Factors associated with independent nurse prescribers' antibiotic prescribing practice: a mixed-methods study using the Reasoned Action Approach

BACKGROUND

The number of nurse prescribers is increasing, yet little evidence exists about their antibiotic prescribing behaviour.

AIM

To measure nurse independent prescribers' (NIPs) intention to manage patients, presenting with an upper respiratory tract infection (URTI) for the first time, without prescribing an antibiotic and to examine the determinants of this behaviour.

METHODS

This was a mixed-method study using the Reasoned Action Approach (RAA). Content analysis of data from 27 telephone interviews with NIPs informed the development of a questionnaire which was tested for validity and reliability and used in a national survey of NIPs across Scotland. Descriptive and inferential statistical analysis was carried out to determine intention to manage patients without prescribing an antibiotic and the significant influences on this intention.

FINDINGS

From 184 participants it was found that NIPs intended to manage patients, presenting with a URTI for the first time, without prescribing an antibiotic. Key determinants were perceived norm, perceived behavioural control, and moral norm. Significant beliefs were positive social influence from other non-medical prescribers (P = 0.007) and nurse prescribers (P = 0.045), the enablers of prescriber experience and confidence (P ≤ 0.001), and the barrier of pressure from patients/carers (P = 0.010).

CONCLUSION

The findings provide reassurance that NIPs intend to prescribe appropriately. The identification of nurse-specific barriers and enablers to this intention should be acknowledged and targeted in future interventions to manage this behaviour.

SAT0016 DEVELOPMENT OF FIBROBLAST-LIKE SYNOVIOCYTE ASSAYS FOR TARGET DISCOVERY IN RHEUMATOID ARTHRITIS

Background:

The rheumatoid arthritis (RA) synovium is characterized by an overabundance of fibroblast-like synoviocytes (FLS), which play a central role in the initiation and perpetuation of disease via multiple mechanisms.1FLS promote disease progression by producing high levels of proinflammatory factors, migrating to and invading cartilage and bone, and promoting self-proliferation and resistance to apoptosis. Our current understanding of the molecular mechanisms that govern FLS-mediated pathology in the synovial joint remains incomplete. Importantly, almost 30% of treatment-naïve early RA patients exhibit a strong fibroid phenotype that correlates with relatively poor response to disease-modifying anti-rheumatic drugs.2Yet, current therapies in RA are not directly aimed at FLS pathology, creating an opportunity for novel therapeutic target discovery.

Objectives:

Our aim is to develop a broad suite of screening-amenable assays in RA patient-derived FLS for the discovery of target pathways that control multiple pathological properties, including cytokine secretion, migration, and invasion.

Methods:

A sensitive high-throughput RA-FLS secretion assay was developed to examine the ability of small-molecule inhibitors to block the production of interleukin (IL)-6 and matrix metalloproteinase (MMP)-3 in response to stimuli. To create a physiologically relevant stimulus, a surrogate synovial fluid cocktail (composed of 12 factors) was defined and titrated for optimal concentration selection. Small-molecule inhibitors (N=170) of diverse biological pathways were screened using the full cocktail or individual stimulation (TNFα, IL-1α, or IL-17) to characterize assay performance. In addition, an FLS platelet-derived growth factor (PDGF)-mediated migration screening assay was developed using a live cell imaging system (IncuCyte) to quantify real-time FLS migration.

Results:

Due to the variability and limited volume of synovial fluid, we developed a surrogate synovial fluid cocktail to mimic the relevant stimulation of RA-FLS in the inflamed joint. The surrogate cocktail was composed of 12 factors: TNFα, IL-1α, IL-17, IFNγ, OSM, LIF, GM-CSF, IP-10, VEGF, PDGF, AREG, and FGF2. Individual titration of these factors demonstrated that only 3 stimulatory factors (TNFα, IL-1α, and IL-17) resulted in a robust increase of IL-6 production. Importantly, when all 12 factors were combined, a synergistic increase in IL-6 and MMP-3 production by FLS was observed. Screening results identified several reference compounds, including an inhibitor of transforming growth factor-b–activated kinase 1 (TAK1), that was previously reported to block cytokine secretion in FLS.3Treatment with this compound showed complete inhibition of IL-6 and MMP-3 secretion. In addition to the cytokine secretion assay, treatment of FLS with this TAK1 inhibitor resulted in almost complete inhibition of migration (Fig. 1).

