Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand

OBJECTIVE

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported.

METHODS

First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity.

RESULTS

Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Māori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Māori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log₂(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Māori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084.

CONCLUSIONS

In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Māori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score.

TRIAL REGISTRATION NUMBER

ACTRN12615000676516.

Lifestyle and health behaviour change support in traditional acupuncture: a mixed method survey study of reported practice (UK)

Aims

Complementary medicine therapists such as traditional acupuncturists are a large resource for supporting public health targets to improve health behaviours. Our objectives were to determine the prevalence and patterns of UK acupuncturists’ provision of lifestyle change support, test theory-based hypotheses about facilitators and barriers to supporting lifestyle changes and to explore associated characteristics and attitudes.

Methods

A mixed methods design in which British Acupuncture Council members (Sept 2019-April 2020) completed an online questionnaire assessing prevalence of lifestyle change support, typical patterns across patients and behaviours, Theory of Planned Behaviour constructs, practitioner characteristics and open-text responses regarding additional behaviours and clinical decisions to introduce lifestyle change.

Results

Three hundred fifty-two traditional acupuncturists participated (Mean age = 51.5 years, SD 9.9; 81.8% (n = 288) female). 57.7% (n = 203) reported offering support for lifestyle change during their most recent consultation. 91.7% (n = 323) reported supporting lifestyle change ‘always or most of the time’ for patients with chronic conditions and 67.9% (n = 239) reported this for patients with acute conditions. The pattern of typical support for different health behaviours ranged from 44.6% (n = 157) for smoking reduction (acute conditions) to 95.2% (n = 335) for diet support (chronic conditions). A linear regression model found that frequency of support for lifestyle change in acute patients was predicted by acupuncturists’ attitudes to both clinical role and importance of health behaviours, confidence in their ability to provide lifestyle change support and use of fewer behaviour change techniques. The decision to first offer lifestyle change support was guided by perceived patient receptiveness, whether presenting condition/diagnosis were likely to improve with lifestyle change and whether a strong therapeutic relationship was established.

Conclusions

Traditional acupuncturists’ reports suggest their work supports key public health targets for promoting healthy behaviours. Less frequent support for alcohol/smoking may reflect user characteristics but may suggest training needs for acupuncturists. Increase could be made for support in acute presentations, however the importance of patient receptiveness, linking advice to condition, and therapeutic alliance should be explored further. There may be important differences between acupuncture practice and mainstream healthcare (e.g. high level of contact, longer visits, holistic approach) which impact mechanisms of action of behaviour change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03719-6.

Understanding and addressing vaccine hesitancy in the context of COVID-19: development of a digital intervention

OBJECTIVES

Severe Acute Respiratory Coronavirus 2 (SARS-CoV-2) was identified in late 2019, spreading to over 200 countries and resulting in almost two million deaths worldwide. The emergence of safe and effective vaccines provides a route out of the pandemic, with vaccination uptake of 75-90% needed to achieve population protection. Vaccine hesitancy is problematic for vaccine rollout; global reports suggest only 73% of the population may agree to being vaccinated. As a result, there is an urgent need to develop equitable and accessible interventions to address vaccine hesitancy at the population level.

STUDY DESIGN

& Method: We report the development of a scalable digital intervention seeking to address COVID-19 vaccine hesitancy and enhance uptake of COVID-19 vaccines in the United Kingdom. Guided by motivational interviewing (MI) principles, the intervention includes a series of therapeutic dialogues addressing 10 key concerns of vaccine-hesitant individuals. Development of the intervention occurred linearly across four stages. During stage 1, we identified common reasons for COVID-19 vaccine hesitancy through analysis of existing survey data, a rapid systematic literature review, and public engagement workshops. Stage 2 comprised qualitative interviews with medical, immunological, and public health experts. Rapid content and thematic analysis of the data provided evidence-based responses to common vaccine concerns. Stage 3 involved the development of therapeutic dialogues through workshops with psychological and digital behaviour change experts. Dialogues were developed to address concerns using MI principles, including embracing resistance and supporting self-efficacy. Finally, stage 4 involved digitisation of the dialogues and pilot testing with members of the public.

DISCUSSION

The digital intervention provides an evidence-based approach to addressing vaccine hesitancy through MI principles. The dialogues are user-selected, allowing exploration of relevant issues associated with hesitancy in a non-judgmental context. The text-based content and digital format allow for rapid modification to changing information and scalability for wider dissemination.

960Dietary intakes of patients with first Acute Coronary Syndrome: the MENZACS study

Background

In New Zealand (NZ) approximately 10,000 people experience an acute coronary syndrome (ACS) annually. Little is known about the diets of people who present with first ACS.

Methods

The Multi-Ethnic NZ study of Acute Coronary Syndromes (MENZACS) is a multi-centre, longitudinal cohort study of patients with first-time ACS. At baseline, patients complete a validated short food frequency questionnaire (FFQ) asking about dietary intakes in the 12 months preceding their event. Participants are followed up for rehospitalisation and mortality.

