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Directed early axonal outgrowth from retinal transplants into host rat brains.

Axons from retinae transplanted to the brain stem of neonatal rats exhibit two patterns of outgrowth that can be experimentally uncoupled from each other depending upon the location of the graft. Retinae placed close to the surface of the rostral brain stem (as much as 5 mm from the tectum) emit axons that project toward the superior colliculus along the subpial margin of the rostral brain stem. In contrast, axons from grafts embedded deep within the midbrain parenchyma project through the neuropil directly to the overlying superior colliculus, as long as the retina is within about 1 mm of the tectal surface. The present study shows that, as long as the retina is located outside the superior colliculus, and regardless of whether the axons derive from grafts in subpial or intraparenchymal locations, the earliest projections are oriented towards the superior colliculus. We have also found, however, that axons from retinae transplanted directly onto the superior colliculus can form projections that extend along the subpial margin away from the tectum. There are several major conclusions that may be drawn from these observations. First, the final tectopetal, transplant-derived projection does not result from the reorganization of an initially random outgrowth but is directed from the start toward an appropriate region of termination. Second, it appears that the interaction of retinal axons with a primary target alters the ability of the growth cone to respond to directional cues along the optic tract. Thus, although adding support to the proposal that optic axons attain the superior colliculus through an interaction involving substrates distributed along the optic tract and diffusible factors originating in the target region, it is increasingly clear that such interactions are likely to be complex and hierarchical.

Animals↗

Comparative macroarray analysis of morphine containing Papaver somniferum and eight morphine free Papaver species identifies an O-methyltransferase involved in benzylisoquinoline biosynthesis.

Benzylisoquinoline alkaloids constitute a group of about 2,500 structures and are mainly produced by plants of the order Ranunculales. But only the opium poppy, Papaver somniferum, and Papaver setigerum are able to produce morphine. In this study, we started to investigate by gene expression analysis the molecular basis for this exceptional biosynthetic ability. A sequencing project from P. somniferum seedlings was initiated using a method based on the amplified fragment length polymorphism technique that resulted in 849 UniGenes. These cDNAs were analysed on macroarrays for differential expression between morphine-containing P. somniferum plants and eight other Papaver species, which accumulate other benzylisoquinolines instead of morphine. Three cDNAs showing increased expression in P. somniferum compared to all the other Papaver species were identified. Whereas two showed no significant homology to any known protein, one putatively encoded an O-methyltransferase. Analysis of substrate specificity of the heterologously expressed protein and mass spectrometric identification of the enzymatic products identified this protein as S-adenosyl-L-methionine:(R,S)-3'-hydroxy-N-methylcoclaurine 4'-O-methyltransferase (EC 2.1.1.116). Unlike other O-methyltransferases of different positional specificities implicated in benzylisoquinoline metabolism, the enzyme only accepted tetrahydroxylated tetrahydrobenzylisoquinolines as substrates; methylation was tolerated only at the 6-hydroxy position.

Benzylisoquinolines↗

Application of an improved column characterisation system to evaluate the within and between batch variability.

The selection of a reversed-phase liquid chromatographic column with suitable selectivity for a particular separation is difficult if the brand name of the column is not known. A project to develop a chromatographic test procedure to characterize reversed-phase liquid chromatography C18 columns was started earlier and resulted in a fast, simple, repeatable and reproducible test procedure using four column parameters. Here, this procedure is used to evaluate the diversity of columns originating from the same batch as well as from different batches. The determination of one of the parameters, the retention factor of 2,2'-dipyridyl, was improved and a simplified test procedure is proposed.

2,2'-Dipyridyl↗

Where are all the blood-pressure genes?

