Contraception prescribing in England during the COVID-19 pandemic

BACKGROUND

National lockdowns in England due to COVID-19 resulted in rapid shifts in healthcare provision, including in primary care where most contraceptive prescriptions are issued. This study aimed to investigate contraception prescribing trends in primary care during the pandemic and the impact of socioeconomic deprivation.

METHODS

Prescribing data were accessed from the English Prescribing Dataset for the first year of the COVID-19 pandemic (1 March 2020-28 February 2021) and the year prior (1 March 2019-29 February 2020). Data were analysed by geographical region (London, Midlands and East of England, North of England, South of England) and contraceptive type (progestogen-only pill (POP), combined oral contraception (COC), emergency hormonal contraception (EHC) and contraceptive injections). Differences in prescribing rates were calculated using Poisson regression. Pearson correlation coefficients were calculated for the Index of Multiple Deprivation (IMD) scores for each Clinical Commissioning Group (CCG) in the North East and North Cumbria (NENC).

RESULTS

Contraception prescribing rates decreased overall during the COVID-19 pandemic in England (Poisson regression coefficient (β)=-0.035), with a statistically significant (p<0.01) decrease in all four regions. Prescriptions decreased for COC (β=-0.978), contraceptive injections (β=-0.161) and EHC (β=-0.2005), while POP (β=0.050) prescribing rates increased. There was a weak positive correlation between IMD and prescribing rates in NENC (p>0.05).

CONCLUSIONS

Contraception provision was impacted by COVID-19 with an overall decrease in prescribing rates. The deprivation results suggest that this may not be a significant contributing factor to this decrease. Further research is recommended to better understand these changes, and to ensure that services respond appropriately to population needs.

Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study

OBJECTIVE

To examine the uptake of postnatal contraception (PNC) and experiences of PNC care across a geographical region of England.

DESIGN

Cross-sectional online survey.

SETTING

The North East and North Cumbria Integrated Care System (ICS).

POPULATION

Women who had completed a pregnancy in the previous 3 years.

METHODS

The uptake of PNC by accessed method(s) and the availability of preferred method(s) is described, and adjusted odds ratios are reported for group differences in uptake by characteristics of interest.

MAIN OUTCOME MEASURES

Uptake of medically prescribed/administered contraception and uptake of long-acting reversible contraception (LARC) during the postnatal period, and access to preferred PNC methods.

RESULTS

Although almost half of respondents (47.1%; n = 1178) reinitiated some form of sexual activity during the postnatal period, only 38.7% (n = 969) of respondents accessed a medically prescribed/administered contraceptive method postnatally, and only 15.5% (n = 389) of respondents accessed a LARC. It is a matter of concern that 18.8% (n = 451) of respondents indicated that they were unable to access their preferred PNC. In multivariate analysis, younger age, lower household income, higher multiparity, operative delivery, unplanned pregnancy and not breastfeeding were significant predictors of higher PNC uptake.

CONCLUSIONS

The uptake of PNC in this cohort was low, with almost a fifth of women unable to access their preferred method. However, there was some evidence that women belonging to groups perceived to be at risk of rapid repeat pregnancy were more likely to access reliable PNC methods.

Effectiveness and implementation of lower-intensity weight management interventions delivered by the non-specialist workforce in postnatal women: a mixed-methods systematic review

