Educational opportunities in palliative care: what do general practitioners want?

It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.

Rolling circle amplification for scoring single nucleotide polymorphisms

The analysis of the genetic basis of phenotypic traits is moving towards the complex diseases prevalent in wealthy populations. There is an increasing requirement for the detection of different types of sequence variation, particularly single-nucleotide polymorphisms (SNPs). SNPs occur about once every 100 to 300 bases. High-density SNP maps will help to identify the multiple genes associated with complex diseases such as cancer, diabetes, vascular disease, and some forms of mental illness.

Intravenous gentamicin and ceftazidime in penetrating ocular trauma: a swine model

PURPOSE

A swine model of ocular trauma was used to determine the extent of penetration of systematically administered gentamicin and ceftazidime to the vitreous cavity of traumatized and normal eyes.

METHODS

Forty-six pigs received a scleral laceration to the right eye and then underwent surgical repair. Thirty-six animals received intravenous gentamicin, and 10 pigs were given ceftazidime.

RESULTS

The level of gentamicin in the vitreous of traumatized and nontraumatized eyes did not achieve the minimum inhibitory concentrations (MIC) for Pseudomonas and Haemophilus species despite multiple and large intravenous doses. Ceftazidime concentrations in traumatized eyes were above the minimum inhibitory concentration for these organisms.

CONCLUSIONS

Ceftazidime achieves an intravitreal concentration 33 times the minimum inhibitory concentration of Haemophilus species and twice that of Pseudomonas species in traumatized eyes after systemic administration, a finding that lends support to its use as a prophylactic agent in the management of penetrating ocular trauma. Gentamicin does not appear to enter the traumatized eye at appreciable levels after systemic administration, and, therefore, it is not recommended for use as a prophylactic agent in the management of penetrating ocular trauma.

High resolution mapping of the binding site on human IgG1 for Fc gamma RI, Fc gamma RII, Fc gamma RIII, and FcRn and design of IgG1 variants with improved binding to the Fc gamma R

Immunoglobulin G (IgG) Fc receptors play a critical role in linking IgG antibody-mediated immune responses with cellular effector functions. A high resolution map of the binding site on human IgG1 for human Fc gamma RI, Fc gamma RIIA, Fc gamma RIIB, Fc gamma RIIIA, and FcRn receptors has been determined. A common set of IgG1 residues is involved in binding to all Fc gamma R; Fc gamma RII and Fc gamma RIII also utilize residues outside this common set. In addition to residues which, when altered, abrogated binding to one or more of the receptors, several residues were found that improved binding only to specific receptors or simultaneously improved binding to one type of receptor and reduced binding to another type. Select IgG1 variants with improved binding to Fc gamma RIIIA exhibited up to 100% enhancement in antibody-dependent cell cytotoxicity using human effector cells; these variants included changes at residues not found at the binding interface in the IgG/Fc gamma RIIIA co-crystal structure (Sondermann, P., Huber, R., Oosthuizen, V., and Jacob, U. (2000) Nature 406, 267-273). These engineered antibodies may have important implications for improving antibody therapeutic efficacy.

Molecular characterization of a novel recombinant strain of human astrovirus associated with gastroenteritis in children

We report a naturally occurring human astrovirus (HAstV) strain detected in two different geographic locations. We identified two isolates of this strain in a diarrhea outbreak at a child care center in Houston, Texas; and two isolates in diarrhea stool samples from two children in Mexico City. All four isolates were detected in stool samples by enzyme immunoassay (EIA). One of the Mexican isolates was typed by EIA and all four isolates were HAstV-5 by typing RT-PCR. The four isolates were >97% nucleotide-identical in two different genomic regions: ORF1a (246 nt), and the 3' end of the genome (471 nt). One isolate from each geographic location was further sequenced in the transition region from ORF1b to ORF2 (1255 nt) and this region of the two isolates showed > or = 99% nt identity. Phylogenetic analyses of sequences of eight HAstV antigenic types and the novel strain in the transition region demonstrated the new strain being closely related to HAstV-3 in ORF1b, but closest to HAstV-5 in ORF2. These results and high sequence identity among all HAstV antigenic types in the transition region and RNA structural predictions supported a potential recombination site at the ORF1b/ORF2 junction. This is the first evidence that recombination occurs among human astroviruses.

Using case vignettes to train clinicians and utilization reviewers to make level-of-care decisions

Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function. This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Directed mutation of the basic domain of v-Jun alters DNA binding specificity and abolishes its oncogenic activity in chicken embryo fibroblasts

Overexpression of v-Jun in chicken embryo fibroblasts (CEF) leads to oncogenic transformation phenotypically characterized by anchorage independent growth and release from contact inhibition (focus formation). The mechanisms involved in this oncogenic conversion however, are not yet clear. Because Jun is a transcription factor, it has been assumed that oncogenic transformation results directly from deregulated AP-1 target gene expression. However, a number of experimental observations in avian cell culture models fail to correlate oncogenesis with AP-1 activity suggesting that transformation induced by v-Jun may occur through an indirect mechanism. To test this possibility, we introduced point mutations into the basic DNA binding domain of v-Jun and created mutants that exhibit altered binding specificity. When expressed in CEF, these mutants fail to deregulate three known v-Jun target genes (JTAP-1, apolipoprotein A1, c-Jun) thus demonstrating in vivo specificity changes. Each of the binding specificity mutants was also tested for its ability to induce oncogenic transformation. Interestingly, expression of these mutants in CEF results in a phenotype indistinguishable from the vector control with respect to growth rate, focus formation and the ability to form colonies in soft agar. These results are consistent with a model requiring direct AP-1 target deregulation as a prerequisite of v-Jun induced cell transformation. With this in mind, we generated a series of additional mutants that retain the ability to bind AP-1 sequence elements, but vary in their oncogenic potential. We demonstrate the use of these mutants to screen v-Jun induced gene targets for a functional role in cell transformation.

