Unicompartmental knee replacement for patients with partial thickness cartilage loss in the affected compartment

It is recommended that in medial compartment osteoarthritis (OA) unicompartmental knee replacement (UKR) should not be undertaken unless there is bone on bone. This recommendation is not evidence based and it is important to know if it is correct as there are many patients with pain and partial thickness cartilage loss (PTCL) who could potentially benefit from UKR. The aim of this study was to determine if the recommendation is valid. From our database of over 1000 patients treated with the Oxford UKR, we identified 29 with medial OA that had PTCL, confirmed at operation, but otherwise satisfied the recommended indications. This group was matched with 29 knees that had bone exposed (BE) on both sides of the medial compartment and 29 knees that had bone loss (BL) on both sides of the medial compartment. There was no significant difference in the demographics or preoperative scores between the three groups. At a mean follow up of 2 years (range 1-6) the Oxford Knee Score (OKS) of the PTCL group (mean 36 SD 10) was significantly (p < 0.001) worse than the OKS of either the bone exposed group (mean 43 SD 4) or the bone loss group (mean 43 SD 5). 21% of those with PTCL did not benefit substantially from the operation (increase in OKS ≤ 6), whereas all patients in the other groups did. We conclude that the results of UKR for PTCL are unpredictable and therefore that UKR should only be done for medial compartment OA if there is bone on bone. There is a need to develop a method to identify which patients with PTCL will do well so that this subgroup could be treated with UKR.

Minimally invasive Oxford phase 3 unicompartmental knee replacement: results of 1000 cases

This prospective study describes the outcome of the first 1000 phase 3 Oxford medial unicompartmental knee replacements (UKRs) implanted using a minimally invasive surgical approach for the recommended indications by two surgeons and followed up independently. The mean follow-up was 5.6 years (1 to 11) with 547 knees having a minimum follow-up of five years. At five years their mean Oxford knee score was 41.3 (sd 7.2), the mean American Knee Society Objective Score 86.4 (sd 13.4), mean American Knee Society Functional Score 86.1 (sd 16.6), mean Tegner activity score 2.8 (sd 1.1). For the entire cohort, the mean maximum flexion was 130° at the time of final review. The incidence of implant-related re-operations was 2.9%; of these 29 re-operations two were revisions requiring revision knee replacement components with stems and wedges, 17 were conversions to a primary total knee replacement, six were open reductions for dislocation of the bearing, three were secondary lateral UKRs and one was revision of a tibial component. The most common reason for further surgical intervention was progression of arthritis in the lateral compartment (0.9%), followed by dislocation of the bearing (0.6%) and revision for unexplained pain (0.6%). If all implant-related re-operations are considered failures, the ten-year survival rate was 96% (95% confidence interval, 92.5 to 99.5). If only revisions requiring revision components are considered failures the ten-year survival rate is 99.8% (confidence interval 99 to 100). This is the largest published series of UKRs implanted through a minimally invasive surgical approach and with ten-year survival data. The survival rates are similar to those obtained with a standard open approach whereas the function is better. This demonstrates the effectiveness and safety of a minimally invasive surgical approach for implanting the Oxford UKR.

Constitutional translocation breakpoint mapping by genome-wide paired-end sequencing identifies HACE1 as a putative Wilms tumour susceptibility gene

BACKGROUND

Localisation of the breakpoints of chromosomal translocations has aided the discovery of several disease genes but has traditionally required laborious investigation of chromosomes by fluorescent in situ hybridisation approaches. Here, a strategy that utilises genome-wide paired-end massively parallel DNA sequencing to rapidly map translocation breakpoints is reported. This method was used to fine map a de novo t(5;6)(q21;q21) translocation in a child with bilateral, young-onset Wilms tumour.

METHODS AND RESULTS

Genome-wide paired-end sequencing was performed for approximately 6 million randomly generated approximately 3 kb fragments from constitutional DNA containing the translocation, and six fragments in which one end mapped to chromosome 5 and the other to chromosome 6 were identified. This mapped the translocation breakpoints to within 1.7 kb. Then, PCR assays that amplified across the rearrangement junction were designed to characterise the breakpoints at sequence-level resolution. The 6q21 breakpoint transects and truncates HACE1, an E3 ubiquitin-protein ligase that has been implicated as a somatically inactivated target in Wilms tumourigenesis. To evaluate the contribution of HACE1 to Wilms tumour predisposition, the gene was mutationally screened in 450 individuals with Wilms tumour. One child with unilateral Wilms tumour and a truncating HACE1 mutation was identified.

CONCLUSIONS

These data indicate that constitutional disruption of HACE1 likely predisposes to Wilms tumour. However, HACE1 mutations are rare and therefore can only make a small contribution to Wilms tumour incidence. More broadly, this study demonstrates the utility of genome-wide paired-end sequencing in the delineation of apparently balanced chromosomal translocations, for which it is likely to become the method of choice.

The role of foot and ankle assessment of patients with lower limb osteoarthritis

OBJECTIVES

Physiotherapists do not routinely examine the feet of patients with lower limb osteoarthritis, and there is no widely used tool for measuring foot posture. However, differences in foot posture have been demonstrated between patients with medial compartment osteoarthritis of the knee and osteoarthritis of the hip, and guidelines for managing these patients include interventions such as orthotics which presume foot assessment. This study considers a new clinical tool, the Foot Posture Index (FPI). It examines its utility in a physiotherapy outpatient setting with a cohort of patients with medial compartment osteoarthritis of the knee and osteoarthritis of the hip, and investigates the relationship of FPI scores with the range of dorsiflexion of the ankle.

