Online songwriting reduces loneliness and postnatal depression and enhances social connectedness in women with young babies: randomised controlled trial

OBJECTIVE

Loneliness is a public health challenge associated with postnatal depression (PND). This study developed and tested an online songwriting intervention, with the aim of reducing loneliness and symptoms of PND and enhancing social connectedness among women with young babies.

STUDY DESIGN

This was a two-armed non-blinded randomised controlled trial (RCT, ISRCTN17647261).

METHODS

Randomisation was conducted in Excel using a 1:1 allocation, with participants (N = 89) allocated to an online 6-week songwriting intervention (Songs from Home) or to waitlist control. Inclusion criteria were women aged ≥18 years, with a baby ≤9 months old, reporting loneliness (4+ on UCLA 3-Item Loneliness Scale) and symptoms of PND (10+ on Edinburgh Postnatal Depression Scale [EPDS]). Loneliness (UCLA-3) was measured at baseline, after each intervention session and at 4-week follow-up. The secondary measures of PND (EPDS) and social connectedness (Social Connectedness Revised 15-item Scale [SC-15]) were measured at baseline, postintervention and at 4-week follow-up (Week 10). Factorial mixed analyses of variance with planned custom contrasts were conducted for each outcome variable comparing the intervention and control groups over time and across baseline, Weeks 1-6 and the follow-up at Week 10 for each outcome variable.

RESULTS

Compared with waitlist control, the intervention group reported significantly lower scores postintervention and at follow-up for loneliness (P < 0.001, η²_P = 0.098) and PND (P < 0.001, η²_P = 0.174) and significantly higher scores at follow-up for social connectedness (P < 0.001, η²_P = 0.173).

CONCLUSIONS

A 6-week online songwriting intervention for women with young babies can reduce loneliness and symptoms of PND and increase social connectedness.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Creative interventions for symptoms of postnatal depression: A process evaluation of implementation

BACKGROUND

This article is a process evaluation of a three-arm randomised controlled trial (RCT) comparing the effects of creative interventions on symptoms of postnatal depression (PND) in new mothers.

METHODS

Analyses of quantitative evaluation data from 91 participants and qualitative interviews and focus groups with 80 participants and 3 members of staff.

RESULTS

Key assumptions of the RCT, including how the delivery of the intervention was achieved and what the intervention involved, are explored. Data suggest that the intervention was delivered as planned with a high level of fidelity. Key uncertainties surrounding the project, in particular unanticipated challenges that had to be overcome during the RCT, are also discussed and simple recommendations for improvement are made.

CONCLUSION

This process evaluation aims to illuminate the outcome and mechanisms data from the RCT and enable organisations or individuals to ascertain the feasibility of establishing their own creative classes for women with symptoms of PND.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Time-dependent upregulation of electron transport with concomitant induction of regulated excitation dissipation in Haslea diatoms

Photoacclimation by strains of Haslea "blue" diatom species H. ostrearia and H. silbo sp. nov. ined. was investigated with rapid light curves and induction-recovery curves using fast repetition rate fluorescence. Cultures were grown to exponential phase under 50 µmol m^-2 s^-1 photosynthetic available radiation (PAR) and then exposed to non-sequential rapid light curves where, once electron transport rate (ETR) had reached saturation, light intensity was decreased and then further increased prior to returning to near growth light intensity. The non-sequential rapid light curve revealed that ETR was not proportional to the instantaneously applied light intensity, due to rapid photoacclimation. Changes in the effective absorption cross sections for open PSII reaction centres (σ_PSII') or reaction centre connectivity (ρ) did not account for the observed increases in ETR under extended high light. σ_PSII' in fact decreased as a function of a time-dependent induction of regulated excitation dissipation Y(NPQ), once cells were at or above a PAR coinciding with saturation of ETR. Instead, the observed increases in ETR under extended high light were explained by an increase in the rate of PSII reopening, i.e. Q_A^- oxidation. This acceleration of electron transport was strictly light dependent and relaxed within seconds after a return to low light or darkness. The time-dependent nature of ETR upregulation and regulated NPQ induction was verified using induction-recovery curves. Our findings show a time-dependent induction of excitation dissipation, in parallel with very rapid photoacclimation of electron transport, which combine to make ETR independent of short-term changes in PAR. This supports a selective advantage for these diatoms when exposed to fluctuating light in their environment.

