Single-nucleotide polymorphisms in the RB1 gene and association with breast cancer in the British population

A substantial proportion of the familial risk of breast cancer may be attributable to genetic variants each contributing a small effect. pRb controls the cell cycle and polymorphisms within it are candidates for such low penetrance susceptibility alleles, since the gene has been implicated in several human tumours, particularly breast cancer. The purpose of this study was to determine whether common variants in the RB1 gene are associated with breast cancer risk. We assessed 15 tagging single-nucleotide polymorphisms (SNPs) using a case–control study design (n⩽4474 cases and n⩽4560 controls). A difference in genotype frequencies was found between cases and controls for rs2854344 in intron 17 (P-trend=0.007) and rs198580 in intron 19 (P-trend=0.018). Carrying the minor allele of these SNPs appears to confer a protective effect on breast cancer risk (odd ratio (OR)=0.86 (0.76–0.96) for rs2854344 and OR=0.80 (0.66–0.96) for rs198580). However, after adjusting for multiple testing these associations were borderline with an adjusted P-trend=0.068 for the most significant SNP (rs2854344). The RB1 gene is not known to contain any coding SNPs with allele frequencies ⩾5% but several intronic variants are in perfect linkage disequilibrium with the associated SNPs. Replication studies are needed to confirm the associations with breast cancer.

Using social marketing to increase recruitment of pregnant smokers to smoking cessation service: a success story

OBJECTIVES

To explore what it is like to be a pregnant smoker in Sunderland and to inform the development of a Smoking Cessation Programme; to use qualitative techniques to develop a cessation programme tailored to pregnant smokers.

STUDY DESIGN

The intervention follows years of social marketing research and development in Sunderland, Wearside, UK.

METHODS

Information derived from nine focus groups (mainly with women from deprived areas, social class C2D and E) provided insights into the issues facing smoking pregnant women. This information was then used to overcome barriers to smoking cessation using the principles of social marketing. The number of women recruited into a specially designed smoking cessation support initiative was compared with women recruited into comparable groups in the North East.

RESULTS

Recruitment of pregnant (and non-pregnant) smokers to the new NHS smoking cessation programme in Sunderland has increased during the intervention phase compared with neighbouring Primary Care Trust areas (in which different smoking cessation interventions targeted at pregnant women were being undertaken).

CONCLUSIONS

This innovative intervention has been successful in generating ideas, guiding development of a customer-friendly service and encouraging women to come forward for smoking cessation support during their pregnancy. The target population have welcomed the approach, and health professionals have enjoyed and benefited from the role play with professional actors.

Influences of orthodontic appliances on oral populations of mutans streptococci

A study was conducted to assess the influence of fixed appliances on the mutans streptococcal in a group of patients receiving orthodontic treatment. Mutans streptococcal counts in stimulated saliva of 27 patients were obtained at baseline, and at 1-month intervals for 4 months. The difference in mutans streptococcal counts at baseline and at the 4-month sampling was less than an order of magnitude in 18 of the patients, between 1 and 2 orders of magnitude in eight of the patients, and 3 orders of magnitude in one patient. Restriction endonuclease digests of genomic DNA from representative mutans streptococci isolates taken from baseline and 4-month saliva samples, as well as from 4-month tooth and appliance surfaces, were examined by pulsed field gel electrophoresis, after restriction endonuclease digestion. Results of the DNA banding patterns associated with isolates from 19 patients showed that, for 12 patients, all isolates examined represented the same clone of Streptococcus mutans, whereas for six patients two different S. mutans clones were detected. One patient yielded three different clones of S. mutans. A much larger number of baseline, as well as post-appliance, isolates will have to be examined from each patient in future studies, in order to determine if the number of different S. mutans clones harbored by individual patients is related to orthodontic treatment.

Long-term (> or =8 years) outcome after Palmaz-Schatz stent implantation

The purpose of this single-center study was to evaluate the long-term (> or =8 years) outcome of Palmaz-Schatz intracoronary stenting and to identify independent predictors of outcome. Although short-term results of Palmaz-Schatz intracoronary stenting have been promising, with a reduction in both angiographic restenosis and clinical cardiac events up to 3 years, longer-term follow-up has not been established. We analyzed clinical outcome in 426 consecutive patients at least 8 years after coronary stenting. Demographic, clinical, and procedural predictors of restenosis, survival, and event-free survival, defined as freedom from death, myocardial infarction (MI), and coronary revascularization (target stented site, target vessel, and any revascularization) were analyzed. Before discharge, 28 patients (6.6%) sustained at least 1 major cardiovascular event: 3 deaths (0.7%), 18 MIs (4.2%), and 17 repeat revascularizations. Surviving patients were followed for 8.9 years (interquartile range 8.4 to 9.4). After discharge, 59 patients (13.9%) died, 47 (11.1%) sustained an MI, and 188 (44.4%) underwent coronary revascularization. The 8-year event-free survival (freedom from death, freedom from death/MI/target-stented site revascularization, and freedom from death/MI/any coronary revascularization) was (mean +/- SE) 0.86 +/- 0.01, 0.62 +/- 0.03, and 0.47 +/- 0.02, respectively. Unstable angina, lower left ventricular ejection fraction, and saphenous vein graft stenting were found to be independent predictors of death during follow-up. Hypertension, unstable angina, multivessel disease, and multiple stent implantation were found to be independent predictors of the composite of death/MI/any coronary revascularization during follow-up. This study provided a useful assessment of very long-term outcome in survival, event-free survival, and predictors of major cardiac events 8 to 10 years after Palmaz-Schatz stent implantation.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