Lower-intensity interventions delivered in primary and community care contacts could provide more equitable and scalable weight management support for postnatal women. This mixed-methods systematic review aimed to explore the effectiveness, implementation, and experiences of lower-intensity weight management support delivered by the non-specialist workforce. We included quantitative and qualitative studies of any design that evaluated a lower-intensity weight management intervention delivered by non-specialist workforce in women up to 5 years post-natal, and where intervention effectiveness (weight-related and/or behavioural outcomes), implementation and/or acceptability were reported. PRISMA guidelines were followed, and the review was prospectively registered on PROSPERO (CRD42022371828). Nine electronic databases were searched to identify literature published between database inception to January 2023. This was supplemented with grey literature searches and citation chaining for all included studies and related reviews (completed June 2023). Screening, data extraction and risk of bias assessments were performed in duplicate. Risk of bias was assessed using the Joanna Briggs Institute appraisal tools. Narrative methods were used to synthesise outcomes. Seven unique studies described in 11 reports were included from the Netherlands (n = 2), and the United Kingdom, Germany, Taiwan, Finland, and the United States (n = 1 each). All studies reported weight-related outcomes; four reported diet; four reported physical activity; four reported intervention implementation and process outcomes; and two reported intervention acceptability and experiences. The longest follow-up was 13-months postnatal. Interventions had mixed effects on weight-related outcomes: three studies reported greater weight reduction and/or lower postnatal weight retention in the intervention group, whereas four found no difference or mixed effects. Most studies reporting physical activity or diet outcomes showed no intervention effect, or mixed effects. Interventions were generally perceived as acceptable by women and care providers, although providers had concerns about translation into routine practice. The main limitations of the review were the limited volume of evidence available, and significant heterogeneity in interventions and outcome reporting which limited meaningful comparisons across studies. There is a need for more intervention studies, including process evaluations, with longer follow-up in the postnatal period to understand the role of primary and community care in supporting women's weight management. Public Health Wales was the primary funder of this review.

Experiences of medical practitioners in the Australian Defence Force on live tissue trauma training

INTRODUCTION

Care of battle casualties is a central role of military medical practitioners. Historically, certain trauma procedural skills have been learnt through live tissue training. However, faced with opposition from community members and academics, who argue equivalence of non-animal alternatives, this is now being phased out. This study explores Australian military medical practitioners' experiences of and attitudes towards live tissue training.

METHOD

We performed a phenomenologically driven qualitative exploration of individuals' experiences of live tissue trauma training. 32 medical officers volunteered for the study. In-depth interviews were conducted with 15 practitioners (60% Army, 20% Air Force, 20% Navy; 33% surgical, 53% critical care, 13% general practice). Qualitative data were subjected to content analysis, with key themes identified using manual and computer-assisted coding.

RESULTS

Live tissue training was valued by military medical practitioners, particularly because of the realistic feel of tissues and physiological responsiveness to treatment. Learner-perceived value of live tissue training was higher for complex skills and those requiring delicate tissue handling. 100% of surgeons and critical care doctors regarded live tissue as the only suitable model for learning repair of penetrating cardiac injury. Live tissue training was felt to enhance self-efficacy, particularly for rarely applied skills. Though conscious of the social and ethical context of live tissue training, >90% of participants reported positive emotional responses to live tissue training.

CONCLUSION

In contrast to published research, live tissue training was thought by participants to possess characteristics that are not yet replicable using alternative learning aids. The experienced positive values of live tissue training should inform the decision to move towards non-animal alternatives.

A Qualitative Evaluation of a Health Access Card for Refugees and Asylum Seekers in a City in Northern England

Refugees and asylum seekers residing in the UK face multiple barriers to accessing healthcare. A Health Access Card information resource was launched in Newcastle upon Tyne in 2019 by Newcastle City Council, intended to guide refugees and asylum seekers living in the city, and the professional organisations that support them, to appropriate healthcare services provided locally. The aim of this qualitative evaluation was to explore service user and professional experiences of healthcare access and utilisation in Newcastle and perspectives on the Health Access Card. Eleven semi-structured interviews took place between February 2020 and March 2021. Participants provided diverse and compelling accounts of healthcare experiences and described cultural, financial and institutional barriers to care. Opportunities to improve healthcare access for these population groups included offering more bespoke support, additional language support, delivering training and education to healthcare professionals and reviewing the local support landscape to maximise the impact of collaboration and cross-sector working. Opportunities to improve the Health Access Card were also described, and these included providing translated versions and exploring the possibility of developing an accompanying digital resource.

Impact of the COVID-19 pandemic on expectant and new parents' experience of pregnancy, childbirth, breast feeding, parental responsiveness and sensitivity, and bonding and attunement in high-income countries: a systematic review of the evidence

OBJECTIVES

To review the evidence on how pregnancy, birth experience, breast feeding, parental responsiveness and sensitivity, and bonding and attunement were impacted by COVID-19.

