Design of NORA, the National Osteoporosis Risk Assessment Program: a longitudinal US registry of postmenopausal women

NORA is an observational registry of postmenopausal US women with periodic collection of event and treatment data that will create a database including several hundred thousand subjects. It will utilize peripheral and central measurements of bone density and relate these to other risk factors, treatment patterns, and the natural history of osteoporosis. Initiated in the fall of 1997, the registry will be open to women throughout the United States who agree to complete baseline and on-going surveys. The database created by NORA will provide a resource that is unmatched in size and scope in the medical field and will allow for future research in a number of areas including patient outcomes, types of follow-up employed in clinical practice, diagnostic cost modelling, and osteoporosis therapy use (type, patient compliance, persistence and satisfaction). In addition, upon approval by the Steering Committee, women enrolled in the registry may be randomly selected to receive additional educational materials or questionnaires on a variety of topics of interest to specific researchers.

Automatic query mapping among genomic databases: a pilot exploration

As databases in the human genome project proliferate, it is important for users of one genomic database to identify similar or inconsistent data in other autonomously developed genomic databases. To do so, the user needs to issue the same query across multiple databases. We describe an approach that allows a query issued against one database to be automatically mapped to an equivalent query against another structurally different database. Our approach features two components: 1) a database designed to capture knowledge (metadata) that describes the correspondences among individual database components and 2) a module that utilizes the metadata to perform query mappings. As a demonstration, we apply our query mapping approach to two chromosome map databases (DB/12 and GDB).

Induction of apoptosis and cell cycle arrest by CP-358,774, an inhibitor of epidermal growth factor receptor tyrosine kinase

The epidermal growth factor receptor (EGFR) is overexpressed in a significant percentage of carcinomas and contributes to the malignant phenotype. CP-358,774 is a directly acting inhibitor of human EGFR tyrosine kinase with an IC50 of 2 nM and reduces EGFR autophosphorylation in intact tumor cells with an IC50 of 20 nM. This inhibition is selective for EGFR tyrosine kinase relative to other tyrosine kinases we have examined, both in assays of isolated kinases and whole cells. At doses of 100 mg/kg, CP-358,774 completely prevents EGF-induced autophosphorylation of EGFR in human HN5 tumors growing as xenografts in athymic mice and of the hepatic EGFR of the treated mice. CP-358,774 inhibits the proliferation of DiFi human colon tumor cells at submicromolar concentrations in cell culture and blocks cell cycle progression at the G1 phase. This inhibitor produces a marked accumulation of retinoblastoma protein in its underphosphorylated form and accumulation of p27KIP1 in DiFi cells, which may contribute to the cell cycle block. Inhibition of the EGFR also triggers apoptosis in these cells as determined by formation of DNA fragments and other criteria. These results indicate that CP-358,774 has potential for the treatment of tumors that are dependent on the EGFR pathway for proliferation or survival.

The effect of communication mode on the development of phonemic awareness in prelingually deaf students

Two groups of prelingually deaf children and a hearing control group participated in an experiment examining the effect of communication mode on the development of phonemic awareness. Sixteen of the deaf students (mean grade 6.9) were trained orally, using spoken language as their principal means for communication at home and at school. Another 16 deaf students (mean grade 6.9), all of them deaf children of deaf parents, acquired sign language as their primary language. The mean grade of the hearing control group was 6.5. The performance of the two deaf groups indicates that permanent auditory deprivation leads to substantially reduced phonemic awareness but does not entirely block its development. Contrary to expectation, the development of phonemic awareness in individuals with impaired hearing was not significantly affected by their preferred communication mode. Results further suggested that, for deaf individuals with excellent skills in sign language, the functional impairment caused by prelingual deafness may be restricted to the processing of phonological information.

