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Biomedical subjects

P Davis

Publications and source records attributed to P Davis.

At least 73 records · Page 4Linked to original sources

Opiate aromatic pharmacophore structure-activity relationships in CTAP analogues determined by topographical bias, two-dimensional NMR, and biological activity assays.

Topographically constrained analogues of the highly mu-opioid-receptor-selective antagonist CTAP (H-D-Phe-c[Cys-Tyr-D-Trp-Arg-Thr-Pen]-Thr-NH(2), 1) were prepared by solid-phase peptide synthesis. Replacement of the D-Phe residue with conformationally biased beta-methyl derivatives of phenylalanine or tryptophan (2R,3R; 2R,3S; 2S,3R; 2S,3S) yielded peptides that displayed widely varying types of biological activities. In an effort to correlate the observed biological activities of these analogues with their structures, two-dimensional (1)H NMR and molecular modeling was performed. Unlike the parent (1), which is essentially a pure mu antagonist with weak delta agonist activities in the MVD bioassay, the diastereomeric beta-MePhe(1)-containing peptides exhibited simultaneous delta agonism and mu antagonism by the (2R,3R)-containing isomer 2; mu antagonism by the (2R,3S)-containing isomer 3; weak mu agonism by the (2S,3R)-containing isomer 4; and delta agonism by the (2S,3S)-containing isomer 5. Incorporation of beta-MeTrp isomers into position 1 led to peptides that were mu antagonists (2R,3R), 8; (2R,3S), 9, or essentially inactive (<10%) in the MVD and GPI assays (2S,3R), 10; (2S,3S), 11. Interestingly, in vivo antinociceptive activity was predicted by neither MVD nor GPI bioactivity. When D-Trp was incorporated in position 1, the result (7) is a partial, yet relatively potent mu agonist which also displayed weak delta agonist activity. Molecular modeling based on 2D NMR revealed that low energy conformers of peptides with similar biological activities had similar aromatic pharmacophore orientations and interaromatic distances. Peptides that exhibit mu antagonism have interaromatic distances of 7.0-7.9 A and have their amino terminal aromatic moiety pointing in a direction opposite to the direction that the amino terminus points. Peptides with delta opioid activity displayed an interaromatic distance of <7 A and had their amino terminal aromatic moiety pointing in the same direction as the amino terminus.

Analgesics, Opioid↗

Idiopathic stabbing headache associated with monocular visual loss.

BACKGROUND: Idiopathic stabbing headache, which is a brief, sharp, severe jabbing pain that is confined to the head, responds well to treatment with indomethacin sodium. It may occur as a primary entity but more likely is associated with other types of headache, including migraine. SETTING: Emergency department of a teaching hospital. PATIENT: A 27-year-old man presented to the emergency department with stabbing, sharp pain in the right temporal area associated with complete of loss vision in his right eye. The patient had a history of migraine with aura since 1995. RESULT: The patient was treated with oxygen inhalation and indomethacin, with complete resolution of his symptoms. CONCLUSION: A case of idiopathic stabbing headache associated with monocular visual loss was relieved by oxygen and indomethacin therapy.

Adult↗

Alpha-azido acids for direct use in solid-phase peptide synthesis.

Several new alpha-azido acids have been synthesized and their use in solid-phase peptide synthesis has been demonstrated. The azido group allows for high activation of the carboxyl group as an acid chloride without formation of byproducts and with no detectable racemization. An analog of Leu-enkephalin has been prepared and tested in the mouse vas deferens and guinea pig ileum bioassays: it displays moderate activity at the delta-opiod receptor.

Animals↗

Evaluation of a problem-based learning workshop using pre- and post-test objective structured clinical examinations and standardized patients.

