Risk communication in the hyperacute setting of stroke thrombolysis: an interview study of clinicians.

OBJECTIVE: Communicating treatment risks and benefits to patients and their carers is central to clinical practice in modern healthcare. We investigated the challenges of risk communication by clinicians offering thrombolytic therapy for hyperacute stroke where treatment must be administered rapidly to maximise benefit. METHOD: Semistructured interviews with 13 clinicians from three acute stroke units involved in decision making and/or information provision about thrombolysis. We report on clinicians' accounts of communicating risks and benefits to patients and carers. Framework analysis was employed. RESULTS: We identified the major challenges facing clinicians in communicating risk in this context that is, disease complexity, patients' capacity and time constraints, and communicating quality of life after stroke. We found significant variation in the data on risks and benefits that clinicians provide, and ways these were communicated to patients. Clinicians' communication strategies varied and included practices such as: a phased approach to communicating information, being responsive to the patient and family and documenting information they gave to patients. CONCLUSIONS: Risk communication about thrombolysis involves complex uncertainties. We elucidate the challenges of effective risk communication in a hyperacute setting and identify the issues regarding variation in risk communication and the use of less effective formats for the communication of numerical risks and benefits. The paper identifies good practice, such as the phased transfer of information over the care pathway, and ways in which clinicians might be supported to overcome challenges. This includes standardised risk and benefit information alongside appropriate personalisation of risk communication. Effective risk communication in emergency settings requires presentation of high-quality data which is amenable to tailoring to individual patients' circumstances. It necessitates clinical skills development supported by personalised risk communication tools.

The development of a designated dental pathway for looked after children.

OBJECTIVE: To explore the impact of a community-based dental care pathway on the dental care of children entering residential or foster care. DESIGN: The study used qualitative data collected during interviews with children who used the service, their carers and key professionals involved in the pathway, and routine quantitative data concerned with care entry and the dental service use. RESULTS: The dental pathway facilitated dental care access for children entering statutory care, met the dental needs of service users even when dental care provision proved challenging, and offered a consistent dental service regardless of care moves. Improved interagency integration and support was reported by key professionals as was better dissemination and documentation of dental assessments and outcomes. CONCLUSION: The dental care pathway had a beneficial impact on the dental access and experiences of children who used it, promoted better interagency working and facilitated record keeping. These findings call for extension of the service to a wider population to allow further evaluation of its impact and efficacy in different regional areas and contexts.

Glucocorticoid-induced osteopenia in the mouse as assessed by histomorphometry, microcomputed tomography, and biochemical markers.

Glucocorticoids are potent anti-inflammatory molecules used in the treatment of asthma, rheumatoid arthritis, inflammatory bowel disease, and other inflammatory and dermatological diseases, as well as in posttransplantation immunotherapy. Although glucocorticoids have been prescribed for many years, their potential side effects, when administered orally, can prevent their long-term use. The most serious side effect observed in the clinic is glucocorticoid-induced osteoporosis (GIOP). To develop a small animal model to characterize glucocorticoid-induced bone loss, we carried out a series of experiments using BALB/c mice given daily intraperitoneal doses of the synthetic glucocorticoid, dexamethasone. Following dexamethasone treatment, the mice became osteopenic, with highly significant decreases in bone formation rate and mineral apposition rate, as assessed by standard histomorphometry. Moreover, 3 week treatment with dexamethasone resulted in a decrease in trabecular thickness and trabecular number with an increase in surface-to-volume ratio of trabeculae in the distal femur, as measured using microcomputed tomography (micro-CT). The serum bone formation marker, osteocalcin, was dose-dependently decreased in all mice treated with dexamethasone and showed a parallel extent of regulation to the bone formation rate changes. In addition, serum levels of leptin, recently identified as playing a role in the regulation of bone mass, increased following dexamethasone treatment. BALB/c mice therefore represent a useful model system in which the detrimental effects of glucocorticoids on bone can be studied.

The antimicrobial properties of melanocytes, melanosomes and melanin and the evolution of black skin.

