Making community pharmacies psychologically informed environments: a pilot study to improve delivery of care for people with a drug problem

Introduction

Community pharmacies are key in the delivery of care to people who use drugs (PWUD), providing specialist harm reduction, and treatment interventions such as naloxone, Injecting Equipment Provision and opiate replacement treatment. PWUD are disproportionately burdened with mental ill-health and frequently report trauma history which impacts on engagement. A successful approach in the homeless sector, is that of Psychologically Informed Environments (PIE). The core elements of a PIE are: creating a space which engenders a sense of safety and wellbeing; reflective practice so staff can develop a shared model of working; training and support for staff; and considering the therapeutic aspects of service provision to vulnerable people (1).

Aim

This pilot study tested training pharmacy staff in applying a psychologically informed environments approach to improve the delivery of care to PWUD.

Methods

Three pharmacies were recruited from those with high involvement with PWUD. A range of location and type of pharmacy were included. Whole pharmacy teams were invited to an evening training session. Bespoke training was provided by clinical psychologists with PIE expertise.

Training was assessed by anonymous quantitative questionnaires using rating scales. Changes in the attitudes of staff were assessed by questionnaire before and 6 months after training. Descriptive statistics were applied. Qualitative interviews with staff at 6 months (planned for 3 months) explored what changes, were made after PIE training to adapt the delivery of care. The study used peer researcher-led telephone interviews for patient/client feedback on observed changes and experiences in participating pharmacies. Recruitment was via the three pharmacy teams due to covid restrictions. Thematic analysis was applied to qualitative data. Normalisation Process Theory provided a framework for assessing change.

Results

Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rating training structure and delivery as very good or excellent. Covid-19 lockdowns restricted follow-up data collection which took place at six months rather than three. Attitude scores were positive (>0) for all participants at baseline (median 15.0) increasing to 20.0 at 6 months. This was not statistically significant (S=4, p=0.549).

Staff interviews revealed training had encouraged staff to reflect on communication and considered the impact of current practice which could be discriminatory e.g. their use of first names, use of private areas and level of explanation to people. The increased mental health challenges for patients from Covid-19 restrictions gave an opportunity for staff to apply their new skills to this patient group and others who were struggling with isolation, as staff across pharmacies noted mental health challenges for patients. Five patients from two pharmacies were interviewed but time delays in data collection meant changes in delivery of care were difficult to recall.

Conclusion

The study was limited by small sample size and covid-related delays. However, findings indicated that training whole pharmacy teams in PIE was well received and justifies a larger study. The approach allowed staff to reflect on practice and identify previous, potentially discriminatory practice. The importance of clear and compassionate communication was evident.

Reference

(1) Johnson R, Haigh R. Social psychiatry and social policy for the 21st century ‐ new concepts for new needs: the ‘psychologically‐informed environment.’ Ment Heal Soc Incl. 2010;14(4):30–5.

Research and recovery: Can patient participation in research promote recovery for people with complex post-traumatic stress disorder, CPTSD?

BACKGROUND

A new diagnosis of complex post-traumatic stress disorder, CPTSD, has been agreed by the World Health Organization, WHO, and evidence is needed for what psychological treatment might be effective, particularly from those with experience of the disorder. We used a novel participatory approach to explore patient views and simultaneously studied the impact on the patient researchers of the research process itself. In this paper, we report on the latter section of the study how the involvement in research of patients with CPTSD affected their mental health. Symptoms of CPTSD may include emotional dysregulation, feelings of self-worthlessness and difficulties in relationships.

OBJECTIVE

The aim of this study section was to explore whether patients' mental health could be promoted through empowering them to participate in research on CPTSD.

DESIGN

The study had a qualitative, participatory design. The clinician who led the research (first author) held group meetings with patient researchers to explore the impact of the research process. The clinician also kept notes on the process in a reflective log.

SETTING AND PARTICIPANTS

Six patient researchers participated in research with other patients with lived experience of CPTSD in an NHS outpatient unit in a London hospital.

INTERVENTION STUDIED

The research process itself was analysed in group meetings with researchers which the clinician recorded and transcribed.