Effect of singing interventions on symptoms of postnatal depression: three-arm randomised controlled trial

This study assessed whether a novel psychosocial intervention could reduce symptoms of postnatal depression (PND) in the first 40 weeks post-birth. Analyses were carried out of 134 mothers with symptoms of PND randomised into 10 weeks of group singing workshops or group play workshops for them and their babies, or usual care (trial registration: NCT02526407). Overall, among all mothers with symptoms of PND, there was a non-significant faster improvement in symptoms in the singing group (F 4,262 = 1.66, P = 0.16, η 2 = 0.012). When isolating mothers with moderate-severe symptoms of PND, this result became significant, with a faster improvement in symptoms in the singing group (F 3.9,139.8 = 2.74, P = 0.033, η 2 = 0.028). Declaration of interest None.

Quality control metrics improve repeatability and reproducibility of single-nucleotide variants derived from whole-genome sequencing

Although many quality control (QC) methods have been developed to improve the quality of single-nucleotide variants (SNVs) in SNV-calling, QC methods for use subsequent to single-nucleotide polymorphism-calling have not been reported. We developed five QC metrics to improve the quality of SNVs using the whole-genome-sequencing data of a monozygotic twin pair from the Korean Personal Genome Project. The QC metrics improved both repeatability between the monozygotic twin pair and reproducibility between SNV-calling pipelines. We demonstrated the QC metrics improve reproducibility of SNVs derived from not only whole-genome-sequencing data but also whole-exome-sequencing data. The QC metrics are calculated based on the reference genome used in the alignment without accessing the raw and intermediate data or knowing the SNV-calling details. Therefore, the QC metrics can be easily adopted in downstream association analysis.

Using X-mode L, R and O-mode reflectometry cutoffs to measure scrape-off-layer density profiles for upgraded ORNL reflectometer on NSTX-U

The pre-existing ORNL scrape-off-layer (SOL) reflectometer that operated with the X-mode R-cutoff at 6-27 GHz to measure SOL density profiles on NSTX is being upgraded to be functional at the increased magnetic fields on NSTX-U spherical tokamak. Rather than increasing the operating frequencies to measure the higher X-mode R-cutoff frequencies on NSTX-U, it will be shown that the combined use of the X-mode R, L and O-mode cutoffs at 6-27 GHz can obtain the desired SOL density profiles. The potential capabilities and obstacles of this technique to measure SOL density profiles and possibly SOL magnetic field profiles on NSTX-U will be discussed.

Corallina and Ellisolandia (Corallinales, Rhodophyta) photophysiology over daylight tidal emersion: interactions with irradiance, temperature and carbonate chemistry

The photophysiology of three geniculate coralline algal species (Corallina officinalis, C. caespitosa and Ellisolandia elongata) was determined in intertidal rock pools in the south-west UK at Combe Martin (51°12'31N 4°2'19W) and Heybrook Bay (50°31'66N 4°11'41W), at the start, middle and end of summer (September 1 and 2) and winter (February 9 and 10) daylight tidal emersion periods, in relation to prevailing irradiance, temperature and carbonate chemistry conditions. Algal photophysiology was assessed from rapid light curves performed using pulse amplitude modulation fluorometry. Corallina and Ellisolandia experienced significant fluctuations in irradiance, temperature and carbonate chemistry over seasonal and tidal cycles. Rock pool carbonate chemistry was predictable (R² = 0.82, P < 0.0001) by photodose (summed irradiance) plus water temperature, but not significantly related to photophysiology. In contrast, Corallina and Ellisolandia relative maximum electron transfer rate showed a significant negative relationship (R² = 0.65, P < 0.0001) with irradiance plus water temperature. At a seasonal resolution, photoacclimation to maximize both light harvesting during winter months and photoprotection during summer months was observed for all species. Dynamic photoinhibition was apparent over both summer and winter tidal emersion, in relation to irradiance fluctuations. More effective photoinhibition was apparent during summer months, with greater sensitivity to irradiance and slower recovery in F_v/F_m, observed during winter. With sustained high irradiance over tidal emersion, the establishment of high pH/low inorganic carbon conditions may impact photochemistry. This study represents the first assessment of C. officinalis, C. caespitosa and E. elongata photophysiology underpinned by clear species concepts and highlights their ability to adapt to the dramatically fluctuating conditions experienced in intertidal rock pools.