Conclusion:

Novel FLS assays were developed to discover new targets and interrogate pathways involved in multiple disease-driving mechanisms of FLS in RA. In order to mimic the inflammatory environment present in the RA synovium, we developed a 12-factor surrogate synovial fluid cocktail. A synergistic release of both IL-6 and MMP-3 was demonstrated following cocktail stimulation compared to individual cytokines. This points to the important contribution that multiple factors play in the FLS pathogenic processes and will allow us to uncover pathway interactions that may not be captured with single stimuli. In addition, the development of a real-time, 96-well, imaging-based assay to interrogate FLS migration will allow us to identify targets that control this critical pathological function of FLS.

References:

[1] Bartok B, et al.J Immunol. 2014;192(5):2063-2070.

[2] Humby F, et al.Ann Rheum Dis. 2019;78(6):761-772.

[3] Jones DS, et al.Nat Chem Bio. 2017;13(1):38-45.

Disclosure of Interests:

Debbie Ruelas Employee of: Gilead, Chen Chen Employee of: Gilead, Hoa Truong Employee of: Gilead, Victor Lira Employee of: Gilead, Yasamin Moazami Employee of: Gilead, Kevin Currie Employee of: Gilead, Julie A. Di Paolo Employee of: Gilead, Helen Yu Employee of: Gilead, Gundula Min-Oo Employee of: Gilead

Estimated number of adult survivors of childhood cancer in United States with cancer-predisposing germline variants

PURPOSE

To estimate the absolute number of adult survivors of childhood cancer in the U.S. population who carry a pathogenic or likely pathogenic variant in a cancer predisposition gene.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) Program, we estimated the number of childhood cancer survivors on December 31, 2016 for each childhood cancer diagnosis, multiplied this by the proportion of carriers of pathogenic/likely pathogenic variants in the St. Jude Lifetime Cohort (SJLIFE) study, and projected the resulting number onto the U.S.

RESULTS

Based on genome sequence data, 11.8% of 2450 SJLIFE participants carry a pathogenic/likely pathogenic variant in one of 156 cancer predisposition genes. Given this information, we estimate that 21 800 adult survivors of childhood cancer in the United States carry a pathogenic/likely pathogenic variant in one of these genes. The highest estimated absolute number of variant carriers are among survivors of central nervous system tumors (n = 4300), particularly astrocytoma (n = 1800) and other gliomas (n = 1700), acute lymphoblastic leukemia (n = 4300), and retinoblastoma (n = 3500). The most frequently mutated genes are RB1 (n = 3000), NF1 (n = 2300), and BRCA2 (n = 800).

CONCLUSION

Given the increasing number of childhood cancer survivors in the United States, clinicians should counsel survivors regarding their potential genetic risk, consider referral for genetic counseling and testing, and, as appropriate, implement syndrome-specific cancer surveillance or risk-reducing measures.

Understanding the relationship between pet owners and their companion animals as a key context for antimicrobial resistance-related behaviours: an interpretative phenomenological analysis

Objectives: Drivers of antimicrobial resistance (AMR) are diffuse and complex including a range of interspecies behaviours between pet owners and their animals. We employed interpretative phenomenological analysis (IPA) to explore the relationship between pet owners and their companion animals in relation to AMR. Design: Cross sectional, qualitative study. Methods: Semi-structured interviews were conducted with twenty-three British pet owners, transcribed verbatim and subjected to Interpretative Phenomenological Analysis (IPA). Results: Three, inter-related Superordinate themes are presented 1) 'They're my fur babies': unconditional love and anthropomorphism; 2) 'They share everything with you': affection and transmission behaviours; and 3) 'We would err on the side of caution': decision making and antibiotic use'. Conclusions: Affectionate behaviours between companion animals and their owners pose a risk for AMR transmission but they are so deeply treasured that they are unlikely to be amenable to change. In contrast, the promotion of appropriate antibiotic stewardship for pet owners and vets may offer a viable pathway for intervention development, benefitting from synergies with other interventions that target prescribers.

