Using the capability, opportunity, and motivation model of behaviour to assess provider perception of implementing solution-focused goal-setting in paediatric rehabilitation

Adoption of family and child goal-setting in paediatric rehabilitation is important to positive long-term outcomes. Solution-focused coaching (SFC) has been identified as a promising approach to ensuring this type of goal-setting occurs, while the actual implementation of SFC by health care providers (HCPs) is low. This study utilized the capacity, opportunity, and motivation model of behaviour change (COM-B) to identify which strengths and difficulties health care providers (HCPs) perceived with respect to SFC goal-setting in paediatric rehabilitation. A self-report survey was developed and administered to HCPs at a paediatric rehabilitation hospital. Each survey question was based upon a COM-B sub-component. Demographic information was collected from HCPs, and descriptive statistics were used to rank perceived COM-B components from strongest to weakest. Results indicate HCPs view the provision of SFC goal-setting as an important practice, while they also perceive difficulties to actual delivery due to: lack of adequate individual skill, lack of experience with this type of goal-setting, and insufficient preparation for clients to engage in sharing their goals. HCPs also perceived lack of organizational processes to support the practice within their teams. Recommendations for intervention are provided.

1310 FRAILTY, LONELINESS AND SOCIAL ISOLATION IN THE UK BIOBANK COHORT

Background

Three challenges for ageing populations are frailty (a state of reduced physiological reserve), social isolation (objective lack of social connections), and loneliness (subjective experience of feeling alone). These are associated with adverse outcomes. This study aims to examine how frailty in combination with loneliness or social isolation is associated with all-cause mortality and hospitalisation rate using data from UK Biobank, a large population-based research cohort.

Methods

502,456 UK Biobank participants were recruited 2006-2010. Baseline data assessed frailty (via two measures: Fried frailty phenotype, Rockwood frailty index), social isolation, and loneliness. Adjusted cox-proportional hazards models assessed association between frailty in combination with loneliness or social isolation and all-cause mortality. Negative binomial regression models assessed hospitalisation rate.

Findings

Frailty, social isolation, and loneliness are common in UK Biobank (frail as per frailty phenotype 3.38%, frail as per frailty index 4.68%, social isolation 9.04%, loneliness 4.75%). Social isolation/loneliness were more common in frailty/pre-frailty. Frailty is associated with increased mortality regardless of social isolation/loneliness. Hazard ratios for frailty (frailty phenotype) were 3.38 (3.11-3.67) with social isolation and 2.89 (2.75-3.05) without social isolation, 2.94 (2.64-3.27) with loneliness and 2.9 (2.76-3.04) without loneliness. Social isolation was associated with increased mortality at all levels of frailty; loneliness only in robust/pre-frail. Frailty was also associated with hospitalisation regardless of social isolation/loneliness. Incidence rate ratios for frailty (frailty phenotype) were 3.93 (3.66-4.23) with social isolation and 3.75 (3.6-3.9) without social isolation, 4.42 (4.04-4.83) with loneliness and 3.69 (3.55-3.83) without loneliness. At all levels frailty, social isolation/loneliness are associated with increased hospitalisation Results were similar using the frailty index definition.

Conclusion

Social isolation is relevant at all levels frailty. Risk of loneliness is more pronounced in those who are robust or pre-frail. Proactive identification of loneliness, regardless of physical health status may provide opportunities for intervention.

Brain activity changes associated with pain perception variability

Pain perception can be modulated by several factors. Phenomena like temporal summation leads to increased perceived pain, whereas behavioral conditioning can result in analgesic responses. Furthermore, during repeated, identical noxious stimuli, pain intensity can vary greatly in some individuals. Understanding these variations is important, given the increase in investigations that assume stable baseline pain for accurate response profiles, such as studies of analgesic mechanisms. We utilized functional magnetic resonance imaging to examine the differences in neural circuitry between individuals displaying consistent pain ratings and those who experienced variable pain during a series of identical noxious stimuli. We investigated 63 healthy participants: 31 were assigned to a "consistent" group, and 32 were assigned to a "variable" group dependent on pain rating variability. Variable pain ratings were associated with reduced signal intensity in the dorsolateral prefrontal cortex (dlPFC). Furthermore, the dlPFC connectivity with the primary somatosensory cortex and temperoparietal junction was significantly reduced in variable participants. Our results suggest that investigators should consider variability of baseline pain when investigating pain modulatory paradigms. Additionally, individuals with consistent and variable pain ratings differ in their dlPFC activity and connectivity with pain-sensitive regions during noxious stimulation, possibly reflecting the differences in attentional processing and catastrophizing during pain.

