O-091 From Family Planning to Fertility Planning - ‘FertPlan’ awareness amongst contraceptive healthcare providers and users

Study question

Are women and healthcare professionals seeking or providing contraception aware of age-related decline in female fertility and information support regarding fertility awareness?

Summary answer

89.9% of contraceptive users and 71% of providers stated lack of awareness regarding age and fertility emphasising website as the preferred information resource.

What is known already

The last 50 years has seen an upward trend in the age at which women are giving birth. The birth rate for women aged 35 to 39 has trebled since 1980 and is now at its highest ever level. Delaying childbearing may mean that some women will inevitably leave it too late and become childless involuntarily. Women are also seeking fertility treatment at older ages, however, success rates decrease dramatically with age. It is not clear whether women who delay their fertility are aware of the decline in fertility with age, and whether healthcare professionals discuss fertility planning with women.

Study design, size, duration

We conducted two independent anonymous questionnaire surveys of reproductive age women seeking contraception and healthcare professionals(HCP) providing contraception in the UK following research ethics approval, to determine their awareness of the age-related decline in fertility, information resource and potential barriers to provision of information. . This was a prospective study design conducted over a year period using an online questionnaire. A total of 249 participants completed the survey.

Participants/materials, setting, methods

138 reproductive age women on contraception consented and participated in the study by completing the online questionnaire. Of these, 96.4% were of white origin,1.4% mixed ethnicity, 1.4% Asian origin and 0.7% Black.

111 HCP providing contraceptive advice in family planning clinics or in General practice completed the survey. Of these, 6 were allied healthcare professionals ie specialist nurses. Data was collated and analysed using percentages and descriptive statistics.

Main results and the role of chance

Of the total 138 female contraceptive users, 87 were aged 30-39 years whilst 35 were 40-45 years. 51.4% of women indicated no concern about their future fertility, whilst the remainder gave roughly uniformly distributed ratings of concern from unconcerned to highly concerned. However, one third of all women (31.1%) believed that age-related fertility decline occurred after 40 years. 89.9% of women felt fertility awareness and education is important.

Of the total 111 HCP, ∼one in 10 HCP (11.7%) misconstrued the female age-related decline to begin from 40 years onwards. The contraceptive providers also were misinformed regarding age related decline in IVF success rate with 45% of them citing 40 years or over to be the age that contributed to decline in IVF success. Despite these figures, majority (71.2%) of HCP agreed there was lack of fertility awareness and 33.3% felt fertility education should be commenced as early as school age. 27% HCP always discussed future fertility whilst 33.3% discussed most of the times. The most commonly-stated barriers to providing information were lack of time, self-perceived lack of knowledge, and women not asking.

73.2% of reproductive age contraceptive users and 85.6% HCPs expressed website to be the most preferred option for information resource.

Limitations, reasons for caution

To the best of our knowledge, this is one of the first studies seeking fertility awareness amongst those practising family planning. As this was not a qualitative interview based study, the findings are open to interpretation and one must exercise caution.

Wider implications of the findings

This study highlights clear need for fertility education and awareness amongst contraceptive providers and users. By providing resources to inform, we may increase awareness and confidence amongst both groups thereby empowering women to make informed choices about their future fertility by integrating Fertility planning within Family Planning.

Trial registration number

Not applicable (IRAS 248991 and R&D Ref 8999)

Evaluating Knowledge and Skills Retention of Helping Babies Breathe Training among Trainees over the Period of Time in Kavre, Nepal

Introduction: Helping Babies Breathe and Helping Babies Survive (HBS) programs are designed to develop basic neonatal resuscitation skills and knowledge aimed at the first minutes after birth. The programs were implemented at Scheer Memorial Adventist Hospital in Banepa, Kavre, Nepal. This study aimed to evaluate the success of training participants and maintaining their skills over time. Methods: The programs were implemented at SMAH over three years for staff and students involved in maternal / foetal medicine. Skills and knowledge of 119 participants were evaluated prior to training, after training, and again at five separate time intervals using standardised tests.  Results: The training resulted in increased scores on knowledge testing from pre-test to post-test. Knowledge retention over time was shown to have a statistically significant decrease from post-test to retest. An objective structured clinical examination A performance did not show statistically significant decrease over time from post-test to retest.  For the objective structured clinical examination B, there was a statistically significant decrease in scores over time from post-test to retest. Conclusions: The training resulted in a significant improvement in passing scores on knowledge and skills testing. While a statistically significant decrease in scores on testing was seen, the clinical significance of these decreases is questionable. This study shows that with implementation and continued practice, both knowledge and skills for basic neonatal resuscitation can be achieved and maintained.

Long-term river invertebrate community responses to groundwater and surface water management operations

River flow regimes have been transformed by groundwater and surface water management operations globally, prompting widespread ecological responses. Yet, empirical evidence quantifying the simultaneous effects of groundwater and surface water management operations on freshwater ecosystems remains limited. This study combines a multi-decadal freshwater invertebrate dataset (1995-2016) with groundwater model outputs simulating the effects of different anthropogenic flow alterations (e.g. groundwater abstraction, effluent water returns) and river discharges. A suite of flow alteration- and flow-ecology relationships were modelled that tested different invertebrate community responses (taxonomic, functional, flow response guilds, individual taxa). Most flow alteration-ecology relationships were not statistically significant, highlighting the absence of consistent, detectable ecological responses to long-term water management operations. A small number of significant statistical models provided insights into how flow alterations transformed specific ecological assets; including Ephemeroptera, Plecoptera and Trichoptera taxa which are rheophilic in nature being positively associated with groundwater abstraction effects reducing river discharges by 0-15%. This represents a key finding from a water resource management operation perspective given that such flow alteration conditions were observed on average in over two-thirds of the study sites examined. In a small number of instances, specific invertebrate responses displayed relative declines associated with the most severe groundwater abstraction effects and artificial hydrological inputs (predominantly effluent water returns). The strongest flow-ecology relationships were recorded during spring months, when invertebrate communities were most responsive to antecedent minimum and maximum discharges, and average flow conditions in the preceding summer months. Results from this study provide new evidence indicating how groundwater and surface water resources can be managed to conserve riverine ecological assets. Moreover, the ensemble of flow alteration- and flow-ecology relationships established in this study could be used to guide environmental flow strategies. Such findings are of global importance given that future climatic change and rising societal water demands are likely to further transform river flow regimes and threaten freshwater ecosystems.

