'It makes life worthwhile!' Peer mentoring in long-term care-a feasibility study

Objectives: Loneliness and depression are of increasing concern in long-term care homes made more urgent by viral outbreak isolation protocols. An innovative program called Java Mentorship was developed that engaged community volunteers and resident volunteers (mentors) as a team. The team met weekly, received education, and provided visits and guidance in pairs to socially disengaged residents (mentees). The purpose of this study was to assess the feasibility of conducting a larger study.Method: We conducted a mixed-methods pre-post study to evaluate the program. We collected feasibility data associated with the program implementation, including assessment of the sample and ability to recruit; procedures for data collection; retention, program adherence and acceptability; and residents' responses including loneliness, depression, purpose in life, social identity and sense of belonging outcomes. We enrolled community mentors (n = 65), resident mentors (n = 48) staff facilitators (n = 24) and mentees (n = 74) in 10 Canadian sites.Results: Most feasibility objectives were met, and adherence and acceptability were high. Some resource challenges and low retention rates among resident mentors were noted. We found a 29% reduction in depression scores (p = .048; d = .30) and 15% reduction in loneliness scores (p = .014; d = .23). Purpose in life, social identity and sense of belonging were unchanged. Interviews among participants indicated high acceptability and positive perceptions of the program.Conclusion: The study findings reveal a potential role for mentorship as a viable approach to reducing loneliness and depression in long-term care settings and lay the groundwork for future research.

The Impact of Peer Mentoring on Loneliness, Depression, and Social Engagement in Long-Term Care

Loneliness, depression, and social isolation are common among people living in long-term care homes, despite the activities provided. We examined the impact of a new peer mentoring program called Java Mentorship on mentees' loneliness, depression, and social engagement, and described their perceptions of the visits. We conducted a mixed-methods approach in 10 homes in Ontario, Canada, and enrolled residents as mentees (n = 74). We used quantitative surveys and qualitative interviews to understand their experience. After 6 months, mentees (n = 43) showed a 30% reduction in depression (p = .02, d = .76), a 12% reduction in loneliness (p = .02, d = .76), and a 60% increase in the number of monthly programs attended (p = .01, d = .37), with small-to-medium effect sizes. The analysis of mentee's interviews revealed positive perceptions. This program offers an innovative, nonpharmacological alternative to the treatment of loneliness and depression.

Use of fall risk increasing drugs in residents of retirement villages: a pilot study of long term care and retirement home residents in Ontario, Canada

BACKGROUND

Falls continue to be a problem for older people in long-term care (LTC) and retirement home (RH) settings and are associated with significant morbidity and health care use. Fall-risk increasing drugs (FRIDs) are known to increase fall risk and represent modifiable risk factors. There are limited data regarding the use of FRIDs in contemporary LTC and RH settings, and it has not been well documented to what extent medication regimens are reviewed and modified for those who have sustained falls. The objective of this study is to characterize medication related fall risk factors in LTC and RH residents and on-going use of medications known to increase fall risk.

METHODS

Retrospective chart review of residents aged >65 who sustained one or more falls living in LTC or RH settings.

RESULTS

105 residents who fell one or more times during 2009-2010 were identified with a mean age of 89 years, a mean of nine scheduled medications and seven diagnoses, and 83% were women. Residents in LTC were ostensibly at higher risk for falls relative to those in RH settings as suggested by higher proportion of residents with multiple falls, multiple comorbidities, comorbidities that increase fall risk and visual impairment. Post fall injuries were sustained by 42% of residents, and residents in RH sustained more injuries relative to LTC residents (47 vs 34%). Use of FRIDs such as benzodiazepines, antipsychotic, antidepressant and various antihypertensive drugs was common in the present sample. No medication regimen changes were noted in the 6-month post fall period.

CONCLUSIONS

The present study documented common use FRIDs by LTC and RH residents with multiple falls. These potentially modifiable falls risk factors are not being adequately addressed in contemporary practice, demonstrating that there is much room for improvement with regards to the safe and appropriate use of medications in LTC and RH residents.

HEALTH SELECTION THEORY: AN EXPLANATION FOR THE PARADOX BETWEEN PERCEIVED MALE WELL-BEING AND MORTALITY

Paradoxically, men report better health and quality of life than women, but men experience higher mortality rates than women at most ages. One conclusion from these findings is that men have been selected to disregard signs of ill health, or even to deceive themselves about their health, to their detriment because presenting themselves as healthy has fitness benefits. We hypothesize that men have been sexually selected to present themselves to women as healthy but that the cost of not attending to their minor health problems results in earlier mortality than women. We present a review of the human and primate literature that supports health selection theory, the hypothesis that females have preferentially selected males who present themselves as healthy.

