Does convenience matter in health care delivery? A systematic review of convenience-based aspects of process utility

OBJECTIVES

To systematically review the existing literature on the value associated with convenience in health care delivery, independent of health outcomes, and to try to estimate the likely magnitude of any value found.

METHODS

A systematic search was conducted for previously published studies that reported preferences for convenience-related aspects of health care delivery in a manner that was consistent with either cost-utility analysis or cost-benefit analysis. Data were analyzed in terms of the methodologies used, the aspects of convenience considered, and the values reported.

RESULTS

Literature searches generated 4715 records. Following a review of abstracts or full-text articles, 27 were selected for inclusion. Twenty-six studies reported some evidence of convenience-related process utility, in the form of either a positive utility or a positive willingness to pay. The aspects of convenience valued most often were mode of administration (n = 11) and location of treatment (n = 6). The most common valuation methodology was a discrete-choice experiment containing a cost component (n = 15).

CONCLUSIONS

A preference for convenience-related process utility exists, independent of health outcomes. Given the diverse methodologies used to calculate it, and the range of aspects being valued, however, it is difficult to assess how large such a preference might be, or how it may be effectively incorporated into an economic evaluation. Increased consistency in reporting these preferences is required to assess these issues more accurately.

Meeting the health information needs of prostate cancer patients using personal health records

BACKGROUND

There is interest in the use of health information technology in the form of personal health record (phr) systems to support patient needs for health information, care, and decision-making, particularly for patients with distressing, chronic diseases such as prostate cancer (pca). We sought feedback from pca patients who used a phr.

METHODS

For 6 months, 22 pca patients in various phases of care at the BC Cancer Agency (bcca) were given access to a secure Web-based phr called provider, which they could use to view their medical records and use a set of support tools. Feedback was obtained using an end-of-study survey on usability, satisfaction, and concerns with provider. Site activity was recorded to assess usage patterns.

RESULTS

Of the 17 patients who completed the study, 29% encountered some minor difficulties using provider. No security breaches were known to have occurred. The two most commonly accessed medical records were laboratory test results and transcribed doctor's notes. Of survey respondents, 94% were satisfied with the access to their medical records, 65% said that provider helped to answer their questions, 77% felt that their privacy and confidentiality were preserved, 65% felt that using provider helped them to communicate better with their physicians, 83% found new and useful information that they would not have received by talking to their health care providers, and 88% said that they would continue to use provider.

CONCLUSIONS

Our results support the notion that phrs can provide cancer patients with timely access to their medical records and health information, and can assist in communication with health care providers, in knowledge generation, and in patient empowerment.

Screening for diabetes using an oral glucose tolerance test within a western multi-ethnic population identifies modifiable cardiovascular risk: the ADDITION-Leicester study

AIMS/HYPOTHESIS

The aim of this study was to determine the frequency of undiagnosed glucose abnormalities and the burden of cardiovascular disease (CVD) risk among south Asians and white Europeans attending a systematic screening programme for type 2 diabetes (ADDITION-Leicester) and to estimate the achievable risk reduction in individuals identified with glucose disorders.

METHODS

Random samples of individuals (n = 66,320) from 20 general practices were invited for a 75 g OGTT and CVD risk assessment. Ten-year CVD risk among screen-detected people with diabetes or impaired glucose regulation (IGR) (impaired fasting glycaemia and/or impaired glucose tolerance [IGT]) was computed using the Framingham-based ETHRISK engine and achievable risk reduction was predicted using relative reductions for treatments extracted from published trials.

RESULTS

A total of 6,041 participants (48% male, 22% south Asian) aged 40-75 years inclusive were included. Undiagnosed glucose disorders occurred more frequently in south Asians than white Europeans; age and sex adjusted odds ratios were 1.74 (95% CI 1.42-2.13) and 2.30 (95% CI 1.68-3.16) for IGT and diabetes respectively. Prevalence of any undetected glucose disorder was 17.5% in the whole cohort. Adjusted 10-year risk was similar in screen-detected people with IGR and diabetes (18.3% vs 21.6%), and was higher in south Asians across the glucose spectrum. Absolute CVD risk reductions of up to 13% in those with screen-detected type 2 diabetes and 6% in IGR are achievable using existing cardioprotective therapies.

