Understanding paramedic work in general practice in the UK: a rapid realist synthesis

BACKGROUND

General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact.

METHODS

The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories.

RESULTS

Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models.

CONCLUSIONS

Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts.

Prompt identification of struggling candidates in near peer-led basic life support training: piloting an online performance scoring system

BACKGROUND

Bristol Medical School has adopted a near peer-led teaching approach to deliver Basic Life Support training to first year undergraduate medical students. Challenges arose when trying to identify early in the course which candidates were struggling with their learning, in sessions delivered to large cohorts. We developed and piloted a novel, online performance scoring system to better track and highlight candidate progress.

METHODS

During this pilot, a 10-point scale was used to evaluate candidate performance at six time-points during their training. The scores were collated and entered on an anonymised secure spreadsheet, which was conditionally formatted to provide a visual representation of the score. A One-Way ANOVA was performed on the scores and trends analysed during each course to review candidate trajectory. Descriptive statistics were assessed. Values are presented as mean scores with standard deviation (x̄±SD).

RESULTS

A significant linear trend was demonstrated (P < 0.001) for the progression of candidates over the course. The average session score increased from 4.61 ± 1.78 at the start to 7.92 ± 1.22 at the end of the final session. A threshold of less than 1SD below the mean was used to identify struggling candidates at any of the six given timepoints. This threshold enabled efficient highlighting of struggling candidates in real time.

CONCLUSIONS

Although the system will be subject to further validation, our pilot has shown the use of a simple 10-point scoring system in combination with a visual representation of performance helps to identify struggling candidates earlier across large cohorts of students undertaking skills training such as Basic Life Support. This early identification enables effective and efficient remedial support.

Abstract 1201: ALK amplification and rearrangements are recurrent targetable events in congenital and adult glioblastoma

Purpose: Anaplastic Lymphoma Kinase (ALK) aberrations have been identified in pediatric type infant gliomas, but their occurrence across age groups, functional effects, and treatment response have not been broadly established.

Experimental Design: We performed a comprehensive analysis of ALK expression and genomic aberrations in both newly-generated and retrospective data from 371 glioblastomas (156 adult, 205 infant/pediatric and 10 congenital) with in vitro and in vivo validation of aberrations.

Results: ALK aberrations at the protein or genomic level were detected in 12% of gliomas (45/371) in a wide age range (0-80 years). Recurrent as well as novel ALK fusions (LRRFIP1-ALK, DCTN1-ALK, PRKD3-ALK) were present in 50% (5/10) of congenital/infant, 1.4% (3/205) of pediatric, and 1.9% (3/156) of adult GBMs. ALK fusions were present as the only candidate driver in congenital/infant GBMs, and were sometimes focally amplified. In contrast, adult ALK fusions co-occurred with other oncogenic drivers. No activating ALK mutations were identified in any age group. Novel and recurrent ALK rearrangements promoted STAT3 and ERK1/2 pathways and transformation in vitro and in vivo. ALK-fused GBM cellular and mouse models were responsive to ALK inhibitors, including in patient cells derived from a congenital GBM. Relevant to treatment of infant gliomas, we showed that ALK protein appears minimally expressed in the forebrain at perinatal stages and no gross effects on perinatal brain development was seen in pregnant mice treated with the ALK inhibitor ceritinib.

Conclusions: These findings support expanded evaluation of brain-penetrant ALK inhibitors in clinical trials across infant, pediatric, and adult GBMs.

Citation Format: Anne-Florence Blandin, Ross Giglio, Maya Srikanth Graham, Guadalupe Garcia, Seth Malinowski, Jared K. Woods, Shakti Ramkissoon, Lori Ramkissoon, Frank Dubois, Kate Schoolcraft, Jessica W. Tsai, Dayle K. Wang, Robert Jones, Jayne Vogelzang, Kristine Pelton, Sarah Becker, Fiona Watkinson, Claire Sinai, Elizabeth Cohen, Matthew Booker, Michael Tolstorukov, Veerle Haemels, Liliana Goumnerova, Karen Wright, Mark Kieran, Katie Fehnel, David Reardon, Arnault Tauziede-Espariat, Rishi Lulla, Benjamin Carcamo, Stanley Chaleff, Alain Charest, Frederik De Smet, Azra H. Ligon, Adrian Dubuc, Melanie Pagès, Pascale Varlet, Patrick Wen, Brian Alexander, Susan Chi, Sanda Alexandrescu, Ralf Kittler, Robert Bachoo, Rameen Beroukhim, Pratiti Bandopadhayay, Keith L. Ligon. ALK amplification and rearrangements are recurrent targetable events in congenital and adult glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1201.