Results

Here we present the dietary intakes of the 2,015 participants enrolled into MENZACS. We excluded 90 participants who did not start the FFQ and 42 participants who had extreme energy intakes. For men (n = 1489), the median energy intake was 8637 kJ, and the median percentage of energy from carbohydrate, protein, fat, and saturated fat were 40.3%, 17.9%, 34.7% and 17.8%, respectively. For women (n = 394), the median energy intake was 7499 kJ, and the median percentage of energy from carbohydrate, protein, fat and saturated fat were 40.3%, 18.4%, 35.6%, and 18.0%, respectively.

Conclusions

Both men and women reported high saturated fat intakes in the year preceding their first ACS. Future work will examine dietary predictors of rehospitalisation and mortality, as well as analyse baseline blood samples for Lipoprotein(a) and lipidomics.

Key messages

Patients in hospital with first time ACS are able to complete a short food frequency questionnaire, with little missing data.

Parental Posttraumatic Stress Symptoms in the Context of Pediatric Post Intensive Care Syndrome: Impact on the Family and Opportunities for Intervention

Objective

Pediatric intensive care unit (PICU) survivors and their families experience ongoing impacts on physical, cognitive, and psychosocial functioning, described as Post-Intensive Care Syndrome (PICS). The objective of this study was to determine whether the posttraumatic stress symptoms (PTSS) of parents predict the impact of critical illness on families following PICU admission beyond other factors (e.g., sex, race/ethnicity, age, insurance status, illness severity, family involvement or death).

Method

We conducted a retrospective analysis of data from 88 children aged 1 month to 18 years who were hospitalized with critical illness and acquired brain injury in the PICU and their families. Patients and their families participated in a 1-3 month post-discharge follow-up assessment, during which data on demographics, medical diagnoses, parent self-report of PTSS, and family impact of critical illness (via the Pediatric Quality of Life Family Impact Module) were collected. We used a hierarchical linear regression to determine whether parent PTSS predicted family impact above and beyond demographic and injury/illness factors.

Results

One-third of parents reported elevated PTSS. Among those with complete available data (n = 56), PTSS were the only significant predictor of family impact (β = -.52, t = -3.58, p = .001), with the overall model accounting for 41% of variance.

Conclusion

In addition to the direct effects on parents of children who survive the PICU, PTSS may negatively impact families and interfere with rehabilitative progress. We provide a rationale and conceptual model for integrating interventions designed to address parent PTSS into post-PICU care.

Describing a new food group classification system for UK biobank: analysis of food groups and sources of macro- and micronutrients in 208,200 participants

PURPOSE

The UK Biobank study collected detailed dietary data using a web-based self-administered 24 h assessment tool, the Oxford WebQ. We aimed to describe a comprehensive food grouping system for this questionnaire and to report dietary intakes and key sources of selected nutrients by sex and education.

METHODS

Participants with at least one valid 24-h questionnaire were included (n = 208,200). Dietary data were grouped based on the presence of nutrients as well as culinary use, processing, and plant/animal origin. For each food group, we calculated the contribution to energy intake, key macronutrients, and micronutrients. We also identified the top contributors to energy intake, free sugars and saturated fat by sex and education.

RESULTS

From the 93 food groups, the top five contributors to energy intake (in descending order) were: desserts/cakes/pastries; white bread; white pasta/rice; bananas/other fruit; semi-skimmed milk. Wine, beer, and fruit juices were the top beverage contributors to overall energy intake. Biscuits, and desserts/cakes/pastries were the highest contributors to free sugars, total fat, and saturated fat intakes, but also contributed to the calcium and iron intakes. Top contributors to energy, saturated fat, and free sugars were broadly similar by sex and education category, with small differences in average nutrient intakes across the population.

CONCLUSION

This new food classification system will support the growing interest in the associations between food groups and health outcomes and the development of food-based dietary guidelines. Food group variables will be available to all users of the UK Biobank WebQ questionnaire.

Correction to: Describing a new food group classification system for UK biobank: analysis of food groups and sources of macro- and micronutrients in 208,200 participants

A correction to this paper has been published: https://doi.org/10.1007/s00394-021-02591-3

Physical activity, dietary protein and insulin-like growth factor 1: Cross-sectional analysis utilising UK Biobank

BACKGROUND

Insulin-like growth factor-I (IGF-1) is an anabolic hormone that stimulates cell growth and division. The effects of IGF-1 may be beneficial (muscle growth/repair) or detrimental (increased risk of several types of cancer and mortality) for health. Dietary protein and physical activity are thought to be factors that modulate IGF-1.

OBJECTIVE

This study analysed the relationships dietary protein vs IGF-1 and physical activity vs IGF-1 independently with a large sample size, and determined if/how physical activity affected the association between dietary protein and IGF-1 in healthy adults.

METHODS

Regression models were used to assess the association between dietary protein and/or physical activity on serum IGF-1 in a cross-sectional sample of 60,677 healthy adults that were enrolled in the UK Biobank project.

RESULTS

Dietary protein was positively associated with IGF-1 (0.030 nmol/L;95%CI 0.027-0.033;p < 0.001). Individuals undertaking 10-50 excess MET h/week of physical activity had 0.129 nmol/L greater IGF-1 than participants completing less than 10 excess MET h/week (95%CI 0.028-0.230). The "high" category of physical activity (>50 excess MET h/week) was not correlated with IGF-1 (-0.055 nmol/L;95%CI -0.185-0.076). When dietary protein and physical activity were included in the same model, physical activity did not change the relationship between dietary protein and IGF-1, nor visa-versa.

