618 A Registrar - Delivered Urology Experience Improves Medical Student Knowledge of the Subject and Increases Interest in a Surgical Career

Introduction

Exposure to Urology is thought to vary considerably between medical schools, leading to a lack of competence by foundation doctors in basic urological skills and knowledge, and perhaps low interest in a urological / surgical career. In our hospital students had no dedicated Urology placement until 2020.

Method

A weeklong Urology placement was designed for 3rd year students. This comprised tutorials on topics set out by the university curriculum, a catheter insertion simulation session, and regular theatre and ward rounds. Most students also had the opportunity to insert a catheter on the ward / theatre. Students were encouraged to complete The National Catheter Education Programme, an online course providing a point for CST applications. This placement is registrar delivered, giving a more accurate idea of what a surgical career involves. Student feedback was obtained on the first and last days to ascertain self-rated confidence on a Likert-type scale regarding urological key topics, as well as career intentions.

Results

Self – rated knowledge on the 5 identified topics at the start of the week was most likely to be “Poor,” and by the end “Good” or “Very good.” By the end of the week most students indicated they were much more likely to pursue a career in surgery, although the same response was not seen as strongly for the subspeciality of Urology.

Conclusions

The placement continues to run and develop based on feedback. We look forward with interest to the publication of LEARN (uroLogical tEAching in bRitish medical schools Nationally) — a multicentre audit – to further inform this project.

Intermittent PI3Kδ inhibition sustains anti-tumour immunity and curbs irAEs

Phosphoinositide 3-kinase δ (PI3Kδ) has a key role in lymphocytes, and inhibitors that target this PI3K have been approved for treatment of B cell malignancies1-3. Although studies in mouse models of solid tumours have demonstrated that PI3Kδ inhibitors (PI3Kδi) can induce anti-tumour immunity4,5, its effect on solid tumours in humans remains unclear. Here we assessed the effects of the PI3Kδi AMG319 in human patients with head and neck cancer in a neoadjuvant, double-blind, placebo-controlled randomized phase II trial (EudraCT no. 2014-004388-20). PI3Kδ inhibition decreased the number of tumour-infiltrating regulatory T (Treg) cells and enhanced the cytotoxic potential of tumour-infiltrating T cells. At the tested doses of AMG319, immune-related adverse events (irAEs) required treatment to be discontinued in 12 out of 21 of patients treated with AMG319, suggestive of systemic effects on Treg cells. Accordingly, in mouse models, PI3Kδi decreased the number of Treg cells systemically and caused colitis. Single-cell RNA-sequencing analysis revealed a PI3Kδi-driven loss of tissue-resident colonic ST2 Treg cells, accompanied by expansion of pathogenic T helper 17 (TH17) and type 17 CD8+ T (TC17) cells, which probably contributed to toxicity; this points towards a specific mode of action for the emergence of irAEs. A modified treatment regimen with intermittent dosing of PI3Kδi in mouse models led to a significant decrease in tumour growth without inducing pathogenic T cells in colonic tissue, indicating that alternative dosing regimens might limit toxicity.

Identification of Distinct Long COVID Clinical Phenotypes Through Cluster Analysis of Self-Reported Symptoms

Background

We aimed to describe the clinical presentation of individuals presenting with prolonged recovery from coronavirus disease 2019 (COVID-19), known as long COVID.

Methods

This was an analysis within a multicenter, prospective cohort study of individuals with a confirmed diagnosis of COVID-19 and persistent symptoms >4 weeks from onset of acute symptoms. We performed a multiple correspondence analysis (MCA) on the most common self-reported symptoms and hierarchical clustering on the results of the MCA to identify symptom clusters.

Results

Two hundred thirty-three individuals were included in the analysis; the median age of the cohort was 43 (interquartile range [IQR], 36–54) years, 74% were women, and 77.3% reported a mild initial illness. MCA and hierarchical clustering revealed 3 clusters. Cluster 1 had predominantly pain symptoms with a higher proportion of joint pain, myalgia, and headache; cluster 2 had a preponderance of cardiovascular symptoms with prominent chest pain, shortness of breath, and palpitations; and cluster 3 had significantly fewer symptoms than the other clusters (2 [IQR, 2–3] symptoms per individual in cluster 3 vs 6 [IQR, 5–7] and 4 [IQR, 3–5] in clusters 1 and 2, respectively; P < .001). Clusters 1 and 2 had greater functional impairment, demonstrated by significantly longer work absence, higher dyspnea scores, and lower scores in SF-36 domains of general health, physical functioning, and role limitation due to physical functioning and social functioning.