CONCLUSIONS/INTERPRETATION

Population screening with an OGTT identifies a significant burden of modifiable CVD risk, especially within south Asian groups. Strategies enticing this population to consider screening programmes are urgently needed as significant risk reduction is possible once a glucose abnormality is identified.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00318032.

FUNDING

The project is funded for support and treatment costs by NHS Department of Health Support for Science and project grants.

How do peanut and nut-allergic consumers use information on the packaging to avoid allergens?

BACKGROUND

Recent legislation has sought to improve the information printed on packaged foods relevant to the safety of food allergic consumers. We aimed to understand the complex risk assessment decisions made by peanut and nut-allergic adults when purchasing food, with particular reference to use of printed package information.

METHODS

The behaviour and 'thinking aloud' of 32 participants were recorded during their normal food shop, followed by a semi-structured interview. During the interview they were given 13 potentially problematic packaged foods, and asked if they would purchase the product and what their reasons were. Transcribed data from the shop, interview and 13-product task were analysed to explore use of allergy advice boxes, ingredients lists and other packaging information.

RESULTS

Some participants used the ingredients list as their primary check for allergens, but most used the allergy advice box. Package-based information was generally considered reliable, but some supermarket and brand labels were trusted more than others. Images and product names were used to draw inferences about the presence of nuts. A number of improvements were suggested by participants, particularly a request for more 'nut free' labelling.

CONCLUSIONS

Food labels were used in conjunction with nonpacket-based strategies (e.g. previous experience) to make choices. External factors (e.g. trust of manufacturer) informed interpretation of and confidence in labels. Images and product names, not intended by manufacturers as an allergen risk assessment aid, were also used to inform choices.

The challenges for nut-allergic consumers of eating out

BACKGROUND

For individuals with a nut allergy, the avoidance of allergens is particularly challenging in situations where they are not preparing their own food. Many allergic reactions occur when eating outside the home.

OBJECTIVE

To identify and explore the challenges faced by nut-allergic individuals (NAIs) when they are eating in restaurants and other eating establishments.

METHODS

A qualitative interview study was conducted with 32 adults with a clinical history of allergy to peanuts and/or tree nuts.

RESULTS

The main strategies that participants adopted to manage the risk of allergic reactions when eating outside the home were avoidance and communication. They avoided types of restaurants, meal courses or particular foods. Seeking familiarity was a key strategy that enabled NAIs to reduce uncertainty and anxiety. Language differences were a major barrier to confident communication about food content. The need to check whether the food on offer may contain nuts was a source of social embarrassment for many participants and the desire to avoid this sometimes led to increased risk taking. Some did not disclose their allergy to restaurant staff as they feared a conservative reaction that would further constrain food choices. NAIs often have to plan where to eat out. The consequent lack of spontaneity was a source of regret to some.

CONCLUSION AND CLINICAL RELEVANCE

Communication patterns of nut-allergic adults are often grounded in legitimate everyday social considerations around embarrassment, choice and spontaneity. Education and training strategies are needed that recognize and take account of this. Focusing on communication deficits of NAIs may be unhelpful; responsibility for food safety must be shared with the food industry.

Rationale and design of the ADDITION-Leicester study, a systematic screening programme and randomised controlled trial of multi-factorial cardiovascular risk intervention in people with type 2 diabetes mellitus detected by screening

Background

Earlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in Type 2 Diabetes Mellitus (T2DM). Latent phase identification through screening requires structured, appropriately targeted population-based approaches. Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from randomised intervention trials in screen-detected T2DM cases. UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM. To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care. Here we describe the rationale and methods of a systematic community screening programme and randomised controlled trial of cardiovascular risk management within a UK multiethnic setting (ADDITION-Leicester).

Design

A single-blind cluster randomised, parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care.