Pumps or Multiple Daily Injections in Pregnancy Involving Type 1 Diabetes: A Prespecified Analysis of the CONCEPTT Randomized Trial

OBJECTIVE

To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT).

RESEARCH DESIGN AND METHODS

This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA_1c. The primary outcome was change in HbA_1c from randomization to 34 weeks' gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes.

RESULTS

At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA_1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA_1c (-0.55 ± 0.59 vs. -0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA_1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02).

CONCLUSIONS

In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.

Refractory Pseudomonas Bacteremia in a 2-Year-Old Sterilized by Bacteriophage Therapy

Here, we report a complex case that involved a pediatric patient who experienced recalcitrant multidrug-resistant Pseudomonas aeruginosa infection complicated by bacteremia/sepsis; our antibacterial options were limited because of resistance, allergies, and suboptimal source control. A cocktail of 2 bacteriophages targeting the infectious organism introduced on 2 separate occasions sterilized the bacteremia.

Recent H- diagnostics, plasma simulations, and 2X scaled Penning ion source developments at the Rutherford Appleton Laboratory

A vessel for extraction and source plasma analyses is being used for Penning H^- ion source development at the Rutherford Appleton Laboratory. A new set of optical elements including an einzel lens has been installed, which transports over 80 mA of H^- beam successfully. Simultaneously, a 2X scaled Penning source has been developed to reduce cathode power density. The 2X source is now delivering a 65 mA H^- ion beam at 10% duty factor, meeting its design criteria. The long-term viability of the einzel lens and 2X source is now being evaluated, so new diagnostic devices have been installed. A pair of electrostatic deflector plates is used to correct beam misalignment and perform fast chopping, with a voltage rise time of 24 ns. A suite of four quartz crystal microbalances has shown that the cesium flux in the vacuum vessel is only increased by a factor of two, despite the absence of a dedicated cold trap. Finally, an infrared camera has demonstrated good agreement with thermal simulations but has indicated unexpected heating due to beam loss on the downstream electrode. These types of diagnostics are suitable for monitoring all operational ion sources. In addition to experimental campaigns and new diagnostic tools, the high-performance VSim and COMSOL software packages are being used for plasma simulations of two novel ion thrusters for space propulsion applications. In parallel, a VSim framework has been established to include arbitrary temperature and cesium fields to allow the modeling of surface physics in H^- ion sources.

Altered Energy Metabolism Pathways in the Posterior Cingulate in Young Adult Apolipoprotein E ɛ4 Carriers

The APOE gene, encoding apolipoprotein E, is the primary genetic risk factor for late-onset Alzheimer’s disease (AD). Apolipoprotein E ɛ4 allele (APOE4) carriers have alterations in brain structure and function (as measured by brain imaging) even as young adults. Examination of this population is valuable in further identifying details of these functional changes and their association with vulnerability to AD decades later. Previous work demonstrates functional declines in mitochondrial activity in the posterior cingulate cortex, a key region in the default mode network, which appears to be strongly associated with functional changes relevant to AD risk. Here, we demonstrate alterations in the pathways underlying glucose, ketone, and mitochondrial energy metabolism. Young adult APOE4 carriers displayed upregulation of specific glucose (GLUT1 & GLUT3) and monocarboxylate (MCT2) transporters, the glucose metabolism enzyme hexokinase, the SCOT & AACS enzymes involved in ketone metabolism, and complexes I, II, and IV of the mitochondrial electron transport chain. The monocarboxylate transporter (MCT4) was found to be downregulated in APOE4 carriers. These data suggest that widespread dysregulation of energy metabolism in this at-risk population, even decades before possible disease onset. Therefore, these findings support the idea that alterations in brain energy metabolism may contribute significantly to the risk that APOE4 confers for AD.

Advances in x-ray framing cameras at the National Ignition Facility to improve quantitative precision in x-ray imaging

We describe an experimental method to measure the gate profile of an x-ray framing camera and to determine several important functional parameters: relative gain (between strips), relative gain droop (within each strip), gate propagation velocity, gate width, and actual inter-strip timing. Several of these parameters cannot be measured accurately by any other technique. This method is then used to document cross talk-induced gain variations and artifacts created by radiation that arrives before the framing camera is actively amplifying x-rays. Electromagnetic cross talk can cause relative gains to vary significantly as inter-strip timing is varied. This imposes a stringent requirement for gain calibration. If radiation arrives before a framing camera is triggered, it can cause an artifact that manifests as a high-intensity, spatially varying background signal. We have developed a device that can be added to the framing camera head to prevent these artifacts.

The ISIS pre-injector reconfiguration

With the introduction of a new "low energy beams" group at ISIS, the decision was taken to expand the ion source area. This paper will explain what actions were taken, how this has improved the present working environment and how the space will be used to accommodate a medium energy beam transport (MEBT) section after the existing radio-frequency quadrupole. The MEBT will incorporate three 202.5 MHz re-bunching cavities and will achieve a transmission of 96% with minimal emittance growth.