The Prostate Cancer Rehabilitation Clinic: a biopsychosocial clinic for sexual dysfunction after radical prostatectomy

Purpose

The most prevalent intervention for localized prostate cancer (pca) is radical prostatectomy (rp), which has a 10-year relative survival rate of more than 90%. The improved survival rate has led to a focus on reducing the burden of treatment-related morbidity and improving the patient and partner survivorship experience. Post-rp sexual dysfunction (sdf) has received significant attention, given its substantial effect on patient and partner health-related quality of life. Accordingly, there is a need for sdf treatment to be a fundamental component of pca survivorship programming.

Methods

Most research about the treatment of post-rp sdf involves biomedical interventions for erectile dysfunction (ed). Although findings support the effectiveness of pro-erectile agents and devices, most patients discontinue use of such aids within 1 year after their rp. Because side effects of pro-erectile treatment have proved to be inadequate in explaining the gap between efficacy and ongoing use, current research focuses on a biopsychosocial perspective of ed. Unfortunately, there is a dearth of literature describing the components of a biopsychosocial program designed for the post-rp population and their partners.

Results

In this paper, we detail the development of the Prostate Cancer Rehabilitation Clinic (pcrc), which emphasizes multidisciplinary intervention teams, active participation by the partner, and a broad-spectrum medical, psychological, and interpersonal approach.

Conclusions

The goal of the pcrc is to help patients and their partners achieve optimal sexual health and couple intimacy after rp, and to help design cost-effective and beneficial rehabilitation programs.

Exploring the behavioural drivers of veterinary surgeon antibiotic prescribing: a qualitative study of companion animal veterinary surgeons in the UK

Background

Multi-drug resistant bacteria are an increasing concern in both human and veterinary medicine. Inappropriate prescribing and use of antibiotics within veterinary medicine may be a contributory factor to antimicrobial resistance (AMR). The ‘One Health’ Initiative aims to work across species and environments to reduce AMR, however; little is currently known about the factors which influence antibiotic prescribing among veterinary surgeons in companion animal practice.

This paper reports on qualitative data analysis of interviews with veterinary surgeons whose practice partially or wholly focuses on companion animals (N = 16). The objective of the research was to explore the drivers of companion animal veterinary surgeons’ antibiotic prescribing behaviours. The veterinary surgeons interviewed were all practising within the UK (England (n = 4), Scotland (n = 11), Northern Ireland (n = 1)). A behavioural thematic analysis of the data was undertaken, which identified barriers and facilitators to specific prescribing-related behaviours.

Results

Five components of prescribing behaviours were identified: 1) confirming clinical need for antibiotics; 2) responding to clients; 3) confirming diagnosis; 4) determining dose, duration and type of antibiotic; and 5) preventing infection around surgery (with attendant appropriate and inappropriate antibiotic prescribing behaviours). Barriers to appropriate prescribing identified include: business, diagnostic, fear, habitual practice and pharmaceutical factors. Facilitators include: AMR awareness, infection prevention, professional learning and regulation and government factors.

Conclusion

This paper uses a behavioural lens to examine drivers which are an influence on veterinary surgeons’ prescribing behaviours. The paper contributes new understandings about factors which influence antibiotic prescribing behaviours among companion animal veterinary surgeons. This analysis provides evidence to inform future interventions, which are focused on changing prescribing behaviours, in order to address the pressing public health concern of AMR.

Barriers and enablers to meticillin-resistant Staphylococcus aureus admission screening in hospitals: a mixed-methods study

BACKGROUND

To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours.

AIM

To identify factors which influence staff compliance with hospital MRSA screening policies.

METHODS

A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance.

FINDINGS

Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which 'make doing the right thing easy' influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important.