Methods

ADDITION-Leicester consists of community-based screening and intervention phases within 20 general practices coordinated from a single academic research centre. Screening adopts a universal diagnostic approach via repeated 75g-Oral Glucose Tolerance Tests within an eligible non-diabetic population of 66,320 individuals aged 40-75 years (25-75 years South Asian). Volunteers also provide detailed medical and family histories; complete health questionnaires, undergo anthropometric measures, lipid profiling and a proteinuria assessment. Primary outcome is reduction in modelled Coronary Heart Disease (UKPDS CHD) risk at five years. Seven thousand (30% of South Asian ethnic origin) volunteers over three years will be recruited to identify a screen-detected T2DM cohort (n = 285) powered to detected a 6% relative difference (80% power, alpha 0.05) between treatment groups at one year. Randomisation will occur at practice-level with newly diagnosed T2DM cases receiving either conventional (according to current national guidelines) or intensive (algorithmic target-driven multi-factorial cardiovascular risk intervention) treatments.

Discussion

ADDITION-Leicester is the largest multiethnic (targeting >30% South Asian recruitment) community T2DM and vascular risk screening programme in the UK. By assessing feasibility and efficacy of T2DM screening, it will inform national disease prevention policy and contribute significantly to our understanding of the health care needs of UK South Asians.

Trial registration

Clinicaltrial.gov (NCT00318032).

Anemia is a common but neglected complication of adjuvant chemotherapy for early breast cancer

In this study, we set out to determine the frequency and severity of anemia and the corrective interventions used during adjuvant chemotherapy for breast cancer.

We conducted a retrospective electronic chart review of 702 patients who received adjuvant breast cancer chemotherapy at four BC Cancer Agency centres in 2002 and 2003. For these patients, we recorded the initial hemoglobin reading and the date of the first hemoglobin reading in the ranges 110–119 g/L, 100–109 g/L, 90–99 g/L, and <90 g/L. We also recorded any discussion about, or delivery of, interventions for anemia [transfusion, epoetin (epo) or both].

Median age of the study population was 51 years, and it varied with chemotherapy type. Among the patients, 12% had a hemoglobin reading <120 g/L before the start of chemotherapy. Overall, the proportion of patients with at least one hemoglobin reading <120 g/L was 78%; <110 g/L, 54%; <100 g/L, 31%; and <90 g/L, 14%. Depending on chemotherapy type, a hemoglobin reading <100 g/L occurred in 5% to 54% of patients. Intervention rates increased as hemoglobin declined. For 99 patients with a hemoglobin reading <90 g/L, a discussion of anemia was documented in the treatment chart in 49% of cases, a transfusion was delivered in 23%, epo was used in 11%, and transfusion and epo were both delivered in 5%.

Anemia was relatively common and varied with chemotherapy type. Documentation of a discussion of anemia occurred in fewer than 20% of the patients with a hemoglobin reading of 90–99 g/L and in only half the patients with a hemoglobin reading <90 g/L. Intervention rates were low at hemoglobin readings for which randomized trials have shown that intervention can improve quality of life.

Postmortem evidence of interactions of bottlenose dolphins (Tursiops truncatus) with other dolphin species in south-west England

Reports of violent interactions between bottlenose dolphins (Tursiops truncatus) and harbour porpoises (Phocoena phocoena) in the coastal waters of the UK are well documented. Examination of stranded cetaceans by the Cornwall Wildlife Trust Marine Strandings Network and the UK Cetacean Strandings Investigation Programme has indicated that seven animals, of four other species, found stranded in south-west England, had pathology consistent with bottlenose dolphin interaction, including two juvenile and two adult common dolphins (Delphinus delphis), one juvenile pilot whale (Globicephala melas), one juvenile Risso's dolphin (Grampus griseus) and one adult striped dolphin (Stenella coeruleoalba). Although recorded traumatic lesions were often not as severe as those found in harbour porpoises, it is probable that the interactions did contribute to stranding and/or death in all four of the juvenile animals examined. Furthermore, analysis of photographs taken before establishment of the Marine Strandings Network revealed rake (teeth) marks consistent with bottlenose dolphin interaction on one stranded common dolphin in 1992. A number of causes have been suggested for these interactions in harbour porpoises stranded in the UK and it is possible that any combination of these factors may also be implicated in the cases described in this report.

