Using a qualitative co-design approach to identify recommendations for improving access to medication reviews for people from ethnic minority communities

Introduction

Reviews of medication are vital to support medicine effectiveness and optimise person-centred care outcomes. However, inequalities negatively impact ethnic minority populations when accessing medicine review services.1 It is important to identify opportunities to improve access for these communities. Previous studies have demonstrated the significance of overcoming accessibility barriers, but specific detail about how best to achieve this is lacking.2,3 Through co-design workshops, this study seeks to integrate the voices of those people from ethnic minority populations to gain better insight into improving access to medicines review services for ethnic minority communities.

Aim

This qualitative, person-centred co-design study sought to build greater knowledge and understanding by involving representatives from communities whose needs may remain unmet. When considering the value that medication reviews can offer in optimising a person’s medication, this study aimed to: (i) better understand existing barriers that may impact those from ethnic minority communities when accessing services and to (ii) identify measures that may facilitate improved service accessibility for these groups.

Methods

A series of co-design workshops, with four groups of patient-stakeholders, were conducted between September-November 2021; they took place in-person or via video call whilst adhering to COVID-19 restrictions. Existing evidence-based perceptions affecting access to medicines services were critiqued and recommendations were generated to improve access for ethnic minority patients. The workshops were audio-recorded and transcribed verbatim to enable thematic analysis. QSR NVivo (Version 12) facilitated data analysis. The Health Research Authority granted ethical approval (ref: 21/HRA/1426).

Results

Twelve participants were recruited: including 8 UK citizens, 2 asylum seekers and 2 participants in receipt of residency visas. In total, 4 different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and co-create recommendations. Three recommendations were developed and centred on: (i) delivering culturally competent medicines review services; (ii) building awareness of medicines review services and how to access them; and (iii) enabling better discussions with patients from ethnic minority communities.

Discussion/Conclusion

The results have important implications for overcoming ethnic inequalities in access to medicines reviews. The data highlighted the significance of raising awareness of the medicine review services and understanding each person’s lived experiences in order to address barriers that currently affect access. Delivering medication review services with cultural competency is vital; steps should be taken to address potential language barriers and build patient-provider relationships through in-person medication reviews. Collaborative co-production approaches could enable better design, implementation and delivery of medication services that are accessible and culturally competent, in order to best meet the needs of ethnic minority communities. Steps should be taken to address knowledge gaps around cultural competence training to enable the creation of pharmacies as inclusive, person-centred healthcare settings. Methods for improving person-centred communication within pharmacies should be further explored. Close, collaborative working with individual populations could enable specific tailoring of medicines review services that best meet the needs of the community. The National Institute for Health Research Applied Research Collaboration (NIHR ARC) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualisation. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and the findings were reported, with cultural competence and sensitivity.

References

1. Robinson A, et al. A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: perspectives of healthcare professionals. Health Expectations, 2021. DOI: 10.1111/hex.13410.

2. Robinson A, et al. “He or she maybe doesn’t know there is such a thing as a review”: a qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities. Health Expectations, 2022. DOI: 10.1111/hex.13482.

3. Latif A, et al. A qualitative exploration to understand access to pharmacy medication reviews: views from marginalized patient groups. Pharmacy, 2020. DOI: 10.3390/pharmacy8020073.

Mapping Local Failure Following Bladder Radiotherapy According to Dose

AIMS

To determine the relationship between local relapse following radical radiotherapy for muscle-invasive bladder cancer (MIBC) and radiation dose.

MATERIALS AND METHODS

Patients with T2-4N0-3M0 MIBC were recruited to a phase II study assessing the feasibility of intensity-modulated radiotherapy to the bladder and pelvic lymph nodes. Patients were planned to receive 64 Gy/32 fractions to the bladder tumour, 60 Gy/32 fractions to the involved pelvic nodes and 52 Gy/32 fractions to the uninvolved bladder and pelvic nodes. Pre-treatment set-up was informed by cone-beam CT. For patients who experienced local relapse, cystoscopy and imaging (CT/MRI) was used to reconstruct the relapse gross tumour volume (GTVrelapse) on the original planning CT . GTVrelapse D98% and D95% was determined by co-registering the relapse image to the planning CT utilising deformable image registration (DIR) and rigid image registration (RIR). Failure was classified into five types based on spatial and dosimetric criteria as follows: A (central high-dose failure), B (peripheral high-dose failure), C (central elective dose failure), D (peripheral elective dose failure) and E (extraneous dose failure).

RESULTS

Between June 2009 and November 2012, 38 patients were recruited. Following treatment, 18/38 (47%) patients experienced local relapse within the bladder. The median time to local relapse was 9.0 months (95% confidence interval 6.3-11.7). Seventeen of 18 patients were evaluable based on the availability of cross-sectional relapse imaging. A significant difference between DIR and RIR methods was seen. With the DIR approach, the median GTVrelapse D98% and D95% was 97% and 98% of prescribed dose, respectively. Eleven of 17 (65%) patients experienced type A failure and 6/17 (35%) patients type B failure. No patients had type C, D or E failure. MIBC failure occurred in 10/17 (59%) relapsed patients; of those, 7/11 (64%) had type A failure and 3/6 (50%) had type B failure. Non-MIBC failure occurred in 7/17 (41%) patients; 4/11 (36%) with type A failure and 3/6 (50%) with type B failure.