Conclusions

Clusters of symptoms are evident in long COVID patients that are associated with functional impairments and may point to distinct underlying pathophysiologic mechanisms of disease.

Targeting the tumor mutanome for personalized vaccination in a TMB low non-small cell lung cancer

BACKGROUND

Cancer is characterized by an accumulation of somatic mutations, of which a significant subset can generate cancer-specific neoepitopes that are recognized by autologous T cells. Such neoepitopes are emerging as important targets for cancer immunotherapy, including personalized cancer vaccination strategies.

METHODS

We used whole-exome and RNA sequencing analysis to identify potential neoantigens for a patient with non-small cell lung cancer. Thereafter, we assessed the autologous T-cell reactivity to the candidate neoantigens using a long peptide approach in a cultured interferon gamma ELISpot and tracked the neoantigen-specific T-cells in the tumor by T-cell receptor (TCR) sequencing. In parallel, identified gene variants were incorporated into a Modified Vaccinia Ankara-based vaccine, which was evaluated in the human leucocyte antigen A*0201 transgenic mouse model (HHD).

RESULTS

Sequencing revealed a tumor with a low mutational burden: 2219 sequence variants were identified from the primary tumor, of which 23 were expressed in the transcriptome, involving 18 gene products. We could demonstrate spontaneous T-cell responses to 5/18 (28%) mutated gene variants, and further analysis of the TCR repertoire of neoantigen-specific CD4+ and CD8+ T cells revealed TCR clonotypes that were expanded in both blood and tumor tissue. Following vaccination of HHD mice, de novo T-cell responses were generated to 4/18 (22%) mutated gene variants; T cells reactive against two variants were also evident in the autologous setting. Subsequently, we determined the major histocompatibility complex restriction of the T-cell responses and used in silico prediction tools to determine the likely neoepitopes.

CONCLUSIONS

Our study demonstrates the feasibility of efficiently identifying tumor-specific neoantigens that can be targeted by vaccination in tumors with a low mutational burden, promising successful clinical exploitation, with trials currently underway.

Publisher Correction: Actively personalized vaccination trial for newly diagnosed glioblastoma

The additional author support information was erroneously omitted from the Supplementary Information. This has been corrected online.

Actively personalized vaccination trial for newly diagnosed glioblastoma

Patients with glioblastoma currently do not sufficiently benefit from recent breakthroughs in cancer treatment that use checkpoint inhibitors1,2. For treatments using checkpoint inhibitors to be successful, a high mutational load and responses to neoepitopes are thought to be essential3. There is limited intratumoural infiltration of immune cells4 in glioblastoma and these tumours contain only 30-50 non-synonymous mutations5. Exploitation of the full repertoire of tumour antigens-that is, both unmutated antigens and neoepitopes-may offer more effective immunotherapies, especially for tumours with a low mutational load. Here, in the phase I trial GAPVAC-101 of the Glioma Actively Personalized Vaccine Consortium (GAPVAC), we integrated highly individualized vaccinations with both types of tumour antigens into standard care to optimally exploit the limited target space for patients with newly diagnosed glioblastoma. Fifteen patients with glioblastomas positive for human leukocyte antigen (HLA)-A*02:01 or HLA-A*24:02 were treated with a vaccine (APVAC1) derived from a premanufactured library of unmutated antigens followed by treatment with APVAC2, which preferentially targeted neoepitopes. Personalization was based on mutations and analyses of the transcriptomes and immunopeptidomes of the individual tumours. The GAPVAC approach was feasible and vaccines that had poly-ICLC (polyriboinosinic-polyribocytidylic acid-poly-L-lysine carboxymethylcellulose) and granulocyte-macrophage colony-stimulating factor as adjuvants displayed favourable safety and strong immunogenicity. Unmutated APVAC1 antigens elicited sustained responses of central memory CD8+ T cells. APVAC2 induced predominantly CD4+ T cell responses of T helper 1 type against predicted neoepitopes.

