Contact with a component of the polymerase II holoenzyme suffices for gene activation

In yeast strains bearing the point mutation called GAL11P (for potentiator), certain GAL4 derivatives lacking any classical activating region work as strong activators. The P mutation confers upon GAL11, a component of the RNA polymerase II holoenzyme, the ability to interact with a portion of the dimerization region of GAL4. The region of GAL11 affected by the P mutation is evidently functionally inert in ordinary cells, suggesting that this mutation is of no functional significance beyond creating an artificial target for the GAL4 dimerization fragment. From these observations and further analyses of GAL11, we propose that a single activator-holoenzyme contact can trigger gene activation simply by recruiting the latter to DNA.

Predictive, pre-natal and diagnostic genetic testing for Huntington's disease: the experience in Canada from 1987 to 2000

Predictive and pre-natal testing for Huntington's Disease (HD) has been available since 1987. Initially this was offered by linkage analysis, which was surpassed by the advent of the direct mutation test for HD in 1993. Direct mutation analysis provided an accurate test that not only enhanced predictive and pre-natal testing, but also permitted the diagnostic testing of symptomatic individuals. The objective of this study was to investigate the uptake, utilization, and outcome of predictive, pre-natal and diagnostic testing in Canada from 1987 to April 1, 2000. A retrospective design was used; all Canadian medical genetics centres and their affiliated laboratories offering genetic testing for HD were invited to participate. A total of 15 of 22 centres (68.2%), currently offering or ever having offered genetic testing for HD, responded, providing data on test results, demographics, and clinical history. A total of 1061 predictive tests, 15 pre-natal tests, and 626 diagnostic tests were performed. The uptake for predictive testing was approximately 18% of the estimated at-risk Canadian population, ranging from 12.5% in the Maritimes to 20.7% in British Columbia. There appears to have been a decline in the rate of testing in recent years. Of the predictive tests, 45.0% of individuals were found to have an increased risk, and a preponderance of females (60.2%) sought testing. A greater proportion of those at < or = 25% risk sought predictive testing once direct CAG mutation analysis had become available (10.9% after mutation analysis vs 4.7% before mutation analysis, p = 0.0077). Very few pre-natal tests were requested. Of the 15 pre-natal tests, 12 had an increased risk, resulting in termination of pregnancy in all but one. Diagnostic testing identified 68.5% of individuals to be positive by mutation analysis, while 31.5% of those with HD-like symptoms were not found to have the HD mutation. The positive diagnostic tests included 24.5% of individuals with no known prior family history of HD.

Drug release characteristics of unimolecular polymeric micelles

Biodegradable, unimolecular polymeric micelles possess several features that are attractive for drug delivery applications: Thermodynamic stability, ability to encapsulate and solubilize a hydrophobic guest molecule, biodegradability, as well as size and surface characteristics that prevent rapid clearance by the RES. Here we investigate the potential of these unimolecular polymeric micelles to release a drug for an extended time. Lidocaine was used as a model drug for in vitro studies using a horizontal diffusion cell and cellulose membrane that prevented polymer transport from the source to the receiver compartment. The transport of free lidocaine from source to receiver under sink conditions was zero-order and complete within 8 h. The transport of lidocaine initially encapsulated in polymer was zero-order for the first 14 h, and 96% of the lidocaine was detected within 24 h.

Gene activation by recruitment of the RNA polymerase II holoenzyme

The single amino acid "P" (potentiator) mutation in the holoenzyme component GAL11 creates an interaction between that protein and the dimerization region of GAL4. That interaction triggers strong gene activation when the GAL4 fragment is tethered to DNA. Here we show that, among a series of variants of the GAL4 dimerization region and different GAL11P alleles, the strength of the interaction as quantitated in vitro correlates with the degree of activation in vivo; swapping the protein fragments bearing the GAL4 dimerization region and the GAL11P mutation such that the latter is tethered to DNA and the former is attached to the holoenzyme does not diminish gene activation; gene activation in this system is squelched by overproduction of either a fragment bearing the GAL4 dimerization region or a fragment of GAL11 bearing a P mutation; and neither GAL11 nor GAL11P is a target of an acidic activating region. These results argue that the GAL4-GAL11P interaction triggers gene activation simply by recruiting the holoenzyme to DNA. Consistent with this view, we also show that fusion of LexA to another holoenzyme component, SRB2, creates an activator, and that an SRB2 mutant predicted on genetic grounds to interact especially efficiently with a holoenzyme containing a specific mutant form of polymerase also activates more efficiently when tethered to DNA.