Use of precision agriculture technology to investigate spatial variability in nitrogen yields in cut grassland

Spatial variability in N uptake and utilisation by swards within uniformly managed field units could be responsible for a significant proportion of the NH3, N2O, NO3- and NOx (NO and NO2) 'pollutants' generated by agriculture and released to the environment. An investigation was commenced, therefore, to quantify, map and explain the spatial variability in sward N yield in a 'large' silage field and to assess the potential for managing this variability using some of the latest precision agriculture technology. Sward dry matter (DM) and N yields were predicted from the results of plant tissue analyses using mathematical models. Sward N yields were found to vary greatly across the field seemingly because of differences in net soil N mineralisation, but the pattern of variability appeared to remain constant with time. Conventional soil analysis of a range of soil chemical and physical properties, however, failed to explain this variability. It was concluded that the N-yield distribution map might be used in place of soil analysis as the basis for varying the rates of N application to different parts of the field with the twin objectives of maximising fertiliser use efficiency and minimising N emissions to air and water.

Measuring developmental outcomes of lead exposure in an urban neighborhood: the challenges of community-based research

The Developmental Research on Attention and Memory Skills (DREAMS) Project measures developmental outcomes of approximately 330 children at risk for lead exposure within an ethnically diverse, inner-city neighborhood. This study is one project of the Phillips Neighborhood Healthy Housing Collaborative, a 6-year-old collaboration between residents of the Phillips community in Minneapolis, university researchers, and representatives of various public and private agencies. Our experience carrying out this research is used to highlight both the benefits of, and the challenges to, measuring exposure outcomes in inner-city children using a community-based research approach. Challenges to working within a community collaborative, to studying an ethnically diverse and economically disadvantaged neighborhood, and to utilizing neighborhood residents as project staff are discussed. The strategies used to address these issues are presented to offer ideas for surmounting the challenges inherent in community-based research. The investigation of community environmental health problems through a community-based research approach can result in improved methodology, enhanced quality of data collected, and increased effectiveness of data dissemination. In addition, it can lead to important findings that inform the scientific community and create positive community changes. It is paramount, however, that potential obstacles be anticipated and planned for, or else be detected early and promptly responded to, in a manner that preserves scientific rigor while respecting community needs and values.

In-stent restenosis: long-term outcome and predictors of subsequent target lesion revascularization after repeat balloon angioplasty

OBJECTIVES

We sought to evaluate the long-term clinical outcome of patients undergoing successful balloon angioplasty for in-stent restenosis, and to determine correlates of the need for subsequent target lesion revascularization (TLR).

BACKGROUND

In-stent restenosis can be safely treated by repeat percutaneous intervention. Reported subsequent TLR rates have varied from 20% to 80% and seem related to the type of restenotic lesion.

METHODS

The study population comprised 234 patients with follow-up data who were successfully treated with repeat balloon angioplasty for in-stent restenosis in 257 lesions between May 1995 and January 1998 at our institution.

RESULTS

Clinical follow-up was available at 459 (286 to 693) days after the repeat procedure. Event-free survival was 78.5% and 74.6% at 12 and 24 months, respectively. Recurrent events occurred in 58 patients (24.8%), including 6 deaths (2.6%), 4 myocardial infarction (1.7%) and repeat target vessel revascularization in 50 patients (21.4%). Independent predictors of repeat TLR were time to in-stent restenosis <90 days (Hazard ratio 4.67, p < 0.001), minimal luminal diameter after repeat procedure (Hazard ratio 0.38, p = 0.034) and the angiographic pattern of in-stent restenosis (Hazard ratio 1.65, p = 0.036).

CONCLUSIONS

Balloon angioplasty is an effective means of treating in-stent restenosis. The long-term results are acceptable particularly for focal restenotic lesions. Further restenosis is more common in patients with early initial recurrence, more proliferative lesions and a poorer angiographic result from repeat angioplasty.

[Percutaneous angioplasty of unprotected left main coronary disease with implantation of systematic stenting. Immediate and mid-term results]

The authors report the immediate and medium term results of percutaneous angioplasty of unprotected left main coronary disease with systematic stenting. Between March 1994 and December 1998, out of 6,006 patients undergoing coronary angioplasty, 92 had significant unprotected left main stem disease. The majority of patients was male (74 men, 80%) with an average age of 74.3 +/- 8.1 years. Between March 1994 and October 1996, only patients with a surgical contraindication were treated by angioplasty (n = 39). After October 1996, the indications were extended to patients who did not have surgical contraindications (n = 53). During the hospital phase, 4 patients (4%) died (ventricular arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage: 1). No non-fatal infarction with or without Q waves were observed, and no emergency coronary bypass surgical procedures were required. The angiographic success rate was 100%. During follow-up (7.3 +/- 5.8 months), 6 other patients died, 13 required a repeat coronary angioplasty, 4 for restenosis of the left main coronary artery, and 2 underwent coronary bypass surgery. The actuarial survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years. Percutaneous angioplasty for unprotected left main coronary disease with systematic stenting was performed with acceptable hospital and medium term results.

