Discordance in patient classification using T-scores

In their original study report, "Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis," the World Health Organization (WHO) explicitly stated that any T-score criterion for osteoporosis is sensitive to bone mineral density (BMD) measurement site and technique, as well as the young adult reference population. Yet, the T = -2.5 criterion introduced by WHO is used for many different BMD techniques, despite the fact that it was based primarily on the relationship between forearm measurements and prevalent hip fracture in postmenopausal Caucasian females. It is reasonable to expect that a T-score threshold of -2.5 may be inappropriate for different skeletal sites and measurement techniques. This may explain the large variation in osteoporosis prevalence observed when different skeletal sites are measured. In this study, we compared the prevalence of osteoporosis (based on the T = -2.5 criterion) at different skeletal sites using the manufacturer's normative data. We determined the expected mean T-score for a 60-yr-old Caucasian female at the heel (ultrasound), hip (dual X-ray absorptiometry [DXA]), spine (PA DXA, lateral DXA, and quantitative computed tomography [QCT]), and forearm (DXA). Assuming a normal distribution of T-scores at a fixed age, we computed the expected percentage of 60-yr-old Caucasian women that would be classified as osteoporotic using the -2.5 standard deviation criterion for each technique. At age 60 yr, the expected mean T-score ranged from -2.5 (spine QCT) to -0.7 (heel). Prevalence estimates ranged from 3% at the heel to 50% for spinal QCT. It was also noted that the sites with the strongest relationship to hip fracture risk (the hip and heel) showed the least age-related T-score decline and lowest estimated prevalence. We conclude that a single T-score criterion cannot be universally applied to all BMD measurements. The discrepancies in the prevalence of osteoporosis are the result of several factors, including differences in age-related bone loss at different skeletal sites, differences in the young adult reference populations used by the various bone densitometry devices, and technology-related differences. Using estimated BMD by heel ultrasound, few patients will have T-scores below -2.5, whereas most postmenopausal women will fall below this level for spine bone density measurements performed by lateral DXA or QCT. Based on these data, it may be necessary to provide a T-score criterion specific to the type of densitometric evaluation performed.

Neuronal database integration: the Senselab EAV data model

We discuss an approach towards integrating heterogeneous nervous system data using an augmented Entity-Attribute-Value (EAV) schema design. This approach, widely used in implementing electronic patient record systems (EPRSs), allows the physical schema of the database to be relatively immune to changes in domain knowledge. This is because new kinds of facts are added as data (or as metadata) rather than hard-coded as the names of newly created tables or columns. Because the domain knowledge is stored as metadata, a framework developed in one scientific domain can be ported to another with only modest revision. We describe our progress in creating a code framework that handles browsing and hyperlinking of the different kinds of data.

Cationic porphyrins: novel delivery vehicles for antisense oligodeoxynucleotides

Cationic porphyrins form stable complexes with oligodeoxynucleotides. To evaluate delivery, we used a 20mer phosphorothioate oligomer (Isis 3521) targeted to the 3'-untranslated region of the PKC-alpha mRNA, and complexed it with porphyrin. The expression of PKC-alpha protein and mRNA in T24 bladder carcinoma cells was reduced by approximately 80 +/- 10% at a concentration of oligomer of 3 microM, and 9 microM porphyrin. The expression of PKC-beta1, -delta and -straightepsilon isoforms was unaffected by this treatment, but elimination of PKC-zeta protein and mRNA were observed. However, treatment with the porphyrin complex of Isis 3522, an oligomer which is directed at the 5' coding region of the PKC-alpha mRNA, was equally effective as Isis 3521 with respect to PKC-alpha, but did not affect PKC-zeta protein or mRNA levels. Since Isis 3521 has an 11-base region of complementarity with the PKC-zeta mRNA, wheras Isis 3522 has only a 4-base region, the effect of Isis 3521 on PKC-zeta protein and mRNA expression may be due to irrelevant cleavage. Depending upon the desired application, this new strategy may offer several advantages over other methods of antisense oligodeoxynucleotide delivery including efficiency, stability, solubility, relatively low toxicity and serum compatibility. Porphyrins may thus be a potentially useful delivery vehicle for antisense therapeutics and/or target validation.