DESIGN

Cross-sectional observational study.

SETTING

A specialist orthopaedic hospital.

PARTICIPANTS

In total, there were 60 participants: 20 patients with medial compartment osteoarthritis of the knee, 20 patients with osteoarthritis of the hip, and a control group of 20 age-matched healthy volunteers.

OUTCOME MEASURES

A single measurement of the FPI and range of dorsiflexion.

RESULTS

Significant differences in FPI scores and range of dorsiflexion were seen between groups. On average, patients with osteoarthritis of the hip had more supinated, plantarflexed feet, and patients with medial compartment osteoarthritis of the knee had pronated feet. Healthy controls fell within the normal range. Patients with osteoarthritis of the hip had a median FPI score of -4.5, patients with medial compartment osteoarthritis of the knee had a median FPI score of 7.0, and the healthy controls had a median FPI score of 1.0. The median difference in FPI scores between patients with osteoarthritis of the hip and medial compartment osteoarthritis of the knee was 12 [95% confidence interval (CI) 10 to 13]; between patients with osteoarthritis of the hip and the healthy group was 6 (95% CI 3 to 9); and between patients with medial compartment osteoarthritis of the knee and the healthy group was 5 (95% CI 3 to 8). The median difference in dorsiflexion scores between patients with osteoarthritis of the hip and medial compartment osteoarthritis of the knee was 10 degrees (95% CI 8 to 15); between patients with osteoarthritis of the hip and the healthy group was 10 degrees (95% CI 7 to 15); and between patients with medial compartment osteoarthritis of the knee and the healthy group was 0 degrees (95% CI -3 to 5). Foot posture and range of dorsiflexion were moderately positively correlated (rho 0.57), with pronated feet having a greater range of dorsiflexion.

CONCLUSION

The FPI is sufficiently sensitive to measure differences in foot posture of patients with medial compartment osteoarthritis of the knee and osteoarthritis of the hip, and is easy to use. Accurate foot assessment is useful as foot postures may be influenced by specific physiotherapy treatment modalities and orthotic interventions.

A novel gel-based method for self-collection and ambient temperature postal transport of urine for PCR detection of Chlamydia trachomatis

OBJECTIVES

The aim of this study was to develop a novel urine transport method to be used in self-collection-based screening for Chlamydia trachomatis. The method needed to be suitable for C trachomatis PCR detection, be economical and suitable for transport by standard envelope mailing.

METHODS

An anhydrous gel composed of super-absorbent polymer and buffering agent was used to desiccate urine into a dry granulous state, which could subsequently be reconstituted upon arrival at a laboratory. DNA was then extracted from the reconstituted solution using the Roche MagNA Pure protocol for the detection of C trachomatis by PCR. Collections of urine specimens from three populations with widely differing chlamydia prevalence (100%,n = 56; 47%, n = 70; 3%, n = 97) were used. We determined the gel method's impact on C trachomatis PCR sensitivity and specificity using neat and gel-processed urine specimens. An equine herpes virus PCR was used to test for assay inhibition.

RESULTS

Overall, the sensitivity of the gel-based method ranged from 94.6-100% compared with neat urine, with a specificity of 100%. No PCR inhibition or decrease in analytical sensitivity was observed using the gel-processed extracts.

CONCLUSIONS

The gel-based method was found to be suitable for the detection of C trachomatis by PCR. In addition, its ease of use, effectiveness at ambient temperature and low cost makes it well-suited for self-collection kits used in population-based C trachomatis screening, particularly for geographically and socially isolated individuals.

Development of a method for detection of Giardia duodenalis cysts on lettuce and for simultaneous analysis of salad products for the presence of Giardia cysts and Cryptosporidium oocysts

We report a method for detecting Giardia duodenalis cysts on lettuce, which we subsequently use to examine salad products for the presence of Giardia cysts and Cryptosporidium oocysts. The method is based on four basic steps: extraction of cysts from the foodstuffs, concentration of the extract and separation of the cysts from food materials, staining of the cysts to allow their visualization, and identification of cysts by microscopy. The concentration and separation steps are performed by centrifugation, followed by immunomagnetic separation using proprietary kits. Cyst staining is also performed using proprietary reagents. The method recovered 46.0% +/- 19.0% (n = 30) of artificially contaminating cysts in 30 g of lettuce. We tested the method on a variety of commercially available natural foods, which we also seeded with a commercially available internal control, immediately prior to concentration of the extract. Recoveries of the Texas Red-stained Giardia cyst and Cryptosporidium oocyst internal controls were 36.5% +/- 14.3% and 36.2% +/- 19.7% (n = 20), respectively. One natural food sample of organic watercress, spinach, and rocket salad contained one Giardia cyst 50 g(-1) of sample as an indigenous surface contaminant.