Ultra-High-Throughput Screening of Natural Product Extracts to Identify Proapoptotic Inhibitors of Bcl-2 Family Proteins

Antiapoptotic Bcl-2 family proteins are validated cancer targets composed of six related proteins. From a drug discovery perspective, these are challenging targets that exert their cellular functions through protein-protein interactions (PPIs). Although several isoform-selective inhibitors have been developed using structure-based design or high-throughput screening (HTS) of synthetic chemical libraries, no large-scale screen of natural product collections has been reported. A competitive displacement fluorescence polarization (FP) screen of nearly 150,000 natural product extracts was conducted against all six antiapoptotic Bcl-2 family proteins using fluorochrome-conjugated peptide ligands that mimic functionally relevant PPIs. The screens were conducted in 1536-well format and displayed satisfactory overall HTS statistics, with Z'-factor values ranging from 0.72 to 0.83 and a hit confirmation rate between 16% and 64%. Confirmed active extracts were orthogonally tested in a luminescent assay for caspase-3/7 activation in tumor cells. Active extracts were resupplied, and effort toward the isolation of pure active components was initiated through iterative bioassay-guided fractionation. Several previously described altertoxins were isolated from a microbial source, and the pure compounds demonstrate activity in both Bcl-2 FP and caspase cellular assays. The studies demonstrate the feasibility of ultra-high-throughput screening using natural product sources and highlight some of the challenges associated with this approach.

Helping pharmacists to reduce fall risk in long-term care: A clinical tool to facilitate the medication review process

BACKGROUND

One-third to one-half of adults older than 65 fall at least once per year. Fall prevention through medication management requires little effort and has consistently been shown to reduce risk of falls. The objective of this study was to further develop and perform preliminary pilot testing of an algorithm designed to assist consultant pharmacists in systematically identifying medications that might be modifiable, in order to reduce the risk of falls in older adults. We hypothesized that algorithm use would increase the number of fall-related medication change recommendations made to physicians.

METHODS

Four consultant pharmacists were trained to use the algorithm during their routine medication reviews over a 3-week period. An informal survey was administered at the end of the study period to assess the algorithm.

RESULTS

Overall, 51% of residents of long-term facilities had 1 or more recommendations for medication changes related to reducing fall risk (range 0-3 recommendations per resident), with an average 0.675 recommendations made per resident. There were more recommendations for men compared with women and for residents receiving more medications, but the number of recommendations did not correspond with age. All 4 pharmacists agreed that the algorithm was useful and worthwhile.

DISCUSSION

The absolute 20% increase in recommendations related to falls supports the study hypothesis. Time was cited as a barrier to using the algorithm, but this should decrease with continued use of this tool.

CONCLUSION

This preliminary study furthered the development of and confirmed the possible utility and acceptability of a fall risk-reducing algorithm that may be used in practice.

Social identification moderates cognitive health and well-being following story- and song-based reminiscence

OBJECTIVES

Reminiscence is a popular intervention for seniors, but, with mixed evidence supporting its efficacy, questions have been raised about the mechanisms underlying improvement. The present paper addresses this question by investigating the degree to which health effects depend on the development of a shared sense of group identification. This is examined in the context of traditional story-based reminiscence as well as novel forms of song-based reminiscence.

METHOD

As the focus of a manualized intervention, 40 participants were randomly assigned to secular song (n=13), religious song (n=13), or standard story reminiscence (n=14) groups. These were run over six weeks with cognitive performance, anxiety, and life satisfaction measured before and after the intervention. Measures of group fit were included to examine whether social identification contributed to outcomes.

RESULTS

No evidence of change emerged over time as a function of intervention form alone, but analysis of identification data revealed significant interactions with the type of reminiscence group. Specifically, initial fit with the story reminiscence group was associated with enhanced cognitive outcomes and greater life satisfaction, while fit with the religious song reminiscence group was associated with greater life satisfaction and less anxiety.

CONCLUSION

These findings show that group identification is a key moderator through which reminiscence promotes health outcomes. Implications for theory and practice highlight an inherent limitation in randomized controlled trials insofar as they may compromise participants' group identification.

Psychotropic and Cognitive-Enhancing Medication Use and Its Documentation in Contemporary Long-term Care Practice

Background: In long-term care (LTC) settings, use of psychotropic medications to manage behavioral and psychological symptoms of dementia and use of cognitive enhancers are commonplace. It is important that these medications are properly used to ensure resident well-being, and thus, it is paramount to understand use of these medications in contemporary practice to develop appropriate quality improvement initiatives. Objective: To characterize psychotropic and cognition-enhancing medication use LTC residents and current trends in documentation. Methods: Cross-sectional chart review of residents aged >65 years with dementia receiving psychotropic medications and/or cognitive enhancers. Results: From 180 residents, 84 (82% female) met inclusion criteria (average age 86 years). The prevalence of psychotropic medication use was as follows: cognitive enhancers, 71%; antidepressants, 98%; antipsychotics, 61%; sedative hypnotics, 23%. Quetiapine was the most commonly used antipsychotic (48%), followed by risperidone (28%) and olanzapine (15%), all of which were dosed within accepted guidelines. The duration of therapy ranged from 2 to 5 years for antipsychotic medications and 1¼ to 3 years for antidepressants. Documentation documentation rates were hightest for psychotropics versus cognitive enhancers. There was no documentation of attempts to lower doses or discontinue psychotropic medications or cognitive enhancers. Conclusions: Many, but not all psychotropics used were acceptable choices. The duration of therapy appears to be excessive for antipsychotic medications. Documentation of ongoing need for medications varied and could be improved on to better assess residents’ medication regimens. Further research will inform efforts to enhance the care of these residents.