METHODS

We searched eight literature databases and websites of relevant UK-based organisations. The review focused on evidence during pregnancy and the early years (0-5 years). Studies of any study design published in English from 1 March 2020 to 15 March 2021 and conducted in high-income countries were included. Screening and data extraction were undertaken in duplicate. Evidence was synthesised using a narrative approach. Study quality of included studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

The search yielded 9776 publications, of which 26 met our inclusion criteria. Significant knowledge gaps on how COVID-19 affected pregnancy and breast feeding limited healthcare providers' ability to provide consistent evidence-based information and care at the start of the pandemic. There was an enduring sense of loss about loved ones being restricted from taking part in key moments. Parents were concerned about the limitations of virtual healthcare provision. Some parents reported more opportunities for responsive breast feeding and improved parent-infant bonding due to reduced social and work pressures. Women from minoritised ethnic groups were less likely to continue breast feeding and attributed this to a lack of face-to-face support.

CONCLUSIONS

The evidence suggests that new and expectant families have been both negatively and positively impacted by the COVID-19 pandemic and the resulting restrictions. The impacts on parents' opportunities to bond with their young children and to be attuned to their needs were felt unequally. It is important that emergency response policies consider the mother and the partner as a family unit when making changes to the delivery of maternal and child health and care services, so as to mitigate the impact on the family and existing health inequalities.

PROSPERO REGISTRATION NUMBER

CRD42021236769.

Systematic review of copper intrauterine contraception continuation in young nulliparous women based on intrauterine device type

OBJECTIVES

No copper intrauterine device (IUD) type is known to better suit young nulliparous women who tend to experience higher rates of IUD discontinuation compared with their older parous counterparts. A systematic review to determine which IUDs have higher continuation rates in young nulliparous women was undertaken.

DESIGN

Systematic review and meta-analyses of available evidence based on IUD type.

DATA SOURCES

AMED, BNI, CINAHL, DARE, EMBASE, EMCARE, HMIC, MEDLINE, PsycINFO, PubMed, TRIP, and the Cochrane Library electronic databases were searched from inception to 11 May 2022; as well as the Bandolier, Medicines and Healthcare products Regulatory Agency, Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, Department of Health, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines, WHO and Google Scholar websites.

ELIGIBILITY CRITERIA

All studies on IUDs currently available in the UK or comparable (same design and size) to those available in the UK, involving nulliparous women of any age including those aged under 30.

DATA EXTRACTION AND SYNTHESIS

Independently extracted data were assessed as low risk of bias using the Mixed Methods Appraisal Tool. Random effects meta-analyses of proportions were performed where data, including subgroups, were amenable to quantitative synthesis. Heterogeneity was reported using tau² and I² statistics, and sensitivity analyses were also performed.

RESULTS

Nineteen studies involving 13 045 nulliparous women were included but the heterogeneity of participant ages, parity and IUD types made quantitative synthesis of outcome data in totality inappropriate. The highest continuation rate obtained was 91.02% (95% CI 88.01% to 93.64%) for the smaller TCu 380A at 12 months post insertion.

CONCLUSIONS

Evidence for IUD use in young nulliparous women based on IUD type remains limited. Smaller sized IUD types appear better suited to this group of IUD users, however, more research is needed.

PROSPERO REGISTRATION NUMBER

CRD42019120969.

Does prepregnancy weight change have an effect on subsequent pregnancy health outcomes? A systematic review and meta-analysis