CONTEXT: The potential for discovery of underlying genetic causes for common conditions, such as hypertension, is a major justification for the human genome project. Hopes have been raised that personalised molecular prognostic and therapeutic strategies will result from genomic studies. STARTING POINT: The largest and most recent searches of the genome (Mark Caulfield and colleagues, Lancet 2003; 361: 2118-23; Michael Province and colleagues, Am J Hypertens 2003; 16: 144-47) have found limited evidence of genes that determine hypertension, and even less evidence for the existence of causative DNA variants (alleles) within these genes. Previous genomic studies did not reach a consensus on the likely location of blood-pressure genes. The difficulty in identifying genetic causes for common conditions might be because the causative alleles are numerous, with small individual impact, and are distributed unevenly between populations. WHERE NEXT?: Without comprehensive and reliable description of the alleles associated with hypertension, using genetics for diagnosis remains tenuous. However, the discovery of a single allele proven to be associated with control of blood pressure could lead to the discovery of relevant and novel physiological targets for the prevention and treatment of hypertension.

Alleles↗

Applying industrial hygiene to chemical and petroleum projects.

An effective strategy to prevent health hazards will utilize industrial hygiene principles in all phases of a project, including process development, the design bases, the final design, during construction, and during and after start-up. The involvement of industrial hygiene in engineering design results in cost-effective minimization of health hazards from toxic chemicals and harmful physical agents. Measurements of post start-up emission levels and employee exposures can be utilized to evaluate the performance of the controls which were implemented in the design. This will aid in the development of future designs and identify where research is needed to develop better controls to prevent health hazards.

Chemical Industry↗

Successes and failures in the implementation of evidence-based guidelines for clinical practice.

BACKGROUND: The development and implementation of (evidence-based) clinical practice guidelines is one of the promising and effective tools for improving the quality of care. However, many guidelines are not used after dissemination. Implementation activities frequently produce only moderate improvement. It is important to study specific guideline programs in detail to learn from their successes and failures. OBJECTIVES: Experiences with more than 10 years of development and dissemination of clinical guidelines for family medicine in the Netherlands are presented in this paper. RESULTS: More than 70 evidence-based guidelines have been set in a rigorous procedure and have been spread via a variety of strategies. Knowledge and acceptance of the guidelines in the target group is high. In particular, a multifaceted approach with written (scientific journal, support materials) and personal approaches (local consensus discussions, contact with colleagues, outreach visits by peers) seems to be effective in the dissemination. The guideline recommendations are followed in on average 67% of the decisions, but there is a large variation between different physicians and between different guidelines. Specific strategies designed to handle possible obstacles to implementation are needed to improve adherence. Specific implementation projects showed the importance of a "diagnostic analysis" of the target group and target setting before the start of the implementation. CONCLUSIONS: A program to implement a guideline should be well designed, well prepared, and preferably pilot tested before use. Such a program should be built into the normal channels and structures for improving care. More research into the details of implementation is needed to better understand the critical determinants of change in practice.

Evidence-Based Medicine↗

Providing low-cost sexually transmitted diseases services in two semi-urban health centers in Central African Republic (CAR): characteristics of patients and patterns of health care-seeking behavior.

BACKGROUND: While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa. GOAL: To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure. DESIGN: STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds. RESULTS: Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD. CONCLUSIONS: Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.

Adolescent↗

FIELDS of dreams, fields of tears: a perspective on the fibrate trials.

Endpoint studies have been performed with fibrates in coronary heart disease since 1971. The results have been confusing - starting with initial benefits in small studies, but contradicted by either minimal benefits in the Coronary Drug Project or adverse noncardiovascular (non-CV) effects in the World Health Organization Clofibrate Study. Fibrates returned for patients with low HDL-C and low LDL-C after a 25% event reduction were seen in the Veterans Affairs HDL Intervention Trial. The greater prominence ascribed to the lipid triad of the metabolic syndrome and the increasing prevalence of diabetes increased the topicality of fibrates given their main action of converting small dense to light buoyant LDL. The Fenofibrate Intervention in Event Lowering in Diabetes (FIELD) Study has carried on the tradition. Fenofibrate therapy in 9795 patients comprising a mixed low-risk primary and a medium-risk secondary prevention cohort resulted in an 11% reduction in coronary events (p = 0.16), a similar but significant reduction in CV events (p = 0.04; number needed to treat = 70). The benefits were concentrated in primary prevention and on nonfatal myocardial events, but the study was confounded by asymmetrical statin drop-in due to the LDL-C-lowering effect of fenofibrate. Safety was generally good, including in combination with statins, but old concerns about sudden death, pancreatitis and venous thrombosis returned. Unexpected benefits were seen with fenofibrate on microvascular endpoints including microalbuminuria and retinopathy. Fenofibrate is a reasonable second-line therapy for dyslipidaemia in diabetes and safe in combination therapy. Its benefits on microvascular disease and in combination therapy require further confirmation.