A randomized trial investigating the 12-month changes in physical activity and health outcomes following a physical activity consultation delivered by a person or in written form in Type 2 diabetes: Time2Act

BACKGROUND AND AIMS

Physical activity is a cornerstone of Type 2 diabetes management but is underutilized. Physical activity consultations increase physical activity in people with Type 2 diabetes but resources are often limited. Time2Act is a randomized control trial to study the 12-month effectiveness of a physical activity consultation delivered by a person or in written form, in contrast to standard care, for people with Type 2 diabetes.

METHODS

A total of 134 inactive people with Type 2 diabetes in a contemplation or preparation stage were randomized to either intervention or standard care. Objective (accelerometer) and subjective (7-day recall) physical activity levels were measured over 1 week, along with physiological [blood pressure, body mass index (BMI), waist circumference] and biochemical [glycated haemoglobin (HbA(1c)), total and high-density lipoprotein (HDL) cholesterol] measures at baseline, 6 and 12 months.

RESULTS

Neither a physical activity consultation delivered by a person nor in written form was better than standard care at increasing physical activity levels or improving health outcomes in the full study cohort. Total and HDL cholesterol, waist circumference and both systolic and diastolic blood pressure improved over 12 months in all groups, whilst HbA(1c) improved over 6 months. In a subgroup (baseline pedometer steps < 5000/day), the physical activity consultation delivered by a person significantly increased physical activity over 12 months and the standard care group significantly decreased.

CONCLUSIONS

More research is needed which not only investigates the most economical and effective methods to promote physical activity, but also the best setting to conduct physical activity consultations and the participant factors affecting uptake of physical activity in Type 2 diabetes.

Impact of a reduced dose intensity of adjuvant anthracycline based chemotherapy in a population-based cohort of stage I-II breast cancers

Background:

Reductions in the dose intensity (DI) of adjuvant anthracycline-based chemotherapy in early stage breast cancer are frequently required due to treatment toxicity or poor tolerance, but the implications of a minimal reduction in DI on clinical outcome remain uncertain.

Patients and methods:

Women with stage I–II breast cancer treated with adjuvant adriamycin and cyclophosphamide (AC) from 1990–95 were identified in a provincial breast cancer database. Cases were classified into four cohorts: (1) all cycles delivered at full dose and on time; (2) one single dose reduction or dose delay; (3) >1 dose reduction or dose delay; (4) <2 cycles of chemotherapy delivered.

Results:

484 eligible cases were identified (cohort (1): n = 268; (2): n= 88; (3): n= 89; (4) n= 39). Slight imbalances in lymph node status (p=0.05) and adjuvant hormonal therapy (p=0.05) were observed between the cohorts. Fifty-five per cent (267/484) of the patients had node-positive disease and 33% (158/484) were ER+. 45% of cases had a reduction in DI. With a median follow-up of 9.6 years, there were no significant differences in relapse-free survival (p=0.94), breast cancer-specific survival (p=0.87) or overall survival (p=0.86) between the four cohorts. Outcomes were independent of hormone receptor status.

Conclusions:

Although toxicity related reductions in the DI of adjuvant AC chemotherapy for early stage breast cancer are common, they did not appear to significantly impact on clinical outcomes in this population-based cohort of women with stage I–II breast cancers.