Poisoning from "Spanish fly" (cantharidin)

Cantharidin, known popularly as Spanish fly, has been used for millennia as a sexual stimulant. The chemical is derived from blister beetles and is notable for its vesicant properties. While most commonly available preparations of Spanish fly contain cantharidin in negligible amounts, if at all, the chemical is available illicitly in concentrations capable of causing severe toxicity. Symptoms of cantharidin poisoning include burning of the mouth, dysphagia, nausea, hematemesis, gross hematuria, and dysuria. Mucosal erosion and hemorrhage is seen in the upper gastrointestinal (GI) tract. Renal dysfunction is common and related to acute tubular necrosis and glomerular destruction. Priapism, seizures, and cardiac abnormalities are less commonly seen. We report four cases of cantharidin poisoning presenting to our emergency department with complaints of dysuria and dark urine. Three patients had abdominal pain, one had flank pain, and the one woman had vaginal bleeding. Three had hematuria and two had occult rectal bleeding. Low-grade disseminated intravascular coagulation, not previously associated with cantharidin poisoning, was noted in two patients. Management of cantharidin poisoning is supportive. Given the widespread availability of Spanish fly, its reputation as an aphrodisiac, and the fact that ingestion is frequently unwitting, cantharidin poisoning may be a more common cause of morbidity than is generally recognized. Cantharidin poisoning should be suspected in any patient presenting with unexplained hematuria or with GI hemorrhage associated with diffuse injury of the upper GI tract.

Mapping Antimicrobial Stewardship in Undergraduate Medical, Dental, Pharmacy, Nursing and Veterinary Education in the United Kingdom

Objectives

To investigate the teaching of antimicrobial stewardship (AS) in undergraduate healthcare educational degree programmes in the United Kingdom (UK).

Participants and Methods

Cross-sectional survey of undergraduate programmes in human and veterinary medicine, dentistry, pharmacy and nursing in the UK. The main outcome measures included prevalence of AS teaching; stewardship principles taught; estimated hours apportioned; mode of content delivery and teaching strategies; evaluation methodologies; and frequency of multidisciplinary learning.

Results

80% (112/140) of programmes responded adequately. The majority of programmes teach AS principles (88/109, 80.7%). ‘Adopting necessary infection prevention and control precautions’ was the most frequently taught principle (83/88, 94.3%), followed by 'timely collection of microbiological samples for microscopy, culture and sensitivity’ (73/88, 82.9%) and ‘minimisation of unnecessary antimicrobial prescribing’ (72/88, 81.8%). The ‘use of intravenous administration only to patients who are severely ill, or unable to tolerate oral treatment’ was reported in ~50% of courses. Only 32/88 (36.3%) programmes included all recommended principles.

Discussion

Antimicrobial stewardship principles are included in most undergraduate healthcare and veterinary degree programmes in the UK. However, future professionals responsible for using antimicrobials receive disparate education. Education may be boosted by standardisation and strengthening of less frequently discussed principles.

The effect of chronically elevated intraocular pressure on the rat optic nerve head extracellular matrix