Efficacy of intravascular catheter lock solutions containing preservatives in the prevention of microbial colonization

There is little published evidence regarding whether heparin lock solutions containing preservatives prevent catheter-related infections. However, adverse effects from preservative-containing flushes have been documented in neonates, leading many hospitals to avoid their use altogether. Infection control records from 1982 to 2008 at St. Jude Children's Research Hospital (SJCRH) were reviewed regarding the incidence of catheter-related infections and the use of preservative-containing intravenous locks. In addition, the antimicrobial activities of heparin lock solution containing the preservatives parabens (0.165%) or benzyl alcohol (0.9%), and 70% ethanol were examined against Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, Bacillus cereus, Pseudomonas aeruginosa and Candida albicans, and compared with preservative-free saline with and without heparin. Growth was assessed after exposure to test solutions for 0, 2, 4 and 24h at 35 °C. The activities of preservatives were assessed against both planktonic (free-floating) and sessile (biofilm-embedded) micro-organisms using the MBEC Assay. Infection control records revealed two periods of increased catheter-related infections, corresponding with two intervals when preservative-free heparin was used at SJCRH. Heparin solution containing preservatives demonstrated significant antimicrobial activity against both planktonic and sessile forms of all six microbial species. Ethanol demonstrated the greatest antimicrobial activity, especially following short incubation periods. Heparin lock solutions containing the preservatives parabens or benzyl alcohol, and 70% ethanol demonstrated significant antimicrobial activity against both planktonic and sessile micro-organisms commonly responsible for catheter-related infections. These findings, together with the authors' historical infection control experience, support the use of preservatives in intravenous lock solutions to reduce catheter related infections in patients beyond the neonatal period.

A probe-based method for confirmation of methicillin-resistant Staphylococcus aureus and detection of Panton-Valentine leukocidin and tst virulence genes

Probe-based detection of mecA, lukS/F-PV (Panton-Valentine leukocidin), and tst virulence genes in 435 isolates of Staphylococcus aureus had comparable sensitivity and specificity to end-point polymerase chain reaction as a reference standard.

Increasing prevalence of nasal and rectal colonization with methicillin-resistant Staphylococcus aureus in children with cancer

BACKGROUND

Infections with methicillin-resistant Staphylococcus aureus (MRSA), in community-settings, especially with strains carrying the Panton-Valentine Leukocidin (PVL) genes, have increased markedly in recent years. Colonization with S. aureus is a risk factor for infection. However, there are few studies that examine colonization and infection with PVL-positive strains of MRSA in cancer patients.

PROCEDURE

The epidemiology of colonization and infection with MRSA was studied in children with cancer during two time periods: 2000/2001 and 2006/2007. PVL genes were screened and spa typing performed on the isolates.

RESULTS

The prevalence of colonization with MRSA increased from 0.6% in 2000/2001 to 2.9% in 2006/2007 (P = 0.0003). MRSA colonization at admission was associated with infection (P < 0.0001; RR 38.32; 95% CI: 23.36-62.84). The prevalence of infection increased from 0.99% in 2000/2001 to 3.78% in 2006-2007 (P = 0.0002). Of the 32 colonized patients, 18 (56%) had infection. None of the 14 colonized but non-infected patients had dual colonization of nares and rectum, while 8 of the 18 infected patients had colonization of both of these sites (P = 0.004). Ten patients (31%) were colonized with PVL-positive strains. Patients colonized with PVL-positive strains were more likely to be colonized both in the nares and rectum (P = 0.005), and more likely to have infection (P = 0.001). Recurrent MRSA infections were seen in 22% of patients.

CONCLUSION

An increasing prevalence of colonization with MRSA was observed in children with cancer at our institution. Colonization with MRSA especially with PVL-positive strains was associated with infection.

