Developing a national undergraduate medical education pain management and substance use disorder curriculum to address the opioid crisis: a program evaluation pilot study

BACKGROUND

Pain and addiction are one of the most common reasons for adults to seek health care, yet educational programs focused on pain are often underrepresented in medical school curricula. In January 2021, the Association of Faculties of Medicine of Canada (AFMC) launched an online national, bilingual, competency-based curriculum for undergraduate medical (UGME) students in pain management and substance use in response to the opioid crisis and to bridge the content gaps in programs across Canada. The purpose of this study is to evaluate the pilot of this national curriculum.

METHODS

UGME students, from across Canada, participated in the program evaluation by completing online pre- and post-program surveys that assessed the influence of the curriculum on participants' knowledge as well as the value, usability, and feasibility of this curriculum.

RESULTS

Participants' perceived confidence in their new knowledge and in utilizing resources required to maintain their knowledge significantly increased (75% and 51% respectively). Their perceived knowledge that addressed the 72 learning objectives within the curriculum significantly increased from pre- to post-program. Over 90% of participants reported that the curriculum was valuable, feasible, and usable. The most frequently discussed program strengths were the clear and comprehensive content, interactive and well-organized design, and relevance of curriculum content for future clinical practice. The overall weakness of the curriculum included the length, repetition of content, the lack of clarity and relevance of the assessment questions, end-user technology issues, and French translation discrepancies. Participant's recommendations for improving the curriculum included streamlining content, addressing technology issues, and enhancing the clarity and relevance of assessment questions embedded within each of the modules.

CONCLUSION

Participants agreed that an online pain management and substance use curriculum is a valuable, usable, and feasible learning opportunity. Given the severity of the opioid crisis in Canada, these online modules provide a curriculum that can be integrated into existing UGME programs or can provide self-directed learning.

Patient-reported health outcomes of SARS-CoV-2-tested patients presenting to emergency departments: a propensity score-matched prospective cohort study

OBJECTIVE

This study aimed to compare the long-term physical and mental health outcomes of matched severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive and SARS-CoV-2-negative patients controlling for seasonal effects.

STUDY DESIGN

This was a retrospective cohort study.

METHODS

This study enrolled patients presenting to emergency departments participating in the Canadian COVID-19 Emergency Department Rapid Response Network. We enrolled consecutive eligible consenting patients who presented between March 1, 2020, and July 14, 2021, and were tested for SARS-CoV-2. Research assistants randomly selected four site and date-matched SARS-CoV-2-negative controls for every SARS-CoV-2-positive patient and interviewed them at least 30 days after discharge. We used propensity scores to match patients by baseline characteristics and used linear regression to compare Veterans RAND 12-item physical health component score (PCS) and mental health component scores (MCS), with higher scores indicating better self-reported health.

RESULTS

We included 1170 SARS-CoV-2-positive patients and 3716 test-negative controls. The adjusted mean difference for PCS was 0.50 (95% confidence interval [CI]: -0.36, 1.36) and -1.01 (95% CI: -1.91, -0.11) for MCS. Severe disease was strongly associated with worse PCS (β = -7.4; 95% CI: -9.8, -5.1), whereas prior mental health illness was strongly associated with worse MCS (β = -5.4; 95% CI: -6.3, -4.5).

CONCLUSION

Physical health, assessed by PCS, was similar between matched SARS-CoV-2-positive and SARS-CoV-2-negative patients, whereas mental health, assessed by MCS, was worse during a time when the public experienced barriers to care. These results may inform the development and prioritization of support programs for patients.

Trabecular bone score in people with cystic fibrosis

People with cystic fibrosis (CF) are at increased risk of fractures. Our study found that low trabecular bone score (TBS) (a measure of bone strength) may help identify people with CF at risk of fractures especially when combined with bone density measured by DXA, age, hemoglobin A1c, and transplant status.

INTRODUCTION

People with cystic fibrosis (CF) are at increased risk of fractures. This study aims to evaluate the association of trabecular bone score (TBS) with fractures in CF.

METHODS

A cross-sectional study of adults with CF who completed bone density between 2009 and 2019. TBS was applied to lumbar spine studies.

RESULTS

A total of 202 people with CF were included. A history of fracture was present in 36 (17.8%) subjects. Patients with history of fractures had higher hemoglobin A1c (A1C) (7.8 ± 2.7% vs. 6.7 ± 1.7%, p = 0.024), lower femoral neck (FN) Z/T-score (- 1.05 ± 1.08 vs. - 0.44 ± 1.08, p = 0.012), and lower TBS (1.36 ± 0.13 vs. 1.40 ± 0.11, p = 0.05) compared to those without. Lung transplant recipients had a higher prevalence of fractures (50% vs. 14.1%, p < 0.001). The odds ratio (95%CI) of having a fracture for subjects with TBS (≤ 1.2 vs. > 1.2) stratified by FN Z/T-score (≤ - 2.0 or >  - 2.0) was 3.88 (0.92, 16.35), p = 0.07. ROC analysis showed TBS was significantly associated with fractures (p < 0.05); however, FN BMD was superior. A model combining FN BMD, age, A1c, transplant, and TBS improved ROC compared to FN BMD + age (0.837 vs. 0.779, p = 0.031).