The extracellular matrix of the optic nerve head is altered in both human glaucoma and in experimental primate models of this disease. However, the relationship of this change to glaucomatous optic nerve degeneration is unknown. This report describes similar matrix alterations in rats with unilateral elevated intraocular pressure. Brown Norway rats received episcleral vein injections of hypertonic saline to produce prolonged elevations of intraocular pressure. After up to 6 months of pressure elevation, optic nerve head sections from the rats were evaluated by light microscopic immunohistochemistry using antibodies to collagens I, III, IV and VI, laminin, elastin and chondroitin and dermatan sulfate proteoglycans. In experimental eyes with 11 days or more of pressure elevation, depositions of collagen IV, collagen VI and laminin were found within regions of the optic nerve head that, in normal eyes, are occupied solely by nerve bundles. Collagen I and III deposition appeared to be more dependent on the level and duration of the pressure rise. Eyes with lower mean intraocular pressures showed deposits of interstitial collagens primarily at the level of the sclera, while eyes with higher mean pressure elevations had depositions in the neck regions as well. Chondroitin and dermatan sulfate proteoglycans were deposited in a pattern similar to that of collagen I. No extracellular matrix deposition was seen in the orbital optic nerve in any experimental eye. These extracellular matrix changes in rats replicate previous findings in human glaucomatous eyes and monkey eyes with experimentally elevated pressures. They also suggest a sequence of extracellular matrix protein deposition in response to pressure elevation. The optic nerve head deposition of matrix materials in response to elevated intraocular pressures may affect the susceptibility of remaining axons to pressure by changing the physical properties of their support tissues, by affecting the support functions of astrocytes and by changing the microenvironment of injured axons. This model may be useful for studying these and other aspects of the process of axonal injury resulting from elevated intraocular pressure.

A cross-sectional observational study of unmet health needs among homeless and vulnerably housed adults in three Canadian cities

Background

Homeless persons experience a high burden of health problems; yet, they face significant barriers in accessing health care. Less is known about unmet needs for care among vulnerably housed persons who live in poor-quality or temporary housing and are at high risk of becoming homeless. The objectives of this study were to examine the prevalence of and factors associated with unmet needs for health care in a population-based sample of homeless and vulnerably housed adults in three major cities within a universal health insurance system.

Methods

Participants were recruited at shelters, meal programs, community health centers, drop-in centers, rooming houses, and single room occupancy hotels in Vancouver, Toronto, and Ottawa, Canada, throughout 2009. Baseline interviews elicited demographic characteristics, health status, and barriers to health care. Logistic regression was used to identify factors associated with self-reported unmet needs for health care in the past 12 months.

Results

Of the 1,181 participants included in the analysis, 445 (37%) reported unmet needs. In adjusted analyses, factors associated with a greater odds of reporting unmet needs were having employment in the past 12 months (AOR = 1.40, 95% CI = 1.03–1.91) and having ≥3 chronic health conditions (AOR = 2.17, 95% CI = 1.24–3.79). Having higher health-related quality of life (AOR = 0.21, 95% CI = 0.09–0.53), improved mental (AOR = 0.97, 95% CI = 0.96–0.98) or physical health (AOR = 0.98, 95% CI = 0.96–0.99), and having a primary care provider (AOR = 0.63, 95% CI = 0.46–0.85) decreased the odds of reporting unmet needs.

Conclusions

Homeless and vulnerably housed adults have a similar likelihood of experiencing unmet health care needs. Strategies to improve access to primary care and reduce barriers to accessing care in these populations are needed.

Aging, frailty and complex networks

When people age their mortality rate increases exponentially, following Gompertz's law. Even so, individuals do not die from old age. Instead, they accumulate age-related illnesses and conditions and so become increasingly vulnerable to death from various external and internal stressors. As a measure of such vulnerability, frailty can be quantified using the frailty index (FI). Larger values of the FI are strongly associated with mortality and other adverse health outcomes. This association, and the insensitivity of the FI to the particular health variables that are included in its construction, makes it a powerful, convenient, and increasingly popular integrative health measure. Still, little is known about why the FI works so well. Our group has recently developed a theoretical network model of health deficits to better understand how changes in health are captured by the FI. In our model, health-related variables are represented by the nodes of a complex network. The network has a scale-free shape or "topology": a few nodes have many connections with other nodes, whereas most nodes have few connections. These nodes can be in two states, either damaged or undamaged. Transitions between damaged and non-damaged states are governed by the stochastic environment of individual nodes. Changes in the degree of damage of connected nodes change the local environment and make further damage more likely. Our model shows how age-dependent acceleration of the FI and of mortality emerges, even without specifying an age-damage relationship or any other time-dependent parameter. We have also used our model to assess how informative individual deficits are with respect to mortality. We find that the information is larger for nodes that are well connected than for nodes that are not. The model supports the idea that aging occurs as an emergent phenomenon, and not as a result of age-specific programming. Instead, aging reflects how damage propagates through a complex network of interconnected elements.

The increasing role of pharmacists in antimicrobial stewardship in English hospitals

OBJECTIVES

To evaluate the development of pharmacist-led antimicrobial stewardship activities in English hospitals.