Assessing sources of inconsistencies in genotypes and their effects on genome-wide association studies with HapMap samples

The discordance in results of independent genome-wide association studies (GWAS) indicates the potential for Type I and Type II errors. We assessed the repeatibility of current Affymetrix technologies that support GWAS. Reasonable reproducibility was observed for both raw intensity and the genotypes/copy number variants. We also assessed consistencies between different SNP arrays and between genotype calling algorithms. We observed that the inconsistency in genotypes was generally small at the specimen level. To further examine whether the differences from genotyping and genotype calling are possible sources of variation in GWAS results, an association analysis was applied to compare the associated SNPs. We observed that the inconsistency in genotypes not only propagated to the association analysis, but was amplified in the associated SNPs. Our studies show that inconsistencies between SNP arrays and between genotype calling algorithms are potential sources for the lack of reproducibility in GWAS results.

Medium to long term results of the Exeter bipolar hemiarthroplasty for femoral neck fractures in active, independent patients. 5-13 year follow-up

We present the clinical and radiographic outcome of 49 Exeter bipolar hemiarthroplasties for femoral neck fractures in 49 patients with a median age of 71 years at the time of operation. Median length of follow-up was 7.1 years (5 to 13). There was one dislocation, and one peri-prosthetic fracture. There were no revisions for infection, acetabular erosion or stem loosening. Twenty-six patients had died by the time of final follow-up with an overall 5 year cumulative survival of 60.2%. Thirty day mortality was 36% in patients with an ASA score of 3. We present excellent clinical and radiological medium to long term results with no evidence of acetabular erosion. However, careful patient selection is necessary to avoid high early mortality rates.

Cement venogram: as a result of high femoral cement pressurisation. A report of 3 cases

Current femoral cementing techniques for total hip arthroplasty (THA) have improved over recent years. High pressurisation is achieved using a cement gun with a proximal seal and a cement restrictor, maximising the microinterlock at the bone cement interface. However, there are concerns regarding over pressurisation of the femoral canal resulting in an increased risk of cardiorespiratory collapse secondary to embolic phenomena. We report on three cases over a one year period of cement within a vein (cement venogram) on a post-operative radiograph following THA. We feel that the cement venogram is an important indicator of high pressurisation and that its incidence may be on the increase with improved cementing techniques.

The functional importance of the N-terminal region of human prolylcarboxypeptidase

The renin-angiotensin-system cascade pathway generates the vasopressor and prothrombotic hormones, angiotensin II (Ang II) and angiotensin III (Ang III) from angiotensinogen. One of the key enzymes for the generation of angiotensin 1-7 (Ang 1-7) and angiotensin 2-7 (Ang 2-7) from Ang II and III, respectively, is prolylcarboxypeptidase (PRCP). To understand the contribution of the N-terminal region to catalysis, an N-terminal truncated form, lacking 179 N-terminal residues of PRCP (rPRCP(40)) was constructed. The circular dichroism (CD) spectrum of rPRCP(40) illustrated that it was structured with significant helical content as indicated by local minima at approximately 220 and 208nm. The main products of Ang III metabolized by rPRCP(40) were Ang 2-7 plus phenylalanine as determined by LC-MS. Angiotensin I (Ang I) blocked the metabolism of Ang III by rPRCP(40). These investigations showed that the C-terminal region of the rPRCP(40) contributes to PRCP's catalytic function, and provided additional experimental evidence for this suggestion.

An in silico ensemble method for lead discovery: decision forest

Recent progress in combinatorial chemistry and parallel synthesis has radically changed the approach to drug discovery in the pharmaceutical industry. At present, thousands of compounds can be made in a short period, creating a need for fast and effective in silico methods to select the most promising lead candidates. Decision forest is a novel pattern recognition method, which combines the results of multiple distinct but comparable decision tree models to reach a consensus prediction. In this article, a decision forest model was developed using a structurally diverse training data set containing 232 compounds whose estrogen receptor binding activity was tested at the U.S. Food and Drug Administration (FDA)'s National Center for Toxicological Research (NCTR). The model was subsequently validated using a test data set of 463 compounds selected from the literature, and then applied to a large data set with 57,145 compounds as a screening example. The results show that the decision forest method is a fast, reliable and effective in silico approach, which could be useful in drug discovery.