BACKGROUND: Osteoporosis is a health care issue in which family physicians play a major role. Although awareness of osteoporosis is high, recent studies suggest that application of recent advances in its treatment to the clinical setting may be low. We have developed a problem-based learning intervention for osteoporosis in which paired rheumatologists and family physicians developed nine problem-solving clinical scenarios. An educational matrix was used to link specific case scenarios with individual teaching objectives, developed via a previous needs assessment. Family physicians participated in the workshop, developing best practice responses to the clinical scenarios with a trained facilitator and content expert. METHODS: To assess the impact of this intervention, family physicians participated in a pre- and post-test evaluation, using objective structured clinical examinations and standardized patients. Objective structured clinical examination stations tested knowledge, skills, and judgment relating to osteoporosis with respect to risk factors, use of appropriate investigations including bone mineral densitometry (BMD), strategies for the prevention of osteoporosis (both pharmacologic and nonpharmacologic), treatment options for established osteoporosis (bisphosphonates and hormone replacement therapy), and management of recent osteoporosis fracture. Participants were evaluated using a predetermined score generated by their responses to objective structured clinical examinations and standardized patients (max. score = 101). Evaluations were conducted anonymously, although participants had access to their own pre- and post-test results for personal feedback. The impact of the workshop was assessed by comparing pre- and post-test responses by group, by individual, and by station. RESULTS: Participants demonstrated a significant improvement in their post-workshop scores. Of 40 participants, 26 showed improvement in score (> +10), 13 showed modest change (+1 to +10), and 1 showed a marked decrease (> -10). The greatest improvements were seen in the management of the male osteoporosis patient, determination of risk factors for osteoporosis, and the use and interpretation of bone mineral densitometry. Family physicians reported general satisfaction with the content and format of both the workshop and the evaluation process. IMPLICATIONS: We conclude that this type of problem-based learning intervention workshop results in improved knowledge, skills, and judgment in the management of osteoporosis by family physicians as objectively assessed using a pre- and post-test format including objective structured clinical examinations and standardized patients.

Clinical Competence↗

Utilisation and costs of investigations, and accuracy of diagnosis of polymyalgia rheumatica by family physicians.

To determine the utilisation and costs of investigations, and the accuracy of polymyalgia rheumatica (PMR) by family physicians, a retrospective chart review of 123 patients referred to a tertiary care rheumatology clinic was undertaken. The accuracy of diagnosis of PMR in the cohort was 24%. A variable number of investigations and costs occurred prior to referral, ranging from $110 in those with an unspecified locomotor diagnosis, through $74 in those with a correct diagnosis of PMR, to $24 where no diagnosis was entertained. In general, these costs were considered higher than necessary to make the diagnosis compared to those advocated by rheumatologists. We conclude that there is a low accuracy of diagnosis of PMR and an overutilisation of investigations, with resultant increased costs, by family physicians referring patients with PMR. Appropriate educational interventions are required to address both diagnostic and investigational needs.

Aged↗

The "supply hypothesis" and medical practice variation in primary care: testing economic and clinical models of inter-practitioner variation.

Medical practice variation (MPV) is marked, apparently ubiquitous across the health sector, well documented, and continues to be a focus of professional and policy interest. MPV have stimulated two paths of investigation, one economic in emphasis and the other more-clinical in orientation; while health economists have stressed the potential role of income incentives in medical decision-making, health services research has tended to emphasise clinical ambiguity as a factor in practitioner decisions. Both sets of explanations converge in an implicit "supply hypothesis" that posits contextual practitioner and practice attributes as influential in clinical decisions. Data on inter-practitioner variation are taken from a large and representative regional survey of general practitioners in New Zealand, a country in which unsubsidised fee-for-service is the predominant mode of remuneration in primary care. The paper assesses the impact on three important areas of clinical decision-making prescribing, test ordering, request for follow-up -- of three key conceptual dimensions -- income incentives, physician agency, and clinical ambiguity (operationalised as local doctor density, practitioner encounter initiation, and diagnostic uncertainty respectively). Predictions are made about inter-practitioner variations in the rate of clinical activity in the three areas. The results of the analysis using multi-level statistical techniques are: 1. the extent of competition -- local doctor density -- seems to have no effect on the pattern of clinical decision-making; 2. doctor-initiated visits are, if anything, associated with lower rates of intervention; 3. diagnostic uncertainty is associated with higher rates of investigations and follow-up, both of which have clinical plausibility; 4. there is no significant interaction effect between density and uncertainty. It is concluded that, for the clinical activities studied and for the practitioner attributes as operationalised in this investigation, a clinical, rather than an economic, model of practitioner decision-making provides a more plausible interpretation of inter-practitioner variation in rates of clinical activity in general practice. The "supply hypothesis" requires further analytical refinement and empirical assessment before it can be applied as a generic explanatory framework for MPV.

Family Practice↗

Use of focus groups to assess the educational needs of the primary care physician for the management of asthma.