Development of the front end test stand and vessel for extraction and source plasma analyses negative hydrogen ion sources at the Rutherford Appleton Laboratory

The ISIS pulsed spallation neutron and muon facility at the Rutherford Appleton Laboratory (RAL) in the UK uses a Penning surface plasma negative hydrogen ion source. Upgrade options for the ISIS accelerator system demand a higher current, lower emittance beam with longer pulse lengths from the injector. The Front End Test Stand is being constructed at RAL to meet the upgrade requirements using a modified ISIS ion source. A new 10% duty cycle 25 kV pulsed extraction power supply has been commissioned and the first meter of 3 MeV radio frequency quadrupole has been delivered. Simultaneously, a Vessel for Extraction and Source Plasma Analyses is under construction in a new laboratory at RAL. The detailed measurements of the plasma and extracted beam characteristics will allow a radical overhaul of the transport optics, potentially yielding a simpler source configuration with greater output and lifetime.

Abstract 3989: P-Cadherin overexpression modulates insulin-like growth factor signaling in oral squamous carcinoma cells

Altered expression of cadherin cell adhesion proteins is a frequent occurrence in epithelial tumor development. P-cadherin, a component of normal epithelia, has been ascribed both causative and preventive roles in tumor development, contingent upon the tissue of origin. In oral epithelia, histological studies demonstrate an upregulation of P-cadherin during dysplasia, and a subsequent loss of P-cadherin in later stage oral squamous carcinomas. A possible mechanism by which P-cadherin may modulate tumor development is via alterations in ligand-mediated signaling of receptor tyrosine kinases, a phenomenon that has previously been demonstrated for both E- and N-cadherin. To better understand the role that P-cadherin plays in tumor development, retroviral transduction was used to deplete or overexpress P-cadherin in two oral squamous carcinoma cell lines. Six growth factors were independently utilized to screen for P-cadherin-dependent alterations in signaling, with the greatest effects occurring in response to insulin-like growth factor (IGF) and fibroblast growth factor (FGF). The increased level of P-cadherin in IGF-treated cells greatly altered the kinetics of mitogen-activated protein kinase (MAPK) signaling, but had little direct effect on the activation of the phosphoinositide 3-kinase (PI3K) pathway. P-cadherin overexpression increased steady-state levels of Snai1 protein, with further increases noted upon IGF administration. Inhibition of either MAPK or PI3K signaling pathways in P-cadherin overexpressing cells resulted in decreased Snai1 expression. Ser-9 phosphorylation of GSK-3β was unchanged after IGF treatment, suggesting P-cadherin contributes to Snai1 stability independent of GSK3β activity. P-cadherin over-expressing cells treated with IGF showed a time-dependent decrease in P-cadherin levels. This decrease was accompanied by a decrease in detectable levels of immunofluorescence staining of P-cadherin at cell borders. The internalization of P-cadherin could be inhibited by treatment with dynasore, a dynamin inhibitor. Also, increases in motility were found in P-cadherin overexpressing cells compared to normal cells. Our data suggests that the increase in P-cadherin seen in early oral cancer may promote tumor aggressiveness by altering cell behavior, and increasing EMT- related signaling. The contribution of P-cadherin to tumor development may be helpful in identifying biological targets for oral cancer therapies in dysplastic tissue.

Citation Format: Desseree Lysne, Michelle Perkins, James Johns, Matthew Van Dam, Darren Cuevas, Kathryn Lawson. P-Cadherin overexpression modulates insulin-like growth factor signaling in oral squamous carcinoma cells. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3989. doi:10.1158/1538-7445.AM2013-3989

Anti-eosinophil activity and clinical efficacy of the CRTH2 antagonist OC000459 in eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, Th2-type inflammatory disease. Chemoattractant receptor-homologous molecule on Th2 cells (CRTH2) is a prostaglandin D(2) (PGD(2)) receptor, expressed by Th2 cells and other inflammatory cells, including eosinophils and basophils, that mediates chemotaxis and activation. OC000459 is a selective CRTH2 antagonist and would be expected to suppress eosinophilic tissue inflammation. The purpose of this study was to evaluate the efficacy and safety of an OC000459 monotherapy in adult patients with active, corticosteroid-dependent or corticosteroid-refractory EoE.

METHODS

In this randomized, double-blind, placebo-controlled trial, 26 adult patients (m/f = 22/4; mean age 41 years, range 22-69 years) with active EoE, dependent or resistant to corticosteroids, were treated either with 100 mg OC000459 (n = 14) or placebo (n = 12) twice daily. Pre- and post-treatment disease activity was assessed clinically, endoscopically, histologically, and via biomarkers. The primary end point was the reduction in esophageal eosinophil infiltration.

RESULTS

After an 8-week OC000459 treatment, the esophageal eosinophil load decreased significantly, from 114.83 to 73.26 eosinophils per high-power field [(eos/hpf), P = 0.0256], whereas no reduction was observed with placebo (102.80-99.47 eos/hpf, P = 0.870). With OC000459, the physician's global assessment of disease activity improved from 7.13 to 5.18 (P = 0.035). OC000459 likewise reduced extracellular deposits of eosinophil peroxidase and tenascin C, the effects not seen with placebo. No serious adverse events were observed.

CONCLUSIONS

An 8-week treatment with the CRTH2-antagonist, OC000459, exerts modest, but significant, anti-eosinophil and beneficial clinical effects in adult patients with active, corticosteroid-dependent or corticosteroid-refractory EoE and is well tolerated.