Bioinformatics approaches for cross-species liver cancer analysis based on microarray gene expression profiling

Background

The completion of the sequencing of human, mouse and rat genomes and knowledge of cross-species gene homologies enables studies of differential gene expression in animal models. These types of studies have the potential to greatly enhance our understanding of diseases such as liver cancer in humans. Genes co-expressed across multiple species are most likely to have conserved functions. We have used various bioinformatics approaches to examine microarray expression profiles from liver neoplasms that arise in albumin-SV40 transgenic rats to elucidate genes, chromosome aberrations and pathways that might be associated with human liver cancer.

Results

In this study, we first identified 2223 differentially expressed genes by comparing gene expression profiles for two control, two adenoma and two carcinoma samples using an F-test. These genes were subsequently mapped to the rat chromosomes using a novel visualization tool, the Chromosome Plot. Using the same plot, we further mapped the significant genes to orthologous chromosomal locations in human and mouse. Many genes expressed in rat 1q that are amplified in rat liver cancer map to the human chromosomes 10, 11 and 19 and to the mouse chromosomes 7, 17 and 19, which have been implicated in studies of human and mouse liver cancer. Using Comparative Genomics Microarray Analysis (CGMA), we identified regions of potential aberrations in human. Lastly, a pathway analysis was conducted to predict altered human pathways based on statistical analysis and extrapolation from the rat data. All of the identified pathways have been known to be important in the etiology of human liver cancer, including cell cycle control, cell growth and differentiation, apoptosis, transcriptional regulation, and protein metabolism.

Conclusion

The study demonstrates that the hepatic gene expression profiles from the albumin-SV40 transgenic rat model revealed genes, pathways and chromosome alterations consistent with experimental and clinical research in human liver cancer. The bioinformatics tools presented in this paper are essential for cross species extrapolation and mapping of microarray data, its analysis and interpretation.

Kv1.3 channel gene-targeted deletion produces "Super-Smeller Mice" with altered glomeruli, interacting scaffolding proteins, and biophysics

Mice with gene-targeted deletion of the Kv1.3 channel were generated to study its role in olfactory function. Potassium currents in olfactory bulb mitral cells from Kv1.3 null mice have slow inactivation kinetics, a modified voltage dependence, and a dampened C-type inactivation and fail to be modulated by activators of receptor tyrosine signaling cascades. Kv1.3 deletion increases expression of scaffolding proteins that normally regulate the channel through protein-protein interactions. Kv1.3-/- mice have a 1,000- to 10,000-fold lower threshold for detection of odors and an increased ability to discriminate between odorants. In accordance with this heightened sense of smell, Kv1.3-/- mice have glomeruli or olfactory coding units that are smaller and more numerous than those of wild-type mice. These data suggest that Kv1.3 plays a far more reaching role in signal transduction, development, and olfactory coding than that of the classically defined role of a potassium channel-to shape excitability by influencing membrane potential.

Comparative molecular field analysis (CoMFA) model using a large diverse set of natural, synthetic and environmental chemicals for binding to the androgen receptor

A large number of natural, synthetic and environmental chemicals are capable of disrupting the endocrine systems of experimental animals, wildlife and humans. These so-called endocrine disrupting chemicals (EDCs), some mimic the functions of the endogenous androgens, have become a concern to the public health. Androgens play an important role in many physiological processes, including the development and maintenance of male sexual characteristics. A common mechanism for androgen to produce both normal and adverse effects is binding to the androgen receptor (AR). In this study, we used Comparative Molecular Field Analysis (CoMFA), a three-dimensional quantitative structure-activity relationship (3D-QSAR) technique, to examine AR-ligand binding affinities. A CoMFA model with r2 = 0.902 and q2 = 0.571 was developed using a large training data set containing 146 structurally diverse natural, synthetic, and environmental chemicals with a 10(6)-fold range of relative binding affinity (RBA). By comparing the binding characteristics derived from the CoMFA contour map with these observed in a human AR crystal structure, we found that the steric and electrostatic properties encoded in this training data set are necessary and sufficient to describe the RBA of AR ligands. Finally, the CoMFA model was challenged with an external test data set; the predicted results were close to the actual values with average difference of 0.637 logRBA. This study demonstrates the utility of this CoMFA model for real-world use in predicting the AR binding affinities of structurally diverse chemicals over a wide RBA range.