FINDINGS

Participation in research may promote increased self-confidence and social inclusion for those with CPTSD.

CONCLUSION

Involvement in research may be seen as an empowering intervention because patients felt it contributed to recovery.

A participatory study of patient views on psychotherapy for complex post-traumatic stress disorder, CPTSD

BACKGROUND

A new diagnosis of Complex Post-traumatic Stress Disorder, CPTSD, is included in ICD-11 which was adopted in May 2019 by the World Health Organisation, WHO. In addition to the symptoms of PTSD, CPTSD includes emotional dysregulation, negative self-concept, and disturbances in relationships. It may be a helpful diagnosis for trauma survivors with experiences of human mistreatment such as torture and abuse.

AIMS

This study explores the views of patients in the community on psychotherapy for the diagnosis of CPTSD, taking a qualitative, participatory approach.

METHOD

Twenty-four former patients from an NHS secondary mental health service in London interviewed each other about their treatment. Participants also collaborated in data analysis. All had a diagnosis of PTSD, with additional symptoms of CPTSD identified at assessment.

RESULTS

The key factor in recovery was rebuilding relationships, beginning with the therapist. Groupwork was helpful in promoting relationships with others, as it may result in shame reduction. Involvement in the wider community through peer support groups was also valuable.

CONCLUSIONS

The rebuilding of relationships based on trust was an active mechanism of change and recovery from CPTSD. Participants felt that sufficient time, at least one year of psychotherapy with weekly sessions, was needed.

Public opinion of drug treatment policy: exploring the public's attitudes, knowledge, experience and willingness to pay for drug treatment strategies

BACKGROUND

Research evidence is strong for opiate replacement treatment (ORT). However, public opinion (attitudes) can be at odds with evidence. This study explored the relationships between, attitudes, knowledge of drugs and a range of socio-demographic variables that potentially influence attitude. This is relevant in the current policy arena in which a major shift from harm reduction to, rehabilitation is underway.

METHODS

A cross sectional postal questionnaire survey in Scotland was conducted where the drug, treatment strategy has changed from harm-reduction to recovery-based. A random sample (N=3000), of the general public, >18 years, and on the electoral register was used. The questionnaire was largely structured with tick box format but included two open questions for qualitative responses. Valuation was measured using the economic willingness-to-pay (WTP) method.

RESULTS

The response rate was 38.1% (1067/2803). Less than 10% had personal experience of drug, misuse but 16.7% had experience of drug misuse via a friend/acquaintance. Regression modelling revealed more positive attitudes towards drug users in those with personal experience of drug misuse, (p<0.001), better knowledge of drugs (p=0.001) and higher income (those earning >£50,000 per, annum compared to <£15K; p=0.01). Over half of respondents were not willing to pay anything for drug treatment indicating they did not value these treatments at all. Respondents were willing-to-pay most for community rehabilitation and least for methadone maintenance treatment. Qualitative analysis of open responses indicated many strong negative attitudes, doubts over the efficacy of methadone and consideration of addiction as self-inflicted. There was ambivalence with respondents weighing up negative feelings towards treatment against societal benefit.

CONCLUSIONS

There is a gap between public attitudes and evidence regarding drug treatment. Findings suggest a way forward might be to develop and evaluate treatment that integrates ORT with a community rehabilitative approach. Evaluation of public engagement/education to improve knowledge of drug treatment effectiveness is recommended.

How well prepared are medical students for their first year as doctors? The views of consultants and specialist registrars in two teaching hospitals

OBJECTIVE

To evaluate (1) the extent to which first year doctors (foundation year 1 doctors, F1s) in two teaching hospitals in the Trent Deanery were rated by specialist registrars (SpRs) and consultants as being well prepared for practice; (2) the importance ascribed by SpRs and consultants to the various items of core knowledge, skills and attitudes outlined in the publication of the General Medical Council, Tomorrow's Doctors.

METHOD

SpRs and consultants were asked to rate: how well prepared F1s were in a range of items of core knowledge, skills and attitudes that a new medical graduate must possess as outlined in Tomorrow's Doctors; the importance for a new doctor of each item of core knowledge, skills and attitudes; and how well the medical school had prepared F1s in respect of key generic issues related to their practice.