Facilitators and barriers to patient-centred goal-setting in rehabilitation: A scoping review

Objective

Identify, map, and synthesize existing reviews, to extract and analyse the most prominent barriers and facilitators to applying patient-centred goal-setting practice in rehabilitation using the Capability, Opportunity Motivation Behaviour (COM-B) model.

Design

Scoping review.

Data source

A primary search was conducted in MEDLINE, CINAHL, EMBASE, PsychInfo, and Cochrane. Citation chaining was employed.

Review methods

All types of review (systematic, scoping, and narrative) studies published up to June 14, 2022 that included physical and neurological rehabilitation, patient-centeredness, and goal-setting were reviewed. Studies were scrutinized for relevance, quality was not assessed. The most prominent barriers and facilitators were synthesized using thematic content analysis and mapped onto the COM-B model.

Results

Twenty-six review studies covering a range of conditions and settings, acute to community were included. Barrier and facilitators were identified at patient, provider, and organizational level. Barrier themes include provider's existing beliefs about goal-setting, lack of skills, and integration into clinical routines. Patient barriers related to capacity and opportunity to participate. Organizational barriers include lack of clinical guidelines, patient preparation, insufficient provider time, and high productivity expectations. Facilitators included goal-setting guidelines, training and education of providers and patients, revised clinical routines, performance monitoring, adequate time, and resources.

Conclusion

Healthcare providers should be the primary target of intervention. A provider's motivation to change current practice is the most prominent barrier, followed closely by capacity and opportunity. Patients require information, training, and structured engagement opportunities. Organizations play a key role in creating the optimal environmental conditions to enable patient-centred goal-setting.

Anesthetic Considerations for Functional Neurosurgery

Functional neurosurgery is a rapidly growing field that uses surgical resection, ablation, or neuromodulation to treat an assortment of neurologic and psychiatric disorders, the most common of which are movement disorders and epilepsy. Anesthesiologists caring for patients undergoing neurofunctional procedures should be aware of the anesthetic implications of patients' underlying disease as well as procedure-specific concerns, such as the effects of anesthetics on intraoperative neuromonitoring and limited access to patients due to stereotactic frames or intraoperative imaging.

Improvements in pain, medication use and quality of life in onabotulinumtoxinA-resistant chronic migraine patients following erenumab treatment - real world outcomes

Background

The CGRP antagonists offer a novel therapeutic approach in migraine. Their utility in patients with severe forms of chronic migraine is a subject of particular interest. We present outcomes of 9 months of erenumab treatment in a cohort of patients with difficult-to-control chronic migraine, all of whom had prior unsatisfactory response to onabotulinumtoxinA.

Methods

We offered erenumab to 98 patients with a prior unsatisfactory response to onabotulinumtoxinA. Eighty of 98 had trialled greater occipital nerve injections (82%), 32/98 peripheral neurostimulation (33%) and 18/98 intravenous dihydroergotamine (18%). Thirty eight of 98 (39%) met the definition of triptan overuse and 43/98 (44%) analgesic overuse. All patients met the EHF criteria for ‘resistant migraine’. Outcome measures (recorded monthly) included days with headache limiting activities of daily living (“red”), not limiting (“amber”), headache free (“green”), and requiring triptans or other analgesics. Quality of life scores - headache impact test 6 (HIT-6), patient health questionnaire 9 (PHQ-9) and pain disability index (PDI) - were also measured.

Results

Mean number of red days improved by − 6.4 days (SE 0.67, 95%CI − 7.7 to − 5.1, p=0.001) at 3 months; − 6.8 days (SE 0.96, 95%CI − 8.80 to − 4.9, p=0.001) at 6 months and − 6.5 days (SE 0.86, 95%CI − 8.3 to − 4.8, p=0.001) at 9 months. Repeated measures ANOVA confirmed improvements in the number of red (p=0.001), green (p=0.001), triptan (p=0.001) and painkiller days (p=0.001) as well as scores of the HIT-6 (p=0.001), PHQ-9 (p=0.001), and PDI (p=0.001) across the duration of study.

Conclusion

We observed improvements in pain, medication use and quality of life in onabotulinumtoxinA-resistant chronic migraine patients following erenumab treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-020-01214-2.

