[Clinical implications of acoustic neuromas growth rate in volumetric study]

OBJECTIVE

The pattern of neuroma growth is of great importance in choosing the appropriate management. This paper tests the clinical impact of tumor growth rate assessed by volumetry. There is a conviction that some slowly growing tumors could be observed for many years.

METHOD AND PATIENTS

Volume measurements were performed on T1- weighted MR images (spin echo sequences) after injection of gadolinium using a special dedicated software. The studied group included 17 patients in whom at least two MRI examinations were carried out and tumor growth was confirmed. The intervals between initial and the first follow-up examination were 14.2 months on the average. In 7 cases tumor evolution was observed in 2 periods (3 MRI studies) and in 4 cases in 3 periods (4 MRI studies).

RESULTS

The growth rate depended on tumors volume and clinical stage (P<0.01). Small tumors can be observed more safely than advanced tumors because their increase in mass is lower.

CONCLUSION

The observation with the tumoral volume measurements appears to be a useful and accurate tool to estimate the tumor growth rate. The growth rate is a major factor for choosing the appropriate management.

Principles of risk and safety

Studies of error and adverse events in medicine have brought a growing awareness of the extent of harm to patients. The psychology of human error strongly suggests that individual liability to error is strongly influenced by the conditions and organisation of the working environment and the nature of the task, in particular the complex and inherently uncertain judgements frequently made in medicine. Research into accidents in medicine and other high risk areas has lead to a much broader concept of causation, with less focus on individuals and more on pre-existing organisational factors. These ideas have been adapted to practical use in healthcare in the analysis of adverse events and in working towards developing safer systems of care. The final section of the paper summarises the implications of this approach for healthcare in terms of an overall systems approach, the need for basic information about clinical incidents, the benefits of systematic investigation and analysis, the nature of safety interventions, the need to study success as well as failure and the need to develop an open, safety aware culture in healthcare.

[The monaural pseudo-stereophonic hearing aid (BAHA) in unilateral total deafness: a study of 29 patients]

For many years, unilateral total deafness has been considered a minor handicap which does not require the fitting of a hearing aid. If the condition did give a major problem, the usual recommendation for this type of hearing loss was a CROS system which, in addition to problems of function and aesthetics, gave poor results. Faced with increasing demands from these patients, and given the good performance of bone conduction implants (BAHA), we decided to try to implant these devices on the deaf side, which allowed, by way of transcranial conduction, stimulation of the functioning ear and the re-establishment of a certain degree of stereophonic hearing. This study of 29 patients who were tested by stereophonic audiometry pre- and post-implantation shows that this type of aiding is beneficial, with improvement of the threshold of intelligibility against background noise of between 5 and 15 dB during Hirsch's test, correction of the "dead angle" on the deaf side, and improvement in localisation of sound in space. From the functional point of view, 88% of patients were satisfied with their aid, which they wore for 8 or 9 hours per day, and had a marked improvement in their hearing performance under various conditions which had proved very difficult for them before they were fitted with the aid. These results all demonstrate the effectiveness of the implant used in this way. The fact that sounds are received on the totally deaf side goes a long way towards establishing satisfactory hearing. True stereophonic hearing could not be established in any of the cases, because this requires input from two ears. It is for this reason that we have termed this type of aid as monaural pseudo-stereophonic.

Allogeneic hematopoietic stem cell transplantation in ovarian carcinoma: results of five patients

Allogeneic hematopoietic stem cell transplantation is often used to treat hematologic malignancies. The efficacy of this procedure is due to both myeloablative conditioning and graft-versus-leukemia (GVL). However, the disadvantages of allogeneic transplantation include graft-versus-host disease (GVHD), relapse from the original tumor, and patient susceptibility to opportunistic infections. Lately, allogeneic transplantation has been developed to treat solid tumors, with the expectation that graft-versus-tumor (GVT), like GVL, will have a significant anti-tumor effect. This effect has been demonstrated in renal carcinomas, and with less evidence in breast cancers. Five patients with malignant ovarian tumors resistant to chemotherapy underwent allogeneic transplantation, four from bone marrow, and one from peripheral blood stem cells. All donors were HLA-identical siblings. One patient received a myeloablative conditioning regimen, while the other four received a non-myeloablative regimen. Two patients received donor lymphocyte infusions (DLI). Four of the patients presented with acute or chronic GVHD associated with tumor regression of at least 50%. These tumor regressions were measured by CA-125 levels and CT scans. The fifth patient died of rapid progression just after transplantation. Of the four transplantation survivors, three received a non-myeloablative regimen which did not seem to reduce treatment effectiveness. While it did reduce toxicity, one of these patients died of GVHD after 127 days. DLI was administered to two patients. These infusions seemed to promote GVHD which was able to control disease progression for one patient and had no apparent effect on the other. Allograft of hematopoietic stem cells might be of interest in ovarian cancer. The results in one patient also suggest that DLI may be an effective immunotherapy, although doses and timing need to be determined. The number of cases presented is small, however, and clinical experience on a larger scale will be required to determine the real clinical efficacy of graft versus cancerous ovarian cells.