Evaluation of the RapID Yeast Plus System for the identification of yeast

We evaluated the RapID Yeast Plus System using 117 fresh and frozen clinical yeast isolates. The Uni-Yeast-Tek System was used to establish the correct identification. The Vitek System was used as the arbiter for any discrepant results, along with morphology. Of 117 isolates tested, the RapID Yeast Plus System identified 96.6% correctly. The RapID Yeast Plus System is an accurate and reliable alternative to other commonly used yeast identification systems.

Gender differences in coping with infertility: a meta-analysis

Infertility is a stressor that affects both husbands and wives. The literature suggests that infertility is more stressful for women, although most studies have not included men/husbands. If the experience of infertility is different for women and men, the next question is whether women and men cope differently. Meta-analytic procedures were used to review the empirical evidence (1966-1995) on gender differences in coping with infertility among heterosexual married couples; all studies used a standardized coping measure [The Ways of Coping Checklist-Revised (Folkman et al., 1986)]. Significant gender differences were found for half the strategies studied: Women used the strategies of Seeking Social Support, Escape-Avoidance, Planful Problem-Solving, and Positive Reappraisal to a greater degree than their partners. The findings suggest that coping at both the individual and the couple level be considered in the treatment of infertile couples and that gender be considered before planning an intervention.

Recombinant adenoviral vector-lipofectAMINE complex for gene transduction into human T lymphocytes

We have evaluated, as a vector for gene transfer into human T lymphocytes, a recombinant adenovirus (rAd-MFG-AP) carrying a modified, membrane-exposed, alkaline phosphatase (AP) as reporter gene. CD3+ cells were selected from the buffy coat of healthy donors by the immunomagnetic technique. The positive cell population, comprising 96+/-2% CD3+ cells, was cultured with clinical-grade cytokine(s) for 3-7 days prior to rAd-MFG-AP transduction and the transgene expression was evaluated 48 hr later by indirect immunofluorescence flow cytometry assay with an anti-alkaline phosphatase antibody. The best efficiency of transduction was achieved on incubation of CD3+ cells with IL-2 plus either IL-12 (AP+ cells, 12+/-3%) or IL-7 (AP+ cells, 11+/-3%). To increase further the efficiency of transduction, we have combined LipofectAMINE and rAd-MFG-AP with the aim to enhance the uptake of viral particles into the target cells. The percentage of CD3+ cells transduced by rAd-MFG-AP-LipofectAMINE complex was 24+/-4% (range, 20-35%) after incubation with IL-2 plus IL-7 and 22+/-4% (range, 18-32%) after incubation with II-2 plus IL-12. Forty-eight hours after the incubation with rAd-MFG-AP, the transduced T lymphocytes were subjected to fluorescence-activated cell sorting and fractionated into AP+ and AP- cell subpopulations. The AP+ cell fraction, comprising 96.8% of AP+ cells, was evaluated by FACScan analysis for T lymphocyte surface antigens. The immunophenotyping of the transduced T lymphocytes has shown that there was not a particular subtype of T lymphocytes more susceptible to rAd-MFG-AP transduction. In addition, the transgene expression did not modify T lymphocyte functions, as demonstrated by results obtained by cytotoxicity assay before and after rAd-MFG-AP-LipofectAMINE complex transduction. In conclusion, human T lymphocytes can be efficiently transduced, under clinically applicable conditions, by adenovirus-LipofectAMINE complex after 7 days of culture with IL-2 and IL-12 or IL-7.

Coronary stenting in diabetics: Immediate and mid-term clinical outcome

Balloon angioplasty in diabetics is associated with acceptable immediate results but with high rates of restenosis, target vessel revascularization, and late mortality. The impact of coronary stenting on the outcome of these patients remains controversial. We reported the immediate and mid-term clinical outcome of 272 consecutive diabetic patients, representing 12.5% of the population undergoing coronary stenting between May 1995 and April 1997. Diabetes mellitus was insulin-requiring in 58 patients and non-insulin-requiring in 214. Stenting performed on large vessels (mean diameter >/=3 mm) was successful in 99.2% of nondiabetic patients and in all cases in diabetics. During in-hospital stay, the complications rate, including mortality, nonfatal myocardial infarction, emergency coronary bypass surgery, and stent subacute thrombosis, was similar in nondiabetic patients, insulin-requiring, and non-insulin-requiring diabetics (2.55%, 0%, and 2.0%, respectively). No complication occurred in the insulin-requiring group. One patient (0.5%) died from myocardial infarction and another (0.5%) presented a nonfatal myocardial infarction (subacute stent thrombosis) in the non-insulin-requiring group. The clinical follow-up (mean length 13 +/- 8 months) was obtained in 93% and 97% of the insulin-requiring and non-insulin-requiring diabetics, respectively. Overall mortality was significantly higher in insulin-requiring patients (9.3% vs. 2.4%). Nonfatal myocardial infarction and target lesion revascularization rates were similar in the two groups (0% vs. 0.5% and 8.2% vs. 10.5%). These results suggest that coronary stenting in diabetics could be performed with acceptable immediate and mid-term results. Cathet. Cardiovasc. Intervent. 47:279-284, 1999.