Cross-cultural adaptation and its impact on research in emergency care

The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.

Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives

Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of ‘the potential for Paramedic roles in Irish General Practice’.

Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers.

Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GPs, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GPs, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments.

Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.

Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives

Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of ‘the potential for Paramedic roles in Irish General Practice’. Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers. Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GP’s, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GP’s, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments. Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.

Factors affecting the documentation of spoken safety-netting advice in routine GP consultations: a cross-sectional study

BACKGROUND

Previous studies have reported how often safety-netting is documented in medical records, but it is not known how this compares with what is verbalised and what factors might influence the consistency of documentation.

AIM

To compare spoken and documented safety-netting advice and to explore factors associated with documentation.

DESIGN AND SETTING

A cross-sectional study, using an existing GP consultations archive.

METHOD

Observational coding involving classifying and quantifying medical record entries and comparison with spoken safety-netting advice in 295 video-/audio-recorded consultations. Associations were tested using logistic regression.

RESULTS

Two-thirds of consultations (192/295) contained spoken safety-netting advice that applied to less than half of the problems assessed (242/516). Only one-third of consultations (94/295) had documented safety-netting advice, which covered 20.3% of problems (105/516). The practice of GPs varied widely, from those that did not document their safety-netting advice to those that nearly always did so (86.7%). GPs were more likely to document their safety-netting advice for new problems (P = 0.030), when only a single problem was discussed in a consultation (P = 0.040), and when they gave specific rather than generic safety-netting advice (P = 0.007). In consultations where multiple problems were assessed (n = 139), the frequency of spoken and documented safety-netting advice decreased the later a problem was assessed.

CONCLUSION

GPs frequently do not document the safety-netting advice they have given to patients, which may have medicolegal implications in the event of an untoward incident. GPs should consider how safely they can assess and document more than one problem in a single consultation and this risk should be shared with patients to help manage expectations.

Regression discontinuity analysis for pharmacovigilance: statin example reflected trial findings showing little evidence of harm

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RDA can be used with routine healthcare data, resulting in findings similar to Randomized controlled trials.

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Application of regression discontinuity analysis (RDA) in epidemiology should include examination of the assumptions.

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RDA should employ sensitivity analyses and negative control analyses.

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RDA should carefully consider choice of model and bandwidth.

Objectives

The study aims to explore the use of regression discontinuity analysis (RDA) to examine effects of prescription of statins on total cholesterol and adverse outcomes (type 2 diabetes, rhabdomyolysis and myopathy, myalgia and myositis, liver disease, CVD, and mortality).

Study Design and Setting

We conducted a prospective cohort study using the Clinical Practice Research Datalink including patients with QRISK scores of 10 to 30 in 2010 to 2013 who were last followed-up in October 2016. Comparing patients with QRISK≥20 and QRISK<20, we explored RDA assumptions, provided proof of concept analyses (total cholesterol as outcome), and investigated the effect of statins prescription on adverse outcomes.

Result

RDA confirmed statin prescription reduced total cholesterol (Mean difference (MD) -1.33 mmol/L, 95%Confidence Interval (CI) -1.93 to -0.73). RDA provided little evidence for adverse effects on diabetes, myalgia and myositis, liver disease, CVD, or mortality. The RDA analysis findings are similar to RCT results. Findings from non-RDA analysis agree with published observational studies.

Conclusion

RDA can be used with large routine clinical datasets to provide evidence on effects of medications which are prescribed according to a threshold. Testable RDA assumptions were satisfied, but confidence intervals were wide, partly due to the low compliance with the prescribing threshold.