CONCLUSION

Relapse following radiotherapy occurred within close proximity to the original bladder tumour volume and within the planned high-dose region, suggesting possible biological causes for failure. We advise caution when considering margin reduction for future reduced high-dose radiation volume or partial bladder radiotherapy protocols.

Contributions of GeneXpert® to TB diagnosis in Myanmar

BACKGROUND: Xpert^® MTB/RIF, a rapid, molecular TB diagnostic assay, can detect Mycobacterium tuberculosis and rifampin resistance directly from clinical sputum samples in <2 h with high sensitivity and specificity. The added diagnostic value of Xpert over smear microscopy at a national level in Myanmar has not been previously reported.METHODS: We evaluated 339,358 Xpert and demographic records captured from January 2015 to December 2018 as part of the Myanmar National TB Program Data Utilization and Connectivity Project to examine the additional diagnostic yield of Xpert relative to smear for the detection of M. tuberculosis for TB diagnosis in Myanmar, with a focus on people living with HIV (PLHIV) and sample type.RESULTS: Use of Xpert increased TB case detection by 40% compared to smear microscopy results. Among PLHIV, use of Xpert increased TB case detection by almost 100% compared to smear microscopy results.CONCLUSION: Xpert testing identified more patients with TB than smear microscopy alone, particularly in cohorts with significant proportions of PLHIV. The use of Xpert as a screening tool in countries with a high burden of TB could lead to significantly increased diagnosis of TB at a regional and national level.

A randomized controlled trial to assess the influence of a picture-based antiemetic medication calendar on medication-taking behavior in adults receiving chemotherapy

OBJECTIVE

A prospective open-label randomized controlled trial to assess the role of a picture-based medication calendar on adherence to antiemetic regimens for adult patients receiving chemotherapy and assess the effect on other medication taking behaviors as well as patient satisfaction with the tool.

METHODS

Participants were randomly assigned 1:1 to routine care with or without calendar.

RESULTS

Adherence, stratified by education (university or postgraduate, p = 0.09; grade school, high school or college p = 0.32), was non-significantly different between study arms. At least 70% of intervention arm participants moderately or completely agreed that the calendar helped with medication taking behaviors. There was no statistical difference between study arms for perceived regimen complexity (p = 0.16). Medication Use and Self Efficacy score (adjusted for age) used to assess perceived self-efficacy with medication taking behaviors were not statistically significant between study arms (p = 0.09).

CONCLUSION

The picture-based medication calendar did not statistically affect adherence to scheduled antiemetics among outpatients receiving chemotherapy for solid organ tumor origins. However, participants indicated that the calendar was effective for keeping track of medications, had an easy-to-understand layout, and provided help around when and how to take medications related to the oncology regimen.

The Intensity-Modulated Pelvic Node and Bladder Radiotherapy (IMPART) Trial: A Phase II Single-Centre Prospective Study

AIMS

Node-positive bladder cancer (NPBC) carries a poor prognosis and has traditionally been treated palliatively. However, surgical series suggest that a subset of NPBC patients can achieve long-term control after cystectomy and lymph node dissection. There is little published data regarding the use of radiotherapy to treat NPBC patients. This is in part due to concerns regarding the toxicity of whole-pelvis radiotherapy using conventional techniques. We hypothesised that, using intensity-modulated radiotherapy (IMRT), the pelvic nodes and bladder could be treated within a radical treatment volume with acceptable toxicity profiles.

MATERIALS AND METHODS

The Intensity-modulated Pelvic Node and Bladder Radiotherapy (IMPART) trial was a phase II single-centre prospective study designed to assess the feasibility of delivering IMRT to treat the bladder and pelvic nodes in patients with node-positive or high-risk node-negative bladder cancer (NNBC). The primary end point was meeting predetermined dose constraints. Secondary end points included acute and late toxicity, pelvic relapse-free survival and overall survival.

RESULTS

In total, 38 patients were recruited and treated between June 2009 and November 2012; 22/38 (58%) had NPBC; 31/38 (81.6%) received neoadjuvant chemotherapy; 18/38 (47%) received concurrent chemotherapy; 37/38 (97%) patients had radiotherapy planned as per protocol. Grade 3 gastrointestinal and genitourinary acute toxicity rates were 5.4 and 20.6%, respectively. At 1 year, the grade 3 late toxicity rate was 5%; 1-, 2- and 5-year pelvic relapse-free survival rates were 55, 37 and 26%, respectively. The median overall survival was 1.9 years (95% confidence interval 1.1-3.8) with 1-, 2- and 5-year overall survival rates of 68, 50 and 34%, respectively.

CONCLUSION

Delivering IMRT to the bladder and pelvic nodes in NPBC and high-risk NNBC is feasible, with low toxicity and low pelvic nodal recurrence rates. Long-term control seems to be achievable in a subset of patients. However, relapse patterns suggest that strategies targeting both local recurrence and the development of distant metastases are required to improve patient outcomes.