Collectivism/individualism and its relationship to behavioral and physiological immunity

The interaction between the behavioral and physiological immune systems provides fertile ground for research. Here, we examine the interactions between fear of disease, collectivism/individualism, disgust, visual perception and salivary IgA. First, we parsed collectivism/individualism into ancestry and psychological processes and examined their relationships to fear of disease. Both ancestral and psychological collectivists scored higher on a test of hypochondria than individualists. Additionally, in two studies we exposed participants to slides of diseased, injured or healthy individuals. Diseased and injured stimuli were rated as equally disgusting, while diseased stimuli were rated as more disgusting than healthy stimuli. We measured salivary IgA in participants before and after they viewed the stimuli. Participants provided information on their ancestral collectivism or individualism. Salivary IgA levels increased after participants viewed images of diseased or injured individuals. Participants with collectivist ancestry tended to react to the diseased and injured images with an increase in IgA, while levels of IgA remained the same or decreased in individualists in one study but we failed to replicate the effect in the second study. An increased salivary IgA response to potentially diseased individuals is adaptive, because salivary IgA plays an important role in protecting individuals from contracting an infection. The response may be related to increased preoccupation with disease states.

Filtration effectiveness of HVAC systems at near-roadway schools

Concern for the exposure of children attending schools located near busy roadways to toxic, traffic-related air pollutants has raised questions regarding the environmental benefits of advanced heating, ventilation, and air-conditioning (HVAC) filtration systems for near-road pollution. Levels of black carbon and gaseous pollutants were measured at three indoor classroom sites and at seven outdoor monitoring sites at Las Vegas schools. Initial HVAC filtration systems effected a 31-66% reduction in black carbon particle concentrations inside three schools compared with ambient air concentrations. After improved filtration systems were installed, black carbon particle concentrations were reduced by 74-97% inside three classrooms relative to ambient air concentrations. Average black carbon particle concentrations inside the schools with improved filtration systems were lower than typical ambient Las Vegas concentrations by 49-96%. Gaseous pollutants were higher indoors than outdoors. The higher indoor concentrations most likely originated at least partially from indoor sources, which were not targeted as part of this intervention.

PRACTICAL IMPLICATIONS

Recent literature has demonstrated adverse health effects in subjects exposed to ambient air near major roadways. Current smart growth planning and infill development often require that buildings such as schools are built near major roadways. Improving the filtration systems of a school's HVAC system was shown to decrease children's exposure to near-roadway diesel particulate matter. However, reducing exposure to the gas-phase air toxics, which primarily originated from indoor sources, may require multiple filter passes on recirculated air.

New Diarylheptanoids and a Hydroxylated Ottelione from Ottelia alismoides

Ten new diarylheptanoids (2, 3, 4, 5a-d, 6, 7, and 8) have been isolated from an extract of Ottelia alismoides. The structures of these previously unknown metabolites were determined by NMR spectroscopic analysis. A previously unknown, hydroxylated analog of the known otteliones A and B (1a and 1b)–namely, 3a-hydroxyottelione (13)–was also isolated. The 1H NMR analysis of the Mosher esters of alcohols derived from otteliones A and B (S-17/R-17 and S-20/R-20) are also reported.

New diarylheptanoids and a hydroxylated ottelione from Ottelia alismoides

Ten new diarylheptanoids (2, 3, 4, 5a-d, 6, 7, and 8) have been isolated from an extract of Ottelia alismoides. The structures of these previously unknown metabolites were determined by NMR spectroscopic analysis. A previously unknown, hydroxylated analog of the known otteliones A and B (1a and 1b)--namely, 3a-hydroxyottelione (13)--was also isolated. The 1H NMR analysis of the Mosher esters of alcohols derived from otteliones A and B (S-17/R-17 and S-20/R-20) are also reported.

Case study of empirical and computational chemical shift analyses: reassignment of the relative configuration of phomopsichalasin to that of diaporthichalasin

Phomopsichalasin was isolated and assigned structure 1 over 15 years ago. Analysis of its proton NMR data led us to hypothesize that not all aspects of the relative configuration of this structure were correct. We have used both empirical and computational methods to propose an alternative structure. Diaporthichalasin was reported several years ago, and its structure was assigned as 7, a diastereomer of structure 1, and confirmed by a single-crystal X-ray study. We have shown that diaporthichalasin and phomopsichalasin are identical; that is, both have structure 7. Additional aspects of NMR interpretation that provide guidance for avoiding some of the pitfalls that can lead to incorrect structure assignments are discussed. These recommendations/reminders include (i) the use of complementary solvents for acquiring NMR data that break accidental chemical shift degeneracy, (ii) the importance of assigning coupling constants as extensively as possible, and (iii) exercising caution when interpreting correlations in 2D spectra where overlapping resonances are involved.