Rotated drawing: the range of performance and anatomical correlates in a series of 16 patients

Recently there has been interest in an unusual neuropsychological disorder in which the patient copies a complex drawing in a position which is grossly rotated relative to the original. This disorder is of interest partly because of its relationship to current theories of the process of object recognition, but the range of performances typically seen, as well as its anatomical correlates, remain obscure. We report 16 cases who produced grossly rotated drawings of the Rey and Taylor Complex Figures. These patients were drawn from an unselected series of 240 cases, with a wide variety of lesion types and sites. The performances of the 16 patients displayed striking similarities. We describe the formal features of these drawings and plot their anatomical correlates.

Management of postmenopausal osteoporosis for primary care

OBJECTIVE

The shift in health care delivery from a subspecialty to primary care system has transferred the responsibility of preventing osteoporotic fractures from specialists in metabolic bone disease to the web of physicians--family practitioners, general internists, pediatricians, and gynecologists--who provide the bulk of primary care. The challenge for this group of physicians is to decrease the rising prevalence of osteoporotic hip and vertebral fractures while operating within the cost parameters. It is the goal of this brief summary to provide primary practitioners with focused guidelines for the management of postmenopausal osteoporosis based on new and exciting developments. Prevention and treatment will change rapidly over the next decade and these advances will require changes in these recommendations.

DESIGN

We identified patients at risk for osteoporosis and provided indications for bone mass measurement, criteria for diagnosis of osteoporosis, therapeutic interventions, and biochemical markers of the disease.

RESULTS

Prevention and treatment are discussed, including hormone replacement therapy and use of calcitonin, sodium fluoride, bisphosphonates, and serum estrogen receptor modulators.

CONCLUSIONS

Postmenopausal osteoporosis should no longer be an accepted process of aging. It is both preventable and treatable. Primary care physicians must proactively prevent and treat osteoporosis in their daily practice, and combination therapies are suggested.

A methodology for sampling and accessing homeless individuals in Melbourne, 1995-96

A methodology for sampling homeless populations in inner Melbourne was developed to study their health status and prevalence of tuberculosis. This paper describes the design, development and implementation of the project. The results of health status and tuberculosis analysis are published elsewhere. Involvement and interaction with local service providers and agencies to homeless people was central to the project throughout. A definitional construct of homelessness was developed, drawn from local and overseas literature and contemporary local experience. The study's aim was to obtain a representative sample of homeless individuals in various levels of accommodation and a convenience sample of those who were unaccommodated (streets and parks). A comprehensive sampling frame of accommodation options was constructed from available databases, and systematic sampling applied to produce a sample of 396 beds, from which 284 participants were enrolled. Convenience sampling of unaccommodated homeless individuals produced 100 participants. All agreed to undergo a comprehensive questionnaire, blood and Mantoux testing, the latter being completed successfully in 94%. Commonsense, cultural sensitivity and a non-threatening approach were critical to the success of the project and the security of the field workers. The methods described attempt to address recognised difficulties of sampling from homeless populations and should be reproducible both in the future and elsewhere. Potential for selection bias remains the main threat to validity, which the described methodology combined with adequate resources should help to address.

[A comparison of the monitor and alternator findings of digital thoracic images with the aid of a computer-supported procedure]

PURPOSE

To compare softcopy and hardcopy reading of chest radiographs a software tool was designed for creating lesions with clearly defined size, location and contrast.

METHOD

An ROC study was performed using a set of chest radiographs with 300 simulated small nodules and linear details displayed on film and on a 1 K monitor. Six observers participated in the study. ROC curves were generated on the basis of 7200 decisions.

RESULTS

There was no significant difference in observer performance overall (AUC = Area under curve). Monitor: 0.84 +/- 0.08 vs. AUC, Film: 0.84 +/- 0.08). Slight, but not statistical significant differences were found in the detection of low-contrast lung nodules and of linear lung details.

CONCLUSION

Soft-copy reading using a high quality 1 K CRT display provides the same accuracy for the detection of subtle computer-simulated lesions as hardcopy reading. A software tool could be used for assigning optimal characteristics of CRT- and hardcopy displays using clearly defined lesions as a gold standard.