CONCLUSIONS

TBS ≤ 1.2 may identify people with CF at high risk of fractures. A model combining FN BMD, age, A1c, transplant, and TBS was significantly associated with fractures compared to FN BMD + age. Future studies are needed to evaluate the prediction of fractures in people with CF using clinical and bone parameters.

A-46 Impairments in Memory for “Who”, “When”, and “Where” are Detectable in Middle-Aged Adults

Objective

We conducted a cross-sectional study to examine age-¬related differences in performance on a new test assessing memory for “who, when, and where” and associations among these elements. The test was designed to assess aspects of episodic memory by simulating an everyday experience of meeting a series of different people in different places across time.

Method

Healthy young (ages 18¬-25), middle-aged (ages 40-55), and older adults (ages 60+) were asked to remember a sequence of pictures of different faces paired with different places. After viewing the sequence, the participants were asked to pair each face with the correct place and put the face-place pairs in the correct sequence. Participants also completed a battery of standardized neuropsychological tests.

Results

Young adults remembered significantly more face-place pairs in the correct sequence than middle-aged (p < .05) and older adults (p < .05). There were no significant differences between middle-aged and older adults in the number of face-place pairs in correct sequence. Furthermore, young adults remembered significantly more face-place pairs irrespective of sequence than older adults (p < .05). There were no significant differences between young and middle-aged adults or between middle-aged and older adults in the number of correct face-place pairs irrespective of sequence.

Conclusions

Using a new test that incorporates aspects of episodic memory, we found evidence for age-related differences in test performance beginning in middle age. We found that performance on the test correlated with performance on standardized measures of verbal memory and executive functioning but not visual confrontation naming.

Transient osteoporosis of the hip: review of the literature

Transient osteoporosis of the hip (TOH) is a temporary clinical condition of unknown etiology which usually resolves with conservative therapy though may be complicated by fracture or progression to avascular necrosis (AVN). TOH may be slightly more prevalent in men but when it occurs in women, it is most often seen in the latter part of pregnancy. Though fracture is a rare complication of TOH when it occurs, it is most often associated with TOH occurring in pregnancy. Magnetic resonance imaging (MRI) is the best method to diagnosis TOH. Low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and homogenous pattern of edema (the femoral head and/or neck) with normal subchondral area are in favor of TOH. A shortened course to recovery is reported by use of bisphosphonates, calcitonin, or teriparatide. Based on reported cases, core decompression is not superior to medical therapy. Transient osteoporosis of the hip, which often has no known etiology, usually resolves with conservative therapy but may predispose the patient to fracture or avascular necrosis. Diagnostic method of choice is magnetic resonance imaging. Bisphosphonates, calcitonin, or teriparatide are reported as a useful approach to reduce duration of recovery.

A critical hybrid realist-outcomes systematic review of relationships between medical education programmes and communities: BEME Guide No. 35

BACKGROUND

The relationships between medical schools and communities have long inspired and troubled medical education programmes. Successive models of community-oriented, community-based and community-engaged medical education have promised much and delivered to varying degrees. A two-armed realist systematic review was undertaken to explore and synthesize the evidence on medical school-community relationships.

METHOD

One arm used standard outcomes criteria (Kirkpatrick levels), the other a realist approach seeking out the underlying contexts, mechanisms and outcomes. 38 reviewers completed 489 realist reviews and 271 outcomes reviews; 334 articles were reviewed in the realist arm and 181 in the outcomes arm. Analyses were based on: descriptive statistics on both articles and reviews; the outcomes involved; the quality of the evidence presented; realist contexts, mechanisms, and outcomes; and an analysis of underlying discursive themes.

FINDINGS

The literature on medical school-community relationships is heterogeneous and largely idiographic, with no common standards for what a community is, who represents communities, what a relationship is based on, or whose needs are or should be being addressed or considered.

CONCLUSIONS

Community relationships can benefit medical education, even if it is not always clear why or how. There is much opportunity to improve the quality and precision of scholarship in this area.

Waist-to-height ratio and cardiometabolic risk factors in adolescence: findings from a prospective birth cohort

OBJECTIVE

To examine the associations between body mass index (BMI) and waist-to-height ratio (WHtR) measured in childhood and adolescence and cardiometabolic risk factors in adolescence.

METHODS

Secondary data analysis of the Avon Longitudinal Study of Parents and Children, a population based cohort. Data from 2858 adolescents aged 15.5 (standard deviation 0.4) years and 2710 of these participants as children aged 7-9 years were used in this analysis. Outcome measures were cardiometabolic risk factors, including triglycerides, low density lipoprotein cholesterol, high density lipoprotein cholesterol, insulin, glucose and blood pressure at 15 years of age.