Women's sexuality, well-being, and the menstrual cycle: methodological issues and their interrelationships

Although many studies report that women's sexual behavior varies across their menstrual cycles, the research findings remain inconsistent. In this study, we addressed two methodological issues in research on the menstrual cycle: how ovulation is measured/inferred and whether data using menstrual cycles or participants' scores averaged across cycles as units of analysis yield similar results. We also employed an abstinent comparison group in addition to examining how emotional well-being was related to libido and sexual behavior through factor and regression analysis. Data were obtained from 97 participants. There were no significant differences in the results of analyses performed using cycles with known LH surges to determine ovulation versus cycles based on backward counts. However, we concluded that statistical power might be compromised when the known timing of ovulation was less accurate. Likewise, we found few overall differences in the results when we analyzed data using cycles with known LH surges compared to participants' averaged data across cycles. Women, including those in the abstinent group, reported increased sexual behavior prior to ovulation. Allosexual behavior was positively related to libido, and negatively related to positive and "premenstrual" emotional factors. Autosexual behavior was predicted by libido and an energetic/creative emotional factor. Our findings support hypotheses that women's sexual behavior is related to both mating and pair-bond formation.

Cation currents in human airway epithelial cells induced by infection with influenza A virus

Influenza A viruses cause lung disease via an incompletely understood mechanism that involves the accumulation of liquid within the lungs. The accumulation of lung liquid is normally prevented by epithelial Na(+) absorption, a transport process regulated via several pathways including phosphoinositide-3-kinase (PI3K). Since the influenza A virus encodes a non-structural protein (NS1) that can activate this kinase, we now explore the effects of NS1 upon the biophysical properties of human airway epithelial cells. Transient expression of NS1 depolarized electrically isolated cells maintained in glucocorticoid-free medium by activating a cation conductance identical to the glucocorticoid-induced conductance seen in single cells. This response involved PI3K-independent and PI3K-dependent mechanisms. Infecting glucocorticoid-deprived cells with influenza A virus disrupted the normal electrical coupling between neighbouring cells, but also activated a conductance identical to that induced by NS1. This response to virus infection was only partially dependent upon NS1-mediated activation of PI3K. The presence of NS1 allows influenza A to modify the biophysical properties of infected cells by activating a Na(+)-permeable conductance. Whilst the activation of Na(+)-permeable channels may be expected to increase the rate of Na(+) absorption and thus reduce the volume of liquid in the lung, liquid does normally accumulate in influenza A-infected lungs. The overall effect of influenza A on lung liquid volume may therefore reflect a balance between the activation and inhibition of Na(+)-permeable channels.

The menstrual cycle and sexual behavior: relationship to eating, exercise, sleep, and health patterns

Patterns of eating, exercise, sleep, and health were investigated across 180 menstrual cycles of 89 women who engaged in sex with a male (n = 45; cycles = 85), a female (n = 21; cycles = 37), or abstained from sex (n = 33; cycles = 58) from January 2005 to December 2007 (10 contributed to 2 groups). Cycles were divided into 5 phases based on their luteinizing hormone surges. Daily questionnaires and saliva for IgA and cortisol analyses were obtained. Women indicated that they ate more (p < .008) and did not sleep as well (p = .02) during their luteal and premenstrual phases. Participants were less likely to experience food cravings and did not satisfy their cravings when they were ovulatory (p < .001). Additionally, a greater proportion of lesbians skipped breakfast (p = .01) and exercised less than heterosexuals (p = .05). Sexually active women had lower cortisol and IgA levels than abstinent women (p = .02). Our study discovered, and confirmed, systematic differences in eating, sleeping, and health patterns across women's menstrual cycles.

Production of a recombinant antibody fragment in whole insect larvae

Infection of insect cells with baculovirus expression constructs is commonly used to produce recombinant proteins that require post-translational modifications for their activity, such as mammalian proteins. However, technical restraints limit the capacity of insect cell-based culture systems to be scaled up to produce the large amounts of recombinant protein required for human pharmaceuticals. In this study, we designed an automated insect rearing system and whole insect baculovirus expression system (PERLXpress) for the expression and purification of recombinant proteins on a large scale. As a test model, we produced a recombinant mouse anti-botulinum antibody fragment (Fab) in Trichoplusia ni larvae. A recombinant baculovirus co-expressing the Fab heavy and light chains together with N-terminal sequences from the silkworm hormone bombyxin, to direct proteins into the secretory pathway, was constructed. Fifth instar larvae were reared and infected orally with recombinant (pre- occluded) baculovirus using the automated system and harvested approximately after 4 days. The total yield of recombinant Fab was 1.1 g/kg of larvae, resulting in 127 mg of pure Fab in one production run. The Fab was purified to homogeneity using immobilized metal affinity chromatography, gel filtration, and anion exchange chromatography. The identity of the purified protein was verified by Western blots and size-exclusion chromatography. Purified recombinant Fab was used to detect botulinum toxin in ELISA experiments, demonstrating that the heavy and light chains were properly assembled and folded into functional heterodimers. We believe that this is the first demonstration of the expression of a recombinant antibody in whole insect larvae. Our results demonstrate that a baculovirus-whole larvae expression system can be used to express functionally active recombinant Fab fragments. As the PERLXpress system is an automated and linearly scalable technology, it represents an attractive alternative to insect cell culture for the production of large amounts of human pharmaceuticals.