46. INNOVATION AND DESIGN: IMPROVING CONTACT TRACING IN SEXUAL HEALTH CLINICS

Contact tracing (CT) is an integral part of sexually transmitted infection (STI) management. Although routinely conducted in most sexual health clinics (SHCs), the methods used may vary. To improve CT required novel approaches. First we audited the outcomes of current contact tracing methods. A major finding of this audit was that while CT was routinely recommended, outcomes were poorly recorded. We developed a sticker to be placed in the charts of clients with a traceable STI. This indicated the number of contacts requiring notification, and how many had been notified and treated at our clinic. This enabled a standardised approach to CT records and improved ability to audit outcomes. It also focused clinicians on the need to ensure followup of CT and to offer assistance when CT had not been done. Next, a brochure was developed to give to clients when diagnosed with a traceable STI. This brochure mentioned the reasons for contacting patterns, dispelled some myths that have been found in previous studies about telling partners and provided ideas about how to tell partners. In conjunction with this a SMS was developed, that could be sent to index cases' mobile phones, allowing them to forward the SMS to partners. This was seen as an ideal method for young people who frequently had mobile numbers of past partners but little other contact details. It was also able to be simple and quick. The next step will be reauditing the CT outcomes once the SMS and brochure are in established use.

Towards standard methods for the detection of Cryptosporidium parvum on lettuce and raspberries. Part 2: validation

We report the results of interlaboratory collaborative trials of methods to detect oocysts of the protozoan parasite Cryptosporidium parvum on lettuce and raspberries. The trials involved eight expert laboratories in the United Kingdom. Samples comprised 30 g lettuce, and 60 g raspberries. Lettuce samples were artificially contaminated at three levels: low (8.5-14.2 oocysts), medium (53.5-62.6 oocysts), and high (111.3-135.0 oocysts). Non-contaminated lettuce samples were also tested. The method had an overall sensitivity (correct identification of all artificially contaminated lettuce samples) of 89.6%, and a specificity (correct identification of non-contaminated samples) of 85.4%. The total median percentage recovery (from all artificially contaminated samples) produced by the method was 30.4%. The method was just as reproducible between laboratories, as repeatable within a laboratory. Raspberry samples were artificially contaminated at three levels: low (8.5-26.8 oocysts), medium (29.7-65.7 oocysts), and high (53.9-131.3 oocysts). Non-contaminated raspberry samples were also tested. The method had an overall sensitivity (correct identification of all artificially contaminated raspberry samples) of 95.8%, and a specificity (correct identification of non-contaminated samples) of 83.3%. The total median percentage recovery (from all artificially contaminated samples) produced by the method was 44.3%. The method was just as reproducible between laboratories, as repeatable within a laboratory. The results of the collaborative trial indicate that these assays can be used effectively in analytical microbiological laboratories.

Towards standard methods for the detection of Cryptosporidium parvum on lettuce and raspberries. Part 1: development and optimization of methods

No standard method is available for detecting protozoan parasites on foods such as soft fruit and salad vegetables. We report on optimizing methods for detecting Cryptosporidium parvum on lettuce and raspberries. These methods are based on four basic stages: extraction of oocysts from the foodstuffs, concentration of the extract and separation of the oocysts from food materials, staining of the oocysts to allow their visualization, and identification of oocysts by microscopy. The concentration and separation steps are performed by centrifugation, followed by immunomagnetic separation using proprietary kits. Oocyst staining is also performed using proprietary reagents. The performance parameters of the extraction steps were extensively optimized, using artificially contaminated samples. The fully developed methods were tested several times to determine their reliability. The method to detect C. parvum on lettuce recovered 59.0+/-12.0% (n=30) of artificially contaminated oocysts. The method to detect C. parvum on raspberries recovered 41.0+/-13.0% (n=30) of artificially contaminated oocysts.

The Oxford medial unicompartmental knee replacement using a minimally-invasive approach

This prospective study describes the complications and survival of the first 688 Phase 3 Oxford medial unicompartmental knee replacements implanted using a minimally-invasive technique by two surgeons and followed up independently. None was lost to follow-up. We had carried out 132 of the procedures more than five years ago. The clinical assessment of 101 of these which were available for review at five years is also presented. Nine of the 688 knees were revised: four for infection, three for dislocation of the bearing and two for unexplained pain. A further seven knees (1%) required other procedures: four had a manipulation under anaesthesia, two an arthroscopy and one a debridement for superficial infection. The survival rate at seven years was 97.3% (95% confidence interval 5.3). At five years, 96% of the patients had a good or excellent American Knee Society score, the mean Oxford knee score was 39 and the mean flexion was 133 degrees. This study demonstrates that the minimally-invasive Oxford unicompartmental knee replacement is a reliable and effective procedure.

The relative significance of preoperative oral antibiotics, mechanical bowel preparation, and preoperative peritoneal contamination in the avoidance of sepsis after radical surgery for ulcerative colitis and Crohn's disease of the large bowel

This paper reports the results of a prospective, random, controlled study of two régimes of preparation of the bowel in 100 patients undergoing elective radical surgery for non-specific inflammatory disease of the colon.

Every patient received identical dietary preparation for surgery. No aperients or enemas were given in view of the inflamed state of the bowel. All patients received phthalylsulphathiazole, and in addition 50 patients chosen at random were given Colomycin. The two groups who did or did not receive Colomycin were well matched in respect of age, sex, type of operation, and steroid therapy.

The addition of Colomycin to the standard régime of mechanical preparation and sulphonamides conferred no benefit to the patient in terms of postoperative complication rates. However, significantly increased rates of wound sepsis and paralytic ileus were found in patients who had a loaded colon at laparotomy or in whom faecal contamination of the peritoneal cavity occurred during operation.