CONCLUSION

To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

Genetic Risk for Subsequent Neoplasms Among Long-Term Survivors of Childhood Cancer

Purpose Childhood cancer survivors are at increased risk of subsequent neoplasms (SNs), but the germline genetic contribution is largely unknown. We assessed the contribution of pathogenic/likely pathogenic (P/LP) mutations in cancer predisposition genes to their SN risk. Patients and Methods Whole-genome sequencing (30-fold) was performed on samples from childhood cancer survivors who were ≥ 5 years since initial cancer diagnosis and participants in the St Jude Lifetime Cohort Study, a retrospective hospital-based study with prospective clinical follow-up. Germline mutations in 60 genes known to be associated with autosomal dominant cancer predisposition syndromes with moderate to high penetrance were classified by their pathogenicity according to the American College of Medical Genetics and Genomics guidelines. Relative rates (RRs) and 95% CIs of SN occurrence by mutation status were estimated using multivariable piecewise exponential regression stratified by radiation exposure. Results Participants were 3,006 survivors (53% male; median age, 35.8 years [range, 7.1 to 69.8 years]; 56% received radiotherapy), 1,120 SNs were diagnosed among 439 survivors (14.6%), and 175 P/LP mutations were identified in 5.8% (95% CI, 5.0% to 6.7%) of survivors. Mutations were associated with significantly increased rates of breast cancer (RR, 13.9; 95% CI, 6.0 to 32.2) and sarcoma (RR, 10.6; 95% CI, 4.3 to 26.3) among irradiated survivors and with increased rates of developing any SN (RR, 4.7; 95% CI, 2.4 to 9.3), breast cancer (RR, 7.7; 95% CI, 2.4 to 24.4), nonmelanoma skin cancer (RR, 11.0; 95% CI, 2.9 to 41.4), and two or more histologically distinct SNs (RR, 18.6; 95% CI, 3.5 to 99.3) among nonirradiated survivors. Conclusion The findings support referral of all survivors for genetic counseling for potential clinical genetic testing, which should be prioritized for nonirradiated survivors with any SN and for those with breast cancer or sarcoma in the field of prior irradiation.

Acceptability of temporary suspension of visiting during norovirus outbreaks: investigating patient, visitor and public opinion

BACKGROUND

Noroviruses are a leading cause of outbreaks globally and the most common cause of service disruption due to ward closures. Temporary suspension of visiting (TSV) is increasingly a recommended public health measure to reduce exposure, transmission and impact during norovirus outbreaks; however, preventing patient-visitor contact may contravene the ethos of person-centred care, and public acceptability of this measure is not known.

AIM

To investigate the acceptability of TSV during norovirus outbreaks from the perspectives of patients, visitors and the wider public.

METHODS

Cross-sectional survey of patients (N = 153), visitors (N = 175) and the public (N = 224) in three diverse areas in Scotland. Health Belief Model constructs were applied to understand ratings of acceptability of TSV during norovirus outbreaks, and to determine associations between these levels and various predictor variables.

FINDINGS

The majority (84.6%) of respondents indicated that the possible benefits of TSV are greater than the possible disadvantages. Conversely, the majority (70%) of respondents disagreed that TSV 'is wrong as it ignores people's rights to have contact with family and friends'. The majority (81.6%) of respondents agreed that TSV would be more acceptable if exceptions were made for seriously ill or dying patients. Correlational analysis demonstrated that overall acceptability was positively related to perceived severity (r = 0.65), identified benefits (r = 0.54) and implementing additional communication strategies (r = 0.60); acceptability was negatively related to potential barriers (r = -0.49).

CONCLUSIONS

There is greater service user and public support for the use of TSV than concerns around impinging upon patients' rights to have visitors. TSV should be considered as an acceptable infection control measure that could be implemented consistently during norovirus outbreaks.

Are you serious? From fist bumping to hand hygiene: Considering culture, context and complexity in infection prevention intervention research

Infection prevention is an under-resourced research and development topic, with limited evidence for practice in the most basic of measures. A survey of IPS R&D members indicated that what might appear to be simple interactions and interventions in healthcare, such as hand shaking and hand hygiene, should be considered complex interventions taking account of behaviour at the individual and social level as well as contextual factors. Future studies need to be designed utilising comprehensive approaches, for example, the Medical Research Council complex interventions framework, tailored to the country and more local cultural context, if we are to be serious about evidence for infection prevention and control practice.

Leap for Life: innovative patient education to optimize outcomes among patients with cardiovascular disease

OBJECTIVE

To evaluate the Leap for Life cardiovascular risk factor education program based on outcome measurements of self-reported hospital readmission, goal achievement, satisfaction, and educational model preference.