RESULTS

Both BMI and WHtR measured at ages 7-9 years and at age 15 years were associated with cardiometabolic risk factors in adolescents. A WHtR ≥0.5 at 7-9 years increased the odds by 4.6 [95% confidence interval 2.6 to 8.1] for males and 1.6 [0.7 to 3.9] for females of having three or more cardiometabolic risk factors in adolescence. Cross-sectional analysis indicated that adolescents who had a WHtR ≥0.5, the odds ratio of having three or more cardiometabolic risk factors was 6.8 [4.4 to 10.6] for males and 3.8 [2.3 to 6.3] for females. The WHtR cut-point was highly specific in identifying cardiometabolic risk co-occurrence in male children and adolescents as well as female children (90 to 95%), but had poor sensitivity (17 to 53%). Similar associations were observed when BMI was used to define excess adiposity.

CONCLUSIONS

WHtR is a simple alternative to age and sex adjusted BMI for assessing cardiometabolic risk in adolescents.

Pelvic fractures associated with long-term bisphosphonate therapy - case report

Long term bisphosphonate use has been associated with "atypical" subtrochanteric and diaphyseal fractures of the femoral shaft. We are reporting a case of pelvic fractures in addition to atypical long bone fractures, in a patient with osteopenia treated with bisphosphonate for 8 years, and teriparatide for 2 years. After 5 years of bisphosphonate therapy the patient suffered an atraumatic fracture of the femoral shaft. With an additional 3 years of bisphosphonate use she fractured both the upper and lower pubic rami on the left side. Bone histomorphometry performed on a biopsy of right iliac crest was negative for malignancy and calcification defects. It showed normal to low/normal bone turnover which correlated well with a low NTX level. Post-surgical X-rays revealed cortical thickening of the femur and beaking at the femoral shaft fracture, the classic findings associated with alendronate-related fractures. The pelvic fractures also reveal beaking at the fracture sites. Spontaneous fracture of the pelvis with unusual characteristics, in a patient with an atypical fracture of the femur suggests that the pelvic fracture may be related to long term bisphosphonate therapy.

Knowledge, attitudes and behaviours associated with the provision of hepatitis C care by Canadian family physicians

The role of primary care physicians in providing care for hepatitis C virus (HCV) infection is increasingly emphasized, but many gaps and challenges remain. This study explores family physicians' knowledge, attitudes and practices associated with providing care for HCV infection. Seven hundred and forty-nine members of the College of Family Physicians of Canada (CFPC) completed a self-administered survey examining knowledge, attitudes and behaviours regarding HCV infection screening and care. Multivariate analyses were performed using the outcome, HCV care provision, and variables based on a conceptual model of practice guideline adherence. Family physicians providing basic-advanced HCV care were more likely to be older, practice in a rural setting, have injection drug users (IDU) in their practice and have higher levels of knowledge about the initial assessment (OR = 1.77; 95% CI = 1.23-2.54) and treatment of HCV (OR = 1.74; 95% CI = 1.24-2.43). They were also less likely to believe that family physicians do not have a role in HCV care (OR = 0.41; 95% CI = 0.30-0.58). Educational programmes should target physicians less likely to provide HCV care, namely family physicians practicing in urban areas and those who do not care for any IDU patients. Training and continuing medical education programmes that aim to shift family physicians' attitudes about the provision of HCV care by promoting their roles as integral to HCV care could contribute to easing the burden on consultant physicians and lead to improved access to treatment for HCV infection.

Abstract PD10-08: Quantitative and Standardized Measurement of Estrogen Receptor Predicts Response to Radiation Therapy in Breast Cancer

Background: It has been repeatedly demonstrated that ER-positive patients have a significantly increased response to tamoxifen, however, continuous association between relative risk and quantitative ER expression has yet to be fully established. Additionally, although it has been hypothesized that estrogen receptor positivity and tamoxifen treatment may play a role in radiation therapeutic response, an assessment of whether quantitative levels of ER predict response to radiation therapy has yet to be determined. Materials and Methods: Fluorescence immunohistochemistry with AQUA® technology was used to quantitatively assess ER expression on a cohort (n = 568) of retrospectively collected breast cancer specimens from patients treated with tamoxifen (20mg) ± radiotherapy (RT). Staining, image acquisition and AQUA analysis was performed at two independent sites using two different standardized digital pathology platforms. AQUA technology is a completely standardized and objective platform with minimized operator interaction that provides tumor-specific, quantitative and continuous expression score data.

Results: A comparison between completely independent sample staining and quantitative assessment at two sites showed highly significant correlation, with AQUA score values approaching unity (Pearson's R=0.94; linear slope = 0.999) and indistinguishable means (p=0.93). Assessment of the same tissue slides on two different instrument platforms (HistoRx PM2000 v. Aperio Scanscope FL) also showed highly significant correlation (Pearson's R=0.95; linear slope = 1.01; p = 0.89). Continuous ER AQUA scores showed a highly significant association with 5-year disease-free survival by itself (HR = 0.80 (95%CI: 0.70-0.91); p=0.001) and when put into a model with nodal status and tumor size (HR=0.80 (95%CI: 0.68 — 0.94); p=0.006). The cohort was then divided at the median AQUA score representing relative low and high ER expressing patients. The low ER expressing group showed significant benefit from RT for 5-year disease-free survival (HR = 0.56 (95%CI: 0.32-0.95); p=0.03) and maintained significance at the 10% level when nodal status and tumor size were adjusted for in the model (HR = 0.60 (95%CI: 0.32 — 1.10); p=0.097). In contrast, the high ER expressing group showed no benefit (HR = 0.81 (95%CI: 0.43-1.52); p=0.51) for radiation treatment. No benefit for either group was observed for 15-year overall survival. Discussion: Taken together, these data demonstrate that quantification of ER, beyond simple positive/negative characterization, could provide valuable predictive information for the treatment of breast cancer, specifically for predicting a group more likely to respond to radiation therapy and sparing patients from a potentially harmful treatment. These data will need further validation on an independent cohort designed to differentiate radiation response. Furthermore, these data indicate that true quantification of ER expression provides a continuous recurrence risk assessment for patients being treated with tamoxifen. Because these data are standardized across sites and imaging platforms, misclassification of patients is significantly reduced as compared to the current standard by which ER expression is determined.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD10-08.