Paramedics working in general practice: a scoping review

Background: The term ‘paramedic’ has traditionally related to a healthcare professional trained to provide pre-hospital emergency care; however, paramedics are increasingly taking on novel additional non-emergency roles. General practice is facing unprecedented demand for its services related to rising expectations, an aging society and increased prevalence of chronic disease. Paramedics may be recruited to work in general practice to meet some of these demands. We undertook a scoping review to map the current literature considering paramedics working in general practice and inform follow-on research. Methods: We employed the six-stage scoping review framework developed by Arksey and O’Malley. Our research question was ‘to identify the scope of practice, nature of training/qualifications, challenges faced, and impacts of paramedics working in general practice’. Results: After searching PUBMED (Medline, n = 487), EMBASE (n = 536) and the Cochrane Library (n = 0) in June 2020, we identified eleven full-text articles that met our inclusion criteria. The literature suggests that paramedics have diverse skills that enable roles within general practice, some of which are context specific. Additional training is considered necessary to facilitate the transition from emergency care to general practice. We found no research that quantitatively assessed the impact of paramedics working in general practice on healthcare expenditure or patient health outcomes. Conclusions: There is a paucity of empiric scientific literature considering paramedic working in general practice. Further research is needed to inform training pathways, the structure of clinical practice and to measure outcomes.

The diversity and function of sourdough starter microbiomes

Humans have relied on sourdough starter microbial communities to make leavened bread for thousands of years, but only a small fraction of global sourdough biodiversity has been characterized. Working with a community-scientist network of bread bakers, we determined the microbial diversity of 500 sourdough starters from four continents. In sharp contrast with widespread assumptions, we found little evidence for biogeographic patterns in starter communities. Strong co-occurrence patterns observed in situ and recreated in vitro demonstrate that microbial interactions shape sourdough community structure. Variation in dough rise rates and aromas were largely explained by acetic acid bacteria, a mostly overlooked group of sourdough microbes. Our study reveals the extent of microbial diversity in an ancient fermented food across diverse cultural and geographic backgrounds.

Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences

OBJECTIVES

People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals.

DESIGN

Scoping review. The search strategy and data synthesis were informed by people with dementia and carers.

DATA SOURCES

Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019.

ELIGIBILITY CRITERIA

Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using charting techniques and findings were synthesised according to content and themes.

RESULTS

Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress.

CONCLUSIONS

The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.

Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews

Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.

Differential Occupancy of Two GA-Binding Proteins Promotes Targeting of the Drosophila Dosage Compensation Complex to the Male X Chromosome

Little is known about how variation in sequence composition alters transcription factor occupancy to precisely recruit large transcription complexes. A key model for understanding how transcription complexes are targeted is the Drosophila dosage compensation system in which the male-specific lethal (MSL) transcription complex specifically identifies and regulates the male X chromosome. The chromatin-linked adaptor for MSL proteins (CLAMP) zinc-finger protein targets MSL to the X chromosome but also binds to GA-rich sequence elements throughout the genome. Furthermore, the GAGA-associated factor (GAF) transcription factor also recognizes GA-rich sequences but does not associate with the MSL complex. Here, we demonstrate that MSL complex recruitment sites are optimal CLAMP targets. Specificity for CLAMP binding versus GAF binding is driven by variability in sequence composition within similar GA-rich motifs. Therefore, variation within seemingly similar cis elements drives the context-specific targeting of a large transcription complex.

FlyRNAi.org--the database of the Drosophila RNAi screening center: 2012 update

FlyRNAi (http://www.flyrnai.org), the database and website of the Drosophila RNAi Screening Center (DRSC) at Harvard Medical School, serves a dual role, tracking both production of reagents for RNA interference (RNAi) screening in Drosophila cells and RNAi screen results. The database and website is used as a platform for community availability of protocols, tools, and other resources useful to researchers planning, conducting, analyzing or interpreting the results of Drosophila RNAi screens. Based on our own experience and user feedback, we have made several changes. Specifically, we have restructured the database to accommodate new types of reagents; added information about new RNAi libraries and other reagents; updated the user interface and website; and added new tools of use to the Drosophila community and others. Overall, the result is a more useful, flexible and comprehensive website and database.