Is a Retrolaminar Approach to the Thoracic Paravertebral Space Possible?: A Human Cadaveric Study

BACKGROUND AND OBJECTIVES

The retrolaminar block (RB) is used for truncal analgesia, but its mechanism of neural blockade remains obscure. We sought to learn the pattern of local anesthetic spread after thoracic RB using cadaveric models.

METHODS

In 8 fresh cadavers, an ultrasound-guided T4 RB was performed with 20 mL of methylene blue 1% and bupivacaine 0.5%. For comparison, an RB at T9 in 1 cadaver and a T4 thoracic paravertebral block in another cadaver were performed. Subsequently, posterior and anterior thoracic dissections were performed to examination where the dye spread.

RESULTS

After T4 RB, dye was noted to spread in the ipsilateral retrolaminar plane (all 8 cadavers, median cephalad spread 3.5 cm, caudad spread 10.7 cm, lateral spread 2.5 cm), the contralateral retrolaminar plane (6 cadavers), the paravertebral space (5 cadavers, median of 3 segments, T3-T5), the intercostal space (5 cadavers, median of 3.5 cm laterally), the T4 epidural space (6 cadavers), and the intervertebral foramina (4 cadavers, median of 2 segments, T4-T5). After T9 retrolaminar injection, dye was noted in the ipsilateral retrolaminar plane (5.5 cm cephalad, 13.5 cm caudad, and 2.5 cm lateral), the contralateral retrolaminar plane, and the epidural space. Dye after T4 traditional paravertebral block spread to T1-T6 paravertebral space with 15-cm lateral spread.

CONCLUSIONS

Injectate spread to the paravertebral space, epidural space, intercostal space, and intervertebral foramina is possible in the RB but is quite variable. In comparison to the thoracic paravertebral block, injectate spread within the paravertebral space is more limited.

Patient preferences for topical treatment of actinic keratoses: a discrete-choice experiment

BACKGROUND

The treatment of actinic keratosis (AK) is a potentially effective strategy for the prevention of cutaneous squamous cell carcinoma (cSCC). However, the patient perspective on potential benefits of AK treatment in terms of skin cancer reduction has received little attention to date.

OBJECTIVES

(i) To investigate patient preferences for topical treatments for AK using a discrete-choice experiment (DCE); (ii) to evaluate patient willingness to trade between clinical benefit and medical burden.

METHODS

The DCE was conducted as part of a study to establish the feasibility of a phase III randomized controlled trial evaluating the prevention of cSCC using currently available topical interventions. Preferences were elicited by asking patients to make a series of choices between treatment alternatives with different hypothetical combinations of attribute levels. Willingness to trade between treatment attributes was estimated using a flexible-choice model that allows for the heterogeneity of patient preferences.

RESULTS

A total of 109 patients with AK completed the DCE. The majority of patients who expressed valid preferences were willing to accept some reduction in both prophylactic and cosmetic efficacy to reduce the burden of the treatment regimen, the severity of skin reaction and other adverse effects. Patients may reject treatment if the perceived therapeutic benefit is outweighed by the subjective burden of treatment.

CONCLUSIONS

Evidence of significant variation in the perceived utility of treatments across patients highlights the importance of taking individual patient preferences into account to improve AK treatment acceptability and adherence.

Immediate tangential excision accelerates wound closure but does not reduce scarring of mid-dermal porcine burns

Current evidence supports the use of excision to remove eschar from deep dermal and full-thickness burns. However, the role of excision of mid-dermal burns remains unclear. This study aimed to develop a porcine model that could produce reproducible middermal thermal burns that undergo tangential excision; and investigate the effects of immediate tangential excision (30 minutes postburn) on healing and scarring. An aluminum bar preheated in hot water (70°C) was applied for 20 or 30 s to produce a total of sixteen mid-dermal burns per pig on each of six pigs. Thirty minutes after burn creation, half of the burns were tangentially excised. Four partial- thickness wounds per pig were created as controls. Depth of burn injury (1 and 24 h), reepithelialization (7 and 10 d) and scar depth (28 d) were assessed microscopically. Total scar surface area was grossly evaluated on day 28. Exposure of porcine skin to a preheated aluminum bar at 70 °C for 20 or 30 sec resulted in reproducible mid-dermal burns, where immediate excision enhanced complete wound closure as judged by complete re-epithelialization, but did not reduce initial depth of injury, scar contraction and scar depth. Immediate surgical intervention is sufficient to enhance wound closure, but not to mitigate mid-dermal burn scar formation. This work provides a suitable animal model to evaluate novel therapies that may be used to inhibit burn progression, accelerate wound closure and decrease scarring, especially those therapies unable to penetrate burn eschar.