SETTING

Four hospitals and one senior center of Baylor Health Care System in the Dallas, Texas, area.

DESIGN

Administration of a satisfaction questionnaire and resurvey of participants by telephone at 3, 6, and 12 months.

PATIENTS

161 patients with cardiovascular disease enrolled in the Leap for Life program during calendar year 1997. Patients were primarily male (59%), with an average age of 66 years; they had an average of 4 cardiovascular disease risk factors.

RESULTS

Of the 152 participants who took part in the telephone follow-up, 19% reported a hospital admission with a cardiovascular diagnosis during the 12-month follow-up period. Twenty-one percent reported meeting all of their goals; 56%, some of their goals; and 23%, none of their goals. All stated that the educational sessions met their informational needs, and 75% preferred the Leap for Life setting over other educational settings. CONCLUSION AND NEXT STEPS: These data provide initial validation of the program and are being used as a starting point for another assessment that involves individualized health enhancement measures and 6- and 12-month follow-up of participants using a survey designed to assess readiness, lifestyle changes, and quality of life.

Consumer health information. What the research is telling us

BACKGROUND

Consumer health information is a necessary component of patient care and consumer participation.

OBJECTIVE

To outline the findings of the 'Assessing the Quality of Consumer Health Information Project' and discuss strategies for improving consumer information.

DISCUSSION

The pamphlets identified in this study were not developed with consumer input with consequent deficits apparent. Providers and consumers appeared to use the information for very different purposes but both groups were critical of the ambiguous terminology and lack of quantified data. The provision of relevant information is a fundamental prerequisite of consumer participation in decision making in health care. Such information needs to be available, accurate, and understandable.

Recombinant human chorionic gonadotropin (rhCG) in assisted reproductive technology: results of a clinical trial comparing two doses of rhCG (Ovidrel) to urinary hCG (Profasi) for induction of final follicular maturation in in vitro fertilization-embryo transfer

OBJECTIVE

To compare the efficacy and safety of 250 microg and 500 microg of recombinant hCG with 10,000 U USP of urinary hCG in assisted reproduction technology.

DESIGN

Open, comparative, randomized, prospective clinical study.

SETTING

Twenty tertiary care U.S. infertility centers.

PATIENT(S)

Two hundred ninety-seven ovulatory infertile women undergoing a single cycle of assisted reproduction technology.

INTERVENTION(S)

Patients were randomized 1:1:1 to 250 microg of recombinant hCG SC, 500 microg of recombinant hCG SC, or 10,000 U USP urinary hCG IM after completing gonadotropin stimulation.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved per patient receiving hCG. Also, measures of oocyte maturity, embryo development, and luteal function, as well as pregnancy and pregnancy outcome. Adverse safety events, laboratory changes, local tolerance, and immunogenicity were also assessed.

RESULT(S)

Mean numbers of oocytes retrieved per treatment group were equivalent, 13.6, 14.6, and 13.7 with 250 microg of recombinant hCG, 500 microg of recombinant hCG, and urinary hCG, respectively. The numbers of 2PN fertilized oocytes on day 1 after oocyte retrieval, and 2PN or cleaved embryos on the day of embryo transfer, were significantly higher with 500 microg of recombinant hCG than with the lower dose. However, the incidence of adverse events also tended to be higher with this dose.

CONCLUSION(S)

Recombinant hCG is effective and well tolerated in the induction of final follicular maturation and luteinization in women undergoing assisted reproduction technology. Recombinant hCG (250 microg) SC is equivalent to 10,000 U USP of urinary hCG in this indication.

Direct measurement of cutaneous pressures generated by pressure garments

Pressure garments are the mainstay of burn scar management despite limited scientific evidence. This study demonstrates a simple method of directly measuring the cutaneous pressures generated by a pressure garment. The results show pressure garments generate an increase in subdermal pressures in the range 9-90 mmHg depending on the anatomical site. Garments over soft sites generate pressures ranging from 9 to 33 mmHg. Over bony prominences the pressures range from 47 to 90 mmHg. This method is believed to be more representative of the pressures generated than the interpositional techniques that measure garment-skin interface pressure, as it avoids garment distortion, the interference effect of the measurement device (size, conformation, area) and directly measures subdermal pressures. The method should be useful for larger research projects on pressure therapy and also for clinical management of pressure garments in the treatment of hypertrophic scar.