Abstract P4-08-02: A Comparison between AQUA Quantitative Fluorescent Immunohistochemistry and Conventional Immunohistochemistry for Hormone Receptors

Background: We have previous data showing that quantitation of hormone receptors can be highly informative in determining risk of early relapse in ER positive early breast cancer treated with tamoxifen or exemestane. Both quantitative immunohistochemistry (QIHC) and flouresecent immunohistochemistry (F-IHC as measured by AQUA technology) are highly prognostic over a wide expression range. We have explored the results of both assays to determine if current assays provide maximum information using current approaches.

Patients &

Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative AQUA and IHC analysis (using image quantitation) of ER and PgR was performed centrally (Edinburgh & HistoRx). Results from both assays were compared and their prognostic impact on DFS at 2.75 years examined.

Results: Both AQUA and QIHC demonstrated linear relationships between intensity of staining for either ER or PgR and DFS at 2.75 years. For both PgR and ER AQUA provided significantly greater prognostic information that QIHC. However AQUA staining explained only 29% and 68% of the variability in ER and PgR QIHC results by logistic regression. Using both AQUA and QIHC data in a forward stepwise selection survival model demonstrated that AQUA and QIHC provided similar prognostic information over 70% and 50% of the range for ER and PgR respectively. High ER QIHC and low ER AQUA scores, and low PgR IHC and high PgR AQUA scores provided prognostic information unique to either platform.

Conclusion: Both QIHC and AQUA analysis of HR expression provides significant and highly important information on DFS risk in early breast cancer. It appears that these two platforms provide overlapping prognostic information and that the range of ER and PgR expression which impacts patient outcome is wider than measured by either system alone. Further investigation of the clinical significance of this broader range of hormone receptor expression in treatment decisions is warranted.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-02.

Involvement of closely related strains of a new clonal group of Listeria monocytogenes in the 1998-99 and 2002 multistate outbreaks of foodborne listeriosis in the United States

In 1998-99, a multistate outbreak of listeriosis in the United States was associated with contaminated hot dogs and was caused by a strain of Listeria monocytogenes serotype 4b that had been only rarely encountered before in the national PulseNet database. Upon further characterization, the strains from this outbreak were designated as Epidemic Clone II (ECII). ECII isolates exhibited diversification in a genomic region ("region 18") that was otherwise conserved among L. monocytogenes of serotype 4b. Additional unique genetic markers were identified through genome sequencing of one of the isolates from the 1998-99 outbreak. In 2002, another multistate outbreak of listeriosis also involved bacteria of serotype 4b and was attributed to contaminated turkey deli meats. Molecular subtyping data revealed that the macrorestriction patterns of the isolates from the 1998-99 and 2002 outbreaks were closely related. In addition, the 2002 outbreak isolates harbored chromosomal genetic markers found to be unique to, and typical of, the 1998-99 outbreak isolates, including diversification in genomic region 18. Macroarray- based subtyping using chromosomal sequences confirmed the close genetic relatedness between the isolates from the two outbreaks. Genomic content was highly conserved among isolates from each outbreak, with differences detected only in prophage and internalin-like gene sequences. However, since these differences were observed among isolates from each of the outbreaks, they did not differentiate the 1998-99 isolates as a group from those of the 2002 outbreak. Two of 15 randomly chosen serotype 4b clinical isolates from a non-outbreak period (calendar year 2003) appeared to be closely related to the 1998-99 and 2002 outbreak isolates. These findings suggest that both multistate outbreaks of listeriosis in the United States involved closely related members of a single clonal group (ECII) that had not been identified in outbreaks prior to 1998. Since the outbreaks involved different food vehicles and processing plants, the findings suggest establishment of ECII in a still unidentified reservoir in the United States, from which the organisms were introduced to different processing plants.

Nationwide outbreak of listeriosis due to contaminated meat

We used molecular subtyping to investigate an outbreak of listeriosis involving residents of 24 US states. We defined a case as infection with Listeria monocytogenes serotype 4b yielding one of several closely related patterns when subtyped by pulsed-field gel electrophoresis. Patients infected with strains yielding different patterns were used as controls. A total of 108 cases were identified with 14 associated deaths and four miscarriages or stillbirths. A case-control study implicated meat frankfurters as the likely source of infection (OR 17.3, 95% CI 2.4-160). The outbreak ended abruptly following a manufacturer-issued recall, and the outbreak strain was later detected in low levels in the recalled product. A second strain was recovered at higher levels but was not associated with human illness. Our findings suggest that L. monocytogenes strains vary widely in virulence and confirm that large outbreaks can occur even when only low levels of contamination are detected in sampled food. Standardized molecular subtyping and coordinated, multi-jurisdiction investigations can greatly facilitate detection and control of listeriosis outbreaks.