Batrachochytrium dendrobatidis in amphibians of Cameroon, including first records for caecilians

Amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) has been hypothesised to be an indigenous parasite of African amphibians. In Cameroon, however, previous surveys in one region (in the northwest) failed to detect this pathogen, despite the earliest African Bd having been recorded from a frog in eastern Cameroon, plus one recent record in the far southeast. To reconcile these contrasting results, we present survey data from 12 localities across 6 regions of Cameroon from anurans (n = 1052) and caecilians (n = 85) of ca. 108 species. Bd was detected in 124 amphibian hosts at 7 localities, including Mt. Oku, Mt. Cameroon, Mt. Manengouba and lowland localities in the centre and west of the country. None of the hosts were observed dead or dying. Infected amphibian hosts were not detected in other localities in the south and eastern rainforest belt. Infection occurred in both anurans and caecilians, making this the first reported case of infection in the latter order (Gymnophiona) of amphibians. There was no significant difference between prevalence and infection intensity in frogs and caecilians. We highlight the importance of taking into account the inhibition of diagnostic qPCR in studies on Bd, based on all Bd-positive hosts being undetected when screened without bovine serum albumin in the qPCR mix. The status of Bd as an indigenous, cosmopolitan amphibian parasite in Africa, including Cameroon, is supported by this work. Isolating and sequencing strains of Bd from Cameroon should now be a priority. Longitudinal host population monitoring will be required to determine the effects, if any, of the infection on amphibians in Cameroon.

Optimizing the front end test stand high performance H- ion source at RAL

The aim of the front end test stand project is to demonstrate that chopped low energy H(-) beams of high quality can be produced. The beam line currently consists of the ion source, a 3 solenoid low energy beam transport and a suite of diagnostics. A brief status report of the radio frequency quadrupole is given. This paper details the work to optimize the ion source performance. A new high power pulsed discharge power supply with greater reliability has been developed to allow long term, stable operation at 50 Hz with a 60 A, 2.2 ms discharge pulse and up to 100 A at 1.2 ms. The existing extraction power supply has been modified to operate up to 22 kV. Results from optical spectroscopy measurements and their application to source optimization are summarized. Source emittances and beam currents of 60 mA are reported.

Epidemiology of salmonellosis in garden birds in England and Wales, 1993 to 2003

Salmonellosis has been reported as an important cause of mortality of garden birds in several countries, including Norway and Scotland. We investigated the frequency of the disease in garden birds submitted for postmortem examination by members of the public in England and Wales between 1993 and 2003, inclusive. We found salmonellosis to be the most frequent cause of death due to infectious disease in the garden birds submitted. This disease was confirmed in 7 of the 45 bird species that were examined postmortem, with the greenfinch (Carduelis chloris) and the house sparrow (Passer domesticus) most frequently affected. Salmonella Typhimurium definitive phage type (DT) 40, DT56 variant(v), and DT160 accounted for the majority of isolates. Salmonellosis incidents chiefly occurred in the English Midlands, the English/Welsh border region, and southern England. Variation in the temporal and spatial distribution of the phage types occurred over the study period. While birds were examined throughout the year, there was a marked winter seasonality in salmonellosis. A significant sex bias was observed in affected greenfinches, with males more frequently diagnosed with salmonellosis than females. No sex bias was observed for other affected species. Further research is required to determine if salmonellosis is an important constraint to the populations of affected species and if disease outbreaks are driven by human factors, such as provisioning.

The front end test stand high performance H- ion source at Rutherford Appleton Laboratory

The aim of the front end test stand (FETS) project is to demonstrate that chopped low energy beams of high quality can be produced. FETS consists of a 60 mA Penning Surface Plasma Ion Source, a three solenoid low energy beam transport, a 3 MeV radio frequency quadrupole, a chopper, and a comprehensive suite of diagnostics. This paper details the design and initial performance of the ion source and the laser profile measurement system. Beam current, profile, and emittance measurements are shown for different operating conditions.

Transition pathways for young people with complex disabilities: exploring the economic consequences

BACKGROUND

Disabled young people with complex needs face particular challenges when they reach adulthood and seek to move from school to employment or further education. There are potentially substantial personal and social costs arising from these challenges.

METHODS

We sought evidence from recent UK research, policy and related literatures; undertook exploratory statistical analyses of birth cohort data; and analysed information provided by 30 disabled young people requiring high levels of practical and communication support.

RESULTS

The personal, family and social costs that result from unsuccessful transition are substantial and wide-ranging. Health service and local authority expenditure are important elements, but do not allow young people to achieve the educational or employment goals to which they aspire, resulting in considerable costs for the state, whether through missing opportunities to contribute to the economy or through dependence on welfare benefits.

CONCLUSIONS

The considerable sums currently spent on disabled children and young people are clearly not enough, or not deployed appropriately, to enable those who reach adulthood to fulfil their ambitions, or to meet government policy intentions for young people to achieve economic well-being.

Skeletal deformities and mortality in grey herons (Ardea cinerea) at Besthorpe heronry, Nottinghamshire

Dead and sick grey heron chicks with multiple fractures of the leg and wing bones and/or bone deformities have been reported at Besthorpe Nature Reserve heronry in north Nottinghamshire since 1996. Forty-five grey heron carcases were examined, 35 from the Besthorpe colony and 10 from other colonies where bone disease was not known to occur. On the basis of the results of radiological studies, postmortem examinations, peripheral quantitative computed tomography scanning and four-point bending tests, it was concluded that the skeletal abnormalities were probably due to metabolic bone disease.

Improving seizure control in dogs with refractory epilepsy using gabapentin as an adjunctive agent

OBJECTIVE

To assess whether there is a change in seizure activity in dogs with refractory epilepsy that are receiving appropriate doses of phenobarbitone and/or potassium bromide, when gabapentin is added to the therapeutic regimen.