1143. Measuring Up! Benchmarking Antimicrobial Use in Canadian Children’s Hospitals

Background

Inappropriate antimicrobial use (AU) is recognized as a leading cause of antimicrobial resistance. However, quantifying AU in hospitals is challenging due to variability in information systems. Point prevalence surveys (PPS) provide a means to quantify AU in a cross-sectional manner within and between institutions. The aim of the study was to describe and compare the prescription patterns of AU across pediatric hospitals in Canada using PPS.

Methods

Two PPS (November 2018 and February 2019) were conducted at each of the 15 Canadian pediatric hospitals. For each PPS, AU data were collected for all inpatients ≤ 18 years (excluded mental health and birthing units) on the survey date. Data, including admitting diagnosis, age, comorbidities, Infectious Diseases consult, admitting service, documented pathogen(s), and antimicrobial(s) prescribed, was collected and entered into a RedCap database.

Results

In total, we surveyed 3826 patient-days. The mean proportion of children receiving at least one antimicrobial was 35.2% [range 25.1% to 42.9%]. Of the 1951 antimicrobials prescribed, the most common were third-generation cephalosporins [3GC] (16%; 321), aminopenicillins (15%; 297), TMP-SMX (11%; 207), piperacillin–tazobactam (10%; 193) and first-generation cephalosporins (9%; 181). Overall, the frequency of carbapenems, quinolones and vancomycin use was 4% (79), 3% (65) and 8% (151), respectively. Of the antimicrobials used for targeted or empiric therapy (n = 1541), 373 (24.2%) were for pneumonia, 278 (18%) for intra-abdominal infections and 251 (16.3%) for fever without a source. For the treatment of community-acquired pneumonia (CAP) (n = 178), aminopenicillins and 3GC use was 31% and 37%, respectively.

Conclusion

Our study used a standardized approach to assess AU to obtain benchmarking data for Canadian pediatric hospitals. About one-third of children hospitalized in Canadian pediatric hospitals are prescribed at least one antimicrobial. Of patients on treatment for CAP, only 31% were prescribed aminopenicillins. More detailed analysis of the rationale for AU, and assessment of appropriateness is required to fully understand antimicrobial prescribing practices in pediatric hospitals and develop stewardship initiatives.

Disclosures

All authors: No reported disclosures.

What the public think about participation in medical research during an influenza pandemic: an international cross-sectional survey

OBJECTIVES

The public and patients are primary contributors and beneficiaries of pandemic-relevant clinical research. However, their views on research participation during a pandemic have not been systematically studied. We aimed to understand public views regarding participation in clinical research during a hypothetical influenza pandemic.

STUDY DESIGN

This is an international cross-sectional survey.

METHODS

We surveyed the views of nationally representative samples of people in Belgium, Poland, Spain, Ireland, the United Kingdom, Canada, Australia and New Zealand, using a scenario-based instrument during the 2017 regional influenza season. Descriptive and regression analyses were conducted.

RESULTS

Of the 6804 respondents, 5572 (81.8%) thought pandemic-relevant research was important, and 5089 (74.8%) thought 'special rules' should be applied to make this research feasible. The respondents indicated willingness to take part in lower risk (4715, 69.3%) and higher risk (3585, 52.7%) primary care and lower risk (4780, 70.3%) and higher risk (4113, 60.4%) intensive care unit (ICU) study scenarios. For primary care studies, most (3972, 58.4%) participants preferred standard enrolment procedures such as prospective written informed consent, but 2327 (34.2%) thought simplified procedures would be acceptable. For ICU studies, 2800 (41.2%) preferred deferred consent, and 2623 (38.6%) preferred prospective third-party consent. Greater knowledge about pandemics, trust in a health professional, trust in the government, therapeutic misconception and having had ICU experience as a patient or carer predicted increased willingness to participate in pandemic-relevant research.

CONCLUSIONS

Our study indicates current public support for pandemic-relevant clinical research. Tailored information and initiatives to advance research literacy and maintain trust are required to support pandemic-relevant research participation and engagement.

Anxiety and anxious-depression in Parkinson's disease over a 4-year period: a latent transition analysis

BACKGROUND

Depression and anxiety in Parkinson's disease are common and frequently co-morbid, with significant impact on health outcome. Nevertheless, management is complex and often suboptimal. The existence of clinical subtypes would support stratified approaches in both research and treatment.

METHOD

Five hundred and thirteen patients with Parkinson's disease were assessed annually for up to 4 years. Latent transition analysis (LTA) was used to identify classes that may conform to clinically meaningful subgroups, transitions between those classes over time, and baseline clinical and demographic features that predict common trajectories.

RESULTS

In total, 64.1% of the sample remained in the study at year 4. LTA identified four classes, a 'Psychologically healthy' class (approximately 50%), and three classes associated with psychological distress: one with moderate anxiety alone (approximately 20%), and two with moderate levels of depression plus moderate or severe anxiety. Class membership tended to be stable across years, with only about 15% of individuals transitioning between the healthy class and one of the distress classes. Stable distress was predicted by higher baseline depression and psychiatric history and younger age of onset of Parkinson's disease. Those with younger age of onset were also more likely to become distressed over the course of the study.

CONCLUSIONS

Psychopathology was characterized by relatively stable anxiety or anxious-depression over the 4-year period. Anxiety, with or without depression, appears to be the prominent psychopathological phenotype in Parkinson's disease suggesting a pressing need to understanding its mechanisms and improve management.