International guidelines recommend women with an overweight or obese body mass index (BMI) aim to reduce their body weight prior to conception to minimize the risk of adverse perinatal outcomes. Recent systematic reviews have demonstrated that interpregnancy weight gain increases women's risk of developing adverse pregnancy outcomes in their subsequent pregnancy. Interpregnancy weight change studies exclude nulliparous women. This systematic review and meta-analysis was conducted following MOOSE guidelines and summarizes the evidence of the impact of preconception and interpregnancy weight change on perinatal outcomes for women regardless of parity. Sixty one studies met the inclusion criteria for this review and reported 34 different outcomes. We identified a significantly increased risk of gestational diabetes (OR 1.88, 95% CI 1.66, 2.14, I²  = 87.8%), hypertensive disorders (OR 1.46 95% CI 1.12, 1.91, I²  = 94.9%), preeclampsia (OR 1.92 95% CI 1.55, 2.37, I²  = 93.6%), and large-for-gestational-age (OR 1.36, 95% CI 1.25, 1.49, I²  = 92.2%) with preconception and interpregnancy weight gain. Interpregnancy weight loss only was significantly associated with increased risk for small-for-gestational-age (OR 1.29 95% CI 1.11, 1.50, I²  = 89.9%) and preterm birth (OR 1.06 95% CI 1.00, 1.13, I²  = 22.4%). Our findings illustrate the need for effective preconception and interpregnancy weight management support to improve pregnancy outcomes in subsequent pregnancies.

Academic achievement and needs of school-aged children born with selected congenital anomalies: A systematic review and meta-analysis

Children with congenital anomalies have poorer intellectual and cognitive development compared to their peers, but evidence for academic achievement using objective measures is lacking. We aimed to summarize and synthesize evidence on academic outcomes and special education needs (SEN) of school‐aged children born with selected major structural congenital anomalies. Electronic databases (MEDLINE, EMBASE, Scopus, PsycINFO, CINAHL, ProQuest Natural Science and Education Collections), reference lists and citations for 1990–2020 were systematically searched. We included original‐research articles on academic achievement in children with non‐syndromic congenital anomalies that involved school test results, standardized tests and/or SEN data. Random‐effects meta‐analyses were performed to estimate pooled mean test scores in mathematics and/or reading where possible and pooled odds ratios (ORs) for SEN in children with severe congenital heart defects (CHDs) and children with orofacial clefts (OFCs). Thirty‐nine eligible studies (n = 21,066 children) were synthesized narratively. Sixteen studies were included in meta‐analyses. Children with non‐syndromic congenital anomalies were at a higher risk of academic underachievement than controls across school levels. Children with severe CHD (pooled OR = 2.32, 95% CI: 1.90, 2.82), and children with OFC (OR = 1.38 (95% CI: 1.20, 1.57), OR = 3.07 (95% CI: 2.65, 3.56), and OR = 3.96 (95% CI: 3.31, 4.72) for children with cleft lip, cleft palate and cleft lip/palate, respectively) had significantly higher ORs for SEN than controls. Children with non‐syndromic congenital anomalies underperform academically and have higher SEN rates compared to their peers. Early monitoring and development of differential SEN are important to promote academic progress in these children.

Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis

OBJECTIVE

There has been an unprecedented rise in infant mortality associated with deprivation in recent years in the United Kingdom (UK) and Republic of Ireland. A healthy pregnancy can have significant impacts on the life chances of children. The objective of this review was to understand the association between individual-level and household-level measures of socioeconomic status and adverse pregnancy outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Nine databases were searched (Medline, Embase, Scopus, ASSIA, CINAHL, PsycINFO, BNI, MIDRIS and Google Scholar) for articles published between 1999 and August 2019. Grey literature searches were also assessed.

STUDY SELECTION CRITERIA

Studies reporting associations between individual-level or household socioeconomic factors on pregnancy outcomes in the UK or Ireland.

RESULTS

Among the 82 353 search results, 53 821 titles were identified and 35 unique studies met the eligibility criteria. Outcomes reported were neonatal, perinatal and maternal mortality, preterm birth, birth weight and mode of delivery. Pooled effect sizes were calculated using random-effects meta-analysis. There were significantly increased odds of women from lower levels of occupation/social classes compared with the highest level having stillbirth (OR 1.40, 95% CI 1.23 to 1.59, I²98.62%), neonatal mortality (OR 1.39, 95% CI 1.22 to 1.57, I²97.09%), perinatal mortality (OR 1.39, 95% CI 1.23 to 1.57, I²98.69%), preterm birth (OR 1.41, 95% CI 1.33 to 1.50, I²70.97%) and low birth weight (OR 1.40, 95% CI 1.19 to 1.61, I²99.85%). Limitations relate to available data, unmeasured confounders and the small number of studies for some outcomes.