Belief in public efficacy, trust, and attitudes toward modern genetic science

Government and policymakers want to engage the public in a dialogue about the conduct and consequences of science and increasingly seek to actively involve citizens in decision-making processes. Implicit in this thinking is that greater transparency and public inclusion will help dispel fears associated with new scientific advancements, foster greater public trust in those accountable, and ultimately increase the acceptability of new technologies. Less understood, however, are public perceptions about such high-level involvement in science and how these map onto public trust and attitudes within a diverse population. This article uses the concept of public efficacy -- the extent to which people believe that the public might be able to affect the course of decision making -- to explore differences in trust, attentiveness, and attitudes toward modern genetic science. Using nationally representative data from the 2003 British Social Attitudes Survey, we begin by examining the characteristics of those who have a positive belief about public involvement in this area of scientific inquiry. We then focus on how this belief maps on to indicators of public trust in key stakeholder groups, including the government and genetic scientists. Finally, we consider the relationship between public efficacy and trust and attitudes toward different applications of genetic technology. Our findings run contrary to assumptions that public involvement in science will foster greater trust and lead to a climate of greater acceptance for genetic technology. A belief in public efficacy does not uniformly equate with more trusting attitudes toward stakeholders but is associated with less trust in government rules. Whereas trust is positively correlated with more permissive attitudes about technologies such as cloning and gene therapy, people who believe in high-level public involvement are less likely to think that these technologies should be allowed than those who do not.

Physical activity consultation for people with Type 2 diabetes: evidence and guidelines

Physical activity is an important, but often underused, therapeutic strategy within diabetes care. To date, little is known about the best way to promote physical activity in diabetes care. Physical activity consultation is an intervention designed to promote physical activity behaviour change. This article provides guidelines on how to conduct a physical activity consultation with people who have Type 2 diabetes, and reviews the evidence surrounding the effectiveness of this intervention in this population. The trans-theoretical model is the underlying theory of behaviour change for the physical activity consultation intervention. The review identifies research which supports the use of this model for understanding physical activity behaviour in people with Type 2 diabetes. The review outlines a number of modifiable variables associated with physical activity behaviour change in this population. How each of these variables is addressed within the guidelines for conducting a physical activity consultation is identified. Finally, limited but consistent research highlights the effectiveness of physical activity consultation for promoting physical activity in people with Type 2 diabetes.

Monitoring tumor response to ZD4190 therapy with an 18F labeled angiogenesis imaging agent

10507

Background: While a number of novel therapies are being developed to inhibit the growth or survival of tumor vasculature, there are limited methods available for measuring changes in tumor vascularity. In order to quantify tumour vascularity by PET imaging, we examined an 18F-radiolabeled small peptide (AH111585) containing an RGD (Arg-Gly-Asp) sequence. This peptide binds with high affinity (nM) to avβ3 integrin, a cell adhesion receptor that is highly expressed on tumor neovasculature, but expressed at low levels on mature endothelium and epithelial cells. 18F-AH111585 was used to examine the response of human lung tumor xenografts to treatment with ZD4190, a small molecule inhibitor of VEGF signaling. Methods: MicroPET (using 18F-AH111585) and microCT imaging data was acquired pre and post 3 doses of ZD4190 (100 mg/kg, p.o., over 3 days) or vehicle in CD-1 nude mice bearing Calu-6 tumor xenografts. 18F-AH111585 was administered 2 h prior to microPET imaging (10 min) to allow for tumor uptake and background tissue clearance. Tumor and background tissue uptake was determined from the images (expressed as %id/g). Results: Uptake of 18F-AH111585 in Calu-6 tumors was reduced following 3 doses of ZD4190, with an average reduction of 31.8 ± 4.6 % (calculated from imaging ROI data), whereas increased 18F-AH111585 uptake was observed in tumors of vehicle treated mice (average increase of 26.9 ± 9.4 %). The difference between treated and control group uptake was statistically significant (P<0.01; two- tailed t-test). Tumor size (assessed via caliper measurement) remained comparable over the duration of treatment. Skeletal muscle, used as a reference tissue for ROI analysis, demonstrated equivalent uptake pre and post therapy. Conclusions: The data demonstrate that 18F-AH111585 can detect changes in tumor uptake following acute treatment with a VEGF signaling inhibitor (ZD4190). The results suggest that this imaging agent may be useful for monitoring changes in tumor vascularity.

No significant financial relationships to disclose.