False negative rates in Drosophila cell-based RNAi screens: a case study

Background

High-throughput screening using RNAi is a powerful gene discovery method but is often complicated by false positive and false negative results. Whereas false positive results associated with RNAi reagents has been a matter of extensive study, the issue of false negatives has received less attention.

Results

We performed a meta-analysis of several genome-wide, cell-based Drosophila RNAi screens, together with a more focused RNAi screen, and conclude that the rate of false negative results is at least 8%. Further, we demonstrate how knowledge of the cell transcriptome can be used to resolve ambiguous results and how the number of false negative results can be reduced by using multiple, independently-tested RNAi reagents per gene.

Conclusions

RNAi reagents that target the same gene do not always yield consistent results due to false positives and weak or ineffective reagents. False positive results can be partially minimized by filtering with transcriptome data. RNAi libraries with multiple reagents per gene also reduce false positive and false negative outcomes when inconsistent results are disambiguated carefully.

Cross-species RNAi rescue platform in Drosophila melanogaster

RNAi-mediated gene knockdown in Drosophila melanogaster is a powerful method to analyze loss-of-function phenotypes both in cell culture and in vivo. However, it has also become clear that false positives caused by off-target effects are prevalent, requiring careful validation of RNAi-induced phenotypes. The most rigorous proof that an RNAi-induced phenotype is due to loss of its intended target is to rescue the phenotype by a transgene impervious to RNAi. For large-scale validations in the mouse and Caenorhabditis elegans, this has been accomplished by using bacterial artificial chromosomes (BACs) of related species. However, in Drosophila, this approach is not feasible because transformation of large BACs is inefficient. We have therefore developed a general RNAi rescue approach for Drosophila that employs Cre/loxP-mediated recombination to rapidly retrofit existing fosmid clones into rescue constructs. Retrofitted fosmid clones carry a selection marker and a phiC31 attB site, which facilitates the production of transgenic animals. Here, we describe our approach and demonstrate proof-of-principle experiments showing that D. pseudoobscura fosmids can successfully rescue RNAi-induced phenotypes in D. melanogaster, both in cell culture and in vivo. Altogether, the tools and method that we have developed provide a gold standard for validation of Drosophila RNAi experiments.

A case study of the reproducibility of transcriptional reporter cell-based RNAi screens in Drosophila

A second generation dsRNA library was used to re-assess factors that influence the outcome of transcriptional reporter-based whole-genome RNAi screens for the Wnt/Wingless (wg) and Hedgehog (hh)-signaling pathways.

Off-target effects have been demonstrated to be a major source of false-positives in RNA interference (RNAi) high-throughput screens. In this study, we re-assess the previously published transcriptional reporter-based whole-genome RNAi screens for the Wingless and Hedgehog signaling pathways using second generation double-stranded RNA libraries. Furthermore, we investigate other factors that may influence the outcome of such screens, including cell-type specificity, robustness of reporters, and assay normalization, which determine the efficacy of RNAi-knockdown of target genes.

Design and implementation of high-throughput RNAi screens in cultured Drosophila cells

This protocol describes the various steps and considerations involved in planning and carrying out RNA interference (RNAi) genome-wide screens in cultured Drosophila cells. We focus largely on the procedures that have been modified as a result of our experience over the past 3 years and of our better understanding of the underlying technology. Specifically, our protocol offers a set of suggestions and considerations for screen optimization and a step-by-step description of the procedures successfully used at the Drosophila RNAi Screening Center for screen implementation, data collection and analysis to identify potential hits. In addition, this protocol briefly covers postscreen analysis approaches that are often needed to finalize the hit list. Depending on the scope of the screen and subsequent analysis and validation involved, the full protocol can take anywhere from 3 months to 2 years to complete.