Using hand performance measures to predict handedness

Handedness is defined by the individual's preference to use one hand predominately for unimanual tasks and the ability to perform these tasks more efficiently with one hand (Corey, Hurley, & Foundas, 2001). It is important to use performance variables to measure handedness because they are more objective than traditional hand preference questionnaires (Bryden, Pryde, & Roy, 2000a). The current study develops a predictive model of handedness as measured by the Waterloo Handedness Questionnaire (WHQ) using several performance indicators of handedness. A total of 120 individuals (60 right-handers and 60 left-handers) were asked to complete four performance-based tasks: the Grooved Pegboard (GP), the Annett pegboard (AP), finger tapping (FT), and grip strength (GS) as well as an observational measure of preference, the Wathand Box Test (WBT). Backward linear regression analysis showed that the Wathand Box measure and the laterality quotients for several performance measures (GP place, AP, and FT) combined to act as the most accurate predictors of hand preference. The predictive model of handedness developed is as follows: WHQ = -2.760- - 0.667(GP place) + 0.809(FT) + 0.234(WBT) - 0.748(AP) with an explained variance of 0.836. These results illustrate, as Corey et al. (2001) suggested, that the best predictive model of handedness combines preference measures and several performance measures that tap into different elements of motor performance. By developing this model, it is possible to get an accurate measure of handedness using objective measures.

Expression of intermediate-conductance, Ca2+-activated K+ channel (KCNN4) in H441 human distal airway epithelial cells

Electrophysiological studies of H441 human distal airway epithelial cells showed that thapsigargin caused a Ca(2+)-dependent increase in membrane conductance (G(Tot)) and hyperpolarization of membrane potential (V(m)). These effects reflected a rapid rise in cellular K(+) conductance (G(K)) and a slow fall in amiloride-sensitive Na(+) conductance (G(Na)). The increase in G(Tot) was antagonized by Ba(2+), a nonselective K(+) channel blocker, and abolished by clotrimazole, a KCNN4 inhibitor, but unaffected by other selective K(+) channel blockers. Moreover, 1-ethyl-2-benzimidazolinone (1-EBIO), which is known to activate KCNN4, increased G(K) with no effect on G(Na). RT-PCR-based analyses confirmed expression of mRNA encoding KCNN4 and suggested that two related K(+) channels (KCNN1 and KCNMA1) were absent. Subsequent studies showed that 1-EBIO stimulates Na(+) transport in polarized monolayers without affecting intracellular Ca(2+) concentration ([Ca(2+)](i)), suggesting that the activity of KCNN4 might influence the rate of Na(+) absorption by contributing to G(K). Transient expression of KCNN4 cloned from H441 cells conferred a Ca(2+)- and 1-EBIO-sensitive K(+) conductance on Chinese hamster ovary cells, but this channel was inactive when [Ca(2+)](i) was <0.2 microM. Subsequent studies of amiloride-treated H441 cells showed that clotrimazole had no effect on V(m) despite clear depolarizations in response to increased extracellular K(+) concentration ([K(+)](o)). These findings thus indicate that KCNN4 does not contribute to V(m) in unstimulated cells. The present data thus establish that H441 cells express KCNN4 and highlight the importance of G(K) to the control of Na(+) absorption, but, because KCNN4 is quiescent in resting cells, this channel cannot contribute to resting G(K) or influence basal Na(+) absorption.

Preference and performance measures of handedness

Handedness cannot be predicted using a single performance measure, and preference measures of handedness are unreliable because of their subjectivity. This report was designed to examine the relationship between hand performance and hand preference using six different measures: the Waterloo Handedness Questionnaire (a measure of hand preference), the Wathand Box (a performance-based indicator of hand preference), two pegboard tasks, finger tapping, and grip strength and to determine the most accurate performance-based predictor of hand preference as measured by the Waterloo Handedness Questionnaire. Multiple linear regression analysis showed that together, the Wathand Box score and the lateralized place phase of the grooved pegboard task were the most accurate predictors of hand preference.

