General practice. All stressed up and nowhere to go?

A survey of 1,545 staff in general practices in South East region found that GPs and practice managers were the most stressed. GPs believed that dealing with difficult patients was particularly stressful. The relationships between the senior partner and practice manager and the GP-nurse relationship were seen as crucial. The relationship between GPs and nurses is characterised by ambivalence and uncertainty. The division of labour between GPs and practice managers needs clarification if the government's proposals for improving general practice are to succeed.

Receptor tyrosine kinase signaling regulates different modes of Groucho-dependent control of Dorsal

Transcriptional control of the Drosophila terminal gap gene huckebein (hkb) depends on Torso (Tor) receptor tyrosine kinase (RTK) signaling and the Rel/NFkappaB homolog Dorsal (DI). DI acts as an intrinsic transcriptional activator in the ventral region of the embryo, but under certain conditions, such as when it is associated with the non-DNA-binding co-repressor Groucho (Gro), it is converted into a repressor. Gro is recruited to the enhancer element in the vicinity of DI by sequence-specific transcription factors such as Dead Ringer (Dri). We examined the interplay between DI, Gro and Dri on the hkb enhancer and show that when acting over a distance, Gro abolishes rather than converts DI activator function. Reducing the distance between DI- and Dri-binding sites, however, switches DI into a Gro-dependent repressor that overrides activation of transcription. Both of the distance-dependent regulatory options of Gro - quenching and silencing of transcription - are inhibited by RTK signaling. These data describe a newly identified mode of function for Gro when acting in concert with DI. RTK signaling provides a way of modulating DI function by interfering either with Gro activity or with Dri-dependent recruitment of Gro to the enhancer.

hairy stripe 7 element mediates activation and repression in response to different domains and levels of Krüppel in the Drosophila embryo

The Drosophila gap gene Krüppel (Kr) encodes a zinc finger-type transcription factor required for controlling the spatial expression of other segmentation genes during early blastoderm stage. Here we show that two independent and transferable repressor domains of Krüppel act to control expression of the pair-rule gene hairy, and that the minimal cis-acting element of hairy stripe7 (h7) mediates either Krüppel-dependent activation or repression in different regions of the blastoderm embryo. The C-terminal region of Krüppel which encompasses the predominant repressor domain is not essential for activation, but is required to fully suppress h7-mediated transcription in response to high levels of Krüppel activity. This domain contains an interaction motif for dCtBP, a homologue of the human co-repressor CtBP. dCtBP activity is, however, dispensable for Krüppel-mediated repression in the embryo since Krüppel-mediated repression functions in the absence of dCtBP. Possible modes of h7-mediated gene regulation in response to the different domains and levels of Krüppel are discussed.

How tumor cells make use of CD44

A variant of CD44 containing exon v3 sequences is expressed in the apical ectodermal ridge of the limb bud during embryogenesis. This variant is modified by heparan sulfate moieties and acts as low affinity receptor for FGFs. These FGFs are presented by CD44 to mesenchymal cells which induces their proliferation and limb outgrowth. We suggest that a similar growthfactor presentation mechanism accounts for the function of CD44 variants on metastasizing tumor cells.

Disenchantment, ambivalence, and the precautionary principle: the becalming of British health policy

Before the election of May 1997, Britain's Conservative government was committed to giving general practitioners a lead role in health service development. However, a qualitative study of managers and primary care workers, charged with implementing the initiative in the south of England, revealed that while many relished the opportunity to make service provision more responsive to local needs, they were concerned that such changes might fragment the National Health Service and damage the relationship between doctor and patient. This ambivalence gave rise to a precautionary principle, in which innovative change was stifled by the desire to avoid adverse consequences. This "becalming" of health policy stemmed from disenchantment with both rational comprehensive planning and quasi-market incrementalism, leaving the government without an ideological basis on which to develop a new organizational form for health sector decision-making. The new Labour government pledged to eradicate the irrationality associated with the internal market. However, a return to the old NHS planning model is not proposed, and Labour is equally committed to involving GPs in commissioning health services at the local level, suggesting that the tension between centralized planning and local incrementalism may continue to undermine the development and implementation of health policy.