Behavioral analysis of CREB alphadelta mutation on a B6/129 F1 hybrid background

The cyclic AMP (cAMP)-response element binding protein (CREB) is an activity-dependent transcription factor that plays a role in synaptic plasticity and memory storage in Aplysia, Drosophila, and rodents. Mice with targeted deletions of two CREB isoforms (alpha and delta; CREB alphadelta mice) have been characterized on a mixed genetic background of C57BL/6 (B6) and 129/SvEv (129), as well as on a defined F1 hybrid of B6 and FVB/N, and these results suggest that the phenotype of CREB alphadelta mice depends critically on genetic background. In an examination of the hypothesis that the role of CREB in learning and memory can be influenced by strain differences, we analyzed mice with the CREB alphadelta mutation on an F1 hybrid background of B6 and 129 strains. CREB alphadelta mice on this background had impaired short-term and long-term cued and contextual fear conditioning and normal spatial learning in the Morris water maze. Our results suggest that at least some aspects of hippocampal function are normal in CREB alphadelta mice, and that CREB alphadelta mice on the B6/129 F1 background have alterations in amygdala function. These studies underscore the importance of controlling for genetic background in the behavioral analysis of knockout and transgenic mice.

Protein-tyrosine kinase Pyk2 mediates endothelin-induced p38 MAPK activation in glomerular mesangial cells

Endothelin-1 (ET-1), a member of a family of 21 amino acid peptides possessing vasoconstrictor properties, is known to stimulate mesangial cell proliferation. In this study, ET-1 (100 nm) induced a rapid activation of p21(ras) in human glomerular mesangial cells (HMC). Inhibition of Src family tyrosine kinase activation with [4-Amino-5-(4-methylphenyl)-7-(t-butyl)pyrazolo[3,4-d]pyrimidine] or chelation of intracellular free calcium with 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid acetoxymethyl ester significantly decreased ET-1dependent p21(ras) activation and suggested the involvement of the cytoplasmic proline-rich tyrosine kinase Pyk2. We have observed that Pyk2 was expressed in HMC and was tyrosine-phosphorylated within 5 min of ET-1 treatment. ET-1-induced activation of Pyk2 was further confirmed using phospho-specific anti-Pyk2 antibodies. Surprisingly, Src kinase activity was required upstream of ET-1-induced autophosphorylation of Pyk2. To determine whether Pyk2 autophosphorylation mediated ET-1-dependent p21(ras) activation, adenovirus-mediated transfer was employed to express a dominant-negative form of Pyk2 (CRNK). CRNK expression inhibited ET-1-induced endogenous Pyk2 autophosphorylation, but did not abolish ET-1-mediated increases in GTP-bound p21(ras) levels. ET-1-induced activation of the p38 MAPK (but not ERK) pathway was inhibited in HMC and in rat glomerular mesangial cells expressing the dominant-negative form of Pyk2. These findings suggest that the engagement of Pyk2 is important for ET-1-mediated p38 MAPK activation and hence the biological effect of this peptide in mesangial cells.

Sleep and memory: a molecular perspective

This review synthesizes data from behavioral studies examining the role of sleep in memory storage with what is known about the molecular mechanisms of memory consolidation. There are striking similarities in the effects on memory storage of post-training pharmacological manipulations and post-training manipulations of sleep. For example, inhibition of protein synthesis is most effective if it occurs at a time post-training when rapid eye movement (REM) sleep is required for memory consolidation. The neurochemical changes that occur across sleep/wake states, especially the cholinergic changes that occur in the hippocampus during REM sleep, might provide a mechanism by which sleep modulates specific cellular signaling pathways involved in hippocampus-dependent memory storage.

Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial

BACKGROUND AND OBJECTIVES

This study compared the effectiveness of two booster strategies designed to improve retention of skills and knowledge in neonatal resuscitation by family practice residents.

METHODS

Residents were randomly allocated to one of three groups: video, hands on, or control. Residents in the two experimental groups received a "booster" 3-5 months after the Neonatal Resuscitation Program (NRP) course. All participants completed the follow-up test 6-8 months after taking the course. The main outcome measures consisted of the NRP written examination and the performance checklists.

RESULTS

A total of 44 residents completed the study (video, n = 13; hands-on, n = 14; control, n = 17). Overall, participants had significantly lower scores at follow-up than at baseline, indicating deterioration in both neonatal skills and knowledge. Residents in the hands-on booster group made significantly fewer errors across all five checklists in life-supporting but not in lifesaving scores than those allocated to the control and video groups.

CONCLUSIONS

The beneficial effect of mannequin practice or video boosters on skills and knowledge retention was less than what had been anticipated, and no benefit could be demonstrated in comparison to the control group. Deteriorating knowledge and skills remain a major concern, since boostering by hands-on or video at 3-5 months do not seem to have an impact on the retention of knowledge or lifesaving skills.