A biological issue that has not been satisfactorily resolved is the role of melanin in skin and other animal tissues. A hypothesis is outlined here to account for the evolution of black skin and the ubiquity of melanin in vertebrate tissues. Evidence is presented that melanization of skin and other tissues forms an important component of the innate immune defense system. A major function of melanocytes, melanosomes and melanin in skin is to inhibit the proliferation of bacterial, fungal and other parasitic infections of the dermis and epidermis. This function can potentially explain (a) the latitudinal gradient in melanization of human skin; (b) the fact that melanocyte and melanization patterns among different parts of the vertebrate body do not reflect exposure to radiation; (c) provide a theoretical framework for recent empirical findings concerning the antimicrobial activity of melanocytes and melanosomes and their regulation by known mediators of inflammatory responses.

Chemoradiation for inoperable non small cell lung cancer: a phase II study using a regimen with acceptable toxicity.

Over the past few years there have been numerous schedules of combined modality therapy proposed as being useful in the management of inoperable non-small cell lung cancer (NSCLC). These have generally involved the use of high dose radiation therapy to doses of the order of 60 Gy combined with chemotherapy given prior to or concurrently with the radiation. Concurrent chemotherapy has been given with the intention of being both active in NSCLC and with the role of being a possible radiosensitiser. The most commonly employed drugs have been cisplatin, etoposide, 5-fluorouracil, vindesine and mitomycin. Although response rates of the primary tumour to the combined therapy have been optimistic, there has not been a great survival benefit with the median survival in most series remaining at just over 12 months. In this study we have prospectively treated a group of patients with non-metastatic inoperable NSCLC with a regimen of known acceptable toxicity. These patients were inoperable because they were unfit for surgery or had locally advanced disease. The local radiological response rate was 86% and the median survival for the whole group was 13 months. Adenocarcinomas appeared to do significantly worse than squamous cell carcinomas. Toxicity was acceptable and lower than reported in other similar series. There was one treatment related death. We feel that this combination of radiation therapy and chemotherapy is a reasonable compromise for a disease which still has a very poor outlook.

A gloverin-like antibacterial protein is synthesized in Helicoverpa armigera following bacterial challenge.

A bacteria inducible antibacterial protein, P2, was isolated from the old world bollworm Helicoverpa armigera. Fifth-instar larvae were injected with live Escherichia coli NCTC 8196. P2 was isolated by HPLC using reversed-phase and size-exclusion columns. In addition, P2 was isolated by an alternative method of sequential cation-exchange and reversed-phase HPLC. The structure of P2 was determined by N-terminal Edman degradation and mass spectrometry. P2 had similar mass (14.1 kDa) structure and activity to gloverin, an inducible glycine-rich antibacterial protein isolated from Hyalophora gloveri [Axén, A.; Carlsson, A.; Engström, A.; Bennich, H. Eur. J. Biochem. 247:614-619; 1997]. At the N-terminus P2 had approximately 60% identity with gloverin. P2 is basic, heat stable, and displayed rapid antibacterial action. P2 was active against the Gram-negative bacteria tested and was inactive against the Gram-positive bacteria, Candida albicans, a bovine turbinate cell line, and pestivirus.

Isolation from an ant Myrmecia gulosa of two inducible O-glycosylated proline-rich antibacterial peptides.

Reported here is the isolation and characterization of two antibacterial peptides synthesized in an ant Myrmecia gulosa in response to bacterial challenge. The peptides were purified by reversed-phase high performance liquid chromatography and characterized by peptide sequencing and mass spectrometry. Both peptides were formed from 16 amino acids, were rich in proline ( approximately 30%), and had N-acetylgalactosamine O-linked to a conserved threonine. The activity of a synthetic non-glycosylated isoform was markedly reduced demonstrating that glycosylation was necessary for maximum activity. The peptides were active only against growing Escherichia coli. They were inactive against stationary cells, Gram-positive bacteria, the yeast Candida albicans, two species of mammalian cells, and bovine pestivirus.

Radioimmunotherapy of colorectal carcinoma xenografts in nude mice with yttrium-90 A33 IgG and Tri-Fab (TFM).