These results suggest that antibiotic sterilization of the large bowel, whatever its intrinsic merits, is no substitute for adequate mechanical preparation and meticulous attention to surgical technique.

Reliability and responsiveness of the shuttle walking test in patients with chronic low back pain

BACKGROUND AND PURPOSE

Walking is an important functional activity and the shuttle walking test has been shown to be a useful test for patients with chronic airways obstruction and heart failure. The test has been used in low back pain research over recent years and has increasingly been used as an outcome measure to investigate treatment efficacy in patients with low back pain. The aim of the present study was to determine the reliability and responsiveness of the shuttle walking test within a group of patients with low back pain (with or without sciatica).

METHOD

Reliability of the shuttle walking test was determined on a group of patients with low back pain (n = 44) using the Bland and Altman (1986) limits of agreement and the intraclass correlation coefficient (ICC). Responsiveness was assessed using the standardized effect size. The mean distance walked within a patient population (n = 337) was compared with an age- and sex-matched group of healthy subjects (n = 122).

RESULTS

The shuttle walking test obtained an ICC score of 0.99, whereas the limits of agreement test gave a mean difference of 2.5 m with upper and lower limits of agreement of 52 m and -47 m, respectively. Patients undertaking fitness training reached an effect size of 1.2 compared to a control group of 0.23 and 0.94 for a group undergoing various orthopaedic treatments.

CONCLUSIONS

The present study has shown that the shuttle walking test is a reliable and responsive test within a group of patients with low back pain, with or without sciatica. It is simple to administer and provides a quick method of measuring one aspect of a patient's physical function.

Localization of a gene (MCUL1) for multiple cutaneous leiomyomata and uterine fibroids to chromosome 1q42.3-q43

Dominant transmission of multiple uterine and cutaneous smooth-muscle tumors is seen in the disorder multiple leiomyomatosis (ML). We undertook a genomewide screen of 11 families segregating ML and found evidence for linkage to chromosome 1q42.3-q43 (maximum multipoint LOD score 5.40). Haplotype construction and analysis of recombinations permitted the minimal interval containing the locus, which we have designated "MCUL1," to be refined to an approximately 14-cM region flanked by markers D1S517 and D1S2842. Allelic-loss studies of tumors indicated that MCUL1 may act as a tumor suppressor. Identification of MCUL1 should have wide interest, since this gene may harbor low-penetrance variants predisposing to the common form of uterine fibroids and/or may undergo somatic mutation in sporadic leiomyomata.

Time and cost analysis of repacking medications in unit-of-use containers

OBJECTIVES

To evaluate the effects of repacking drugs in unit-of-use containers in community pharmacies. The purpose of this study was to examine whether unit-of-use repacking reduces routine mechanical "counting and pouring" to allow more time for pharmaceutical care.

DESIGN

Simulation pilot study to evaluate the differences between the existing and proposed systems. Based on the literature, four variables--optimum pack size, time savings, packaging costs, and shelving requirements--were selected for evaluation. Historical prescription data from a chain were used in determining the sample drugs and their optimum pack sizes. Workflow analysis and time study were used to estimate the time savings. Manufacturer bottles, repack bottles, and shelves were measured to determine the impact of using unit-of-use containers on storage requirements.

SETTING

Three community pharmacies in a major drugstore chain in Cincinnati, Ohio.

RESULTS

The 25 fastest-moving solid oral dosage forms, representing 21.6% of all drugs dispensed by the chain, were selected as the sample drugs for the study. The workflow analysis and time study revealed that 0.79 minutes could be saved per prescription if repacked drugs were used. There was an increased cost of approximately $0.05 for every repack bottle used in place of a prescription vial. It was calculated that repacking in unit-of-use containers would increase storage requirements in the pharmacy by 2.5 times if current inventory levels were maintained.

CONCLUSION

Repacking drugs in unit-of-use containers is potentially an inexpensive method to increase usable time in the pharmacy that does not require an increase in personnel or the purchase of additional technology at the store level.

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.

Immature human monocyte-derived dendritic cells migrate rapidly to draining lymph nodes after intradermal injection for melanoma immunotherapy

Injected antigen-loaded immature monocyte-derived dendritic cells (DCs) may be incapable of migrating from skin to draining lymph nodes for antigen presentation. The in vivo migratory capacity of intradermally administered immature monocyte-derived DCs was therefore investigated during a phase I/II clinical trial for metastatic melanoma. DCs cultured from adherent monocytes in the presence of autologous serum, granulocyte-macrophage colony stimulating factor and interleukin-4 were pulsed with antigen and labelled with technetium-99m hexamethylpropylene-amineoxime (99mTc-HMPAO) ex vivo, then injected intradermally. A 99mTc-HMPAO control containing an equivalent amount of radioactivity was injected into the opposite thigh. The pelvis was then imaged with a gamma camera. The DCs were characterized as immature by functional and phenotypic analysis. Labelled DCs travelled to the draining inguinal lymph nodes within 10 min, and the draining lymph nodes were clearly outlined up to 4 h after injection. Free NmTc outlined draining lymph nodes after 10 min but was cleared from the nodes within 1 h. Thus, immature human monocyte-derived DCs migrate rapidly to and remain in draining lymph nodes after intradermal injection for immunotherapy.

Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic

In Bambari and Bria, 2 towns in the Central African Republic (CAR), we analysed a patient-led partner referral programme within enhanced sexually transmitted disease (STD) services. New (index) patients received syndromic management, counselling about notifying and treating contacts, and vouchers for distribution. From October 1993 to February 1996, 5232 and 4320 patient visits, of which 1814 (35%) and 4320 (30%) were contact referral visits, were logged in Bambari and Bria, respectively. Vouchers were distributed for at least 90% of contacts. Index and contact patients had similar age and sex distributions. In both towns, having a spouse (Bambari: odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4–1.7; Bria: OR 1.9, 95% CI 1.5–2.3) was a factor associated with successful referral of a partner. Successful referral was accomplished by both male and female patients. Appropriate counselling techniques and vouchers facilitated partner referral. Further research on how to reach casual partners would enhance STD control efforts using patient-led partner referral.

Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic

In Bambari and Bria, 2 towns in the Central African Republic (CAR), we analysed a patient-led partner referral programme within enhanced sexually transmitted disease (STD) services. New (index) patients received syndromic management, counselling about notifying and treating contacts, and vouchers for distribution. From October 1993 to February 1996, 5232 and 4320 patient visits, of which 1814 (35%) and 4320 (30%) were contact referral visits, were logged in Bambari and Bria, respectively. Vouchers were distributed for at least 90% of contacts. Index and contact patients had similar age and sex distributions. In both towns, having a spouse (Bambari: odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4-1.7; Bria: OR 1.9, 95% CI 1.5-2.3) was a factor associated with successful referral of a partner. Successful referral was accomplished by both male and female patients. Appropriate counselling techniques and vouchers facilitated partner referral. Further research on how to reach casual partners would enhance STD control efforts using patient-led partner referral.

Marimastat in recurrent colorectal cancer: exploratory evaluation of biological activity by measurement of carcinoembryonic antigen

Marimastat is a specific inhibitor of matrix metalloproteinases that has been shown to be effective in cancer models. A pilot, escalating-dose study of oral marimastat was performed in patients with recurrent colorectal cancer, in whom evaluation of serological response was made by measurement of carcinoembryonic antigen (CEA) levels. The study assessed the safety and tolerability of 4 weeks administration of marimastat, and determined a dose range producing detectable serological effects. Patients were recruited with a serum CEA level greater than 5 ng ml(-1), and rising by more than 25% over a 4-week screening period. Patients were treated for 28 days and entered into a continuation protocol if a serological response or clinical benefit was observed. Pharmacokinetic and safety data determined that groups of patients were recruited sequentially at 25 mg and 50 mg twice daily, and, thereafter, 10 mg twice daily, 10 mg once daily, 5 mg once daily and 20 mg once daily. A biological effect (BE) was defined as a CEA value on day 28 no greater than on day 0; a partial biological effect (PBE) was defined as a rise in CEA over the 28-day treatment period of less than 25%. Of 70 patients recruited, 63 completed the 28-day treatment period, and 55 were eligible for cancer antigen analysis. Examination of the dose-effect relationships provides evidence for a causal relationship between marimastat and biological effects: the proportion of patients with BE or PBE was higher with twice daily dosing (16 out of 25, 64%) than with once daily dosing (11 out of 30, 37%) (P = 0.043, chi2 test). Furthermore, the median rates of rise of CEA fell markedly during treatment compared with the screening period for patients receiving twice daily marimastat (P<0.0001), but not for patients receiving marimastat once daily (P = 0.25). Musculoskeletal adverse events emerged as the principal drug-related toxicity of marimastat, occurring in a dose- and time-dependent fashion. It was concluded that marimastat was associated with dose-dependent biological effects in cancer patients. The occurrence of musculoskeletal side-effects define 25 mg twice daily as the upper limit of the dose range for continuous use in further studies. Therefore, a dose range of 20 mg once daily to 25 mg twice daily seems appropriate for further studies, which should aim to demonstrate the efficacy of the drug in terms of conventional clinical end points and describe the long-term tolerability of this novel agent.

Fish immunology: the utility of immortalized lymphoid cells--a mini review

Long term cell lines can be readily established at high frequency with PBLs from normal channel catfish. Depending upon the mode of stimulation, morphologically and functionally distinct catfish lymphoid cell lines resembling B cells, T cells and monocytes have been developed. These fish cell lines appear unique from their putative mammalian counterparts in that they are immortalized without the need for exogenous factors or overt attempts at transformation.

Nonadherent cultures of human monocytes kill Mycobacterium smegmatis, but adherent cultures do not

Human peripheral blood monocytes are permissive for the growth of Mycobacterium tuberculosis, but the fate of nonpathogenic Mycobacterium smegmatis in these cells is not known. Since M. smegmatis may be used as a host with which to express and screen for M. tuberculosis genes needed for survival in monocytes, we determined whether human peripheral blood monocytes could restrict the growth of Mycobacterium smegmatis. Adherent human peripheral blood monocytes were permissive for the growth of M. smegmatis, as measured by ex vivo [3H]uracil uptake. However, human peripheral blood monocytes which were cultured nonadherently in Teflon wells were able to restrict the growth of M. smegmatis while remaining permissive for the growth of M. tuberculosis H37Ra. The loss of viability of M. smegmatis in nonadherent cells was correlated with an increase in nonspacious phagocytic vacuoles. The killing of M. smegmatis was not blocked by NG-monomethyl-L-arginine, suggesting that it was not due to the production of reactive nitrogen intermediates. Incubation of the monocytes for 1 to 7 days before infection had no effect on the fate of M. smegmatis, suggesting that adherence versus nonadherence, and not differentiation, was the key determinant for the difference in functional ability. Nonadherent human peripheral blood monocytes may be a more appropriate model than adherent cells for the study of factors employed by bacterial to survive within monocytes and for selection screening of bacterial genes needed for intracellular survival.