Less fog on the Tyne? Programme budgeting in Newcastle and North Tyneside

Programme Budgeting (PB) has been widely promoted as a model for the better conduct of the work of Health Authorities in the National Health Service in the United Kingdom. This paper reports on a project which looked at the development of PB in Newcastle and North Tyneside Health Authority (NNTHA), concentrating on the construction of a computerised tool for the compilation and analysis of programme budgets. The main activities carried out were a survey of user requirements for PB, a survey of data availability, the collection of data to construct programme budgets, and development of a relational database for storing and manipulating PB information. The main source of data was the Contract Minimum Data Set, which was supplemented by data from a number of other sources to give comprehensive information on spending in NNTHA. Costed activity data were produced, which could be aggregated in a large number of ways, such as by care setting (inpatient, outpatient, community, general practice, etc.), disease group (ICD9 chapter headings), case mix (Healthcare Resource Groups) and socio-demographic variables (age/sex, locality of GPs practice).

Urinary diagnosis of gonorrhoea and Chlamydia in men in remote aboriginal communities

AIMS

(1) To evaluate the acceptability and validity of an intervention based on urine tests for diagnosis and treatment of gonorrhoea and chlamydia in men in remote Aboriginal communities. (2) To provide a prevalence estimate of these infections in the male population in the surveyed communities.

METHODS

First-void urine samples from 460 men in remote communities and 33 men in the Alice Springs Gaol were tested for gonorrhoea and chlamydia with at least one of polymerase chain reaction (PCR), enzyme immunoassay (EIA) and culture (gonorrhoea only).

RESULTS

One hundred and three men (20.9%) were infected with gonorrhoea or chlamydia. The prevalence of infection for gonorrhoea only was 11.7%, for chlamydia only 4.1% and for dual infection 5.1%. Eighty-eight infected men and 45 of their sexual partners were recorded as having been treated within two months of testing. PCR tests detected the largest number of infections and were the easiest to use.

CONCLUSIONS

The prevalence of these infections was higher than anticipated. Urine PCR tests were acceptable to men and are well suited to the remote-community setting. As an effective alternative to urethral swabs, they permit a range of community-based strategies to address high rates of infection with gonorrhoea and chlamydia.

Factors associated with weight change among clients of a residential weight control program indicating binge and nonbinge traits

The long-term effects of a 12- and 26-day residential weight control program on weight change were determined in 187 men and women, 1 to 5 years after treatment. Subjects completed a paper/pencil questionnaire assessing current diet, weight control techniques, exercise behaviors, behavior modification techniques, binge eating, and dieting behavior. General linear modeling was used to investigate the association between behaviors maintained posttreatment and current weight among subjects who demonstrated behaviors indicative of binge traits (BT) and nonbinge traits (NBT). Results indicate that dissimilar variables are predictive of weight change in the BT and NBT groups. Engaging in exercise behaviors and reduced attempts at dieting lead to greater weight loss in NBT individuals. The use of preplaning techniques was found to be indicative of greater weight loss in BT individuals. These findings suggest the importance of identifying individuals who indulge in binge-eating behaviors prior to intervention in order to deliver the appropriate treatment methods.

Bone mass measurements: the case for selected screening?

Osteoporosis, a consequence of loss of bone mass, results in serious health and economic problems, particularly fractures of the hip and spine. Fractures are, in the majority of cases, the result of low bone mineral density (BMD). Technology is now available that allows accurate and sensitive measurement of BMD. The state of the art technology is dual x-ray absorptiometry (DXA), which, unfortunately, is not widely available and is relatively expensive. BMD measurement by DXA is the most individually objective predictor of fracture risk and, therefore, may be a reasonable method for universal screening of women. The pros and cons of mass screening to identify women with low bone mass and increased fracture risk are discussed.

Family structure, personality, drinking, smoking and illicit drug use: a study of UK teenagers

Data from a survey of 7722 15-16 year old school students in the United Kingdom were used to examine relationships between family structure and using alcohol, tobacco and illicit drugs. Respondents living with both parents were significantly less likely to participate in all of these, with girls more affected, particularly as regards cigarette smoking and illicit drugs. For other families, it made little further difference whether the mother, the father or both were absent. The effects were reduced on controlling four other variables. The latter were: psychological symptoms, social support, involvement in hobbies and reading, and engagement in behaviours such as riding mopeds, going out with friends, aggression and delinquency. It is suggested that these variables may mediate the effects of family structure.