CONCLUSIONS

The positive association between dietary protein and IGF-1 was not influenced by physical activity. The former association was stronger than the latter. Thus, when seeking to adjust IGF-1 for possible health concerns, regulating dietary protein may be more pertinent than physical activity as a primary intervention.

Post-intensive care syndrome in a cohort of infants & young children receiving integrated care via a pediatric critical care & neurotrauma recovery program: A pilot investigation

OBJECTIVE

Children treated in the pediatric intensive care unit (PICU) often face difficulties with long-term morbidities associated with neurologic injuries and lifesaving PICU interventions termed Post-Intensive Care Syndrome (PICS). In an effort to identify and address critical issues related to PICS, we developed an integrated model of care whereby children and families participate in follow-up clinics with a neuropsychologist and a critical care physician. To demonstrate preliminary impact, we present pilot findings on the early identification and treatment of PICS in a cohort of infants and young children in our program through a combination of multi-professional direct assessment and parent proxy questionnaires.

METHOD

Thirty-three infants and children, ages 3-72 months, participated in our initial follow-up clinic where issues related to physical health/recovery, development/cognition, mood/behavior, and quality of life were screened 1-3 months after discharge from the PICU.

RESULTS

In comparison to pre-hospitalization functioning, direct assessment revealed new neurological concerns identified by the critical care physician in 33.3% of participants and new neurocognitive concerns identified by the neuropsychologist in 36.4% of participants. Caregiver reported measures showed significant issues with patient cognitive functioning, emotional functioning, sleep, and impact on the family. Participants and families experienced significant difficulties related to changes in functioning and disability. Parents/caregivers and clinicians demonstrated agreement on functioning across a variety of indicators; however, important divergence in assessments were also found highlighting the importance of multiple assessments and perspectives.

CONCLUSIONS

New PICS morbidities are common in the early phase of recovery after discharge in infants, young children and their families. Results demonstrate the benefits and need for timely PICU follow-up care that involves collaboration/integration of physicians, neuropsychologists, and families to identify and treat PICS issues.

Reproducibility of dietary intakes of macronutrients, specific food groups, and dietary patterns in 211 050 adults in the UK Biobank study

To detect modest associations of dietary intake with disease risk, observational studies need to be large and control for moderate measurement errors. The reproducibility of dietary intakes of macronutrients, food groups and dietary patterns (vegetarian and Mediterranean) was assessed in adults in the UK Biobank study on up to five occasions using a web-based 24-h dietary assessment (n 211 050), and using short FFQ recorded at baseline (n 502 655) and after 4 years (n 20 346). When the means of two 24-h assessments were used, the intra-class correlation coefficients (ICC) for macronutrients varied from 0·63 for alcohol to 0·36 for polyunsaturated fat. The ICC for food groups also varied from 0·68 for fruit to 0·18 for fish. The ICC for the FFQ varied from 0·66 for meat and fruit to 0·48 for bread and cereals. The reproducibility was higher for vegetarian status (κ > 0·80) than for the Mediterranean dietary pattern (ICC = 0·45). Overall, the reproducibility of pairs of 24-h dietary assessments and single FFQ used in the UK Biobank were comparable with results of previous prospective studies using conventional methods. Analyses of diet-disease relationships need to correct for both measurement error and within-person variability in dietary intake in order to reliably assess any such associations with disease in the UK Biobank.

Factor Analysis of the Childhood Autism Rating Scale in a Sample of Two Year Olds with an Autism Spectrum Disorder

The Childhood Autism Rating Scale (CARS), (Schopler et al. in J Autism Dev Disord 10(1):91-103, 1980) is a 15-item observation-based rating scale that yields a total score reflective of autism symptom severity. This study investigated the factor structure of the CARS in a sample of 2-year-old children with DSM-IV-TR (American Psychiatric Association in Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Publishing, Washington, 2000) diagnoses of AD or PDD-NOS. Following a preliminary internal cross-validation, principal axis factor analysis was completed (N = 282). The results indicate a three-factor solution: Social Communication, Stereotyped Behaviors and Sensory Sensitivities, and Emotional Reactivity. The factors are meaningful, with the first two reflective of DSM-5 symptom domains. This study supports the continued relevance of the CARS in ASD assessment, and extends its utility in 2-year-old children.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.

B-54 Insights into a Novel Integrated Screening Clinic: Parent Perceptions of Emotional Functioning in Acute Recovery Phase Following Pediatric Neurocritical Care

Objective

Children with traumatic brain injury (TBI) requiring neurocritical care are at high risk for neurocognitive, emotional, physical, and psychosocial difficulties, collectively known as Post-Intensive Care Syndrome. Our study sought to characterize parent ratings of emotional functioning in the acute recovery phase based upon mechanism of injury.

Method

Twenty children (Mdn = 12.6 years, IQR = 9-15; 65% male) were screened as part of a multidisciplinary follow-up clinic 1-month following hospital discharge. Emotional functioning was assessed using PROMIS Parent Proxy Report for Anxiety and Depression. A brief neurocognitive battery estimated presence of cognitive impairment. MANCOVA was used to compare emotional functioning across injury mechanism (high velocity injury [HVI], 65%; fall, 35%).