A splice variant of CD44 expressed in the apical ectodermal ridge presents fibroblast growth factors to limb mesenchyme and is required for limb outgrowth

Signals from the apical ectodermal ridge (AER) of the developing vertebrate limb, including fibroblast growth factor-8 (FGF-8), can maintain limb mesenchymal cells in a proliferative state. We report here that a specific CD44 splice variant is crucial for the proliferation of these mesenchymal cells. Epitopes carried by this variant colocalize temporally and spatially with FGF-8 in the AER throughout early limb development. A splice variant containing the same sequences expressed on model cells binds both FGF-4 and FGF-8 and stimulates mesenchymal cells in vitro. When applied to the AER, an antibody against a specific CD44 epitope blocks FGF presentation and inhibits limb outgrowth. Therefore, CD44 is necessary for limb development and functions in a novel growth factor presentation mechanism likely relevant in other physiological and pathological situations where a cell surface protein presents a signaling molecule to a neighboring cell.

The CD44 protein family

The designation CD44 describes a group of type I transmembrane proteins which share N-terminal and C-terminal sequences. These molecules differ in the central extracellular domain by the use of sequences encoded by ten variant exons which may be completely absent or included in various combinations and by cell type specific addition of glycosaminoglycan and carbohydrate moieties. Expression of variant proteins is observed in normal tissues such as on keratinocytes, dendritic cells and activated lymphocytes in the adult organism and on morphogenetically active epithelium such as the apical ectodermal ridge (AER) in the embryo. Certain CD44 proteins expressed on the AER can act as low affinity fibroblast growth factor receptors and are vital for epithelial-mesenchymal cell communication. CD44 variant proteins have also been implicated in tumour growth and metastasis and we speculate that CD44 mediated growth factor presentation may also be decisive in metastasis formation. Molecular strategies designed to block growth factor presentation by CD44 may aid in the therapy of metastatic cancer.

Clinical evaluation of an acellular allograft dermal matrix in full-thickness burns

A multicenter clinical study assessed the ability of an acellular allograft dermal matrix to function as a permanent dermal transplant in full-thickness and deep partial-thickness burns. The study consisted of a pilot phase (24 patients) to identify the optimum protocol and a study phase (43 patients) to evaluate graft performance. Each patient had both a test and a mirror-image or contiguous control site. At the test site, the dermal matrix was grafted to the excised wound base and a split-thickness autograft was simultaneously applied over it. The control site was grafted with a split-thickness autograft alone. Fourteen-day take rates of the dermal matrix were statistically equivalent to the control autografts. Histology of the dermal matrix showed fibroblast infiltration, neovascularization, and neoepithelialization without evidence of rejection. Wound assessment over time showed that thin split-thickness autografts plus allograft dermal matrix were equivalent to thicker split-thickness autografts.

Information management and technology in England's large acute NHS hospitals. National strategy versus local reality

Discusses the NHS Executive's information management and technology (IM&T) strategy and its relationship to the 1991 reforms. Examines the recommendation for large acute hospitals to adopt integrated hospital information support systems (HISS). Reports that a recent census of these hospitals, undertaken by the authors, suggests that the implementation of the strategy's recommendations has been slow at the local level. Attempts to diagnose the factors that are impeding implementation, using the evidence provided by the census. Identifies four main problem areas: the lack of success of past IM&T initiatives undermines confidence in the current strategy; the strategy is poorly aligned with other policy initiatives; the legacy of discrete, proprietary information systems within hospitals makes the creation of an integrative information environment difficult to accomplish without massive investment in new systems; and there are implicit contradictions between the following: the absence of a comprehensive post-implementation evaluation of the economic, technological and cultural feasibility of HISS at any of the three HISS pilot sites; the strategy's advocacy of HISS as the way forward for large acute hospitals; the requirement for a comprehensive business case to support any substantial investment in IM&T. Concludes that a massive rethink of policy is required, with a much greater emphasis on research, development and independent evaluation.

Do the teaching hospitals of the University of Queensland really want a four-year medical course? A guarded yes

OBJECTIVE

To gauge the measure of support among clinical teaching staff for the University of Queensland's proposals to introduce a four-year graduate entry integrated medical curriculum.