OBJECTIVES: To determine the educational needs of primary care physicians, in the management of patients with asthma. DESIGN: Focus group discussions with physicians, pharmacists, respiratory therapists and patients. SETTING: Metropolitan Edmonton, Alberta, Canada. PARTICIPANTS: Out of an original mail request to 100 potential recruits, 52 people attended the focus group sessions. These included physicians, pharmacists, respiratory therapists, adult patients and paediatric patients accompanied by their parents. MAIN OUTCOME MEASURE: Consensus of the specific group being interviewed using facilitator-mediated responses, to identify problems in the care of asthma patients and appropriate educational methods to improve the situation. RESULTS: Both diagnostic and treatment concerns were identified by the primary care physicians and others in the study. Confusion with infection was the most common diagnostic problem. Major treatment problems involved confusion about aspects of management strategy and a lack of communication between physicians, patients and other members of the health care team. Poor patient compliance and patients changing doctors frequently were also of major concern. There were inconsistencies in the treatment of asthma between physicians. While most physicians felt that they were up-to-date in management, Asthma Control Guidelines were seldom followed. CONCLUSIONS: There is an urgent need for continuing medical education, not only in management but also in communication with patients and with other members of the health care team. The data permit the development of an ongoing educational programme which is practical and designed to deal with the issues identified in this survey.

Alberta↗

Postnatal corticosteroids in preterm infants: systematic review of effects on mortality and motor function.

BACKGROUND: Postnatal corticosteroid therapy has been proved in randomized controlled trials to reduce ventilator dependence and the rate of chronic lung disease in preterm infants with few serious short-term side effects. However, there are other consequences that might follow postnatal corticosteroid therapy that are more important, including mortality or cerebral palsy. OBJECTIVES: To review the evidence from reported randomized controlled trials on the effects of postnatal corticosteroid on long-term mortality and motor dysfunction, including cerebral palsy. METHODS: The methods involved a meta-analysis of reported randomized controlled trials, following guidelines of the Cochrane Collaboration, including calculation of event rate differences (ERD) and 95% confidence intervals (CI). RESULTS: The mortality rate difference was non-significant both statistically and clinically (ERD - 0.1% favouring corticosteroids, 95% CI -2.9% to 2.8%). There were no subgroups in which a beneficial effect of postnatal corticosteroids on survival could be demonstrated. The rate of motor dysfunction in survivors was significantly higher in survivors from the postnatal corticosteroid group (ERD 11.9% favouring controls, 95% CI 4.6% to 19.2%). The rate of survival, free of motor dysfunction, was significantly lower in the postnatal corticosteroid group (ERD 7.8% favouring controls, 95% CI 0.5% to 15.1%). CONCLUSIONS: Although postnatal corticosteroids have short-term benefits, they do not increase the survival rate, and they may cause motor dysfunction in survivors. A large-scale, placebo-controlled randomized trial, with survival free of sensorineural impairments and disabilities as the major endpoint, is urgently needed.

Adrenal Cortex Hormones↗

Differential mitochondrial distribution in human pronuclear embryos leads to disproportionate inheritance between blastomeres: relationship to microtubular organization, ATP content and competence.

It has been suggested that mitochondrial DNA defects that effect metabolic capacity may be a proximal cause of failures in oocyte maturation, fertilization, or early embryonic development. Here, the distribution of mitochondria was examined by scanning laser confocal microscopy in living human pronuclear oocytes and cleavage stage embryos, followed either by measurements of the net ATP content of individual blastomeres or anti-tubulin immunofluorescence to determine the relationship between mitochondrial distribution and microtubular organization. The results indicate that specific patterns of perinuclear mitochondrial aggregation and microtubular organization are related, and that asymmetrical mitochondrial distributions at the pronuclear stage can result in some proportion of blastomeres with reduced mitochondrial inheritance and diminished ATP generating capacity. While the inability to divide appears to be a development consequence for an affected blastomere, for the embryo, reduced competence may occur during cleavage if several blastomeres inherit a mitochondrial complement inadequate to support normal cellular functions. The findings provide a possible epigenetic explanation for the variable developmental ability expressed within cohorts of morphologically normal early cleavage stage human embryos obtained by in-vitro fertilization.

Adenosine Triphosphate↗

Dyspepsia in children and adolescents: a prospective study.