Current difficulties and the possible future directions in scar assessment

The quantitative assessment of the results of burn management is notoriously difficult. With the focus changing from survival to cosmetic and functional outcome, the scar assessments are increasingly important. The scar is a sum of the injury and all subsequent interventions on the way to healing. As such it is a complex structure, abnormal in its colour, depth, contour and pliability. To develop a quantitative system we believe it is vital to be able to track accurately an area of injury through time. Further, that physiological data acquired by a number of measurement tools be fused accurately to the morphologically correct information.

Early use of pressure masks to avoid facial contracture during the pregrafting phase

This article introduces the concept of early application of pressure therapy as a form of splinting in the pregrafting phase. It is based on the principles of (1) the use of pressure therapy to reduce contraction and hypertrophic scar formation and (2) the knowledge that most wound contraction occurs within the initial few weeks of healing. This idea has most application in facial burns, where wound contraction can be disfiguring and functionally disabling, and in situations where unavoidable delay in debridement and grafting may be present. The idea is illustrated with a case report.

Community dwelling elderly are appropriate subjects for intensive dietary choice restriction studies

There is a traditional belief that the elderly have difficulty coping with dietary change, and therefore have a diminished likelihood of successfully responding to nutritional interventions or restrictions. Using a controlled mild zinc-deficiency feeding study as a model for strict dietary intervention, we assessed psychological responses to severe dietary choice restriction in 15 Caucasian, elderly (66.12 +/- 4.43 years) males (n= 7) and females (n = 8). Participants completed the Medical Outcomes Study Short Form 36-Item Questionnaire (SF-36) as an index of QOL and the Multi-dimensional Health Locus of Control (MHLC) as a measure of health beliefs at pre-intervention baseline, post-intervention, and follow-up. No subjects dropped out nor were any meals missed during the entire 21-day feeding study period. No significant differences were detected across time on the MHLC (Internal F = 0.53, P = 0.6; Powerful Others F = 0.28, P = 0.8; Chance F = 1.1, P = 0.4.) by one-way ANOVA. Similarly, for the SF-36 no significant differences were found across time (F = 0.76, P = 0.5). Our results suggest that restricting dietary choices does not negatively impact older adult subjects and that they can cope well with dietary choice restriction and change. Older adults should not be overlooked for nutritional intervention solely due to age considerations.

Large tandem duplication associated with a Mu2 insertion in Zea mays B-Peru gene

The b locus of Zea mays encodes a transcriptional activator of the anthocyanin biosynthetic pathway. The B-Peru allele is expressed in the aleurone layer of the seed, which results in dark purple pigmentation of this tissue. An unstable Mutator-induced B-Peru mutant allele, b-Perum220, displays weak, variable pigment and a high germinal reversion rate not characteristic of other Mutator insertions. Characterization of relevant regions of b-Perum220 revealed a Mu2 element insertion in one copy of a 534 bp sequence. This 534 bp sequence is tandemly triplicated in the progenitor B-Peru allele, upstream of the B-Peru transcription start site. In addition to the Mu2 insertion, the b-Perum220 allele contains a newly formed large tandem duplication of 4.0 kb, which includes the promoter region and the first three exons of the B-Peru gene. The Mu2 element does not reside at any of the duplication breakpoints. The molecular study of eleven independent germinal revertants revealed five structural classes including structures in which the 4.0 kb tandem duplication is partially or completely deleted, the Mu2 element is partially or completely deleted, or a combination of these events has occurred. We hypothesize that most of the revertants arose by unequal recombination between the duplicated regions. Based on these structural analyses, models are discussed to explain the reduced b gene expression in b-Perum220.