Parents of children with neurogenic bowel dysfunction: their experiences of using transanal irrigation with their child

BACKGROUND

Neurogenic bowel dysfunction in children is a lifelong condition often resulting in the need for active bowel management programmes, such as transanal irrigation. Parents are central in the decision-making process to initiate and carry out treatments until such a time their child becomes independent. Minimal research has focussed on examining parents' experiences of undertaking transanal irrigation with their child. This study aimed to explore parents' experiences of learning about and using irrigation with their child and how parents motivated their children to become independent.

METHODS

Semi-structured telephone interviews were conducted with parents with experience of using transanal irrigation with their child. Interviews were undertaken by a parent researcher. Data were analysed using qualitative content analysis.

RESULTS

Eighteen telephone interviews (16 mothers, 1 father and 1 carer) were conducted. Parents shared how they had negotiated getting started and using transanal irrigation with their child. They discussed a sense of success derived from their confidence in using and mastering irrigation, the process of making decisions to continue or stop using irrigation and how they motivated themselves and their child to continue with the irrigation regime. Challenges included minimizing their child's distress during the irrigation procedure and how they negotiated and moved towards their child becoming independent.

CONCLUSION

Despite the emotional difficulty parents experienced as a result of the invasive nature of transanal irrigation most parents reported an improvement in their child's faecal continence which positively impacted on the child and family's lives. The child's physical ability and emotional readiness to develop independent irrigation skills in the future concerned some parents. The experiences shared by parents in this study has the capacity to inform transanal irrigation nursing and medical care.

A population-based study of prostate cancer chemotherapy

The use of chemotherapy in the treatment of prostate cancer is a relatively recent development, with no published data on the patterns of care in the UK. We carried out a population-based study to assess variation in the use of prostate cancer chemotherapy over time in a UK cancer network.

Late CT surveillance in nonseminoma germ cell tumors (NSGCT)

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Background: Testicular cancer is the commonest solid malignancy in 18-35 year old men. With the introduction of cisplatin, most patients with metastatic disease are cured.Over recent years a risk of late relapse (>2 years after first line therapy) has been recognised in 2- 6% of NSGCTs. Appropriate follow-up strategies have not been determined. To investigate, the utility of long term CT surveillance we initiated a study to see if late CT could detect late relapses at an early stage.

Methods: Eligible patients had been treated for Stage IM – Stage IV NSGCT diagnosed 5 years prior to entry. CT scans were at study entry and 5 years. Patients are reviewed annually with tumour markers and clinical examination. We plan to recruit 300 patients. This reports details the outcome of a planned interim analysis of the first round of screening after recruiting 100 patients

Results: 108 patients have been enrolled into the study since 2006. Full clinical data was available for 88 patients. Median age was 31 years at diagnosis. 52 patients had evidence of teratoma differentiated (TD) in the primary.Stage at treatment was IM (1), II (45), III (6) and IV (36). Treatment was BEP [bleomycin, cisplatin and etopside (3 cycles: 30), (4 cycles: 20)], CBOP/BEP (16) and other platinum schedule (8) at diagnosis. 27 patients relapsed.Overall 38 had retroperitoneal lymph node.TD noted in 28. 10 had a metastatectomy [brain (2), pelvic mass (1:TD), pulmonary (6;TD:2), neck (2), iliac node (1:TD)]. Study scan was reported normal in 71 patients. None of these have relapsed however 1 patient died of interval lung cancer. Radiological abnormalities were identified in14 patients. 4 underwent surgery (3 RPLND and 1 lung nodule excision). 2 were benign and 2 had TD.1 patient had liver lesions proven to be cysts on ultrasound. 8 had small volume nodal abnormalities which are stable on repeat imaging. 1 is on annual CT surveillance for indeterminate lung nodules.4 patients are awaiting the initial study scan

Conclusions: Late CT scan detected significant abnormalities in patients treated for NSGCT leading to surgery. Abnormalities not deemed appropriate for surgical intervention are being followed up surveillance scans.

No significant financial relationships to disclose.

Adaptive-predictive organ localization (a-POLO) in the clinic: Updated results in hypofractionated bladder radiotherapy

282

Background: The A-POLO strategy allows the optimal 'plan of the day' to be selected online for radiotherapy (RT) delivery. The methodology is implemented in a phase II study of patients with muscle-invasive bladder cancer who are not suitable for cystectomy/daily RT and are receiving hypofractionated RT.

Methods: Planning scans were performed at 0 and 30 minutes post void (CT0 and CT30). Three conformal plans were created (small, intermediate, large) ( Table ). Patients were prescribed 6Gy weekly for 5–6 weeks. A pre-RT cone beam CT (CBCT) scan and online set-up correction were performed. The plan giving the optimal target coverage was selected by 2 observers. Offline plan selection was also carried out by an independent observer. A post-RT CBCT was acquired to calculate the percentage of the CTV covered by 95% of the dose (V95). The mean A- POLO volume was compared to our previous institutional standard PTV (1.5cm isotropic margins) (PTViso). Outcome data were collected.