Mass screening for retrocochlear disorders: low-field-strength (0.2-T) versus high-field-strength (1.5-T) MR imaging

BACKGROUND AND PURPOSE

In patients with clinical symptoms suggestive of a retrocochlear disorder, contrast-enhanced T1-weighted spin-echo (SE) high-field-strength MR imaging is considered the criterion standard in assessing vestibular schwannoma. However, only 10-20% of its findings are pathologic. Our purpose was to prospectively compare the performance of low-field-strength MR imaging in screening for retrocochlear disorders, with high-field-strength MR imaging as the criterion standard.

METHODS

A total of 287 patients with suspected retrocochlear disease underwent axial 1.5-T MR imaging with a T1-weighted SE sequence before and after contrast enhancement and with a high-resolution T2-weighted construction interference in steady state sequence. At immediate follow-up, the same patients underwent axial 0.2-T T1-weighted SE imaging without additional contrast enhancement. Results were classified as negative, positive, or uncertain and were analyzed in light of the patients' clinical symptoms.

RESULTS

MR imaging at 1.5 T depicted 63 disorders (21.95%), including 53 schwannomas, three other tumors, and seven other disorders (ie, gadolinium-enhancing inner ear, facial nerve, or meninges). MR imaging at 0.2 T showed evidence of 58 disorders; five disorders were not detected, although all schwannomas and other tumors were seen, including those smaller than 2 mm, and only two (28.6%) of the other disorders were detected. When correlated with clinical data, results showed that the five undetected disorders occurred in patients with unusual clinical signs.

CONCLUSION

MR imaging at 0.2 T provided high sensitivity in detecting vestibular schwannoma of the internal auditory canal or cerebellopontine angle; it can be used for mass screening for this disease. Positive and uncertain imaging findings should be followed up with high-field-strength MR imaging.

[Frontal sinus osteomas: neuro-ophthalmological complications]

Osteomas are the most frequent benign tumors of the paranasal sinuses. They often grow in the frontal sinus near the nasofrontal duct. They remain frequently asymptomatic and they tend to be an incidental finding on radiographic studies. Rarely, they extend out of the sinus limits. Two cases with neuro-ophthalmological complications are reported and discussed. A 19-year-old female presented with a progressive left visual impairment and orbital bone deformity. A CT-scan revealed a large calcified mass in both frontal sinuses, with left intraorbital and frontobasal extension. A 21-year-old man suffered from acute frontoethmoidal sinusitis. Radiological exams revealed a right frontal sinus osteoma with bilateral nasofrontal ducts obstruction. The frontal sinus cavities were filled with a large mucocele with intracranial extension. Both patients were successfully treated using frontobasal craniotomy with complete osteoma and mucocele removal and cranio facial bone reconstruction. Neuro-ophthalmological or intrasinusal complications of osteomas lead to radical treatment. CT-scan and MRI analysis for surgical purpose and strategy are emphased.