BACKGROUND: Dyspepsia is poorly characterized in the pediatric population. The goal of the current study was to describe the clinical constellation and natural history of dyspepsia in children and adolescents seen in a pediatric gastroenterology practice. METHODS: A standardized questionnaire was administered by a pediatric gastroenterologist to all subjects 5 or more years of age (and their parents or guardians) treated in a referral pediatric gastroenterology practice for 1 month or more of abdominal pain or discomfort, nausea, or vomiting. Subjects with dyspepsia and dyspepsia subtypes (ulcer-like, dysmotility-like) were identified by using previously defined adult criteria. Evaluation and treatment were performed at the discretion of the attending pediatric gastroenterologist. RESULTS: During a 1-year period, 257 patients were screened with 127 subjects fulfilling criteria for dyspepsia (59% girls, 85% white; median age, 11.7 years; median duration of symptoms, 8 months). Symptoms were ulcer-like in 26% and dysmotility-like (nausea predominance) in 15% of subjects. In those with dyspepsia, irritable bowel syndrome and gastroesophageal reflux were noted in 24% and 43%, respectively. Esophagogastroduodenoscopy and biopsy were performed in 56 subjects with 21 (38%) having mucosal inflammation (Helicobacter pylori in 5). The remaining 35 subjects (62%) were considered to have functional dyspepsia. Duration of symptoms less than 1 year and vomiting were risk factors for mucosal inflammation. Follow-up at 6 months to 2 years revealed 70% of subjects were either asymptomatic or much improved regardless of the cause of dyspepsia. CONCLUSION: Most children and adolescents with dyspepsia do not have serious disease. In our referral population H. pylori infection was unusual, and no peptic ulceration was found. Most subjects with functional dyspepsia have improvement of symptoms over time.

Adolescent↗

Transport of bifunctional proteins across respiratory epithelial cells via the polymeric immunoglobulin receptor.

Neutrophil elastase (NE) contributes to progression of the lung disease characteristic of cystic fibrosis (CF). We developed a strategy that permits the delivery of alpha(1)-antitrypsin (alpha(1)-AT) to inaccessible CF airways by targeting the respiratory epithelium via the polymeric immunoglobulin receptor (pIgR). A fusion protein consisting of a single-chain Fv directed against human secretory component (SC) and linked to human alpha(1)-AT was effectively transported in a basolateral-to-apical direction across in vitro model systems of polarized respiratory epithelium consisting of 16HBEo cells transfected with human pIgR complementary DNA, which overexpress the receptor, and human respiratory epithelial cells grown in primary culture at an air-liquid interface. When applied to the basolateral surface, the anti-SC Fv/alpha(1)-AT fusion protein penetrated the respiratory epithelia, with transcytosis of the fusion protein being related to the amount of SC detected at the apical surface. Significantly less fusion protein crossed the cells in the opposite direction. In addition, because the antihuman SC Fv/alpha(1)-AT fusion protein was transported vectorially and deposited into the small volume of apical surface fluid, the antiprotease component of this protein was concentrated atop the epithelium. Thus, in cell models, this system is capable of concentrating the antiprotease of the fusion protein, in the thin film of epithelial surface fluid to a level expected to be therapeutic in the airways of many patients with CF.

Animals↗

Pseudomonas aeruginosa induction of apoptosis in respiratory epithelial cells: analysis of the effects of cystic fibrosis transmembrane conductance regulator dysfunction and bacterial virulence factors.

Airway epithelial cells can respond to infection by activating several signaling pathways. We examined the induction of apoptosis in response to Pseudomonas aeruginosa PAO1 in normal cells and several cystic fibrosis (CF) and corrected cell lines. Epithelial cells in monolayers with tight junctions, confirmed by apical ZO-1 staining demonstrated by confocal microscopy, were entirely resistant to PAO1-induced apoptosis. In contrast, cell lines such as 9HTEo(-) cells that do not form tight junctions were susceptible, with 50% of the population apoptotic after 6 h of exposure to PAO1. CF transmembrane conductance regulator (CFTR) dysfunction caused by different mechanisms (trafficking mutations, overexpression of the regulatory domain or antisense constructs) did not alter rates of apoptosis, nor were differences apparent in terminal deoxyribonucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling detection of apoptotic airway cells from PAO1 infected cftr -/- or control mice. Bacterial expression of specific adhesins, complete lipopolysaccharide, and a functional type III secretion system were all necessary to evoke apoptosis even in susceptible epithelial cells. Unlike other mucosal surfaces, the airway epithelium is highly resistant to apoptosis, and this response is activated only when the appropriate epithelial conditions are present as well as fully virulent P. aeruginosa capable of coordinately expressing both adhesins and cytotoxins.

Animals↗

Do physician practice styles persist over time? Continuities in patterns of clinical decision-making among general practitioners.