Results: A total of 77 RT fractions were delivered to 14 patients. The small plan was delivered for 38 (49%) fractions and the large for 6 (8%) fractions. The concordance rate between online and offline plan selection was 71/77 (92%). The mean CTV V95 was 99% (patient mean range 97–100%). The mean time between the pre- and post-treatment CBCT was 15 minutes. The mean reduction between PTViso and mean A-POLO PTV was 42% (range 16– 59%). 2 patients had grade (G) 3 (CTCv3.0) treatment-related acute toxicity. There have been no treatment-related G4 acute or G3 late toxicities. With a median follow-up of 7.3 months 10 patients are alive with 8 disease free (1 local and 1 distant relapse).

Conclusions: Implementation of A-POLO RT is feasible, well tolerated, and associated with good concordance in 'plan of the day' selection. An individualized treatment plan can be delivered with each fraction to achieve a reduction in PTV compared to PTViso with maintenance of target coverage.

[Table: see text]

No significant financial relationships to disclose.

Planning outcomes and acute toxicity of intensity-modulated radiotherapy (IMRT) for treatment of bladder and pelvic lymph nodes

297

Background: We implemented an IMRT protocol for simultaneous treatment of bladder and pelvic lymph nodes (LN) and report the planning outcomes and acute toxicity of patients treated using this technique.

Methods: 13 patients were treated with a 5-field step and shoot IMRT technique. Inclusion criteria were: radiological evidence of pelvic LN metastases; stage T3/T4; high risk pathology or post-cystectomy with persistent/recurrent disease. Anisotropic margins were applied to the whole bladder CTV (0.5 cm laterally/inferiorly, 1 cm posteriorly, 1.5 cm superiorly/anteriorly) to create PTV1. 0.5 cm margins were applied to the pelvic LN CTV to create PTV2. PTVs 1/2 were prescribed 52 Gy in 32 fractions. 1 cm margins were applied to the involved bladder to create PTV3 (prescribed 64Gy). 0.5 cm margins were applied to the involved LN volumes to create PTV4 (prescribed 60 Gy). Post cystectomy patients were planned using PTVs 2/4 only. Dose volume histograms for organs at risk (rectum, femoral heads and other bowel) were calculated and compared with local dose constraints. Acute toxicity was assessed according to common toxicity criteria v3.0 and recorded weekly during treatment. Treatment verification was performed by cone beam CT.

Results: All treatment plans achieved target coverage of > 95% volume to > 95% prescription dose for each PTV. All patients achieved rectal and femoral head dose constraints. 2 patients did not meet V45 other bowel constraints but proceeded with treatment as all other dose limits were achieved. At the time of abstract submission 13 patients had completed treatment. 2 were treated for relapse post-cystectomy and did not have GU toxicities recorded. Maximum experienced acute toxicities were recorded. 9/11 patients experienced acute GU toxicity (G1=3, G2=1, G3=5). 6/13 patients experienced acute GI toxicity (G1=3, G2=3). 9/13 patients developed other acute toxicities (G1=7, G2=2). No patients developed ≥G3 non-GU toxicity.

Conclusions: Bladder and pelvic LN IMRT allows patients with high risk locoregional bladder cancer to meet preset dose constraints, appears feasible and has a comparable rate of acute toxicity to conventional bladder-only radiotherapy treatment.

No significant financial relationships to disclose.

Chemokine receptor 5 (CCR5) deletion polymorphism in North Indian patients with coronary artery disease

BACKGROUND

Polymorphisms in genes coding for chemokine receptors, CCR2 and CCR5 have been studied as genetic markers of coronary artery disease (CAD). V64Ile polymorphism in CCR2 has been implicated in the manifestation of myocardial infarction in different populations, but data on association of the CCR5 deletion variant in etiology of CAD are conflicting. In the present study we tested genetic association between CCR5 Delta32 polymorphism and CAD among North Indians (Uttar Pradesh).

METHODS

Two hundred angiographically proven patients with coronary artery disease and two hundred age, sex and ethnically matched controls were genotyped for CCR5 Delta32 polymorphism by polymerase chain reaction. Genotype/allele frequencies were compared in patients and controls using the chi-square test.

RESULTS

The frequency of the heterozygote genotype in the population, including both patient and control group, was 3% and the frequency of the mutant allele Delta32 was 1.5%. CAD patients had a three times higher (4.6% vs. 1.5%) frequency of heterozygote genotype but the differences were statistically not significant. Association analysis did not achieve statistical significance, though odds ratio of 3.13 was observed for heterozygote genotype.

CONCLUSIONS

The allele frequency of the CCR5 Delta32 polymorphism in CAD patients is 2.25% and 0.75% among controls but the differences were not significant. Overall this fits well with the pattern of CCR5 Delta32 allele frequency in Indian subcontinent where it varies from 1 to 3%. The heterozygote (+/ Delta32) genotype does not seem to have any protective role against development of CAD in this population. In fact, North Indian CAD had a higher frequency of CCR5 Delta32 allele suggesting a possible susceptibility trend (odds ratio 3.08, CI 0.83-11.46, chi-square 2.167, NS).

Why breast feeding fails

Vanessa is a 34-year-old lawyer married to a police officer. Her first baby was born after a perfect pregnancy and labour until fetal distress necessitated an easy Ventouse extraction late in the second stage. Baby F had normal Apgar scores and weighed 2920 g. This paper records a conversation between Vanessa (V) and her father (F) about breast feeding.