A managed behavioral health organization operated by an academic psychiatry department

As a means of adapting to managed care, the psychiatry department at Wake Forest University developed a managed behavioral health organization (MBHO) to manage the care of enrollees in QualChoice, the health maintenance organization of the Wake Forest University Baptist Medical Center. Before the academic MBHO was created, care was managed by a for-profit MBHO. In this case study, financial and utilization data were obtained from both MBHOs and from QualChoice. The data confirm that the academic MBHO was able to offer competitive rates for its services. It also was able to increase enrollees' use of the medical center's own providers and facilities by making more referrals than were made by the for-profit MBHO. Developing a managed behavioral health organization can allow academic psychiatry departments, either individually or as consortia, to preserve the patient base they require for teaching, research, and financial stability.

Propionibacterium acnes as a cause of visually significant corneal ulcers

PURPOSE

To report Propionibacterium acnes as a cause of vision-threatening infectious keratitis and to discuss culture isolation and antibiotic treatment.

METHODS

Retrospective case series presentation collected from three academic medical centers.

RESULTS

Six cases of P. acnes infectious keratitis are presented, all of which were associated with a compromised corneal barrier or environment. All cases were culture-positive on thioglycolate broth; none became positive before 7 days of growth. No other organisms were isolated from any culture, and the growth of P. acnes occurred in some cases despite negative gram stains.

CONCLUSION

P. acnes can produce vision-debilitating keratitis when the cornea is compromised. Growth in culture should be monitored for at least 10 days to ensure isolation of this fastidious organism. P. acnes may respond to several different antibiotics that have gram-positive coverage, but it should be treated with vancomycin to enhance clearance of the organism.

The chicken c-Jun 5' untranslated region directs translation by internal initiation

The 5' untranslated region (UTR) of the chicken c-jun message is exceptionally GC rich and has the potential to form a complex and extremely stable secondary structure. Because stable RNA secondary structures can serve as obstacles to scanning ribosomes, their presence suggests inefficient translation or initiation through alternate mechanisms. We have examined the role of the c-jun 5' UTR with respect to its ability to influence translation both in vitro and in vivo. We find, using rabbit reticulocyte lysates, that the presence of the c-jun 5' UTR severely inhibits translation of both homologous and heterologous genes in vitro. Furthermore, translational inhibition correlates with the degree of secondary structure exhibited by the 5' UTR. Thus, in the rabbit reticulocyte lysate system, the c-jun 5' UTR likely impedes ribosome scanning resulting in inefficient translation. In contrast to our results in vitro, the c-jun 5' UTR does not inhibit translation in a variety of different cell lines suggesting that it may direct an alternate mechanism of translational initiation in vivo. To distinguish among the alternate mechanisms, we generated a series of bicistronic expression plasmids. Our results demonstrate that the downstream cistron, in the bicistronic gene, is expressed to a much higher level when directly preceded by the c-jun 5' UTR. In addition, inhibition of ribosome scanning on the bicistronic message, through insertion of a synthetic stable hairpin, inhibits translation of the first cistron but does not inhibit translation of the cistron downstream of the c-jun 5' UTR. These results are consistent with a model by which the c-jun message is translated through cap independent internal initiation. Oncogene (2000) 19, 2836 - 2845

Providing palliative care in primary care: how satisfied are GPs and district nurses with current out-of-hours arrangements?

The complex needs of palliative care patients require an informed, expert, and swift response from out-of-hours general medical services, particularly if hospital admission is to be avoided. Few general practitioners (GPs) reported routinely handing over information on their palliative care patients, particularly to GP co-operatives. District nurses and inner-city GPs were least satisfied with aspects of out-of-hours care. Most responders wanted 24-hour availability of specialist palliative care. This indicates a need to develop and evaluate out-of-hours palliative care procedures and protocols, particularly for GP co-operatives, and to improve inter-agency collaboration.

Engineering Chinese hamster ovary cells to maximize sialic acid content of recombinant glycoproteins

We have engineered two Chinese hamster ovary cell lines secreting different recombinant glycoproteins to express high levels of human beta1,4-galactosyltransferase (GT, E.C. 2.4.1.38) and/or alpha2, 3-sialyltransferase (ST, E.C. 2.4.99.6). N-linked oligosaccharide structures synthesized by cells overexpressing the glycosyltransferases showed greater homogeneity compared with control cell lines. When GT was overexpressed, oligosaccharides terminating with GlcNAc were significantly reduced compared with controls, whereas overexpression of ST resulted in sialylation of >/=90% of available branches. As expected, GT overexpression resulted in reduction of oligosaccharides terminating with GlcNAc, whereas overexpression of ST resulted in sialylation of >/=90% of available branches. The more highly sialylated glycoproteins had a significantly longer mean residence time in a rabbit model of pharmacokinetics. These experiments demonstrate the feasibility of genetically engineering cell lines to produce therapeutics with desired glycosylation patterns.