Abstract P5-16-01: Documenting and sharing breast cancer knowledge from National Cancer Institute designated comprehensive cancer centers (NCI-CCCs) with community oncologists

Introduction:Tumor boards (TB) at National Cancer Institute Designated Comprehensive Cancer Centers (NCI-CCC) are an important source of multidisciplinary education. Unfortunately, expert knowledge from NCI-CCCs is not systematically documented and made accessible to oncologists in the community. This represents a lost opportunity to capture and share clinical expertise that can impact patient care in community centers. Using an online oncologist-only social network, we sought to demonstrate the feasibility of systematically documenting expert insights from TBs and department conferences at NCI-CCCs in order to expand their reach and provide educational benefit to the greater oncology community.

Methods: A pilot program was developed at the University of Texas MD Anderson Cancer Center (MDACC) to design a process in which discussions at departmental breast cancer conferences would be distilled down to clinical questions and answers (Q&A) and posted on theMednet.org, an online social Q&A website of over 3,800 US oncologists. An educational breast cancer conference was selected during a site visit. A faculty member was selected to distil discussions about patient management from the selected conference into a question that addressed the clinical situation being discussed. After the question was posted, the oncologist leading the discussion answered the question on theMednet. The Q&A was then indexed and stored for easy search retrieval and disseminated in a weekly newsletter to all registered medical oncologists. A detailed manual was created to document operating procedures for implementation at additional institutions.

Results: After developing the process at MDACC, the program was expanded to 2 additional NCI-CCCs- University of Pittsburgh (UPMC) and UCLA. The educational breast cancer conferences selected varied by site and were the new patient planning conference at MDACC, tumor board at UPMC, and multidisciplinary clinic at UCLA. The most significant factor for success was involvement of one faculty member who regularly identified educational questions and additional faculty who posted their answers. Between December 2016 and May 2017, 17 answers to 17 questions were posted and shared with over 1,200 medical oncologists via an email newsletter. All questions were focused on topics not answered by NCCN or ASCO guidelines. The majority of questions focused on management decisions around chemotherapy and endocrine therapy. Answers were viewed by 339 oncologists at 260 institutions in 47 states. This included 190 community practices and 70 academic medical centers.

Conclusion: We developed a process of capturing and sharing expert knowledge at NCI-CCC breast cancer conferences on questions not answered by current guidelines. These discussions are otherwise not documented or shared outside of academic centers. By translating discussions into actionable Q&A on an online oncologist network, we made them easily accessible to oncologists at nearly 200 community practices. Future efforts will be aimed at implementing the program into the breast cancer programs at additional NCI-CCCs.

Citation Format: Kalra M, Karuturi M, Tripathy D, Jankowitz R, McCann K, Brufsky A, Hurvitz S, Bogler O, Housri S, Housri N. Documenting and sharing breast cancer knowledge from National Cancer Institute designated comprehensive cancer centers (NCI-CCCs) with community oncologists [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-16-01.

Spontaneous food allergy in Was-/- mice occurs independent of FcεRI-mediated mast cell activation

BACKGROUND

Food allergies are a growing health problem, and the development of therapies that prevent disease onset is limited by the lack of adjuvant-free experimental animal models. We compared allergic sensitization in patients with food allergy or Wiskott-Aldrich syndrome (WAS) and defined whether spontaneous disease in Was^-/- mice recapitulates the pathology of a conventional disease model and/or human food allergy.

METHODS

Comparative ImmunoCAP ISAC microarray was performed in patients with food allergy or WAS. Spontaneous food allergy in Was^-/- mice was compared to an adjuvant-based model in wild-type mice (WT-OVA/alum). Intestinal and systemic anaphylaxis was assessed, and the role of the high-affinity IgE Fc receptor (FcεRI) in allergic sensitization was evaluated using Was^-/- Fcer1a^-/- mice.

RESULTS

Polysensitization to food was detected in both WAS and food-allergic patients which was recapitulated in the Was^-/- model. Oral administration of ovalbumin (OVA) in Was^-/- mice induced low titers of OVA-specific IgE compared to the WT-OVA/alum model. Irrespectively, 79% of Was^-/- mice developed allergic diarrhea following oral OVA challenge. Systemic anaphylaxis occurred in Was^-/- mice (95%) with a mortality rate >50%. Spontaneous sensitization and intestinal allergy occurred independent of FcεRI expression on mast cells (MCs) and basophils.