High performance laser diode bars with aluminum-free active regions

We present operating and lifetest data on 795 and 808 nm bars with aluminum-free active regions. Conductively cooled bars operate reliably at CW power outputs of 40 W, and have high efficiency, low beam divergence, and narrow spectra. Record CW powers of 115 W CW are demonstrated at 795 nm for 30% fill-factor bars mounted on microchannel coolers. We also review QCW performance and lifetime for higher fill-factor bars processed on identical epitaxial material.

Determining the angle of screw placement for internal fixation of calcaneal fractures

OBJECTIVE

This study was designed to determine the angle off the perpendicular to the lateral calcaneal wall at which a screw would need to be angled to avoid entering the subtalar joint medially. It also determined the distance inferior to the articular surface at which a screw would need to be placed to avoid that penetration if the screw was placed perpendicular to the lateral calcaneal wall.

METHODS

Eight specimens were dissected and the calcaneus was removed. The measurements were taken from portions of the subtalar joint.

RESULTS

To avoid medial penetration, a screw at the anterior portion of the posterior facet would need to be angled 5 degrees plantar medially or placed 1.5 millimeters below the edge of the articular surface. In the midportion, placements are 20 degrees or 10 millimeters; posteriorly, placements are 32 degrees or 15 millimeters.

CONCLUSION

This study shows that using a lateral approach, it is possible to position internal fixation screws without disrupting the articular surfaces of the medial subtalar joint.

Isolation of the vastus medialis oblique muscle during exercise

The purpose of this study was to selectively challenge the vastus medialis oblique muscle in comparison with the vastus lateralis, the vastus intermedius, and the vastus medialis longus muscles by performing nine sets of strengthening exercises. These knee rehabilitation exercise included isometric knee extension with the hip at neutral, 30 degrees external, and 30 degrees internal rotation; isokinetic knee extension through full range; isokinetic knee extension in the terminal 30 degrees arc; sidelying ipsilateral and contralateral full knee extension; and stand and jump from full squat. Electrical activity of the vastus medialis oblique, the vastus lateralis, the vastus intermedius, and the vastus medialis longus muscles was measured in eight uninjured subjects. Our study showed that isometric exercises in neutral and external rotation of the hip will challenge both the vastus medialis oblique and the vastus lateralis muscles. The results suggest that the electromyographic activity of the vastus medialis oblique muscle was not significantly greater than that of the vastus lateralis, the vastus intermedius, and the vastus medialis longus muscles during the nine sets of exercises. Results suggest that the vastus medialis oblique muscle cannot be significantly isolated during these exercises.

Results of stenting of unprotected left main coronary artery stenosis in patients at high surgical risk

From March 1994 to September 1996, 39 patients underwent stenting of the unprotected left main coronary artery because of high surgical risk. Stenting appeared to improve clinical outcome, but there was a significant mortality rate at long-term follow-up.

Isolated pulmonary cryptococcosis in pregnancy

BACKGROUND

Isolated pulmonary cryptococcosis in an immunocompetent parturient host is a rare event. Little is known about this condition, its prognosis, and its treatment in the immunocompetent pregnant woman.

CASE

A 28-year-old woman, para 3, was diagnosed with isolated pulmonary cryptococcosis postpartum. She had delivered a healthy neonate at term who revealed no clinical features compatible with maternal-fetal transmission. The woman was monitored closely throughout the course of her disease and radiogic, clinical, and serologic resolution was achieved after treatment with fluconazole.

CONCLUSION

Patients with pulmonary cryptococcosis present with clinical pictures similar to other well-known diseases such as septic pulmonary emboli or choriocarcinoma. Treatment with triazole antifungal therapy yielded favorable results in our patient with this rare condition.

Randomized trial of daily versus three-times-weekly prophylactic ganciclovir after lung and heart-lung transplantation

BACKGROUND

Cytomegalovirus is an important cause of morbidity and mortality risk after lung transplantation. Ganciclovir, when given for a period of up to 3 months after lung transplantation, has been shown to reduce the incidence and severity of cytomegalovirus. However, daily prophylaxis is associated with considerable expense, inconvenience, and morbidity risk. The goal of this study was to determine whether 3-times-weekly dosage is as effective as daily prophylaxis with ganciclovir in preventing cytomegalovirus disease.

METHODS

Seventy-two consecutive subjects who had either donor or recipient cytomegalovirus seropositivity were randomized to the daily group (n = 35) or the 3-times-weekly group (n = 37). All subjects received twice-daily ganciclovir treatment for 2 weeks. Thereafter, subjects received either daily or 3-times-weekly ganciclovir dosing until 90 days after transplantation. Subjects were then monitored for 28 +/- 13 months to identify outcomes and complications.

RESULTS

There were no significant differences between the daily and 3-times-weekly groups with respect to survival free from cytomegalovirus infection or survival free from cytomegalovirus disease. In both groups, cytomegalovirus infection and disease frequently emerged after the termination of prophylaxis. However, in most cases the cytomegalovirus syndromes observed were mild and in many cases could be treated on an outpatient basis. There was no significant difference between the groups in the incidence of obliterative bronchiolitis or time to onset of grade 2 bronchiolitis obliterans syndrome. Overall patient survival was better in the daily group, but the survival advantage did not appear to be related to a reduction in cytomegalovirus-related disease. Complications of ganciclovir prophylaxis included leukopenia in 2 subjects in the 3-times-weekly group and catheter-related sepsis in 6 subjects from each group.