A convenient microscale colorimetric method for terminal galactose on immunoglobulins

A new approach for quantitative determination of terminal galactose (Gal) residues of immunoglobulins was developed by combining exoglycosidase digestion with the classical colorimetric estimation of reducing sugars. The ferricyanide colorimetric method was modified to increase the stability of the chromophore (Prussian blue) and adapted to determine the amount of terminal Gal residues present in immunoglobulins. The method involves the release of covalently bound Gal from immunoglobulins by Diplococcus pneumoniae beta-D-galactosidase (specific for beta(1,4) linked galactose), removal of the glycoprotein and enzyme from the reaction mixture by heat denaturation or ethanol precipitation, followed by colorimetric measurement of the released sugar using the ferricyanide assay. The ferricyanide method was modified to enhance the solubility and stability of the chromophore by increasing the concentration of aqueous sulfuric acid and sodium dodecyl sulfate (SDS). The linear range of the modified method was from approximately 11 to 111 microM Gal. Typical variation in assay results was on the order of 5%. Using the modified method, the terminal Gal content of a recombinant chimeric monoclonal antibody (anti-CD20, rIgG) expressed in Chinese hamster ovary (CHO) cells was determined and evaluated for batch-to-batch consistency. The method was used to optimize pH, time, temperature, and enzyme concentration for beta-galactosidase digestion for maximal release of terminal Gal residues from rIgG.

Nutrition in ESRD patients: rationale and plan for an initiative

End-stage renal disease (ESRD) continues to be a major public health problem in the United States. There has been an exponential growth in the incidence rate, at an average of 5% to 8% per year over the past decade. Dialysis remains the predominant therapeutic modality. Unfortunately, however, the morbidity and mortality rates remain unacceptably high for the dialysis patient population. Malnutrition has been consistently suggested as a major contributor to the high morbidity and mortality rates. However, the exact magnitude of the problem is poorly defined. The physiological and pathophysiological mechanisms have not been adequately determined. Finally, any interventional approach and its potential beneficial effect are yet to be carefully defined and explored. This National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) initiative, with input from the ad hoc advisory committee, and strengthened with public comments, is intended to address these deficiencies, and the broad issue of nutrition and nutritional derangement and their detrimental effects on the ESRD patient population.

Transcervical recovery of fetal cells from the lower uterine pole: reliability of recovery and histological/immunocytochemical analysis of recovered cell populations

The aim of this work was to isolate, enumerate and attempt the identification of fetal cells recovered from the lower uterine pole. Immediately before elective termination of pregnancy at 7-17 weeks gestation, samples were recovered by transcervical flushing of the lower uterine pole (n = 108) or transcervical aspiration of mucus from just above the internal os (n = 187), and their contents examined using histological, immunohistochemical and molecular techniques. Syncytiotrophoblasts were identified morphologically in 28 out of 89 (31%) and 50 out of 180 (28%) flushings and aspirates respectively (mean 29%). Immunocytochemistry with monoclonal antibodies (mAbs) recognizing trophoblast or epithelial cell antigens on a smaller number of samples (n = 69) identified putative placental cells in 13 out of 19 (68%) and 25 out of 50 (50%) flushings and aspirates respectively (mean 55%). These included groups of distinctive cells with a small, round, hyperchromatic nucleus, strongly reactive with mAbs PLAP, NDOG1 and FT1.41.1. Smaller groups of larger, amorphous cells, usually containing multiple large, pale staining nuclei, reactive with mAb 340 and to a lesser degree with mAb NDOG5 were also observed. Taking cellular morphology and immunophenotype into consideration, the smaller uninucleate cells were likely to be villous mesenchymal cells, while the larger cells were possibly degrading villous syncytiotrophoblast. There was no significant difference in the frequency of fetal cells obtained by the two recovery methods. Squamous or columnar epithelial cells, labelled strongly with antibodies to cytokeratins or human milk fat globule protein, were observed in 97% (29 out of 30) of aspirates. The use of cervagem in a small number of patients prior to termination of pregnancy did not appear to influence the subsequent recovery of placental cells. Y-specific DNA was detected by polymerase chain reaction (PCR) in 13 out of 26 (50%) flushings and (99 out of 154) 64% aspirates analysed (mean 62%). In-situ hybridization (ISH) revealed Y-specific targets in 40 out of 69 (60%) of aspirates analysed. A comparison of PCR data obtained from transcervical recovered samples and placental tissues showed a concordance of 80% (76 out of 95), with 10 false positives. Comparing the PCR data from tissues with data derived by ISH from 41 aspirates gave a concordance of 90% with two false positives. Although syncytiotrophoblasts were much more likely to be present in samples containing immunoreactive placental cells, the detection rates of fetal-derived DNA were similar regardless of the morphological and/or immunological presence of placental cells. We conclude that the transcervical recovery of fetal cells, while promising, requires considerable additional effort being expended in further research and development, particular in the sampling procedure.