METHODS

Distribution of an electronic questionnaire to antimicrobial pharmacists or chief pharmacists in National Health Service hospitals in England.

RESULTS

Since a previous study, in 2005, overall numbers of specialist antimicrobial pharmacists, and their levels of experience, had increased. Over 95% of hospitals provided empirical usage guidance, antimicrobial formularies and surgical prophylaxis guidelines. Two-thirds of pharmacy departments provided antimicrobial usage reports in terms of defined daily doses at least yearly, and over 80% conducted yearly antimicrobial point prevalence studies. The vast majority of pharmacy departments indicated a willingness to supply data and audit results to a national database for benchmarking purposes.

CONCLUSIONS

The increasing role of specialist pharmacists and general pharmacists in antibiotic stewardship in acute care in England has enabled hospitals to deliver on the antibiotic stewardship agenda, although opportunity remains to expand this role further and ensure greater multidisciplinary engagement.

Structure and composition of the rodent lamina cribrosa

To define the architecture and extracellular matrix composition of the lamina cribrosa in rodents, normal, adult pigmented rat and guinea pig eyes were frozen and sectioned for light microscopic immunohistochemistry. Antibodies specific for collagens I, III, IV and VI, laminin, elastin, and chondroitin and dermatan sulfate proteoglycans were exposed to longitudinal and cross-sections of optic nerve heads and their binding distributions observed with the avidin-biotin-peroxidase complex technique. Cross-sections of the intraocular portion of the rat optic nerve head revealed a horizontally oval shape with distinct, vertically oriented, laminar beams. The guinea pig optic nervehead cross-section was circular, with randomly oriented beams. In both animals, collagens I, III and VI were found throughout the laminar beams, along with elastin fibrils. Collagen IV and laminin antibodies deposited along laminar beam margins and within the beams, representing astrocytic and vascular endothelial cell basement membranes. Both animals showed evidence for dermatan and chondroitin sulfate-containing proteoglycans in all connective tissue structures of the nerve head. In the rat, chondroitin-4 sulfate proteoglycans appeared localized to the sclera and laminar beams. The rat and the guinea pig optic nerve head possess an identifiable lamina cribrosa with structural proteins nearly identical to that of the primate. Both animals may provide affordable alternative animal models for in vivo studies on the role of the lamina cribrosa in glaucomatous optic nerve damage.

Growth and development of infants with end-stage renal disease receiving long-term peritoneal dialysis

The growth and development of four infants with end-stage renal disease receiving long-term peritoneal dialysis was studied during the first year of life. In each patient, dialysis was begun before 4 weeks of age. A nutritional regimen was designed to attain a daily weight gain appropriate for height age while minimizing the blood urea nitrogen level. A neurodevelopmental evaluation of gross and fine motor, cognitive, language, and psychosocial skills was performed at least every 3 months. At age 1 year, the mean height standard deviation score (SDS) was -1.33 +/- 0.2. Weight for height was greater than 95th percentile in one patient and normal in three. Mean caloric and protein intake were 105 +/- 20 kcal/kg/d (11.4 +/- 2.7 kcal/cm/d) and 2.7 g/kg/d (0.30 +/- 0.11 g/cm/d), respectively. Mean blood urea nitrogen was 53.6 +/- 17.8 mg/dL. Developmentally, three of the patients were functioning in the normal range and one was mildly retarded. However, gross motor skills were delayed in all patients. Although infants with end-stage renal disease are usually severely growth retarded and developmentally delayed, our observations suggest that early nutritional intervention and dialysis can yield improved results.

A negative SimpliRED D-dimer assay result does not exclude the diagnosis of deep vein thrombosis or pulmonary embolus in emergency department patients

STUDY OBJECTIVE

To determine whether a negative SimpliRED D-dimer assay result excludes the diagnosis of deep vein thrombosis (DVT) or pulmonary embolus (PE) in emergency department patients.