DESIGN

A prospective study of 17 dogs with a refractory seizure disorder, 16 of which have idiopathic epilepsy.

PROCEDURE

Patients were stabilised using phenobarbitone and/or potassium bromide to produce tolerable therapeutic serum concentrations and dosed additionally with gabapentin at 35 to 50 mg/kg/d (divided twice or three times daily) for 4 months. Owners recorded seizure activity and side effects during this period in a standardised diary. Patients underwent monthly physical examinations and venepuncture to assess selected serum biochemical analytes, as well as phenobarbitone and bromide concentrations. Patients were further monitored for long-term response to adjunctive gabapentin therapy.

RESULTS

There was no significant decrease in the number of seizures over the study period for the entire cohort, however three dogs stopped seizuring completely. There was a significant increase in the number of patients who showed an increase in the interictal period (P > 0.001). Serum alkaline phosphatase activity and triglyceride concentrations were elevated at baseline. There were no significant changes in biochemical analytes during the course of the study period. Side effects observed initially on addition of gabapentin included sedation and hind limb ataxia. The former resolved spontaneously after a few days; the latter after a slight reduction in bromide dose. Long-term, a further two patients became seizure free and ten patients remained on gabapentin indefinitely. No long-term side effects have become apparent.

CONCLUSION

Addition of gabapentin to phenobarbitone and/or potassium bromide increased the interictal period and shortened the post-seizure recovery in some canine epileptics. In some dogs, seizures were prevented completely, while in others there was an increase in interictal period. The short-half life of gabapentin has advantages for seizure control, however its present high cost may prohibit therapy in large dogs.

MINERVA: a multi-modality plugin-based radiation therapy treatment planning system

Researchers at the INEEL, MSU, LLNL and UCD have undertaken development of MINERVA, a patient-centric, multi-modal, radiation treatment planning system, which can be used for planning and analysing several radiotherapy modalities, either singly or combined, using common treatment planning tools. It employs an integrated, lightweight plugin architecture to accommodate multi-modal treatment planning using standard interface components. The design also facilitates the future integration of improved planning technologies. The code is being developed with the Java programming language for interoperability. The MINERVA design includes the image processing, model definition and data analysis modules with a central module to coordinate communication and data transfer. Dose calculation is performed by source and transport plugin modules, which communicate either directly through the database or through MINERVA's openly published, extensible markup language (XML)-based application programmer's interface (API). All internal data are managed by a database management system and can be exported to other applications or new installations through the API data formats. A full computation path has been established for molecular-targeted radiotherapy treatment planning, with additional treatment modalities presently under development.

MINERVA—a multi-modal radiation treatment planning system

Researchers at the Idaho National Engineering and Environmental Laboratory and Montana State University have undertaken development of MINERVA, a patient-centric, multi-modal, radiation treatment planning system. This system can be used for planning and analyzing several radiotherapy modalities, either singly or combined, using common modality independent image and geometry construction and dose reporting and guiding. It employs an integrated, lightweight plugin architecture to accommodate multi-modal treatment planning using standard interface components. The MINERVA design also facilitates the future integration of improved planning technologies. The code is being developed with the Java Virtual Machine for interoperability. A full computation path has been established for molecular targeted radiotherapy treatment planning, with the associated transport plugin developed by researchers at the Lawrence Livermore National Laboratory. Development of the neutron transport plugin module is proceeding rapidly, with completion expected later this year. Future development efforts will include development of deformable registration methods, improved segmentation methods for patient model definition, and three-dimensional visualization of the patient images, geometry, and dose data. Transport and source plugins will be created for additional treatment modalities, including brachytherapy, external beam proton radiotherapy, and the EGSnrc/BEAMnrc codes for external beam photon and electron radiotherapy.

Pro-nociceptive effects of neuromedin U in rat

The neuropeptide neuromedin U (NMU) has been shown to have significant effects on cardiovascular, gastrointestinal and CNS functions. The peptide was first isolated from the porcine spinal cord and later shown to be present in spinal cords of other species. Little is known about the distribution of neuromedin U receptors (NMURs) in the spinal cord and the spinal action of the peptide. Here we report on the expression of NMURs and a potential role in nociception in the rat spinal cord using a combination of behavioral and electrophysiological studies. Receptor autoradiography showed that NMU-23 binding was restricted to the superficial layers of spinal cord, a region known to be involved in the control of nociception. In situ hybridization analysis indicated the mRNA of NMUR2 was located in the same region (laminae I and IIo) as NMU-23 binding, while the mRNA for NMU receptor 1 was observed in a subpopulation of small diameter neurons of dorsal root ganglia. Intrathecal (i.t.) administration of neuromedin U-23 (0.4-4.0 nmol/10 microl) dose-dependently decreased both the mechanical threshold to von Frey hair stimulation and the withdrawal latency to a noxious thermal stimulus. Mechanical allodynia was observed between 10 and 120 min, peaking at 30 min and heat hyperalgesia was observed 10-30 min after i.t. administration of NMU-23. A similar mechanical allodynia was also observed following i.t. administration of NMU-8 (0.4-4 nmol/10 microl). A significant enhancement of the excitability of flexor reflex was induced by intrathecal administration of NMU-23 (4 nmol/10 microl). Evoked responses to touch and pinch stimuli were increased by 439+/-94% and 188+/-36% (P<0.01, n=6) respectively. The behavioral and electrophysiological data demonstrate, for the first time, a pro-nociceptive action of NMU. The restricted distribution of NMU receptors to a region of the spinal cord involved in nociception suggests that this peptide receptor system may play a role in nociception.