Antagonistic effects of IL-4 and TGF-beta1 on Langerhans cell-related antigen expression by human monocytes

In this study, we analyzed the specific effects of transforming growth factor beta (TGF-beta1) and/or IL-4 on monocyte-derived cells. Monocytes were cultured with GM-CSF, GM-CSF/TGF-beta1, GM-CSF/IL-4, or GM-CSF/IL-4/TGF-beta1 before cell morphology, phenotype, and function were assessed. As expected, interleukin-4 is mandatory for monocyte differentiation into potent allostimulatory DC. In its absence, monocyte-derived cells share many phenotypic and functional features with macrophages. However, it is interesting that the cells express E-cadherin, independent of exogenous TGF-beta1, and addition of the cytokine induced CCR6 expression. Most importantly, a subset of monocytes cultured with GM-CSF/TGF-beta1 expresses Langerin, as confirmed by electron microscopy analysis. Langerin engagement with specific monoclonal antibodies induces its internalization and the formation of typical Birbeck granules. Monocytes cultured in GM-CSF/IL-4 did not express the LC markers E-cadherin, CCR6, or Langerin. The simultaneous addition of TGF-beta1 allows most of the cells to express E-cadherin but rarely CCR6 and Langerin. Taken together, the results add further evidence that LC can derive from monocytes and demonstrate an antagonistic effect of IL-4 and TGF-beta1 on monocyte differentiation toward the LC pathway.

A novel MADS-box gene subfamily with a sister-group relationship to class B floral homeotic genes

Class B floral homeotic genes specify the identity of petals and stamens during the development of angiosperm flowers. Recently, putative orthologs of these genes have been identified in different gymnosperms. Together, these genes constitute a clade, termed B genes. Here we report that diverse seed plants also contain members of a hitherto unknown sister clade of the B genes, termed B(sister) (B(s)) genes. We have isolated members of the B(s) clade from the gymnosperm Gnetum gnemon, the monocotyledonous angiosperm Zea mays and the eudicots Arabidopsis thaliana and Antirrhinum majus. In addition, MADS-box genes from the basal angiosperm Asarum europaeum and the eudicot Petunia hybrida were identified as B(s) genes. Comprehensive expression studies revealed that B(s) genes are mainly transcribed in female reproductive organs (ovules and carpel walls). This is in clear contrast to the B genes, which are predominantly expressed in male reproductive organs (and in angiosperm petals). Our data suggest that the B(s) genes played an important role during the evolution of the reproductive structures in seed plants. The establishment of distinct B and B(s) gene lineages after duplication of an ancestral gene may have accompanied the evolution of male microsporophylls and female megasporophylls 400-300 million years ago. During flower evolution, expression of B(s) genes diversified, but the focus of expression remained in female reproductive organs. Our findings imply that a clade of highly conserved close relatives of class B floral homeotic genes has been completely overlooked until recently and awaits further evaluation of its developmental and evolutionary importance. Electronic supplementary material to this paper can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00438-001-0615-8.

Isolation and characterization of a protein-tyrosine kinase and a phosphotyrosine-protein phosphatase from Klebsiella pneumoniae

Two proteins of Klebsiella pneumoniae, termed Yor5 and Yco6, were analyzed for their capacity to participate in the reversible phosphorylation of proteins on tyrosine. First, protein Yco6 was overproduced from its specific gene and purified to homogeneity by affinity chromatography. Upon incubation in the presence of radioactive adenosine triphosphate, it was found to effectively autophosphorylate. Two-dimensional analysis of its phosphoamino acid content revealed that it was modified exclusively at tyrosine. Second, protein Yor5 was also overproduced from the corresponding gene and purified to homogeneity by affinity chromatography. It was shown to contain a phosphatase activity capable of cleaving the synthetic substrate p-nitrophenyl phosphate into p-nitrophenol and free phosphate. In addition, it was assayed on individual phosphorylated amino acids and appeared to dephosphorylate specifically phosphotyrosine, with no effect on phosphoserine or phosphothreonine. Such specificity for phosphotyrosine was confirmed by the observation that Yor5 was able to dephosphorylate protein Yco6 previously autophosphorylated. Together, these data demonstrate that similarly to other bacterial species including Acinetobacter johnsonii and Escherichia coli, the cells of K. pneumoniae contain both a protein-tyrosine kinase and a phosphotyrosine-protein phosphatase. They also provide evidence that this phosphatase can utilize the kinase as an endogenous substrate, which suggests the occurrence of a regulatory mechanism connected with reversible protein phosphorylation on tyrosine. Since Yco6 and Yor5 are both involved in the synthesis of capsular polysaccharide and since capsules are essential to the virulence of K. pneumoniae, we suggest that reversible protein phosphorylation on tyrosine may be part of the cascade of reactions that determine the pathogenicity of bacteria.

Results of the MXM Digisonic auditory brainstem implant clinical trials in Europe

OBJECTIVE

To assess the potential benefit of the MXM auditory brainstem implant for patients with neurofibromatosis type 2.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral centers.