Results

Groups did not differ on age, gender, and presence of cognitive impairment. After controlling for severity, mechanism of injury had a significant effect on both anxiety (p = .026) and depression (p = .004). The HVI group had mildly elevated anxiety (M = 50.5, SD = 12.2) and depression (M = 54.2, SD = 10.6) scores, while the fall group had anxiety (M = 38.0, SD = 6.2) and depression (M = 39.0, SD = 7.3) scores within normal limits.

Conclusions

In the acute recovery phase following TBI, anxiety and depression symptoms are more common after HVI than falls, even when controlling for severity of injury. The HVI group includes injuries resulting from motor vehicle accidents which may have a broader impact on the family and may explain higher rates of emotional distress in this patient group compared to other mechanisms of TBI. Additional research is needed to further explore variables related to emotional functioning following TBI and how they change over the course of recovery.

Diet and risk of glioma: combined analysis of 3 large prospective studies in the UK and USA

BACKGROUND

Available evidence on diet and glioma risk comes mainly from studies with retrospective collection of dietary data. To minimize possible differential dietary recall between those with and without glioma, we present findings from 3 large prospective studies.

METHODS

Participants included 692 176 from the UK Million Women Study, 470 780 from the US National Institutes of Health-AARP study, and 99 148 from the US Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Cox regression yielded study-specific adjusted relative risks for glioma in relation to 15 food groups, 14 nutrients, and 3 dietary patterns, which were combined, weighted by inverse variances of the relative risks. Separate analyses by <5 and ≥5 years follow-up assessed potential biases related to changes of diet before glioma diagnosis.

RESULTS

The 1 262 104 participants (mean age, 60.6 y [SD 5.5] at baseline) were followed for 15.4 million person-years (mean 12.2 y/participant), during which 2313 incident gliomas occurred, at mean age 68.2 (SD 6.4). Overall, there was weak evidence for increased glioma risks associated with increasing intakes of total fruit, citrus fruit, and fiber and healthy dietary patterns, but these associations were generally null after excluding the first 5 years of follow-up. There was little evidence for heterogeneity of results by study or by sex.

CONCLUSIONS

The largest prospective evidence to date suggests little, if any, association between major food groups, nutrients, or common healthy dietary patterns and glioma incidence. With the statistical power of this study and the comprehensive nature of the investigation here, it seems unlikely we have overlooked major effects of diet on risk of glioma that would be of public health concern.

Dietary intake of total polyphenol and polyphenol classes and the risk of colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort

Polyphenols may play a chemopreventive role in colorectal cancer (CRC); however, epidemiological evidence supporting a role for intake of individual polyphenol classes, other than flavonoids is insufficient. We evaluated the association between dietary intakes of total and individual classes and subclasses of polyphenols and CRC risk and its main subsites, colon and rectum, within the European Prospective Investigation into Cancer and Nutrition (EPIC) study. The cohort included 476,160 men and women from 10 European countries. During a mean follow-up of 14 years, there were 5991 incident CRC cases, of which 3897 were in the colon and 2094 were in the rectum. Polyphenol intake was estimated using validated centre/country specific dietary questionnaires and the Phenol-Explorer database. In multivariable-adjusted Cox regression models, a doubling in total dietary polyphenol intake was not associated with CRC risk in women (HRlog2 = 1.06, 95% CI 0.99-1.14) or in men (HRlog2 = 0.97, 95% CI 0.90-1.05), respectively. Phenolic acid intake, highly correlated with coffee consumption, was inversely associated with colon cancer in men (HRlog2 = 0.91, 95% CI 0.85-0.97) and positively associated with rectal cancer in women (HRlog2 = 1.10, 95% CI 1.02-1.19); although associations did not exceed the Bonferroni threshold for significance. Intake of other polyphenol classes was not related to colorectal, colon or rectal cancer risks. Our study suggests a possible inverse association between phenolic acid intake and colon cancer risk in men and positive with rectal cancer risk in women.

Prospective evaluation of antibody response to Streptococcus gallolyticus and risk of colorectal cancer

The gut microbiome is increasingly implicated in colorectal cancer (CRC) development. A subgroup of patients diagnosed with CRC show high antibody responses to Streptococcus gallolyticus subspecies gallolyticus (SGG). However, it is unclear whether the association is also present pre-diagnostically. We assessed the association of antibody responses to SGG proteins in pre-diagnostic serum samples with CRC risk in a case-control study nested within a prospective cohort. Pre-diagnostic serum samples from 485 first incident CRC cases (mean time between blood draw and diagnosis 3.4 years) and 485 matched controls in the European Prospective Investigation into Nutrition and Cancer (EPIC) study were analyzed for antibody responses to 11 SGG proteins using multiplex serology. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariable conditional logistic regression models. Antibody positivity for any of the 11 SGG proteins was significantly associated with CRC risk with 56% positive controls compared to 63% positive cases (OR: 1.36, 95% CI: 1.04-1.77). Positivity for two or more proteins of a previously identified SGG 6-marker panel with greater CRC-specificity was also observed among 9% of controls compared to 17% of CRC cases, corresponding to a significantly increased CRC risk (OR: 2.17, 95% CI: 1.44-3.27). In this prospective nested case-control study, we observed a positive association between antibody responses to SGG and CRC development in serum samples taken before evident disease onset. Further work is required to establish the possibly etiological significance of these observations and whether SGG serology may be applicable for CRC risk stratification.