Selection of novel ligands from a whole-molecule randomly mutated C5a library

Novel antagonists of the proinflammatory leukocyte chemoattractant C5a have been produced from a phage display library of whole-molecule random mutants. The cDNA for the inflammatory polypeptide C5adR(74) was used as template in a PCR reaction doped with the mutagenic nucleoside triphosphates dPTP [dP: 6-(2-deoxy-beta-D-ribofuranosyl)-3,4-dihydro-8H-pyrimido-[4,5-c][1,2]oxazin-7-one] and 8-oxodGTP (8-oxodG: 8-oxo-2'-deoxyguanosine) to allow the introduction of mutations in a highly controlled manner throughout the cDNA. The resultant library of mutants was displayed on bacteriophage M13 using a jun/fos linker sequence. Functional polypeptides were isolated by several rounds of selection against the receptor for C5a expressed on the surface of CHO cells. From this selection procedure, a limited number of variants of C5adR(74) were obtained. When expressed as free polypeptide, the binding affinities of the selected C5adR(74) sequences were increased 5-fold relative to wild-type protein. Site-directed mutagenesis of the C-terminus of these variants resulted in the production of antagonists of C5adR(74) activity.

A 2-year follow-up of the effectiveness of traditional child psychotherapy

This study examined outcomes at a 2-year follow-up assessment for child psychotherapy as it typically is delivered in outpatient settings. The treatment condition (53 children, mean age = 10.5 years) and control condition (53 children, mean age = 10.0 years) were compared with regard to rates of linear and curvilinear change for psychopathology, adaptive functioning, and consumer satisfaction. Although both conditions showed curvilinear as well as linear improvement in behavioral and emotional problems, relatively little support was found for the effectiveness of traditional child psychotherapy or for the presence of a psychotherapy "sleeper effect."

Analysis of receptor/ligand interactions using whole-molecule randomly-mutated ligand libraries

We report a novel method for the analysis of protein ligands using a whole molecule mutagenesis/phage display system. The cDNA for the inflammatory polypeptide C5a was used as template in a PCR reaction doped with mutagenic nucleoside triphosphates (dP and 8-oxo-2'deoxyguanosine (8-oxodG)) to allow introduction of mutations in a highly controlled manner throughout the cDNA. The resultant library of mutants was displayed on the surface of phage and functional polypeptides were selected by several rounds of selection against the cells bearing the receptor for C5a. Following selection only a limited number of residues in C5a were found to be mutated, suggesting that mutations in key residues involved in the maintenance of structure and in receptor binding had been eliminated. The selected C5a sequences had a higher affinity for receptor than wild type phage-C5a conjugates. As this method for analysing the functional characteristics of proteins does not rely on knowledge a priori of structure, it may be useful for affinity maturation or analysis in a wide range of protein ligand/receptor systems.

Rising incidence of prostate cancer in Scotland: increased risk or increased detection?

OBJECTIVE

To assess the extent to which the increasing incidence of prostate cancer in Scotland can be explained by increased detection, particularly through transurethral resection of the prostate (TURP) and use of the prostate-specific antigen (PSA) test. Subjects and methods This population-based study was confined to men resident in Scotland and aged > or =50 years. Temporal trends were examined in age-specific and age-standardized incidence, mortality and TURP rates, and PSA testing rates during 1981-1996. Also analysed were the geographical variations in age-standardized incidence and mortality rates during two distinct periods, 1984-1986 (before PSA testing) and 1994-1996 (after PSA testing). Finally, incidence rates and relative survival at 5 years were calculated by age group and 5-year periods of diagnosis during 1968-1992.

RESULTS

The incidence of prostate cancer in men aged > or = 50 years increased from an age-standardized rate of 142.0 per 100 000 in 1981 to 240.9 in 1996, with the steepest increase occurring between 1992 and 1993. The mortality rate increased similarly until 1993, but was relatively stable thereafter, falling slightly in 1996. In 1981-1988, incidence rates were closely correlated with TURP rates (r = 0.98, P<0.001). In 1989-1996, incidence was closely correlated with PSA testing rates (r = 0.98, P<0.001). By 1994-1996, incidence rates varied substantially between Scottish mainland health boards (range 167.7-303.0 per 100 000), with much less variation in mortality rates (90.7-110.0). Relative survival has increased recently in all age groups although, in the era before PSA testing, survival was reasonably stable despite increasing incidence.

CONCLUSION

Although there may have been a true increase in risk, much of the observed increase in the incidence of prostate cancer in Scotland between 1981 and 1996 has been caused by increased detection, leading recently to considerable variation among different areas of the country. The extent to which this represents the early diagnosis of tumours which would eventually cause symptoms or be life-threatening, or detection of latent disease which would never have become symptomatic, is not clear. There is no evidence so far that the increased incidence is associated with any substantial reduction in mortality.