Regulatory application of SAR/QSAR for priority setting of endocrine disruptors: A perspective

Some seven years have passed since the U.S. legislature mandated the EPA to develop and implement a screening and testing program for chemicals that may disrupt the delicate endocrine system. The envisioned EPA program has evolved to incorporate a tiered scheme of in vitro and in vivo assays, and considered QSAR as a viable method to set testing priorities. At the U.S. FDA's National Center for Toxicological Research (NCTR), the Endocrine Disruptor Knowledge Base Project has developed models to predict estrogen and androgen receptor binding. Our approach rationally integrates various QSAR models into a sequential "Four-Phase" scheme according to the strength of each type of model. In four hierarchical phases, models predict the inactive chemicals that are then eliminated from the pool of chemicals to which increasingly precise but more time-consuming models are subsequently applied. Each phase employs different models selected to work complementarily in representing key activity-determining structure features in order to absolutely minimize the rate of false negatives, an outcome we view as paramount for regulatory use. In this paper, the QSAR models developed at NCTR, and particularly how we integrated these models into the "Four-Phase" system will be discussed for a number of datasets, including 58 000 chemicals identified by the U.S. EPA.

An integrated "4-phase" approach for setting endocrine disruption screening priorities--phase I and II predictions of estrogen receptor binding affinity

Recent legislation mandates the US Environmental Protection Agency (EPA) to develop a screening and testing program for potential endocrine disrupting chemicals (EDCs), of which xenoestrogens figure prominently. Under the legislation, a large number of chemicals will undergo various in vitro and in vivo assays for their potential estrogenicity, as well as other hormonal activities. There is a crucial need for priority setting before this strategy can be effectively implemented. Here we report an integrated computational approach to priority setting using estrogen receptor (ER) binding as an example. This approach rationally integrates different predictive computational models into a "Four-Phase" scheme so that it can effectively identify potential estrogenic EDCs based on their predicted ER relative binding affinity (RBA). The system has been validated using an in-house ER binding assay dataset for 232 chemicals that was designed to have both broad structural diversity and a wide range of binding affinities. When applied to 58,000 chemicals identified by Walker et al. as candidates for endocrine disruption screening, some 9100 chemicals were predicted to bind to ER. Of these, only 3600 were expected to bind to ER at RBA values up to 100,000-fold less than that of 17beta-estradiol. The method ruled out 83% of the chemicals as non-binders with a very low rate of false negatives. We believe that the same integrated scheme will be equally applicable to endpoints of other endocrine disrupting mechanisms, e.g. androgen receptor binding.

On a hiding to nothing? Assessing the corporate governance of hospital and health services in New Zealand 1993-1998

In New Zealand the governance of public sector hospital and health services has changed significantly over the past decade. For most of the century hospitals had been funded by central government grants but run by locally elected boards. In 1989 a reforming Labour government restructured health services along managerialist lines, including changing governance structures so that some area health board members were government appointments, with the balance elected by the community. More market oriented reform under a new National government abolished this arrangement and introduced (1993) a corporate approach to the management of hospitals and related services. The hospitals were established as limited liability companies under the Companies Act. This was an explicitly corporate model and, although there was some modification of arrangements following the election of a more politically moderate centre-right coalition government in 1996, the corporate model was largely retained. Although significant changes occurred again after the election of a Labour government in 1999, the corporate governance experience in New Zealand health services is one from which lessons can, nevertheless, be learnt. This paper examines aspects of the performance and process of corporate governance arrangements for public sector health services in New Zealand, 1993-1998.

Structure-activity relationships for a large diverse set of natural, synthetic, and environmental estrogens