Metabolic Mediators of the Association Between Adult Weight Gain and Colorectal Cancer: Data From the European Prospective Investigation into Cancer and Nutrition (EPIC) Cohort

Evidence indicates that gaining weight in adult life is associated with an elevated risk of colorectal cancer; however, biological mechanisms that may explain this association remain unclear. We evaluated the mediation effect of 20 different biomarkers on the relationship between adult weight gain and colorectal cancer, using data from a prospective nested case-control study of 452 incident cases diagnosed between 1992 and 2003 and matched within risk sets to 452 controls within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. The proportions of mediated effects (%) were estimated on the basis of differences in percent effect changes in conditional logistic regression models with and without additional adjustment for individual biomarkers. Greater adult weight gain (≥300 g/year vs. <300 g/year) was associated with a higher risk of colon cancer (multivariable-adjusted relative risk = 1.54, 95% confidence interval: 1.07, 2.24) but not rectal cancer (relative risk = 1.07, 95% confidence interval: 0.68, 1.66). This association was accounted for mostly by attained waist circumference (reduction of 61%) and by the biomarkers soluble leptin receptor (reduction of 43%) and glycated hemoglobin (reduction of 28%). These novel data suggest that the observed association between adult weight gain and colon cancer could be primarily explained by attained abdominal fatness and biomarkers of metabolic dysfunction.

Cell-type specific expression of p11 controls cocaine reward

BACKGROUND

The high rate of comorbidity between depression and cocaine addiction suggests shared molecular mechanisms and anatomical pathways. Limbic structures, such as the nucleus accumbens (NAc), play a crucial role in both disorders, yet how different cell types within these structures contribute to the pathogenesis remains elusive. Downregulation of p11 (S100A10), specifically in the NAc, elicits depressive-like behaviors in mice, but its role in drug addiction is unknown.

METHODS

We combined mouse genetics and viral strategies to determine how the titration of p11 levels within the entire NAc affects the rewarding actions of cocaine on behavior (six to eight mice per group) and molecular correlates (three experiments, five to eight mice per group). Finally, the manipulation of p11 expression in distinct NAc dopaminoceptive neuronal subsets distinguished cell-type specific effects of p11 on cocaine reward (five to eight mice per group).

RESULTS

We demonstrated that p11 knockout mice have enhanced cocaine conditioned place preference, which is reproduced by the focal downregulation of p11 in the NAc of wild-type mice. In wild-type mice, cocaine reduced p11 expression in the NAc, while p11 overexpression exclusively in the NAc reduced cocaine conditioned place preference. Finally, we identified dopamine receptor-1 expressing medium spiny neurons as key mediators of the effects of p11 on cocaine reward.

CONCLUSIONS

Our data provide evidence that disruption of p11 homeostasis in the NAc, particularly in dopamine receptor-1 expressing medium spiny neurons, may underlie pathophysiological mechanisms of cocaine rewarding action. Treatments to counter maladaptation of p11 levels may provide novel therapeutic opportunities for cocaine addiction.

Integrating user perspectives into the development of a web-based weight management intervention

The objective of this study was to adapt the design of our weight management intervention to the needs, expectations and capabilities of potential users. In study 1, we interviewed 25 people about their experiences of weight management. The findings of these interviews were combined with findings from existing theory and research in a process of 'intervention planning' that informed the design of the intervention. Study 2 comprised in-depth think-aloud studies with a further 16 people interested in using a web-based intervention to manage their weight, in order to elicit reactions to the intervention techniques and materials. In study 1, overly intrusive and restrictive aspects of eating self-regulation were commonly cited reasons for failure to maintain weight management long-term. We therefore designed an intervention with a more flexible approach to autonomous self-regulation. This approach was broadly welcomed in study 2, but there were indications that some participants might have difficulty effectively implementing self-regulation techniques independently. A flexible and autonomous approach to changing eating habits is attractive to potential intervention users but may be difficult for some users to implement successfully.

Predictors of unintentional injuries to school-age children seen in pediatric primary care

OBJECTIVE

To identify predictors of unintentional injury to school-age children seen in pediatric primary care.

METHODS

Members of a managed health care system (295 children ages 5-11 years and their mothers) participated. We used Time 1 measures of child, maternal, and family functioning and health care utilization to predict rates of unintentional child injury for the following year. Multiple regression analyses were performed to identify variables contributing to prospective injury rates.

RESULTS

The final regression model included eight Time 1 variables and accounted for 21% of the variance in Time 2 injury rates. Significant predictors of increased injury liability were younger child age, more children at home, child behavior problems, child social competence, three indices of reduced child health, and maternal anxiety.

CONCLUSIONS

We discuss the utility of these predictors for pediatric psychologists in targeting primary care preventive interventions to families at risk for unintentional child injury.

Prevention of medication errors. Developing a continuous-quality-improvement approach

Medication errors can be a serious problem that exposes patients to preventable risks. Although medication errors are often considered primarily a nursing issue, every health care provider plays an important role in medication error prevention. A continuous quality improvement philosophy with involvement of a multidisciplinary team is the optimal method for identifying and correcting the causes of medication errors. Careful analysis of the medication distribution system and identification of system flaws is an integral part of the continuous quality improvement process.