Impact of irinotecan and oxaliplatin on overall survival in patients with metastatic colorectal cancer (MCRC): A population- based study

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Background: Over the past 10 years, chemotherapeutic options for MCRC has significantly expanded from 5-FU based therapy, to include irinotecan and oxaliplatin. The effect of the availability of these treatments on overall survival is evaluated among patients in 3 time cohorts referred to the British Columbia Cancer Agency (BCCA). Methods: Patients with newly diagnosed or relapsed metastatic colorectal cancer referred to the BCCA in 1995/96, 2000 and 2003/04 were included. In 1995/96, 5-FU was the only palliative chemotherapy agent available at BCCA and irinotecan and oxaliplatin were available in 2000 and 2003, respectively. A one year period was used for the irinotecan cohort to minimize overlap between groups. Overall survival estimates were generated using the Kaplan Meier method. Survival was calculated from time of diagnosis of distant metastatic disease to either death or last contact date. Results: Cohorts were generally similar, however, a significantly higher proportion of patients received chemotherapy in more recent eras ( Table 1 ). Only 25% of patients received both irinotecan and oxaliplatin in 2003/4 and only 10 % received biologic therapies. An improvement in median survival of 3.6 months was observed. The improvement in the treated subgroup was 4.2 months. Outcomes of patients untreated with chemotherapy were unchanged between cohorts. Conclusions: In this population based study, the proportion of patients with MCRC treated with chemotherapy significantly increased between 1995/6 and 2000/2003/4. Patients treated with chemotherapy experienced a 4.2 month increase in median survival in 2003/4 compared to 1995/6. Survival improvements were only significant in the time period when all three effective chemotherapies (5FU, irinotecan and oxaliplatin) were available. As bevacizumab was not available until 2006, its survival impact in this population is not yet known.

[Table: see text]

No significant financial relationships to disclose.

Streptococcus gallolyticus subsp. pasteurianus septicaemia in goslings

Increased mortality was observed in a group of 2-3-week old goslings. At post mortem examination, gross lesions included congestion and haemorrhages in the viscera. Histopathological lesions included generalised congestion of tissues with multifocal bacterial colonies, an acute septic fibrinoid splenitis, and an acute septic hepatitis, all consistent with acute septicaemia. Gram-stained sections of liver and lung confirmed the presence of Gram-positive bacteria and Streptococcus gallolyticus subsp. pasteurianus (Streptococcus bovis biotype II/2) was isolated in pure growth from two of the goslings, and in mixed growth from a third.

A population-based study of trastuzumab-mediated cardiotoxicity among early stage breast cancer patients treated with adjuvant trastuzumab

10640

Background: Given the risk of cardiotoxicity demonstrated with trastuzumab (T) in the MBC literature, adjuvant T trials incorporated stringent cardiac monitoring. In 2005, several of these trials were reported with impressive DFS improvements. As a result of these trials, women in the province of British Columbia with HER-2 positive early stage breast cancer were offered T either concurrently or sequentially with their primary chemotherapy regimen. Given the paucity of data surrounding adjuvant T-mediated cardiotoxicity among the general population, we performed a retrospective review of cardiac toxicity among all patients receiving adjuvant T at the BCCA. Methods: Patients receiving adjuvant T between July 1, 2005 and December 31, 2005 either sequentially or concurrently with their primary chemotherapy regimen were identified by screening the BCCA pharmacy database. A chart review was conducted and the T start date; LVEF values at 0, 3 and 6 months; and patients with symptoms suggestive of congestive heart failure were identified. The mean LVEF values at 0, 3 and 6 months were calculated. Results: 133 patients received adjuvant T alone after completing their primary chemotherapy. The mean baseline LVEF was 60.5%. Of the 101 and 11 patients available for analysis at 3 and 6 months, the mean LVEF was 58.5% and 58.4%, respectively. 5 patients (3.8%) developed symptoms of CHF. 58 patients received adjuvant T concurrently with their primary chemotherapy (four cycles of AC followed by four cycles of concurrent paclitaxel and T). Of these, only 18 patients had an LVEF measured at 0 and 3 months, with a mean LVEF of 64.6% and 63.6%, respectively. Of the 7 patients who also had an LVEF measured at 6 months, the mean was 60.5% for an absolute decrease of 4.1% from baseline. One patient (1.7%) had symptomatic CHF. Conclusions: A clinically meaningful rate of cardiotoxicity is seen with both sequential and concurrent adjuvant T. In particular, we have demonstrated a higher rate of cardiotoxicity with adjuvant T alone than was observed in the HERA trial. These findings support ongoing stringent cardiac monitoring among the general population treated with adjuvant T.