CONCLUSIONS

We conclude that intravenous ganciclovir given 3 times weekly for 3 months after transplantation is as effective as daily ganciclovir given for a similar time period. The 3-times-weekly dosing regimen did not result in increased infection, disease, or sequelae of cytomegalovirus infection when compared with the daily regimen.

Clinical data for use in assessing quality: lessons learned from the Texas Nurses' Association Report Card Project

The purpose of this report is to describe the Texas Nurses' Association Report Card Project. As part of ANA's Safety and Quality Initiative, the project was designed as a feasibility study to determine whether clinically based quality indicator data could be collected in standard ways across acute care agencies in Texas. Clinicians from 12 agencies, under leadership of the professional association (Texas Nurses' Association), participated in this initial effort to reach consensus on clinical indicator definitions and on how to collect clinical data for each indicator. Data were collected for falls and injuries, bacteremias, pressure ulcers, skill mix, nursing hours per patient day, patient satisfaction (with nursing, hospital stay, education, and pain management), and nurse satisfaction. The process used is described, as well as the findings and the lessons learned. The importance of standard definitions and precise and standard primary sources for the data are emphasized for the phase II report card efforts to follow.

[Implantation of coronary stents in diabetic patients. Short- and medium-term clinical results]

Coronary balloon angioplasty is associated with a high incidence of restenosis in diabetics and of revascularisation of the culprit lesion and increased long-term mortality. The authors report the short and medium-term results of coronary stenting in diabetics. Between May 1995 and April 1997, 2,182 patients underwent coronary stenting. This population included 272 diabetics : 58 insulin-dependent and 214 non-insulin dependent (oral antidiabetics). Stents were implanted in vessels with mean diameters of 3 mm and over. During the hospital period, the complication rate (mortality, non-fatal myocardial infarction, emergency coronary bypass surgery, subacute thrombosis of the stent) was comparable in non-diabetics, insulin-dependent and non-insulin-dependent diabetics (2.55, 0 and 2.0% respectively). One patient (0.5%) died and another (0.5%) had non-fatal myocardial infarction (thrombosis of the stent) in the non-insulin-dependent group. No complications were observed in the insulin-dependent diabetic group. The mean clinical follow-up of 13 months (3-26 months) was respected in 93 and 97% of diabetics. The non-fatal myocardial infarction rate and revascularisation of the culprit lesion were comparable in the insulin and non-insulin-dependent groups (0 versus 0.5% and 8.2 versus 10.5% respectively) but global mortality was higher in the insulin-dependent diabetics (9.3 versus 2.4%).

How easy is it for young people to obtain cigarettes, and do test sales by trading standards have any effect? A survey of two schools in Gateshead

Smoking prevalence among young people continues to rise and cigarettes are easily available from many shops. Test sales are used by trading standards departments to try to reduce under-age sales, but it is not known whether this has any real impact on cigarette purchase and consumption. This study aims to evaluate the impact of test sales on purchase and consumption of cigarettes by young people. A survey of two schools in Gateshead, one in the intervention area and one acting as a control was carried out. A series of test sales were targeted to shops within 1.5 km of the intervention school. A questionnaire was administered in both schools among year 10 pupils, age 14-15 years, prior to the intervention and again 1 year later. The outcomes measured were number of successful test sales, reported availability of cigarettes and change in smoking prevalence following the intervention. Some 224 pupils from both schools were surveyed in 1995 and 163 pupils from the new cohort of year 10 pupils in 1996. Prior to the intervention, the levels of regular smoking in the intervention school were 39% for girls and 26% for boys. In the control school these levels were 24% and 14%, respectively. The intervention by trading standards resulted in no purchases and hence no prosecutions, but children reported being able to buy cigarettes with ease from the nearby shops; only three (2.5%) reported sales refused in 1995 and five (5.8%) in 1996. Not surprisingly there was no significant change in smoking prevalence in either school in 1996. This study suggests that test sales may not be effective in modifying cigarette availability to young people and that they are not a reliable measure of access to cigarettes by children.

Androgen receptor (AR) immunoreactivity in rat pudendal motoneurons: implications for accessory proteins

Pudendal motoneurons in male rats are located in two sexually dimorphic motoneuronal pools: the spinal nucleus of the bulbocavernosus (SNB) and the dorsolateral nucleus (DLN). SNB motoneurons innervate sexually dimorphic muscles bulbocavernosus (BC) and levator ani (LA) and the sexually monomorphic external anal sphincter (EAS) muscle. DLN motoneurons innervate either the sexually dimorphic ischiocavernosus (IC) muscle or the sexually monomorphic external urethral sphincter (EUS) muscle. Previous observations indicate that the size of BC, LA, and IC motoneurons in males is sensitive to adult androgen manipulations, whereas the size of EAS and EUS motoneurons is not, raising the question of whether this difference in androgen sensitivity among pudendal motoneurons reflects a difference in androgen receptor (AR) expression. AR immunocytochemistry using the PG-21 antiserum was carried out on spinal cord tissue from normal adult male rats in which specific pudendal motoneuronal subpopulations were identified with retrograde markers. Over 90% of BC, LA, and IC motoneurons displayed AR immunoreactivity in their nuclei. Among motoneurons in the SNB, significantly fewer EAS motoneurons had AR-positive nuclei, which may contribute to the reported failure of EAS motoneurons to morphologically respond to changes in androgen levels. However, within the DLN, despite the fact that IC but not EUS motoneurons are reported to respond to androgen with an increase in soma size, IC and EUS motoneurons had the same proportion of AR-positive nuclei. These results indicate that androgen receptors, while necessary, are not sufficient to confer androgen sensitivity to cells.