Fatal anaphylaxis following jack jumper ant sting in southern Tasmania

The "jack jumper" ant (Myrmecia pilosula) is a major cause of anaphylaxis in Tasmania. We describe four deaths attributed to stings by this ant between 1980 and 1999. All victims were men aged 40 years or over with significant comorbidities; two were taking angiotensin-converting enzyme inhibitors, which may increase risk of severe anaphylaxis. Three victims had known ant-sting allergy, but only one carried adrenaline, which he did not use. Another believed he was protected by previous attempts at hyposensitisation with whole ant-body extract. There is potential to prevent deaths by careful education of people with known allergy, prescribing of adrenaline for auto-injection and development of an effective hyposensitisation therapy.

Nothing is going to stop me now: obstacles perceived by low-income women as they become self-sufficient

As low-income women struggle to become self-sufficient, they encounter many obstacles. The literature identifies physical and mental health problems, inadequate childcare, inadequate occupational skills, lack of transportation, criminal histories, and limited educational abilities as major barriers to be overcome in this transition. Qualitative data collected from low-income women attending Innovative Alternatives for Women, an occupational skills and health information training center which was developed and implemented by a nurse, refutes several of the previously identified obstacles. Inadequate childcare and transportation were not seen as barriers to success by the program participants, but were viewed as socially acceptable reasons for not working. Eight obstacles were identified by the program participants as being the real reasons for their lack of success. The identified obstacles included the following: lack of self-esteem, especially relating to school; "bad" relationships with men; lack of support from family and friends; limited life options; lack of training for nonwelfare recipients; lack of quality programs; criminal histories; and fear of success.

Plasma alkalinization for tricyclic antidepressant toxicity: a systematic review

OBJECTIVE

To review the evidence that plasma alkalinization improves the outcome in tricyclic antidepressant toxicity.

METHODS

Medline search from 1966 to October 2000 (articles in all languages were included) and examination of bibliographies. Published papers including animal studies, in vitro studies, human case reports, case series and retrospective studies were reviewed.

RESULTS

Our search identified 115 publications, all of which were retrieved. Human studies included eight case reports, four case series, one controlled study and two retrospective chart reviews. No randomized controlled human trials were found. Twelve animal studies were identified that investigated pH manipulation or saline load and their effects on physiological parameters in tricyclic antidepressant toxicity.

CONCLUSIONS

The practice of alkalinization for tricyclic antidepressant toxicity is based on animal studies, case reports and opinion. The mechanism of action appears to be multifaceted and may vary between different tricyclic antidepressants. Significant interspecies variation makes extrapolation from animal studies to humans difficult. Alkalinization therapy appears reasonable in patients with compromising dysrhythmias and shock when supportive interventions have been ineffective; however, the available evidence does not support prophylactic alkalinization in the absence of life-threatening cardiovascular toxicity.

Effect of ambulance 12-lead ECG recording on times to hospital reperfusion in acute myocardial infarction

OBJECTIVE

To review the evidence that recording a prehospital 12-lead electrocardiogram (ECG) reduces time from hospital arrival to initiation of reperfusion therapy for acute myocardial infarction (AMI).

DATA SOURCES

Medline search from 1966 to the present (articles in all languages) and examination of bibliographies.

STUDY SELECTION

Published studies of prehospital 12-lead ECG recording that included control groups and reported time intervals from hospital arrival to start of reperfusion therapy.

DATA EXTRACTION

Eight articles satisfied selection criteria (two randomised controlled trials, four non-randomised interventional studies and two prospective observational studies).

DATA SYNTHESIS

Widely varying study methodologies precluded meta-analysis. All studies had methodological problems, but hospital delays were consistently reduced. Such improvements appear to be small in hospitals where delays are already minimal.

CONCLUSIONS

Little evidence is available to support routine prehospital 12-lead ECG recording if the median hospital time to reperfusion is already less than 30 minutes. Improvement of in-hospital treatment times may be a better initial strategy than prehospital 12-lead ECG recording, as this will benefit more patients and allow ambulance services to better allocate their available resources.

Selectivity of diadenosine polyphosphates for rat P2X receptor subunits

The pharmacological activity of diadenosine polyphosphates was investigated at three recombinant P2X receptors (rat P2X1, rat P2X3, rat P2X4) expressed in Xenopus oocytes and studied under voltage-clamp conditions. For the rat P2X1 receptor, only P1,P6-diadenosine hexaphosphate (Ap6A) was a full agonist yet 2-3 folds less potent than ATP. At rat P2X3, P1,p4-diadenosine tetraphosphate (Ap4A), P1,P5-diadenosine pentaphosphate (Ap5A) and Ap6A were full agonists and more potent than ATP. Ap4A alone was equipotent with ATP at rat P2X4, but only as a partial agonist. Compared to known data for rat P2X2 and human P2X1 receptors, our findings contrast with rat P2X2 where only Ap4A is a full agonist although four folds less potent than ATP. At rat and human orthologues of P2X1, Ap5A was a partial agonist with similar potency. These data provide a useful basis for selective agonists of P2X receptor subunits.