Developing a Teaching Video on Mechanical Ventilation Weaning to Facilitate Effective Nursing Research

This article describes the process of developing a teaching video associated with conducting a nursing research study and directed at educating critical care staff nurses about the process of successfully weaning patients from mechanical ventilation. Techniques on developing the script and filming and editing the video are presented. The results of this process included staff empowerment and a teaching video used by 10 hospitals in a multi-site research project.

Development of altered taste preferences in tumor-bearing rats

Experimental tumors induce a decline in food intake that may derive from changes in taste or the development of taste aversions. The preferences of tumor-bearing (TB) and non-tumor-bearing (NTB) rats for five chemicals (three palatable and two aversive taste stimuli) were studied in an animal model of experimental cancer employing the methylcholanthrene (MCA) sarcoma. In protocol 1, five groups of Fischer 344 rats were given 23-h, two-bottle preference tests (taste solution vs. water) daily from day 3 after tumor implantation until spontaneous death occurred. Both NTB and TB rats avoided quinine hydrochloride and hydrochloric acid solutions throughout the experiment indicating that tumor growth produced no disruption in the animals' perception of these normally aversive tastes. In both groups, preference for sucrose (88% to 97%) and saccharin (75% to 93%) remained high until days 22 and 17 respectively, but tended to decline with advanced tumor growth. In both cases, a reduction in total calorie intake preceded the changes in sucrose or saccharin preference by several days. With or without a tumor, rats exhibited approximately 50% preference for NaCl at all times. In protocol 2, a four-bottle preference test (sucrose vs. saccharin vs. NaCl vs. water) was administered before tumor implantation and again 3 weeks later when a decline in food intake was evident. Both TB and NTB rats displayed a dominant preference for sucrose over saccharin, NaCl, and water at the pre- and posttests. However, a comparison of the difference scores (pre- minus postimplantation) of NTB and TB rats showed a small but significant suppression of TB animals' preference for sucrose. The altered preferences for sweet but not salt taste stimuli suggest that food-related taste cues may be more susceptible to the development of taste aversions during cancer. However the contribution of taste changes to the anorexia of cancer remains unclear and it is possible that the changes in taste preference may be secondary to the reduction in food intake.

A transmembrane protein-tyrosine phosphatase contains spectrin-like repeats in its extracellular domain

We report the first chicken transmembrane protein-tyrosine phosphatase, ChPTP lambda, isolated from a brain cDNA library and preB cells. ChPTP lambda has transcripts of about 5.6 kilobases and is abundant in spleen, intestine, and fibroblasts transformed by oncogenic ras or erbA/B. It has five alternative splicing products varying near their amino termini, and the largest one contains 1237 amino acids. The extracellular domain of ChPTP lambda has several features including a Ser/Thr/Pro-rich region, one fibronectin type III module, and spectrin-like repeats (the first case that spectrin-like repeats were found in the non-cytoplasmic compartment). These repeats were also found in other phosphatases, including CD45 and yeast acid phosphatases PHO5 and PHO3. Antibodies to ChPTP lambda recognized several protein species whose M(r) range from 170,000 to 210,000. ChPTP lambda exhibited phosphotyrosine-specific phosphatase activity. Since CD45 also has these features in the extracellular domain and the two protein-tyrosine phosphatases share 70% similarity in the intracellular domains, we propose that ChPTP lambda and CD45 belong to the same gene family.

Effect of a clinical psychopharmacy consultation service on patient outcomes

The effect of a psychopharmacy consultation service on outcomes in patients with psychiatric disorders was studied. The medical records of 30 randomly selected patients who had been hospitalized between August 1990 and July 1992 at a private psychiatric institution and who had been seen by the psychopharmacy consultation service during that period were reviewed. Data obtained included (1) patient demographics, (2) patient information generated by the psychopharmacy consultation, (3) the types of recommendations made by the psychopharmacy specialist and whether the recommendations were accepted by the physician, and (4) the clinical outcome. Forty-three psychopharmacy consultations for the 30 patients were evaluated. A total of 125 recommendations were made by the consultation service; of these, 75 (60%) were accepted. The consultations were divided into consultations for which at least a majority of the resulting recommendations were accepted by the physician (n = 29) and consultations for which less than a majority of the recommendations were accepted (n = 14). For the majority group, 23 (79%) of the 29 consultations were associated with a positive outcome, compared with 2 (14%) of the 14 consultations in the less-than-majority group. Similarly, positive outcomes were significantly more frequent in the majority-group patients (16/21 [76%]) than in the less-than-majority-group patients (2/9 [22%]). The frequency of positive outcomes was higher among patients for whom most of the recommendations of a clinical psychopharmacy consultation service were accepted than among patients for whom most recommendations were not accepted.