Evidence of off-target effects associated with long dsRNAs in Drosophila melanogaster cell-based assays

To evaluate the specificity of long dsRNAs used in high-throughput RNA interference (RNAi) screens performed at the Drosophila RNAi Screening Center (DRSC), we performed a global analysis of their activity in 30 genome-wide screens completed at our facility. Notably, our analysis predicts that dsRNAs containing > or = 19-nucleotide perfect matches identified in silico to unintended targets may contribute to a significant false positive error rate arising from off-target effects. We confirmed experimentally that such sequences in dsRNAs lead to false positives and to efficient knockdown of a cross-hybridizing transcript, raising a cautionary note about interpreting results based on the use of a single dsRNA per gene. Although a full appreciation of all causes of false positive errors remains to be determined, we suggest simple guidelines to help ensure high-quality information from RNAi high-throughput screens.

FlyRNAi: the Drosophila RNAi screening center database

RNA interference (RNAi) has become a powerful tool for genetic screening in Drosophila. At the Drosophila RNAi Screening Center (DRSC), we are using a library of over 21 000 double-stranded RNAs targeting known and predicted genes in Drosophila. This library is available for the use of visiting scientists wishing to perform full-genome RNAi screens. The data generated from these screens are collected in the DRSC database () in a flexible format for the convenience of the scientist and for archiving data. The long-term goal of this database is to provide annotations for as many of the uncharacterized genes in Drosophila as possible. Data from published screens are available to the public through a highly configurable interface that allows detailed examination of the data and provides access to a number of other databases and bioinformatics tools.

Severe gestational (incidental) thrombocytopenia: to treat or not to treat

Thrombocytopenia is common in pregnancy and is diverse in etiology. Immune thrombocytopenic purpura (ITP) may affect both mother and the newborn. Gestational (incidental) thrombocytopenia in an otherwise fit woman, at term is the most frequent type of thrombocytopenia and poses no clinical consequences for mother or infant. We report six women who presented with severe thrombocytopenia during pregnancy. Five were treated in late pregnancy, either with intravenous immunoglobulin (IVIg), or IVIg followed by steroids. There was no response, and four received a platelet transfusion during delivery. The platelet counts in all the infants were normal and the maternal thrombocytopenia resolved spontaneously after delivery in all cases. Our observations suggest that this is a group of patients with a severe form of gestational thrombocytopenia. The severe form of gestational thrombocytopenia appears to be rare, and recognition is important, as it may recur in subsequent pregnancies and does not require any therapeutic intervention.

Trisomy 2 in an acardiac twin in a triplet in-vitro fertilization pregnancy

A case is reported of twin reversed arterial perfusion (TRAP) sequence in a triamniotic dichorionic triplet pregnancy conceived by in-vitro fertilization which was diagnosed at 25 weeks of gestation by colour Doppler sonography. It highlights the risk of monochorionicity-associated morbidity in multiple pregnancies obtained by assisted conception and stresses the importance of chorionicity determination by early ultrasound examination. Cytogenetic analysis of skin from the acardius showed trisomy 2 in all cells, whereas the karyotype in the monochorionic triplet was normal. This is an example of heterokaryotypic monozygotism where the chromosomal abnormality must have occurred during the early cleavage divisions. Aneuploidy as a possible aetiological factor of TRAP sequence is discussed.

Diprosopus (partially duplicated head) associated with anencephaly: a case report

Craniofacial duplication (diprosopus) is a rare form of conjoined twin. A 16 year old mother with a twin pregnancy delivered one normally formed baby boy and one diprosopus male. The malformed baby was 33 weeks of gestation with a single trunk, normal limbs and various degrees of facial duplication. Of the following structures there were two of each: noses, eyes, ears (and one dimple), mouths, tongues and, with bilateral central cleft lips and cleft palates. This was associated with holoprosencephaly and craniorachischisis. Internal organs showed no duplication. There were multiple congenital anomalies including diaphragmatic hernia, small lungs, two lobes of the right lung, ventricular septal defect, small adrenal gland and small left kidney with short ureter. The body also had a short neck, small chest cavities and kyphosis. X-ray revealed duplication of the vertebral column. The case presented here represents a type II of diprosopia of Rating (1933) and is the least common type reported. We also reviewed 22 recently reported cases of diprosopus. In addition to facial duplication, anencephaly, neural tube defect and cardiac malformations represent the more common congenital abnormalities associated with diprosopus. The pathogenesis of diprosopus is not well understood. Factors that play a role in diprosopus are probably similar to those factors (genetic, environmental and abnormal placental circulation) which affect monozoygotic twins as observed in this case report. Early ultrasonography diagnosis of diprosopus permits one to consider a vaginal therapeutic abortion.