Development and clinical validation of multiplex TaqMan® assays for rapid diagnosis of viral gastroenteritis

There is a need to provide rapid, sensitive, and often high throughput detection of pathogens in diagnostic virology. Viral gastroenteritis is a serious health issue often leading to hospitalization in the young, the immunocompromised and the elderly. The common causes of viral gastroenteritis include rotavirus, norovirus (genogroups I and II), astrovirus, and group F adenoviruses (serotypes 40 and 41). This article describes the work-up of two internally controlled multiplex, probe-based PCR assays and reports on the clinical validation over a 3-year period, March 2007 to February 2010. Multiplex assays were developed using a combination of TaqMan™ and minor groove binder (MGB™) hydrolysis probes. The assays were validated using a panel of 137 specimens, previously positive via a nested gel-based assay. The assays had improved sensitivity for adenovirus, rotavirus, and norovirus (97.3% vs. 86.1%, 100% vs. 87.8%, and 95.1% vs. 79.5%, respectively) and also more specific for targets adenovirus, rotavirus, and norovirus (99% vs. 95.2%, 100% vs. 93.6%, and 97.9% vs. 92.3%, respectively). For the specimens tested, both assays had equal sensitivity and specificity for astrovirus (100%). Overall the probe-based assays detected 16 more positive specimens than the nested gel-based assay. Post-introduction to the routine diagnostic service, a total of 9,846 specimens were processed with multiplex 1 and 2 (7,053 pediatric, 2,793 adult) over the 3-year study period. This clinically validated, probe-based multiplex testing algorithm allows highly sensitive and timely diagnosis of the four most prominent causes of viral gastroenteritis.

Gouty synovitis after total knee arthroplasty: a case report

We report a case of acute gouty synovitis after total knee arthroplasty (TKA) in a patient with no history of gout. The diagnosis was confirmed by the presence of urate crystals in the synovial fluid. Acute gouty synovitis, though rare, should be considered in the differential diagnosis of an inflammed knee after TKA to avoid unnecessary surgical revision.

Strategies for studying mouse and human immune responses to human papillomavirus type 16

Cytotoxic T lymphocytes (CTL) are an important protective mechanism in viral infection and can be effective against tumours. We have investigated the tumour-associated E6 and E7 genes of human papillomavirus type 16 as CTL targets. In H-2b mice we have defined epitopes in E6 and E7 which can readily generate CTL in vivo and we have shown that HLA-A2.1 transgenic mice can generate an HLA-A2.1-restricted response. We have been unable to reveal a primed CTL response in humans. These paradoxical findings imply that human papillomavirus may fail to stimulate a systemic CTL response and/or employ strategies for evading or down-regulating such a response.

Criteria for establishing that a virus is oncogenic

To prove that a particular infectious agent causes a disease is much more difficult in human subjects than in other animals for both ethical and practical reasons. Where the disease is a malignant tumour with a long latent period the situation is even more difficult. For these reasons, it is often necessary to concentrate in the first instance on association of the virus with the disease, and this is discussed in the context of papillomaviruses. Association of a virus with a tumour may occur for a variety of reasons other than the virus being the cause of the tumour. This is illustrated by several examples of parvoviruses and DNA tumour viruses. Conversely, the absence of any sign of virus or viral nucleic acid in a tumour does not prove that the tumour was not induced by a virus. Apart from association of a virus with a tumour it is also necessary to show that the virus in question is oncogenic. Again this cannot normally be done directly, so that indirect evidence from animal experiments or from in vitro transformation is likely to be the best available alternative. In the final analysis the best proof of oncogenicity may be the effectiveness of intervention directed at the virus.