CONCLUSIONS

This review identified consistent evidence that lower occupational status, especially manual occupations and unemployment, were significantly associated with increased risk of multiple adverse pregnancy outcomes. Strategies to improve pregnancy outcomes should incorporate approaches that address wider determinants of health to provide women and families with the best chances of having a healthy pregnancy and baby and to decrease pregnancy-related health inequalities in the general population.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019140893.

Inter-library comparisons: a report on progress, with particular reference to public libraries

This paper describes comparative studies, an aspect of library management in which there is growing interest.

The paper is in three Parts. The first outlines in general terms the objectives of 'interfirm' or 'inter-organisation' comparisons for management. It refers to some important features of effective comparisons, and distinguishes between 'true' interfirm comparisons and general statistical surveys. Part 2 describes the programme of work so far undertaken in the development of inter-library comparisons as a man agement tool. The stages of this work (funded by the British Library R & D Department) are described, together with the findings which emerged as the work progressed. Part 2 ends with a brief assessment of the results of the public library 'pilot' comparison, which involved 27 library systems, and describes plans for further action in this field. Reference is also made to the substantial development work undertaken in 1980 relating to comparisons for academic libraries; and to the possibility of future development work relating to special libraries. The third Part describes the scope and con tent of the main ('pilot') comparison so far undertaken for public libraries; examples of the format of the results of that comparison are given in the Appendices.

Anatomical variations of the scalene triangle: dissection of 10 cadavers

STUDY DESIGN

Cadaver dissection to study the anatomy of the scaleni muscles and surrounding structures.

OBJECTIVES

To analyze in depth the anatomy of the scaleni muscles and surrounding structures, and to further document anatomical variations which have been reported in the literature.

BACKGROUND

The literature reported variations in the attachments of the scaleni muscles, as well as the presence of a scalenus minimus muscle. The importance of these muscles in the respiratory and musculoskeletal systems led us to study these muscles with dissection.

METHODS AND MEASURES

We performed anatomical dissection on 10 cadavers. The findings from the cadavers were analyzed and reported.

RESULTS

The attachments of the 3 primary scaleni muscles (anterior, medius, and posterior) were variable. The actual width of the scaleni muscles (anterior, medius, and posterior) at the C6 tubercle and at the first rib also varied. A scalenus minimus was present in one cadaver and presumably present in 2 others. The scalenus anterior muscle arose in 20% of the specimens from C3 to C6, in 30% of the specimens from C3 to C7, in 20% of the specimens from C4 to C5, and in 30% of the specimens from C4 to C6. The scalenus anterior muscle arose from C3 in 50% of the dissections. An attachment to C7 was observed in 30% of the cadavers. The widths of the scalenus anterior muscles at their insertion were between 8 and 17 mm. The scalenus medius muscle arose in 40% of the specimens from C2 to C6. In 60% of the cadavers, the scalenus medius muscle had an attachment to C7. Fifty percent of the scalenus medius muscles arose from C2 and 50% also had an origin from C1. The widths of the scalenus medius muscles at their insertion were between 10 and 20 mm with a mean of 15.5 mm. Fifty percent of the scalenus posterior muscles arose from C4 to C6 and 50% arose from C5 to C6.

CONCLUSIONS

Variations were found in the attachments and the size of the scaleni muscles. These variations may effect the size of the scalene triangle, and thus, may potentially result in varied signs and symptoms in patients who have cervical, thoracic, and rib dysfunctions. Clinical implications were postulated.

Injuries in the adolescent population in Scotland: patterns and types of injuries sustained

OBJECTIVE

To provide information on the incidence, sex distribution, type, site and severity of injuries requiring medical attention reported in a nationally representative sample of Scottish teenagers studied longitudinally.

DESIGN

Health visitors administered structured interviews with parents (usually mothers). Quantitative data were analysed using SPSS-PC, and qualitative and textual data were coded using the Abbreviated Injury Score (AIS).

SETTING

Scotland.