Phase II study of liposomal doxorubicin in refractory ovarian cancer: antitumor activity and toxicity modification by liposomal encapsulation

PURPOSE

A phase II study of liposomal doxorubicin was conducted in patients with ovarian cancer who failed to respond to platinum- and paclitaxel-based regimens. Liposomal doxorubicin was selected as a result of its superior activity against ovarian cancer xenografts relative to free doxorubicin and activity in refractory ovarian cancer patients that was noted during the phase I study.

PATIENTS AND METHODS

Thirty-five consecutive patients were accrued in two institutions (22 in one and 13 in the other). All had progressive disease after either cisplatin or carboplatin and paclitaxel, or at least one platinum-based and one paclitaxel-based regimen. Patients received intravenous (I.V.) liposomal doxorubicin 50 mg/m2 every 3 weeks with a dose reduction to 40 mg/m2 in the event of grade 3 or 4 toxicities, or a lengthening of the interval to 4 weeks (and occasionally to 5 weeks) with persistence of grade 1 or 2 toxicities beyond 3 weeks.

RESULTS

Nine clinical responses (one complete response [CR], eight partial responses [PRs]) were observed in 35 patients (25.7%), with seven of these having been confirmed by two consecutive computed tomographic (CT) measurements. The median progression-free survival was 5.7 months with an overall survival of 1.5 to 24+ months (median, 11 months). Although 13 patients experienced grade 3 or 4 nonhematologic skin and mucosal toxicities (either hand-foot syndrome or stomatitis), with dose modifications, the treatment was very well tolerated. Nausea that was clearly attributable to the drug, hair loss, extravasation necrosis, or decreases in ejection fraction did not occur.

CONCLUSION

Liposomal doxorubicin has substantial activity against ovarian cancer refractory to platinum and paclitaxel. The responses achieved with liposomal doxorubicin were durable and maintained with minimal toxicity. This liposomal formulation should be evaluated further in combination with other drugs in less refractory patients.

Toward reducing the spread of HIV in northeastern Thai villages: evaluation of a village-based intervention

This paper presents results of the evaluation of an intervention designed for northeastern Thai villages and particularly for village women. The intervention was based on established principles of behavior change, social learning theory, and community health promotion, and it was grounded in elicitation research. A total of 600 women and 479 men and 12 villages participated in the evaluation which used data collected from face-to-face knowledge, attitude, practices (KAP) surveys, focus groups, and village meetings in a quasi-experimental pre- and post-control group design. Eight of the nine outcome goals set for the intervention were achieved with significant increases in married women taking the initiative in reducing the risk posed to them by the sexual activities of their husbands.

Case study: Ganser syndrome in children and adolescents

Six cases of the Ganser syndrome have been previously described in the literature and are reviewed here. They are imperfect representations of the originally described syndrome. This article describes a case of the Ganser syndrome in a 12-year-old boy who, after a mild head injury, presented with three of four of the core symptoms. The nature of the Ganser syndrome remains unclear, but this case study highlights dissociation and abnormal illness behavior as being important in the production of the symptoms. Classically the course is short-lived, although this report raises the possibilities of a much more chronic course.

Regulation of motilin release: studies with ex vivo perfused canine jejunum

The regulatory process of motilin release was studied in segments of canine jejunum isolated and perfused ex vivo. The secretion of motilin in the effluent venous system of the isolated intestine was measured by radioimmunoassay in response to various pharmacological agents injected intra-arterially. Muscarinie agonist and antagonist, respectively, increased and decreased the release of motilin. The stimulatory effect of carbachol was still documented after tetrodotoxin (10(-5) M) was injected in the system to block neural influence on M cells. Bombesin and morphine also increased the release of motilin. The effect of bombesin was still documented in the presence of atropine or tetrodotoxin, but the stimulatory morphine effect was blocked by atropine. Both phenylephrine and octreotide decreased the release of motilin stimulated by carbachol in a jejunal segment pretreated and denervated with tetrodotoxin. Therefore, a revised model for the regulation of motilin release from M cells of intestinal mucosa can now be proposed. Cholinergic and bombesin receptors are present on M cells to encode a stimulatory signal, whereas adrenergic and somatostatin receptors are responsible for inhibitory transmission. The stimulatory effect of morphine is mediated via a muscarinic transmitter.