Enhancing early discharge with home follow-up: a pilot project

Although early hospital discharge of mothers and infants reduces health care costs, it also decreases the opportunities for women to learn the mothering role with the help of health care providers. This article describes the development of a program in which hospital staff nurses provide follow-up care to new mothers and their infants in the home. In addition, it compares the nonroutine health care expenditures in the postpartum period of mother-infant dyads receiving this service and of dyads who did not.

High-dose chemotherapy, autologous bone marrow or stem cell transplantation and post-transplant consolidation chemotherapy in patients with advanced breast cancer

This study was designed to determine the complete response (CR) rate, event-free survival (EFS) and overall survival (OS) in patients with metastatic breast cancer treated with an adriamycin-based induction regimen, high-dose chemotherapy consisting of cyclophosphamide and thiotepa with autologous bone marrow or stem cell reinfusion, followed by post-transplant 5-fluorouracil and cisplatin. Forty-eight consecutive patients were enrolled and 35 received two to four cycles of a cytoreductive chemotherapy regimen followed by high-dose chemotherapy which included cyclophosphamide and thiotepa. Thirty-three patients with non-progressive disease received at least one cycle of post-transplant 5-fluorouracil and cisplatin. Fifty percent of patients with evaluable disease responded to induction chemotherapy. Three of the 34 patients (9%) evaluable for response to high-dose chemotherapy achieved CR, eight (24%) achieved partial response (PR), 12 (35%) had stable disease (SD) and 11 (32%) had progressive disease (PD). The median time to neutrophil recovery was 11.5 days (range, 8 to 40 days) post- reinfusion. The median time to platelet independence was 14.5 days (range, 8 to 44 days). The median follow-up is 24.5 months (range, 1 to 96 months). The actuarial probability of EFS for all patients is 17% at 4 years. The EFS for patients receiving all four cycles of post-transplant chemotherapy is 27% at 4 years, compared to 36% at 1 year for patients not receiving any post-transplant chemotherapy. Ten of the 48 patients (21%) are alive, and seven of these (15%) have no evidence of disease. High-dose chemotherapy with autologous bone marrow or peripheral blood-derived stem cell transplantation followed by post-transplant consolidation chemotherapy in patients with metastatic breast cancer results in a proportion of patients without evidence of disease at 4 years.

Transrectal ultrasound guided manipulation of the canine prostate with minimum intervention

The canine prostate is a widely used and well established animal model for the assessment of therapeutic effects of laser technology in the search for better options for the treatment of benign prostatic hyperplasia. Conventionally for such experiments, the canine prostate is approached by laparotomy or transperineal urethrotomy. We have demonstrated a technique involving the use of ultrasound guided biopsy of the liver and prostate, and percutaneous laser treatment of the prostate, which has proved to be effective in reducing adverse effects on the experimental animals but without compromising scientific requirements for the experiments. We conclude that state-of-the-art percutaneous procedures not only refine animal intervention significantly but are also technically feasible for most laser studies using the canine prostate as an experimental model in the live animal.

Incorporating political socialization theory into baccalaureate nursing education

Political socialization theory explains how an individual develops a political belief system. As the health care system undergoes dramatic changes, nursing faculty should use political socialization theory to enhance the education of student nurses. A political thread can be woven through the nursing curricula, and students can be socialized to the political role. The new generation of nurses must incorporate a political component into their professional role identity. Political socialization theory can guide nursing faculty as knowledge of the political system and political skills are incorporated into nursing curricula.

Sequential changes in serum iron and ferritin in patients undergoing high-dose chemotherapy and radiation with autologous bone marrow transplantation: possible implications for treatment related toxicity

In an effort to define the pattern of iron flux during high-dose chemotherapy or chemo/radiotherapy, we prospectively measured serum iron, iron binding capacity, and ferritin in patients undergoing autologous bone marrow transplantation for various malignancies. Sequential measurement of serum iron from days -7 to +12 was carried out in 88 evaluable patients, and simultaneous measurement of iron, ferritin, and total iron binding capacity was carried out in 32 patients. We found that there was a predictable rise in serum iron on day -2 or -3, and that this was accompanied by an increase in the saturation of transferrin. In addition, there was a similar increase in serum ferritin levels, which peaked by day +2. We suggest that the timing of this change in serum iron and saturation of transferrin may be important in mediating endothelial cell damage and, hence, organ toxicity in the setting of AuBMT. Based on these findings, we suggest that large clinical studies could be a source of patient samples to measure surrogate endpoints such as lipid peroxidation products (malondialdehyde or isoprostanes), or protein oxidation products following high-dose chemo/radiotherapy to determine the role of iron in cellular injury. It is possible that pharmacological manipulations to reduce free radical production or to chelate iron during the days prior to bone marrow reinfusion might help to reduce tissue injury in the setting of bone marrow transplantation.