The recruitment of research participants: a review

Social workers are involved in the recruitment of research participants in a variety of ways. Increased knowledge regarding recruitment issues will allow social workers to expand their role and improve their performance in this area. These individuals should be aware that there is a large body of literature addressing recruitment. This selective review of the literature prior to mid-1992 will focus on the Coronary Primary Prevention Trial, volunteer effects, recruitment sources, the recruitment process, impediments to recruitment, bias in recruitment, the amount of time required to recruit and the impact of recruitment and participation on individuals. This will be followed by a discussion of issues to be addressed in arriving at solutions to recruitment problems.

Effects of lymphocyte activation on transfer RNAs

The influences of mitogen activation on the functional capacity of rat splenic tRNAs were evaluated. The specific amino acid acceptor activity, pmol of a specific amino acid accepted per nmol of tRNA, of isolated splenic tRNAs from in vivo Concanavalin A (37 h)-treated rats were up to 8 times the specific amino acid acceptor activities of splenic tRNAs from control rats. Control splenic tRNAs were treated with purified liver tRNA nucleotidyltransferase in vitro to repair the 3'[CCA] terminus of tRNAs, and subsequently assayed in an aminoacylation reaction. The specific amino acid acceptor activities were slightly increased over those tRNAs not repaired with tRNA nucleotidyltransferase, indicating the presence of a low level of defective but repairable tRNAs in the control rat spleen. Furthermore, our results indicate that cyclosporin A (inhibitor of lymphocyte activation) blocks the Concanavalin A stimulation of tRNA charging ranging from 16 to 93%.

Expression of 9E3 mRNA is associated with mitogenicity, phosphorylation, and morphological alteration in chicken embryo fibroblasts

Transformation of chicken embryo fibroblasts (CEF) with viruses encoding src, ros, yes, and fps as well as ras, mos, middle T, erbA and erbB, myc, and crk stimulated 9E3 mRNA expression. Treatment of CEF with agents that modulate cell shape or attachment to the substratum caused an increase in 9E3 mRNA without an increase in tyrosine phosphorylation. 9E3 mRNA was also increased in CEF in response to several agents which modulate phosphorylation, including phorbol myristic acetate, vanadate, and okadaic acid, which suggests that the rapid induction of 9E3 mRNA expression in CEF by the src protein occurs downstream of morphological or phosphorylation events.

Physician adaptation to health maintenance organizations and implications for management

The growth of health maintenance organizations (HMOs) and other forms of managed care presents a challenge to traditional patterns of private practice. In Dane County, Wisconsin (Madison Metropolitan Area), the proportion of the population enrolled in closed-panel HMOs increased dramatically, from 10 percent in 1983 to over 40 percent by 1986. This study surveyed 850 practicing physicians regarding their expectations before, and experiences after this rapid change to competitive HMOs. Although most physicians expected a loss of earnings and lower-quality care, the majority reported that neither declined. However, most physicians expected and reported a decline in their autonomy. Primary care physicians were most supportive of the change to HMOs. The implications of these findings for management practices are discussed.

Modulation of arachidonic acid metabolism by Rous sarcoma virus

Arachidonic acid (C20:4) metabolites were released constitutively from wild-type Rous sarcoma virus-transformed chicken embryo fibroblasts (CEF). 3H-labeled C20:4 and its metabolites were released from unstimulated and uninfected CEF only in response to stimuli such as serum, phorbol ester, or the calcium ionophore A23187. High-pressure liquid chromatography analysis showed that the radioactivity released from [3H]arachidonate-labeled transformed cells was contained in free arachidonate and in the cyclooxygenase products prostaglandin E2 and prostaglandin F2 alpha; no lipoxygenase products were identified. The release of C20:4 and its metabolites from CEF infected with pp60src deletion mutants was correlated with serum-independent DNA synthesis and with the expression of the mRNA for 9E3, a gene expressed in Rous sarcoma virus-transformed cells which has homology with several mitogenic and inflammatory peptides. 3H-labeled C20:4 release was not correlated with p36 phosphorylation, which argues against a role for this protein as a phospholipase A2 inhibitor. CEF infected with other oncogenic viruses encoding a tyrosine kinase also released C20:4, as did CEF infected with viruses that contained mos and ras; however, infection with a crk-containing virus did not result in stimulation of 3H-labeled C20:4 release, suggesting that utilization of this signaling pathway is specific for particular transformation stimuli.

Estradiol regulation of reactions involved in turnover of the amino acid acceptor terminus of tRNA in the rat uterus

Estradiol (E2) increases the specific amino acid acceptor activity of rat uterine tRNAs by increasing the proportion of certain tRNAs with intact and functional 3'-CCA acceptor termini. Activities of tRNA nucleotidyltransferase and 3'-exoribonuclease which synthesize and degrade this terminus, respectively, were measured and neither enzyme was modified by hormone treatment. Since cytidine triphosphate (CTP) levels are below reported Km values for nucleotidyltransferase, changes in CTP concentrations may regulate nucleotidyltransferase activity. An E2-induced 3-fold increase was seen in CTP synthetase activity (conversion of uridine triphosphate, UTP, into CTP). Uterine CTP levels in controls are minute (9 nmol/uterus, approx. 90 microM), and are increased 2.5-fold in E2(12 h)-treated rats. The rate of incorporation of [3H]UTP into the 3'-CCA terminus of tRNA was measured as coupled CTP synthetase-nucleotidyltransferase reactions and a 2.5-fold increase in incorporation occurred 8-12 h after E2 treatment. Injection of azaserine, (inhibitor of CTP synthetase) reduced E2-induced increases in CTP levels, CTP synthetase activity, and leucine acceptor activity of tRNAs. These results indicate that E2 regulates CTP levels by modulation of CTP synthetase activity, and that regulation of synthesis and/or repair of the 3'-CCA terminus of tRNA is proportional to E2-induced uterine cytosolic CTP levels.