Role of gastrin/CCK-B receptors in meal-stimulated acid secretion in rats

Gastrin is the principal hormonal mediator of gastric acid secretion. Using an in vivo, intact, anesthetized rat model, we studied the role of gastrin/cholecystokinin (CCK)-B receptors in regulating the release of histamine and somatostatin during intragastric stimulation of acid secretion during a peptone meal. In pylorusligated, adult male rats (each implanted with a gastric cannula and portal venous and splenic artery catheters), after a 30-min basal period, gastric acid secretion was stimulated for 90 min either by an intravenous infusion of gastrin-17 (15 micrograms.kg-1.h-1) or by extragastric titration of 5 ml 8% peptone meal at pH 5.5. Basal and stimulated acid outputs and portal venous plasma gastrin, histamine, and somatostatin concentrations were measured before and after close-arterial injection of a new, relatively selective, gastrin/CCK-B receptor antagonist GR143330X. GR143330X reduced basal acid output by 50% but not basal plasma gastrin, histamine, or somatostatin concentrations. GR143330X reduced gastrin-stimulated acid output by 80%, plasma histamine by 70%, and plasma somatostatin by 34%. During intragastric peptone meal stimulation GR143330X reduced the acid response by 42% during the 30- to 60-min period but not during the 60- to 90-min period. GR143330X reduced the plasma histamine response by 72 and 68%, and the plasma somatostatin response by 32 and 54% during the 30- to 60- and 60- to 90-min periods, respectively. GR143330X did not block the gastrin response to peptone at any time. These results indicate that GR143330X is an effective agent for blocking gastrin-stimulated acid secretion and histamine and somatostatin release in rats. Furthermore, we show for the first time in an intact, in vivo, anesthetized rat model that meal-stimulated activation of gastrin/CCK-B receptors stimulates acid secretion in part by regulating the release of histamine and somatostatin.

Perceived comfort and pressure distribution in casual footwear

INTRODUCTION:: Footwear manufacturers view comfort as a basic customer need that is growing in importance and is increasingly competing with fashion as a reason for buying shoes. A number of researchers have suggested that pressures and forces between the foot and the insole may influence perceptions of comfort (Chen et al., 1994). To date, no study has attempted to measure the relationship between pressure variables and perceived comfort in a range of commercially available footwear and, furthermore, little attention had been given to the dorsum of the foot with respect to comfort and pressure distribution. METHODS:: Twenty male subjects without foot pathology walked the length of a 10 m walkway at a self-selected pace. A 'perception of comfort' questionnaire was designed to measure perceived plantar comfort in six regions (rearfoot medial, rearfoot lateral, midfoot medial, midfoot lateral, forefoot medial and forefoot lateral) and perceived dorsal comfort in two regions (flex-line and lacing). Ten commercially available shoes were selected to represent two distinct groups in terms of perceived comfort: comfortable and uncomfortable. Plantar and dorsal pressure data were collected using a Pedar in-shoe system and Mikro-EMED system (Novel GmbH) respectively. Analysis of variance tests were used to determine differences (p<0.01) between the two shoe groups. RESULTS:: Peak Pressure was found to be significantly greater for the uncomfortable group both for the total plantar surface and for the all regions of the foot measured. Maximum force was significantly greater for the uncomfortable group for the rearfoot and forefoot regions but significantly lower for the midfoot regions of the plantar surface. For the dorsal surface maximum force was found to be significantly greater for the uncomfortable group. Contact area was significantly greater for the comfortable group in the midfoot regions of the plantar surface but was significantly lower for the comfortable group at the dorsal surface. DISCUSSION:: This study showed that perceived comfort at the plantar and dorsal surfaces could be related to peak pressure and maximum force in all regions and contact area in the midfoot region of the plantar surface and the total dorsal surface. The relationship between perceived comfort and peak pressure was consistently negative across the entire surface of the foot, whereas the relationship between maximum force and perceived comfort varied depending on foot region. This emphasises the need for researchers to address specific regions of the shoe when measuring comfort. The findings of this study suggest that pressure measurement systems could be used by footwear manufacturers' attempting to improve the comfort of their footwear.