Successful treatment of hypereosinophilic syndrome in a dog

An 11-year-old crossbred dog was presented with a history of episodic vomiting, diarrhoea, abdominal discomfort and coughing. These signs had been present for several years. Marked peripheral eosinophilia (10.3 x 10(9)/L) was found. No underlying cause of reactive eosinophilia was apparent. Bone marrow aspiration biopsy showed hyperplasia of the eosinophilic cell line, with some increase in immaturity, although all cells were morphologically normal. There were numerous eosinophils in bronchial wash fluid and eosinophilic infiltrates were evident in biopsies of pancreas, liver, small intestine and colon but not stomach. Hypereosinophilic syndrome was diagnosed. The dog responded well to twice daily treatment with hydroxyurea and prednisolone. Clinical signs are well-controlled 16 months later.

'Here's the weavery looming up': verbal humour in a woman with high-functioning autism

A case study of Grace, a 29-year-old woman with high-functioning autism, is presented. Grace is unusual for a person with autism in that she produces a great deal of humorous and creative word play. She is also unusual in that she writes and then audio-records 'letters' to her family, and produces copious cartoon-like drawings which she annotates, with the result that multiple examples of her humour are available in permanent form. We present examples of Grace's use of puns, jokes, neologisms, 'portmanteau' words, irreverent humour, irony, sarcasm and word play based on her obsessional interests. The examples are used to illustrate the forms and content of Grace's humour, and are discussed in relation to current theories of autism and of normal humour.

Spinal delta-opioid receptors mediate suppression of systemic SNC80 on excitability of the flexor reflex in normal and inflamed rat

Due to low central nervous system (CNS) bioavailability of delta-opioid peptides, little is known about the effect of systemic administration of delta-opioid receptor ligands. The present study examined the effect of non-peptidergic delta-opioid receptor agonists, (+)-4-[(alphaR)-alpha-((2R,5R)-4-Allyl-2,5-dimethyl-1-piperazinyl)-3-methoxybenzyl]-N,N-diethylbenzamide (SNC80) and (-)dibenzoyl-L-tartaric acid salt (SNC86), on the activity of alpha-motoneurons in decerebrate-spinal rats. The flexor reflex was facilitated by C-afferent conditioning inputs, shown by a decrease in mechanical threshold and increase in touch- and pinch-evoked responses. Systemic administration of SNC80 (10 micromol/kg) prevented and reversed the neuronal hyperactivity. We further examined the effect of this agonist on the hypersensitivity of the flexor reflex induced by intraplantar injection of Freund's adjuvant. SNC80 dose-dependently (1, 3, 5 and 10 micromol/kg) increased the mechanical threshold and decreased touch-, pinch- and Abeta-afferent inputs-evoked responses. Similar effects were seen with SNC86 (5 micromol/kg). Pretreatment with either naloxone (20 micromol/kg, i.p.) or (Cyclopropylmethyl)-6,7-dehydro-4,5alpha-epoxy-14beta-ethoxy-5beta-methylindolo [2',3':6',7']morphinan-3-ol hydrochloride (SH378; 5 micromol/kg, intraarterially (i.a.)), a novel selective delta-opioid receptor antagonist, completely abolished the anti-hypersensitivity effect of SNC80. The effect of SNC80 remained following intrathecal administration of mu-opioid receptor antagonist D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH(2) (CTOP; 1.5 nmol). These results indicate that systemic injection of SNC80 exerted antihypersensitivity in models of both acute and tonic nociception and these effects are mediated mainly through a spinal delta-opioid mechanism.

An integrated multi-media package for learning clinical phonetics and linguistics

Competence in the phonetic and linguistic analysis of normal and disordered spoken language is a basic requirement for all students and practitioners of speech and language therapy. This paper presents a learning package specifically designed for individuals who need to acquire or update practical skills and theoretical knowledge in clinical linguistic analysis. VISUAL-CLIP (VIdeo SUpported Active Learning in Clinical LInguistics and Phonetics) is a student-centred, interactive, multi-media tutorial in clinical linguistics and phonetics, based on digitised video- and audio-taped speech data from a child with a complex communication disorder. Data can be analysed from different perspectives and at different levels of difficulty using separate but inter-linked modules on phonetics, phonology, grammar, semantics and pragmatics. Case history information, formal assessment results, theoretical background and an annotated bibliography are also integrated into the CD-ROM based package.

Language and conversational abilities in Williams syndrome: how good is good?

Grammatical performance of individuals with Williams syndrome (WS) has been reported as being unimpaired, despite their comparatively low IQ and poor general cognitive ability. Specific language impairment (SLI) is often seen as the converse of WS, showing poor linguistic ability relative to level of cognitive functioning. Detailed profiles of language functioning in four children with WS and four with SLI are presented which show a much less clear-cut picture than is often portrayed and suggest that children with WS may be less linguistically able than is commonly reported. A comparison of results on standardised tests with performance in real conversations shows that not only the children with SLI but also those with WS have significant linguistic difficulties. This has clear implications for their management by speech and language therapists.

Temporary inactivation of the retrorubral fields decreases the rewarding effect of medial forebrain bundle stimulation

Prior studies indicate that lesioning the retrorubral fields (RRF) decreases the rewarding effect of medial forebrain bundle (MFB) stimulation, although these studies did not make the RRF their primary target. This study directly investigates the role of the RRF in MFB self-stimulation using transient lidocaine-induced inactivation of target tissue rather than permanent lesioning. In 18 rats with MFB stimulation electrodes, inactivation of the RRF via 0. 5 and 1.0 microl of 4% lidocaine produced immediate, substantial upward shifts in the frequency required to maintain half-maximal self-stimulation response rates whereas injecting comparable volumes of saline did not. Bilateral inactivation was particularly effective, especially at medium and high stimulation currents, although unilateral inactivation ipsilateral to the stimulation site was also effective. Contralateral inactivation alone did not substantially change the stimulation's reward value, although contralateral inactivation appeared to contribute to the effectiveness of bilateral inactivation. The frequency required to maintain half-maximal responding returned to baseline levels by 15-20 min after lidocaine infusion. In seven rats whose infusion sites were not in the RRF, lidocaine inactivation did not consistently degrade the stimulation's reward value. These results indicate that some neural elements located in the RRF contribute to the rewarding effect of MFB stimulation. Possible roles for these elements in the anatomical substrate for MFB self-stimulation are discussed.