Bruxing patterns in children compared to intercuspal clenching and chewing as assessed with dental models, electromyography, and incisor jaw tracing: preliminary study

The purpose of the present study was to compare bruxing patterns in children with chewing and maximum intercuspal clenching as defined in a clinical and laboratory environment. Six non-bruxing controls and six children who actively bruxed according to parent reports were evaluated. Both control and experimental subjects were assessed by an initial questionnaire, intraoral examination, extraoral examination, dental study models, incisor mandibular tracking, and bilateral surface electromyographic recordings (e.g., EMG). Bruxing was defined as grinding, clenching, or both in combination. The clinical examination consisted of an intraoral examination of the dentition, number of occlusal contacts, and wear facets. Dental study models were used to substantiate the intraoral findings for occlusal contact and wear facets. The mandibular incisors position was tracked during opening, closing, laterotrusion, protrusion, and chewing and compared to the bruxing movements in the experimental subjects. Bilateral surface EMG signals from the temporalis and masseter muscles were recorded in three maximum intercuspal clenches, ten chewing cycles on sugarless gum, and during simulated bruxing. The dental contacts were equal in number bilaterally in both control and bruxing subjects. Both groups demonstrated wear facets, but the bruxing subjects had more facets. The wear facets indicated lateral excursions but not clenching. Only the incisor jaw tracking and bilateral EMG differentiated the bruxing patterns. In those subjects (n = 4) who clenched during bruxing, the EMG pattern was not similar to that of intercuspal clenching and demonstrated its own unique muscle recruitment for the temporalis and masseter muscles. In the subjects who exhibited lateral excursions for bruxing (n = 2), the pattern of muscle recruitment of the two-closing muscles in terms of amplitude was similar for both the bruxing and chewing gum. Our findings support a concept that bruxing may depend upon factors that modify coactivation of muscle recruitment and do not depend upon occlusal contacts.

Human subject screening: a dynamic process

INTRODUCTION

The history of disqualified (DQ) subjects from 1973-1993 at Armstrong Laboratory, Wright Patterson AFB, is presented for both sustained and impact acceleration panels.

METHODS

Candidate and subject medical records were reviewed for screening results, recommendation for panel duty, and any follow-up medical findings. The generation and interpretation of the medical screening criteria and DQ rates are discussed. MEDICAL SCREENING CRITERIA: The mechanisms for change, those factors influencing change, and the interpretation of the screening criteria for Armstrong Laboratory's acceleration panels determine the panel's composition, which is reflected in the DQ rates.

RESULTS

The centrifuge had a 5% (7/132) disqualification (DQ) rate from 1973-93 with 29% (2/7) due to musculoskeletal and 71% (5/7) for medical reasons. All were DQ during 1973-88. The impact panel had a DQ rate of 18% (36/195) with 71% (24/34) DQ due to musculoskeletal and 29% (10/34) for medical reasons. Only 28% (10/36) were DQ during 1973-88, while during 1989-93, 72% (26/36) were DQ.

CONCLUSIONS

The differences in DQ rates between the centrifuge and impact facility were due to the variability or conservatism of individual physicians, interpretation of the medical screening criteria, and the type of research being done. These factors effect the composition of the human subject panels. This determines to which target population the research data can be applied. If the subjects do not represent pilots due to inappropriate screening, then there is no benefit from the research and, therefore, there can be no risk incurred by the subjects.

Pityriasis rubra pilaris: an unusual cutaneous complication of AIDS

Pityriasis rubra pilaris is an uncommon hyperkeratotic, papulosquamous disorder that has been reported in patients infected by HIV. We recount a case of pityriasis rubra pilaris in an HIV-seropositive man. A 36-year-old man with a history of ulcerative colitis and recurrent otitis externa had diffuse psoriaform erythroderma. He was treated initially with methotrexate and isoretinoin without clinical improvement. Skin examination showed large, erythematous, orange, scaly patches on the upper extremities and thickening of the nail beds. The palms and soles were hyperkeratotic. Skin biopsy revealed changes that were consistent with pityriasis rubra pilaris. Six months before the onset of symptoms, results of an enzyme-linked immunosorbent assay (ELISA) and Western Blot assay for HIV were negative. Six months after symptoms, results of repeat enzyme-linked immunosorbent assay and Western blots for HIV were positive (CD4+ T-cell count = 200 cells/ mm3). Clinical course had been complicated by episodes of Staphylococcus aureus bacteremia, mucocutaneous candidiasis, and development of localized squamous cell carcinoma of the skin. The increased severity of pityriasis rubra pilaris should prompt clinicians to consider coinfection with HIV in patients who have disease that is refractory to treatment. Clinicians also should remain vigilant for the development of squamous cell carcinoma.

Comparison of acceleration subjects to other populations: spinal anomaly distribution

Two Armstrong Laboratory (AL) human volunteer subject panels (sustained and impact acceleration) at Wright Patterson AFB, OH, were compared to each other and to other samples of different populations in terms of spinal anomalies. These sample populations were obtained from the scientific literature: French, Norwegian, Netherlands, and U.S. pilots; U.S. Air Force (AF) and Navy subjects, and from representative "normal" civilian populations, and then compared using the proportion parameters for various spinal anomalies. There were only a few common parameters between the two panels and between each panel compared with the foreign military, human subjects, and "normal" population. However, there were two to six times as many similar spinal anomaly incidence rates between the AL panels and the U.S. pilot sample. It was reassuring that the AL subject panels used in AF acceleration research have more in common with AF pilots than other populations in regards to spinal anomalies, even though the pilot sample may not be representative of the true pilot population. Recommendations are to establish a common reference point in nomenclature and description of spinal anomalies (modeled after the French) and to start collecting spinal radiographs on all U.S. pilots. These radiographs would not be for screening but for establishing a database following the occupational pathology of flying. This data would also facilitate comparisons with research acceleration panels, as well as with foreign air forces. Informed decisions can then be made regarding screening criteria for the future as aircraft and ejection seat performance envelopes continue to expand.