Glomerular hyperfiltration: a new marker of metabolic risk

Chronic kidney disease coexists with metabolic syndrome and this relationship may be apparent before overt manifestations of cardiovascular disease. To investigate early stages of the natural history of associations between renal function and metabolic syndrome, we phenotyped 1572 young (mean age=18.4 years), apparently healthy men for metabolic risk factors and estimated their creatinine clearance based on the Cockcroft-Gault equation. High metabolic risk (clustering of at least three metabolic risk factors) was revealed in 8.7% (137) of the subjects and was associated with a 6.9-fold increase in the odds of glomerular hyperfiltration (95% confidence interval (CI): 3.9-11.5) when compared to reference (from none to two metabolic risk factors). Overweight, elevated blood pressure, and low high-density lipoprotein (HDL) cholesterol increased the multivariate-adjusted odds ratio of glomerular hyperfiltration to 6.6 (95% CI: 3.8-11.6), 1.8 (95% CI: 1.0-3.0), and 2.5 (95% CI: 1.5-4.3), respectively. Systolic and diastolic blood pressures clustered together with leptin in the factor analysis and this blood pressure-adiposity component correlated with estimated creatinine clearance (r=0.329, P<0.0001) and explained on its own 10.2% of the variance in the estimated renal function. Our data reveal the silent epidemics of metabolic risk among young, apparently healthy men. Furthermore, the results indicate that high metabolic risk is associated with glomerular hyperfiltration before overt manifestations of cardiovascular disease.

A single-blinded case controlled study on effects of cardiopulmonary circulation on hearing during coronary artery bypass grafting

OBJECTIVES

To evaluate the effect of extra-corporeal (cardiopulmonary) bypass on hearing during coronary artery bypass grafting.

DESIGN

Prospective (single-blinded) controlled study.

SETTING

District General Hospital.

PARTICIPANTS

Fifty-two patients undergoing coronary artery bypass grafting completed this study. Comparison was made between 14 control patients undergoing off-pump coronary artery bypass grafting and 38 study patients undergoing on-pump coronary artery bypass grafting. The age range of patients was 48-81 years, with 50% between 64 and 66 years.

MAIN OUTCOME MEASURES

Pure tone audiograms were performed in all patients before and after coronary artery bypass grafting. Data were analysed for any significant difference between pre- and post-operative pure tone audiograms.

RESULTS

Mann-Whitney U-test demonstrated no difference between the area generated between mean pre- and post-operative audiograms (P = 0.754). No significant difference between off versus on pump was demonstrated for average differences at 250-500 Hz, 4 kHz, 4-8 kHz and 8 kHz. Wilcoxon matched-pairs signed-rank test demonstrated no difference between right and left ears for each individual frequency. Spearman's test to analyse the effect on vessel number or minutes on bypass pump revealed no significant difference at 4-8 kHz (P = 0.550 for number of vessels and P = 0.276 for minutes on pump.)

CONCLUSION

In this study, it was not possible to demonstrate any statistically significant deleterious effect of extra-corporeal (cardiopulmonary) bypass on hearing during coronary artery bypass grafting.

An evaluation of peripheral blood eosinophil/basophil progenitors following nasal allergen challenge in patients with allergic rhinitis

OBJECTIVE

To evaluate the effect of a single nasal allergen challenge on peripheral blood eosinophil/basophil (Eo/B) progenitor cells and induced sputum eosinophil counts in subjects with allergic rhinitis.

METHODS

Sixteen adults entered a sequential nasal control and allergen challenge study, outside the pollen season. Blind assessment of peripheral blood Eo/B progenitor colony forming units (CFU), induced sputum and nasal lavage cell counts was made before and 24 h after both challenges. Subjects recorded their rhinitis symptoms and nasal peak inspiratory flow, hourly at home, following both challenges.

RESULTS

When comparing the values 24 h after the control vs. the allergen challenge, there were no significant differences in Eo/B progenitor CFU (control (mean, SD): 3.6 (1.0)/10(6) cells; allergen: 4.4 (1.1)/10(6) cells) or sputum eosinophils (control (median, inter-quartile range): 1.0 (0.3-1.7)%; allergen: 0.7 (0.0-1.3)%) despite a significant increase in the percentage (median (inter-quartile range) of eosinophils in nasal lavage (control: 0.6 (0.1-0.9)%; allergen; 1.9 (0.9-8.1)% and significant worsening of nasal peak inspiratory flow and rhinitis symptoms.

CONCLUSIONS

Despite a significant increase in nasal symptoms and lavage eosinophil counts, a single nasal allergen challenge was not sufficient to elicit a measurable haemopoietic response in circulation, or an increase in sputum eosinophil counts.