Evaluation of Pepscan analyses for epitope mapping of anti-MUC1 monoclonal antibodies--a comparative study and review of five antibodies

Many murine monoclonal antibodies against MUC1 mucin have been analysed for reactivity against short overlapping peptides with sequences based upon that of the 20 amino acid tandem repeat of the MUC1 protein core, in order to identify the minimum binding units or epitopes. This report summarises the findings using a set of overlapping heptamers to identify the epitopes of 5 established anti-MUC1 antibodies. The results are evaluated and reviewed in comparison to those obtained using other length peptides and other assay formats for epitope mapping using the Pepscan technique.

Mexiletine in the symptomatic treatment of diabetic peripheral neuropathy

OBJECTIVE

To evaluate the efficacy and safety of mexiletine in the symptomatic treatment of diabetic peripheral neuropathy (DPN).

METHODS

In this prospective, double-blind study, 29 patients were randomized to receive mexiletine 600 mg/d or matching placebo for 3 weeks. A four-item symptom score (FIS), which rated pain, dysesthesias, paresthesias, and nightly exacerbations of symptoms, and a 100-mm visual analog scale (VAS), which rated pain intensity, were completed by patients before and after treatment. At the end of treatment independent patient and investigator global assessments were made. Patients reported adverse effects after 1 and 3 weeks of treatment.

RESULTS

Treatment groups were similar at baseline. The difference between the median changes in FIS scores (mexiletine = 5.5, placebo = 2) was not statistically significant. Overall symptom response was similar in both treatment groups as demonstrated by both global assessments (p = 0.19). The mean change in VAS score from baseline to posttreatment was determined for both groups and the difference between these mean scores was 16.5 mm (95% CI, -7.1 to 40.2 mm) (p = 0.16). Inadequate statistical power (1-beta = 0.40) may have resulted from small sample size, small magnitude of effect, or variability in the measured effect. Adverse effects were more common in the mexiletine group, though not statistically significant. One patient receiving mexiletine was hospitalized for palpitations.

CONCLUSIONS

Because of conflicting reports of mexiletine's efficacy in the treatment of symptomatic DPN, this drug should be reserved for patients unresponsive or intolerant to standard therapy, without evidence of heart disease, and with sensations of burning heat, formication, or stabbing pain.

Intravenous pamidronate for hypercalcemia of primary hyperparathyroidism

Intravenous pamidronate disodium has been used successfully in the treatment of malignancy-associated hypercalcemia and Paget's disease of bone. Although the definitive treatment of primary hyperparathyroidism (PHPT) is surgical, intravenous pamidronate has been used to treat hypercalcemia of PHPT when surgery was contraindicated. We report two cases of PHPT in which intravenous pamidronate effectively reduced hypercalcemia and significantly improved the clinical symptoms. The results of our study and the experience in the literature suggest that pamidronate is a safe and effective method of reducing serum calcium in patients with PHPT when definitive surgery is contraindicated or must be postponed.

Judicial decision-making in contested custody cases: the influence of reported child abuse, spouse abuse, and parental substance abuse

This study examined the relationship between allegations of maltreatment and substance abuse, and custody awards in Florida. Information concerning the presence, or absence, of these reports was collected on 60 contested initial disposition, or disposition modification cases, and was used to model judicial decision-making. Substantiated reports of child and spouse abuse occurred very infrequently in our sample. Conversely, substance abuse allegations occurred much more frequently. Judges appeared responsive to allegations of abuse with regard to awards of primary physical residence, despite the lack of substantiated evidence. Maltreatment allegations had no apparent impact, however, on awards of shared, versus sole, custody. Additionally, reports of parental substance abuse also had no apparent impact on judicial decision-making. Implications of these results are discussed.

Herbimycin A blocks IL-1-induced NF-kappa B DNA-binding activity in lymphoid cell lines

The mechanism by which interleukin-1 alpha (IL-1 alpha) activates NF-kappa B DNA-binding activity is not completely understood. While it is well established that protein kinase C can activate NF-kappa B, neither protein kinase C nor protein kinase A appears to be critical in the induction of NF-kappa B by IL-1 alpha. Since a number of growth factors signal via protein tyrosine kinase, in this study we examined a possible involvement of protein tyrosine kinase in the IL-1 alpha-induced NF-kappa B. The results showed that in the murine pre-B cell line 70Z/3 and in the murine T cell line EL-4 6.1 C10 IL-1 alpha-induced NF-kappa B was associated with transient increase in protein tyrosine kinase activity. Pre-treatment of these cell lines with herbimycin A, an inhibitor of tyrosine kinase activity, blocked the IL-1 alpha-enhanced protein tyrosine kinase activity and the IL-1 alpha-induced NF-kappa B DNA-binding activity. Herbimycin A at concentrations sufficient to block IL-1 alpha-induced NF-kappa B did not block the phorbol 12-myristate 13-acetate (PMA)-induced NF-kappa B. The data suggest that IL-1 alpha and PMA activate NF-kappa B by different pathways and that induction of NF-kappa B DNA-binding activity by IL-1 might be dependent on protein tyrosine phosphorylation.