Generation of a human hybridoma producing a pure anti-HLA-A2 monoclonal antibody

We report the production and characterization of a human monoclonal IgM hybridoma antibody recognizing antigen HLA-A2. B lymphocytes obtained from the peripheral blood of a multiparous volunteer 1 week postpartum were transformed in vitro by Epstein-Barr virus, screened by a microlymphocytotoxicity assay, and electrofused with the heterohybridoma fusion partner, K6H6/B5. A specifically anti-A2 secreting hybridoma cell line. MBW1, was then identified and cloned. The cytotoxic IgM antibody produced showed complete correlation (r = 1.00) with the A2 antigen on a large panel of unrelated donors' lymphocytes, and no cross-reactivity with A28, Aw68, or Aw69 antigens was observed.

Effect of pituitary gonadotrophins on proliferation of primary cultures of human ovarian stroma

Proliferation of ovarian stromal cells is a common phenomenon in peri- and post-menopausal ovaries. It is generally assumed to be secondary to the rise in circulating gonadotrophins at the menopause, though the process by which it occurs is poorly understood. This study aimed to examine the effect of menopausal levels of pituitary gonadotrophins on the growth of primary cultures of ovarian stroma. A culture system was developed using primary explants of ovarian stroma on a collagen substrate. The effect of follicle stimulating hormone (FSH; 10(-5) g/l) and luteinizing hormone (LH; 10(-5) g/l) on the proliferation of cultures derived from the cortices and medullae of ten ovaries was evaluated using a dual radiothymidine labelling technique. FSH was stimulatory to cortical cultures from 9/10 ovaries and medullary cultures from 7/10 ovaries, while LH was stimulatory to cortical cultures from 6/9 ovaries and medullary cultures from 5/10 ovaries. The responsiveness of the cultures did not correlate with the degree of hyperplasia in vivo. This study demonstrates that pituitary gonadotrophins may modulate the growth of stromal cells in culture, and thus may play a role in the process whereby stromal proliferation occurs in peri- and post-menopausal ovaries.

Use of antimicrobial agents in a university teaching hospital. Evolution of a comprehensive control program

A comprehensive control program for utilization of anti-microbial agents in a large tertiary university teaching hospital regulates both dosage and duration of therapy and requires the prior approval of an infectious disease specialist for utilization of restricted antimicrobial agents. Benefits of the program include more cost-effective antimicrobial therapy and increased physician education in the use of these drugs. Gross savings in pharmacy costs for antibiotics during the first year of the program (1985) amounted to +483,032 for an average monthly savings of +40,252. Gross savings for 1986 were +211,786 with monthly savings of +17,648. The control of the use of one agent may lead to overuse of another agent. Antimicrobial prescribing patterns of physicians are quickly influenced by changing regulations of the program. An ongoing surveillance and review program of in-hospital utilization of antimicrobial agents is necessary to maintain effective and flexible controls.

Late Niemann-Pick disease with neurovisceral storage: a classification problem

A 51 year old man presented in 1969 with slowly progressive cerebellar ataxia of unknown origin. He was admitted to hospital aged 68 after a fall, and a ruptured spleen was removed at laparotomy. Histological analysis of the spleen suggested Niemann-Pick disease, which was subsequently confirmed. He deteriorated and died of bronchopneumonia shortly afterwards: subdural haemorrhage with storage material in neurones was found at necropsy. This late onset case of Niemann-Pick disease with neurovisceral storage is unusual and may represent a variant.

Multiple sclerosis: effects of activated T-lymphocyte-derived products on organ cultures of nervous tissue

Supernatants from multiple sclerosis (MS) T-lymphocytes cause damage to both myelin and glial cells in cerebellar cultures assessed visually and by radiolabel release. Control T-lymphocytes, even after phytohaemagglutinin (PHA) stimulation, yielded supernatants which induced only slight damage, and at later times patients with other neurological diseases (OND) gave variable results. These differences suggest that MS T-lymphocytes are pre-activated in vivo to produce demyelinating factors while control T-lymphocytes are not pre-activated to the same extent. The visual evidence of activation of cerebellar macrophage-like cells was a common finding after MS T-lymphocyte supernatant treatment but there was no correlation with the severity of demyelination. There was a positive correlation between the percentage IL-2 receptor-bearing lymphocytes and the degree of supernatant-induced in vitro demyelination.

Pharmacokinetic properties of mezlocillin in ambulatory elderly subjects

Twelve healthy ambulatory elderly subjects (mean age, 73-78 years) randomly received either a 4-g or 5-g dose of mezlocillin intravenously. One week later the regimen was repeated and patients crossed over to the other dose. Peak serum concentrations were 165 mg/L and 281 mg/L for the 4-g and 5-g doses, respectively. For both doses, differences in t1/2 beta (1.32 hr vs 1.13 hr), AUC (275 mg.hr/L vs 403 mg.hr/L), CL (207 mL/min vs 174 mL/min), CLR (59 mL/min vs 45 mL/min), CLNR (152 mL/min vs 130 mL/min) were not statistically significant. The differences in Varea (22.4L vs 168.8L, P less than or equal to .01) and Cmax (216.6 mg/L vs 317 mg/L, P less than or equal to .05) were statistically significant. Comparison with pharmacokinetic parameters obtained in younger subjects following the 5-g dose reveals that in the elderly the AUC, Varea, and CLNR are higher whereas the CL and CLR are lower. The elderly demonstrated an increase in nonrenal clearance compared with young subjects that is not fully compensatory. The increased AUC in the elderly group suggests that clinical studies examining mezlocillin doses and dose intervals in the treatment of serious infections are warranted in infected elderly patients.