Lesions and inactivation implicate dorsolateral hindbrain in MFB self-stimulation

Two experiments explored the role of the motor nucleus of the trigeminal nerve (Mo5) and surrounding area in the rewarding effects of medial forebrain bundle (MFB) stimulation. In the first, eight rats received serial bilateral lesions of the target region. The reward value of MFB stimulation was assessed at 200, 400, and 800 microA using the rate-frequency curve shift paradigm. In five rats, no lesions affecting the motor nucleus or its surrounding area affected the frequency required to maintain half-maximal response rate at any current. One rat with a relatively ventrally placed lesion showed substantial enhancement of stimulation reward value at two currents, while two rats with lesions affecting the area around the descending fibers of the superior cerebellar peduncle (scp) showed substantial increases in required frequency. In the second experiment, six rats received uni- and bilateral injections of lidocaine to temporarily inactivate the target area. Two rats with injections centered near the descending fibers of the scp showed substantial increases in required frequency, as great as 0.30 log(10) units. Two rats with injections slightly rostral to these showed little change in required frequency. Two rats with injections in the ventral cerebellum, just lateral to the fastigial nucleus, showed increases in required frequency, particularly following injections contralateral to the MFB stimulation site. These data are interpreted to imply a role for the area around the lateral pole of the scp, perhaps including axons arising from the cerebellum, in MFB stimulation reward.

Literature searching and document delivery: organisational issues

An overview of financial, staffing and administrative issues regarding online literature searching and document supply is given in this article. Online literature searching and the requesting of documents have been problematic in the past due to costs and lack of information technology. Electronic document delivery requires better Internet access but MIME compatible e-mail can be used. Institutional issues regarding requests include the question 'who should order?'--the end user or intermediary ordering by the institution, and the need for trained information professionals within medical institutions. Payment mechanisms can be by credit card, institutional subscription, institutional account with the supplying library or by voucher system. Organisational Document Supply Networks (LoansomeDoc) now exist that have set charges for certain services between members or different costs for different member types and with agreed payment mechanisms. An area of increasing importance for document delivery (due to international treaties) is copyright. If such legislation is not to adversely affect information access, professionals must be involved in the creation and amendment of such legislation. Finally, a list of references are given many of which include internet addresses.

Determination of the origin of charge heterogeneity in a murine monoclonal antibody

PURPOSE

The aim of this study was to elucidate the molecular basis of charge heterogeneity found in a purified monoclonal IgG1 antibody, MMA383.

METHODS

Cation exchange chromatography (CEX) and isoelectric focusing (IEF) were used to monitor charge heterogeneity. CEX in conjunction with carboxypeptidase B digests of the antibody was used to determine the contribution of C-terminal lysines to MMA383 charge heterogeneity. Potential chemical degradation sites were identified by peptide mapping of individual chains, with peptide identification by mass spectrometry (MALDI-TOF MS). Peptide sequencing was used to determine specific deamidation sites. Binding constants of predominant isoforms were compared by surface plasmon resonance (SPR).

RESULTS

Extensive charge heterogeneity of purified MMA383 was detected by CEX and IEF. Removal of C-terminal lysines simplified the IEF pattern to nine predominant isoforms. Quantitation of isoaspartate in each of the isoforms indicated deamidation of MMA383 as a major cause of charge heterogeneity. CEX of the individual isoform chains suggested the presence of one deamidation site on each of the heavy and light chains. The two sites of deamidation were identified using peptide mapping, sequencing and mass spectrometry. SPR results showed no significant difference in the binding parameters among the isoforms.

CONCLUSIONS

C-terminal lysine microheterogeneity and deamidation of Asn141 in the heavy chain and Asn161 in the light chain are the major causes of MMA383 charge heterogeneity. Identification of the two deamidation sites will allow replacement of these amino acids in order to create a product less susceptible to degradation.

Quality care in an era of retrenchment

SOURCE AND PURPOSE: Constraints in the healthcare delivery system are resulting in unprecedented challenges to quality nursing care. In response to concerns expressed by readers in a JSPN survey, we solicited input from prominent SPN members.

CONCLUSIONS

Quality care can be sustained through nurses' creativity, flexibility, leadership, and collaboration. The context for quality care is an organizational environment with attention to critical analysis, careful resource utilization, and improved outcomes.

PRACTICE IMPLICATIONS

Nurses can not only maintain premium standards of quality care but, by assuming leadership, help shape the future of health care.

Lesions of midline midbrain structures leave medial forebrain bundle self-stimulation intact

Previous work with psychophysically-based collision methods and pharmacological manipulation suggests a role in medial forebrain bundle (MFB) self-stimulation for neurons lying along the midline between the cerebral hemispheres, in the mid- and/or hindbrain. Also, recently-proposed models of the anatomical substrate for medial forebrain bundle stimulation reward suggest that at least part of the directly-activated axons of this substrate arise from mid- and/or hindbrain somata, bifurcate, and send bilateral projections to the MFB of each hemisphere. Branches of these axons are thought to cross the midline at some point near the ventral tegmental area. This study examines the effects on MFB stimulation reward of lesioning midbrain structures that lie along the midline between hemispheres. In 13 rats, lesions of the median raphe, the decussation of the superior cerebellar peduncle, or the interpeduncular nucleus were all ineffective in altering the stimulation frequency required to maintain half-maximal levels of operant responding for stimulation reward. These results are discussed in terms of implications for recent models of the anatomical substrate for brain stimulation reward.