Cardiovascular Diseases↗

APA/HRSA National Faculty Development Scholars Program: community-based teaching track.

OBJECTIVES: Goals and objectives of the APA/HRSA National Faculty Development Scholars Program are described in a companion article in this supplement. Program objectives of the Community-Based Teaching Track were to 1) identify individuals with faculty development skills to serve as regional leaders, conducting local and regional workshops; 2) create a national network of leaders, thereby promoting sustainability; and 3) increase educational contributions of office-based preceptors. Participant objectives were to 1) meet expectations of the program; 2) possess knowledge, skills, and attitudes needed to recruit and retain community-based preceptors; 3) possess knowledge and skills needed to conduct faculty development workshops for practitioners; and 4) form local and national collegial networks. METHODS: Academicians and practitioners were selected to form 2 cohorts, starting in 1999 (N = 20) and 2000 (N = 22), respectively. Workshops were developed on the basis of projected needs and iterative needs assessments of the participants. Each participant was required to conduct workshops between meetings, first locally and then regionally or nationally. OUTCOMES: Forty-two participants conducted 307 workshops attended by 3815 individuals. Participants reported specific knowledge and skills gained from the program and increases in multiple areas of competence. Networks were formed, leading to collaborative regional and national presentations and formation of an APA Faculty Development Special Interest Group. Participants reported increased recruitment of training sites and preceptors, with enhanced relationships. CONCLUSION: Program and participant objectives of the Community-Based Teaching Track were met, including implementation of multiple new workshops, development of skills, and creation of a support network to enhance the sustainability of that success.

Ambulatory Care↗

Transcranial Magnetic Stimulation for Patients with Exposure Therapy Resistant Obsessive-Compulsive Disorder (TETRO): Study Protocol for a Multicenter Randomized Controlled Trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a disabling mental disorder, characterized by obsessions, compulsions, and substantial morbidity. Approximately 50% of adults with OCD fail to achieve satisfactory outcomes from first-line treatments, such as exposure therapy with response prevention (ERP), with or without medication. This leads to chronic social, educational, and occupational impairment. While invasive procedures such as deep brain stimulation are available for severe, treatment-refractory cases, a need remains for less invasive alternatives. Repetitive transcranial magnetic stimulation (rTMS), a noninvasive intervention, shows promise in reducing OCD symptoms. Unlike in depression, rTMS is not yet reimbursed for OCD in the Dutch healthcare system. OBJECTIVE: This study examines the efficacy and cost-effectiveness of low-frequency (1Hz) rTMS targeting the presupplementary motor area (pre-SMA) compared to sham rTMS as an adjuvant treatment to ERP in adults with OCD with inadequate response to first-line treatment. METHODS: A total of 250 adults with OCD will be enrolled in this multicenter randomized controlled trial. Participants will be randomly assigned to ERP combined with either active or sham 1Hz rTMS over the pre-SMA. Treatment is administered 4 times weekly for at least 5 weeks (20 rTMS-ERP sessions), with optional extension of 1 to 2 weeks, up to 28 rTMS-ERP sessions. Clinical assessments occur at baseline, weekly during treatment, posttreatment, and at 3, 6, and 12 months follow-up. Participants undergo pre- and posttreatment (functional) (MRI) scans, including a symptom provocation task. Blood sampling takes place pre- and posttreatment and at 3-month follow-up. The primary outcome is OCD severity at posttreatment, as measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Secondary outcomes include functional improvement, quality of life, and societal costs. Pretreatment symptom profiles, genotype, and brain network topology will be analyzed as predictors of response and relapse risk. Pre-to-post treatment change in blood-based and magnetic resonance (MR)-based neuroplasticity markers will help explore differential mechanisms between ERP alone and combined rTMS-ERP. We expect that the verum rTMS protocol will be cost-effective compared to sham-rTMS. RESULTS: Recruitment started in April 2022, and as of February 2026, 201 participants have been enrolled. Posttreatment assessments are projected to be completed in December 2026, with final one-year follow-up evaluations anticipated by the end of 2027. CONCLUSIONS: To our knowledge, this study is the first adequately powered randomized controlled trial examining efficacy, cost-effectiveness, and mechanism of action of rTMS for OCD as adjuvant therapy to ERP. In case of efficacy and/or cost-effectiveness, it will pave the way for rTMS as insured health care for adults with OCD in the Netherlands, and possibly other European countries. Furthermore, this trial will provide insight into the mechanisms of treatment response to intensive ERP, with and without adjunctive rTMS, as well as potential side effects, individual variability, and long-term outcomes in adults with OCD.