CONCLUSIONS

Was^-/- mice provide a model of food allergy with the advantage of mimicking polysensitization and low food-antigen IgE titers as observed in humans with clinical food allergy. This model will facilitate studies on aberrant immune responses during spontaneous disease development. Our results imply that therapeutic targeting of the IgE/FcεRI activation cascade will not affect sensitization to food.

Approach to fever assessment in ambulatory cancer patients receiving chemotherapy: a clinical practice guideline

BACKGROUND

This guideline was prepared by the Fever Assessment Guideline Development Group, a group organized by the Program in Evidence-Based Care at the request of the Cancer Care Ontario Systemic Treatment Program. The mandate was to develop a standardized approach (in terms of definitions, information, and education) for the assessment of fever in cancer patients receiving chemotherapy.

METHODS

The guideline development methods included a search for existing guidelines, literature searches in medline and embase for systematic reviews and primary studies, internal review by content and methodology experts, and external review by targeted experts and intended users.

RESULTS

The search identified eight guidelines that had partial relevance to the topic of the present guideline and thirty-eight primary studies. The studies were mostly noncomparative prospective or retrospective studies. Few studies directly addressed the topic of fever except as one among many symptoms or adverse effects associated with chemotherapy. The recommendations concerning fever definition are supported mainly by other existing guidelines. No evidence was found that directly pertained to the assessment of fever before a diagnosis of febrile neutropenia was made. However, some studies evaluated approaches to symptom management that included fever among the symptoms. Few studies directly addressed information needs and resources for managing fever in cancer patients.

CONCLUSIONS

Fever in patients with cancer who are receiving systemic therapy is a common and potentially serious symptom that requires prompt assessment, but currently, evidence to inform best practices concerning when, where, and by whom that assessment is done is very limited.

DNA vaccination with electroporation induces increased antibody responses in patients with prostate cancer

We are evaluating the use of electroporation (EP) to deliver a novel DNA vaccine, p.DOM-PSMA(27). This vaccine encodes a domain (DOM) of fragment C of tetanus toxin to induce CD4(+) T cell help, fused to a tumor-derived epitope from prostate-specific membrane antigen (PSMA) for use in HLA-A2(+) patients with recurrent prostate cancer. We report on safety and tolerability and on antibody response to DOM as a first indication of the effect of EP in patients. In this open label phase I/II, two-arm, dose escalation trial DNA was delivered either by intramuscular injection or by intramuscular injection followed by EP (DNA+EP), with five patients per dose level. Three vaccinations were given at 0, 4, and 8 weeks,with booster doses at 24 and 48 weeks; here we allowed crossover between study arms if supported by the safety and immunological data. In the 20 patients in the first two dose cohorts we observed that beyond brief and acceptable pain at the injection site, EP did not appear to add toxicity to the vaccination. We evaluated humoral responses to DOM. Low anti-DOM IgG antibody responses were observed after intramuscular injection of DNA without EP (at week 12: mean 1.7- vs. 24.5-fold increase over baseline with DNA+EP). These could be boosted by delivery of DNA+EP at later time points. Delivery of DNA+EP at all five vaccinations yielded the highest levels of anti-DOM antibody. Responses persisted to 18 months of follow-up. These data establish EP as a potent method for stimulating humoral responses induced by DNA vaccination in humans.

Idiotype gene rescue in follicular lymphoma

Beyond the morphological, immunophenotypic, and genetic information used for the diagnosis of lymphoid malignancies, molecular analyses have deepened our insights into the development of B-cell lymphomas. We have learned that B-cell tumors can be grouped according to the mutational status of their immunoglobulin variable (V) region genes, and this has become an important prognostic tool in chronic lymphocytic leukemia. The analysis of V genes also has allowed us to more precisely place B-cell lymphomas relative to their normal B-cell counterparts and to the germinal center where somatic hypermutation takes place. It has become evident that many of the common B-cell tumors arise at this site and are able to respond to stimuli, which govern normal B-cells. In this chapter, we focus on the analysis of V genes in follicular lymphomas based on the experience in our laboratory and provide a detailed guide for this analysis.

Non-local Concepts and Models in Biology

In this paper, we consider local and non-local spatially explicit mathematical models for biological phenomena. We show that, when rate differences between fast and slow local dynamics are great enough, non-local models are adequate simplifications of local models. Non-local models thus avoid describing fast processes in mechanistic detail, instead describing the effects of fast processes on slower ones. As a consequence, non-local models are helpful to biologists because they describe biological systems on scales that are convenient to observation, data collection, and insight. We illustrate these arguments by comparing local and non-local models for the aggregation of hypothetical organisms, and we support theoretical ideas with concrete examples from cell biology and animal behavior.

