3 levels positively correlated to IGF-1 levels (r = 0.614, P = 0.0005). By contrast, circulating IGFBP-1 and IGFBP-2 were inversely related to IGF-1 levels. All five peptides were subjected to multiple regression analysis and related to BW. Significant relationships between the predicted BW and the actual BW were observed in these infants (r = 0.802, P = 0.0006). The BWs of a cohort of unrelated North American infants were also predicted using the Chilean-derived equation and found to be significantly related to their actual BWs (r = 0.453, P = 0.0033). These relationships were strengthened by the inclusion of estimated gestational age (EGA) as an independent variable. These data point to particularly important roles for IGF-1 and IGFBP-3 in regulating fetal growth at term, and suggest that they are regulated in a coordinated manner during the latter stage of gestation. Furthermore, they suggest that IGFBPs play multiple, and potentially opposing, regulatory roles in modulating IGF action. Lastly, an integrated expression of IGF activity derived from one population significantly correlated with newborn BW in a geographically and culturally distinct population.

Diabetic retinopathy: examination practices and referral patterns of general practitioners

OBJECTIVE

To investigate general practitioners' (GPs') examination and referral practices for diabetic retinopathy.

METHODS

A questionnaire survey of a random stratified sample of 500 Victorian GPs.

RESULTS

The response rate was 88%. 53% of GPs examined none or less than half of their patients with diabetes for diabetic retinopathy. Those who did examine for retinopathy rarely performed funduscopy through a dilated pupil and 65% reported that they never did. Only 37% had dilating drops in their surgery. Only 45% often or always tested visual acuity. 88% often or always referred patients at the recommended frequency to an ophthalmologist.

CONCLUSIONS

Although most GPs do not perform dilated fundus examinations, they report referring their patients with diabetes for assessment by an ophthalmologist at an early stage to prevent vision loss. Referral chain breakdown may explain the discrepancy between GPs' reported referral rates and the lower rates of ophthalmic examination reported in the Melbourne Visual Impairment Project.

Infection of a subclavian venous stent in a hemodialysis patient

Endovascular stent placement to prevent restenosis after angioplasty is being increasingly employed. A 63-year-old hemodialysis patient with a right forearm gortex graft developed ipsilateral arm edema, and a right subclavian vein stenosis was diagnosed. This vascular stenosis was presumably secondary to previous placement of temporary access catheters. The subclavian vein stenosis was treated with angioplasty, endovascular stenting, and warfarin, which resulted in resolution of the arm edema. Three weeks after stenting, the patient developed fever to 104 degrees F, chills, and right arm and shoulder edema. All blood cultures grew Staphylococcus aureus, and an Indium-labeled white blood cell scan was positive at the sight of the subclavian stent. Infectious disease consultants recommended urgent removal of the infected stent, but the extensive surgery required posed considerable risk of major morbidity. We elected to conservatively treat the patient. With loss of all upper-extremity access sites, the patient was converted to peritoneal dialysis. Despite the patient's ambulatory status, a femoral venous Hickman catheter was placed and tunneled through the abdominal subcutaneous soft tissue. The patient received 9 weeks of antibiotics by the Hickman catheter with an infusion pump, and warfarin was continued. There has been complete clinical resolution of infection and subclavian thrombosis. Endovascular stents are being used more commonly, and this is the first description, to our knowledge, of a stent infection. The stent infection was successfully managed without surgical removal.

Nonoperative initial management versus silon chimney for treatment of giant omphalocele

Giant omphalocele is a major clinical challenge for pediatric surgeons. Whereas small- to medium-sized defects can be repaired primarily, larger omphaloceles cannot be closed at birth because the liver and small bowel have lost the right of domain to the abdomen. Two divergent strategies have evolved for treating these giant defects: (1) use of a silon chimney with gradual reduction of the contents of the sac, and (2) initial nonoperative management (epithelialization) of the omphalocele followed by repair of the residual ventral hernia. In an 18-year retrospective study, we have reviewed our experience with these treatment methods. Ninety-four infants underwent treatment for omphalocele between 1975 and 1993. Primary closure (PC) was possible in 55 patients, silon chimney (SC) was used in 15, and 7 had nonoperative management (NM) with epithelialization. In the remaining 17 infants, surgery was believed to be inappropriate because of the lethality of their associated anomalies. Major (but potentially survivable) anomalies were present in 26% of PC, 13% of SC, and 71% of the NM group patients. The majority of the liver was present in 73% of SC- and 86% of NM-treated omphaloceles. There was a decrease in length of stay, time to enteral feeding, and mortality over the 18-year period. However, those patients whose defects could not be closed primarily had consistently longer hospital stays. This was particularly true for the SC patients. The decreased use of total parenteral nutrition seems to reflect a shift from SC to NM rather than a decrease in the interval to full enteral feeding in any given treatment group over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Cooperation of Src homology domains in the regulated binding of phosphatidylinositol 3-kinase. A role for the Src homology 2 domain

Fibroblasts transformed by the v-Src oncoprotein exhibit elevated activity of the enzyme phosphatidylinositol 3'-kinase (PI 3-kinase), which binds to, and is activated by, a wide range of receptor tyrosine kinases as well as v-Src and transforming polyoma middle T/c-Src complexes. Here we consider the role of the v-Src homology (SH) domains, SH3 and SH2, and the tyrosine kinase catalytic domain, in the stimulation of v-Src-associated PI 3-kinase activity in response to rapid activation of the oncoprotein. As shown by others, we find that the v-Src SH3 domain tightly binds the PI 3-kinase p85 regulatory subunit in normal growing chicken embryo fibroblasts. However, we also find that in transformed cells there is additional efficient binding of PI 3-kinase to the v-Src SH2 domain in a catalytically active form. Furthermore, the binding of p85 to the SH2 domain, which is almost undetectable in quiescent cells, is rapidly stimulated upon activation of temperature-sensitive v-Src and consequent cell cycle entry, demonstrating that binding is a target for regulation. We also show that v-Src-associated PI 3-kinase differs considerably from PDGF receptor-associated enzyme by a different mode of binding, a lack of substantial allosteric activation, and a dependence on the tyrosine kinase activity of v-Src. The rapidly induced binding and activation of PI 3-kinase thus provides sensitive regulation of recruitment of PI 3-kinase to its substrates and into other signaling complexes at the cell membrane, which involves all the Src homology domains.