METHODS

This prospective, institutional review board-approved, clinical trial enrolled consecutive adult ED patients with the suspected diagnosis of venous thromboembolism (VTE) (DVT or PE). Initial ED evaluation included the SimpliRED D-dimer assay (American Diagnostica Inc, Greenwich, CT). Physicians were blinded to assay results. The diagnosis of DVT was made with positive findings on lower-extremity ultrasonography. PE was confirmed by a high-probability ventilation/perfusion (V/Q) scan, a positive pulmonary angiogram, or a positive finding on lower-extremity ultrasonography. A presumptive diagnosis of VTE was made in patients who had VTE at follow-up or unexplained death during the study period.

RESULTS

One hundred ninety-eight patients were enrolled during the study period. Twenty-five patients were excluded from data analysis; 9 had no diagnostic testing and 16 were lost to follow-up. Of the 173 patients analyzed, 57 (33%) had VTE-16 of 48 evaluated for DVT and 41 of 125 for suspected PE. The SimpliRED assay had a sensitivity of 65% and a negative predictive value of 81% for detection of VTE. In patients evaluated for DVT alone, the sensitivity was 56% and the negative predictive value was 77%. For patients with suspected PE, the sensitivity and negative predictive value were 68% and 83%, respectively.

CONCLUSION

In contrast to earlier reports on the SimpliRED D-dimer assay, a negative result failed to exclude the diagnosis of VTE in our ED population.

Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine

Emergency physicians work in a fast-paced environment that is characterized by frequent interruptions and the expectation that they will perform multiple tasks efficiently and without error while maintaining oversight of the entire emergency department. However, there is a lack of definition and understanding of the behaviors that constitute effective task switching and multitasking, as well as how to improve these skills. This article reviews the literature on task switching and multitasking in a variety of disciplines-including cognitive science, human factors engineering, business, and medicine-to define and describe the successful performance of task switching and multitasking in emergency medicine. Multitasking, defined as the performance of two tasks simultaneously, is not possible except when behaviors become completely automatic; instead, physicians rapidly switch between small tasks. This task switching causes disruption in the primary task and may contribute to error. A framework is described to enhance the understanding and practice of these behaviors.

Mapping of a new SGBS locus to chromosome Xp22 in a family with a severe form of Simpson-Golabi-Behmel syndrome

Simpson-Golabi-Behmel syndrome (SGBS) is an X-linked overgrowth syndrome with associated visceral and skeletal abnormalities. Alterations in the glypican-3 gene (GPC3), which is located on Xq26, have been implicated in the etiology of relatively milder cases of this disorder. Not all individuals with SGBS have demonstrated disruptions of the GPC3 locus, which raises the possibility that other loci on the X chromosome could be responsible for some cases of this syndrome. We have previously described a large family with a severe form of SGBS that is characterized by multiple anomalies, hydrops fetalis, and death within the first 8 wk of life. Using 25 simple tandem-repeat polymorphism markers spanning the X chromosome, we have localized the gene for this disorder to an approximately 6-Mb region of Xp22, with a maximum LOD score of 3.31 and with LOD scores <-2.0 for all of Xq. These results demonstrate that neither the GPC3 gene nor other genes on Xq26 are responsible for all cases of SGBS and that a second SGBS locus resides on Xp22.

Substance use and access to health care and addiction treatment among homeless and vulnerably housed persons in three Canadian cities

Introduction

We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study.

Methods

In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10≥6), problematic alcohol use (AUDIT≥20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment.

Results

Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43–2.64) and unmet mental (AOR 3.06; 95% CI 2.17–4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18–4.54).

Conclusions

Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care.

Specificity of cyclin E-Cdk2, TFIIB, and E1A interactions with a common domain of the p300 coactivator

The p300 and CREB binding protein (CBP) transcriptional coactivators interact with a variety of transcription factors and regulate their activity. Among the interactions that have been described, the COOH-terminal region of p300 binds to cyclin E-cyclin-dependent kinase 2 (cyclin E-Cdk2) and TFIIB, as well as to the E1A gene products of adenovirus. Inhibition of Cdk activity by Cdk inhibitors, such as p21 or p27, potentiates NF-kappaB activity and provides a mechanism to coordinate cell cycle progression with the transcription of genes expressed during growth arrest. In this report, we analyze the specific domains of p300 required for the binding of p300 to cyclin E-Cdk2, TFIIB, and E1A and the ability of these proteins to interact with p300, alone or in combination. 12S E1A, an inhibitor of p300-dependent transcription, reduces the binding of TFIIB, but not that of cyclin E-Cdk2, to p300. In contrast, 13S E1A, a pleiotropic transcriptional activator, does not inhibit TFIIB binding to p300, although it enhances the interaction of cyclin E-Cdk2 with p300. Modification of cyclin E-Cdk2 is most likely required for association with p300 since the interaction is observed only with cyclin E-Cdk2 purified from mammalian cells. Domain swap studies show that the cyclin homology domain of TFIIB is involved in interactions with p300, although the homologous region from cyclin E does not mediate this interaction. These findings suggest that p300 or CBP function is regulated by interactions of various proteins with a common coactivator domain.