Human subject research at Armstrong Laboratory, 1973-93: medical and musculoskeletal disqualifications

The reasons for disqualification of human subjects from 1973-93 at Armstrong Laboratory, formerly the Harry G. Armstrong Aeromedical Research Laboratory (AAMRL), are presented for both sustained and impact acceleration panels. Evaluations for both medical and spinal anomalies were accomplished. The rationale for each disqualification is discussed, demonstrating the variability in each panel physician's clinical judgment in the context of personal bias, the ethical framework surrounding the use of human volunteers, and the existing research milieu.

Post-translational processing and renal expression of mouse Indian hedgehog

The full-length mouse Indian hedgehog (Ihh) cDNA was cloned from an embryonic 17.5-day kidney library and was used to study the post-translational processing of the peptide and temporal and spatial expression of the transcript. Sequence analysis predicted two putative translation initiation sites. Ihh translation was initiated at both initiation sites when expressed in an in vitro transcription/translation system. Expression of an Ihh mutant demonstrated that the internal translation initiation site was sufficient to produce the mature forms of Ihh. Ihh post-translational processing proceeded in a fashion similar to Sonic and Drosophila hedgehog; the unprocessed form underwent signal peptide cleavage as well as internal proteolytic processing to form a 19-kDa amino-terminal peptide and a 26-kDa carboxyl-terminal peptide. This processing required His313 present in a conserved serine protease motif. Ihh transcript was detected by in situ RNA hybridization as early as 10 days postcoitum (dpc) in developing gut, as early as 14.5 dpc in the cartilage primordium, and in the developing urogenital sinus. In semiquantitative reverse transcription-polymerase chain reaction experiments, Indian hedgehog transcript was first detected in the mouse metanephros at 14.5 dpc; transcript abundance increased with gestational age, becoming maximal in adulthood. In adult kidney, Ihh transcript was detected only in the proximal convoluted tubule and proximal straight tubule.

Reliability of trans-cervical recovery of placental cells from the lower uterine pole using a minimally invasive procedure. Evidence based on fetal sexing and analysis of recovered cell populations

OBJECTIVE

Efficient recovery of placental cells (and their subsequent characterisation) from the lower uterine pole (L.U.P) by trans-cervical flushing or aspiration.

SUBJECTS

Women attending for termination of pregnancy (7-17 weeks' gestation) for social reasons. All patients gave their consent to the procedures outlined below.

METHODS

Trans-cervical intrauterine flushing (using 0.15 M NaCl) or mucus aspiration. Embryo transfer catheters were used in both procedures. Fetal sexing was achieved by gene amplification of Y-specific DNA sequences (Y-PCR), and by in situ hybridisation (bright-field and fluorescence) to the Y-chromosome. Data were compared with results obtained from fetal tissues recovered following termination of pregnancy. Gender-independent tests for fetal cells utilised immunocytochemistry with trophoblast-specific antibodies and dual immunocytochemistry/ISH, where appropriate.

RESULTS

(1) Fetal sexing by Y-PCR: 71/122 (58%) aspirates contained Y-specific DNA. In addition, the sexing of 72/86 (84%) aspirates and their corresponding samples of placental tissue, agreed exactly. (2) Microscopic detection of fetal cells. Placentally-derived syncytiotrophoblast was detected in 17/45 (38%) flushings and 39/173 (23%) aspirates. In most other Y-PCR+ samples which were negative for syncytiotrophoblast, Y-chromosome-bearing nuclei of unknown origin, were observed by ISH and immunocytochemical evidence for cytotrophoblastic cells was also uncovered.

CONCLUSIONS

Since Y-derived DNA can be detected in > 50% of flushings and aspirations, and gender-independent evidence for placental cells was obtained, regardless of fetal sex, we believe that most or all of these samples contained placental cells, including trophoblasts and naked nuclei. Trans-cervical placental cell recovery is a potentially valuable alternative to more invasive methods of aneuploid detection which require amniocentesis and CVS, provided its level of accuracy and above all, safety, can be evaluated.

Riding a Trojan horse: computerized psychiatric treatment planning using managed care principles

Efforts to curtail health care costs have triggered new emphasis on resource management and accountability, entailing explicit documentation of the rationale for treatment and the resulting outcome of care. This article discusses the development of a computerized psychiatric treatment planning database that embodies principles and language of managed care, including specific admission criteria, severity ratings, and time frames for completion of interventions. The program is designed to balance goals of clinical utility, usefulness of the database as a tool for utilization review, quality improvement, and health services research, while providing an interface that is acceptable to clinicians.