Transmission disequilibrium testing of dopamine-related candidate gene polymorphisms in ADHD: confirmation of association of ADHD with DRD4 and DRD5

Attention-deficit hyperactivity disorder (ADHD) is one of the most common childhood behavioral disorders. Genetic factors contribute to the underlying liability to develop ADHD. Reports implicate variants of genes important for the synthesis, uptake, transport and receptor binding of dopamine in the etiology of ADHD, including DRD4, DAT1, DRD2, and DRD5. In the present study, we genotyped a large multiplex sample of ADHD affected children and their parents for polymorphisms in genes previously reported to be associated with ADHD. Associations were tested by the transmission disequilibrium test (TDT). The sample is sufficient to detect genotype relative risks (GRRs) for putative risk alleles. The DRD4 gene 120-bp insertion/deletion promoter polymorphism displayed a significant bias in transmission of the insertion (chi(2)=7.58, P=0.006) as suggested by an analysis of a subset of these families. The seven repeat allele of the DRD4 48-bp repeat polymorphism (DRD4.7) was not significantly associated with ADHD in the large sample in contrast to our earlier findings in a smaller subset. We replicate an association of a dinucleotide repeat polymorphism near the DRD5 gene with ADHD by showing biased nontransmission of the 146-bp allele (P=0.02) and a trend toward excess transmission of the 148-bp allele (P=0.053). No evidence for an association was found for polymorphisms in DRD2 or DAT1 in this sample. The DRD5 146-bp (DRD5.146) allele and the DRD4 240-bp (DRD4.240) allele of the promoter polymorphism emerge as the two DNA variants showing a significant association in this large sample of predominantly multiplex families with ADHD, with estimated GRRs of 1.7 and 1.37, respectively.

Cerebral dominance and schizophrenia-spectrum disorders in adults with intellectual disability

Studies of the general population without intellectual disability have suggested an association between atypical handedness and schizophrenia-spectrum disorders (SSDs). Mixed handedness is taken as an index of diminished cerebral dominance or laterality. The present study addressed the question of whether such findings extend to the neurodevelopmentally 'at risk' population of adults with intellectual disability and SSDs compared with appropriate controls. Fourteen patients with a dual diagnosis of intellectual disability and SSD were compared with 14 controls with intellectual disability alone. Assessments of self-reported hand preference and relative hand skill were completed. Self-report of hand preference revealed highly significantly greater mixed-handedness in the SSD group. Furthermore, relative hand skill performance was significantly diminished for the dominant hand. The discrepancy between dominant and non-dominant hand functioning was lower in the SSD group and this association was highly significant. The results of the present study support the usefulness of such detailed laterality assessment in this population. Mixed laterality, over and above that of the population with general intellectual disability and developmental disorder, was associated with SSD. These results are consistent with the neurodevelopmental hypothesis of schizophrenia and its cognitive neuropsychiatric/neuropsychological sequelae.

Evidence for linkage of a tandem duplication polymorphism upstream of the dopamine D4 receptor gene (DRD4) with attention deficit hyperactivity disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is a common childhood-onset neurodevelopmental disorder. Evidence from twin, adoption, and family studies provide support for a genetic contribution to the etiology of ADHD. Several candidate gene studies have identified an association between a 7-repeat variant in exon 3 of the dopamine 4 receptor gene (DRD4) and ADHD. However, in spite of the positive reports finding association of the exon 3 VNTR with ADHD, several other polymorphisms within DRD4 have been identified that conceivably could contribute to risk for ADHD. Recently, another common polymorphism of the DRD4 gene has been described involving a 120-bp repeat element upstream of the 5' transcription initiation site. In this report, we describe results of analysis of the DRD4 120-bp repeat promoter polymorphism in a sample of 371 children with ADHD and their parents, using the transmission disequilibrium test (TDT). Results showed a significant preferential transmission of the 240-bp (long) allele with ADHD. Exploratory analyses of the Inattentive phenotypic subtype of ADHD strengthened the evidence for linkage. These data add further support for the role of DRD4 variants conferring increased risk for ADHD, and imply that additional studies of DRD4 and other related genes are needed.

External quality assessment in the examination of blood films for malarial parasites within Ontario, Canada

OBJECTIVE

To assess laboratory practice in the examination of blood films for malarial parasites.

METHOD

Ontario medical laboratories, licensed by the Ministry of Health, are required to participate in external quality assessment by the Laboratory Proficiency Testing Program, which assesses performance of laboratory assays and also examines the total testing process. Educational strategies are used to improve performance.