Blood lead levels in emergency department patients with retained lead bullets and shrapnel

OBJECTIVE

To determine whether patients with retained lead shrapnel who present to the ED have elevated whole blood lead levels (BLLs) compared with matched control patients.

METHODS

Test subjects were patients with x-ray evidence of retained lead shrapnel who presented to any of three urban EDs, and consented to inclusion in the study. BLLs were obtained from 15 ED patients, and data regarding time since injury and symptoms of plumbism were collected. Control subjects consisted of 15 ED patients, without similar lead exposure, matched for age, sex, race, and place of dwelling as determined by zip code, who also presented to any of the same three EDs.

RESULTS

The mean (+/-SD) BLL in the test subjects was 17+/-9.78 microg/dL (range 7-50 microg/dL). Time since impalement ranged from 1 to 45 years. The mean BLL in the control subjects was 7+/-3.77 microg/dL (0-16 microg/dL). This difference was statistically significant (two-tailed t-test p = 0.002).

CONCLUSIONS

In this preliminary study, the patients with retained lead shrapnel who presented to the ED had significantly elevated BLLs, compared with the matched control subjects. Chronic plumbism may be considered in patients with retained lead shrapnel, and a history should be taken to assess the presence of symptoms referable to plumbism. These patients may require long-term follow-up to assess the development of elevated blood lead level and lead toxicity.

Interprofessional communication in the emergency department: residents' perceptions and implications for medical education

OBJECTIVES

Objectives of the current study were to: i) assess residents' perceptions of barriers and enablers of interprofessional (IP) communication based on experiences and observations in their clinical work environments, ii) investigate how residents were trained to work in IP collaborative practice, iii) collect residents' recommendations for training in IP communication to address current needs.

METHODS

Focus group study including fourteen Emergency Medicine (EM) residents, who participated in four focus groups, facilitated by an independent moderator. Focus group interviews were audiotaped, transcribed verbatim, independently reviewed by the authors, and coded for emerging themes.

RESULTS

Four themes of barriers and enablers to IP communication were identified: i) the clinical environment (high acuity; rapidly changing health care teams, work overload, electronic communications), ii) interpersonal relationships (hierarchy, (un)familiarity, mutual respect, feeling part of the team), iii) personal factors (fear, self-confidence, uncontrolled personal emotions, conflict management skills), and iv) training (or lack thereof). Residents indicated that IP communication was learned primarily through trial and error and observing other professionals but expressed a preference for formal training in IP communication.

CONCLUSIONS

Based on this pilot study, barriers to effective IP communication in the ED were inherent in the system and could be exacerbated by relational dynamics and a lack of formal training. Opportunities for both curricular interventions and systems changes were identified and are presented.

Women's perceptions about treatment decision making for ovarian cancer

OBJECTIVES

To identify in women with advanced epithelial ovarian cancer who had just undergone surgery the extent to which they (1) perceived that they had treatment options, (2) understood the treatment related risks and benefits, and (3) preferred to participate in the treatment decision-making process.

METHODS

This qualitative study included women who underwent initial surgery for stage 3 or 4 ovarian cancer and who had received less than two cycles of chemotherapy. In depth semistructured interviews were conducted with 21 patients between June 1999 and February 2001. The interviews were content analyzed according to the themes that arose in the interview.