Effects of opioid antagonists naloxone and naltrexone on neuropeptide Y-induced feeding and brown fat thermogenesis in the rat. Neural site of action

Neuropeptide Y administered intracerebroventricularly and into the paraventricular nucleus of the hypothalamus stimulates feeding and decreases brown adipose tissue thermogenesis. Although specific neuropeptide Y antagonists are not yet available, previous studies had shown that the opioid antagonist naloxone blocked neuropeptide Y-induced feeding when both drugs were injected intracerebroventricularly. We wanted to find out if naloxone injected into specific brain sites would block neuropeptide Y effects on feeding and brown fat thermogenesis. Rats were double injected in specific brain sites with neuropeptide Y and either naloxone or naltrexone (a congener of naloxone). Food intake and brown fat measures were assessed. Naloxone or naltrexone in the paraventricular nucleus weakly decreased paraventricular nucleus neuropeptide Y-induced feeding and did not affect neuropeptide Y-induced reductions in brown fat activity. Peripheral naloxone blocked intracerebroventricular neuropeptide Y-induced feeding and brown fat alterations. Fourth ventricular naloxone decreased paraventricular nucleus neuropeptide Y-induced feeding, and naltrexone given into the nucleus of the solitary tract blocked paraventricular nucleus neuropeptide Y-induced alterations in feeding and brown fat. These data indicate that neuropeptide Y in the paraventricular nucleus may act on feeding and brown fat thermogenesis through opioidergic pathways in the nucleus of the solitary tract.

Non-syncytial sources of fetal DNA in transcervically recovered cell populations

We have previously shown that fetal DNA can be detected in swabs and flushings obtained from the lower uterine pole prior to the termination of pregnancy. The presence of syncytiotrophoblast vesicles in transcervically retrieved samples suggested that this distinctive placental tissue was an abundant source of fetal DNA and a valuable resource in prenatal diagnosis strategies. In a more extensive study involving 150 terminations of pregnancy between 7 and 17 weeks gestational age, 29% of transcervically retrieved samples contained visible syncytial vesicles. Flushing of the uterine pole more frequently contained syncytia than direct aspiration (39% compared with 26% of samples) but this difference was not statistically significant. No samples > 14 weeks gestational age contained syncytia. Polymerase chain reaction analysis using Y-sequence specific-nested primers indicated the presence of fetal DNA in the absence of intact syncytial vesicles. We therefore examined samples by in-situ hybridization using Y-specific DNA probes. Positive labelling was observed in syncytial vesicles where present and in clumps of unidentified fetal cells. In addition, high numbers of naked nuclei were labelled in samples devoid of syncytia. These isolated nuclei are possibly derived from disrupted syncytia, and may be an important and hitherto overlooked contributory factor in fetal material which collects at the lower uterine pole.

The temperature-composition phase diagram and mesophase structure characterization of monopentadecenoin in water

The temperature-composition phase diagram of monopentadecenoin, a monoacylglycerol with a cis monounsaturated fatty acid 15 carbon atoms long (C15:1c10) in water was constructed using x-ray diffraction. Low- and wide-angle diffraction patterns were collected from samples of fixed hydration as a function of temperature in the heating direction on x-ray-sensitive film. The temperature and hydration ranges investigated were 0-104 degrees C and 0-60% (w/w) water, respectively. The phases identified in the system include the lamellar crystalline phase, the lamellar liquid crystalline phase, the fluid isotropic phase, and two inverted cubic phases belonging to space groups la3d (Q230) and Pn3m (Q244). Particular attention has been devoted to the issues of phase equilibrium, phase boundary verification, and structure characterization. The phase diagrams of monopentadecenoin, monomyristolein (C14:1c9), and monoolein (C18:1c9) are compared, and the impact of molecular structure on mesophase stability and structure is discussed.

RU 486: an alternative to surgical abortion

After 5 years of use in more than 100,000 European women, RU 486, an antiprogestin medication used as a medical abortifacient, has recently come under scrutiny in the United States. This article discusses the current and potential uses of RU 486. Also addressed are the history, advantages, and disadvantages of medical abortion (including the acceptability of the method from a woman-centered perspective); new clinical trials; and ethical issues.

The temperature-composition phase diagram of monomyristolein in water: equilibrium and metastability aspects

The temperature-composition phase diagram of monomyristolein in water was constructed using x-ray diffraction. Low- and wide-angle diffraction patterns were collected from samples of fixed hydration as a function of temperature in the heating direction on x-ray-sensitive film and/or image plates. The phases identified in the system include the lamellar crystalline phase, the lamellar liquid crystalline phase, the fluid isotropic phase, and two inverted cubic phases. Particular attention has been devoted to the issues of phase equilibrium and phase boundary verification. Cubic phase undercooling was examined by adjusting the temperature of several samples in the cubic phase to a value where the lamellar liquid crystalline phase represents equilibrium behavior. Cooling-induced structure and phase changes were monitored continuously over a 30-min period by recording low-angle diffraction patterns from the samples using a streak camera. The cubic-to-lamellar transition rate decreased with increasing sample hydration. Additionally, the transition proceeded more rapidly at an incubation temperature of 25 degrees C compared to that at 0 degrees C. A mechanism is proposed that accounts for the hydration and temperature sensitivity of the phase transition under nonequilibrium conditions.