Inhibition of mediator release in systemic mastocytosis is associated with reversal of bone changes

A 59-year-old male presented with systemic mastocytosis with extensive skeletal involvement resulting in vertebral compression fractures and bone pain. Histomorphometric analysis of bone revealed increased mast cells, elevated static parameters of bone resorption, and low bone formation. Serum calcium, phosphorus, and alkaline phosphatase were normal; however, serum 1,25-dihydroxyvitamin D3 and osteocalcin levels were low. Histamine levels in plasma and urine were elevated. Following therapy with ketotifen, the patient had resolution of bone pain along with decreased flushing and pruritus. Elevated plasma and urine histamine levels normalized, as did 1,25-dihydroxyvitamin D3 and osteocalcin levels. Indices of low bone formation improved on therapy. Eroded surfaces improved but remained elevated. This case is the first demonstration that bone symptoms and histomorphometric change in systemic mastocytosis are reversed with inhibition of mast cell degranulation. The role of mast cells and their products in bone metabolism is poorly understood, but the therapy of bone disease in systemic mastocytosis should include inhibition of the release of mast cell products along with the use of histamine antagonist.

Comparison of bone and parathyroid hormone as stimulators of osteoclast development and activity in calvarial cell cultures from normal and osteopetrotic (mi/mi) mice

Osteoclast development was studied in cell cultures prepared from calvaria of neonatal osteopetrotic (mi/mi) mice or their normal littermates, using tartrate-resistant acid phosphatase (TRAPase), as an osteoclast marker. In cultures from normal mice, treatment with 10 nM PTH for 4-5 days stimulated the formation of osteoclasts. However in cultures from mi/mi mice, this response was only 7% +/- 5% that of normal mice and they were significantly smaller than osteoclasts of normal mice. Mineralized bone particles elicited osteoclast development in cultures from both normal and mi/mi mice, and osteoclast size was identical for both genotypes. Seventy-eight to 96% of the TRAPase-positive cells bound 125I-CT, as demonstrated by autoradiography. 125I-CT binding characteristics were identical in cultures from both genotypes treated with bone particles, exhibiting a Kd of 3.3-3.6 x 10(-10) M. Addition of PTH stimulated 45Ca release from the added bone particles only in the case of cultures prepared from normal mice, and CT inhibited this response. Cells from normal mice were capable of excavating bone from the surface of smooth cortical bone wafers, but such excavations were rarely seen in the case of calvarial cells from mi/mi mice. Thus, PTH-driven differentiation of osteoclasts is arrested in calvarial cell cultures from mi/mi mice, but mi/mi preosteoclasts retain the ability to express certain osteoclast markers in response to bone derived signals. We hypothesize that the lack of activity of mi/mi osteoclasts is due to the failure of mi/mi preosteoclasts to respond appropriately to resorptive agents, or to cytokines elicited by these agents.

Expression and characterization of the tau subunit of phosphorylase kinase

A cDNA encoding the entire tau subunit of rabbit skeletal muscle phosphorylase kinase was reconstructed and inserted into a plasmid containing the Escherichia coli ptac promoter and a constructed plasmid containing the ptac promoter and bacterial chloramphenicol acetyl transferase (CAT) gene, respectively. A significant phosphorylase kinase activity was found, in the first case. In the second case, a fused protein containing 73 amino acids from the CAT protein was obtained. After renaturation, the CAT-tau subunit protein shows enzymatic activity similar to the HPLC-purified and renatured tau subunit.

Increase in the activity of tryptophan hydroxylase from cortex and midbrain of male Fischer 344 rats in response to acute or repeated sound stress

Exposure of male Fischer 344 rats to an acute sound stress consisting of 100 dB tones of 2-s duration presented at random 60-s intervals for 2 h, increased cortical and midbrain tryptophan hydroxylase activity, measured in vitro, 50% over that from sham-stressed animals. This increase in enzyme activity was observed when animals were killed immediately, but not 1 h, after termination of the sound stress. It was non-additive with the increase in activity induced by incubation of enzyme under phosphorylating conditions and could be reversed in vitro with alkaline phosphatase. Graded increases in enzyme activity were obtained with increments of sound intensity (90-120 dB). In contrast to acute stress, chronic sound stress (110 dB) repeated over a period of 1, 2 or 6 weeks (3 sessions per week each of 2-h duration) produced a 50% increase in cortical enzyme activity that persisted 24 h after the termination of the stress and was not reversed by alkaline phosphatase. However, a further increase in enzyme activity could be produced if the chronically stressed animals were exposed to an acute 2-h stress (110 dB) immediately before being killed. This additional increase in activity was reversible in vitro by alkaline phosphatase and non-additive with that produced by incubation under phosphorylating conditions. In summary, acute sound stress produced a prompt, reversible activation of tryptophan hydroxylase. Repeated exposure to sound stress induced a persistent increase in enzyme activity that was detected 24 h after the last stress.