RESULTS

A 1995 survey indicated shortcomings in detection and identification of malarial parasites in blood films. Consequently, recommendations for the investigation of malarial parasites in blood were issued. In 1996 and 1997, 16 workshops were conducted. A 1997 follow-up external quality assessment survey indicated that problems persist as 27% of laboratories failed to correctly speciate Plasmodium falciparum. Good Practice Guidelines were issued in 1998.

CONCLUSION

Further education and assessment are required. Laboratories lacking expertise must establish referral arrangements with more proficient laboratories.

The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes

OBJECTIVES

The purpose of this study was to assess safety and efficacy of enhanced external counterpulsation (EECP).

BACKGROUND

Case series have shown that EECP can improve exercise tolerance, symptoms and myocardial perfusion in stable angina pectoris.

METHODS

A multicenter, prospective, randomized, blinded, controlled trial was conducted in seven university hospitals in 139 outpatients with angina, documented coronary artery disease (CAD) and positive exercise treadmill test. Patients were given 35 h of active counterpulsation (active CP) or inactive counterpulsation (inactive CP) over a four- to seven-week period. Outcome measures were exercise duration and time to > or =1-mm ST-segment depression, average daily anginal attack count and nitroglycerin usage.

RESULTS

Exercise duration increased in both groups, but the between-group difference was not significant (p > 0.3). Time to > or =1-mm ST-segment depression increased significantly from baseline in active CP compared with inactive CP (p = 0.01). More active-CP patients saw a decrease and fewer experienced an increase in angina episodes as compared with inactive-CP patients (p < 0.05). Nitroglycerin usage decreased in active CP but did not change in the inactive-CP group. The between-group difference was not significant (p > 0.7).

CONCLUSIONS

Enhanced external counterpulsation reduces angina and extends time to exercise-induced ischemia in patients with symptomatic CAD. Treatment was relatively well tolerated and free of limiting side effects in most patients.

Detection of virtually all mutations-SSCP (DOVAM-S): a rapid method for mutation scanning with virtually 100% sensitivity

Dideoxy fingerprinting (ddF) was used as a tool to search for a generic set of conditions with sufficient power to detect virtually all mutations. For each condition tested, a very large sample of mutation-containing, single-stranded segments (about 1500) were analyzed with ddF. Correlation coefficients identified pairs of conditions in which single-strand conformation polymorphism (SSCP) mobilities were poorly correlated. The data strongly suggest that tertiary structure (e.g., base-sugar and sugar-sugar interactions) rather than secondary structure is the predominant determinant of mobility shifts by SSCP. Five conditions were selected with sufficient redundancy to detect all the mutations. The sensitivity of detection of virtually all mutations-SSCP (DOVAM-S) was determined by blinded analyses on samples containing additional mutations scattered throughout the eight exons and splice junctions in the factor IX gene. The factor IX gene sequence (2.5 kb) was scanned in one lane by 15 PCR-amplified segments (125 kb of sequence scanned per gel). All of the 84 single-base substitutions were detected in the blinded analyses, the first consisting of 50 hemizygous mutant and wild-type (WT) samples and the second consisting of 50 heterozygous mutant and WT samples. DOVAM-S is estimated to be five times faster than fluorescent DNA sequencing for the detection of virtually all mutations when the five conditions are applied.

Calculation vs calibration curve for INR determination. Results of an interlaboratory proficiency scheme

We surveyed 271 laboratories participating in a quality assessment program to ascertain whether the use of a calibration curve for determining the international normalized ratio (INR) would improve interlaboratory accuracy and precision. Lyophilized warfarinized samples with INR values assigned through manual calibration against internationally assigned rabbit reference thromboplasts were assayed for prothrombin time. Calibration analysis on the results was performed by linear regression. In all but 1 sample, the mean INR value computed by the calibration method was closer to the "true" value than the mean for the conventional calculation method using the International Sensitivity Index (ISI); the ISI calculation consistently overestimated the true value. Interlaboratory variation decreased using the calibration method. Variation from reagent to reagent was greater than from instrument to instrument, but was reduced by the calibration method. The specificity of the ISI for instrument type did not seem to alter the findings. Use of in-house calibrators to verify the ISI improved precision but not necessarily accuracy. The formation of a stable calibration line is consistent over time, but further studies are required to confirm whether such calibration improves the accuracy and precision of INR determination in practice.