RESULTS

In most of the items of core knowledge, skills and attitudes covering 8 of the 11 topic areas of Tomorrow's Doctors, F1s were seen as not prepared for starting work, especially in regard to clinical and practical skills and the more challenging communication skills. They were best prepared in asking for help and in basic communication skills.

CONCLUSIONS

Overall, F1s in the study were not well prepared either to perform the tasks that await them or in terms of most of the specific background knowledge and skills necessary for the successful execution of those tasks. The level of preparedness raises important issues about medical training and transition from medical graduate to first year doctor. Further research is needed to determine whether this situation exists in other regions of the UK.

A Good Friend is Hard to Find: Friendship Among Adolescents With Disabilities

We asked 27 Euro American teens ages 16 to 17 with developmental disabilities in Los Angeles to describe friendships. Eleven characteristics of friendship reported in the research literature (similarity, proximity, transcending context, companionship, reciprocity, mutuality, intimacy, support, trust/loyalty, conflict management, and stability) were mentioned by at least some teens. However, most teens focused on companionship, doing activities across contexts, similarity in interests/personality, sheer proximity, and stability. Gender did not influence number or types of themes reported. Teens with higher IQ/Vineland Communication scores mentioned more friendship themes and were less positive about their friendships. Most teens reported some satisfying friendships, and friendships between peers with developmental disability usually were more stable and positive than friendships with typically developing peers.

Specialist drug misuse nurse's motivation, clinical decision-making and professional communication: an exploratory study

UK guidelines advocate a multidisciplinary shared care approach to manage drug-related problems. While general practitioners (GPs), consultants and pharmacists have been researched, there has been little research into the role of nurses in this field. This study examined nurses specialized in the field of substance misuse. It specifically explored their motivation for entering this area, interaction with other health professionals and their role in clinical decision-making. Seventeen face-to-face interviews were undertaken with nurses from the study population of the 21 nursing staff currently employed in one service. Responses were tape-recorded, transcribed and analysed using qualitative methods. The majority of nurses entered this field because of a specific interest in its patients and their problems. Various professionals interacted with nurses: specialist medical staff, who served as an expert resource and pharmacists through the dispensing of substitute drugs. GP participation in services was inconsistent forcing some nurses to take undue responsibility for clinical decision-making. It is essential that nurses entering this field have an interest in this field and positive attitudes towards drug users, and greater emphasis should be placed on this attribute when selecting new employees. If a shared care model is to be successful, it is important that all GPs accept their responsibilities and relieve pressure currently placed on specialist services. Alternatively, it may be necessary to adopt a new model of care.

The health and lifestyle of Scottish fishermen: a need for health promotion

It has long been known that fishing is one of the most dangerous occupations. In the year 2001, 33 boats were lost and 10 fishermen killed in UK waters. Despite the dangerous nature of the occupation, very little research has been conducted on fishermen's health and safety. The few studies that have been conducted are spread widely around the globe, and tend to focus on mortality rates and accidents. Few studies considered fishermen's lifestyle behaviours. To address this gap in current knowledge research was conducted to gain an understanding of health and lifestyle issues affecting Scottish fishermen. Data was collected using a postal questionnaire survey in the Scottish fishing population and health diaries in a small subsample. High rates of smoking were prevalent and passive smoking was a considerable problem. Fewer fishermen drank alcohol compared to the general population, but fishermen lacked knowledge about what safe levels of alcohol consumption were. Diet was lacking in fruit and vegetables, and meals were eaten at very erratic intervals. Fishermen may benefit from health promotion and education in the areas of smoking, diet and alcohol consumption.

General practice management of illicit drug users in Scotland: a national survey

AIMS

To describe the level of involvement of general practitioners (GPs) in the management of illicit drug dependency; nature of current practice in the management of illicit drug dependency; influence of guidelines on practice; GP training experience and needs; and to consider the policy implications of the findings.

DESIGN

A cross-sectional postal questionnaire survey.

SETTING

General practice in Scotland.