Managing informed purchasing. A survey of decision makers

As part of an ongoing study developing and evaluating the use of programme budgeting (PB) and marginal analysis (MA) within purchasing organizations, conducts a survey of a health authorities' requirements of a decision-making tool based on PBMA. PB is a management decision-making system. It provides a summary of resource use categorized according to the programme or end product to which it applies. This explicit description of current activities focuses attention on competition for resources among programmes and on the effectiveness of resource use within programmes. MA is an economist's tool to evaluate options for changing the balance of resource use between or within programmes. Finds general support for PBMA techniques, although this waned with the higher functions of the tool. There was consensus that a health authority ought to know fundamentals like, for example, what proportion it spends on tackling coronary heart disease; and a majority view that PB will assist in revealing the key margins for service review.

Effects of azathioprine withdrawal in kidney recipients with stable function two years after transplant

To assess the effects of azathioprine withdrawal, renal recipients with grafts > 2 yr function (103 study patients) were tapered off azathioprine over a 1-yr period and compared to 69 patients 2 yr after transplant who were not tapered (controls). Of the 103 study patients, 16 (15%) were living-donor transplants and 87 were cadaveric. Of the 69 control patients, 9 (13%) were living related transplants and 60 were cadaveric. The mean HLA match for those tapered was 3.3 Ag and 3.1 Ag for those remaining on azathioprine. Two study patients restarted azathioprine on their own. Age, sex, and cause of renal failure in both groups was similar. Of the 101 study patients remaining, 9 (8.8%) returned to dialysis due to biopsy proven chronic rejection. There were no acute rejection episodes. Six of the 69 control patients (8.7%) also returned to dialysis for the same reason. Of the 92 patients who have completed the taper, 85 have been off azathioprine for six or more months. There was not a significant difference between the mean 12- and 24-month creatinine levels of the study patients (1.6 mg%, 1.7 mg%) and those of the controls (1.5 mg%, 1.8 mg%). The mean 12- and 24-month hematocritis of patients tapered (41.3%, 40.8%) were comparable with patients not tapered (42.3%, 42.8%). Of interest, the mean hematocritis of both study and control patients rose from 28.9% and 33.5%, respectively, to 41.3% and 42.3% 1 yr following entry into the study. The mean 12- and 24-month white blood counts of those tapered (8.9, 8.7) did not differ significantly from those continued on azathioprine (8.8, 8.8). In stable renal transplant patients on triple drug immunosuppression for at least 2 yr, azathioprine can be discontinued, in a tapered protocol, without an increased risk of graft loss or compromise of renal function.

Deliberate self-harm in adolescents: hopelessness, depression, problems and problem-solving

This study looks at a group of adolescents who have taken overdoses and examines the type and severity of their problems. It measures hopelessness and depression, and whether these adolescents feel their parents understand them. The study also examines the ways in which these adolescents perceive their overdose as a problem-solving mechanism.The study shows that hopelessness in adolescent self-harm is an important independent variable over and above the level of depression. The adolescents report a wide range of problems with severe and significant problems particularly in the area of family relationships and school.Finally, the paper postulates links between severity of problems, hopelessness and deficits in problem-solving abilities, and suggests areas for potential therapeutic interventions.