Early-onset periodontitis associated with Down's syndrome--clinical interventional study

Individuals with Down's syndrome (DS) have an increased prevalence of periodontal disease compared with otherwise normal, age-matched control groups and other mentally handicapped patients of similar age distribution. The exaggerated immune-inflammatory response of the tissues cannot be explained by poor oral hygiene alone and might be the result of an impaired cell-mediated and humoral immunity and a deficient phagocytic system. As far as the progression and severity of destruction, the oral manifestations of DS patients are consistent with the juvenile periodontitis (JP) disease pattern. The purpose of the present study was 1) to assess the periodontal clinical and microbiological status of 10 DS patients aged 20 to 31 years (mean: 26.3 years) relative to that of 11 patients with cerebral palsy (CP) aged 23 to 53 years (mean: 36 years) without defective immunological functions, and 2) to determine the effect of supragingival plaque control and oral hygiene instruction in these patient groups. Subsequent to the initial examination and a professional tooth cleaning program, clinical and microbiological parameters were monitored over a period of 12 weeks. The clinical examination included the recording of plaque index (P1), gingival index (GI), probing depth (PD), and clinical attachment level (CAL). Subgingival plaque samples were always obtained from the same pocket with the highest disease activity (deepest bleeding site at baseline examination) in each subject for a morphotype analysis by dark field microscopy and for identification and quantitation of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Eikenella corrodens, Bacteroides forsythus, Fusobacterium nucleatum, Treponema denticola, and Campylobacter rectus by DNA probes. The results of the baseline examinations demonstrated that DS patients and patients with cerebral palsy had inflamed gingiva associated with a high amount of plaque. The mean probing depth and percentage of sites with probing depth> 4 mm corresponded to age and poor oral hygiene in CP patients. Deep pockets in DS patients demonstrated a high prevalence of periodontal disease compared with age-matched children with mental retardation and non-handicapped patients. Regarding the young age of onset, the severe destruction of periodontal tissues and pathogenesis of periodontitis in DS patients are consistent with the juvenile periodontitis disease pattern. The missing clinical benefit and alteration of the subgingival flora following supragingival plaque control in DS patients underlined the alteration in the immunological response.

Proficiency testing of hemoglobinopathy techniques in Ontario laboratories

The Laboratory Proficiency Testing Program has been in effect for 20 years. During the past 6 years, samples were distributed for screening, investigation, and identification of hemoglobinopathies to test laboratory proficiency. Six samples for hemoglobin (Hb) S screening were distributed to from 37 to 163 laboratories that perform screening tests for sickle cell disease, and 10 samples were distributed to from 52 to 71 laboratories that perform Hb electrophoresis. Assessment of unacceptable results was based on clinical significance of the errors; educational follow-up was implemented to address these results. Most participants demonstrated acceptable performance. The error rates for sickle cell screening were 2.7% to 19.7%; the poorest performance was noted for Hb SC disease. The error rates for Hb electrophoresis were 1.4% to 36.8%; the poorest performance was noted in the investigation of Hb H disease and alpha-thalassemia trait. Improved survey performance was observed in the screening for Hb S trait and in the investigation of Hb H disease, which illustrates the benefits of proficiency testing and its positive effect on laboratory services.

The human papillomavirus type 16 E7 protein is associated with the nucleolus in mammalian and yeast cells

In this study we show, by immunofluorescence and electron microscopy immuno-gold labelling, that the major transforming protein of Human Papillomavirus type 16 E7 is associated with the nucleolus of cells derived from the HPV16-positive cervical carcinoma line CaSki. The E7 nucleolar staining appeared to be cell cycle dependent, being considerably reduced in the G2 phase. The total level of the protein in the cell, however, remained constant during all phases. We also show that the cellular protein Rb1, which is targeted by E7, is localised in the nucleus and nucleolus in CaSki cells. Thus, it is possible that the presence of E7 in the nucleolus correlates with a hypothetical function(s) of Rb1 in this particular intranuclear compartment. The nucleolar localisation of HPV16 E7 protein was also observed in the fission yeast Schizosaccharomyces pombe, suggesting that a targeting mechanism of HPV16 E7 protein into the nucleolus is common to both mammalian and yeast systems. Nucleolar localisation of HPV16 E7 protein may be independent from Rb1 since no Rb1 related proteins have been identified in fission yeast.