Humans↗

An introduction to qualitative research concepts for nurses.

Qualitative methods are increasingly used to explain complex concepts within nursing practice. This paper defines qualitative research and offers practical advice for getting started and interpreting such research. Phenomenology, ethnography and grounded theory are explored briefly, with examples of research projects. Data collection and analysis are also discussed.

Anthropology, Cultural↗

Production integrated treatment of textile wastewater by closing raw material cycles.

A method for the in-house treatment of partial wastewater flows and the recycling of treated process water into the textile finishing process was developed in order to recycle effluents from textile finishing industry and feed them back into the production process. The method is based on a two-stage biological anaerobic-aerobic process to split colouring wastewater agents and to degrade organic substances contained in the water as well as a chemical stage to remove the remaining color of the water with the help of ozone. In the framework of a research and development project a demonstration plant for a treatment capacity of 1440 m3 per working day was installed and started in a textile finishing company. At the plant, a wastewater flow and a recycling flow are treated separately in two different treatment lanes. Approximately 40% of the total wastewater flows, i.e. 576 m3/d are treated in the wastewater lane, and a maximum of 60% of total wastewater, i.e. 864 m3/d are treated in the recycling lane. Thanks to the preliminary treatment of wastewater flows, which are discharged into the municipal sewage works, a reduction of average COD levels in the sewage works effluents could be achieved.

Bioreactors↗

Administrative support helps keep your LOS low.

Reducing length of stay is an ongoing process, not a project, and requires constant monitoring and performance improvement efforts. Keep close tabs on patient flow. If numbers start to rise, begin your campaign for additional staff. Institute cross-training, so staff can perform a number of tests within the ED. Work closely with lab staff to make sure that the ED's patients always receive top priority.

Emergency Service, Hospital↗

Health policy on the town meeting agenda.

American Health Decisions, a movement that started in Oregon, has spread to several other states. Through the media and widespread public discussion, the projects aim to increase public awareness about the individual and societal dimensions of ethical choices in health care.

Advisory Committees↗

[The changing situation of the school for the physically disabled owing to the rising numbers of most severely and multiply disabled pupils (author's transl)].

The author outlines a group of disabled who are suggested to be inadequately covered by the usual targets of rehabilitation (reintegration in the labour market, independence in the activities of daily living, starting a family--in short: "normality"), because of the presence of severe and extensive disabilities or disability combinations. Starting from an analysis of the living situation these children are facing in their childhood, and a projection on the living situations to be expected in adulthood, the essential principles of an educational concept are developed which, at the price of departure from established educational ideas, is intended, ideally, to enable the course of education to be adjusted to the living situation of the individual. These individualised programmes must be based on an established right to being different, and insistence on the inalienability of equal value and equal rights as a task of education in the schools for the physically disabled.