The monoclonal antibody A33 recognises a tumour-associated antigen on human colorectal carcinoma, and has undergone preliminary evaluation in the clinic where selective localisation to hepatic metastases has been demonstrated [Welt et al. (1994) J. Clin. Oncol. 12, 1561-1571]. A33 and an A33 tri-fab fragment (TFM) were labelled with 90Y via a stable macrocyclic ligand for biodistribution and therapy studies in nude mice bearing SW1222 colon carcinoma xenografts. Biodistribution studies demonstrated tumour localisation for both A33 IgG and TFM with low bone, liver and kidney levels. Clearance of TFM from the blood was much faster than IgG and this led to lower tumour accumulation for TFM but superior tumour-blood ratios. The maximum per cent injected dose per g localised to tumour was 35.9% +/- 5.3% for A33 IgG and 12.9% +/- 4.6% for A33 TFM with tumour-blood ratios at 48 h after administration of 5.6 +/- 1.8 and 29.2 +/- 9.8 respectively. Autoradiography studies with 125I-labelled A33 IgG and TFM demonstrated a homogeneous distribution within tumour tissue which was not observed with other anti-colorectal tumour antibodies. TFM penetrated into the tumour tissue more rapidly than IgG. In therapy studies, a single dose of 90Y-A33 IgG (250 microCi per mouse) or 90Y-A33 TFM (300 microCi per mouse) led to complete regression of 2-week-old tumour xenografts with long-term tumour-free survivors. A transient drop in white blood cell count was observed with both IgG and TFM but was significantly more pronounced with IgG. The cell count fell to 8.4% of control for IgG, whereas with TFM cell counts fell to 51% of control before recovery. These results indicate that the more rapid blood clearance of 90Y-TFM confers reduced toxicity compared with 90Y-IgG although similar therapeutic effects are achieved. When the dose of 90Y-IgG was adjusted to give the same dose to tumour achieved with 300 microCi 90Y-TFM, a lesser therapeutic effect was observed. This may be owing to more rapid tumour penetration achieved with TFM. Both A33 IgG and TFM demonstrated potent anti-tumour effects against human tumour xenografts in this mouse model system. The stability of these 90Y-labelled conjugates and their effective tumour penetration are promising for the development of humanised reagents for clinical studies.

Antimicrobial mode of action of secretions from the metapleural gland of Myrmecia gulosa (Australian bull ant).

Secretions from exocrine metapleural glands of Myrmecia gulosa (Australian bull ant) exhibit broad-spectrum antimicrobial activity. Treatment of the yeast Candida albicans with metapleural secretion resulted in the rapid and total leakage of K+ ions from cells within 10 min. Ultrastructural analysis of the bacteria Bacillus cereus, Escherichia coli, and Pseudomonas aeruginosa, and cells and protoplasts of Candida albicans demonstrated gross damage of the cell membrane and aggregation of the cytoplasmic matrix of treated cells. Degradation of membrane-bound organelles was also observed in Candida albicans. The antimicrobially active components of metapleural secretions were nonpolar and interacted with the phospholipid bilayer, causing damage to the structural integrity of liposomes and the release of carboxyfluorescein. The data suggest that the antimicrobial agents in metapleural secretion act primarily by disrupting the structure and function of the phospholipid bilayer of the cytoplasmic membrane.

Immunodominant antigens of zoospores from ovine isolates of Dermatophilus congolensis.