PATIENTS

Fourteen patients with neurofibromatosis type 2 and bilateral acoustic neuromas underwent implantation with the MXM auditory brainstem implant during surgery to remove the second-side tumor.

RESULTS

There were no complications related to the auditory brainstem implantation. Auditory sensations were present for 12 of 14 patients (86%). Global results indicated an improved quality of life for the patients receiving auditory sensations, in part because of their auditory orientation within the environment. Eighty-nine percent of patients tested with an open-set sentence test demonstrated enhancement of speech understanding as a result of lip-reading improvement when auditory brainstem implant sound was combined with lip-reading. A few patients (36%) had some speech understanding in sound-only mode. One patient was able to have limited phone conversations.

CONCLUSION

These results indicate that significant auditory benefit can be derived from the MXM auditory brainstem implant.

Risks of elective cardiac surgery: what do patients want to know?

OBJECTIVE

To examine patients' individual requirements for risk disclosure before surgery.

DESIGN

Structured interview and questionnaire.

SETTING

50 patients interviewed following coronary artery bypass grafting or valve replacement or repair.

MAIN OUTCOME MEASURES

Patient assessment of the nature and probability of risks they would have wished to be informed of from a pool comprising death and 13 postoperative complications.

RESULTS

Out of 50 patients, 21 (42%) wanted no risk information at all, 25 (50%) did not want to be advised of the risk of death, and 27 (54%) did not want information about the risk of permanent stroke. This contrasts with standard practice of routinely informing patients of the risk of death and stroke. However, there were pronounced individual patient preferences. Three groups of patients emerged: those requiring little or no risk information, those requiring information about major risks, and those requiring full risk disclosure. Patients were not generally concerned about the specific probabilities of any risk.

CONCLUSIONS

Clinicians counselling patients before operation should routinely discuss patient preferences before risk disclosure, distinguishing among a preference for "no risk information", "all potentially relevant risks", and "those risks considered significant or likely to occur". The fact of individual patient preferences may undermine the concept of the "reasonable patient" in determination of the legal requirements for risk disclosure. Future studies, in addition to replicating the present findings, should examine the reasons underlying individual patient preferences and the long term implications of degrees of risk disclosure, particularly when adverse outcomes occur.

[Bacterial epidemiological study of acute otitis media in children observed at home in the Nord Pas-de-Calais region]

BACKGROUND

The aim of this work is the study of the bacteriologic epidemiology of acute otitis media in infants observed at home in Nord Pas-de-Calais area, and the analysis of bacteria associated to recurrent otitis and clinical failure.

OBSERVATIONS

A total of 295 specimens of ear pus specimens were collected from children (mean age: 18 months; average: one month-12 years). Pneumococcus strains were isolated from 52% of samples and 80% of these showed resistance to penicillin. H. influenzae was found in 35% of specimens and the half produced a beta lactamase. Pneumococcus is the predominant pathogen isolated in prolonged otitis media, while H. influenzae is preferentially found during recurrent otitis media. The main bacteriologic cause of failure traitement was penicillin-intermediate or -resistant pneumococci. The therapy administered 48 to 72 hours before collection of ear pus sample in therapeutic failure was ineffective (oral cephalosporins or macrolides), or administered to low dosage (50 mg/kg/j).

CONCLUSION

Our results demonstrate, in opposition to other studies, Streptococcus pneumoniae as the most frequent pathogen in acute otitis media. They also show the excellent correlation between antibiotic therapy and clinical failures.

[Pendred's syndrome. Current features]

Introduction Pendred's syndrome is a recessive autosomal disease, traditionally defined as the association of deaf-mutism, goiter and dysfunctional iodide organization revealed by the perchlorate discharge test. It represents 4 to 10% of the causes of congenital hypoacusis. Although described more than a 100 years ago, the association of thyroid and cochleo-vestibular damage remained unclear for many years. Genetic abnormalities Progress in molecular biology has revealed that the disease is related to alterations in the PDS gene situated on chromosome 7. The PDS gene is responsible for the production of pendrine, protein involved in anion (l-, Cl-) transportation, notably in the apical pole of the thyreocyte and the cochlear duct, where the endolympha is produced. Practical implications The truncation of pendrine related to the genetic alterations be responsible for the morpho-functional alterations in the cochlear apparatus and the thyroid. In this perspective, Pendred's syndrome would appear as a genetic disorder in anion transportation.