OBJECTIVES: This study seeks to determine whether there are identifiable differences in patterns of clinical decision-making among family physicians, and whether these patterns persist over time. METHODS: A representative cross-sectional survey of general practice encounters in the Waikato region of New Zealand in 1979-1980 was repeated in 1991-1992. Patterns of clinical decision-making were operationalised as practitioner rates for writing a prescription, ordering a laboratory test or radiological examination and the recommendation of a future follow-up office visit at a specified date. Comparable data were available for a cohort of 50 physicians in both surveys. Multi-level techniques and a simulation exercise were used to study the patterns of decision-making over time. RESULTS: Raw, unadjusted correlations for the 50 family physicians between the two surveys were 0.24, 0.14 and 0.55 for rates of prescribing, investigations and follow-up, respectively. However, these correlations increased substantially, to 0.55, 0.41 and 0.70, once account was taken of case mix, data clustering and inter-practitioner variation in patient sample size. The extent of this recovery of the underlying correlations was confirmed in a parallel simulation exercise. CONCLUSIONS: This study confirms the existence of substantial and durable individual practice styles in primary medical care, with implications for the development and successful implementation of clinical guidelines.

Cross-Sectional Studies↗

Chronic lung injury in preterm lambs: abnormalities of the pulmonary circulation and lung fluid balance.

Chronic lung disease of early infancy, or bronchopulmonary dysplasia, is a frequent complication of prolonged mechanical ventilation after premature birth. Pulmonary hypertension and edema are common features of this condition, which is often attributed to long-term, repetitive overinflation of incompletely developed lungs. The overall objective of this work was to examine the effects on the pulmonary circulation and lung fluid balance of different ventilation strategies using large versus small inflation volumes in an animal model of bronchopulmonary dysplasia. We studied 16 newborn lambs that were delivered prematurely (124+/-3 d gestation, term = 147 d) by cesarean section and mechanically ventilated for 3 to 4 wk. Ten lambs were ventilated at 20 breaths/min, yielding a tidal volume of 15+/-5 mL/kg, and six lambs were ventilated at 60 breaths/min, yielding a tidal volume of 6+/-2 mL/kg. All lambs received surfactant at birth and had subsequent surgery for closure of the ductus arteriosus and catheter placement to allow serial measurements of pulmonary vascular resistance and lung lymph flow. Chronic lung injury, documented by serial chest radiographs and postmortem pathologic examination, developed in all lambs irrespective of the pattern of assisted ventilation. Pulmonary vascular resistance, which normally decreases during the month after birth at term, did not change significantly from the first to the last week of study. Lung lymph flow, an index of net transvascular fluid filtration, increased with time in lambs that were ventilated at 20 breaths/min, but not in lambs ventilated at 60 breaths/min. Lymph protein concentration decreased with time, indicative of increased fluid filtration pressure, without evidence of a change in lung vascular protein permeability. Postmortem studies showed interstitial lung edema, increased pulmonary arteriolar smooth muscle and elastin, decreased numbers of small pulmonary arteries and veins, and decreased capillary surface density in distal lung of chronically ventilated lambs compared with control lambs that were killed either 1 d (same postconceptional age) or 3 wk (same postnatal age) after birth at term. Thus, chronic lung injury from prolonged mechanical ventilation after premature birth inhibits the normal postnatal decrease in pulmonary vascular resistance and leads to lung edema from increased fluid filtration pressure. These abnormalities of the pulmonary circulation may contribute to the abnormal respiratory gas exchange that often exists in infants with bronchopulmonary dysplasia.

Animals↗

'Platonic jealousy': a conceptualization and review of the literature on non-romantic pathological jealousy.

Romantic jealousy has long been of interest to psychodynamically oriented clinicians. More recently empirical investigations have emerged into the causes and treatments of romantic jealousy. What has not kept pace with this interest is a wider research agenda into non-romantic forms of jealousy. While work has appeared in relation to specific groups or topics, such as sibling rivalry, no attempt has been made to draw together the material on non-romantic jealousy. In this paper the theoretical and empirical material on non-romantic jealousy is reviewed in order to answer two fundamental questions. Firstly, is non-romantic jealousy necessarily pathological? Secondly, to what extent is it helpful to subsume all forms of non-romantic jealousy under one term? It is suggested that while non-romantic jealousy is not always pathological, the term non-romantic jealousy may be a useful differentiating term, not least in highlighting an important area for future research.

Humans↗

Comprehension and production of gestures by children with normal and impaired language at ages 4, 5, and 6.

12 children with normal verbal language, ages 4, 5, and 6, were matched with 12 children with impaired verbal language. When the two groups were compared for comprehension and production of nonverbal gestures as well as verbal language, the latter group scored more poorly in both areas. Implications for speech-language pathologists and other professionals in the assessment and remediation of language in language-impaired children are mentioned.

Age Factors↗