PARTICIPANTS

A 1 : 4 randomized sample (n = 926) of general practice principals, stratified according to age, gender and number of practice partners.

MEASUREMENTS

A structured postal questionnaire.

FINDINGS

A 63% response rate was achieved after two reminders (n = 583). Sixty per cent of respondents treated drug users, 51.5% provided methadone maintenance but only 58% used doses in the recommended range. Maintenance prescribing of dihydrocodeine and benzodiazepines was provided by 24% and 44.8% of respondents, respectively. While 79.3% had received the national clinical guidelines only 22.5% believed this had influenced their practice. Only a third of respondents had received drug dependency training. Beliefs about whether prescribing for drug misusers is part of a GPs professional remit was split.

CONCLUSIONS

There was relatively high involvement with drug users, with methadone maintenance being the most common treatment provided. Maintenance prescribing of dihydrocodeine and benzodiazepines were common despite a lack of clinical evidence supporting the effectiveness of these treatments. This may reflect the nature of the presenting drug problems and highlights the difficulties some GPs may face in managing multiple drug dependencies within current guidelines. Further local training to implement guidelines along with trials of alternative treatments currently outwith guidelines should be considered.

Community pharmacy services for drug misusers in Scotland: what difference does 5 years make?

AIMS

To assess current levels of participation of community pharmacists in needle exchange provision, assess participation in dispensing any drugs for drug misuse, explore methadone dispensing practice, assess involvement in health promotion for drug misusers, assess levels of training in drug misuse and compare all of the above with data from 5 years previously.

DESIGN

A cross-sectional postal questionnaire.

SETTING

All community pharmacies in Scotland (n = 1162).

PARTICIPANTS

A total of 969 pharmacists managing community pharmacies on a day-to-day basis (response rate 83.4%).

MEASUREMENTS

Descriptive data were collected on demography, drug misuse services provided and training. Data were combined with a dataset from an identical survey conducted 5 years previously for statistical comparison.

RESULTS

Levels of needle exchange provision has not changed significantly (9.7% in 2000 compared to 8.6% in 1995). Of all respondents, 71.5% now dispense drug for the management of drug misuse, 68.9% dispense methadone and 56.7% provide a supervised methadone consumption service. The number of methadone clients receiving methadone through pharmacies has increased from 3387 in 1995 to 8792 in 2000 and the mean number of clients dispensed methadone per pharmacy has increased from 7.3 in 1995 to 13.2 in 2000; 65.1% of all methadone clients now consume their methadone under pharmacist supervision. The proportion of pharmacists dispensing methadone who provide a supervised consumption service has increased significantly from 37% to 82.8%. Considerable changes in pharmacy practice are evident with significant increases in the number of pharmacists who always lay down ground rules, ask for identification on first visits, make up prescriptions in advance and provide verbal advice and leaflets on the management of drug misuse. Training in drug misuse doubled from 31.8% to 66.8%.

CONCLUSIONS

Community pharmacy involvement with drug misusers has increased dramatically in the last 5 years. However, this increase is largely in methadone dispensing and supervision. Pharmacists appear to be more proactive in providing advice and information, perhaps as a result of greater training.

The health of fishermen in the catching sector of the fishing industry: a gap analysis

Offshore fishing is a sizeable industry in the UK and it is one of the most dangerous occupations. Long hours, extreme weather and working with heavy machinery contribute to a high mortality rate in fishermen. Despite a long-standing acknowledgement of the dangers and high mortality associated with fishing, there has been little research in this field. Although there have been developments within the industry in terms of safety, there has been little emphasis on the relationship between health, the environment and performance at work. This paper reviews the international literature on the health of fishermen, and describes the main findings and highlights gaps in current evidence. Areas for further research that would inform the future development of an evidence-based occupational health service for the offshore fishing industry are discussed.

Repeat prescribing: a role for community pharmacists in controlling and monitoring repeat prescriptions

BACKGROUND

Traditional systems of managing repeat prescribing have been criticised for their lack of clinical and administrative controls.

AIM

To compare a community pharmacist-managed repeat prescribing system with established methods of managing repeat prescribing.