Competition of Li(I) and Mg(II) for ATP binding: a 31P NMR study

We have examined the changes in the 31P NMR chemical shifts of ATP in aqueous solution, upon addition of NaCl and LiCl at ambient temperature. NaCl and LiCl cause qualitatively similar downfield changes, although the effect of LiCl is somewhat larger. For a 2:1 mixture of Na-ATP or tris-ATP and MgCl2 at 0 degrees C, separate beta-P peaks are observed for uncomplexed ATP and ATP complexed with Mg(II) at 121.6 MHz. Addition of LiCl slightly shifts the uncomplexed Na-ATP or tris-ATP peak downfield but does not measurably shift the Mg-ATP peak or change relative intensities. Thus, Li behaves more like Na than Mg in its ATP complexation behavior, making this system a poor model for competition between Li and Mg for macromolecular binding.

Recanalization of tube overgrowth: a useful new indication for laser in palliation of malignant dysphagia

Overgrowth of an esophageal prosthesis by cancer is a late complication of insertion which presents a difficult management problem. We have treated 14 such patients; 9 had Celestin tubes and 5 Atkinson tubes in situ for a median of 7 months. The median patient age was 75 years; 3 had squamous cell carcinomas and 11 adenocarcinomas; 12 were at the lowest thoracic esophagus or cardia, and 2 were anastomotic. Eleven tubes were overgrown at the top, two at the bottom only, and one at both ends. Dysphagia was graded from 0 to 4 (0 = normal; 4 = dysphagia for liquids). All patients but one improved with treatment. The median pre-treatment grade was 4 (range, 2 to 4) and post-treatment was 2 (0 to 3). This improvement was significant (p less than 0.01) Wilcoxon-signal rank). Most patients required only one or two endoscopies. The median survival was 9 weeks from first laser session (range, 3 to 36 weeks). We feel these results justify laser treatment in most patients in whom cancer overgrowth causes blockage of an esophageal prosthesis.

Plasma antigen levels of the lipoprotein-associated coagulation inhibitor in patient samples

Human plasma contains an inhibitor of tissue factor-initiated coagulation known as the lipoprotein-associated coagulation inhibitor (LACI) or also known as the extrinsic pathway inhibitor (EPI). A competitive fluorescent immunoassay was developed to measure the plasma concentration of LACI in samples from normal individuals and patients with a variety of diseases. The LACI concentration in an adult control population varied from 60% to 160% of the mean with a mean value corresponding to 89 ng/mL or 2.25 nmol/L. Plasma LACI levels were not decreased in patients with severe chronic hepatic failure, warfarin therapy, primary pulmonary hypertension, thrombosis, or the lupus anticoagulant. Plasma LACI antigen was decreased in some, but not all patients with gram-negative bacteremia and evidence for disseminated intravascular coagulation. Plasma LACI levels were elevated in women undergoing the early stages of labor (29%), in patients receiving intravenous tissue-type plasminogen activator (45%), and in patients receiving intravenous heparin (375%). A radioligand blot of the pre- and post-heparin plasma samples shows the increase to be in a 40-Kd form of LACI. Very low levels of plasma LACI antigen were found in patients with homozygous abetalipoproteinemia and hypobetalipoproteinemia, diseases associated with low plasma levels of apolipoprotein B containing lipoproteins. Following the injection of heparin into one patient with homozygous abetalipoproteinemia, the plasma LACI antigen level increased to a level comparable with that in normal individuals after heparin treatment.

Concentration of vitamin B6 and activities of enzymes of B6 metabolism in the blood of alcoholic and nonalcoholic men

The purpose of this study was to compare concentrations of vitamin B6 compounds and the activities of enzymes that synthesize or catabolize pyridoxal 5'-phosphate in the plasma and erythrocytes of nonalcoholic and alcoholic subjects. Blood was obtained from male nonalcoholics and chronic alcoholics with minimal liver damage and normal hematology. Plasma, erythrocyte, and urinary B6 compounds were analyzed by high performance liquid chromatography, and pyridoxal phosphate was also measured enzymatically. Erythrocyte pyridoxine kinase and pyridoxine phosphate oxidase and erythrocyte and plasma pyridoxine phosphate phosphatases were assayed. Plasma pyridoxal phosphate concentration was significantly lower in the alcoholics (31.3 +/- 3.6 nmol/liter) than in the nonalcoholics (58.7 +/- 7.5 nmol/liter). The concentrations of the other B6 compounds in plasma, erythrocytes, and urine were not different in the two groups. Plasma alkaline pyridoxine phosphate phosphatase activity was significantly higher in the alcoholics (4.05 +/- 0.36 nmol/(h.mg] than in the nonalcoholics (3.01 +/- 0.18 nmol/(h.mg]. The activities of erythrocyte kinase, oxidase, and phosphatases were not significantly different in the two groups. The relationship of plasma pyridoxal phosphate concentration to its metabolites and the activities of the enzymes involved in its metabolism was determined. Plasma pyridoxine phosphate phosphatase activity assayed at pH 9.0 or 7.4 correlated negatively with plasma pyridoxal phosphate concentration. The low pyridoxal phosphate concentration observed in the plasma of the alcoholic subjects may in part be related to increased plasma phosphatase activity.