Interferon alpha selectively affects expression of the human myeloid cell nuclear differentiation antigen in late stage cells in the monocytic but not the granulocytic lineage

The human myeloid cell nuclear differentiation antigen (MNDA) is expressed constitutively in cells of the myeloid lineage, appearing in myeloblast cells in some cases of acute myeloid leukemia and consistently being detected in promyelocyte stage cells as well as in all later stage cells including peripheral blood monocytes and granulocytes. The human myeloid leukemia cell lines, HL-60, U937, and THP-1, express similar levels of immunochemically detectable MNDA. Although, the level of MNDA mRNA in primary monocytes is very low it was up-regulated at 6 h following the addition of interferon alpha. The effect of interferon alpha on the MNDA mRNA is also observed in the cell lines HL-60, U937, and THP-1. The MNDA mRNA level in primary granulocytes was unaffected by addition of interferon alpha and other agents including interferon gamma, endotoxin, poly (I).poly (C), and FMLP. The MNDA mRNA level in the myeloid cell lines was also unaffected by the latter four agents. Induction of differentiation in the myeloid cell lines with phorbol ester induces monocyte differentiation which was accompanied by a decrease in MNDA mRNA level. This reduced level of mRNA could then be elevated with subsequent interferon alpha treatment. The effects of phorbol ester on MNDA mRNA appeared to be associated with induced differentiation since inhibiting cell proliferation did not alter the level of MNDA mRNA and cell cycle variation in MNDA mRNA levels were not observed. The ability of interferon alpha to up-regulate MNDA mRNA in phorbol ester treated myeloid cell lines is consistent with the observations made in primary monocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Hippocampal damage does not impair instrumental appetitive conditioning with delayed reinforcement

The present study evaluated the effects of bilateral hippocampal lesions on appetitive instrumental conditioning with delayed (5-s interval) reinforcement in rats. Acquisition of a bar press response was considerably slower than rates observed with immediate reinforcement; however, no significant differences between hippocampally lesioned and control groups were noted regarding training to criteria or ratio of responses to reinforcements. These results suggest that the hippocampus is not essential for the association of temporally discontinuous stimuli, and that deficits in other forms of associative learning, such as spatial cognition, must be mediated by the loss of other functions. Putative functions and underlying substrates are discussed for response modulation and sensory (cue relations) associations.

Stereotactic brachytherapy for malignant glioma using a relocatable frame

Interstitial brachytherapy for recurrent gliomas normally necessitates the invasive application of a stereotactic frame by screw-fixation which must be kept on for several hours. The use of a relocatable stereotactic frame offers many advantages over conventional systems. We present our experience in 18 patients and verify that the frame used is accurate, comfortable, well tolerated and associated with no major disadvantages.

Quantitation of DNA and protein impurities in biopharmaceuticals

The development of drugs and biologicals for human injection generated from recombinant DNA and hybridoma technologies has resulted in new standards for product purity. We discuss the regulatory position relative to impurities in these biopharmaceuticals, focusing on the analytical goals for quantitation. Current methods for making these measurements are reviewed, and a new system designed for improved analysis is described. Assay results for both contaminating DNA and proteins are presented.

Temporal change in diagnostic criteria as a cause of the increase of malignant melanoma over time is unlikely

To assess whether the increase in malignant melanoma incidence could be due, at least in part, to changes in histological criteria of malignancy, pathologists in Australia, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, the United States and the USSR reviewed diagnoses of 50 consecutive pigmented naevi (40 junctional and compound; 10 intradermal) and 20 consecutive malignant melanomas made in each participating centre around 1930, around 1955 and around 1980. Collaborating pathologists re-read the material, 2,665 cases in all, either from the original slide (82%) or from a recut block (17%), gave their diagnosis and indicated whether the lesion was benign (B), dubious benign (DB), dubious malignant (DM) or malignant (M). As the distribution of review diagnoses was much the same whether the original slide or one made from a recut block was read, the material was pooled. Overall, 2.8% of cases originally reported as B/DB were reviewed as DM/M, while 4.4% of the DM/M diagnoses were held to be B/DB. The shifts between categories were greatest around 1955 and least around 1980, suggesting increasing uniformity of interpretation. All available blocks were recut and sections sent to IARC for review: 1.7% (22) of 1293 B/DB diagnoses were considered to be DM/M and 3.3% (18) of 551 DM/M diagnoses were considered to have been B/DB. The consistently low frequency of shift in diagnostic category, whether the material was reviewed in the collaborating laboratories or by one pathologist at IARC, in a study designed to give maximum attention to those lesions--the junctional and compound naevi--in which a change in opinion as to malignancy would be most likely to arise, suggests that pathologists, irrespective of geographical location, are using common criteria. These findings argue against changes in histological interpretation as being responsible for more than a small portion of the continuous increase of some 3% to 8% per annum observed in malignant melanoma incidence. Other explanations, such as an increase in the frequency or potential for malignant transformation of precursor lesions, must be sought. The anatomical distribution of the malignant melanomas examined followed the usual site pattern by sex, and their thickness was observed to decrease over the period of the study in most centres.

Sensor-based system for rapid and sensitive measurement of contaminating DNA and other analytes in biopharmaceutical development and manufacturing

The Threshold System provides for rapid and highly sensitive measurements of a variety of analytes at low concentration. The operating principles of the measurement system, including signal detection utilizing a proprietary silicon sensor, are described. The first application to run on the Threshold System is a quantitative assay for picogram levels of total DNA. This assay is of great value for monitoring levels of contaminating DNA in purified and in-process biopharmaceuticals. After sample pretreatment, the total assay time is less than two hours. The assay performance characteristics are described, along with data demonstrating sensitivity, precision, and accuracy. Pretreatment procedures for biopharmaceutical proteins are discussed. Two additional applications on Threshold are introduced. First, a universal ligand-binding assay system provides quantitative measurement of antigens or antibodies, in a variety of biological media, with speed, sensitivity, and precision. Second, preliminary results of rapid DNA-probe measurements on Threshold are presented.