METHOD

A randomised controlled intervention study (19 general medical practices, 3074 patients, 62 community pharmacists). Patients on repeat medication were given sufficient three-monthly scripts, endorsed for monthly dispensing, to last until their next clinical review consultation with their general practitioner (GP). The scripts were stored by a pharmacist of the patient's choice. Each monthly dispensing was authorised by the pharmacist, using a standard protocol. The cost of the drugs prescribed and dispensed was calculated. Data on patient outcomes were obtained from pharmacist-generated patient records and GP notes.

RESULTS

A total of 12.4% of patients had compliance problems, side-effects, adverse drug reactions, or drug interactions identified by the pharmacist. There were significantly more problems identified in total in the intervention group. The total number of consultations, deaths, and non-elective hospital admissions was the same in both groups. Sixty-six per cent of the study patients did not require their full quota of prescribed drugs, representing 18% of the total prescribed costs (estimated annual drug cost avoidance of 43 Pounds per patient).

CONCLUSION

This system of managing repeat prescribing has been demonstrated to be logistically feasible, to identify clinical problems, and to make savings in the drugs bill.

Attitudinal factors associated with community pharmacists' involvement in services for drug misusers

AIM

To assess the relationship between pharmacists' attitudes towards drug misusers and the availability and provision of services for drug misusers.

DESIGN

A cross-sectional postal questionnaire survey.

SETTING

All community pharmacies in Scotland (n = 1142).

PARTICIPANTS

A total of 864 pharmacists managing community pharmacies on a day-to-day basis (response rate 79%).

MEASUREMENTS

Descriptive data were collected on demography, drug misuse services provided and training in drug misuse. Attitude statements were used to measure attitudes to drug misusers, the role of the pharmacist in dispensing controlled drugs and providing injecting equipment, providing advice on drug misuse and financial aspects of service provision. Statements were incorporated into a scale which was correlated with behavioural data on whether and how services were provided.

RESULTS

The attitude scale had good internal reliability and was unidimensional. Pharmacists that provided needle/syringe exchanges, sold needles/syringes, dispensed methadone, supervised the consumption of methadone and provided health promotion services to drug misusers had significantly more positive attitudes towards drug misusers. Attitudes were associated with health board area, sex and number of years registered as a pharmacist. After controlling for these characteristics, attitude was an independent predictor of whether needles/syringes were sold, methadone was dispensed and methadone consumption supervised.

CONCLUSIONS

Addressing negative attitudes could encourage more pharmacists to provide services and enhance the process of service delivery.

Prescribing and dispensing for drug misusers in primary care: current practice in Scotland

BACKGROUND

Substitute prescribing has increased in Scotland, as in the rest of the UK. Both GPs and pharmacists are becoming increasingly involved in service provision for drug misusers, but anecdotal evidence has suggested considerable variation in prescribing and dispensing practice.

OBJECTIVE

We aimed to gain baseline data on (i) current prescribing practice by medical practitioners and drug agencies, (ii) dispensing practice by community pharmacists across Scotland for the management of drug misuse and (iii) variations in practice between health boards.

METHODS

A structured questionnaire was posted to all community pharmacies in Scotland (n = 1142), in order to gather information on prescribing from prescriptions held at the time of the survey and information on current dispensing practice in managing drug misusers.

RESULTS

The response rate was 79%. Sixty-one per cent of pharmacists were currently dispensing drugs for the management of drug misuse. The most frequently prescribed drug was methadone, dispensed by 46% of pharmacists, followed by diazepam (37%), dihydrocodeine (26%) and temazepam (25%). Sixty-five per cent of methadone prescriptions were dispensed daily on request from the prescriber. Of the 3387 people receiving a methadone prescription, 32.9% had to consume their daily dose on the pharmacy premises under a pharmacist's supervision. Nineteen per cent of pharmacies currently provided a service to supervise the consumption of methadone by clients and a further 14% were prepared to but had no current demand. The proportion of prescriptions requiring supervision of methadone consumption varied considerably between health board areas.

CONCLUSIONS

Methadone is the most widely prescribed drug for drug misuse across Scotland, but there is considerable variation between health board areas in how prescribing is managed. Prescribing practice should be revised locally, in a process involving GPs and pharmacists. Pharmacists have an important role in preventing drug misuse in primary care, but need further support to optimize good practice.