New survey shows rift between health executives and radiologists

This report marks International Radiology Group's first annual survey of hospital administrators and diagnostic imaging department heads. The survey was conducted to determine how the managers of diagnostic imaging departments at a broad range of hospitals evaluate the quality and cost effectiveness of their departments. In particular, the survey addresses how administrators and department heads evaluate the working relationships they have developed with radiologists affiliated with their facilities.

Health indicators and risks among people experiencing homelessness in Melbourne, 1995-1996

During the study's first stage, 284 homeless people from crisis and long-term accommodation sites were surveyed using stratified, systematic sampling. The second stage involved a survey of a convenience sample of 100 homeless people from squats and the streets. Participants completed a questionnaire, Mantoux testing was performed and blood taken for gamma-interferon assay, liver and renal function tests. The group's health status was poor, with 72% experiencing medical conditions in the preceding two years and 77% symptoms in the month prior to interview. Bronchitis, asthma and gastroenteritis were the most commonly reported conditions; productive and persistent coughing, shortness of breath and wheezing the commonest symptoms. Twenty-one per cent had Mantoux reactions 15 mm or greater, 28% a raised GGT and 19% a raised ALT. Seventy-seven per cent smoked, 74% were current drinkers, 28% had injected drugs at some time in their lives and 14% were regularly injecting drugs. Forty-four per cent had experienced mental illness, 49% of whom reported depression and 15% schizophrenia. Homeless people in Melbourne have poor health status and engage in behaviours that place their health at risk. The high number of respiratory and gastro-intestinal complaints, the high level of cigarette smoking and injecting drug use (IDU) and the proportion likely to be infected with Mycobacterium tuberculosis (MTb) are all issues with important health consequences. Participants recruited from the street had significantly poorer health and engaged in more risk behaviours than those from accommodation sites; those from the accommodated sample were more likely to be infected with Mtb.

The Bridge to Health Project: a collaborative model for assessing the health of a community

The Bridge to Health Project, a collaborative effort of 70 health related organizations, was designed to collect population-based health status data about approximately a half million residents in a primarily rural region in northeast Minnesota and northwest Wisconsin. Funding and staff support were provided by a regional medical center. The importance of sound survey methodology, role clarification, adequate staff support, and a well organized process to foster collaboration have applicability to other regions considering a collaborative process of health status assessment.

Funding. Adding to local divisions

The white paper proposal to fund primary care groups according to a set formula is beset with difficulties. At present there appears to be no suitable formula for allocating funds at sub-district level. Applying to primary care the national formula now used to allocate funds to health authorities would change current spending considerably and could lead to greater inequities.

Capillary electrophoresis determinative and LC-MS confirmatory method for screening selected imidazolinone herbicides from soil

Residues of imazapyr, imazamox, imazapic, imazethapyr, imazaquin, and imazamethabenz (meta and para) are extracted from soil with 0.5 N sodium hydroxide. The pH is adjusted to 2.0-2.2, and the resulting precipitate is filtered. Compounds are trapped onto a tC18 solid-phase extraction (SPE) cartridge, then eluted from the cartridge and passed through a strong anion exchange (SAX) SPE cartridge onto a benzenesulfonic acid strong cation exchange (SCX) cartridge using ethyl acetate. After eluting the analytes from the SCX cartridge using saturated potassium chloride in methanol, the solution is evaporated and redissolved in 1% formic acid in water. The sample is then desalted using a tC18 SPE cartridge and eluted with methanol. After evaporating the methanol to dryness, the compounds are partitioned from acidic solution (pH 3.5) into methylene chloride. The methylene chloride is evaporated to dryness and the residues are then dissolved in Milli-Q water (Millipore, Bedford, MA, U.S.A.) in preparation for analysis by capillary electrophoresis. Results are calculated by direct comparison of the sample peak heights to the peak heights of bracketing standards. The validated sensitivity of the method (LOQ, limit of quantitation) is 2.0 ppb for each compound. Confirmation for individual residues greater than 2.0 ppb is provided by liquid chromatography-electrospray ionization mass spectrometry (LC-ESMS) of the final extract.

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.