Enzyme markers of collagen synthesis in carbon tetrachloride-induced fibrosis and during colchicine modification of CCl4-induced liver injury

Serum galactosylhydroxylysyl glucosyltransferase (S-Glu-Gal-Hyl-Tase), liver galactosylhydroxylysyl glucosyltransferase (L-Glu-Gal-Hyl-Tase), liver hydroxylysyl galactosyltransferase (L-Gal-Hyl-Tase), and liver prolyl hydroxylase (L-PH) activities were measured in rats during the development of CCl4-induced cirrhosis (0.2 ml of 33% CCl4 in light mineral oil two times weekly for 10 weeks followed by 6 weeks of no treatment). Serum and liver markers of collagen synthesis increased in a time-dependent manner reaching maximum activity at 6 weeks (S-Glu-Gal-Hyl-Tase, two times; L-PH, two times). These enzyme levels returned to normal during the 4-week recovery period. In a separate 4-week experiment, colchicine (10 micrograms/rat/day) was administered with CCl4. Colchicine prevented the increase in S-Glu-Gal-Hyl-Tase, L-Glu-Gal-Hyl-Tase, and L-Gal-Hyl-Tase induced by CCl4 and resulted in a smaller increase in L-PH. These results demonstrate that S-Glu-Gal-Hyl-Tase elevation occurs following CCl4 because of increased liver collagen synthetic activity and the hepatocellular injury produced by CCl4.

Platelet aggregation in non-insulin-dependent diabetes is associated with platelet fatty acids

Platelet aggregation was measured in 15 patients having non-insulin-dependent diabetes mellitus (NIDDM) at the time of diagnosis and after three months of dietary treatment. Mean fasting plasma glucose fell from 13.0 to 8.8 mmol/l (p less than 0.0002), glycosylated haemoglobin fell from a mean of 11.3% to 9.0% (p less than 0.005) and insulin levels fell from a mean of 17.5 to 13.8 mU/l (p less than 0.005). Platelet aggregation showed a variable response and did not correlate with plasma glucose, glycosylated haemoglobin or plasma insulin. Multiple linear regression analysis was carried out on the aggregation values against the biochemical variables and platelet phospholipid fatty acid levels following logarithm transformation. Platelet linolenic acid and eicosapentaenoic acid levels were significantly inversely associated with aggregation but the difference between the relationship at diagnosis and after three months was not statistically significant. The association between platelet omega 3 fatty acids and platelet aggregation suggest that dietary change aimed at increasing the proportions of these fatty acids might favourably influence vascular disease in NIDDM via an effect on platelet function.

Serum and liver enzymes of collagen synthesis in hepatic murine schistosomiasis mansoni

Serum galactosylhydroxylysyl glucosyltransferase (S-GGT), liver galactosylhydroxylysyl glucosyltransferase (L-GGT), liver hydroxylysyl galactosyltransferase (L-GGal-T) and liver prolyl hydroxylase (L-PH) activities were measured in CF1 female mice each week for 10 weeks after infection with Schistosoma mansoni (50 cercariae per mouse). None of the enzyme activities measured were significantly increased in the first six weeks following the infection. However, the activities increased thereafter reaching a maximum of seven-fold for S-GGT, five-fold for L-GGT, three-fold for L-GGal-T and ten-fold for L-PH compared with control animals. The increase in S-GGT activity was positively correlated with L-GGT (r = 0.788), L-GGal-T (r = 0.774) and L-PH (r = 0.800). The present data suggest that during the first six weeks of the development of murine hepatic schistosomiasis mansoni infection, few eggs bombard the liver. The biochemical changes during this period are mild. During weeks 7 to 10, which is the active fibrotic stage, the liver biochemical markers of collagen synthesis increase rapidly and lead to fibrotic morphological features that are the chronic irreversible hepatic changes characteristic of this infection. The data reported here indicate that the aggressive fibrotic changes in liver during weeks 7 to 10 of murine schistosomiasis infection are predicted by S-GGT activity.

Trends in radiopharmaceutical dispensing in a regional nuclear pharmacy

Dispensing trends for radiopharmaceuticals at a regional nuclear pharmacy over a 51-month period were studied. dispensing records of a regional nuclear pharmacy were analyzed with a forecasting procedure that uses univariate time data to produce time trends and autoregressive models. The overall number of prescriptions increased from 3500 to 5500 per quarter. Radiopharmaceuticals used in nuclear cardiology studies increased from less than 0.1% to 17.5% of total prescriptions dispensed, while radiopharmaceuticals used for brain imaging showed a steady decline from 29% to 11% of total prescriptions dispensed. The demand for other radiopharmaceuticals increased in areas such as renal studies, bone studies, lung studies, liver-function studies, and Ga-67 tumor-uptake studies, and declined slightly for static liver studies. Changes in dispensing trends for radiopharmaceuticals will continue as the practice of nuclear medicine concentrates more on functional studies and as newer imaging techniques become used for other purposes.