Combined treatment of acute EAE in Lewis rats with TNF-binding protein and interleukin-1 receptor antagonist

Experimental autoimmune encephalomyelitis (EAE) is a term given to describe a collection of animal models representing the human disease multiple sclerosis (MS). Although not fully understood, the involvement of cytokines and the immune system in either EAE or human MS is well established. Past efforts have shown that inhibition of proinflammatory cytokines tumor necrosis factor (TNF-alpha) or interleukin-1 (IL-1) result in amelioration of acute EAE in Lewis rats. The present study examined this model for the effect of concomitant inhibition of both TNF-alpha and IL-1, which resulted in a modest but significant therapeutic effect that was superior to inhibition of either single agent alone with respect to four of the five variables used to follow the progression of disease in this model, i.e., clinical severity, frequency of disease, loss of body weight, and day of onset. These results are in accordance with the idea that combination treatments are likely to prove superior to single agent therapy in the treatment of autoimmune inflammatory disease.

In vivo neurotrophic effects of GDNF on neonatal and adult facial motor neurons

Motor neurons require neurotrophic factor(s) for their survival during development and for maintenance of function in adulthood. In vivo studies have shown that motor neurons respond to a variety of molecules, including ciliary neurotrophic factor, members of the neurotrophin family, and the insulin growth factor IGF-1 (refs 3-13). Here we investigate the potential motor neuron neurotrophic effects of glial-cell-line-derived neurotrophic factor (GDNF), initially identified as a neurotrophic factor for substantia nigra dopaminergic neurons. We find that GDNF is retrogradely transported, in a receptor-mediated fashion, by spinal cord motor neurons in neonatal rats. Local application of GDNF to the transected facial nerve prevents the massive motor neuron cell death and atrophy that normally follows axotomy in the neonatal period. In adult rats, GDNF administered locally or systemically can markedly attenuate the lesion-induced decrease of choline acetyltransferase immunoreactivity in the facial nucleus. Our data indicate that GDNF has very profound neurotrophic effects in vivo on developing as well as on adult motor neurons, and is the most potent motor neuron trophic factor found so far.

Formation of heterodimers from three neurotrophins, nerve growth factor, neurotrophin-3, and brain-derived neurotrophic factor

Three neurotrophic factors, brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), and nerve growth factor (NGF) form noncovalent homodimers in solution. Since they are highly homologous proteins, it seemed probable that two monomers of these proteins might associate together to form a heterodimer. This was tested by denaturing the two different proteins together in 6 M guanidine HCl and refolding them in phosphate-buffered saline. When the refolded mixture of BDNF and NT-3 was subjected to Mono S cation exchange chromatography, a new peak was observed eluting between NT-3 and BDNF, which accounted for about 30% of the protein used. This new protein species migrated as a single band upon native gel electrophoresis with mobility between that of the NT-3 homodimer and the BDNF homodimer, indicating that a complex had been formed. Sedimentation equilibrium data show that the dissociation constant of this heterodimer is < 3 x 10(-10) M. The heterodimer was stable upon incubation at 37 degrees C in phosphate-buffered saline over 11 days. Having determined that the heterodimer is highly stable, it was subjected to various biological assays. Autophosphorylation assay using TrkB receptor showed that the heterodimer is indistinguishable from the BDNF or NT-3 homodimer in the ability to induce phosphorylation of the receptor. It was also indistinguishable from the homodimers in the neurotrophic activity using chick dorsal root ganglion explant. In the sympathetic neuron survival assay, the heterodimer behaved more similarly to NT-3, whereas in the dopamine uptake assay, it was intermediate between the two homodimers. In addition, the heterodimer was shown to be retrogradely transported in the dorsal root ganglion neurons. A heterodimer between NGF and BDNF is formed but much less effectively than the NT-3.BDNF heterodimer, and it is not stable even at 4 degrees C. These results indicate that BDNF and NT-3 have an intersubunit contact surface for dimerization resembling each other's but different from the contact surface of NGF.