The influence of a small insert, in the footbed of a shoe, upon plantar pressure distribution

INTRODUCTION:: A recent development in plantar pressure distribution research, has been the study of the effects of sensory input on pressure distribution. It has been suggested that proprioceptive and exteroceptive information received from the plantar surface of the foot plays an important role in adapting to high pressures in shoes. Robbins and Gouw (1991) suggested that surface irregularities should be added to the insoles of running shoes to gain correct sensory input. Hayda et al. (1994) found that placing a pad proximal to the metatarsal heads produced significant reductions in forefoot plantar pressures around the first and second metatarsal heads. A development by Villeneuve (1993), 'La Posteropodle', utilized a small insert to maintain postural equilibrium, by stimulating the mechanoreceptors in the plantar surface of the foot. The aim of this study was to measure changes in plantar pressure distribution using a small circular insert. METHODS:: Ten non-pathological male subjects were tested whilst walking, after one day of wearing a pair of oxfords (hard) and running shoes (soft), containing an insert of 4 mm in height placed on a 0.8 mm EVA insole. The foot was split into five sections: (1) midfoot, (2) first metatarsal head, (3) 2nd and 3rd metatarsal heads, (4) 4th and 5th metatarsal heads, (5) the phalanges. A PEDAR system (Novel GmbH) was used to collect in-shoe plantar pressure data, with data collections at the beginning and end of a working day. Subjects were tested under two conditions: (1) the insert 5 mm proximal to the metatarsal heads, between the 2nd and 3rd heads, (2) a control, with no insert. RESULTS:: Preliminary results indicate that whilst wearing a hard shoe the insert had the effect of shifting peak pressures from the first metatarsal head, to the area of the second and third metatarsal heads. Peak pressures were found to be lower with the insert present. This has not yet been tested for significance. With the running shoe there appeared to be no significant differences between conditions with and without the insert. There were also no differences between the beginning and end of the day, for both shoe types. DISCUSSION:: From the results it appears that the insert is successful in both shifting peak pressures from the medial to the lateral forefoot, whilst reducing peak pressures simultaneously. This was only evident in the hard shoe condition however, suggesting that the footbed of the running shoe was perhaps too soft to allow the insert to influence sensory input sufficiently. These findings indicate that there may be implications for the use of small orthotics. Further study is required, however, to fully substantiate this hypothesis.

Does the APACHE II scoring system equate with the Nottingham Patient Dependency System? Can these systems be used to determine nursing workload and skill mix?

The development of a holistic patient dependency system for intensive care in Nottingham has enabled nursing staff to analyse their patient's needs more comprehensively and relate them to existing staffing levels. A recent publication (Chellel et al., 1995) implied that some units were using medical scoring systems to predict workload and that practitioners were dissatisfied with current scoring systems. Patient dependency scores were correlated with APACHE II scores by regression analysis on 1,743 patients from the Adult Intensive. Care Unit at the University Hospital, Nottingham. Analysis revealed that APACHE II had little ability to predict patient dependency and, therefore, is unreliable at predicting nursing workload and skill mix.

Videofluoroscopic evaluation of dysphagia in motor neurone disease with modified barium swallow

The role of videofluoroscopy with the modified barium swallow in the assessment and management of motor neurone disease (MND) is discussed. Nine patients (age range 40-82) with dysphagia secondary to MND were assessed over a four-year period. The examinations were carried out by a multiprofessional team of radiologist, speech and language therapist and dietitian assessing the preoral, oral and pharyngeal phases of swallowing. Preoral feeding abnormalities were present in four out of nine patients, oral phase abnormalities in eight out of nine patients, while 33% of patients demonstrated abnormality in all three phases. Where aspiration occurred (four out of nine cases), no cough reflex was noted. On the basis of these examinations management changes were introduced in all patients. Nonoral feeding was continued or introduced in three patients. Videofluoroscopic examination with the modified barium swallow may be helpful in planning suitable feeding regimes for dysphagia in MND.

Effectiveness of counseling in the health promotion of HIV-positive clients in the community

The purpose of this study was to examine the effects of a nurse's counseling intervention on high-risk sexual behaviors of HIV-positive patients and to explore the relationship of gender, race, age, and education to high-risk sexual behaviors. A convenience sample of 20 adults who were newly diagnosed with HIV and were being treated at an inner-city out-patient clinic was used. Subjects were administered a questionnaire to determine their precounseling AIDS knowledge and precounseling sexual behaviors. A registered nurse then counseled them about safe-sex practices. After 2-3 months the questionnaire was readministered to determine the effects of counseling on AIDS knowledge and high-risk sexual behaviors. Although statistical analysis indicated a significant main effect for change in high-risk sexual behaviors after counseling, there were no significant relationships among change and the individual demographic variables of age, gender, race, and education. Pretest knowledge was not found to influence pretest behavior, nor was posttest knowledge found to affect posttest behavior. Paired t tests indicated a significant change in high-risk sexual behavior scores after counseling but no significant change in knowledge scores.

Identification of a binding motif for ankyrin on the alpha-subunit of Na+,K(+)-ATPase

Cytoskeleton membrane associations are important for a variety of cellular functions. The anion exchanger of erythrocytes (AE1) and Na+,K(+)-ATPase of polarized epithelial cells provide well studied examples of how integral membrane proteins are anchored via the linker molecule ankyrin to the spectrin-based membrane cytoskeleton. In the present study we have generated several recombinant fragments of the large (third) cytoplasmic domain (CD3) of Na+,K(+)-ATPase to define binding sites of ankyrin on CD3 at a molecular level. We provide evidence that a cluster of four amino acids, ALLK, is essential for binding of ankyrin to both recombinant CD3 and to native Na+,K(+)-ATPase. Once bound, conformational changes might uncover further binding sites for ankyrin on Na+,K(+)-ATPase. A motif related to the ALLK cluster is also present in the cytoplasmic domain of AE1 where this sequence (ALLLK) turned out to be also important for ankyrin binding. These motifs are highly conserved during evolution of both Na+,K(+)-ATPase and AE1, further underlining their potential role in cytoskeleton to membrane linkage.