RESULTS

Five themes were identified. (1) Knowledge of treatment benefits and risks. Women understood that the treatment had both survival and quality of life benefits. Women could clearly articulate the risks of chemotherapy. (2) Readiness to make a decision. When making treatment decisions, women described being overwhelmed by the effects of concurrent drugs like analgesics, the severity of the illness, unexpected diagnosis of cancer and grief, and feeling pressured into a decision. (3) Perception of a treatment choice. Most women felt that they made their treatment decision; however, most women did not perceive that they had a treatment choice. Thus, treatment decision making is really a process of coming to terms with the disease and the recommended treatment. (4) Physician-patient relationship. All women suggest that their doctor knew the right treatment for them and they felt confident in their cancer physician. (5) Social supports. Women described supports through decision-making processes that included individuals who advocated for them, faith, and past experience with the cancer system. Hindrances to decision making included people who were negative, the cancer label, and employers.

CONCLUSIONS

Women with advanced epithelial ovarian cancer did not describe the treatment decision-making process as shared; rather they described an interaction that was directed largely by the physician. These women attribute this form of decision-making to their advanced age, severity of illness, immediate ramification of treatment choices, and lack of advocacy for a different model of interaction. Thus, the onus is on the physician to ensure that there is an environment for shared decision-making in the event that the patient is interested in such an interaction.

A redintegration account of the effects of speech rate, lexicality, and word frequency in immediate serial recall

Short-term serial recall performance is strongly affected by the nature of the items to be remembered. For example, memory span declines with decreasing speech rate (i.e., increasing pronunciation duration) of the items and, for a given speech rate, memory for non-words is poorer than for words. Similarly, words of high natural language frequency are recalled better than low-frequency words. Existing descriptive models have identified redintegration as underlying many of those effects. Redintegration refers to the process by which partially retrieved memorial information is converted into an overt response. This article presents a process model of redintegration based on a non-linear dynamic network, which is shown to handle the effects of speech rate, lexicality, and word frequency on memory span. Unlike previous descriptive efforts, the redintegration model also predicts the shape of the underlying serial position curves.

The relationship between maternal periodontitis, adverse pregnancy outcome and miscarriage in never smokers

BACKGROUND

It has been postulated that associations between periodontal disease and systemic conditions may be because of the confounding effects of smoking. In addition, studies of this type rarely investigate the adverse pregnancy outcome of miscarriage.

AIM

The aim of this prospective study was to investigate a relationship between periodontal disease in pregnancy and subsequent adverse pregnancy outcomes in a population of never smokers.

MATERIALS AND METHODS

Pregnant women were recruited at 12 weeks gestation. Demographic, behavioural and medical data were collected. A periodontal examination was performed and data on each subjects' pregnancy outcome were collected.

RESULTS

A total of 1793 women reported never previously smoking. Of these, 7.3% had a pre-term birth and 0.9% a late miscarriage. As expected in this population, we found no associations between poorer periodontal health and either pre-term birth or low birth weight (LBW). In contrast, the subjects who experienced a late miscarriage had a higher mean probing depth at mesial sites compared with the subjects that gave birth at term (2.69 mm versus 2.41 mm, p=0.006).

CONCLUSIONS

There was an association between some measures of periodontal disease and late miscarriage; however, there was no association between periodontitis and pre-term birth or LBW in this population.

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada

OBJECTIVE

Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study.

METHODS

In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months.

RESULTS

Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders.

CONCLUSIONS

Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

Detection of submicroscopic aberrations in patients with unexplained mental retardation by fluorescence in situ hybridization using multiple subtelomeric probes

PURPOSE

To further assess the frequency of subtelomeric aberrations in a selected population and to examine the feasibility of a clinical testing.

METHODS

Patients were selected based on the following criteria: (1) mental retardation (IQ < 70) or developmental delay with dysmorphic features; (2) a normal karyotype at the level of resolution of 450 to 500 bands; and (3) exclusion of other possible etiologies by a full genetic assessment and relevant tests. Fluorescence in situ hybridization (FISH) was performed using multiple subtelomeric probes. Abnormal findings were confirmed by 24-color spectral karyotyping or FISH with a specific subtelomeric probe, and family studies were carried out to determine inheritance.

RESULTS

Clinically significant aberrations were detected in 6 of 150 proband patients (4%), while deletion of the 2q subtelomeric region appeared to be a common variant (6%).

CONCLUSIONS

FISH with multiple subtelomeric probes is a valuable clinical test for establishing a definitive diagnosis for patients with unexplained mental retardation/developmental disorders.