SUBJECTS

Responses were received in respect of 958 (68%) of the estimated 1,416 teenagers enrolled in the British Cohort Study (BCS 70), and resident in Scotland in 1986/7.

RESULTS

43% of subjects were reported as having experienced one or more unintentional injury events requiring medical attention between the ages of 10 and 16/17. Boys experienced significantly more injuries than girls. Neither social class nor region appeared to be a significant risk factor for reported injury.

CONCLUSION

Patterns of accidents in Scottish adolescents are reported. Further areas for study are suggested.

Lithium therapy, hypercalcemia, and hyperparathyroidism

Lithium is a monovalent cation that influences calcium metabolism in various tissues including the brain, kidney, heart, and parathyroid gland. Mr. A received treatment with lithium for 19 years because this medication proved to be effective in the management of his bipolar illness. However, he developed hypercalcemia, hypertension, and episodes of severe bradyarrhythmia (one of them requiring admission to the medical intensive care unit), with lithium levels within the therapeutic range. An extended endocrine workup showed hyperparathyroidism, with elevated serum parathyroid hormone levels, hypercalcemia, hypocalciuria, and normal serum phosphate levels. These biochemical findings are different from those of primary hyperparathyroidism and are attributed to direct actions of the lithium in the kidney. Discontinuation of the lithium did not result in reversal of the abnormal findings. The patient had surgery, and hyperplasia of the parathyroid gland was found. After parathyroidectomy, the bradyarrhythmia subsided and the patient showed improvement both in his psychiatric condition and hypertension. Preliminary observations in nine other lithium-induced hypercalcemic patients show a high frequency of arrhythmias with bradycardia and conduction defects. These findings suggest that hypercalcemia with lithium increases the risk of cardiac arrhythmia and emphasize the need for regular laboratory and electrocardiographic monitoring of patients on maintenance lithium therapy.

L-Dopa and dopamine-producing gene cassettes for gene therapy approaches to Parkinson's disease

As an aid in the development of vector systems for use in gene therapy paradigms of central nervous system disorders such as Parkinson's disease, we have developed L-Dopa or dopamine-producing gene cassettes. Specifically, a human tyrosine hydroxylase cDNA (HTH-2) was rendered constitutively active by truncation of the N-terminal regulatory domain (tHTH). In addition, a bicistronic construct capable of directing the production of dopamine was created by inserting an internal ribosome entry site downstream of tHTH followed by the coding sequences of aromatic amino acid decarboxylase. All three constructs generated immunoreactive peptides of the predicted size, were enzymatically active, and produced L-Dopa (HTH-2, tHTH) or dopamine (bicistronic construct) following transient transfection of COS-7 cells. These constructs, in conjunction with viral or nonviral expression systems, may be efficacious in gene therapy approaches to Parkinson's disease.

The effects of soft tissue mobilization on the immature burn scar: results of a pilot study

The purpose of this pilot study was determine the effects of soft tissue mobilization (STM) on range of motion (ROM), scar pliability, and vascularity. Patients received either one treatment session of standard physical therapy or standard physical therapy plus 10 to 15 minutes of STM. Before and after ROM, scar pliability and vascularity measurements were obtained. The student's t test was used to compare measurements and revealed the STM group (n = 5) had significant (p < 0.10) gains in wrist extension and radial deviation, and the control group (n = 5) had significant gains in wrist extension and ulnar deviation. No significant difference was found in ROM, scar pliability, and vascularity when the STM group was compared to the control group. Further study of a larger sample over multiple treatment sessions is necessary to determine the true efficacy of STM.