Lessons in cooperation: four hospital consortia relate their quality improvement experiences

BACKGROUND

In 1989, The Robert Wood Johnson Foundation launched a demonstration project to test a consortium approach to quality improvement. As part of this project, four hospital consortia in various parts of the United States are currently sharing quality resources (for example, training) and collaborating on various improvement efforts. The purpose of the project is to demonstrate that hospitals can take on more difficult problems and accomplish more in cooperation with each other than on their own.

CASE STUDIES

The Institute for Quality Healthcare (Iowa City, Iowa) has built a comparative database so that 40 member hospitals can make meaningful comparisons on various aspects of performance; The Vermont Program for Quality in Health Care has lowered the postoperative infection rate in Vermont by monitoring compliance with consensus guidelines; Interwest Quality of Care, Inc, which has member organizations in Utah, Wyoming, and Idaho, has adapted and disseminated guidelines for diabetic care; and The Public Hospital Institute, in Berkeley, California, has worked with the Joint Commission on Accreditation of Healthcare Organizations to develop a written guide to help surveyors understand the unique operational traits of public hospitals.

LESSONS LEARNED

Projects such as those with champions in several member organizations and comparative data analysis lend themselves more easily to cooperative work than others. They also provide some strategies for collaboration, such as continually reinforcing the principles of collaboration, obtaining a fully informed commitment, beginning with initiatives that are likely successes, and being serious and vocal about the commitment to confidentiality.

CONCLUSIONS

Collaborators in quality improvement gain important resources, such as better information, more relevant reference databases, colleagues and support for quality improvement specialists, and economies of scale in education programs, training materials, and interaction with vendors. However, the difficulties in collaboration are great. Hospitals must continually consider not only "What's in this for me," but also "What can we accomplish as a group that is greater than what each of us can do alone?"

Presentation of endometriosis to general surgeons: a 10-year experience

The presentation and management of 24 patients with endometriosis (median age 34 (range 21-68)years) presenting to general surgeons over a period of 10 years (1985-1994) was reviewed. Patients presented with an abdominal wall swelling related to a previous Pfannenstiel incision (seven patients), umbilical swelling (four), inguinal canal swelling (two), incidentally following appendicectomy (five), terminal ileal obstruction (two), rectal bleeding (two) and urinary symptoms (two). Endometriosis was not suspected in most patients but was confirmed by surgical excision or resection with minimal morbidity. No recurrence occurred during a median follow-up of 53 (range 9-113) months. Endometriosis is a disease rarely seen by general surgeons and is often diagnosed incidentally or on histological examination. Cyclical symptoms associated with menstruation are present in 50 per cent of patients and should suggest the diagnosis in those presenting with scar-related and/or subcutaneous swellings. Simple excision or resection of the presenting lesion provides adequate treatment but, since pelvic endometriosis may be present, referral to a gynaecologist is recommended in every case.

Monitoring evoked potentials during surgery to assess the level of anaesthesia

The hypnotic and analgesic components of anaesthesia can be assessed using middle latency auditory evoked potentials (MLAEPs) and somatosensory evoked potentials (SEPs). To monitor these potentials reliably during clinical anaesthesia, we have developed an evoked potential (EP) system based around a portable personal computer, a DSP board and an isolated pre-amplifier unit. Unlike many currently available systems, this amplifier is largely immune to diathermy interference due to excellent isolation via a digital fibre optical link, small size and RF screening and filtering. The pre-amplifier unit has integral auditory and somatosensory stimulators, and automatic calibration and impedance checking. Stimulus intensity and profile are under software control and SEP stimulus level is constantly monitored. The unit is powered by two AA cells and battery status continuously monitored by the PC software. Up to eight channels of EEG may be recorded and displayed in a smoothly scrolling window and as moving average MLAEPs and SEPs.

A biomechanical comparison of lateral retinacular releases

A lateral patellar retinacular release that transects the tendon of the vastus lateralis muscle may result in significant complications. To avoid such complications, the superior extent must be limited, and maximizing the inferior extent may be important in achieving an adequate release. The effective release of the patella from its lateral retinaculum was examined for 2 incision lengths using 10 fresh-frozen human cadaveric knees and comparing the medial displacement of the patella relative to the femur for 3 study groups (control, intact retinacula; Group A, retinacula cut from the inferior third of the vastus lateralis tendon down to the anterolateral arthroscopic portal; and Group B, retinacula cut from the inferior third of the vastus lateralis tendon down to the tibial tubercle) when a 22-N medially directed force was applied to the patella with the knee at 30 degrees and 60 degrees of flexion. The extended release (Group B) resulted in a significantly more effective release when compared with the standard release (Group A) or control group. This technique may allow an adequate release of the patella while preserving the function of the vastus lateralis muscle.