Cost-benefit analysis of an aminoglycoside monitoring service

The clinical and financial impact of an aminoglycoside monitoring service was determined. All patients admitted to a 74-bed general medicine unit and treated with tobramycin or gentamicin during a six-month study period were eligible for the study. The first three months served as a control period during which pharmacists used published audit criteria and modifications of those criteria to monitor the appropriateness of gentamicin and tobramycin use in patients but did not attempt to intervene in aminoglycoside prescribing. During the next three months, pharmacists provided physicians with recommendations for choice of drug, coordinated blood sampling times, and designed individualized dosage regimens for all patients treated with gentamicin or tobramycin. Data for financial analysis were obtained from pharmacy profiles and medical records, and the cost:benefit ratio for the service was calculated. A total of 118 patients were included in the study. Significant improvements in appropriateness of tobramycin therapy, adequacy of loading dose, frequency of monitoring for ototoxicity, and serum concentration monitoring were noted in the intervention group. Despite an increase in gentamicin use from 20% in the control group to 61% in the intervention group, the incidence of aminoglycoside toxicity did not increase significantly. The cost:benefit ratio was 1.13, which indicates that the service is an appropriate use of resources. The aminoglycoside monitoring service had a favorable impact on the use and cost of aminoglycoside antibiotics. Expansion of the service to all areas of the hospital served by satellite pharmacies could reduce drug expenditures by as much as $55,000 per year.

Comparison of in vitro demyelination and cytotoxicity of humoral factors in multiple sclerosis and other neurological diseases

The distribution and nature of serum factors causing in vitro demyelination and glial lysis were investigated in multiple sclerosis (MS), other neurological diseases (OND), ill control and control groups. MS sera were unique in affecting only CNS myelin and glia whereas stroke and Guillain-Barré syndrome (GBS) sera brought changes to both CNS and PNS tissue. Through both visual scoring of myelin damage and the quantitative measurement of radiolabel release from cerebellar cultures, it was evident that the MS and OND groups have similar myelino- and cytotoxic effects. This may reflect MS and OND sera sharing similar humoral factors. 74% MS, 68% OND and 22% of control scores were above a score threshold designed to exclude culture handling trauma effects. When classified by their current disease state MS patients with severe and mild disease yielded higher in vitro scores than did those with moderate disease who comprised an older age group. No other clinical features of MS patients gave any association with in vitro serum effects. The rare demonstration of bound Fab IgG in cultures after MS serum tests indicates that immune mechanisms are unlikely to make a large contribution to serum-induced demyelination and cellular change in vitro.

In vitro toxicity of MS sera correlates with new clinical signs

In vitro toxicity of sera from 10 MS patients was followed for up to 3 years. Myelinotoxicity and cytotoxicity measured as radiolabel release from rat cerebellar explants were almost continuously higher in than in controls while peaks of radiolabel release were associated with the emergence of new clinical signs in the MS patients.

Role of complement in demyelination in vitro by multiple sclerosis serum and other neurological disease sera

Multiple sclerosis (MS) sera can demyelinate and cause selective cellular changes to organ cultures of rodent CNS which suggests possible immunoglobulin involvement. The complement dependence of this serum action was investigated using complement-inactivating agents and radiolabelled rat cerebellar cultures. After heat inactivation at 56 degrees C, the in vitro effects of MS, chronic relapsing experimental allergic encephalomyelitis (cr-EAE) and Guillain-Barré syndrome (GBS) sera were severely reduced or eliminated as measured by radiolabel release. On introducing a source of fresh complement, the cr-EAE and GBS serum effects were largely restored whereas MS serum effects remained suppressed. Inactivation of serum complement with mercaptoethanol and Zymosan was associated with marked reduction in serum myelinotoxicity; some restoration of in vitro effects was possible on adding fresh complement although this occurred to a greater extent with cr-EAE and GBS than with MS sera. Inactivation of the alternative complement pathway brought a limited reduction in MS serum activity in vitro which was not restored with fresh complement. It is concluded that complement is involved only to a limited extent in MS serum myelinotoxic effects and that MS serum effects in vitro are due to several components of which thermolabile substances make a significant contribution and are as yet uncharacterised.