Child↗

How to succeed in a multipractice study.

BACKGROUND: In designing a multipractice study on the prescribing habits of general practitioners (GPs) in a Norwegian county, we took into account positive and negative experiences from earlier research on how to improve participation and retention of physician investigators. METHODS: The GP recruitment took place in two phases. The first step was to establish a local network and a sense of community among GPs in the county. The second step consisted of a personal visit by the project leader to all of the practices in the county during the three months before the study started. RESULTS: One hundred and forty-nine (96%) of a total of 156 GPs participated during the first one-month data collection period, registering 43,619 patient contacts. Only six GPs refused to participate, and one GP could not participate because of illness. During the second data collection period, four of the original nonparticipants asked to join, which gave a rate of enrollment of 98% (153 of 156). This time 46,839 contacts with patients were registered. None of the participants dropped out of the study. CONCLUSIONS: Our design for achieving high recruitment and participation rates was successful. We found that in conducting multipractice studies it was essential to spend enough time and resources on establishing a close collaborative relationship with GPs before, during, and after the study.

Data Collection↗

Treatment of hypertension and adherence to treatment guidelines in clinical practice: an Italian study.

Despite the results from clinical trials in patients with hypertension and the development of a long list of guidelines for the management of hypertension, many physicians and other healthcare professionals still manage hypertension using approaches that clearly diverge at least partially from the recommendations of these guidelines. Whatever the underlying reasons for physicians' failure to adhere to these guidelines, it is one of the main causes of the high percentage of treated patients with uncontrolled hypertension. This article is a report of the outcomes of a project designed to identify specific discrepancies between hypertension guidelines and clinical practice in Italy then guide the physicians to reach a consensus on hypertension management through discussions with their peers. A total of 1120 internists from all 20 regions in Italy were recruited to participate in workshops conducted between June 2002 and July 2004. They were divided into 57 groups to discuss at least 7 key topics, including the blood pressure level at which to start drug therapy, target-organ damage, isolated systolic hypertension, pulse pressure, clinical trials, generic drugs, and fixed combination drug therapy. The project findings confirmed that the vast majority of internists agree with the guidelines but do not adhere to them completely in clinical practice. Through open discussions that allowed them to identify common viewpoints, the participants may have developed a better awareness of and insight into the guidelines for hypertension management. Hopefully this strategy for group participation will lead to improvements in the management of hypertension throughout Italy.

Guideline Adherence↗

The Utrecht Health Project: optimization of routine healthcare data for research.

BACKGROUND: Research on the impact of changes in healthcare policy, developments in community and public health and determinants of health and disease during lifetime may effectively make use of routine healthcare data. These data, however, need to meet minimal criteria for quality and completeness. Research opportunities are further improved when routine data are supplemented with a standardized 'baseline' assessment of the full population. This formed the basis for a new study initiated in a newly developed large residential area in Leidsche Rijn, part of the city of Utrecht, the Netherlands. METHODS: All new inhabitants are invited by their general practitioner to participate in the Utrecht Health Project (UHP). Informed consent is obtained and an individual health profile (IHP) is made by dedicated research nurses. The IHP is the starting point for the UHP research database as well as for the primary care electronic medical records. Follow-up data are collected through continuous linkage with the computerized medical files recorded by the general practitioners. UHP staff in each practice takes care of quality management of registration as well as data handling. RESULTS: Currently, over 60% of invited new residents in the area have given informed consent with participation steadily increasing. DISCUSSION: The Utrecht Health Project combines key elements of traditional epidemiologic cohort studies with the current power of routine electronic medical record keeping in primary care. The research approach optimizes routine health care data for use in scientific research.

Adolescent↗