Fatigue in persons with renal failure who require maintenance haemodialysis

Fatigue is a highly prevalent symptom experienced by persons who live with chronic illness, including those with renal failure who require maintenance haemodialysis. Fatigue, however, is a non-specific and invisible symptom and is a phenomenon that is poorly understood by health care professionals. This study examined the symptom of fatigue as experienced by a group of 39 adult haemodialysis patients. The theory of unpleasant symptoms formed the conceptual framework for the study. A descriptive correlational design was utilized to examine fatigue from an inductive approach, considering relevant physiological, psychological and situational variables based on a review of the literature. Data were collected using a structured self-report questionnaire and biochemical data from retrospective monthly blood tests. The results of the study indicated that high levels of fatigue are experienced, with correspondingly low levels of vitality, in all the areas measured - general fatigue, physical fatigue, reduced motivation, reduced activity and mental fatigue, by adult haemodialysis patients. Individual variation was noted in the dimensions of fatigue predominantly expressed. Fatigue was significantly associated with the presence of symptoms such as sleep problems, poor physical health status and depression. No associations between fatigue and the biochemical and situational variables measured were noted. Further examination of the data revealed complex relationships between the physiological and psychological factors examined. Depression was significantly associated with physical health status, sleep problems, symptoms and anxiety. Correlations were also noted between symptoms and poor physical functioning, sleep problems and depression. Based on the results, a revised version of the theory of unpleasant symptoms relating to fatigue is presented.

Population outbreaks in a discrete world

We present and analyze a simple three-patch host-parasitoid model where population growth is discrete. The model gives solutions that are qualitatively similar to the stable large-amplitude patterns in space found in reaction-diffusion theory. In the context of host-parasitoid interactions, the large-amplitude portions of the solution can be thought of as spatially localized host population outbreaks. Here, we show that the biological requirements for localized population outbreaks in a discrete world are identical to those found in reaction- diffusion theory. Furthermore, the model conveniently allows investigation into the robustness of these population outbreaks under the influence of density-dependent dispersal behavior. We find that localized population outbreaks in space can still occur with modest amounts of pursuit and aggregative behavior by parasitoids. We end by showing that evidence from a real host-parasitoid system is consistent with the predictions of the model.

Suicide within 12 months of contact with mental health services: national clinical survey

OBJECTIVE

To describe the clinical circumstances in which psychiatric patients commit suicide.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death.

MAIN OUTCOME MEASURES

Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending.

RESULTS

10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases.

CONCLUSIONS

Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

Mental disorder and clinical care in people convicted of homicide: national clinical survey

OBJECTIVES

To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

Eighteen month sample of people convicted of homicide.

MAIN OUTCOME MEASURES

Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services.

RESULTS

718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide.

CONCLUSIONS

There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions.

On the stabilizing role of stage structure in piscene consumer-resource interactions

A stage-structured consumer-resource model is investigated using plausible biological parameter estimates. The model, developed from patterns in energy allocation across fish life-history strategies, explicitly considers the effects of delays in maturation on juvenile growth and mortality. It is found that stage structure in the consumer fish population tends to locally stabilize consumer-resource dynamics for realistic parameters. Additionally, it is shown that stage structure bounds nonequilibrium behavior relative to the case without stage structure. Finally, it is shown that the increased stability and bounding of solutions has the seemingly paradoxical consequence of promoting nonequilibrium dynamics when even small amounts of noise are added to the system.

Planning health care for people with HIV infection and AIDS

In recent years planners of health services have been urged to design a comprehensive range of services which are responsive to the needs of people with HIV infection and AIDS and those who might be worried about HIV transmission. Models of care have been tried and tested and pilot services which aim to inform the development of the services scrutinised. Though in general this community care is seen as the preferred option with adequate backup support from acute services. More than anything, there is a recognition that the service must be responsive to local needs. Because patterns of HIV infection and prevalence of AIDS are so variable there is no substitute for the systematic development of timely local knowledge as the basis of local planning.