Ethanolamine glycerophospholipid formation by decarboxylation of serine glycerophospholipids in myelinating organ cultures of cerebellum

Serine decarboxylation as a source of glycerophospholipid ethanolamine is known to occur in mammals. However, early investigators failed to demonstrate the pathway in brain. In the present study serine is shown to be decarboxylated to glycerophospholipid ethanolamine in myelinating organ cultures of rat cerebellum up to 32 days in vitro. The pattern of incorporation of L-[3-14C]serine into culture phospholipids strongly suggests a precursor-product relationship between serine glycerophospholipids (SGP) and ethanolamine glycerophospholipids (EGP), with serine label appearing in the ethanolamine moiety of EGP. The time course of labelling was similar for both acid-stable and acid-labile EGP. In contrast DL-[1-14C]serine failed to label EGP significantly due to the loss of serine carbon C1 on decarboxylation. Through the systematic hydrolysis of phospholipids from cerebellar cultures incubated with L-[3-14C], it was clear that in SGP, acid-stable EGP, and acid-labile EGP greater than to 70% of radiolabel resides in the base moiety of each of these molecular species. It is proposed that serine decarboxylation as a source of EGP ethanolamine may be important in the early stages of brain development.

New approach to study of in vitro toxicity of multiple sclerosis and other sera

The in vitro effects of MS and control sera were quantified by the measurement of radiolabel released from myelinated cultures of rat cerebellum and compared with a visual assessment of myelin damage. Radiolabel release gave a sensitive index of serum effects in vitro which was free of the score assignment decisions that are associated with the visual assessment of myelin damage. Examination of the patterns of radiolabel release elicited by MS and control sera on cultures labelled with either L-[5-3H]tryptophan or galacto-D-[6-3H]cerebroside indicates that MS serum effects are not simply a stronger expression of the weak control serum effects.

Variability of fiber type distributions within human muscles

The variability of fiber type distributions between different regions of the same human muscle is believed to be small, based on the sampling of between two and four sites. The objective of the present investigation was to determine the variability of slow-twitch (ST) and fast-twitch (FT) fiber distributions using a more extensive sampling technique than those previously employed. The soleus, biceps, triceps, and vastus lateralis muscles were excised from each of four young men who had died suddenly. Between 13 and 17 sites were sampled from each of the muscles; 3 transverse areas were then examined within each sample. Fiber type distributions were determined from photographs of sections stained for myofibrillar adenosine triphosphatase at pH 10.3, 10.0, or 4.3. The numbers of fibers counted in the four muscles ranged between a mean of 13,660 and a mean of 21,601. The variability in fiber type distributions observed between sites and areas within a site were statistically greater (P less than 0.01) than could be expected from muscles whose fiber type distributions are equally distributed throughout the muscle. It was concluded that sampling between 3 and 5 sites in the different muscles was necessary to reduce the between-site standard deviation to 5%.

Effect of intrauterine contraceptive device on uterine haemostasis: a morphological study

The effect of the intrauterine contraceptive device (IUCD) on uterine haemostasis was studied at various stages of the menstrual cycle in a series of 46 patients by light- and electron-microscopy and by following the distribution of an infusion of 51Cr-labelled autologous platelets. The endometrium in contact with the IUCD in the majority of cases showed grooving with atrophy and mild chronic inflammation in the surrounding tissues. The adjacent stroma also showed increased vascularity and occasional foci of haemorrhage but the increased blood loss associated with the presence of the IUCD could not be attributed to mechanical erosion or stromal blood vessels by the device. During menstruation the presence of an IUCD does not appear to inhibit the formation of fibrin/platelet thrombi although both in control and IUCD patients there was a striking paucity of platelet/fibrin thrombi in circumstances where their formation should be enhanced. In contrast to other workers we have not observed that gaps or breaks in the endothelial lining of endometrial blood vessels occur with any greater frequency in patients fitted with an IUCD. The principal mechanism by which uterine haemostasis is achieved remains to be established.

Heparin-like activity in uterine fluid

Uterine fluid was collected from a group of normal patients and a group of patients with menorrhagia. Heparin-like activity was detected in 34 out of 38 samples using an anti-Xa heparin assay. The heparin-like activity in uterine fluid was inhibited by adding the heparin antagonist hexadimethrine bromide to the assay. Concentrations of fibrinogen-fibrin degradation products (FDPs) were measured in five samples of uterine fluid. FDPs in the concentration detected had no effect on the anti-Xa assay. Heparin-like activity was higher in the group with menorrhagia, although the differences were not significant. Heparin-like activity increased throughout the menstrual cycle and decreased during menstruation, suggesting a possible cyclical variation in activity. There was no correlation between mast cell numbers in the endometrium and myometrium and heparin-like activity in uterine fluid and no correlation between the numbers and the stage in the menstrual cycle. In a few patients with intrauterine contraceptive devices (IUCDs) heparin-like activity was increased.

Abnormal myelin maturation in vitro: the role of cerebrosides

Myelinating neonatal rat cerebellar explants were maintained for up to 130 days in vitro. Myelin fractions were extracted from explants of different ages and purified by density gradient centrifugation. Three fractions obtained were termed "light myelin", "heavy myelin" and "membrane fraction" and were deficient in glycolipids compared to myelin fractions prepared from 15-day-old rat cerebellum. The culture myelin has an apparently normal ultrastructure but may not be as stable as myelin with a normal glycolipid composition.

Hepatic damage associated with mineral oil deposits

The case of a 33 year old male is reported. Hepatic inflammation and scarring were associated with deposits of mineral oil in portal triads. This is believed to be the first reported case of hepatic damage resulting from mineral oil accumulation. Possible sources of the oil are considered.