Behavioural differences of school-age children who were small-for-dates babies

Twenty-one children aged between five and nine years who were small for gestational age (SFD) at birth and whose intra-uterine head growth was shown by ultrasonography to be slowing before 35 weeks were observed in a special room, using video-cameras. Their behaviour was compared with that of 21 matched control children who had had normal birthweight. The children in the SFD group were quieter, more compliant and less active than the control group, and their play behaviour suggested that they were less advanced developmentally. The behaviour of the mothers of the SFD group showed that they were aware of their child's problems and tried to compensate for it by teaching the child while they were waiting for the observational session to start, by sitting closer to the child during a drawing test, and by using more words to explain it.

Antigenic and genetic characterization of a novel hemagglutinin subtype of influenza A viruses from gulls

Influenza A virus isolates from ring-billed, Franklin, blackback, and herring gulls in the United States possess a hemagglutinin (HA) distinct from the 12 reference HA subtypes. Serological assays (hemagglutination inhibition and double-immunodiffusion) with specific antisera to reference strains and to a representative gull isolate showed that the HA of the gull virus was not antigenically related to that of any known subtype. The gull virus did not replicate in ducks or chickens but did replicate in ferrets. Comparison of the nucleotide sequences (and deduced amino acid sequences) of the 3' 20% of the HA genes of these viruses indicates that the gull viruses represent a genetically distinct group. We propose that this HA, which has been detected only in gull isolates thus far, be called the H13 subtype.

Electronic measurement of locomotion by means of pressure-sensitive floor mats

This paper describes a method of adapting an observation room to record a child's position in the room and to give an index of the amount of locomotion. The adaptation consisted of under-carpet pressure mats, linked electronically to digital counters. This recording system showed a highly significant correlation with observational measurements of the same aspects of behaviour. It has potential as an aid in the diagnosis of abnormal behaviour states.

Fluoride resistance and adherence of selected strains of Streptococcus mutans to smooth surfaces after exposure to fluoride

The fluoride resistance and smooth surface adherence characteristics of Streptococcus mutans were examined using tooth model and radioactive cell assays. Resistance to 600 ppmF by S. mutans isolated from the plaque of radiation-induced xerostomia patients receiving daily topical applications of a caries preventive 1% NaF gel was transient. Resistance induced in vitro in two strains of S. mutans by exposure to gradually increasing levels of NaF was apparently permanent. Smooth surface adherence by both fluoride-sensitive and -resistant strains of S. mutans 6715 in a tooth model system was slightly diminished by 1% NaF gel. Fluoride-resistant strains retained 89 to 93% of their adherence capability in 600 ppmF, as determined by the cell radiolabeling assay.

Mode of delivery and the lecithin/sphingomyelin ratio

Babies born by elective Caesarean section are more likely to develop the respiratory distress syndrome that babies born vaginally. We studied the amniotic fluid and pharyngeal lecithin/sphingomyelin (L/S) ratios in three groups of babies born at term: 20 were delivered vaginally after elective induction of labour; 20 were delivered by elective Caesarean section; and 14 by Caesarean section after spontaneous onset of labour. Babies born after induction of labour had higher pharyngeal L/S ratios than babies born by elective Caesarean section. Those born by Caesarean section after spontaneous onset of labour had significantly higher pharyngeal L/S ratios than those in both of the elective delivery groups. There were no significant differences in the amniotic fluid L/S ratios of the two groups who underwent elective delivery. Regression analysis showed a significant relationship between length of labour and increase in the L/S ratio. These results indicate that, during labour, there is a release of fetal lung surfactant into the airways.

Maturity of fetal lungs tested by production of stable microbubbles in amniotic fluid

Lung surfactant in amniotic fluid, and hence the maturity of the fetal lungs, can be assessed by observation of stable microbubbles (less than 15 micron diameter). Bubbles are formed by agitation with a Pasteur pipette and examined in hanging drops under the 10 x power of a microscope. Either after a count of bubbles, or after a general survey of hanging drops, the fluid is given a stable microbubble rating. A 'strong' rating indicates that the idiopathic respiratory distress syndrome will not occur after delivery, and that the lecithin/sphingomyelin ratio will indicate maturity. Complete absence of stable microbubbles suggests a high risk of respiratory trouble for the newborn infant, as does a weak or lower rating in the 30 to 37 week gestational age group. The test takes 5 to 10 minutes to perform, is cheap and easy, is not affected by blood, but may be affected by meconium. If a 'strong' rating is found, measurement of the L/S ratio can safely be omitted.

Free cortisol in obesity; effect of fasting

Plasma and urinary corticosteroids were measured in 13 obese subjects before and after high and low protein diets, and after fasting. During isocaloric high and low protein diets, urinary 17-oxogenic steroids and to a lesser extent urinary free cortisol excretion rose and fell in parallel with protein intake. Plasma unbound cortisol levels were not much changed by high or low protein intake. However, during 7 to 11 days total fasting, there was a highly significant rise in plasma unbound cortisol at 24.00. A smaller rise occurred at 09.00. The overall effect was a considerable diminution of the day-night variation of plasma unbound coritsol levels during fasting, and a rise in prevailing unbound cortisol levels and urinary free cortisol excretion. In 3 subjects tested these changes were reversed immediately by glucose re-feeding.