An examination of touch between nurses and elderly patients in a continuing care setting in Northern Ireland

The use of touch is an inherent part of nursing practice. This investigation examined the amount and type of touch received by elderly patients from nurses. It also attempted to assess elderly patients' perceptions of instrumental and expressive touch given by nurses. The Extended Model of Interpersonal Interaction formed the conceptual framework for the study. Non-participant observation and semi-structured interviews were the methods employed for data collection. Results tentatively suggest that most nurse-patient touch interactions in a care of the elderly ward are instrumental in nature. Expressive touches are predominantly given to body extremities. The gender of the nurse initiating touch and the part of the body touched influence the elderly patients' perception of the touch interaction. In particular, expressive touching behaviours by nurses that involve the leg, face and around the shoulders are perceived as uncomfortable. The only touching behaviour perceived as comfortable by all respondents was instrumental touching of the arm and shoulder by a female nurse. Elderly patients may misinterpret the goal or the motivation behind touch initiation by a nurse. Therefore, an awareness and a sensitivity towards elderly patients' needs and desires for tactile communication are required by nurses.

Intergeneric conjugation in Thiobacillus versutus

In plate matings with Escherichia coli HB101/pUW965::Tn5 (KmR) Thiobacillus versutus reacted as an efficient recipient, producing 10(-2) to 10(-3) kanamycin resistant (KmR) T. versutus exconjugants per donor cell. Analysis of agarose gels of plasmid DNA extracted from the exconjugants confirmed that the suicide vector pUW964 did not persist in the recipient, implying that the kanamycin resistance of the exconjugants is based on effective transposition of Tn5 in T. versutus as well as function of the E. coli kanamycin gene. Transfer was equally efficient when a nalidixate-resistant T. versutus mutant was used as recipient. Hybridization evidence for the presence of Tn5 was consistently negative. The significance of this anomalous result is discussed.

Attitudes towards and use of general practitioner services among homosexual men with HIV infection or AIDS

In a study of 263 homosexual men positive for the human immunodeficiency virus (HIV), it was found that 87% were registered with a general practitioner and of these, 55% said that the general practitioner knew their HIV status. Of the 104 men who had experienced symptoms, 39% had consulted the general practitioner for HIV-related advice. A total of 49% of those who were not registered used a specialist outpatient clinic for all their medical needs. Of those who were registered and whose general practitioner was aware of their HIV status but who did not consult their doctor, 72% used a specialist outpatient clinic. Reasons for not consulting the general practitioner included fears of breach of confidentiality and lack of confidence in the general practitioner's understanding of HIV. Fifteen per cent of the sample continued to see a general practitioner who was unaware of their HIV status, for non-HIV related advice. The needs of patients must be taken into account when planning more integrated hospital and community care for those with HIV infection or the acquired immune deficiency syndrome (AIDS).

The role of informal carers in supporting gay men who have HIV related illness: what do they do and what are their needs?

Despite calls for a shift from hospital to community based care for people with HIV infection there has been some speculation about whether the facilities will actually be available. One central element of community care is informal care. Structured interviews with 125 people who were supporting gay men with HIV related illness including AIDS (hereafter PWA) provide information about the characteristics of people who were helping on an informal basis, what they did, and what support they needed for themselves. It was mostly male friends and partners who were offering support. Half the carers were carrying out specific physical tasks, though much of the support was more general, particularly emotional support. Where both people had experienced symptoms some reciprocity of caring was taking place. Resistance to being labelled a 'carer' was evident. Carers felt themselves inadequately supported both practically and emotionally and were specific about what could be done to change this.

The work of a specialist AIDS home support team: the views and experiences of patients using the service

The work of a specialist AIDS home support team whose role is to ensure continuity of care between hospital and community for patients with HIV infection is viewed from the patients' perspective. Information comes from a wider interview study in which 265 gay men positive for HIV were asked about their perceptions of and satisfaction with a variety of different services. Of the group, 119 (46%) reported involvement with the home support team. The team was seen as providing links between patients, the hospital and the community, as well as offering security for those who expected to need help in the future. For the most part, the team were seen in a favourable light when compared to other professionals and 53% felt they received a considerable amount of reassurance and support from them.