Zoospores of Dermatophilus congolensis were analysed by SDS-PAGE and western blotting. The electrophoretic profiles of zoospores from 13 isolates of D. congolensis were similar but not identical when stained with Coomassie blue or silver. Immunodominant polypeptides with apparent molecular masses of 76 and 31 kDa were identified in western blots of 13 of 13 and 12 of 13 isolates respectively of D. congolensis reacted with hyperimmune, ovine, antizoospore sera. Identical immunodominant polypeptides were observed in western blots reacted with sera obtained from naturally infected sheep. Initial characterisation of the 76 and 31 kDa polypeptides indicated that they were probably surface exposed because (i) antibodies eluted from the surface of live zoospores after adsorption of hyperimmune antizoospore serum, reacted principally against the 76 and 31 kDa subunit polypeptides in western blots, (ii) adsorption of hyperimmune antizoospore serum with live zoospores resulted in significant diminution of reactivity against both the 76 and 31 kDa polypeptides in western blots, (iii) indirect fluorescent immunostaining of zoospores with antiserum prepared against gel-purified 76 kDa polypeptide, resulted in intense staining of the zoospore outer coat. Immuno-gold electron microscopy of negatively stained zoospores with antiserum prepared against gel-purified 31 kDa polypeptide identified this antigen as a flagella subunit.

Prostatic cancer with bone metastases: serum alkaline phosphatase (SAP) as a predictor of response and the significance of the SAP "flare".

The predictive value of serum alkaline phosphatase (SAP) and of prostatic acid phosphatase (PAP) for response to treatment (NPCP criteria) was retrospectively assessed in patients with bone metastases from prostate cancer. Fifty-one patients had SAP measured at the start of treatment and at 1 and 2 months. In 31 of these, corresponding PAP levels were also available at each time point. SAP/PAP profiles at 2 months were classified as "increased" (increment 15% or greater), "decreased" (reduction greater than 15%) or "stable", compared with baseline levels. An additional category, SAP "flare", was also identified (SAP increment greater than 15% at 1 month, with subsequent fall at 2 months). There was a strong association between the SAP profile at 2 months and the response category, whereas the PAP profile at 2 months was more weakly associated. Using results from the 31 patients with both SAP and PAP profiles, the level of SAP was significantly better in predicting the category of response (SAP: sensitivity 94%, specificity 79%; PAP: sensitivity 53%, specificity 57%). An SAP "flare" was associated with response in 8 of 12 patients. An increase in SAP at 1 month is therefore a poor guide to progressive disease and should not be used in isolation to discontinue treatment early. The SAP profile is of value as an earlier predictor of response than X-rays or bone scans and is more reliable than the PAP profile in monitoring patients with prostate cancer and bone metastases.

Epilepsy and behaviour of the Mongolian gerbil: an ethological study.

Ethological procedures were used to compare behaviour characterizing seizure-sensitive and seizure-resistant gerbils and to examine motor components of their major convulsions. Seizure-sensitive gerbils showed less social investigation when encountering an unfamiliar resident than their seizure-resistant counterparts. Sequence analysis showed the motor components of major seizures to segregate into three largely independent groups comprising elements associated with clonic-tonic spasms, with subsequent extensor immobility and with returning abnormal activity which preceded the resumption of normal behaviour. In grade 4 and 5 convulsions, the motor components of clonic-tonic spasms included the elements "rigid upright posture," "foreleg treading," "fall over," "mouth spasms." Straub tail and opisthotonus which were not seen in grade 3 seizures. The durations of clonic spasms and extensor immobility were longer in seizures of grades 4 and 5 than in those of grade 3. The abnormal motor activity following extensor immobility was complex and unrelated to seizure severity. It is suggested that observational studies in epilepsy may contribute to our understanding of the underlying pathophysiological processes.

Initial chemotherapy followed by surgery in malignant thymoma.

Initial combination chemotherapy with cisplatinum, adriamycin and cyclophosphamide was given prior to surgery in a young woman with an unresectable malignant thymoma. Complete remission was achieved following three cycles of chemotherapy. Subsequent thymectomy revealed no evidence of residual malignancy. Prolonged remissions following cisplatin-based chemotherapy have recently been achieved in metastatic thymoma. Initial chemotherapy should now be considered prior to surgery or radiotherapy in those patients presenting with very bulky or unresectable disease.

Management of patients with advanced breast cancer.

Although patients with recurrent breast cancer are not curable with presently available treatments, the duration of survival after the development of metastases has increased to about three years. This has been due to optimal supportive care as well as the use of endocrine therapy, chemotherapy and radiotherapy for symptom control. With these methods quality of life can usually be maintained for much of this period.