SETTING

The three largest teaching hospitals of the University of Queensland Faculty of Medicine.

METHODS

A questionnaire was sent to 565 consultants and 493 junior medical staff regarding deficiencies of the present six-year course, deficiencies in present methods of selecting students, and possible solutions.

RESULTS

154 (68%) full-time consultants, 174 (51%) visiting consultants and 197 (40%) junior staff replied. Ninety per cent of the consultants and 60% of the junior staff were current teachers. Respondents strongly supported the need for major change, the integration of biomedical sciences into clinical teaching and the use of problem-based learning. Regarding selection, over 80% of respondents considered graduate entry to have no advantage over undergraduate entry, but there was strong support for an external examination including sciences. There was also strong support for broadening entry criteria to include common sense, motivation and empathy. Seventy-two per cent of consultants and 82% of juniors opposed the proposals in their present form. However, 52% of consultants (but only 23% of juniors) would support the concept of a four-year integrated course if the issue of selection criteria could be resolved.

CONCLUSION

A majority of consultants support the concept of a four-year integrated curriculum which uses problem-based learning methods. They do not support the proposed selection criteria based upon graduate entry, but would support a predominantly science-based selection process, not necessarily restricted to graduate applicants, but incorporating broader personal characteristics than are used at the present time.

Fundholding in northern region: the first year

OBJECTIVE

To describe the experiences of 10 fundholding practices in the Northern region during 1991-2 and to elicit subjective assessments of the impact of their change in status on practice management and patient care.

DESIGN

Semistructured interviews were conducted with clinicians and practice managers; other staff in the practices were asked to fill in questionnaires. Questions were asked about the preparatory year, the impact of fundholding on clinical practice and practice management, perceptions of the costs and benefits of fundholding, and views about the future of the scheme.

SETTING

10 of the 28 first wave fundholding practices in the Northern region, March-July 1992.

RESULTS

Two interviews were conducted in nine practices and one interview in the tenth practice. Replies to the questionnaire were received from 35 general practitioners (73%) and 89 (58%) nonmedical staff. Practices sought independence in applying for fundholding status and found the preparatory year challenging and time consuming. General practitioners thought that the greatest change had occurred in relationships with consultants and the least change in relationships with patients. Most respondents thought that fundholding had changed the way they worked. The perceived benefits of fundholding were mentioned more often than the perceived costs.

CONCLUSIONS

The results offer some encouragement to the proponents of fundholding, but more longitudinal studies are needed to evaluate the misgivings of critics of the scheme. Fundholders are uncertain about their ability to make savings year after year, particularly in an increasingly cost contained environment.

The shelf operation for hip dysplasia in adolescence

Failure of normal acetabular development is inevitable in congenital dislocation of the hip when it is unrecognised until late infancy or early childhood. Numerous stabilising procedures have been described, one of the first being the shelf operation or acetabuloplasty. This procedure fell into disrepute because the shelf was often located too high or was too small to prevent upward migration of the femoral head. The technique described emphasises the importance of resecting the thickened capsule and exposing the lateral margin of the acetabulum to allow a substantial portion of the outer cortex of the ilium to be turned down both laterally and anteriorly over the femoral head. Twenty cases of acetabuloplasty have been followed up for an average period of nine years. The results have been assessed from the point of view of function, relief of pain, and degree of support of the femoral head as demonstrated radiologically. The shelf operation is a simple and safe procedure, and provided it gives adequate support to the subluxated femoral head it will ensure a stable, mobile joint capable of standing up to reasonable use for many years. If deterioration should occur in later life, total hip replacement may be undertaken more easily than if the joint had been allowed to undergo progressive subluxation.

Severe irreducible slipping of upper femoral epiphysis: a review of 14 cases treated by subtrochanteric osteotomy

Children with signs of slipping of the upper femoral epiphysis often present in an Accident Service, particularly after a severe, acute slip. In some cases the displacement is irreducible and correction of the persistent deformity by either cervical or trochanteric osteotomy is required. This paper is a review of 14 cases of irreducible slipped upper femoral epiphysis treated by subtrochanteric osteotomy. Clinical and radiological assessment of these cases some years later shows a high proportion of successful results and suggests that this is a safe and satisfactory method of treating this condition.