Immature human dendritic cells express asialoglycoprotein receptor isoforms for efficient receptor-mediated endocytosis

In a search for genes expressed by dendritic cells (DC), we have cloned cDNAs encoding different forms of an asialoglycoprotein receptor (ASGPR). The DC-ASGPR represents long and short isoforms of human macrophage lectin, a Ca(2+)-dependent type II transmembrane lectin displaying considerable homology with the H1 and H2 subunits of the hepatic ASGPR. Immunoprecipitation from DC using an anti-DC-ASGPR mAb yielded a major 40-kDa protein with an isoelectric point of 8.2. DC-ASGPR mRNA was observed predominantly in immune tissues. Both isoforms were detected in DC and granulocytes, but not in T, B, or NK cells, or monocytes. DC-ASGPR species were restricted to the CD14-derived DC obtained from CD34(+) progenitors, while absent from the CD1a-derived subset. Accordingly, both monocyte-derived DC and tonsillar interstitial-type DC expressed DC-ASGPR protein, while Langerhans-type cells did not. Furthermore, DC-ASGPR is a feature of immaturity, as expression was lost upon CD40 activation. In agreement with the presence of tyrosine-based and dileucine motifs in the intracytoplasmic domain, mAb against DC-ASGPR was rapidly internalized by DC at 37 degrees C. Finally, intracellular DC-ASGPR was localized to early endosomes, suggesting that the receptor recycles to the cell surface following internalization of ligand. Our findings identify DC-ASGPR/human macrophage lectin as a feature of immature DC, and as another lectin important for the specialized Ag-capture function of DC.

A multicenter study of the Vibrant Soundbridge middle ear implant: early clinical results and experience

OBJECTIVE

The Vibrant Soundbridge (VBS; Symphonix Devices, Inc., San Jose, CA, U.S.A.) is an active, semi-implantable, middle ear hearing device that directly drives the ossicular chain and is used in the treatment of patients with mild to severe sensorineural hearing loss. The benefits of the VBS and the effects of surgery were examined and compared with the preoperative aided condition in 25 patients with implants.

STUDY DESIGN

Single-subject repeated-measures evaluations were performed with each patient acting as his or her own control. Objective audiologic measures and subjective questionnaires also were used.

SETTING

Five tertiary referral and teaching hospitals.

SUBJECTS

Adult patients had bilateral sensorineural hearing loss (average hearing loss, 56 dB; range, 33-80 dB). Twenty-one patients had worn a conventional hearing aid before surgery (11 binaurally, 10 monaurally). Four patients had not used a conventional hearing aid before surgery.

INTERVENTION

Rehabilitative.

RESULTS

No significant change in residual hearing after surgery was observed. Functional gain was significantly superior with the VBS. No significant differences were observed for aided speech recognition in quiet. A significant improvement in communication in various listening conditions was reported with the VBS as compared with conventional hearing aids.

CONCLUSION

The VBS surgical implantation procedure does not affect the residual hearing level in the implanted ear, nor does it present any unacceptable risk. Measurable benefit from the VBS in comparison with conventional amplification was demonstrated with regard to the provision of superior usable amplification and greater ease in communication in daily listening environments for the majority of patients.

Antifilaggrin antibodies in early rheumatoid arthritis may predict radiological progression

OBJECTIVE

To elucidate the possibility that autoantibodies to filaggrin, detected in patients with early RA (having a disease duration of not more than one year), may predict joint destruction assessed after five years of observation.

METHODS

This is a 5 yr extension of a previous study (1) of 112 consecutive patients with early RA. Serum antifilaggrin autoantibodies were detected by immunoblotting (AFA) and by indirect immunofluorescence ("AKA"). DAS28, pain on a VAS. HAQ, and CRP were measured. Plain X-ray films were taken from hands and forefeet and a Larsen score was calculated.

RESULTS

Ninety-two of the original 112 patients had baseline X-rays available and constituted the study material. At 5 year follow-up, 67 of these 92 have been assessed and for 63 of these X-rays were available. For the whole patient material, significant radiological progression, measured by Larsen scores, occurred while disease activity and function (pain VAS, DAS28, CRP, and HAQ) improved significantly over five years. The groups of patients having AFA or "AKA" at baseline had significantly (p=0.006 and p<0.001, respectively) higher Larsen scores five years later than the groups without these antibodies. No clear relation of these antibodies to disease activity or function was demonstrated, except that the group of patients with "AKA" had significantly higher median CRP (p=0,003) after five years.