The biological responses of axotomized adult motoneurons to brain-derived neurotrophic factor

Recent studies showed that brain-derived neurotrophic factor (BDNF) prevents developing motoneurons from naturally occurring and axotomy-induced cell death. Here we examined whether adult motoneurons retain responsiveness to BDNF. Consistent with previous studies, we found that adult spinal and brainstem motoneurons expressed the mRNA of BDNF receptor, trkB. In addition, the trkB immunoreactivities were readily detected in the adult spinal and brainstem motoneurons. We then demonstrated that axotomized adult motoneurons responded to exogenous BDNF. BDNF administered locally markedly attenuated the lesion-induced decrease of ChAT immunoreactivity and activity and enhanced the lesion-induced reexpression of low-affinity NGF receptor immunoreactivity in adult facial motoneurons. Furthermore, we found BDNF administered subcutaneously, intravenously, and into the cerebral ventricle attenuated the lesion-induced decrease of ChAT immunoreactivity in adult facial motoneurons in a dose-dependent fashion. Our data indicate that adult motoneurons retain their responsiveness to BDNF, suggesting that BDNF may be useful as a therapeutic agent for adult motoneuron disease.

Distribution of intracerebral ventricularly administered neurotrophins in rat brain and its correlation with trk receptor expression

To assess the potential effectiveness by which injected neurotrophins can diffuse throughout the brain, we used autoradiographic and immunohistochemical techniques to examine the brain distributions of nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and neurotrophin-3 (NT-3) after a single injection into the lateral cerebral ventricle (ICV) in rats. As described previously, ICV-injected NGF labeled cholinergic neurons in the basal forebrain. Injection of BDNF resulted in few or no labeled neurons in the basal forebrain or in the substantia nigra. However, very intense labeling was associated with the ventricular walls and immediate parenchyma. The distribution of NT-3 after ICV injection was intermediate between that of NGF and BDNF. In the basal forebrain, similar neurotrophin distributions were observed in neonate versus adult animals. Our in situ hybridization analysis has shown that mRNA encoding the BDNF receptor(s) (trkB) is highly expressed by ependymal cells as well as by many neurons and glia. On the other hand, expression of the high-affinity NGF receptor (trkA) is restricted to cholinergic neurons in basal forebrain and striatum. In addition, staining with antisera specific for the trkA or trkB receptors demonstrated that their expression patterns closely reflect their mRNA distributions. Taken together, these data suggest that the presence of the trkB receptor on the ependymal layer of the ventricle and its expression throughout the brain parenchyma represents a significant impediment to the adequate diffusion of ICV-injected BDNF into the brain for delivery to target neurons.

The Caenorhabditis elegans unc-60 gene encodes proteins homologous to a family of actin-binding proteins

Mutations in the unc-60 gene of the nematode Caenorhabditis elegans result in paralysis. The thin filaments of the muscle cells are severely disorganized and not bundled with myosin into functional contractile units. Here we report the cloning and sequence of unc-60. Two unc-60 transcripts, 1.3 and 0.7 kb in size, were detected. The transcripts share a single exon encoding only the initial methionine, yet encode proteins with homologous sequences. The predicted protein products are 165 and 152 amino acids in length and their sequences are 38% identical. Both proteins are homologous to a family of actin depolymerizing proteins identified in vertebrate, plant and protozoan systems. We propose that the unc-60 locus encodes proteins that depolymerize growing actin filaments in muscle cells, and that these proteins are required for the assembly of actin filaments into the contractile myofilament lattice of C. elegans muscle. unc-60 has an essential function in development, since one unc-60 allele, s1586, has a recessive lethal phenotype. Our characterization of s1586 has shown that it is a small deletion which disrupts both coding regions.