Sub-femtomole quantitation of proteins with Threshold, for the biopharmaceutical industry

The Threshold system provides for rapid quantitation of a variety of analytes at sub-femtomole levels, which is fewer than 6 x 10(8) molecules. The operating principles of the measurement system will be described, including the means for chemical modulation of the signal and the subsequent signal detection utilizing a proprietary silicon sensor. The Immuno-Ligand Assay is a universal ligand-binding assay system which provides quantitative measurement of proteins (including antibodies) in a variety of biological media. Assay performance will be described, along with data demonstrating sensitivity, precision and accuracy, for a variety of analytes of interest to the biopharmaceutical industry.

Picogram quantitation of total DNA using DNA-binding proteins in a silicon sensor-based system

We report a rapid and reproducible method to quantify total DNA at picogram levels. Two high-affinity DNA-binding proteins are used to construct a sandwich assay and a semiconductor sensor is used for quantitation. Single-stranded DNA-binding protein (SSB) from Escherichia coli is conjugated with a linker molecule, biotin, for specific capture of the DNA complex onto a membrane. Monoclonal anti-DNA antibody is conjugated with an enzyme, urease, for signal generation. To detect DNA, a sample is denatured to form single-stranded DNA and then incubated with a reagent containing both DNA-binding protein conjugates and streptavidin. After incubation of the reagent with the DNA sample for 1 h at 37 degrees C to form a complex of streptavidin--biotin--SSB--DNA--anti-DNA--urease, the mixture is filtered through a biotin-coated nitrocellulose membrane which binds the streptavidin component of the complex. The unbound reagent is washed off the membrane, and then the captured DNA complex is detected with a light-addressable potentiometric sensor which measures the pH change catalyzed by the urease in the complex. This assay can detect 2 pg of DNA with a quantitation coefficient of variation of less than 10% in the range 10 to 200 pg.

The destination and dependency of patients discharged from care of the elderly units in the West Midlands

Between November 1988 and January 1989 a prospective survey was undertaken on patients aged 65 years and over who were discharged from the care of geriatricians in seven District General Hospitals. The survey aimed to provide a regional perspective on patient dependency by relating dependency at discharge to the discharge destination. The findings show that the majority of patients were relatively independent and most returned home. A significant number of the very dependent patients were discharged to the community with private residential and nursing homes making an important contribution to the placement of highly dependent patients.

Are malignant melanoma time trends explained by changes in histopathological criteria for classifying pigmented skin lesions?

The incidence of malignant melanoma in developed countries has been rising rapidly in recent years. Its causes and the reasons for this trend are uncertain. Changes in histopathological criteria for classifying pigmented skin lesions could explain the rising incidence rates. With support from the International Agency for Research on Cancer, this hypothesis is explored but not substantiated for time trends in the South Western Region, United Kingdom.

Glucagon stimulation of brown adipose tissue growth and thermogenesis

Despite long-standing observations of a whole-body thermogenic effect of glucagon, the role of glucagon in activating thermogenesis in brown adipose tissue has not often been studied. We investigated the ability of administered glucagon to produce alterations in brown adipose tissue similar to changes produced by accepted stimuli of brown fat activity: cold, norepinephrine, and overfeeding. Eighteen days of glucagon injections (1 mg/kg) to male Sprague-Dawley rats produced, relative to saline-injected controls, decreases in feed efficiency and increases in brown adipose tissue weight, protein content, DNA content, and mitochondrial mass as reflected in cytochrome oxidase activity. The observed changes were similar, though of lesser magnitude, to changes produced in these same parameters induced by administration of norepinephrine (250 micrograms/kg) for a positive control group. Four days of glucagon administration (1 mg/kg) produced increases in specific activity of cytochrome oxidase and lipoprotein lipase. After 8 days of glucagon administration, changes in whole-pad activity similar to those seen with 18 days of administration were present. Glucagon also increased whole-pad lipoprotein lipase activity after 4 and 8 days. Surgically denervated interscapular brown adipose tissue retained its ability to respond to exogenous glucagon, though the magnitude of the response was diminished. Guanosine 5'-diphosphate (GDP) binding to brown adipose tissue mitochondria was measured as an assessment of functional state after 5 days of glucagon (1 mg/kg). There was an increase in GDP binding relative to controls whether expressed as picomoles per milligram mitochondrial protein or nanomoles per pad.(ABSTRACT TRUNCATED AT 250 WORDS)

Neutron dosimetry with detectors of finite size. II. Experiments and calculations

In a previous article a theory for detector response in fields of fast neutrons was presented. In the present paper this theory is subjected to experimental tests. For detectors of sizes comparable to the ranges of the neutron produced charged particles the theory predicts the variation of the detector response with detector size and elemental composition of the detector. A tissue-equivalent ionization chamber exposed to a field of 252Cf neutrons was used in the experimental tests of the theory. The size dependence of the response was investigated by varying the chamber gas pressure and the effects of different elemental compositions (mainly hydrogen content) was investigated by using different gases in the chamber (H2, CH4, TE-gas N2, Air, CO2, and Ar). The theory was evaluated both by using chord length distributions to characterize the chamber cavity and with a simplified version using a single mean chord length. The agreement between theory and experiment is generally good.