A herpes simplex virus-1 vector containing the rat tyrosine hydroxylase promoter directs cell type-specific expression of beta-galactosidase in cultured rat peripheral neurons

A defective herpes simplex virus-1 (HSV-1) vector system was used to study cell type-specific expression of the tyrosine hydroxylase (TH) gene. HSV-1 particles containing 663 bp (pTHlac 663), 278 bp (pTHlac 278), or 181 bp (pTHlac 181) of the rat TH promoter driving E. coli LacZ were used to infect superior cervical ganglia (SCG: TH-expressing tissue) and dorsal root ganglia (DRG:non-TH-expressing tissue) cultures. One day after infection, expression of beta-galactosidase was visualized by X-gal cytochemistry. Following viral transduction with pTHlac 663 at a multiplicity of infection of 0.2, 14.4% of the SCG neurons were X-gal positive whereas only about 0.9% of DRG neurons were X-gal positive. Infection with either pTHlac278 or 181 resulted in 3-fold more X-gal-positive DRG neurons. These results suggest that (i) the defective HSV-1 vector system may be useful in defining regulatory promoter motifs; (ii) 663 bp of the rat TH promoter contains sufficient information for cell type-specific expression in peripheral nervous system neurons; and (iii) sequences between -278 and -663 contain an element(s) that represses gene expression in non-catecholamingeric neurons.

The human aromatic L-amino acid decarboxylase gene can be alternatively spliced to generate unique protein isoforms

Aromatic L-amino acid decarboxylase (AADC) is expressed in a wide variety of tissues, including those where it is known to convert L-DOPA and 5-hydroxytryptophan to dopamine and serotonin, respectively. AADC has been cloned from many species and shown to undergo alternative splicing within its 5' untranslated region. Here, we report that the human AADC gene can undergo additional alternative splicing of exon 3, generating two different protein isoforms (termed AADC480 and AADC442). Both transcripts are widely expressed, with AADC442 predominating in many neuronal and nonneuronal tissues. When homogenates were prepared from COS-7 cells transfected with expression vectors containing either cDNA, AADC480 catalyzed the decarboxylation of both L-DOPA and 5-hydroxytryptophan. AADC442 was inactive in either assay. These findings suggested that AADC442 may have a different function in non-monoamine-expressing tissues. Taken together, these results suggest that the human AADC gene undergoes complex processing, leading to the formation of both tissue-specific transcripts as well as unique protein isoforms.

Overexpression of Bcl-2 attenuates MPP+, but not 6-ODHA, induced cell death in a dopaminergic neuronal cell line

In order to investigate the role of Bcl-2 in dopaminergic cells, we established a dopaminergic neuronal cell line (MN9D) stably expressing human Bcl-2 (MN9D/Bcl-2) or neomycin (MN9D/Neo). Overexpression of Bcl-2 in MN9D cells attenuated cell death due to treatment of mitochondrial electron transport inhibitors including N-methyl-4-phenylpyridinium, whereas it did not prevent cell death induced by reagents generating reactive oxygen species including 6-hydroxy-dopamine. Moreover, the rate of glucose uptake in MN9D/Bcl-2 was significantly lower than that in MN9D/Neo after MPP+ treatment. Thus, Bcl-2 may counter aberrations in mitochondrial electron transfer processes by altering energy metabolism within the MN9D cells.

Is Bell's palsy a reactivation of varicella zoster virus?

Despite various pointers to an infectious aetiology, the cause of Bell's palsy remains obscure. We examined paired sera from 62 patients with facial palsy and 50 age and sex matched contemporaneous controls. Significantly more patients than controls had IgM antibodies by ELISA to varicella zoster virus (56.5% vs. 20%, P = 0.0001) and herpes simplex virus (41.9% vs. 18%, P = 0.006). Additionally, significantly more patients than controls were positive for CF antibody to varicella zoster virus (14.5% vs. 0%, P = 0.004) but not to herpes simplex or cytomegalovirus. Significantly more controls than patients (54% vs. 25.8%, P = 0.002) had no evidence of antigenic stimulation by any of the herpesvirus group. No significant difference between patients and controls in seropositivity by IgM ELISA to cytomegalovirus. Epstein-Barr virus and IFA for human herpes virus 6 was found. Furthermore, there was no significant difference between the two groups as to evidence of recent infection by the following agents: rubella virus and Borrelia burgdorferi by IgM ELISA, influenza A. influenza B, adenovirus, respiratory syncytial virus, mumps and measles. Mycoplasma pneumoniae, Coxiella burnetii and chlamydia spp. by complement fixation test. The first reported case of clinically and serologically proven Mycoplasma pneumoniae pneumonia associated with Bell's palsy is described. The rate of complete recovery at 6-8 weeks after onset was not significantly different in patients who were given steroids compared to those who were not. Ear related symptoms were the most common, occurring in 12 of 65 cases, but only three (4.6%) had clinical shingles (vesicles in ear).(ABSTRACT TRUNCATED AT 250 WORDS)