Ionizing radiation stimulates octamer factor DNA binding activity in human carcinoma cells

In mammalian cells, the octamer motif (ATGCAAAT) binding proteins, Oct-1 and Oct-2, play an important role in the transcriptional transactivation of several ubiquitously expressed genes as well as cell-specifically expressed genes. To date, a role of the octamer binding proteins in damage-stimulated response is not known. In this report, we demonstrate that DNA-binding activity of Oct-1, as demonstrated by the electrophoretic mobility shift assay, is significantly induced in a dose-dependent manner upon treatment of human head and neck squamous carcinoma cells (PCI-04A) with ionizing radiation (5 Gy: 5-fold; 15 Gy: 11-fold). By comparison, activities of other transcription factors were modestly increased (15 Gy: AP-1, 2.5-fold; NF-kappaB, 2.6-fold; SP-1, 5-fold). Radiation stimulation of Oct-1 activity was also noted in two other human cancer cell lines, albeit to a lesser extent (MDA-MB231 breast carcinoma cells and PC-3 prostate carcinoma cells (5 Gy: approximately 2-fold). These data represent the first report of the activation of an octamer factor DNA binding activity in response to environmental cues and suggest a novel role of Oct-1 in the radiation signaling cascade in these cancer cells.

Epidemiology of Kaposi's sarcoma in Scotland, 1976-1996

Based on data from the Scottish Cancer Registry, the epidemiology of Kaposi's sarcoma (KS) in Scotland during the period 1976-96 is described. In males, the annual age-standardized incidence rate (World standard population) increased from less than 0.09 per 100,000 before 1986 to 0.44 in 1991 and then decreased to around 0.17. Peak incidence is now at ages 30-39 compared with ages 80+ during the period 1976-82; and by 1986-96 the standardized incidence ratio for the Health Board which includes Edinburgh had risen to almost four times the national level. These changes are largely consistent with the pattern of HIV infection in Scotland. However, in both sexes, relative to other neoplasms, and in international terms, KS remains rare in Scotland. For patients diagnosed during 1976-92, cumulative observed survival at 5 years was 8.7% at ages 0-49 compared with 49.8% at ages 50-84, reflecting the more aggressive course of AIDS-related KS, as well as the co-morbidity and competing causes of death associated with AIDS.

The effectiveness of traditional child psychotherapy

This study used a randomized design to evaluate the effectiveness of child psychotherapy as typically delivered in outpatient settings. Overall results were similar to the results of nonrandomized studies of traditional child psychotherapy: Little support was found for its effectiveness, with treatment producing an overall effect size of -.08. Despite the lack of significant differences between treatment and control groups in regard to changes in child functioning, parents of children who received treatment reported higher levels of satisfaction with services than control group parents whose children received academic tutoring. Overall, the findings highlight the importance of developing, validating, and transporting effective treatments to clinical settings.

The effectiveness of traditional child psychotherapy

This study used a randomized design to evaluate the effectiveness of child psychotherapy as typically delivered in outpatient settings. Overall results were similar to the results of nonrandomized studies of traditional child psychotherapy: Little support was found for its effectiveness, with treatment producing an overall effect size of -.08. Despite the lack of significant differences between treatment and control groups in regard to changes in child functioning, parents of children who received treatment reported higher levels of satisfaction with services than control group parents whose children received academic tutoring. Overall, the findings highlight the importance of developing, validating, and transporting effective treatments to clinical settings.

Cryptococcal rib osteomyelitis in a pediatric patient

A case of cryptococcal rib osteomyelitis in a pediatric patient is described. Isolated cryptococcal osteomyelitis in pediatric patients is a rare entity, and only 10 cases have been reported in the literature. The radiological findings are reviewed to include chest films, nuclear bone scan, and computed tomographic imaging scan. Because of its rarity, the management of isolated cryptococcal osteomyelitis is controversial. Although antifungal antibiotics and surgery are the two therapeutic options, the treatment of cryptococcal osteomyelitis has not been standardized yet. This patient was treated successfully with limited resection of the involved rib and antifungal chemotherapy. This article describes the second case in the literature of cryptococcal rib osteomyelitis in a pediatric patient, reviews the literature of similar cases, and evaluates the current role of surgery in its treatment.

Rearrest among mentally ill offenders

The importance of criminal recidivism among mentally ill offenders lies in resource allocation and community services for the mentally ill. It has been suggested that jails are used, in part, simply to house the mentally ill. The objective of this study is to determine whether mentally ill criminal offenders have higher rates of rearrest than non-mentally ill offenders. A sample of mentally ill offenders (n = 127) was drawn at random from all admissions to the psychiatric unit at the King County Jail in Seattle, Washington, in 1990. They were compared with a sample (n = 127) of non-mentally ill offenders also jailed in King County during 1990; the two groups were frequency matched on age, gender, and crime at index arrest. Both groups were followed for up to four years to until the next arrest. After 12 months, 54.3 percent of the mentally ill group and 51.2 percent of the non-mentally ill group were rearrested. Using the log rank test in Kaplan-Meier survival analysis, no statistical difference in the relative risk of rearrest occurred for the mentally ill group (relative risk = .84; 95% CI = .84-1.34). Adjustment for housing, marital status, and previous criminal history had little effect on this finding. The presence of substance abuse or psychosis at the index arrest did not affect rearrest significantly. Mentally ill offenders, as a whole, may not be at increased risk for rearrest. However, there may be specific high-risk subgroups that can benefit from early intervention.