Allogeneic peripheral blood stem cell transplantation using normal patient-related pediatric donors

Successful allogeneic peripheral blood progenitor cell (PBPC) transplantation has recently been reported by several transplant centers. This is a first report describing allogeneic PBPC transplantation in five patients using related pediatric donors between the ages of 4 and 13 years. Donors underwent 3 or 4 days of rhG-CSF treatment (6 micrograms/kg q 12 h) for stem cell peripheralization prior to PBPC collection, which was performed by continuous-flow apheresis on day 4 or 5. Venous access was exclusively by ante-cubital veins. A median of 2.2 times (range 1.4-3.6) the donor's total blood volume (TBV) was processed per procedure. In cases where the donor's TBV was < 2 liters, the blood cell separator was primed with human serum albumin (HSA-5%), and anticoagulation was performed using a combination of heparin (pre-apheresis bolus + continuous infusion (CI)) and/or ACD-A (CI at a reduced rate). The median number of CD34+ cells collected per kg of donor body weight (b.w.) and per liter of donor blood processed during each procedure was 128 x 10(4) (range 58 x 10(4)-314 x 10(4)). Between one and two aphereses were sufficient to collect a safe CD34+ cell engraftment dose of 3 or 4 x 10(6)/kg of recipient b.w. Two PBPC recipients were parents, and three were siblings. After freezing and thawing, the median number of CD34+ cells per kg of recipient b.w. thawed and transfused was 8.5 x 10(6) (range 3.2 x 10(6)-9.7 x 10(6)). The time to PMN > 1000/microliters was between 10 and 16 days (four out of five evaluable patients), and platelets > 20000/microliters were reached between day 13 and 14 post-transplantation (three out of five evaluable patients). Two out of three evaluable patients developed grades one and three acute GVHD, and one out of three developed chronic GVHD. Two patients died of sepsis and VOD at day 10 and 19, respectively. Two adult patients are alive and in cytogenetic and molecular remission of CML at +339 and +227 days post-allotransplantation. One 3-year-old girl with hemophagocytic lymphohistiocytosis is in remission at +304 days post-transplantation. Using pediatric donors for allogeneic PBPC transplantation appears to be safe, yields a sufficient amount of progenitors for prompt engraftment, and results in clinical outcome similar to adult PBPC allotransplantation.

Cannabis use in the community

BACKGROUND

The illegal use of cannabis has been increasing in many Western countries for the past two decades. Recently, some interest has been shown in modifying legislation and control. The need for general practitioners to be aware of the short- and long-term consequences of cannabis use is increasing, and more information is required about its effects on behaviour, psychological states and the respiratory and cardiovascular systems. The use of general practice populations to study the prevalence of cannabis use and its damaging effects is less represented in the literature than it should be, considering the extent of cannabis consumption.

AIM

A study was carried out in 1995 to determine the prevalence of cannabis use in a general practice population and any associated health problems. As a pilot study, samples of cannabis were obtained for forensic analysis.

METHOD AND PATIENTS

Two questionnaires were used. One very short enquiry about the use, if any, of the drug, and a longer one about the effects of its use. Data concerning medical effects were included from patients' case notes. Samples of cannabis were obtained for forensic examination.

RESULTS

A very high proportion (61%) of patients surveyed indicated some cannabis use (past or present). Thirty-seven per cent had used it in the previous 12 months. Users could be broadly divided into transitory experimenters, regular users and heavy users. Medical problems included those attributed to associated tobacco smoking, other illegal drug use and psychological problems. Benefits perceived by patients recording use were many. Polydrug use and legislation issues were difficult to separate from the effects of cannabis itself. Chest infections, anxiety and depression, and drug dependence were common diagnoses, and 13 of the 32 females in the study group had evidence of cervical smear abnormalities.

CONCLUSIONS

Few serious damaging effects from cannabis use itself were identified, although chest infections and anxiety problems were common. Tobacco damage, associated drug use and criminal or legal issues dominated and obscured the important perceived benefits and the scientific understanding of the effects and side effects of the drug. More research into several identified areas is required.

Detachable balloon occlusion of vascular malformations in young patients

Two patients (11 and 23 months old, respectively) had successful transcatheter occlusion of congenital arterio-venous or veno-venous malformations using detachable silicone balloons. Patient 1 with a cervicofacial hemangioma had selective embolization of the feeding artery with two balloons. Patient 2, with a veno-venous malformation between a systemic vein and pulmonary vein also had selective embolization of the lesion with two balloons. Follow-up examinations confirm a successful outcome in both cases.