Case mix management education in a Canadian hospital

The Sunnybrook Health Science Centre's matrix organization model includes a traditional departmental structure, a strategic program-based structure and a case management-based structure--the Clinical Unit structure. The Clinical Unit structure allows the centre to give responsibility for the management of case mix and volume to decentralized Clinical Unit teams, each of which manages its own budget. To train physicians and nurses in their respective roles of Medical Unit directors and Nursing Unit directors, Sunnybrook designed unique short courses on financial management and budgeting, and case-costing and case mix management. This paper discusses how these courses were organized, details their contents and explains how they fit into Sunnybrook's program of decentralized management.

Activated neutrophils depress myocardial function in the perfused rabbit heart

OBJECTIVE

To examine the effect of activated neutrophils on myocardial function in the absence of ischemic and/or reperfusion injury.

DESIGN

Studies were carried out in five groups of Langendorff perfused rabbit hearts: control; nonactivated rabbit neutrophil infusion; phorbol myristate acetate-activated rabbit neutrophil infusion; nonactivated human neutrophil infusion; and phorbol myristate acetate-activated human neutrophil infusion.

RESULTS

Both groups receiving activated neutrophils showed significant deterioration in ventricular force, rate of ventricular force development (dF/dt) and rate of ventricular relaxation (-dF/dt), and significant increases in coronary vascular resistance. Myocardial lipid peroxidation was assessed but there was no significant difference among groups. Myocardial prostacyclin production was significantly increased in hearts receiving the phorbol myristate acetate-activated human neutrophil infusion.

CONCLUSION

It is concluded that myocardial perfusion with activated neutrophils results in depression of myocardial function and an increase in coronary vascular resistance even in the absence of ischemic/reperfusion injury.

Species and regional differences in the expression of cell-type specific elements at the human and rat tyrosine hydroxylase gene loci

The expression of the catecholamine biosynthetic enzyme, tyrosine hydroxylase (TH), is confined to several different types of neuroendocrine cells. Using a transient assay system, we examined more than 10 kb of the human TH gene and 6.5 kb of 5' flanking sequences of the rat TH gene for DNA elements that confer cell-type specific expression. Surprisingly, these elements do not appear to be conserved in position or sequence across species. When plasmids containing DNA sequences - 749 bp from the transcription start site of the rat gene were introduced into PC12 cells, up to sixfold higher levels of expression were observed as compared to the same fragments introduced into HepG2 cells or LAN-1 cells. In contrast to the rat gene, analogous fragments of the human 5' promoter failed to confer cell-type specific expression. However, when plasmids containing a truncated thymidine kinase promoter and either orientation of a 760 by 3' human TH gene fragment were introduced into PC12 and LAN-1 cells, we observed a six- and 3.5-fold increase, respectively, over that observed for HepG2 cells. Subsequent deletion of this fragment led to significant activation of transcription in PC12 and HepG2 cell lines. These data indicate the presence of multiple elements contributing to the cell-type specific expression of tyrosine hydroxylase genes.

Isometric torque of the quadriceps femoris after concentric, eccentric and isometric training

Twenty-seven normal, healthy women participated in this study, which investigated three methods of increasing the isometric strength of the quadriceps femoris through a six-week training program. Three experimental exercise groups were formed: A, eccentric, B, concentric, and C, isometric. The peak isometric torque of the quadriceps femoris was determined on the Cybex II Isokinetic Dynamometer before and after training. A total of 18 exercise sessions per subject were held. A two-way ANOVA with repeated measures revealed that while all three experimental groups significantly increased in isometric strength, no one method of training was superior. No interaction occurred in the population between the effects of pre- and posttraining scores and the type of training. The relationship between the experimental design and knee joint biomechanics may have precluded significant differences in strength gain among the experimental groups.