The Genome Sequence DataBase: towards an integrated functional genomics resource

During 1998 the primary focus of the Genome Sequence DataBase (GSDB; http://www.ncgr.org/gsdb ) located at the National Center for Genome Resources (NCGR) has been to improve data quality, improve data collections, and provide new methods and tools to access and analyze data. Data quality has been improved by extensive curation of certain data fields necessary for maintaining data collections and for using certain tools. Data quality has also been increased by improvements to the suite of programs that import data from the International Nucleotide Sequence Database Collaboration (IC). The Sequence Tag Alignment and Consensus Knowledgebase (STACK), a database of human expressed gene sequences developed by the South African National Bioinformatics Institute (SANBI), became available within the last year, allowing public access to this valuable resource of expressed sequences. Data access was improved by the addition of the Sequence Viewer, a platform-independent graphical viewer for GSDB sequence data. This tool has also been integrated with other searching and data retrieval tools. A BLAST homology search service was also made available, allowing researchers to search all of the data, including the unique data, that are available from GSDB. These improvements are designed to make GSDB more accessible to users, extend the rich searching capability already present in GSDB, and to facilitate the transition to an integrated system containing many different types of biological data.

The perurethral technique for ultrasound directed follicle aspiration in an in-vitro fertilization and embryo transfer programme: a report of 636 patient cycles

The data from 636 patient cycles from an outpatient-based in-vitro fertilization and embryo transfer programme are presented. Between 1984 and 1988, 545 women (86%) underwent ultrasound directed follicle aspiration (UDFA) exclusively by the perurethral route. The mean follicle aspiration rate was 93%, and the mean number of oocytes per procedure was 5.8. The complication rate was 6%, but none was major. From July 1985 the clinical pregnancy rate per UDFA was 17% and per embryo transfer 21%. The perurethral approach was used in combination with another UDFA route in 91 women (14%) but the need to change route decreased with increasing operator experience. Perurethral UDFA is an efficient and safe method for harvesting oocytes.

Measurement of myocardial blood flow by ultrafast computed tomography

Myocardial blood flow was analyzed by radioisotope-labeled microspheres and ultrafast computed tomography (CT) in 16 closed-chest, anesthetized dogs. The first set of 10 dogs had CT and microsphere measurements before and after chromonar-induced increases in myocardial blood flow. A second set of six dogs had flows measured at control and during temporary reductions in regional flow produced by balloon cuff occlusion of the left anterior descending coronary artery. All dogs had four-slice, 20-instance CT scans after injection of a medium bolus (0.35 ml/kg) of contrast medium into a femoral vein simultaneous with injection of microspheres into the left atrium. CT myocardial flow was calculated as the change in myocardial CT numbers divided by the area from a blood pool time-density curve. A wide range of myocardial blood flows was produced as determined by microspheres (0 to 6.7 ml/min/g). Global flow of the first set of dogs was shown to have excellent correlation (r = .95, n = 17) for a limited range (.4 less than X less than 1.4 ml/min/g) of flows. Regional flows of these measurements demonstrated less correlation (r = .63, n = 110) but extended the range of flow to 1.7 ml/min/g. At higher flows (greater than 2.5 ml/min/g) the correlation for global and regional flows was not significantly different than zero. Regional ischemic flow correlation extended the linear range of flow to 0 ml/min/g (r = .62, n = 17). These results show that CT can measure myocardial blood flow over a limited but clinically relevant range of flows defined as slightly above normal to ischemic. These results indicate that another preparation of CT flow measurement must be sought for quantification of myocardial perfusion values significantly above normal.