Understanding structural requirements for a chemical to exhibit estrogen receptor (ER) binding has been important in various fields. This knowledge has been directly and indirectly applied to design drugs for human estrogen replacement therapy, and to identify estrogenic endocrine disruptors. This paper reports structure-activity relationships (SARs) based on a total of 230 chemicals, including both natural and xenoestrogens. Activities were generated using a validated ER competitive binding assay, which covers a 10(6)-fold range. This study is focused on identification of structural commonalities among diverse ER ligands. It provides an overall picture of how xenoestrogens structurally resemble endogenous 17beta-estradiol (E(2)) and the synthetic estrogen diethylstilbestrol (DES). On the basis of SAR analysis, five distinguishing criteria were found to be essential for xenoestrogen activity, using E(2) as a template: (1) H-bonding ability of the phenolic ring mimicking the 3-OH, (2) H-bond donor mimicking the17beta-OH and O-O distance between 3- and 17beta-OH, (3) precise steric hydrophobic centers mimicking steric 7alpha- and 11beta-substituents, (4) hydrophobicity, and (5) a ring structure. The 3-position H-bonding ability of phenols is a significant requirement for ER binding. This contributes as both a H-bond donor and acceptor, although predominantly as a donor. However, the 17beta-OH contributes as a H-bond donor only. The precise space (the size and orientation) of steric hydrophobic bulk groups is as important as a 17beta-OH. Where a direct comparison can be made, strong estrogens tend to be more hydrophobic. A rigid ring structure favors ER binding. The knowledge derived from this study is rationalized into a set of hierarchical rules that will be useful in guidance for identification of potential estrogens.

QSAR models using a large diverse set of estrogens

Endocrine disruptors (EDs) have a variety of adverse effects in humans and animals. About 58,000 chemicals, most having little safety data, must be tested in a group of tiered assays. As assays will take years, it is important to develop rapid methods to help in priority setting. For application to large data sets, we have developed an integrated system that contains sequential four phases to predict the ability of chemicals to bind to the estrogen receptor (ER), a prevalent mechanism for estrogenic EDs. Here we report the results of evaluating two types of QSAR models for inclusion in phase III to quantitatively predict chemical binding to the ER. Our data set for the relative binding affinities (RBAs) to the ER consists of 130 chemicals covering a wide range of structural diversity and a 6 orders of magnitude spread of RBAs. CoMFA and HQSAR models were constructed and compared for performance. The CoMFA model had a r2 = 0.91 and a q2LOO = 0.66. HQSAR showed reduced performance compared to CoMFA with r2 = 0.76 and q2LOO = 0.59. A number of parameters were examined to improve the CoMFA model. Of these, a phenol indicator increased the q2LOO to 0.71. When up to 50% of the chemicals were left out in the leave-N-out cross-validation, the q2 remained significant. Finally, the models were tested by using two test sets; the q2pred for these were 0.71 and 0.62, a significant result which demonstrates the utility of the CoMFA model for predicting the RBAs of chemicals not included in the training set. If used in conjunction with phases I and II, which reduced the size of the data set dramatically by eliminating most inactive chemicals, the current CoMFA model (phase III) can be used to predict the RBA of chemicals with sufficient accuracy and to provide quantitative information for priority setting.

Home treatment

BACKGROUND

Deinstitutionalisation has stressed where care is no longer taking place. Home treatment in rehabilitation reflects the steady increase in emphasis on support and treatment for individuals with long-term disorders where it matters for them--in their own homes.

MATERIALS AND DISCUSSION

Whether dealing with individuals discharged after long periods in hospital or with the increasing number who have experienced repeated short-term admissions, most modern day rehabilitation takes place in the patients' homes and neighbourhoods. We are increasingly convinced that this decentralisation is a positive strength, not a problem. Its advantages include improving social inclusion and the ability to conduct more accurate, personalised assessments of disabilities and strengths. Skills training is more focused and we discuss the components of home treatment and assertive community treatment as they are relevant to rehabilitation. This involves both medication and practical help, brokerage and involvement with the voluntary sector.

CONCLUSIONS

Rehabilitation remains, at its core, a set of relationships between whole individuals (not just skills and needs). A home-based approach is proposed as the norm, not the exception. It is based on a rounded understanding of the patient as a unique person and emphasises the importance of a strong working alliance.

Corporate governance of public health services: lessons from New Zealand for the state sector

New Zealand public hospitals and related services were grouped into 23 Crown Health Enterprises and registered as companies in 1993. Integral to this change was the introduction of corporate governance. New directors, largely from the business sector, were appointed to govern these organisations as efficient and effective businesses. This article presents the results of a survey of directors of New Zealand publicly-owned health provider organisations. Although directors thought they performed well in business systems development, they acknowledged their shortcomings in meeting government expectations in respect to financial performance and social responsibility. Changes in public health sector provider performance indicators have resulted in a mixed report card for the sector six years after corporate governance was instituted.