Expression of a binding protein for FGF is associated with epithelial development and skin carcinogenesis

Fibroblast growth factors (FGF)-1 and -2 are found in most embryonic and adult normal and tumor tissues, where they are immobilized in the extracellular matrix (EM). Mobilization of these FGFs is part of a tightly controlled process resulting in the activation of high-affinity receptors. Recently, we have shown that a novel human FGF-binding protein (FGF-BP) mediates the release of immobilized FGF-2 from the EM. Here we isolated genomic and cDNA clones of the mouse FGF-BP homologue and studied its expression during embryonic development and skin carcinogenesis. The murine gene contains two exons that generate a 1.2 kb mRNA and predicts an 18 kDa secreted protein that is 63% identical to its human homologue. FGF-BP mRNA expression during embryogenesis is restricted to skin, intestine and lung. In the developing skin, FGF-BP expression starts at embryonic day 9, reaches peak levels perinatally and is downregulated during postnatal development. Development regulation in the intestine is similar, but in lungs and ovaries high expression was also observed in the adult. FGF-BP mRNA expression in the adult skin is dramatically increased during early stages of carcinogen-induced transformation in vivo and by ras-activation in vitro. Finally, mouse FGF-BP binds to FGF-2 and can function as a modulator of FGF in FGF-responsive cells. Our results suggest a potential function of FGF-BP during development and tumorigenesis.

Gene transfer by adenovirus in smooth muscle cells

We report adenovirus-mediated gene transfer into airway smooth muscle cells in cultured cells and organ-cultured tracheal segments. Incubation of cultured rat tracheal myocytes with virus (5 x 10(8) pfu/ml) for 6 h resulted in beta-galactosidase expression in 94.8 +/- 2.5% of cells (n = 4). Following incubation of thin (less than 200 microns diameter) equine trachealis muscle segments with virus in organ culture (5 x 10(8)-5 x 10(10) pfu/ml) the average expression of the Lac Z gene was approximately 19 +/- 10% (n = 9). Expression was markedly improved, however, in segments from neonatal rats (13-21 days). In two experiments in which the mucosa and serosa were removed, nearly all cells expressed beta-galactosidase, whereas in a third experiment in which the tissue was not dissected, about 40% of cells were stained. Viral infection had no effect on tension development of strips following organ culture. In vitro gene transfer may provide a useful method to alter protein expression and examine the effect of this alteration on excitation/contraction coupling in smooth muscle.

A transactivator of c-myc is coordinately regulated with the proto-oncogene during cellular growth

A recently cloned nuclear protein, which binds a far upstream element (FUSE) of the human c-myc proto-oncogene, stimulates promoter driven expression in undifferentiated cells. In concert with a loss of c-myc expression, both FUSE binding protein (FBP) mRNA and protein levels disappeared in HL60 cells after PMA-induced differentiation, due to a drop in the rate of transcription that was measured by nuclear runoff. During the differentiation of these cells, the brief half-lives of FBP mRNA (3 h) and protein (1.5 h) did not change, allowing for the rapid down-regulation of nuclear protein levels, as detected by immunohistochemical staining. Like c-myc, FBP is expressed in proliferating cells from a variety of lineages, but not in quiescent cells. When T cells and fibroblasts were stimulated to transit from G0 into the cell cycle, there was a dramatic rise of both FBP mRNA and DNA sequence specific nuclear FBP binding activity, which correlated with the appearance of c-myc mRNA. In contrast to the transient expression of many other immediate early growth response genes, both FBP and c-myc expression were sustained for more than 24 h. In fibroblasts, the coordinate expression of FBP and c-myc throughout all phases of the cell cycle is consistent with FBP's role as a growth-dependent regulator of c-myc expression.

Targeted melting and binding of a DNA regulatory element by a transactivator of c-myc

A far upstream element (FUSE) of c-myc stimulates promoter activity when bound by a newly identified trans-acting protein, which is expressed in cycling cells. Since FUSE binding protein (FBP) binds only the noncoding strand (NCS) of its regulatory element in a sequence-specific manner, and not double-stranded (ds) DNA, formation of the protein DNA complex in vivo first requires unwinding of the DNA helix. In this report, we show evidence that FBP forces strand separation of short stretches of linear dsDNA. Because FUSE is contained within a region of helical instability that is partially unwound in negatively supercoiled DNA, it is a target for more extensive duplex strand separation by FBP, which first exposes and then selectively binds its NCS cognate sequence. In contrast, other single-stranded DNA binding proteins (SSBs) do not demonstrate this FUSE targeting activity. The novel linkage of regional dsDNA melting with cis-element binding by a transcriptional activator has broad implications in the regulation of eukaryotic gene expression.

Steam press burns of the hand

Steam presses pose an occupational hazard to workers in the dry cleaning industry. Three patients with thermal burns to the hand from steam press accidents were recently treated at this institution. Each patient sustained deep second and third degree burns to the dorsum of the hand. Two patients required split-thickness skin grafts and have retained full range of motion and returned to full employment. One patient sustained destruction of extensor tendons and required a groin flap for coverage. Late tendon reconstruction will be necessary. Investigation revealed that older steam press models do not have an emergency release lever in case of accidental closure on a worker's hand. Although newer models are equipped with a thigh-activated emergency release lever, a contact burn remains likely if the press closes on the operator's hands. Some of the newest models have an attached safety bar that prevents the press from closing on the operator's hands. It is recommended that older models either be modified with the attachment of a safety bar or replaced entirely.