Constant infusion of morphine for intractable cancer pain using an implanted pump

In the past, pain control for chronic pain syndromes using narcotic infusion has been carried out primarily via the intrathecal (subarachnoid) route. This report presents one of the first large series of terminally ill cancer patients with intractable pain treated with continuous epidural morphine infusions by means of implanted pumps and epidural spinal catheters. The purpose of the study was to demonstrate that the epidural route is effective with minimal complications, and that screening with temporary epidural catheter infusions results in a high rate of subsequent pain relief. A multidisciplinary team (neurosurgeon, anesthesiologists, psychiatrists, oncologists, and nurse clinicians) evaluated and treated all of the patients studied. Percutaneous placement of temporary epidural catheters for a trial assessment was performed by the anesthesiologists. Pain evaluations were conducted independently by psychiatrists using both verbal and visual analog scales. From 1982 to 1988, 41 (59.4%) of 69 patients evaluated for eligibility experienced good pain control during trial assessment and were subsequently implanted with Infusaid infusion pumps. Preinfusion pain analog values were 8.6 +/- 0.3 and postimplantation values at 1 month were 3.8 +/- 0.4 (p less than 0.001). Over this same 1-month period. requirements of systemic morphine equivalents decreased by 79.3% with epidural infusions as compared to preinfusion requirements (p less than 0.001). There were no instances of epidural scarring, respiratory depression, epidural infections, meningitis, or catheter blockage. One patient developed apparent drug tolerance and three patients required further catheter manipulations. This series strongly suggests that significant reductions in cancer pain can be obtained with few complications and a low morphine tolerance rate using chronic epidural morphine infusion. Anesthesiology and psychiatry input, along with temporary catheter infusion screening and quantitative pain evaluations using analog scales, are essential.

First-trimester maternal serum alpha-fetoprotein screening for chromosome defects

Low maternal serum alpha-fetoprotein values during the second trimester of pregnancy are associated with an increased risk of Down syndrome in the fetus. In this study a sensitive, monoclonal-based radioimmunoassay for alpha-fetoprotein was used to determine whether such an association also applies to the first trimester and if maternal serum alpha-fetoprotein screening could successfully detect a significant number of pregnancies in which the fetus had a trisomy or other chromosome disorder. Sera were obtained prospectively from 540 women just before chorionic villus sampling for prenatal diagnosis of chromosome defects (largely because of advanced maternal age) at 8 to 12 weeks' fetal age and assayed for alpha-fetoprotein under code without knowledge of the cytogenetic results. Eight of 27 (29.6%) of all serious chromosome defects were associated with low maternal serum alpha-fetoprotein values (less than or equal to 0.6 multiples of the median). Overall, 59 of 540 patients (10.9%) had maternal serum alpha-fetoprotein values less than or equal to 0.6 multiples of the median, eight of whom had a fetus with a serious chromosome defect. Women whose maternal serum alpha-fetoprotein value was less than or equal to 0.6 multiples of the median had one in eight odds of carrying a fetus with a trisomy and one in seven odds of the fetus having any serious chromosome defect. From this study of a group of women at higher risk, we conclude that first-trimester maternal serum alpha-fetoprotein screening for chromosome defects is feasible. A prospective study to determine detection efficiency is now required of a consecutive routine pregnancy population in whom gestational age is determined by menstrual dates as is usually the case in clinical practice.

Going up in smoke: the case of British American tobacco in Kenya

Faced in the developed world by increasing restrictions on cigarette advertising and sales, and with declining markets, the tobacco transnationals are opening up new markets in developing countries, where they face few controls and little health education. As cigarette sales increase in the Third World, so does the evidence of an increasing incidence of smoking-related diseases. This paper considers the case study of BAT (Kenya) Ltd, a subsidiary of the London-based transnational, which since 1974 has encouraged both local leaf production and increased cigarette sales in Kenya. We examine: the relationship between BAT (K) and the Kenya state, the recruitment of farmers into the leaf growing scheme, how BAT (K)'s directorships interlock with those of other leading Kenyan firms and the implications of these for the company's power and influence; BAT (K)'s marketing strategies, how successful they have been, and how they compare with codes of conduct agreed in developed countries; and we estimate the likely success of possible strategies to combat the smoking hazard in Kenya. We conclude that although BAT (K) might make minor concessions to the "health lobby' in Kenya, it is sufficiently powerful, and the leaf growing programme is given sufficient Government support, as to make fundamental changes unlikely in the near future.