Life-threatening pica: liver abscess from perforating foreign body

A case is presented of a patient with a psychiatric illness and pica who developed a pyogenic liver abscess due to perforation of the duodenum by a pen. This report emphasizes the importance of ultrasound and computed tomography in making a rapid diagnosis. The relative superiority of ultrasound was revealed because an anaesthetic was not required for scanning, and in addition to the liver abscess, the precise location of the perforating foreign body was demonstrated.

Induction of the antigen 85 complex of Mycobacterium tuberculosis in sputum: a determinant of outcome in pulmonary tuberculosis treatment

Sputum quantitative culture, acid-fast smear, days-to-positive by BACTEC, and Mycobacterium tuberculosis antigen 85 complex were monitored during therapy in 42 patients with pulmonary tuberculosis (TB). By BACTEC, 4 patients were persistently positive on days 90-180, and treatment ultimately failed in 2 of these. Antigen 85 expression increased in subjects in whom disease persisted (persisters) from days 0 to 14 when the difference between persisters and nonpersisters was statistically significant (P = .002). Only antigen 85 complex values at day 14 suggested TB persistence at or after day 90. All subjects with day 14 antigen 85 complex values < 60 pg/mL responded rapidly to treatment and were cured. Of those with values > 60 pg/mL, in 33% TB persisted at or after day 90 and treatment failed in 17%. Biologic factors expressed early in therapy, not related to compliance or resistance, may exert a substantial influence on outcome. The antigen 85 complex is critical in cell wall biosynthesis and is induced by isoniazid in vitro. Its induction may represent an adaptive transition to a persistent state during therapy.

Midbrain periaqueductal lesions do not degrade medial forebrain bundle stimulation reward

To investigate the possible role of the midbrain central grey and dorsal raphe in medial forebrain bundle (MFB) self-stimulation, 12 rats received monopolar stimulation electrodes in both the lateral hypothalamic and ventral tegmental MFB and an ipsilateral lesioning electrode in either the central grey or dorsal raphe. Baseline rate-frequency data were collected at several currents at each stimulation site until the frequency required to maintain half-maximal responding stabilized and then an electrolytic lesion was made by passing either 20 or 60 s of anodal constant current through the lesioning electrode. Post-lesion rate-frequency data indicated that lesions of the central grey and dorsal raphe had little appreciable effect on the rewarding nature of MFB stimulation. One rat's lesion damaged the median raphe and produced sustained downward shifts in required frequency, suggesting post-lesion enhancement of the stimulation's rewarding effect.

Lesions of pontomesencephalic cholinergic nuclei do not substantially disrupt the reward value of medial forebrain bundle stimulation

This study examines the effects of lesioning the pedunculopontine tegmentum (PPTg) and laterodorsal tegmentum (LDTg) on the reward effectiveness of medial forebrain bundle (MFB) stimulation. Although the focus is on the effects of unilateral lesions made ipsilateral to stimulation sites in the hypothalamic and ventral tegmental MFB, the effects of contralateral lesions of both targets are also investigated. Reward effectiveness was assessed using the rate-frequency curve shift paradigm. In nine rats with unilateral PPTg lesions and five rats with unilateral LDTg lesions, the frequency required to maintain half-maximal response rats was generally not changed by more than 0.1 log units relative to prelesion baseline mean. In three rats with contralateral PPTg lesions and four rats with contralateral LDTg lesions, required frequency was also not substantially changed. The results are interpreted in terms of a previously proposed hypothesis regarding the role in MFB self-stimulation of ascending cholinergic input from the pontomesencephalon to ventral tegmental dopaminergic neurons.

Are outcome data regarding the survivors of neonatal care available from routine sources?

AIM

To determine whether existing information and surveillance systems can be used to provide follow up data on groups of infants at increased risk of disability--for example, the survivors of neonatal intensive care.

METHODS

A survey was made of maternity, neonatal, and community child health information systems and surveillance programmes in the Trent Regional Health Authority. Children known to have received neonatal intensive care in Trent between 1 August 1992 and 31 July 1993, and a random sample of normal children in two health districts (data quality check) were included. A data linkage study was made to determine whether follow up information about a random sample of infants, known to be at increased risk of poor outcome, could be identified on community child health databases. Two widely accepted datasets (birth and 2 years) were used as standards for this exercise. The quality of data was audited.

RESULTS

All clinical items of the birth minimum dataset were routinely recorded by at least one agency in each health district in Trent. Of the descriptive items, only the mother's age on leaving full time education was not collected. At 2 years, all clinical items were collected as part of the routine surveillance programme, but data were recorded using a system which severely limited interpretation. Data quality, in terms of the number of errors introduced at data entry, was very good with only 1.1% of the check items (4/368) incorrectly recorded. Only two districts had organised electronic transfer of data between maternity, neonatal, and community child health systems. The mother's NHS number, although available, was not routinely recorded by any system. The NHS number of the infant was routinely collected by six out of 12 community paediatric services. Data linkage was attempted in six districts with appropriate community child health databases. Just over 70% of the intensive care sample was successfully linked with follow up information on child health systems.

CONCLUSIONS

The existing programmes for routine child surveillance could provide outcome data for high risk groups of infants, such as the survivors of neonatal intensive care. However, the present coding system used for data entry is inadequate. Furthermore, rates of identification, without the use of a unique identifier (NHS number) for each subject, are currently insufficient for monitoring health status in later life.