[Table: see text]

Human Vero cytotoxigenic Escherichia coli (VTEC) O157 infection linked to birds

Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infections are a threat to public health. VTEC O157 has been isolated from gulls but evidence of transmission to humans from birds has not been reported. We recount an incident of VTEC O157 infection affecting two sibling children who had no direct contact with farm animals. An outbreak control team was convened to investigate the source of infection, its likely mode of transmission, and to advise on control measures. Human and veterinary samples were examined and the human isolates were found to be identical to an isolate from a sample of bird (rook) faeces. Cattle, rabbit and environmental samples were negative. This report provides evidence that birds may act as intermediaries for human infection with VTEC O157.

Botulinum toxin injection after biliary sphincterotomy

BACKGROUND AND STUDY AIMS

Endoscopic biliary sphincterotomy in patients with sphincter of Oddi dysfunction (SOD) is associated with a high risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), which may be secondary to residual pancreatic sphincter hypertension. It was hypothesized that botulinum toxin injection could be used to reduce pancreatic sphincter hypertension temporarily in SOD patients after biliary sphincterotomy, thereby reducing the rate of procedure-induced pancreatitis.

PATIENTS AND METHODS

All patients undergoing ERCP with manometry due to a suspected biliary SOD were asked to participate in the study. Patients with elevated basal sphincter pressures were randomly assigned to receive either botulinum toxin or a sham saline injection after biliary sphincterotomy. Fifty units of botulinum toxin were delivered via a sclerotherapy needle in the form of two 25-U injections of 0.25 ml each into the pancreatic sphincter. In patients in the sham arm, 0.50 ml of saline was injected into the duodenal lumen.

RESULTS

Between 12 February 1999 and 29 November 2000, a total of 98 patients were referred for ERCP with manometry; 86 consented to participate in the study, and 26 had elevated baseline pressures and underwent random assignment. Twelve received botulinum toxin injection and 14 were randomly assigned to receive the sham injection. A total of six patients in the sham group (43 %) developed procedure-induced pancreatitis, compared with three patients in the botulinum toxin group (25 %; P = 0.34).

CONCLUSIONS

Biliary sphincterotomy in patients with sphincter of Oddi dysfunction without pancreatic protection is risky and should no longer be carried out. This study demonstrates that botulinum toxin injection into the residual pancreatic sphincter after biliary sphincterotomy is technically feasible and safe, showing a trend toward a reduced post-ERCP pancreatitis rate in patients with sphincter of Oddi dysfunction. Further studies will need to confirm the validity of these experimental results before this technique can be used routinely.

Complex chimeras to map ligand binding sites of GPCRs

Family 1a GPCRs are thought to bind small molecule ligands in a pocket comprising sequences from non-contiguous transmembrane helices. In this study, receptor-ligand binding determinants were defined by building a series of complex chimeras where multiple sequences were exchanged between related G-protein coupled receptors. Regions of P2Y(1), P2Y(2) and BLT(1) predicted to interact with nucleotide and leukotriene ligands were identified and receptors were engineered within their transmembrane helices to transpose the ligand binding site of one receptor on to another receptor. Ligand-induced activation of chimeras was compared with wild-type receptor activation in a yeast reporter gene assay. Binding of ligand to a P2Y(2)/BLT(1) chimera confirmed that the ligand binding determinants of BLT(1) are located in the upper regions of the helices and extracellular loops of this receptor and that they had been successfully transferred to a receptor that normally binds unrelated ligands.