CONCLUSIONS

The present study shows that antifilaggrin autoantibodies may predict radiological progression. The prognostic value of these antibodies will be further evaluated in relation to other potential markers in a larger patient material.

Efficacy of essential oil of Ocimum basilicum L. and O. gratissimum L. applied as an insecticidal fumigant and powder to control Callosobruchus maculatus (Fab.)

Essential oils from sweet basil, Ocimum basilicum, and African basil, O. gratissimum, (Labiatae) grown in Guinea were obtained by steam distillation. Following exposure of newly emerged adult beetles (Callosobruchus maculatus) to 12h of fumigation using pure essential oils at a dose of 25&mgr;l/vial, 80% mortality was recorded for O. basilicum, 70% for O. gratissimum and 0% in the control. A significant difference was observed between the responses of males and females with males exhibiting greater sensitivity. When 1g of aromatized powder was applied to adults, a 50% lethal concentration at 48h was found to be 65&mgr;l/g for O. basilicum and 116&mgr;l/g of O. gratissimum oils. The essential oils from the two plant species exhibited a significant effect both on the egg hatch rate and on the emergence of adults. The egg hatch rate was reduced to 3% with O. basilicum and 15% with O. gratissimum using an essential oil concentration of 30&mgr;l, whereas the egg hatch rate for the control was 95%. When compared with the control (97%), adult emergence dropped to 0% with O. basilicum and to 4% with O. gratissimum. Storage bioassays were run to assess the long-term effect of powders aromatized with essential oils of Ocimum. Complete protection was observed over 3 months starting at a dose of 400&mgr;l in the case of both oils. From a germination test, it was concluded that aromatized powders have no significant effect on the seed germination rate. After 5d, a rate of 88% germination was seen in seeds treated with aromatized powder and protected from insects, compared with 97% for untreated seeds that were not exposed to insects.

Body size as an indicator of parasitoid quality in male and female Anagyrus kamali (Hymenoptera: Encyrtidae)

The parasitoid Anagyrus kamali Moursi was recently introduced into the Caribbean as a biological control agent against the hibiscus mealybug, Maconellicoccus hirsutus Green. In the laboratory, parasitoid size, as measured by left hind tibia length, was positively correlated with several indicators of the parasitoid's fitness: longevity, mating preference, fecundity, reproductive longevity, progeny emergence and sex-ratio. When fed ad libidum with honey drops, large male parasitoids lived significantly longer (29.1 +/- 6.5 days) than small ones (18.4 +/- 5.7 days). Large females also lived significantly longer (35.4 +/- 10 days) than small females (27.9 +/- 9.6 days). Females showed no significant mating preference between large and small males. Lifetime fecundity was positively correlated with the size of adult females and ranged from 37 +/- 21 eggs for small females to 96 +/- 43 eggs for large ones. The reproductive longevity, daily oviposition rate, and number of progeny were also higher among large parasitoids. The sex ratio of progeny from small female parasitoids was higher (0.76 +/- 0.24) than that of large individuals (0.47 +/- 0.18).

[Regionalization of rehabilitation services. Survey of users of a Quebec center]

OBJECTIVE

To understand the situation of and difficulties encountered by users of a supraregional rehabilitation institute when they are transferred from the institute to facilities in their own regions, and to discover how they address these difficulties.

DESIGN

Qualitative descriptive study.

SETTING

Regions in Quebec served by a physical rehabilitation institute (Institut de réadaptation en déficience physique de Québec).

PARTICIPANTS

Thirty-nine people who used services at the institute and then sought rehabilitation in their own regions.

METHOD

Telephone survey using a validated questionnaire with both open-ended and closed questions.

MAIN FINDINGS

About 69% of users had difficulty obtaining adequate follow up in their regions; the regions lacked professionals with expertise; more efficient methods of communication are required; and physicians' role in providing continuity of care needs to be recognized.

CONCLUSION

Providing continuity of care on a regional basis is a formidable challenge for the entire health and social services network, but ways of meeting this challenge are within reach.