The experience of having a positive HIV antibody test

Little is known about the logistics of taking an HIV antibody test and yet knowledge of people's experiences of having a test result is helpful to evolving a sensitive and client oriented service and can provide some guidelines for organisation issues around testing. This paper reports the experiences of 252 gay men who had an HIV test which proved to be positive. The most frequent reasons for people to take a test were perception of personal risk or were related to perceived health problems. Ten per cent of people did not know they had had a test until they were told they were anti HIV positive--lack of knowledge was related mostly to the place where the test was done. Over one third of people said they knew little about the test or its implications before they contacted anyone, over half said they did not receive information at the time of the test and 41% when they were given the result. There were few changes over time in the experience of having a test.

AIDS in the Nineties: from science to policy. Care in the community and by the community

As the numbers of people with HIV infection increase the favoured option for care in the future is to increase community and home care. Without doubt also the statutory services have recognized the need to make prevention, educational and care services sensitive and appropriate to the client group they aim to serve and many unconventional systems are being put into place in order to do this. The reality of community care is so often care by the family and volunteers and there has to be some attempt to support informal carers materially and emotionally. Without the work of these groups it would be impossible for governmental or formal agencies to provide the necessary degree of quality of care. It would seem that a combination of pressure from the 'communities' affected by HIV/AIDS and flexibility in providing care by statutory and voluntary groups has made it possible to provide different schemes of community care or at least made suitable service delivery happen more quickly and more appropriately than might otherwise have been the case. There was some feeling at the conference that it would be comforting to think that some of these innovations, hard won for HIV/AIDS, could be replicated for groups of patients in the community who may not have such a vocal advocacy group to back them.

Role of scintigraphy in establishing optimal perfusion in hepatic arterial infusion pump chemotherapy

Since 1982, physicians at the Medical College of Ohio, Toledo, have performed 41 hepatic intraarterial chemotherapy infusion pump implantations for palliative treatment of metastatic liver disease from various primary tumors of the gastrointestinal tract. Radionuclide hepatic arterial pump imaging has proven to be a very reliable, cost-effective, and uncomplicated method of evaluating liver perfusion as it relates to pump function, catheter integrity, and positioning. Confirmation of satisfactory hepatic perfusion is the key to acceptable treatment by this modality. In combination with periodic computed tomography (CT) scanning and CEA determinations, scintigraphy plays a major role in establishing effective therapy and aids in determining causal factors behind treatment failures.

Oil wives and intermittent husbands

An investigation was conducted in the Aberdeen area on wives of oil men working either off-shore or on-shore. No differences were found in measures of general health; but 'off-shore wives' were shown to experience mood and behavioural changes, linked to the pattern of swiftly recurring partings and reunions. While a majority of such wives appeared to tolerate or even thrive on their style of life, 10% had reactions sufficiently pronounced to deserve the label of Intermittent Husband Syndrome or 'caseness'. Many others would have benefited from more effective preventive and support services.

The psycho-social consequences of intermittent husband absence: an epidemiological study

This paper examines the psycho-social effects on wives of their husbands' intermittent absence on off-shore oil rigs. It is based on data gathered from a random sample of wives living in the Aberdeen area, and it proceeds in three stages. The analysis begins with a comparison between wives whose husbands work on- and off-shore, it goes on to examine differential reaction to husband absence in the off-shore group and concludes with an attempt to estimate prevalence of the 'intermittent husband syndrome'. All the available evidence suggests that the psycho-social effects of intermittent husband absence have been exaggerated. The mental and physical health of wives of men working off-shore was similar in most respects to the health of wives whose husbands work on-shore. Within the sample of wives whose husbands worked off-shore those most affected by intermittent husband absence were 'Novices' (newly married wives with preschool children and no previous experience of husband absence), those with outside employment and those experiencing irregular absences. But even among such groups with fairly pronounced mood and behaviour changes there was little evidence of raised levels of morbidity. When defined in terms of specified levels of reactivity, marital conflict and morbidity prevalence of the 'intermittent husband syndrome' was found to be around 10%.

Facilitation of kindled seizures in rats fed choline-supplemented diets

Different groups of rats were maintained on choline-deprived (CD), choline-supplemented (CS) or standard rat chow diets beginning at a body weight of approximately 100 g, and electrically kindled in the amygdala beginning not less than 40 days later. The CS group kindled significantly faster than the CD group, whereas the CD and chow-fed groups did not differ in their rate of kindling. This result is consistent with both the known effects of the dietary manipulation of choline on brain acetylcholine level, and the idea that acetylcholine has a role in amygdaloid kindling.