Influences of neurotrophins on mammalian motoneurons in vivo

Several recently reported investigations have shown that a member of the neurotrophin family of neuronal growth factors, brain-derived neurotrophic factor (BDNF), supports motoneurons in vitro and rescues motoneurons from naturally occurring and axotomy-induced cell death (Oppenheim et al., 1992b; Sendtner et al., 1992b; Yan et al., 1992; Koliatsos et al., 1993; Henderson et al., 1993). In the current study, we have explored the issue of whether BDNF and other neurotrophins act to regulate motoneuron survival during development and asked whether synthesis of motoneuron transmitter enzymes is also regulated. We first examined whether spinal motoneurons in newborn animals could retrogradely transport iodinated neurotrophins from their targets in a specific, receptor-mediated manner. We found that motoneurons readily transported NGF, BDNF, and neurotrophin-3 (NT-3). The retrograde transport of one factor could be completely or largely blocked by excess of unlabeled homologous factor, but only partially blocked by excess of unlabeled heterologous factors. Since previous studies have shown that these three neurotrophins bind to the low-affinity NGF receptor, p75NGFR, with similar affinity, our data suggest that the retrograde transport of neurotrophins by motoneurons may be mediated by additional components, such as the trk family of proto-oncogenes. Consistent with this hypothesis, we demonstrate here that motoneurons express mRNA for two members of the trk family, trkB and trkC. Furthermore, both trkB and trkC were expressed by E13, consistent with a role for BDNF and NT-3 in regulating important developmental events involving motoneurons such as naturally occurring cell death. In order to determine which members of the neurotrophin family influence motoneuron survival and to assess the generality of their effects, we evaluated the abilities of NGF, BDNF, and NT-3 to save both spinal and cranial motoneurons after neonatal axotomy. Locally applied BDNF saved 40-70% of motoneurons which would ordinarily die after axotomy in lumbar and cranial motor pools, depending on the treatment protocol employed. NT-3 also exhibited some ability to rescue motoneurons and saved 20-25% of motoneurons which would die in the absence of treatment. Finally, we asked whether neurotrophins could influence synthesis of transmitter enzymes by motoneurons as well as their survival after axotomy. Locally applied BDNF and NT-3 could partially prevent the decrease of protein contents in L4 and L5 ventral roots which normally follows sciatic nerve transection. However, treatment with these neurotrophins did not prevent the decrease in choline acetyltransferase (ChAT) activity in L4 and L5 ventral roots which results from this procedure.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of macrophage colony-stimulating factor on haemopoietic recovery after autologous bone marrow transplantation

Macrophage colony-stimulating factor (M-CSF) is active in the late stages of monocyte maturation, activates mature monocyte-macrophages and enhances their production of various other cytokines. We have examined the effects of a 21 d course of escalating doses of M-CSF purified from human urine (hM-CSF) on recovery following autologous bone marrow transplantation (ABMT) in 20 patients with malignant lymphomas. Four patients were treated at each dose level of 4, 8, 16, 32 and 64 x 10(6) U/m2/d and results compared to 46 concurrent controls. There was no significant difference in recovery to an absolute neutrophil count (ANC) of 0.5 x 10(9)/l (median 20 d in hM-CSF group versus 22 in controls) or in recovery of platelets to 50 x 10(9)/l (32 d versus 39 d, 0.05 less than P less than 0.1); hM-CSF patients received a median of 81 platelet units following ABMT (controls 112 units, P = NS). hM-CSF patients had a median of 5.5 d with fever greater than 37.5 degrees C (control 8, P = NS), received parenteral antibiotics for 14.5 d (control 17, P = NS) and had a 50% incidence of bacteraemia (control 48%). hM-CSF treated patients were discharged by a median of day 29 following transplantation (control 33, P less than 0.05). Platelet and neutrophil recovery correlated significantly with the number of marrow mononuclear cells (MNC) reinfused in the hM-CSF group (P = 0.05 and P = 0.014 respectively) but not in controls. Subgroup analysis showed that hM-CSF patients receiving greater than 2 x 10(8) MNC/kg body weight reached an ANC of 0.5 x 10(9)/l by a median of day 16.5 (control 18.5, NS), became platelet transfusion independent by day 17 (control 29, P less than 0.05) and reached a platelet count of 50 x 10(9)/l by day 21 (control 40, P less than 0.05). No significant toxicity attributable to hM-CSF treatment was seen. These results suggest that hM-CSF accelerates platelet recovery following ABMT and that relatively large marrow innocula are required to see this effect.